When I was in school, I was a gifted student who was also eventually diagnosed with attention-deficit/hyperactivity disorder (ADHD). Though I originally found relief through this diagnosis, I later needed to adopt a broader perspective on what ailed me and what agency I possessed to address it.
First, a few caveats: although I have worked in biomedical research and I am now a student of Chinese medicine, I have never conducted research about nor do I treat patients with ADHD, so what follows is personal anecdote only. I write this in the hope that patient advocacy can exist in healthy dialogue with the efforts of healthcare providers and researchers to better understand ADHD and other disorders of executive functioning.
I am also a proponent of integrative medicine—someone who believes that pharmacological, nutritional, natural, and environmental interventions should all be on the table for patients, and that providers should help patients navigate through all potential options, assessing the costs and benefits of each without bias to any one paradigm. Through my story, I hope you will see why I believe so strongly in this approach.
Frame 1: Willpower
I have all the agency: my struggles are a personal failing, and the only solution is to try harder.
My experience as a young child in school may be familiar to some Third Factor readers who were also labeled gifted in childhood: while I was routinely recognized by the adults as being smart, I was just as often chastised for not living up to what others saw as my full potential. Being a naturally intellectually curious child for whom most aspects of schoolwork initially came easily, it was not difficult for me in elementary and middle school to earn mostly As and Bs with little effort.
But I was not the top performer, and that confused my parents and teachers. They believed that, because I wasn’t more competitive about my grades, I was wasting my gifts. I struggled to make sense of the values the adults around me lived by. Their emphasis on competition, success, and fear of failure confused me, as I tended to be intrinsically motivated by a love of learning.
There was, however, another reason I sometimes fell short of others’ expectations academically. I was prone to daydreaming, distraction, and “spaciness,” misplacing my school supplies, notebooks, and sometimes even my assignments because my thoughts had been elsewhere. Although I loved learning, I struggled to regulate my impulse to think or talk about whatever topic interested me in the moment versus what I was supposed to be focusing on in the classroom. As I aged, this problem started to both worsen and get me into more and more trouble with school. My parents would return from parent-teacher conferences with feedback from teachers along the lines of, “She’s smart, but her lack of organization is so terrible that we fear she’ll struggle to succeed in life.”
My parents would return from parent-teacher conferences with feedback from teachers along the lines of, “She’s smart, but her lack of organization is so terrible that we fear she’ll struggle to succeed in life.”
But the school never offered resources to help understand and address my lack of organization. It was on me and my parents to figure it out together, and my parents weren’t sure how concerned they should even be, as I was maintaining a decent grade point average despite my organizational difficulties. Teachers always framed my disorganization and distractibility as something I should inherently know how to overcome with personal discipline. (To be fair, they probably didn’t understand what was going on with me, either.) Making it worse, my combination of being gifted and being very tall made it easier for adults to see me as if I were older than I was, and they therefore held me more responsible for things than they would with other kids my age. Some teachers even interpreted my distractibility as ungratefulness. These teachers saw lack of focus as a deliberate disregard of the educational opportunities that I had, or they interpreted it as a sign I thought I was above them.
As an extremely sensitive young child who wanted nothing more than to be seen in the eyes of adults as “good,” these characterizations were painful. There were countless times in my childhood that I vowed to work and overcome the flaws that had been pointed out to me, but despite my best efforts, I usually failed. I would make a promise to myself that the next day I wouldn’t forget to bring my assignment to class, or that I wouldn’t zone out when the teacher was talking, only to find myself waking up out of a long daydream without my assignment or any idea what the teacher had just said. As it became more clear to me that I lacked the willpower to overcome repeated failures to “get it together,” I started to internalize this not only as a personal weakness but as a moral failing.
There were countless times in my childhood that I vowed to work and overcome the flaws that had been pointed out to me, but despite my best efforts, I usually failed.
While I remained an A and B student for most of elementary and middle school, my issues with distractibility, disorganization, forgetfulness, and fidgeting intensified as I reached high school, as had my shame over them. At this point, I became anxious about anything related to school. By my junior year of high school, the idea of attending school all day and completing certain homework assignments triggered panic attacks. I started cutting school, oftentimes leaving to sit at the local diner and read philosophy books. Clearly, it was not that I was unable to focus on anything academic—what I was reading for pleasure outside of school was oftentimes more advanced than my assigned reading for class—but I had trouble connecting to my natural love for learning while in the school environment.
