As you read this, I want you to think about a few clients.
Not the straightforward ones. Not the cases that fit neatly into anxiety, depression, or trauma frameworks. I’m talking about the clients who have been in therapy for years—engaged, insightful, motivated—and still feel stuck in ways that don’t quite resolve.
They show up. They do the work. They implement strategies. They reflect deeply.
And yet… nothing fully changes in the day-to-day functioning.
Often, they’ve seen multiple providers. They may have completed psychological or neuropsychological testing after long waitlists and significant cost. And still, the results land somewhere in the middle—“rule out ADHD,” “traits present but not fully meeting criteria,” or formulations that leave everyone asking the same quiet question: what are we missing here?
Let’s stay with that question for a moment.
Because what I see most often is not a lack of effort. It is not a lack of insight. And it is not resistance to treatment.
It is a missing ADHD-informed lens.
Try harder is not the issue—try different is
One of the most important clinical shifts I teach providers is this: ADHD work is rarely about “try harder.” It is about “try differently.”
Most systems are built through a neurotypical framework—assume intention, add structure, increase insight, reinforce behavior. That works well… until it doesn’t.
With ADHD, the issue is often not motivation. It is executive functioning structure.
So the intervention has to match the nervous system.
For example, something as simple as medication adherence (when appropriate) is often framed as “just remember to take it.”
But in ADHD-informed care, we slow down and ask: where is the breakdown actually happening?
Is the medication stored in a place that is disconnected from routine? Is there a missing step—like a glass of water—that becomes the barrier? Is the system dependent on memory instead of design?
So instead, we build supports:
- medication next to the toothbrush
- toothbrush already tied to a consistent morning routine
- water placed in the same location
- fewer steps, less friction, more environmental scaffolding
This is not overcomplication. This is meeting the nervous system where it actually is.
When insight is high but functioning is low
Another pattern I see constantly is this: high insight, high motivation, low consistency.
Clients will say things like:
“I know exactly what I need to do… I just can’t do it consistently.”
“I should be able to handle this.”
“I can do it for a few days and then everything falls apart.”
And this is where clinicians often understandably reach for anxiety, depression, or trauma frameworks.
But I want you to pause here and ask a different question:
Is this a motivation issue… or an executive functioning mismatch?
Because when ADHD is present, the struggle is often not knowledge. It is initiation, sequencing, prioritization, and follow-through—especially in everyday tasks like getting out the door on time, remembering steps, or maintaining routines without external structure.
With the right supports in place, these same clients often function exceptionally well. Without them, even simple tasks become disproportionately difficult.
ADHD is often hidden inside other diagnoses
In practice, ADHD is frequently re-labeled through other lenses:
- inattentive presentations → depression or low motivation
- hyperactive presentations → anxiety or agitation
- emotional dysregulation → trauma responses
- chronic overwhelm → stress or adjustment issues
And sometimes those are partially true.
But often they are incomplete.
There are also important intersections that further complicate recognition:
- hormonal shifts (postpartum changes, PMDD, estrogen fluctuations) that amplify ADHD symptoms
- substance use patterns that may reflect long-term self-regulation attempts
- OCD-like patterns that overlap with cognitive over-control and executive dysfunction
When ADHD is not part of the formulation, something important is often missing from the clinical picture.
When assessments don’t bring clarity
You’ve likely seen this too: assessments that land in the “almost” category.
Borderline inattentive scores. “Rule out ADHD.” “Does not fully meet criteria.” Or results that suggest ADHD in one domain but are interpreted cautiously because the presentation is not stereotypical.
Especially when trauma history is present, or when symptoms are internalized rather than externalized, ADHD is often deferred rather than explored.
And in that gap, clients are left without a coherent explanation for their lived experience.
What changes when ADHD is finally recognized
Let me describe what often happens when ADHD is accurately identified—not assumed, but genuinely understood.
There is often an immediate emotional shift.
Clients say things like:
“Oh my gosh… this actually makes sense.”
“So I’m not just failing at life.”
“No one has ever explained it like this before.”
And something reorganizes internally.
Not because life suddenly becomes easy—but because the framework finally fits the experience.
Treatment becomes more effective. Shame decreases. Self-understanding becomes more compassionate. And in many cases, clients are finally able to build systems that work for them rather than against them.
Sometimes, this is also the point where clients no longer need weekly therapy in the same way—not because they are “fixed,” but because they finally have clarity and structure that supports functioning.
A clinical question worth sitting with
One of the simplest but most revealing questions I encourage clinicians to ask is:
Is there a family history of ADHD?
Often, the answer reveals patterns in siblings, parents, or extended family members who were never formally identified—but show similar lifelong patterns of executive dysfunction.
This is one of the most underused but clinically useful pieces of information in assessment.
A competency issue, not a character issue
What I consistently see is not a lack of care from providers or clients. It is variability in ADHD competency.
Highly intelligent, highly capable individuals are struggling with basic daily functioning in ways that don’t match their insight or motivation.
And yet ADHD is not always confidently explored as a primary organizing framework.
That gap matters.
Because when ADHD is missed, clients don’t just lose a diagnosis—they lose time, clarity, and often years of treatment that never fully addressed the root pattern.
A final invitation
This is where I return to the same clinical stance again and again: stay curious.
Not certain. Not assumptive. But willing to look again.
Willing to ask, “Could ADHD explain more of this than I initially thought?”
This is why I created the “Spotting ADHD” workshop for providers—a starting point for clinicians who want to strengthen diagnostic confidence and recognize ADHD beyond the stereotypical hyperactive presentation. I also offer consultation for clinicians and teams working through complex diagnostic presentations.
But whether learning happens through my work or elsewhere, the point is the same:
We cannot treat what we are not willing to clearly see.
And when ADHD is accurately recognized, something shifts—not just in diagnosis, but in clarity, in treatment effectiveness, and in how a person understands themselves.
That shift is often the difference between ongoing confusion… and finally having a framework that fits.
And that is worth getting right.