ADHD: It's Not What You Think

ADHD is widely misunderstood, leading to misdiagnosis and unnecessary stigma and shame. The formal diagnostic criteria is outdated and incomplete. It doesn’t reflect the latest data or the widespread experience of ADHD experts.

In this episode, Jenny breaks down our current understanding of ADHD, some key features you have never heard of, and how it all ties together. By the end of this crash course, you’ll know more about ADHD than 90% of people, and even more than most physicians!

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Need help applying this to your life? Ready for more strategies like this, but personalized to YOU? Set up your free consult and let’s talk about your unique situation and how coaching can help:
https://getcoached.jennyhobbsmd.com/consult
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Everything on this podcast and website is for informational purposes only and should not be used as medical advice. Views are our own, and do not necessarily represent those of our past or present employers or colleagues.

Transcript

00:09
Welcome to Rethink Your Rules with Jenny Hobbs, MD, a fresh perspective on relationships, success and happiness for high achieving moms.

00:23
Hey there, it's Jenny. Welcome back to Rethink Your Rules. And today we are talking about one of my favorite special interests, which is ADHD and adults. I have been meaning to go through this with you for a while. It might even be a couple of episodes because I wanna make sure it's not too overwhelming. But for those of us who are in the world of understanding ADHD and sort of diving into the pages and pages.

00:50
of information on the internet and the studies and the podcast. There is this whole other understanding of ADHD that I have noticed is completely different from what most people picture when they think of it. And I want to try today to give you a brief overview of some of the things that I have learned through these hours of researching to understand my kids and myself better. And I think it will really benefit you.

01:14
First of all, because I think a number of people probably listening to this podcast who resonate with me likely have some features that could suggest undiagnosed ADHD or children who have it. And so I definitely want you to kind of be listening to see if any of this might fit with you because we know ADHD is very treatable and having a diagnosis is a very useful thing for your mindset as well. But I also think even if you don't fit into this category, there...

01:41
are opportunities to understand other people better. When someone is behaving in these ways I'm gonna talk about, maybe considering whether or not they may have an undiagnosed ADHD situation going on. So maybe they're not trying to be super annoying and interrupt you and be late to everything and miss all their deadlines and lash out at you when they're frustrated. Maybe they actually are wired differently and those things are very challenging for them. And so maybe you can.

02:09
keep that in mind and interact with them. If they're close enough to you, maybe even consider bringing it up with them. I know for most people, it's unexpected, I think, but it actually makes you sometimes feel better once you know you have the diagnosis because it gives you an understanding of what's going on, even though obviously there also is a lot of grief with the diagnosis as well in certain ways. I guess I'm of the opinion. I've always been of the opinion that...

02:37
knowing what's really going on, even if it's hard to hear, is still better because then you have the truth and then you can deal with it. I always think that's better than being blind to what's really going on. Awareness is always better, I guess, is what I'm trying to say there. First of all, when we think about ADHD, the most common picture that most of us have is someone who is hyperactive. Typically, it's a white boy who's hyperactive in the classroom. That is because that is really where it was traditionally first noticed, which makes sense

03:07
those situations were by far the most problematic for everyone, right? So you could see the overt hyperactive behavior, it was disrupting the class. So people needed a name for it, they needed to talk about it. And that was what was defined and that was what was studied and that was what was treated initially. And I think by now most of us realize that in addition to the hyperactive component, there's also an inattentive component. And some people primarily have that inattentive component so they don't have as much

03:33
overt hyperactivity with their body, but they may be easily distracted. Those are the kids sitting in the back of the classroom, not paying attention, and they may go under the radar and not ever be diagnosed because they're not causing a problem to anyone. But they may not be performing to the levels of their abilities in class and things like that and it may be affecting them in other ways. So classically, we always think about those two types, the predominantly hyperactive, the predominantly inattentive, or a combined of those two.

04:01
And again, really mostly described in children, it was thought to be almost completely a disease of children or a diagnosis of children for many years, and that most, if not all, people sort of grew out of it over time, which is different than what we're kind of currently thinking now. And I'll talk about that in a second. And then the other piece of this inattentive hyperactive picture that a lot of people also are familiar with, and if you look at our diagnostic criteria that psychiatrists use in the US, the DSM, it will say this as well. So you've got the...

04:30
hyperactivity, the inattentiveness, and then you also have impulsivity, right? So making these quick decisions to do something really unsafe, whether in a car or with drugs, or, you know, like kind of this really volatile kind of picture, a lot of unsafe choices. And we know that from the data, people who have ADHD do end up with a lot more accidents. And I think they even have potentially a shorter life expectancy, which is kind of crazy, but definitely more likely to end up in problems with the law, get kicked out of school.

