Turning Toward ADHD

Turning Toward ADHD

Where I stop and a professional begins

This is an essay in the philosophy of psychology. It is not therapy, it is not treatment, and it is not a clinical opinion — because I do not have one to give. I am a writer and a student. I am not a physician, a psychologist, a psychiatrist, or a therapist, and nothing between these covers has been reviewed, endorsed, or approved by anyone who is.

What I have is a theory, woven completely through my own experience, and a habit of reading the literature carefully enough to know where my theory stops. Everywhere those two things touch, I have tried to draw the line in ink rather than hide it. Where I am telling you what happened to me, I say so. Where I am telling you what researchers have found, I cite it. Where I am guessing — and I guess often, because that is what philosophy is for — I say that too.

The line matters more in this piece than in the four before it, because this one talks about medication — and about the things medication cannot do by itself.

So let me be as clear as I know how: never start, stop, adjust, skip, or reorganize a prescribed medication because of anything you read here. Not this essay, not any essay. That conversation belongs to you and the person who prescribed it, and there is no sentence I could write that would be worth more than their judgment about your body.

One more thing before we begin. ADHD is diagnosed by a clinician, not by recognizing yourself in a stranger's paragraph. Inattention has a great many causes, and most of them are not this one. If what follows sounds like your life, that is a reason to talk to someone qualified — not a reason to have arrived at an answer.

Three ways of knowing

Every piece in this series marks how each claim is known. This one uses all three.

Experienced — I lived it, and I am the only witness. Observed — I watched it happen to someone else, and their details are anonymized or omitted. Studied — I read it in the literature, and it is cited at the back.

You will see the boundaries marked as you go. I call them register seams. They exist because a metaphor that wanders into a clinic can do real harm, and because you deserve to know, at every moment, whether you are reading evidence or reading me.

The squirrel

Much like the other four I have walked through — depression, suicidal thoughts, addiction, anxiety — I have a theory. One that is completely woven through my own experience, and in no way replaces the opinion of a professional.

I want to open the door on my attention deficit, and show you the squirrel that keeps running by and taking my attention.

Did you see it?

You get it, though.

I didn't, for a long time. I have always thought in metaphors and symbols. That is why I have quite a lot of them on hand to write these things, to be honest.

So where are we? Or where am I, at this point in time.

I have walked through some of the darkest of shadows and come out the other side.

Unscathed?

No. Let me not say that. I kept bouncing back and forth between depression and anxiety, and then still ADHD. What I came out with was not an absence of damage. It was a way of reading it.

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Below this line I am reading, not remembering. Every claim is cited at the back.

The pill and the dragon

There is a thing I noticed about the drugs they prescribe for it. They have a half-life. Not only in the body — in the story.

Early on, the results can be extraordinary. Work. School. The people you love. And then, for some, the quiet starts costing more than it did.

Here I have to be careful, because this is exactly the place where a metaphor becomes a lie.

What the literature actually says is contested, and the mainstream finding deserves to go first. In one long-term follow-up of a hundred and eight children who had responded well to methylphenidate and were tracked for three to ten years, fewer than three percent lost their response in a way that could not be explained by something other than tolerance. Most people who do well on these medications keep doing well. That is the headline, and it is not mine to bury.

But there is an underdog in this literature, and I want to give it its due, because it is the reading that matches what I have watched.

A retrospective review of a hundred and sixty-six patients found tolerance in roughly a quarter of them — and every single one of those cases came from the group taking more than the recommended ceiling. A more recent review argues that tolerance is real, under-recognized, and under-studied, in part because the patients it happens to are the patients who drop out of the studies that would have counted them. And twelve months of methylphenidate has been shown to raise striatal dopamine transporter availability by around a quarter, which is at least a plausible mechanism for why the world without the medication can start to feel worse than it did before there was any.

Whether the dose increases that do happen are tolerance, or growth, or a dose that was never quite right to begin with — researchers are still arguing about that, in print, this year.

I am not here to settle it. I am here to say that the argument exists, and that if you are living inside it, you are not imagining things.

