Driven to Distraction (Revised) Page 10

  The themes of ADD run throughout: inconsistency, and inconsistency again, creativity, provocative behavior, winning personality, varying motivation, exasperating forgetfulness, disorganization and indifference, underachievement, impulsivity, and the search for excitement rather than discipline.

  I put Will’s story in this book not to chide the school or the teachers or parents for missing the diagnosis of ADD. Nobody picked up on it, nobody, from parents to pediatrician, to school, to anybody else, because nobody knew what to look for. When Will was in school, not many people were that conversant with ADD. Nobody is to blame for the diagnosis being missed. If anything, the teachers and parents should be praised for their continuing, patient effort to help Will work to his potential. The damage they did, although real, was inadvertent.

  Without knowing about ADD, one looks at Will’s reports and simply sees a boy who is terribly inconsistent and probably needs to buckle down. But when you know there is such a thing as attention deficit disorder, and what the symptoms are, then it is astonishing how all Will’s teachers’ comments fall into place, describing various manifestations of Will’s ADD.

  The situation is like one of those trick photographs: when you’re shown it the first time, you see nothing but a black and white blotchy mess. Then, when you are told it is actually a photograph of the face of a cow, the cow’s face jumps out at you, clear as can be, and you can never look at the photograph again without seeing the face of that cow.

  How much happier and more productive Will’s school years could have been if people had known he had ADD all along. The moral condemnation that seeps into so many of the comments could have been excised, the inconsistency of Will’s academic work could have been understood in terms other than those of laziness or selfishness or irresponsibility. His intermittent poor performance could have found remedies more effective than exhortation or disapprobation, and, in short, Will could have gotten more out of school.

  Another reason for including Will’s story is to stress that the child with ADD need not be flunking out of school, or have a specific learning disability, or be so hyperactive as to be disruptive, or a major discipline problem. He, or she, can be like Will: an attractive, well-liked student, given to periods of high achievement as well as periods of low, moving along from grade to grade without anybody thinking anything much was wrong that a little growing up or a kick in the pants wouldn’t cure.

  By the time a solid diagnosis of ADD had been made for Will he was about to flunk out of college. By then his self-image had solidified around such ideas as “I’m lazy”; “I’m a born B.S. artist”; “I never really come through when I should”; and “I’m talented, but I don’t dare to give it my best shot in case I might fail.”

  As Will learned about ADD, he had mixed reactions, reactions that are not uncommon, particularly among young men. On the one hand, Will felt a sense of relief. He was excited to know there was a name for his problem other than laziness, a cause for his trouble other than “badness” of character. And he was excited that there was treatment available. On the other hand, Will was skeptical. A part of him did not believe in the diagnosis. It was too perfect to be true. A part of him felt much more comfortable with calling himself lazy than with accepting the idea of ADD.

  Will felt more at home seeing his life in terms of a sort of macho struggle, a struggle he was losing, a struggle to “buckle down” or to “shape up,” than in seeing himself as not totally in control, the victim of a syndrome called ADD.

  In addition to resisting the diagnosis, Will also resisted the treatment, which included medication. He didn’t want to rely on a pill, as he put it, to think straight. In fact, the medication, which in Will’s case was Ritalin, worked very well to help him focus. However, Will would only take it erratically. When he took it, his grades improved; when he stopped it, they went back down. This linear correspondence between school performance and taking the medication, if anything, impressed Will too much. It left him feeling that it was the medication, not himself, that was getting the good grades. So he would discontinue the medication in an effort to prove he could make it on his own. This cycle of Will’s taking the medication followed by improved grades followed by stopping the medication followed by falling grades repeated itself a dozen times during Will’s college career. He never reached the point where he could see the medication as a legitimate treatment, like eyeglasses, instead of a crutch or even a form of cheating. Will subjected his life to a rigorous, if idiosyncratic, code of honor. And taking medication sometimes went against his code of honor.

  This kind of deep-seated self-reliance is not uncommon among young males diagnosed with ADD. It was preferable to Will to go it on his own, albeit with great difficulty in focusing and concentrating, than to rely on a medication, however helpful it may have been. It was easier for him to make use of coaching—tips from family, therapist, and others who knew about ADD.

  With this combination of insight, support, intermittent medication, and intermittent hard work, Will eventually put together a fairly good college career, after a near-disastrous start. He continues to wrestle with the diagnosis of ADD. He also continues to be warm, gregarious, friendly, creative—and often depressed, due to his underachieving. He fiercely resists using the diagnosis of ADD as a crutch. At the same time, he continues to be brought up short by the limitations ADD places upon him.

