ADHD has a way of making good streaks feel like ticking time bombs. There’s a rush that comes from finally feeling on top of things. But smoldering underneath the momentum is a burning fear: When will I mess up next?
Can I really be blamed for living like I’m waiting for the other shoe to drop? It’s been this way even before my late diagnosis of inattentive ADHD at 40. It comes from a pattern: No matter how many checklists I prepare or planners I use but don’t stick to (if you know, you know), there’s always something important that I’ll miss despite all the other things I’ve managed to achieve. Sometimes it’s forgetting to toss out the empty protein bar wrapper. Sometimes it’s leaving the garage door open or the front door unlocked.
I do so well — until I don’t. It’s almost like I’ve come to learn to fear success because it means failure is lurking.
The Other Shoe Syndrome: Bracing for Failure
When I inevitably mess up, the shame doesn’t trickle in. It crashes over me like a tidal wave. There’s shock, embarrassment, frustration, self-disgust, and confusion. Was my progress even progress at all? The crushing disappointment of it all chips away at my self-confidence — the same self-confidence I am fighting to maintain and model for my two young children. It’s the kind of spiral that makes you feel like you’re back in middle school, excited to present in front of the class, only to realize that you’ve completely misunderstood the assignment.
You know the “put a finger down” game? Where you lower a finger down for every experience you can relate to?
Let’s play. Put a finger down if you’ve ever been told:
“You always need a reminder. Can’t you just be more organized?”
“I feel like I’m constantly nagging you. Why do you put me in that position?”
“It’s like you don’t care about…”
“It just seems lazy to me, like you don’t want to do the work.”
“Now that you have an ADHD diagnosis, everything’s about ADHD.”
It’s hard for everyone to stay on top of things. That said, neurotypical people don’t quite understand the painstaking effort it takes neurodivergent brains to do the things their brains do with more ease. They also don’t understand that inconsistency is part of ADHD – a central part of ADHD that we find bewildering, too. It’s crucial to understanding where the fear of success comes from; we know we can’t keep up our hard work.
A single comment is all it takes to unravel. A forgotten protein bar wrapper is not just a crumbled piece of packaging but proof that I’m too much and not enough. And it hurts when my loved ones don’t always see how hard I tried to remember to throw it away.
Then the negative self-talk begins: How could you forget that? What is wrong with you? Why can’t you just remember to do the thing?
Next is going into hiding or a huge breakdown. Or both.
Then the cycle resets. Things are good for a time, so I feel good. And then a mistake consumes me.
Alongside the shame, self-doubt, and fear of messing up is something that I’m trying to become better at recognizing: resilience.
I’m not going to BS you: I still spiral, shut down, and feel like a walking dumpster fire most days. But once the tears dry and the heartache in my chest softens, it is undeniable that something in me keeps wanting to go forward and do better for myself. (I guess it’s why I end up with good streaks.)
The same brain that leaves front doors unlocked and empty wrappers atop counters is the same brain that sees patterns others don’t. It’s the same brain that has built a career in health fighting like hell for people who feel overwhelmed and discarded by the system.
So while the question of, “When will I mess up next?” is still there, so is another question upon which all neurodivergent minds should fixate: “When will I succeed next?”
Fear of Success with ADHD: Next Steps
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What if the very hormone designed to help you survive is actually the reason you’re struggling to thrive?
My mother relentlessly saved and sacrificed so that she could enjoy her life in retirement. But two years into retirement, she was diagnosed with early onset Alzheimer’s.
Here’s what I’ve learned since becoming a Functional Diagnostic Nutrition Practitioner: she didn’t just “get” Alzheimer’s two years after retirement. It was building and building for years before that. She was making it worse with lifestyle choices: the over-exercising that women in their 40s and 50s often do, eating trans fats during the low-fat craze of the 80s and 90s.
Had I known what I know now, her outcome might have been different.
This is why I’m passionate about functional health. This is why thousands of practitioners are learning to identify and address the root causes of dysfunction before they become disease. If we can reach people in that gray space (when things are out of balance but before they become diagnosable conditions), we can change their trajectory. We can save lives.
As functional health practitioners, we see it every day: clients who’ve tried everything, followed every protocol, cleaned up their diet, and taken all the right supplements, yet they’re still stuck in that frustrating place of “I’m okay, but I’m not great.”
The missing piece? Understanding cortisol and its profound impact on every system in the body.
If you’ve ever wondered why some clients get amazing results while others plateau, or why you yourself might be experiencing symptoms that doctors dismiss as “normal aging,” this deep dive into cortisol will change everything.
What Is Wellness, Really?
Before we dive into cortisol, let’s get clear on what we’re actually working toward. At FDN, we don’t believe in “fine” or “okay.” We believe in abundant vitality.
Picture this as a spectrum:
The Right Side (The Medical Model): Symptoms → Sickness → Disease → Death
The Middle (Neutral Health): No symptoms, but no energy either. This is the “I’m fine, I guess” zone where most people live.
The Left Side (True Wellness): High energy, optimal function, metabolic fire, abundant vitality, joy for life.
Here’s the thing: neutral health equals a neutral life. When you’re operating from “I’m okay, I don’t have any complaints,” you’re not building empires, writing books, raising joyful kids, or showing up as your best self in relationships.
Good health, abundant vitality, is your birthright. It’s not just for the lucky few.
The Body’s Incredible Healing Power (And What’s Limiting It)
Your body is a self-healing machine. You know this because when you get a cut, it heals. When you break a bone, it mends. When you catch a cold, you recover.
But this healing ability isn’t infinite. If it were, we’d never age or die.
So what’s the difference between what your body can heal and what it can’t?
It’s a savings versus spending problem.
Think of your body as having a bank account called “Vital Reserve.” This is your innate intelligence: your body’s natural ability to function at 100% and fix imbalances before they become problems.
Where do you spend this precious currency? On your environment.
This has always been the case. Our paleolithic ancestors spent their Vital Reserve on not knowing if food would be available, dealing with harsh weather, avoiding predators, and navigating tribal conflicts.
Today? We spend it on mental-emotional stress, environmental toxins, and poor lifestyle habits that are constantly draining our account.
The main spender of Vital Reserve is stress.
The Modern Stress Problem: It’s Not What You Think
When most people think of stress, they picture this: work deadlines, traffic, relationship conflicts, financial pressure. And yes, these mental-emotional stressors are huge.
But there are two other categories most people completely miss:
Physical Stressors:
Sitting too long
Blue light exposure from screens
Too much coffee
Not exercising enough (or exercising too much)
Needing wine to fall asleep
Poor sleep quality
Environmental Stressors:
Depleted soils
EMF exposure
Chemicals in food, water, and air
Toxins our paleolithic ancestors never encountered
Plus, there’s the existential stress of modern life: What’s my purpose? How do I make my life meaningful when I’ll likely be forgotten in 100 years?
All of these are constantly withdrawing from your Vital Reserve account.
Meet Cortisol: Your Body’s “Energy on Credit” System
Cortisol is your primary stress hormone, and it’s actually designed to help you survive. When your environment throws stressors at you, cortisol says, “We need to put internal spending on hold and take all available resources to deal with this external threat.”
Cortisol breaks the body down for quick energy. We call this “catabolic.”
Why would your body have a mechanism for breaking itself down? Because sometimes you need energy RIGHT NOW. When your boss says, “This project is actually due in 30 minutes,” you can’t drive to the store, buy food, cook it, eat it, digest it, and then produce energy. You need quick fuel immediately.
So cortisol reaches for easy-to-break-down tissues like cartilage, tendons, connective tissue, and muscle, converting them to blood sugar.
Here’s the kicker: Cortisol is also a natural painkiller and anti-inflammatory. It masks the damage it’s doing, which is why it makes you feel amazing in the moment: clear thinking, quick reactions, pain-free movement.
Think of cortisol as your body’s credit card. You’re borrowing energy now and promising to pay it back later through rest, recovery, and healing.
When “Energy on Credit” Becomes a Problem
Throughout history, humans dealt with stress that was intense but occasional and short-lived. A wild animal attack, a natural disaster, a tribal conflict: these were serious but temporary.
Take a moment to think about this: Does this describe the stress in your life?
For most of us, stress is intense, constant, and never-ending. We wake up stressed, work stressed, drive home stressed, and lie in bed stressed about tomorrow’s stress.
This creates what we call “catabolic debt”: you’re constantly running up charges on your cortisol credit card without ever paying it back.
Chronic stress is not within our biological design.
Consider this: Anthropological studies show paleolithic humans worked only 15-20 hours per week. How many of you work only 15-20 hours per week? (And remember, “work” includes housework, childcare, and all the other responsibilities that don’t stop when you leave the office.)
They lived in close communities with cooperative resource sharing and had each other’s backs. Think about your own life: Do you know your neighbors? If you do, would they really have your back if things got serious?
Most of us are duplicating resources instead of sharing them. We’re all figuring out our own childcare, making our own meals, maintaining our own everything. There’s no interdependence, no shared load.
The cost of modern life is enormous:
70-80% of doctor visits are for stress-related illnesses
People with high anxiety are 4-5 times more likely to die from heart attack or stroke
Stress contributes to 50% of all illnesses
The Stress Response Curve: Your Roadmap to Understanding Where You Are
This is where it gets really interesting. Understanding this curve will change how you see your health (and your clients’ health) forever.
We all start in the green zone: Homeostasis. When you experience occasional stressors, cortisol and adrenaline spike, you handle the situation, then return to baseline to rest and repair.
But when stress becomes chronic, you move into the orange zone: Acute Stress. You’re constantly producing cortisol and adrenaline, never returning to homeostasis.
Here’s the thing: on your way up this curve, you feel AMAZING. Remember when you could pull all-nighters and still ace exams? When you could eat junk food without consequences? When you had laser focus for 12-16 hours straight?
That’s the acute phase. You’re running on cortisol, and it feels like superpowers.
Then you hit Peak Production. Your body says, “We’ve put way too much on the cortisol credit card. We have to cut back.”
Now you fall into the Compensatory Phase. Your cortisol numbers might look normal to a doctor, but the distribution is all wrong. Maybe you have too much in the morning and crash by afternoon, or you spike at night and can’t sleep.
Plus, you have a relativity problem. You’re used to feeling like Superman from the acute phase, so normal cortisol levels feel terrible by comparison.
Continue down this path, and you reach the Exhaustive Phase. Like a phone on low battery mode, everything still works but at 30% capacity and not for long. You’re devoting everything to just getting through the day.
The Hidden Cost: What Happens to Your Body’s Core Systems
At FDN, we focus on six foundational systems that chronic stress systematically shuts down. We call them the H-I-D-D-E-N systems, and understanding what happens to each one under chronic stress is crucial for practitioners:
H – Hormones DHEA is your anabolic hormone: the one responsible for building you back up after cortisol breaks you down. This is how you pay off your cortisol credit card. But when stress is constant, DHEA steps back and says, “I’ll come back when it’s safe to focus internally, but right now we need to keep spending on the environment.” DHEA becomes chronically low, which means your healing potential becomes chronically low.
