Driven to Distraction (Revised)

by Edward M. Hallowell

  This is apparent in the field of learning disorders. In our educational system, despite reform, the operative principle is still sink or swim. School is a fair marketplace, we seem to believe. The smart will excel. If you don’t excel, well, then you are not smart. Pretty words to the contrary, most students, parents, and teachers still seem to agree on the concept of smart/stupid. They seem to think that the idea that intelligence may be a more complicated matter than smart versus stupid is just a fancy way of dancing around the truth: you either have it or you don’t.

  Such thinking can turn school into one long, dismal ordeal.

  We now have the knowledge to identify children with learning disorders early on and thus spare them the emotional trauma of daily being misunderstood, daily being labeled dumb, daily not getting it, and daily wondering why.

  Think for a moment of the importance of the innocent curiosity a child brings to school. Think of the little tendrils of knowledge and of self-esteem embedded in that curiosity. If nourished, those tendrils will grow, over the many years the child will spend in school, college, and beyond, into a solid store of knowledge, a feeling of confidence around learning new ideas, and a buoyant sense of self. Think of the look on the face of a three-year-old as she tries to blow bubbles, or the face of a four-year-old trying to make a house of cards, or a five-year-old balancing on his first bicycle. Think of the look of concentration on that face and think of how important it is to the child to get it right. Remember in your own life, when you were a child, the feeling of excitement and danger as you tried something new. Remember how the one thing you feared more than anything else was not failure but being made fun of, being humiliated. Think of the faces of children everywhere as they open their minds to learn.

  Keep those faces in mind, the little girls and boys in the early grades, all trusting the adults to show them the way, all eager and excited about life and what will come next, and then just follow those faces over time. Follow the face of a little girl who doesn’t read very well and is told to try harder; who tends to daydream and is told she better pay attention; who talks out in class when she sees something fascinating, like a butterfly on the windowpane, and is told to leave the class and report to the principal; who forgets her homework and is told she will just never learn, will she; who writes a story rich in imagination and insight and is told her handwriting and spelling are atrocious; who asks for help and is told she should try harder herself before getting others to do her work for her; who begins to feel unhappy in school and is told that big girls try harder. This is the brutal process of the breaking of the spirit of a child. I can think of no more precious natural resource than the spirits of our children. Life necessarily breaks us all down somewhat, but to do it unnecessarily to our children in the name of educating them—this is a tragedy. To take the joy of learning—which one can see in any child experimenting with something new—to take that joy and turn it into fear—that is something we should never do.

  And yet it happens every day with children with learning problems. We can prevent it by applying the knowledge we have in defining the learning style of each individual child.

  In my work with adults with ADD I hear many stories of school days gone wrong. People tell these stories much in the same manner as victims of trauma. There is a numb period when I hear all the facts. Not much emotion, just a long narrative of what it was like to be in school. Gradually, as I empathize with what it must have been like for them, the emotion begins to emerge: the hurt, the anger, the disappointment, the fear.

  “You just don’t know how much I hated going to school,” Franny, a woman in her thirties, said to me. “It was all a blur. My main idea was just to get through the day without getting hurt. I always said ‘I don’t know’ rather than risk giving a wrong answer. I actually loved to read and to make up stories, but all the teachers saw was the slow reader, the late papers, the messy handwriting, the bad spelling. One teacher actually said to me, ‘Your handwriting looks like a moron’s.’ She wasn’t even a mean teacher. She just thought she was motivating me to try harder. But a ten-year-old doesn’t hear things that way. I began to think I was a kind of moron: one that liked to read and make up stories, but could never do anything with them because she couldn’t write or spell. I really thought I was defective. My whole self-image became one of being different. I became afraid of making friends. Each year I’d have one or two sort-of friends. The other most marginal kids in the class. We became friends by default. One year we actually called ourselves the rejects, you know, pronounced ree-jex.”