The body registers the change. Sleep. Appetite. In children who take it consistently, a modest cost in height, on the order of an inch. Those are the small quiet costs, and they should be watched. They are not deterioration, and they are not a reason to stop.

Because there is a ceiling, and the ceiling is real. The label on methylphenidate says dosages above sixty milligrams a day are not recommended, and that is not a suggestion. Past the wall a prescriber has other moves: pausing the medication under supervision — there is an actual name for this, a structured treatment interruption, sometimes a drug holiday — or optimizing the dose, or changing the molecule altogether.

I used to call that tolerance reduction balancing, before I ever learned it had a clinical name. I will keep my phrase, because it is mine and it says what I meant by it. But the words a doctor uses are the words worth asking for.

That being said, everyone is different. There are people who walk the face of this earth who take the smallest dose, every day, and never want for more. Under controlled conditions, only about one child in six was still taking the same drug at the same dose after fourteen months, and most of the changes were increases. But the increases were modest — around thirteen percent, on average, across more than a year.

Modest is not nothing.

It is also not a dragon.

The same lever

Reward is reward. The brain runs one currency through one circuit, and alcohol, and amphetamine, and the small hot pleasure of finally finishing something all pay into the same account. People who take these medications and find their focus describe a loop I recognize from the bottle in Turning Toward Addiction: the thing works, the working feels good, the feeling good asks for the thing.

Both reach for the same lever, in one way or another.

That is the philosophy. Here is the fact, and the fact cuts against the philosophy, and I would rather print it than protect my own metaphor.

Treating ADHD does not make addiction more likely. It makes it less likely. A meta-analysis of six studies found roughly a two-fold reduction in the risk of a substance use disorder among young people treated with stimulants. A study of nearly three million patients found that during the months they were actually taking their medication, men had thirty-five percent lower odds of a substance-related problem, and women thirty-one percent lower.

So when I say the pill reaches for the same lever as the bottle, I am describing the inside of my own head, and offering it to you in the hope that you find your own parallel there.

I am not saying: put down the pill.

Please do not put down the pill because of an essay.

The band-aid

I have called the pill a dragon and I have called it a lever, and both of those are unfair to it. So let me say what I actually think it is.

A band-aid.

And I want to be careful with that word, because I have heard it used as an insult and I do not mean it as one. A band-aid is what stops the bleeding. That is not nothing. Ask anybody who is bleeding.

But nobody has ever mistaken a band-aid for the whole of medicine.

The literature says this more plainly than I would have dared to. The trial that tested it takes as its starting premise that adult ADHD is left incompletely treated by medication by itself — that is the reason the trial exists. Eighty-six adults, all already on medication, all still symptomatic. Half received cognitive behavioral therapy; half received relaxation with educational support. On one rating scale the responders were fifty-three percent against twenty-three. On another, sixty-seven percent against thirty-three.

And those who responded were still holding their gains at six months, and at twelve.

Read that last part again, because it is the whole argument.

The gains held.

That is the thing a pill cannot do. A pill works while it is in you. It wears off at a predictable hour and it takes its gift back on the way out. A skill does not wear off. Nobody has ever had to re-dose a habit.

In children the shape of the finding is the same. In the largest trial of its kind, medication management alone and medication combined with behavioral treatment came out about even on the core symptoms — the drifting, the fidgeting, the interrupting. That is the result that keeps medication in the room, and it should keep it there.

But on everything standing around the core symptoms — oppositionality, anxiety, academic performance, social skills, the relationship between a parent and a child — the combined approach was consistently better than routine community care, and neither treatment alone reliably was.

And then there is the sentence I would put on the ceiling of every waiting room, so that people lying awake could read it.

The children in the combined group did as well on lower doses of medication than the children on medication alone.

Go back to the ceiling. Sixty milligrams. The wall. The argument about tolerance that researchers are still having in print, this year, the one I told you not to feel crazy for standing inside of.

Now notice what the other thing does to that wall. It moves you further away from it.

If the ceiling is what frightens you, the evidence does not say to take less and suffer. It says to add the thing that was missing, and then you will need less.

