Driven to Distraction (Revised)
Page 35
The model for ADD that seems to fit best from our point of view, however, comes from the school of thought that thinks more in terms of inhibition and disinhibition than motivation or arousal. Chelune, Gualtieri, Lou, and a number of other researchers and clinicians have framed ADD as an inability to stop receiving messages rather than as an inability to receive the right messages. These people always feel a press for the next thing and the next thing and the next thing. The ADD individual is captive to the events of the external world. Although the difference may seem semantic, it is significant in the way we describe ADD. It stresses that the positive components of the syndrome will assist the problematic ones. Instead of framing the syndrome as an inability to pay attention to cues, this definition focuses on the ability of someone with ADD to pay attention to many more cues than the average person. Instead of describing ADD as an inability to concentrate, this model presents it as the ability to concentrate on everything. The world always is alive and ripe with sources of interest. This analysis is supported by the scientific findings and also has the benefit of removing the stigma of laziness and the burden of guilt with which ADD people have struggled most of their lives. It allows them to start considering their strengths, rather than dwelling on weaknesses.
The disinhibition model fits with what we know about the functional neuroanatomy and the neurochemistry of the brain. As noted earlier, the frontal cortex and its associated systems and neurotransmitters are crucial for the process of inhibiting behaviors, thoughts, actions, emotions—the impulses with which we all live but which some of us regulate more easily than others. If there is a problem in maturation in the frontal systems in ADD, or a problem in regulation of the dopamine system that feeds into the frontal areas, ADD very well could be described as a problem with inhibitory capacity.
If ADD is a problem with inhibiting, we can understand the phenomenon of time collapsing in on itself for people with ADD: instead of being able to carve out discrete activities that would create a sensation of separate moments, the person cannot stop the relentless flow of events. Everything runs together, unbraked, uninhibited. We hear the ADD adult so painfully describing the verbal rush, the inability to stop the words, and the verbal paralysis, or stuttering, derived from the inability to stop the thoughts long enough to find the words. The social intrusiveness that is so characteristic of those who have ADD is the inability to stop at the other’s boundaries. The failure to form intimate relationships is the inability to pause long enough even to listen to the other person, let alone to understand and respect the other’s needs. The impulsivity, the lack of planning, and the outbursts are the inability to restrain the flow of action and feeling.
We also see people with ADD hyperfocusing on an activity, like rockclimbing or driving or work, probably because it allows them to forget about the expectations associated with “time.” Our patients frequently report that they are their most calm when completely caught up in the thrill of it all, whatever the “all” may be. It could be fun, a catastrophe, or a life-or-death crisis. These situations allow the ADD person not only to get into forward motion, but also to forget, to disregard that they need brakes in the first place. In an emergency, it’s full speed ahead. What a relief.
The clinician’s challenge is to find a way to allow the ADD person to put on the brakes. From a biological perspective, one of the most successful strategies has been the use of medications. The medications employed to treat ADD interact with the catecholamine system in such a way as to correct the dysregulated attentional processes and stop the rush of experience. As detailed in chapter 8, the medications commonly used include the stimulants and the tricyclic antidepressants. The stimulants—Ritalin, Cylert, Dexedrine—act on the catecholamine system. The tricyclics—desipramine and imipramine—act on the catecholamine system and on the serotonin system, with the greatest effect being on norepinephrine. Both types of drugs increase the levels of the neurotransmitters they affect, allowing more of the particular neurotransmitter to be available for use by the brain.
Because we do not know precisely what is causing the ADD, we cannot know exactly where the drugs are working. They could work at the beginning or at the end of the line, in the lower brain or in the cortex. If they work in the lower part of the brain, and effect the modulation of arousal, they might be up-regulating the entire system and letting only relevant stimuli make its way to the frontal lobes. If they work directly in the front regions of the brain, they might awaken an otherwise sleepy cortex. Wender speculates that the drugs work in the middle of this loop, in the limbic system. He proposes that the action of norepinephrine in the limbic system is impaired, and since incoming stimuli from the lower brain must pass through the limbic system before reaching the frontal lobes, it is possible that a problem in regulation of this area would cause the disinhibition in the frontal regulatory processes.
Either way, we feel the effects of the drugs in the cortex, the treetops of our brains. The drugs enhance the functioning and use of neurotransmitters in the frontal regions and smooth out regulatory and attentional functioning. Their effectiveness has been documented in numerous studies, through numerous means. The use of stimulants generally improves scores in continuous-performance tests, school performance, behavioral rating scales, and self-reports.
And the effect is immediate, unlike the drug action in almost any other neurobiologic disorder. The immediacy of action indicates that the drugs have a direct effect at the synaptic level, the cellular juncture where one neuron passes a message to the next. Right away they improve the way one brain cell communicates with another, as if they have come along and swept out the blockage in the synapse. Other medications that affect the brain, such as those used to treat depression, schizophrenia, panic, and anxiety, work to reset the neuronal network. They gradually change receptor sensitivity to neurotransmitters, or otherwise change the structure of the neuronal communication system. They work as traffic coordinators instead of street sweepers, rerouting information along different channels.