Then sex hormones get the message: “We don’t have enough resources to fund fertility right now.” Sex hormones plummet, taking motivation and joy for life with them. This is when you get to that neutral state where you’re thinking, “I have dreams I want to pursue, but it’s just too much effort. I’ll just watch Netflix instead.”
I – Immune Your immune system is expensive to run. Under chronic stress, it says, “I cost a ton of money, so I’m going to operate at 30% capacity and not for very long.” Now you’re getting sick often, it takes forever to heal, you can’t shake that cough, and if anyone around you is sick, you know you’re going down.
D – Digestion Digestion costs a lot of energy to function properly. When you’re spending everything on stress, digestion goes into low-power mode. Now you’re only digesting at 30% capacity. Even if you’re eating the cleanest diet in the world, you can’t use it. You’re not getting the building blocks to repair or the nutrients your body needs to power metabolic functions at full capacity.
D – Detoxification Detoxification is another huge system that’s expensive to run. When your body’s bank account is overdrawn from cortisol debt, detox says, “I don’t have enough money to find these toxins, bind them up, and effectively remove them. So I’ll put them in storage instead.” Your body shoves toxins into fat cells, brain tissue, and bones, creating a toxic backlog that makes you feel slow, gives you acne, throws off digestion, and impairs hormone production.
E – Energy Production Your mitochondria can’t function optimally when all resources are diverted to stress response. This leads to that “tired but wired” feeling where you’re exhausted but can’t actually rest.
N – Nervous System Sleep, mood, and cognitive function all suffer. This is where we see the brain fog, insomnia, anxiety, and depression that so many people struggle with.
The fundamental principle of FDN: These systems don’t operate in isolation. You can’t just say, “Oh, you have classic hormone symptoms, so let’s run a hormone test.” You miss immunity, digestion, detoxification: all the other systems contributing to what we call “Metabolic Chaos.”
This is why the “take this supplement for that symptom” approach rarely works long-term. You’re not dealing with isolated problems: you’re dealing with systemic dysfunction where multiple systems are compromised simultaneously.
Real-Life Case Studies: The Stress Curve in Action
Let’s look at three real clients to see how this plays out. As FDN practitioners, we use what we call “clinical correlation,” which means we never look at lab numbers in isolation. We always consider how someone feels alongside their test results.
Case Study 1: Adam – The Acute Phase Crash
Profile: 35-year-old male, broker at a mid-size investment firm, former athlete still crushing CrossFit workouts
Symptoms: Weight gain, trouble concentrating, loss of muscle mass despite rigorous workouts, headaches
Doctor’s Assessment: “Your results are unremarkable. This is normal aging.”
Lab Results:
Cortisol sum: 9 (acute phase)
Four-point pattern: Way too high in morning, drops low at noon, crashes severely in afternoon, bounces back up at night
The Reality: How do we know Adam isn’t on the left side of the stress curve going up into acute phase? His symptoms tell us everything. If he were on the way up, he’d feel amazing and wouldn’t be in our office. Instead, he’s on the right side coming down from peak production.
His cortisol pattern explains everything: sky-high morning cortisol makes him feel wired and anxious, the afternoon crash leaves him unable to concentrate (not ideal for an investment broker), and the nighttime spike disrupts his sleep.
Even though his DHEA looks “normal,” when we compare it to his cortisol level of 9, he’s clearly catabolic dominant. He’s breaking down faster than he’s building up, which explains why his intense CrossFit sessions aren’t building muscle: they’re just adding more stress to an already overloaded system.
The Reality: Caitlyn’s cortisol sum looks normal, but the distribution is completely dysfunctional. She can barely drag herself out of bed in the morning, crashes hard in the afternoon (imagine trying to accurately record legal proceedings when your cortisol is plummeting), and lies awake at night because her cortisol spikes just when it should be lowest.
She also has a relativity problem. When she was in the acute phase, she felt like Superman. Now that she’s in compensatory with “normal” cortisol levels, she feels terrible by comparison. Her DHEA is low, confirming she’s still in catabolic debt despite the lower cortisol numbers.
Case Study 3: Maggie – The Exhaustive Phase Crisis
Profile: 43-year-old chef at a popular five-star restaurant, diagnosed with hypothyroid
Symptoms: Weight gain in hips and belly, trouble keeping up at work, depression, irregular menstrual cycle
Lifestyle: Working 60+ hours per week, consistently sleeping only 5 hours per night
Medical Status: Seeing a counselor, considering antidepressant medication
Lab Results:
Cortisol sum: 3.1 (exhaustive phase)
Four-point pattern: Way too low in morning, drops low at noon, slight bounce in afternoon, drops again at night
DHEA: Very low
Clinical correlation: Still catabolic dominant despite low cortisol
The Reality: Maggie’s body is operating like a phone on low battery mode: everything still works, but at 30% capacity and not for long. Her thyroid has downregulated because there’s literally not enough energy in the system to maintain normal function.
The depression isn’t just psychological: it’s physiological. Her body can’t afford to fund optimal brain function. Even though her cortisol is very low and her DHEA is very low, she’s still cortisol dominant and in catabolic debt.
This is why understanding the stress curve is so crucial. Three people, three different phases, three different approaches needed.
The Path Forward: Why Understanding Cortisol Changes Everything
Here’s why this matters for you as a health practitioner:
1. It explains why some clients plateau. If you’re not addressing the stress component, you’ll hit a ceiling on healing no matter how perfect the diet or supplement protocol.
2. It validates your clients’ experiences. When someone says, “I used to be able to handle so much more,” or “I don’t feel like myself anymore,” you now understand the physiology behind it.
3. It gives you a roadmap for intervention. Different phases require different approaches. Someone in the acute phase needs different support than someone in the exhaustive phase.
4. It highlights the importance of comprehensive testing. A single cortisol measurement tells you almost nothing. You need the full pattern plus clinical correlation.
The FDN Approach: Test, Don’t Guess
At FDN, we don’t just talk about stress: we measure it. We use what we call “clinical correlation,” which means we never look at lab numbers in isolation. We always consider how someone feels alongside their test results.
We look at:
Four-point cortisol patterns throughout the day (not just a single measurement)
DHEA levels and the cortisol-to-DHEA ratio
How stress is affecting all the H-I-D-D-E-N systems
The complete picture of metabolic chaos
Progress tracking with tools like the Metabolic Chaos Scorecard
Then we address it systematically through our DRESS protocol:
D – Diet: Personalized nutrition based on lab findings, not generic “healthy eating” advice
R – Rest: Sleep optimization and recovery strategies tailored to your stress phase
E – Exercise: Right-sized movement for your current capacity (over-exercise is just as harmful as under-exercise)
S – Stress Reduction: Targeted techniques for your specific stressors: mental/emotional, physical, environmental, and lifestyle factors
S – Supplementation: Targeted support based on actual lab results, not guesswork
This isn’t about generic protocols. It’s about understanding exactly where someone is on the stress curve and what their body needs to heal.
Key Takeaways for Health Practitioners
Cortisol isn’t the enemy. A lot of people talk about cortisol as if it’s the villain—commercials make it sound like cortisol just makes you “old and fat.” That’s not what cortisol does. Cortisol is a vital hormone for navigating stress. The problem is chronic stress disrupting its natural rhythm.
Understanding the stress curve is diagnostic gold. It explains why clients feel the way they do and gives you a framework for intervention. Different phases require different approaches.
Clinical correlation is everything. You can’t just look at lab numbers in isolation. A cortisol sum of 5 might be “normal” to a doctor, but if your client feels terrible and the distribution is dysregulated, that tells you the real story.
You can’t ignore stress and expect lasting results. No matter how perfect your diet protocol or how targeted your supplements, chronic stress will cap healing potential. There’s a ceiling you’ll never break through if you don’t address the stress component.
The body’s systems are interconnected. You can’t just “fix hormones” without addressing how stress is affecting immunity, digestion, detoxification, and all the other H-I-D-D-E-N systems. This is why comprehensive testing and systematic protocols are crucial.
Metabolic Chaos requires a systematic approach. When multiple systems are compromised simultaneously, you need a framework like DRESS that addresses all aspects of healing, not just isolated symptoms.
Your Next Steps
If you’re ready to master functional lab testing and learn how to identify and address cortisol dysregulation in your practice, FDN provides the training, community, and ongoing support you need.
Because here’s the truth: your clients deserve more than “fine.” They deserve abundant vitality. And you deserve the confidence that comes from knowing exactly how to help them achieve it.
When you understand cortisol (really understand it), you hold the key to unlocking transformation for every client who walks through your door.
Ready to become the practitioner who always knows what to do next?
The answer lies in data-driven functional health. The answer lies in understanding that robust health isn’t just about the absence of symptoms: it’s about the presence of vitality.
And it starts with the hormone you can’t ignore: cortisol.
Want to learn more about becoming a Functional Diagnostic Nutrition Practitioner?
Discover how our comprehensive training program gives you the tools to master cortisol testing, interpretation, and protocols that get results. Because when you know how to test, you never have to guess. View an indepth case study here.
There’s a quiet grief that has settled in my bones over the years — a subtle, enduring, invisible sadness I never expected when I first became a parent. It’s the grief of constantly co-regulating my child, who is autistic with ADHD, and whose big emotions are often beyond their control.
Co-regulation means being present, constantly shifting my own emotional state, even when I’m not ready, to match the urgency of my child’s. I’ve learned to steady my breath when theirs quickens, to lower my voice, to adjust the environment, to make them feel safe. But when the storm passes, there’s often no space for me to process the emotional toll it’s taken.
Co-regulation is not just about calming my child in a single moment of distress but about managing their entire emotional landscape day after day, which can vary considerably. It means that I am hypervigilant about my child’s needs, always ready to step in, always holding my breath in anticipation of the next emotional storm. I feel like the safety net that keeps it all from crashing down, but what happens when I can no longer be that lifeline?
Extreme Emotional Labor, Grief, and Parental Burnout
Parental self-regulation is part of co-regulation, but it doesn’t come easy, especially with a highly dysregulated child. Most days feel like I’m perpetually “on,” suppressing my own emotions because my child needs me to be stable. There is hardly opportunity to recuperate before the next emotional explosion. Who holds me when I need to fall apart? This constant emotional labor, this unyielding responsibility, is the grief that no one sees.
This grief is compounded by isolation. People offer sympathy, but they rarely understand what it is to co-regulate a child with unique needs.
There is also anticipatory grief about the future — how my child’s needs will evolve as they grow older. What will independence look like for them? Will they find lasting relationships, joy, fulfillment? These worries weigh heavily on me, and I feel guilty for not being more hopeful.
Under the Grief: The Myth of the Perfect Parent
In the midst of it all, there are durable moments of love, hope, and connection that make it worthwhile. There are times when my child looks at me with a calmness that tells me they’ve found peace, moments when our bond feels unbreakable. Co-regulating has deepened my understanding of love and what it means to be there for someone, no matter how difficult the journey.
But even in those moments, the grief lingers. It’s woven into the fabric of our lives, an ever-present companion. And I’ve come to realize that the grief of co-regulating my child is part of a larger, often unspoken narrative we’ve internalized about parenting — that it requires constant sacrifice, self-effacement, and emotional depletion. The idea that we must become martyrs in our efforts to be the “perfect parent.”