There is even a trial on the order of operations. Start children with a modest dose of behavioral treatment, add medication only for the ones who still need it, and you arrive at better outcomes at a lower cost than you get by starting with the medication.

Not instead of.

Only: not alone. And, where it can be managed, not first.

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Above this line, evidence. Below it, only me — and this is the thing I most wanted to say.

So here is my theory. It is a theory. I have proven nothing.

The pill is a band-aid. Not a bad one, and not a lie. It closes the thing long enough that you can stop attending to the bleeding and start attending to the wound.

But a band-aid left on for thirty years does not heal anything. It keeps the wound out of the light. You learn to move around it. You tell yourself the arrangement is working, because nothing is dripping.

And I should say exactly what I mean by the wound, because I am not claiming what you might think I am claiming.

ADHD does not leave. It is not cured, not by therapy and not by hourglasses, and anyone who tells you otherwise is selling you something. But the wound is not the ADHD. The wound is what a life builds around it, over decades, when nobody ever told you what you were working with.

That is the part that closes.

What closed it for me — and I can speak for exactly one person here — was everything else. Therapy. Sleep I stopped negotiating with. Work I could actually finish. People who told me the truth when it cost them something. A room arranged so the squirrel had fewer places to run. And yes, the meditation, and the hourglass, and the long stupid patience of learning to stand in one moment at a time.

I do not think the drugs are bad. I have never once thought that.

I think they are the first thing. And we have built a world that treats them as the only thing. And then we act surprised, years later, to find the wound still lying there underneath, exactly where we left it.

And if the pill is all you have right now — because therapy costs money you do not have, or sits behind a waiting list nine months long, or lives in a city you cannot drive to — then hear this before you turn the page. You are not doing it wrong. You are doing it with what you were handed.

The distance between what the guideline recommends and what an actual person can actually reach is not a personal failing.

It is the subject of the last section of this essay, and it makes me angrier than anything else in it.

What about me?

It is not really the shape of my life anymore, though I understand why people reach for it. I understand it the way I have come to understand every other lever in these five essays.

That is neither here nor there. I said I would talk about me, so let's talk about me.

I had walked through all those other doors and uncovered what seemed to be the root cause of most of them. The way I look at it, the brain produces thought far faster than the mouth can speak or the fingers can type. In my case these days, I go back and edit things before I post them, and then I come back later and add to, or take away from, those same essays, to bring them up to what I know now.

That is something I will get to in a little bit.

There is a face I wear that says I am paying attention.

Jung called that face the persona — the mask turned toward the world, and not the thing standing behind it. It is not a lie, exactly. It is the part of me that learned what a room expects, and gave it. Every person reading this owns one, and most of the time it is a kindness.

But pulling it off does not reveal the shadow. That is the mistake I made for years, and it is the mistake the phrase invites. Taking off the mask only stops the shadow from having somewhere to hide behind it.

What is behind mine has never held still long enough to be named.

ADHD, to me, seemed to be the silly little devil that kept zipping around to different places for no particular reason at all. Sometimes the past. Sometimes the future. Sometimes this caused depression. Sometimes it caused anxiety. Sometimes those things caused a relapse.

I cannot explain why I fell down the mountain so many times. I can only testify to how I climbed back out.

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A short one. The little devil brings friends, and someone has counted them.

Nearly seven in ten adults with ADHD carry at least one other psychiatric condition. Insomnia disorder shows up in something like forty-four percent of them. Anxiety and depression walk alongside it at rates I recognize from the inside.

But notice that the arrow does not have to point the way I want it to. ADHD is associated with insomnia. Associated. Not proven to cause it. And in that same study, the adults on stable pharmacological treatment had less insomnia, not more — which is one more reason not to read my metaphor as advice.

If this is your life, take it to someone who can put a name to it. Not an essay. A person, with a license.

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And now the part I actually came here to say.

The mirrored scale

Consider the balance scale we spoke of in the last essay, with the needle pointing up. Imagine that to the left is the past, and to the right is the future. The now is the middle, where you should be.

ADHD is quick little unexplainable jerks between the two.

This next part is going to be hard to explain. Imagine that scale. Then imagine another one, mirrored over the top of it. It means the same thing — left, past; right, future.

