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Delivered from Distraction
Delivered from Distraction
- ISBN 13:
9780345442314
- ISBN 10:
0345442318
- Edition: Reprint
- Format: Trade Paper
- Copyright: 12/27/2005
- Publisher: Ballantine Books
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Summary
In 1994, Driven to Distraction sparked a revolution in our understanding of attention deficit disorder. Widely recognized as the classic in the field, the book has sold more than a million copies. Now a second revolution is under way in the approach to ADD, and the news is great. Drug therapies, our understanding of the role of diet and exercise, even the way we define the disorderall are changing radically. And doctors are realizing that millions of adults suffer from this condition, though the vast majority of them remain undiagnosed and untreated. In this new book, Drs. Edward M. Hallowell and John J. Ratey build on the breakthroughs of Driven to Distraction to offer a comprehensive and entirely up-to-date guide to living a successful life with ADD. As Hallowell and Ratey point out, "attention deficit disorder" is a highly misleading description of an intriguing kind of mind. Original, charismatic, energetic, often brilliant, people with ADD have extraordinary talents and gifts embedded in their highly charged but easily distracted minds. Tailored expressly to ADD learning styles and attention spans, Delivered from Distractionprovides accessible, engaging discussions of every aspect of the condition, from diagnosis to finding the proper treatment regime. Inside you'll discover whether ADD runs in families new diagnostic procedures, tests, and evaluations the links between ADD and other conditions how people with ADD can free up their inner talents and strengths the new drugs and how they work, and why they're not for everyone exciting advances in nonpharmaceutical therapies, including changes in diet, exercise, and lifestyle how to adapt the classic twelve-step program to treat ADD sexual problems associated with ADD and how to resolve them strategies for dealing with procrastination, clutter, and chronic forgetfulness ADD is a trait, a way of living in the world. It only becomes a disorder when it impairs your life. Featuring gripping profiles of patients with ADD who have triumphed, Delivered from Distractionis a wise, loving guide to releasing the positive energy that all people with ADD hold inside. If you have ADD or care about someone who does, this is the book you must read. From the Hardcover edition.
Author Biography
Read moreEDWARD M. HALLOWELL, M.D., is an instructor at Harvard Medical School and director of the Hallowell Center for Cognitive and Emotional Health in Sudbury, Massachusetts, an outpatient treatment center serving children and adults with a wide range of emotional and learning problems. He is the co-author of Driven to Distraction and the author of The Childhood Roots of Adult Happiness, and Worry, among other titles. He lives in Arlington, Massachusetts, with his wife and three children. He welcomes hearing from readers, and can be reached through his website at www.DrHallowell.com.
JOHN J. RATEY, M.D., is an associate professor of psychiatry at Harvard Medical School. He has lectured extensively and published many articles on the topic of treating adults with ADD. Dr. Ratey is the author of A User’s Guide to the Brain and the co-author of Driven to Distraction. He lives in Cambridge, Massachusetts, where he has a private practice.
From the Hardcover edition.
JOHN J. RATEY, M.D., is an associate professor of psychiatry at Harvard Medical School. He has lectured extensively and published many articles on the topic of treating adults with ADD. Dr. Ratey is the author of A User’s Guide to the Brain and the co-author of Driven to Distraction. He lives in Cambridge, Massachusetts, where he has a private practice.
From the Hardcover edition.
Table of Contents
Read more| Preface to the New Edition | vii | ||||
| Acknowledgments | xvii | ||||
| A Note on Authorship | xxi | ||||
| How to Read This Book | xxv | ||||
| Introduction: Welcome to the World of ADD, Where Landing Is Learned in Midair | xxvii | ||||
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| 336 | (7) | |||
| Appendix: A Compendium of Resources | 343 | (26) | |||
| Index | 369 |
Supplemental Materials
Read moreWhat is included with this book?
The New copy of this book will include any supplemental materials advertised. Please check the title of the book to determine if it should include any access cards, study guides, lab manuals, CDs, etc.
The Used, Rental and eBook copies of this book are not guaranteed to include any supplemental materials. Typically, only the book itself is included. This is true even if the title states it includes any access cards, study guides, lab manuals, CDs, etc.
Excerpts
Read moreChapter 1
THE SKINNY ON ADD:
READ THIS IF YOU CAN’T READ THE WHOLE BOOK
Most people who have ADD don’t read books all the way through. It’s not because they don’t want to; it’s because reading entire books is very difficult—sort of like singing an entire song in just one breath.
We want to make this book accessible to people who don’t read books all the way through. For those people, our most dear and treasured brothers and sisters in ADD, we offer this first chapter, set off from the rest of the book. Reading this will give you a good idea of what ADD is all about. If you want to learn more, ask someone who loves you to read the whole book and tell you about it. Or you can listen to it on a tape or CD.
We offer this chapter in the ADD-friendly format of Q&A. You can get the skinny on ADD in these thirty questions and answers. For more detail and research-based answers, you can refer to the chapters of particular interest.
For those blessed readers who intend to read the entire book, some of what’s in this Q&A will appear again, but some of it won’t, so you too should read this section.
Q&A ON ADD
Q: What is ADD?
A: Attention deficit disorder, or ADD, is a misleading name for an intriguing kind of mind. ADD is a name for a collection of symptoms, some positive, some negative. For many people, ADD is not a disorder but a trait, a way of being in the world. When it impairs their lives, then it becomes a disorder. But once they learn to manage its disorderly aspects, they can take full advantage of the many talents and gifts embedded in this sparkling kind of mind.
Having ADD is like having a turbocharged race-car brain. If you take certain specific steps, then you can take advantage of the benefits ADD conveys—while avoiding the disasters it can create.
The diagnostic manual of mental problems, called the DSM-IV, defines ADD by a set of eighteen symptoms. To qualify for the diagnosis you need six. These diagnostic criteria are listed in chapter 12. But be careful when you read them. They describe only the downside of ADD. The more you emphasize the downside, the more you create additional pathology: a nasty set of avoidable, secondary problems, like shame, fear, and a sharply diminished sense of what’s possible in life.
The pathology of ADD—its disorderly side—represents only one part of the total picture.
The other part, the part that the DSM-IV and other catalogs of pathology leave out, is the zesty side of ADD. People with ADD have special gifts, even if they are hidden. The most common include originality, creativity, charisma, energy, liveliness, an unusual sense of humor, areas of intellectual brilliance, and spunk. Some of our most successful entrepreneurs have ADD, as do some of our most creative actors, writers, doctors, scientists, attorneys, architects, athletes, and dynamic people in all walks of life.
Q: What is the difference between ADHD and ADD?
A: It’s just a matter of nosology, the classification of disorders. There is an arbitrariness to it all. By the current DSM-IV definition, ADD technically does not exist. By the DSM-IV definition, the term ADHD includes both ADHD with hyperactivity (the H in ADHD) and ADHD without hyperactivity. Technically, this means you can have ADHD with no symptoms of H, hence there is no need for the term ADD. But ADD, the old term, is still used by many clinicians, including the authors of this book. Whichever term you use, the important point to know is that you can have ADHD (or ADD) without showing any signs of hyperactivity or impulsivity whatsoever. ADHD without hyperactivity or impulsivity is more common among females.
