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Adult ADD Reader
Table of Contents Introduction......................................................................................................................... 3 By Cynthia Hammer
Attention Deficit Hyperactivity Disorder ........................................................................... 5 By Russell A. Barkley, Ph.D.
A Scientific Explanation for a Crazy-Quilt Career............................................................. 8 How to Diagnose and Treat Attention Deficit Disorder By Douglas B. Richardson
Shadow Syndromes........................................................................................................... 13 People with Mild Forms of Serious Disorders By John J. Ratey, M.D.
Suggested Diagnostic Criteria for ADD in Adults ........................................................... 16 By Drs. Edward Hallowell and John Ratey
General Adult ADD Symptom Checklist ......................................................................... 19 By Daniel G. Amen, M.D.
A Physician's Perspective ................................................................................................. 23 By Theodore Mandelkorn, M.D.
50 Tips on the Management of Adult Attention Deficit Disorder .................................... 34 By Edward M. Hallowell, M.D. and John J. Ratey, M.D.
Management of ADD Within Families............................................................................. 38 by Edward HalloweII, M.D.
Tips on ADD in Couples................................................................................................... 41 by Edward M. HallowelI, M.D. and John J. Ratey, M.D.
How Most Adults Begin Treatment for ADD................................................................... 44 by Thomas Phelan, Ph.D.
Diagnosis Shock: A Common Response .......................................................................... 46 By Thomas Phelan, Ph.D.
Effectively Communicating Adult ADHD Diagnosis ...................................................... 49 By Kevin R. Murphy, Ph.D.
AD/HD “To Do” List........................................................................................................ 50 By Cynthia Hammer, M.S.W.
Is Therapy, and this Therapist, for You? .......................................................................... 53 By Cynthia Hammer, M.S.W.
Paying Attention To Attention Deficit In Adults.............................................................. 56 By John J. Ratey, M.D.
The Adult Experience Of ADD ........................................................................................ 59 By Thomas Phelan, Ph.D.
Adult ADD: Issues And Concerns.................................................................................... 61 By Thomas P. Phelan, Ph.D.
Living and Loving with Attention Deficit Disorder ......................................................... 63 Couples Where One Partner Has ADD By Edward Hallowell, M.D.
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Adult ADD Reader
If Your Spouse Has ADD ................................................................................................. 69 What It’s Like to Be Married to Someone with ADD By Kathleen Nadeau. Ph.D.
Your ADD Spouse ............................................................................................................ 72 Care of the ADD Adult By R. Brian Howell
The Emotional Experience of Attention Deficit Disorder ................................................ 74 By Edward Hallowell, M.D.
Hypersensitivity R Us ....................................................................................................... 81 By R. Brian Howell
Women and ADD ............................................................................................................. 82 By Kathleen Nadeau, Ph.D.
Keeping Up with Mona Can Kill Your Self-Esteem ........................................................ 86 Self-Esteem Issues in Adults with AD/HD....................................................................... 87 By Cynthia Hammer, M.S.W.
Attention Deficit Causes Problems in the Workplace ...................................................... 90 By Daniel Amen, M.D.
Be All That You Can Be… in the Workplace .................................................................. 92 By Cynthia Hammer, M.S.W.
The Americans with Disabilities Act................................................................................ 95 Mood Disorders ................................................................................................................ 97 A Confounding Diagnosis By Irving J. Kohlberg, M.D.
Healing the Chaos Within................................................................................................. 99 The Interaction Between ADD, Alcoholism and Children and Grandchildren of Alcoholics By Daniel G. Amen, M.D.
Our Expanding ADD Knowledge................................................................................... 103 by Corydon C. Clark, M.D.
ADD, Alcoholism and Other Addictions........................................................................ 108 By Wendy Richardson, MA, LMFCC
How ADD Affects Your Waking-Sleeping Cycle.......................................................... 111 By Daniel Amen, M.D.
Confront Your Clutter..................................................................................................... 115 By Caroline Koehnline, M.A.
Seven Easy Steps to Procrastination ............................................................................... 117 Author Unknown
You Know You Have ADD When… ............................................................................. 117 Author Unknown
Choosing and Working with a Coach ............................................................................. 119 Author Unknown
An ADD Story—Sad, but, Too Often, True ................................................................... 121 By Darryl Peterson
Did My Ritalin Stop Working?....................................................................................... 124 By Cynthia Hammer, M.S.W.
How We Survived as an Undiagnosed ADD Family...................................................... 127 by Cynthia Hammer, M.S.W.
Resources ........................................................................................................................ 135 Contributors .................................................................................................................... 136
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Adult ADD Reader
Introduction By Cynthia Hammer If you have purchased this reader because you are wondering if you might have add or adhd 1 , you might have a variety of responses to the enclosed material. Perhaps it will be immediately clear to you that you have ADD, and you set about getting diagnosed and treated. This is the dramatic response that is written about in newspaper articles. A parent takes his child in to be diagnosed for ADD, recognizes him or herself, bursts into tears, is diagnosed and treated, and experiences a dramatic improvement in his life. While not denying that such scenarios do occur, it is not the journey I went on to develop my awareness and acceptance of having ADD. It took me over a year after learning about ADD to realize I had this disorder and another year in treatment to develop a positive attitude. For any of you who may be reluctant to start your journey, I assure you that learning to accept and manage your ADD will bring you more satisfaction and contentment with your life than you have ever experienced. Although my brother and nephew were diagnosed with ADD over ten years ago, no bells went off in my head when we started to have problems with two of our children. (Russell Barkley, Ph.D. says 40% of children diagnosed with ADD have a parent with the same disorder while Dr. Mandelkorn, M.D. says that over 90% of those diagnosed with ADD have a relative somewhere in the immediate or extended family who also has the condition.) I knew there was a familial connection to the condition but thought what our children were exhibiting was plain, old-fashioned misbehavior. If we could parent better, they would behave better. Off and on I had read library books about ADD, Sometimes I would think it described one or another of my sons, but then again, it did not sound quite like them. So it went for several years. Then my husband heard a pediatrician talk on ADD. He came home convinced it described one son. We took him to be diagnosed and started him in treatment. After a year of attending treatment sessions with my son, along with more reading and attending CHADD meetings, I tentatively told the pediatrician treating my son that I thought I had ADD and he, without any tentativeness, agreed! The prime reason it took so long to help my children and myself is denial. No one wants to admit there is something the matter. They don't want to have impairment. They don't want to be different from "normal” people. The condition is called a “disorder,” such a hopeless sounding label .My relatives with ADD were having major problems in their lives. I had a reluctance to associate my children with the same condition. Wasn’t this consigning them to a bleak future? Wouldn't it be more hopeful to keep working on better parenting skills than to say they had this disorder. I thought ADD was a handicapping condition that would be diagnosed and that would be it. I focused on denying the disorder, instead of on how treatment could bring benefit and improvement. After accepting the diagnosis and treatment for my sons, why did it take so long to see the condition in myself? Denial, along with two other factors, was at work. ADD is difficult to self-identify because of its complexity and the lack of clarity in the description of the symptoms. One author would stress certain 1
Most practitioners now recognize that Attention Deficit Disorder exists both with and without hyperactivity so ADD will be used as the generic term to cover both conditions
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features or describe them in a way that I could relate to. I would say, 'Yes, that's me!" Another author would describe other features and it wouldn't sound like me! I should have paid more attention to the wording that introduces a list of characteristics, where it says, for example, "will demonstrate 8 of the following 20 characteristics." I didn't need to have all the characteristics to have the condition, but the characteristics had to be of a degree and pervasiveness that they caused significant turmoil in my life. The other factor that makes self-identification difficult is related to an ADD characteristic—lack of selfawareness. For example, I could feel I had offended a co-worker, but I had no insight or understanding of how or why. I was too fearful of what they might say to ask them. ADDers do not realize how they come across to others. (This is why it is helpful to have outside evaluations of your behaviors from people closely associated with you.) In many ways, people with ADD delude themselves that they are doing just fine; it's the others that they work with or associate with who have the problems. ADDers always have good reasons to justify why they did something the way they did, and they do not understand why others might have a problem with that. My lack of self-awareness made me unable to examine my own actions and say to myself, "This is typical ADD behavior." However, I was able to look at my son's troublesome behaviors and recognize that I did similar things. What he did (or did not do) that annoyed me were things that I did! As I analyzed my son's annoying behaviors, I began to have some understanding of how I annoyed and frustrated others. Another factor in my developing awareness was my supervisor. Her grandson recently had been diagnosed with ADD, and she had read about the condition. She knew my two children had been diagnosed, and we sometimes would share information. During my annual evaluation, she brought up some points about my work that could use improvement, e.g., my inability to be a team player; my penchant for getting excited about a new project, but dropping it when only partly finished, blithely expecting someone to finish it because I had moved on to other things; and my not prioritizing my work so that the most important things got done. She said I was a mixed bag and that made it hard to evaluate me. I did some things very, very well and other things inadequately. I recognized these behavior patterns as common to ADD. When I mentioned that I thought I might have ADD (again my tentativeness), she said she thought so too. After getting diagnosed by a knowledgeable physician, I entered treatment, and like the condition itself, my emotions became very complicated. Of course, I felt relief, mentally saying over and over again, "So that explains it!" After starting on medicine, I immediately noticed improvements in my functioning and relationships. The education and counseling I received helped me learn which behaviors were related to ADD, and I instituted techniques for managing or minimizing their disruptive influence. So it surprised me, when almost a year after being diagnosed, I blurted out, "I've been in a grieving process," I hadn’t been aware of feeling this way until the words came out of my mouth. Why is there grief! I have two explanations. To accept the diagnosis and treatment, I had a loss in myselfimage. Prior to knowing I had ADD, I knew I was an "individual." I did some things, maybe many things, differently than others, but I had a pride in most of my characteristics and abilities. Now I was learning that those characteristics that made me special are a disorder. Even though I had not seen the connection, my special characteristics had made my life more difficult than it is for "normal" people. I felt like a disabled person. As I became more aware of how I came across to others, I felt shame and embarrassment. There was something the matter with me. Others could see it. Often they were reacting negatively to me because of how I acted. Even though part of me could see that my relationships were improving because of treatment, another part of me withdrew from relationships. I felt awkward and selfconscious, feeling that I was "less" than others. The second reason for grief was a realization that my whole life had been less than it could have been. If only someone had only known about my ADD years ago.... If only I had been diagnosed and treated years
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earlier.... Much in my life would have been better. These thoughts kept going through my mind. I reflected on the inappropriate actions I had taken, the people I had offended, the mistakes I had made. I felt ADD was accountable for all that had been bad in my life. Many ADD adults, in addition to grief, experience anger as they recall their life experiences. They have so many unhappy memories of being demeaned, berated, and made to feel inadequate. Now they wonder why no one knew there was something "wrong." They wonder why they weren't treated with more kindness, patience, understanding and love. It would have made such a difference! With treatment, both of these emotions—grief and anger—subside and resolve. I came to realize that knowing I have ADD did not make me a new person. I stayed the person I was, my unique, special self. Only now I can better control the kind of person I am, and I am better at perceiving how I come across to others so I can adjust my behavior accordingly. Knowing about my ADD and getting treatment for it did not make me less, as I initially thought. I am all that I was, and now I have the potential to be even more. In this context I like to think of the American advertising slogan, "New and improved." While I am not a new model, I am improved! Life is a continuing adventure.
Attention Deficit Hyperactivity Disorder 2 By Russell A. Barkley, Ph.D. Attention Deficit Hyperactivity Disorder (ADHD) is the most recent term for a specific developmental disorder of both children and adults that is comprised of deficits in sustained attention, impulse control, and the regulation of activity level to situational demands. This disorder has had numerous different labels over the past century, including hyperkinetic reaction of childhood, hyperactivity or hyperactive child syndrome, minimal brain dysfunction and Attention Deficit Disorder (with or without Hyperactivity).
Major Characteristics Poor sustained attention or persistence of effort to tasks, particularly those, which are relatively tedious, boring, and protracted. This is frequently seen in repetitive tasks, shifting from one uncompleted activity to another, frequent loss of concentration during lengthy tasks, and failing to complete routine assignments without supervision. Impaired impulse control or delay of gratification. This is often noted in the individual's inability to stop and think before acting, to wait one's turn while playing or conversing with others to work far larger, longer-term rewards rather than opting for smaller, immediate ones, and to inhibit behavior as a situation demands.
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Reprinted with permission. From ATTENTION-DEFICIT HYPERACTIVITY DISORDER: A CLINICAL WORKBOOK, copyright 1991. The Guilford Press, 72 Spring St., NY, NY 10012. For orders, call 1-800365-7006.
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Excessive task-irrelevant activity or poorly regulated activity to situational demands. Individuals with ADHD are typically noted to be excessively fidgety, restless, and “on the go.” They display excessive movement that is not required to complete a task, such as wriggling feet and legs, tapping things, rocking, or shifting position while performing relatively boring tasks. Trouble sitting still or inhibiting movement as a situation demands is often seen in younger children with ADHD. Deficient rule following. ADHD individuals frequently have difficulty following through on instructions or assignments, particularly without supervision. This is not due to poor language comprehension, defiance, or memory impairment. It seems as if instructions do not regulate behavior as well in ADHD individuals. Greater than normal variability during task performance. Although there is not yet a consensus for including this characteristic with the others of ADHD, much research has accumulated to suggest that ADHD individuals show wide swings or considerably greater variation in the quality, accuracy, and speed with which they perform assigned work. This may be seen in highly variable school or work performance where the person fails to maintain a relatively even level of accuracy over time in performing repetitive or tedious tasks. Although normal individuals, particularly young children, may show some of these features, what distinguishes the ADHD from normal individual is the considerably greater degree and frequency with which these characteristics are displayed.
Other Characteristics of this Disorder Early onset of the major characteristics. Many ADHD individuals have demonstrated their problems since early childhood (mean age of onset is 3 to 4 years of age) and the vast majority have had their difficulties since 7 years of age. The major characteristics show considerable situational variation in that the impairments are less likely to be seen in situations involving one-to-one activities with others, particularly if they are with their fathers or other authority figures. ADHD individuals also do better when the activities they are doing are novel, highly interesting, or involve an immediate consequence for completing them. Group situations or relatively repetitive, familiar, and uninteresting activities are likely to be most problematic for them. Relatively chronic course. Most children with ADHD manifest their characteristics throughout childhood and adolescence. Although the major features improve with age, most ADHD individuals remain behind others their age in their ability to sustain attention, inhibit behavior, and regulate their activity level.
Adult Outcome It has been estimated that between 15 and 50 percent of children with ADHD ultimately outgrow their problems or at least achieve a point in life where their symptoms are no longer maladaptive. Most ADHD individuals will continue to display their characteristics into young adulthood. The professional literature has only recently recognized that adults may display these features as well, and have manifested them since childhood. Between 35 and 60 percent of ADHD individuals will have problems with aggressiveness, conduct, and violation of legal or social norms during adolescence, and 25 percent are likely to become antisocial in adulthood. The most common area of maladjustment is in schoolwork, where ADHD individuals are more likely to be retained in grade, to be provided special education, to be suspended for inappropriate conduct, or be expelled or quit. ADHD individuals frequently have less educational attainment by adulthood than matched samples of normal individuals followed over the same time period. Approximately 35 percent of ADHD children will display a learning disability (i.e., delay in reading, math, spelling, writing, or language) besides their
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ADHD features. Among those ADHD individuals who develop conduct disorders or antisocial behavior in adolescence, substance abuse, especially using cigarettes and alcohol, are noted in the majority. ADHD individuals without conduct disorder show no greater tendency to substance abuse than do normal people.
Frequency ADHD occurs in approximately 3 to 5 percent of the population, with a sex ratio of 3 to 1 boys to girls. It is found in almost all countries and ethnic groups. It is more commonly seen in individuals with a history of conduct disorder, learning disabilities, or tics or Tourette's Syndrome,
Etiologies ADHD appears to have a strong biological basis, and it is likely to be inherited in many cases. In others, it may be associated with greater-than-normal pregnancy or birth complications. In a few, it arises as a direct result of disease or trauma to the central nervous system. Research has not supported the popular views that ADHD is frequently due to the consumption of food additives or preservatives, or to sugar. While a few ADHD individuals show an exacerbation of their features by allergies, these allergies are not viewed as the cause of ADHD. Individuals with seizures or epilepsy, or others, who must take sedatives or anticonvulsant drugs, may develop ADHD as a side effect of their medication or find their pre-existing ADHD features exacerbated by these medicines.
Treatment No treatments have been found to cure this disability, but many exist that have shown some effectiveness in reducing the level of symptoms or the degree to which they impair adjustment. The most substantiated treatment is the use of stimulant medications. It is often recommended that other treatments be used first or in conjunction with the stimulant medications. These other treatments include training the parents of ADHD children in more effective child management skills, modifying classroom behavior management methods used by teachers, adjusting the length and number of assignments given to ADHD children at one time, and providing special educational services to those ADHD children with more serious degrees of the disorder. Other treatments with some promise but which are not yet fully proven are social skills training, training in self-control methods, or use of antidepressant medication where stimulants are ineffective. For ADHD adults, educating the individual in practical methods of coping with their disability while using stimulant medications may be effective in the more severe cases. Treatments with little or no evidence for their effectiveness include dietary management (elimination of sugar or food additives), long-term psychotherapy, high doses of vitamins, chiropractic treatment, or sensory-integration therapy, despite their widespread popularity. The treatment of ADHD requires a comprehensive behavioral, educational, and sometimes medical evaluation followed by education of the individual or their caregivers as to the nature of the disorder and methods proven to assist with its management. Treatment is likely to be multi-disciplinary, requiring the assistance of the mental health, educational, and medical professions at various points in its course. Treatment must be provided periodically over long time intervals in assisting ADHD individuals to cope with their behavioral disability.
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A Scientific Explanation for a Crazy-Quilt Career 3 How to Diagnose and Treat Attention Deficit Disorder By Douglas B. Richardson Attention underachievers, job hoppers and lifelong outsiders. This article may be for you. I want to address those of you who, among other things, may have bounced around in your career and never really seemed to get ahead catch a break or realize your true potential. Perhaps you've experienced difficulty organizing and completing tasks, or maybe your temper gets you in trouble, your finances and personal relationships are in shambles or you act impulsively and make snap decisions. It could be you've been called lazy or unmotivated so often that you've come to believe it, or that you’re given to mood swings and frequent boredom. Some may even say that you've "never really grown up." Ring some bells? If you didn't wince with some pained self-recognition while reading this list, you may now turn the page—we're not talking to or about you. But if current research is correct, probably 2-5% of all adult Americans is qualified to continue reading. Look around you. Although you may open feel different, out-or-control and alone... you're not, not if you really are an "ADD Adult."
Different Circuits Psychologists and behaviorists have long identified and studied 9 childhood developmental phenomenon called Attention Deficit Disorder, or ADD-also called ADHD, for Attention. Deficit/Hyperactivity Disorder. It's now generally believed that true ADD isn't a matter of psychological maladjustment or dysfunction, but is "organic." That is, it stems from physiological, neurological and/or biochemical factors (although environmental and developmental factors certainly affect the functioning and self-image of someone with ADD). And it doesn't go away. You don't "get over" ADD, like the mumps. You can't will its effects out of existence. On the contrary, ADD apparently is wired into your central perceiving and computing apparatus. Once researchers and professionals get beyond that basic agreement, controversy abounds. Some think ADD has simply become a convenient bucket in which to dump symptom stemming from a variety of causes and. For children with ADD, however, the pattern of behavior that results from these causes is clear enough to create a set of established diagnostic criteria. They focus on issues of inattention, impulsivity, a poor ability to understand and follow rules, hypersensitivity to environmental stimuli problems controlling temper or impulses, procrastination (which, in the care of ADD, is actually an required fear response) and inconsistent performance. The long-term effects of these dysfunctions are predictable: a pervasive sense of failure, a belief that you really art lazy or irresponsible, and a sense of being easily overwhelmed by life. Almost universally, children with ADD suffer from eroded self-esteem and a sense of somehow not fitting in. Here's where it gets interesting for those with troubled careers: Until recently, most experts believed that ADD resolved itself naturally. While it might require control and treatment in children (often with a drug called Ritalin, which has a calming, organizing effect in ADD cases involving hyperactivity), conventional wisdom was that it would disappear during adolescence. Kids, the thinking went, simply outgrew ADD. The corollary 3
This article is reprinted by permission from the National Business Employment Weekly, © Dow Jones & Co. Inc. All rights reserved. For subscription information, call 1-800-JOB-HUNT
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to this belief was that if you saw ADD-like behavior in adults, it was the result of maladjustment, laziness, weak character or rebellion. New research now strongly suggests that ADD doesn't spontaneously disappear. Rather, it continues an into adult life, and the extent to which it manifests itself and screws up your personal life and work performance depends both on the severity of the disorder, and on how effectively you learn to compensate for its effect. Some clinicians now speak of ADD-RT, that is, Attention Deficit Disorder, Residual Type, meaning, "It didn't go away after all." The experts are jousting with one another about technical diagnostic criteria, with much concern about how-to rule out ADD look-alikes (particularly anxiety and other "acting out "disorders). Among those who agree that adult ADD exists, there seems to be consensus on only one other major point: that adult ADD, even if not diagnosed in childhood, could have been uncovered during these early years.
It's Not Just Me? This fine diagnostic point may be lost on people who are trying to function as adults and wonder what current behaviors, tendencies or feelings are valid of ADD (and what they can do about it). The selfassessment process is complicated by the fact that true ADD can range from mild, almost undiagnosable symptoms (with no history of hyperactivity whatever), to extreme, constantly out-of-control manifestations. In the latter cases, there's little doubt about diagnosis and, ironically, it is apt to take a kinder view of people whose behavior reflects a highly visible disorder. It's with subtler cases that the person affected has less sense that something is wrong, and where the outside world is mart inclined to impose unflattering moral judgments: You’re undisciplined, have no willpower, are disruptive and unmotivated. You must have "The Peter pan Syndrome," they say, “You just won't grow up!” Adult ADD has passed at least one litmus test of popular credibility A recent two-page article in a major newsweekly focused almost exclusively on several florid, out-of-control casts, including one man who had lost 123 jobs in his thoroughly miserable work life before being diagnosed as ADD-RT. He started Ritalin (still an unusual and controversial course of treatment in adults), and has found a sense of equilibrium for the first time. Much current interest centers on adults at the margins of ADD diagnosis, those who have achieved enough and present themselves well enough to get hired, but whose inconsistent performance, quirky work habits or volatile temperament impedes their progress. One reason why ADD is overlooked during childhood is that those afflicted never showed remarkably antisocial or hyperactive behavior. Frequently, ADD is associated with high intelligence and creativity, and those with the disorder—often not recognizing that they're different from anyone cite—develop ways of compensating for ADD's disruptive influences. Although easily bored, they may have found a variety of mental and physical techniques to keep themselves in the highly stimulated state they crave.
Diagnostic Criteria 1. Even with the evolving nature of current knowledge, it's possible to describe some suggested diagnostic criteria for adults who wonder if their careers have been held in the lifelong thrall of certain forces they didn't recognize and couldn't understand. According to Drs. Edward M. Hallowell and John J. Ratey, you may be entitled to label yourself as adult ADD if many of the following 20 dysfunctions or discomforts are persistently present in your thinking or behavior: 2. A sense of under achievement and of not meeting personal goals (regardless of actual achievement levels). 3. Constant trouble getting organized and a tendency for little things to add up to create what seem like huge obstacles.
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4. Chronic procrastination, with or without the conscious fear that you won't be able to do something right. 5. Fast starts and a lot of projects going at once, but poor follow-through. 6. A tendency to say whatever comes to mind without considering its impact, appropriateness or timing; extreme candor, often enhanced by a tone of absolute correctness or self-righteousness, 7. A continuing craving for high stimulation, new thrills and new sensations—something on the outside that can catch up with the whirlwind raging inside. 8. A tendency to become easily bored. 9. Easy distractibility and a desire to “tune out" in the middle of a page or conversation, coupled with the occasional ability to hyper-focus on interesting material or topic. 10. High creativity, intuition, natural intelligence or puzzle-solving ability. 11. A disinclination for structure, rules or "proper channels." 12. A low tolerance for frustration 13. Impulsivity, in thought, action or words. 14. A tendency to worry needlessly and endlessly. 15. A pervasive sense of impending doom: "If nothing has gone wrong, it's just about to." 16. Mood swings or depressed feelings, especially when leaving someone or winding up a project. 17. Restlessness. Not the hyperactivity you see in a child, but a surfeit of nervous energy, pacing, drumming fingers and feeling edgy at rest. 18. Addictive tendencies, either to substances or to activities, such as gambling. 19. Chronic problems with low self-esteem. Years of conditioning told you that you're a lazy, weird, undisciplined klutz, and now you believe it. Frustration and under achievement convince you there’s no way up or out. 20. An inaccurate self-perception. You may read other people and situations with great intuitive insight, but don't accurately gauge the impact you have on them. 21. A family history of ADD or manic-depressive illness (bipolar disorder), whether formally diagnosed or not, as well as behaviors and feelings not explained by other medical or psychiatric conditions.
Careers Held Hostage Whether caused by ADD or another ailment, any of these behavioral patterns will adversely affect job performance and satisfaction. Frequently, the byproduct of these behaviors it an inability to maintain a sense of self-worth, malting it hard to develop interpersonal working relationships, much less intimate personal relationships. Developing an attention to detail and a tolerance for repetitive tasks may be your greatest problem. Ironically, a highly structured work environment can be both a boon and a bane: Externally imposed discipline and rules may provide welcome relief from a personal inability to plan. Indeed, people with Adult ADD often become inappropriately dependent on others, not for the informal support of a mentoring relationship, but for a sort of quasi-parental discipline. When this is perceived by the employer as a lack of maturity or an inability to work independently, you get a black mark. Moreover, even when you actively seek structure as an alternative to internal chaos, that structure may feel confining or even physically uncomfortable.
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Because that "outside world" assumes that ADD related behaviors are deliberate and controllable, their repeated emergence—no matter how hard you try to conform, manage time and impose self-discipline— often leads to the conclusion that you're a rebel or "loose cannon" who doesn't care if you perform well on the job. Few people understand that ADD adults can't perform according to conventional measures. Your discomfort, therefore, can be intense, including a pervasive sense of failure with little insight about how to understand or address its symptoms.
What To Do? First, anyone for whom this discussion is setting off loud reverberations is well-advised to seek a clinical professional capable of confirming the ADD diagnosis, as well as evaluating or ruling out other possible causes for the troublesome behaviors and feelings. This may not be an easy task because, so far, relatively few psychotherapists or counselors have had experience or training in working with ADD adults. Yet ADD support groups and information referral resources are springing up nationwide. You might try contacting your local mental health association to identify an ADD support group in your area or search the Internet for resources. Once the diagnosis is confirmed, a variety of reactions, paths, priorities and modalities await, depending on the severity of the disorder, your symptoms and behaviors, degree of discomfort, age and other available resources. Many people react to their ADD diagnosis with intense relief. Here, finally, is an explanation that can put a variety of their behaviors, preferences and dislikes into a clear historical focus. This insight blows like a fresh breeze. For some adult ADD sufferers - generally those with mild or marginal dysfunction—that's it. The recognition that there's a reason for their quirks is all that's necessary. These are the people who already have mastered a variety of coping behaviors. Or, they've sought or stumbled onto jobs that tread lightly on their vulnerabilities while honoring their strengths, such as creativity, spontaneity, intuition, high intelligence, a tolerance for ambiguity, little need for structure, and an enthusiasm for new challenge and projects. Even for such borderline cases, several storm warnings are in order. First, along with the sense of relief that they're simply cross-wired neurologically (not psychologically) can come a deep sadness or anger. These people may simultaneously experience anger at the "outside world" for not having identified their problem earlier, and a sense of lost. Past opportunities to achieve are gone forever. Second is the tendency toward using ADD as an excuse, to yourself and others, rather than as an explanation. It's understandable but ultimately immature for you to ask for a discount from the legitimate demands of your work environment: "Hey! Don't blame me! It's not my fault. I've got this permanent neurological condition." One adjustment that's required once you learn about ADD is deciding how you'll adroitly describe the disorder and its predictable consequences to others without acting like a cripple. For most adult ADD sufferers, response and treatment to the disorder involve some combination of education; the development of coping techniques and external structure, support and coaching; and various forms of psychotherapy and, perhaps, medication. Dr. Lynn Weiss advocates a three-step sequence: 1. Accept the diagnosis and come to grips with your anger and sadness; 2. Rebuild your self-esteem and recover from a lifetime of abuse; and 3. Restructure end learn new skills (ask others for help; learn self-pacing; master distractions; structure work and workspace, etc.).
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Regardless of the severity of your ADD-related dysfunction or discomfort, support groups are widely recognized as an invaluable aid in establishing a stable and productive self-image. Dr. Dan McClure, an ADD expert in Charlottesville, VA, says that, “the importance of the support group to any and all (other) interventions cannot be understated... [and is] essential to treating the adult with ADD."
Career Considerations Support groups not only offer a sense of community, perspective and understanding and understanding to those who may have felt isolated much of their lives, they also provide a vehicle for sharing practical information on managing the disorder, reality-testing and working through crises and other difficult situations on and off the job. ADD and ADHD have been legally classified as disabilities under the Americans with Disabilities Act (ADA), which confers some legal rights on those with the condition, but probably won't make you feel any better or help you adjust to a new workplace any faster. However, employers today art mom inclined toward "job engineering" to accommodate various handicaps and, if properly approached and educated, many will show considerable sensitivity to the behavioral byproducts of ADD. Remember, though, that it isn't a company's obligation to recognize and respond to ADD. The ADD adult must take the initiative to discuss the condition and its implications with an employer, and this entails some evident risks: disbelief, stigmatization, being patronized or having your evident strengths underutilized The alternative, however, is worse: trying to hide or disguise the disorder’s recurring symptoms. If your boss sets only an undesirable behavior with no explanation he's entitled to suspect laziness, rebellion, immaturity or psychological maladjustment.
Looking for the Upside While many with adult ADD see themselves as misfits, others have succeeded in finding roles that draw on their particular strengths without being keyed to their deficits. There are work settings where ADD adults can perform comfortably and develop what Dr. Kevin Murphy of the University of' Massachusetts Medical Center calls a "success identity." Think, for example, about what kind of jobs or roles might include some of the following attributes ascribed to ADD adults: •
A high level of variety (consulting? customer relations?) or physical activity (coaching? adventurebased education? corporate wellness programs? performing arts?).
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A greater emphasis on creative intelligence, conceptual strengths and active behavior than on attention to detail, repetition of tasks or highly regulated tasks (strategic planning? conducting seminars? architecture? landscape gardening?).
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"Project" orientation, that is, activity that involves beginnings, middles and ends, then new beginnings again (litigation? career counseling? carpentry? writing articles? program development? curriculum design?).
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Relatively immediate gratification and feedback rather than long-term or deferred goals (crisis management? shareholder relations? event management?).
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A high degree of autonomy and "running room" (franchise ownership? a sole proprietorship? joint ventures or loose affiliations?).
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Acquisition and use of a specialized skill set that lets you be recognized as an expert (very supportive of one's self-esteem).
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Roles requiring a lot of energy and strong persuasive skills (development/fundraising? sports marketing?)
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Jobs that allow variations in the pace of work: high activity periods followed by "recharging" time, rather than a steady-state pace.
A confirmed diagnosis of adult ADD is a life sentence, but it certainly isn't a death sentence to your career. Like any other handicap, such as color blindness or dyslexia, its effects shouldn't be denied but must be actively addressed and accommodated With the determination to escape the isolation ADD tends to impose, a careening career path often can be set back on track and years of self-doubt and self-reproach put behind you. Managing ADD can be hard work, but then anything worth wanting is worth working for.
Shadow Syndromes People with Mild Forms of Serious Disorders By John J. Ratey, M.D. Neuropsychiatry has undergone a major conceptual shift since the 1960s. In those days everyone was speculating about neurotransmitter levels in mental illness. (Neurotransmitters are the chemicals, like dopamine and serotonin that carry messages between the brain's nerve cells.) Researchers focused upon neurotransmitters—or, rather, the breakdown products of neurotransmitters that can be found in blood and urine—because, given the technology of the day that was what they could study. Blood, urine, spinal fluid: these were the substances researchers could actually collect and measure. We could not look inside the skull. The advent of the brain scan changed everything. Brain scans allow neurologists to move inside the skull: to look at the brain's structure and watch the brain in action as it processes thoughts and emotions. We now have available anew echo-planar magnetic resonance imaging technique that can capture an image of the brain changing every twenty-five milliseconds. In the words of Dr. Joel Yager of UCLA's Neuropsychiatric Institute, soon we will actually be able to watch the "mind boggle."Thus far, this approach has been enormously fruitful. Alan Zametkin of the National Institute of Mental Health has discovered certain areas of the brain involved in attention deficit disorder, areas that appear to be metabolizing glucose too slowly compared to normal brains; others have found the areas affected in obsessive-compulsive disorder—areas which, in this case, appear to be metabolizing glucose too quickly. Now that we can actually look at the brain in action, we have begun, inevitably, to think in terms of brain geography as well as chemistry. In the future we will speak of certain areas of the brain, areas we call microenvironments, and we will think of medication in terms of its ability to target those locations. We will also be adding the elements of time and recursivity to the mix: the way in which a change in one location of the brain, over time: filters out to cause changes in other locations. These downstream changes feed back, in turn, into the original site of alteration, affecting it once again. This does not mean that all talk of chemical imbalances will fade away, but instead that the notion of a chemical imbalance will become more precise as neuroscience advances. Prozac, for instance, is known to raise serotonin levels in the brain, so naturally psychiatrists concluded that it is the rise in serotonin that relieves the depression. But in fact this rise takes place the first day a patient takes the pill, yet the depression does not lift until three to six weeks later. Obviously, something else is going on—something that has to do with the brain's geography and timing, with the particular areas of the brain in which Prozac does or does not find docking sites, and with feedback loops between and among these areas.
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Thus, in the future we will see the language of "brain chemicals," "imbalances," and "levels" joined, and sometimes replaced, by the language of microenvironments, timing, and recursivity. Already, psychiatrists talk about "frontal-lobe types": these are the sticky people we can't get off the telephone. Such people often have problems involving differences in the frontal lobe, hence the nickname. It is a population that has become known by the place in their brain that is not working properly—not by the neurotransmitter that is "out of balance."
Normal People and Their Problems When you think about life in terms of the brain's geography, you quickly develop a real appreciation for Freud's dictum that normal people are not all that normal. The brain is infinitely complex, and a difference in just one tiny area can produce major differences in behavior and emotion—either for good or for ill. Because everyone's brain is different, it is easy to see why all of us may end up with our own particular brain-based emotional difficulties, as well as with our own unique talents and strengths. The biology of the brain's development in early life also points to the possibility that all of us may end up with our own unique mental issues. At the moment of conception tiny differences in genetic endowment from one child to the next will result in major differences in their fully developed brains. Then, as the fetal brain grows, small differences in the biology of the mother's womb (due to hormones, nutrition, viruses, drugs, cigarettes, etc.) will also produce significant differences in the finished brain. In short, the very- complexity of the brain's development makes it likely that all of us end up with parts of our brain that "grew well" and parts that did not grow so well. Every brain is unique, and every brain is going to have its talents and its problems. From the outside those problems are going to look like emotional issues, or cognitive deficits, or both. Even if you were lucky enough to come into this world with a brain that processes information and deflects stress with the best of them, there is No guarantee of making it to middle-age with those capacities intact. One of the important truths in life-a truth that is sometimes lost in the rush to the new biology—is that the biology of our brains is not fixed at birth. The brain develops in response to its environment, which means that painful life experiences leave their mark. We now- possess a fair amount of evidence indicating that psychological trauma actually alters the physical makeup of the brain, that a single episode of major depression in response to a devastating life event scars not only our souls but our gray matter as well. Moreover, some psychiatrists now speculate that, like the long-distance runner's knees, the brain's capacity to handle stress may decline with age. In short, even the golden baby who begins life with a happy face and bright eyes is likely to acquire a few dents and scrapes along the way. Thus, whether for reasons of inborn genetics or reasons of the inevitable wear and tear of life, we may- all have our mental "weaknesses." And until recently, these weaknesses were seen simply as personality flaws that we, typically, blamed on our parents. The man, who can't talk about his feelings, the mother who screams at her children one moment and smothers them in kisses the next, the wallflower. the loner, the needy neighbor you can't get off the telephone: the absent-minded professor, the confirmed bachelor, the overprotective mom who won't take her children to the park for fear they might catch a bug, the husband who tantrums like a four-year old while his children cower before him, the gifted person who cannot seem to live up to his or her potential—all of these "types" have always seemed to be just that: types. The thought—that such ordinary, everyday phenomena as a bad temper or an "inferiority complex" (a popular problem back in the 1950s) might have a biological basis has, until recently, not crossed our minds. But neuropsychiatry is now discovering that a great deal of what we thought was due to (poor) upbringing in fact is heavily influenced by the genetics, structure, and neurochemistry of the brain. Every one of the
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troublesome personalities made famous by our popular press likely has its roots in an unsuspected brain difference: the "Peter Pan syndrome," the "Cinderella complex," the "women who love too much," the "men who can't love," the "codependent"—the list goes on. All of these people are doubtless going to turn out to have brain differences that contribute to their Peter Panness or their Cinderellaness or their codependentness—differences that may also contribute to higher levels of creativity or energy or personal magnetism in their lives as well. Of course, differences in the brain cut both ways: as studies of artists with manic-depressive illness have shown, a brain difference that handicaps us in one realm may- also endow us with greater capacities in another. Our purpose in writing our recent book, Shadow Syndromes: was not to pathologize every nook and cranny of everyday life, but to offer help for those areas in which our brain differences do hurt more than help. Until now there has been No biologically-based help for the difficult personalities among us because no one has suspected that their problems might have biological facets.
Shadow Syndromes In order to take a closer look at normal "craziness," we can learn from the kinds of "craziness" that are not so normal. When we speak of schizophrenia or severe manic-depression, there is No question in anyone's mind that the person is ill. And it is easy enough for us to believe that these illnesses are biological in origin (though it was not so long ago that these illnesses, too, were blamed upon bad parents.) The confusion begins when you see patients who do not fit the classic categories, but who nevertheless have very real difficulties in life. Are these difficulties due entirely to upbringing and environment, or do they, too, have some basis in the brain's biology? Modem psychiatry has been struggling to make sense of these people for fifty years. Doctors diagnose their patients according to the syndromes described in the DSM-IV, the Diagnostic and Statistical Manual, Fourth Edition. A syndrome is a set of behaviors that consistently appear together: a set of behaviors the patient, the doctor, or the patient's friends and family can observe and describe. A syndrome is not, at this point, a physical marker like the positive result on a test for HIV antibodies that establishes a diagnosis of HIV-positive. When a psychiatrist diagnoses the syndrome of panic disorder, for example, he cannot—yet—perform a MRI magnetic resonance imaging) that tells him whether the patient does or does not qualify for the diagnosis (although we may be closest to such a test for this particular disorder). Instead, he looks for symptoms: a pounding chest, rapid heartbeat, shortness of breath or hyperventilation, sweating or coldness and changes in temperature regulation, the fear that one is having a heart attack, sometimes a feeling that the person is going to pass out, sometimes a feeling that he or she is going to go crazy. This is the set of symptoms that make up the syndrome. The problem is, every patient is different—including every patient with the same diagnosis. As a result, the number of syndromes recognized by practicing psychiatrists has leapt in the 40 years since the first edition of the DSM appeared in 1952. That volume described 8O categories of abnormal behavior. DSMII, published in 1968, more than doubled this number to 145 syndromes, and DSM-II raised the total to 230. DSM-IV, which appeared in 1994, lists 410 in all. What the ever-increasing number of possible diagnoses means is that a person who comes into a psychiatrist's office complaining of being "depressed," for example, could be categorized as belonging to one of four major categories—bipolar disorder, major depression, "other specific affective disorders," or "at4·pical affective disorder"—with several subcategories included within each of these main categories. A patient diagnosed as bipolar could then be further characterized as mixed, manic, or depressed, for instance.) It is a complex business. As time goes by, we find that the art of diagnosis grows ever more fragmented; seemingly sound diagnostic categories keep breaking down. Emotional problems do not fit the "concrete blocks" of the
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DSM-I, -II, or -III; real people come into the office with bits of this and pieces of that. A patient might show signs of panic disorder, signs of major depressive disorder, and signs of a narcissistic personality disorder all in the same package. He or she may have parts of a whole array of syndromes, and yet not suffer from all of the symptoms of any one syndrome. Or he may fit every aspect of a syndrome down to the smallest detail and yet be so mildly affected compared to either people suffering from that problem that even a good therapist might miss the diagnosis. Finally, a patient may exhibit only one or two symptoms from a particular syndrome, a condition long known as a forme fruste in conventional medicine. A patient with a forme fruste of Graves disease, for instance, might have the bulging eyes without the sweaty hands, rapid heartbeat, irritability, and weight loss that accompany a full-fledged case of the illness. A forme fruste is an incomplete expression of an illness, though the term is little used today. The phrase "shadow syndrome" is substituted because the meanings of the word "shadow," both literal and metaphorical, capture the nature of a mild mental disorder. In the literal sense, a shadow is an indistinct form of something all too vivid and real, just as a shadow syndrome is an indistinct and seldom obvious form of a severe disorder. And metaphorical shadows cast a pall (cast a shadow) across a day that might otherwise be sunny and clear. This is what shadow syndromes do in the realms of work and love: they cast a shadow. As the diagnostic categories splinter, inevitably the line between normal and abnormal begins to blur. Sooner or later the classically trained psychiatrist begins to notice that not only are there a number of very troubled people who do not fully fit the DSM categories: there are also many, many not-so-troubled people who do fit these categories, to some degree. When you look at everyday people wending their way through everyday life you notice that most people seem to have minor bits of this syndrome, small pieces of that. In a way, the very mildness of his illness adds to his problems because it is likely to go undiagnosed. The "subsyndromal" person, the person who is only a "little bit" manic-depressive, or a "little bit" clinically depressed, is likely to struggle on alone, wondering what is the matter with him—or, all too often, what is the matter with everyone else. The new neurology can affect our sense of who we are. Where once we thought of ourselves as the victims of dysfunctional families, some of us are beginning to see ourselves, instead, as the "victims" of dysfunctional brain chemistry—and our parents as, perhaps, victims of the same chemistry themselves. We are beginning to understand ourselves in new ways, not just as a collection of personality traits, but as a collection of biological traits as well. In this new understanding we can begin the journey out from the shadows and into the clear light of day.
