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 childlike exuberance.
6. A frequent 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. An intolerance of boredom.
A corollary of number 6. Actually, the person with ADD seldom feels bored. This is because the millisecond he senses boredom, he swings into action and finds something new; he changes the channel.
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 times.
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 hyperfocus 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 unresolved problem with authority figures. Rather, it is a 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.
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.
12. Impulsive, either verbally or in action, as in impulsive spending of 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 dangers.
Worry becomes what attention turns into when it isn’t focused on some task.
14. Sense of insecurity.
Many adults with ADD feel chronically insecure, no matter how stable their life situation may be. They often feel as if their world could collapse around them.
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.
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 a 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 an activity, such as gambling, or shopping, or eating, or overwork.
18. Chronic problems with self-esteem.
These problems are the direct and unhappy result of years of frustration, failure, or of just not getting it right. Even the person with ADD who has achieved a great deal usually feels in some way defective. What is impressive 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. They usually see themselves as less effective or powerful than other people do.
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 probably 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. (It may not have been formally diagnosed, but in reviewing the history, the signs and symptoms must have been there.)
C. Situation not explained by other medical or psychiatric condition.
* * *
The criteria above are based on our clinical experience. They emphasize the full range of symptoms associated with adult ADD. Paul Wender has proposed another set of criteria for the diagnosis of ADD adults that has been used by many practitioners and researchers in the field. These criteria focus on the core symptoms of adult ADD without going into associated symptoms or findings, such as substance abuse or family history. These are commonly referred to as the “Utah Criteria,” because Wender, a pioneer in the field of ADD, is a professor of psychiatry at the University of Utah School of Medicine.
UTAH CRITERIA FOR ADULT ADD
I. A childhood history of ADD with both attentional deficits and motor hyperactivity, together with at least one of the following characteristics: behavior problems in school, impulsivity, overexcitability, and temper outbursts.
II. An adult history of persistent attentional problems and motor hyperactivity together with two of the following five symptoms: affective lability, hot temper, stress intolerance, disorganization, and impulsivity.
While there are many points of agreement between our criteria and the Utah criteria, the main difference between the two is that we do recognize a syndrome of ADD without hyperactivity while the Utah criteria do not. Wender himself recognizes that ADD without hyperactivity exists as a clinical syndrome. However, his Utah criteria do not include it because they, having been developed for research purposes, select a more homogenous set of patients by excluding those without a history of hyperactivity.
In our experience (and in the experience of many others) we have seen a host of individuals, particularly women, who fit the clinical picture of ADD perfectly, by both sets of criteria, except that they do not have a history of hyperactivity. They do respond well to treatment with stimulant medication or other standard medications used for ADD. Their symptoms cannot be explained by any condition other than ADD, and they do not respond as well to any medical treatment other than the treatment for ADD. Therefore, we include this nonhyperactive group as meeting our diagnostic criteria for adult ADD.
Whatever diagnostic criteria one refers to, it cannot be stressed too firmly in this book how important it is not to diagnose oneself. An evaluation by a physician to confirm the diagnosis and to rule out other conditions is essential.
Having laid out some diagnostic criteria, what does this syndrome look like in real life? What is the typical picture of the adult with ADD? There is no one defining portrait because the syndrome includes so many subtypes. However, to get a further feel for ADD in adults, let’s look at a few snapshots of different people with ADD:
Elizabeth is a forty-six-year-old woman who has struggled with dyslexia since she was a child. What she didn’t realize until recently was that she also has ADD. “I always knew I couldn’t read. Well, I could read, but not very well. What I didn�
�t understand was why I lived in such a disorganized state all the time. I thought I was just spacey, you know, the ‘dizzy dame’ stereotype. I really bought into that. I thought I was simply inept. Then I went to this women’s group and I found out about ADD and everything makes sense for the first time. Why I procrastinate. Why I have no confidence. Why I space out in the middle of conversations. Why I can never seem to get it together. I just wish I had found out about this earlier.”
Now a successful businessman and an upstanding member of his community, Harry sheepishly brought me a folder an inch-and-a-half thick from his first twelve years of school. Although he was a very bright boy who scored well on aptitude tests, in his file there were approximately sixty letters home to Harry’s parents from the rabbi who was head of the school. The letters all seemed to begin with words like, “We regret to inform you …” Harry said his main memory of school was sitting in the rabbi’s office watching him pick up an old-fashioned Dictaphone into which he would always utter the same forbidding words: “To be added to the cumulative file of Harry …” Harry dreaded the cumulative file. “It is full of the misery of my youth. I want you to expunge it for me,” he said. Although it could not be expunged, it could be explained through the lens of ADD. It at last gave Harry an answer to why he could never “do school,” as he put it. “It has gnawed at my self-respect all these years. I’ve always hid from people the fact I had so much difficulty finishing my degree. Now I know why.”
Jack works as an editor for a magazine. He does well, although he has a reputation for being rude. He leaves meetings abruptly, without warning, fails to return telephone calls, insults writers without knowing that he’s doing it, makes no attempt to hide it when he’s bored, changes the subject almost in mid-sentence, and in general lacks tact. “He’s brilliant,” an associate says, “but he’s so unpredictable. You’ll be talking to him, and you’ll look away for a moment, and when you look back, he won’t be there anymore. You’ll be thinking you’re having this really interesting conversation, then poof!—he’s gone. It’s annoying, to say the least. On the other hand, he’s great to have around because he’s so full of ideas and energy.”