We are often conditioned to believe that if we’re not always giving, always doing, always available, that we’re failing our children. The myth of the “perfect parent” tells us that our own needs are secondary, that love for our children means putting ourselves last – a construct that is especially harming to parents of neurodivergent children. But the truth is, we do our children a disservice when we sacrifice ourselves to this extent. We also risk losing the sense of who we are outside of being caregivers.
I’m learning that to set boundaries and prioritize my own well-being is uncomfortable, inconvenient, and often met with judgment. There’s grief in this too — the grief of wanting to take up space without apology, of being seen as less than for simply existing as I am. But I know the cost of not speaking up is greater. When I sacrifice my voice, I lose my health, my confidence, and my joy.
Despite the grief and discomfort, I keep moving forward — balancing the pain and love, exhaustion and connection, finding strength in the quiet understanding that I am doing the best I can. I am my child’s lifeline, but I am also mine.
Co-Regulation: Next Steps for Neurodivergent Families
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As I cleaned out my desk drawer recently, I stumbled upon a collection of pictures I intended to share but never did: school photos, holiday cards, baby pictures. Sweet moments now engulfed in flames of guilt. Not a single picture had ever been mailed out as I had planned.
The shame was immediate. I thought back to the wedding thank-you notes, Christmas cards of years past, and other items that I likewise never got around to mailing. I remembered the many times I thought, “I’ll get to it later.” But later stretched into years, and now here we are.
The regret is present and heavy as I equate my lack of follow-through with incontrovertible proof of my laziness and carelessness. That I’m a terrible parent and friend by extension.
I’m no stranger to automatic thoughts like these and to trips down the shame spiral — journeys familiar to practically everyone with ADHD. But I’m also becoming more adept at the essential art of reframing.
Though I live with ADHD, I am still learning and accepting that the condition impacts my ability to:
hold on to important information
initiate tasks without external pressure
manage time – because my perception of it is different
remember things I can’t see – if something isn’t in front of me, it easily slips my mind
Break the ADHD Shame Cycle
Nowadays, I’m getting better at reminding myself that some challenges are not a matter of willpower, but of how my brain is wired. When I notice myself spiraling into shame, I pause and ask myself four questions:
Do I love my child?
Am I a good person?
Is shame helping me in any positive way?
What does help? Utilizing strategies, self-acceptance, and forgiveness.
So, I talk back to that critical voice. I’ve even given it the name “Britta.” (Inspired by the well-intentioned but often chaotic character from the show Community.) I challenge those ANTs (automatic negative thoughts) and recognize when my rejection sensitivity is kicking in.
Then, I focus on next steps. Can I take some action to rectify the problem, or is it a matter of letting go and moving on? Do I need to work backward from the desired outcome to determine next steps? Do I need to call an accountability buddy (a body double) to help me focus?
For now, I’ve decided to let go and keep the photos in the drawer. This time, though, I add a handwritten note for future me, designed to halt shame in its tracks. It reads: “These unsent pictures do not mean that you are a bad mother. You are a mom with ADHD who is navigating a full life, and that is perfectly acceptable.”
Shame Cycle and ADHD: Next Steps
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You want to feel close. You want to be present during sex. But instead, your brain won’t stop buzzing. You’re thinking about your to-do list, or that weird sound the fan is making, or how your bra strap suddenly feels like a vice grip. Your brain might obsessively loop on whether you’re “doing it right” or if your partner is satisfied. The mood is gone, and now you’re stuck in your head wondering, “Why can’t I just focus and enjoy this?”
As a clinical sexologist and sex therapist who specializes in ADHD, I hear this all the time. Women with ADHD, especially, come in feeling broken or ashamed because they can’t seem to stay in the moment, even when they want to. They wonder if they have low libido, or if something is wrong with their relationship, or worse, with them.
But the issue often isn’t low desire. It’s about ADHD-related challenges that cause low bandwidth. These issues can show up in surprising ways during intimacy, and when they do, we often misinterpret them.
ADHD Women and Sex: Why It Feels Like “Too Much”
For many people with ADHD, sex is unpredictable, overstimulating, or emotionally confusing. Sensory overload, distraction, and a flooded nervous system all make it difficult to access pleasure, let alone stay present long enough to enjoy it.
Some people shut down in these moments. Others mask what they’re feeling to avoid hurting their partner’s feelings. Many just disconnect and then spiral with guilt, wondering why they can’t “just be into it.” They think they simply aren’t meant to enjoy sex.
But here’s the thing: ADHD brains often need structure, stimulation, and clarity to stay engaged. And most sex advice out there doesn’t account for that.
Many ADHD Brains Need Structure and Stimulation to Enjoy Sex
As part of my doctoral research, I studied 65 women who had or suspected they had ADHD. I wanted to understand how attention struggles affected sexual satisfaction and whether certain sexual environments might actually support focus and presence like I saw happening for so many of my clients.
Specifically, I looked at BDSM. Yes, that’s right: Bondage, Discipline, Dominance, Submission, Sadism, and Masochism. But not in the sensationalized way you might be picturing. I studied it as a structured, consensual, often sensory-rich form of intimacy that might provide what ADHD brains are missing in more “typical” sex.
And what I found was compelling: The more a participant struggled with attention, the more likely she was to engage in BDSM, and report feeling more satisfied and focused on those experiences.
It turns out that many of the elements of BDSM naturally align with the needs of an ADHD brain:
Clear roles and expectations: You know what’s happening, what’s coming next, and what your role is, which reduces cognitive overwhelm.
High stimulation: Touch, sound, and movement are often more intense, which can help ADHD brains stay present.
Built-in communication: Most BDSM dynamics involve clear negotiation, check-ins, and feedback, which helps reduce second-guessing and overthinking.
Permission to pause: The emphasis on consent means there’s always space to slow down, stop, or readjust without shame.
For many participants, BDSM was about clarity, focus, and feeling more in their bodies.
What This Means for You
If you have ADHD and find yourself struggling with presence or satisfaction during sex, it doesn’t mean you’re broken, “bad at sex,” or even that you have low desire. It might just mean that the way you’re approaching intimacy isn’t working for your brain.
This doesn’t mean everyone needs to jump into kink. But it does suggest that you may benefit from:
More structured, intentional intimacy
Higher levels of sensation or novelty
Clear communication about what feels good or overwhelming
Environments that reduce unpredictability and distraction
In other words, it’s not about “fixing” your desire. It’s about finding the context where desire can actually show up.
How to Enjoy Sex: Let’s Rethink ADHD and Sex Drive
What if instead of asking, “How can I stop overthinking during sex?” or, “How do I get in the mood?” we started asking:
What does my body need to feel safe right now?
What type of stimulation helps me stay present?
How much downtime or prep does my brain need before switching into intimacy mode?
These are ADHD-informed questions. And they often reveal that the desire is there; it’s just waiting for the right environment.
ADHD and Sex Drive: Next Steps
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I thought I sucked at life. On the outside, I was positive and upbeat, a married mom of three, a business owner. I had a mortgage, an investment property, a postgraduate degree in psychology. I had friends, prospects, blonde highlights. On the inside, I felt broken.
I faked enthusiasm for most conversations. I was either painfully uninterested in the small talk of the other school moms, or wishing I could mitigate my ever-present fatigue with a nap by midday. Every social event left me exhausted by anxious rumination. Why did I say that? What did they think of me? I’m so hopeless.
By the end of the day, every noise felt like nails on a chalkboard: my kids scraping their dinner plates, the neighbor’s electric gate buzzing, my husband swallowing his beer. The touch of my children, wanting a cuddle, made me recoil. I had to sleep alone to avoid the distressing sounds of someone else’s breathing.
My adulthood was peppered with jobs abandoned, degrees unfinished. I loved my role as a telephone counselor but felt the excruciating closeness of my colleagues’ cubicles like a cheese grater on an open wound. I adored owning my own coffee van, thriving in the autonomy and pride of working alone, but I didn’t have energy once I got home. I often spent weekends in bed, my body and mind depleted in burnout. I spent hours applying makeup and doing my hair before leaving my house, hyperconscious of how I would be perceived. Later, I would pick at my skin until it bled as I pored over the minutia of the day. Did everything go okay? Was I okay?
I already had diagnoses of ADHD and complex trauma, but I still had many questions. Why did everyone else seem to move so easily through life? Why couldn’t I be at ease around others instead of agonizing over how much eye contact I gave during conversation? Why was I so sensitive to sounds, smells, and my environment? Why did I never miss others when they weren’t around, and feel the sting of rejection so sharply, and hide behind the couch when my doorbell rang even though I desperately wanted to connect?
I already suspected the diagnosis, of course. A lot of us do. Although I don’t have hyperfixations or stereotypical obsessional interests in trains, my “for you” page on TikTok has been entirely neurodivergent for the past few years. That’s me! I would think as I scrolled through video after video of late-diagnosed, high-masking autistic women sharing their experiences. I do that! I feel that! That’s me. And then my inner critic would come in. No, it isn’t. You’re just pathetic. You’re unlikeable, lazy, worthless. You’re not okay, and you suck at life. For 40 years, I believed that voice.
So, while I suspected autism, I had my doubts, too. Sure, it costs me enormous amounts of planning, exhaustion, and recovery just to be a human in this world, but that’s normal, right?
Um, nope. That’s autism — at least how it manifests for me. When my big YES moment came and my evaluator confirmed my diagnosis, I felt an exhausted sort of calm. That question-mark box inside of me gently ticked itself in sage green, my favorite color. My experience is real. I’m not defective. I’m not faking the enormous strength it takes me to show up in this world.
Peeling back the layers of my diagnoses with my psychologist, processing my past, and medicating my dopamine-deficient brain not only uncovered my social and sensory sensitivities but helped me to understand them.
My brain is beautiful, and different, and it has tried so very hard to fit in in this world. I have been very good at fitting in, and I have paid the price for it every day. Taking off the neurotypical mask is a scary process because I don’t know what lies underneath. What I do know is I am tired of putting it on every day. I don’t have enough spoons of energy, and I’m finally beginning to say so.
I don’t have to say yes to social events I don’t wish to attend. I can be open about the fact that my social battery can suddenly and inexplicably run out, and that I want — no, need — to go home and sit in the shower to regulate. I can talk about the weird things I find interesting and laugh about the weird things most people consider normal. I can mourn the decades lost in muddling through and be grateful for the financial privilege of obtaining an autism assessment. I can also be horrified that others will go through their lives without validation, understanding, and support instead of celebrating their unique brains.
So, yes, I do suck at life. I suck at expending more energy than I have in pretending to be like everyone else, just because I have the ability to hide my differences. I suck at knowing what to say and how to act around people, and I suck at pretending that certain noises and smells don’t bother me or that my feelings aren’t so very tender.
But for the first time, I can try on the idea that this is OK. That there might be a whole new way of living that supports my needs, sensitivities, and dreams. Where I can thrive as my true, messy self and be proud of who I am.
My diagnosis and these words are my first tentative steps into this new world. It’s a little bit scary, and my navigation system may look different from yours. What is guiding me now is better understanding, and a determination to believe myself when I say that I don’t suck. I am okay, and I have been okay, all along.