But.

The difference between these two scales is that one of them is rooted in anxiety and depression, and the new mirrored one is rooted in the unknown. In the Self, not the Ego.

It is not just you. It is everything else.

That being said: on the mirrored scale, the left, the past, is no longer depression and madness. It is reminiscence. Positive memory. Balance the needle again. Think of the good things behind you.

And here is where I have to stop and say something plainly, because I was about to write a sentence that wasn't true.

I was going to tell you to reject the bad memories at face value, and that Jung had said something similar.

Jung said close to the opposite. He wrote that no one becomes conscious of the shadow without considerable moral effort, and that becoming conscious of it means recognizing the dark aspects of your own personality as present and real. The series you are holding is named for that instruction. You turn toward. You do not turn away.

And the evidence agrees with him in its own flat way: try not to think of a thing, and the thing gets louder. That rebound has been measured.

So let me be precise about what I actually do, because it is not suppression, and I nearly mislabeled my own practice.

I do not reject the memory.

I reject its authority.

Face it, and tell it no.

The memory stays. It stays integrated, it stays mine, I have already turned toward it across four other essays and I am not taking that back. What changes is that it no longer gets to decide which way the needle points. That is not denial. It is the withdrawal of a permission I never meant to grant.

Jung has a name for the part of this I can actually defend. He called it the transcendent function: consciously choosing your attitude toward what rises out of you, holding the tension between the two sides, and waiting for a third thing to appear that neither side could have made alone.

The needle moves right on this mirrored scale, and that is dreams. Possibilities. Premonitions. Not anxiety, not rooted in the Ego, the I, but rooted in the Self, the greater good.

The hourglass

So where do we stand?

Picture both needles pointing "up," but mirrored, so that they point at each other. You stand in between them. That is the explanatory gap of your own life.

Now draw an X over that image. You stand at the intersection of the two lines, which is also, exactly, the place where the two needles fail to touch. Figure 1 is what I see when I close my eyes.

Figure 1. The Hourglass of Subjective Experience. The lower scale is the Ego: its past is depression, its future is anxiety. The upper scale is mirrored and rooted in the Self: its past is reminiscence, its future is dreaming. Both needles point "up," toward each other, and never meet. The gap between their tips is the explanatory gap, and it is the same point at which the two diagonals cross. You are the crossing. — This is a philosophical figure, drawn by the author to picture an argument. It is not a clinical model, and nothing in it has been measured.

Kind of looks like an hourglass, doesn't it.

Let me explain.

You look toward the past, and it can make you depressed. But consider — it can also make you happy. Thinking about the things that matter. Remembering the things that are important. The ones that not only carve and shape an ego that lasts, but the memories that keep us whole instead of fragmented as individuals.

You look toward the future, and it can make you anxious. But it can also make you a dreamer. An idea machine. A think tank. The creativity flows when this needle moves this way, for me.

Look at the last two and a half months. What words can even explain the complete hundred-and-eighty-degree turn in my path? The simple understanding of my own explanatory gap.

Understanding this place, to me, is understanding what makes you you. It is what shapes your ego. Your superpositioned realities, and all of them. Pasts that happened that you need to let go of. Pasts you should not forget. Futures you should not worry about. Futures you should hold close to your heart to stay focused.

Focused.

How does one do that, when they are living under the premise of this needle?

Flip the hourglass.

Stop living in the past and the future, and just live. You will be amazed what comes out.

For me, this was the very last step that unlocked a meditational balance in my brain that will take a million years to explain on paper. So for now, picture the flipped hourglass.

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Because I am about to tell you that stillness helped, and you should know what is actually known about that.

There is a literature here, and it is friendlier than I expected without being a promise. In a randomized trial, mindfulness-based cognitive therapy added to treatment as usual reduced clinician-rated ADHD symptoms in adults, compared with treatment as usual alone. Meta-analyses report improvements in symptom severity, emotion regulation, and quality of life, with effect sizes that vary and methods that are still uneven.

A promising companion. Not a cure, and not a replacement for anything.

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Mine again.

