Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder

by Edward M. Hallowell

People were ready to understand the symptoms of ADD not as moral failings or evidence of “badness” or “lack of discipline,” but as a neurological condition not under the control of individual will.

At the heart of the moral model beats the conviction that willpower controls all human emotion, learning, and behavior. Under this model, the cure for depression is to cheer up. The cure for anxiety is to suck it up. And the cure for ADD is to try harder. While trying harder helps just about everything, telling someone with ADD to try harder is no more helpful than telling someone who is nearsighted to squint harder. It missed the biological point.

ADD is more impairing than any syndrome in all mental health that is treated on an outpatient basis. More impairing than anxiety, more impairing than depression, more impairing than substance abuse. The “morbidity” of untreated ADD is profound. Twenty-five percent of the prison population has undiagnosed ADD. Most of the kids in the juvenile justice system have untreated ADD. Traffic accidents are eight times more common than in the general population. If you have ADD, you are 40 percent more likely to get divorced than if you don’t, and 30 percent more likely to be unemployed. Estimates run as high as 40 percent of the addicted population having ADD, and a significant proportion of the eating-disordered population.

I also see how essential a comprehensive treatment plan is, a plan that incorporates education, understanding, empathy, structure, coaching, a plan for success and physical exercise as well as medication. I see how important the human connection is every step of the way: connection with parent or spouse; with teacher or supervisor; with friend or colleague; with doctor, with therapist, with coach, with the world “out there.” In fact, I see the human connection as the single most powerful therapeutic force in the treatment of ADHD.

Now is the time to use all that we’ve learned to shine the light of knowledge into the dank, dark dungeons of ignorance and stigma that still retard progress in mental health and cause millions of people to suffer unnecessarily. Nowhere does the use of knowledge lag further behind the knowledge we have than in mental health. That must end. Now. Now is the time to cast fear aside, now is the time to put an end to the shame individuals and families often feel when they seek help in the field of mental health.

And this is the case with so many people who have ADD. They are very likable, although they get into the most difficult of patches. They can be exasperating in the extreme—one mother called me about her son, who had ADD and had just inadvertently almost set fire to his school, and asked me if she could run over him in her truck—but they can also be unusually empathic, intuitive, and compassionate, as if in that tangled brain circuitry there is a special capacity to see into people and situations.

(1) deficits in attention and effort, (2) impulsivity, (3) problems in regulating one’s level of arousal, and (4) the need for immediate reinforcement.

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

When I was a little kid, I was all over the place, but I wasn’t angry. I think it built up, in school. All the failures. All the frustration.” Jim clenched his fists without knowing it as he talked about his feelings. “It got so I knew before I started something it wasn’t going to work out. So all I had left was tenacity. I wouldn’t give up.

Due to repeated failures, misunderstandings, mislabelings, and all manner of other emotional mishaps, children with ADD usually develop problems with their self-image and self-esteem. Throughout childhood, at home and at school they are told they are defective.

Month after month, year after year, the tapes of negativity play over and over again until they become the voice the child knows best. “You’re bad,” they say in many different ways. “You’re dumb. You just don’t get it. You’re so out of it. You really are pathetic.” This voice pulls the child’s self-esteem down and down, out of the reach of the helping hands that might be extended, into the private world of adolescent self-reproach.

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

As a child, her symptoms were typical: hyperactivity, thrill-seeking, trouble in school, emotional intensity, and impulsivity. She also had many of the positive qualities that are often not mentioned when one hears about ADD: spunk, resilience, persistence, charm, creativity, and hidden intellectual talent.

“You’re joking,” I said, “but I have a hunch this has been more painful for you than you let on.”

“Yes, she was,” Polly said. “Her first words didn’t come until about twenty-two months, and little sentences didn’t come until she was three.

“Lots of kids who have ADD also have something else, something we don’t have a name for, something good. They can be highly imaginative and empathic, closely attuned to the moods and thoughts of the people around them, even as they are missing most of the words that are being said.

