Is ADHD a spectrum? What that does (and doesn’t) mean

“Isn’t everyone a little ADHD?” If you have ADHD, you’ve heard it. Maybe you’ve felt the flash of rage, and the sadness underneath, because the question can make it sound like your life-altering brain difference is being reduced to a personality quirk. But there’s a more thoughtful version that could be worth asking: Is ADHD a spectrum?

Psychiatrist and writer Dr. Awais Aftab, author of the newsletter “Psychiatry at the Margins,” helps host Rae Jacobson untangle what that word “spectrum” actually means. A spectrum doesn’t mean everyone is a little bit ADHD. But he helps explain how we draw the line between neurodivergent and neurotypical, and what it really means for something to be a “disorder.” They get into why diagnosis rates may be rising in a world of 1,000 emails a day, the role of medication, and why changing environments won’t help everyone equally.

Rae also gets honest about the whiplash of ADHD narratives, from “broken” to “superpower” to “we’re all a little like this,” and about rebuilding a sense of self along the way. It gets emotional.

• Read: Psychiatry at the Margins

• Read: Awais Aftab in The New York Times

• Watch: The fawn response: The survival instinct behind people-pleasing | Hyperfocus

Awais Aftab: We now live in a world that demands a lot of us, you know, in terms of attention, concentration, cognitive task, and everything. So it is no surprise that more people would show impairment.

Rae Jacobson: "Isn't everyone a little ADHD?"

If you have ADHD, like me, this is probably something you've heard more times than you can count. And maybe when you hear it, you have the same reaction I do: a frisson of light rage. And maybe you want to say what I want to say, which is, "Hello, chatty stranger, when you ask that, it pokes a part of me that is very sad because that question can feel dismissive and invalidating to those of us for whom this is a life-altering brain difference."

And also, good question, because everyone does sometimes have ADHD-like traits, and even people who are diagnosed with ADHD sometimes experience it differently. So both shut up and also I get it.

As you can see, I am a joy at cocktail parties. Let the invites pour in. One of the reasons this question is so frustrating is that it's something I've never felt like there was a great answer for, besides, I don't know, "Screw you."

But lately, I've been hearing a better and more thoughtfully complex version of it: Is ADHD a spectrum? It's an idea I've heard from various people in various camps with various interpretations of what the word "spectrum" even means.

One of those people is Dr. Awais Aftab. He's a psychiatrist and a writer and a professor at Case Western Reserve University. He publishes a newsletter called "Psychiatry at the Margins," and he treats patients with ADHD.

I am a big fan of Awais's writing. In fact, one of his New York Times op-eds made me cry. And a mildly embarrassing spoiler alert, I cried also just a little during this interview.

So today on "Hyperfocus," Dr. Awais Aftab helps me untangle some of my toughest questions about the nature of ADHD: Should we think about ADHD as a spectrum, and if we did, what would that actually mean? And one of the bigger questions that I've been wrestling with: What would it mean to truly rethink, not just clinically, but personally, how we talk about ADHD?

(02:11) Understanding the concept of a spectrum in mental health.

The spectrum I feel like that most people are familiar with in this context is probably the autism spectrum. It's like the one where you hear that word the most. What is a spectrum in the context of mental health?

Awais: I would say a lot of people use the word "spectrum" in a kind of somewhat ambiguous and in a fuzzy manner. I think the general idea is that, in the case of a spectrum, we are dealing with a condition that varies along a certain axis: there's kind of mild, kind of moderate, there's severe. It'll be like a dial that you can slowly go up.

In that general sense, actually, a lot of conditions in psychiatry and medicine fit the spectrum kind of criteria, even though we do not explicitly use the word "spectrum."

I think there's one confusion when we talk about spectrum, and it's this idea that, "Hey, if autism is a spectrum or if ADHD is a spectrum, then everyone, you know, is a little bit ADHD or everyone is a little bit autistic." That's not true. Something could exist on a spectrum, and yet it can be the case that many people or a large number of people do not show any meaningful value on that criterion.

