Pay attention!

Dr. Edward Hallowell talks about adult ADD and why the neurochemical imbalance that causes you to space out may actually be a blessing in disguise.

By Christopher Dreher
Published February 11, 2005 9:00PM (EST)

On a recent night, it was standing room only in the lecture room at the Wellesley Free Library in Wellesley, Mass., and after Dr. Edward Hallowell finished his talk, the line of people wanting a book signed snaked out into the hallway. It's the sort of crowded reception you'd expect for a celebrity doctor who specializes in weight loss or maybe plastic surgery, though Hallowell's field of expertise is a brain disorder that afflicts tens of millions of people, yet whose symptoms are still considered by some to be a sign of poor behavior rather than neural chemistry.

In 1994, Hallowell published "Driven to Distraction," a groundbreaking bestseller about attention-deficit hyperactivity disorder (ADHD), and he became the most recognized ADHD specialist and researcher. (The clinical term is ADHD, but it's often simply called ADD, partly because hyperactivity is not a requirement for the disorder.) His book has sold over a million copies and is still considered one of the indispensable bibles of ADD literature by both patients and therapists.

Although subheaded "Recognizing and Coping With Attention Deficit Disorder From Childhood Through Adulthood," the book's major impact was in calling attention to the disorder in children. Hallowell and coauthor John J. Ratey estimate that ADD affects 5 to 8 percent of the general public. During the decade since the book was published, ADD represented a miracle diagnosis for many parents who couldn't handle their disruptive, hyperactive children. It also became the most studied childhood psychiatric disorder, while the word "Ritalin" entered the American lexicon and behavioral drugs to treat ADD became an industry worth hundreds of millions of dollars annually. Yet to many people, the explosion of ADD diagnoses meant a rash of overdiagnosing and overprescribing, and they insisted that Ritalin and other behavioral drugs were being used as a substitute for parental attention and signaled eroding family values.

Hallowell, who himself has ADD, and Ratey recently released a follow-up book, "Delivered From Distraction: Getting the Most out of Life With Attention Deficit Disorder," which includes the latest research and medical findings on ADD, as well as the authors' unique strategies for dealing with the disorder. What's especially noteworthy about the new book is how much more attention Hallowell and Ratey give to adults than in the previous book, indicating a shift in recent years as psychiatrists have been diagnosing adults in record numbers. (When I talked to Hallowell, he pointed out that ads for Strattera drove public awareness of adult ADD. "It was a market-driven issue that led to increased interest," he said.) The new book also has a self-diagnosis section and guidelines for ADD and marriage, family life, sex, dealing with children, and how to live with an ADD spouse.

While there are still a number of questions about adults and ADD (perhaps best illustrated by these dueling headlines that appeared last fall in HealthDay and the New York Daily News: "Adult ADHD: An Overlooked Problem" and "It Doesn't ADD Up: Do You Have Attention Deficit Disorder, Or Are You Simply Overworked?"), new studies provide some alarming facts. For example, in September, Dr. Joseph Biederman, a professor of psychiatry at Harvard Medical School, released a study claiming that ADD costs Americans suffering from the disorder about $77 billion in lost income a year, more than the total cost of drug abuse or depression.

But in his new book, Hallowell insists that ADD is not just a pathology and can actually be a source of creative and intellectual gifts, if treated properly. "The best way to think of ADD is not as a mental disorder," he writes in the introduction, "but as a collection of traits and tendencies that define a way of being in the world."

Salon spoke to Hallowell about ADD's positive side, its role in everything from sex to crime, and why the American gene pool is filled with ADD.

What's changed since you wrote "Driven to Distraction" in 1994?

Back when "Driven to Distraction" came out, most people had never heard of ADD. The problem now is that people know about it but they don't understand it. We find ourselves having to correct a lot of factual errors while back then we just had to provide information. The average person still might think the only treatment is medication, or they might have all sorts of misconceptions about ADD. They think that it's overdiagnosed or that it's an excuse or that it means you're stupid or that you have to be hyperactive to have it. That's all wrong information, and because of that people who really have the disorder might end up getting no treatment or the wrong treatment.

This new book is an attempt to get them the right information so they can get the tremendous help this diagnosis and treatment offers. It really is remarkable the kind of turnaround a person can experience. They can go from profound frustration and underachievement to major reversal, not only professionally but in their personal lives as well. A marriage can be saved, and a family can go from struggling bitterly every day to getting along. A career can go from a feeling of chronic frustration and a sense of "I don't get it" and "I'm not getting where I want to go" to the exact opposite.

Have your thoughts on ADD changed since the last book?

The biggest difference is that I now really see the condition as a potential gift. It's a potential gift because people with ADD tend to have -- embedded in the disability, embedded in the problem -- sparkling qualities such as creativity, energy, intuition, the ability to think outside the box, tenacity, feistiness. Embedded in what's going wrong is a lot that can be made to go right. Take one of the core symptoms: impulsivity. Well, what is creativity but impulsivity gone right? You don't plan to have a creative idea; it happens impulsively. You don't say, "Well, it's 10 o'clock in the morning, time for my creative idea," and lay it like an egg. It happens by the random collision of thoughts, and then suddenly you say, "Wow, a new idea!" So the point of treatment is to take this condition and unwrap the gifts. It's often wrapped in a lot of problems like disorganization, procrastination, distractibility, impulsivity, restlessness. You don't want to just curtail the negative symptoms. It's even more important to look for and try to promote and develop the positive attributes.