Suggested Diagnostic Criteria for ADD in Adults By Drs. Edward Hallowell and John Ratey 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:
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Adult ADD Reader
1. A SENSE OF UNDERACHIEVEMENT, OF NOT MEETING ONE’S GOALS (REGARDLESS OF HOW MUCH ONE HAS ACTUALLY ACCOMPLISHED). . This symptom is put 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” mount up to create huge obstacles. 3. CHRONIC PROCRASTINATION. 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 #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. 5. TENDENCY TO SAY WHAT COMES TO MIND WITHOUT NECESSARILY CONSIDERING THE TIMING OR APPROPRIATENESS OF THE REMARK. Like the child with ADD in the classroom, the adult with ADD gets carried away in enthusiasm. An idea comes and it must be spoken, tact or guile yielding to child-like exuberance. 6. A RESTIVE SEARCH FOR HIGH STIMULATION. The adult with ADD is always on the lookout for something novel, something engaging, something in the outside world that can catch up with the whirlwind that’s rushing inside. 7. A TENDENCY TO BE EASILY BORED. A corollary of #6. Boredom surrounds the adult with ADD like a sink-hole, ever ready to drain off energy and leave the individual hungry for more stimulation. This can easily be misinterpreted as a lack of interest; actually it is a relative inability to sustain interest over time. As much as the person cares, his battery pack runs low quickly. 8. EASY DISTRACTIBILITY, TROUBLE FOCUSING ATTENTION, TENDENCY TO TUNE OUT OR DRIFT AWAY IN THE MIDDLE OF A PAGE OR A CONVERSATION, OFTEN COUPLED WITH AN ABILITY TO HYPERFOCUS AT TIME. The hallmark symptom of ADD. The “tuning out” is quite involuntary. It happens when the person isn’t looking, so to speak, and the next thing you know, he or she isn’t there. The often extraordinary ability to hyerfocus is also usually present, emphasizing the fact that this is a syndrome not of attention deficit, but of attention inconsistency. 9. OFTEN CREATIVE, INTUITIVE, HIGHLY INTELLIGENT. Not a symptom, but a trait deserving of mention. Adults with ADD often have unusually creative minds. In the midst of their disorganization and distractibility, they show flashes of brilliance. Capturing this “special something” is one of the goals of treatment, 10. TROUBLE IN GOING THROUGH ESTABLISHED CHANNELS, FOLLOWING PROPER PROCEDURE. Contrary to what one might think, this is not due to some manifestation of boredom and frustration; boredom with routine ways of doing things and excitement around novel approaches, and frustration with being unable to do things the way they’re supposed to be done.
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11. IMPATIENT, LOW TOLERANCE FOR FRUSTRATION. Frustration of any sort reminds the adult with ADD of all the failures of the past. “Oh no,” he thinks, “here we go again.” So he gets angry or withdraws. The impatience has to do with the need for stimulation and can lead others to think of the individual as immature or insatiable. 12. IMPULSIVE, EITHER VERBALLY OR IN ACTION, AS IN IMPULSIVE SPENDING OR MONEY, CHANGING PLANS, ENACTING NEW SCHEMES OR CAREER PLANS, AND THE LIKE. This is one of the more dangerous of the adult symptoms, or, depending on the impulse, one of the more advantageous. 13. TENDENCY TO WORRY NEEDLESSLY, ENDLESSLY; TENDENCY TO SCAN THE HORIZON LOOKING FOR SOMETHING TO WORRY ABOUT ALTERNATING WITH INATTENTION TO OR DISREGARD FOR ACTUAL DANGER. Worry is what attention turns into when it isn’t focused on some task. 14. SENSE OF IMPENDING DOOM, INSECURITY, ALTERNATING WITH HIGH-RISK TAKING. This symptom is related to both the tendency to worry needlessly and the tendency to be impulsive. 15. MOOD SWINGS, DEPRESSION, ESPECIALLY WHEN DISENGAGED FROM A PERSON OR PROJECT. Adults with ADD, more than children, are given to unstable moods. Much of this is due to their experience of frustration and/or failure, while some of it is due to the biology of the disorder. 16. RESTLESSNESS. One usually does not see, in an adult, the full-blown hyperactivity one may see in a child. Instead one sees what looks like “nervous energy”: pacing, drumming of fingers, shifting position while sitting, leaving the table or room frequently, feeling edgy while at rest. 17. TENDENCY TOWARD ADDICTIVE BEHAVIOR. The addiction may be to a substance such as alcohol or cocaine, or to any activity, such as gambling, or shopping, or eating, or overwork. 18. CHRONIC PROBLEMS WITH SELF-ESTEEM. These are the direct and unhappy result of years of conditioning, years of being told that one is a klutz, a space cadet, an underachiever, lazy, weird, different, out of it, and the like. Years of frustration, failure, or of just not getting it right do lead to problems with self-esteem. What is imperative is how resilient most adults are, despite all the setbacks. 19. INACCURATE SELF-OBSERVATION. People with ADD are poor self-observers. They do not accurately gauge the impact they have on other people. This can often lead to big misunderstandings and deeply hurt feelings. 20. FAMILY HISTORY OF ADD OR MANIC-DEPRESSIVE ILLNESS OR DEPRESSION OR SUBSTANCE ABUSE OR OTHER DISORDERS OF IMPULSE CONTROL OR MOOD. Since ADD is genetically transmitted and related to the other conditions mentioned, it is not uncommon (but not necessary) to find such a family history.
B. Childhood History of ADD, and C. Symptoms Not Explained by Other Medical or Psychiatric Condition
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Adult ADD Reader
General Adult ADD Symptom Checklist By Daniel G. Amen, M.D. In conjunction with other diagnostic techniques, Dr. Amen says he "uses the following general adult ADD checklist to help further define ADD symptoms. No ADD adult has all of the symptoms, but if you notice a strong presence of more than 20 of these symptoms, there is a strong likelihood of ADD." Read this list of behaviors and rate yourself (or the person who has asked you to rate him or her) on each behavior listed. Use the following scale and place the appropriate number next to the item. 0 = never; 1 = rarely; 2 = occasionally; 3 = frequently; 4 = very frequently **IMPORTANT: This is not a tool for self-diagnosis. Its purpose is simply to help you determine whether ADD may be a factor in the behavior of the person you are assessing using this checklist. Only an experienced professional can make an actual diagnosis.
Past History 1. __*History of ADD symptoms in childhood, such as distractibility, short attention span, impulsivity or restlessness. ADD doesn't start at age 30. 2. __History of not living up to potential in school or work (report cards with comments such as "not living up to potential") 3. __History of frequent behavior problems in school (mostly for males) 4. __History of bedwetting past age 5 5. __Family history of ADD, learning problems, mood disorders or substance abuse problems
Short Attention Span/Distractibility 6. __*Short attention span, unless very interested in something 7. __*Easily distracted, tendency to drift away (although at times can be hyperfocused) 8. __Lacks attention to detail, due to distractibility 9. __Trouble listening carefully to directions 10. __Frequently misplaces things 11. __Skips around while reading, or goes to the end first, trouble staying on track 12. __Difficulty learning new games, because it is hard to stay on track during directions 13. __Easily distracted during sex, causing frequent breaks or turn-offs during lovemaking 14. __Poor listening skills 15. __Tendency to be easily bored (tunes out)
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Restlessness 16. __Restlessness, constant motion, legs moving, fidgetiness 17. __Has to be moving in order to think 18. __Trouble sitting still, such as trouble sitting in one place for too long, sitting at a desk job for long periods, sitting through a movie 19. __An internal sense of anxiety or nervousness
Impulsivity 20. __Impulsive, in words and/or actions (spending) 21. __Say just what comes to mind without considering its impact (tactless) 22. __Trouble going through established channels, trouble following proper procedure, an attitude of "read the directions when all else fails" 23. __Impatient, low frustration tolerance 24. __A prisoner of the moment 25. __Frequent traffic violations 26. __Frequent, impulsive job changes 27. __Tendency to embarrass others 28. __Lying or stealing on impulse
Poor Organization 29. __Poor organization and planning, trouble maintaining an organized work/living area 30. __Chronically late or chronically in a hurry 31. __Often have piles of stuff 32. __Easily overwhelmed by tasks of daily living 33. __Poor financial management (late bills, check book a mess, spending unnecessary money on late fees)
Problems Getting Started and Following Through 34. __Chronic procrastination or trouble getting started 35. __Starting projects but not finishing them, poor follow through 36. __Enthusiastic beginnings but poor endings 37. __Spends excessive time at work because of inefficiencies 38. __Inconsistent work performance
Negative Internal Feelings 39. __Chronic sense of underachievement, feeling you should be much further along in your life than you are 40. __Chronic problems with self-esteem
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Adult ADD Reader
41. __Sense of impending doom 42. __Mood swings 43. __Negativity 44. __Frequent feeling of demoralization or that things won't work out for you
Relational Difficulties 45. __Trouble sustaining friendships or intimate relationships, promiscuity 46. __Trouble with intimacy 47. __Tendency to be immature 48. __Self-centered; immature interests 49. __Failure to see others' needs or activities as important 50. __Lack of talking in a relationship 51. __Verbally abusive to others 52. __Proneness to hysterical outburst 53. __Avoids group activities 54. __Trouble with authority
Short Fuse 55. __Quick responses to slights that are real or imagined 56. __Rage outbursts, short fuse
Frequent Search for High Stimulation 57. __Frequent search for high stimulation (bungee jumping, gambling, race track, high stress jobs, ER doctors, doing many things at once, etc.) 58. __Tendency to seek conflict, be argumentative or to start disagreements for the fun of it
Tendency To Get Stuck (thoughts or behaviors) 59. __Tendency to worry needlessly and endlessly 60. __Tendency toward addictions (food, alcohol, drugs, work)
Switches Things Around 61. __Switches around numbers, letters or words 62. __Turn words around in conversations
Writing/Fine Motor Coordination Difficulties 63. __Poor writing skills (hard to get information from brain to pen) 64. __Poor handwriting, often prints 65. __Coordination difficulties
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The Harder I Try The Worse It Gets 66. __Performance becomes worse under pressure. 67. __Test anxiety, or during tests your mind tends to go blank 68. __The harder you try, the worse it gets 69. __Work or schoolwork deteriorates under pressure 70. __Tendency to turn off or become stuck when asked questions in social situations 71. __Falls asleep or becomes tired while reading
Sleep/Wake Difficulties 72. __Difficulties falling asleep, may be due to too many thoughts at night 73. __Difficulty coming awake (may need coffee or other stimulant or activity before feeling fully awake)
Low Energy 74. __Periods of low energy, especially early in the morning and in the afternoon 75. __Frequently feeling tired
Sensitive To Noise or Touch 76. __Startles easily 77. __Sensitive to touch, clothes, noise and light
Scoring When you have completed the above checklist, calculate the: Total Score:
_______
Total number of items with a score of three (3) or more: _______ Score for item #1:
_______
Score for item #6:
_______
Score for item #7:
_______
Dr. Amen suggests: “More than 20 items with a score of three or more indicates a strong tendency toward ADD.” Note: The three items with * are essential to make the diagnosis. He adds: “One of the most common ways I diagnose ADD in adults is when parents reluctantly tell me that they have tried their child's medication and that they found it very helpful. They report it helped them concentrate for longer periods of time. They became more organized and were less impulsive. Trying your child's medication is not something I recommend!”
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A Physician's Perspective By Theodore Mandelkorn, M.D.
Table of Contents Introduction Who Should Take Medications, and Why? What Improvement Should Be Seen? Who Should Prescribe Medications? Medical Trials What is the Correct Medication? What is the Correct Dosage? What About "Natural" Therapies? Summary References Appendix A: Overview Of Medications Non-Stimulant Medications Atomoxetine, 24 Hours (Strattera) Clonidine, Tablets: 4-5hours, Patch: 5-6 Days (Catapres) Stimulant Medications Overview, Safety Profile, And Side Effects Methylphenidate Tablets, 2-4 Hours (Ritalin IR) Dextro-Methylphenidate, 4-6 Hours (Focalin) Methylphenidate Sustained Release, 6 Hours (Ritalin SR20) Methylphenidate Long Acting, 8 Hours (Ritalin LA) Methylphenidate Controlled Dispense, 8 Hours (Metadate CD) Methylphenidate Extended Release, 12 Hours (Concerta) Dextroamphetamine Tablets, 4 Hours (Dexedrine, Dextrostat) Dextroamphetamine Spansules, 6 Hours (Dexedrine) Amphetamine Salts Tablets, 6 Hours (Adderall Tablets) Amphetamine Salts Extended Release, 12 Hours (Adderall XR) Pemoline, 24 Hours (Cylert) Appendix B: Resources
Introduction Human beings are rarely created in perfect form, so we all arrive in this world with unique differences. Some differences are blessings; others are handicaps. Poor vision, for example, is a common handicapping condition that affects millions of people throughout the world. I consider poor vision a condition of "human-ness." People can also have other medical conditions such as diabetes, asthma, thyroid conditions, ADHD, etc.—all are well recognized differences that can impair the pursuit of a normal life style if not dealt with in some manner. ADHD is characterized by a prolonged history of inattention, impulsiveness and, sometimes, variable amounts of hyperactivity. It is important to emphasize that all of these symptoms are normal human characteristics. Most of us are forgetful and inattentive at times. We all at times become nervous and
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fidgety, and we certainly are impulsive to some degree. It is part of our "human-ness." ADHD, therefore, is not diagnosed by the mere presence of these normal and characteristic human behaviors, but by the DEGREE to which we manifest these symptoms. ADHD individuals have an over-abundance of these normal characteristics. They have less CONTROL of these behaviors and therefore a more variable and frequently poor outcome of their day.
Who Should Take Medications, and Why? If a person meets the clinical criteria for a diagnosis of ADHD and is not succeeding academically and/or socially up to age-appropriate expectations, medication should be a PRIMARY OPTION for therapeutic intervention. ADHD is a medical condition. Recent research out of Harvard University has documented an abnormality in the dopamine transporter system in the central nervous system of ADHD adults. (1) This transporter system is responsible for moving neurotransmitter chemicals from the synaptic space back into the nerve cell. ADHD adults have approximately 70% more dopamine transporter than non-ADHD individuals and thus appear to have an overactive transport system. Returning to the vision analogy, there are a number of options open to an individual who has compromised eyesight. One option is to attempt to correct the problem by wearing glasses to improve the visual acuity. Perhaps glasses will totally correct the problem or perhaps they will help only partially. After glasses are in place, we are in a position to assess what further problems are interfering with success. Then we can address these issues as well. The opportunity to eliminate the symptoms of a medical condition partially or completely should be available to all. Many children and adults with ADHD benefit enormously from the use of medication. The medications that are in use today act as transporter blockers, thus serving to normalize this aspect of the brain chemistry. Most families who understand ADHD and its clinical manifestations prefer to try medication as a PART of their treatment plan. Over 90% of individuals with ADHD will have a positive response to one of the medical treatments.
What Improvement Should Be Seen? In the early 1930's, Dr. Charles Bradley noted some dramatic effects of stimulant medications on patients with behavior and learning disorders. He found that the use of stimulants "normalized" many of the systems that we use for successful living. People on medication IMPROVED their attention span, concentration, memory, motor coordination, mood, and on-task behavior. At the same time they DECREASED daydreaming, hyperactivity, immature behavior, defiance, and oppositional behavior. It was evident that medical treatment allowed intellectual capabilities that were already present to function more successfully. (2, 3) When medication is used appropriately, patients notice a significant improvement in control. Objective observers should notice better control of focus, concentration, attending skills, and task completion. Many individuals are able to cope with stress and frustration more appropriately with fewer temper outbursts, less anger and better compliance. They relate and interact better with family members and friends. Less restlessness, decreased motor activity and impulsiveness are noted. ADHD individuals often complain of forgotten appointments, incomplete homework, miscopied assignments, frequent arguments with siblings, parents, spouses, workmates, along with excessive activity and impulsive behaviors. With medication, many of these problems dramatically improve. It is very important to remember what medicine does and does not do. Using medication is like putting on glasses. It enables the system to function more appropriately. Glasses do not MAKE you behave, write a term paper or even get up in to morning. They allow your eyes to function more normally IF YOU
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CHOOSE to open them. You, the individual, are still in charge of your vision. Whether you open your eyes or not, and what you choose to look at, are controlled by you. Medication allows your nervous system to send its chemical messages more efficiently, and thus allows your skills and knowledge to function more normally. Medication does not provide skills or motivation to perform. Patients successfully treated with medications typically can go to bed at night and find that most of the day went the way they had planned.
Who Should Prescribe Medications? A licensed physician can prescribe medications only. This person may serve as a coordinator to assist with the multiple therapies often needed, such as educational advocacy, counseling, parent training and social skill assistance. Parents should look for a physician who has a special interest and knowledge in dealing with ADHD individuals. This professional should be skilled in working closely with families to try the many and varied medical treatments that are available until the correct therapeutic response is attained. Members of C.H.A.D.D chapters are an excellent resource for referrals to appropriate professionals.
Medical Trials It is necessary to establish a team of observers to appropriately evaluate a medication trial. Gather information from sources that spend time with the patients. This might include significant others, parents, teachers, grandparents, tutors, piano teachers, coaches, etc. As gradually increasing dosages are administered, input is gathered from these observers. Various ADHD rating scales are available to assist in gathering factual data. The most important assessment, however, is dependent on whether the ADHD patient's quality of success in life has improved. For this information, I find no scale takes the place of conversations with patient and family members. When evaluating patients during a trial of medication, it is important to maintain treatment throughout the waking day, seven days a week. Treating them only at school or in the workplace is totally inadequate. I need all involved observers, especially parents and/or significant others, assisting in the evaluation process. Furthermore, I want to know if treatment has an effect on non-academic issues. Recent studies have found that treatment is necessary for most ADHD individuals throughout the full day, thus allowing full development not only of academic or work skills, but also the all-important social skills that are utilized with friends and family. After the trial of medication, if positive results are evident, then the family and the patient can make informed decisions as to when the medication is helpful. Most patients need the medication throughout the day and evening.
What Is The Correct Medication? At the present stage of medical knowledge, there is no method of predicting which medication will be most helpful for any individual. At best, physicians can make educated decisions based on information about success rates with individual medications. Over 80% of ADHD individuals will respond favorably to the stimulant medications, methylphenidate and amphetamines. Both of these categories of medications may need trials to assess which is best. If one stimulant does not work, the others should be tried, for experience has proven that individuals may respond quite differently to each one. Another good alternative medication is atomoxetine (Strattera), a new non-stimulant medication for ADHD that was approved by the FDA in December 2002. Each family and physician must be willing to try different medications in order to determine the best and most effective therapy. This is the only way to find the appropriate medical treatment. In some children who have multiple diagnoses such as ADHD and depression, or ADHD and anxiety, or ADHD and Tourette syndrome, combinations of medications are being successfully utilized for treatment.
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What Is The Correct Dosage? If stimulant medications work, there is a best dose for each individual. Unfortunately, medical knowledge is not at a point where it can predict what the correct medication or dose will be. This is not an unusual circ*mstance in medicine, however. For a person with diabetes, for example, we must try different forms and amounts of insulin to achieve the best control of blood sugar levels. For people with high blood pressure, there are many medications that can be effective, and often a trial of multiple medications and dosages is necessary to determine the best treatment. For stimulant medications, there is no magic formula. The dose cannot be determined by age, body weight or severity of symptoms. In fact, it appears that the correct dose is extremely individual and is not at all predictable. Again, similar to people who need glasses, the kind of prescription and the thickness of the lenses are not dependent on any measurable parameter other than what the individuals say enables them to see well. The dose of medication is determined solely by what ADHD patients need to most effectively reduce their symptoms. One must be willing to experiment with carefully observed dosage changes to determine the correct dosage. The appropriate dosage does not seem to change very much with age or growth. Medication continues to work effectively through the teenage years and through adulthood. For atomoxetine, the dosage at the present time is calculated according to weight. This is the only medication for ADHD for which this is true.
What About "Natural" Therapies? At this time, there is no evidence that natural therapies are therapeutic. There are many anecdotes about various "magical" cures for ADHD, but none have been found to be valid. Remember: multiple anecdotes do not mean proof. Natural therapies such as grape seed extract, blue algae, biofeedback, magnets, megavitamins, diet, and other "natural products" have not yet shown any lasting therapeutic benefit. At this time traditional medical therapy is the most effective treatment for ADHD. This is quite similar to other medical treatments such as insulin, THE best form of treatment for Type 1 diabetes, or thyroid pills THE best therapy for inactive thyroid gland. Furthermore, natural health food treatments are not regulated by the government and are therefore highly suspect for contamination. Please be cautious when experimenting with alternative therapies on your family members.
Summary Individuals with ADHD with present with a variety of well-defined symptoms and behaviors. Medication may be extremely helpful in alleviating some of these symptoms and will allow the other therapeutic modalities to be much more successful. Families must be willing to work closely with their physician to identify the correct medications and establish the best dosage levels.
References Dougherty, D.D. Dopamine transporter density in patients with ADHD. Lancet 1999; 354: 2132. Bradley, C. The behavior of children receiving Benzedrine. Am J Psychiatry 1939; 99: 577-585. Bradley, C. Benzedrine and Dexedrine in treatment of children's behavior disorders. Pediatrics 1950; 5: 24-37.
Appendix A: Overview Of Medications It is important to note that medical treatment should always be given for the entire waking day, seven days a week. There are few medical conditions that we do not elect to treat in the evenings, on weekends or holidays. No one chooses to turn down his or her brain chemistry during his or her wakeful hours.
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Therefore, all medical treatment for ADHD should last for at least 12 hours daily and 24 hours when possible. With this in mind, I have highlighted (***) the medications that should be preferred treatments for ADHD.
Non-Stimulant Medications ***ATOMOXETINE 24 hours (Strattera) This is a new medication for ADHD, which was released by the FDA in December 2002. It is a nonstimulant medication, which is not abusable and can be written without Schedule II restrictions. This is the first medication that lasts 24 hours and therefore gives full therapeutic effect throughout the day and night. It has great implications for homework, driving, social relations in the evening, etc. It is my expectation that treatment of ADHD in the future will probably utilize more of the 24-hour continuous therapies as they become available. Early reports suggest atomoxetine works for 50-60% of individuals with ADHD. Form
Capsules: 10mg, 18mg, 25mg, 40mg, 60mg.
Dosage
Weight based dose: first four days=0.5mg/kg; target dose (day five and after)=1.2mg/kg. This medication must be taken with food to prevent nausea.
Action
Very slow acting and will take 4-8 weeks (or more) to reach therapeutic effect. If the patient is already taking stimulant medications, suggest continuing them and adding the Strattera for the first 4-6 weeks, then tapering the stimulant slowly until discontinued.
Possible Side Effects
No long-term safety information is available for this medication. Primary side effect in children is sleepiness. If this occurs, give the dose at night or lower the dose until this improves. Then raise dose if possible. Adults can experience more noted effects: transitory dry mouth and dizziness, insomnia, sleepiness. Non-transitory effects include possible bladder spasm, sexual dysfunction (uncommon but often results in discontinuation of medication). Occasionally a child or adult will get very agitated. If this occurs, discontinue the medication.
Pros
24-hour coverage. Less effect on appetite than stimulants. Marked improvement in sleep pattern for many. Marked improvement in mood in many patients. Not a stimulant and not abusable.
Cons
Very little information is available at this time to fully evaluate safety profile.
Clonidine Tablets 4-5 Hours, Patches 5-6 Days (Catapres) Form
Patches applied to back or shoulder. Catapres TTS-1, TTS-2, TTS-3. Tablets . Clonidine tablets 0.1mg, 0.2mg, 0.3mg.
Dosage
Very individual, usually .1-.3 mg.
Action
Works quickly. Tablets work within 1 hour, patches within 1 day.
Effects
Often will improve ADHD symptoms, particularly aggressive and hyperactive behaviors. Not too helpful for focus and attention. Decreases motor and vocal tics. Can have a dramatic effect on oppositional defiant behavior and anger management. Often used as one dose at night about 1½ hours before bedtime to assist with getting to asleep.
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Possible Side Effects
Major side effect is tiredness, particularly if dose is raised too quickly. This disappears with time. Dizziness, dry mouth. Some will notice increased activity, irritability.
Pros
Excellent delivery system if patch is used. No pills required
Cons
Does not usually work as well as stimulants. Patch can cause skin irritation in many individuals and may not be tolerated. Can effect cardiac conduction (heart rate and rhythm) in high doses and must not be left around for animals or small children to accidentally ingest.
Stimulant Medications Some general comments can be made about stimulant medications as a class of medications. The longer acting medications have clear advantages over the short acting medications, not only in duration of therapeutic effect throughout the day, but also in smoothness of the therapeutic effect. It is very difficult for an individual with ADHD to remember to take multiple doses of medication during the day. Multiple dosing increases the risk of missing doses, which results in the return of symptoms at inopportune times. The afternoon dosing is frequently missed, causing significant difficulties. Furthermore, each additional dose serves as an unnecessary reminder that treatment for this condition is needed and "something is wrong." The reason for medical treatment is to "normalize" the day. My general rule is to always use 12-hour medications unless they are not effective or have intolerable side effects. In such a case, the six or eight hour medications should be tried, because some individuals tolerate them better and find them more effective. However, if the six or eight hour medication is used, a second dose should be given to allow patients to have the therapeutic benefit for the full day.
Safety Profile The stimulant medications are one of the most studied treatments in the history of medicine. The medications have been used extensively in children and adults over the past 50 years with no evidence to date of long term concerning side effects. At this time there is no conclusive evidence that use of stimulants causes any long term lasting effects on growth, although there may be some delay in height and weight gain in some individuals. The short acting stimulants are extremely abusable and are valued highly on the street. It is best to always use the long acting preparations, which are not abusable to avoid the temptation of misuse and abuse.
Common Side Effects The following side effects are often noted with the use of stimulants. In general, the side effects with the short acting medications are more pronounced and bothersome than with the long acting medications. Thus, long acting meds are somewhat more tolerable for long-term treatment and are certainly a marked improvement for long term therapeutic effect. Appetite Suppression Most will note decreased appetite during the effective hours of the medication. This often means minimal lunch intake. I suggest a small protein lunch such as milk, peanut butter crackers, beef or turkey jerky to get through the day. A milk shake after school helps. Many find their appetite returns late in the evening (around 8-9pm) when their medication wears off, and they need to be allowed to eat at that time. If weight gain is a continued concern, I often add cyproheptadine (Periactin) 4mg, ½ tablet at breakfast and dinner. Periactin is an antihistamine similar to Benedryl,
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which enhances appetite and often results in 1-2lbs weight gain per month. Remember that good nutrition is helpful for all, and these individuals should emphasize protein intake in their diet. Sleep Disturbance Many ADHD individuals will have sleep difficulties before they begin their medical treatment. At night, their brain continues its activity and starts thinking of the day. Using stimulant medications may either improve or worsen this problem. In those with no prior sleep difficulty, stimulants can create significant sleep issues. ADHD individuals do not usually have a problem with sleeping through the night (sleep disorder) but often do have problems with starting the sleep. A clear-cut bedtime routine helps (bath or shower and then read in bed) with the elimination of caffeine, computers, computer games and television at least one hour before bedtime. Interestingly, adding stimulant medication actually allows a percentage to sleep better at night, and this technique should be tried. It only takes one night to see if a dose of short acting stimulant will enable sleep initiation. Some patients, however, require more assistance. Many patients will use a small dose of Clonidine tablets given one hour before bedtime to help with sleep initiation. Clonidine is a mild sedative, not a sleeping pill, and it is non addictive. Approximately 60-90 minutes after taking the medication, a brief sleepy phase will occur that lasts about 20 minutes. If the patient is in bed and trying to go to sleep, it is very effective. It will NOT make someone stop playing computer games and go to bed. Mood Changes One of the biggest complaints about stimulants is that they can cause mood changes. These come in a number of different forms. Rollercoaster Effect Short acting medications have a continuous cycling of the blood level, either rising or falling throughout the day. This can lead to significant mood changes, particularly at the end of the fourhour cycle when the medication is wearing off. This problem with cycling is greatly diminished with the use of eight hour and twelve hour medications. Rebound Effect Stimulants can often wear off very rapidly, and in some individuals this can cause a rebound, a marked change in demeanor often characterized by irritability, loss of patience, and a worsening of the ADHD core symptoms. Rebound can occur in the evening when the medication wears off and can also be evident in the morning on first arising. The morning rebound may require an early dose of immediate release methylphenidate (MPH) prior to the administration of the long acting dose at breakfast. Rebound effect is markedly reduced in frequency and severity in the long acting stimulants. Irritability and Anxiety All of the stimulants have the possibility of causing a generalized irritability, and sometimes even anger, which is not tolerable over a long period of time. They can cause anxiety and panic disorder and may aggravate existing anxiety. Often, changing from one stimulant to another will reduce this side effect, so it is worth trying different stimulants to identify the best one for each patient. Overdose Effect When using the stimulants it is necessary to gradually raise the dose to find the most effective therapeutic level. Sometimes in doing this, one gets an overdose effect. The stimulants are incredibly safe. They have been studied for over 50 years, and there is no evidence at this time of any long term serious complications when used appropriately for ADHD. However, if ADHD individuals take too high a dose, they will experience an overdose effect which appears as a dulling
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of the personality: They complain of being somewhat physically lethargic, subdued, dull, less conversational, less apt to laugh and be social. By simply lowering the dose for one day, these symptoms will disappear. Tic Formation All of the stimulants have the possibility of temporarily causing a tic disorder or aggravating an existing one. There is no evidence that the use of stimulant medications will cause permanent formation of tic disorder or Tourette syndrome. Children who already have tics (10% of children have mild tics at some point in childhood) and individuals with Tourette syndrome will find a number of different scenarios with the use of medication. Approximately 1/3 will actually notice that the tics improve (lessen) with the use of stimulants, 1/3 will see no change at all, and 1/3 will find the tics worsen with use of stimulants. If the stimulants are effective and tics are worse, a medication to help control the tics is usually added to the treatment.
Methylphenidate Tablets 2-4 Hours (Ritalin IR) Form
Short acting tablets. Methylphenidate (MPH) 5mg, 10mg, 20mg.
Dosage
Very individual. Average 5-20mg tablets every 2-4 hours.
Action
Immediate release (IR) MPH starts to take effect in 15 minutes, which is extremely helpful for some individuals. Some children need an early morning dose 20 minutes BEFORE arising in the am, followed by a long acting medication at breakfast. Often used as a booster for evening coverage.
Possible Side Effects
See above
Pros
Very easy to use for short periods of coverage, such as early morning and evening.
Cons
Must be administered frequently during the day (3-5 times/day). Inconvenient to use at school and work. Often causes rebound and rollercoaster effect. Very abusable.
Dextro-Methylphenidate 4-6 Hours (Focalin) Focalin is an isomer product of methylphenidate. Methylphenidate is composed of two mirror image molecules, and it has been determined that the right-hand side of the molecule contains most of the therapeutic activity. Therefore the left-hand side has been eliminated, giving a cleaner formulation of methylphenidate. Form
Tablets: 2.5mg, 5mg, and 10mg.
Dosage
The same as methylphenidate, but divide the dose by half.
Action
The same as methylphenidate, but in some individuals up to 6 hours duration.
Possible Effects
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Side
Same as MPH but possibly to a slightly less degree.
Pros
A cleaned up version of MPH that may last a bit longer with slightly decreased side effects.
Cons
Same as MPH. Very abusable.
Adult ADD Reader
Methylphenidate Sustained Release 6 Hours (Ritalin SR20) Replaced by Ritalin LA.
Methylphenidate Long Acting 8 Hours (Ritalin LA) Form
Capsules: 20mg, 30mg and 40mg.
Dosage
Very individual. Average: 20-40 mg daily or twice a day, every 8 hours.
Action
Same as methylphenidate, but eliminates the noontime dose.
Possible Side See above. Effects Pros
Eliminates midday dosing. Works more smoothly than IR methylphenidate and is more effective than methylphenidate SR.
Cons
Only works for eight hours and therefore subjects the patient to loss of focus and control in mid afternoon. This requires an afternoon booster to be administered.
Methylphenidate Controlled Dispense 8 Hours (Metadate CD) Form
Capsules: 20mg (10mg and 30mg to be available in 2003)
Dosage
Very individual. Average: 2-3 capsules in the am.
Action
Same as methylphenidate.
Possible Effects
Side
See above.
Pros
Works more smoothly than IR methylphenidate. Sometimes is effective when Concerta and Ritalin LA are not effective. Not abusable.
Cons
Works for only eight hours. (See Ritalin LA)
***Methylphenidate Extended Release 12 Hours (Concerta) Form
12-hour long-acting tablet... uses a unique delivery system that delivers a constant therapeutic level of methylphenidate for twelve full hours. Concerta: 18mg, 27mg, 36mg, 54mg.
Dosage
Dosage will vary as with all methylphenidate products: Concerta 18mg = Ritalin 5mg three times-a-day Concerta 27mg = Ritalin 7.5mg three times-a-day Concerta 36mg = Ritalin 10mg three times-a-day Concerta 54mg = Ritalin 15mg three times-a-day
Action
12 hours of consistent therapy with no highs or lows throughout the day. A few individuals will only get 8-9 hours of effective therapy and will need either a higher dose or a second dose.
Possible Side Effects
See above.
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Pros
Unique delivery system avoids multiple dosing throughout the day. No dosage at school. No rebounding with missed doses. Fewer side effects, less mood swings, better therapeutic response for many individuals. No daytime dosing. Less anxiety and worry. Not abusable.
Cons
Does not work for all individuals who use methylphenidate. If ineffective, should try Ritalin LA and/or Metadate CD. May need a short acting booster to cover the evening hours.
Dextroamphetamine Tablets 4 Hours (Dexedrine, Dextrostat) Form
Short acting tablets 5mg, 10mg.
Dosage
Very individual. Average 1-3 tablets each dose every 4-5 hours.
Action
Rapid onset of action, approx. 20 min. Lasts 4-5 hours.
Possible See above. Side Effects Pros
Excellent safety record. Rapid acting. Some patients who do well on dextroamphetamine prefer the tablets to the spansules. The rapid onset in tablet form is apparently more effective for these individuals.
Cons
Same as MPH. Very abusable.
Dextroamphetamine Spansules 6 Hours (Dexedrine) Form
Long acting. Dexedrine Spansules 5mg, 10mg, 15mg.
Dosage
Very individual. Average is 5-20 mg.
Action
Very individual. May take up to one hour to be effective. Usually lasts 6-8 hours. In some individuals it may last all day. In others it may only last 4 hours. Most will take twice a day, six-hour intervals
Possible Side Effects
See above
Pros
Excellent safety record. May be the best drug for some individuals. Long acting, smooth course of action. May avoid lunchtime dose at school.
Cons
Slow onset of action. May require a short acting medication at the start of the day. Very abusable.
Amphetamine Salts Tablets 6 Hours (Adderall) Form
Long acting tablets: 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 30mg.
Dosage
Very individual, usually between 5mg and 20mg, once or twice each day.
Action
Usually lasts 6 hours. May be given once or twice a day depending on length of therapeutic effect. Duration of effect varies from person to person.
Possible Side See above.
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Effects Pros
Only needs to be given once or twice a day. Often less side effects than the short acting medications.
Cons
Can cause irritability in a small percentage of patients. Very abusable.
***Amphetamine Salts Extended Release 12 Hours (Adderall XR) Form
Uses a unique delivery system that delivers a constant therapeutic level of amphetamine salts for twelve full hours. Capsules: 5mg, 10mg, 15mg, 20mg, 25mg, 30mg.
Dosage
Very individual. Average 15-30mg daily.
Action
Long acting 12-hour control of ADHD symptoms for coverage during most of the day.
Possible Side See above. Effects Pros
Very effective. Same as Adderall with longer duration of action. Cannot be abused.
Cons
May need a booster to cover the evening hours.
Pemoline 24 Hours (Cylert) Form
18.75mg, 37.5mg , 75mg tablets. 37.5 mg chewable tablets.
Dosage
Very individual.
Action
Good medication for ADHD symptom relief, similar to other stimulants.
Cylert has a BLACK BOX warning from the FDA. This medication is associated Possible with risk of liver failure leading to death, and its use requires blood tests every two Side Effects weeks. It should be used as a last resort with very careful and continuous supervision. Pros
Not abusable.
Cons
Significant risk.
Appendix B: Resources For an excellent reference book regarding all of the medications that might be used for ADHD individuals, including not only medications for ADHD but also medications for all of the associated comorbid conditions, please refer to the following book: Straight Talk About Psychiatric Medications For Kids by Timothy Wilens, M.D.
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50 Tips on the Management of Adult Attention Deficit Disorder By Edward M. Hallowell, M.D. and John J. Ratey, M.D. The treatment of ADD begins with hope. Most people, who discover they have ADD, whether they are children or adults, have suffered a great deal of pain. The emotional experience of ADD is filled with embarrassment, humiliation, and self-castigation. By the time the diagnosis is made, many people with ADD have lost confidence in themselves. Many have been misunderstood repeatedly. Many have consulted with numerous specialists, only to find no real help. As a result, many have lost hope. The most important step at the beginning of treatment is to instill hope once again. Individuals with ADD may have forgotten what is good about themselves. They may have lost, long ago, any sense of the possibility of things working out. They are often locked in a kind of tenacious holding pattern, bringing all theory, considerable resiliency, and ingenuity just to keeping their heads above water. It is a tragic loss, the giving up on life too soon. But many people with ADD have seen no other way than repeated failures. To hope, for them, is only to risk getting knocked down once more. And yet, their capacity to hope and to dream is immense. More than most people, individuals with ADD have visionary imaginations. They think big thoughts and dream big dreams. They can take the smallest opportunity and imagine turning it into a major break. They can take a chance encounter and turn it into a grand evening out. They thrive on dreams, and they need organizing methods to make sense of things and keep them on track. But like most dreamers, they go limp when the dream collapses. Usually, by the time the diagnosis of ADD has been made, this collapse has happened often enough to leave them wary of hoping again. The little child would rather stay silent than risk being taunted once again. The adult would rather keep his mouth shut than risk flubbing things up once more. The treatment, then, must begin with hope. We break down the treatment of ADD into five basic areas (1). Diagnosis (2). Education (3). Structure, support, and coaching (4). Various forms of psychotherapy (5). Medication. In this article we will outline some general principles that apply both to children and adults concerning the non-medication aspects of the treatment of ADD. One way to organize the non-medication treatment of ADD is through practical suggestions.
Fifty Tips Insight and Education 1. Be sure of the diagnosis. Make sure you're working with a professional who really understands ADD and has excluded related or similar conditions such as anxiety states, agitated depression, hyperthyroidism, manic depressive illness, or obsessive compulsive disorder. 2. Educate yourself. Perhaps the single most powerful treatment for ADD is understanding ADD in the first place. Read books. Talk with professionals. Talk with other adults who have ADD. You'll be able to design your own treatment to your own version of ADD. 3. Coaching. It is useful for you to have a coach, for some person near to you to keep after you in a supportive way. Your coach can help you get organized, stay on task, give you encouragement, or
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remind you to get back to work. Friend, colleague, or therapist (it is possible, but risky for your coach to be your spouse), a coach is someone to stay on you to get things done, exhort you as coaches do, keep tabs on you, and in general be in your corner, on your side. A coach can be tremendously helpful in treating ADD. 4. Encouragement. ADD adults need lots of encouragement. This is in part due to their having many self-doubts that have accumulated over the years. But it goes beyond that. More than the average person, the ADD adult withers without encouragement and positively thrives when given it. The ADD adult will often work for another person in a way he won't work for himself. This is not "bad," it just is. It should be recognized and taken advantage of. 5. Realize what ADD is NOT, i.e., conflict with mother, etc. 6. Educate and involve others. Just as it is key for you to understand ADD, it is equally, if not more important, for those around you to understand it - family, friends, people at work or at school. Once they get the concept they will be able to understand you much better and to help you out as well. It is particularly helpful if your boss can be aware of the kinds of structures that help people with ADD. 7. Give up guilt over high-stimulus seeking behavior. Understand that you are drawn to high stimuli. Try to choose them wisely, rather than brooding over the "bad" ones. 8. Listen to feedback from trusted others. Adults (and children, too) with ADD are notoriously poor selfobservers. They use a lot of what can appear to be denial. 9. Consider joining or starting a support group. Much of the most useful information about ADD has not yet found its way into books but remains stored in the minds of the people who have ADD. In groups this information can come out. Plus, groups are really helpful in giving the kind of support that is so badly needed. 10. Try to get rid of the negativity that may have infested your system if you have lived for years without knowing what you had was ADD. A good psychotherapist may help in this regard. Learn to break the tapes of negativity that can play relentlessly in the ADD mind. 11. Don't feel chained to conventional careers or conventional ways of coping. Give yourself permission to be yourself. Give up trying to be the person you always thought you should be—the model student or the organized executive, for example—and let yourself be who you are. 12. Remember that what you have is a neurological condition. It is genetically transmitted. It is caused by biology, by how your brain is wired. It is NOT a disease of the will, or a moral failing. It is NOT caused by a weakness in character, or by a failure to mature. Its cure is not to be found in the power of the will, or in punishment, or in sacrifice, or in pain. ALWAYS REMEMBER THIS. Try as they might, many people with ADD have great trouble accepting the syndrome as being rooted in biology rather than weakness of character. 13. Try to help others with ADD. You'll learn a lot about the condition in the process, as well as feel good to boot.
Performance Management 14. External structure. Structure is the hallmark of the non-pharmacological treatment of the ADD child. It can be like the walls of the bobsled slide, keeping the speedball sled from careening off the track. Make frequent use of: a. lists b. notes to self—color coding—rituals c. reminders—files
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15. Color-coding. Mentioned above, color-coding deserves emphasis. Many people with ADD are visually oriented. Take advantage of this by making things memorable with color: files, memoranda, texts, schedules, etc. Virtually anything in the black and white of type can be made more memorable, arresting, and therefore attention-getting with color. 16. Use pizzazz. In keeping with #15, try to make your environment as peppy as you want it to be without letting it boil over. 17. Set up your environment to reward rather than deflate. To understand what a deflating environment is, all most adult ADDers need do is think back to school. Now that you have the freedom of adulthood, try to set things up so that you will not constantly be reminded of your limitations. 18. Acknowledge and anticipate the inevitable collapse of x% of projects undertaken, relationships entered into obligations incurred. 19. Embrace challenges. ADD people thrive with many challenges. As long as you know they won't all pan out, as long as you don't get too perfectionistic and fussy, you'll get a lot done and stay out of trouble. 20. Make deadlines. Think of deadlines as motivational devices rather than echoes of doom. If it helps, call them lifelines, instead of deadlines. In any case, make them and stick to them. 21. Break down large tasks into small ones. Attach deadlines to the small parts. Then, like magic, the large task will get done. This is one of the simplest and most powerful of all structuring devices. Often a large task will feel overwhelming to the person with ADD. The mere thought of trying to perform the task makes one turn away. On the other hand, if the large task is broken down into small parts, each component may feel quite manageable. 22. Prioritize. Avoid procrastination. When things get busy, the adult ADD person loses perspective: paying an unpaid parking ticket can feel as pressing as putting out the fire that just got started in the wastebasket. Prioritize. Take a deep breath. Put first things first. Procrastination is one of the hallmarks of adult ADD. You have to really discipline yourself to watch out for it and avoid it. 23. Accept fear of things going too well. Accept edginess when things are too easy, when there's no conflict. Don't gum things up just to make them more stimulating. 24. Notice how and where you work best: in a noisy room, on the train, wrapped in three blankets, listening to music, whatever. Children and adults with ADD can do their best under rather odd conditions. Let yourself work under whatever conditions are best for you. 25. Know that it is O.K. to do two things at once: carry on a conversation and knit, or take a shower and do your best thinking, or jog and plan a business meeting. Often people with ADD need to be doing several things at once in order to get anything done at all. 26. Do what you're good at. Again, if it seems easy, that is O.K. There is no rule that says you can only do what you're bad at. 27. Leave time between engagements to gather your thoughts. Transitions are difficult for ADDers, and mini-breaks can help ease the transition. 28. Keep a notepad in your car, by your bed, and in your pocketbook or jacket. You never know when a good idea will hit you, or you'll want to remember something else. 29. Read with a pen in hand, not only for marginal notes or underlining, but also for the inevitable cascade of "other" thoughts that will occur to you.