When we are dealing with that kind of situation, the challenge then becomes, at what point do we say that, yes, this is something that warrants being recognized as a clinical problem?

Rae: In other words, if ADHD exists on a dial with zero being no symptoms and 10 being severe symptoms, everyone in the world will exist somewhere on that scale. But there's some line, some number that divides the neurotypical people from the neurodivergent ones. So who decides where that line is or how it's measured?

Officially, it's the people behind the diagnostic manuals, like the DSM. They say you need a certain number of symptoms at a certain level to get a diagnosis.

But Awais told me that a lot of clinicians see that cutoff as semi-arbitrary. They lean more on whether or not symptoms are causing real distress or getting in the way of your life.

This makes it different from, say, diabetes, which is another condition that exists on a spectrum. In diabetes, there's a blood test that can tell you whether you're diabetic, prediabetic, or just not diabetic at all. That doesn't exist for ADHD. There is no blood test or brain scan that can definitively tell you whether you reach the threshold for ADHD or not.

To be very clear, this is not at all unique to ADHD. That doesn't exist for almost any mental health condition — not autism, not bipolar disorder, not schizophrenia. Instead, we rely on other measures like self-reports. But researchers keep trying to find biomarkers, something you could see on a brain scan or a blood test that would prove where on the spectrum you belong.

Awais: I think collectively we have a bit of an ambivalent relationship with self-report where we recognize its reality, but I think many aspects of our culture and we as collective society are also kind of skeptical of self-reports, too. We tend to be dismissive of many kinds of claims that people can make about themselves. And then we start thinking of all sorts of motivations about why a person might want to exaggerate their difficulties.

The inherent subjectivity of these, I think, is one aspect of it which makes it difficult and uncomfortable. There's this tendency to want to seek refuge in biomarkers and to be able to reduce the problem in some sense to neurological functioning or neurological —

Rae: Something you can see, like a —

Awais: As something you can see, something —

Rae: — like an image.

Awais: Right.

(05:50) Defining ADHD as a clinical disorder versus a neurological profile.

Rae: I think part of the reason I'm asking about that is because sometimes it feels like people hold up the fact that there is not an obvious biomarker to say that a lot of these things just like, "Uh, they're they're kind of not real." Like you said, self-reporting is really complicated. This feels very inexact because it is.

I want to ask you, and I know this is kind of a straight question, but do you think ADHD is a disorder? What is ADHD to you?

Awais: So it's a more complicated question than may seem on surface. Definitely ADHD is real as a clinical condition and clinical problem, I think as real as any other mental disorder or psychiatric disorder there is.

I think it becomes a disorder in my view when it starts having a negative impact on a person's life, when it is causing significant impairment, where they're not able to do the things that we normally expect people in similar circumstances to be able to do.

Rae: So, yes, Awais thinks ADHD is a disorder. And personally, for those of us who live on the side of the line that represents significant impairment, that's never really been a question. ADHD is something that makes our lives harder in so many ways, and in ways that it's not hard for people who don't have brains like ours.

But also, our brains exist in concert with the world. Someone who experiences serious impairment, for example, in grade school might not have that same level of impairment in, say, their art practice. But even then, it's not that simple.

Awais: There are people with kind of like, you know, you can think of them as ADHD tendencies who have distractibility, who have difficulties with sustained attention, but they are not impaired because they are able to find the right kind of environment for them, the right kind of niche for them, and they thrive in that, and that works for them. So I don't think those people are disordered or they have a disorder.

Disorder for me is a clinical judgment that is very much based in distress, impairment, and negative consequences to a person's life. If a person has adjusted well to their neuropsychological characteristics, they may have a certain neurological profile or neuropsychological profile, but they don't have a disorder anymore.

I think this is where some of this ADHD — whether ADHD is a disorder or not — debate comes in, because some people have the neuropsychological profile, but not the impairment. It is only when the impairment is present that it becomes a disorder in the clinical sense.