High-Masking Autistic Women: Next Steps
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High-intensity interval training (HIIT) is a popular form of exercise that involves alternating between short, intense bursts of movement and brief periods of rest. As an ADHD coach, I’ve always considered the HIIT method to be well-suited for people with ADHD outside of fitness. The short intervals of work and rest are manageable and work to sustain focus and mental engagement.
With my own clients, I’ve adapted HIIT into a protocol for helping them manage dreaded tasks and get things done. I call it high-intensity interval tasking. Here’s how it works:
High-Intensity Interval Tasking: Getting Chores Done with ADHD
1. Think of a task that you consistently struggle to start or finish. I’m choosing folding and putting away laundry into drawers and closets. (Ugh!)
2. Decide how much time you want to allot to the task (this includes rest time, which we’ll get to). Note that you’re not basing it off how much time you have, but how much time you can realistically devote to the task without becoming frustrated or burning out. With that in mind, could you commit to a total of 5 minutes? 10? 15?
3. Within this timeframe, determine the ideal duration of your “work” (high intensity) intervals and your “rest” cycles. For example, two minutes of work and one minute of rest.
4. Use a timer, your Alexa device, or a free third-party interval timer app to set your work and rest points for the timeframe you chose.
5. Start the timer (I’m choosing 15 minutes) and begin folding clothes with as much intensity as possible for the work period you allotted. In this case, I’ve set aside two minutes. Note that intensity doesn’t necessarily equate to speed but to effort. Another way to think of intensity is “intention.” What does it mean to give it your all for two minutes? Do you have to fold laundry in another room to stay focused? Do you need music to help you stay motivated while you fold and put clothes away?
6. Stop when the timer goes off and rest for the time you noted. (One minute in this case.) Do what you will as you rest — scroll through your phone, pace around — just make sure to respect the rest time you’ve given yourself.
7. Start folding and storing away clothes again with intensity/intention when the timer goes off again.
8. Continue the process until the timeframe completes.
If you find yourself getting distracted or not working as intensely as you know you can, try shortening your work intervals. A few seconds of focused, intentional work may be better and more motivating than minutes of distracted work. Over time, your ability to work intensely on a task should improve.
Doing Chores & Getting Things Done with ADHD: Next Steps
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My heart races as I listen to my kids in the other room. I can tell their play has taken a turn and is now getting sticky. I listen a little longer to see if they can work it out. Nope — things have escalated. I move quickly, hoping to break it up, but it’s too late. My youngest is crying and yelling, while my other kid still looks like they want to hurt someone.
I hate seeing my kids fight. I do all I can to prevent it, but it is inevitable. Siblings fight, and that’s normal. (Even as a therapist, it’s hard for me to accept this!) What I can control is my response to the fighting. I can step in, set loving limits, and try to teach my children that, while some conflict is normal, there are productive ways to manage emotions and handle disagreements so that things can go a little better next time. Here’s how I, as a therapist and a mom of three, including a child with ADHD, manage sibling conflicts in my home.
1. Do not take sides. This one is hard — if one kid is crying, then we often assume that the other one must be at fault, right? No, not necessarily. (The crying kid, for example, might have been bugging their sibling all week until they hit a breaking point.) The point is, fault is somewhat beside the point. It’s best to approach sibling fights with the understanding that your kids are dysregulated, struggling, and in need of your help.
2. Wait to talk. If children have reached the point of fighting, then they’ve reached the point where they’ve “flipped their lid” as psychiatrist Daniel Siegel, M.D., puts it. This is when the thinking part of their brain goes offline. It takes about 20 minutes to regulate and get out of this fight-or-flight mode.
If you try to talk to your children before their brain comes back online, they will likely not be able to take in what you’re saying, no matter how logical or comforting your words may be. If anything, you’ll just add to their stress response.
So, what should you do? Separate your children if possible and wait. Tina Payne Bryson, Ph.D., refers to this as a “time in” in her book co-authored with Siegel, No-Drama Discipline. Give your children time and space to allow their prefrontal cortexes to come back online. If needed, remind them about self-regulation tools, like deep breathing, counting to 10, or listening to calming music.
3. Approach each sibling separately. In private, talk to each child about what happened, and don’t assume that you know what started the issue. Even if you do know, allowing your child to explain will help them feel better. (Think about how you, as an adult, feel when you get to explain yourself instead of being shut down.) When a child feels heard and understood, it helps regulate their nervous system. They can calm down quicker and think more clearly.
4. Validate and acknowledge. Talking to your children separately will also give you space to validate feelings without making anyone feel bad or like you’re taking sides. If your child says, “She always takes my stuff without asking! I am never going to let her touch anything of mine again!” You can say, “I’d be angry, too, if someone touched my things without asking.” Or, “Yes, it is hard to have a sibling who often takes your stuff without asking.” Never make your child feel like what they’re upset about is trivial. It’s never a small matter to them, and brushing off their feelings will only intensify them.
Contrary to what most parents fear, validating your child won’t cause them to double down on their anger or commit to, say, NEVER let their sibling touch their stuff again. Validating will simply allow your child to vent and regulate.
5. What could you do next time? Finally, the step where many of us would like to begin: the conversation about how the situation can be handled differently next time. It’s tempting to jump straight to lessons learned, but this is a conversation that can only be had once brains are back online and everyone is regulated.
The conversation can start like this: “Hey, I know it is really hard when your sibling takes your stuff without asking. Is there another way this could be handled?” Giving your child a chance to problem-solve will strengthen this essential skill and help them feel more in control.
Offer ideas if they need help, like, “If you see your sister playing with your stuff, you could say, ‘Hey, you did not ask me to play with that. I’d like for you to ask me before you grab my stuff, please.’” On your end, notice if any patterns come up around fighting. Are fights happening when routines are disrupted? When one child feels ignored? When one child has too much pent-up energy? When your children are hungry or thirsty? When rules and expectations are not fully understood?
Big emotions are normal, especially if you’re raising neurodivergent children. But you can teach your children to regulate and resolve conflicts by meeting them with curiosity, compassion, and understanding.
Siblings Fighting: Next Steps
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Many of my clients describe rejection sensitive dysphoria (RSD) — the intense fear and pain associated with rejection and criticism, real or perceived — as overwhelming, confusing, and isolating. I agree with them, as I’ve experienced it myself.
The more I’ve reflected, the more I’ve come to understand that RSD — with its all-consuming episodes accompanied by shame and a desire to withdraw or spiral — is about far more than rejection or emotional sensitivity.
RSD gets to our deep-seated fears about letting the world see the real us. RSD is really about the panic of being unmasked. I see this as “unmasking dysphoria,” a trauma-linked reaction to being exposed in ways that feel unsafe.
The Cost of Masking
Neurodivergent people learn to mask, or hide the traits that make them different, to navigate environments not built for their brains. It’s not a choice but a survival strategy to avoid punishment, misunderstanding, or exclusion.
Masking takes on many forms. It can look like overcommitting (to ward off suspicions of incompetence), manufacturing urgency (because external pressure is needed to finish tasks), scripting and rehearsing conversations, and obsessively rereading messages. It can look like keeping a low profile to avoid saying something impulsive or “stupid” and being exposed.
Masking requires constant self-monitoring and adjusting, leading many people to feel on edge all the time. Some of my clients describe it as a low-level fear of getting in trouble for doing something wrong, a feeling enforced by past instances of being reprimanded for their symptoms.
Masking, especially in the long-term, harms mental health. It forces people to internalize that their natural way of being is wrong and unacceptable. This chronic invalidation and exclusion of the self is a form of trauma that rewires the nervous system. Even if it doesn’t meet the traditional definition of trauma, it changes how we emotionally respond to the world. It’s why moments when the mask slips feel not just uncomfortable, but unsafe.
This Isn’t Just Sensitivity
Many people, with or without ADHD, are sensitive to criticism. But RSD runs deeper. It’s about fear of exposure.
The people who experience RSD most intensely are those who have mastered masking. They have gone to great lengths to hide their neurodivergence, allowing the world only to see (a version of) competence, not the immense mental load beneath.
But when traits they’ve worked so hard to suppress suddenly show, things collapse. The world has caught a glimpse of their true, flawed self. They spiral, withdraw, and melt down, not because anyone rejected them, but because they no longer feel safely hidden.
This is how I felt when I froze during a mock interview recently, despite prepping for days. I felt ashamed beyond embarrassment.
My brother said, “This is just an RSD episode — you’re not thinking clearly. It’s going to pass.” He was right. But the shame wasn’t about the interview. It was about the mask slipping and a part of me being exposed that I’ve spent my life trying to manage or hide.
It’s not always about fear of public exposure. A client lost his passport, canceling a vacation no one else knew about. There was no rejection involved. But he still spiraled into shame because his hidden disorganization surfaced. It was the loss of his mask, even to himself, that hurt.
A Different Framing: Unmasking Dysphoria
RSD is a trauma-related response to involuntary unmasking. What appears as emotional overreaction often reflects the nervous system’s response to unmasking and thus perceived exposure, regardless of whether the person consciously recognizes it.
Not all triggers link directly to ADHD traits or obvious masking. Triggers can be breakups, delayed texts, or vague feedback. The core fear remains: being too much, too difficult, or defective. Many with ADHD carry these narratives after adapting to unwelcoming environments. In those moments, what surfaces isn’t just fear. It’s unmasking dysphoria.
This view aligns with principles of trauma-informed care, which recognize how feeling safe, having a sense of control over one’s life, and understanding past experiences shape emotional responses.
Key points:
The real trigger is the perception of being unmasked.
The emotional intensity isn’t fragility but collapse after years of effortful self-monitoring.
These feelings tie back to identity, shame, and safety.
Why the Reframe Matters
As a trauma-informed clinician and a person with lived experience, I believe this framing deserves deeper research, especially for those with ADHD who carry emotional wounds from chronic invalidation. Better understanding the why behind RSD can guide interventions beyond surface emotion regulation toward reducing shame and increasing self-acceptance and healing.
This understanding also helps validate the exhaustion caused by masking and honors its protective role. It encourages separating performance from worth and treating the emotional collapse as a predictable, reasonable trauma-related response.
Ultimately, this shift moves the focus from sensitivity to survival and pathology to context —allowing people to receive deeper support, develop self-understanding, and show up fully and unapologetically.
Rejection Sensitivity, Masking, and ADHD: Next Steps
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Lying is characterized as a common expression of ADHD. It is also widely seen as a character flaw. But people with ADHD don’t bend the truth because they’re inherently flawed; we often lie for one or more of the following perfectly good reasons:
1. Impulsivity. We may blurt out something that isn’t true, and then not feel like we’re able to take it back.
2. Fear of punishment. Those of us with ADHD know what it is to slip up and face consequences — at school, at home, in the workplace, and in life all around. Bending the truth helps us avoid punishment when being criticized for one more thing may be too much to bear.
3. Forgetfulness. We don’t always remember what we say or do. We remember it one way and swear it happened (or didn’t) that way even if it didn’t.