Q: What is the typical profile of a person who has ADD?
A: The core symptoms of ADD are excessive distractibility, impulsivity, and restlessness. These can lead both children and adults to underachieve at school, at work, in relationships and marriage, and in all other settings.
In addition, people who have ADD often also exhibit:
Advantageous characteristics:
• Many creative talents, usually underdeveloped until the diagnosis is made
• Original, out-of-the-box thinking
• Tendency toward an unusual way of looking at life, a zany sense of humor, an unpredictable approach to anything and everything
• Remarkable persistence and resilience, if not stubbornness
• Warm-hearted and generous behavior
• Highly intuitive style
Disadvantageous characteristics:
• Difficulty in turning their great ideas into significant actions
• Difficulty in explaining themselves to others
• Chronic underachievement. They may be floundering in school or at work, or they may achieve at a high level (getting good grades or being president of the company does not rule out the diagnosis of ADHD), but they know they could be achieving at a higher level if only they could “find the key.”
• Mood often angry or down in the dumps due to frustration
• Major problems in handling money and making sensible financial plans
• Poor tolerance of frustration
• Inconsistent performance despite great effort. People with ADHD do great one hour and lousy the next, or great one day and lousy the next, regardless of effort and time in preparation. They go from the penthouse to the outhouse in no time at all!
• History of being labeled “lazy” or “a spaceshot” or “an attitude problem” by teachers or employers who do not understand what is really going on (i.e., having ADD)
• Trouble with organization. Kids with ADD organize by stuffing book bags and closets. Adults organize by putting everything into piles. The piles metastasize, soon covering most available space.
• Trouble with time management. People with ADD are terrible at estimating in advance how long a task will take. They typically procrastinate and develop a pattern of getting things done at the last minute.
• Search for high stimulation. People with ADD often are drawn to danger or excitement as a means of focusing. They will drive 100 mph in order to think clearly, for example.
• Tendency to be a maverick (This can be an advantage or a disadvantage!)
• Impatience. People with ADD can’t stand waiting in lines or waiting for others to get to the point.
• Chronic wandering of the mind, or what is called distractibility. Tendency to tune out or drift away in the middle of a page or a conversation. Tendency to change subjects abruptly.
• Alternately highly empathic and highly unempathic, depending upon the level of attention and engagement
• Poor ability to appreciate own strengths or perceive own shortcomings
• Tendency to self-medicate with alcohol or other drugs, or with addictive activities such as gambling, shopping, sexualizing, eating, or risk-taking
• Trouble staying put with one activity until it is done
• Tendency to change channels, change plans, change direction, for no apparent reason
• Failure to learn from mistakes. People with ADD will often use the same strategy that failed them before.
• Easily forgetful of their own failings and those of others. They are quick to forgive, in part because they are quick to forget.
• Difficulty in reading social cues, which can lead to difficulty in making and keeping friends
• Tendency to get lost in own thoughts, no matter what else might be going on
Q: Aren’t most people somewhat like this?
A: The diagnosis of ADD is based not upon the presence of these symptoms—which most people have now and then—but upon the intensity and duration of the symptoms. If you have the symptoms intensely, as compared to a group of your peers, and if you have had them all your life, you may have ADD. An apt comparison can be made with depression. While everyone has been sad, not everyone has been depressed. The difference lies in the intensity and the duration of the sadness. So it is with ADD. If you are intensely distractible, and have been forever, you may have ADD.
Q: What causes ADD? Is it inherited?
A: We don’t know exactly what causes ADD, but we do know it runs in families. Like many traits of behavior and temperament, ADD is genetically influenced, but not genetically determined. Environment combines with genetics to create ADD. Environmental toxins may play a role, watching too much television may play a role, and excessive stimulation may play a role.
You can see the role of genetics just by glancing at basic numbers. We estimate that about 5 to 8 percent of a random sample of children have ADD. But if one parent has it, the chances of a child developing it shoot up to about 30 percent; if both parents have it, the chances leap to more than 50 percent. But genetics don’t tell the whole story. You can also acquire ADD through a lack of oxygen at birth; or from a head injury; or if your mother drank too much alcohol during pregnancy; or from elevated lead levels; perhaps from food allergies and environmental or chemical sensitivities; from too much television, video games, and the like; and in other ways we don’t yet understand.
Q: Other than its being heritable, is there any other evidence that ADD has a biological, physical basis to it, as opposed to psychological or environmental?
A: Brain scans of various kinds have shown differences between the ADD and the non-ADD brain. Four different studies done in the past decade using MRI (magnetic resonance imaging) all found a slight reduction in the size of four regions of the brain: the corpus callosum, the basal ganglia, the frontal lobes, and the cerebellar vermis. While the differences are not consistent enough to provide a diagnostic test for ADD, they do correlate with the symptoms we see in ADD. For example, the frontal lobes help with organization, time management, and decision-making, all areas that people with ADD struggle with. The basal ganglia help to regulate moods and to control impulsive outbursts, which people with ADD also struggle with. And the cerebellum helps with balance, rhythm, coordinated movements, language, and other as yet to be proven functions. It may be that the cerebellum is far more important in regulating attention than we realize today.
Q: How many people have ADD?
A: Roughly 5 to 8 percent (many experts would put that figure much higher, some lower) of the American population has ADD. The majority of adults who have it don’t know it because people used to think ADD was only a children’s condition. We now know that adults have it too. Of the roughly 10 million adults in the United States who have ADD, only about 15 percent have been diagnosed and treated. Until we have a precise diagnostic test for ADD, however, it will be impossible to give truly accurate figures. Studies around the world—in China, Japan, India, Germany, Puerto Rico, and New Zealand—show comparable figures.
Q: Does ADD ever go away on its own?
A: Yes. The symptoms of ADD disappear during puberty in 30 to 40 percent of children, and the symptoms stay gone. ADD therefore persists into adulthood 60 to 70 percent of the time. As the brain matures, it changes in ways that may cause the negative symptoms to abate. Then ADD becomes a trait rather than a disorder. In addition, sometimes the child learns how to compensate so well for his ADD during puberty that it looks as if the ADD has gone away. However, if you interview that child closely, you will discover the symptoms are still there, but the child is struggling mightily—and successfully—to control them. These people still have ADD and would benefit from treatment.
Q: Is ADD overdiagnosed among children?
A: Yes, but also no. It is overdiagnosed in some places, underdiagnosed in others. There are schools and regions where every child who blinks fast seems to get diagnosed with ADD. At the same time, there are places around the country where doctors refuse to make the diagnosis at all because they “don’t believe in ADD.” ADD is not a religious principle; it is a medical diagnosis derived from such solid evidence as genetic studies, brain scans, and worldwide epidemiological surveys.
It is important that we educate doctors, as well as teachers, parents, and school officials, about ADD, so that we can solve the problems of both overdiagnosis and underdiagnosis.
Q: What is the proper procedure to diagnose ADD?
A: There is no surefire test. The best way to diagnose ADD is to combine several tests. The most powerful “test” is your own story, which doctors call your history. As you tell your story, your doctor will be listening for how your attention has varied in different settings throughout your life. In the case of ADD it is important that the history be taken from at least two people, such as parent, teacher, and child, or adult and spouse, since people with ADD are not good at observing themselves.
