Who Owns ADHD?

In February, a study from the University of Washington made its quiet way into the ADHD conversation. It didn’t accuse anyone of malpractice. It didn’t declare a crisis. It simply observed something curious: only about a quarter of licensed psychologists actively advertise ADHD care.

In isolation, that statistic feels startling. ADHD diagnoses have surged in the years following the pandemic. Adult awareness has grown. Medication demand has climbed. Social media has amplified lived experience. And yet, according to this study, most psychologists do not publicly position themselves as ADHD providers.

The narrative that followed was almost inevitable: psychologists are underserving the ADHD community.

But that framing carries assumptions.

Advertising is not the same as competence. Nor is visible branding the same as absence of care. Many clinicians treat ADHD without building their practice identity around it. Still, perception shapes demand, and demand shapes markets. When a community feels underserved, something fills the vacuum.

In North America, that “something” is increasingly the specialist hub.

Across cities, multidisciplinary ADHD centres are opening their doors. Psychologists collaborate with coaches, dieticians, occupational therapists, sometimes psychiatrists. The promise is integration — care that is no longer fragmented, no longer dependent on patients coordinating between professionals who may never speak to each other.

It is a persuasive model. Bring everyone into one ecosystem. Reduce communication breakdown. Replace the scattered referral chain with a coordinated team.

It sounds efficient, modern, corrective.

And perhaps, in that context, it is.

But healthcare systems do not exist in abstraction. They are shaped by funding models, training pipelines, cultural narratives, and public policy priorities. What emerges in Seattle does not automatically translate to Cape Town.

If we shift the lens to South Africa, the question subtly changes.

What would our version of that “25%” even look like?

The South African Variable

In the United States, the gap is often framed as a choice of focus — a clinician deciding whether to specialise. In South Africa, scarcity is less elective.

Per capita, South Africa has roughly 1.5 to 2.5 psychologists per 100,000 people, compared to around 30 per 100,000 in the U.S. Scarcity here is not rhetorical. It is structural.

Even within that limited workforce, most psychologists trained in neurodevelopmental work are Educational Psychologists who primarily see children. Adult ADHD often lands in the rooms of Clinical Psychologists whose training emphasised mood disorders, trauma, and anxiety. The result can be what many adults describe as a diagnostic merry-go-round — treatment aimed at depression or anxiety without addressing the executive dysfunction driving it.

But the pressure does not end with training.

South Africa’s legislative framework introduces another layer. ADHD medication such as methylphenidate remains classified as Schedule 6, requiring a new physical script every 30 days. While telehealth and longer refills expanded in the U.S., South African patients often remain locked into a month-to-month prescription cycle.

For psychologists, who cannot prescribe, this creates an indirect burden. Patients must see a GP or psychiatrist monthly for script maintenance. The financial and cognitive load of this recurring administrative loop often drains both budget and energy — leaving little capacity for the therapeutic or coaching work that actually addresses executive function gaps.

Funding structures compound the strain. ADHD remains excluded from Prescribed Minimum Benefits (PMB) status. Unlike Bipolar Disorder or Schizophrenia, it is not legally required to be funded from the chronic benefits basket. As a result, many private patients absorb between roughly 35% and 62% of ADHD-related costs out of pocket.

In this environment, the integrated hub model — psychologist, prescribing doctor, coach — becomes less a systemic solution and more a premium service accessible to a minority.

The American “visibility gap” begins to look very different here.

But What About ADHD Coaching?

Parallel to these structural constraints, coaching in South Africa has grown steadily.

It is young. It lacks a singular philosophical core. There is no protected title, no mandated accreditation pathway, no universal standard. The field includes deeply thoughtful, evidence-informed practitioners — and it also includes those who promise dramatic transformation with little methodological grounding.

That variability makes institutions uneasy.

And when institutions grow uneasy, they reach for a familiar instrument: regulation.

But the language of regulation often carries another dynamic beneath it — professional territoriality. Established disciplines historically protect scope boundaries carefully, especially when adjacent fields emerge that operate in overlapping terrain.

