Never Enough

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition that is most often diagnosed among children. During the COVID-19 pandemic, however, prescriptions for stimulant and nonstimulant ADHD medications dramatically increased in older individuals, particularly among adults ages 20–39 and young women (1).

I received an ADHD diagnosis during my intern year of psychiatry residency at the age of 27. I had mixed feelings about this label. On the one hand, I was relieved to finally have an explanation for how I think and experience the world. On the other hand, I wondered whether I was truly “dysfunctional enough.” Every DSM diagnosis ends with the same phrase: “must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Was I not just another lazy procrastinator who needed to work harder? After all, I did well enough to get into medical school. Pressure and anxiety motivated me to study just enough to pass, which in my preclinical years could mean getting a 76 when the passing score was 75 (a popular saying among my classmates was P=MD, or a passing score makes one a doctor). My attention was drawn elsewhere: I committed myself to far too many student organizations, and I would start five different projects and then feel like a failure when I struggled to finish any of them. A few months before step 1 of the United States Medical Licensing Examination, everything finally caught up to me. Failing my first practice test was my wake-up call that perhaps my lack of focus was not all about discipline and willpower.

I think one reason it took me so long to consider a diagnosis of ADHD, let alone seek treatment, was my background as a Chinese American woman. During my childhood, neither my mother nor I suspected that I might have ADHD, which is frequently underdiagnosed and undertreated among Asian American and Pacific Islander (AAPI) children and adults (2–5). ADHD treatment guidelines are not standardized in Asian countries; guidelines do not even exist in China and Taiwan (6). Furthermore, studies on ADHD overwhelmingly focus on cisgender boys, a pattern that is only exaggerated in the literature on Asian children (7, 8). There is not enough consideration of gender norms and socialization.

Cross-cultural studies of ADHD suggest that the core syndromes and features of ADHD do not vary much across cultures, but the prevalence and threshold of what is considered pathological do (9). When my mother and I filled out the questionnaires for my evaluation, she kept insisting that I was “normal.” Are these behaviors and symptoms not characteristic of all children? Are they not character flaws to be controlled through discipline rather than medications? Why should my parents be concerned as long as I was quiet and obedient, performed well in school, and avoided embarrassing them? In light of Chinese Confucian values, disruptive hyperactive traits stand out more than inattention. Some ADHD behaviors, such as hyperfocus, can even make individuals appear hardworking and dedicated.

If I did not appear dysfunctional, then perhaps I was (and still am) compensating. For example, I organized obsessively, maintained a regimented sleep schedule, and deleted social media apps from my phone. There were social consequences with these strategies: going to bed early on the weekends limited my time with family and loved ones, while staying connected with friends became harder without social media. I scripted and prepared for not only presentations and meetings but also everyday conversations. I have alarms, reminders, calendars, and lists to keep track of my life. At the end of medical school, I started taking medications for what I initially thought was just a problem maintaining wakefulness. Still, ADHD leaves its mark on how I live and work. I can take hours to write an e-mail or fill out a form because of the need to triple-check my work. Is my name spelled right? Is my address correct? My notes can accidentally turn into long essays. I am always the last one to leave the hospital.

When I disclosed my diagnosis to my mother, she was surprised, but she did not reject it like I had anticipated. Instead, we had a conversation about what ADHD looks like in women and common misconceptions about it. As a provider, I am grateful for this experience because it has taught me more about ADHD and neurodivergence than anything in my formal education so far. When I see patients now, I almost always ask questions about neurodivergence, especially with girls, women, and gender-diverse individuals. I also do not rely solely on DSM criteria when screening for ADHD; instead, I ask detailed questions about hobbies, workflow, and factors that support or hinder focus (e.g., interest, stress, and competition).

I wanted to share this story because I know there are many other AAPI women like me who compensated and flew under the radar despite all the internal shame and guilt over not being good enough. Even now, I am still trying to finish all those projects I started in medical school. However, instead of continuing to dwell on what I cannot do, I now have different tools and strategies to chart my path forward. Now, I can finally tell myself that I am enough.