(08:31) How environment influences ADHD impairment across the spectrum.

Rae: Actually, that brings me to our spectrum core, honestly, because when you say that, it makes me wonder. One of the things that can be held up, I feel, against the idea of ADHD as a disorder at all is that if you are in a different context, sometimes those symptoms are less of a problem, or maybe they're even adaptive.

I have found that to be an argument that people will make to say, "No, this is not a problem. This is just something where like, you know, maybe you need a different job, or maybe you need to go work on a farm," which — another conversation we will have someday is how that operates under capitalism. Let's talk.

But I have to wonder if this spectrum framing, in your conception of it, would help people be able to see that you can still have something that, in varying contexts, is a real and serious disorder deserving of care and respect and the type of help that we would associate with something that is impairing. And it can be something that, when circumstances are different, those traits can be present, but not impairing.

Awais: I think what people are getting confused on or what people are kind of neglecting in conversations like that is that this relationship between a particular kind of neuropsychological state of functioning and its responsiveness or suitability for different contexts, it is severity-dependent. It is most pronounced at the mild end of the spectrum and less pronounced at the severe end.

Typically, at the severe end of psychiatric disorders, including things like ADHD and autism, the deficits are so severe that they are obvious in all contexts. And this is the reason that historically, when these conditions were recognized, it were the severe cases that were recognized first.

For ADHD, you might know that in the beginning it was called minimal brain dysfunction.

Rae: Yes.

Awais: Right. And the kids were so severely impaired that, regardless of how suitable the school environment would have been, they would have shown up as, "Hey, something odd and unusual is going on here."

Rae: So as Awais sees it, the environment has a big impact on whether some people with ADHD-like brains end up meeting criteria for the disorder part of ADHD. But he's also very clear that changing your environment does not work the same across the spectrum.

For people with more significant ADHD symptoms, a different job or the right learning environment might help a little. But as Awais explains, the impairment will still be noticeable. So environmental change can have a big effect for those on the milder end of the spectrum. But that effect, it could be good or bad.

(11:17) Environmental mismatch and the modern rise of ADHD diagnoses.

Awais: This is one of the reasons, I think, when people ignore the person-environment context, that's why they find the high rates of or increasing rates of ADHD kind of puzzling. They'd be like, "Oh, why would there be this sudden increase in ADHD over the last couple of decades?"

Well, we now live in a world that demands a lot of us in terms of attention, concentration, cognitive task, and everything. So it is no surprise that more people would show impairment in the modern world with the sorts of jobs we have and the sorts of tasks we have.

Someone who, let's say, has kind of mild ADHD problems, they might not have shown impairment as a factory worker, for example, doing manual work. Right? But you take the same person and you put them in a modern office environment and they have to answer a thousand emails a day and manage a calendar, and suddenly things are different.

Rae: Do you think that this like, "Oh, if you got a better job or a different job — I shouldn't say better — maybe your experience with ADHD would be lessened," do you think that that means that people shouldn't get medicated, and they should just like wing it?

Awais: No, I don't think so. I actually find that sort of line of reasoning rather frustrating and annoying myself.

Rae: You and me both.

Awais: Yes. The goal of clinical treatment, medical treatment, is to enable a person to function better and to reach their full potential and for them to be able to flourish and do the things that they want to accomplish.

The goal of clinical treatment or expectations for a clinical treatment should not be that people give up what they want to do and that they make do with less, but rather we allow them to be able to have the same sorts of opportunities that we expect other people in the society to have.

With regard to ADHD, we want to make sure that schools and classrooms are designed in a way that they accommodate a wider variety of neuropsychological profiles where they're not excessively boring, where students are not just expected to sit in a desk and just pay attention to kind of useless material for hours, right?

We want to make sure that we are not medicating people just to force them to adjust to some kind of an unhealthy environment. But provided we are mindful of that ethical aspect of it, intervening on the individual to help them better adapt to situations that other people in the society adapt to is a perfectly reasonable way to approach treatment.