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Mood Management 30. Have structured "blow-out" time. Set aside some time in every week for just letting go. Whatever you like to do—blasting yourself with loud music, taking a trip to the race track, having a feast—pick some kind of activity from time to time where you can let loose in a safe way. 31. Recharge your batteries. Related to #30 most adults with ADD need feeling guilty about it. One guiltfree way to conceptualize it is to call it time to recharge your batteries. Take a nap, watch TV, meditate. Some-thing calm, restful, at ease. 32. Choose "good," helpful addictions such as exercise. Many adults with ADD have an addictive or compulsive personality such that they are always hooked on something. Try to make this something positive. 33. Understand mood changes and ways to manage these. Know that your moods will change willy-nilly, independent of what's going on in the external world. Don't waste your time ferreting out the reason why or looking for someone to blame. Focus rather on learning to tolerate a bad mood, knowing that it will pass, and learning strategies to make it pass sooner. Changing sets, i.e. getting involved with some new activity (preferably interactive) such as a conversation with a friend or a tennis game or reading a book will often help. 34. Related to #33, recognize the following cycle, which is very common among adults with ADD: a. Something "startles" your psychological system, a change or transition, a disappointment or even a success. The precipitant may be quite trivial. b. This "startle" is followed by a mini-panic with a sudden loss of perspective, the world being set topsy-turvy. c. You try to deal with this panic by falling into a mode of obsessing and ruminating over one or another aspect of the situation. This can last for hours, days, even months. 35. Plan scenarios to deal with the inevitable blahs. Have a list of friends to call. Have a few videos that always engross you and get your mind off things. Have ready access to exercise. Have a punching bag or pillow handy if there’s extra angry energy. Rehearse a few pep talks you can give yourself, like, ‘’You’ve been here before. These are the ADD blues. They will soon pass. You are OK." 36. Expect depression after success. People with ADD commonly complain of feeling depressed, paradoxically, after a big success. This is because the high stimulus of the chase or the challenge or the preparation is over. The deed is done. Win or lose, the adult with ADD misses the conflict, the high stimulus, and feels depressed. 37. Learn symbols, slogans, sayings as shorthand ways of labeling and quickly putting into perspective slip ups, mistakes, or mood swings. When you turn left instead of right and take your family on a 20minute detour, it is better to be able to say, "There goes my ADD again," than to have a 6-hour fight over your unconscious desire to sabotage the whole trip. These are not excuses. You still have to take responsibility for your actions. It is good to know where your actions are coming from and where they're not. 38. Use "time-outs" as with children. When you are upset or over stimulated, take a time-out. Go away. Calm down. 39. Learn how to advocate for yourself. Adults with ADD are so used to being criticized; they are often unnecessarily defensive in putting their own case forward. Learn to get off the defensive. 40. Avoid premature closure of a project, a conflict, a deal, or a conversation. Don't "cut to the chase’’ too soon, even though you're itching to. 41. Try to let the successful moment last and be remembered, become sustaining over time. You'll have to consciously and deliberately train yourself to do this because you'll just as soon forget.
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42. Remember that ADD usually includes a tendency to over focus or hyperfocus at times. This hyper focusing can be used constructively or destructively. Be aware of its destructive use: a tendency to obsess or ruminate over some imagined problem without being able to let it go. 43. Exercise vigorously and regularly. You should schedule this into your life and stick with it. Exercise is positively one of the best treatments for ADD. It helps work off excess energy and aggression in a positive way, it allows for noise-reduction within the mind, it stimulates the hormonal and neurochemical system in a most therapeutic way, and it soothes and calms the body. When you add all that to the well-known health benefits of exercise, you can see how important exercise is. Make it something fun so you can stick with it over the long haul, i.e. the rest of you life.
Interpersonal Life 44. Make a good choice in a significant other. Obviously this is good advice for anyone. But it is striking how the adult with ADD can thrive or flounder depending on the choice of mate. 45. Learn to joke with yourself and others about your various symptoms, from forgetfulness, to getting lost all the time, to being tactless or impulsive, whatever. If you can be relaxed about it all to have a sense of humor, others will forgive you much more. 46. Schedule activities with friends. Adhere to these schedules faithfully. It is crucial for you to keep connected to other people. 47. Find and join groups where you are liked appreciated, understood, enjoyed. People with ADD take great strength from group support. 48. Reverse of #47. Don't stay too long where you aren't understood or appreciated. Just as people with ADD gain a great deal from supportive groups, they are particularly drained and by negative groups. 49. Pay compliments. Notice other people. In general, get social training, as from your coach. 50. Set social deadlines. Without deadlines and dates your social life can atrophy. Just as you will be helped by structuring your business week, so too you will benefit from keeping your social calendar organized. This will help you stay in touch with friends and get the kind of social support you need.
Management of ADD Within Families by Edward HalloweII, M.D. 1. Make an accurate diagnosis. This is the starting point of all treatment for ADD. 2. Educate the family. All members of the family need to learn the facts about ADD as the first step in the treatment. Many problems will take care of themselves once all family members understand what is going on. The education process should take place with the entire family, if possible, as everybody needs to know what is going on. Each member of the family will have questions. Make sure all these questions get answered.
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3. Try to change the family 'reputation" of the person with ADD. Reputations within families, like reputations within towns or organizations, keep a person in one set or mold. Recasting within the family the reputation of the person with ADD can set up brighter expectations. If you are expected to screw up, you probably will; if you are expected to succeed, you just might. It may be hard to believe at first, but having ADD can be more a gift than a curse. Try to see and develop the positive aspects of the person with ADD, and try to change his family reputation to accentuate these positive aspects. Remember, this person usually brings a special something to the family, special energies, special creativity, special humor. 4. Make it clear that ADD is nobody's fault. It is not mom or dad's fault, it is not brother or sister's fault, it is not grandmother's fault and it is not the fault of the person who has ADD. It is nobody's fault. It is extremely important this be understood and believed by all members of the family. Lingering feelings that ADD is just an excuse for irresponsible behavior or that ADD is caused by laziness will sabotage treatment. 5. Make it clear that ADD is a family issue. Unlike some medical problems, ADD touches upon everybody in the family in a daily, significant way. It affects the early morning behavior, it effects dinner table behavior, it affects vacations, and it affects quiet time. Let each member of the family become a part of the solution, just as each member of the family has been part of the problem. 6. Pay attention to the "balance of attention” within the family. Try to correct any imbalance. Often, when one child has ADD, his siblings get less attention. The attention may be negative, but the child with ADD often gets more than his share of parents' time and attention day in and day out. This imbalance of attention can create resentment among siblings, as well as deprive them of what they need. Bear in mind that being the sibling of a child with ADD carries its own special burdens. Siblings need a chance to voice their own concerns, worries, resentments, and fears about what is going on. Siblings need to be allowed to get angry as well as to help out. Be careful not to let the attention in the family become so imbalanced that the one person with ADD is dominating the whole family scene, defining every event, coloring every moment, determining what can and cannot be done, controlling the show. 7. Try to avoid "the big struggle." A common entanglement in families where ADD is present but not diagnosed, or diagnosed but unsuccessfully treated, ‘the big struggle' pits the child with ADD against his parents, or the adult with ADD against his spouse, in a daily struggle of wills. The negativity that suffuses "the big struggle" eats away at the whole family. Just as denial and enabling can define the alcoholic family, so can "the big struggle" define (and consume) the ADD family. 8. Once the diagnosis is made, and once the family understands what ADD is, have everybody sit down together and negotiate a deal. To avoid "the big struggle," to avoid an ongoing war, it is best to get into the habit of negotiation. This can take a lot of work, but over time some kind of negotiated settlement can be reached. The terms of the settlement should be made explicit; at best they should be put into writing. They should include concrete agreements by all parties as to what is promised, with contingency plans for meeting and not meeting the goals. Let the war end with a negotiated peace. 9. If negotiation bogs down at home, consider seeing a family therapist, a professional who has experience in helping families listen to each other and reach consensus. Since families can be explosive it can be very helpful to have a professional around to keep the explosions under control. 10. Within the context of family therapy, role playing can be helpful to let members of the family show each other how they see them. Since people with ADD are very poor self-observers, watching others play them can vividly demonstrate behavior they may be unaware of rather than unwilling to change. Video can help in this regard as well.
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11. If you sense "the big struggle" is beginning, try to disengage from it. Try to back away. Once it has begun, it is very hard to get out of. The best way to stop it, on a day-to-day basis, is not to join it in the first place. Beware of the struggle becoming an irresistible force. 12. Give everyone in the family a chance to be heard. ADD affects everyone in the family, some silently. Try to let those, who are in silence, speak. 13. Try to break the negative process and turn it into a positive one. Applaud and encourage success when it happens. Try to get everyone pointed toward positive goals, rather than gloomily assuming the inevitability of negative outcomes. One of the most difficult tasks a family faces in dealing with ADD is getting onto a positive track. However, once this is done, the results can be fantastic. Use a good family therapist, a good coach, whatever—just focus on building positive approaches to each other and to the problem. 14. If you have not already done so, make it clear who has responsibility for what within the family. Everybody needs to know what is expected of him or her. Everybody needs to know what the rules are and what the consequences are. 15. As a parent, avoid the pernicious pattern of loving the child one-day and hating him the next. One day he exasperates you and you punish him and reject him. The next day he delights you and you praise him and love him. It is true of all children, but particularly true of those with ADD, that they can be little demons one day and jewels of enchantment the next. Try to keep some even keels in response to these wide fluctuations. If you fluctuate as much as the child, the family system becomes very turbulent and unpredictable. 16. Make the time for you and your spouse to confer with each other. You should try to present a united front The less you can be manipulated the better. Consistency helps in the treatment of ADD. 17. Don't keep ADD a secret from the extended family. It is nothing to be ashamed of, and the more the members of the extended family know about what is going, the more help they can be. In addition, it would not be unlikely for one of them to have it and not know about it as well. 18. Try to target problem areas. Typical problem areas include study time, morning time, bedtime, dinnertime, times of transition (leaving the house and the like) and vacations. Once the problem area has been identified, everyone can approach it more constructively. Negotiate with each other as to how to make it better Ask each other for specific suggestions. 19. Have family brainstorming sessions. When a crisis is not occurring, talk to each other about how a problem area might be dealt with. Be willing to try anything once to see if it works. Approach problems as a team with a positive can-do attitude. 20. Make use of feedback from outside sources, teachers, pediatrician, therapist, other parents and children. Sometimes a person won't listen to or believe something someone in the family says, but will listen to it if it comes from the outside. 21. Try to integrate ADD into the family just as you would any other condition and normalize it in the eyes of all family members as much as possible. Try not to let it dominate your family. In times of crisis this may not seem possible, but remember that the worst of times do not last forever. 22. ADD can drain a family. ADD can turn a family upside down and make everybody angry with everybody else. Treatment can take a long while to be effective. Sometimes the key to success in treatment is just to persist and to KEEP UP A SENSE OF HUMOR. Although it is hard not to get discouraged if things just seem to get worse and worse, remember that the treatment of ADD often seems ineffective for prolonged periods. Get a second consultation get additional help, but don't give up.
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23. Never worry alone. Try to cultivate as many supports as possible. From pediatrician to family doctor to therapist, from support group to professional organization to national conventions, from friends to relatives to teachers and schools, make use of whatever supports you can find. It is amazing how group support can turn a mammoth obstacle into a solvable problem, and how it can help you keep your perspective. You'll find yourself saying, "You mean we're not the only family with this problem?" Even if this does not solve the problem, it will make it feel more manageable, less strange and threatening. Get support. Even if it is just someone to grow gray hairs with you. Never worry alone. 24. Pay attention to boundaries and over-control within the family. People with ADD often step over boundaries without meaning to. It is important that each member of the family knows that he or she is an individual, and not always feel under the collective will wielded by the family. In addition, the presence of ADD in the family can so threaten parents' sense of control that one or another parent becomes a little tyrant, frantically insisting on control over all things all the time. Such a hypercontrolling attitude raises the tension level within the family and makes everybody want to rebel. It also makes it difficult for family members to develop the sense of independence they need to have to function effectively outside the family. 25. Keep up hope. Hope is a cornerstone in all treatment of ADD, Always have someone in mind that you can call who will hear the bad news but also be able to pick up your spirits. Always bear in mind the positive aspects of ADD—energy, creativity, intuition, good heartedness—and also bear in mind that many, many people with ADD do very well in life. When ADD seems to be sinking you and your family, remember things will get better.
Tips on ADD in Couples by Edward M. HallowelI, M.D. and John J. Ratey, M.D. In couples the symptoms of Attention Deficit Disorder (ADD) can be particularly vexing. The distractibility, impulsivity, and excess energy associated with the syndrome can perturb intimate relationships in ways that leave each partner exhausted, angry, hurt, and misunderstood. This is doubly unfortunate because two people suffer. However, if the situation can be subtly regulated, the ADD couple can find satisfaction commensurate with the high energy the couple usually possesses. The following guidelines or "tips" might be helpful in settling the chaos that is so often present in the ADD relationship and moving on towards a satisfying mutual relationship of love and understanding. 1. Make sure you have an accurate diagnosis. There are many things that look like ADD, from too much coffee to anxiety states to dissociative disorders to hyperthyroidism. Before embarking on a treatment of ADD consult with your physician to make sure what you have is really ADD and not something else. 2. Once you are sure of the diagnosis, learn as much as you can about ADD. There is an increasing body of literature out on the topic. The more you and your mate know, the better you will be able to help each other. The first step in the treatment of ADD—whether it is in a couple or elsewhere—is education.
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3. Declare a truce. After you have made the diagnosis and have done some reading, take a deep breath and wave the white flag. You both need some breathing space to begin to get your relationship on new footing. 4. Set up a time for talking. You will need some time to talk to each other about ADD—what it is, how it affects your relationship, what each of you wants to do about it, what feelings you have about it. Don't do this on the run, i.e., during TV commercials, while drying dishes, in between telephone calls, etc. Set up some time. Reserve it for yourselves. 5. Spill the beans. Tell each other what is on your mind. ADD shows up in different ways in different couples. Tell each other how it is showing up between you. Tell each other just how you are being driven crazy, what you like, what you want to change, what you want to preserve. Get it all out on the table. Try not to react until all the beans have been spilled. 6. Write down your complaints and your commendations. It is good to have it in writing what you want to change and what you want to preserve. Otherwise you'll forget. 7. Make a treatment plan. Brainstorm with each other as to how to reach your goals. You may want some professional help with this phase, but it is a good idea to try starting it on your own. 8. Add structure to your relationship. 9. Lists. 10. Bulletin boards. 11. Notepads in strategic places like by bed, in car, in bathroom and kitchen. 12. Write down what you want the other person to do and give it to him in the form of a list every day. 13. Keep a master appointment book for both of you. Make sure each of you checks it every day. 14. Avoid the pattern of mess-maker and cleaner upper. You don't want the non-ADD partner to "enable" the ADD partner. Rather set up strategies to break this pattern. 15. Avoid the pattern of pesterer and tuner-outer. You don't want the non-ADD partner to be forever nagging and kvetching at the ADD partner to pay attention, get his act together, come out from behind the newspaper, etc. 16. Avoid the pattern of the victim and the victimizer. You don't want the ADD partner to present himself as a helpless victim left at the merciless hands of the all-controlling non-ADD mate. 17. Avoid the pattern of master and slave. Akin to #16. However, in a funny way it can often be the nonADD partner who feels like the slave to her or his mate's ADD. 18. Avoid the pattern of sado-masoch*stic struggle as a routine way of interacting. Prior to diagnosis and intervention, many ADD couples spent most of their time attacking and counter-attacking each other. The idea is to try to get past that and into the realm of problem solving. What you have to beware of is the covert pleasure that can be found in the struggle. 19. In general, watch out for the dynamics of control, dominance and submission that lurk in the background of most relationships, let alone ADD relationships. Try to get as clear on this as possible, so that you can work toward cooperation, rather than competitive struggle. 20. Break the tapes of negativity. Many ADD couples have long ago taken on a resigned attitude of there's-no-hope-for-us. 21. Use praise freely. Encouragement, too. Begin to play positive tapes. 22. Learn about mood management. Anticipation is a great way to help anyone, and especially someone with ADD, deal with the highs and lows that come along.
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23. Let the one who is better organized take on the job organization. However, this job must then be adequately appreciated, noticed, and compensated. 24. Make time for each other. If the only way you can do this is by scheduling it, then schedule it. This is imperative. Clear communication, the expression of affection, the taking up of problems, playing together and having fun—all these ingredients of a good relationship cannot occur unless you spend time together. 25. Don't use ADD as an excuse. Each member of the couple has to take responsibility for his or her actions. Don't blame it on ADD. On the other hand, while one mustn't use ADD as an excuse, knowledge of the syndrome can add immeasurably to the understanding one brings to the relationship.
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How Most Adults Begin Treatment for ADD by Thomas Phelan, Ph.D. It is common for adults to seek treatment for themselves after their ADD child has been successfully diagnosed and treated. In the course of the child's evaluation and therapy, they learned that ADD is usually hereditary, and that it is not outgrown. When discussing the developmental histories of their children, many adults reflect on their own child-hoods, which are often remarkably similar to their kids. Involvement in parent support groups reinforces their awareness of residual ADD as they meet parents with histories similar to theirs. Sometimes a frustrated spouse (usually the wife) knows she has an ADD child and is convinced she also has an ADD husband. She "encourages" her husband to do something about his problem, but often the husband is defensive and denies there's anything wrong with him. It certainly doesn't help when the husband feels that getting an evaluation for ADD is the emotional equivalent of eating crow. Some adults do their own diagnosing by trying out their child's stimulant medication. This is not recommended since it can backfire when the medication or the dosage tried is inappropriate. Others have such a good response to their child's medication that they bite the bullet and go into treatment, realizing they can't borrow meds from their kids for the rest of their lives. As more books are written on adult ADD and more publicity is given to this topic, many self identify and then seek a clinician for a formal diagnosis followed by treatment.
The Evaluation Process The diagnosis of adult ADD requires several steps. These include 1) the self-report of the adult himself. 2) Observation of her behavior in the office, 3) an interview with spouse or other family member, and 4) the collection and review of certain data.
1. Self-report Many adults come into the clinician's office with their diagnosis made. "I'm an ADD adult and I'd like to know what I can do about it." The self-assessment is often correct, but the professional doing the evaluation still must check it, since there are a few people shopping around for a more acceptable diagnosis for their chronic ills. These people sometimes aren't ADD at all, and may in fact be schizophrenic, alcohol or drug abusers, have anxiety disorders or socio-pathic personalities. And there are, of course, times when these conditions, like drug abuse, exist along with Attention Deficit Disorder. What are the ADDults common presenting symptoms? There are three general problem areas: depression, job concerns and marital dissatisfaction. Both men and women report pervasive feelings of melancholy and dissatisfaction with life. Women more honestly describe the sense of low self-esteem that usually goes along with this, while ADD males vacillate between blaming everyone else for their troubles and being aware of their own shortcomings. Job concerns are brought up more often by men than women. Difficulty concentrating, poor organizational skills, and difficulty getting along with others give rise to a feeling that the person isn't progressing as quickly as he would like. Job problems have been brought up in their periodic performance appraisals and leave a residue of intense anger as well as nagging self-doubts.
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Women usually mention marital problems. Women, in general, are desiring more from a relationship than men so they may be the more frustrated with their state of the union and thus more likely to seek help for this. Many women are frustrated because of the ADD characteristics of their husband, but find it hard to persuade their mate to enter into counseling. If these fellows ever do show up to counseling, the would-be therapist has quite a job, trying to build a therapeutic relationship. With some ADD adults the complaints are less specific and sometimes are presented in a confusing manner. Complaints of not being in a very good mood much of the time are common. These complaints may be mixed together with vague hints of low self-esteem. A common theme that emerges is how aggravating other people are. The list of culprits seems endless, ranging from kids to wife to friends to government. Other, less well-defined complaints, have to do with not feeling well-organized, difficulty persevering with different tasks, and a feeling of frequent memory loss or confusion.
2. Office Behavior Approximately 80% of ADD children will sit still in a doctor's office, probably because the situation is new and somewhat intimidating. Therefore office behavioral observations are not always helpful in making the diagnosis for the little ones. The case is different for the adults. Their office behavior frequently shows a number of characteristics that can be observed and identified and which do manifest Attention Deficit Disorder symptoms. Rapid speech is common to those with ADHD. A steady flow of ideas may almost overwhelm the interviewer. The ideas are not well organized, quickly shifting from one topic to another. The listener struggles to figure out what is the point of a particular story. The ADDult may seem anxious, restless, driven, and sometimes has an almost "haunted" look, as if she can't escape some dark cloud that follows her everywhere. Eye contact is often broken. The person will appear lost in thought, pausing for a few seconds, staring off into space. One of the most common occurrences when interviewing ADDults is their tendency to interrupt you. The symptom of difficulty delaying gratification (or the fear they will forget what they want to say) operates here. They suddenly get a good idea and simply can't wait to share it with you. So—irrespective of where you were in your sentence or thought—they just burst in with their thought. Some ADDults are aware of this behavior and gently chide themselves about it from time to time, but that doesn't necessarily cut down the frequency of this behavior. The overall mood of the adult may alternate between melancholy and irritation. Many things irritate them people, and the emotional aftermath of this is sadness or brief depressive episodes. They initially blame all their woes on the behavior of other people, but once they trust the therapist, they begin to feel and express their real sadness about what they think of themselves.
3. Interview with spouse or other family members In evaluating for possible adult ADD, it is important for the clinician to talk with others who know the possible ADD adult. For one thing, ADD adults, just like ADD kids, are not usually good historians. They don't remember a lot of important things. In addition, they are not objective and have a distinct tendency to minimize certain aspects of their problems. While they might be quite candid, for example, when discussing their concentration difficulties, they may omit or de-emphasize how they express their hostility at home with the family. Another reason for involving the spouse is that he/she will usually be very helpful if/when a diagnosis is made and treatment progresses.
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The person to be interviewed should be seen separately so he/she can talk freely. Many times the stress they feel is painfully obvious, and they welcome the opportunity to ventilate their own frustrations. They may describe their ADD mate as a moody individual, with the predominant moods being anger and depression. They may feel it is very difficult to talk to their spouse and get anywhere, since everything appears to be taken as a criticism. Other common problems spouses relate involve intolerance of the children, arbitrary and inconsistent discipline, and a host of unfinished projects around the house. Some spouses describe feeling guilty because they avoid their mate or feel relieved when he/she is not around.
4. Collection and review of other relevant data With suspected adult ADD the same information is helpful that is useful in diagnosing kids. The only problem is that it is not as available. School records, including report cards, achievement tests, psychological tests, etc., are extremely helpful if they can be located. These pieces of information are also interesting to the person being evaluated, and they can help stimulate many important, as well as painful, memories. Questionnaires, such as the Conners, also can be useful, but they were really designed for use with children. Some evaluators, though, ask the client's mother, if available, to fill out the Conners as best she can as it would have applied when the client was about eight years old. Sometimes the client fills out the same questionnaire. This is certainly not a perfect procedure, but often, the situations back in grammar school were so dramatic and problematic that very useful information is obtained. It is useful to go through the prognostic indicators for ADD from the DSM IV with the client or with the client and his mother. Reviewing socio-economic status (when a child) IQ, level of aggressiveness, hyperactivity, social skills, early detection, and family strength (or parental psychopathology) can be very enlightening. If old psychological testing can be found, it is helpful. Again, most clients take an interest in reviewing it and having it explained to them. If testing was never done, it might be a good idea to consider an adult IQ test and some achievement tests that have adult norms. Keep in mind that if medication is to be a part of treatment, the choice of medicine and its titration should be done before any testing so as to get the most accurate result. Another helpful piece of information is the physical exam. This is probably even more important than with children. Adults, being older, have a greater range of possible physical problems, and may also have difficulties with drug or alcohol misuse.
Diagnosis Shock: A Common Response By Thomas Phelan, Ph.D. For many adults diagnosed with Attention Deficit Disorder, the discovery of their problem has a number of positive as well as negative aspects. Many of these people feel they are in a state of shock for a while as the "news" sinks in. The initial reaction to the diagnosis is often, "You mean it has a name?" It's as if now there is something inside them—a diagnosable disorder—that is not the same as their inner selves.
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On the positive side, there is a realization that all this trouble may not have been my fault. It wasn't "just me" that was doing it. All the people who criticized me in the past didn't know the whole story. The ADD adult begins to feel she is not alone. Other people, in fact, lots of other people, suffer from the same problem. Sometimes comparing notes with these other ADD adults can be a very beneficial experience. Also, on the positive side, is the feeling that something can be done about the problem. "I don't have to be this way all the time." One of the most dramatic examples of this for many people occurs with their first experience with medication. Some ADD men and women experimented with their children's stimulant medications; while others waited for their own prescriptions. For those who respond well to medication, the experience can feel like a religious awakening. They look at things and actually see them, paying attention to details that were previously unrecognized. They may suddenly be able to sit still during a conversation and really listen to what someone else is saying, without feeling the restless urgency to either speak or leave. They can organize their daily activities and work more productively. Many ADD adults take antidepressant medication, either in addition to or instead of stimulants. Though its effects can take a week or two to kick in, a positive response to antidepressants can also be an enlightening experience. Some say they never know how depressed they were until they started feeling better. For years they had just taken that lousy feeling for granted. On the negative side, the diagnosis of ADD can bring a sense of many wasted years. "If only I had known, I could have been saved a lot of trouble." This notion can give rise to considerable anger toward those who didn't do anything about the problem in years past, especially one's parents. Even though this makes little sense—as back then there was no way anyone's parents could have known much about this kind of thing—the resentment can still be strong, especially when the ADD symptom of emotional overarousal adds its contribution. Following the diagnosis, other negatives can arise. Dramatic initial responses to medicine, for example, can generate hopes for a permanent cure or a permanently altered state of being. Over a period of time, however, one realizes that ADD doesn't go away and that it is not curable. The effects of stimulant medications only last a short time, and they usually can't be taken in the evening. Medications cost money and for many the idea of taking pills for the rest of their lives is not appealing. Some adults find that the ADD symptoms of disorganization and forgetfulness make it hard to stick to a regular medication regime. For some men and women, Attention Deficit Disorder becomes an obsession. Diagnosis shock becomes a permanent condition. Their whole lives begin to revolve around ADD. All their thoughts and behaviors are now interpreted as manifestations of their ADD. The actions of other family members are seen in the same light. The rest of the world may be seen in a new light, and many, unsuspecting people will be secretly diagnosed. Comments such as, "My boss is so ADD I can't believe it!" or "There's too many ADD kids on this team for it to work," become commonplace. Those who become obsessed with ADD can do much good. Many make sizable contributions to the development of support groups across the country. They do much to increase awareness of ADD in the schools and the communities in which they live. In doing this they help themselves cope with their own problem and help many children avoid what they went through years ago.
The Long Road: Managing Adult ADD Treatment for ADD in adults is quite similar to the treatment in children. A "multimodal" approach is helpful, using several different strategies to attack the various aspects of the problem. This can include education about ADD, individual, marital, and family counseling, social skills training and medication.
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Adults need to be educated about ADD just as children do, but the adults are usually more interest in learning about the disorder and how it affects them. Much educational material is available. It is helpful for the ADD adult to become acquainted with it and then to discuss it in counseling. Many learn the basic symptoms of ADD and then use this knowledge to shed light on their behavior. This insight is often the necessary first step in individual counseling. The therapist assists the ADD individual express his dismay and anger for having these symptoms, and take responsibility for being the way she is and dealing with it. Accepting the fact of emotional over arousal in one's personality, for example, is not to be taken as license to abuse one's spouse or children. Individual counseling can also help a person come to a more realistic sense of self-esteem, an aspect of his existence, which has usually taken quite a pounding over the years. Marital counseling is often needed with ADD adults. A spouse's years of frustration should be listened to (although not beaten to death), and something done to prevent the future from being as difficult. Since the non-ADD spouse is often the underdog in the marital relationship, a therapist can help the couple come up with a more democratic way of dealing with each other. The focus of marital counseling should not be solely on ADD, since the ADD spouse will also have some legitimate gripes about their marriage partner that need to be addressed. Periodic family counseling can assist the children and parents in dealing with the usual problems that come with daily living, as well as those that are related to ADD. It is quite common, of course, for ADD parents to have ADD kids, and this can make for a very difficult combination around the house. The ADD adult will often find it helpful to become acquainted with some specific parenting strategies, such as counting, charting, or positive reinforcement, rather than just shooting from the hip whenever problems arise. For adults, social skills training usually takes place in individual counseling sessions, rather than in a group setting. Therapists who treat ADD find it a refreshing change to work with an adult who wants to change his or her ways of relating to others, rather than with an ADD child who is still blaming their social ills on everyone else. Compared to children, ADD adults have more opportunities to generalize their learnings with the therapist to the real world, and many are delighted with the benefits of their efforts. Medication can play a big role in helping to effect these social changes. Listening skills, for example, are often significantly enhanced by stimulant medications used in conjunction with counseling. Antidepressants can have a profound calming effect, reducing the fidgitiness and restlessness that spouses, children or co-workers can find so irritating. Many of the same medications that are used with ADD adults are used with ADD children. (old info on medication deleted by editor).Medication therapy can involve much experimental trial and error to figure out what medicine or combination of medicines will work. When medication works, it becomes a critical part of the overall multimodal treatment plan.
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Effectively Communicating Adult ADHD Diagnosis 4 By Kevin R. Murphy, Ph.D. Effective treatment for adults with ADHD begins when they are diagnosed. How the diagnosis is communicated to them is critical to both their understanding of the disorder and their willingness to engage in and follow through with treatment. If clinicians can help patients understand the disorder, frame it as something that is treatable, and instill hope and optimism for the future, then patients are more likely to feel motivated to work at treatment. This should also result in more positive outcomes. Conversely, if patients are left with only a vague notion of what ADHD is, are confused or unsure of how they might be helped, and are not activated to feel hope, then they are far less likely to persevere and achieve a positive outcome. Clinicians can have substantial control over this process. The following framework can assist clinicians in developing a strategy to effectively communicate the diagnosis to adults. Assuming an experienced professional who understands adult ADHD makes an accurate diagnosis, the first step is to explain the rationale for arriving at the diagnosis and any other comorbid conditions. For example, explaining that patients: (1) endorsed many of the core symptoms of ADHD; (2) had an onset in early childhood: (3) have no other psychiatric or medical condition that could account for their symptoms, and (4) have behavior at school. and/or work histories that are consistent with the diagnosis, can help them begin to understand ADHD. This is not enough, however. The next step is to continue educating patients about what ADHD is and how it manifests itself in their lives. Patients need to have at least a general understanding that they have a neuro-developmental condition, not a character defect or moral shortcoming. Often they have internalized negative messages from parents, teachers, spouses, and employers and have come to believe they are dumb, lazy, incompetent, or unmotivated. Such demoralization is quite common in the ADHD adults we have seen. They should be told that the reason for many of the problems they experienced in school, work, and/or social relationships, was largely due to a subtle neurological deficit in the brain that they had little or no control over. Their problems were not the result of willful misconduct, low intelligence, or lack of effort. In short, these inaccurate and unhealthy notions should be reframed in a more positive and hopeful light so patients can begin to rebuild their self-esteem and believe successful treatment is possible. The message should be that with proper treatment. including education, medication, behavior strategies, hard work, and the support of family and friends, they can make significant and sometimes dramatic improvements in their lives. As an additional educational resource, the University of Massachusetts Adult ADHD Clinic provides a packet of educational literature to all patients at the end of the evaluation. This typically includes a fact sheet about ADHD, advice as to which books may be informative for them and copies of newsletter articles on ADHD in adults. Information on medications may also be given if these have been recommended for a trial. It can also be helpful to provide some specific examples of treatment strategies that are relevant to the problems the patient is currently experiencing. For example, patients who are disorganized and forgetful may benefit from being told about making lists, keeping an appointment calendar, posting visual reminders in strategic locations, blocking time in schedules for priority tasks, breaking long tasks into small units, scheduling mini-rewards into projects, and the like. Or, if the patient were a college student, it would be useful to describe specific types of classroom modifications, class schedule adjustments, study habits, and other suggestions that could help the student succeed. 4
Kevin Murphy,, (1993) “Effectively Communicating Adult ADHD Diagnosis”. THE ADHD REPORT, 1(3). (pp.-7). Reprinted with permission. To receive a sample copy of THE ADHD REPORT, call 1-800-365-7006 or e-mail: [emailprotected]
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As noted above, education about medication is important. Explaining how medication might help patients improve their ability to focus and concentrate may provide further hope. Answering questions about side effects and providing enough accurate information so the patient can make an informed decision about trying medication is also important. Patients often have mistaken notions and unrealistic fears about medication that need to be addressed before they are willing to take it. Providing fact sheets in addition to these oral explanations can give them further information to digest and share with significant others in their family life following the session. Patients with job problems are often poorly matched with their jobs. They rarely fail due to incompetence or poor ability. In fact, most have great strengths and high potential if they find the right job. Pointing out their strengths and communicating a belief that they can succeed if they find the proper "fit" is another way to instill hope. Sometimes referral to a vocational assessment specialist can provide a finer-grain analysis of patients' interests and abilities and how these might best match with various vocations. If treatment is successful long-term goals that patients always thought were unattainable (such as returning to school or getting a higher level job) may become possible. With support and encouragement, these patients may decide they are willing to undertake the challenge they have avoided for so long. Creating this spark of hope, balanced with the reality that real change requires hard work and sustained effort, can help set the proper tone. Clinicians can go a long way toward setting a therapeutic atmosphere of hope and optimism in patients who are so accustomed to hearing the opposite about themselves. Armed with this combination of hope, knowledge, and awareness of ADHD, patients will be in a much better position to benefit from treatment, to learn to adapt better to current tasks and responsibilities, and to lead more fulfilling lives than has previously been the case.
AD/HD “To Do” List By Cynthia Hammer, M.S.W.
Determine If You Might Have AD/HD 1. Read or listen to Driven to Distraction by Drs. Hallowell and Ratey (available in hardback, paperback and audio at most libraries and major books stores). 2. Read other books on AD/HD or watch videos on adult AD/HD. Your local library may have materials. 3. Watch the 80-minute video, AD/HD in Adults, which you can purchase at Dr. Daniel Amen’s web site, www.amenclinic.com. This is an excellent video and covers all the essentials. 4. Complete Dr. Amen’s Adult AD/HD Questionnaire and have others who know you well complete the questionnaire on you (self-scoring questionnaire available at his web site www.amenclinic.com, or at the web site www.addresources.org). 5. Reflect on life and determine if AD/HD symptoms have been there since early childhood.
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6. If unable to proceed with the above steps or any of the steps below, in spite of good intentions, perhaps your first step should be to enlist the help of a mentor or AD/HD coach. Locate AD/HD Coaches at the web site, www.addresources.org, under “Local, state and national resources” or at the website, www.add.org under “Yellow Pages.”
Find a Qualified Person to Make a Formal AD/HD Diagnosis 1. Read the articles “ADD 101” and “Tips for Finding an AD/HD Clinician.” at the web site www.addresources.org. 2. Talk with others who have been diagnosed. On-line there are AD/HD support groups at www.support-groups.com, www.yahoo.groups.com and www.add..about.com. 3. Clarify your insurance coverage and your finances. Realize that spending money for an AD/HD diagnosis and treatment will be the best money you have ever spent. 4. Determine if you will see a psychiatrist, a family practice doctor, a psychologist or other clinician. Psychiatrists generally have more familiarity with adult AD/HD than family doctors, although both are M.D.s and could, if knowledgeable, diagnose AD/HD and prescribe medications. Some physician assistants and nurse practitioners can also diagnose AD/HD and prescribe medications. Psychologists and other therapists may be qualified to diagnose AD/HD, but are not able to prescribe medications. This can cause difficulties as you can get the diagnosis, but where will you get the primary treatment—stimulant medication? 5. Locate an AD/HD clinician that works with adults. There is an article at www.addresources.org that gives “Tips for Locating an AD/HD Clinician.” 6. Ask what time and expense will be involved in getting a diagnosis. 7. Learn what information you should bring with you to your appointment. 8. If satisfied, make an appointment. 9. If you’ve been diagnosed with AD/HD earlier in your life, try to obtain records as this can save time and money in the diagnosis process.
Know What is Necessary to Make an AD/HD Diagnosis 1. Knowledgeable AD/HD Clinician listens to your history
Know What May Be Included in Making An AD/HD Diagnosis, Depending on Clinician 1. Complete some questionnaires and/or rating scales 2. Take a TOVA test 3. Complete a battery of psychological tests 4. Bring in early school reports, etc. for clinician review
Obtain Medical Treatment—This is Key and Must Come First! 1. The primary and most proven effective, treatment for AD/HD is stimulant medication—ADDerall XR, Concerta, Dexedrine, Ritalin, Ritalin LA and Focalin. In addition, there are a few non-stimulant medicines that are helpful to some people—Strattera, Wellbutin and Effexor, and sometimes, Cylert. One of these medicines, at the right dose, will help most people with AD/HD.
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2. Clinicians should have you try more than one medicine, at varying doses, to determine which is most helpful to you. Trials of each stimulant medicine need be only a week or less, as all the stimulants are very fast acting. (i. e. within hours of taking a pill you will feel its impact.) The impact is shortlived—ranging from 2 to 8 hours depending on the individual person and the medication taken. The non-stimulant medications used to treat AD/HD will generally need to be tried for several weeks before determining their helpfulness. 3. Note a few troublesome behaviors you have that are AD/HD-driven and chart the frequency of these behaviors as you try the various medications as varying doses. This will help determine which medicine, if any, is most helpful. 4. Medication for AD/HD should make it possible for you to have a moment’s reflection before acting— i.e. you will be less impulsive—and should allow you to direct your focus where you wish. 5. If your clinician is unwilling to prescribe the stimulants for you, ask why not? It may be because he is uncomfortable prescribing a controlled substance, which is not an appropriate answer for meeting your needs. 6. If you have a history of drug addiction, the clinician may prescribe Stratera, Wellbutin, Effexor, or Cylert, which have been found helpful for AD/HD, although not generally as helpful as the stimulants. You may need to locate a clinician comfortable prescribing stimulants to someone with an addiction history that is not currently abusing substances. 7. Read The Link between AD/HD and addictions: Getting the Help You Deserve by Wendy Richardson.
Explore additional Treatments for AD/HD 1. Being properly medicated or having your brain chemistry improved by other methods, is the cornerstone of AD/HD treatment. 2. A small number of people is not helped by medications or react poorly to taking medication. 3. There are alternative treatments for AD/HD which, by testimony only, people have reported as helpful. Among these alternative treatments are: blue-green algae, ginkgo bilboa, pycnogenal, special nutritional supplements, essential fatty acids, amino acids and neurofeedback. Consult a knowledgeable naturopath or other therapist as appropriate. 4. Other helpful treatments include those prescribed for general good health, but become even more critical for people with AD/HD to incorporate into their life. ___Regular exercise ___Adequate, regular sleep ___Good nutrition and regular meals ___Relaxation and stress reduction techniques; ___Balanced lifestyle between work and play ___Sex in moderation
Initial Coping Strategies 1. Learn about AD/HD—what it is and what it isn’t—Resources include books, AD/HD magazines, reputable Internet sites, conferences and support groups. Information on all these resources can be found at: www.addresources.org; www.add.about.com and www.add.org. 2. Have those involved with you learn about AD/HD.
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3. Realize that nothing has changed by getting an AD/HD diagnosis. You only have been given a name for what has always existed. 4. Expect to be both relieved and sad after receiving your diagnosis. Relieved to know that something is the matter; yet sad to learn something is the matter and that is wasn’t learned about earlier. 5. Recognize that you will get better. Getting your AD/HD diagnosis is a positive, helpful step in building a better life for yourself. 6. Forgive yourself for your past failings. 7. Focus on learning and taking the steps to make your future better. 8. Accept that improvements will come slowly, so go easy on yourself.
Rome wasn’t built in a day.
9. Realize that acquiring new habits and behaviors takes time. 10. Celebrate each desired new habit or behavior you acquire. 11. Meet and share ideas and concerns with others who have been diagnosed with AD/HD. There are many AD/HD chat rooms and email lists on the web. 12. Attend or start an AD/HD support group such as ADD RESOURCES. 13. Make one or two friends with AD/HD that you can talk with about your experiences. 14. Become comfortable with telling people, in a simple, non-aggressive, way that you have AD/HD. 15. Find ways to describe, in simple terms, how AD/HD negatively and positively impacts your life. 16. Learn to laugh at your AD/HD-moments. 17. If unable to accomplish these “to do” items, seek the assistance of an AD/HD therapist or coach.
Is Therapy, and this Therapist, for You? 5 By Cynthia Hammer, M.S.W. Selecting a clinician to make an ADD diagnosis and/or provide therapy can be difficult. How to make the best choice? How to evaluate your choice? Which kind to choose? Will the expense be a factor? What your medical insurance will pay for can limit your choices, although I feel being diagnosed and treated for ADD will probably be the best spent money in your life. Psychiatrists are medical doctors (M.D.s) who receive special training in psychiatry. Note that only M.D.s, physician assistants (PAs), and certain nurse practitioners can prescribe medications. 5
Much of the material for this article was adapted from a wonderful book by Barbara Yoder, The Recovery Resource Book
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Psychologists (Ph.D.) have doctorate degrees in psychology while social workers (M.S.W.s, ACSWs or CSWs) and marriage and family counselors (MFTs or CMFTs) have master degrees in their respective disciplines. They, also, may be certified, demonstrating a higher level of training, by their professional organization or by the state. That's the C in their abbreviations. Most therapy sessions last about an hour and the cost ranges from $75 to $150/hr, with some clinicians offering sliding scale. Generally, psychiatrists charge the most. Plan to briefly interview one or more therapists on the phone before you set-up an initial appointment. Ask about their training and background. Describe the kinds of issues you want help with. Make absolutely sure that the therapist is familiar with ADD in adults. Therapists for ADD adults should be more directive than is typical in a "therapeutic relationship." ADDults can talk ad nauseam without achieving any insight or direction from their "emoting" or "ventilating." They need structure and guidance to stay focused, to stay on topic. If you find one that seems good via the phone, set up a longer, in-person interview. Some therapists will let you come in for an initial half-hour session and charge half their regular rate. Others expect you to devote a full hour session to getting acquainted and seeing if you can work together. Pay attention to your feelings during this initial session. It's important that you find someone who makes you feel comfortable and who gently challenges you to explore your inner life and past experiences. When you find a counselor you like, plan to give therapy about six sessions before deciding whether to go on with it or not. It usually takes that long to uncover areas of concern and begin to identify your issues. Six months to a year of counseling is often needed to work through most problems. With ADDults, this can go faster. After we deal with an issue, we're ready to move on. We like things fast. No dwelling on the past; we tend to not be reflective. Watch out for therapists who want to continue the therapy relationship when you feel ready to end it. They may need to "help" you more than you need to be helped. Many ADDults don't require intensive long-term therapy to get their lives on track and to improve their self-esteem and confidence if they don't have a lot of lifetime baggage that needs to be worked through. Often, medication, learning about what ADD is and isn't, putting good coping skills in place, exercising regularly and taking good care of themselves, along with belonging to an ADD support group, even via the computer, are enough. Sometimes, instead of therapy, ADDults only need "coaching." They benefit by having someone who regularly checks in with them to see how things are going; someone who helps the ADDult develop and carry out strategies that will work for him in achieving his goals. After you stop therapy, it may take a few months or longer before you fully integrate the knowledge you gained in counseling into your daily life. That's to be expected: Good things—like new, healthy behavior—always take time to develop.
