Understanding ADHD: Myths, medication, and new beginnings

There are few topics harder to avoid right now than ADHD. It's on social media, in broadsheet newspapers (where, naturally, ADHD is a completely fatuous nonsense and people should just get on with their lives), it's in parliament and it's in schools. In short, ADHD is trendy.

Like many trends, the last ones to get to it are the middle-aged, who immediately relegate it to the realm of the naff. They'll get their Taylor Swift t-shirts when they're licenced to a supermarket clothing department, and their already-in-progress embrace of TikTok will be its trendy end, as it was Facebook and Instagram before it.

For those who come across ADHD in their later life, it's like discovering a stomach-turning, stunning secret. The ADHD-er is Jim Carrey's Truman Burbank in The Truman Show, slowly coming to understand that the reason why he felt slightly different all this time was because… well, he was.

At the conclusion of the film, Jim Carrey's character faces a choice – the familiar old world of falsehoods, or the possibility of the new? I do love a good ending and I won't detail this one, but I'd definitely like an extra scene or two where Truman has to spend hours in line getting his passport arranged or can't get anywhere because people keep asking for selfies.

After my own ADHD diagnosis, and as part of continued endeavours to not be a complete hypocrite, I sought therapeutic support. After a series of frankly alarming experiences, I made a decision about my own private counselling practice and made a dramatic and characteristic pivot – I came out of the ADHD closet. In the years since, I've worked with hundreds of clients and couples affected by ADHD, and have had to unfortunately turn away countless more.

In my practice, I've found myself increasingly discussing the misconceptions surrounding ADHD medication. It's a topic that comes up with almost clockwork regularity, often accompanied by a hefty dose of scepticism. The chief objection, unsurprisingly, centres on the use of medication itself.

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The medical model

There's a prevailing fallacy that equates ADHD medication with the typical medical model – as if it were as straightforward as taking an antibiotic for an infection. It's crucial to understand that medication, while potentially beneficial, isn't a one-size-fits-all solution. Nor is it really a 'solution' at all. The reality of treating ADHD is far more complex and nuanced, involving a range of strategies that extend well beyond the realm of pharmaceuticals.

If you're reading this, chances are you know your ADHD. But for the sake of clarity, ADHD, or more accurately AD/HD (attention-deficit/hyperactivity disorder), is a complex neurodevelopmental disorder. That slash is significant and often forgotten, highlighting that attention deficit and hyperactivity are distinct yet related aspects of the condition.

Our current diagnostic criteria lists three types of AD/HD:

• predominantly inattentive
• predominantly hyperactive-impulsive
• combined type

Your 'type' is determined by a series of diagnostic questions. Your medication, the focus of this article, is often determined by that type.

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The impact of ADHD

ADHD's impact on adult life is pervasive and often profound. In academic and professional settings, individuals struggle with task completion, time management, and maintaining focus, establishing a corrosive pattern of underperformance that either leaves the individual with a chronic sense of underachievement, or a lifetime of exhaustive overcompensation to maintain a sense of normalcy.

The ADHD individual's interpersonal relationships can often bear the brunt of their lived symptomology, with inattention and impulsivity straining connections with partners, friends, and colleagues.

In sessions with couples and individuals, behaviours and interactions can often be plotted by the askew chemistry of the ADHD brain; the misfiring distribution of chemicals that regulate mood and emotion turning seemingly everyday challenges into overwhelming ordeals affecting everything from stress management to decision-making. Multiplied over a lifetime, the accumulation of these lived experiences can have a catastrophic effect on the sufferer's self-esteem, if indeed any exists to begin with.

The ADHD adult can often be observed as a curiosity of contradiction; the success in business that constantly loses his keys, or the definitely-not-based-on-a-true-story empathetic and undoubtedly insightful therapist who connects deeply with clients yet occasionally double-books appointments.

These people aren't lazy or careless, as is often the stick with which they're beaten. They're navigating the choppy seas of a world misaligned with their cognitive processes. Their lives are often stories of broken hearts, lost opportunities, regret and a sense of not fitting in.

My work focuses on the emotional impact of ADHD. By the time our paths cross, the unknowing ADHD adult has lived a life in some form, as I had it once brilliantly described to me, "Walking up a downward escalator – I'll get there, it'll just take longer and it's harder."

Among the many common comorbidities, my many ADHD clients have almost universally presented with some form of repeating depressive mood, lacking self-esteem and anxiety. Substance abuse or other impulsive, compulsive behaviour is
common, as is sexual dysfunction and chronic use of pornography, particularly in men.

Women (so frequently misdiagnosed if diagnosed at all), can often present with dysregulated behaviours around food – the sad, morbid truth of this connection being underlined by the use of stimulant medication Elvanse, one of the medications used to treat ADHD in the UK, also being used to treat binge-eating disorder.

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Misconceptions about ADHD medication

This is one of the most common barriers I come up against. “I don't want to be on medication for the rest of my life”, “I don't want to be reliant on something” and “It's just speed, isn't it?” are the most common. It's a delicate line to walk, wanting to validate and acknowledge someone's feelings while also providing the contextualising counter-point, but one I walk daily.