Frame 2: Disability
I have no agency: my struggles are due to an immutable disability and the only solution is medication.
I remember sitting in my high school counselor’s office at the beginning of my senior year, explaining to him how I wanted to drop out of school. I was tapping my foot and folding and unfolding a wrapper to a Jolly Rancher that I had taken from his candy jar. Finally, he stopped me mid-sentence and said, “Can you stop playing with that candy wrapper? It’s distracting.”
Tears started to well up in my eyes as I proclaimed that I knew my habits were annoying, but that I couldn’t help them. Seeing my emotional fragility, he asked me to make another appointment soon. During that appointment, he told me he was referring me to get tested for ADHD. He explained to me that ADHD is not a sign of intellectual inferiority or a moral failing; it’s just a neurological difference. This meant that everything I was suffering—from the lack of focus in class, to difficulty organizing my thoughts for long papers, to misplacing items around my house, to having annoying habits like interrupting others and being disruptive—were most likely due to a disability that I could not control. What’s more, I could go on medicine and get certain accommodations in school that would make it much easier for me to participate.
I was referred to both a psychiatrist to start me on medication and an educational psychologist who could officially diagnose me so that I could receive academic accommodations. The psychiatrist got me my prescription months before I had the official psychological testing done, but the stimulants were an effective stopgap while I awaited further evaluation. They worked pretty much immediately, and I found myself able to sit through classes easily and to complete my homework assignments on time. Moreover, for the few hours that their effects lasted, I did not feel anxious; instead, I was confident.
This felt great, of course. But there were ways in which it was too good to be true, and the pros and cons of medication versus other potential interventions were never discussed with me. I was led to believe that medication was my only option—that if I did not take it, I could not do school, and that if I did take it, I could. In addition, my anxious relationship with school was never addressed, only temporarily covered up. While my distraction and lack of focus may very well have been the cause of academic anxiety, there were nonetheless negative beliefs that I had internalized that affected my overall self-esteem in a way that should have been addressed with psychotherapy. In addition, I had been living since childhood with a condition called postural orthostatic tachycardia syndrome (POTS), a syndrome which causes a rapid heart rate. No one checked with my primary care doctor to see if stimulants were contraindicated for me as they also quicken the heart rate. This mistake later came back to haunt me.
I was led to believe that medication was my only option—that if I did not take it, I could not do school, and that if I did take it, I could. In addition, my anxious relationship with school was never addressed, only temporarily covered up.
Towards the end of my senior year in high school, I was evaluated by the educational psychologist, undergoing eight hours of testing. She endeavored to paint a full picture of what was going on with me. In addition to administering the Brown Scales to evaluate ADHD symptoms, I took an adult IQ test, many academic aptitude tests, and was evaluated for mental health issues and personality disorders.
After all of this, my psychologist wrote a twenty-plus page report on her assessment of the problem. While she did not confirm or deny that I had ADHD—this was something she did not feel comfortable doing, not having assessed me over a longer period of time—she noted that I had a large degree of impairment to my executive functioning which, according to her, could be due to a number of causes. On top of that, she described how my impairments played out and interacted with my giftedness. In the culmination of her report, she outlined several additional non-pharmacological interventions that I could try, and she recommended that I be reassessed in a few months to see if I experienced a reduction of symptoms after doing so. She also recommended that I continue to receive counseling for anxiety and other ill feelings about school.
My psychologist wrote a twenty-plus page report on her assessment of the problem. While she did not confirm or deny that I had ADHD—this was something she did not feel comfortable doing, not having assessed me over a longer period of time—she noted that I had a large degree of impairment to my executive functioning which, according to her, could be due to a number of causes.
The level of detail and openness to multiple possibilities which the educational psychologist evaluated my symptoms is what every child who is suspected of having ADHD should receive. However, I did not fully appreciate nor take advantage of the gift she had provided me at the time. Her over-twenty-page report on my struggles with executive functioning was enough to get me academic accommodations in school and ensure I would continue to have access to prescribed stimulants, and so I took those things from her and did not proceed with any of her other suggestions. I wanted to believe the narrative that I had a disability, that my struggles were not my fault, and that I did not owe the world any more work on myself. My long history of a worsening relationship with school had left me dejected and insecure and I did not have the motivation, nor did I feel like I had enough loving support from myself or others to face looking at my flaws under a microscope any longer.
What did not occur to me was that it could both be true that my struggles, which started in childhood, were not initially my fault and that addressing and assessing my current agency in the situation as an adult would be worthwhile for me.