Rating Your Therapist 6 How do you rate your therapist after you've been to her for several sessions? What if you're not completely comfortable with the process and don't know if it's because you're new to therapy and don't know what to expect or if this is the wrong therapist for you. You could use the following questionnaire to help evaluate, Rate each statement according to the following scale: 6
From The Deadly Diet by Terence Sandbek
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4 3 2 1 0
This statement is true. It is true most of the time. It is true some of the time. It is seldom true. It is never true.
1. ___ I feel comfortable with the therapist. 2. ___ The therapist seems comfortable with me. 3. ___ The therapist is casual and informal rather than stiff and formal. 4. ___ The therapist does not treat me as if I am sick, defective, and falling apart. 5. ___ The therapist is flexible and open to new ideas rather than pursuing one point of view. 6. ___ The therapist has a good sense of humor and a pleasant disposition, 7. ___ The therapist is very willing to tell me how she feels about me. 8. ___ The therapist admits limitations, not pretending to know things she doesn't. 9. ___ The therapist is willing to acknowledge being wrong and apologizes for errors or for being inconsiderate, instead of justifying the behavior. 10. ___ The therapist answers direct questions instead of asking me what I think. 11. ___ The therapist reveals things about himself spontaneously or in response to my inquiries, but not by bragging or talking incessantly and irrelevantly. 12. ___ The therapist encourages a feeling that I am as good as he is. 13. ___ The therapist acts as my consultant, rather than the manager of my life. 14. ___ The therapist encourages differences of opinion rather than telling me that I am resisting if I disagree with her. 15. ___ The therapist is interested in seeing people who share my life or seems willing to. This includes family, friends, lovers, work associates or other significant people in my life. 16. ___ The things the therapist says make sense to me. 17. ___ In general, my contacts with the therapist lead to my feeling more hopeful and having higher selfesteem. ___ Total
Interpreting Your Score You would probably not feel comfortable working with a therapist who rated below 50 points. Certainly, you shouldn't even consider working with some whose score fell below 40 points. Don't think you have to stay with a particular therapist simply because you have started or have been with the same person for months. It is your time, money and well being that are at stake. If you try several therapists with different styles and personalities and none seems satisfactory, perhaps it is better to work with the one who has the highest score rather than using an absolute figure. Even after visiting a specific therapist for several sessions, you can still change therapists if you are not making progress of if the therapist is not going in the direction you desire. Remember, the therapist always works for you! You are the boss and must call the shots.
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Paying Attention To Attention Deficit In Adults By John J. Ratey, M.D. Until recently mental health professionals have not paid much attention to disorders of attention in adults despite the fact that attentional disorders have major ramifications for intellectual, cognitive, and emotional experience. Our failure as clinicians to appreciate this comes from the myth that in adolescence there is a resolution of childhood attention deficit disorder (ADD) symptoms, either through the myelinization of the cortex, hormonal change, or through some other developmental advance. This view of ADD as a strictly childhood disorder has been debunked by recent longitudinal studies. The outcome for kids with the severest forms of ADD has been thought to range from underachievement to severe delinquency. A summary of long-term out come studies by Hechtman and Weiss focuses on obvious adult dysfunction and reaches the conclusion that it is only the children with the most disruptive and destructive behavior who come to psychiatric attention later in life. Generally, it is only the worst cases of ADD—in which children are destructive or failing at school—which come to the attention of mental health professionals. However, most studies find ADD's presence in adulthood associated with other less obvious disorders including personality disorders and alcoholism and syndromes such as "episodic dyscontrol." This article will focus on an under-identified group of adult patients who had milder problems in childhood and less obvious areas of dysfunction in adulthood. These people were not identified in childhood either because their dysfunction was mild or because high intelligence or socioeconomic advantage helped them compensate for their difficulties. As early problems with attention, learning skills, or impulsivity were compensated for, patient, family, and school quickly and gladly forgot the suggestion of some underlying neurologic problem. Only when the adult finds that despite his best efforts he consistently achieves below potential or is thwarted in relationships or career by his restlessness that he looks for help.
Diagnosis and Misdiagnosis We—a psychiatrist, psychoanalyst, and neuropsychologist—have seen over seventy adults with ADD. Some forty percent of these patients presented with disorders of mood, for example, depression, dysthymia, and bipolar disorder. Others were referred with diagnoses of impulse disorders, obsessivecompulsive disorder, substance abuse or with a range of anxiety symptoms from generalized anxiety to panic. Only a small part of our sample was antisocial personalities. Most in our sample had adapted adequately, some harnessing their talents while compensating for their deficits. Many were successful and productive. Some were innovative thinkers with creative talents. Others were leaders in business. A number were on the faculties of the colleges, universities, and medical schools in the Boston area. Most presented with an uneven picture, with success in some areas of living and utter failure in others. A majority had interpersonal problems, while others had underachievement in school and work. All had a gnawing feeling that they were not living up to their potential in the major domains of their lives. The common personality feature of these individuals was their feeling of driveness. Some described themselves in terms suggesting they were puppets at the mercy of some inner force. Their inner world is
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constantly shifting and changing. Their distractibility is both a blessing and a curse as they are able to distract themselves out of one feeling state into another but can't stick with any. One patient reported that at times he would become depressed by his failures. He would then immerse himself in complex problems or designing a new addition to his house, and he would quite literally forget that he was depressed. This is characteristic of the group. The depression they report is as reactive to the environment as the individual himself is. Some individuals are considered energetic and charismatic. Yet even they have labile moods and are easily disgruntled, discouraged, and depressed. They become distracted and their attention is constantly looking for a new stimulus to land on thus being torn away from the present focus. Others present as withdrawn and lethargic. Individuals overwhelmed by stimulation may retreat into shyness, apathy or intellectual, solitary pursuits. Quietly suffering, they are often overlooked as children, because they do not create any disturbance in school. Instead, they are the daydreamers and in fact are mentally hyperactive but the noise they experience is internal. Grown up they may be the absent-minded professor. Adults with ADD are often immature—full of fleeting passions, childlike enthusiasm, and a tendency to lag behind others in achieving lifesteps. They are aware that they cannot perform to the level of their abilities and are constantly frustrated, angry or depressed. They cannot stop the buzzing or whirling in their heads that disrupts the concentration necessary for achievement. Their apparently needless failure leads to self-doubt, disgust, and hate. They often turn to intense physical or mental activity or drugs and alcohol to self medicate. Their major internal goal is usually to reach a state of calmness and equilibrium which paradoxically, they find when they are "living on the edge" immersed in a mental or emotional struggle or responding to a physical challenge. Thus, they are risk takers and always pressing for the next height which tends to organize them and calm their inner distress. When they came to us, most of these patients had previously been under the care of other psychiatrists, psychoanalysts, or psychologists. A few had been diagnosed as having learning disabilities or conduct problems in childhood, but most were not identified as having ADD. Many had been referred as refractory patients, not responding to treatment despite what seemed a clear symptom picture. Therapy was found wanting by patients and therapists alike, and posed yet another failure with which patients had to deal. Psychotherapy sessions were often characterized as a bouncing from topic to topic, thought to thoughts, with in many cases no center or core and very little feeling attached, despite the patient's intense desire to cooperate. This pattern is unproductive and fatiguing for both therapist and patient. The frenetic superficial manner seen in psychotherapy is also characteristic of their life's relationships and friendships. Their intimate relationships are jeopardized by their inability to sit with another and maintain the attention needed to sustain intimacy. One patient, for example, was committed to the idea of a lasting relationship, but after falling in love again and apparently moving toward marriage, came into a therapy session therapy session berating himself as a "selfish male" for getting bored in the relationship and wanting out. The most difficult aspect of treatment is dealing with these issues of intimacy. ADD adults have developed all manner of avoidance techniques because they have found that they are too distracted to stay too long in any one relationship.
Treatment Brief treatment involves identification of the patient's problems with attention and distractibility, and specifically now these might be associated with a history of subpotential performance. It is also important to identify how attention problems have affected the patient's relationships, which are often tumultuous. Identification of attention as the primary problem often leads to relief of guilt and enhances selfdisclosures. Most patients readily acknowledge deficits in their personality—deficits for which they have assumed responsibility.
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Identifying problems of attention as primary helps to focus discussion and understanding in therapy. Patients share a common sense that something was wrong, but are puzzled as to what exactly was going on. They feel guilty, demoralized, blame themselves, and want help. For most, who have compensated well in their lives, identifying attention problems alleviates much guilt and contributes to raising selfesteem. Significant problems with distraction and disorganization and its attendant anxiety and mood shifts are often helped by medication. Many patients report that the medication has finally stopped the noise in their head or the ringing in their ears. For the first time they can stop and focus; they can relax; they can sit quietly to read or think. (Editor’s note: paragraph on medicines deleted as no longer current) Providing assistance in structuring his or her environment can further help the patient. This may involve establishing external means of keeping affairs in order such as using an appointment book, a computer with hard drive, or a microcassette tape recorder. Structuring the environment also includes the choice of significant other, mates, colleagues, or mentors who will help provide order, continuity, and direction. Another important point is to help the person to plan episodes of high stimulation. The therapist can validate the need for this type of distraction, as the socially successful ADD patient is liable to be a workaholic, who hyper-focuses on work, driven by the need for constant challenges and new worlds to conquer. Thus, they need aid in designing vacations and encouragement to engage in other high stimulus activities, which provide leisure and prevent burnout. Longer-term therapy helps in exploring problems of attention past and present, managing mood liability, stabilizing relationships and alleviating guilt and discouragement. After the individual has achieved a certain degree of stability, it is possible to begin the long haul of addressing and restructuring character. Often, individuals with ADD develop adaptive and therefore difficult to relinquish, defenses. These might include social withdrawal (to avoid confusion and failure), obsessive-compulsive defenses (to help order their inner and outer chaos), and denial, which have allowed the patient to function with their disability, but which limits the range of their experience even after the disorder has been understood and treated. The therapist provides some means to the patient of accepting and understanding the bio-psychosocial handicap of ADD so that the patient can work around their difficulties and not be denied life's satisfactions in love, work, and play.
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The Adult Experience Of ADD By Thomas Phelan, Ph.D. For a long time it was believed that Attention Deficit Disorder would be outgrown by the time a person was an adolescent. This idea probably came from the general observation that most hyperactive children seemed to calm down as they got older. Since the most obvious symptom—moving around a lot— lessened, people assumed the rest of the problem was gone too. However this is not the case. Most ADD children continue to have ADD symptoms into adulthood along with the added problems from "growing up ADD." The most prominent of these "extras" are low self-esteem, depression, and major interpersonal difficulties. That is why the term "comorbidity" is often used to describe ADD adults as they frequently have more than one diagnosis. Paradoxically, for therapists treating them, Attention Deficit adults can be the most rewarding (as well as the most frustrating) The eight symptoms common to ADD children also appear in adults, often in modified forms.
1. Inattention (Distractibility) Adults with ADD have trouble concentrating and staying on task. Often they do not finish as much as they would like. Inattentiveness also affects them around the house. They will go from project to project without finishing a thing. Many ADD homemakers find that they can't stay on top of the household chores. Their day is one endless series of frustrations with nothing getting done. Inattentiveness can frustrate Attention Deficit adults in social situations. They have difficulty focusing on conversations with others. Some find big parties or family get-togethers distressful with so many conversations going on at once. ADDults get distracted from the conversation they are supposed to be paying attention to. They run the risk of embarrassment when it becomes apparent to others that they have lost the train of discussion. ADDults often look bored or disinterested to others—another social fax pas—because they get restless and fail to maintain eye contact.
2. Impulsivity This symptom may still be there in adults, but it is much more restrained than in ADD children. Usually ADDults have been "burned" enough by past impulsive actions that they exercise more self-control. This is especially true in social situations with strangers when some ADD adults can be downright quiet! If they are socially at ease, however, these adults have a marked tendency to interrupt, blurt things out and become loud and boisterous.
3. Difficulty Delaying Gratification Impulsivity and difficulty with delay are similar problems. Impulsivity refers to action taken without thought and without waiting. Difficulty with delay is the impatience and frustration stimulated by having to think first or wait before taking action. In conversations ADDults have a terrible time waiting to express their opinion. They lack the patience for academic, "schoolish" tasks such as balancing the checkbook, filing a tax return, or paying bills. They want to get these boring tasks over with quickly. This often results in messy, unchecked work that later comes back to haunt them.
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Some ADDults have serious problems managing money because they spend it too quickly. Since credit cards offer the promise of never having to wait for anything, ADDults often push the credit limits on all their cards. Unfortunately, spending money can easily become an antidote to boredom. ADD adults, when inactive, are easily bored. They feel a sense of emptiness and melancholy that is hard to describe but which they will do almost anything to avoid.
4. Emotional Over-Arousal In ADD children this symptom is manifested primarily in "hyper-silly" behavior and in ferocious tempers. In adults the hyper-silly behavior is much less common, but the ferocious tempers can persist. Though these emotional outbursts may be restrained in public, they sometimes show themselves on the job. Their bad temper may come across as persistent irritability or moodiness. Unfortunately, at home the temper is often given full range and is unleashed on spouse and children. Spouses have a hard time asserting themselves with their ADD husband or wife because such interactions with them will probably provoke their anger. Spouses feel like they are always walking on eggs as the mood of the ADD person is unpredictable. In addition, an ADD parent may have a low frustration tolerance when it comes to dealing with their kids. Since ADD tends to be hereditary, many of the kids are Attention Deficit themselves. Their behavior makes the anger control problem doubly difficult. People who are not Attention Deficit have no idea of the strain that emotional over-arousal puts on the self-control of an ADDult. They do not want to feel that everything is a big deal, but they do. Non-ADD adults know what it is like to be irritable at the end of a long day, but this is an unusual experience for them. For ADDults, it is a regular, daily occurrence. It is as though an event stimulates four times the adrenaline in them than in someone else.
5. Hyperactivity As they get older, most ADDults become less physically active. A general fidgeting or restlessness may replace gross-motor hyperactivity. Some ADDults are unable to sit still for very long. Others continue to be hyperactive, but the hyperactivity takes a verbal form. Their speech may be rapid, nonstop, and have a driven quality to it. They may not be very good listeners.
6. Noncompliance Certainly, adults in general, as well as ADD adults, have fewer problems following rules than do children. Perhaps this is because they encounter fewer situations in which someone else is telling them what to do. Still, studies indicate that as many as 25% of ADD adults have serious problems with antisocial behavior. Other studies of incarcerated adults suggest that a large percentage of them grew up with unrecognized Attention Deficit Disorder. Many ADDults function adequately, even well, in the workplace when they are their own bosses. Others, however, have difficulty with supervision, which stirs up the old "antiparent" antagonisms they experienced as kids. Rules may stimulate an automatic opposition, and supervisors may be seen as stupid and irrational. Because of an ADDult's frequent inability to get his/her act together around the house, along with their emotional liability, spouses sometimes feel as if they have another kid to deal with rather than a marriage partner. Trying to parent your ADD spouse, however, is fraught with danger. Attempts at advice or correction are often met with temper outbursts. As a result, many non-ADD spouses keep their mouths shut, while inside they feel considerable resentment toward their "partner."
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7. Social problems How one gets along with the human race is extremely important to all of us, and ADD adults are no exception. Unfortunately, many of them feel isolated and lonely. It is hard for them to maintain longlasting relationships, and by the time they are adults, some have simply quit trying. Inside they may often blame everyone else for their problems, but they also, often, have the feeling that they are the real source of their own troubles. At home their temper and bossiness pose persistent difficulties for their spouse and kids. At work their talkativeness, restlessness, tendency to complain and general irritability drive co-workers away. On the other hand, sometimes ADDults are enjoyed for their lively personalities and their ability to get a party or other activity going. This can help their social life considerably.
8. Disorganization Many ADDults have trouble juggling the different aspects of their lives. They have difficulty with dates, times and appointments. Their memories can be amazingly erratic. Their homes, some times, are monuments to their tendency to start and not finish things. The bathroom upstairs may have been torn up for the last six months. There are still paint cans on the floor of the kids' half-painted bedroom. The car has been parked outside all winter because the garage-cleaning project never got done. On the job ADDults have difficulty starting with a task, especially if it is boring and it is solely up to them to keep it going. It is not unusual for them to feel like born procrastinators. Because they get bored, they avoid certain tasks—like paper and pencil jobs—that they know will be uninteresting. Instead, they find the easiest or most interesting task to do instead. The problem with this way of operating is that their job of choice may not be what really needs to be done at that moment. Procrastination gets ADD adults into sizable trouble. The undone tasks build up. They feel more and more embarrassed but still can't bring themselves to get started. Then a supervisor who has discovered the gap in their work confronts them, and they have no reasonable explanation for why it was not done. For many ADD men and women, of course, life is satisfying. Most are married, have jobs, and are selfsupporting. A few, who are bright, have reasonable social skills, and use their extra energy to good purpose, become outstanding achievers. But even with these more fortunate ADDults, the impact of Attention Deficit continuously adds rough edges to their existence.
Adult ADD: Issues And Concerns By Thomas P. Phelan, Ph.D. While there is no doubt that ADD adults exist, there are still several questions that need to be answered.
1. Where are all the ADD adults? If 5% of our children qualify as Attention Deficit, and about 60% of them don't outgrow the problem, it is very likely that over 3% of the adult population are experiencing significant ADD symptoms. Yet there definitely aren't this many men and women seeing therapists who have a diagnosis of ADD. Undoubtedly, many don't come in for treatment, and others may be misdiagnosed.
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2. What happens to ADD girls when they become adults? There is a tendency for ADD girls to be less hyperactive than ADD boys are. They present fewer behavioral problems. For these reasons girls are less likely to be singled out, - and therefore, often go undiagnosed. As adults, these women still experience the concentration problems and disorganization that affected them as children, but they present a tricky diagnostic dilemma to a therapist. Their developmental history, typically, doesn't include hyperactivity, emotional over arousal, aggression, and other overt social problems. Women with ADD may present as primarily depressed. Some professionals believe, therefore, that ADD women seeking psychological treatment may be misdiagnosed. Of course, diagnosing depression and treating it with psychotherapy and antidepressant medication isn't a bad idea, though the woman's basic difficulty with concentration will still go untouched. Many ADD adults, men and women, are going to qualify for more than one diagnosis. The second diagnosis often is depression. A bigger problem occurs when these women are seen as having manic-depressive illness (also known as bipolar disorder). Because of their moodiness and melancholy, some mental health professionals label these ADD women as bipolar "rapid cyclers." This means that the manic and depressed cycles are of short duration (days) and come more often. ADD moodiness, however, is a daily or hourly occurrence, very different from bipolar rapid cycling. If ADD women are diagnosed as bipolar and are treated with lithium, and possibly major tranquilizers, (such as Mellaril), their problems are not being effectively addressed.
3. How do you counsel or treat ADD adults effectively? With Attention Deficit Disorder, the client's problems often interfere with their treatment compliance and, therefore, with the effectiveness of their therapy. Because of their forgetfulness, missing appointments, coming to the office on the wrong day or at the wrong time are not unusual. Their medication use can be erratic. This can lessen the effectiveness of stimulants but it can destroy any benefit from anti-depressants, which need to be taken daily
4. How long can a therapist deal with large numbers of ADD clients? Dealing with ADD children is quite taxing, partly because of the large cast of characters that must come along for treatment to be effective. Parents, teachers, pediatricians, siblings, special education personnel and others often have to be involved. Similarly, when treating an ADD adult, other people in the adult's life often can be very helpful, but this requires more time coordinating everyone and a lot more phone calls. In addition, the family members of ADD people, children and adults, often have their own psychological problems (e.g., depression, alcoholism, hysteria, anxiety) that complicate the picture and make it harder to work with them. It is a scenario tailor-made for rapid therapist burnout.
5. What about insurance coverage for treatment? With the numbers, mostly children, diagnosed thus far, insurance companies are reluctant to provide coverage, citing pre-existing condition rules or claiming that ADD is not a medical diagnosis. Adults who have a comorbid condition may get some assistance as the therapist can legitimately bill for the other condition while not being able to bill for the ADD. These insurance difficulties along with the difficulties in evaluating adult ADD in the first place create quite a challenge for any therapist.
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6. How does one find a therapist to treat adult ADD? It's not easy, but the situation is improving. More and more therapists and physicians are becoming aware and knowledgeable about Attention Deficit Disorder in adults. It will still be awhile before enough good ones are available to meet the need. (Editor's note: ADD RESOURCES has a directory of ADD clinicians and coaches through out the country at www.addresources.org
Living and Loving with Attention Deficit Disorder Couples Where One Partner Has ADD By Edward Hallowell, M.D. Knowing about Attention Deficit Disorder can save a marriage or a relationship. If one member of the couple has ADD, daily arguments and bad feelings may be due to ADD rather than poisoned personalities or irreconcilable differences. Not knowing about ADD, a couple may feel lost or at war, while with the knowledge of ADD they could be finding a new path for themselves. In couples where one or both partners have ADD, life can list and yaw from day to day. As one member of a couple said to me, "I never know what to expect. I can't rely on him for anything. Why didn't he tell me he had ADD when we got married? I mean, it's really a circus." The distractibility, impulsivity, and excess energy associated with the syndrome can disrupt intimate relationships in ways that leave each partner exhausted, angry, hurt, and misunderstood. In addition ADD can affect one's sexuality adversely. However, if the situation is subtly regulated, both people can work together, instead of being at odds, and find satisfaction commensurate with the high energy they usually possess. Since the diagnosis of ADD in adults is still relatively new, most couples where ADD is present don't know about the ADD. They find they are fighting over issues like attentiveness or responsibility or punctuality or caringness and they think these matters are entirely under voluntary control. However, if ADD is present, these issues may not entirely be under the individual's voluntary control. The "fault" may lie not with either member of the couple, but with the neurological problem of Attention Deficit Disorder. Knowing this can save a marriage. The perspective of ADD can give a couple a whole new way of understanding each other, as well as of getting treatment. The diagnosis is so often overlooked because the couple's problems can look like just ordinary couples' problems. A husband comes home and tunes out reading the newspaper, has trouble paying attention when talking about feelings, drinks too much, and struggles with self-esteem while not paying attention to his wife's repeated attempts to get close to him. Or a wife daydreams chronically, feels depressed, complains of never having reached her potential, and feels trapped at home. These symptoms, in both instances, are entirely consistent with ADD, but few people would think of ADD because the symptoms also are consistent with ordinary, everyday couples' problems. What a great help it would be in those couples where ADD is at the root of the problem to make the diagnosis and get treatment, rather than divorce. The impact of ADD upon sexuality is poorly understood. However, we have seen many people in our practice, both men and women, who complain of either an inability to pay attention during sex well enough to enjoy it, or the opposite: a hyperfocused hypersexuality. How these traits relate to ADD is hard
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to say. But the symptoms occur often enough to deserve mention. Listen to one woman's account, contained in a note anonymously left for me after a lecture I had given: Dear Dr. Hallowell: I enjoyed your talk very much, and wanted to ask you this question, or, more accurately make this comment during the discussion period, but frankly I was too embarrassed. So I am leaving you this note in the hope that the concerns it raises can be of help to other people. I am a forty-twoyear-old woman. I'm quite attractive, if I do say so myself, and I love my husband. He is devoted to me. I am the woman of his dreams, he says. However, until I was diagnosed with ADD a year ago, I had never had an org*sm. In fact, my husband and I never had a satisfactory sex life. He had adored me from the start—I think that's why he stayed with me. But sex between us? It was boring at best. For the longest while I thought the problem was that I was just frigid. I was raised a Catholic, and I figured I just never got past the impact the nuns had on me. But it tore me up inside. Because I had sexual feelings, I had them all the time. I just couldn't focus them, in bed with my husband. I read lots of erotic literature, I had incredible urges toward other people, none of which I acted on—and I saw several different therapists to work on what I thought was my mental block. How could I feel so sexy, look sexy, dress sexy, be married to an incredible man, and yet think of tomorrow's shopping list as he's making love to me? Once in a while I guess that's normal, but all the time? The worst part was I really started to hate myself for this and to feel tremendously inadequate. I hate to say this, but I even thought of just running away—you know, the slow boat to nowhere. But I never would have left. The kids, my husband, I couldn't leave them, although, as miserable as was at times, I think they might have been happier without me. Then I got lucky. A friend referred me to a new therapist, and this woman knew about ADD. She made the diagnosis in two sessions and started me on treatment. What a difference! I have never read anywhere about how ADD affects sexuality, but in my case the change was incredible! Now I could focus, now I could be there. After a while I didn't even need the medication. It was a matter of realizing that it was ADD, and not some inadequacy or hidden guilt on my part. Then it was a matter of taking steps to have sex at the right time, of providing soothing music to take over the daydreaming part of my mind, and of talking to my husband openly about it. He was really great. It turns out he had been blaming himself as much as I had been blaming myself.
It is amazing how subtle, but how crucial this discovery has been for me. I can't help thinking there are a lot of women out there who are simply distractible, but who think they are sexually inadequate or just bored instead. Now I can have org*sms, but more than that, I approach sex with enthusiasm instead of dread. I can be there, with my husband, instead of somewhere else. I have learned how to enjoy myself sexually. I would never have done this if I had not found out about ADD. The treatment has helped me in all areas of my life, but it has helped me sexually more than anything has. My main problem was in staying focused, and I never knew it. I kept thinking it was something much worse, more complicated, and unfixable. And when I consider how relatively simple—yet powerful—the answer was, I just wanted to share it with you in the hope you will share it with others.
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Since I never had a chance to thank the anonymous author of that note, let me say, now, thank you, wherever you are. Your note started me paying attention to an aspect of ADD most people have largely overlooked. So far I have gathered a great deal of anecdotal evidence, full of inconsistency; but many people do indeed report that ADD effects their sexuality, either in the direction of non-responsiveness or toward hypersexuality. Usually, treatment helps both groups of people. Moving on to more general couples' issues, let's look at a couple where one member has ADD. Sam’s therapist whom Sam had been seeing because Mary felt it was the only alternative to separation referred Sam and Mary Rothman to me. Now both in their early forties, they had been married eight years, and they had one child, a boy, David, age five. They arrived fifteen minutes late for their first appointment. Sam blamed the traffic. "The traffic wouldn't have mattered if we had left on time," Mary quickly added. "She's right," Sam said. "But that's the way I am. I'm late everywhere. "Why kind of work to you do?" I asked. "I’m an emergency room physician," he answered. "But I haven't practiced in a few years. I was a jazz musician for a while, and right now I'm trying to make it as a freelance writer. "How's it going?" I asked. "It's tough, but I'm getting work. So far, at least. "Sam, let's tell him why we're here," Mary interjected. "Do you want me to, or do you want to?" Sam asked, looking at Mary. They had seated themselves at opposite ends of my couch. Both looked younger than they were, Sam, tall, trim, with thick curly black hair, and Mary, shorter, black hair parted down the middle with maybe one or two gray hairs visible, tortoise shell glasses, and a notebook in her hands. "We're here because," Mary began, then paused, as if gathering many thoughts. "We're here because quite frankly this man is making my life into a living hell. No, he doesn't beat me or cheat on me, or drink, or gamble, he just behaves like an irresponsible little boy. I don't mind that he changes jobs because he finds being a doctor isn't interesting enough. I don't mind that he gets up in the middle of the night because he's bored and wants to go flying, I don't mind that he makes plane reservations for Australia for all of us without even asking me about it and then calls me a wet blanket for not being overjoyed, I don't mind that he travels more than he's at home, I don't mind that our life insurance is so expensive it's not worth having because of his flying and gliding and skydiving, I don't mind that Sam is incapable of picking things up or remembering where anything is or keeping track of anybody's birthday or anniversary, I don't mind that he can't watch one TV show for more than five minutes without needing to see what else is on even if he's liking the show he's watching, I don't mind any of that so much. But what I do mind is that he doesn't know that I exist. He is so wrapped up in himself that I might as well be a robot. He has no conception of what my inner life is. He doesn't even know that I have an inner life. He doesn't know who I am. After eight years of marriage, the man I'm married to doesn't know me. And he doesn't know that he doesn't know me. That's what makes it hell. None of this bothers him. He's just so oblivious. That is why we're here, doctor. That is why we're here. At least that's my side of it. Would you like to tell yours, honey?" We both looked at Sam. Sam took a deep breath and let it out slowly. "You always did have a way with words. But what can I say? She's right. But I don't do it on purpose. Plus the stuff about your inner life isn't fair. I know you have an inner life. I think I know what's on your mind most of the time, in fact. "Oh, really?" Mary said. "Then tell me. "Well, I'm on your mind for one thing,” Sam began. "There, you see," Mary interrupted, "he's so self-centered he thinks he's the only thing on my mind.
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"May I cut in here for a minute?" I asked. "There was a reason you came to see me, as opposed to some other psychiatrist, am I right?" "Yes," Sam said. "At my wife's insistence I started psychotherapy a few months ago. Mary sighed at that remark and rolled her eyes, but she let Sam talk on. "My shrink, you don't mind if I call them, or you, a shrink do you? Anyway Harry, which is actually what I call my shrink, I like him, you know I wasn't sure I would, no offense but psychiatry isn't one of the fields of medicine I trust all that much, anyway, Harry said he thought maybe I had ADD, and if we were to get couples therapy, maybe it would make sense to kill two birds with one stone, so to speak, and do it with someone who knows about ADD. Make sense?" "That's another thing," Mary put in. "After he rambles on he says, ‘Make sense?' You know reflexively but you're thinking, "No, that didn't make sense at all." "Actually, I did understand this time,” I said. "As I think Harry told you, he called me before you came here to tell me his concerns. "O.K., great," Sam said. "Harry's on the job. As we reviewed Sam's history, the evidence mounted for a diagnosis of ADD. "But," Mary asked, "how do you tell ADD from being selfish? I mean, I'm not a psychiatrist, but isn't there such a thing as pathological narcissism? That's what I think Sam has. He's only aware of himself. "But maybe we could look at it a bit differently," I suggested. "He seems only to be aware of himself because he's constantly being distracted, or he's being drawn to some form of high stimulation to avert boredom. "So he finds me boring," Mary said. "No, it's not you. It's everyday life. He hasn't learned how to focus in on everyday life and be there. Instead he needs the emergency room, speaking concretely as well as metaphorically, to get his attention. "I don't find you boring, Mary. Really, I do not," Sam said, emphatically. "But if I matter to you, why don't you pay attention to me, why don't you remember things? Even if you don't care about them, if you cared about me, you'd remember, because you'd know how much they matter to me. "But you see," I interrupted, "it might be that he can't remember, at least not the way other people do. "But he got through medical school, Mary said. "It was a struggle," Sam quickly added. "You don't know. All the flashcards, the cram sessions, my friends would coach me before exams. It wasn't easy. "Plus there was the high intensity of the situation to motivate and focus you, I added. "So our marriage is too low intensity to keep his attention, is that what you're saying?" "Not exactly, but I doubt you'd want your marriage to be under the gun the way medical school is," I said. "But that's my whole problem," Mary said. "It seems like the only way I can get any of his attention at all is to put everything under the gun. And I'm tired of living this way. I want him to take some of the responsibility. I don't care whether you call it ADD or selfishness or just being a jerk, I'm tired of it. I want him to get to know me. I want him to worry with me about where David's going to school instead of just nodding, I don't want to feel like I have to squeeze everything I have to say into the five seconds of attention he gives me every day. I don't want to feel like I'm married to this immature person who's still trying to find himself. Can't he just grow up?" "If I told you that the kinds of things you are saying are precisely the kinds of things that usually get said to people with adult ADD, what would you think?" I asked. "I’d say, ‘So what?' I still want a life. Mary and Sam found a life, it is fair to say. It took some time, because, in addition to making the diagnosis of ADD, other work had to be done, much of which was done by Harry in his individual sessions with Sam, some of which was done in our couples therapy. Once Sam's ADD was diagnosed, he started on medication, and it worked very well. The medication allowed him to focus in a sustained way, as he never had before. It took him out of the self-centered, fast-paced, constantly stimulated, always
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distracted cloud he's come to live in and deposited him in the ordinary here and now. It allowed him to get to know his own feelings, to get to know his wife, and to be truly present wherever he was. The struggle didn't end with the diagnosis, however. Sam and Mary had to work very hard to make their marriage last. It took persistence and a daily, habitual tending to things. Sam had to unlearn a number of habits, and Mary had to get past a backlog of anger and resentment without killing Sam in the process. That they loved each other and wanted to be together provided the motivation. But it was by no means easy. In addition to the individual getting treatment for ADD, couples therapy is often quite helpful. ADD does not occur in a vacuum. The partner of an individual with ADD can benefit from a receptive forum as much as the person with ADD can. The stresses on the partner can mount, as he or she tries to hold things together, keep the family from sinking, either financially or emotionally, and generally try to bring some order out of the chaos. Chaos surrounded a man named Edgar when he came to see me. He brought his wife with him, but he wanted to speak with me alone, first, he said. Edgar came to see me because he had been thrown out of the system. His extended family decided they had had enough. Since they owned the car business Edgar worked for, they had the power to fire him. One day they called him in and told him that because he was so irresponsible they could no longer employ him. They would see to it that he didn't starve, but he was no longer welcome in the business or at their homes. "What can I tell you?" he said, looking at me through very thick glasses, chewing a piece of gum, his forehead wrinkled in worry. "I’m obnoxious. I'm extremely obnoxious. My family couldn't stand me anymore so they threw me out. It's probably just a matter of time before my wife does the same." Then the wrinkles in his forehead relaxed and he smiled. He lowered his voice now, speaking sotto voce, so as not to be overhead, even though there was no one else in my office. "But you know what? I like being the way I am. It's me. I've gotta be me, and all that, you know? So I blow a few grand on a cruise to nowhere. So why shouldn't she be thrilled? So I ride down the highway with Dylan blasting, smoking a joint. So what? It's how I do my best thinking. I can't sit in an office and look at the nice little people in the showroom and make my plans for the day and be a good little schmuck. It's just not me. Is that so bad? Am I a worthless piece of scum just because I haven't been to the dentist in ten years? That was on their list, can you believe that? What's it to them if I go to the dentist? Who likes to go to the dentist? So I get excommunicated for that? I'm telling you, Doc, I may be obnoxious, but I don't deserve what's happening to me. "Do you really mean that you're obnoxious?" I asked. "Yes, I am. But I can't help it. I see something that I want to do, and before I've had the chance to think about it, I'm doing it. I've stopped making promises to Amanda I've broken so many of them. I'm impossible, just like she says. You know what I really like to do? I like to go down to the showroom about three o'clock in the morning when I can't sleep and turn on the radios of all the cars on the floor and just let 'em blast. It's a really great feeling, standing in there with all the light on and all the radios blaring when outside everybody else is asleep. I can have the world to myself then, the way I like it, on my terms. "But the family—" I started to say. "Just about pukes," Edgar answered. "They say, 'How does that look to the rest of the world, someone playing around in the showroom in the middle of the night?' They say, ‘Grow up, Edgar,' and I say, ‘You’re right, I'II try.' But I can't grow up. I guess that's my problem, Doc. I'm just permanently stuck in childhood. Although Edgar's behavior was peculiar, the description of an adult with ADD as immature or childish is not uncommon. People don't know how else to make sense of this kind of behavior, so they attack it as
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being beneath adult standards. They hope to shame the person into changing his ways. That tactic usually doesn't work. "I don't know, Edgar, I said, "why do you think you do these things?" "I don't know, Doc! Jeez, that's why I'm here. You're supposed to tell me. "I'II try to, but I need more information. What are some other things you do that people object to?" "Well, there's the speeding I told you about, and the showroom, the customers, that's a biggie. I mean, what can I tell you? I don't like someone's attitude. I don't have much patience with them. I told one the other day she should work at the Registry of Motor Vehicles, her personality would fit right in. mean, she kept handing me all these forms and not speaking to me, it was annoying, you know what I mean. But, they're right, I shouldn't speak like that to a customer. The customer's always right, and all that. But sometimes I just can't help myself. "Plus, it's kind of fun, isn't it?" I said. "It sure is. They think so, too, underneath it all. They’re gonna miss having me around. Who else have they got to tell those jokers off?" As is usually the case, Edgar's problem was not just ADD. But ADD was a big part of it. His impulsivity, high stimulus seeking, restlessness, tactlessness, and high energy all contributed to the fix he was in. Despite how obnoxious he said he was, he was also quite likable, and I was sure he was right, his family would miss having him around. "Do you ever get sad, Edgar?" I asked. "Try not to, he said. "Don't slow down long enough. What's the point? Red roses for a blue lady and all that? You can have it. My philosophy is live, live, live." He took off his glasses, produced a handkerchief from his back pocket, and wiped his forehead. Later I met with Amanda and Edgar together. Amanda was a kind-faced woman a half a foot taller than Edgar who was as calm as Edgar was excitable. "I can't tell you why I love him, but I do. Isn't that a line in a song? Anyway, it's true. But he does drive me crazy. The thing about it is, he drives himself crazy, too. He's not a bad man, don't let anybody tell you that. He's like a pot that boils over, that's all. Is there any way to turn down the heat?" she asked. "How do you manage life with him?" I asked. "Oh, it's a trip," she said. "Never a dull moment. I'm just getting a little tired, and I know he is fed up with these messes. After a few weeks of getting to know Edgar and getting some tests, I was confident that he had ADD. His ADD had to be discriminated from mania, and it was on the basis of childhood history, his current situation that showed periods of agitation but not mania, and psychological testing that that discrimination was made. Rather than seeing Edgar individually, I decided to see him with Amanda. It was as important that Amanda understand what was going on as Edgar. His capacity for insight was minimal, at first, and his ability to observe himself was not reliable. This was why it was crucial to have Amanda involved. She became his coach, so to speak, reminding him of what he otherwise would forget. For most situations, this kind of couples' therapy would not work, because it identifies one member of the couple as the patient. But for ADD, it is a realistic way to proceed. With Amanda's help, and with the help of medication, Edgar was able, over time, to develop some capacity to reflect before acting, to find relaxation and focus by means other than fast cars, loud music, and marijuana, and to think before speaking. He even made an appointment to see the dentist. He wanted more results quicker. He often asked me to increase the dose of the medication, or to go at him harder in therapy. "I can take it, Doc. Sock it to me." I had to explain to him that more wasn't always better, and that some of his expectations for a "total overhaul" as he called it were a bit beyond reach just now.
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After six months, it was time to say good-bye. I met with both of them for one last visit. His family had given him his job back, conditionally, and, Amanda told me, they had indeed missed him. Since he lived quite a distance from me, I was referring Edgar to a therapist in his area for ongoing support. "Thanks a lot, Doc," Edgar said, still chewing a piece of gum. "I never thought I'd say that to a man in your line of work, if you know what I mean. "Edgar! " Amanda said, slapping his knee. "Do you know what you're thanking me for?" I asked. "Now don't get wise with me, Doc," Edgar said. "Of course I know what I'm thanking you for. I'm thanking you for doing a very respectable job of shrinking my head. "Edgar!" Amanda said again. Throughout our work with Edgar, Amanda and I, against the common conventions of couples' therapy, had sort of championed each other when Edgar turned on us. "That's quite all right," I said. "In fact, that's an excellent compliment. But I was just wondering if what we've been saying in here makes sense to you now that we're finishing. "I'II tell you the truth, Doc. I can't remember most of what you've told me. Amanda here, the rod and staff of my life, has written all kinds of things down and she reads them to me when we get home, and she makes lists and does all the things you've said we should do, and she sees to it that I do the things I'm supposed to do, including taking the medication. But do I know what we've been doing here? Well, sort of. I know I have ADD. That much I've learned. Don't ask me what it means, exactly, except whatever it is I feel much different now. Just not as edgy. Not as nudgy.” "Do you miss the pot and speeding in the car?" I asked. "The truth?" Edgar asked. "The truth is I don't. Can you believe that? In fact, it scares me to think of it now. But maybe that's just because I've spent so much time lately with Amanda and you. We'll have to see what tomorrow brings. The last I heard, Edgar and Amanda were together, Edgar was working, and life was pretty good.
If Your Spouse Has ADD What It’s Like to Be Married to Someone with ADD By Kathleen Nadeau. Ph.D. As we work with more and more ADD adults in our practice, we find ourselves dealing with not only the issues which the ADD adult brings, but just as importantly, the issues and stresses that ADD symptoms cause within a marriage. Many support groups have sprung up around the country to help parents of ADD children. Spouses of ADD adults need support as well, but little or nothing exists for them at present. Our hope is that this article may help raise awareness of the issues, which confront the spouses of ADD adults, and may prompt people to seek the assistance they need to function better within those marriages. What's it like to be the spouse? Well, like all general questions, the answer has to be "That depends." ADD families can run the gamut. On one end of the continuum is the couple in which both spouses have ADD. In one such family the primary problem is the constant level of confusion and crisis. Both spouses tend to act spontaneously, with a minimum of planning, which leads to confusion on a daily basis. "But I thought you were going to drive John to soccer practice! Didn't you remember my car has to go into the shop today!" '"You never told me you were taking your car in. Didn't you remember that my adult ed. course starts this week and you promised to take John to soccer after my course began!" In families such
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as this, a family treatment approach needs to focus on very simple, structured, practical organizational techniques for the whole family. Conflicts usually occur due to mutual blaming. Each spouse is more aware of the spouse's failure to plan than of their own forgetfulness. The saving grace for such families, however, is that neither spouse tends to expect or demand a high level of neatness or organization of the other. If both spouses are relatively comfortable with confusion and crossed signals, then the tension level between them is much lower. Problems do occur with great frequency, however. Neither spouse may make good use of time, keep adequate financial or medical records, anticipate upcoming expenses, or keep their cars in good running order. The opportunities for crisis within such a family are countless. While marriages like the one described above certainly exist, a more common match seems to be an ADD adult married to a focused, organized spouse. Due to their own difficulties with managing the details of adult life, ADD adults are often attracted to organizers. The “organizer" may be the one to make dental and medical appointments, call repairmen, balance the checkbook and take care of the taxes. Sometimes these marriages evolve into almost a mother-son or father-daughter relationship, where one spouse is consistently over-functioning while the ADD spouse is supported, sometimes even encouraged, in the role of the irresponsible, dependent one. Problems can begin to develop in such a marriage for a number of reasons. Eventually one or both spouses may begin to feel resentful. The "organizer" may begin to want and expect more help from their spouse. Sometimes this happens after children enter the marriage and the level of responsibility rises. The spouse who has easily kept the apartment clean and the checkbook in order is less able to manage a larger house and the myriad of responsibilities that come with children. Tension and conflict begins to develop, as the organizer is increasingly frustrated. The ADD spouse, with the best of intentions, volunteers or agrees to take over some of the responsibilities. Unfortunately, with little experience and poor organizational skills the task may be done poorly, late, or forgotten altogether. This can be interpreted as "You just don't care do you! You expect me to do everything around here!" Alternatively, sometimes the ADD spouse begins to resent the degree of control their "organizer" exercises over him or her. A typical pattern for ADD adults is to become better focused and organized as they mature into their thirties. The organized and perhaps somewhat controlling spouse, who was needed and relied upon in earlier years, may later be seen as too dominating. As the ADD spouse matures, he or she may begin to assert him or herself, and may begin to feel that their spouse's expectations are oppressive and unnecessary. They may resent that their natural enthusiasm and spontaneity is constantly over-ridden by their more careful, controlled partner. Couples’ therapy will need to focus on helping each spouse to shift their roles. The "organizer" may fear that if he or she is no longer as needed by their spouse that they may lose that spouse's love. As much as the organizer may resent the burden of responsibility he has taken on, he may also feel very secure in believing the spouse "can't get along without me." The "organizer" may come to learn, in therapy, that they have value for their spouse in other ways, and that their pseudo-parental role is no longer appropriate. The ADD spouse, on the other hand, needs to learn that he or she can't simply announce their desire for their spouse to quit supervising them. They must also take on part of the responsibilities they are asking their spouse to relinquish.
