Synopsis of Treatment of ADD, Part 4

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 7 of 7)

People with ADD do look out windows. They do not stay on track. They stray. But they also see new things or find new ways to see old things. They are not just the tuned-out of this world; they are also tuned in, often to the fresh and the new. They are often the inventors and the innovators, the movers and the doers. Good Do-Bees they may not always be, but we should be wise enough not to force them into a mold they'll never fit.

But what of these devilish windows? Is it so bad — a sure mark of educational decline — to look out them? I wonder instead if it isn't the duller child who does not look out windows.

Penny's eye certainly found its way there. As she sat, her right cheek comfortably contained in the palm of her right hand, the fingers of her left hand tapped soundlessly on the wooden desk while she gazed out the window. I looked to see what she saw, but I could only see sky and an ascending branch of a nearby tree. That's one thing about window-staring: you can never really tell what the other person is seeing out there.

Every now and then, usually in response to a noise of some sort, Penny would look toward the blackboard and the numbers that were accumulating. Today's board was sprouting fractions by the minute. Penny must have seen something in them because she'd wrinkle her brow now and again when she'd look at them. She didn't seem troubled, just serenely uncomprehending. Then she'd brush back her hair, and, as if following the trail of a speck of dust, slowly turn her head back to the window. She made no noise. She caused no disturbance whatever. If anything, her serenity lent a calming influence to the classroom. It was easy to imagine how she could go unnoticed over the years.

I introduced myself to her after class, as there was a break for recess. Her parents had told her I'd be coming. "Hello, Dr. Hallowell," she said with a big smile. "My mom said you're a nice man."

"Well, you have a nice mom," I said. "Did she tell you anything else?"

"I don't think so," Penny said, her face contorting into a there's-something-I'm-supposed-to-remember-but-I-can't look.

"That's OK," I said. "Do you want to get outside for recess?"

"Mom said you might want to talk to me," Penny said.

"Just for a second. Your mom and dad came to see me to ask if I could help out with how things go for you in school and stuff. Do you like school?"

"Oh, yes," Penny said enthusiastically.

"What do you like about it?" I asked.

"I like the teacher and I like the other kids, and I like the walk to get here from home and I like the time to sit and listen —"

"What do you listen to?" I asked.

"Oh, to anything," Penny said. "Mostly my own thoughts. I like to make up stories in my head. Mom and I have a kind of game —"

"She told me about it," I said. "Sounds like fun. Is that what you were doing during math class this morning?"

"Yes," she said. "I was making one up about fat old men who looked like sixes and funny old women who looked like nines and they went dancing together and turned into eights."

"That's great, Penny," I said. "Do you think the eights will get back to sixes and nines?"

"Maybe," she said, pulling at the yellow-spangled stretch band around her ponytail. "I was actually going to have them lie down and become binoculars that could see very far away."

"All the way to Faraway Land," I said.

"Yes," she said, blushing a little bit that I knew the name of the place in the stories.

"Is there anything you don't like about school?" I asked.

Penny looked down at her sneakers. "I'm behind all the time. I don't get the homework."

"Maybe we can find you some help with that," I said. "Recess is almost over, I bet. Maybe we could meet sometime later when you're not in school."

"Sure," Penny said. "But you'll have to speak to my mom. She makes all my appointments."

"Of course," I said. "Great meeting you, Penny. See you later."

Becky Truesdale was a young teacher just out of a teaching internship at a private school near Boston. She knew a lot about ADD and learning disabilities. "I'm so glad you could come," she said to me. "I didn't want to call on Penny in class so you could see how she is when she's left alone. She's really smart, you know."

"Mmm," I said, "and she seems happy, at least today." I thought I heard a trace of a southern accent in Becky's words. "Are you from the south?" I asked, the impulsivity of my own ADD overcoming the tact and sequentiality I should have given the exchange.

"Why, yes," Becky said, not annoyed by my change of subject. "I grew up in Charleston until my family moved to Maine."

"Quite a change."

"That's for sure. And you?"

"I actually lived for a few years in Charleston myself," I said. "As a kid." We paused. "How long have you known Penny?" I asked.

"Just since the beginning of the school year. Six weeks. Not long enough to know her well, but long enough to like her. She reminds me of a young artist or something, sitting in the back daydreaming."

Do you think she's depressed?" I asked.

"No," Becky said with a laugh. "Far from it. She brightens right up whenever you talk to her. The other kids like her. Even when she stands off, they don't pick on her. It's as if they accept that that's just her way."

"What is your main concern about her?" I asked.

"That she really isn't with us," Becky said without hesitation. "And I'm afraid that the further she goes in school the more of a problem that will become. Even in this class she misses a lot, but somehow she compensates. Still, I know she could be learning more."

Becky and I talked until the end of recess. I thanked her for her help and said goodbye, promising to stay in touch.

There was a list of conditions in my mind that could explain Penny's situation. After I met with Penny in person again, met with her parents once more, and got some neuropsychological testing done, that list had narrowed to two: attention deficit disorder without hyperactivity and both expressive and receptive language disabilities.

ADD exacerbates learning problems in the same way that nearsightedness does: you can't focus as well as you should, so you are not able to use the talents you have to the fullest. The first step in treatment is to get glasses, or treat the ADD, and then reassess the extent of the residual learning disability.

Just making the diagnosis, giving a medical name with a rational treatment to what Penny's parents had thought was an immutable quirk of temperament, helped a lot. Once everybody understood what was going on, we started medication. While the medication by itself would not be sufficient treatment, the results in this instance were dramatic and quick.

There are several medications used in the treatment of ADD. They all help the individual to focus better. In a sense, they act like internal eyeglasses, increasing the brain's ability to focus on one task over time while filtering out competing stimuli or distractions.

Of the various medications available, we chose Norpramin for Penny. Norpramin is in the class of medications referred to as the tricyclic antidepressants. Although medications in this group are called antidepressants, they have many other uses than for the treatment of depression, including the treatment of ADD, both in children and adults. The most common other group of medications used to treat ADD are the stimulants, which include Ritalin and Dexedrine. Used properly, both groups are extremely safe and effective. We chose Norpramin for Penny because it can be taken just once a day, instead of the two or three a day required for the stimulants.

Within a few days of Penny's starting medication, her parents as well as Becky were on the phone to me. They were all amazed. She was tuned in in class, focused on the work at hand, participating actively and creatively. Most of all, she was really enjoying school, and in ways she had not enjoyed it before. She was enjoying learning. The medication's only side effect in Penny's case was mild dry mouth, caused by the anticholinergic property of the tricyclics (that is, they block the neurotransmitter acetylcholine, which mediates various bodily functions, including salivation) as happens with many over-the-counter cold remedies. This is tolerable and may be counteracted with a Life Saver or other lozenge. The medication did not take anything away from Penny; she could still daydream when she wanted to.

While this was only the beginning of the treatment, it was in many ways the most moving part for everyone, including me. As Penny's mother put it to me in one of our follow-up visits, "It's as if a veil has been lifted from Penny's eyes. She can see us and we can see her. She's still my dreamer, but now it's on purpose that she dreams."

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.