4. Rejection sensitivity. It’s not an exaggeration to say that, for some people, the experience of rejection reaches death-of-a-loved-one levels. Fear of rejection, and the very real, very debilitating distress it can cause, may push us to tell a palatable lie rather than a painful truth.
I relate to all of these reasons for truth-bending. But there is a lot more to it — aspects of which touch on the complex, unspoken parts of the social contract, and how much information we owe others.
There’s lying, and then there’s leaving out information. As a fairly private person, I am selective about what I share. I may give out some details, but not all. And many times I have been accused of lying for not telling the full story. Sometimes it’s not about privacy, but about conserving energy. I leave out information if it would require me to speak or think for longer than I have my bandwidth will allow.
Lying, Or Needing Time to Process?
Related to energy-spending is processing speed. With a neurodivergent brain, it does take me longer than average to process certain things. Unfortunately, this has put me in uncomfortable situations where I am perceived as having lied.
I remember an incident from a decade ago that still stings. Ahead of an event, I indicated spare ribs in the dinner RSVP card, or at least I thought I did. Turns out I had ordered prime rib. On the day of, fully convinced that I ordered spare ribs, I told the event coordinator when my food arrived, “I didn’t order this.” “Yes, you did,” she responded, and added that I should just say I don’t want the dish instead of pretending that I didn’t order it.
I froze. I was confused, thrown off by the coordinator’s reaction, and I was called a liar. I needed a minute to process what had happened and explain myself, but that wasn’t afforded to me. So I gave in and said, “I don’t want it.”
Now imagine growing up with undiagnosed ADHD, as I did, where these experiences happened over and over and over.
I am a private person, in part, because I have struggled with a lifetime of feeling like I talk too much. I worry about oversharing.
Recently, a friend asked me about the medals on my walls. I have medals for completing virtual tours through The Conqueror Challenges. And I have medals that celebrate my sobriety milestones. In that moment, I only told my friend about medals in the former category.
Was it wrong to leave out the truth that some of my medals had to do with freedom from substances? I have zero shame about those medals, and I am proud to be substance-free. Everyone, including my friend, knows I no longer drink or use any other type of mind-altering substance.
But I left out those medals because mentioning them may have led to a longer conversation where I might have rambled, gone off topic, or accidentally gone into “trauma dumping” territory. Still, if this is a friend we’re talking about, shouldn’t I have felt comfortable sharing? Does my omission count as a lie?
Lying, or Not Given the Benefit of the Doubt?
Living with ADHD puts us in situations that often cause us to question our relationship to the truth. We withhold information for fear of oversharing, only to learn that the information was vital to the story. Or we withhold information because we’re not comfortable sharing. Sometimes telling a white lie feels like the end of the world. And, sometimes, when we bring our whole selves, it backfires, and we’re not sure why. We overthink social situations that most would quickly forget about.
No matter the reason for bending or concealing the truth, it’s frustrating and defeating when we’re viewed as flawed people who seek to intentionally deceive and harm. What we need – what we’ve always needed – is the benefit of the doubt.
Why Do People with ADHD Lie? Next Steps
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Is getting to work on time a riddle you can’t solve? Do you still arrive late even when you wake up earlier and rush through your morning routine? You’re far from alone. Tardiness is a common manifestation of ADHD, which is why I encourage you to try these “WORKS” tips to improve your on-time arrival rate.
How to Stop Being Late to Work
Wake up with enough time
“Enough” is key here. Give yourself the time you need to carry out your morning routine and get out of the door. Consider everything that you typically do, from brushing your teeth and feeding your pet to packing your lunch. Don’t just estimate – time yourself and go at your usual pace – to see how long it takes to complete all of your morning steps. Be sure to factor in any steps that sneakily but surely take up time, like snoozing or scrolling through your social media feed.
Once you know how long everything takes, then it’s a matter of making decisions. If you’re surprised by the duration of your routine, where can you streamline or remove some steps? If phone-scrolling is a must, can you keep it to 5 minutes instead of 10?
If you like your morning routine as is — even if that includes snoozing and scrolling through your phone — can you wake up earlier to fit it all in or save scrolling as a reward for arriving early to work? Try setting earlier alarms and placing alarm clocks across your room so you’ll have to exit your bed to shut them off. If this doesn’t work, you know you need to eliminate or condense steps in your morning routine.
Organize the night before
Reduce morning chaos and shorten your routine by preparing as much as you can the evening prior. Consider the following tips, and brainstorm other ways to benefit your future self.
Keep a glass of water on your nightstand and drink it upon waking
Pack your breakfast and lunch
Pack your work bag with your keys, wallet, and other essentials
Load up your automated coffee maker and set the timer for 7 a.m.
Pace your routine
Pace yourself with a timed morning music playlist or with consecutive alarms. Use these pacers to help you know when to wrap up certain steps. Consider keeping analog clocks around your home to better see the passage of time. If you have smart speakers, program them to count down to your departure time.
Know your commute
Getting out of the door is just one part of your morning routine. The next part – your commute – is obviously just as important.
For the next week, time yourself from the moment you leave your door to the moment you “clock in.” Be sure to include the time it takes to park, walk to the door, get to your floor, and make your way to your desk or work station. Calculate an average duration and notice the time that you typically arrive.
Consider whether your commute needs a revamp. Could you explore other routes or modes of transportation to get to your work site? Could you leave before peak travel hours?
If you’re consistently late to work, then a shift in mindset might be in order. There is no “on time” – there is only early or late. In other words, if you’re supposed to be at work at 9 a.m., plan to arrive at 8:30 a.m. That way, even if you’re running late, you’ll still be early. Use Google or Waze to recommend a departure time, then factor in an extra 15 minutes to build a buffer for weather and traffic issues.
Seek accountability
Find an accountability partner to help maintain motivation and on-time arrivals. Ask a co-worker or supervisor to check on your timely arrival. Consider commuting with someone else who will be counting on you. In some cities, carpooling can also allow you to utilize the High Occupancy Vehicle lane, which could decrease your drive time and stress.
How to Stop Being Late to Work: Next Steps
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As a clinical psychologist, I specialize in diagnosing and supporting neurodivergent adults. But my clients tell me that they’re cancelling their kids’ pending evaluations for autism, ADHD, or other conditions in other clinics, citing HHS database fears. I’ve also received emails asking whether it’s safe to seek or obtain a diagnosis given the current political climate.
A colleague who diagnoses autism and ADHD in adults reports that people on the practice’s waitlist have been cancelling their appointments, and that no-shows have increased since news of the HHS registry first broke. Another colleague of mine in a children’s autism clinic has developed language to assure patients that their privacy will remain protected.
The neurodivergent community is on edge. The fear-mongering dialogue from the HHS — and from its head, Robert F. Kennedy, Jr., who said that “autism destroys families” — is affecting people’s ability to trust scientific experts.
Medical Opinion: Don’t Cancel Your Autism Evaluations and Appointments
I can’t predict what the government will do. As a medical provider, I can say that we are bound by Health Insurance Portability and Accountability Act (HIPAA) agreements to protect patient information, and that de-identified data has been used to understand health trends at a population level for as long as we’ve had insurance systems and the Centers for Disease Control and Prevention (CDC). As profoundly upsetting as the administration’s language has been regarding autism, ADHD, and neurodivergence, I can’t help but think about the growing power of the neurodivergent community. Not all is lost, and there are steps you can take today to remain informed and take charge of your family’s health.
If you are waiting for an autism evaluation for your child — and it’s likely that they’ve been on a waiting list for years, given the ongoing shortage of providers — I believe it would be best to go through with the evaluation. Share your privacy concerns with your provider and ask how they’re protecting your family’s medical information. A diagnosis opens the door to appropriate supports, and its benefits far outweigh any risks at this point, in my opinion. The longer a diagnosis and proper supports are delayed, the greater the impact on a child’s self-esteem and emotional health. In other words, the harm caused by further delaying an evaluation is not worth it.
If you are an adult seeking an evaluation, I encourage you to keep your appointment. An adult evaluation can inform your understanding of yourself and support your therapeutic goals. If you are concerned about what will happen to your medical information, know that most providers who perform adult evaluations don’t take insurance, so there isn’t any insurance system in which to put your information. Still, you should ask about how the practice ensures privacy within their electronic health records system.
If you are worried about pursuing an evaluation, know that you also have the option of working with a therapist who can help you with any presenting issues.
The Neurodivergent Community Is Powerful
One of the most powerful forms of resistance is to carry on — to go about our lives and flourish despite our fears, and to continue to advocate. The level of advocacy from this community, from people with lived experience to providers, is unlike anything I’ve ever seen. Autistic parents move mountains to advocate for their children. They create programs where there are none. They find resources, protect, and innovate. Over the last 20 years, the formation of neurodiversity-affirming communities around the world has transformed how we do research and support these families. More informed and empowered than ever before, the neurodivergent community’s ability to protect themselves, advocate, and create change has never been stronger — or more important.
Autism Registry Concerns: Next Steps
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These are the qualities of an untrustworthy person – qualities I lived and breathed while (trying) to manage my undiagnosed ADHD.
ADHD – especially untreated – is a condition of inconsistency. We’re inexplicably “on” one day and “off” the next. It causes us to struggle to understand our behaviors and work out why we did (or didn’t) do something.
I’d say one thing but do another; make a plan, then forget it. I’d blurt out random things and make the simplest mistakes. I was scared to make future commitments because I couldn’t be sure what I’d be like when the day arrived – brilliant, or so off that it was hard to leave the house.
I was inconsistent in mood, attention, behavior, focus, and even goals. I had no inkling that there was any pattern to it. I wanted to do interesting things but committing to something out of the ordinary – like writing this blog post – risked months of dread, guilt, and procrastination.
A lifetime of inconsistency led to some strange consequences. Making even a small error would trigger an intense emotional reaction. Around other people, I tried to stay quiet, to hold in the ‘weirdness.’ And I’d check my work again, again, and again.
Why Don’t I Trust Myself? The Roots of Inconsistency
Before I knew anything about ADHD, I thought I had a clear picture of the root of my problems: anxiety and low self-confidence. I worked my way through the go-to tools: cognitive behavioral therapy, books about social skills, special breathing techniques, you name it. I even read Self-Esteem for Dummies.
Over the years, it all helped. But while I could stand up straighter, smile at myself in the mirror, and name three of my greatest qualities, I still was caught in spirals of procrastination, zoning out, obsession, and impulsiveness.
My old friend anxiety kept my brain awake enough to let me drive a car, find my keys, and pay my bills. Low self-confidence kept me out of sticky situations but led to a smaller life over time.
Then I heard about inattentive ADHD and what it looks like in women. Many, many hours of research later, I was finally able to make sense of my experiences and actions. As I learned about executive dysfunction and common support strategies, I was able to recognize those I was already using – and where I was tripping myself up.
But I was also assured that my brain would inevitably function fabulously in certain situations. The wealth of insight around the web from people who live with ADHD nudged me toward greater self-awareness. (After I read on the web that an unofficial trait of ADHD is argumentativeness, I asked a friend if that applied to me. He laughed in my face – I think that’s a yes.)