Money Management ADD adults can easily get in over their heads financially due to their lack of organization and inattention to details. Purchases may be of other major household expenses which are on the horizon. Some ADD adults' lives are cluttered with purchases which no longer hold their interest—exercise equipment
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gathering dust, expensive camera equipment, once used, but long forgotten. Sometimes the financial problems are not due to impulsive spending, but rather to poor organization. Bills are lost and never paid. Credit problems develop due to a pattern of chronic delinquency in paying bill. Poor financial records may lead to problems at tax time. Withdrawals from cash machines go unrecorded. Checking accounts are overdrawn because an accurate balance is never calculated. Often the ADD spouse needs to realize and accept that he or she needs some degree of external control and support such as having their spouse be the bill payer, having a set amount of pocket money each week, or having credit cards with low charge limits.
Clutter and Disorganization The general level of tidiness and cleanliness around the house is often a chronic issue between an ADD and non-ADD spouse. Huge amounts of clutter easily develop due to poor organization. Papers are kept with the intention of "getting around to them eventually." Materials and equipment from hobbies may be semi-permanently spread across the family room or bedroom. Pleas from the spouse to "clean up that mess" can go unheeded for years. Often what is interpreted as stubborn refusal on the part of the ADD spouse is really an inability of theirs to plan, structure, and carry out what feels like an impossible task. In some marriages a compromise is reached by giving the ADD spouse a "messy room," the door of which can be shut. Rarely, however, is the solution so simple. Organizers end up feeling they’re always giving and never getting. The 'organizer’ can easily come to feel that everything rests on their shoulders. They may criticize, complain, and periodically fight about it, but it seems like it always boils down to, "If it's going to get done, I'm the one who has to do it." They may feel that they are so locked into their role of caretaker that there is no one at home to ever meet their needs. Therapy for such a spouse needs to need to control the time and manner of how things are done may repeatedly override their desire for the spouse to pitch in.
Forgetfulness One of the hallmarks of the ADD adult is absentmindedness or forgetfulness. This forgetfulness can cause minor annoyances such as locking oneself out of the car or leaving the grocery list at home, to major difficulties such as forgetting to write down and remember important dates or appointments. The spouse may experience repeated disappointments over forgotten birthdays or anniversaries, or forgotten commitments.
Chronic Lateness Related to the problem of forgetfulness is the problem of chronic lateness. ADD adults are frequently poor time managers. They may tend to become so involved in something that they lose all track of time. They may consistently underestimate how long a given activity will require. As the ADD adult overbooks his day, he may rush from one commitment to another, always late. Even with a reasonably scheduled day, the possibility of lateness always lurks for the ADD adult. If he feels he has plenty of time he may try to catch 10 more minutes of sleep, read just one more article in the morning paper, or run just one quick errand on the way. It is all too easy for the spouse of the ADD person to interpret the chronic lateness as a lack of caring, particularly since the ADD adult usually hates to be kept waiting himself! The very person who keeps everyone else waiting on a daily basis may become impatient and frustrated when the tables are turned.
Frequent Moves and Job Changes Many ADD adults have a history of difficulties with supervisors and co-workers. This may result in a spotty job history. Moves and changes may result from boredom, impatience, or unrealistic expectations. Sometimes decisions about moves can be made impulsively without considering many of the
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consequences. Even if the ADD spouse remains in a long-term position, his or her work life may be characterized by frustration and strife.
Social, Interpersonal Problems Some ADD adults have poorly developed social skills. They may be oblivious to more subtle social cues. For example, a very talkative ADD adult may be unaware that the individual he is talking to has lost interest in his long monologue. Other interpersonal difficulties may develop because the ADD adult hasn't learned to couch his opinions in diplomatic terms. At times of disagreement the ADD adult may be swept away on the tide of his strong feelings and not realize that he is behaving offensively or inappropriately. Interrupting others in conversation is a frequent pattern among some ADD adults. Such patterns not only cause difficulties for the ADD adult, but may also cause discomfort and embarrassment for their spouse in social settings. Diagnosis and treatment of the ADD adult is essential. Counseling of the ADD adult, in combination with medication is essential. He or she needs to recognize problem areas, take responsibility for them, and learn strategies to improve organization and memory. Counseling can also increase awareness of the interpersonal issues, which need to be addressed both at home and at work. Contrary to what the public was told in the past, ADD adults can benefit greatly from medication. The medication management of an ADD adult is not a simple matter, however, and needs to be handled by a physician, often a psychiatrist or neurologist, who is very experienced in the treatment of ADD adults. Couples counseling, as part of the counseling program for the ADD adult, can be extremely helpful. In couples counseling the issue of "using ADD as an excuse" can be addressed. The couple can be assisted in becoming better problem solvers, and identifying the roles they have fallen into and developing better ways of relating. Couples’ counseling also helps the spouse learn to take problems caused by ADD less personally so that chronic problems can be de-fused.
Your ADD Spouse Care of the ADD Adult By R. Brian Howell Don't we just drive you crazy? We are inattentive, impulsive and distractible: all the things that can lead to misunderstanding and trouble. Imagine all those years living with us. What a pain! Then imagine what it was like for us to go through our lives, not knowing what was different about us, Then one day there was a name for it: Attention Deficit Disorder. We were elated to have an explanation, NOT AN EXCUSE, for our inability to fit the "norm." Later the elation was replaced by grief, when we realized that things could have been better in our life. We understood all the missed opportunities and the difficulties we caused those around us. We are not easy to live with. We don't communicate (or we communicate too much) and we don't always follow through. We procrastinate. We break the rules, and we generally have a difficult time fitting in. Many people have told us that we are lazy or stupid; we have thought we were crazy. There is an upside. We are, in spite of our seeming indifference, loving and caring. We are fun to be around when we are "on." We are highly creative and usually intelligent. We may make up only 5% of the population, but we make things happen. Society needs effective ADD people. Remember how we
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were when you married us? What was it that attracted you? We were exciting and different from others you knew. However, not being aware of ADD, has caused many emotion-filled problems between us. That person you were first attracted to is still there. There are numerous chapters on ADD in couples in the ADD literature. There are many marriage counselors who could act as arbiters and teach us how to co-exist. There are even couple seminars (some religious) that purport to help people get along better. However, there are some simple things we can do together to help reduce the struggle. ADD is not an excuse for any undesirable behavior. It may be an explanation, but you should not let us use our ADD as an excuse. Having said that, it is sure that nagging or trying to change us will not work. We are not defective; we are ADD/ADHD. You can help by Iearning all you can about ADD. Educating yourself about ADD is no more than you would do if we had major medical problem. Wouldn't you want to know all you could? Please understand that there is no cure and that ADD is going to be part of our lives. Accept us as we are and help us to accept ourselves. ADD is not a bad habit, lack of character, immaturity or the result of poor parenting. ADD is a genetic, neurobiological disorder. We have funny wiring and we cannot always find the on/off switch. We need to be accepted for who we are, not what we do and don’t do. We need to be ourselves, not what others want us to be. Try not to be our coach or our parent. We are your mates, not your children. Give us the space we need to function. Make sure we know your expectations and remind us when we missed the mark. Allow us to be responsible for ourselves, with thoughtfulness for our quirks and needs. We do the same for you. You can't change our ADD, but it can be improved if we work together. ADDers need internal and external space. We need room to move and think. We may not want to talk when you do, but that does not mean that we are ignoring you. We need to schedule times for serious discussion. This is important because if we don't schedule it, we will not be listening. We want to be able to give you our full attention. A good time to talk is after we have had time to prepare ourselves to "be there." Communicate your needs to us. Don't shout! Although we can be spontaneous and impulsive, we don't like surprises. We don't like to be interrupted when we are focusing on a task. We don't like to be startled. Remember to make noise when you are coming up on us while we are working as we have a large startle response. Laugh with us; our days are filled with funny situations. We do funny things and we think funny thoughts. Our lives together do not have to be full of seriousness and tragedy. We can add fun to your lives. Doing things together (like jobs) can insure that they get done. There are chores that we don't like to do and we will not do them. Maybe we can develop strategies to exchange unwanted jobs. We are better off if they can be broken down into smaller tasks. Remind us and leave notes. "To do" lists really help. Once we understand, we don't require continued direction. Help us recognize when we are overloaded and don't give us more to do at those times. Publish or perish! Let us know what is going on through notes and reminders. If we are going out socially on Friday, don't expect us to remember. We can't be reminded too often; however, it must be down in a non-threatening, non-judgmental way. Nagging only forces us deeper into ourselves and reminds us that we are failing you. We hate structure but we need it. You can help us find strategies that will keep us on task. The list should be published well in advance of the time a task needs to be accomplished. A few gentle reminders will help, but try not to pick at us. If you put it on the list and remind us it is there, then it becomes our responsibility. You have every right to be annoyed if we fail to follow through. Sometimes, things have to be done right away, and there is not time to add them to the list. In that case, let us know
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what needs to be done and give us some time to start. Don't expect us to happily drop what we are doing and start working on something else. Having to stop something we are enjoying and do something else leads to frustration and then to anger. We are quick to anger, as you have experienced, and that bothers us. It is usually the trivial and unimportant where we lose our temper. We have forgotten it within a few minutes; however, you have not forgotten and feel you were the target. Most of the time you were not. It is like blurting. We get a head of steam and there is no stopping us. You need to step back and ask us if we really intended to get angry with you. We need to be asked about our anger immediately, and it needs to be worked out right them. Walking on eggshells around us or saving it until later does not help. Most of our problems could be helped with humor and reassurance. Developing strategies together and sharing responsibilities is important. Doing things together and making them fun will also help. But most of all, lists and reminders are necessary. Life with us can be a trial, but we are the same super person you married. Together we need to develop strategies for our home, work, and social lives. Give us space, help, and understanding and together we will conquer anything.
The Emotional Experience of Attention Deficit Disorder By Edward Hallowell, M.D. Let me begin by saying that I would rather present this to you extemporaneously than from a prepared text. But, because I have Attention Deficit Disorder myself, without a prepared text I might begin by talking about Attention Deficit Disorder and end up debating who was the greatest Red Sox centerfielder of all time. It is both the charm and the bedevilment of the ADD mind: it tends to go where enchantment leads it, with little braking power or ability to confirm. Let me also acknowledge a few personal biases so that you will know where I am coming from before I lead you there. When it comes to ADD I am a radical moderate. That is to say, I am passionate about trying to preserve a balanced view of this disorder. It disturbs me that the diagnosis of ADD has become a kind of fad, with ardent proponents and equally ardent opponents. I am sometimes asked if I believe in Ritalin as if it were a religious tenet or if I believe in ADD as if it were a magical incantation. I can only tell you that I am neither an opponent nor a proponent but an investigator who, like all of you, is trying to understand children and use whatever tools are at hand to help them. My radical moderation does not, however, leave me emotionally neutral on the topic. Having grown up with ADD myself in the days when it was called everything from dyslexia to minimal brain dysfunction, and having struggled within various schools to sit still and pay attention, I feel very strongly about the importance of diagnosing ADD and understanding the emotional experience of having it. The last is what I am going to talk with you all about. But before proceeding, let me give a quick definition. If you think in terms of two words, you will have a good feel for ADD—distractible and impulsive. The syndrome is characterized by difficulty in paying attention, sitting still, sustaining attention through the completion of a task, following directions of more than a few steps, waiting one's turn, tolerating frustration, and containing energy.
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Boys have the syndrome more than girls do, but girls do have it. Onset is before age seven. It may go away during adolescence or persist late into adulthood. We don't know what causes it, but it seems clear there is a genetic factor The keys to treatment are as follows: First, make the diagnosis. No diagnosis, no treatment. Second, educate the people involved. In teaching the child, family, and school about ADD, one lifts a tremendous burden from them. This alone brings relief and helps avert the usual secondary problems with self-esteem. Third, look for specific strategies that might help. A careful history from child, parents and teachers will often reveal various tricks each has discovered that wiII aid in treatment. Fourth, structure. These kids do best in an environment that structures externally what the kids have trouble arranging internally. Fifth, consider medication, most commonly Ritalin, but there are several others. Medication alone is not adequate treatment. Psychotherapy may or may not be necessary. When it is, there are primary uses for it. First, a therapist may help the client and the family to understand what is going on with this particular person and what can help. Second, psychotherapy can deal with the secondary problems of poor self esteem and impaired social relationships. Just as a child with undiagnosed myopia may perform poorly and be called stupid and so develop a poor self-image secondary to the primary problems of nearsightedness, a child or adult with ADD may develop a host of psychological problems secondary to the primary neurological problem of ADD. With that as introduction, let me take you now into the world of Maxwell McCarthy, a fictional character, a boy whom I have made up, a composite of the hundreds of ADD kids I have known or treated. When Maxwell was born, his mother held him in her arms and cried tears of joy. He was the most adorable baby she had ever seen. He was the son Sylvia and Patrick McCarthy had wished for after their two daughters. Maxwell stared up at his Mom as his dad leaned across the pillows and drew little circles with his forefinger on Maxwell's wrinkled forehead. "I’m so happy," Sylvia said. "He looks like my father," Patrick said. "You can't tell this soon, silly." "I just have a feeling," Patrick replied. His father, Maxwell McCarthy, after whom this new Maxwell was named, had been a prominent Boston lawyer, the rod and staff of Patrick's life, his hero and his guide. The values of intellectual achievement and rock solid integrity combined with a hard-drinking, convivial bonhomie made the senior Maxwell an almost legendary figure. As Patrick looked down at his son, now, he saw some of his old man in him. The large head size he concluded meant brains. The twinkle in the baby's eyes meant joie-devivre. And the integrity would come from a disciplined upbringing. A gurgling, swaddled package now, Maxwell McCarthy was destined for great things. Sylvia's fantasies drifted more toward the simple but boundless joy of holding this little baby. Oh, she had thought about his future before he was born and she hoped for him what she hoped for her other children, that he could have the advantages she hadn't had when she was growing up. Her family had been torn apart by mental illness, depression, and alcoholism. She had worked her way through law school, where she met Patrick, and she was now juggling part-time legal work with being a mother of, as of now, three. In the process, she'd lost all contact with her family, and she was never far from the sadness of that, an undertow tugging at her ankles in the sand. As she looked down at Maxwell, she thought, "We will be good to you, beautiful one." As an infant and toddler Max never liked to be left alone. He was gregarious and active. When he learned how to walk, it was almost impossible to childproof the house, Max was so fast. Cute as he was, it was exhausting to take care of him. As one of his baby-sitters said, somewhat vengefully after a long night with Max, "You have a very high-maintenance baby." By the time he was four, young Max had a
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nickname, "Mad Max." "How shall I put it to you?" said Max's day care provider to Sylvia and Patrick. "He is very enthusiastic." "You can be straight with us," Patrick said sternly, for the moment forgetting he was surrounded by teddy bears, little bunnies and storybooks, not leather-bound tomes. "Well, it's just that he likes to do so many things, he's all over the place. The minute he starts one thing he's into another. He's a bundle of joy, but he also can be very disruptive in the group." In the car on the way home Patrick said, "What Miss Rebecca of Sunnybrook Farm was trying to tell us is that Max is a brat." "She was not," said Sylvia. "He's just rambunctious, like you used to be." "I was not. I had discipline. Standards. Max has no standards." "He's only four, for crying out loud," Sylvia said. "Can't you let him be a little boy?" "Sure. Just not a spoiled little boy." "Oh. And I suppose his behavior is all my fault," said Sylvia. "I didn't say that," Patrick replied. "No, you didn't say that, but since I'm home twice as much as you, you've made it pretty clear to me who has primary responsibility for the kids. But Pat, boys need dads." "Oh, so it's my fault now. Clever way of turning it around." They drove on in silence. At age six, Max entered the first grade at Meadow Glen, a co-ed private school. Things went all right at first, but then one day, as the kids were on the floor doing projects in pairs, Max suddenly took his jar of paint, smashed it on the floor, kicked the project he and his partner were making across the room, and started punching himself in the face. His teacher took him outside to calm down while the co-teacher stayed with the other children. "What happened in there?" his teacher asked Max. "Everything I make breaks," he said, tears beading down his cheeks. "That's not true," his teacher said. "Your project was looking very good." “It was not," Max said. "It sucked." "Max, you know we can't talk like that here." "I know," Max said sadly. "I need more discipline and better standards." Later, at the request of the teacher, some testing was done on Max, but as it turned out it was only intelligence testing. Max had a Full Scale IQ of 145, with a ten-point split between performance and verbal. "You see? He's plenty smart," Max's Dad would say. "What he needs is to buckle down." Through the early years, Max's grades were fine. The comments on his report cards, however, were upsetting, comments like, "Despite my best efforts I cannot persuade Max to pay attention consistently," or "Although he doesn't mean to be, Max is a constant disruption in class," or "His social adjustment lags behind," or "He is so obviously bright—but he is a born daydreamer." As for Max himself, he felt confused. He tried to do what he was told, like sitting still or paying attention or keep his hands to himself, but he found that, in spite of his best efforts, he couldn't do these things. So he kept getting into trouble. He hated his nickname at home, Mad Max, but whenever he complained about it, his sisters teased him, and when they teased him, he hit them, and when he hit them, he got in trouble. He didn't know what to do. "I don't know what to do with you," his father said one day. "Why don't you send me back to the dealership like you did with the Fiat? Maybe they have a lemon law for kids." He had learned about the lemon law through listening to many conversations between his parents. "Oh, Max," his father said, trying to give him a hug, " We wouldn't trade you for anything. We love you."
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"Then how come, Max asked, pulling away, "How come you said to Mom that all the problems in this family are because of me?" "I never said that, Max." "Yes, Dad you did," Max said softly. "Well, I didn't mean it if I did. It's just that we need a game plan for you, like when we watch the Patriots I tell you about the game plan. What kind of game plan can we come up with to keep you out of trouble?" "Well, Dad, you say it's up to the coach to come up with a game plan that works, and if he can't do that they should fire the coach. You’re the coach around here, aren't you Dad, you and Mom?" "Yes, Son, we are. But we can't be fired. And we need your help." "I'II try harder," Max said. He was nine years old at the time. That night he wrote on a piece of paper, "I wish I was dead," then crumpled it up and threw it in the wastebasket. His life, however, was not all gloom. For one thing, he was, as his second grade teacher put it, "Chock full of spunk." And, as that same teacher said, he was cute as a button. He was smart, no doubt about that, and he did love to get into things. He could turn a telephone booth into a playground and a telephone book into a novel. His father thought Max was more creative than just about anyone he'd ever met. He just wished he could help Max contain it. What Max couldn't do was behave. Conform. Sit still. Raise his hand. And he didn't know why he couldn't. Because there was no explanation, he began to believe the worst: that he was bad, a spaceshot, a dingbat, a functional retard, all names he'd been called. When he asked his mother what functional retard meant, she asked him where he'd heard the term. "I read it in a book," Max said, lying. "What book?" his mother asked. "Just a book. What does it matter what book? Do you think I keep records?" "No, Max, I just wondered if maybe someone called you that and you don't want to tell me who. As soon as she said it, his mother realized her mistake, but the words were out and irretrievable. "Max, it doesn't mean anything," his mother hurried to add as she tried to hug him. "Let me go," he said. "Max, it means nothing. Whoever said it is stupid." "Like Dad?" Max said, staring into his mother's eyes through tears. By the sixth grade, Max's grades became erratic, ranging from the best in the class to barely passing. "How is it," one of his teachers asked him, "that one week you can be one of the best students I've ever had and the next week act as if you weren't even in the room?" "I don't know," said Max glumly, by now getting used to this line of questioning. "I guess I've got a funny brain." "You've got a very good brain," the teacher responded. "A brain is only a brain," said Max philosophically, "but a good person is hard to find." The teacher looked astonished at this precocious remark, astonished and perplexed, which Max picked up on. "Don't try and figure me out," Max said with resignation in his voice. "I just need more discipline. I'II try harder. Later, at a parent-teacher conference one of the teachers offered this description. "Watching Max sit at his desk in class is like watching a kind of ballet. A leg will come up, then an arm will arch around it, and then a foot will appear as the head disappears from sight. This is often followed by a crash. Then, often, a swear. You know, he's so hard on himself, it's hard for me to come down on him." Max's parents listened, felt guilty, and sighed. Although Max thought quite poorly of himself by now, his spunk and pride kept him from talking with anyone about it. However, he did have conversations with himself. Sometimes he would beat up on himself.
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"You're bad, bad, bad," he would say. “Why don't you change?" Then he would make a list of resolutions. "Study harder. Sit still. Get homework done on time. Don't do things that make Mom and Dad worry. Keep your hands to yourself." Brought up Catholic, sometimes he talked to God. "Why did you make me so different?" he asked. Other times, the best times, he would wander unperturbed with his thoughts, from one image or idea to the next, so that big chunks of time could pass without his even noticing it. Often this happened when he was reading a book. He would start on page one and by the time he was in the middle of page three he would be off in a fantasy on a moonwalk or winning a football game with a rushing touchdown in the last minute. The daydream could go on for a half-hour or so as Max sat staring at page three. This was one of his greatest pleasures, but also a real obstacle to getting his homework in on time. Although Max had friends, he at times annoyed them by what they took to be his selfishness. As he got older, he found it hard to follow the conversation in a group of friends and so he stared off, blankly. "Hey, what's with you, McCarthy?" his friends said. "You on drugs or something?" But because of his basically cheerful personality—he had learned how to put up a good front—and because his raw intelligence could carry him academically, Max avoided social or academic catastrophe. By ninth grade his family had grown accustomed to him as Mad Max; instead of fighting back, he took the teasing and added to it by making fun of himself, tripping over his feet intentionally or pointing to his head and saying, "Crazy." His mother moved his room to the basem*nt. "At least the mess can be contained in one place out of sight," she said. "Since you're constitutionally incapable of straightening your room, at least we can move you to the least offensive spot." That suited Max just fine. In contrast to the time he drew circles on his son's forehead when he looked at him as a baby in the hospital, Max's father now just hoped and prayed that Max could survive in this cruel world, that he would find some niche for himself where his creativity and good-nature were rewarded and his gargantuan carelessness and irresponsibility did not get him fired. When his mother looked at him now, she thought of him as her lovable genius-goof. At times she felt very guilty at not having been able to straighten Max out, but after three children and more professional compromises than she cared to think of, she was trying to learn to go easy on herself. Indeed, she felt relief that the family had not been destroyed by the problems Max had caused earlier on. This period of relative calm and accommodation ended as Max encountered the greater stimulations the world of high school offered. He felt an internal restlessness that could be soothed by engaging in some external situation of equally high energy. He began to find release in athletics, becoming a fanatical long distance runner and wrestler. He talked about "the pleasure in the pain of the long distance run" and the mental relief, the feeling of "absolute psychic clarity" in the last half mile. He was also an excellent wrestler. He was especially good at the move at the start of a period when you explode out of your opponent's grasp. Here at last was a place where he couId legitimately go crazy, where, at last, he could release all the energy he had stored in his cells and slash through the bonds of good behavior as if escaping from a briar patch. In wrestling Max could break free. He also loved the agony of getting down to the lowest weight for a meet. "I hate it, of course," he would say, "but I also love it. It focuses my mind on one thing, one goal." He offered a quotation from Samuel Johnson as analogy. "Depend upon it, sire, when a man knows he is to be hanged in a fortnight, it concentrates his mind wonderfully." But, as relatively adaptive as his sports were, he also began to flirt with danger. He began experimenting with drugs, particularly cocaine, which he noticed calmed him and helped him focus. He was always on the go. He had more girlfriends than he could keep straight. All this left him little time for studying. He continued to play a game he called "chicken," walking into exams totally unprepared and seeing if he
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could fake his way through. He began to discover that he couldn't do this as well as he had in grade school. In a part of his being, he knew he was courting disaster. On his way out the door one day, he casually said to his mother, "You know, Mom, I'm a walking time bomb." Thinking he was joking, she answered with a laugh, "At least you're not a dud." The family had learned long ago to turn Max's self-deprecatory remarks into jokes. They weren't unfeeling; they just didn't know what else to do. What happened next could have happened in many different ways. Or, it could not have happened at all. There are many adult Maxes out there who have managed not to trip and fall. They simply live frenetic lives, a whirligig of high stimulation, and often, high achievement, with an abiding sense that their world is on the brink of collapse. But Max, fortunately, did trip and fall. It could have been academic failure or drugs or alcohol or some high-risk prank. In Max's case, though, it was the unusual route of wrestling. In an effort to make weight, he violated all the rules; he was found comatose and thoroughly dehydrated in his basem*nt room. When he was hospitalized, his family doctor was sensitive enough to see this episode as a signal of some pretty serious psychological problems. In the course of Max's evaluation, neuropsychological testing revealed, in addition to Max's already documented high IQ, a number of other issues. There was good evidence that he had Attention Deficit Disorder. Second, projective testing revealed extremely low self-esteem as well as recurring depressive themes and images. In marked contrast to his cheerful exterior, Max's inner life was, in the words of the psychologist, "Full of chaos and impulse surrounded by a fog of depression, heated by desperation. At a parent-child meeting with the psychologist, Max's mother broke down in tears. "It's not your fault Either, Dad." "It's nobody's fault," the psychologist interrupted, and began to explain to Max and his parents what they had been living with for these many years. "But if it's this attention deficit thing," his mother said, "why didn't we pick it up earlier? I feel so guilty." "It often goes undiagnosed," the psychologist said, "particularly in bright children. The more Max listened the more things began to fit together and make sense to him. What he had known about himself, dimly, intuitively, for a long while finally had a name. "Just giving it a name really helps," Max said. "Better than calling you Mad Max," his father said. "I guess we all have some guilt to deal with." "But the good news is that there are some corrective steps we can take now," the psychologist said. "It won't be an easy process, but life will be a lot better than it has been." I will end my story of Max at this point, rather than take you through his treatment. Although he is a fictional character, he has a life, the way fictional characters do, and so may be curious about how his story ends. I am tempted to tell you to go buy the book I am working on, but I won't be that coy. Max's story and his family's, although bumpy, ends happily. In fact, Max becomes a high school English teacher, a wrestling coach, and an informal specialist in so-called difficult adolescents. In addition to finding the right medication, his treatment consisted in large part of undoing, in therapy, many of the negative numbers he'd done on himself or had done to him. In addition, he needed coaching on learning how to live with the brain he had, which we all have to do. It is worth noting that not all brains have the same style. Let us hope that we can begin to appreciate differences instead of punishing them. While Max's story ends happily, many similar stories do not. If I may digress for a moment, we live in a hazardous time for children. Children are learning the dangers of the world at a terribly young age and are being asked to become conversant with such disturbing topics as sexual abuse, nuclear war, drug abuse, and AIDS, as early as the first grade. They are doing so as changing social patterns create more and more
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single parent and dual career families and greatly reduce the daily support of the extended family. Everyone is turning to schools to fill the void. Teachers are becoming parents to many kids, and schools are becoming homes. Next to parents, teachers and coaches can be the single most formative adult influence in a child's life; schools must work hard to preserve and replenish their hearts. All this is to say that we're really up against it, we who love children. In order for the work to continue to be rewarding, particularly with ADD kids, we need a lot of support. With Max it was hard work. I tell you his story, rather than giving you numbers and statistics, to try to impart a feel for this syndrome, and a sense of its impact over time. There are a few points from Max's story that I'd like to highlight. First of all, he came from a relatively stable family. I want to dispel any notion that ADD is someone's fault. While inadequate parenting can exacerbate the situation, it does not cause it. We don't know what causes it—our best evidence says it's genetic—but we do know it is not the result of bad mothering or fathering. Second, Max's high IQ delayed the diagnosis of ADD. When a child is obviously bright and gets good grades, one erroneously fails to consider ADD as a possibility. A corollary to this point is that the diagnosis of ADD should not carry with it an educational death sentence. After all the testing and psychiatric interviews children go through en route to the diagnosis, many a parent and child leaves the consulting room where the diagnosis of ADD has just been pronounced thinking they have been told, in very fancy language, that the child is stupid. A frequent though hidden component of the emotional experience of ADD is the feeling of being defective or retarded. It is very important that parents and teachers reassure the child about this matter. While one doesn't rejoice at the diagnosis of ADD, neither need one despair. Third is the crucial differentiation between the primary and secondary aspect of ADD that I alluded to earlier. The longer the diagnosis of ADD is delayed, the greater the secondary self-esteem problems may become. There are a great many adults out there in the world with undiagnosed ADD who think of themselves in all sorts of unnecessary negative terms. They may have fast-track hyperkinetic personalities, be impatient, restless, impulsive, often intuitive and creative but unable to follow through, frequently unable to linger long enough to develop a stable intimate relationship. Usually they have selfesteem problems that began in childhood. The earlier the diagnosis can be made, the better these secondary problems can be managed, the sooner one can begin the creative process of learning to live with one's brain without the obstacles of moralistic or taunting labels. Fourth, I want Max's story to stress that ADD occurs within a developmental framework. That is to say, it evolves overtime, just as the child's personality and cognitive ability evolve over time. It is not a stagnant phenomenon but a dynamic one, and its influence changes over time. Fifth, although we tend to focus on the cognitive aspects of ADD, it is equally important to pay attention to how this disorder affects relations between people. Max's friends thought he was egocentric or on drugs as a way of explaining his spacing out or failing to connect with them. Many adults also misinterpret the emotional style of the ADD child. People with ADD often do not pick up on he subtle social cues and messages that are crucial in getting along with others. These people may appear to be blasé or indifferent or self-centered or even hostile, when they are simply confused or unaware of what is going on around them. As they become more confused they may get angry or they may withdraw, both responses causing interpersonal damage. Bear in mind that just as the child may have trouble focusing on his math assignment, so he may also have a hard time listening to an account of what his friend did over the summer. These problems with people over the long run can be just as damaging to one's ability to get on in the world as the cognitive problems. Sixth, the family problems I alluded to in Max's story can be severe indeed and contribute heavily to the painful experience of ADD. These kids are often the source of family squabbles or marital discord.
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Parents get so angry and frustrated that they lash out, not only at the child, but also, at each other. Soon, full-scale battles erupt, as the child becomes the scapegoat for everything that's wrong with the family. This same process can happen in the classroom. Two or three children with diagnosed ADD can turn a happy classroom into a war zone and a kind and competent teacher into a burned out wreck. In this way the emotional experience of ADD expands to take in whole families or entire classrooms. There are other important issues I did not highlight in Max's story, most notable the emotions that surround taking medication for ADD and the impact of ADD upon other family members. Let me leave you with two thoughts. First a personal plea. Let us try to remember with these kids that they are doing the best, and let us help to educate others so that a more compassionate attitude can grow up around problems in learning. Second, let me say thank you both for myself and for the many kids like me who having benefited from your patience and perseverance. For the frustration we may have caused you we apologize, although you have to admit that sometimes we livened up an otherwise dull afternoon. But truly thank you for sticking with us; we could not have made it without you.
Hypersensitivity R Us By R. Brian Howell Aren't we lucky? Have you ever wondered why you were so sensitive? Are you distracted by every noise, every movement? Don't you ever wonder why your sense of smell, taste, touch, hearing, vision and mood are so much greater than those around you? Hypersensitivity is an ADD trait that is not discussed in many publications. It is not part of the diagnostic criteria in DSM IV. Physicians and researchers give hypersensitivity little notice. Many people just don't know how sensitive we are and how much energy it costs us. This is true for most ADD people, however, some may be hypo-sensitive. Hyper means greater than normal while hypo means less than normal. Not only are many ADDults hyperactive; they are hypersensitive. It may be the same neurochemicals or genetics that cause the hypersensitivity. I remember, in childhood, my space was about three feet in all directions. If anyone got closer I was very uncomfortable. I hated to be touched, poked, nudged or jostled. My skin crawled whenever someone touched me. I was sensitive to certain fabrics. I could not wear wool. Creams, salves, goo, grime or anything sticky irritated me. I thought I was weird, but I didn't know I had ADD either. I just knew that I was very different. Now that I have been diagnosed ADD, I understand so many things about my life. It has been helpful to know there was a reason I was different. Many ADDult are sensitive to touch. One told me being hugged felt like a snake was crushing him. Others report that physical closeness is very uncomfortable for them. I was probably a fussy, finicky kid. My son was, and he did not like to be held. Hearing is another sensitive area for ADDults. For some it is a problem to feel quiet and still. This is how one ADDult describes his hearing sensitivity; “I could hear my heart beat and my blood rush whenever I tried to medicate. Then I would hear all the sounds of the house, finally sounds from outside would intrude and I would have to give up." Many report that they
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have had their hearing checked and found they had above average sensitivity to sound. I know when am concentrating any sound out of the ordinary will pull me away. I remember looking out the window a lot in school. It was not intentional, but there were just so many interesting sounds out there, and class was dull. Vision is another area where we excel. Good or bad eyesight, glasses or not, we are visually active people who notice the smallest things. It amazes me how much non-ADD people miss. It's as if they are walking around in a fog! ADDers are constantly vigilant. We are always scanning our environment. We are attracted to movement. We are alert to danger. I know how stressed I get in crowds because every movement distracts me. Our visual hypersensitivity can cause us many problems. Do you ever sense that people think you are not listening to them? It's considered impolite to be talking to someone while your eyes are darting everywhere, attracted by every movement in the room. Several said that their roving eyes caused them social problems, and it was a problem for spouses and other family members. "My eyes dart from here to there so much that I feel like I am watching a tennis match," is how one person described the problem. The great part of visual hypersensitivity is that we sure know what is going on around us. We do not have to be hyperactive to be hypersensitive. I remember many times when I was very calm and controlled yet all my senses were still “on alert.” This hypersensitivity takes its toil on our energy. We pay for our vigilance. One of the CompuServe members said it was like being in a constant "fight or flight'' state. One of my responses that I find most frustrating is my over-reactive startle response. I have to remind people not to sneak up on me as I physically rise off the floor when startled. Hypersensitivity varies from person to person Some report a strong sense of smell and taste. My sense of smell is not strong, although I am hypersensitive to the smell and taste of food. I love to eat and do so with great gusto. Hypersensitivity would be a prized trait if we were living in a hunting society. In our society, hypersensitivity can be a weakness or strength, depending on whether we give in or compensate. It is important to listen to what our senses are telling us. I think we do that better than anyone. Stay aware of your sensitivities and not get distracted. Learn to make your sensitivities a positive aspect of ADD. Develop a greater awareness of what is going on within us. Once we know what is happening inside ourselves, we can compensate and turn a problem into an opportunity. I think much of our creativity and intelligence comes to us because of what we sense and how we react to each situation.
Women and ADD By Kathleen Nadeau, Ph.D. In A Comprehensive Guide to Attention Deficit Disorder in Adults (edited by the author), there is a chapter entitled, "Women and ADD." Interestingly, two years ago, when the publisher sent an initial outline for the book to various professionals for comment and critique, a highly respected ADD expert questioned the need for a chapter specifically focused on women and ADD. Clearly, it had not occurred to him that women with ADD face issues unique to their gender. His question troubled me, and underlined the need to educate both professionals and the public at large about the under-diagnosed and misunderstood group of women with ADD. I am very pleased there is a chapter on women and ADD in
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Drs. Hallowell and Ratey book, Answers to Distraction. As the professional community becomes more knowledgeable about women's issues, they will provide more appropriate and effective treatment. As the general public becomes better informed, perhaps women with ADD will receive more support, encouragement and acceptance from their friends, family and co-workers. In this article I will discuss issues pertinent to women which stem both from internal, biological differences and from external, societal expectations. I will describe how females with ADD may be effected differently at different stages in their lives.
Neurobiological Differences As Dr. John Ratey and Andrea Miller write, as co-authors with me on the chapter on women and ADD in the Comprehensive Guide, neurobiological differences between girls and boys may play a pivotal role in diagnostic difficulties. Girls appear to manifest their symptoms differently, experience them differently and tolerate them more easily. Research suggests that rising testosterone levels in the male brain may slow the formation of later developing regions of the brain such as the frontal lobes. In contrast, the frontal lobes of the female brain seem to be more developed. This stronger frontal lobe functioning in the female brain may make the symptoms of ADD less debilitating and less noticeable. On the other hand, research by Zametkin's group at NIMH suggests that there are greater measurable differences between girls with ADD and their nonADD peers, than between boys with and without ADD. This greater disparity may result in the much greater sense of estrangement, discussed later in this article, experienced by adolescent girls with ADD in relating to their female peers.
Childhood Gender differences in the ADD population begin in childhood. It is documented that more boys than girls are identified with ADD. It is much less clear, however, that the ratio of identified boys to identified girls is a true reflection of the incidence in the general population. Studies show that girls are identified at a later age than boys and that the ADD diagnosis for girls typically accompanies a diagnosis of learning disabilities. In other words, ADD in girls may be overlooked unless accompanied by a learning disability. Under-diagnosis and later-in-life diagnosis results from a number of factors. Studies show that boys receive more attention from teachers and resource providers than girls. Likewise, parents of inattentive boys more frequently seek help than parents of inattentive girls. Secondly, symptoms, which are likely to result in early diagnosis, are hyper-activity and behavior problems. These symptoms are more frequent and more marked in boys than in girls. Hyperactivity in girls may be manifested quite differently than in boys. Girls may be hyper-talkative, hyper-social and hyperemotionally responsive. This hyper-emotionality can be easily misdiagnosed as anxiety or depression, with no consideration given to the underlying ADD. Under-diagnosis and later diagnosis means that girls are not able to gain the benefits of early treatment and intervention. While many girls with ADD fall into the "primarily inattentive type," those girls who do manifest hyperactivity, impulsivity and inattention are likely to receive very different responses from parents and teachers than do boys who have these same traits. Whereas young males may be described as "all boy," young females are less comfortably tolerated. They may be viewed negatively, as "unladylike" and "different." While a hyperactive boy receives encouragement to channel his energy into sports, a hyperactive girl is likely to be told to control her hyperactive, impulsive behaviors. At the other end of the ADD continuum are those girls who have ADD of the "primarily inattentive type." These little girls may be overlooked, as they passively sit at their desks, day-dreaming. Such little girls, who cause no problems in the classroom, may be manifesting signs of ADD without hyper-activity. While this lack of understanding is beginning to change as a result of teacher education programs, it is
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almost certain that any adult female who has ADD of the "primarily inattentive type" was overlooked in her school years. Little girls are more motivated than little boys to be "teacher pleasers." Some young girls with ADD try so hard to conform to teacher expectations and to gain acceptance that their ADD symptoms are masked at school, and are only evident at home, where they "fall apart" following an exhausting effort to meet expectations throughout the school day. Such little girls, who are compliant at school, but disorganized, emotional and hyper-reactive at home, are easily misdiagnosed. Pediatricians and counselors may assume that misbehavior at home is from parent-child difficulties or inconsistent parenting.
Puberty and Adolescence At puberty the neurochemical dysregulation of ADD is compounded by the hormonal dysregulations associated with the menstrual cycle. Clinical evidence suggests dysregulation of the catecholamine system related to ADD is seriously exacerbated by pre-menstrual symptoms. Adolescent girls and women with ADD may suffer from severe mood swings, depression, anxiety and explosive outbursts of anger during the premenstrual phase. Girls with ADD, who already struggle with a faulty inhibitory system, may find the cyclic disorganizing influence of the menstrual cycle greatly intensifies their difficulty with judgment and behavioral inhibitions. While it is a well known that most children and adults with ADD experience difficulty in the interpersonal realm, little has been written about how this problem effects teenage girls differently than teenage boys. While male teens interact with one another primarily through activities, a more intense demand is placed on female adolescents to develop interpersonal skills. They are expected to have excellent verbal skills, to understand subtle social interplay, to read non-verbal cues, and to conform to rather rigid, subtle and intricate rules of social behavior. Girls with ADD are at a distinct disadvantage in this demanding and competitive social arena. "Thin skin," hyper-activity, impulsivity, bluntness, and social faux pas resulting from poor inhibitory ability may cause teenage girls with ADD to feel like social outcasts. Hyperactive female adolescents may exhibit impulsive, risk-taking and sexually promiscuous behavior. These behaviors, typically are condemned in girls, much more strongly than in boys. Studies show that impulsive, risk-taking females experience much shame, self-blame and low self-esteem as they enter adulthood and look back on their adolescence. Girls with ADD of the "primarily inattentive type," present a very different social picture, often appearing awkward, retiring and perhaps painfully shy. They may feel unable to "fit in" and gain peer acceptance. No matter whether hyperactive or inattentive, a girl with ADD will typically report more discomfort and lower self-esteem in her teen years due to lack of peer acceptance than is reported by male ADD teens.
Adulthood There are numerous struggles for women trying to fulfill the roles expected of her by herself, her family and society. The most painful challenge for a woman with ADD may be her over-whelming sense of inadequacy in n with ADD have intensified with the emergence of the "dual-career couple" over the past two decades. Women now need to fulfill all of the traditional requirements of motherhood and homemaking, and to function efficiently and tirelessly while shifting from the demands of professional life to the multiple demands at home. While many men with ADD choose efficient, organized marital partners who can function as their primary support system, women, even those with ADD, are typically expected to be the family support system. Let's take a look at the types of workplace accommodations usually required by individuals with ADD for optimal performance, and then compare those accommodations with the job of mother and homemaker.
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In redesigning a workplace to accommodate the needs of an individual with ADD, many of the following recommendations would be made: •
A quiet, non-distracting work place.
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Regular meetings with a supervisor to monitor and facilitate the progress on long-term projects.
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Assistance in establishing and maintaining priorities as workload demands shift.
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Requests and communications provided in writing to reduce forgetfulness.
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Periods of uninterrupted work time without phone calls.
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Work assignments of high interest and with intellectual or creative challenge.
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Minimum requirements to keep track of the schedules and work of others.
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Reduction/reassignment of tasks which are difficult for ADD person to perform.
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Reduction in work stress and overtime to prevent burnout.
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Positive feedback, recognition of effort and encouragement to maintain morale.
