Synopsis of Treatment of ADD

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.

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1. Diagnosis: The first step in treatment is making the diagnosis. Often this carries with it considerable relief as the individual feels, "At last there's a name for it!" The therapy begins with the diagnosis.

2. Education: The more one can learn about ADD, the more successful the therapy will be. A thorough understanding of what ADD is allows you to better understand where ADD affects your life and what to do about it. It also allows you to take the key step of explaining it to other people.

3. Structuring: Structure refers to the external limits and controls people with ADD so urgently need. Such concrete, practical tools as lists, reminders, simple filing systems, appointment books, goals, daily planning, and the like can greatly reduce the inner chaos of an ADD life and improve productivity as well as one's sense of control.

4. Coaching and/or Psychotherapy: The person with ADD will greatly benefit from having a "coach," someone standing on the sidelines with a whistle around his neck calling out encouragement, instructions, and reminders, and in general helping to keep things going on task. People with ADD thrive with this sort of structured encouragement, and they feel lost without it. Group therapy can provide this most excellently. Traditional psychotherapy may also be indicated if depression, problems with self-esteem, or other internal problems exist.

5. Medication: There are several medications that can help correct many of the symptoms of ADD. The medication works like a pair of eyeglasses, helping the individual to focus. It can also reduce the sense of inner turmoil and anxiety that is so common with ADD. The medication works by correcting a chemical imbalance of neurotransmitters that exists in ADD in the parts of the brain that regulate attention, impulse control, and mood. While medication is not the whole answer, it can provide profound relief, and when it is used properly, it is very safe.

In Jim's case treatment went very well. By the time we parted company, he had changed his life. Within eight months he began to put together his own computer consulting business, specializing in some kind of software manipulation I never did understand, but one that few others could understand and a lot of people wanted, so his business grew. Being his own boss, he didn't have the kinds of troubles with superiors he'd had before. Of course, he did have to relate appropriately with clients, and this was a skill he worked on. He settled into his relationship with Pauline in a way that pleased them both. He had developed a series of techniques for managing himself, as he put it. No longer shooting himself in the foot, he was beginning to make use of the creative brain he'd always had.

Case 2: Carolyn

Carolyn Deauville came to see me one afternoon, "just to chat." When she made the appointment, she told me over the phone, long distance, in her rich southern accent, "Honey, I know what I've got. I just want you to sit there and nod and listen."

Carolyn strode into my office, all five feet ten inches of her, wearing a pastel orange chiffon dress with a white sash and a beige broad,brimmed hat. She wore peach-colored lipstick and smelled of a perfume that immediately filled the room, very pleasantly, but not subtly. Like her perfume, Carolyn filled the room quickly. "You don't mind if I do this?" she asked, lighting up a Vantage. Exhaling smoke, she opened her blue eyes wide and looked fight at me. "I feel like we're old friends. I've heard you speak. I've read some of your articles. We both have ADD. I'm a therapist, you're a therapist. Lord, we're practically neighbors. Except I'm from three thousand miles away in California."

"California?" I asked. "I would have guessed —"

"From my accent, you would have guessed somewhere in the South, and you would have been fight, since I grew up in New Orleans. But marriage number two took me to the Golden Gate, and I've never been back."

"You said on the phone you just wanted to chat."

"I've been a psychologist for twenty years now and I've been specializing in ADD for the past ten. I've never told anyone my story, and I thought you'd be a good person to start with, since I liked you from the way you talked."

We agreed to have a few appointments. She was in town with her husband at a convention for his business. She'd be here a few days.

As her story unfolded, I had to marvel at her resilience and ingenuity. "I'm an orphan, or at least I used to be. My mother got pregnant and Catholic teenage girls in Louisiana in the thirties didn't have abortions. So here I am. I was adopted when I was two. What a mismatch my mother and I were. She was a wonderful lady and I love her dearly, but she was so ladylike and organized, and I, well, I wasn't. My mama couldn't civilize me, try as she might. I sat with my legs apart, I bit my nails, I let my skirt ride up, I got dirty all the time, I was a real pigpen. My first vivid memory is running away from Summation Bible School at age four. It was so boring. Jimmy Tundooras and I tiptoed out the back door and ran down the dirt road toward the river. After a little while Jimmy got scared and went back, but not me. I wandered all over town until I fell down asleep. They found me late that afternoon in a ditch by the side of the road. Did Mama give me what for. Must've wondered why she ever went to that orphanage.