What did not occur to me was that it could both be true that my struggles, which started in childhood, were not initially my fault and that addressing and assessing my current agency in the situation as an adult would be worthwhile for me.
I relied heavily on prescribed stimulants to function for the next ten years of my life. I was able to go to college and graduate with honors, to pursue a master’s degree in biostatistics, and finally to get accepted into a PhD program in epidemiology without ever having to address anything behaviorally, because when I took the stimulants, I temporarily behaved like an ideal student. Although my underlying issues were still there, the stimulants allowed me to work uninterrupted for many hours and little sleep.
Towards the end of my master’s program, however, cracks started to appear in my façade. I got diagnosed with reactive hypoglycemia and started having difficulty managing my blood glucose levels, which was worsened by the fact that the stimulants masked many of the early warning signs that an episode was approaching. The stimulants also left me with no appetite; as a result, I rarely ate three nutritious meals a day and started to border on being underweight. I was also able to bury a lot of other issues that were plaguing me in my personal life by taking my stimulants, locking myself in the library to study, and pushing all other worries aside.
By the time I got to my PhD program, the cracks in my façade started to break it entirely. As what I believe was a result of multiple factors including chronic poor health and the long-term use of prescription stimulants, my health collapsed. All of a sudden, the woman who could exist on very little sleep started accidentally falling asleep during the day, not being able to wake up for 16 hours. While I had maintained a 3.8 GPA in my master’s program, in my PhD program, I was sleeping in, missing classes, and barely getting by. My blood glucose levels became even more difficult to manage, and drops would leave me with brain fog and mood swings. Moreover, the effectiveness of the stimulants started to wane. Although they still made me more alert and more focused, the other symptoms I was experiencing started to overpower them. Finally, the battle between my body and my determination to ignore my body was lost; in the second semester of my PhD program, I fainted, fell, and lost consciousness while out with friends. Because my blood pressure levels were so low, I was taken to the hospital and remained there for several days.
Finally, the battle between my body and my determination to ignore my body was lost; in the second semester of my PhD program, I fainted, fell, and lost consciousness while out with friends.
For several months, my life became consumed with doctor’s appointments as I got sent to specialist after specialist to determine what was wrong with me. The process of obtaining a medical diagnosis for my physical health symptoms was a long story and not worth elaborating on here. What is important to note was that, at the time, I was initially reluctant to admit that the stimulants played any role in my health collapse.
After several more months of struggling to get by in school while juggling my ill physical and mental health, I decided to withdraw my PhD program. My health insurance had been provided by the school I was attending, so I became uninsured until I was able to find employment and thus temporarily lost my ability to refill my prescriptions for stimulants and other medications I was taking. After a very difficult time going through withdrawal from all the medications I was on (which I would not recommend doing outside the supervision of a doctor) I eventually noticed that I was starting to feel better. It was at that time that I started to suspect that my medications, including the stimulants, had negatively interacted with the other medical conditions I had.
Frame 3: Choices in Context
I have limited agency: my struggles are part of a multi-causal pattern with inputs from my own inherent neurobiology, environmental stimuli, nutrition, and the nature of the systems I’m embedded in. In what domains do I have the power to make new choices and in what domains should I accept and work around my limitations?
After six years in the workforce during which I never returned to taking stimulants, I re-enrolled in graduate school. This time around, I was studying to become a licensed acupuncturist and herbalist through a doctoral program in Chinese medicine. I had found much relief for my lifelong struggle with anxiety through Eastern interventions like acupuncture and yoga and was excited to study so that I could provide similar things to others.
While it might be plausible to assume that someone who had already been to school for two other advanced degrees would fly through a program in natural health, this was not the case. My program started off with 21 credits per semester and, in addition to hands-on classes, I had to memorize a large body of content to pass comprehensive exams, which included information in biomedicine. It was no less difficult than my other graduate school program, and school without stimulants was difficult. I would procrastinate with my studying, stay up all night, get little sleep, and often rush to class the next day, forgetting something. Although I passed all my classes, I did fail a few tests and all my old anxieties surrounding school and doubts about my work ethic started resurfacing. I questioned whether I should seek out a prescription for stimulants again. After considering the risks and remembering my past, however, I decided that wasn’t the best decision for my health. I instead looked at how ADHD was treated within my own field and considered new options.