  It turned out that Franny had both dyslexia as well as ADD. Her treatment was complicated by the damage school had done to her self-esteem. However, she ended up doing well, starting her own business as a remedial tutor specializing in women with learning disorders.

  If there is any question of an associated learning disorder or learning disability in the presence of ADD, neuropsychological testing can help elucidate exactly what the obstacle to learning is. The more specific the definition of the problem, the better targeted the therapy can be. Testing can address such questions as: Is there a specific math disability or is there only ADD? At what level is this individual reading? What are the relative cognitive strengths and weaknesses in the individual’s profile?

  The tests are part of what is called a neuropsychological battery. These are mostly paper-and-pencil tests. Some are like the reading-comprehension tests we all took in grade school. Others are like games. The subject is asked to put together parts of a maze or is asked to trace a geometric figure from memory. Others ask the subject to make up a story based on a picture or a series of statements, while others ask him to solve math problems. All in all, if the tests are done by a sensitive examiner, they are not unenjoyable, and sometimes they are quite fun. Usually, they are most revealing. Included in the battery are tests of attention, tests of memory, tests of observational acuity, tests of auditory comprehension, tests of spatial relations, tests of word retrieval, tests of vocabulary, tests of computational ability, tests of general knowledge, and tests of impulsivity. Sometimes tests of vision and hearing are included in the battery, and sometimes there is a neurological examination as well.

  People with both dyslexia and ADD are often the most creative and intuitive of the ADD population. With proper diagnosis and treatment they can do very well.

  ADD with Agitation or Mania

  Sometimes ADD can look like manic-depressive illness due to the high energy level involved in both syndromes. Manic-depressive illness is characterized by periodic momentous mood swings, from very high to very low. The very high moods, called periods of mania, can resemble ADD in that they include highly active behavior, easy distractibility, impulsivity, and an apparent disregard for personal safety.

  One can distinguish mania from the high energy of ADD by the level of intensity. An average person could simulate the energized state of ADD, but could not voluntarily reproduce the energy level of mania. Mania is the most extreme form of non-drug-induced drivenness that we know. The manic person can go without sleep for days, traveling the globe or spending his life’s savings on wild schemes or making grandiose claims of self-importance or talking nonstop from morning until night.

  The manic individual is truly out of control. He cannot slow down. He does not just talk fast, he talks as if the words were being propelled from his mouth, a disconcerting symptom referred to as “pressured speech.” Listening to someone who is in the grip of mania gives one the feeling of wanting to duck; the words seem to be thrown at you. A manic’s mind leaps from topic to topic, like a frog jumping lily pads, alighting for a moment here only to spring away to another place. This symptom is aptly called “flight of ideas.” It makes logical conversation of any length just about impossible. Let me give an example, taken from my days working on a psychiatric inpatient unit:

  “Good morning, Mr. Jones.”

  “Why good morning, Doctor, and good morning to all the lovely little squiggles you have
on your tie, and to squiggles everywhere, who, by the way, are outward representations of chaos, a soon-to-be-quantified branch of physics and mathematics, which, if you haven’t boned up on your integrals, will leave you without much hope of doing more than passing over the topic, as the cow passes over the moon in the ditty which you may have heard when you were a child. You were once a child, Doctor? It is safe to assume that we all were children once, that is a safe assumption, the first three letters of which are a-s-s so don’t be an ass and assume anything, as my old teacher used to say. Sound advice, especially for a planetary stargazer, wouldn’t you say? There is more in the stars than there is in every brain put together, like link sausages, a delicious breakfast at that!”

  While the individual with ADD can branch from topic to topic, he does not do so with the suddenness or pressuredness that the manic does, as in the example above. And while the person with ADD may be restless and full of energy, he is not driven by nearly the same horsepower as the manic.

  The two syndromes can actually coexist. The person with ADD may become manic for a period of time, and may cycle into depression as well.