To supplement the history, there is a relatively new physical test called the quantitative electroencephalogram, or qEEG, that is quite reliable in helping to diagnose ADD. It is a simple, painless brain-wave test, and it is about 90 percent accurate. Though well worth getting, it is not definitive by itself.
In complex cases where the diagnosis is unclear or there is a suspicion of coexisting conditions, especially if there is a history of head injury or other brain trauma, a SPECT scan can help. The SPECT brain scan is not widely available, though we believe it could help a great deal in psychiatry if it were.
In addition to the history, which should include questions based upon the DSM-IV diagnostic criteria, and the qEEG and sometimes the SPECT, other standardized sets of questions, such as the ADHD Rating Scale or the Brown scale, add confidence to the diagnosis. Your doctor can tell you about these tests. None are necessary, but all are helpful.
Finally, neuropsychological testing can help pin down the diagnosis as well as expose associated problems—such as hidden learning disabilities, anxiety, depression, and other potential problems.
Practically speaking, if you are going to see a busy primary-care doctor for your evaluation, the time available to take a history may be brief, and access to neuropsychological testing nonexistent. In these instances, the qEEG becomes even more valuable, as well as the standardized rating scales, especially the DSM-IV criteria.
The best diagnostic procedures also include a search for talents and strengths, as these are the key to the most successful treatments.
Q: Should you always order the qEEG, neuropsychological testing, or a SPECT scan?
A: All three can be helpful, but no, none is absolutely necessary, unless the diagnosis is in doubt, or you suspect associated learning disabilities such as dyslexia, or other coexisting conditions, like brain damage due to an old head injury, or bipolar disorder, or hidden substance abuse. In such cases, you might encourage your doctor to consider getting you neuropsychological testing, a qEEG, or a SPECT scan.
Q: Whom should I see to get a diagnosis?
A: The best way to find a doctor who knows what he is doing is to get a referral from someone you know who has had a good experience with that doctor. (We have provided a list of specialists at the end of this book.)
The degree the person has is much less important than his experience. People from diverse disciplines may be capable of helping you. Child psychiatrists have the most training in ADD, and keep in mind that most child psychiatrists also treat adults. However, child psychiatry is an underpopulated specialty; therefore, child psychiatrists are hard to find. Developmental pediatricians are also good with ADD, but, of course, they do not treat adults and they are also in short supply. Some regular pediatricians are excellent at diagnosing and treating ADD, while others—those who have not had much experience with ADD—are understandably less skilled. Some family practitioners and some internists are good. Adult psychiatrists tend not to have training in ADD. However, most psychologists do.
If you cannot get a referral from someone you know, ask your primary-care doctor if she is expert in ADD, and if not, to whom would she recommend that you go.
It is worth the hassle to look around. I see patients every day who wasted years because they went to see the wrong person.
Q: What are the most common conditions that may occur along with ADD?
A: Dyslexia and other learning differences, depression, oppositional defiant disorder, conduct disorder, antisocial personality disorder, substance abuse, post-traumatic stress disorder, anxiety disorders, bipolar disorder.
Q: What other problems should one be on the lookout for?
A: Trouble in school, at work, or at home. Underachievement, even if there are no signs of what others consider to be trouble. Sometimes when the ADD is diagnosed and treated, the trouble, whatever it is, or the underachievement remit. But often they need special attention in their own right. Tutoring, career counseling, family therapy, couples therapy, individual therapy, or coaching can all help.
Q: What else should one watch out for regarding the diagnosis of ADD and getting treatment?
A: Many people in the United States today—including those who have ADD and those who do not—suffer from what I call disconnectedness. They do not have the close, sustaining relationships that they need. While we are elaborately connected electronically in modern life, we are poorly connected interpersonally. Studies have shown that such disconnectedness leads not only to anxiety, depression, and underachievement but also to substance abuse, disruptive behavior, and a host of medical problems in both children and adults. Try to develop a connected interpersonal life for you and your family as seriously as you strive to maintain a proper diet or an exercise program.
Q: What about bipolar disorder in children? Does it look like ADD? How do you tell them apart?
A: It is important to keep bipolar disorder in mind whenever the possibility of ADD arises in a child. Some experts believe that if you give a child who has bipolar disorder stimulant medication, you run the risk of doing serious harm. These children can become violent, depressed, even suicidal. This is just another reason why you must see a well-trained professional for a proper diagnostic evaluation.
Several items help distinguish between ADD and bipolar disorder. First of all, in bipolar disorder there is usually a family history on both parents’ sides of bipolar disorder, alcoholism, major depression, or all of these. Second, in bipolar disorder the leading symptom is rapidly fluctuating moods independent of what is going on in the environment. In ADD the leading symptom is fluctuating attention. Third, the child with bipolar disorder often has a daily variation: he becomes highly active at night and in the morning he is like a hibernating bear, all but impossible to get out of bed. You can see this in ADD too, but it is more accentuated in bipolar disorder.
Q: What is the best treatment for ADD?
A: It varies. The best approach to treating ADD is to follow an individualized, comprehensive plan specifically designed for you, based upon your particular situation and needs. One size does not fit all. Work with your doctor to create the best approach for you (or for your child, or for whomever has the ADD). This plan should always be open to revision. If it doesn’t work, change it.
Q: What are the most common, key ingredients of such a comprehensive plan?
A: I divide the best plan into eight areas, as follows:
1.Diagnosis, as well as identification of talents and strengths
2.Implementation of a five-step plan that promotes talents and strengths (detailed in chapter 22)
3.Education
4.Changes in lifestyle (e.g., reduce TV and other electronics, increase time with family and friends, increase physical exercise)
5.Structure
6.Counseling of some kind, such as coaching, psychotherapy, career counseling, couples therapy, family therapy
7.Various other therapies that can augment the effectiveness of medication or replace the use of medication altogether, such as an exercise program that stimulates the cerebellum, targeted tutoring, general physical exercise, occupational therapy, and nutritional interventions
8.Medication
Q: In what ways are diagnosis, identification of talents and strengths, and implementation of a plan that promotes talents and strengths part of the treatment?
A: Getting a name for what’s been going on with you usually brings relief. When you get the ADD diagnosis, you can finally shed all those accusatory, “moral” diagnoses, like lazy, weak, undisciplined, or, simply, bad.
The identification of talents and strengths is one of the most important parts of the treatment. People with ADD usually know their shortcomings all too well, while their talents and strengths have been camouflaged by what’s been going wrong.
The moment of diagnosis provides a spectacular opportunity to change that. The best way to change a life of frustration into a life of mastery is by developing talents and strengths, not just shoring up weaknesses. Keep the focus on what you are, rather than what you are not. The older you get, the more time you should spend developing what you’re good at. Work with someone who can help identify what you’re good at. In the long run that’s where you will find fulfillment.
Q: What is the five-step plan that promotes talents and strengths?
A: The first step is to connect—with a teacher, a coach, a mentor, a supervisor, a lover, a friend (and don’t forget God or whatever your spiritual life leads you toward). Once you feel connected, you will feel safe enough to go to step 2, which is to play. In play, you discover your talents and strengths. Play includes any activity in which your brain lights up and you get imaginatively involved. When you find some form of play you like, you do it over and over again; this is step 3, practice. As you practice, you get better; this is step 4, mastery. When you achieve mastery, other people notice and give you recognition; this is step 5. Recognition in turn connects you with the people who recognize and value you, which brings you back to step 1, connect, and deepens the connection.
