Shrinking the Shame of ADHD

Ten-year-old Harry finds a sand dollar on the beach; racing over to show his parents this treasure, he plows right through the sand castle that his eight-year-old sister, Carrie, had just started building. Carrie bursts into tears, shouting “I hate you! I hope you die! You always do this! I’ve been working for hours on my pretty castle and you’ve ruined everything!” Harry and Carrie’s parents exchange a familiar look: another beautiful morning at the shore has been derailed by the ADHD-driven behavior of their children.

ADHD contributes to a host of age-inappropriate behaviors. The inattentiveness, impulsivity, and poor emotional regulation driven by ADHD causes social transgressions that disrupt human interactions. Inattention leads children and adults to knock over, bump into, and break items; misplace or lose belongings; miss social cues; ignore words directly addressed to them; procrastinate to avoid starting challenging tasks; fail to complete tasks; and make careless mistakes.

Impulsiveness contributes to blurting out comments – particularly utterances too candid to be socially acceptable – and to jumping into situations without thinking of, or preparing for, the consequences. Emotional dysregulation produces outbursts of feelings that appear to others to arise too quickly, reach too extreme an intensity, and often ignore important aspects of the social context triggering the event.

Years ago, psychiatrist Michael Jellinek estimated that by age 12, children with ADHD likely hear 20,000 negative comments directed at their aberrant behaviors during just their hours in school. (This calculation was then popularized by psychiatrist William Dodson.) Most of these children receive additional criticism in their households. Many children with ADHD elicit a steady stream of feedback that their actions or inactions are inappropriate or bad. The prevailing negativity washing over these youngsters convinces many that they themselves are wrong or defective.

Although some emotion researchers parse these feelings somewhat differently, you experience guilt when you break a social rule that you agree with. Shame, however, involves judging that your actions fail to live up to your internal standards, thereby revealing that you are inherently bad. Toddlers as young as fifteen months can develop shame, but guilt does not arise until ages three to five, when rule-based learning starts. Socialization, the primary job of most parenting and schooling, attempts to instill appropriate guilt in children so that they will follow society’s rules, without shaming children and making them feel like damaged goods. While different cultures possess different standards regarding which behaviors are appropriate, all groups instill some rules and norms.

Guilt and shame accrete around three different aspects of ADHD: problematic ADHD-driven behaviors, stigma around the condition itself, and feeling that negative attitudes towards others who are identified with ADHD may reflect poorly on oneself. I call these categories embarrassment by action, by essence, and by association.

A technique from dialectic behavioral therapy (DBT) helps address guilt stemming from ADHD-based actions. In addition to triggering an internal feeling state, emotions also promote bodies to physically respond in characteristic ways. Guilt and shame cause you to bow your head, blush, and speak more quietly or not at all. By acting in ways that counter these body tendencies, we can actually move out of the negative feelings more quickly.

Standing up straight and speaking out loud help dissipate feelings of shame and guilt. DBT further recommends that to reduce guilt, you should declare: “This is what I did. I do feel it violated a social rule. And I will change my behavior in this specific way in order to avoid making this error again.” Thus Harry might proclaim: “I ran up the beach without looking and ruined my sister’s sand castle. I am sorry that I damaged something she was working on. Next time I will try to look where I am running.”

Sometimes, upon reflection, you decide that the guilt is inappropriate, and that while you did violate a social rule, it is not a rule that aligns with your own moral values. In these cases, you change the out loud declaration of the guilt-reduction formula to: “This is what I did. I don’t feel it was wrong, so I don’t need to avoid doing this in the future.” So you might say, for example, “I jaywalked by crossing the street in the middle of the block, but I looked both ways and no traffic was coming. This appears safe and reasonable to me so I will do it again.” Actions such as marching in Gay Pride parades or raising a fist in a Black Power salute similarly employ this approach of resisting inappropriate social rules that attempt to induce guilt and shame regarding sexual orientation or race.

For those with ADHD, both medications and talking therapies can help shape behavior. Medications not only improve attentiveness, but they also measurably reduce impulsive actions and assist with modulating emotions. By utilizing cognitive behavioral therapy (CBT) approaches tailored to ADHD, individuals can also learn to reduce distractions, improve sustained attention, and develop new behavioral patterns to minimize the disruption of ADHD in their own lives and on the lives of those around them. Neither medication nor CBT eradicates ADHD, but they can reduce problematic behaviors that were caused by ADHD.

Confronting shame about the essence of ADHD involves peeling back unacknowledged underlying assumptions, which usually reveal that you feel unworthy because you have defects. When one tells a shameful person “nobody’s perfect,” the statement is so trite that most immediately discount it and don’t stop to absorb the truth it contains. Often I tell patients that except for the six or seven perfect people on this planet, everyone has flaws. Other than the alliteration, I enjoy this phrasing because it makes people pause, think, and conclude, actually, that everybody really does have imperfections.

Working through shame about your essence requires confronting that each of us is different, and that difference does not equate to defectiveness. Many religions teach that we are all “damaged goods,” but this damage or deficiency is in comparison to an idealized standard that nobody attains in life. Failing to achieve perfection does not detract from our value as humans. It matters not whether you consider ADHD a gift, a difference, a condition, a disorder, or a disease, because our human essence is not diminished (or enhanced) by any particular set of traits.

Our English language compounds confusion by blurring these distinct concepts: your faulty (imperfect) brain is not your fault (blameworthy). We can be less than perfect without being bad.