  Not surprisingly, Will’s ADD took a toll on his parents. They are no-nonsense Yankee types who all along thought Will was a creative, talented kid who just couldn’t get his act together. They tried all the tactics parents of adolescents try: they yelled at him, they grounded him, they ignored him, they fought with him, they negotiated with him, they sent him to a psychotherapist, they hovered over him, they bribed him, they scolded him, they pleaded with him, they hugged him. They always loved him, and they never gave up on him, but they felt endlessly exasperated at his inconsistency and apparent lack of effort. They wanted the best for him, and they ached for him while helplessly watching him apparently let so much promise slip away.

  After the diagnosis of ADD was made, and after Will had spent a couple of years in college, he said something to his mom which prompted a letter, which I excerpt here.

  Dear Will,

  We know so well how much you care—about us, about the family, about doing well, about honesty and pride and compassion. You are an incredible person and have been ever since you were a little boy. I’ve always said that you were born smiling. You were. People looked at you when you were a baby, and they smiled back. You had an innate something that just made people happy—and you were happy.

  It killed me to watch that happy little boy fade into a frustrated adolescent. Where did Will go? Dad and I tried to understand. We hadn’t a clue that there was even such a thing as ADD, and neither did you. So, what do you do when you watch a kid not do his work, but then try, and then not try, and then be sad, etc., etc. I yelled at you and tried to wake you up. Wrong tactic. Dad talked soberly and grounded you. Again, wrong tactic. We were trying to reach you on the only levels we knew. And all that time, we knew we were missing the boat. We knew that we hadn’t found the key. [Once the diagnosis was made], Dad and I knew we had blown it with you.

  So, Will. What do we say? Sorry? We are. I hope you know that. We are so damned sorry. Part of it wasn’t our fault because no one knew what ADD was, etc. But a lot of it was our fault, because we knew something was wrong and we didn’t find out what it was. That is what parents are supposed to do. We were trying, but we screwed up. It’s not because we didn’t care about you. We cared.

  Do you believe that? I could see that you might not. But actually, I know that you know just how much we cared, and care.… We look on you as a really terrific person who we love to have be around us. I think of you as one of my best friends as well as my little kid (no longer). Who do I call when something goes wrong with one of the other kids? How much do I ask for your advice? You must see how much I value your judgment.…


  But I also think you are struggling to figure out who you are and what you want out of life. Any kid your age worth anything is in the same situation. Some don’t show it obviously, but most kids are worried and wondering. There’s a lot to worry about. On top of this, you are trying to figure out how to deal with ADD. You are right when you say that Dad and I don’t really understand it. We don’t, but we are trying. We want to. And we want to help you get a handle on it. I think that you beat it last year—although you are still fighting it and will always have to—last spring you won. It was great! I think you are making tremendous progress dealing with a disability that is so insidiously difficult that it’s amazing you don’t just quit. But that isn’t you and never has been.

  Frustration! We do understand frustration. When you have a little kid you absolutely adore, you will understand better how frustrated Dad and I have been. At you, sure—but on your behalf even more. We wanted you to feel successful and happy. You might not think that we do, but we do. We understand—we hate it that you have to deal with ADD—and we can’t fix it. Dad wants to fix it. But we can’t. Only you can do that, and it is an ongoing process. What we can do is tell you that we understand and care very, very much. We want to help in any way that we can, but it is up to you now to let us know how.…

  Always, always we loved you and were solidly behind you no matter what scrape you got yourself into. Always. I think that is one of the few things you can count on in your life. Your parents think you are great. And there is nothing that, as a team, we can’t beat. You’ll figure out ADD. I think you are well on your way.…

  Love,

  Mom

  3

  “Sequence Ravelled Out of Sound”

  ADULT ADD

  I felt a Cleaving in my Mind—

  As if my Brain had split—

  I tried to match it—Seam by Seam—

  But could not make them fit.

  The thought behind, I strove to join

  Unto the thought before—

  But Sequence ravelled out of Sound—

  Like Balls—upon a Floor.

  —Emily Dickinson (1864)

  Emily Dickinson captures with her customary startling simplicity the distress of the ADD mind. Although of course not written explicitly about ADD, this lyric poem gives a wonderfully apt description of the subjective experience of ADD. “I felt a Cleaving in my Mind— / As if my Brain had split.” Not a cleft, but a cleaving; the use of the gerund just adds to the activity of the description. How many of us with ADD have felt, as we whirl around from one project to the next, trying to stay abreast of the mounting mass of details, that our brains were about to split? And then we look down to find our projects rolling around, like balls upon the floor. Most adults with ADD are struggling to express a part of themselves that often seems unraveled as they strive to join the thought behind unto the thought before.