"My next best memory is sitting on top of the water tower. Must not have been a day over six. Once I learned how to climb up to the top of that tower, I did it all the time. Sometimes, after I learned to read, I'd put a book in my teeth and climb up and sit all afternoon reading. Can you believe it? Whenever I drive past a water tower today, I shiver. They're very high! Back then I remember dangling my feet over the side and looking down and saying, 'O-o-o-o-e-e-e.'"

"Didn't anybody tell you not to go up there? I asked.

"Nobody knew I did," she answered in a whisper, as if it were supposed to remain secret to this day. "Oh, I was a devil of a kid, or so Mama said, but she loved me, too. It's just that I was always into things. Saturdays. I hated Saturdays. Some inexplicable uneasiness would come over me on Saturdays. I didn't know why then, but looking back I can see that it was because on Saturday all my sins of the week would be discovered. Mama was a schoolteacher and too busy to notice during the week, but come Saturday she'd inspect my clothes and find that one white cotton glove I needed for church was missing, or was filthy dirty. Or that I'd tom the sash for my dress. Or that a bunch of clothes were missing. I was in the habit of giving away clothes to the kids at the orphanage. I didn't know that I was adopted, so I don't know why I gave my clothes away, but I did. Mama would despair."

"And your father?" I asked.

"Daddy was like the pied piper. He loved children, and he loved me. Which was lucky, because I needed all the love I could get. Especially after I started school and after Warren was born. After all the trouble Mama had getting pregnant, what does she do but produce a menopause baby, Warren, my brother. He was an angel as much as I was a devil. They might as well have put a halo over his head. And school? Well, my first memory of school is getting spanked by Mrs. Kimble for not being able to lie still on my pallet. I never did lie still, or sit still for that matter.

"I was slow to learn how to read, but once I did, I was a voracious reader. Little Women, The Secret Garden, Hans Brinker — these were my books. On top of the water tower, under the kitchen table, wherever I could find a spot to be left alone, I'd tug a book out of my pocket and read. Math was a disaster. They had flash cards, and one student would pass them out to all of us. I used to save my dessert to bribe whoever was doing the passing out to give me the easy cards. I especially liked the zero cards, one plus zero equals...? I always despaired when they had a dessert I couldn't sequester in my pocket or under my dress, like pudding. Even pie I got pretty good at hiding."

"You do sound like a happy kid, in spite of it all," I said.

"I was. I've always been happy. I think it's temperament, and it's the luckiest thing in the world. Even when I had every reason not to be, I was happy. I always found a way. Once, in second grade, I was being punished for having smacked Nancy Smitt by being told to stand behind a table away from the other kids. This was on a morning parents were coming through to visit, so it was supposed to be particularly embarrassing and humiliating for me to have to stand off to the side behind this table. Well, what did I do? The table came about up to my midsection, so I just robbed up against it and let my mind drift away as everybody passed through. I'm sure no one noticed, and I'm sure I hardly even knew that I was masturbating right there in public view in the second-grade classroom.

"I always did talk too much," Carolyn said, as if she thought she still did. But I didn't think so. I loved hearing her story, particularly the way she told it, from incident to incident, all in the thickest and softest southern voice. "The hardest thing about it all was getting teased so much. I was so reactive. All my emotions were on the surface. Someone would make a face at me, and I'd stick my tongue out right back. Someone would whisper something about me, and I'd jump on their back. Also, I cried really easily. Someone would hurt my feelings, and boohoo, the tears would come. Well, you know how kids hone in on that. So I was always getting teased. Daddy would coach me on how to ignore it, but I never could. In third grade I beat up two boys on the playground, and that was at a time when girls simply did not fight, let alone fight boys. Mama was mortified, but Daddy took me aside and told me he was proud.

"Poor Mama, she got mortified a lot. In sixth grade my teacher got so fed up with looking at my messy desk — strewn with bits of paper, balled-up gum, a bent fork, and even old desserts — that she took a few brown paper bags and emptied it all for me to take home to show my mother after school. Mama was mortified once again.

"She tried so hard to make me be a lady. I wanted to peroxide my hair, but she said no. What did I do? I was such a slob. I took lipstick and tried to streak my hair with that instead. It just became a greasy mess. I was forever stuffing my chest with rolled-up socks. Except I didn't do that very skillfully either. One day a sock popped out of my dress in tenth-grade science class. You can imagine the reaction.

"Somehow, though, I got through. All my reading must have paid off, because I scored high on achievement tests and got a scholarship to college. At the time, I was amazed I did so well on the tests, as was everybody else. There were even whispers that I must have cheated. But knowing what I know, I think I did well because I was so motivated I went into one of those hyperfocused states people with ADD can go into. For once Mama wasn't mortified. And I scraped my way through college and got into graduate school, which I did part-time since I was having babies. Then I quit school completely for a few years before going back and finishing my Ph.D. and becoming the woman you see sitting before you now."

