What Is Attention Deficit Disorder? Part 3

Driven To Distraction : Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood
by Edward M. Hallowell, M.D., John J. Ratey, M.D.

(Page 3 of 7)

"You have ADD?" Jim asked, apparently taken aback. "You seem so calm."

"Practice," I said, smiling. "Actually, I'm sure for you there are times when you can be quite focused and relaxed. For me, doing this kind of work is one of those times. But the practice part is true also, and we'll get into that."

From this point Jim's treatment began. Actually, it had begun already. Just finding out about the syndrome, finding at last that there is a name for it, constitutes a large part of the treatment for most people.

"What is it with me?" he asked in one session. "I don't mean to be rude. But this guy calls me up and he starts to tell me the materials I sent him were the wrong ones, when I knew perfectly well they were the right ones, he just didn't know why they were the right ones, and so he thought they were the wrong ones, and so immediately that started to annoy me, but it wasn't even that that got to me, it was his tone of voice. Can you believe it? I knew from the first second he started on the phone that I wanted to hang up on him or punch him."

"You had like a rage reaction," I offered.

"Damn straight. And when I think about it now, I get mad all over again. So I tried to do what you said. Pause. Think of the consequences. This was a good customer. I didn't want to lose him and I didn't want him bad-mouthing me to his friends. So I paused. But the more I paused, the more he talked on, in this really slow, dumb voice, on and on, and! wahted to scream at him, 'Get to the point!' So instead, I just cleared my throat. But then he said to me, 'Don't interrupt me, I'm not finished.' Well, I lost it. I told him I thought we could be on the phone until next Christmas and he still wouldn't be finished and I had better things to do and I hung up. Can you believe that?"

I laughed. "I think you did very well. At least up until you lost it. The guy was pushing your buttons. And let's face it, there are going to be times where you're going to get annoyed and you're going to lose it. Treatment for ADD won't take that away completely, and you wouldn't want it to, would you?"

"I guess not. But is this part of ADD, this rage reaction, as you call it?"

"Yes," I said. "It's part of the impulsivity. If you think of ADD as a basic problem with inhibition, it helps explain how ADD people get angry quicker. They don't inhibit their impulses as well as other people. They lack the little pause between impulse and action that allows most people to be able to stop and think. Treatment helps with that but it doesn't cure it completely."

"You know what the funny thing was?" he asked. "The guy called me back the next day and said he was sorry we had developed a communication problem between us the day before and maybe we could start over. A communication problem, can you believe that? I said sure, only let me start this time. I explained to him in ten seconds why what I had sent him was what he needed, he said he understood and said thank you, I said, 'No, it is me who should thank you, I'm sorry for our communication problem yesterday,' and we said goodbye, best of friends." Jim slapped his knee.

"How do you like that?" I said. "Your guardian angel must have been on duty."

"But where does it come from, this anger?"

"Can you tell me?" I asked.

"I think it's built up over the years. When I was a little kid, I was all over the place, but I wasn't angry. I think it built up, in school. All the failures. All the frustration." Jim clenched his fists without knowing it as he talked about his feelings. "It got so I knew before I started something it wasn't going to work out. So all I had left was tenacity. I wouldn't give up. But, damn, why didn't I, with all the screw-ups I had to show for my efforts?"

Jim was beginning to get into what is a large and very important part of ADD, although, strictly speaking, it is not part of the neurological syndrome itself. He was starting to talk about the secondary psychological problems that typically develop in the wake of the primary neurological problem of ADD.

Due to repeated failures, misunderstandings, mislabelings, and all manner of other emotional mishaps, children with ADD usually develop problems with their self-image and self-esteem. Throughout childhood, at home and at school they are told they are defective. They are called dumb, stupid, lazy, stubborn, willful, or obnoxious. They hear terms like "spaceshot" or "daydreamer" or "out in left field" all the time. They are blamed for the chaos of family mealtimes or the disaster of family vacations. They are reprimanded for classroom disturbances of all sorts and they are easily scapegoated at school. They are the subject of numerous parent-teacher conferences. Time and again, an exasperated teacher meets a frustrated parent in a meeting that later explodes all over the child who isn't there. He feels the shock waves afterward. "Do you know what your teacher said? Do you know how embarrassed your mother and I were?" Or, from the teacher, "I understand you have no greater control of yourself at home than you do in school. We must work on this, mustn't we?"

Month after month, year after year, the tapes of negativity play over and over again until they become the voice the child knows best. "You're bad," they say in many different ways. "You're dumb. You just don't get it. You're so out of it. You really are pathetic." This voice pulls the child's self-esteem down and down, out of the reach of the helping hands that might be extended, into the private world of adolescent self-reproach. Liking yourself in adolescence is hard enough work for any child. But for the child with ADD it is especially difficult.

"You kept up your efforts, but it must have been tough," I said to Jim.

"It sure was," he responded with a kind of ruefulness in his voice that said to me, You don't know the half of it."

"Tell me about it," I said.

"It's just that I wouldn't know where to begin. By high school they almost had me convinced I was just plain stupid. I mean, I couldn't figure it out. I could understand the stuff in class. I could follow what was said. I could even jump ahead in my mind. But when it came to writing the papers or getting the assignments organized or taking tests, everything just went out the window. I would try. Believe me, I would try. I got lectures all the time on how I didn't try, but I did try. It's just that the bigger sledge hammer didn't work. I'd lock myself in my room and before you knew it I was gone. Doing something else. Reading. Listening to music. Then I'd catch myself and try and get to studying again, but goddamn it, it just didn't work." Jim's voice got harsh and his face turned red.