No matter what your age, you can use this five-step process to promote talents and strengths. Beware, however, of jumping in at step 3. That’s the mistake many parents, teachers, coaches, and managers in the workplace make: they demand practice and offer recognition as the reward. This leads to short-term achievement but fatigue and burnout in the long run.
For the cycle to run indefinitely and passionately, it must generate its own enthusiasm and energy, not be prodded by external motivators. To do that, the cycle must start in connection and play.
Q: Why is education part of the treatment?
A: Treatment really means learning how to fit the brain you have into the world most enthusiastically and constructively. The diagnosis becomes therapeutic through education—learning what ADD is in your case. Diagnosis means “to know through.” As you learn about your mind, and as you learn how ADD has affected your life, you gradually “know through” this condition, how it lives in you. The more you know about the kind of mind you have—whether or not you call it ADD—the better able you will be to improve your life.
Furthermore, the process of education will help identify your talents and strengths, or your potential talents and strengths. Take time, look hard, and get help in identifying these. You may not be able to see them yourself. People who have ADD often don’t think they have any talents or strengths.
If there were but one rule for treating ADD it would be this: Find out what you’re good at, and do it. Or, as my brother-in-law who is a teaching golf pro says, “Forget what the books say. Just do what you need to do to put the ball in the hole.”
Q: What if you’re not good at anything, or what if what you’re good at is illegal, dangerous, or simply lacking in any social value, like playing Nintendo?
A: Everyone has the seed of a talent. Everyone has some interest that can be turned into a skill that is legal, reasonably safe, and has value both to that person and to society. Everyone. The work of treating ADD is to find that talent or interest. It may be hidden or camouflaged. For example, if the activity you’re good at is selling drugs, well, that means you have entrepreneurial and sales talents and interests that could be plugged into some legal venture. If the activity you’re good at is driving down the highway at 110 mph, then you may have a career in some risk-filled, highly stimulating arena like investing on the commodities exchange or being an investigative reporter. If what you’re good at has no social value, like playing Nintendo, you might want to get a job at a computer-game store, or you might want to take a course in designing computer games.
The germ of a great career often lies hidden in the illegal, dangerous, or useless activities we love. Look for that germ cell. If you can’t find it, get someone else to help you look.
Q: What do you mean by “structure”?
A: By “structure,” I mean any habit or external device that helps make up for what is missing internally, in your mind. For example, the ADD brain is low on filing cabinets. So, you need to set up more filing cabinets outside the brain in order to replace piles with files. An alarm clock is an example of structure. So is a key chain, as well as a basket to put the key chain in every day when you get home. The habits of putting your key chain in the basket and putting your documents into the files also exemplify structure. Useful devices and new habits can help more than any medication.
Q: What are the most important lifestyle changes?
A: The six lifestyle changes I stress the most are:
1.Positive human contact. Due to our disconnected culture, people these days don’t get enough smiles, hugs, waves hello, and warm handshakes. Positive human contact is as important as, if not more so than, a good night’s sleep or a proper diet.
2.Reduce electronics (e.g., television, video games, the Internet). Studies have shown that too much “electronic time” predisposes to ADD.
3.Sleep. Enough sleep is the amount of sleep that allows you to wake up without an alarm clock. Without enough sleep, you’ll act like you have ADD whether or not you have it.
4.Diet. Eat a balanced diet. Eat protein as part of breakfast. Protein is the best long-lasting source of brain fuel. Don’t self-medicate with drugs, alcohol, or carbohydrates. Consider taking the various supplements discussed in chapter 25.
5.Exercise. Regular exercise is one of the best tonics you can give your brain. Even if it’s just walking for fifteen minutes, exercise every day. Exercise stimulates the production of epinephrine, dopamine, and serotonin, which is exactly what the medications we treat ADD with do. So exercising is like taking medication for ADD in a holistic, natural way.
6.Prayer or meditation. Both of these help to calm and focus the mind.
Q: What is coaching and tutoring as it applies to ADD?
A: An ADD coach is someone other than a parent or a spouse who can help a person get organized and stay on track. Coaches are available in many shapes and sizes, from the ultraexpensive executive coaches to the ultrainexpensive grandpa who coaches for free. There are national coaching organizations you can contact online for more information.
For many people, the most important intervention is targeted tutoring—tutoring targeted to correct specific problems or symptoms. This is usually reserved for children and young adults, but adults may benefit as well. The tutoring should be targeted to the specific need of the individual, as determined by the history and testing. For example, if you have trouble with written output, the tutoring should address that specifically; if you have trouble with arithme- tic, the tutoring should address that; if you have a reading problem, you should get help specifically aimed at that. It is important to address areas of cognitive weakness as early as you can. For global issues of time management, compensatory skills, and self-esteem, a professional educational therapist is best trained in counseling and learning theory. To learn about finding such a professional, go to www.aetonline.org.
Q: What other nonmedication therapies help?
A: The time-tested ones have already been mentioned: identifying and promoting strengths; education; structure; lifestyle changes; coaching, counseling, and tutoring.
Although as yet unproven, physical exercises specifically designed to stimulate the cerebellum may become mainstream interventions. There are various programs that do this, such as the Dore method, the Brain Gym, the Interactive Metronome, and the groups of exercises prescribed by occupational therapists.
Nutritional remedies can also help. Adding omega-3 fatty acids to the diet is useful for health in general. We suggest fish oil as the best source of the omega-3 fatty acids. Adding antioxidants to the diet can also help. Grape-seed extract is one of nature’s most potent sources of antioxidants; so are blueberries.
Q: What about medication?
A: You should never take medication until you know the facts and only if you feel comfortable doing so. Learn what is known before you decide. You’ll find that the facts are actually reassuring. When used properly, the medications for ADD are safe and effective. Research shows that medication is the single most effective treatment for ADD. It works for 80 to 90 percent of people who try it. When it works, it increases mental focus, which leads to improved performance in all domains of life. The most commonly used medications are the stimulants, like Ritalin or Adderall, or their long-acting equivalents, like Concerta, Ritalin LA, or Adderall XR. The nonstimulant amantadine has been used to great advantage in treating ADD, as has bupropion (Wellbutrin) and the newest nonstimulant, Strattera. If you are considering taking medication for ADD, be sure to see a doctor who has experience in prescribing them, as subtle adjustments can make a big difference.
Q: What are the dangers of stimulant medications?
A: All can cause a variety of side effects. The most common is appe- tite suppression. Occurring much less frequently are headache, elevated blood pressure, elevated heart rate, nausea, vomiting, insomnia, the development of tics or twitching, feelings of jitteriness or anxiety, feelings of agitation or even mania, and feelings of depersonalization or paranoia. All these side effects can be reversed by lowering the dose of the medication, changing the medication, or stopping it altogether.
Q: What else should I know about stimulant medications?
A: Here are some quick facts about stimulants, or STs:
• STs take effect in about twenty minutes and last from four to twelve hours, depending upon which one is taken.