I learned how to plan my day in a way that my brain can “see.” I do things at a pace and plan that works for me. For example, rather than write this blog post in one sitting, I’ve taken to writing it in multiple locations, while wearing ear plugs, for 15 minutes at a time, while checking in on my emotional state. No matter the task, I regularly ask myself, “How does my ADHD play into this?” and “What will make this task easier for Future Me?”
Learning to Trust Myself – Even with ADHD
I’ve experienced some unexpected changes now that I trust myself more. For one thing, I now believe that it’s okay to make mistakes. I can calm down after the inevitable Big Feelings, and I know how to motivate myself to make amends. I even have an “oops quota” – if I go over my limit, I know it’s a sign that I need to tweak my systems. My ADHD-friendly systems take care of me, and I take care of them.
I can also now resist the urge to apologize for being the way I am. True, if you say, “How are you?” I may tell you in exquisite detail, or I may stare at you and not be able to think of a response. So what? I’m learning the words to explain why I do what I do, without framing it as a deficit. I want to get good at standing up for my right to be myself.
Perfection isn’t a prerequisite for self-trust (or to gain the trust of others). It’s consistency in another form: knowing that I do my best, learn from my mistakes, practice honesty, and pull through most of the time. Understanding my version of ADHD has transformed my ability to trust myself.
Learning about ADHD not only solved the mysteries of my inconsistency, but it helped ease my anxiety and increase my confidence. It released me from the fear that I was simply a bad person. It freed me up to create new, better stories about myself. Now, I can be pretty sure that if I say I’ll do something, I’ll probably do it… like writing this blog post!
Why Don’t I Trust Myself? Next Steps
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My daughter shouts at me every day, and sometimes I shout right back.
ADHD gives me plenty of skills I can model for my kids, but good frustration tolerance isn’t one of them. I can make up silly songs on demand, but I’m rubbish at remaining unruffled when my 6-year-old’s temper flares.
My younger child is a lovable ball of brightness, kindness, and fun, but many things short her circuit and invoke her iron will, from unsolicited carrots to socks that won’t reach their requisite height.
She might well be neurodivergent herself. (We’re waiting in line for assessment.) But whatever the root of her proneness to grievance, it feels like we’re peas in a pod. My patience is apt to desert me the second she loses hers.
There are things I can give her directly to help her stay grounded and happy: empathy, boundaries, nutritious meals, plenty of nourishing cuddles, choice where possible, my fullest attention, the conscious uncoupling of me and my phone. But kids need a stable, consistent caregiver who they can watch and copy. If I can’t manage my own frustration, how will she ever handle hers?
Modeling Calm When Anger Strikes
I’ve been thinking a lot about how to model calm when it counts, and it strikes me that there are two things I need to nail if things are to be less shouty around here.
Most of what gives me balance is basic. Exercise, fresh air, and eating well. Walking up hills and through parks. Pilates and painting and learning new things. Time with no screens or voices to allow me to drift and dream.
They’re simple remedies, but my mental health slides if I fail to give them priority. Luckily, my partner has his own list too, so we tag-team to tick off as much as we can.
2. Keeping my cool in the moment
Much harder to master is the consistent deployment of effective strategies when my daughter digs her heels in.
When my child gets stuck in an emotional vortex, reason cannot reach her. I know how that feels myself and I’m often inclined to join her. But some recent therapy has helped me to see that I do have a choice in the moment. I can either hop aboard the resentment express and trot out a pointless monologue that spikes my cortisol and guarantees escalation. Or I can pause and make a conscious decision about how I’d like to proceed.
It’s not easy. The stress in my body is physical and real. I feel it in my chest and my neck. My ears ring and my heart races. But there are ways of letting it go. I can notice the tightness and relax the tension. My mind will often follow. I can focus on breathing more slowly and deeply (if I’m actually breathing at all). I can silently soothe myself in the tone of a grown-up who knows this will pass. When I pull it off, I’m not faking or in toxic denial. I just feel a lot more balanced and able to ride out the storm.
I get a chance to deploy my new tactics in the art of non-reaction on a Saturday, when we fancy a walk in the woods. The little one won’t get dressed, of course. Weekends are for lying down, she declares, as she burrows under our duvet, tucking it in around her to secure her fortress against potential incursion.
We could be here a while, I think. Last week we aborted completely. I implore her to put on some clothes. She kicks off the covers and thrashes around, emitting a grating whine. My chest tightens, my heart rate quickens, and I want to launch into my lecture.
But I stop. I breathe. I remember that calm breeds calm and that staying centred will help us both. She performs a series of loud exhalations, but I say to her softly that we’re leaving. Voices do not get raised. I exit the room and in minutes she’s clothed and skipping out to the van.
She briefly objects to my offensive plan to take a jacket just in case. But I let it wash over me and it burns out fast. Off we go in peace.
The same trick works on Tuesday when I commit a transgression with celery and she CANNOT EAT THIS LASAGNA (she does) and again on Friday when it puts to bed a debate over whether jellybeans constitute breakfast (they don’t).
Modeling Calm, One Little Test at a Time
There are blips involving poached eggs and car seats. I’m tired and hormonal and late – and I yell. But part of my internal deal is that I’m kind to myself when I fail. Improvement is still improvement if it’s only some of the time.
I’m buoyed by how things are going. My girl is more flexible and she’s proud of herself when she lets things go. I’m feeling quite proud of me, too.
So maybe I can crack this. Maybe soon I’ll add “measured response to frustration” to the list of things I can pass to my children. It’s not as fun as singing ditties about teachers or toilets, but it’s arguably a more essential skill that will serve them well in life.
How to Be a Calm Parent: Next Steps
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Losing track of time – while a maddening manifestation of ADHD time blindness – is not a hopeless certainty. From alarms and task chunking to time-estimation exercises, the strategies below can help you develop a more “ACCURATE” sense of time.
8 Ways to Stop Losing Track of Time
Alarms
If you aren’t already, get into the habit of setting alarms (on your phone or other devices) to keep you on track. You can use alarms in multiple ways:
as prompts (like to remind you to check your email at a certain time)
as transition warnings (e.g., “10 minutes to go before your meeting”)
as check-ins (e.g., “Did you check your email when you said you would?”)
as time markers (like an alarm with distinct chimes on the hour)
Place analog/visual clocks in all your spaces so that you can readily see time passing with the hands on the clock. Consider other visual time-keeping tools, like hourglasses and the Time Timer, a clock that shows the passage of time via a disappearing red disk.
Comparison
Come up with a list of activities that you know take 5, 15, 30, 60 and 90 minutes. When you are estimating the length that an activity will take, use your list to compare. Will doing the dishes take longer than….
listening to two songs in a row (5 to 6 minutes)?
listening to five songs in a row (13 to 15 minutes)?
watching an episode of a sitcom (30 minutes)?
watching an episode of a TV drama (45-55 minutes)?
watching a movie (90 minutes)?
Unique Visuals
Take your to-do list a step further by adding your tasks to your calendar as time-blocked activities. Keep your daily calendar as visible and eye-catching as possible, with different colors for each task/activity. Throughout the day, compare what you’re doing to what’s on your visual schedule to see if you are keeping the correct pace.
From morning to evening, routines do an amazing job of keeping us on schedule. Doing the same activities over and over will eventually give you an intuitive benchmark and take the guesswork out of time estimation, at least for part of your day.
Audio Playlist
Use timed playlists as fun cues to signal the passage of time. A study playlist, for example, can subtly remind you that you have 5 minutes left until your break once a certain song starts to play. You can also create playlists that match the length of a task (like a 10-minute bedroom cleanup).
Task Chunking
Avoid getting lost in a large task by breaking it down into smaller parts, which can also help with time estimation. Working in shorter intervals can also help you reset your focus.
Estimation
Not sure how long various task or activities take? Play the estimation game and guess the length of time for a task and then time yourself while doing it. Compare your estimate with the actual time (be honest) and then adjust your expectations accordingly. Doing this often can improve your time estimation skills across the board.
Losing Track of Time? Next Steps
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“Call a dog by a name enough times and he will eventually respond to it.”
I read these words shortly after I was diagnosed with ADHD at age 44. Those 15 words, which appeared in a book meant for ADHD families, left me stunned for weeks. They helped me understand my entire life experience far more than any other sentence – or any person, for that matter – ever had.
Despite all evidence to the contrary and much work on my part to see myself differently, I still identify to some degree with the above labels. And I know that I’m not the only one. I think of the many women today who learn that they grew up with undiagnosed ADHD, and that girls today still struggle to get properly diagnosed with ADHD.
A diagnosis as a child would have been incredible. But beyond that, I wish I had grown up hearing the following words of encouragement – the things all girls with ADHD need to hear to build their self-esteem and avoid viewing their symptoms as character flaws.
1. “You’ll need to stand up for yourself over and over. And that’s OK.” Though things are getting better, ADHD is still stigmatized and misunderstood. What’s more, girls are still socialized and expected to be obedient and compliant. When we push back, it is viewed a lot differently than when boys do it. Assertiveness and self-advocacy, especially for girls with ADHD, are essential life skills that build confidence and self-reliance.
2. “We will stand up for you.” Self-advocacy only works if girls with ADHD know that trusted adults have their backs, too. Girls need to know they’re not alone when they stand up for themselves.
3. “Accommodations are a legal entitlement, not a favor.” Growing up, I had family members who genuinely believed that any accommodations, such as extra time on tests, were a way for lazy students to get out of doing schoolwork. Anything that was different “wasn’t fair” to the other students. What critics don’t understand is that a neurotypical environment is already inherently unfair to individuals with ADHD, and the reason we are chronically dismissed and overlooked is because our disability can be largely invisible. No matter how hard we try, most of us will never succeed without external support.
The reason the Americans with Disabilities Act (ADA) became law is to equalize the playing field for individuals with disabilities. My customized accommodations aren’t a special favor; they’re what I need.
4. “Other girls with ADHD need you as a friend.”Shame and isolation have a lot to do with why experts miss ADHD in women and girls. Throughout my entire childhood, every adult in my life blamed me for my symptoms, and my father told me that one of the reasons I struggled to make friends was because other kids knew about my poor grades.
But what girls like me need most of all are friendships with other girls with ADHD. Bonding over common problems, social challenges, and struggles at home and at school all reduce shame and stigma while building strong connections. Greater awareness leads to feeling confident in asking for help and support. Most importantly, I wouldn’t have felt so alone for so long.
5. “Other people don’t decide your value.” Throughout my entire life, I let my parents, siblings, teachers, doctors, and bosses decide my value based on their inaccurate and sexist views of me. Now that I know better — that I’m not fundamentally deficient — I want every woman and girl to hear this: No one else decides our value.
Don’t give your power away to someone who doesn’t have any idea about what living with ADHD is like, especially when they don’t care. We all have our strengths, and there are so many different ways for our talents to shine. But we’ll never realize that if we listen to our uninformed critics.
Girls with ADD: Next Steps
Maria Reppas lives with her family on the East Coast. Her writing has been in the Washington Post, USA Today, Newsweek, New York Daily News, Ms. Magazine, and Business Insider. Visit her on Twitter and at mariareppas.com.
SUPPORT ADDITUDE Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.