Now let's consider the work of homemaker and mother. That job could be described in the following ways: •
A noisy, distracting work environment.
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Little or no opportunity for guidance and supervision to improve performance.
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No assistance in establishing, maintaining or changing priorities as work demands shift.
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Most requests made verbally, in passing, with little time or opportunity for writing them down.
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Little likelihood of uninterrupted work time.
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Repetitive, mundane tasks are the primary component of the job. The more creative, interesting aspects of homemaking require overtime in work hours.
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The need to constantly supervise, track, and monitor the schedules and performances of others.
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Efforts often go unrecognized or unrewarded or may be counteracted by others in the home.
The job of mother and homemaker has many elements which provide maximum difficulty and minimum rewards for ADD women. Their houses may be in shambles. Their laundry is rarely completed. Meals are generally haphazard, last minute affairs and their children, who may have ADD as well, frequently misbehave. Women with ADD ask themselves why they do such a poor job of something that "any woman" should be able to accomplish. It is easier to find or create a work environment outside the home, which matches the strengths and interests of an individual with ADD, than it is to modify the job requirements of mother and homemaker. Society expects females to have primary responsibility for maintaining the functioning of the home and for the provision of meals. Society expects the wife and mother to function as the primary parent and as the emotional "command center" of the home. Mothers should be patient, understanding, supportive, encouraging, and focused on the needs of other family members more than on their own needs. Mothers who feel "driven crazy" by the frequent interruptions of their children, who need to take time away to ease frayed nerves, who become irritated, impatient and angry, may view themselves and be viewed by others as "bad mothers" instead of women struggling valiantly with demands which are difficult, if not impossible, for them to meet.
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Mothers are expected to be the family schedulers and timekeepers. When is Billy's dental appointment? Who has soccer practice on Thursday? When is the next teacher conference? Do we need a baby-sitter for this Saturday? Etc., etc. This job requirement—tracking and managing the schedules of others—is to be avoided by individuals with ADD who have enough challenge just tracking their own schedules. ADD mothers, however, rarely have the luxury of delegating this responsibility to some else. Numerous women with ADD report that even though their work outside the home creates additional stress in their lives, the opportunity to spend time in a more quiet, focused and organized environment is an invaluable respite from the noise, interruptions and disorganization in their homes.
Treatment Considerations Treatment needs to focus on gender issues, both biological (hormonal) and social, as well as ADD issues. Women must face the issues faced by men with ADD—forgetfulness, disorganization, distractibility, and under-functioning in the work place—and they must face their female concerns of feminine identity, relationships, and family responsibilities. Although no studies, to the author's knowledge, have been done on the effectiveness of group therapy for women with ADD, issues of connectedness and acceptance are so strong that it seems likely this treatment modality would be a very powerful therapeutic tool. To work effectively with women with ADD, a therapist needs to help them find appropriate pharmacological interventions which address their ADD issues, and the problems they frequently encounter with premenstrual syndrome which interact with and intensify their ADD symptoms. The therapist needs to work on female roles and identity, helping women with ADD move away from patterns of self-blame and shame and move toward a realistic and accepting attitude to better accommodate her needs and develop her competencies and abilities.
Keeping Up with Mona Can Kill Your Self-Esteem By Cynthia Hammer, M.S.W. 7 Our culture is fascinated with Mona, the ideal woman, confident, competent, controlled, and collected. "Why is Mona smiling?"—the age-old question. Let me tell you. She is pleased with herself. Her housework is done. Her cookies are baked, and the scout meeting, three days away, is already organized! Her clothing is impeccable and always in style, as is her hair and make-up. She's never late or forgets important dates, like relatives' birthdays. She never raises her voice (sometimes called shouting), as she never is out of control. On a good day, I admire Mona. I'm fascinated such creatures exist. I've known a few Monas and I'm always in awe. There's a mystique, a mystery, about them. How do they manage? Do they have an inside track? Is there a way I can acquire what they seem to have naturally? There was a "Mona" on my water ballet team years ago. She must have had a special bathing cap or some secret I was never privy to. She left practice promptly, with a perfect hairdo, every little curly cue exactly in place. I left much later, with nothing in place! My hair, instead of perfect, was straight and damp with chlorine water.
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Cynthia thanks Sari Solder for some of the concepts developed in this article.
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On good days I admire all Monas and say, "More power to them." On bad days, Mona looks and acts superior. She may be the ideal woman; but, to an ADD woman, Mona can seem critical, caustic, callous and cruel. She comments when my children are too rough, or the dog barks incessantly or the lawn isn't mowed, or the tools are left outside, and on and on. I worry these perfect woman talks critically about me to others and that what she says is true. "She's a messy housekeeper." "She has no pride in her home or her appearance." "She doesn't take very good care of her children." "She shouldn't have had children." Mona makes me ashamed, ashamed that I haven't figured out how to do what she does, as well as she does, even though, God knows, I have tried. With Mona's help, most of me got hidden in a closet a long time ago—the parts of me that I didn't want known, the parts of me that didn't fit the Mona image. But I got tired of closet living! (Shortly after I got Ritalin and an ADD diagnosis!) I like more space, more movement, more variety, and, certainly, much more excitement than closet living allows. I realized that Motionless Mona is not the role model for me. It's too hard to walk in her footsteps. Just the effort wears me out. Why, I ask myself, continue to struggle to be only a poor imitation of the real thing. Why not be my own original or model myself on a woman more to my style? Give up the elusive goal of becoming the perfect woman and blossom, instead, as an imperfect woman with many remarkable characteristics. Monica in Motion seems to be such a woman—unusual, multi-faceted, ever-changing, vibrant and alive, one of a kind, creative, open, strong, bold and beautiful in her own way. Okay, I admit she's a bit controversial and might not be to everyone's taste, but since when did we have to please everyone? Monica in Motion is totally different from old Mona-What's-Her-Face who's been touted and glorified for so long. I think, for too long. Monica in Motion is my kinda girl. How about you? Watch out Mona. I'm on the move. I no longer have my worth to prove. Motionless Mona, you contented cow, Calmness suits you. I don't know how! The liberated woman with ADD never will contented be. As her style has punch and variety, Energetic, dynamic, lively and fun.Monica in Motion. She's the one!
Self-Esteem Issues in Adults with AD/HD By Cynthia Hammer, M.S.W. When I am asked to speak in the community on Attention Deficit Disorder, I often start by holding one hand behind my back and saying, “ I was born with one hand tied behind my back. As I was growing up, no one knew I had a hand tied behind my back—not my parents, not my teachers, not my friends, not even myself. As you probably realize, when you have one hand tied behind your back, there are some things you can do well—like eating soup with a spoon—and some things you can’t do well at all—like cutting a steak which requires a fork and knife. No one could understand why I could do some things well one day, and couldn’t do other things equally well on another day.
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They assumed I just wasn’t trying hard enough—that I was lazy—that I was stupid. Usually, in annoyance, frustration or the spirit of trying to motivate me, they said unkind and hurtful things, like; “We never can count on you.” “You always do something wrong.” “How many times do I have to tell you? Are you dumb or something?” No one ever considered that I had one hand tied behind my back. And this is what my life was like, with one hand tied behind my back. Receiving constant criticisms from others that I wasn’t performing up to standards. And then, one day, when 49 years old, I am eating in a restaurant. The waitress comes up and blithely says to me, “Did you know you have one hand tied behind your back?’ And, oh, what a difference her comment has made to me. Although this story is not directly about me having live with undiagnosed ADD for 49 years, I can never tell this story without getting emotional. My hurt feelings come flooding back on me. People in the audience, who have ADD, also get emotional as they share with me my experiences of having lived with an undiagnosed disability. They, too, are recalling all the times others, as well as themselves, made angry, belittling, critical, and negative comments about how well they were performing. Getting diagnosed with ADD and finding a medicine that was helpful made a world of difference in how I perceived myself and how I functioned. But these improvements didn’t happen overnight. The medicine seemed to immediately help me to function better, but it took additional years to learn new behaviors and habits and to build self-confidence and self-esteem based on the newly, improved me. A first step for me in improved self-esteem actually took place years before I learned I had ADD. I had attended a seminar by Selma H. Fraiberg, author of the classic book, The Magic Years, about child development. During her presentation, she had the audience take part in a guided imagery. We were to close our eyes, and imagine someone that we truly loved and cared for came into the room and sat down in the chair opposite us. We were then to take the next three minutes to tell that person, in a loving way, all the things we admired and appreciated about that person. I remember visualizing my mother sitting in the chair opposite me and I told her of all the wonderful characteristics I appreciated about her. Ms. Fraiberg then instructed us to bade that person good bye and to visualize ourselves coming to sit in the opposing chair. We were to take the next three minutes, still keeping our eyes closed, to tell ourselves what we loved about ourselves, what unique qualities and characteristics we particularly admired. I sat there for the three minutes and could think of nothing positive to say about my self. My undiagnosed ADD life had put this possibility beyond my reach. And the few positive attributes I thought of, came with a “but” attached. “You are a good cook, but not every night.” “You are an honest person, but you often let people down.” There were no unconditionally good things about me! I was almost in tears, and I felt so much shame, believing that everyone in the audience knew I had no good qualities. (Although we were all sitting there with our eyes closed!) Selma then talked about a healing process. When we review our day, at the end of the day, we had to give equal time and consideration to the things we had done right that day…no longer just focusing on what we had done wrong. So I slowly practiced seeing the things that I did right, giving myself credit for the things I did well. Becoming aware of one’s negative self-talk is the first step in the healing process. Taking action to reduce or eliminate the negative self talk is the second step and finally, inserting lots of positive self-talk is the final step—all this in the context of improving or eliminating undesirable ADD behaviors.
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I had an ADD friend who was working on becoming aware of his negative self-talk. One common method is called “thought-stopping.“ Any time you catch yourself engaged in negative self-talk, you do something to distract yourself—to stop your self. Common methods are snapping a rubber band against your wrist, picking up an object to look at or handle, slamming your hand on your desk or some hard objects, etc. Anyway, my friend Brian decided to go the rubber band route. And remember, earlier, Brian was known to quip, “I work for the worst boss imaginable. He is always criticizing me.” The punch line to this quip is, “And I work for myself.” After Brian had been using the rubber band method of though stopping for a week, I asked how it was going. He replied, “I have a very sore wrist.” But in another week, he had stopped most of his negative self-talk! It wasn’t until I read Learned Optimism by Martin E. Seligman though, that I learned how to truly reduce negativity and replace it with positive thoughts and feelings. Seligman’s concept is simple: When you do something that you wish you hadn’t, you view the event as temporary, reversible, isolated, and unique. You try to take as little personal blame for what went wrong as seems reasonable. You tell yourself things like, “Yes, I screwed up this time, but that doesn’t mean I screw up all the time.” “I was late for my appointment today, but that doesn’t mean I’m will be late for all my appointments.” “Yes, I didn’t do well on this test, but I know I can do better next time.” When you do something unfortunate, you say things to yourself to reduce the damage to your self-esteem. You say things to yourself that will get you up and moving forward, things that will energize you to try again. On the reverse side of the coin, when you do something good or something good happens in your life, you try to enlarge on the event, to squeeze the most benefit to your self-esteem and self-confidence as possible from the event. When good things happen, you say things to yourself to make the event seem repeatable, global, and reflect on your personal credit. “I did well on that test because I studied hard. I am a good student.” “I cooked a great meal last night. I know how to be a good hostess.” “Everyone loved my performance. I have talent as an actor.” The way I envision the concepts of Learned Optimism to myself is: When bad things happen, it is a fire that I need to put out as quickly as possible. By stomping on the fire, saying the things that diminish its negative power, I quickly eliminate negativity in my life...When something positive happens to me, it is like there is a tiny hole in the roof and the sun is shining through. I try to say the things to myself that will make that hole larger so that more sun can shine in on my life. “Eliminate the negative and encourage the positive.” Its that simple. If Selma could only see me now! It is so seldom that I put any energy into worrying about what I did wrong as I have so much that is going right in my life. That is what I focus on. That is what energizes me. But as I said earlier, the actions of the ADD person need to be changing as they are changing their selftalk. They need to see and believe that they are functioning better. I remember Dr. Ned Hallowell saying that one reason it is difficult for people with undiagnosed and treated ADD to accept praise when they do something well, is because they often don’t know how they did it. They have no assurance that their good performance is repeatable. They often feel, when they do something well, that it was a fluke. To overcome this apprehension, this inability to truly take credit for things we do well because we aren’t sure we can duplicate the performance, we need to start seeing that, yes, we can duplicate the performance. We can be consistent and not sporadic. “I can be neat and tidy at the table when eating soup and also when eating steak.” I can perform consistently in many environments, in many situations. I can count on myself and people can count on me. For some people this improvement in functioning can come just with proper medication, self-awareness and “pulling oneself up by the boot straps.” (I.e. learning what needs to be improved and working on self-improvement.) For others, counseling or coaching might also be part of the improvement formula.
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From my experience, acquiring good self-esteem is a sequential process. I take a small step forward, realize I have made improvement, praise my self for improvement, (Remember Learned Optimism) have increased self-confidence because of the improvement I have made, which motivates me to take another step forward. I view getting “better” after the ADD diagnosis as climbing a flight of circular stairs, each step taking me slowly up and up until I have achieved satisfactory functioning and high self-esteem. I want to close this article including a list prepared by Suzana Santos and Mark Goulston, M.D.: Self-esteem should not be confused with self-confidence—self-confidence is believing in your competence, whereas self-esteem is believing in your worthiness. You build self-esteem the old fashioned way, you e-a-r-n it—through dedication, effort, and sacrifice. When you have developed it, your reward is to feel whole and satisfied. You show your gratitude not only by giving generously back to the world, but by being gracious in victory and graceful in defeat. Self-esteem is crucial to how much or how little contentment you feel at the end of your life.
Ten Criteria for High Self-Esteem 1. How much you do to raise and DON'T do to lower the self-esteem of others. 2. How long you sustain an effort outside of your comfort zone to help the common good. 3. How full an effort you give to a fair decision that you disagree with. 4. How easily you ask for help or assistance. 5. How quickly and sincerely you thank someone who has helped you. 6. How quickly you offer help without the other person having to ask for it. 7. How fully you forgive and forget after you've been hurt and how quickly you move on. 8. How quickly you recognize and earnestly you apologize for your failures of commission or omission. 9. How enthusiastically you congratulate someone else on an achievement or good fortune. 10. How much more you give to the world than you take from it. You know you have achieved the highest level of healthy self-esteem when you can say yes to each of the ten items above. Good luck to you in your journey to self-discovery, self-fulfillment and high selfesteem.
Attention Deficit Causes Problems in the Workplace By Daniel Amen, M.D. Bill, 32, was just fired from a job he loved. He knew it was his fault, but he just couldn't organize his time to do the required work. He missed deadlines, drifted off in meetings and was often late to work. His wife would be angry. This was the third job he had lost in their three-year marriage. As a child Bill had taken Ritalin for troubles in school but he was taken off the medication when a teenager. His doctor
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told him all kids outgrow the problems he was having. That was bad advice! At age 32, Bill still has Attention Deficit Disorder. ADD is a neurological problem that affects at least five percent of the population. The main symptoms are a short attention span, distractibility, impulsiveness and hyperactivity or restlessness. Until recently most professionals thought children outgrew the disorder during their teen years. While it's true that the hyperactive component lessens over time, the other symptoms of impulsivity, distractibility and short attention span remain for most into adulthood. Current research shows that 70 to 80 percent of the children with ADD never fully outgrow it. When left untreated, it significantly affects relationships, selfesteem and employment. What is the impact of ADD on the workplace? It costs millions of dollars every year in decreased productivity, absenteeism and employee conflicts. Yet ADD remains vastly undiagnosed. ADD can be both positive and negative in the workplace. On the positive side, people with ADD are usually high in energy, enthusiastic, creative and full of ideas. If they surround themselves with people who organize them and manage the details, they can be very successful. Unfortunately, many people with ADD are not this lucky. Often they have serious problems at work. Here are some of the difficulties they may encounter: • The harder they try, the worse it gets. Research shows that the more people with ADD try to concentrate, the worse it gets for them. Their brain turns off when it's supposed to turn on. When their supervisor puts pressure on them to perform, they often fall off in their work. The boss interprets this decreased performance as willful misconduct and serious problems result. When supervising someone with ADD, it's much more effective to praise and encourage rather than apply pressure. •
Distractibility. Distractibility is particularly evident during meetings. People with ADD tend to look around the room, drift off, appear bored, forget where the conversation is going and interrupt with extraneous information. Their distractibility and short attention span may cause them to take much longer to complete their work than their co-workers.
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Forgetfulness. Forgetfulness is common in ADD and is a serious handicap on the job. Missed deadlines, forgotten reports and steps left undone are just a few of the examples.
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Impulsivity. Often the lack of impulse control gets the ADD person fired. They say inappropriate things at inappropriate times. I once had a patient fired from thirteen jobs because he had trouble controlling his mouth. Poorly thought-out decisions along with difficulty in going through established channels at work also relate to impulsivity. This may cause resentment from co-workers. Impulsivity may lead to such problem behaviors as lying and stealing.
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Conflict-seeking. Many people with ADD are in constant turmoil with one or more people at work. They seem to "unconsciously" pick out people who are vulnerable and have verbal battles with them. They have a tendency to embarrass others, which doesn't endear them to anyone.
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Disorganization. Disorganization is a hallmark of ADD. People with ADD tend to have many piles of stuff. Paperwork is hard for them to keep straight, and they often have a filing system only they can figure out.
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Chronic tardiness. Many people with ADD are chronically late to work because they have significant problems waking up in the morning or they lose track of time.
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Inability to finish projects. The energy and enthusiasm of people with ADD often push them to start many projects. Unfortunately, their distractibility and short attention span impair their ability to complete them.
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Moodiness and negative thinking. Many people with ADD are worriers, moody and negative. These attitudes come from their past when they had many experiences with failure. Now they anticipate failure.
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Insecure self-assessment. Those with ADD often are poor judges of their own abilities. They may over-value themselves, thinking they are better at their jobs than they really are or they may devalue important assets they have.
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Excessive time at work because of inefficiencies. The symptoms of ADD frequently cause a person to be inefficient on the job. They may need to put in overtime which managers consider excessive. This could result in poor job evaluations or firing. To avoid those problems, some people with ADD take their work home to finish it.
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Tendency toward addictions like food, alcohol, drugs, and even work. Food addictions cause health and self-image problems. Drug and alcohol addictions cause obvious work problems. Work addiction is also a serious problem because it causes burnout and family problems that affect one's work.
With proper diagnosis and treatment, adults with ADD can literally change their lives. They can learn to control or cope with their undesirable behaviors and become valued employees.
Be All That You Can Be… in the Workplace 8 By Cynthia Hammer, M.S.W. Many adults, after being diagnosed with ADD, wonder if they should share that information with their employer. Although disclosure is not required during the hiring process or after being hired, you will not have a legal right to accommodations unless you disclose your disability and provide appropriate documentation of your disorder. When pondering, "To disclose or not to disclose," you might first try putting a number of strategies in place. Strategies, in this context, are things you do yourself, without disclosure, to improve your functioning in your job. With strategies you are not asking your employer to make accommodations for you. Here are some common problems of ADD adults and some workplace strategies they have found helpful.
Hyperactivity If you have a job that requires prolonged deskwork, take frequent breaks and move about. Build physical activity into your coffee breaks and lunchtime. Get a strenuous physical workout before or after work. Learn your high-energy times and low energy times. Pace yourself to accommodate your energy cycle throughout the day. If all else fails and you can't stay still long enough to accomplish your job satisfactorily, look for a job that allows more moving about. 8
Much of the information in this article was adapted from Kathleen Nadeau's material. Learn more of her wonderful coping strategies in her book, which we have for sale, Adventures in Fast Forward.
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Distractibility Create blocks of time when you will not be interrupted. Let others know not to disturb you at these times. Work in blocks of time, trying to stay hyper-focused when on-task. Then take a break before beginning another block of work. Find work that is high-interest for you. This will reduce your distractibility. If thoughts intrude when you are trying to focus on a task, briefly write down your thoughts, and immediately return to the task at hand. Learn to catch your-self when going off-task and to bring yourself back to the task at hand. Maintain an orderly workspace; one that is not visually distracting. If your workplace is messy, and you need to start a task, put the mess out of sight and get to the job at hand. Schedule another time to deal with the set-aside mess.
Disorganization Establish routines for yourself, as this will make your life simpler. There will be less to think about, as certain behaviors become habits for you. There will be more and more things you can do without having to think about them. Find a co-worker to remind you of details and deadlines. Set aside fifteen minutes at the start of each day to plan the day. Start the day with an orderly desk, and straighten it on a weekly basis. Simplify. Don't keep anything you don't need, really need. Clutter is very unhelpful to the disorganized person. Learn to handle your mail efficiently. Handle each piece only once, making on-the-spot decisions on whether to toss, file, or respond to. Vow not to start another project or undertaking, until you've completed the one you are currently working on. Look for jobs with immediate, short-term goals, as these are better suited to the ADD nature. Avoid jobs where you report to many people, where many people report to you or where you need to pay attention to or to take care of many small details.
Poor Sense of Time Be pro-active, instead of re-active. Plan your day, instead of letting it happen to you. Be realistic in your time estimates. Does it really only take thirty minutes to write your monthly report? Build some slack into your day to cover for those unexpected interruptions. Set a time goal for completion of a portion of a task. e.g. I'll get the first two boxes unpacked and put away by 11 a.m. If you have a tendency to become so engrossed in a task you lose track of time, set a timer to beep when you need to move on. Keep your daily planner with you at all times. Don't tell someone you'll do something without writing it down, along with scheduling the time to get the task accomplished. Learn to say "yes" only when you are sure you can follow through on your commitment. Learn to say, "I'm sorry. I'd like to help, but I'm already over-committed" or "Let me think about it and get back to you." A corollary to this is learning to say to ourselves, "No! You can't do that!" when we have an impulse that we need to do such and such right away. Again, stop and ask yourself, "Does this really need to be done?" Does it need to be done now?" Learn how to end phone calls courteously and promptly so they don't eat up huge amounts of your day. Don't let last minute conversations or chores keep you from being on time. Make it your personal goal to always be on time, or better yet, to be early. Get there ahead of time and wait! A strange, new experience! You'll have time to compose your thoughts and make a better appearance.
Procrastination Set minor and major deadlines for yourself. Reward yourself when you've accomplished any task in a timely way. Give yourself small rewards for completing small tasks, such as taking a coffee break, and bigger rewards for completing bigger tasks, such as spending a day bicycling (if that's enjoyable for you).
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Make verbal or written commitments to others. When your personal integrity is on the line, it can help reduce your procrastination. Rotate unpleasant tasks with pleasant tasks. Make the pleasant task the reward for getting the unpleasant task done. Stay away from tedious work when you are low on energy, as you'll only make matters worse. If your procrastination is severe, maybe the task is too onerous for you and will never get done. Try delegating or swapping. If you procrastinate about many tasks at work, it may be a sign that it's the wrong job for you.
Low Frustration Tolerance Analyze which aspects of your job cause you the most stress, and then strategize on ways to change those aspects of your job. Read your frustration levels and take action to correct the situation before you "blow." Avoid working in high stress situations or for intense, demanding individuals. Learn relaxation techniques that you can use in the work place. Maintain a routine; e.g. avoid working under too many deadlines or where overtime is often expected. Look for a job where you can have some autonomy to set your own pace, workload, time alone, hours to work, etc. Find a job where your style is appreciated by your supervisor.
Impulsivity Learn to think the whole task through before beginning. Don't get carried away (and misled) by your initial burst of enthusiasm and energy. Develop the habit of planning your day and penciling out the parameters of any project before beginning. Don't just dive in, confidently expecting all to work out once things are under way. Prioritize your time by making lists of what needs to be done. What has to be done today? What would be nice to get done today? What will you work on once everything else is completed?
Forgetfulness Bring a small tape recorder, with a counter, to important meetings. Also take notes, noting counter numbers, for key points. Then you won't need to listen to the entire tape later. Take notes at all meetings. Don't ever rely on your memory. After meetings where decisions were made, provide others with a written copy of what was agreed on as a way to ensure accuracy. Keep your day planner with you at all times. Write down important commitments, information, comments, etc. Don't count on your memory to remember it, ever. Some ADD adults are able to figure out and implement workplace strategies on their own. Others hire a coach to help them institute and practice strategies with the goal of making them lifetime habits. Other ADD adults, either because of the nature of their work or the nature of their work place, cannot function their best with strategies alone. They need to ask their employer for accommodations. If you decide to explore accommodations with your employer, be aware that the ADA provides for confidentially of your disability records and generally requires that such records be maintained in a separate file, i.e. not your personnel file. Proper documentation of your disorder is crucial and includes the diagnosis, an evaluation of the impact in your particular case and recommendations. The report may point out the positive qualities of individuals with ADD, including high energy and enthusiasm, intensity and creativity. If you have co-existing disorders, consider if they should be included in the report. If the co-existing disorders do not require accommodations, they need not be disclosed. Following are some accommodations that ADD adults have requested in the workplace. They may not be needed or appropriate for you and your job situation. When asking your employer for this kind of help, remember to maintain a co-operative attitude.
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1. A private office or quiet, non-distracting workspace 2. Doing some of the work at home 3. Having computer software for time management 4. Audio or video equipment to record meetings 5. Being provided with checklists, written instructions 6. Receiving verbal instructions clearly and slowly 7. Being excused from the non-essential aspects of the job 8. Getting clerical assistance 9. Flex-time 10. More frequent job performance appraisals, weekly brief meetings with your supervisor to help maintain structure 11. Assistance in setting up and maintaining a filing system 12. Using a typewriter or word processor instead of writing material in longhand. I hope these ideas will get you started in Being All That You Can Be...In the Workplace.
The Americans with Disabilities Act The Americans with Disabilities Act (ADA) became law in l992 and prohibits discrimination against qualified individuals with disabilities in employment, public services, public accommodations and telecommunications. The ADA currently defines a disability as a physical or mental impairment that substantially limits one or more major life activities or having a record of such impairment or being regarded as having such an impairment. These are the major life activities that must be substantially impaired: walking, seeing, hearing, speaking, breathing, learning, sitting, thinking, concentrating, lifting, performing manual tasks, caring for oneself, interacting with others, and working (but not when it affects only one or a narrow range of jobs). The ADA's employment provisions (Title I) require employers with 15 or more employees to provide reasonable accommodation for qualified persons with disabilities who can perform the essential functions of a job (with or without accommodation), unless making the accommodation poses an undue hardship for the employer. Note: the employee must disclose and provide medical verification of the disability before employer may be required to provide reasonable accommodation. Reasonable accommodation is currently defined by ADA as a logical adjustment made to a job and/or environment that enables an otherwise qualified person of disability to perform the duties of that job.
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Essential functions of a job as currently defined by ADA are listed below. Apply these criteria to the job function by function, not to the entire job. Hint: The essential functions of a job are spelled out in a well-written job description.
1. The position exists to perform that function 2. There are a limited number of employees available who can perform that function. 3. The function is highly specialized. The jobholder was hired for his/her expertise to perform that function. 4. Removing the function would fundamentally alter the job. 5. The employer requires employees holding the job to perform that function. Recent court decisions have added "inferred" essential functions 1. Regularly show up for work 2. Exercise good judgment 3. Get along with co-workers 4. Accept work-related criticism 5. Tolerate some work-related stress 6. Follow instructions 7. Not engage in violent/abusive behavior. Undue Hardship for the employer is also defined in the ADA. The employer considers several factors when determining if a requested accommodation poses an undue hardship to the organization. 1. Nature and cost of the proposed accommodation 2. Employer’s size and financial resources 3. Employer’s financial outlook 4. Number of employees 5. Rate of job vacancies (turnover) 6. Number and location of facilities 7. Impact on the employer's work force The Americans with Disabilities Act does not require employers to: 1. Hire unqualified applicants who have a disability 2. Accommodate disabilities, mental or physical, they are unaware of 3. Eliminate essential functions of a job to accommodate a disability 4. Grant an accommodation exactly as requested by the disabled person
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Mood Disorders A Confounding Diagnosis By Irving J. Kohlberg, M.D. Since the 1970's, it has been possible to identify patients who seem to have an overlap between the signs and symptoms of ADD and depressed and/or manic mood disorders. A depressed mood is a mixture of unpleasant feelings described as sad, blue, hopeless, low, "down in the dumps, irritable and/or anxious. A manic mood is the opposite of a depressed mood and is characterized by its intensity. The person may feel wonderful, or extremely irritable, full of rage, or even violent. Some individuals can have periods of depression alternating with periods of mania. These mood swings are referred to as a bipolar, or manic/depressive, disorder. It can be difficult for a physician to differentiate between the symptoms of one of these mood disorders and ADD. One major difference, however, is that the ADD has been present as a constant set of symptoms from infancy or early childhood on, while the mood disorder begins later, sort of superimposed on the ADD. Another distinguishing feature is that the symptoms of the mood disorder often come and go, and seem to have "a life of their own." These symptoms usually occur in cycles, but they can also appear when a child or adult is under unusual stress. Another factor that can help in making the diagnosis is the higher incidence of mood disorders in parents and close relatives of children and adults who have both ADD and mood disorder, than in relatives of individuals who only have ADD. Treatment of a patient with ADD and a mood disorder can be very challenging. Lloyd was a 9-1/2yearold boy who was hospitalized because of running away, attacks on others, property destruction, and threatening to kill himself and "everyone else", as well as saying he'd rather be dead than alive. Past history revealed that he had been treated on and off for ADD since he was quite young and had been seen by a variety of therapists. Over the years his mood swings had become increasingly intense, frequent, and longer in duration. During his hospital stay minor irritations often resulted in uncontrollable, violent temper tantrums with kicking, screaming and property destruction occurring two to three times daily. He was extremely argumentative, changeable, easily hurt, verbally abusive, and irritable with other patients and members of the staff. He denied responsibility for his role in all conflicts. Treatment with a combination of medications resulted in enough improvement in his symptoms to allow him to go home, although he continues to have mood swings and requires close out-patient follow-up and on-going medication adjustments. The treatment for ADD with a mood disorder is more complicated than simply treating ADD with the usual stimulant medication. (Some children and adults, who have not responded to a multimodal treatment approach including stimulant medication may be experiencing an accompanying mood disorder.) Here are some major points to keep in mind: •
A trained physician can identify mood swings in children and adults with ADD
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The overlap in symptoms between these various combinations could be difficult to recognize unless one was familiar with these different syndromes
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The mood disorder appears later and is superimposed on the ADD, which has been present as a constant set of symptoms for years
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The mood swings come and go, and often have a rhythm or cycle of their own, although at times they can
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Some children and adults who have ADD and have not responded to the medications may be suffering from mood disorder as well; and
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The treatment of ADD with a mood disorder requires skill, and combinations of medicines are often necessary to stabilize these individuals feelings and behavior.
Here is a brief discussion of treatments that can be helpful: •
Commonly-used medications for ADD and depression include anti-depressants such as Tofranil (imipramine), Pamelor (nortriptyline), norpramin (desipramine), Prozac (fluoxetine), Zoloft (sertraline) or Paxil (paroxetine) combined with small doses of stimulant medications such as Adderall, Concerta, Ritalin, Strattera or Dexedrine. 9
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Commonly used medications for ADD and mania or manic/depression include: Lithium Carbonate, Tegretol, Depakene and Depakote have been effective, as have combinations of these with one of the antidepressants and/or stimulants. 10
It is extremely important to include individual and/or group pyschotherapy, as well as family therapy when indicated. Despite effective medication, these patients, especially children, and their families, need help understanding what they are being treated for and how the medication works, as well as with low self-esteem, relationships with other children, family troubles and school problems.
Telling the Difference Depressed Children and Adults with ADD have periods of some or all of the following systems:
In ADD with mania, the following symptoms have been reported to have been definitely present in mania and only occasionally in ADD:
Excessive crying, sadness;
An elevated mood with a lot of optimism, self-confidence, cheerfulness;
Suicidal ideas, self injurious actions;
Trouble falling asleep and /or staying asleep, and often a decreased need for sleep;
Anxiety, excessive worrying;
Irritability with recent episodes of anger, hostility and refusal to cooperate;
Irritability, temper tantrums;
Rapid speech and a pressure to keep talking that would be difficult to interrupt;
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Lower doses are often possible when these medications are combined, rather than used alone. Lower doses are often possible when these medications are combined, rather than used alone.
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Agitated, over-activity or underactivity and social withdrawal;
Disordered thinking characterized by a series of quick thoughts and rapidly changing topics. Often it may be difficult to follow what the child or adult is saying. The person may be easily distracted and lose the goal of the thought, and may be planning a lot of new interests or special projects;
Difficulty concentrating; and
A sense of grandiosity or self-righteousness, accompanied by paranoia with distrust of others and feelings of being a victim; and
Changes in appetite and sleep (eating and/or sleeping too much or too little).
Very disruptive behavior in the presence of others. The child or adult may be demanding, threatening, shouting and, when extremely upset, may attack people or destroy property.
Healing the Chaos Within The Interaction Between ADD, Alcoholism and Children and Grandchildren of Alcoholics By Daniel G. Amen, M.D. Marcie and I first met when she brought her 8-year-old son, Matt, to my office. Matt was frequently in trouble at school and home. At school he had problems staying in his seat, finishing his work and arguing with the teacher. At home he got into terrible battles over being ready on time in the morning and doing his chores and homework. An hour's worth of homework often took Matt 3-4 hours to complete with his mother keeping him on task the whole time. There was daily intense turmoil between Marcie and Mart. He knew all of his mother's "anger buttons," and he pushed them repeatedly. Matt's father was frustrated with both. He tried to support Marcie in dealing with Matt, but he worried that Marcie's anger was often excessive. "Once she gets a negative thought about Matt locked into her mind," the father said, "it may be there for hours, even days. "Marcie described herself as a worrier. "If there's not something to worry about, I'll make something up. I tend to get locked into thoughts. This really irritates my husband." Her family complained that Marcie had to have things a certain way or she'd get very upset. Marcie always wanted the house spotless, and the children dressed "just so. ADD runs in families. Marcie, along with her son Matt, was diagnosed with Attention Deficit Disorder (ADD), a neurobiological disorder characterized by a short attention span, distractibility, restlessness, impulsivity and often hyperactivity. Like her son, Marcie struggled in school. She was labeled an underachiever by her teachers. Even though she was never hyperactive or a behavior problem, her mind frequently wandered and it was hard to finish tasks. Despite tests showing superior intelligence, Marcie struggled through high school and barely finished college. Marcie's father was an alcoholic. (ADD frequently is seen in families where there is alcohol abuse). He was not a "skid row drunk." but his drinking caused family turmoil. Her parents fought a lot. Her father lost many jobs, so the family moved frequently. As a teenager Marcie was afraid to bring friends over to her house because she didn't know
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what her father would be like. Marcie attributed her school problems to the turmoil in her family even though her younger sister excelled at school. In my clinical practice I frequently see persons with ADD who carry the emotional scars of growing up in an alcoholic home (ACOA - Adult Children of Alcoholics). Understanding both the alcoholic family history and the ADD is critical to appropriate treatment.
Alcoholism and ADD It is generally accepted that ADD and alcoholism have genetic roots. It is less well known that these conditions often run in the same families. Some clinicians are realizing that many alcoholics have underlying ADD and that they have used alcohol to medicate the restlessness they feel. But using alcohol to treat ADD only makes things worse. Alcohol use increases impulsivity. It is addictive. It causes major family, legal, social, work and health problems. There are better ways to treat ADD than with alcohol. In my experience, when ADD is diagnosed and properly treated, people with alcoholism find it easier to remain sober and follow through with treatment.
Growing Up in an Alcoholic Home Growing up in an alcoholic home may leave scars for life. Children of alcoholics inherit a tendency toward substance abuse ADD, depression and anxiety. These children lacked the consistent environment needed to develop a positive, consistent, internal sense of themselves. The chaos in their lives prevented or interfered with their developmental process. Growing up in an alcoholic family is a significant problem. An estimated 28 million Americans have at least one alcoholic parent. More than half of all alcoholics have an alcoholic parent. In up to 90% of reported child abuse cases, alcohol is a factor. Children of alcoholics are frequently victims of incest, child neglect and other forms of violence and exploitation. Adult children of alcoholics are prone to a range of psychological difficulties. The women have a higher percentage of problems with depression, anxiety, obsessiveness (or getting stuck on thoughts) and ADD. The men have a higher percentage of problems with alcohol and drug abuse, antisocial behavior, underachievement and ADD. Both men and women have a more difficult time parenting because they did not have proper parenting role models.
ACOA Symptoms and Checklist Research shows that many children of alcoholic homes have: •
Difficulty trusting others. The environment where one learns trust; the home, was not trustworthy.
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Difficulty feeling strong emotions; along with denial of feelings. Denial is a major hallmark of an alcoholic home. "After all, we don't talk about such things."
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Difficulty expressing feelings; being unwilling to talk. "How can I talk about chat happened in my home? It's too embarrassing.
These children don't trust, don't feel, don't talk. Many traits of ACOAs are similar to the characteristics of a person with ADD. Below is a list of traits common to ACOAs. The source for this list is Dr. Janet Woititz's book Adult Children of Alcoholics and my own clinical experience. Traits in common with ADD are underlined.
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Adult ADD Reader
Adult Children of Alcoholics: •
guess at what normal behavior is.
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have difficulty following a project through from beginning to end.
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judge themselves without mercy.
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lie when it would be just as easy to tell the truth.
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have difficulty having fun.
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have difficulty with intimate relationships.
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overreact to changes over which they have no control.
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constantly seek approval and affirmation.
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usually feel they are different from other people.
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are super-responsible or super-irresponsible.
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are extremely loyal even in the face of evidence that the loyalty is undeserved.
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are impulsive. They tend to lock themselves into a course of action without giving serious consideration to alternative behaviors or possible consequences. This impulsivity leads to confusion, self-loathing, and loss of control over their environment. In addition they spend an excessive amount of energy cleaning up the mess.
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feel like other people may be talking about them, which, growing up, may have been the case.
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have a sense of being inferior or damaged in some way.
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often feel they are not important enough for others to want to talk to them.
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have a high incidence of learning disabilities.
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tend to misinterpret the words or actions of others.
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get involved with too many things.
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have problems parenting.
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often have problems with drugs or alcohol.
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have frequent problems with anger—are often restless.
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are often intelligent, creative, and artistic.
Additionally, many ACOA's exhibit symptoms of obsessive thinking or compulsive behavior. They have a tendency to get stuck on certain thoughts. They hold grudges. They are worriers. As children they may be very oppositional. They get stuck on the word "No! "When ADD and ACOA issues coexist, it is essential to treat both conditions. Dealing with one issue without the other will lead to ineffective treatment. Clinically, I find it helpful to treat the underlying biological issues first with medication. In my brain-imaging research a high percentage of people with alcoholism, ACOA issues and ADD have brain patterns similar to those seen with people who have obsessive-compulsive disorders. This brain pattern shows increased activity in the front middle part of the brain. This area of the brain allows shifting of attention from thing-to-thing. When this part of the brain is overactive, there is difficulty shifting attention and people tend to get stuck on thoughts (obsessions) or behaviors (compulsions).
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People who have ADD and who are children or grandchildren of alcoholics, and who tend to get stuck on thoughts or behaviors, often do best on a combination of medications: •
a stimulant to treat the poor concentration, distractibility, impulsivity and restlessness, and
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an anti-obsessive medication to treat the tendency to get locket into negative thoughts or behaviors.
The consistently positive response I've seen to this combination of medication is consistent with the biological underpinnings for alcoholism and ADD. Optimizing brain function with proper medication often allows people to more effectively deal with the underlying emotional issues.
Steps to Healing the Chaos Within 1. Stop the denial!! Denial is a huge problem in alcoholic homes. Men seem to deny more than women. Denying there are problems breeds confusion and frustration in all family members. Admit there are problems and seek help! 2. All family members who require help need to be treated. If there is an ADD child and an ADD parent, and only the child is being treated, the treatment will not be optimally effective. Everyone in the family with ADD, ACOA issues, depression or substance abuse needs to work on healing so the family can be healthy as a whole. If one member is in denial the others should still seek treatment. Continue encouraging the resistant person to join them in the healing process. 3. Do not be afraid of medication. ADD has a biological basis. Medications are often essential in the healing process. I like the combination of a stimulant (Ritalin, Dexedrine, Desoxyn or Cylert) with an anti-obsessive (Prozac, Paxil, Zoloft or Anafranil) for people who are children of alcoholics with the symptoms of ADD, depression and/or worrying. 4. Seek help from a professional who has experience in all of these areas. Not all mental health professionals are competent to treat this combination of problems. In fact, many psychiatrists will think you are drug seeking if you ask for Ritalin or Dexedrine. These medications are very safe when properly used. They have been vastly underutilized. If you go to a clinician who's uninformed, he/she may make you feel you're doing something wrong, when, in fact, you're reaching out for what may be, the best and safest treatment. 5. Parent training is essential for adult children of alcoholics who have ADD children. When you grow up in an alcoholic home you often have not learned from healthy parent role models. Raising an ADD child is a very difficult task. Gaining the proper skills is essential for success. Both parents need to be involved in the training for it to have optimal impact. When both parents approach parenting with the same style and goals, there is a high likelihood of success.
Summary ADD and alcohol abuse are genetic disorders. They run in families. ACOA issues are found in many people with ADD and in their families. Without treatment, all of these problems devastate happiness and productivity. Yet these are highly treatable problems. With proper treatment and understanding, generations of people can be helped to live healthy, normal lives.
