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Most people with ADHD respond fairly well to stimulant medication. Of those, about half describe a kind of light switch moment where suddenly they can think straight for the first time in their lives. A lot of those people describe that as bittersweet, as mixed. On the one hand there is huge relief. On the other, grief or outrage, a vibe like, “Wait life has been THIS straightforward for other people all this time?!”
I’m not in that camp. For me stimulants help with focus and energy but it’s not so binary.
Anyway: key parts of our brains need dopamine to run. As well as being a neurotransmitter dopamine is also a hormone, so one alternative way of seeing ADHD is as a hormone disorder which affects concentration, executive functioning, task initiation and so on.
Have you ever seen a person with Parkinson’s Disease trying to initiate a movement and struggling to do so? Dopamine is central to task and movement initiation, and they don’t have enough of it, so they struggle. If you have ADHD and have ever say found yourself unable for an hour or two to feel like getting up off a couch to go to the toilet, even though you’re busting, this is something similar.
That’s the impact of having a low baseline level of dopamine – the background level which changes slowly and gradually. Dopamine is also central to our brain’s reward system – the little happy ping we get when we do certain kinds of things – but that’s at a much shorter timescale. Hacking the short-term system can also help with the long-term one but I’ll get to that later or in another post or something. Suffice to say that people with ADHD need some kind of additional support BOTH when it comes to the baseline dopamine vibe of whether we can be fucked doing anything at all, and when it comes to the short-term dopamine vibe of recognising we’ve actually achieved something.
Anyway: back to baseline dopamine. Imagine someone directing traffic at a busy intersection. We have an area of our brains where something like this happens – the striatum – and it runs on dopamine. If there’s not enough fuel for it, it falls asleep and the traffic is chaos.
Stimulant medications raise the level of baseline dopamine in the system, which in our metaphor is like giving the traffic director a coffee. They wake up and can start working out what should go where and so on, and life becomes easier.
Short acting Ritalin, which I take, raises it for 4-5 hours. I take it in the morning and at lunchtime. It helps, but I do fall off a bit of a dopamine cliff about dinnertime, which isn’t great. But taking it too late in the day messes with my sleep, so usually I don’t unless I need to work in the evening.
I’ve also tried long acting Ritalin; Vyvanse which is long-acting dexamfetamine; and short acting dexies too. I’m more productive on dexies but also more wired and don’t sleep as well, so for the moment Ritalin works well enough. Unlike things like SSRIs, they act immediately – you’ll know the same day whether a stimulant is making any difference.
They’re all tightly controlled because of the effect they have on people without ADHD. That makes life harder for those of us with the condition, because ADHD makes us prone to forgetting to renew scripts, forgetting to schedule psychiatrist appointments to review prescriptions, losing things yadda yadda yadda. But currently that’s just how it is.
Other things increase baseline dopamine too, and they’re worth adding to your menu even if you do take medication. (There’s currently a worldwide shortage of Vyvanse, for instance.)
The most significant is exercise, especially exercise which gets your heart rate up: we get a few hours of good focus from it. Anyone who wants to avoid ADHD medication is likely to need a lot of exercise. For me before I was diagnosed and had other ways to manage ADHD I was VERY reliant on exercise for mood regulation and energy regulation and self-regulation generally. That was fine as long as I had access to it, but if I overtrained or got sick or injured I typically felt pretty awful until I could get back onto it.
Hyperactive types find it easier to exercise regularly – sometimes even compulsively – than Inattentive types. Us Inattentives are daydreamers and can just forget we have bodies with needs, which is yeah nah not great. The main thing is we have to find it interesting. How perfectly designed an exercise program is matters far less than whether we can regularly do the fucking thing, and so having something which is simple enough that we don’t get decision paralysis and fun enough that we want to do it are the keys here.
Natural light will also give a baseline dopamine boost, so arranging to e.g. have your morning coffee outside where you can see the sun is a very good and simple intervention.
And deliberate cold exposure, i.e. cold baths and showers, will boost it for a couple of hours too. They’re not super popular, but they do work.
I think this post is long enough that I should talk about the short-term dopamine system in a separate post. But for the moment: it is very very connected to the life skills we need when we have ADHD. “The pills don’t teach the skills,” as one of my trainers says.
ADHD coaching is not the only way to learn those skills, but it does have certain advantages for people like me. But that’s also a big enough topic to warrant its own post x
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ADHD is both under- and over-diagnosed. It’s under-diagnosed in pretty much anyone who isn’t a hyperactive boy. I am predominantly Inattentive and it didn’t fucking occur to me or anyone else that I had it until I was like 51.
Women are even more under-diagnosed. For a long time doctors thought girls couldn’t even have ADHD; what was going on most of the time was that girls were under far more social pressure to be polite and compliant and learned to mask much better. Also women are likelier to have the Inattentive subtype, which teachers and doctors were and are far less attuned to than the Hyperactive subtypes.
It’s also over-diagnosed, in that trauma, anxiety and depression can cause very many of the same issues as ADHD. So if a diagnostician isn’t careful they can misdiagnose someone with trauma symptoms with ADHD and then prescribe them stimulants that won’t help.
