Week 1 of Medicating for ADHD

In the fall of 2020 I underwent a screening for ADHD. I was in my fourth year of my PhD program and had completed coursework and passed my comprehensive exams. Working as a Teaching Assistant meant that I had sporadic deadlines and no longer had a daily routine to follow. I was struggling immensely to get anything done on my dissertation and had been in therapy for over a year.

The screening for ADHD was familiar to me because I was screened for my school district’s ‘gifted’ program as a kid. It included a series of tests to measure my IQ as well as self-response questionnaires and a few more specific tests for things like impulse control and attention. I did really well on the screening–so well, in fact, that the pscyhologist who tested me wrote in the report that I couldn’t have ADHD and instead was suffering from severe depression that was causing executive functioning problems. I have placed a quote from the summary portion of the screening report below (the doctor uses the wrong pronouns for me but that’s a different story):

Based on the present results, her (sic) cognitive profile does not appear to be consistent with ADHD.
Rather, Ms. Norris’s cognitive complaints seem better attributable to her current psychological functioning. Ms. Norris has a longstanding history of anxiety and depression, complicated with the trauma of the death of her mother at a young age. Both depression and anxiety can have a significant impact on cognition including reducing concentration, attention, memory, and processing speed.
While she spoke more of her symptoms of anxiety and feeling overwhelmed, I suspect depression is more pervasive than she may be aware. Her restlessness, fatigue, and concentration difficulty I think
are largely explained in the context of depression. Additionally, she reported some self-esteem difficulty and feelings of worthlessness, both personally and professionally. She described uncertainty with what she wants to do when she completes school and described sometimes feeling “lost” and “out of place.” I suspect these feelings have become more prevalent as she has gotten further along in school and closer to completing her degree,

Throughout the report, my raw test results were noted and placed within context of the broader population using percentile rankings. In nearly every test I scored Average or Above Average. Receiving this report after being honest and vulnerable with the clinician was devastating. I had a panic attack and was, frankly, inconsolable for hours. After time away from the report and working with a psychiatrist to try different medications I have decided that the tests employed were inappropriate and could not have accurately determined if I have ADHD or not (hooray research design training).

First–my academic success was well documented and as someone in a PhD program it is expected that I have good recall of concepts and theories, strong reading skills, and can meet regular benchmarks for program success. In my view, these tests that I took were basic. I was asked to repeat 2 syllable words after hearing them. As an instructor, I was frequently listening to my students complex responses and then paraphrasing them on the fly. A simple list of words was not going to pose a challenge to me. These tests could not adequately assess the struggles I was facing in my actual day-to-day life.

The motor skill tests were also useless for my age and development. I’m an adult who played sports and through time developed good gross and small motor skills. The test used by the examiner required me to place small pegs into holes. I had played this game as a child and so my previous experience should have made the results null for this study. A better examination of my motor skills would have been to have me walk around the office, climb a flight of stairs, even go through several doorways while being told to go get a specific item from the area/room. When I’m at home I frequently run into the corners of furniture, fall against the wall while walking, and bump into doorframes.

I could give a hundred more examples of the poor research design and why the outcomes pointed to depression as the root cause of my problems, but I want to focus on the positives that I’ve experienced this week instead, and how those things have reaffirmed for me that I do have ADHD. Many adults who have ADHD also suffer from anxiety and depression due to the difficulty of living in a neurotypical world. My sense of worthlessness is driven by my inability to accurately assess my own work, and by my knowledge that I’m smart and “should be doing better work”. In my first semester of graduate school I received a C on an assignment full of typos and wandering thoughts. I had mispelled nearly every author’s name–In a journal article I submitted in December I made mistakes like “Michelle” when the author’s name was “Melissa”. The skills and abilities that I had developed, which served me well during this screening, were developed under duress. I had panic attacks and suffered from insomnia my entire life. I was constantly filled with a fear of failure, which motivated my work, as opposed to being driven by a sense of ability and confidence.

I started seeing my psychiatrist roughly a year ago. After describing my problems, symptoms, and medical history he immediately wanted to put me on a stimulant. I am a child of D.A.R.E and am terrified of drugs. I refused the stimulant but was willing to try an SNRI which produces a similar chemical response but is ‘less intense’. I tried that for a year in conjunction with my anti-depressant (lexapro). It didn’t work. I spent the last year struggling to do anything. In the midst of a pandemic where I truly have nowhere to be, setting routines, deadlines, and goals for myself became impossible. I got a second job as a barista to try and create a sense of urgency in my week. My thought was this: If I lose two days of PhD work to a coffee shop, then I’ll understand that those other three days are important and so I’ll need to do my work. That didn’t work.