"It all comes back, huh," I said.

"It sure does. They'd tell me to try harder. Over and over again. Try harder. And I'd try harder and it wouldn't work. After a while! figured I didn't have the brain to do it. And at the same time I knew I did. But it just didn't work out."

"So you were frustrated all the time. No wonder you felt angry."

"Do you think that's why I started drinking? I felt better after I had a few pops. But doesn't everybody?"

"Sure," I said. "But it is likely that you had special reasons to drink. You were medicating yourself, as so many people with ADD do. Alcohol, marijuana, cocaine are all common. In different ways each of those drugs calms you down. But only in the short run. In the long run, they can all be disastrous."

"I think I knew that. I think that's why I never let myself develop a regular habit. I thought that would really be the end of the line for me." Jim paused. "Why cocaine? I thought that juiced you up."

"It does for most people. For people with ADD, however, it helps them focus. So, without knowing it, when they use cocaine they are medicating themselves."

"No kidding. Anyway, I'm just glad ! found out about this before I let my whole life get away."

"How did it affect your relationships with other people?" I asked. "I didn't think about it at the time, but all the things we've been talking about got in the way with friends and girls and everyone else. I wouldn't listen —"

"Couldn't listen," I corrected him.

"OK, couldn't. But everybody else thought wouldn't. I'd be late for things, or I wouldn't show up at all, having forgot. I wouldn't hear things tight, so I wouldn't respond right — you know the story. People thought I was arrogant or I just didn't care. I did have a short fuse, that much was true. When someone would call me on something, I'd just tell them to kiss off. Didn't make me real popular. But still I had friends. Most important of all, Pauline stuck with me. Sometimes I wonder why. I would forget things, not show up, get angry or depressed for no reason. I'd be talking to her, and then I would disappear into some daydream. I'd promise to do something with her, and then I would forget. Somehow, she didn't dump me. But it sure wasn't easy. We always seemed to be in the midst of some potential argument. There's always been a fight waiting to happen. When I would screw up at work, she offered encouragement, but I could tell she was thinking, What is it with this guy? I was thinking the same thing. I don't think I could have survived this long without Pauline. She's incredible. But the relationship has been awful tough on her. I'm just not an easy guy. I know that. I know I'm exasperating. I'm exasperating to myself. I wish to hell I weren't. Believe me, I'm not like this on purpose. I think Pauline believes that, too, deep down. Otherwise how could she have stuck with me?"

"She probably does. But you're a good guy, Jim. People put up with your annoying habits because you made it worth their while in other ways."

An important, and often overlooked part of both learning disabilities and ADD is the social consequence of having them. ADD can interfere with one's interpersonal life just as dramatically as it does with one's academic or job performance. To make friends, you have to be able to pay attention. To get along in a group, you have to be able to follow what is being said in the group. Social cues are often subtle: the narrowing of eyes, the raising of eyebrows, a slight change in tone of voice, a tilting of the head. Often the person with ADD doesn't pick up on these cues. This can lead to real social gaffes or a general sense of being out of it. Particularly in childhood, where social transactions happen so rapidly and the transgressor of norms is dealt with so pitilessly, a lapse in social awareness due to the distractibility or impulsivity of ADD can preclude acceptance by a group or deny understanding from a friend.

"I sometimes wonder how I made it this far without getting killed," Jim laughed. "Must be the luck of the Irish."

"Could be," I said. "But maybe you learned little tricks along the way without even knowing it. In a sense, having ADD was part of your ethnicity, too. It defined how you were, what was in your bones, just as much as your Irish heritage did, but in different ways."

Jim's treatment lasted about a year. It included psychotherapy once a week as well as small doses of medication. The psychotherapy was more like coaching than traditional psychotherapy in that it was educational, informative, directive, and explicitly encouraging. I cheered Jim on from the sidelines. I helped him build a new understanding of himself, taking into account his ADD, and I helped him build ways of organizing and structuring his life so that ADD wouldn't get in the way so much. The medication helped him focus and stay on task. As he put it, it took the static out of the broadcast.

We will discuss treatment in detail in chapter 8, but as an introduction, here is a synopsis of the most effective components of treatment. Note that while the medications used for ADD can provide remarkable help, they are not the whole treatment by any means. A comprehensive program works best.

About the Author

Edward M. Hallowell, M.D., is an instructor at Harvard Medical School and director of the Hallowell Center for Cognitive and Emotional Health in Sudbury, Massachusetts, an outpatient treatment center serving children and adults with a wide range of emotional and learning problems. He is the co-author of Driven to Distraction and the author of The Childhood Roots of Adult Happiness, and Worry, among other titles. He lives in Arlington, Massachusetts, with his wife and three children. He welcomes hearing from readers, and can be reached through his website at www.DrHallowell.com.

John J. Ratey, M.D., is an associate professor of psychiatry at Harvard Medical School. He has lectured extensively and published many articles on the topic of treating adults with ADD. Dr. Ratey is the author of A User's Guide to the Brain and the co-author of Driven to Distraction. He lives in Cambridge, Massachusetts, where he has a private practice.