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Our Expanding ADD Knowledge by Corydon C. Clark, M.D. Without a doubt, the most important "new" development pertaining to ADHD has been the widespread recognition that this condition does not go away at the end of childhood or adolescence. In at least twothirds of the cases, significant symptoms continue into adult life. The symptoms may be as severe at age 45 as they were at age 5 or 10. The classical "hyper-activity" seen in most ADHD children becomes less prominent as they age, but the severe impulsivity and inattentiveness often continues into adulthood, frequently getting worse and even more impairing. Another important advance in our understanding of ADHD is recognition of the familial nature of the condition. When one care-fully looks at cousins, aunts, uncles and other extended family, ADHD is far more prevalent than in the general population. While only ten years ago there were few studies of the genetics of ADHD, there are now hundreds. Another advance is the growing recognition that ADHD, Tourette’s Syndrome (TS), and Obsessive-Compulsive Disorder (OCD) are, to some extent, genetically linked. In the course of evaluation of an ADHD child, it is common to find an OCD older sibling, an uncle with TS, a parent with OCD/TS, and a grandmother with ADHD/OCD. (editor’s note: Research is expanding this genetic connection to include mood disorders, anxiety disorders, addiction problems, pervasive developmental disorders, autism, and learning disorders)
Another advance in our under-standing occurred, when, after years of study, the DSM-IV made it official—there is something called "ADHD, Inattentive Type," without any evident hyperactivity or impulsivity. The label is confusing, since this is the condition most of us once called "ADD." The new label has generated a lot of debate and criticism. In any event, we now know that as many as 40% of all people with ADHD have the "Inattentive Type" only. In the past, children as well as adults with "Inattentive Type" were frequently criticized but rarely diagnosed. This is slowly changing. ADHD in Adults (all types) is a condition very few clinicians have been trained to recognize until just recently. Most adults with ADHD were mistakenly given one of these three "labels:" 6. Bipolar Disorder; 7. Atypical Depression; 8. Personality Disorder. Some were termed "Antisocial," while others with untreated ADHD were given the label, "Substance Abusers." In the counseling office, these adults usually manifest many of the following symptoms: 1. Significant impulsivity 2. Restlessness and inattentiveness in routine interviews 3. Disruptive, intrusive behavior 4. Very poor "insight" capacity 5. Seems “uncooperative,” and determined to do things their way
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6. Rarely seems to read or complete materials given to them for review 7. Exceptional impatience 8. Projection of blame onto others 9. Failure to "follow-through" 10. Unpredictable, very rapid "mood-swings" While it is easy to confuse these symptoms with Personality Disorders, since many of the outward symptoms are similar, there are several very important differences we find in adults with ADHD. The following information should be obtained to aid in making a diagnosis. A. Careful reconstruction of childhood history will reveal symptom onset very early in many cases during the toddler years: always called 'hyper,' gave baby-sitters and daycare providers fits, napped and fed poorly, and grand-parents, as well as parents, were frustrated by behavior, Many male adults will be found to have been retained as "immature" in kindergarten or first grade. There may have been many conflicts during elementary school: Name on the board, trips to the office, suspensions, etc. Academic problems in school may have mounted over the years, and despite evident intelligence always called "off task," "not working up to potential," "lazy," "unmotivated," etc. Adults with ADHD, especially men, tend to deny and misrepresent past history and give answers like "I did OK." Information from their mother may reveal otherwise. One mother, after hearing her adult son say, "I did okay," exploded in laughter and said: "Oh, yeah! How about the year you spent on a bench outside your fourth grade class!" B. It is vital to inquire if a diagnosis of ADHD was ever suggested by teachers or family doctor, or if the parents inquired about it but were told "he is just a growing boy," or "just all boy." In many cases, the clinician may discover treatment was suggested but the parents declined, or medication was prescribed for a while, and helped, but was stopped at puberty (a typical practice in the 60's and 70's). C. Careful inquiry about family genetic conditions. When this reveals many different family members with likely ADHD, TS, or OCD may be decisive. Obviously, given what we now know about genetics, when a grandmother has TS and a sister has OCD, then the restless, inattentive and temperamental male adult in your office is highly suspect for ADHD. In the event one or more of his children have ADHD, then given behaviors noted above he does also until proven otherwise! D. Adults treated with medications effective for proven ADHD usually show rapid and substantial improvement in these symptoms. Those with Bipolar or Personality Disorders do not. The issue is complicated by another concern: there is an overlap between ADHD and Bipolar as well as Personality Disorders, e.g., some people have both, or even all three! In effect, these are not mutually exclusive conditions, and in the office the clinician may be confronted by a very complicated person who fits criteria for several different conditions, and thus may need multiple forms of treatment for optimal recovery. One final point about adolescents and adults with ADHD: in women, the Inattentive Type is far more common, and by late adolescence often looks more like a mood disorder. Those with "Inattentive Type" were typically well-behaved as children, but prone to day-dreaming, incomplete work, and "poor study habits." Commonly they became more and more forgetful, disorganized, and ineffective as they aged.
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Emergence of "depression" symptoms in adolescents is a very common report, and they may indeed look depressed in the office. Inquiry about their child-hood history of "dreamy," "off task" behavior in class, and especially their problems with completion of homework during elementary and middle school, may be the only immediate cues to ADHD symptoms, but of course when a family history reveals ADHD, TS, or OCD in family members then ADHD Inattentive Type should be strongly suspected. Women with this condition often are a conundrum for clinicians because they are more forgetful, disorganized, and "dysfunctional" than one would expect given their education and family background, and their symptoms of depression may be quite unusual or atypical. "Atypical depression" should always trigger an ADHD inquiry. PTSD and ADHD are often concurrent. This co-morbidity is clearly evident now in offices where children and families are seen for evaluation and treatment. Unfortunately, in some clinical settings the ADHD aspect of the situation is ignored, while in other settings the PTSD issues are overlooked. Cuffe recently summarized the issues related to these concurrent conditions. ADHD children are, of course, more prone to risk-taking behaviors than "normal" children, and are more exploratory, curious, and "disinhibited" than others. They are also, as Barkley has often stressed, less "rule conscious" than normal children. For example, when repeatedly taught never to talk with strangers they fail to remember the rule when new and interesting situations arise. They tend to plunge into trouble without adequate foresight, just as they are prone to dash across the street without looking out for traffic. These children often are born into families in which one or more parents and other family relatives have ADHD-based impulse control problems, e.g. the parents and other family members have problems in self-control similar to the children. The uncle who drops in and spends a week or so before moving on may be very impaired by ADHD and/or substance problems, left in charge of a highly disinhibited, risk-prone child, and sexual and/or physical abuse may be the result. PTSD may, in itself, impair the ability to concentrate and induce hypervigilance, creating an ADHD mimicking syndrome, at least temporarily. Clinicians are advised to carefully evaluate the premorbid history for any symptoms of ADHD, as well as the family history, in any case of PTSD. Attributing school problems, concentration difficulties, mood swings, and episodic anger to a residual of PTSD is often incomplete; many of these children and adults will also have ADHD symptoms requiring treatment. Guidelines for proceeding with this kind of dual-track evaluation (ADHD and PTSD) are easy to write about, but, of course, often present significant challenge in the clinician’s office! These can be summarized as follows: 1. When all evidence points to a child being a reasonably well-adjusted, well-behaved youngster at home and in school prior to a traumatic incident such as molestation or physical abuse, then current symptoms are likely primarily sequelae of trauma. 2. When there is a history of over-activity, disruptive behaviors, substantial "temper" problems, difficulties following directions, and inattentiveness, then when these symptoms become worse after traumatic incidents it is probable both ADHD and PTSD conditions are involved. 3. It is always important, when there is a clear possibility of combined conditions, to take a very careful genetic history of the family. 4. Abuse and neglect, like ADHD, is often multi-generational. The lethal combination of ADHD and abuse is a strong suspect when therapeutic efforts to help resolve the emotional damage from abuse appear insufficiently effective.
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5. Although both conditions may lead to significantly disturbed behavior in the school setting, in most cases of abuse/PTSD that behavior will be relatively transient or temporary, lasting weeks or a month or two, but not many months or years! This is especially true when therapy is being provided for the traumatic issues, and the child or adolescent seems to be making progress dealing with these issues yet the disruptive acting out at school continues. In the case of PTSD children and adolescents with ADHD-Inattentive Type, symptoms of their ADD may be confined to inattention, excessive daydreaming, poor completion of homework, difficulty concentrating in class, and declining effort and grades. 6. It is important to re-emphasize that "mood" problems are often found in children and adolescents with ADHD, and in many settings may be more prominent than are typical ADHD symptoms. Concurrent, effective treatment for both ADHD and PTSD provides children and adolescents with the best possible chance of full recovery and successful adjustment. We now know this is also the case for adults as well. Effective treatment will usually require a combination of parent/client education, psychotherapy, medication, and when the client is a child, some special attention to modification of educational programs in school when necessary.
ADHD and Other Conditions Co-morbidity is an area of increasingly intensive interest and research. "Co-morbidity" is a term for concurrent or associated conditions. In many clients with ADHD, one of the most important questions is: "OK, you evidently have ADHD, and what else?" While we often see ADHD in younger children uncomplicated by other significant conditions, by ages 10 or 11, it is routine to discover the presence of Depression or Dysthymia, Bipolar Disorder, OCD, TS, Panic or other Anxiety Disorders, and many Adjustment Disorders. As clients with ADHD age, it becomes increasingly uncommon to encounter a person with ADHD as the only problem requiring treatment. By age 25 or so, the overwhelming majority of people with ADHD have one or more associated conditions.
Depression and Dysthymia
are the most common of these problems. While medication may adequately treat core ADHD symptoms, clients will often need psychotherapy for these or other mood disorders. Many will benefit from additional medications such as Prozac, Paxil, Zoloft, Luvox, Effexor or Serzone along with psychotherapy to effectively relieve depression and dysthymia.
ADHD and PMS Women with ADHD often report especially severe PMS, and their spouses and children may be very troubled by their exceptional irritability and impatience during this time of the month. Medications such as those mentioned above, as well as Buspar are often extremely effective in relieving PMS symptoms.
ADHD and Bipolar Disorder Intensive research is now underway to sort out the relation ship between ADHD and Bipolar Disorder. These conditions share many symptoms, and differential diagnosis is often difficult. Further, there are clearly some people with both ADHD and Bipolar Disorder. The combination may generate a clinical pattern of exceptional severity, and is evident occasionally in relatively young children as well as in adolescents and adults. Extreme over-reaction to limit setting, severe temper "fits," episodes of violent or assaultive behavior, and very wide fluctuations of mood tend to be characteristic of children, adolescents and adults with ADHD-Bipolar Disorders.
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Although we almost always see some over-reaction to limit setting, some temper tantrums and "fits," some violent ideas and occasional actions, and some mood fluctuation in all ADHD children, especially boys, when these symptoms are extreme, associated Bipolar Disorder is always an important diagnostic consideration. Clinical experience suggests combined treatment is quite effective, e.g. with a stimulant for ADHD plus Depakote, Tegretol or Lithium for Bipolar symptoms. Children and adolescents with a history of brain injury, brain infections, drug or alcohol exposure during fetal development, and/or very impaired cognitive ability periodically appear to have symptoms much like those with ADHD/Bipolar combinations, and may respond well to similar treatment efforts. It is important to emphasize how at risk these children are for severe abuse. Terrific temper fits, violent actions, stubborn refusal to cooperate with parental rules, extreme hostility, and moody or angry defiance obviously are behaviors which provoke the most irrational and poorly controlled of all parental responses. The parent being provoked the most is often a young adult himself or herself, severely impaired with residual ADHD or ADHD/Bipolar symptoms, thus prone to irritability, impatience, rages and violent reactions when even minimally stressed. This parent is periodically incapable of the restraint and judgment we would expect. Given the genetic and familial context in which these often-severe conflicts arise, it should be obvious conjoint treatment of all affected parents as well as children is the only prudent course. We most strongly urge very careful diagnostic and intensive multi-modal treatment efforts be extended to parents, and other important relatives, as well as to children with these conditions. Analysis of "treatment failures" often reveals, in our experience, minimal effort extended to provide effective diagnostic and comprehensive treatment services for parents and other family members. ADHD, especially when combined with Bipolar Disorder, can generate an "abusive environment" with contributions from many family members. The family environment can be greatly improved with effective treatment of all affected family members.
Panic Disorder, With or Without Agoraphobia, and Generalized Anxiety Disorder may be diagnosed in as many as 25-30% of all adolescents and adults who also have ADHD, and in some children as well. Further, it is not uncommon to see some of the typical symptoms of these conditions reverberate in ways which aggravate each other, e.g. a person who is chronically late, forgetful and lost experiences increased anxiety while trying to drive to an appointment, thus triggering increasing fear, panic or phobic symptoms, which then may blossom into a full-blown panic attack. Clients with anxiety conditions, meanwhile, have difficulty with adjusting to residual ADHD symptoms since anxiety increases disorganization, inattention to details, forgetfulness and impairs focus on essential tasks of daily living. These concurrent conditions are now found far more commonly than previously thought, and there may be some genetic/familial contribution. ADHD, Panic Disorder and other Anxiety Disorders tend to have a strong familial history, as is the case with Depression and Bipolar Disorder as well. Again, careful assessment and treatment for both conditions affords the client his/her best opportunity for effective recovery. Finally, we should mention it is always wise to carefully consider ADHD whenever the clinician encounters a person with an evident Adjustment Disorder. The reason is simple: people with ADHD, young and old, are highly volatile and tend to behave in a fashion which brings about many changes, often adverse, and they very commonly have exaggerated symptoms as a result of the change. This
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situation is most commonly encountered when parents split up and a child has evident adjustment problems. In cases of this kind, and many others, it is frequently discovered that disputes over child-rearing were generated by ADHD symptoms in one of the children, and aggravated by undiagnosed or untreated ADHD symptoms in one of the parents. The child may be more moody and testy at school as a consequence of the separation, but treatment only for the adjustment issues will address only one facet of the child’s condition.
ADD, Alcoholism and Other Addictions By Wendy Richardson, MA, LMFCC It is common for people with ADD to turn to addictive substances such as alcohol, marijuana, heroin, prescription tranquilizers, pain medication, nicotine, caffeine, sugar, cocaine and street amphetamines in attempts to soothe their restless brains and bodies. Using substances to improve our abilities, help us feel better, or decrease and numb our feelings is called self-medicating.
Putting Out Fires With Gasoline The problem is that self-medicating works at first. It provides the person with ADD relief from their restless bodies and brains. For some, drugs such as nicotine, caffeine, cocaine, diet pills and "speed" enable them to focus, think clearly and follow through with ideas and tasks. Others chose to soothe their ADD symptoms with alcohol and marijuana. People who abuse substances, or have a history of substance abuse are not "bad" people. They are people who desperately attempt to self-medicate their failings, and ADD symptoms. Self-medicating can feel comforting. The problem is that self-medicating brings on a host of addiction-related problems that over time make our lives much more difficult. What starts out as a "solution" can cause problems including impulsive crimes, domestic violence, addictions, increased high-risk behaviors, lost jobs, relationships, families, and death. Too many people with untreated ADD, learning and perceptual disabilities are incarcerated, or dying from co-related addiction. Self-medicating ADD with alcohol and other drugs is like putting out fires with gasoline. You have pain and problems that are burning out of control, and what you use to put out the fire is gasoline. Your life may explode as you attempt to douse the flames of ADD. An article in American Scientists tells us that, "In the United States alone there are 18 million alcoholics, 28 million children of alcoholics, 6 million cocaine addicts, 14.9 million who abuse other substances, 25 million addicted to nicotine." 11 That adds up to at least 63.5 million Americans addicted to substances. 11
Bum, Cull, Braverman and Comings, "Reward Deficiency Syndrome," American Scientist, March-April (1996), p. 143.
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Who Will Become Addicted? Everyone is vulnerable to abusing any mind-altering substance to diminish the gut wrenching feelings that accompany ADD. There are a variety of reasons why one person becomes addicted and another does not. No single cause for addictions exists; rather, a combination of factors is usually involved. Genetic predisposition, neuro-chemistry, family history, trauma, life stress, and other physical and emotional problems contribute. Part of what determines who becomes addicted and who does not is the combination and timing of these factors. You may have a genetic predisposition for alcohol, but if you choose not to drink you will not become an alcoholic. The same is true for drug addictions. If you never smoke pot, snort cocaine, shoot or smoke heroin, you will never become a pot, co*ke or heroin addict. The bottom line is that people with ADD as a whole are more likely to medicate themselves with substances than those who do not have ADD. Drs. Hallowell and Ratey estimate that 8 to 15 million Americans suffer from ADD; other researchers estimate that as many as 30-50% of them use drugs and alcohol to self-medicate their ADD symptoms. 12 This does not include those who use food and compulsive behaviors to self-medicate their ADD brains and the many painful feelings associated with ADD. When we see ADD, it is import to look for substance abuse and addictions. And when we see substance abuse and addictions, it is equally important to look for ADD.
Prevention and Early Intervention ‘Just Say No!’ may sound simple, but if it was simple, we would not have millions of children, adolescents and adults using drugs every day. For some, their biological and emotional attraction to drugs is so powerful that they cannot conceptualize the risks of self-medication. This is especially true for the person with ADD who may have an affinity for risky, stimulating experiences. This also applies to the person with ADD who is physically and emotionally suffering from untreated ADD restlessness, impulsiveness, low energy, shame, attention and organization problems, and a wide range of social pain." It is very difficult to say no to drugs when you have difficulties controlling your impulses and concentrating and are tormented by a restless brain or body. The sooner we treat children, adolescents and adults with ADD, the more likely we are to help them to minimize or eliminate selfmedicating. Many well-meaning parents, therapists and medical doctors are fearful that treating ADD with medication will lead to addiction. Not all people with ADD need to take medication. For those who do, however, prescribed medication that is closely monitored can actually prevent and minimize the need to selfmedicate. When medication helps people to concentrate, control their impulses, and regulate their energy level, they are less like to self-medicate.
Untreated ADD and Addiction Relapse Untreated ADD contributes to addictive relapse, and, at best, can be a huge factor in recovering people feeling miserable, depressed, unfulfilled, and suicidal. Many individuals in recovery have spent countless hours in therapy, working through childhood issues, getting to know their inner child, and analyzing their behaviors and why they abuse substances. Much of this soul searching, insight and release of feelings is absolutely necessary to maintain recovery. But what if after years of group and individual therapy, and continued involvement in addiction programs, 12
Maureen Martindale, "A Double-Edged Sword," Student Assistant Journal (November-December, l965).
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you still impulsively quit jobs and relationships, cannot follow through with your goals and dreams, and have a fast, chaotic or slow energy level? What if, along with you addictions, you also have ADD?
Treating Both ADD and Addictions It is not enough to treat addictions and not treat ADD, nor is it enough to treat ADD and not treat corelated addictions. Both need to be diagnosed and treated for the individual to have a chance at ongoing recovery. Now is the time to share information so that addiction specialists and those treating ADD can work together. It is critical that chemical dependency practitioners understand that ADD is based in one's biology and responds well to a comprehensive treatment program that sometimes includes medications. It is also important for practitioners to support the recovering person's involvement in Twelve-Step programs and help them to work with their fear about taking medication.
A Comprehensive Treatment Program includes: •
A professional evaluation for ADD and co-related addictions.
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Continued involvement in addiction recovery groups or Twelve Step programs.
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Education on how ADD impacts each individual's life and the people who love them.
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Building social, organizational, communication, and work or school skills.
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ADD coaching and support groups
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Closely monitored medication when medication is indicated.
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Supporting a personas decision to take medication or not. (In time they may realize that medication is an essential part of their recovery.)
Stages of Recovery It is important to treat people with ADD and addictions according to their stage of recovery. Recovery is a process that can be divided into four stages:
Pre-recovery This is the period before a person enters treatment for their addictions. It can be difficult to sort out ADD symptoms from addictive behavior and intoxication. The focus at this point is to get the person into treatment for their addictions or eating disorders. This is not the time to treat ADD with psycho-stimulant medication.
Early Recovery During this period it is also difficult, but not impossible, to sort out ADD from the symptoms of abstinence which include, distractibility, restlessness, mood swings, confusions, and impulsivity. Much of what looks like ADD can disappear with time in recovery. The key is having a life long history of ADD symptoms dating back to childhood. In most cases early recovery is not the time to use psychostimulant medication, unless the individual's ADD is hindering their ability to attain sobriety.
Middle Recovery By now addicts, alcoholics, and people with eating disorders are settling into recovery. This is usually the time when they seek therapy for problems that did not disappear with recovery. It is much easier to diagnose ADD, and medication can be very effective.
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Long-Term Recovery This is an excellent time to treat ADD with medications when warranted. By now, most people in recovery have a life that has expanded beyond trying to stay clean and sober. Their recovery is an important part of their life, and they now have the flexibility to deal with other problems, such as ADD.
Medication and Addiction Psychostimulant medication, when properly prescribed and monitored, is effective for approximately 7580% of people with ADD. These medications include Ritalin, Dexedrine, Adderall, and Desoxyn. It is important to note that, when these medications are used to treat ADD, the dosage is much less than what addicts use to get high. When people are properly medication, they will not feel high or "speedy," instead they will report an increase in their abilities to concentrate, and control their impulses and activity level. The route of delivery is also quite different. Medication to treat ADD is taken orally, while street amphetamines are frequently injected or smoked. Non-stimulant medications, such as Cylert, Effexor, Nortriptyline, Prozac, Wellbutrin, and Zoloft, can also be effective in relieving ADD symptoms for some people. These medications are frequently used in combination with a small dose of a psychostimulant. Recovering alcoholics and addicts are not flocking to doctors to get stimulant medication to treat their ADD. The problem is that many are hesitant, for good reasons, to use medication, especially psychostimulants. It has been my experience that once a recovering person becomes willing to try medication, the chance of abuse is very rare. Again, the key is a comprehensive treatment program that involves close monitoring of medication, behavioral interventions, ADD coaching and support groups, and continued participation in addiction recovery programs.
There is Hope In the last few years I have witnessed the transformation of lives that were once ravaged by untreated ADD and addictions. I have worked with people who had relapsed in and out of treatment programs for ten to twenty years attain ongoing and fulfilling sobriety once their ADD was treated. I have seen people with ADD achieve recovery once their addictions were treated. Each day I understand more about how pervasive ADD is in my life. My clients, friends, family and colleagues are my teachers. I wouldn't wish ADD and addictions on anyone, but if these are the genetic cards that you have been dealt, your life can still be fascinating and fulfilling.
How ADD Affects Your Waking-Sleeping Cycle By Daniel Amen, M.D. Getting up and going to sleep can be real problems for people with ADD. Here are some commonly heard statements from the "Difficult-to-Rouse." for whom getting up can be awful. "Later..." "Just a few more minutes." "I'll get up in a little bit." "Leave me alone." "I'm too tired to get up."
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"OK. I'm up." (Only to lie back down for several hours.) Many ADDults feel groggy or fuzzyheaded in the morning, even after getting a full night of sleep. The harder they try to get out of bed, the worse it gets. One ADDult had such a hard time getting out of bed that she almost got fired from her job. Her boss told her if she was late one more time, she no longer had a job. She actually went to an alarm company and bought a siren to wake her up. She also had three alarm clocks, along with two friends to give her morning wake-up calls. Morning grogginess causes some ADDults to be frequently late and this adds stress to their day. Starting your day late can negatively affect your mood and attitude for the entire day and can cause you other problems, such as getting a speeding ticket, trying to make up for lost time or forgetting important items at home because you were in such a rush to leave the house. Waking up late and rushing adds to the ADDult's feeling of disorganization and lack of control.
Hints for Getting Up 1. Go to bed at a reasonable time so you can get an adequate amount of rest. 2. Buy a radio alarm clock. Find a station that plays the kind of music at your wake-up time that gets you going. Try different kinds of music to see what works best for you. 3. Keep the alarm clock (or clocks) across the room so you have to get out of the bed to turn them off. Don't buy the kind of alarm that turns itself off after 30 seconds. Have one that keeps going...and going...and going. Be selective when buying the alarm clock. Don't coddle yourself. Find one with a really irritating buzzer so annoying you have to get out of bed to turn it off. 4. Take your stimulant medicine while you're still in bed...like a half-hour before you absolutely have to get out of bed. Or if not taking a stimulant, try drinking strong coffee. 5. Have something to do that motivates you in the morning, like getting up for an early morning jog with a friend or walking your dog. 6. Stay away from jobs with early morning hours if possible. 7. Watch your body's cycles. Some people are good in the morning, and some later on in the day. Try to fit your schedule to your body's rhythms.
Going to Sleep Many ADDults have sleep problems. Some "go and go" all day until they drop from exhaustion, while others have difficulty getting asleep. Some ADDults wake frequently during the night or they're hyper in their sleep and constantly in motion. The ADDult, who is hard to wake, becomes even more difficult to wake, and is certainly more irritable, after a poor night's sleep. The person who gets a restful night's sleep is more likely to be more pleasant in the morning. This is what some ADDults have said about their sleeping problems: •
I count sheep to get to sleep, but the damn sheep are always talking to me!
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When I try to sleep, all kinds of thoughts come into my mind. It feels as if my mind spins when I try to calm it down.
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I feel so restless at night. It's hard to settle down, even though I'm dead tired.
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In my head I go over and over the worries from the day. I just can't shut my brain down.
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I have to sleep with a fan on so the noise will drown out my thoughts. I need noise to calm down.
Not getting enough sleep creates a bad cycle of feeling tired and wanting to sleep during the day. Doctors don't know why ADDults tend to have sleep problems. Some think it has to do with a brain chemical called serotonin. When there is not enough of this chemical, sleep is more of a problem. Here are some ways you can increase your serotonin levels prior to bedtime. No one suggestion will work for everyone, but keep trying new tactics until you find what works for you. 1. Eliminate television for 1-2 hours before bedtime, especially any over-stimulating program. 2. Eliminate any mentally or physically stimulating, activity for 1-2 hours before bed, such as sports, challenging computer games or intense conversation. Quiet, peaceful activities are more helpful, such as writing, drawing or reading a book, but a boring book, not an action-packed thriller. 3. Take a quiet, warm bath or shower. 4. Get a back rub or massage. Start from the neck and work down in slow rhythmic strokes. Others find a foot massage relaxing. 5. Soft, slow music often helps people drift off to sleep. Check out music that's written specifically for relaxation. Instrumental music, as opposed to vocal music, seems to be more helpful, although some ADDults need fast, rhythmic music to block out their thoughts. Use what works for you. You could also explore nature sound tapes (rain, thunder, ocean, rivers) or explore having a fan on. 6. Relaxation tapes with guided imagery can help you learn to relax your body and mind. Or try Dr. Amen's sleep tape which was made by a special sound machine, producing sound waves at the same frequency as a sleeping brain. This tape helps the brain "tune in" to a brain wave sleep state. This encourages a peaceful sleep. (Editor’s note: ADD Resources has this tape in their lending library and also for sale). 7. Learn self-hypnosis for relaxation. 8. Restrictive bedding may be helpful, such as a sleeping bag or being tightly wrapped in blankets. 9. A mixture of warm milk, a tablespoon of real vanilla and a tablespoon of sugar could be tried. This increases the serotonin to your brain and helps you to sleep. 10. Have a fairly consistent bedtime. If you have a poor night's sleep, don't nap or go to bed earlier the next night. 11. Develop a bedtime ritual. Do the same things every night in the same way in preparation for bed. This gives your brain the message that, "It's getting time for me to go to bed." 12. If you have a worry on your mind, take time earlier in the day to think about it, (don't save your thinking time for bed) Tell yourself that you have already thought about that and don't need to give it any more thought now—or if a thought persists, write it down on a pad of paper you keep at your bedside as a way of letting it go. 13. Only use your bed for sleeping. If you are having trouble sleeping, get up for a while and return to bed when you feel drowsier. 14. Explore medications if the above suggestions still don't bring the desired results. 15. Medications are sometimes needed if getting to sleep is a chronic problem. There are pros and cons to using medication sleep aides. On the positive side, medication tends to work quickly and can help normalize a disturbed sleep pattern. On the negative side, medications can have side effect such as
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morning grogginess and you can become dependent on them if taken for too long. As these medications tend to lose their effectiveness after a few weeks, they should be used on a short-term basis only. Here are some of the medications doctors prescribe to help promote sleep: •
Over the counter medications such as Benedryl, Unisom, Sominex, Excedrin PM, Nyquil, etc.
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Some antidepressants, such as imipramine (Tofranil), amitriptyline (Elavil), or trazodone (Desyrel). They are helpful in people who have a tendency toward depression.
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Certain blood pressure medications such as Clonidine (Catapres). Clonidine is used to calm down the restlessness or hyperactivity that often goes along with ADD.
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Sleeping medications, such as temazepam (Restoril), trianzolam (Halcion), zolpidem (Ambien) flurazepam(Dalman) estazolam(ProSom)
Getting up and going to sleep can hinder the success of ADDults. Use the techniques outlined above. Be persistent. If one technique doesn't work for you, don't give up. Try others. Here's hoping you soon will have A GOOD NIGHT’S SLEEP. (Editor's note: Dr. Amen reports that Melatonin helps a number of his patients fall asleep. Melatonin is said to reset a person's biological clock and is a natural product available in health food stores. Some ADDults, who suffer from grogginess in the morning or even during the day, have obtained increased energy from Spirulina or Super Blue Green Algae, also available at health food stores.)
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Confront Your Clutter By Caroline Koehnline, M.A. You know what clutter is. It's the unsorted pile of mail, bills and "things that might be important" spilling off your coffee table. It's miscellaneous items shoved into the hall closet when Aunt Minnie visited. Clutter can be paper, fabric, electronic equipment, hardware, boxes and plastic containers. It could be piled up, spread out or stuffed into grocery bags. If it's hanging around and getting in your way, not quite in and not quite out of your life, it's clutter. It's not surprising that many ADDults have clutter problems. Most Americans are a little overwhelmed by the sheer volume of "stuff" flowing into their homes. Staying on top of the flow requires tolerance for mundane tasks, an acceptance of the need to put things away, and an ability to prioritize and make decisions—not common traits of ADDers. Combine this with a dose of perfectionism or a dash of rebelliousness, and clutter can become a nightmare. On the one hand, who cares? What's the big deal? So what if you have some extra stuff around. It's not like having cancer or being addicted to heroin. On the other hand, clutter can keep people from doing what’s important. It distracts. It makes us lose things. It makes us late. Clutter depresses us and shames us. It complicates our already overwhelmingly complicated lives and keeps us from having simple and attractive environments in which to live and work. Deciding you want to de-clutter and actually doing it are very different things. When you sit down with the good intention of finally clearing the coffee table, at least a dozen things occur to you that are more urgent or more interesting. If you do clear off the table, it will be covered again in less than two days. When you finally tackle the hall closet, you know, from past experience that you'll get all the coats piled on the sofa, and then...something else comes up. You'll be further behind than ever. Why bother? You should bother because your living and working environments directly effect the quality of your life. But before attempting to de-clutter, set yourself up for success. You don't want to re-enforce past failures.
Guidelines for Success 1. Do it for the right reasons. If you de-clutter because you think you "should" or because someone else is shaming you into it, sooner or later your rebellious side will sabotage the plan. Instead, inspire yourself. Imagine how much easier your life will be. Imagine what you will be able to do. Think of the time, space and energy you'll have when done.
2. Be specific about what you'd like to change. It's not enough to say, "I want to deal with my clutter." What room? Which part? How do you want it to look when you're finished? If your requests are too vague, they'll be too easily forgotten.
3. Focus on one step at a time. Choose one area. Decide when you'll work on it and for how long. Schedule it on your calendar. Decide what tools you'll need. Boxes? Post-it notes? Markers? Labels? Use a timer and make a deal with yourself
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to stay with a task until it rings. Don' think, "There's so much to do." Think of the ant that moves an entire anthill one-grain of sand at a time.
4. Create systems and make real homes for things. Appointment books, notebooks, calendars, to-do lists and files can help you keep track of daily activities. Having real places for unpaid bills and invitations will make it more likely you'll actually find them again. Consult a professional organizer, visit a store with organizing supplies, and check out books for ideas on creating order. Messie No More by Sandra Felton, Not for Only by Don Aslett, Taming the Paper Tiger by Barbara Hemphill, and How to Conquer Clutter by Stephanie Culp are all helpful.
5. Slowly build your tolerance for spaciousness. One reason the coffee table fills up again is simply that you're used to seeing it that way. When you walk by that clean surface, your brain registers it as "empty" and, therefore," a good place to put things." Empty spaces don't need to be filled with things! Teach yourself that empty spaces can provide the spaciousness you need in your life.
6. Get support. Two of the hardest things about confronting your clutter are isolation and lack of structure. You are on your own. That makes it doubly easy to get distracted. A buddy can make a huge difference when you are facing physically, mentally and emotionally challenging work. Be sure to choose someone who is compassionate, respectful and able to stay on task. A buddy gets you to take your goals seriously, breaking them down into bite-size pieces. He/she helps problem-solve, encourages you and notices and delights in your accomplishments, no matter their size.
7. Be kind to yourself. Because confronting your clutter means dealing with things you've been avoiding, it provides endless opportunities for beating up on yourself. Don't give into the temptation. Speak to yourself with gentle and encouraging words. Confronting clutter is not about getting rid of everything; nor is it about hanging onto everything and getting it all neatly organized. Dealing with your clutter is acknowledging that you must makes choices—about how you will use time, energy, space and other precious resources. Letting go of the things you don't truly want nor need opens the possibility of creating real places in your life for those things that are the most life giving and meaningful to you.
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Seven Easy Steps to Procrastination Author Unknown STEP ONE: Face the thing you have to do. Make it clear to yourself how awful the task is going to be. Make sure you do not want to do it. Get the feeling that you have to do it! STEP TWO: Add to the distastefulness of the task by remembering how much you hated doing it or a similar task on an earlier occasion. STEP THREE: See if you can become afraid of what you have to do by complicating matters. Think of all the things you need to do before you even start the task. Use your imagination. Picture the worst. STEP FOUR: Develop excuses to delay the task. This will make you feel better, temporarily STEP FIVE: Have your right brain devise an alternate activity. It can figure out something else you could do, something you want to do. STEP SIX: Start doing the alternate activity, but keep the task you should be doing in the back of your mind. Build up fear, guilt and anxiety. This will make the task you have to do seem even worse. It strengthens your image (Step Three) of how horrible the task will be. STEP SEVEN: Go to bed, thinking about needing to do the terrible task tomorrow. Struggle to fall asleep as fear, guilt and anxiety disturb your thoughts. Toss and turn all night, and wake up tired. If you conscientiously follow these seven simple steps for all your undesirable tasks, you can put them off indefinitely. You will be filled with stress, irritability, anger, frustration, guilt and, oh, so much more! You will have very little free time to do the things you love. If you take time to play, the undone tasks will haunt you. The better you get at procrastination, the more things you can add to the still-to-be-done list. In no time at all, you are buried in uncompleted tasks. You could even get sick!
You Know You Have ADD When… Author Unknown •
You haven't a clue what's recorded on the videotapes you own because you never got around to labeling them.
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You finally buy the additional parts to finish a household project but now you can't find the original parts anywhere.
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You're picking up your child from an activity, only to remember she's home sleeping in bed.
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You make a list of things to do and misplace the list
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You park your car at the store and can't remember where you parked it or which car you drove.
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You don't have the grocery boy help you out because you don't want him watching you look for your car
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You have a phone number on a slip of paper, but no name to tell you whose number it is. Or, you wrote down the name and phone number on a slip of paper, and then threw the paper away by mistake.
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You go into a room, do several useful things, come out, sit down, and then remember why you really went into that room.
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You borrow your husband's car keys because you can't find yours. You put his keys on the car roof while you get in. You notice yours on the car seat, use them to start the car, and drive off, wondering what it was that "sounded like keys hitting the pavement," as you drive away.
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You pay for your gas at a self-serve station and drive off, forgetting to put in the gas. A few minutes later you notice the fuel gauge still registers "empty" and you think something is the matter with the gauge because you know you just bought gas.
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You live in a hot and arid climate. You come home from the grocery store with lots of frozen food, go in the house and start talking with a family member. The next morning, when looking for your newly purchased lipstick, you remember the groceries, still in the car trunk.
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You go to the store to buy a specific item. While there, you buy two large bags full, but forget what you went to buy.
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Your daughter calls from church and asks why both her Mom and Dad left in separate cars—without her.
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You buy a $200 Voice Reminder but always forget where you leave it. Finally, you leave it in a rental car. Then you wonder everyday whether you should buy another.
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While in the shower, you remember something important you need to do right away. You get out, only to realize your hair is still full of shampoo.
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You are half way to work when you realize you changed jobs two months ago and the new job is in the opposite direction.
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You cut a presentation short to run home because you don't remember turning the lawn sprinkler off. Once home, you discover you forgot to turn it on!
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The last time you were early for anything you forgot to set the clock back one hour for daylight savings.
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You keep telling people you live in the Alpine Terrace apartments, although you moved away from there two years ago. Those apartments are in California, and you now live in Georgia.
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You have your medications in one hand and a glass of water in the other. You drink the water, then notice the meds are still in your other hand.
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You go to pick your child up at his friend's house and realize you have driven right by the house. You turn around, and arrive at home... without your child.
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On a weekend trip, you forget your contact lens case. You put your lenses in a glass of water while taking a shower. When you get out of the shower, you drink the glass of water. Later, you go to put your contact lenses in and remember they were in the glass.
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Whenever the smoke alarm goes off, the comic in your household yells, "It's done."
Remember these when you're having an "ADD Moment."
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Choosing and Working with a Coach Author Unknown Are you wondering what coaching is? A coach works with you to improve your results and your successes. A coach will: 1. Help you set better goals and then reach those goals 2. Ask you to do more than you would have done on your own 3. Get you to focus your efforts better to produce results more quickly 4. Provide you with the tools, support, and structure to accomplish more. How does coaching differ from consulting?...Therapy?...Sports coaching?...Having a best friend? Coaching is a form of consulting. Coaches provide advice and expertise in achieving personal change and excellence. Unlike the consultant who offers advice and leaves, a coach stays to help implement the recommended changes, making sure they really happen and ensuring that the client reaches his in a lasting way. In most therapies, patients or clients work on “issues,” reflect on their past experiences and try to understand the psycho-dynamic causes of their behaviors. Coaching focuses only on the here and now, looking at the problems in the present needing solutions. In this way, it is like solution-focuses therapy. Coaches work with their clients to gain something, such as new skills, not to lose something, such as unhealthy thought patterns. The focus is on achieving personal and professional goals that give clients the lives they want. Professional coaching includes several principles from sports coaching, like teamwork, going for the goal, and being your best. Unlike sports coaching, professional coaching is non-competitive. You develop your own way to achieve your goals. There is not one best way to do it. It is not focused on outdoing someone else. It is focused on strengthening the client’s skills, such as a trainer might do. Having a best friend is always wonderful, but you might not trust your best friend does to advise you on the most important aspects of your life and/or business. A best friend might not be able or willing to provide the consistency in monitoring and feedback that coaching demands. The relationship with your coach has some elements of a good friendship in that a close relationship evolves. The coach knows when to be tender or tough with you, is willing to tell you the truth, and keeps your best interests foremost in the relationship. “A coach is your partner in achieving professional goals, your champion during a turnaround, your trainer in communication and life skills, your sounding board when making choices, your motivator when strong actions are called for, your unconditional support when you take a hit, your mentor in personal development, your co-designer when developing an extraordinary project, your beacon during stormy times, your wake—up call if you don’t hear your own, and most importantly: Your coach is your partner in living the life you know you’re ready for, personally and professional.” Thomas Leonard, President of Coach University.
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People hire coaches because they want more to their life; they want to grow as individuals, and they want to make it easier. When using a coach, people take themselves and their goals more seriously. They immediately start taking more effective and focused actions. They stop focusing on thoughts and behaviors that drag them down. They create a forward momentum to their lives and they set better goals for themselves than they would have without a coach.
Coach Selection Recommendations Rapport is very important. Your relationship with your coach is important to your professional and personal growth. The effective coaching relationship is an effective model for all your other relationships: inspiring, supporting, challenging and productive. Choose someone you will be able to relate to very well. Experience in your field is less important although knowledge of ADD is important. Coaching technology works far a wide variety of people, professions, and situations. A coach with experience in your personal or professional situation may understand you more quickly. However, much of your work with a coach will involve encouraging you to use and develop your personal skills and your expanding network. Therefore, the specific business experience of your coach is not as important as you might think. Coaching technology works independently of the business or professional environment. Location is normally not important. While some coaches do offer on-site coaching, it is normally not necessary nor efficient. You will get the same or better results with telephone coaching at a fraction of your investment with on-site coaching. Interview more than one coach before you decide. Most coaches are happy to speak with you for several minutes in order to get to know you and your situation. You can use this time as an opportunity to gather information and an impression about the coach's style. Compare two or three coaches and select the one who seems most helpful to you. Trust yourself to know what you need. Ask the prospective coach good questions. Great coaches are willing to answer your questions directly and forthrightly. Consider asking questions about depth of experience, qualifications, skills, and practice. For example: •
"How many clients have you coached, and how many are presently active clients?"
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"What is your specialty and how long have you been practicing in that specialty?"
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“What is your knowledge of Attention Deficit Disorder? How many clients have you had with ADD?”
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“What qualifies you to coach people in my situation and how many people in my business you coached?”
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“How do you typically work with a client?”
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“What are the names and numbers of some of your clients so that I may ask about your coaching?”
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“How long do clients usually work with you?”
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“What are your fees?”
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An ADD Story—Sad, but, Too Often, True By Darryl Peterson William Collins is 35 years old. He has been married and divorced three times. He has difficulty keeping a job. Minor things irritate him; he loses his temper and impulsively makes remarks that get him into trouble. Such constant irritability has cost him 20 jobs and three marriages, At times he has been so angry that he stalks his wife, and whenever he loses his temper with his boss, he gets fired. The "explanation" he tells people is that he became bored with the job, that his bosses were all incompetent jerks, and that he "quit." None of his jobs has ever amounted to much any ways because he always has trouble concentrating on high-priority tasks and projects. People constantly remind him to pay attention because he forgets easily. Because of this he did poorly in school and hated every minute of it. His teachers thought he was either "slow," "lazy" or unmotivated and they all thought his major problem was "poor self-esteem." As a teenager he found himself drinking and drugging to excess, and the only time he ever felt normal was when a friend gave him some "speed" (amphetamines). Bill and his school psychologists blamed his problems on his parents. His father was a chronically unemployed alcoholic while his mother was always depressed and suffered many anxiety attacks The psychotherapist Bill consulted after his second divorce reinforced his tendency to blame his parents by claiming his problem came from a "dysfunctional family," and that he would "probably never learn" adequate coping skills. At one point the psycho- therapist wondered whether his anger wasn't really the result of sexual abuse so early in life that he could not remember. However, despite 5 years in insight psychotherapy (a.k.a.-"intellectual understanding cures") with extensive "dream work," his attitudes and behavior did not improve. Bill came to believe that nothing would ever be better for him. A “dysfunctional family” or sexual abuse does not cause Bill’s problems. He has an inborn neurological disorder in the frontal lobes of his brain, most likely caused by some combination of pre-natal and birthing anoxia, prenatal and birthing traumas, and some genetic predispositions (editor's note: this is speculation as research has not yet shown what causes ADD) that caused a psychobiological imbalance in his neocortex that greatly interferes with how his brain should work when its "executive functions" must be effectively engaged. He has ADULT ATTENTION DEFICIT DISORDER with HYPERACTIVITY (ADHD). Ironically, it is a very treatable disorder. But because it was never diagnosed, Bill in essence lost the first half of his life. Bill is not alone. Current estimates run as high as 15 million Americans with this disorder - most of whom, like Bill, have co-occurring problems which emanate from the untreated ADHD, or ADD. These co-occurring problems include low self-esteem, existential angst and torpor, provisional lives, low emotional intelligence, pervasive relationship and marital problems, ineffective parenting skills, substance abuse addictions and failed recovery attempts, depression, anxiety, Post Traumatic Stress Disorder, pessimism addictions and "negaholism," "woundaholism," false-self/pseudo careers, Type A attitudes and behavior, erratic project completion patterns, bouncing-ball work histories and suicidal ideation. Even worse, such "adults," for as long as they do not become fully committed to a multimodal treatment program, will automatically predispose their children for, literally, all of the same problems.