To describe coaching simply as “unregulated” risks triggering a reflex: professional capture.

That would be a mistake.

Not because risk does not exist — it does. Variability must be acknowledged. Public protection matters.

But coaching’s expansion has not been accidental. It has emerged from unmet need — particularly the need for practical scaffolding, implementation support, accountability structures, and environmental redesign. These are domains that short, reimbursable therapy sessions are not always structured to prioritise.

Coaching’s novelty is not its flaw.

It is its unfinishedness.

And unfinishedness can either be shaped collaboratively — or absorbed defensively.

Lived Experience as Operational Knowledge

Beneath the debate about regulation and legitimacy sits a deeper discomfort: what counts as knowledge.

Lived experience in ADHD is often treated as anecdotal. But it is more accurately described as operational knowledge.

Those who have navigated executive dysfunction from the inside frequently develop micro-systems, activation strategies, environmental modifications, and accountability structures that are rarely formalised in academic curricula. Not because the science disputes them, but because professional training often privileges diagnosis and symptom categorisation over behavioural systems engineering.

This is not an argument against psychology.

It is an argument for epistemic humility.

If psychologists specialising in adult ADHD were open to structured collaboration with experienced coaches — not as motivational adjuncts, but as contributors to curriculum design — professional depth could increase rather than dilute.

Coaching does not need to be regulated into conformity.

It needs dialogue rigorous enough to build shared ethical standards without extinguishing accessibility or lived epistemology.

Why the U.S. Model May Not Translate

Specialist hubs in the U.S. reflect a market-driven healthcare ecosystem. Integration is packaged as efficiency. Centralisation is framed as innovation.

In South Africa, multidisciplinary ADHD centres would likely be urban, private, and costly. They may improve coordination for those who can afford them. They may also widen inequity.

And even if they function flawlessly within their walls, they do not address the broader context.

Workplace neurodiversity literacy remains underdeveloped. Policy conversations are often absorbed by other transformation priorities. Executive dysfunction is frequently interpreted as underperformance rather than neurological variation requiring structural accommodation.

Integration inside a clinic does not automatically translate to accommodation outside it.

If we replicate the American hub model without reforming training depth, cross-professional collaboration, funding inequity, and workplace literacy, we risk building boutique excellence rather than systemic change.

The Real Question

The U.S. study asks whether psychologists are underserving ADHD.

South Africa should be asking something more uncomfortable:

Who gets to define what legitimate ADHD expertise looks like?

Because beneath the statistics, beneath the hub models, beneath the funding debates, sits a quieter tension — ownership.

There are members of the professional class who view ADHD as territory. A domain secured by degrees, licensure, and institutional recognition. And when coaching enters the conversation — especially coaching grounded in lived experience — it is sometimes treated not as collaboration, but as intrusion.

That instinct is understandable. Public protection matters. Scope boundaries matter. Scientific rigour matters.

But ownership is not the same as stewardship.

If the reflex is to regulate first and collaborate later, we risk repeating an old pattern: professional consolidation disguised as quality control.

The ADHD ecosystem in South Africa is already fragile. Scarce specialists. Uneven training. Funding exclusions. Legislative hurdles. Workplace illiteracy. To shrink the field further by excluding lived-experience practitioners would not strengthen it — it would narrow it.

The harder move is different.

The harder move is for the professional class to acknowledge that lived experience in ADHD is not a threat to expertise — it is a source of it.

The harder move is to invite coaches into curriculum conversations, ethical framework discussions, and interdisciplinary dialogue not as guests, but as contributors.

The harder move is to accept that knowledge in ADHD care is distributed.

If we fail to do that, specialist hubs will not fix fragmentation. They will centralise it.

And if we truly care about improving outcomes — not protecting turf — then the question is no longer whether psychologists advertise ADHD.

It is whether we are willing to build a system that values competence wherever it emerges.

That will require humility on all sides.

But especially from those who believe they already own the space.