This is basically what we do with other kind of physical impairments. I'm wearing eyeglasses. If someone said, "Oh, you know, your vision — you have weak eyesight, you should give up on being a doctor and just — " Right? That would be unfair.

Similarly, if people struggle with sustained attention and focus and concentration, and we have tools that we can use to help them with that, we should make them available.

What has happened in the past is that, in the early 2000s, there was just this emphasis on seeing ADHD as this brain disorder and portraying ADHD in purely deficit-based terms and pretty negative terms. And then what happened was that people who had been diagnosed with ADHD as kids and were told that, "Oh, you're going to need stimulants for the rest of your life," and then they found a situation that really worked for them, and they were able to find environments that worked for them and they were able to come off medications and thrive, I think they felt a sense of disillusionment and betrayal.

That is problematic. We should not be promoting simple deficit-based accounts of ADHD, but rather I think we should be promoting that, "Hey, this is a problem that arises from the interaction of a person and the environment." And in some cases, it makes sense to intervene on the environment, but in other cases, it would make sense to intervene on the person and give them the tools that they kind of want.

(15:34) Moving past deficit-only narratives toward a balanced spectrum view.

Rae: As you'll hear, the shift from the purely deficit-based model to something else is, for those of us who've lived it, pretty complicated and emotional. Yeah, this is the crying part. Because as I tried to explain to Awais, the changing narratives around ADHD can feel a little head-spinning sometimes.

You're broken. You're so creative. You're stupid.It's a superpower. It's who you are. It's barely anything at all.

Something I've struggled with is that these conversations don't leave much space for the messy process of evolving how we see ourselves, the process of rebuilding self-esteem, of finding our own ways to talk about our own brains that feel right to us.

So many of us were fed this sort of endless deficit model, but then it flipped and we were then fed this idea that ADHD is either a superpower and you're amazing because of your ADHD, and you're just neurospicy and we're all like this a little bit.

I have trouble finding the joy in that because I felt like on some level that wiped out these years of being told something was wrong with you, and experiencing the world as if something was wrong with me. And that is like — it's not something you can just drop.

So — sorry.

When I hear you say all of this now, I love this spectrum idea because I feel like it leaves space for like the subtle, weird mess that it is to have a brain that isn't the way that all brains work.

And I want to know if you feel like this is the way forward. Would this continuum that you so beautifully proposed help us move into a different way of thinking about this? Because I have to say, I really, really hope that it will.

Awais: Yeah, I hope so, too. I think it dissolves a lot of the traditional debates that we have had. I think a lot of the classic 20th-century debates around ADHD and other things, I personally feel that once you are clear about what a spectrum is, and once you are clear on the nature of impairment as being a person and environment interaction, it just withers away to my mind, and it becomes kind of weird that, why are so many people still stuck on debating this?

Rae: Thank you to Dr. Awais Aftab for coming on the show and for being so thoughtful about such a complicated topic.

If you want to follow Awais's work, which I highly recommend, you can check out his Substack, "Psychiatry at the Margins," or read his excellent New York Times op-eds. We'll link to both in the show notes.

Thank you for joining me. If you have questions or stories or anything really, leave us a comment. We love hearing from you. See you in two weeks.

"Hyperfocus" is hosted by me, Rae Jacobson. Our producer is Cody Nelson, and Andrew Rosthal is our senior podcast producer. Julie Subrin helps with booking.

Our music comes from Blue Dot Sessions. Our research correspondent is Dr. K.J. Win. Our associate director of content development is Calvin Knie. Briana Berry is our production director, and Neil Drumming is our editorial director.

If you have any questions for us or ideas for future episodes, write me an email or send a voice memo to hyperfocus@understood.org.

This show is brought to you by Understood.org. Our executive directors are Laura Key, Scott Cocchiere, and Jordan Davidson. Understood is a nonprofit organization dedicated to empowering people navigating neurodivergence. If you want to help us continue this work, donate at understood.org/give.