To complicate things, growing up neurodivergent in an ableist society can lead to you feeling chronically unsafe to be who and what you are, and over time that can give you symptoms which are consistent with trauma too.
Added to all of that a lot of people wonder if ADHD even fucking exists, is it all just made up by drug companies, is it all just because we live in a society that fragments our attention yadda yadda et al.
Let’s step through things simply.
First, yes we live in a society that fragments everyone’s attention. That means that more of us are likely to experience more of the things someone with ADHD experiences, more often. There’s a question of degree and debilitation though. Those of us with ADHD experience this stuff whether the external world is provoking it or not. It’s impacted a non-trivial proportion of our waking hours to a non-trivial extent. So there’s that.
Second, stimulants are a powerful, though incomplete, litmus.
People with ADHD typically get calm and focused on stimulant medication, and we also are very prone to forgetting to take it. People without ADHD tend to get amped up on stimulants and are prone to getting addicted to them. So stimulant medications are used as a diagnostic tool as well as a treatment. If you have executive functioning issues and get prescribed stimulants and suddenly find you can focus and get by more easily, there is a very good chance you have ADHD.
(A minority of people with ADHD don’t respond well to stimulants tho: hence them not being a perfect litmus, as I said above.)
As above, if what you actually have is post-traumatic symptoms that are caused by something OTHER than ADHD, stimulants won’t help you.
One thing I like about ADHD coaching as a methodology is that it’s very forgiving of these things. Unlike stimulant medication the tools we use can help people with ADHD-like symptoms as well as those with an ADHD diagnosis. Two of the clients I currently see started seeing me without a diagnosis: they just wanted a neurodivergent-friendly way to make progress on some areas of life that weren’t going as smoothly as they wanted. Which I like.
Ultimately though our society needs to understand both ADHD and trauma far far better than it currently does. But doubting either of those things exist doesn’t help much imho.
As an adult the question of whether to seek diagnosis boils down to whether you want what a diagnosis can deliver. A formal diagnosis means you can try ADHD medication and see if it works for you; it also means you can access some government funding and can legally argue for reasonable workplace accommodations. It doesn’t automatically shunt you onto a different life-track and y’know, no-one will force you to take ADHD medication if you don’t want to.
Under Australian law you’re not required to disclose a disability to an employer or pretty much anyone else. So you have a lot of agency about what it means.
I found getting a diagnosis and getting coaching transformative: having a language for how my brain works and the specific ways in which that varies from my society’s expectations is hugely helpful to me. Neurotypical kids get taught how to manage their brains from kindergarten; I only started getting evidence-based advice on this when I was like fifty fucking one.
Anyway where am I going with all this. I think that’s all I want to say and anyway I need to go make hot chocolate for my daughter. We’re watching She-Ra and the Princesses of Power yet again: it’s a good time and satisfyingly queer-coded which we like x
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“Neurotypical” is a useful word but imho we over-use it, and sometimes a much better word would be “neuronormative”.
Like, “neurotypical” is a property of individuals. It means your neurotype is typical of the wider society around you, and your thought processes and perceptions and emotions work roughly the way that that society expects them to, and has therefore planned and designed for.
And so it’s become normalised to talk about things like “neurotypicals”, or “neurotypical society”, when we’re trying to point out the ways in which our society pretends people like us don’t exist, and the annoying ways we get treated etc.
There’s three problems with this, for me.
First, you never know if someone else is neurotypical or whether they’re just acting that way, or what we call “masking”. THEY may not even know that themselves, because this conditioning goes so very very deep: it’s how we’re taught to be in the world, after all.
If someone is masking, they need solidarity and hugs, and calling them “neurotypical” does neither. Words have no arms and you need arms to hug properly.
Second, and related, we therefore have no idea of the real prevalence of this “typicality”, or whether there is even such a thing as a neurotypical person. We know our society is organised as though there is, indeed as though that’s the ONLY type of person there is, but that doesn’t mean much.
Third, even if we assume they exist, the existence of neurotypical people isn’t the problem at all; the problem is the social pressure to BE or ACT neurotypical, and organising society as though everyone is neurotypical.
By analogy, if straight people actually exist (I have my doubts, but for the sake of argument let’s assume they do) it’s not really a problem; the problem is the relentless pressure to BE or ACT straight.
That pressure has a name: heteronormativity.
Heteronormativity is bad for queer people, but it’s also very very bad for the theoretical straight people we’re assuming actually exist, because it drastically limits what people feel safe to do or think or feel or be. People exclude and mock and beat each other up and even kill each other over it; but they also do the same to themselves: it’s fucked, basically, and we’d be far better off without it.
Likewise with neuronormativity, the pressure to be and act neurotypical.
Neuronormativity is bad for neurodivergent people, but it’s also very very bad for the theoretical neurotypical people we’re assuming actually exist, because it drastically limits what people feel safe to do or think or feel or be. People exclude and mock and beat each other up and even kill each other over it; but they also do the same to themselves: it’s fucked, basically, and we’d be far better off without it.
