Dysregulated, Not Deficit

Introduction

ADHD has long been viewed through a narrow lens, one shaped by childhood symptoms and stereotypically male presentations. But what happens when these children become adults? Or when the presentation isn't loud and disruptive, but quiet and internal? A recent study from Yale University challenges the traditional paradigm, suggesting that the core issue isn’t a deficit of attention: it’s dysregulation.

The Study at a Glance

The researchers conducted nine focus groups with 43 young adults (aged 18–35) diagnosed with ADHD (median age of diagnosis: 22 years). The majority of the participants identified as female (84%). The late diagnosis is a critical data point in itself, hinting at a systemic failure to recognise ADHD outside of childhood stereotypes.

The goal was simple yet profound: to listen. Discussions explored how ADHD symptoms manifested in daily life, how they evolved across contexts, and whether current diagnostic frameworks reflected participants’ experiences.

Spoiler alert: they don’t.

Key Insights

The thematic analysis revealed that dysregulation, rather than deficit, was the central organising feature of ADHD in young adults:

Attention dysregulation

“I have an abundance of attention at times, it’s just that I can’t direct it. I don’t get to choose what I pay attention to.”

Participants rejected the idea of a “global attention deficit.” Instead, they described hyperfocus, the ability to zero in on tasks of interest for hours as central to their ADHD. While this state can feel like a "superpower," it comes at a severe cost: neglect of basic needs like eating or sleeping, time-blindness, and intense irritability when interrupted.

2. Emotional dysregulation

“I either feel a lot of emotions very intensely or I feel just kind of, I guess neutral, for lack of a better word.”

If there was one finding that participants felt was most neglected, it was the profound role of emotional dysregulation.

Rapid mood shifts: Moving from calm to overwhelm in seconds.
Alexithymia: Difficulty identifying and naming emotions.
Rejection-Sensitive Dysphoria: Extreme emotional pain triggered by perceived rejection or criticism.

Many described these challenges as more debilitating than classic inattention, yet they remain sidelined as "associated features" in diagnostic manuals, not core criteria.

3. Executive dysregulation

“Why am I so paralyzed? Why can’t I just do this one thing, it’s not that hard it shouldn’t be that hard.”

The study found that the term "executive dysfunction" resonated far more deeply with participants than "ADHD." This describes a dysregulation in the brain's management system, leading to:

Paralysis of Initiation: Inability to start tasks, even desired ones.
Difficulty Switching & Stopping: Getting "stuck" in a state or activity.
·The "Graveyard of Unfinished Projects": An inability to sustain effort to completion.

This dysregulation explains the common experience of inconsistent performance and motivation: not laziness, but a system that cannot reliably execute commands.

The Ripple Effect

By connecting these dots, we can see their combined effect creates a devastating ripple effect that permeates every aspect of life, leading to the chronic exhaustion and constant uphill battle so many describe:

The Boom-Bust Energy Cycle: Hyperfocus can be both an asset and a liability. The intense expenditure of mental energy during hyperfocus inevitably leads to a crash of exhaustion and burnout. This isn't a choice; it's a direct consequence of the brain and body having expended their reserves without pacing.
Emotional Energy Drain: Episodes of emotional overwhelm or rejection sensitivity are profoundly exhausting with a single intense emotional spike having the capability to derail an entire day’s productivity.
The Cognitive Load of Coping: The immense effort of masking symptoms and constantly managing distracting environments is a continuous background drain of energy.
The Impact of Environment: Functioning is highly dependent on context. The "right" environment (e.g., controlled noise, minimal clutter) can facilitate focus, while the "wrong" one can induce total paralysis. This highlights that ADHD is not a static deficit but a dynamic mismatch with one's surroundings, forcing the individual to expend even more energy to adapt.

In short, the core dysregulation documented by the study doesn't just cause isolated symptoms; it creates a system that is inherently draining and unsustainable.

Toward a More Nuanced Understanding

Ultimately, this study reframes ADHD not as a fundamental lack, but as a neurologically dysregulated system. By listening to the voices of young adults (including women, whose experiences have too often been marginalised), we gain a more accurate and humane understanding of ADHD. It also reminds us that ADHD does not discriminate; our outdated diagnostic systems do.

The core experience described: the erratic swings from intense hyperfocus to utter exhaustion, the paralysing inability to start, and the draining weight of emotional and social masking remains entirely invisible in current diagnostic criteria.

This framework offers a more holistic explanation for the chronic fatigue, inconsistency, and burnout so many adults with ADHD face. Treatment, therefore, should move beyond sustaining attention alone and focus on pacing, energy conservation, and learning to navigate one's unique cycles to achieve balance. It's not about fixing a deficit, but about regulating a powerful, complex engine.

Reference:

Ginapp CM, Greenberg NR, MacDonald-Gagnon G, Angarita GA, Bold KW, Potenza MN (2023) “Dysregulated not deficit”: A qualitative study on symptomatology of ADHD in young adults. PLoS ONE 18(10): e0292721. https://doi.org/10.1371/journal.pone.0292721

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