  On the other hand, the person who has ADD with a high degree of agitation may be incorrectly diagnosed as having manic-depressive illness. This has practical significance in that the drug most commonly used to treat mania, lithium, usually does not help ADD. Indeed, it may make ADD worse. Therefore, it is important to consider ADD as a possible diagnosis in the agitated individual thought to be manic but who is nonresponsive to lithium. That person may have ADD and may get better when treated with one of the medications used for ADD.

  Let me give an example. A forty-three-year-old man—we’ll call him James—came for an evaluation for adult ADD. He had carried the diagnosis of manic-depressive illness—or in the formal nosology, bipolar disorder—for twelve years. As medication, he was taking 1,800 mg of lithium per day, a very large dose. He told me the dose had been gradually increased since he started taking lithium twelve years ago. He seemed to remain in a constant state of distraction. He didn’t think the lithium had helped him much, but he was afraid to stop it.

  His history was indeed remarkable, particularly his job history. During the year before the diagnosis of bipolar disorder was made, he had held no less than 124 jobs, actual jobs with W-2 forms to prove it. The pattern of getting fired and getting hired in such rapid succession was what had led to his being diagnosed manic. The reasons for his job endings were suggestive of mania. He would get fired because he would go into a loquacious tirade about the evils of the world in the midst of the working day. He would get fired because he would insult his boss, believing his solutions to problems were smarter. Or he would quit because of grandiose ideas of better jobs. Or he would leave to pursue some wild scheme, such as the time he got hoodwinked by a hustler in the mail-order business who promised him riches. Or he would get fired because he was too “hyper” to get along with coworkers.

  A very bright man, with a tested IQ of 144, he was currently working as a night watchman from midnight to 8 A.M. and taking college classes in the evening. He’d held this job longer than he’d held any job, seventeen months, probably because there was no one around to tell him what to do or for him to insult or get carried away with. His classes were not going well, however; he was barely passing, because of an inability to pay attention.

  It seemed to me that James’s history was compatible with ADD as well as with manic-depressive illness. Since the lithium did not appear to be controlling his symptoms, and because other second-tier medications for mania, such as Tegretol, had been tried without success, we decided to give Ritalin a trial. While tapering his lithium gradually, so we could watch for any emergent symptoms of mania, James started taking the Ritalin.

  The results were dramatic. James felt much more alert, focused, and, as he put it, “alive,” on the new medication. His grades at night school soared, averaging around 95. His wife couldn’t believe the difference. “He’s a totally new man. I always knew he was smart, it’s just that now he can use it.”

  Over six weeks he stopped taking lithium completely. No mania emerged. He continued to do well.

  ADD with Substance Abuse

  Of the many masks that ADD wears, substance abuse is one of the most difficult to see behind because the substance abuse itself causes such problems. When someone is alcoholic, is abusing cocaine, or is dependent upon marijuana, we often become so preoccupied with the problems the drug use creates that we fail to consider what purpose the drug must be serving for the user. ADD is one of the underlying causes of substance abuse that is particularly important to look for, because it can be treated.

  There are a host of reasons people drink, or use cocaine, or smoke dope. To find a moment’s pleasure, to flee pain, to fit in, to relax, are common reasons for using drugs. When the use becomes abuse, then it can become an illness in itself. It is widely accepted now that alcoholism is a disease, with its own genetics, natural history, treatment, and prognosis. Whether it is “the pain of being a man,” to use Samuel Johnson’s phrase, that leads people to drink, or drink that creates the alcoholic’s pain is still an open debate. However, it may be that alcoholism is its own cause, without any other factor underlying it.