A conservative estimate would be that 5 percent of school-age children have ADD,

“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’ll try harder.”

Primary symptoms are the symptoms of the syndrome itself: distractibility, impulsivity, restlessness, and so forth. The secondary symptoms, and the ones that are most difficult to treat, are the symptoms that develop in the wake of the primary syndrome not being recognized: low self-esteem, depression, boredom and frustration with school, fear of learning new things, impaired peer relations, sometimes drug or alcohol abuse, stealing, or even violent behavior due to mounting frustration.

He, or she, can be like Will: an attractive, well-liked student, given to periods of high achievement as well as periods of low, moving along from grade to grade without anybody thinking anything much was wrong that a little growing up or a kick in the pants wouldn’t cure.

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

there is a difference at the cellular level, in energy consumption, between the parts of the brain that regulate attention, emotion, and impulse control in subjects with ADD as compared with subjects without ADD.

this is a syndrome not of attention deficit but of attention inconsistency.

Often creative, intuitive, highly intelligent.

10. Trouble in going through established channels, following “proper” procedure.

11. Impatient; low tolerance for frustration. Frustration of any sort reminds the adult with ADD of all the failures in the past. “Oh, no,” he thinks, “here we go again.” So he gets angry or withdraws. The impatience derives from the need for constant stimulation and can lead others to think of the individual as immature or insatiable.

15. Mood swings, mood lability, especially when disengaged from a person or a project. The person with ADD can suddenly go into a bad mood, then into a good mood, then into a bad mood all in the space of a few hours and for no apparent reasons. These mood swings are not as pronounced as those associated with manic-depressive illness or depression.

18. Chronic problems with self-esteem.

19. Inaccurate self-observation.

These examples reflect the stuff adult ADD is made of. Peter’s piles are particularly emblematic. So many adults with ADD have piles, little mess-piles, big mess-piles, piles everywhere. They are like a by-product of the brain’s work. What other people somehow put away, people with ADD put into piles.

Although he felt it happening, he was not aware of what specifically he was doing. It turned out that he had mild ADD, the most problematic manifestation of which was an inability to observe his own behavior and to gauge correctly the responses of other people. This made him appear quite self-centered or indifferent. In fact, his problem was in paying attention, in noticing the subtle cues social fluency depends upon and in regulating his own responses. Before leaping into the psychodynamic realm to explain such “self-centered” behavior, it is worthwhile to check at the doorway of attention. Are the lights on? Is the individual neurologically able to notice the particulars of human interaction, from voice tone to body language, to timing, to irony, and so forth?

Taking stock of oneself in terms of attention and cognitive style is not the aim of most adult introspection. We are more geared to think in terms of who likes whom, or who dislikes who else, or why did our families do this or that, or how can we deal with this fear or that. We analyze ourselves through stories and we quickly jump into the plot.

monosyllabically with anyone in my family. I always thought my attention to that TV was the result of my intense interest in current events, but it’s pretty clear to me now that when I was feeling overwhelmed, going to sit in my favorite chair in my habitual spot in our living room had a salutary effect on my state of mind—it helped break the state of negative hyperfocus I’d fallen into—

And when I haven’t been depressed during these periods, I have become a stimulation hound.

The tension of constructing an explanation, from A to B to C to D, apparently so simple a task, irritates many people with ADD. While they can hold the information in mind, they do not have the patience to sequentially put it out. That is too tedious. They would like to dump the information in a heap on the floor all at once and have it be comprehended instantly. Otherwise, as Douglas says, it’s just not worth the effort. It’s too boring.

They need external structure so much because they so lack internal structure. They carry with them a frightening sense that their world might cave in at any moment. They often feel on the brink of disaster, as if they were juggling a few more balls than they’re able to.

when challenged by open-ended time, he felt he was coming unhinged.