It may be that the stimulants create an equilibrium in the chemistry of the frontal regions of the brain without requiring the whole system to change. This allows tonic control of the frontal systems; that is, the job of the frontal lobes becomes easier and less prone to interruptions. Inhibiting thoughts and feelings and actions becomes easier. The beginnings and endings of moments in time become clear, and deliberation, planning, and pausing finally become possible. Life becomes continuous rather than disjointed.
In many ways, our understanding of the biology of ADD is still in its first chapter. The next few decades will be more exciting as our ability to test, measure, and evaluate the biological processes implicated in neurobiologic disorders expands. Although it is doubtful we will find the magic bullet that can rid an individual of ADD, one day our methods of treatment might be sophisticated enough so that the frustrations and uncertainties of living with the syndrome will be eased, and those with ADD can draw confidently on their thoughts.
ACKNOWLEDGMENTS
One of the great pleasures of writing this book was the help and encouragement we received from many sources.
Our patients helped us first of all. They created this book. By teaching us about ADD and by giving us their stories to share with others, they gave of themselves in a most personal way. We hope this book lives up to their generosity.
Many other individuals helped us. We thank Sandra Freed Thomas, past president of CH.A.D.D., a national ADD organization, for her encouragement from the start; Jill Kneerim, our agent, for her disciplined guidance; Susan Grace Galassi for her early reading of the manuscript and Jonathan Galassi for his support all along; Priscilla Vail for all her help, particularly with the dyslexias and other language problems; the late Carol Rinzler, for so many kinds of help; the team at Pantheon, including our editor, Linda Healey, for her suggestions, which were always helpful, and for her exacting and imaginative reading of the manuscript, which improved it greatly; her assistant, Jennifer
Trone, for skillfully keeping us focused while seeming to remain unobtrusive; and Fred Wiemer for his superb copy editing.
We are thankful to Lyn, Tom, and Tim Bliss for many helpful suggestions; James Hallowell for his persistent skepticism, which helped us keep a balanced view; Ellen D’Ambrosia for her warm support; Peter Metz for his invaluable consultations, freely given no matter how busy he was himself; Kevin Murphy, Russell Barkley, and the rest of the staff of the University of Massachusetts Medical Center ADD Clinic for their help and advice on ADD in adults; Betsy Busch for her always useful advice; Edward Khantzian for his most helpful ideas regarding ADD and addictions; Paul Wender for his encouragement and counsel; Catherine Leveroni, Andrea Miller, and the rest of John Ratey’s staff at Medfield State Hospital for their tireless attention to many details.
We are indebted to Lisa Poast for the list of support groups that appears in the Appendix; Elizabeth Leimkuhler for many observations on ADD in adults; Leopold Bellak, for an early conversation that helped start us thinking; John and Ben Hallowell, for encouraging their little brother to write; and our wives, Sue George Hallowell and Nancy Blackmore, for their ideas and their support, patience, and enthusiasm for this project from beginning to end.
—E. M. H.
—J. J. R.
APPENDIX
Where to Find Help
ADHD Coaches Organization
701 Hunting Place
Baltimore, MD 21229
(888) 638-3999
Fax: (410) 630-6991
www.adhdcoaches.org
Anxiety Disorders Association of America
8730 Georgia Avenue, Suite 600
Silver Spring, MD 20910
(240) 485-1001
Fax: (240) 485-1035
information@adaa.org
www.adaa.org
Attention Deficit Disorder Association (ADDA)
PO Box 7557
Wilmington, DE 19803-9997
(800) 939-1019
adda@jmoadmin.com
www.add.org
Children and Adults with Attention Deficit Disorder
(CHADD)
8181 Professional Place, Suite 150
Landover, MD 20785
(301) 306-7070
Fax: (301) 306-7090
www.chadd.org
CH.A.D.D. is the national and international nonprofit parent-support organization for children and adults with ADD.
Parents Helping Parents: Parent-Directed Family
Resource Center for Children with Special Needs
3041 Olcott St.
Santa Clara, CA 95054
(408) 727-5775
Fax: (408) 727-0182
info@php.com
www.php.com
Organizations to Contact for Information About Learning Disabilities and Dyslexia
The International Dyslexia Society
40 York Rd., 4th Floor
Baltimore, MD 21204
(410) 296-0232
Fax: (410) 321-5069
www.interdys.org
Learning Disabilities Association of America
4156 Library Road
Pittsburgh, PA 15234-1349
(412) 341-1515
Fax: (412) 344-0224
www.ldanatl.org
National Center for Learning Disabilities
381 Park Avenue South, Suite 1401
New York, NY 10016
(212) 545-7510
Fax: (212) 545-9665
www.ncld.org
National Dissemination Center for Children with
Disabilities
1825 Connecticut Ave, NW, Suite 700
Washington, D.C. 20009
(800) 695-0285
Fax: (202) 884-8441
www.nichcy.org
Newsletters
ADDult ADDvice
Attention Deficit Disorder Resources
223 Tacoma Ave S #100
Tacoma, WA 98402
(253) 759-5085
Fax: (253) 572-3700
www.addresources.org
This newsletter includes substantive articles about issues relevant to adults with ADD, as well as a listing of resources and support-group announcements. ADDult News welcomes letters, comments, personal stories, poems, and artwork.