Imagine you were not worried about the future, or the past, and you were concerned only with the moment. Because any given moment of any individual subjective experience is what matters most to that individual.

If that sentence makes you want to argue with me, good. Argue with it. But notice who is doing the arguing, and notice that the voice telling you this will never work for you has been wrong about you before.

Try it. Believe in yourself first, and then in the sentence.

And if you try it and nothing moves — that is not a verdict on how hard you believed. It means this particular door was not yours. There are other doors. Some of them have professionals standing behind them, and that is not a lesser door. It is only one I cannot open from here.

Watch what happens when you start replacing the darkness with light.

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One more thing, and then I will stop. This one is about children, and it is not about me at all.

The child, and the calendar

There is a finding I cannot stop thinking about.

In the eighteen American states that use September first as a school cutoff, children born in August — the youngest in their class by nearly a full year — are diagnosed with ADHD at a rate thirty-four percent higher than their classmates born in September. Eighty-five per ten thousand against sixty-four. They are medicated more, too: fifty-three per ten thousand against forty.

The effect does not appear in states without that cutoff. It does not appear for asthma, or diabetes, or obesity. Just this. Just ADHD.

Read that again. For some number of children, the difference between a diagnosis and no diagnosis is which side of an arbitrary line in a calendar they happened to be born on.

I do not conclude from this that childhood ADHD is a misunderstanding. That is not what the finding says, and it is not what I believe. ADHD in children is among the most carefully validated diagnoses in all of psychiatry, it is substantially heritable, and left alone it costs children real things.

What the finding says is smaller, and sadder, and harder to shake. Sometimes we look at a younger child being younger, and we see a disorder.

I used to think this happened because nobody was interested in doing the harder thing. Medicate and forget. I was wrong, and the numbers are what corrected me.

The guideline already agrees with me. For children under six, the American Academy of Pediatrics recommends behavior therapy first — parent training in behavior management, before medication. For six to eleven, a combination of the two.

And what happens? Roughly fifty-four percent of American children with current ADHD are taking medication. About forty-four percent received behavioral treatment in the past year. And about thirty percent — nearly one in three — received neither. As diagnoses climbed across states, the share of children receiving behavioral treatment went down.

That is not a profession that does not believe in therapy. That is a profession that mostly cannot reach it. Shortages. Cost. Waiting lists. Insurance. The CDC says as much in the flattest language available: access to the right care and support may account for the differences.

We reach for the pill because the pill is what is in reach.

And I want to be careful with the thing you may be expecting me to say next — that the medication is what costs a child their crayons. The evidence does not support it. The most careful review of ADHD and creativity concludes that psychostimulants do not have the negative effect on creativity that people commonly believe. Whatever the pill asks for, it does not appear to ask for that.

The same review found something I like better anyway. The link between ADHD and divergent thinking — the fluency, the flexibility, the originality, the thoughts arriving faster than the fingers — turns up more reliably in people who carry the traits than in people who carry the diagnosis.

The trait, not the disorder. The needle, not the fall.

Which is, I think, the entire essay.

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Nothing below this line is a finding. It is only what I think is true.

My philosophy — and it is philosophy, it is not evidence, and I could not prove a word of it — is that a child arrives already creative. Nobody hands it to them. It is simply what a child is doing when they are being a child, and it looks, from the outside, an awful lot like not paying attention.

And some adults, having lost the thread of it somewhere between then and now, need help to find their way back. Sometimes that help is a pill. There is no shame anywhere in that sentence. I have spent this entire essay trying to make sure there isn't.

Mirrored creativity, unmanaged.

That is all I have ever meant by any of this.

Again — this is not a replacement for actual medical advice. But meant to be held as a companion. An explanation. From one mirror to another. ♡

A note on the seams

This essay makes no clinical claim. Where it touches the empirical literature, it reports what the literature reports, including the parts that cut against the author's own metaphors. Where it leaves the literature, it says so, out loud, on the page. The hourglass in Figure 1 is a drawing of an argument and nothing more. The author is a student of philosophy, not a clinician, and the distance between those two things is the subject of every seam in this book.

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