04:57
teen pregnancy, all kinds of things. So having untreated ADHD leads to a lot of impulsive behaviors, not kind of thinking things through. So that was what we've always thought of. And that's really what the criteria still mostly talk about in the manual that psychiatrists and other mental health professional use. So inattentive, hyperactive, and impulsive. However,

05:19
The DSM is way behind the times, I'm just going to say. So if you spend any time at all talking to anyone who actually treats ADHD, and this is true for children and adults, people who treat all the ages, they will tell you that some of the hallmark features of ADHD are not even mentioned in the DSM. And this is the first problem that we have with really understanding what's going on. So the biggest thing that is really lacking, well, there's really kind of two things that are really lacking from the DSM, in my opinion.

05:49
One of them is the emotional dysregulation. So the inability to calm yourself down when you feel really sad, really angry, really happy, right? So a lot of what you're actually seeing when people are acting impulsive or hyperactive is actually a reflection of this emotional dysregulation, which if you're a parent, this is kind of an important distinction, right? Because...

06:15
if someone is emotionally dysregulated, like their feelings are too big for their body and they can't handle them, the response to that that's going to be effective is going to be quite different than if the problem is they're just like, you know, hitting their sister to be mean, right? And so if you think that like the problem is the hitting and you set rules around the hitting, well, that's great. But if the problem is not really the hitting, but the fact that they don't know they're delayed in their ability to handle their anger appropriately because they have a delayed skill set.

06:44
because of the way their brain is wired, right? Like you punishing them for hitting is not getting at the root of the issue and it's just creating this layer of shame and frustration because they wish they could do what you're asking them to do and they can't and now they just give up and then they think, same with school, right? So if the problem is that they feel terrible about themselves because they're messing something up or they get in trouble and that emotion is so big that it's too scary for them to tell anyone about that and then they fail that class and then they decide, well, I'm actually just stupid and then they get like really.

07:13
depressed and sad and anxious, and then they drop out of school. You can see how this emotional dysregulation really plays a big role, and it's not even mentioned in the criteria. So when my son was diagnosed and we talked initially to our pediatrician and then originally to some psychologists, I mean, the main problem honestly was his emotional lability and his inability to just not hit people and not be so...

07:41
off, you know, have these like crazy temper tantrums that he had always been that way. These like really intense emotions that he could not stop. And honestly, I don't think at that point that I really knew that that was such a hallmark feature of ADHD. And now I talk to friends and family and stuff and people will mention something to me about their kid. And they'll talk about like how they have these like really dysregulated, angry behaviors. And often they're not even considering that that could be ADHD, right? And I'm thinking as I'm hearing it, I'm like, oh my gosh.

08:09
think that it's very likely this kid has ADHD. But no one's even thinking that because they don't appear to have the classical symptoms otherwise. It's just mostly like, gosh, they're really argumentative and not compliant and having these terrible temperamentals. So the emotional dysregulation, or some people call it emotional hyperarousal, that part is really lacking from the DSM criteria. That's really a problem. The...

08:35
The other thing that's related to that, that's a really key feature that's not included is this what we call rejection sensitivity or rejection sensitivity dysphoria. Some people also have another new part that I'm blanking out. Rejection sensitivity dysphoria is it's not just like, oh, someone told me I wasn't good or they didn't want to be my friend and that hurt my feelings. But what they're beginning to understand is that for people who have ADHD, they're

09:04
It literally feels like someone has physically wounded them when they perceive that they have been rejected. It's this overwhelming, intense emotion of rejection and shame that is literally dysphoria. It's like going into a depression almost. Obviously, it's really hard because they tell me I have an ADHD brain. I've never had any other type of brain. I don't know how to compare that experience to other people.

09:33
compared to people I'm very close to, like my husband, for example, I definitely am much more sensitive to rejection and more sensitive even to perceived rejection. So for example, you know, years ago, I had this friend and she did this really fun dinner club with a group of six of us and everyone took their turns hosting and planning this dinner and it was all her idea. And I was the last one to host my dinner. And I had it all set up and everyone was coming. And then...

10:00
She was like, yeah, I've been really busy and I can't come tonight. I've got too much other stuff to do. She'd gone to every other single one and this was her thing. I think someone else backed out too. Then I had this reservation and half the people weren't coming and the person who planned it, who was my really good friend at the time. I remember, that was an example where I'm not sure, but I possibly cried about that for a while at home. The thing is, I think my friend was being honest and she was probably setting a healthy boundary for herself that that time didn't work for her.