Contrary to the practice of psychoanalytic psychotherapists, the ADD therapist must offer concrete suggestions concerning ways of getting organized, staying focused, making plans, keeping to schedules, prioritizing tasks to be done, and, in general, dealing with the chaos of everyday life. The therapist should not do this for the patient, but with the patient, so that the patient can learn to do it for himself.

but with people with ADD it is essential. They need direction. They need structure. The therapist should not tell the patient whom to marry, but the therapist most certainly should coach the patient on how to get organized for a date.

This structuring technique of breaking down large tasks into small ones—in my case a large course into a series of small index cards—is a valuable technique for anyone to learn to use, but it is particularly valuable for those of us who have ADD, because we can quickly feel overwhelmed by big projects or complex undertakings.

The sense of growing panic, the feeling that gibberish is being passed off as coherent conversation, the fear that the world is engaged in meaningless discourse masquerading as meaningful exchange—these are the blurry states individuals with ADD negotiate each day.

I see something that I mean to do and then I don’t do it.

when a person habitually has trouble following through on plans on a minute-to-minute, even second-to-second, basis. This is not due to procrastination per se as much as it is due to the busyness of the moment interrupting or interfering with one’s memory circuits.

Or, on a larger scale, the most important item on your agenda for a given day might be to make a certain telephone call, a call that, say, has crucial business consequences. You mean to do it, you want to do it, you are not afraid of doing it, indeed you are eager to make the call and feel confident about doing it. And yet, as the day progresses, you never get around to making the call. An invisible shield of procrastination seems to separate you from the task.

1. Consider joining or starting a support group. 2. Try to get rid of the negativity that has infested your system. 3. Make copious use of external structure: lists, reminders, files, daily rituals, and the like. 4. When it comes to paperwork, use the principle of O.H.I.O.: Only Handle It Once. 5. Make deadlines. 6. Do what you are good at, instead of spending all your time trying to get good at what you’re bad at. 7. Understand mood changes and ways to manage these. 8. Expect depression after success. 9. Learn how to advocate for yourself. Adults with ADD are so used to being criticized that they are often unnecessarily defensive in putting their own case forward. 10. Learn to joke with yourself and others about your various symptoms. If you can learn to be relaxed enough about the whole syndrome to be able to joke about it, others will forgive you much more easily.

Most adults with ADD need the fresh look I withheld from Bernie for so long because I’d already made up my mind about him. That’s the problem with being an adult: people have already made up their minds about us; we’ve even made up our minds about ourselves. That makes it terribly difficult to get the radical reappraisal that something like making the diagnosis of ADD requires.

Anyway, the depression got a little better after I stopped drinking, but I still have these moods. Black, interminable moods where all I can think of is what a rotten, worthless man I am.” “You start in on yourself,” I said. “Boy, do I ever. I’ll just have at me, call myself every name in the book and then some, go over and over all my failings, and show no mercy. You know, I can talk about it now like I’m talking about a symptom, but when I’m in it, I’m death. I’ll just brood for hours, even a day. I can still function, I can still work, but there’s this relentless voice carping away at me inside.

Let’s consider it as a kind of pernicious variation in your way of paying attention. You lose perspective. Instead of paying attention evenly, you hyperfocus on everything negative. This happens subtly, but profoundly. The next thing you know some mad preacher within you has started to harangue at you and you can’t stop listening. What this adds up to in terms of a diagnosis, combined with everything else you’ve told me, is that I think you may have the adult version of attention deficit disorder.”

“Yes,” I said. “But you have the kind that especially affects mood. You organize around a bad mood and you don’t let go. You hold on to it for dear life. You don’t dare give it up for fear that chaos will replace it.”

People in treatment for ADD usually still struggle with issues of organization, impulse control, and distractibility. But more difficult than that, they struggle with the secondary symptoms that years of living with undiagnosed ADD created. These are symptoms such as impaired self-image, low self-esteem, depression, fearfulness of others, mistrust of self, skittishness in relationships, and anger over the past. These wounds heal very slowly.