Studying Chinese medicine started to give me a different picture of what I was experiencing as distraction and lack of executive functioning. It is based on Daoist concepts of the human body which are seen as a microcosm of the universe, and it treats patients based on patterns rather than diagnoses—a cluster of symptoms which occur together that are not necessarily due to one explicit cause. In Chinese medicine, patterns are due to many non-linearly related causes, including what we have inherited from our ancestors, what we eat, how we breathe, what we consume, emotional factors, environmental factors, and spiritual factors. Chinese medicine practitioners use interventions including acupuncture, herbal medicine, nutritional advice, mindful movement, and lifestyle recommendations such as working fewer hours, drinking less, and finding ways to manage situations that bring on stress or intense emotions.
Studying Chinese medicine started to give me a different picture of what I was experiencing as distraction and lack of executive functioning. In Chinese medicine, patterns are due to many non-linearly related causes, including what we have inherited from our ancestors, what we eat, how we breathe, what we consume, emotional factors, environmental factors, and spiritual factors.
I started treating my symptoms with acupuncture and herbal medicine and saw only mild improvements in my symptoms at first. Over time, however, I noticed my ability to focus for an entire class, while still rare, was becoming more sustained and more frequent. These small victories allowed me to realize that undoing a pattern of poor executive functioning was not immediate nor was it easy, but it was possible. With the mindfulness practices I had acquired over the years, I was able to observe how my anxiety and my low self-esteem interacted with my executive functioning, and so when I started to see small improvements in my ability to focus, the terror of failing started to become less pronounced. I observed that exercising in the morning, before studying, helped me focus as well. In addition, I started psychotherapy, where I spent a lot of the time discussing my anxious relationship to school. I was able to find a primary care doctor who supports integrative approaches to medicine, and with her support, I started to do a lot of work to change my diet to minimize my hypoglycemia episodes, which in turn improved my ability to focus. Since deciding to write this article, I have since become a part-time student instead of a full-time one, giving me time to take a few classes at once and go into a lot of intellectual depth with them on my own, without the stress and boredom that trying to memorize many things very quickly brought me before. Through an approach to school which combines both structured and unstructured studying, I am able to maintain my intrinsic love of learning. The primary thing I’m working on right now is replacing my shame-based approach to motivation with one that relies on and nurtures that intrinsic love.
All these interventions were not a panacea. Rather they were small steps towards a long healing process that is taking a lot of time, dedication, self-awareness, and self-compassion. Viewing the symptoms that I have as a collection of causes and conditions instead of one specific, concrete, and permanent thing allows me to observe how these symptoms seem to worsen or improve depending on different contexts, some of which I have control over and some of which I don’t. At any given time, I strive to see where I am held back, understand what factors in my life I do have control over, and decide to make changes with consideration to all the potential costs and benefits. I also need to forgive myself when my symptoms cause me to fall short of the high goals and expectations that I set for myself. This new lens has allowed me to see where I have agency without jumping to self-recrimination because I have not yet acted on my agency. It also motivates me to design my life around the limitations that I have yet to change—or may never be able to change—and focus on my strengths.
At any given time, I strive to see where I am held back, understand what factors in my life I do have control over, and decide to make changes with consideration to all the potential costs and benefits.
Conclusion
I hope that stories like mine can help illuminate problems with our current approach to treatment and spark questions about how we can do things differently. While I offered a critical account of my own relationship with prescription stimulants, I want to emphasize that I do not believe prescribing or taking them is morally wrong. In many circumstances and for many people, they may be the best option for those diagnosed with ADHD, especially in the short-term. What I am asserting is that while stimulants may be appropriate for those people and those situations, for others, they may not be. For those others, it’s important to offer and thoughtfully consider non-pharmacological options, such as working with educational psychologists, psychotherapists, nutritionists, finding an appropriate exercise routine, making other lifestyle changes, and exploring Eastern therapeutic modalities.
I also want to emphasize that while it has been liberating to no longer see the entirety of my symptoms as a fixed or permanent disability, for many people, the symptoms of ADHD make it difficult for them to function at work or school, and they are functionally disabled. Just because neuroplasticity makes change possible does not mean that change is easy. We should refrain from making harsh or quick judgments of those who are struggling to function and how they choose to cope with that.
As we all exist in a world with limits to our agency, may we see where we have agency and where we can thoughtfully apply it, and may we also see and accept when we have limitations so that we can lend ourselves compassion.
Header image by Artem Kovalev on Unsplash
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