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After finally realizing that his attempts at both psychotherapy and marriage counseling were dead ends, Bill sought help from his family physician. Bill did so pessimistically, however, because all of his previous "health care treatments," and physical exams, had been "strictly physical," and because he'd unknowingly become a pessimism addict since early childhood, largely because of his untreated ADHD and his parents' and teachers' hypercritical reactions to it. In adulthood, his "strictly-physical illness" physician had never once explored with him the possible existence of any "wellness strategies" or "emotional problems." On his next visit, however, Bill aggressively confronted his physician with a copy of Listening to Prozac, by Peter Kramer, M.D., a book, which Bill unintentionally found, on sale at his local drugstore while buying his latest supply of over-the-counter sleeping pills. After a five-minute interview, Bill's physician agreed with Bill's self-diagnosis of lifelong dysthymia and prescribed a trial on Prozac. After three weeks of considerably increased irritability and erratic sleep patterns (above his lifelong "regular levels"), Bill did become somewhat less depressed, but the Prozac had caused a substantial dampening of his already repressed emotional sensitivities and sexual interests. At this point, Bill's wife threatened him with divorce. Bill's physician advised him to "be more patient with the Prozac," but matters became progressively worse. Bill's physician failed to discern Bill's core problem of ADHD, and how its non-treatment was both causing and maintaining his depression, irritability, other previously mentioned dysfunctional patterns, along with his marital disintegration. Quite dramatically, his physician was merely "treating" symptoms while exacerbating Bill's core problem. Bill then landed in an expensive "detox program" for his ever-worsening alcoholism. Never once, while there, was the possibility of ADHD explored by the addiction counselors, psychologists, psychiatrists or other M.D.s involved or his A.A. sponsor. Several months into his progressively successful recovery from alcoholism, Bill learned about me from one of my past clients in A.A. Within the first thirty minutes of our initial meeting, I discerned many of the hallmark symptoms of ADHD in Bill's personal story, his speech and behavior patterns, and his body language. Bill completed a comprehensive, two-hour personal history and ADHD/ADD self-evaluation interview. My suspicions were dramatically confirmed. I gave Bill an extensive anthology of articles on ADHD/ADD, including some special ones on addictions, Type A attitude and behavior, as well as workplace and marriage issues, to take home for reflection. Within three days Bill called me to very enthusiastically announce that he was fully convinced that ADHD was his core problem in life, and that he was now feeling like "35 years of cobwebs have been pulled off my body." Bill's declaration echoes Dr. Edward Hallowell's, the renowned co-author of Driven to Distraction: "The thing to remember is that if the diagnosis can be reliably made, then most of the bad stuff associated with ADD can be avoided or contained. The diagnosis can be extremely like ‘lazy’: ‘stubborn,’ ‘willful,’ ‘disruptive,’ ‘impossible,’ ‘tyrannical,’ ‘a spaceshot,’ brain from the court of moral judgment to the clinic of neuropsychiatric treatment." I referred Bill to a psychiatrist who "truly" specializes in adult ADHD/ADD for a thorough clinical diagnosis and possible medication trial. Bill's evaluation with me was fully confirmed by the psychiatrist. Bill is now in a progressively successful, multimodal treatment program of: 1. ADHD stimulant medication; 2. Cognitive psychotherapy with a clinical psychologist who is truly specialized in adult ADHD/ADD;
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3. Physical care with an integrative, emotional and physical wellness and healing medical doctor; 4. Daily aerobic exercise; 5. ADHD coaching; 6. Holistic lifestyle counseling; and 7. Integrative career/life development counseling to find a new career/life path with a truly meaningful purpose, a transpersonal cause, and a career which will fully capitalizes on Bill's innate ADHD-driven special gifts and talents which he never fully-knew nor, much less, self-actualized. Bill's wife is learning about ADHD and is off her "divorce train." Both of their lives are improving considerably in all areas! Bill's story is a composite of a number of stories of adults with ADD. In some ways, his history and patterns could be similar to yours or some of your friends, loved ones, patients, clients, or co-workers. If so, I urge you to have them to explore a possible ADD diagnosis and then to seek the best ADD treatments available.
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Did My Ritalin Stop Working? By Cynthia Hammer, M.S.W. Last week my ADD surfaced with a vengeance, and many behaviors that I had been adequately controlling or coping with were back! Although the up-beat song by the Rondelleís, “My Boyfriend's Back," kept going through my mind, as I sang, “My ADD's Back," in fact, I wasn't feeling the least bit cheerful about it! What was going on? What was going wrong? Why was I back to a disorganized office so I felt the need to apologize for its appearance? Why was I losing things that only moments before I had in my hand? How come I was forgetting important items I needed to purchase and spending an hour wandering around Ernst's, hoping the thing I needed to buy would occur to me? Where was the list I had made earlier? How come it hadn't made it's way into my purse where it should have been. And more importantly, why was I wasting an hour browsing when I had so many pressing things to do? If you are impatient and like to "cut to the chase, you are advised to proceed immediately to the last paragraph of this article. There you will learn my theory about why ADD can, on occasion, spin out of control. The rest of you (is there anyone reading this who isn't impatient?) can read and learn about the techniques I have put in place over the years that makes my ADD livable, and, most of the time, enjoyable. (After all, this is the page that focuses on coping techniques.) Prior to getting my ADD diagnosis three years ago and starting on Ritalin, I had put a number of coping techniques in place. Kate Kelly, co-author of I'm Not Lazy, Stupid or Crazy), called the process I put myself through, "Pulling oneself up by the bootstraps." It was very difficult, but I was determined to make changes. First, I had the chronically messy house. I wondered how my neighbors, their housework done, were outside visiting and watching their children play by 10 a.m. I was spending the whole day indoors "working" and still had a messy house! My solution to this problem was to force myself not to leave a room until it was clean. I still remember how it felt to stay at the sink washing dishes, day after day, when I longed to be elsewhere, doing other things. I remember how it felt to not allow myself to leave the bedroom until the bed was made and the room picked up. But it worked. Eventually I was able to keep our house consistently presentable. My husband's insistence that we have a cleaning service once a week also helped. Being freed of the boring, repetitious tasks of housecleaning meant I could maintain enthusiasm for the rest that needed to be done. Why had I been so resistant to hiring help? I now know that I felt threatened, believing that hiring help to do what most women did without help was further proof of my inadequacies. Now I think delegation is a great coping technique! I read many books on becoming organized, and I slowly put some of the ideas into place. I was tired of getting dressed to go someplace, only to discover that my outfit had a spot, was missing a button, needed to be hemmed, etc. I would rush to put on something else, only to discover that it, too, had some problem that made it unpresentable. I was running late to start with and not being able to immediately find something to wear was making me even later. Time was wasted, my anxiety level soared and my selfesteem plummeted as I tried on one thing after another, rushed down to the iron or sewing machine, or just gave up and wore it as it was, hoping no one would notice. I remember my well-put-together sister commenting that I had nice clothes in the closet, but that I never got them on.
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It amazes me how far I have come. I now have a board in my closet with cup hooks on it that my necklaces hang from! Doesn't that sound orderly? My scarves are neatly folded in a clear plastic box. Nylons with runs in them are discarded. Everything in my closet is ready to wear, and I have a choice of appropriate clothing. The mad, frantic and pathetic dash to get ready is gone. I don't miss it. Now the excitement and the adrenaline rushes in my life usually come from fun, esteem-building activities. When I started working, my major concern was how would I get dinner for my family. I remember mentioning this to my co-workers, and they looked astonished. Apparently, meal preparation was not a problem for them! But for me, it was a major concern. My mode of operation until then was to not think about what was for dinner until dinnertime and then make a mad dash to the store. How could I do that if I didn't get through with work until 5 p.m. and we usually ate by 6:30 p.m.? Again, a change was in the works. It was like death to force myself to sit down and plan the meals for a week every Saturday morning, and then go to the store and buy what was needed. But experiencing the difference that the meal planning and weekly shopping made in my life motivated me to make this new behavior part of my repertoire. Years ago during the national gas crisis, I learned to plan my errands—what was the most logical route to use, what would be the most gas-efficient way to get everything done. During that time I learned to get prepared for my errands, so that if I were buying window shades I would have the windows measurements with me when I went to the store. I know it sounds laughable, but my earlier self would be in the midst of buying shades, deep in discussion with the salesperson, when I would realize that I didn't know what size I needed. I made lists of errands and made sure I had what I needed to make the errands successful before leaving the house. e.g., a sample of the screw I needed four more of, the exact light bulb I needed to replace in the refrigerator, a sample of fabric that I wanted the paint to match. I had finally learned that I couldn't count on my memory to remember these small details. I learned to use the phone more, prior to going in-person. Did the store have what I needed? Was it in stock? Could they hold it for me at the checkout counter as I would be in around 3 p.m. for it. All these techniques made parts of my life easier and made me feel like I was more competent and capable. Getting the diagnosis of ADD and having a medicine that works for me has really impacted and improved how well I manage. After my diagnosis, there were many more coping techniques I was able to institute. My husband, coming from a Germanic household, is fond of saying, "A place for everything, and everything in its place." You can imagine how often he was saying that around our house! Fortunately, he is a very tolerate guy. But now I, too, adopted this slogan, if we exclude the pile of assorted stuff that quietly accumulates on a kitchen counter, no matter how much I discourage it. If things, inadvertently, get left out over the course of the day, I make a night time cruise of the house to tidy up before going to bed. How reassuring to wake up to a house where "Alles ist in ordnung!" My mother-in-law was one of those clean-as-you-go cooks! You could never tell any meal was even in preparation! Whereas I would be using every pot and pan and have every counter covered with dirty utensils before we sat down to eat. Our kitchens, in those days, never had enough counter space. When I read a letter to Dear Abby asking her what she thought of a homemaker who stuck dirty dishes in the oven to get them out of the way, I thought, what a great idea! I maintained that it was more efficient to do all the clean up at once. But I have slowly learned to be a clean-as-you-go cook and it has made a world of difference. Training myself to always put my credit card back in a certain place in my wallet was worse than training a seal to balance a ball on it's nose. But not holding up a line of people at the store or have the saleslady give me a long, consoling look while I frantically search my purse and wallet has made the effort worthwhile. I have a special place for my keys in my purse, and a special place in the front hall closet
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where I always, (well, almost always), put my purse when I arrive home. There is extra medicine in my desk drawer at work, so I have a second chance to take it if I leave home without taking it. I have envelopes and deposit slips in my desk at work so I can mail in my paycheck as soon as I receive it. (We don't have direct deposit at my workplace, and, can you believe it, I was frequently losing my paycheck. ) If something is a problem for me now, with medication and the diagnosis I have the confidence that I can solve it with ingenuity and determination. An friend with ADD read somewhere that ADD people have power brains, not speed brains. This concept gives me the confidence that I can solve my problems, once I give them my full -focused attention. followed up with my ADD perseverance. It's like I give my problems the old one-two. I use a planning calendar—one big enough to write enough stuff in, but small enough to fit in my large purse. A planning calendar is really useful, but only if you have one that you record everything on and it is with you at all times. My planning calendar has additional pages for making lists of things you want to do or ideas you may have. I learned to make lists a long time ago, but often I lost the list and would need to make another; frequently forgetting items that had been on the earlier list. This would bug me no end. But having the list in the back of my calendar planning book gives it a special place to be until I am ready to tear it out. There is another slogan that has become my maxim, "You can do anything you want; but you can't do everything." This slogan became even more powerful for me after I wrote my personal mission statement. (See Stephen Covey's book Seven Habits of Highly Successful People, which I highly recommend to people with ADD.) My mission statement along with my maxim keeps me focused. I know what my priorities are; I know what is important to me while accepting that I don't have time or energy for everything that might interest me. I have to pick and choose if I am to be successful. My life is more meaningful and fulfilling when I accomplish things, when I complete most of the things I start in a way that I am proud of. My mission statement and maxim keep me to my chosen course. Do I make it sound like everything in my life is great, that ADD is no problem, that, in fact, I love having ADD? No way! It is a continual, and continuing struggle. But recognizing and labeling my ADD behaviors has been tremendously helpful. Some of my troubling behaviors I can overcome or minimize with coping or compensating techniques; while others will probably always be there to annoy me, no matter how much or what I try. But now some of my ADD behaviors bring humor and laughter. There are innumerable times I say to myself, "How could I be so dumb when I'm not even blonde?" (Sorry, I couldn't resist.) These are the same dumb behaviors that I tried to keep hidden all those years. Now I laugh at most of the glitches in my life because I have created enough areas where I know I am functioning well. NOW THE FINAL PARAGRAPH: If my ADD rarely shows because I compensate so well, (this is a tongue in cheek statement), why did it appear with a vengeance last week? My theory is that I was over stressed. I had three major deadlines, one of which is getting this article written, and my brain couldn't handle it. As Dr. Hallowell says, about the worst thing someone can say to an ADD child is, "Try harder." Trying harder just makes our frontal lobes turn off. I can practically feel my brain becoming scattered as I have more and more to deal with. Perhaps each of us has the ability to manage a certain number of balls in the air at once. When the juggling act becomes too complex, everything comes crashing down. So, my new additional maxim will be "Keep life simple" while I learn more about stress reduction methods.
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How We Survived as an Undiagnosed ADD Family by Cynthia Hammer, M.S.W. We existed as a family for over fifteen years before realizing some of us had ADD. How did we do it? Although life post diagnosis and treatment (PD&T) is still not easy, I look back in wonder at what we went through in raising our children and maintaining a family life. Actually, a review of our life has been helpful as I say to myself, "You've come a long way, baby!" In our family the mother, that's me, was diagnosed with ADD four years ago. A middle son, now 20, and the youngest son, now 18, were each diagnosed six years ago, one with ADD with conduct disorder, the other with ADD without hyperactivity. Our oldest son, now 23, does not have ADD, while word is still out on the father. I have "diagnosed" him with ADD, but he refuses the diagnosis. After I got treatment, I became more aware of his "ADD-like" behaviors. Now they irritate me whereas earlier I didn't even notice them. Other couples, where one is diagnosed and the other isn't, have told me this is a common experience. Like the reformed smoker who no longer tolerates even the smell of smoke, my improved-self, who use to be blithely unaware or unaffected by the ADD behaviors in those around me, is now hypervigilant in insisting that they shape up. My husband, Steve, is now aware of his forgetfulness. Our oldest son recently commented that Dad has lost everything he owns at least once! He, laughingly, acknowledged that this was true. However, he would rather believe he has early Alzheimer's Disease than to think he shares our disability of ADD. I can't understand why he feels this way. So far, there's no good treatment for Alzheimer's while there are several effective treatments for ADD. At any event, it has become almost irrelevant. As I point out his behaviors that are ADD-like, he works to change them. Whether or not he has ADD, he is using coping strategies, sans medication, to improve his functioning. My approach with my husband is probably not as sweet and benign as it sounds. I say something like, "Prove to me you don't have ADD by never being late again...by not telling me you'll be home in ten minutes only to appear one hour later...or by not planning to accomplish fifteen things in the next two hours while you sit here using up thirty of those minutes. "Before my D&T his ADD-like behaviors rarely bothered me. While I waited for him, I got involved in one or more projects, and I, too, had lost track of time! "I look back in wonder at what we went through." Dr. Hallowell says ADD in both partners can work very well, and in some ways, he's right. Spouses with untreated ADD are generally very tolerant of each other's behaviors. They are too caught up in their own world to really notice or generally care about what's going on in those around them. Having little time for each other, not following through on commitments, making last minute plans, or generally being a day late and a dollar short is a way of life for each of them so the "fit" between them is pretty good. I think a number of marriages occur between two ADD adults and then they have ADD children! I use to have a number of fender benders, but I never worried about Steve getting unduly upset, as he had his share of them too! Can the pot call the kettle black? We learned not to make snide remarks about lost keys, as we couldn't determine who was misplacing them more often. We had a number of household sets
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but still couldn't find them. Now we have improved. He has his set. I have mine. I think he still loses his more. The erroneous idea persists that if you are doing well, you can't have any-thing wrong with you. Using society's standards and judging by external appearances, we were doing well. Steve is a general surgeon and I have a Master's Degree in Social Work, but we were struggling, and I had no idea that how we lived our lives was more chaotic, disorganized and difficult than for others. Then the children came. Thankfully, our first born son did not have ADD. Dr. Amen says when parents of ADD children have a child without ADD; they hold him up with great pride as proof that they are good parents. The children with ADD, especially when undiagnosed and untreated, repeatedly make their parents feel they are terrible parents and are doing every-thing wrong in child rearing. We were very proud of our first born son, high achieving and capable. We were bewildered, stymied and drained, mentally, physically and emotionally by our other two boys. What are some of my major memories as an undiagnosed ADD mother raising two undiagnosed ADD sons?
No Space of My Own Several years ago I listened to a presentation by a nursing home consultant (I was then working part-time as a social worker in a nursing home) to make us more aware of what loses people experience when moving into a nursing home. She asked each of us what space we had in our homes that was our special place, a space that was recognized as ours, that no one would violate or intrude on. Each staff member responded—about a particular chair, an end of the living room sofa, a corner of a room—that was his or her "special place." I realized I had no place. Living with ADD children, there are no boundaries. I could tell them to stay out of my purse, out of my closet, out of my room, not to use my possessions without first asking, all to no avail. I would knock before entering their rooms, but they seemed incapable of learning or extending this courtesy to others. My husband and I resigned ourselves, be grudgingly, to this state of affairs, although periodically we continued to work on it. For our oldest son their violation of his space and possessions caused continual family stress. He would get angry with us. "Why don't you do something about it?" As I write this, I wonder why we didn't get him a key to his room. Our house is old; the original door keys were lost. It would have required taking out the door latch and bringing it to a locksmith which was probably more complicated than an ADD mom could handle. Being naive and idealistic, I didn't want to think one family member had to lock his room against two other family members. Foolishly, I thought more time and effort on my part would resolve the problem. The younger boys could learn to respect the rights of others. How my thinking has changed! Because my two ADD sons felt they wouldn't mind someone taking their stuff without asking, they never seemed to realize that others might feel differently. They were continually "assuming" the owner wouldn't mind, and I, repeatedly, was telling them, "I thought" and "I assumed" were not acceptable responses. They needed to ask. Of course, if the "borrowed" item was lost or broken, well, that was that, unless someone, i.e., me, the mom, could put in a lot of time and energy figuring our how it would be replaced by the offending party and making sure it would happen. I just wasn't up to that kind of consistency and follow through.
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Embarrassed and Shamed in Public I still remember our first meal out at which we made at reasonable semblance of "a nice family out to dinner." Our sons were then about 9,11 and 13, and we were eating in a Mexican restaurant for the first time. While waiting for the meal, salsa and chips were brought. Our youngest two boys stayed seated at the table, as we talked and ate chips, and we didn't get angry with them. Usually these two boys would start fighting, verbally and physically, with each other as we waited for our food to arrive. Woe be to the restaurant that took too long! We would remember and mark it down as a place we couldn't return to. The restaurant owners probably were relieved we had given them a black mark and wouldn't be returning. Usually, after ordering the food and waiting for its arrival, we sent the younger boys "out" to do whatever they did, just to be out of our sight and minds. Then my husband, our oldest son and I acted like a "normal family, "quietly waiting for our food. When it arrived, one of us would look for the other two boys and invite them back to the table. Invariably, they would have tales of how they found a quarter by crawling under the cigarette machine, how one hit the other and that in hitting him back, they accidentally hit another patron and had gotten bawled out, or how they left the water running in the bathroom sink and it was now spilling onto the floor. Our family is athletic, and all of our sons got involved in soccer leagues. The middle son, although a good player when the ball came his way, invariably would have his mind on other things when the ball was elsewhere on the field. His favorite past time was looking for a four leaf-clover or some other object on the ground. As the ball came up the field towards him, I remember his Dad, his coaches and other eager parents, anxiously, and sometimes angrily, shouting at him, "Pay Attention!" "Keep your mind on the game." "The ball's coming your way!" Our other ADD son had much ability, but also an attitude and an impulsive mouth. If the coach said something he didn't like, he would say something back. His coach was a no nonsense, I- am-the-boss, kind of person. His way of dealing with our son was to let us know that we were deficient as parents by allowing our child to be so insolent. If our child were his, such behavior would have been beaten or threatened out of him long ago. Word would go up and down the line of parents as to what our son had said or done, and there was a buzz. Although our son was the star player on the team, going to his games brought us no pleasure. We tensely anticipated the coach's displeasure, with him and with us. My husband and I were fortunate in being able to afford baby-sitters so we could have time to ourselves. We had a long list of sitters to call. Of course, some were busy when we needed them, but years later, one of them confided to me (I think she was taking a course in the need to be completely honest) that she hadn't really been unavailable, she just hadn't wanted to sit for our boys as they were too much for her too handle.
Forgetfulness, Lack of Awareness and Inconsistency There are probably numerous incidents of my sons forgetting things they needed to do, but the forgetting incidents I remember most are my forgetting incidents. It has taken me awhile to forgive myself for these forgettings and to share them. My oldest son attended a Montessori pre-school held in the teacher's home. I dropped him off one morning at the front gate and drove off. Two hours later I got a call from school's neighbor. School was closed that day (I forgot) and my son had been sitting on the steps waiting for my return. He hadn't gone inside the neighbor's house (she was impressed with his training) but he had given her my phone number so she could call me. I felt so embarrassed with my son—what kind of mother could abandon him like that—and embarrassed with the kind neighbor who must have wondered the same thing.
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Several years later my youngest son, age 9, was starting a new school. On the first day I drove him to school, thinking he would take the bus home. When he didn't appear by 4 p.m., I called the bus system. They hadn't seen him. I called the school principal at home. He didn't know our son's whereabouts. I let my husband know our youngest son was missing, and in desperation, I drove to the school, three miles away, to look for him. He had been "missing" for 2 1/2 hours. "My tears were tears of relief... that I wasn't a total screw-up... and tears of happiness... that he was safe." When 1/2 mile from the school, I saw my son, cheerfully walking home. I honked. He came over and got into the car, and I burst into tears. I had to pull into a parking lot. I was crying too hard to see well enough to drive. A woman driver, concerned, pulled up to ask if everything was all right. I explained that everything was now fine, that my son, who I had thought lost, was found. My tears were tears of relief that I wasn't a total screw-up and tears of happiness that he was safe. My son looked at me quizzically. He was embarrassed by my crying, by my show of emotion regarding his well being. He said, "It's no big deal. It's nothing to cry about. You said you'd pick me up after school, but when you didn't show up, I went to the 'Y' and then started to walk home." Although he had been to the 'Y' numerous times with me in the car, he had never walked there. He had no fear and had total self-confidence about getting himself home. Our middle son early on showed similar independence (and poor judgment). I remember shopping with him at the Mall when he was two. He wandered away in the courtyard, exploring the trash containers, planters, benches and people. I watched to see when he would remember his mother, to feel anxious that he was alone, to be scared at being alone. Fifteen minutes of watching and he was still engrossed and content in his solo wanderings. I needed to go so I called to him, and he reluctantly came. We knew we needed help with our younger sons, and sought professional guidance. Although the psychologist we saw didn't make an ADD diagnosis, he taught us behavior modification with a point system, doling out rewards and punishments. I devised a wonderful system, fairly simple, where our sons could earn positive or negative points on a daily basis. A certain number of negative points took away privileges, while an accumulation of a certain number of positive points would let them acquire things like watching a video, getting a pizza, etc. Points could be saved until a really big prize was obtained. It was the child's choice. Each day I would go over the child's behavior with him and record the earned points for that day on the calendar. We would tally the weekly total on Sundays. The system worked great, and the boys' behavior improved tremendously. One month later, I was again in the therapist's office. He asked me how the point system was working. I was non-pulsed. I was dumb-founded. The system had been working well, but I was no longer doing it. I had no explanation. I went home determined to try again. My renewed effort faltered within a few short weeks. My untreated ADD made it impossible for me to stick with a discipline system that required much organization and consistency. My other great idea—we read numerous books on child rearing—was to have them immediately come redo whatever tasks had been unacceptably performed. My sons would invariably come into the house, throwing books, jacket, papers, miscellaneous stuff, onto the kitchen counter and go turn on the TV or go outside to play. I would insist that they immediately leave whatever they were doing, gather up all their stuff, go outside, come in again, and put it away properly. I would call them whenever I noticed something askew and require them to come immediately to make it right.
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I would point out how much more unpleasant it was to have to re-do the task. "Why not do it right the first time?" This re-do idea seemed to have merit. We made progress when I stuck with it. Then things would fall apart. I'm told it takes three weeks to establish a new habit, although it's rumored that with ADD people, it takes six. I couldn't tell you. We never got any new habits established. Calling them back got so boring, for them and for me. It was such a waste of my time and energy and it interrupted what I was doing. It was easier to do the chore myself and complain about their not doing it. I still don't know how we got our son to start mowing the lawn acceptably. We have a push mower. He likes the physical work of mowing the lawn, but that was it. Weed eating and raking, although also part of his job, did not have the same appeal. Our yard never looked good. He left the mower wherever he wanted and never got to the weed eating and raking, no matter how much shouting I did. He always disappeared. After a week's worth of prodding, the task finally got done, and then it was time to start again. We could have hired someone else to do it, which would certainly have been easier on all of us, but I believe we all need to be held accountable for some things and need to learn to honor our commitments. How did I ever survive? Another discipline idea I tried was successful for quite awhile. I thank Dr. Thomas Phelan for developing a simple discipline system, easily employed by ADD parents, 1-2-3-Magic. (He has a video on this if you need help.) Parents tell their kids what behaviors are unacceptable. Don't focus on them all, only a few of the most irritating ones. Then when they do this behavior the first time in a day, the parent says, "That's one." The second time it happens, the parent says, "That's two." After the child learns you're serious about this, he rarely gets counted to three, but when first initiating this system, there is the usual, very exhausting, testing of (your) limits. Be firm! Be consistent! If you need to count to three, have the consequences known by all in advance and immediately impose them. My boys were too old for time-outs in their room when I learned about 1-2-magic. Imposing a restriction was too difficult for me to enforce, especially if they were uncooperative or so passive-aggressive and argumentative that I got worn out trying to impose, monitor and remember what the restriction was. We had a problem of one child ranking on the other, especially at mealtime. My one-two-three became "That's a one" whenever someone ranked or was rude, and 25 cents was deducted from his allowance. "That's a two" would be another 25 cents. It worked great, and I stuck with this system long enough to have the unpleasant table talk eliminated. This was back when we believed, as a noted child-rearing professional had written, that all children are part of the family. They share in its responsibilities, i.e., help with chores around the house, and share in its privileges, i.e., receive a weekly allowance. It took a lot of energy to persuade and supervise our children's share in "family responsibilities." We eventually gave up. Our more successful system was concise and direct. "We expect two hours of work a week. These are your chores. You need to do them to get your allowance. " Household chores is a house rule, a helpful approach I learned from Dr. Amen's video, "New Skills for Frazzled Parents." (We have this in ADD RESOURCES' lending library.) I could go on about our travails, but I think you get the picture. Those of you living in ADD families are not alone! At any event, in the midst of this turmoil, three of us finally got diagnosed and treated for ADD. That has made a world of difference. As one ADD son says, "People with ADD (untreated) know what to do, they just can't get themselves to do it." And as Dr. Amen says, "If there is ADD in the family, everyone in the family needs treatment, or too much stress remains in the family system." We are all treated now. Everyone in our family has learned about ADD, and we are learning to do what we know we should do. We have moved beyond surviving, to thriving, as a family. I wish you well with yours.
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Enjoying. Paying Attention. No Hurry to get on to something more important. Whatever we are doing is important, experiencing each moment along the way. Time is a gift.
I’m not usually an impulse buyer, but when I saw these words accompanied by a picture of two children with limitless time and fully absorbed in the moment, it struck a chord in me. I bought the poster. When I look at my poster, I think of the total fabric of my life and of the need to make the most of it—the good, the bad; the happy, the sad; the highs and the lows. For a life to have meaning and depth, all events in one's life must be accepted. It's an appealing idea, that every event in a life has meaning and value, even if the meaning and value is only to make you who you are, and to make your life have its unique story. Perhaps you saw "Shadowlands." The movie tells a great love story of a proper, repressed conservative English university professor, Sinclair Lewis, who falls totally and uncharacteristically in love with an outgoing, outspoken and somewhat outrageous American divorcee named Joy, only to learn she is dying of cancer. Although I am a romantic and was enthralled with the love story, the part of the movie that remains with me is Joy's philosophy of life. Beneath the couple's total joy of being in love, there is an incredible underlayment of sadness...to find such happiness only to know it is time-limited....to have their happy times interrupted or sullied by Joy's winces of pain and sudden fatigue...continual reminders there are no guarantees in life. Sinclair wants to pretend his wife isn't ill, to focus only on the happy times, but Joy maintains that if they are to appreciate their happy times, they must fully acknowledge and participate in their times of sorrow. She believes that by knowing one—pain and sorrow—you better know and value the other—happiness and joy. If one's life were only good and troubled and sad times never came, or when they did come, they went unheeded, the good times would be less good. The good times would be less valued. In the movie Joy and Sinclair drive to a peak to look down on a valley. To me their car journey symbolizes life and an acceptance of its whole fabric, the peaks and the valleys. In our culture we seek the "good life" which, to me, vaguely means lots of money, lots of good times, without a worry or care in the world. While no one consciously seeks difficulties or wishes sad or difficult times on another, imagine how bland and boring we would be if we all lived the "good life" and had lived the "good life" all our lives. Perhaps my New England background is showing, but how would we develop "character?" I lived the good life until I was twenty-eight. I was born and raised in a small New England town, actually a factory town where plastics were made. Most of my classmates were second or thirdgeneration Italians. Their fathers worked in the factories while the mothers stayed home. Economically, I was better off than my classmates. My father was an attorney, and while my home wouldn't be considered huge—it was a gray colonial on the top of a tree-lined street—I knew as a child that I lived in one of the most desirable houses in town. During my school years I got good grades, made the various girls sport teams, was editor of the school newspaper and got chosen as a cheerleader. The tragedies in my life were not getting my driver's license when I turned sixteen and not getting into the college of my choice!
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I attended an all-women's college. Although some of my classmates were truly interested in a job after college, most still, half jokingly, said they were at college to get an Mrs. Well, I finished college with a BA and without prospects of an Mrs. The good life for me went onto shaky ground. I looked for my first real job. My starting salary request—this was l965—was $7,000/yr. I was a graduate of a prestigious women's college and I had majored in economics. Presumably, I was God's gift to the business world! After several interviews and no job offer, I was grateful to be hired by the trust department of a large bank for $5,000/yr. Three years later my good life seemed secured. I married Steve, considerate, honest, handsome, and, to boot, a future surgeon. I was earning my master's degree in social work. It never occurred to me that my life would ever be anything but wonderful, that we would ever be anything but happy. I look back now and wonder that I made it to age twenty-five with those attitudes intact. At twenty-seven I gave birth to our daughter, Allison, and when I was twenty-eight, she died. It was a strong and instantaneous lesson for me that no one can count on life always being good. Our daughter died when seventeen months old. She swallowed four cloraquin tablets that my husband and I were to take following our return from the Peace Corps in Africa. They were to prevent malaria. I had put the pills in a pencil holder on the desk in the den. When I put them there, I told myself I should find a safer place. Several times in the next few weeks I told myself we should take the pills, that I needed to relocate them. After Allison died, my husband said, "I should have put them away." He felt responsible, knowing, after three years of marriage, that some things I just didn't get done. When our daughter died I was four months pregnant with our next child. How would I care for that child? How could I keep him safe? I read newspaper stories. A child fell from the window of a six-story tenement. A child drowned in the bathtub while the mother answered the phone. A dog mauled an unattended child. The negligent mothers were arrested. I felt connected to these women. At the same time, I felt guilty. They were being judged by society and I was not. Why wasn't I arrested? Was it because I was in a different socio-economic class? My husband was a physician in his residency. Instead of a court appearance, we received grief counseling (gratis) from a prominent child psychiatrist. Over and over, I thought of the times I hadn't adequately watched my daughter. I remembered how often I had put her at risk through my inattentiveness. The hurt, the pain, the sorrow of her death got buried deep inside. I didn't tell anyone about my daughter for 20 years. How could I have let it happen? What a terrible mother. How would I properly care for my next child? At forty-nine, twenty-two years after Allison's death, I was diagnosed with ADD. Everything became clear. I understood why I hadn't relocated the cloroquin tablets, in spite of my repeated reminders to myself. My ADD diagnosis re-opened my grieving for my daughter, for my husband and for me. Most people are happy when they learn about their ADD because it explains so much. For me learning about my ADD brought only unhappiness because it explained so much. Now, three years later, I accept it all—the good parts of my life and the bad. Working to help ADD be known and understood helps. I feel a bonding with those who struggle to manage their lives in accordance with society's mores and expectations. I know that there, but for a knowledge and treatment of my ADD, would go I.
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If your life only contains good fortune, that's just it, your "good fortune." Sorrow, sadness, troubles, and problems can come knocking anytime, on anyone's door. Buddha once told a woman who was distressed about her own troubles in life to go on a journey. Knock at every door to see if she could meet a single person who did not have some sort of trouble or sorrow in his life. The woman undertook the journey. She traveled for many years and knocked on thousands of doors, but she never found a home free of sorrow. Life is difficult. Accept that and the rest becomes easier. Movies like "Shadowlands" and the words and image on my poster, along with time and personal growth, make me accept everything that happens in my life as part of my life. I no longer say I live the good life, nor would I want to. Instead, I say I live a full life. I have experienced the range of emotions that life has to offer, from fear to courage, from anger to peace and contentment, from anxiety to confidence, from depression to elation. I believe that while we can't control everything that comes into our lives, we can control how we respond, and in our responses, we further determine the kind of people we are.
Enjoying. Paying Attention. No Hurry to get on to something more important. Whatever we are doing is important, experiencing each moment along the way. Time is a gift. —Cynthia Hammer
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Resources
Newsletters ADDult ADDvice ADD Resources, 223 Tacoma Av S, #100, Tacoma, WA. 98402. $45/yr. For membership, which includes our 150 page Adult ADD Reader and quarterly newsletter along with privileges in our lending library with over 450 books, audiotapes and videotapes on ADHD. The ADHD Report Russell A Barkley, Ph.D.. bi-monthly $35. (This is a special rate for adults with ADD.) Rate for clinicians is $65/yr. 1-800-365-7006. ATTENTION and other publications from CH.A.D.D., a parent based organization for group or 499 NW 70th Av., Ste. 308, Plantation, FL 33317 , 305-587-3700. Mind Matters a bi-monthly newsletter from Dr. Edward Hallowell, $49.95/yr. Write: Hallowell Center, PC, 747 Main Street, Concord, MA 01742, 508-287-0810, e-mail [emailprotected]. You can request being put on his mailing list.
Internet Both CompuServe and America on Line have large ADD forums. There is much information on the Internet too. Here are a few of the most complete: • www.pcnet.com/~dodge/addlist.html. •
www.webcom.com/bmainc/bmalinks.html
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www.cmhcsys.com/guide/adhd.htm
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www.add.miningco.com/mlibrary
Purchase Publications by Mail •
ADD Resources, www.addresources.org or 253-759-5085.
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ADD Plus (John Taylor, Ph.D.. D)—1-800-847-1233
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ADD Resources—1-800-409-4908
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ADD Warehouse—1-800-233-9273
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Child Management (Thomas Phelan, Ph.D.. D)—1-800-442-4453
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Mindworks Press (Dr. Daniel Amen)—1-707-429-8150
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Guilford Publications (Russell Barkley, Ph.D.)—1-800-365-7006
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Southeastern Psychological Institute (Edna Copeland, Ph.D.)—1-800-526-5952
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Contributors Daniel Amen, M.D. is a board certified child, adolescent and adult psychiatrist and the medical director of a large ADD clinic in Fairfield, CA. Dr. Amen has evaluated and treated over 2,500 patients with ADD. His wife and two of his three children have ADD, so he writes about this disorder from a personal, as well as a professional perspective. Dr. Amen has won writing and research awards from the US Army and the American Psychiatric Association. He has presented his ground breaking research on brain imaging and ADD across the country. Recently, the Discovery Channel did a special feature on his work. Dr. Amen is the author of seven books including Windows Into the ADD Mind, New Skills for Frazzled Parents, and Don't Shoot Yourself in the Foot. Dr. Daniel Amen, 350 Chadbourne Road, Fairfield, CA 94585. Phone: 707-429-7181 Russell Barkley, Ph.D. is Director of Psychology and Professor of Psychiatry and Neurology at the University of Massachusetts Medical Center. He established the Clinic for Attention Deficit Hyperactivity disorders at the Medical Center. Barkley has written numerous book chapters and scientific papers about ADD. His books include Attention Deficit Hyperactivity Disorder: A Handbook. for Diagnosis and Treatment (Guilford, 1990) and Raising a Child with ADHD: A Parent's Handbook (Guilford, 1993). Russell Barkley, Ph.D., Univ. of Massachusetts Medical Ctr., 55 Lake Av. N, Worcester, MA 01655 phone 508-856-5843 Corydon C. Clark, M.D. is a psychiatrist with a large clinic in Las Vegas, Nevada that serves families with neurobiological disorders. Dr. Clark has written a book on Adult ADD as well as numerous articles on various neurobiological disorders. No current contact information available. Edward Hallowell, M .D. practices child and adult psychiatry in Cambridge, MA where he is also on the faculty of the Harvard Medical School. He consults to various schools in the area, including the Willow Hill School and the Brookwood School. He lectures around the country on topics related to attention deficit disorder, dyslexia, and other forms of learning problems, as well as on topic related to "connectedness" and "disconnectedness" within our society. Dr. Hallowell is the author, with John Ratey, M.D., of two books on ADD, Driven to Distraction and Answers to Distraction, as well as author of a book on the range of neurobiological disorders that occur in children titled, When You Worry About the Child You Love. Edward Hallowell, M.D. Hallowell Clinic, Sudbury, MA 978-287-0810
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Cynthia Hammer, M.S.W., ACSW, is an adult with ADD, and the parent of two sons with ADD, one of whom also has bi-polar disorder. Cynthia learned, when she was 49, four years ago, that she had this condition. Since then she has devoted much of her time and energy to helping other adults and the professionals who treat them learn about this disorder. She is currently the Director of ADD Resoures, a non-profit organization based in Tacoma that serves people with ADD, helping them to achieve their full potential. Cynthia Hammer, ADD Resources, 223 Tacoma Av. So, Tacoma, WA 98402, phone 253-759-5085 R. Brian Howell lives in Tacoma with his wife Carol. He is an Investment Advisor and owns his own company R. Brian Howell & Associates Inc. They have two grown sons. Brian is a co-founder with Cynthia Hammer of ADDult Support of Washington. Brian discovered his ADHD several years ago after his older son was diagnosed. Brian is also a ADHD coach with The National Coaching Network. Brian's philosophy for ADHD is to worry about what works and forget what doesn't. R. Brian Howell, 4041 N. Ruston Way, Ste. 2B, Tacoma, WA 98402, phone 253-759-2914 Carolyn Koehnline, M.A. is a psychotherapist, clutter specialist, and member of the National Association of Professional Organizers. She has a private psychotherapy practice in BeIlingham, Washington working with adults working through major life transitions, and acting as a coach for ADD adults. She also teaches "Confronting Clutter" classes and workshops and does private clutter consultations in the home, focusing on physical, mental emotional "clutter." In addition to her psychological training, Carolyn draws on five years experience owning and operating a housecleaning business, and on her sensibilities as an artist and writer, addressing the subject of "clutter" in practical, playful, and meaningful ways. Carolyn Koehnline, MA, Box 6091, Bellingham, WA 38227 phone 360-676-8717 Irving J. Kohlberg, M.D. is a psychiatrist is private practice in Kirkland, Washington and an assistant clinical professor in pediatrics and psychiatry at the University of Washington and Seattle Children’s Hospital. He specializes in the diagnosis and treatment of ADD and mood disorders, as well as behavioral and emotional problems of children, adolescents and adults. Irving J. Kohlberg, M.D., 2025 112TH Av NE, Ste. #200, Bellevue, WA Tel. 425-452-0163 Theodore D. Mandelkorn, M.D. trained in pediatrics and adolescent medicine and was a mental health fellow under Dr. Michael Rothenberg. An adult with ADHD who has a son with ADHD, Dr. Mandelkorn specializes in the diagnosis and treatment of ADHD. He is a physician with Puget Sound Behavioral Medicine, a clinic that treats teens, children and adults with attention deficit disorder and related conditions children and adolescents. Dr. Mandelkorn lectures nationwide about management and treatment of ADHD Theodore Mandelkorn, For further information visit the website at http://psbmed.com, send email to [emailprotected], or call 206/275-0702.
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Kevin Murphy, Ph.D. became Chief of the Adult ADHD clinic at U. MASS Medical Center in 1992 and is also an assistant professor in the department of psychiatry. He is on the National Advisory Board of CHADD and has authored several articles and a book chapter on ADHD in adults. He has authored a book entitled, Out of the Fog: Treatment Options and Coping Strategies for Adult Attention Deficit Disorder and is currently working on another book with Dr. Russell Barkley on the assessment and treatment of ADHD in adults. Kevin Murphy, Ph.D. Univ. of Massachusetts Medical Ctr, 55 Lake Av N, Worcester, MA 01655, phone 508-856-2552 Kathleen Nadeau, Ph.D. is Director of Chesapeake Psychological Services of Maryland, and editor of the text for professionals A Comprehensive Guide to ADD in Adults: Research, Diagnosis & Treatment. She recently authored Adventures in Fast Forward: Life, Love and Work for the ADD Adult. as well as ADD in the Workplace. Dr. Nadeau has worked in the field of ADD/LD for many years, initially with children and adolescents. She is the co-author of Learning to Slow Down and Pay Attention. and School Strategies for ADD Teens. and author of A College Survival Guide for Students with ADD and LD. Dr. Nadeau has a strong interest in working with students in college and graduate school, in workplace issues for adults with ADD, and in issues of women with ADD. Kathleen Nadeau, Ph.D. 4400 East-West Hwy, Ste. 816, Bethesda, M.D. 20814, Tel. 301-718-8114 Thomas Phelan, Ph.D. is a nationally renowned expert and lecturer on child discipline and ADD. Dr. Phelan has worked with children, adults and families for over twenty years. He is a member of both the Illinois and American Psychological Associations. He is the author of the following books and videos: 12-3 Magic: Training Your Children to do What You Want; All About ADD: Surviving Your Adolescents; Adults with ADD; and Medications for ADD, In addition to writing and producing, Dr. Phelan manages his private practice and maintains an active schedule of lectures, seminars and radio and television appearances. Thomas W. Phelan, Ph.D. 800 Roosevelt Road Glen Ellen, IL 60137 (708)730-3600 John Ratey, M.D. is Medical Director of Medfield State Hospital and Assistant Professor of Psychiatry at Harvard Medical School. He has published numerous scientific papers on aggression and psychopharmacology and ADHD in adults, and has edited a book on new treatments for the developmentally disabled. Dr. Ratey has a private practice in Cambridge, MA where he treats adults with ADHD. He has co-authored two books with Dr. Ned Hallowell entitled Driven to Distraction and Answers to Distraction. and recently co-authored Shadow Syndromes with Catherine Johnson, Ph.D.. John Ratey, M.D. 328 Broadway Cambridge, MA 02133 Wendy Richardson, LMFCC is a Certified Addiction Specialist. She has been working in the mental health field for over twenty years and is nationally recognized as an expert on ADD and co-occurring addictions, eating disorders and relationship issues. She has recently written the book The Link Between ADD and Addiction: Getting the Help You Deserve as well as produced a four hour training video on this topic. Wendy Richardson, LMFCC, 3121 Park Av, Ste. F, Soquel, CA 95073, Tel (408) 479-4742.
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