Driven to Distraction (Revised)

by Edward M. Hallowell

  We are not suggesting here that all depression is due to ADD. Far from it. However, there are some people who are chronically sad who do in fact have ADD and don’t know it.

  The primary disorder—an inability to attend—can lead to the secondary problem of depression. Or the two—ADD and depression—may coexist, both arising independently from the same physiological abnormality.

  ADD with Other Learning Disorders

  The pain of a learning disorder resides not only in the strain one feels in trying to function but in the disconnections one can suffer, a disconnection from language and from thought, from expression and creativity, from books and from words, as well as from people and from feelings.

  Equally, it can be said, I believe, that one of the pleasures of the various disorders is the fanciful variations they bring up. While the child with dyslexia or ADD may stammer, stumble, and reverse, while he may disconnect from the word or the page or the person, he may also soar. He may connect in new and unexpected ways. He may, in his stumbling, stumble onto something new and wonderful. It is therefore vital that we keep the windows of these children’s minds clean, that we keep them free of the smudge and grease of shame, criticism, defeatism, and devaluation.

  Let me tell a story. There was once a little boy who was pronounced writing-phobic. This pronouncement was made by a psychologist. “Karl is writing-phobic,” the report read. “I reach this conclusion based upon psychometric testing as well as projective testing which reveals a partial inability to retrieve certain words under stress as well as an incomplete release of the preverbal memory structures as initiated by image recall and impromptu stimulation. This leads to a relative inhibition of the capacity to form written expressives, that is to say a tendency to avoid external prompts or stressors related to the act of writing. These neurological factors are complicated, on a psychodynamic level, by the fact that Karl has a precocious awareness of his parents’ own internal conflicts. For a boy of eight, he displays an unusual understanding of his mother’s unfulfilled literary ambitions as well as his father’s shame-slash-pride over certain verbal successes vis-à-vis his own career, namely that he is a successful writer for what are commonly referred to as television sitcoms. Thus, the neurological and the psychodynamic combine to create in Karl an intense ambivalence as to whether or not he wants to write, whether or not he should write, whether or not he can write, and what, exactly it means to write. Until these issues are resolved he will remain writing-phobic. It is my advice not to tamper with this delicate balance, but rather to respect Karl’s defensive structure and wait for the issues to resolve. Failing this, resource room time might prove invaluable.”

  My friend, Priscilla Vail, a learning specialist, read this report and laughed out loud. “What does this mean?” she asked herself. Not quite believing the report, Priscilla decided to take a different tack from the one the psychologist had recommended. She told Karl that as much as he might want to write, he would have to constrain all his written output within the bounds of one three-by-five note card per day. She then began to work with him on all sorts of fun projects that involved writing—games, puzzles, mazes, wish lists, fan letters. In no time Karl was asking for a bigger note card. “I don’t know about that,” Priscilla said, stroking her chin. “That’s an awful lot of space you’d have to fill.”

  “Oh, please, Mrs. Vail!” Karl pleaded.

  “Well, if you think you can handle it—”

  “Handle it?” Karl interrupted. “I can handle much more than that!” he said proudly.

  Soon Karl’s written output exceeded that of most professional writers. The “writing phobia” and the resource room were forgotten as Karl eagerly got busy with words without knowing that he wasn’t supposed to be able to.

  I think people come to words much as lovers get together. They stumble onto each other, at the oddest of times, in the strangest of places. They will meet in an empty laundromat on a rainy Sunday afternoon, or they will catch each other’s eyes across a ballroom dance floor in the middle of a wedding waltz. They will meet without appointment and strike up a relationship without an agenda. There may be a long courtship or a whirlwind romance. There may be protracted avoidance, even what looks like a phobia, as in Karl’s case, or there may be an instant avidity, what amounts to love at first sight. Some carry on a kind of epistolary relationship with words, expressing their feelings through the formal prose of elegant notes, while others jump at words and bark them out at the world in the immediate poetry of certain street-corner vendors. Some slap their words up on posters on telephone poles, while others keep them in reserve, like a pistol concealed in a pocketbook. Some read haltingly, like the nervous lover, hat in hand, while others seem born to orate. We all woo language differently, and language grants us her favors in different ways. Sometimes the relationship takes off, although it is rare there is a ride without bumps. While utterly beautiful, endlessly varied, and thoroughly transfixing, language can also be frustrating, confusing, exasperating, and unforgiving.

  Priscilla Vail, one of the great couples counselors we have for troubled-language relationships, knew intuitively and from great experience how to bring Karl together with words. She knew how to coax him from the periphery and onto the dance floor. She knew if she played the right music and showed him a few simple steps, the allure of the dance would overcome Karl’s shy way with words.

  Priscilla knew what all who work with words know: that one’s language is not an inert tool that you take down from the shelf like a hammer. Rather, it is a living companion, whose company you keep for most of your waking life. For many people language is a best friend they take for granted.

  For some others, though, language never comes easily. The company of words is always an effort to keep. These people—and I count myself among them as one who is dyslexic and has ADD—never know quite what to expect from words. Our relationship with words is rooted in unpredictability. One moment we are Abraham Lincoln composing a Gettysburg Address, and the next moment we are as clumsy with words as a boy on his first date.

