A patient described sitting at her desk, knowing she had urgent work to complete, but finding herself scrolling through her phone, checking email, starting multiple tasks without finishing any. "I know what I need to do," she said. "I just can't make myself focus." This wasn't laziness or lack of discipline. This was adult ADHD—specifically, executive dysfunction where the prefrontal cortex, responsible for focus, planning, and impulse control, struggles to maintain attention and direct behavior.
ADHD isn't just "being distracted." It's dysregulation of executive function—the brain's capacity to focus attention, inhibit impulses, plan ahead, and sustain effort. When I assess ADHD, I'm evaluating how the prefrontal cortex regulates attention and behavior. The classic hyperactive child presentation is recognizable, but many adults have subtler presentations: inattentive type without hyperactivity, or symptoms that manifest as chronic disorganization, procrastination, and difficulty completing tasks rather than obvious distractibility.
What makes integrative psychiatry essential for ADHD is recognizing that attention difficulties have multiple drivers. A patient might have classic ADHD with dopamine and norepinephrine dysregulation, but also sleep disruption that worsens executive function, circadian rhythm disruption that affects attention, and sometimes nutritional factors affecting neurotransmitter synthesis. I've seen patients whose ADHD symptoms improved dramatically when we optimized their sleep architecture and stabilized their circadian rhythms—not because ADHD is "sleep-related," but because sleep disruption can worsen the executive function deficits that ADHD depends on.
Patients don't need to understand the neurobiology of the prefrontal cortex and dopamine signaling to benefit from treatment. But they do need to understand that what they're experiencing isn't just "being scattered"—it's neurobiological executive dysfunction. The distinction matters because it changes how we approach treatment. If attention difficulties are purely behavioral, you'd use behavioral interventions. But when they're neurobiological, you need interventions that target the underlying systems: stimulant medications that enhance dopamine and norepinephrine signaling, lifestyle modifications that support executive function, and sometimes interventions that address the sleep and circadian disruption that worsen ADHD.
Here's what I've learned treating hundreds of patients with ADHD: attention difficulties aren't uniform. Some patients have classic ADHD with clear childhood history and obvious symptoms. Others have adult-onset attention difficulties that might be ADHD or might be secondary to other conditions—depression, anxiety, sleep disorders, or stress. Some have ADHD with hyperactivity, others without. Some have ADHD with impulsivity, others primarily inattention. Each requires different approaches. Classic ADHD needs stimulant medications. Attention difficulties secondary to depression might need antidepressants first. Attention difficulties from sleep disorders need sleep treatment.
There's a common misconception that treating ADHD is just about stimulant medications. That's part of it, but not all of it. Attention difficulties require more than medication—they require sleep optimization for proper executive function restoration, circadian rhythm stabilization, stress reduction, and sometimes nutritional support for neurotransmitter synthesis. This is why I assess sleep patterns, circadian rhythms, stress levels, and lifestyle factors alongside traditional psychiatric evaluation. ADHD is exquisitely sensitive to disruption—sleep disruption, stress, and circadian misalignment can all worsen symptoms.
What I tell patients with ADHD: precision matters. Stimulant medications work by enhancing dopamine and norepinephrine signaling in the prefrontal cortex, improving focus and executive function. But they work best when combined with interventions that support the systems maintaining attention: sleep optimization, circadian rhythm stabilization, stress reduction, and sometimes nutritional support. I'm particularly cautious about patients who've been misdiagnosed—attention difficulties can be secondary to depression, anxiety, sleep disorders, or stress. Proper assessment requires careful history-taking and sometimes ruling out other causes.
But here's what most articles don't tell you: attention difficulties can also be a downstream effect of other conditions. Sleep disorders can cause ADHD-like symptoms. Depression can cause attention difficulties. Anxiety can cause attention difficulties. Stress can cause attention difficulties. I've diagnosed patients who thought they had ADHD but actually had sleep apnea or depression causing their symptoms. Proper psychiatric assessment requires ruling out these possibilities—not just assuming attention difficulties mean ADHD.
What I've learned after years of integrating multiple approaches is that ADHD treatment requires addressing multiple systems. Stimulant medications are essential for many patients, but they work best when combined with lifestyle modifications that support executive function: sleep optimization, circadian rhythm stabilization, stress reduction, and sometimes nutritional support. I've seen patients whose ADHD symptoms improved dramatically when we optimized their sleep architecture and stabilized their circadian rhythms alongside medication.
If you're experiencing attention difficulties, here's my practical guidance: get proper assessment—not just for ADHD, but for sleep disorders, depression, anxiety, and other conditions that can cause or maintain attention difficulties. Treatment might involve stimulant medications, but it should also involve lifestyle modifications: optimizing sleep for proper executive function restoration, stabilizing circadian rhythms, reducing stress, and sometimes nutritional support. The goal isn't just to improve focus—it's to restore the brain's capacity for sustained attention and executive function.