10:30
But I, in my mind, was like, well, I hate planning things like this. And then I never know if anyone's going to come. And now I put myself out there. And everyone thinks this is stupid. And this is personal because she went to everyone else's, but not mine. That must mean something. And I can think of so many examples of this where people are planning some kind of trip or something that sounds fun at work. And they are talking about it. And they don't invite me. And it's like, not really intent. They maybe don't know I know about it, but I know that they're not contacting me.

10:58
someone says, oh, I can see a picture that someone got together with someone on Instagram. And I'm like, wait, they didn't invite me, right? Even if I wasn't gonna go. And I can literally take these things so personally. I could give you guys many, many examples, but I won't belabor the point. And if you're a person who has this rejection sensitivity dysphoria, you will know what I'm talking about because you'll know sort of objectively, like you can't prove that that person.

11:23
doesn't like you or that it's meant to be a rejection, right? It might literally be as simple as they have other plans and they can't come to this thing you planned, right? Or whatever the case may be, but you just take it to heart so much. And that this rejection sensitivity dysphoria, I think is both the big emotions that we talked about, but it's also probably a combination of throughout your life when you have ADHD and you are, you know,

11:52
I call it like a too much person, right? When you're too much, you talk too much, you do too much, you move too much, you're too impulsive, you say the wrong thing, all those things, you get a lot of negative responses from people, you get a lot of judgment from people, people look down on you, people like say to your face like that you need to knock it off right.

12:11
And so I think it's a combination of both a lifetime of these like micro traumas where you're rejected for being your authentic self and you're trying to like mask your authentic self so that other people are more comfortable and like you better, which is hard, right? So you're doing all that work and still occasionally like it's not successful and you're getting rejected. And then you have this huge emotional wave that comes on top of all that because you are, as we said, deficient in the ability to regulate your emotions too. So it's like a double whammy.

12:41
And then of course it gets compounded over the years because you are trying so hard to combat that and it's time and time again, it's so exhausting that then even when really nothing's going on, you're kind of like afraid to take a wrong step because you don't know how to read things, right? And there's also a problem in ADHD of not being super aware.

13:07
of things. And so this will happen to me recently, like someone would give me this feedback, which, you know, I actually, when I'm in my like calm, regulated state, I really appreciate feedback. And I always want to get better. And I certainly like I've worked really hard on that, you know, being open to feedback. But sometimes someone will give me their honest feedback. It's their opinion, right? Often, it's just someone's opinion. And I have no, you know, nothing objective to go on. And I hear it. And but then what will happen is I literally start to run through

13:35
obsessively, like a list of all the time something anywhere close to that has ever happened, right? Like if I don't get voted onto something, I think of like every time I didn't get voted and I start to, and I like, my brain will just make it this huge thing where, you know, I, no one ever likes me. I'm never popular. I obviously this whole time, everyone's just been pretending to be nice to me and they all hate me and I never get anything. I mean, like my brain. And so again, if you think about how ADHD works, right, you have this

14:03
this hyperactivity, which is not just physical, but also mental. So your brain is you've all this energy and you're just going, going, going with your brain. Right. And so you combine that with people rejecting you and not liking you because you're a little too much. Right. And then big emotional letdown and the constant worry and anxiety of like, is this feels right to me, but maybe other people don't like it because I'm not like other people. Right. And then your brain's just ruminating on it and you can't let it go. Even if

14:30
you can logically tell yourself it's a waste of time to rehash. I mean, I literally did this this past week. I was rehashing something that happened in high school that I'd completely forgotten about because something that happened now kind of triggered it. And I couldn't turn my brain off. Well, I shouldn't say that. I could turn my brain off and I did. And that's part of why coaching, I think, is incredibly powerful for people with ADHD because we literally need to build.

14:55
skills to turn our brain off and to let these things go and to handle our emotions. Like, we need those to be explicitly spelled out to us more than other people, which for me is what coaching has done for me. Right? So I coached myself through that. But I share that with you just to give you an example of kind of what it's like to be in the ADHD brain and how these symptoms that we talk about kind of all play in together to create

15:23
a lot of energy and time and effort being put into things that other people maybe have no idea your brain is even working on. So if you kind of think about that big picture, you've got the inattentive, the hyperactive, and the impulsive, which is covered in the DSM. But then you really have this big piece of emotional dysregulation and rejection sensitivity, both of which are not at all mentioned. So many, many people don't even recognize.

15:49
that those are part of it, including the people that you're going to, like your primary care doctor or whoever you're mentioning this to, they wouldn't think of that, right? So that's one really big, or two really big pieces to add. There's the rejection sensitivity and the emotional dysregulation. And then the other big part you wanna think about is that the DSM criteria and the traditional mindset is that you have to have had symptoms in two or more places in your life. So like home and school or home and work.