  When I was in high school, back in the sixties, the classification of learning disorders was really pretty simple. There was basically one learning disorder: stupidity. And there was basically one treatment: work harder. Oh, people talked a good game about “special help” and tutoring, and we all knew that some people were good at math and others were good at English and a lucky few were good at both, and some people had heard of dyslexia, but we had no more sophisticated understanding of what was going on than that.

  Now the science of learning has grown in scope and depth. Of course, as our knowledge has increased, matters have grown more complicated. The jargon in the field is cumbersome and test reports are often difficult to comprehend. The terms tossed around include “auditory processing problem,” “visual-spatial dysfunction,” “receptive language disorder,” “nonverbal learning disability,” “word-retrieval problem,” “language-based learning disorder,” etc. All very pungent concepts, but almost impossible to keep straight unless you deal with them every day. Experts in the field appropriate their own set of terms and then compete with each other to see whose lexicon will win out. Committees meet and decree terms and then they meet again and change the terms just as you’ve learned the first set. The committee that convened to write the definition of ADD for the Diagnostic and Statistical Manual of Mental Disorders fourth edition (or, for short, DSM-IV-TR), will come out with a new definition for DSM-V in 2013.

  One can hardly hope that science will slow down so that we can keep up with its nomenclature. However, it is important not to be intimidated by science. Too often, practitioners in the field of learning problems and ADD confuse rather than clarify through their use of arcane terms or references. One should be able to gain access to the important information in this field without the use of a translator’s dictionary.

  Priscilla Vail’s term for many of the children we have described in this book is “conundrum kids.” These k
ids don’t fit any one mold exactly, and we can’t explain all of what is going on. These kids puzzle us as they flounder one day and shine the next, read to beat the band one day and stare out the window the next, solve complex math problems in their spare time but find themselves unable to do any of the math on the test. Anyone who would like to know these children well—and how to help them—should read Priscilla Vail, especially Smart Kids with School Problems, or check out Superparenting for ADD, which I wrote with Peter S. Jensen.

  While the conundrum kids (or, for that matter, the conundrum adults) puzzle us, one part of the puzzle they present is often ADD. In dealing with ADD it is important to know that it is often accompanied by other difficulties in learning. Depending upon what difficulty you are referring to and how you define it, the incidence of other learning disorders coexisting with ADD ranges from 10 percent to 80 percent. Much of the variability here has to do with definition. An excellent book that sorts out the various terms and gives lucid explanation to them all is Diagnosing Learning Disorders by Bruce Pennington, now in its second edition. Another example of a clear writer in an unclear field, Pennington brings together research and interpretation in a framework that is useful to both the lay and professional reader.

  In Pennington’s neuropsychological framework, ADD is one of several so-called learning disorders. A learning disorder refers to a problem in the individual’s neuropsychological system that adversely affects school performance. One can, of course, underachieve in school without having a learning disorder if the poor performance is due entirely to emotional or social factors. Mental retardation constitutes one large grouping of learning disorders, while Pennington’s book takes in the others. The disorders he discusses include, in decreasing order of frequency, dyslexia and other developmental language disorders, ADD, right-hemisphere learning disorders (which include specific problems with math, handwriting, and art, as well as associated problems with social cognition), autism spectrum disorder, and acquired memory disorders (most commonly due to a closed head injury or a seizure disorder). Learning disabilities—specific problems with math, reading, or language—are a subset of learning disorders in Pennington’s classification.

  ADD, then, is one kind of learning disorder. It may be accompanied by other learning disorders, such as dyslexia or an acquired memory disorder. It may also be accompanied by a specific learning disability, such as a math disability.

  This distinction between disorder and disability may be confusing at first. The disabilities are a subset of the disorders. The disabilities impair specific abilities: math disability, language disability, spelling disability. The disorders, on the other hand, are not so specific; they affect cognition in general.

  Since ADD affects all areas of cognition, it will exacerbate any learning disability. ADD is not a specific learning disability in itself; it does not disable any one cognitive function, but is broader than that. A specific math disability may often be found with ADD, as may other specific learning disabilities, particularly difficulty in learning foreign languages.

  Math difficulties warrant careful evaluation. There are different kinds of math problems, ranging from culturally induced problems as may be found among girls who are brought up to believe they should be bad at math and over time become math-phobic, to neurologically based learning difficulties. There are different kinds of difficulties among the neurologically based, some having to do with problems with spatial relations, others having to do with conceptualization, others having to do with memory and data-processing. Once you understand precisely what kind of difficulty you are dealing with, you are then equipped to make the delicate decision of how far to push. There is remedial help available for math disabilities and language disabilities. The help ranges from tutoring to the use of special devices such as Cuisenaire rods (manipulable colored sticks of different lengths that help little children learn calculation) to special schools where intensive support and technical expertise may be found. The special assistance can help a great deal, but it is not curative. The disability does not go away; one simply learns to cope with it as best one can.