Knowledge of the biological basis for ADHD helps some individuals struggling with shame about their condition. Genetics contribute strongly to the development of ADHD, and we can measure group differences in dopamine neurotransmission, regional connectivity, cortical thickness, and patterns of maturation in the brains of those with ADHD compared to those without it. Biology helps clarify that individuals did not choose whether or not they have a brain with ADHD, and that, at least in part, their brain is wired to perform differently than the standard-issue brain (whatever that is).

Knowing that despite the contributions of biology, ADHD always unfolds in a particular social context can also help reduce shame about ADHD. Modern American society actually celebrates some aspects of ADHD (creativity, risk taking, exuberance) even while it views other aspects as disruptors of decorum or productivity. Furthermore, most people, at least occasionally, display the socially disruptive behaviors characteristic of ADHD (being late, forgetting something, blurting comments), without making them less human. And finally, we have been designing technology (calendar reminders, embedded chips to find lost items, immediate access to encyclopedias of knowledge, noise-canceling headphones) to help mitigate many of the problems caused by ADHD. If there is such widespread demand for these tools, and these tools can reduce disruptions caused by ADHD behaviors, this clearly indicates that the problems of ADHD are common and to some extent reparable, placing them in the realm of misfits between the individual and society, rather than demonstrating that individuals with ADHD are defective and lie outside the range of being human.

The crux of eradicating essence-based ADHD shame resides in replacing “you are ADHD” with “you have ADHD.” Although ADHD pervasively and powerfully influences behavior, thoughts and feelings, it never tells us all that is important about an individual. In terms of one’s worth as a human, ADHD tells us virtually nothing.

Guilt by association for those with ADHD arises when you see someone identified as having ADHD behaving in a way that you disapprove of, and fear that it reflects badly on yourself. This can occur when the other person’s behavior triggers the sudden insight “Oh, I do that too!” and you are ashamed by this revelation.

The diversity of symptoms and possible presentations of ADHD allows another form of guilt by association to crop up. Guilt, shame, and resentment can emerge when you observe someone labeled with ADHD acting in a way that seems totally unlike your own behavior, but you fear being tarred by sharing the same diagnosis. These two types of guilt by association can intermingle in instances where you consciously feel unlike the person identified with having ADHD, but part of the fervor of rejecting this connection is an unconscious awareness that your behavior actually might resemble the objectionable actions of that other person with ADHD.

I once led a small group, teaching CBT approaches to individuals with ADHD, that fell apart because of guilt by association. Problems of missed sessions, members showing up late, and procrastination over homework assignments already plague most ADHD groups. Our group disbanded because of one additional dynamic that played out between members. One individual frequently and loudly blurted out comments and then laughed uproariously at his own remarks – not only because they were often humorous, but also with a nervous acknowledgment that they had violated a social norm. A more reserved and inattentive member of the group felt so alienated by the exuberant individual that he would proclaim that he couldn’t have ADHD himself since he differed so much from others in the group. Despite attempts to explain how ADHD can manifest in many different ways, and how the CBT approaches could help all members of the group, the members felt so dissimilar that they stopped showing up.

In addition to understanding that people can manifest symptoms of ADHD differently, working through guilt by association requires understanding that, while ADHD powerfully and pervasively affects behavior, we each have other attributes that make us individuals. These other attributes include intrinsic mental factors (intelligence, sense of humor, degree of extroversion or introversion), as well as social factors (wealth, status, perceived gender or race) that all influence how one displays ADHD traits. Just because you share ADHD with another does not mean that you take on all of their other characteristics, good, bad, or just different. ADHD may be your only area of overlap with another individual.

Finally, keep in mind that ADHD shapes how one processes thoughts, rather than determining their content. While ADHD may directly contribute to blurting out comments or hyper-focusing on a project, ADHD does not create which words are spoken or which project one becomes overly absorbed in.

While President Trump fully fulfills criteria for ADHD, other people with ADHD need not take credit or blame for his racist tweets, cruelty to immigrants, or ignorance regarding the Constitution and separation of powers. Trump is also a right-handed, male, American, ginger-haired, Caucasian, septuagenarian New Yorker. Although he may be a prominent example of dextromanuality or of masculinity, he certainly doesn’t represent all right-handers or all men. And while he does officially represent all Americans, many deal with their shame in this regard by pointing out differences between what they think or feel and the president’s perceived policies or pronouncements.

Use the label of ADHD to learn about your own patterns of behavior and to increase your understanding of yourself and others. Use it to comprehend how you may appear to the world. Use it to develop non-judgmental stances towards human behavior, unless you are certain that one is operating from a place of evil. And use the ADHD label to develop informed ways of dealing with your behaviors, your trajectory through life, your entire existence.

You can consider ADHD a disease, a disorder, an imperfection, a condition, a variation, or an attribute. But if the label doesn’t help you, then don’t use it.

If some of these approaches to reducing possible shame about ADHD sound too cerebral and indirect, remember that our thoughts shape our emotions. However, it may take many, many repetitions of thinking differently before you alter how you feel. It probably took thousands of negative messages that helped create those shameful feelings in the first place. In addition to changing the messages you give yourself, work on cultivating positive feedback about yourself by immersing yourself in supportive relationships and communities.

Shrinking, or even eradicating, the shame attached to ADHD comes down to “you be you.” Although you resemble others in some respects, you are still a unique and valued individual. Employ your self-knowledge about ADHD to inform your decisions and empower your journey through life.