"You never knew you had attention deficit disorder?" I asked.

"Never. Not until I diagnosed myself well after graduate school. What do you think? Do I fit the picture?"

"Yes, you surely do," I said. "How did you feel when you discovered you'd had ADD all along?"

"Just this huge relief. At last there was a name for it, especially all the emotional reactivity that got me teased so much. I had thought I was a typical female hysteric or something. Plus everything else. The not sitting still, the going up the water tower, the fights, being a mess, having trouble in school. Things fit into place. The best thing was getting a name for it. I'd pretty much figured out how to handle it by the time I found out I had it."

"Why did you want to see me?" I asked.

"To get a second opinion," she said. "I've only had myself to confirm my diagnosis."

"Well," I said, "it sounds like pretty classic ADD to me. We could get some testing to get further confirmation. But you could have done that already. And I think you know you have ADD. Are you sure there isn't some other reason you came here?" I asked.

Carolyn, who had told her story virtually without missing a beat or coming up for air, paused. She took her hat off, which revealed her whole face from broad forehead to pointed, definite chin, and she shook out her light brown hair. Tall, elegant, secure, she surprised me by what she said next. "I wanted you to tell me I'd done a good job," she said softly. "That sounds infantile, I'm sure, but you can't imagine what an effort it's been. Actually, I thought perhaps you would know how much it's taken, since you see so many people like me."

"Not many people like you," I said. "You never got any help along the way and you've overcome your obstacles just by intuition and persistence. You've done an amazing job, Carolyn. You've done very well. You should feel proud."

"Thank you," she said. "I needed to hear that from someone who really knew."

Carolyn's story is remarkable in some ways and representative in others. As a child, her symptoms were typical: hyperactivity, thrill-seeking, trouble in school, emotional intensity, and impulsivity. She also had many of the positive qualities that are often not mentioned when one hears about ADD: spunk, resilience, persistence, charm, creativity, and hidden intellectual talent. What was remarkable was that she was able to develop her talents without any special help. She did not get buried under the teasing she received; she did not lose her positive sense of who she was, or who she could be. In many ways the most dangerous aspect of undiagnosed and untreated ADD is the assault to self-esteem that usually occurs. Whatever talents these people may have, they often never get to use them because they give up, feeling lost and stupid. Carolyn is a wonderful example of someone who prevailed.

Case 3: Maria

Maria Berlin came to me for a consultation after reading a piece in the newspaper about ADD in adults. "I didn't know there was such a thing," she said, crossing her legs at the calf as she settled back into my overstuffed office couch. "My husband showed me this article in the paper, and I started to wonder."

"Tell me a little about yourself," I said. It is always hard to know where to jump in when I meet a patient for the first time. There is a standard way of taking a history — name, address, presenting problem, and so forth — but that can be overly structured and not give the person the chance to say what they really want to say. So I usually start with something that invites the person to say whatever he or she thinks matters. Of course, this can be misleading as well, because the inevitable jitters associated with the first appointment can lead one far astray.

Maria, however, got right into things. "I don't know what is wrong with me — maybe there's nothing. Whatever it is, I've been like this for a long time. As long as I can remember. Since I'm now forty-one, that's a long time. My main problem is that I don't get around to doing the things I want to do. Maybe that's just the pace of my life. I'm married and I have two children, eleven and eight, and they take up a lot of my time. But I have been working on my Ph.D. for years, and the dissertation keeps sitting there, half-done, winking at me like a sleeping turtle. Sometimes I wish it would walk away and leave me alone."

"Do you have a regular job as well?" I asked.

"Yes. Well, when I want to, that is. I work at the library in town, and they're very flexible about when I come and go. What I've really been trying to do, aside from finishing my dissertation, is start an exercise clinic for women over forty at our local health club. I have a brochure I've been wanting to write for what seems like forever. The management of the place has been very receptive. If I ever get to it, they'll let me run it as my own business and if I pay them a small rent. They think it would be good publicity for the club."

"Your Ph.D. is in —"

"Totally unrelated. English literature. Don't ask me what the connection between that and exercise is. I'm sure there is one somewhere, but I don't know where. My dissertation is supposed to be on Eugene O'Neill. I fell in love with O'Neill when I read A Long Day's Journey into Night when I was in high school, and that love continued through graduate school. But in case anyone hasn't told you, the best way to fall out of love with something is to write a Ph.D. thesis about it. I'm so tired of O'Neill I could spit. Isn't that sad? I thought at one time I had something original to say about him, but now I could care less."

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.