• You may stop and start STs at will. For example, you can discontinue them over the summer or on weekends. Unlike antibiotics or antidepressants, you do not need to maintain a steady blood level of STs in order to derive benefit. Obviously, when you stop the STs, you lose the benefit until you start them up again.
• If you start on STs and get some benefit, that does not mean you will need to take STs for the rest of your life. Sometimes you learn new habits while taking STs that carry over to when you aren’t taking them, thus allowing you to discontinue the STs.
• There are no known dangers associated with long-term use of STs. The side effects that are going to occur usually occur right away. Long-term dangers may appear, but as yet they have not.
• STs are not addicting or habit forming if taken properly. On the other hand, if you grind them up and snort them or inject them, as some people do, then they are dangerous.
• STs do not lead to the abuse of illicit drugs. To the contrary, studies show that taking STs reduces the likelihood that you will self-medicate with other drugs.
• STs or some other nonstimulant medication, like Strattera or Wellbutrin, will work (i.e., improve mental focus without producing side effects that warrant stopping the medication) 80 to 90 percent of the time in people who have ADD. That means that 10 to 20 percent of the time no medication will help.
• You should never compel anyone to take STs or any other medication for ADD. This can create struggles that lead to bad outcomes.
Q: What alternative medications are there to stimulants?
A: Amantadine may be the best of all medications for ADD, but it is not widely used because when it was first tried the doses were too high and patients reported side effects. A doctor on the faculty of Harvard Medical School, William Singer, has pioneered its use at lower doses with excellent results. Not a controlled substance, not a stimulant, and virtually devoid of side effects, amantadine deserves much wider use.
The new medication Strattera, introduced in the winter of 2003, can also be helpful. Classified as a norepinephrine reuptake inhibitor, it is not a controlled substance. It reduces the negative symptoms of ADD for some people, but not for others. It is impossible to predict in advance who will benefit and who will not. You have to try it (under medical supervision, of course) to find out. In addition, the atypical antidepressant Wellbutrin can help treat ADD. Like Strattera, it is not a controlled substance.
From the Hardcover edition.
THE SKINNY ON ADD:
READ THIS IF YOU CAN’T READ THE WHOLE BOOK
Most people who have ADD don’t read books all the way through. It’s not because they don’t want to; it’s because reading entire books is very difficult—sort of like singing an entire song in just one breath.
We want to make this book accessible to people who don’t read books all the way through. For those people, our most dear and treasured brothers and sisters in ADD, we offer this first chapter, set off from the rest of the book. Reading this will give you a good idea of what ADD is all about. If you want to learn more, ask someone who loves you to read the whole book and tell you about it. Or you can listen to it on a tape or CD.
We offer this chapter in the ADD-friendly format of Q&A. You can get the skinny on ADD in these thirty questions and answers. For more detail and research-based answers, you can refer to the chapters of particular interest.
For those blessed readers who intend to read the entire book, some of what’s in this Q&A will appear again, but some of it won’t, so you too should read this section.
Q&A ON ADD
Q: What is ADD?
A: Attention deficit disorder, or ADD, is a misleading name for an intriguing kind of mind. ADD is a name for a collection of symptoms, some positive, some negative. For many people, ADD is not a disorder but a trait, a way of being in the world. When it impairs their lives, then it becomes a disorder. But once they learn to manage its disorderly aspects, they can take full advantage of the many talents and gifts embedded in this sparkling kind of mind.
Having ADD is like having a turbocharged race-car brain. If you take certain specific steps, then you can take advantage of the benefits ADD conveys—while avoiding the disasters it can create.
The diagnostic manual of mental problems, called the DSM-IV, defines ADD by a set of eighteen symptoms. To qualify for the diagnosis you need six. These diagnostic criteria are listed in chapter 12. But be careful when you read them. They describe only the downside of ADD. The more you emphasize the downside, the more you create additional pathology: a nasty set of avoidable, secondary problems, like shame, fear, and a sharply diminished sense of what’s possible in life.
The pathology of ADD—its disorderly side—represents only one part of the total picture.
The other part, the part that the DSM-IV and other catalogs of pathology leave out, is the zesty side of ADD. People with ADD have special gifts, even if they are hidden. The most common include originality, creativity, charisma, energy, liveliness, an unusual sense of humor, areas of intellectual brilliance, and spunk. Some of our most successful entrepreneurs have ADD, as do some of our most creative actors, writers, doctors, scientists, attorneys, architects, athletes, and dynamic people in all walks of life.
Q: What is the difference between ADHD and ADD?
A: It’s just a matter of nosology, the classification of disorders. There is an arbitrariness to it all. By the current DSM-IV definition, ADD technically does not exist. By the DSM-IV definition, the term ADHD includes both ADHD with hyperactivity (the H in ADHD) and ADHD without hyperactivity. Technically, this means you can have ADHD with no symptoms of H, hence there is no need for the term ADD. But ADD, the old term, is still used by many clinicians, including the authors of this book. Whichever term you use, the important point to know is that you can have ADHD (or ADD) without showing any signs of hyperactivity or impulsivity whatsoever. ADHD without hyperactivity or impulsivity is more common among females.
Q: What is the typical profile of a person who has ADD?
A: The core symptoms of ADD are excessive distractibility, impulsivity, and restlessness. These can lead both children and adults to underachieve at school, at work, in relationships and marriage, and in all other settings.
In addition, people who have ADD often also exhibit:
Advantageous characteristics:
• Many creative talents, usually underdeveloped until the diagnosis is made
• Original, out-of-the-box thinking
• Tendency toward an unusual way of looking at life, a zany sense of humor, an unpredictable approach to anything and everything
• Remarkable persistence and resilience, if not stubbornness
• Warm-hearted and generous behavior
• Highly intuitive style
Disadvantageous characteristics:
• Difficulty in turning their great ideas into significant actions
• Difficulty in explaining themselves to others
• Chronic underachievement. They may be floundering in school or at work, or they may achieve at a high level (getting good grades or being president of the company does not rule out the diagnosis of ADHD), but they know they could be achieving at a higher level if only they could “find the key.”
• Mood often angry or down in the dumps due to frustration
• Major problems in handling money and making sensible financial plans
• Poor tolerance of frustration
• Inconsistent performance despite great effort. People with ADHD do great one hour and lousy the next, or great one day and lousy the next, regardless of effort and time in preparation. They go from the penthouse to the outhouse in no time at all!
• History of being labeled “lazy” or “a spaceshot” or “an attitude problem” by teachers or employers who do not understand what is really going on (i.e., having ADD)
• Trouble with organization. Kids with ADD organize by stuffing book bags and closets. Adults organize by putting everything into piles. The piles metastasize, soon covering most available space.
• Trouble with time management. People with ADD are terrible at estimating in advance how long a task will take. They typically procrastinate and develop a pattern of getting things done at the last minute.
• Search for high stimulation. People with ADD often are drawn to danger or excitement as a means of focusing. They will drive 100 mph in order to think clearly, for example.
• Tendency to be a maverick (This can be an advantage or a disadvantage!)
• Impatience. People with ADD can’t stand waiting in lines or waiting for others to get to the point.
• Chronic wandering of the mind, or what is called distractibility. Tendency to tune out or drift away in the middle of a page or a conversation. Tendency to change subjects abruptly.