  But perhaps more subtle than the disease concept of alcoholism, and of substance abuse in general, is the self-medication hypothesis advanced by Edward Khantzian, a psychoanalyst as well as a specialist in the field of substance abuse. He proposes the idea that people use drugs to treat some underlying bad feeling. They use the drug, whether it be alcohol, cocaine, tobacco, marijuana, or whatever, as a kind of self-prescribed medication for what ails them emotionally. The drug then creates physical and emotional problems of its own, so that repeated use of the drug becomes an attempt to treat the drug’s own side effects, as in having a drink to cure a hangover. But the abuse begins in an attempt to cure some bad feeling. One may use alcohol, for example, to treat depression, or use marijuana to alleviate feelings of low self-esteem.

  This concept is especially useful in understanding the relationship between ADD and substance abuse. Many people who have undiagnosed ADD feel bad and don’t know why. Some feel depressed, as we have mentioned above. Some feel agitated or anxious. Many more feel distracted and unfocused, living in a sort of disjointed limbo, waiting to come in for a landing. This feeling of unease or what psychiatrists call “dysphoria,” doesn’t have a context or even a name. It’s just life, in the minds of the people who feel it. You can live with something all your life but not be aware of it in its own right; it is simply a part of you. So it is with many of our feelings. Until we name them, they are entwined in our sense of self. Naming the feelings gives us some leverage over them. Being able to say “I am sad” can make the sadness less disabling. Once we recognize a feeling, we can attempt to control or change it. On the other hand, people who cannot say “I am sad” or “I am angry” are often directed or overpowered by these emotions in ways they are quite oblivious to.

  So, too, for the dysphoria associated with ADD. It is a peculiar kind of feeling, the distractibility-within-self many ADD people feel. The feeling, unrecognized and untreated, often leads to substance abuse through attempts at self-medication.

  Take cocaine as an example. Cocaine is in the class of drugs we call stimulants. Ritalin, one of the standard prescription medications for the treatment of ADD, is also a stimulant. Most people feel a rush of unfocused energy when they take cocaine. However, people with ADD feel focused when they use cocaine, just as they do when they take Ritalin. Rather than getting high, they suddenly feel clearheaded and able to pay attention. When those who don’t know they have ADD stumble upon cocaine, the drug seems like a cure in that it temporarily alleviates their ADD symptoms, and so they become chronic users. Interestingly enough, in the literature about cocaine, approximately 15 percent of addicts report feeling focused by the cocaine, rather than feeling high. This 15 percent probably have adult ADD and are self-medicating,
albeit unwittingly, with cocaine.

  While cocaine, among the drugs of potential abuse, offers the most specific treatment for the dysphoria associated with ADD, both alcohol and marijuana can be used as well. Alcohol tends to quiet the internal noise many adults with ADD complain of. It also reduces, in the short term, the anxiety commonly associated with ADD. Unfortunately, in the long run, alcohol is a depressant, and the daily withdrawal or hangover associated with chronic abuse increases anxiety. Similarly, marijuana tends to quiet the noise inside, to help the individual, in the words of one of my patients, “chill out.” Unfortunately, this is also only a short-term effect, and the repeated use of marijuana as an antianxiety agent is associated with a decrease in motivation.

  For those addicts who do in fact have ADD, it is essential that the ADD be treated as well as the addiction. By treating the ADD one reduces the likelihood that the individual will go back to abusing the original drug.

  As an example, let me discuss the case of a twenty-three-year-old man I will call Peter. Peter came to me after being released from jail, where he’d spent six months for dealing marijuana. Prior to his arrest, he had developed such a severe marijuana-abuse problem that his whole life centered around the drug. While in jail he read an article about ADD and sent it to his mother. In piecing together his childhood history, both from school and home, she decided it was quite likely he had ADD. However, after Peter was released from prison, he found himself in a bind familiar to many people who have been prosecuted for drug abuse. These people come up against a great deal of prejudice and fear, if not contempt, from the medical community. Most doctors do not welcome convicted felons into their practices. While this is understandable, it is also unfortunate. The very treatment these people are denied is the key to keeping them off drugs and out of jail. It only takes a few rejections from legitimate caregivers to send these people back to their self-medicating, drug-abusing ways.