Adult ADHD: A name that misleads patients
A 28-year-old female web designer. She has lived, for as long as she can remember, with forgetfulness, mental exhaustion, chronic recurrent anxiety symptoms, emotional reactivity, hyper perfectionism, procrastination and difficulty following through with tasks and responsibilities. Her job is at risk. These patterns have shaped her work, her relationships and her sense of self.
Her physical exam is normal. Her blood work is normal. A careful psychiatric screening does not point to another primary diagnosis.
I tell her the exam and the tests are normal. She pauses, then asks quietly: So what do I have?
I explain that, based on her history and the exclusion of other conditions, she meets the criteria for attention deficit/hyperactivity disorder.
She looks confused. “But I’m not hyperactive—and when I focus, I focus extremely well.”
This is usually where the real conversation begins.
Most medical and psychiatric diagnoses can be questioned. Adult ADHD, in particular, is vulnerable to skepticism.
The vulnerability of people to adult ADHD cannot be fully attributed to the lack of a single biomarker or the way clinicians communicate the diagnosis. There is something more fundamental at play. Part of the problem is the name itself.
“Attention Deficit/Hyperactivity Disorder” reduces a complex neurodevelopmental condition to two features that many adult patients do not recognize in themselves. Some are not outwardly hyperactive at all. Others are not persistently inattentive. Instead, they describe attention that fluctuates—drifting at times, locking in at others—often unpredictably, often at a cost.
What we currently call adult ADHD is better understood as a disorder of regulation rather than capacity or deficit. The difficulty is not an absence of attention, motivation or emotional control. It is their inconsistency. These functions come and go, sometimes abruptly, sometimes without clear reason.
Describing adult ADHD in this way does not negate its neurodevelopmental origins. Rather, it clarifies how a developmental vulnerability persists once brain is largely matured. In childhood, the condition reflects delayed or inefficient development of regulatory systems; in adulthood, it manifests as a stable pattern of impaired regulation within executive networks that are structurally developed. The developmental process has largely matured, but the dysregulation remains. Mapping adult ADHD as executive dysregulation syndrome (EDS) therefore preserves its neurodevelopmental roots while more accurately describing its adult expression
Therefore, a name such as EDS can be more accurate and helpful than ADHD—not only as a way of making sense of what patients are actually describing, but as a more precise description of the condition’s defining features in adulthood. Executive dysregulation reflects impaired regulation within systems responsible for attention, impulse control, emotional modulation and motivation. When regulation within these systems is unreliable, the familiar clinical picture we currently label adult ADHD begins to emerge.
Executive dysregulation becomes clinically meaningful only when it is persistent, context-independent and functionally impairing. In adults, the symptoms are typically pervasive and affect several areas of functioning, including job performance, relationships, emotional regulation, and self-management and occur despite intact intelligence and effort.
The central and distinguishing feature of executive dysregulation syndrome is a disproportionate difficulty initiating, sustaining and sequencing goal-directed tasks in the absence of external structure, evident from early life and persisting into adulthood. This task-activation failure differentiates EDS from executive dysfunction that is secondary to mood disorders, anxiety states or situational stressors.
While executive dysregulation can arise through multiple pathways, the pattern described in adult ADHD most consistently implicates frontal-subcortical regulatory networks involved in task initiation, reward sensitivity and effort allocation. The emphasis here is not on identifying a single circuit or biomarker, but on recognizing a reproducible regulatory failure that distinguishes adult ADHD from state-dependent executive impairment seen in depression, anxiety or trauma-related conditions.
The view presented here is not intended to preclude motivational, reward-related or arousal-related processes highlighted by alternative models of ADHD. These processes may be better understood as components of a broader regulatory breakdown governing when and how cognitive, affective and motivational resources are deployed. Executive dysregulation is used here as an organizing framework rather than an exclusionary one.
This way of understanding the condition also requires caution as executive dysregulation may present within anxiety disorders, trauma-related conditions, and mood disorders. Differentiation and differential diagnosis remain essential in adult clinical practice.
The name ADHD has become increasingly unhelpful in adults. When a diagnostic label regularly and consistently fails to match patients’ experience, confound acceptance and interfere with engagement, it has lost at least one of the core purposes of diagnosis. Recasting adult ADHD as EDS provides a more specific and clinically coherent label that better captures the constellation of features that define the disorder in adults. EDS places the problem not on missing attention or surfeit hyperactivity but on unreliable regulation of attention, motivation, emotion and task initiation—the domains that many adult patients intuitively know to be at the heart of their impairment. Whether it is ultimately used as a formal term or simply as a conceptual framework, EDS more accurately represents the adult phenotype of ADHD than the current name does.
The shift in terminology becomes the factor that modifies the narrative for the patient I introduced earlier in this article. When the condition is defined by executive dysregulation instead of insufficient attention or excessive hyperactivity the diagnosis becomes recognizable. She can relate to inconsistency, rather than an inability. It makes sense of, rather than working against, the fact that she can be profoundly disabled and yet able to hyperfocus.
A diagnosis has to make sense to a patient for it to be accepted by them. This is not about using impressive language or coming up with new terms just for the sake of it. It is about offering an explanation that feels true.
Dr. Jabir Jassam is a family physician in Ottawa.