• Alternately highly empathic and highly unempathic, depending upon the level of attention and engagement
• Poor ability to appreciate own strengths or perceive own shortcomings
• Tendency to self-medicate with alcohol or other drugs, or with addictive activities such as gambling, shopping, sexualizing, eating, or risk-taking
• Trouble staying put with one activity until it is done
• Tendency to change channels, change plans, change direction, for no apparent reason
• Failure to learn from mistakes. People with ADD will often use the same strategy that failed them before.
• Easily forgetful of their own failings and those of others. They are quick to forgive, in part because they are quick to forget.
• Difficulty in reading social cues, which can lead to difficulty in making and keeping friends
• Tendency to get lost in own thoughts, no matter what else might be going on
Q: Aren’t most people somewhat like this?
A: The diagnosis of ADD is based not upon the presence of these symptoms—which most people have now and then—but upon the intensity and duration of the symptoms. If you have the symptoms intensely, as compared to a group of your peers, and if you have had them all your life, you may have ADD. An apt comparison can be made with depression. While everyone has been sad, not everyone has been depressed. The difference lies in the intensity and the duration of the sadness. So it is with ADD. If you are intensely distractible, and have been forever, you may have ADD.
Q: What causes ADD? Is it inherited?
A: We don’t know exactly what causes ADD, but we do know it runs in families. Like many traits of behavior and temperament, ADD is genetically influenced, but not genetically determined. Environment combines with genetics to create ADD. Environmental toxins may play a role, watching too much television may play a role, and excessive stimulation may play a role.
You can see the role of genetics just by glancing at basic numbers. We estimate that about 5 to 8 percent of a random sample of children have ADD. But if one parent has it, the chances of a child developing it shoot up to about 30 percent; if both parents have it, the chances leap to more than 50 percent. But genetics don’t tell the whole story. You can also acquire ADD through a lack of oxygen at birth; or from a head injury; or if your mother drank too much alcohol during pregnancy; or from elevated lead levels; perhaps from food allergies and environmental or chemical sensitivities; from too much television, video games, and the like; and in other ways we don’t yet understand.
Q: Other than its being heritable, is there any other evidence that ADD has a biological, physical basis to it, as opposed to psychological or environmental?
A: Brain scans of various kinds have shown differences between the ADD and the non-ADD brain. Four different studies done in the past decade using MRI (magnetic resonance imaging) all found a slight reduction in the size of four regions of the brain: the corpus callosum, the basal ganglia, the frontal lobes, and the cerebellar vermis. While the differences are not consistent enough to provide a diagnostic test for ADD, they do correlate with the symptoms we see in ADD. For example, the frontal lobes help with organization, time management, and decision-making, all areas that people with ADD struggle with. The basal ganglia help to regulate moods and to control impulsive outbursts, which people with ADD also struggle with. And the cerebellum helps with balance, rhythm, coordinated movements, language, and other as yet to be proven functions. It may be that the cerebellum is far more important in regulating attention than we realize today.
Q: How many people have ADD?
A: Roughly 5 to 8 percent (many experts would put that figure much higher, some lower) of the American population has ADD. The majority of adults who have it don’t know it because people used to think ADD was only a children’s condition. We now know that adults have it too. Of the roughly 10 million adults in the United States who have ADD, only about 15 percent have been diagnosed and treated. Until we have a precise diagnostic test for ADD, however, it will be impossible to give truly accurate figures. Studies around the world—in China, Japan, India, Germany, Puerto Rico, and New Zealand—show comparable figures.
Q: Does ADD ever go away on its own?
A: Yes. The symptoms of ADD disappear during puberty in 30 to 40 percent of children, and the symptoms stay gone. ADD therefore persists into adulthood 60 to 70 percent of the time. As the brain matures, it changes in ways that may cause the negative symptoms to abate. Then ADD becomes a trait rather than a disorder. In addition, sometimes the child learns how to compensate so well for his ADD during puberty that it looks as if the ADD has gone away. However, if you interview that child closely, you will discover the symptoms are still there, but the child is struggling mightily—and successfully—to control them. These people still have ADD and would benefit from treatment.
Q: Is ADD overdiagnosed among children?
A: Yes, but also no. It is overdiagnosed in some places, underdiagnosed in others. There are schools and regions where every child who blinks fast seems to get diagnosed with ADD. At the same time, there are places around the country where doctors refuse to make the diagnosis at all because they “don’t believe in ADD.” ADD is not a religious principle; it is a medical diagnosis derived from such solid evidence as genetic studies, brain scans, and worldwide epidemiological surveys.
It is important that we educate doctors, as well as teachers, parents, and school officials, about ADD, so that we can solve the problems of both overdiagnosis and underdiagnosis.
Q: What is the proper procedure to diagnose ADD?
A: There is no surefire test. The best way to diagnose ADD is to combine several tests. The most powerful “test” is your own story, which doctors call your history. As you tell your story, your doctor will be listening for how your attention has varied in different settings throughout your life. In the case of ADD it is important that the history be taken from at least two people, such as parent, teacher, and child, or adult and spouse, since people with ADD are not good at observing themselves.
To supplement the history, there is a relatively new physical test called the quantitative electroencephalogram, or qEEG, that is quite reliable in helping to diagnose ADD. It is a simple, painless brain-wave test, and it is about 90 percent accurate. Though well worth getting, it is not definitive by itself.
In complex cases where the diagnosis is unclear or there is a suspicion of coexisting conditions, especially if there is a history of head injury or other brain trauma, a SPECT scan can help. The SPECT brain scan is not widely available, though we believe it could help a great deal in psychiatry if it were.
In addition to the history, which should include questions based upon the DSM-IV diagnostic criteria, and the qEEG and sometimes the SPECT, other standardized sets of questions, such as the ADHD Rating Scale or the Brown scale, add confidence to the diagnosis. Your doctor can tell you about these tests. None are necessary, but all are helpful.
Finally, neuropsychological testing can help pin down the diagnosis as well as expose associated problems—such as hidden learning disabilities, anxiety, depression, and other potential problems.
Practically speaking, if you are going to see a busy primary-care doctor for your evaluation, the time available to take a history may be brief, and access to neuropsychological testing nonexistent. In these instances, the qEEG becomes even more valuable, as well as the standardized rating scales, especially the DSM-IV criteria.
The best diagnostic procedures also include a search for talents and strengths, as these are the key to the most successful treatments.
Q: Should you always order the qEEG, neuropsychological testing, or a SPECT scan?
A: All three can be helpful, but no, none is absolutely necessary, unless the diagnosis is in doubt, or you suspect associated learning disabilities such as dyslexia, or other coexisting conditions, like brain damage due to an old head injury, or bipolar disorder, or hidden substance abuse. In such cases, you might encourage your doctor to consider getting you neuropsychological testing, a qEEG, or a SPECT scan.
Q: Whom should I see to get a diagnosis?
A: The best way to find a doctor who knows what he is doing is to get a referral from someone you know who has had a good experience with that doctor. (We have provided a list of specialists at the end of this book.)