  When do you decide that the individual has worked long and hard enough at math or at a foreign language before letting it drop? This kind of decision is best made in concert with the school, the family, the individual, and a learning specialist. You do not want to give up too soon, thus limiting what the person can learn. On the other hand, you do not want to slog away endlessly with no apparent gain, losing time and self-esteem in the process. The matter should be evaluated repeatedly, and programs should allow flexibility so that the individual can learn as much as possible without damage to self-confidence.

  The most common learning disorder, and the one about which we know the most, is dyslexia. Its prevalence in this country, depending on how it is defined, is from 10 to 30 percent. Briefly stated, dyslexia is a problem with reading or writing one’s native language that cannot be explained by some other cause such as limited schooling, poor vision or hearing, brain damage or retardation. Since not all dyslexia is the same, we should probably refer to it in the plural, the dyslexias. Some dyslexics have particular trouble spelling. Others are what used to be called “mirror readers,” reversing letters in words, reading “was” for “saw” and so forth. Others do not reverse letters per se, but anticipate letters or sounds incorrectly, and so misread words, for example mistaking “battlefield” for “bachelor” or “filament” for “firmament” or even “metaphor” for “medical.” According to the work of Albert Galaburda at Harvard, the brains of dyslexics appear to be different from normal brains in that they have aberrant nodules on the cerebral cortex. These nodules may interfere with how the brain perceives and processes the phonemes or sound bits that make up words. The underlying phonological processing problem in turn leads to the problems in reading, spelling, and writing characteristic of the dyslexias. The primary symptoms of ADD—erratic attention span, impulsivity, and restlessness—can make reading difficult, and therefore can mimic dyslexia. However, the two are separate disorders. The distinction is of practical significance because the treatments for the two conditions are different.

  The two disorders can coexist or they can occur separately. In terms of overlap, ADD occurs more frequently among dyslexics than in the population at large. However, there is not an increased incidence of dyslexia among the ADD population. Put differently, you are more likely than the average person to have ADD if you have dyslexia; but you are no more likely than the average person to have dyslexia if you have ADD.

  Auditory processing problems also occur frequently with ADD. As the term suggests, an auditory processing problem interferes with the brain’s ability to comprehend fully what it “hears.” The child or adult with this problem has no hearing deficiency; sound enters the brain without problems. However, once the sound gets into the brain, the cerebral cortex has trouble processing it or fully making sense of it.

  For example, a child in class may “hear” the teacher say “George Washington was the first president of the United States” but comprehend it as “George Washington is the president of the United States.” If, when asked about George Washington, he repeats his “revised” version, he will appear foolish or stupid.

  Or a child may have trouble socially because he or she does not process properly what is being said. The same problems can affect an adult, both at work and socially.

  We do not yet appreciate how profoundly auditory processing problems interfere with learning and interacting with others. Particularly in individuals who also have ADD, auditory processing problems can greatly interfere with everyday life.

  A learning disorder, whatever the definition or cause, usually hurts. As an example, consider this, from the novelist John Irving’s recollections of his days as a student at Phillips Exeter Academy:

  I simply accepted the conventional wisdom of the day—I was a struggling student; therefore, I was stupid.

  I was such a poor student, I needed five
years to pass the three-year foreign language requirement; and in my fifth year at Exeter—in my second “senior” year—I was taking Math III for the second time (I had already taken Math II twice). I was such a weak student, I passed Latin I with a D—and flunked Latin II; then I switched to Spanish, which I barely survived.…

  I wasn’t diagnosed as learning-disabled or dyslexic at Exeter; I was just plain stupid. I failed a spelling test and was put in a remedial spelling class; because I couldn’t learn how to spell—I still can’t spell—I was advised to see the school psychiatrist! This advice made no sense to me then—it makes no sense to me now—but if you were a poor student at Exeter, you would develop such a lasting sense of inferiority that you’d probably be in need of a psychiatrist one day.…

  I wish I’d known, when I was a student at Exeter, that there was a word for what made being a student so hard for me; I wish I could have said to my friends that I was dyslexic, or learning-disabled. Instead, I kept quiet, or—to my closest friends—I made bad jokes about how stupid I was.

  It is struggle enough to have a learning disorder, but to have that struggle compounded by a string of invidious labels—stupid, lazy, and the like—puts one’s whole self-esteem in jeopardy. The experience of moral condemnation is so frequent among the learning disordered as to be commonplace. Indeed, it is only recently that anything like an informed, compassionate view has developed. Still, one hears snide jokes all the time in reference to this population: they are “intellectually challenged,” or they are just looking for an excuse to get better grades in school or file a discrimination grievance at work.

  It is worth mentioning here the moral bias in our society that often prevents the diagnosis of ADD—and other learning disorders—from being made. A streak of Puritanism runs deep within American society. Permissive and pioneering as we may be on the one hand, we are strict and conservative on the other. As much as we may be a country of mavericks and entrepreneurs, we are also a country of finger waggers and name callers. As much as we may be a country of compassion for the underdog, we are also a country that believes in self-reliance.