The real issue is in the name. We call it 'medication' because it's a pill and it comes in a packet, but doing so only exacerbates an untruth.

In fact, ADHD medication is no more medicine than glasses or a hearing aid – those that exist to correct a physical condition which is never going to be cured. Sure, you can be 'cured' from your poor eyesight when you wear your glasses, but I don't think we would class wearers as 'addicted' to them. As I sometimes (and as sensitively as I am able) say to clients “You were always reliant on it, you just didn't realise until recently”.

The lowdown on ADHD medication

ADHD medications prescribed in the UK fall into two main categories: stimulants and non-stimulants. Both types aim to address the neurochemical imbalances characteristic of ADHD, primarily by increasing the activity of key neurotransmitters (the connective tissue) in the brain.

Stimulant medications, the first-line treatment for many, include methylphenidate (branded as Ritalin, Concerta, Equasym) and lisdexamfetamine (Elvanse). These work by increasing the levels of neurotransmitters known as dopamine and norepinephrine in the brain, enhancing focus, reducing impulsivity and evening out the distribution of resources. They're available in various formulations – immediate release for short-term effects, and extended release for day-long coverage.

Non-stimulant options, often prescribed when stimulants prove ineffective, or the individual's blood pressure is too high, include atomoxetine (Strattera) and guanfacine (Intuniv). Both interact with the brain in similar but slightly different ways. Atomoxetine functions as a norepinephrine reuptake inhibitor, while guanfacine modulates norepinephrine transmission in the prefrontal cortex, where we humans regulate our attention, impulses and emotional state.

The choice; the result

The choice between and process of what ultimately amounts to experimenting with these medications isn't straightforward. While stimulant medication often provides more immediate and noticeable effects, they carry a higher risk of side effects and potential for misuse. Non-stimulants, though generally slower to show benefits, often have a more consistent effect throughout the day and may be preferable for individuals with other conditions alongside ADHD, or for those for whom there may be concerns about misuse.

For many adults in the UK, starting medication is as though someone has taken the sealed jigsaw box of their life and emptied the contents all over the floor. They have the picture and the component pieces, and now face the painstaking process of reconstituting the familiar picture.

For some, if not most, the emotional impact of that can be huge, most closely related perhaps to loss or grief. The past can take on a melancholic haze, where people, places and events are suddenly seen through the lens of struggle and sadness, while their future can feel exciting yet uncertain.

Although the brain's chemistry will hopefully change for the better, it doesn't change someone's past experiences. It's common for clients to battle the possibilities of the future with the habits of thoughts past – a need for certainty and immediacy to an unknown future in response to “What or who am I going to be?” a common source of discussion. Anger – at caregivers, injustice – is common, also. Sadness. Dilution of powerful responses with “They didn't even know about it then” or “They did their best” near-universal. All of them valid responses, but old tools for a new job.

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The puzzle

The jigsaw puzzle of ADHD treatment isn't complete with medication alone – more, you've completed the border. My clients' broadly positive (although not without difficulty) medication experiences can give rise to magical “I'm-sorted-now” thinking, sometimes bringing an abrupt and premature end to our therapeutic work.

And while medication can (and certainly was for me) be transformative, it's not in of itself a 'fix' any more than the aforementioned glasses fix someone's eyesight or our jigsaw boxes picture makes its construction somehow straightforward. ADHD medication doesn't erase the condition – it simply helps level the brain's playing field.

It's imperative for those in the process of adult ADHD diagnosis (medicated or not) to manage the condition with a holistic approach – a fully-functioning system of diet and exercise, psychoeducational, and therapeutic or emotional support are all crucial cogs in the new machine.

Like assembling a jigsaw, the journey to the right kind of medication can be long and frustrating. The medication titration process is a carefully managed construction of our pieces, not a single-sitting solution and typically involves starting with a low dose of “See how you get on with this one” medication, gradually increasing, decreasing and tweaking under the supervision of a psychiatrist.

Like so many steps along the ADHD-ers journey, it requires qualities and characteristics which are of themselves characteristic in their absence in the person's emotional language; listening to and communicating the body and mind's responses, of patience, and of acceptance that even the right medication won't complete the entirety of the puzzle. Side effects – can include loss of appetite, sleeplessness, a feeling of overstimulation – should be noted, monitored and managed.

It's not uncommon for interpersonal relationships to take on new dynamics or to change.

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The process of medicating ADHD is as complex as the journey to and through it; complex, partly (and inexplicably) left to chance, and a process which contains in-of-themselves complicated, nuanced emotional steps along the way. A little like working with addiction where treatment can hinge on the metronome of the sober mind, if the individual can get past their misconceptions or internal barriers about 'the pills', medication can similarly act as an anchor in the choppy seas of unpacking a new life; a sober captain for a familiar vessel.

This, too, is my job; their optician, helping the person now able to see the world in more than just two-dimensional blobs, but instead with their glasses on and in crystal-clear three dimensions.

Successfully done, what was once the ADHD-ers ceiling can become their floor; solid ground from which to build an exciting new future where their long-held sense of internal capability can be given its best hope of congruence with their lived experience.