The degree the person has is much less important than his experience. People from diverse disciplines may be capable of helping you. Child psychiatrists have the most training in ADD, and keep in mind that most child psychiatrists also treat adults. However, child psychiatry is an underpopulated specialty; therefore, child psychiatrists are hard to find. Developmental pediatricians are also good with ADD, but, of course, they do not treat adults and they are also in short supply. Some regular pediatricians are excellent at diagnosing and treating ADD, while others—those who have not had much experience with ADD—are understandably less skilled. Some family practitioners and some internists are good. Adult psychiatrists tend not to have training in ADD. However, most psychologists do.
If you cannot get a referral from someone you know, ask your primary-care doctor if she is expert in ADD, and if not, to whom would she recommend that you go.
It is worth the hassle to look around. I see patients every day who wasted years because they went to see the wrong person.
Q: What are the most common conditions that may occur along with ADD?
A: Dyslexia and other learning differences, depression, oppositional defiant disorder, conduct disorder, antisocial personality disorder, substance abuse, post-traumatic stress disorder, anxiety disorders, bipolar disorder.
Q: What other problems should one be on the lookout for?
A: Trouble in school, at work, or at home. Underachievement, even if there are no signs of what others consider to be trouble. Sometimes when the ADD is diagnosed and treated, the trouble, whatever it is, or the underachievement remit. But often they need special attention in their own right. Tutoring, career counseling, family therapy, couples therapy, individual therapy, or coaching can all help.
Q: What else should one watch out for regarding the diagnosis of ADD and getting treatment?
A: Many people in the United States today—including those who have ADD and those who do not—suffer from what I call disconnectedness. They do not have the close, sustaining relationships that they need. While we are elaborately connected electronically in modern life, we are poorly connected interpersonally. Studies have shown that such disconnectedness leads not only to anxiety, depression, and underachievement but also to substance abuse, disruptive behavior, and a host of medical problems in both children and adults. Try to develop a connected interpersonal life for you and your family as seriously as you strive to maintain a proper diet or an exercise program.
Q: What about bipolar disorder in children? Does it look like ADD? How do you tell them apart?
A: It is important to keep bipolar disorder in mind whenever the possibility of ADD arises in a child. Some experts believe that if you give a child who has bipolar disorder stimulant medication, you run the risk of doing serious harm. These children can become violent, depressed, even suicidal. This is just another reason why you must see a well-trained professional for a proper diagnostic evaluation.
Several items help distinguish between ADD and bipolar disorder. First of all, in bipolar disorder there is usually a family history on both parents’ sides of bipolar disorder, alcoholism, major depression, or all of these. Second, in bipolar disorder the leading symptom is rapidly fluctuating moods independent of what is going on in the environment. In ADD the leading symptom is fluctuating attention. Third, the child with bipolar disorder often has a daily variation: he becomes highly active at night and in the morning he is like a hibernating bear, all but impossible to get out of bed. You can see this in ADD too, but it is more accentuated in bipolar disorder.
Q: What is the best treatment for ADD?
A: It varies. The best approach to treating ADD is to follow an individualized, comprehensive plan specifically designed for you, based upon your particular situation and needs. One size does not fit all. Work with your doctor to create the best approach for you (or for your child, or for whomever has the ADD). This plan should always be open to revision. If it doesn’t work, change it.
Q: What are the most common, key ingredients of such a comprehensive plan?
A: I divide the best plan into eight areas, as follows:
1.Diagnosis, as well as identification of talents and strengths
2.Implementation of a five-step plan that promotes talents and strengths (detailed in chapter 22)
3.Education
4.Changes in lifestyle (e.g., reduce TV and other electronics, increase time with family and friends, increase physical exercise)
5.Structure
6.Counseling of some kind, such as coaching, psychotherapy, career counseling, couples therapy, family therapy
7.Various other therapies that can augment the effectiveness of medication or replace the use of medication altogether, such as an exercise program that stimulates the cerebellum, targeted tutoring, general physical exercise, occupational therapy, and nutritional interventions
8.Medication
Q: In what ways are diagnosis, identification of talents and strengths, and implementation of a plan that promotes talents and strengths part of the treatment?
A: Getting a name for what’s been going on with you usually brings relief. When you get the ADD diagnosis, you can finally shed all those accusatory, “moral” diagnoses, like lazy, weak, undisciplined, or, simply, bad.
The identification of talents and strengths is one of the most important parts of the treatment. People with ADD usually know their shortcomings all too well, while their talents and strengths have been camouflaged by what’s been going wrong.
The moment of diagnosis provides a spectacular opportunity to change that. The best way to change a life of frustration into a life of mastery is by developing talents and strengths, not just shoring up weaknesses. Keep the focus on what you are, rather than what you are not. The older you get, the more time you should spend developing what you’re good at. Work with someone who can help identify what you’re good at. In the long run that’s where you will find fulfillment.
Q: What is the five-step plan that promotes talents and strengths?
A: The first step is to connect—with a teacher, a coach, a mentor, a supervisor, a lover, a friend (and don’t forget God or whatever your spiritual life leads you toward). Once you feel connected, you will feel safe enough to go to step 2, which is to play. In play, you discover your talents and strengths. Play includes any activity in which your brain lights up and you get imaginatively involved. When you find some form of play you like, you do it over and over again; this is step 3, practice. As you practice, you get better; this is step 4, mastery. When you achieve mastery, other people notice and give you recognition; this is step 5. Recognition in turn connects you with the people who recognize and value you, which brings you back to step 1, connect, and deepens the connection.
No matter what your age, you can use this five-step process to promote talents and strengths. Beware, however, of jumping in at step 3. That’s the mistake many parents, teachers, coaches, and managers in the workplace make: they demand practice and offer recognition as the reward. This leads to short-term achievement but fatigue and burnout in the long run.
For the cycle to run indefinitely and passionately, it must generate its own enthusiasm and energy, not be prodded by external motivators. To do that, the cycle must start in connection and play.
Q: Why is education part of the treatment?
A: Treatment really means learning how to fit the brain you have into the world most enthusiastically and constructively. The diagnosis becomes therapeutic through education—learning what ADD is in your case. Diagnosis means “to know through.” As you learn about your mind, and as you learn how ADD has affected your life, you gradually “know through” this condition, how it lives in you. The more you know about the kind of mind you have—whether or not you call it ADD—the better able you will be to improve your life.
Furthermore, the process of education will help identify your talents and strengths, or your potential talents and strengths. Take time, look hard, and get help in identifying these. You may not be able to see them yourself. People who have ADD often don’t think they have any talents or strengths.
If there were but one rule for treating ADD it would be this: Find out what you’re good at, and do it. Or, as my brother-in-law who is a teaching golf pro says, “Forget what the books say. Just do what you need to do to put the ball in the hole.”
Q: What if you’re not good at anything, or what if what you’re good at is illegal, dangerous, or simply lacking in any social value, like playing Nintendo?
A: Everyone has the seed of a talent. Everyone has some interest that can be turned into a skill that is legal, reasonably safe, and has value both to that person and to society. Everyone. The work of treating ADD is to find that talent or interest. It may be hidden or camouflaged. For example, if the activity you’re good at is selling drugs, well, that means you have entrepreneurial and sales talents and interests that could be plugged into some legal venture. If the activity you’re good at is driving down the highway at 110 mph, then you may have a career in some risk-filled, highly stimulating arena like investing on the commodities exchange or being an investigative reporter. If what you’re good at has no social value, like playing Nintendo, you might want to get a job at a computer-game store, or you might want to take a course in designing computer games.