16:17
And it has to have started before, like when you were in childhood, and you have to have had those symptoms. And there's some problems with that because obviously people, as I've mentioned in the previous podcast about ADHD, women and really smart people and people who are predominantly inattentive often don't get diagnosed in childhood. And so they find out they have it later. But then when you're looking back to see if they meet the criteria from childhood, you're really relying on that person's memory.

16:44
of when they were a kid or what their parents remember, right? And then you're using these suboptimal criteria, which don't even include some of the things. So while it's most likely that people have ADHD throughout their life, it's really hard to include in the criteria that the strict rule that has to be present in childhood because it's probably missing some people who just don't fit that picture or we can't remember or get the information to know when their symptoms really started. So there's that.

17:13
caveat to that as well. And I do think most clinicians kind of recognize there's that little difficulty with childhood, but I will say, you know, there's been an uptick in the number of people recognizing ADHD as adults and looking for diagnosis. And the internal medicine doctors, which is my specialty, we are being asked to really learn more about ADHD in order to offer diagnosis and prescription.

17:42
because there aren't enough psychiatrists to handle the increased demand and mental health nurse practitioners and things like that. There's just so much demand in the past few years. So one of my journals that I got as being an internal medicine doctor, that hat on, had a little info article describing characteristics of ADHD in order to really educate the entire population of primary care doctors out there so that they could be aware of it, right? And because most of us being...

18:11
Doctors for adults did not learn much about ADHD in our training because we were not training to be pediatricians, right? So over the last 20 years, now we have this coming up in adults. So there's this article to explain to everyone how you recognize it. And the reason I tell you all that is to say that even there, those medical experts telling other doctors how to diagnose ADHD are still referring to these ideas that you have to have had it in childhood and you have to have had it in two places.

18:38
And also, there's an interesting line in there where they actually say that if someone was a valedictorian, they likely don't have ADHD because they would have not been able to be successful in school, which is also, as I mentioned in my other episode, really not the correct understanding of ADHD because some people have ADHD wiring but are so smart and so good at holding it together for school that they can be successful academically. Many doctors would fall into this category. I would fall into that category.

19:07
So you have to be a little bit cautious when you're going to a primary care doctor or even to some other mental health professionals. If they're relying so strictly on those old criteria, they may be telling you there's absolutely no way you could have ADHD because you don't meet these criteria and you don't have them from a certain age and you are smart. But those things are actually not 100% true and we're likely missing a lot of people as a result. So...

19:34
I think that is a really good perspective for you to have as you think about this. And I want to just wrap this one up by telling you a more useful and accurate way to conceptualize ADHD that covers all of this and kind of pulls it all together. So the way that the experts recommend thinking about it really is as a deficiency of self-regulation. So the inability to regulate your thoughts when they go crazy thinking that everyone hates you and you can't go to sleep like I was just talking about, right?

20:04
inability to regulate yourself so that you don't talk back to your teacher or inability to regulate your attention. So rather than saying, you know, they can't pay attention, they have a deficiency of attention, which is why the name is confusing, right? It's not that. People with ADHD can focus just fine on things when they like them. The problem is that they can't regulate that focus. So they're either very intensely hyper focused on something they love to the exclusion of all the other things that need to be done for their well-being, right?

20:33
They're trying to do all the things they need to do to take care of themselves, but they can't motivate because that just feels so boring and not interesting. Right? So it's a deficiency of the ability to regulate your attention, your focus, your mood, your actions to just keep yourself regulated. And remember, that's one of our higher brain functions. And they've actually shown the neuroanatomy.

20:56
changes like on MRIs and things like that. And you can see that there is a difference in the way that people with ADHD's brains are wired. So they just don't have that ability that many other people do to say, oh, I really want to keep playing that video game all night long, but I'm gonna stop because I know what I really need to do is get eight hours of sleep so I can have a great day at work tomorrow, right? Or I need to really like not hit my sister like my parents said, so that I can have that reward later on. In that moment, that ability to regulate yourself to do that is diminished.

21:25
And it's not something you can just like think harder or try harder because it's just physically not possible for you. And likewise, a deficiency of the ability to regulate your attention. So like my son, you know, it's like in the morning, he literally could not just remember that he was trying to put on his clothes. I mean, still to this day, I'll go in there and he's gotten halfway dressed and he's like sitting there in his underwear reading a book. And it's been two minutes and all I said was, you know, put on your pants and brush your teeth. And he's, oh, I forgot. Right. So just can't regulate his attention.