Last month I had my regularly scheduled check-in with my psychiatrist. I told him I was finally ready to try stimulants because I was running out of time and coping strategies for my inability to initiate tasks, plan large projects, and switch tasks during the work-day. I’m pretty sure he was thrilled because his only response before writing the prescription order was “I wanted to put you on stimulants from the start”.

I was prescribed 10mg of Adderall XR (extended release). It took me a while to get the actual medication (ADHD problems) but this week I finally started. I’ve actually only taken it twice so far but the results were incredible. When I take the meds my brain feels physically lighter. All of these little intermediate steps to starting a task are no longer daunting or debilitating. I can brush my teeth, pause for a bathroom break, or refill my water bottle with ease. These are not things that I can do on a day without medication.

You see, when I’m not taking a stimulant, all of those small things become impossible “task switches”. Task interruption or task switching is the bane of many neurodivergent people and it is something that keeps me in bed until 10:30 on days when I don’t take meds. How can I possibly manage all of the small things in a timely way that still leaves room for me to sit down and write my dissertation? When a neurotypical person wakes up they are able to think “time to get ready!” and then do it. This is how it goes for me:

  • gather energy to push off blankets
  • gather balance/mobility to stand
  • do I have to pee first or brush my teeth? I can’t tell how badly I need to go yet.
  • What if I start brushing my teeth but then have to pee but then maybe I’ll get thirsty.
  • Oh no I’m already hungry. Should I eat first? If I eat then brush my teeth that might be better. What about my coffee, it tastes gross after toothpaste.
  • (I’m still not out of bed yet)
  • Shit it’s my morning to walk the dog. This means I have to get dressed but I don’t even know what I’m doing today so I can’t figure out what to wear (note: I change my clothes about 3-5x a day)
  • What do I have to do today? Am I leaving the house or should I just stay in pajamas all day?
  • I guess pajamas are fine. I should get up so my dog doesn’t get a UTI. Okay, getting up. Time to trip down the stairs.

Maybe you don’t have ADHD and you go through this enormous list too. That’s fine. Each of these bullet points subtracts about 100 points of focus/attention from my mental tank. So let’s say that I start the day with 500 points. By the end of walking my dog I’m at -400 in this example and I’ve only done 1-2 things on the list (maybe got dressed + walk the dog).

Brushing my teeth is not a smooth transition. Instead, it’s a task switch from ‘walking the dog’.

Now let’s dive into what it takes to actually work as a PhD Candidate. I have a few different writing projects at different points of completion. One is a co-authored book chapter. I knew I had to finish it this week but when I think about it, even on meds, my brain just supplies me with the instructions: “work on book chapter!!”. Great, super helpful. If I sit down and break it into tasks, that takes all my energy for the day. So, I’ve successfully planed the steps out but can’t execute them and now when I try again tomorrow this plan will be overwhelming and useless since I failed at it yesterday.

Instead, about thirty minutes after taking my Adderall I was able to do this:

  • Open most recent file
  • Locate previous comments and complete necessary edits
  • Fill out two sections (roughly 800 words)
  • Revise my writing for style/clarity
  • Answer my partner’s question without getting angry or having to completely stop working
  • Take note of all missing citations
  • Look up citation information
  • Add bibliographic information to my citation manager
  • Re-read relevant passages in citations to double-check page numbers
  • Communicate with my co-author about word-count issues
  • Use citation manager to generate bibliography entries
  • Copy and paste bibliography in alphabetical order, merging it with my co-author’s.
  • Send to co-author for review.

This took me two hours. I had been avoiding it for over a month. I was then able to do a major task switch to a completely different project: backwards planning for the final writing push on my dissertation. This took another 1-2 hours and I was even able to fit in a check-in call with a good friend. Usually, that type of activity would cause my research-writing brain to completely shut down since socializing is also a major task switch. I was excited to get back to work, set a goal for myself within a specific time limit and managed to meet it. Even on my best unmedicated day this would have been impossible.

I’m writing this post on an unmedicated day. My partner just came in the room and asked when we were going down the shore this month. I couldn’t respond for a full 30 seconds because I was so angry at being interrupted. That is the reality of unmedicated ADHD for me. It means that I’ve been awake for 3 hours, haven’t had water or eaten, and feel like both of those things are too overwhelming to tackle. I wish that I had sought out better care and support for myself sooner. And I really wish my parents had done it for me as a kid. Mostly, I wish that people could appreciate how hard it is for me to have gotten where I am today without medication and therapy.

I’m ending this post abruptly because my dog is barking and I can’t focus anymore. I want to close with this: I think that more academics need to share their stories of mental health and their disabilities so that we can all have better conversations with our students and colleagues about ways to make this job actually do-able. Maybe reading this will encourage you to do some self-reflection on how you judge your disabled colleagues and recognize the immense privilege that comes with being neurotypical.

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