Our descent down the rabbit hole of in-app purchasing started innocently enough. My youngest child, Luca, asked me to let him spend $1.99 of his pocket-money to buy coins in an iPad game.
“It takes forever to get these coins when you’re playing,” he said, showing me the game. “I can spend $1.99 and get 800 coins, but only if I do it now! It’s 90% off, but the deal only lasts for 58 more minutes! Please, Mom?”
“Luca,” I said. “When a game tells you something is 90% off, that’s just marketing designed to make you want to spend money.”
“It’s working,” Luca said earnestly. “I do want to spend my money. And it’s my money.”
I sighed.
Luca’s request had come a few days after my husband and I opened a debit account for him and his older brother, Max, for their 9th and 11th birthdays, respectively.
“We told you your savings was your money,” I said to Luca. “But we also said we weren’t going to let you spend it on just anything, remember?”
“This is not just anything. It’s only $1.99 and I’ve been playing this game for weeks and this is the best deal I’ve ever seen. Ever.”
“OK,” I finally said. “This is a yes.”
I pressed my thumb on the sensor to authorize the purchase and a delighted Luca raced off to show Max, my ADHD-wired firstborn.
This, my friends, is when all the trouble really started.
The Big Business of In-App Purchases
Max quickly appeared to demand a similar purchase in a game. Eager to allow my boys to exercise their decision-making muscles, I said yes. So when the boys showed up repeatedly in the following days with additional purchase requests, I kept saying yes.
Two weeks later, both boys had spent more than $150. I was getting very worried. Though I tried to dissuade or delay them each time they came to me, their interest wasn’t waning, even as they burned through their savings. But while Luca’s spending eventually slowed, Max’s didn’t. If anything, he was picking up speed — requesting more expensive purchases, more frequently.
This was very out of character for Max, who had previously been resistant to spending any money — preferring instead to save it and plot about spending it on completely age-inappropriate things, like spear guns for fishing. After his first in-app purchase, it was shocking to see how quickly he transformed from miser to spendthrift.
When Max came to me for the second time in a single day requesting to spend another $26, I decided I wasn’t prepared to let him spend all his savings.
“I think we need a circuit breaker here — a pause,” I told Max. “I think that I should say ‘no’ to in-app purchases for the next week. What do you think?”
Unsurprisingly, Max did not think we needed a circuit breaker.
We settled on this: Max still had the choice to go through with this particular purchase (which he did) and then we would have a 10-day “no purchases” circuit-breaker.
That original circuit-breaker temporarily slowed things down, but it did not completely quell his willingness to spend money.
I know our family is far from alone in these struggles. In moderation, in-app purchases can be an easy way to have a bit of fun in a game. But in-app purchasing has become a billion-dollar business. Many iPad games are sophisticated marketing machines that use gambling tactics and other predatory techniques to market directly to children. The dopamine rush of leveling up in a game after spending money is addictive and the consequences are profound. Some parents report that their kids have become secretive and deceitful — guessing or stealing passwords, using credit cards without permissions, resetting devices to restore permissions, and finding other workarounds that will enable them to keep clicking “purchase.” Our children with ADHD, who struggle with impulse control and regulation, are far less equipped to resist this powerful temptation.
So what can parents do? What do I recommend as a psychologist, as the mother of a demand-avoidant pre-teen with ADHD, and as someone who’s learned a lot about this the hard way in the last couple of years?
My first piece of advice: Keep this Pandora’s Box closed for as long as possible. If you haven’t yet started down this path, don’t.
Invest in games, gaming systems, and subscription services such as Apple Arcade that don’t offer in-app purchases and/or show ads. They are worth the money.
Make it a family norm early on that you don’t download games that offer in-app purchases.
If and when you do download a game that offers in-app purchases, make it clear that you will never authorize any in-app purchases for this game. Take it a step further and disable in-app purchases on your child’s device.
If you ever do decide to allow your child to make in-app purchases, have some discussions first:
1. Set clear limits – but expect boundary-pushing. Establish how much money they have available to spend and how quickly they can spend it. Even with these limits, brace for fallout, pleas, and arguments when their money runs out, and plan ahead for how you will respond to that fallout.
2. Express your wants. The day that Max came to me twice to make an in-app purchase, I told him I had two wants. “I want to allow you to make your own decisions,” I said. “And I want to help you make wise decisions and teach you how to resist the powerful desire to buy things.”
3. Teach your kid about marketingtactics such as price anchoring, charm pricing, and the scarcity effect. When they come to you about a purchase, challenge them to spot the marketing tactics being used on them.
4. Talk to your child about other dynamics that drive in-app purchasing, such as chasing the dopamine buzz, the social pressure of keeping up with friends, the desire to make progress fast in a game, and so on.
5. Talk to your child about their ADHD brain. They should understand that impulse control challenges come with the territory, which makes it especially hard to resist the temptation to buy.
6. Invite your child to problem-solve when issues come up. Be open with your child about any concerning patterns or behaviors you’ve noticed regarding in-app purchases. Ask for their input as you find a viable way forward.
7. Experiment with different approaches and solutions to limit in-app purchases. Some ideas to get you started:
X-day/week blackout periods
weekly or monthly spending limits
waiting periods for spending (e.g., wait 24 hours before making an in-app purchase)
written agreements that include consequences for circumventing the rules
8. Don’t be afraid to feel your way forward. Just because you’ve agreed to a measure doesn’t mean that you will do things this way and forevermore. In fact, don’t expect any solutions you negotiate to hold for longer than a couple of months. Expecting to revisit this issue regularly will help you be more patient and feel less frustrated.
The other day, I asked Max for advice he thought I should give other parents who are in this situation. “Just say no, and NEVER SAY YES,” he responded. “Basically, be way stricter with them than you’ve been with us.”
“But what about families like ours where we’ve already said yes sometimes?” I said. “What can you do then?”
“Well,” Max said, getting more creative. “Tell your kids that the currency for the game has changed, and you can’t get any of that new currency. So, it’s broken. You just can’t do it.”
“So… lie?” I asked. “Yes,” Max said. “Lie.”
In moments when we may be tempted to lie to our kids, I often wish we had in-parenting purchase options — for upgrading patience, boosting problem-solving skills, or short-circuiting conflicts. Alas, the game we’re playing as parents is a no-shortcuts quest.
In App Purchases: Next Steps
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The following is a personal essay, and not a medical recommendation endorsed by ADDitude. For more information about treatment, speak with your physician.
Since October 2022, thousands of individuals with ADHD have faced immense difficulty accessing prescribed stimulant medication – the treatment they need to function and lead healthy lives. No relief is in sight.
Make no mistake that the reason for the ongoing stimulant shortage has much to do with how stimulant medication itself is viewed. After all, the Drug Enforcement Administration (DEA) classifies stimulants as Schedule II drugs for their “high potential for abuse” and sets national drug quotas for these substances based on that classification.12 This drug quota is, arguably, a major factor driving the shortage.3
Like many psychiatrists, I have taken the Schedule II classification of stimulants at face value for most of my career. Prescription stimulants are Schedule II, so they must be very addictive. How do I know? Because they are Schedule II.
This circular thinking has stopped me – and likely others – from noticing the mismatch between this classification and what I observe clinically. And while it may seem like the Schedule II classification is set in stone, it isn’t. In fact, the Controlled Substances Act specifically states that organizations, or even individuals, may petition the DEA to reclassify a substance.4 Shouldn’t we at least question whether these medications belong in Schedule II?
Controlled Substances: What We Get Wrong About Stimulants for ADHD
The DEA classifies drugs into five distinct categories depending upon their medical use and potential for abuse or dependency. Schedule V drugs have the lowest potential for abuse, while Schedule I drugs have a high potential for abuse and no current accepted medical use.
While working as a community psychiatrist, I used to brace myself for the bad outcomes from prescription stimulants. After all, as Schedule II drugs, they sit way up in the DEA’s scale. But what I found was that carefully prescribed stimulants rarely caused issues, whereas other drugs deemed “safer” often did.
Take benzodiazepines, drugs that are used to treat conditions like anxiety and insomnia. With benzodiazepines, tolerance and dependence are common, the withdrawal syndrome is serious, and overdoses can be lethal, especially when combined with opioids. When used long-term, the taper can be rocky and often requires several months to complete.
Comparatively, standard prescription stimulant treatment has minor problems. Withdrawal syndromes are rare and brief. While I have seen occasional misuse, I haven’t seen prescription stimulant overdoses or use disorders. Rather, I’ve seen people gain control of their lives. They graduate college, they hold jobs, and their relationships improve. Early refill requests are rare.
People who are prescribed scheduled benzodiazepines rarely miss a dose and need no reminders. Most of my patients with ADHD, however, struggle to take medications every day and may forget to fill their medications on time.
The stark difference in adherence between benzodiazepines and prescription stimulants likely reflects two things: the symptoms of ADHD itself and the fact that stimulant medications, when taken as prescribed, are much less reinforcing compared to benzodiazepines.
Just ask any child who takes Quillivant, a banana-flavored liquid form of methylphenidate, if they want their morning dose. Many will run, far. Beer and coffee are acquired tastes because the brain pairs their flavors with the good feeling that follows consumption. The ‘drug liking’ effect of alcohol and caffeine reinforces a desire for the taste — a phenomenon that hardly occurs when taking stimulants as prescribed for ADHD. Coffee and alcohol, despite their abuse potential and widespread use, are freely available to most of the public.
Benzodiazepines, for all their dangers, are Schedule IV. Meanwhile, prescription stimulants sit in the Schedule II Hall of Shame, along with fentanyl. Yes, fentanyl – a substance 50 times more potent than heroin and responsible for a majority of the thousands of overdose deaths in the United States in 2023.56 Surely, there must be a classification error here, right?
National overdose deaths involving prescription stimulants is difficult to track because of a coding issue that lumps prescription stimulants with illicit methamphetamines. Fortunately, one study separated the two by looking at substance-related death certificates from 2010 to 2017. Of the 1.2 million total deaths that involved substances, only 0.7% involved prescription stimulants, often used in combination with other substances. Methylphenidate-related deaths accounted for .02% (295) of all substance use-related deaths, or an average of 37 deaths per year. Compared to methylphenidate, there were twice as many deaths involving pseudoephedrine (615), which does not require a prescription, and 160 times more illicit methamphetamine-related deaths (49,602).7
Stimulants Are Safe – and Life-Saving – When Used as Prescribed
The sparsity of stimulant prescription-related deaths may reflect their essential role in treatment. ADHD is associated with greater risk for accidents, injury, premature death, and suicide.8 Multiple studies suggest that treatment with prescription stimulants may lower the risk of these adverse and deadly events.8-11
Unfortunately, the serious risks of illicit methamphetamine use can drive stigma and fear toward prescription stimulants. Many people with ADHD may be hesitant to start stimulants for concerns about heart problems and addiction. While illicit methamphetamine does cause major heart problems and is highly addictive, appropriate prescription stimulant treatment does not carry this risk.12,13 Even in overdose, major cardiovascular events are rare.14 Multiple studies also show that prescription stimulant treatment for ADHD does not increase the risk of developing a substance use disorder (SUD) and may even have a protective effect.15,16
Importantly, there are situations, namely non-oral misuse (e.g., snorting, smoking, or injecting), where prescription stimulants do have high potential for abuse. These routes allow stimulants to enter the brain rapidly and cause a rapid spike in dopamine. The faster and bigger the spike, the more intense the “high” or “drug liking” effect that will reinforce use. Oral routes, on the other hand, more slowly deliver drugs to the brain. This is partly why stimulants, when taken as prescribed, hold a much lower addiction potential.17
Most people with ADHD will never snort or inject their medications. People without ADHD usually won’t, either. Indeed, the Schedule II classification appears to be on behalf of a subset of people, with and without ADHD, who use stimulant medications non-orally. Arguably, a more tailored way to protect this group may lie on the diagnostic side — by taking a careful history, requiring drug screens in adolescents and young adults, and considering non-stimulants when the risks are too high. Many youth will also welcome a matter-of-fact discussion on substance use and harm reduction.