21:53
to say, oh, I'll read my book after I get ready for school. And the other kind of piece of this, or way you could think of it is that it's a disorder of your executive functions, or executive dysfunction disorder. And executive functions, again, are basically the ways that our brain self-regulates. So it's a long list, but it's the kind of things you would think of, like keeping something in your working memory so you can recall what it was you were just doing, remembering something later, staying organized.

22:23
being able to reflect on what worked, what didn't, and make changes going forward, being able to keep from getting distracted when it really matters, being able to delay gratification, being able to plan and organize and prioritize without getting overwhelmed, to manage your time and know how long a task is going to take, or to ensure that you allow enough time to get somewhere, et cetera. So there's a long list of executive functions. And what I'm going to do in the next episode is walk through some specific examples of

22:52
Now that I have been given this diagnosis, how these executive dysfunctions and disorders of self-regulation were evident in my life in the past that were missed by me and other people. I mean, honestly, still to this day, when I tell people I have ADHD, people who've known me my whole life, they don't believe me. So we'll talk about why that might be.

23:18
It wasn't so obvious in my case, which I think will be relevant to many of you who are also high achieving women. The other thing I'm going to do is go through an article that lists specifically how it presents in the workplace for physicians, which is really illuminating and I think will help you, if you are one of my physician listeners, to really look at your colleagues' actions and at least give a quick pause and a thought when they are behaving a certain way to wonder whether or not they're dysregulated behavior or they're distracted behavior or they're

23:47
whatever they're doing that's like taking too long with patients or whatever, you could just give yourself a quick pause and say, I wonder if it's possible this person's wired differently and it's actually a skill that they're not as good at as I am, right? And if they don't know they have ADHD, like they may not know it's a skill they need to work on. They may not know that medication might help them. So rather than shaming those people or being pissed off at them or just assuming that they're doing it to be an asshole, you could give them a...

24:12
And same with when you hear people talking about their kids, you know, like maybe throwing that idea out there. If you hear about a kid who has a really hard time transitioning off of video games and you're thinking, well, they can't have ADHD because they can focus on the video game or they can focus on their schoolwork when they like it or they can focus on whatever, you know, maybe throw it to your friends. Say, hey, like, you know, some kids with ADHD actually have this thing called hyper focus. So maybe it's worth still looking into even though they don't seem to perfectly meet the criteria on paper, etc.

24:38
So these are really good things to just be aware of so you can be a good human out in the world, breaking down the stigma and breaking down the shame that surrounds these things. Because remember, 99% of people, probably even higher than that, are doing the best they know how. They are doing the best they can with the resources they have. So if they are acting impulsively and making bad decisions or whatever the case, just pause and remember.

25:05
maybe this is the best that they can do because of how their brain is wired. Maybe shaming and blaming and arguing with them and making is just going to make it worse and doesn't need to happen. Now you can hold people accountable, absolutely, but just kind of keeping that in mind that you can do it from a place of love and support versus shame. All right, so I always say I'm going to do these shorter and here we are 25 minutes in, which I guess right there tells you how

25:34
I can't really argue with this ADHD diagnosis because the way my hyperactivity has always presented is in talking too much. But I hope that you found it valuable. And as always, I would absolutely love it if you leave us a rating and review. I did finish up the podcast contest. So thank you, ladies. I will be sending out gifts to the women that won. But I need more help getting this word out to more people. So if you can please, please, please leave a rating review. It just takes a minute. It is a hugely...

26:03
impactful way to reach women. Hey, if you think I'm a little bit too much, I get it, but maybe you have a friend who kind of you sound like, gosh, she sounds like a lot like Jenny. Sometimes she talks too much. She drives me crazy. She's always late. Send her this episode. Maybe she will resonate with me. People with ADHD tend to like how I am and people who don't have ADHD are like, yeah, she's a little much. So think of someone who would benefit. Throw in a review, send it to them. I will be so appreciative because I'm...

26:29
I want to be able to reach these women and help them. And I need your help to do it. That's just the way those algorithms work these days. And of course, if you are that person who's resonating with every word I'm saying, please know I am here for you. You can set up a free console anytime we can talk about this. And I do have a couple of spots left for my retreat in October, which is only available as a bonus to women who work with me through the summer. So let's get on a call and I would love to have you there.

27:01
Thanks for listening to Rethink Your Rules with Jenny Hobbs MD. Would you like to learn more about how to apply this to your own life through personalized coaching with Jenny? Visit us on the web at jennyhobbsmd.com to schedule a free consultation. If you found value in what you heard today, please consider subscribing to the podcast and giving us a 5-star rating so we can reach even more women like you!