George does his work from his car. “I don’t know why I have an office. I can’t sit in it for more than a few minutes before I get this really creepy feeling. It’s like I’m being interred. Then I get in my car, go out on the highway, pick up my car phone, and I’m in business. I’ve got to be moving in order to think—that’s all there is to it.”
“I like the way I am,” says Grace, who works in the movie business. “I don’t know if anybody else does, but I’d be bored being any other way. It’s a good thing I’m the boss or I’d get fired. Come and go as I please, take on new work before the old is done, make spot decisions and undo them an hour later. I don’t know how most people live their lives, so predictable. That’s their bag, I guess, but it sure ain’t mine. L.A. is probably the only city I’d survive in. Maybe Manhattan, but the weather’s bad. Finding out about ADD at least gives me a name for it, but I don’t want to change anything. Half this city has ADD, you know. Probably can’t survive in this business without it.”
Peter’s study looks like—well, let him describe it. “I have my piles,” he says. “Everything I do goes into a pile. There are little piles and big piles, stacks of papers, stacks of magazines, stacks of books, stacks of bills. Some stacks are mixed. It’s like a field, little piles with white tops scattered everywhere like mushrooms. There’s no real organization to any of it. I’ll just think that pile looks a little small, I can add something to it, or this space needs a new pile, or these things I’ll move over to this other pile. Somehow or other, I survive. The piles and I must be in some kind of unconscious synchrony, I guess.”
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.
People with ADD also love cars. ADD loves movement. Many adults with ADD report that their best thinking is done while driving. And people with ADD love big cities, all big cities but particularly New York, Las Vegas, and, especially, Los Angeles. ADD might as well have been invented in Los Angeles.
It is not always as obvious as the examples above. For many adults ADD is a subtle but definite part of who they are, like a red thread sewn into a pinstripe suit, changing its look but only visible upon close inspection. The red thread may be a thread of distractibility, or of impulsivity, or of disorganization, sewn into a stripe of creativity or gregariousness or industry. And the treatment may not be to remove the red thread but rather to change its hue only slightly so that it enhances rather than clashes with its surroundings.
One woman, for example, found that she needed help only with technical writing. Since that was a major part of her job, it was important that she do it well. Prior to her discovering she had ADD, it was an excruciating chore for her. She could not focus on it, and the more she tried to focus, the more anxious she became, thus becoming further distracted. She tried tranquilizers, but they only sedated her. Coffee helped some, but it also made her jangly. Once the diagnosis of ADD was made, she tried stimulant medication. It helped her focus quite definitely, and it had no side effects. She found that by taking medication a half hour prior to doing her writing it went much more smoothly for her. She didn’t need the medication for anything else.
To give another brief example: A man was having problems getting along with other people. It was nothing blatant, but he could sense that people pulled away from him. He could feel it even as it happened, as he was talking to someone and the conversation went bland. 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? In this man’s case he needed some coaching and role-playing to learn how to tune into what he was missing. In treating his hidden ADD, his interpersonal life improved greatly.
These are a few of the areas in which mild ADD may interfere with an adult’s life: underachievement; reading one’s interpersonal world accurately; getting started on a creative project, or finishing it; staying with emotions long enough to work them out; getting organized; getting rid of perseverative, negative thinking; slowing down; finding the time to do what one has always wanted to do; or getting a handle on certain compulsive types of behavior.
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. We think of this person or that and we have bits of conversation and we move ourselves along in the scene, from one scene to the next, often quite painfully, but usually as part of a story with a plot. But ADD precedes the plot. It adjusts the lighting and sets the stage. If the lighting is too low or significant props are missing from the stage, the story cannot be fully comprehended. Before getting the story going, before developing the plot lines of one’s ongoing narrative of introspection, it is worthwhile to have a lighting specialist and a propman check the stage out.
Finding out that you have ADD in adulthood is a bit startling. These kinds of conditions, one supposes,
are supposed to be sorted out during childhood. After that, you make do with the brain you have, with the lighting you’ve been wired with. You don’t expect at, say, age forty, to be told you have a learning disorder or that you have ADD. You don’t expect to get therapy to help you read and study better, to learn your way around the stage.
The diagnosis gets made by circuitous routes. With children school should act as a kind of diagnostic screening center for the various learning problems. But adults have no such center. Rare is the workplace that would consider an evaluation for ADD in an employee who was erratic, underachieving, and inattentive. Rare is the spouse who would counter her husband’s flight into distraction by saying, “Honey, have you ever considered you might have ADD?” Adults, by and large, have to stumble into the diagnosis, by word of mouth, by reading a chance article, or by hearing about it through a child.
A common scenario in my office goes as follows. A set of parents makes an appointment for an evaluation for their son or daughter. After I complete the evaluation, while I’m meeting with the child and parents together to go over the findings, one parent, usually the father, clears his throat and asks, in as businesslike a tone as possible, “Umm, doctor, tell me, do you ever see ADD in, uh, adults? I mean, can that ever happen?” Since ADD is genetically carried, it is not unusual for one parent to have it as well as the child.
But when there is no direct connection through a child to a clinician treating ADD, adults are on their own. In the medical community and the mental-health fields, knowledge of adult ADD is not widespread. As our awareness of the disorder increases, this will change. But for now, looking for help, as an adult, can be a frustrating and time-consuming process. At the end of this book we will list some places where reliable help can be found.
The people who come to see me are usually referred by other mental-health professionals. I have seen hundreds of patients over the past years and have come to appreciate the wide variety that exists within the one term, adult ADD. The syndrome is even more heterogeneous in adults than it is in children. Probably a half dozen clinical syndromes are camouflaged under the one diagnostic umbrella term, ADD.
Driven to Distraction (Revised) Page 11