On Stimulant Misuse
A more common issue is oral prescription stimulant misuse — that is, taking someone else’s medication or too much of your own. A 2022 survey showed that 15% of college students reported taking someone else’s prescription stimulant at least once in their lifetime, but most did so less than once a month. Only 0.1% of students reported misusing prescription stimulants more than four times per month.18
Most college students report misusing prescription stimulants for perceived performance enhancement.19 The misuse pattern does not tend to escalate and is lower-risk in nature. This is likely because most students who misuse will only do so orally, which is much less addictive, and they are not using to get high. Some of this misuse may also be an effort to self-medicate. A 2010 study showed that prescription stimulant misusers were seven times more likely to screen positive for ADHD compared to non-misusing students.20
To be clear, it is still a bad idea to misuse prescription stimulants. While the health risks do not appear to warrant schedule II classification, that does not mean “risk free.” All prescription medications carry risks, and risks can vary based on factors like dose, route, and the individual. What is safe for one person can be dangerous for another. For instance, someone with bipolar disorder can become manic from a prescription stimulant. Someone who regularly uses illicit methamphetamine may tolerate high doses of prescription stimulants whereas someone else may become agitated, psychotic or go into renal failure at a much lower dose.14
For those at higher risk for prescription pill misuse, there are also long-acting formulations that were designed to prevent non-oral use. For instance, Concerta (methylphenidate ER) has a hard outer coating that is very difficult to crush.21 This will deter most people. In addition, when studied in a group of adolescents with ADHD and an SUD, Concerta rated only one point higher than placebo in “drug-liking” effect.22
Vyvanse (lisdexamfetamine) is another long-acting formulation that deters abuse. Vyvanse comes as an inactive prodrug and won’t activate until it is converted by an enzyme in the bloodstream. Even if someone snorts or injects it, it will still need to be converted to an active form in the body and will not produce a more rapid effect. Two “drug-liking” studies also suggest lower abuse potential with IV doses not differing from placebo.2324 While a supratherapeutic oral dose had some “liking,” it also measured higher on “drug-disliking.”24
Reclassifying prescription stimulants to a lower tier would more accurately reflect real-world data on addictive potential, health risk, and their public health benefit. Still, any reclassification to a lower tier carries the risk of fueling misconceptions about safety. Some may mistake reclassification as a green light to misuse. Misconceptions on safety may also drive the purchase of counterfeit pills. Make no mistake: Counterfeit prescription stimulants – which can be easily purchased online – kill people. These fake pills are made to look just like real prescription stimulants, but instead contain illicit methamphetamine and/or fentanyl, in unpredictable amounts. Taking even one counterfeit pill can be lethal.25
Prescription stimulant misuse, as a whole, is a problem that deserves our attention. Targeted education needs to occur at the individual, family and school levels. This may include dispelling myths on cognitive enhancement, emphasizing the higher risk with non-oral use, and increasing awareness on counterfeit pills. When young people are taught the actual risks and realities of the current drug landscape, they are given a chance to make safer choices. This strategy is rooted in connecting with at-risk youth and can happen without interfering with the treatment of people with ADHD.
Schedule II Drugs: The Case for Reclassifying Stimulant Medication
Ensuring access to stimulant treatment is essential to the lives of millions of people with ADHD, and it benefits the public at large. While there is widespread oral misuse, the use does not tend to escalate. Non-oral use is higher risk, but less common and rarely fatal, making prescription stimulants an outlier in the Schedule II class.
Prescription stimulants are long overdue for reclassification. For those still on the fence, here is a more conservative approach: Start with rescheduling medications that have abuse-deterring properties, such as Concerta, Vyvanse, and their generic equivalents. By releasing these medications from the chains of Schedule II, more people with ADHD can live their lives.
Do you think prescription stimulants should be reclassified? Share your thoughts in the comments section.
Schedule 2 Drugs and Stimulants: Next Steps
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My 9-year-old son has always been a firework, from the very second of his surprise existence. If my pregnancy test could have displayed two zigzags instead of straight lines, it would have.
He has never followed the path well-trodden. Instead, he has swung from the trees shadowing its path, spinning and tumbling over it like a Ferris wheel free from its hinges. His brain is always busy. It darts and daydreams and never tells him to sit, breathe, and just be.
“I was the same as him when I was a kid,” my husband would say. “He’s just a little boy.”
He often spoke of marked similarities between them, and we thought our son had simply inherited a huge slice of his father’s personality. That this was just “them.” So we attributed his behaviors to that – a child who was beautifully energetic. If he wasn’t spinning or cartwheeling, he was singing or asking questions or making funny little noises. The only time he really rested was when he slept, when dreams took over and his compulsion to “fizz,” as he calls it, quelled.
Father and Son: Drawing ADHD Parallels
Analyzing my child’s behavior, helicoptering his nuances and traits, and researching “ADHD in children” until there was nothing left to Google came easy. Turning the lens to my husband, on the other hand, was trickier.
My husband flitted from job to job, struggled to prioritize, became easily frustrated with any task, and was unfocused. But we had gone through a fair chunk of sadness in the last few years — the death of one of our other sons, the loss of parents, our 9-year-old’s meningitis battle when he was a baby. I put my husband’s erratic nature down to stress and trauma.
All the while, the phone calls from my son’s exasperated teacher mounted, as did the sense that my son’s behaviors in school and at home were indicative of something bigger.
My mother-in-law was a special education teacher for many years. The more I called her to analyze my little boy’s behavior, the more parallels she’d draw between him and my husband. Eventually, the constant joke that they were two peas in a pod became a lightbulb moment for me. I made an appointment with an ADHD specialist – for my son and husband. Sure enough, after a careful evaluation, the specialist diagnosed both of them with ADHD in the same appointment. Their test scores were practically identical, she noted.
Like Father, Like Son
“How do you feel?” the specialist asked my son. She sat next to him on the floor as he clicked LEGOs together and bounced on his knees.
“Exhausted” he said. And my heart sank. Exhausted by trying to concentrate in school and being told off constantly, exhausted by coming home to homework cajoling, exhausted for being reprimanded for his impatience and other behaviors at the outskirts of his control.
I saw my husband’s face crumble a little as he knew that feeling all too well. And I realized that, as a wife and mother, I had failed them. To me, their behaviors were annoying, frustrating, and sometimes inexplicable. I had often said to my son, “Why is it always you? Why are you the one who always gets into trouble?” I sometimes dreamed of an easier marriage to a man who would stick at a job or for a man who would actually listen to me. I had no idea what either of them were going through. It was an incredibly emotional day for everyone.
We walked out of the specialist’s room with a deeper understanding of each other and a feeling that we can all start to be our truer selves.
Our ADHD Family
We’ve only recently entered the neurodivergent universe. We’re perched on a circling satellite looking into a place where words like “disorder,” “impulsivity,” and “disorganization” zoom by. But it’s other zooming words that captivate us — “spontaneity,” “creativity,” “courage.” We are going to run with these as fast as we can.
We’re not alone in entering this universe. We see many other families embarking on this journey, too. Some days we think we have a firm grasp on ADHD – and some days we don’t. And that’s OK, because all we can do is buckle up so the twists and turns don’t jolt the ones we love quite so much.
I would not change my son or husband for anything. We’ll bundle up all of the positives and challenges, stick them into our family jetpack, and navigate the steps, bounces, stumbles, and freefalls of this shared diagnosis together.
ADHD Family Ties: Next Steps
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When I reveal that I have ADHD, I often hear about how “brave” I am for being so “open” and “vulnerable.” Granted, I like hearing that because I’m human and I like compliments. Plus, it’s better than fending off stereotypes about ADHD.
To be totally honest, though, I’m not telling you about my ADHD diagnosis to promote diversity, make you feel more comfortable confiding in me, or whatever other altruistic reason you’re thinking. I’m telling you as an act of self-preservation, often after days of deliberation over whether I will hurt or help my case. Disclosing my ADHD is a carefully calculated risk that’s more about substantive outcomes than feel-good moments.
Explaining ADHD to Someone Who Doesn’t Have It
Disclosing my ADHD is really about showing you the inner workings of my mind. My day-to-day life reminds me of my choir teacher’s advice for onstage performance: “Be like a duck: calm on top and paddling like crazy under the surface.” You can’t see my constant struggles to stay on top of employment, housework, and personal affairs; you can’t hear my every thought scream for my total attention as I fail to hold onto a single one; you certainly can’t feel the smaller effects of ADHD pile on top of each other to create a web of executive dysfunction.
No matter how calm I seem on the surface, underneath I am paddling through constant self-assessments and adjustments.
Without the context of a diagnosis, I’m a mess. I can’t get anywhere on time. My apartment is filled with projects that I dove into, lost interest in, and can’t bring myself to put away. Efforts to reach out are too easily put off and forgotten. And heaven help you if I’m having more trouble with my emotional regulation than usual.
So, in more casual settings, my telling you about my ADHD is to let you know that nothing’s personal. I didn’t show up 10 minutes late and yawn when you were talking because I hate you and want to disrespect your time. While you certainly have the right to boundaries and shouldn’t just put up with certain behaviors, you should also know that my shortcomings do not reflect how I view our relationship. And, hopefully, you don’t hate me as much after I’ve confided in you.
When Disclosing ADHD, Context Matters
From a professional perspective, my honesty about ADHD could mean the difference between remaining employed or yet another job hunt. I’m sure that never occurred to my managers as they went on about my courage and whatnot – that I had actual goals beyond reveling in feel-good honesty. Not that I would recommend that everyone with ADHD should disclose their diagnosis to employers. Most sources suggest not doing so, and for good reason.
Conscious and unconscious biases are inevitable, and anything that could make me stand out as a problem could also be my undoing. Though I have been open about my diagnosis and received ADA accommodations, I will always wonder if my managers are now keeping a closer eye on me for any slip-up that would go unnoticed if made by a co-worker.
Disclosing a diagnosis, especially one like ADHD that forces me to confront some of my deepest insecurities, is unpleasant at best. I don’t do it for fun. My decision to open up to you was difficult and ultimately made in hopes of some sort of action. Maybe that’s just a bit of patience, or some help navigating a world that was not designed for me.
I trust you enough to give you a chance to understand me better, and, in turn, learn how we can grow together. Please take that chance.
Explaining ADHD: Next Steps
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