The germ of a great career often lies hidden in the illegal, dangerous, or useless activities we love. Look for that germ cell. If you can’t find it, get someone else to help you look.
Q: What do you mean by “structure”?
A: By “structure,” I mean any habit or external device that helps make up for what is missing internally, in your mind. For example, the ADD brain is low on filing cabinets. So, you need to set up more filing cabinets outside the brain in order to replace piles with files. An alarm clock is an example of structure. So is a key chain, as well as a basket to put the key chain in every day when you get home. The habits of putting your key chain in the basket and putting your documents into the files also exemplify structure. Useful devices and new habits can help more than any medication.
Q: What are the most important lifestyle changes?
A: The six lifestyle changes I stress the most are:
1.Positive human contact. Due to our disconnected culture, people these days don’t get enough smiles, hugs, waves hello, and warm handshakes. Positive human contact is as important as, if not more so than, a good night’s sleep or a proper diet.
2.Reduce electronics (e.g., television, video games, the Internet). Studies have shown that too much “electronic time” predisposes to ADD.
3.Sleep. Enough sleep is the amount of sleep that allows you to wake up without an alarm clock. Without enough sleep, you’ll act like you have ADD whether or not you have it.
4.Diet. Eat a balanced diet. Eat protein as part of breakfast. Protein is the best long-lasting source of brain fuel. Don’t self-medicate with drugs, alcohol, or carbohydrates. Consider taking the various supplements discussed in chapter 25.
5.Exercise. Regular exercise is one of the best tonics you can give your brain. Even if it’s just walking for fifteen minutes, exercise every day. Exercise stimulates the production of epinephrine, dopamine, and serotonin, which is exactly what the medications we treat ADD with do. So exercising is like taking medication for ADD in a holistic, natural way.
6.Prayer or meditation. Both of these help to calm and focus the mind.
Q: What is coaching and tutoring as it applies to ADD?
A: An ADD coach is someone other than a parent or a spouse who can help a person get organized and stay on track. Coaches are available in many shapes and sizes, from the ultraexpensive executive coaches to the ultrainexpensive grandpa who coaches for free. There are national coaching organizations you can contact online for more information.
For many people, the most important intervention is targeted tutoring—tutoring targeted to correct specific problems or symptoms. This is usually reserved for children and young adults, but adults may benefit as well. The tutoring should be targeted to the specific need of the individual, as determined by the history and testing. For example, if you have trouble with written output, the tutoring should address that specifically; if you have trouble with arithme- tic, the tutoring should address that; if you have a reading problem, you should get help specifically aimed at that. It is important to address areas of cognitive weakness as early as you can. For global issues of time management, compensatory skills, and self-esteem, a professional educational therapist is best trained in counseling and learning theory. To learn about finding such a professional, go to www.aetonline.org.
Q: What other nonmedication therapies help?
A: The time-tested ones have already been mentioned: identifying and promoting strengths; education; structure; lifestyle changes; coaching, counseling, and tutoring.
Although as yet unproven, physical exercises specifically designed to stimulate the cerebellum may become mainstream interventions. There are various programs that do this, such as the Dore method, the Brain Gym, the Interactive Metronome, and the groups of exercises prescribed by occupational therapists.
Nutritional remedies can also help. Adding omega-3 fatty acids to the diet is useful for health in general. We suggest fish oil as the best source of the omega-3 fatty acids. Adding antioxidants to the diet can also help. Grape-seed extract is one of nature’s most potent sources of antioxidants; so are blueberries.
Q: What about medication?
A: You should never take medication until you know the facts and only if you feel comfortable doing so. Learn what is known before you decide. You’ll find that the facts are actually reassuring. When used properly, the medications for ADD are safe and effective. Research shows that medication is the single most effective treatment for ADD. It works for 80 to 90 percent of people who try it. When it works, it increases mental focus, which leads to improved performance in all domains of life. The most commonly used medications are the stimulants, like Ritalin or Adderall, or their long-acting equivalents, like Concerta, Ritalin LA, or Adderall XR. The nonstimulant amantadine has been used to great advantage in treating ADD, as has bupropion (Wellbutrin) and the newest nonstimulant, Strattera. If you are considering taking medication for ADD, be sure to see a doctor who has experience in prescribing them, as subtle adjustments can make a big difference.
Q: What are the dangers of stimulant medications?
A: All can cause a variety of side effects. The most common is appe- tite suppression. Occurring much less frequently are headache, elevated blood pressure, elevated heart rate, nausea, vomiting, insomnia, the development of tics or twitching, feelings of jitteriness or anxiety, feelings of agitation or even mania, and feelings of depersonalization or paranoia. All these side effects can be reversed by lowering the dose of the medication, changing the medication, or stopping it altogether.
Q: What else should I know about stimulant medications?
A: Here are some quick facts about stimulants, or STs:
• STs take effect in about twenty minutes and last from four to twelve hours, depending upon which one is taken.
• You may stop and start STs at will. For example, you can discontinue them over the summer or on weekends. Unlike antibiotics or antidepressants, you do not need to maintain a steady blood level of STs in order to derive benefit. Obviously, when you stop the STs, you lose the benefit until you start them up again.
• If you start on STs and get some benefit, that does not mean you will need to take STs for the rest of your life. Sometimes you learn new habits while taking STs that carry over to when you aren’t taking them, thus allowing you to discontinue the STs.
• There are no known dangers associated with long-term use of STs. The side effects that are going to occur usually occur right away. Long-term dangers may appear, but as yet they have not.
• STs are not addicting or habit forming if taken properly. On the other hand, if you grind them up and snort them or inject them, as some people do, then they are dangerous.
• STs do not lead to the abuse of illicit drugs. To the contrary, studies show that taking STs reduces the likelihood that you will self-medicate with other drugs.
• STs or some other nonstimulant medication, like Strattera or Wellbutrin, will work (i.e., improve mental focus without producing side effects that warrant stopping the medication) 80 to 90 percent of the time in people who have ADD. That means that 10 to 20 percent of the time no medication will help.
• You should never compel anyone to take STs or any other medication for ADD. This can create struggles that lead to bad outcomes.
Q: What alternative medications are there to stimulants?
A: Amantadine may be the best of all medications for ADD, but it is not widely used because when it was first tried the doses were too high and patients reported side effects. A doctor on the faculty of Harvard Medical School, William Singer, has pioneered its use at lower doses with excellent results. Not a controlled substance, not a stimulant, and virtually devoid of side effects, amantadine deserves much wider use.
The new medication Strattera, introduced in the winter of 2003, can also be helpful. Classified as a norepinephrine reuptake inhibitor, it is not a controlled substance. It reduces the negative symptoms of ADD for some people, but not for others. It is impossible to predict in advance who will benefit and who will not. You have to try it (under medical supervision, of course) to find out. In addition, the atypical antidepressant Wellbutrin can help treat ADD. Like Strattera, it is not a controlled substance.
From the Hardcover edition.
Excerpted from Delivered from Distraction: Getting the Most Out of Life with Attention Deficit Disorder by Edward M. Hallowell, John J. Ratey
All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
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