ADDitude
New Hope Media
39 W. 37th Street, 15th Floor
New York, NY 10018
www.attitudemag.com
ADDitude magazine has several free newsletters covering everything from Adult ADD to the latest ADHD research. Subscribe online or call (888) 762-8475.
The ADHD Report
Guilford Publications
72 Spring Street
New York, NY 10012
(800) 365-7006
Fax: (212) 966-6708
Russell Barkley, Editor
To subscribe call (800) 365-7006 or visit www.guilford.com. This is a superb newsletter edited by one of the foremost authorities on the subject. It is a must for any parent, clinician, school official, or individual who wants to stay current with new developments in the field.
Offices to Contact for Information About the Americans with Disabilities Act, Equal Opportunity Issues, Educational Rights, and Legal Advocacy:
Equal Employment Opportunity Commission
131 M Street NE
Washington, D.C. 20507
Phone: (202) 663-4900
Contact the EEOC about employment issues related to the Americans with Disabilities Act. Title 1 of ADA prevents an employer from discriminating against a qualified individual with a mental or physical disability with regards to job-application procedures, hiring, discharge, compensation, advancement, job training, and other conditions and privileges of employment.
Department of Justice
Office of Americans with Disabilities Act
Civil Rights Division
950 Pennsylvania Avenue, NW
Washington, D.C. 20530
(800) 514-0383
Fax: (202) 307-1198
www.ada.gov
Contact the Department of Justice about “public accommodation” issues, as defined by the Americans with Disabilities Act. Title III of the act prohibits any private entity that owns, leases, or operates a place of public accommodation (e.g., restaurants, retail stores, colleges, and graduate schools) from discriminating against an individual on the basis of disability.
Judge David L. Bazelon Center for Mental Health Law
www.bazelon.org
The Bazelon Center is an information and advocacy organization that focuses on laws, policies, and regulations that affect the civil rights of people with mental disabilities.
Office of Civil Rights
U.S. Department of Education
400 Maryland Avenue SW
Washington, D.C. 20202
(800) 872-5327
www.ed.gov
Contact OCR with issues pertaining to Section 504 of the Rehabilitation Act (1973), and the Individuals with Disabilities Education Act (IDEA), both of which provide guidelines for the rights of individuals with ADD in public school settings.
Job Accommodation Network
PO Box 6080
Morgantown, WV 26506-6080
(800) 526-7234
(800) ADA-WORK
www.jan.wvu.edu
Readings and References About ADD
The following list contains books and other resources that we think will be helpful in learning more about ADD and LD in adults and children. It is only a sample, however, of the many excellent and informative publications that are available about attention deficit disorder. The books are presented alphabetically by title, with the exception of the first two.
Answers to Distraction. Revised and Updated. Edward M. Hallowell and John J. Ratey. Anchor Books, New York, 2010. A companion book to Driven to Distraction in which Hallowell and Ratey respond to the most frequently asked questions about ADD.
Delivered from Distraction: Getting the Most Out of Life with Attention Deficit Disorder. Ballantine
Books, New York, 2005. Hallowell and Ratey provide a new screening questionnaire for adults and list methods that physicians, parents, and educators can use to diagnose and treat the ADD child. Includes recommended steps for living a satisfying life with ADD.
ADD and the College Student: A Guide for High School and College Students with ADD. Patricia O. Quinn. Magination Press, Washington, D.C., 2001. A practical guide in a field where much guidance is needed.
ADD-Friendly Ways to Organize Your Life by Judith Kolberg and Kathleen Nadeau. Routledge, New York, 2002. Focusing on the particular dilemmas and challenges of adults with ADD, this book provides organizational skills for life, allowing energy to be focused on strengths, rather than disorder.
ADHD: A Complete and Authoritative Guide by Michael I. Reiff, M.D. American Academy of Pediatrics, Chicago, 2004.
ADHD & Me: What I Learned from Lighting Fires at the Dinner Table by Blake E. S. Taylor. New Harbinger, Oakland, CA, 2008. Written when Blake was seventeen, this is a young person’s account of what it’s like to live and grow up with this common condition.
Attention Deficit Disorder: A Different Perception. Thom Hartmann. Underwood Books, Novato, CA, 1997. An interesting theory. Thom Hartmann has done a great deal to help “normalize” ADD. He is an innovative thinker and a good writer.