  As we are learning more and more about ADD in adults, we are realizing how far-reaching its impact can be.*

  In 1978 Leopold Bellak chaired a conference on what was then called minimal brain dysfunction (now ADD) in adults. The collected papers from this conference were published in 1979 and comprise a remarkable book—accurate, ahead of its time, full of new and exciting data. The presenters at that conference, including Hans Huessy, Dennis Cantwell, Paul Wender, Donald Klein, and others, were onto something new and important. They were reporting on their finding that MBD (or ADD) does not just go away in childhood. Instead, it persists into adulthood and can be as vexing for adults as it can be for children. Unfortunately, it took another decade before people began to recognize the clinical significance of Bellak’s book—how widespread ADD is in adults and what a human toll it exacts when it is not diagnosed.

  Bellak’s book, which is now out of print, was written for a professional audience and was published under the dour title Psychiatric Aspects of Minimal Brain Dysfunction in Adults. In the popular press there is still very little. Paul Wender’s book, The Hyperactive Child, Adolescent, and Adult, is an excellent text for the layperson that includes a brief section on adults. Lynn Weiss, a psychologist from Texas, has written a book entitled Attention Deficit Disorder in Adults that includes a great deal of useful information. But our knowledge of ADD as it appears in adults is still young, and the field is still finding itself.

  Interestingly enough, one of the landmark studies in the entire ADD area, a study that really marked a turning point in establishing a biological basis for ADD, was done not on children but on adults by Dr. Alan Zametkin, at the National Institutes of Mental Health. We will discuss this study in detail in chapter 9, whose subject is the biology of ADD. In brief, what Zametkin proved was that there is a difference at the cellular level, in energy consumption, between the parts of the brain that regulate attention, emotion, and impulse control in subjects with ADD as compared with subjects without ADD. The study was published in 1990 in one of the most highly respected, rigorously edited of all medical journals, the New England Journal of Medicine. While there had been other studies that suggested a biological basis for ADD before, this study was the best designed and the most convincing.

  Subsequent to that study, David Hauser and Alan Zametkin published another study in 1993, again in the New England Journal of Medicine, which added evidence to the biological basis for ADD. Hauser and Zametkin found a strong correlation between a rare form of thyroid dysfunction, called generalized resistance to thyroid hormone (GRTH), and attention deficit disorder. It was interesting enough to find a correlation between a certain kind of thyroid disease and ADD. But to find the kind of correlation they reported—70 percent of people studied who had GRTH also had ADD—added strong evidence to the growing data demonstrating a biological, likely genetic, basis for ADD.

  Since the publication of Zametkin’s study, and then Hauser and Zametkin’s study, and with the ongoing excitement that surrounds research in this field in general, many investigators have become interested in adult ADD. We are only beginning to discover how extensive ADD is—probably over 10 million American adults have it—and we are only beginning to appreciate how dramatically effective treatment for it can be.

  As we have begun to understand the biological basis for it, we are also beginning to know ADD in human terms: how it influences a life, what shape it takes, how it can get in the way, how it can actually help, and how it can best be managed.

  Based on our experience with hundreds of patients, we have compiled the following set of symptoms as being the most frequently reported. The symptoms below are only “suggested” criteria, suggested by us, based upon our experience with adults with ADD. As yet, we do not have any criteria that have been tested and validated by field trials as we do for children. These suggested criteria summarize the symptoms we have seen most commonly in adults with ADD. Other practitioners may well amend them according to their own clinical experience.

  As one reads down the list, certain themes emerge. There is the classic triad of symptoms from childhood: distractibility, impulsivity, and hyperactivity or restlessness. In addition, one sees problems with moods, depression, self-esteem, and self-image. In general, the symptoms are the logical outgrowth of what is encountered in childhood.

  * * *

  SUGGESTED DIAGNOSTIC CRITERIA FOR ATTENTION DEFICIT DISORDER IN ADULTS

  NOTE: Consider a criterion met only if the behavior is considerably more frequent than that of most people of the same mental age.

  A. A chronic disturbance in which at least fifteen of the following are present:

  1. A sense of underachievement, of not meeting one’s goals (regardless of how much one has actually accomplished).

  We put this symptom first because it is the most common reason an adult seeks help. “I just can’t get my act together” is the frequent refrain. The person may be highly accomplished by objective standards, or may be floundering, stuck with a sense of being lost in a maze, unable to capitalize on innate potential.

  2. Difficulty
getting organized.

  A major problem for most adults with ADD. Without the structure of school, without parents around to get things organized for him or her, the adult may stagger under the organizational demands of everyday life. The supposed “little things” may mount up to create huge obstacles. For the want of a proverbial nail—a missed appointment, a lost check, a forgotten deadline—their kingdom may be lost.

  3. Chronic procrastination or trouble getting started.

  Adults with ADD associate so much anxiety with beginning a task, due to their fears that they won’t do it right, that they put it off, and off, which, of course, only adds to the anxiety around the task.

  4. Many projects going simultaneously; trouble with follow-through.

  A corollary of number 3. As one task is put off, another is taken up. By the end of the day, or week, or year, countless projects have been undertaken, while few have found completion.