IS ADHD REALLY ABOUT ATTENTION AND DOES IT MATTER?

Today I read something written by Awais Aftab about ADHD being really about “sustained engagement” and not attention. He is a “practicing” psychiatrist who is starting a series called Therapeutic Window with this piece that was published in the New York Times on September 29, 2026. Dr. Aftab refers to some of his patients describing struggling to stay focused, being forgetful, are disrorganized, are restless and impulsive. He refers to an ongoing debate on whether ADHD is being overdiagnosed while he then refers to “scientists” questioning what actually is ADHD. He refers to a study published in the journal Cell and I could not find the reference and instead it seemed to describe a reference: Distractibility and impulsivity neural states are distinct from selective attention and modulate implementation of spacial attention by, Amengual et al., published in Nature Communications (2022). They concluded that selective/spatial attention is functionally intact in ADHD and symptoms [of ADHD] arise from non-attentional neural processes. However, a Neuroscience review in 2024 Nature Reviews concluded that ADHD is not localized to a single system or circuit, including the attentional circuits, but instead is distributed across arousal, reward, executive, and default-mode systems. This may be why there can seem to be a distinction between distractibility/impulsivity and spatial attention, as if they were separate conditions.

My experience with 100s of adult patients diagnosed with ADHD, having had symptoms since early childhood, is that they are typically not impulsive [or hyperactive] but seem to be inattentive and distractible. These symptoms then seem to respond to the amphetamine type medications for ADHD. However, there have been some of my patients who were very distractible and seemed inattentive and yet their distractibility was related to repeated thoughts about past traumatic experiences that grabbed their attention and distracted them from other tasks that they thought they were prioritizing. These types of distractions do not seem to respond to medications for ADHD but do respond to reductions in the anxiety connected to recalling past traumatic experiences.

My ongoing question is whether the medications that are typically prescribed for ADHD symptoms [amphetamine based] actually help improve the capacity for sustained attention and reduce distractibility. If these medications can help reduce these symptoms then how do they do that?

There seems to be a concensus that these medications work by increasing synaptic dopamine and norepinephrine, thus optimizing activity in the fronto-striatal-cerebellar circuits that are felt to be hypofunctional in ADHD although the FDA label states that the therapeutic mode of action “is not known.” There are competing explanations for what these medications actually do as indicated in an article by Kay et al., in Cell 2025 that states that these medications improved reaction time, reduced impulsivity/premature responding, better distractor suppression and greater effort persistence and motivation. They also reported that studies indicating that the attention and cognitive control networks were improved with these medications were frequently not replicated in larger studies. Kay et al. concluded that these medications modulate arousal and reward/salience systems [including the salience network and parietal memory network, linked by dopaminergic connections to the nucleus accumbens] rather than attentional networks.

Regardless of how exactly these medications work, how can you tell that they are working? The concensus about this seems to be a combination of clinical assessment, rating scales [like the ADHD-RS-IV] and information from other observers. Studies have indicated that up to 75% [even > 90%] of assessment of responses to medications are based on clinical assessment of the patient with 25% also using a rating scale. The assessments are focused on a meaningful [recognized by the patient as significantly helping and observable to the clinician] reduction in inattention and/or hyperactivity/impulsivity with few if any side-effects [monitoring appetite, sleep, heart rate, blood pressure, mood and height at least annually in children] and a clear indications of better performance at home, school and work. There is also recognition that the doses can be increased more rapidly as the onset of action is rapid and that >90% of patients will respond to these medications. Also, titrating to higher tolerated doses improves efficacy.

So, regardless of the actual neuropathological processes that affect people with ADHD, these medications are very helpful and seem to be well tolerated. There also seems to be a very low risk of developing an addiction. This low risk of developing an addiction seems to be supported by my repeated observation that my patients who have ADHD respond to these medications with nothing that would indicate that they are responding like would be typical for an amphetamine type medication. They only have a brief lowering of appetite, feel calmer and less stressed and with no increase in activity or energy beyond the benefit of being more focused. They seem to respond to these medications in a different way compared to non-ADHD people.