I think we ought to treat it that way, but in the medical profession we're not doing that. That's something that sets this book apart from others and what sets my approach apart as well. I think a strength-based treatment is essential to get the best outcome and bring out the latent hidden talents in people.

How did ADD become so popular? What I mean is, how did it garner -- and so far sustain -- so much public interest?

It's because this is such a prevalent and misunderstood issue. Once you start talking about ADD, that becomes obvious. Everyone says, "Yes, gosh, I'm like that" or "My son is like that." And modern life itself is coming to resemble ADD, so more and more people are wising up to the fact that this is something worth knowing about.

A severe case of modern life can render someone to look as if they have ADD. That's something I call pseudo-ADD, and that condition is rampant. It happens with people who are harried, overcommitted, rushing around. The key is, How do you distinguish the inbred, inborn biological attention deficit disorder from a byproduct of modern life?

Well, how do you tell the difference?

There is no proof positive test, meaning we don't have a brain scan yet to tell whether someone has ADD or not. So you take a careful history, and if someone has the symptoms for a long time, and those symptoms are interfering with their life, and if they occur in multiple settings, then it's ADD.

If, on the other hand, the symptoms only occur at work, then it's a work issue, or if they only occur at home, it's a home issue. What you find is that sometimes the symptoms occur at home but they don't occur when someone's on vacation. You might not have true ADD but you end up with the same symptoms, such as distractibility and feeling overloaded, and then you're making impulsive decisions in that context. So the book is useful for both groups.

What are the biggest environmental factors causing pseudo-ADD?

The biggest factor is just simply information overload. The key is that you need to be in charge of [the information] instead of letting it be in charge of you.

In terms of data points, voice mail and e-mail are at the top of the list. And then you have decision points, which are a little bit more stressful because every one of those bits of data usually begets a decision -- "What do I do with this?" -- and that's more stressful. Just receiving the data, the physical act of listening or reading, is hard enough, but then each one of those bits of data leads to a decision. One or two decisions is fine, but when you're dealing with a hundred of them each morning you reach a point where you become distracted and less creative because you start to get impatient and irritable. You end up turning your back on opportunities simply because you're overloaded and it's too much to handle. And that bad feeling of "I just can't take it anymore" leads to diminished efficiency, less open-mindedness and flexibility, and less ability to use your uniquely human capacities to their best advantage.

But again, it depends how you manage it. I'm not a Luddite; I'm not anti-technology. I'm a passionate believer in managing technology so it doesn't manage us. For example, if you text message to advance a business deal, that's great, but if you text message instead of advancing a business deal, that's a problem. Or it's a problem if you have to respond to every text you get. Some people don't realize what a hold this has over them, and it becomes like an addiction, where they feel compelled to answer the telephone whenever it rings. You don't have a full-blown withdrawal syndrome, but you have a mild withdrawal. You define an addiction as anything that when you take it away you go into withdrawal, and when you take away some people's cellphone, e-mail and voice mail they become agitated. They feel naked.

Are addiction and ADD often diagnosed together?

In the addiction population probably 15 percent have undiagnosed ADD. Unfortunately, most addiction specialists don't think of it, so the addiction is treated but not the ADD. That leaves a gaping wound, and it's only a matter of time until they relapse. But if you catch on to the ADD early, it'll make it much easier to give up the addiction.

A man who came to see me had a history of alcoholism and had gotten sober but still felt stuck. Even though he was doing well in his work, he wasn't happy doing it, and also in his relationship he felt stuck. I evaluated him, and he had ADD, and it was a dramatic revelation for him. He said, "My God, I knew getting sober helped me, but this is the other key I've been looking for, and it makes sense of my whole life up until now." Once he realized that, he was able to make some changes at work, such as delegating more administrative details and doing what he was good at instead of trying to get good at what he was bad at -- which is another hallmark of ADD. He brought his wife in and we worked on explaining what was going on in the relationship, and she began to understand him better in terms of brain science instead of character pathology.

Is that why you have tried mixing ADD treatment with a 12-step format?

It's an unusual approach but it can be very helpful. I've observed over the years that a lot of adults with ADD were behaving like addicts. They'd become addicted to negative thinking or procrastination or missed engagements, and in a funny way they couldn't live without it. So I thought, why not try to treat this as though it were an addiction? Some people have really benefited from the 12-step approach. You begin with "I'm powerless over my negative thinking," or "I'm powerless over my tendency to procrastinate."

From what you wrote, one of the worst results of the disorder is that people with ADD acquire negative self-image problems. Is there a specific time in life when that sort of thinking starts?

No, the negative self-image begins when you start to feel frustrated, when you start to underachieve and you don't know why, and that can be anytime. Underachievement and a sense of frustration and feeling down on yourself and down on life are the hallmarks of undiagnosed ADD. And the older you get the more pronounced that becomes, and the longer you go without the diagnosis and treatment the more likely it is that you're going to suffer from this very negative version of yourself. Because all you've been experiencing is underachievement, and you don't understand why, and the more you try the more you come up short, and the longer you're driving on square wheels the more upsetting it is. And believing that you're a loser [for most of your life] is what's so disabling and so terribly, terribly difficult.

I've treated hundreds of people from age 6 to 86 who have been experiencing chronic frustration and they don't understand why they feel like a loser. And then you supply them with the simple insight that they lack focus due to the way their brain is wired, and you provide them with focus, and suddenly they start to achieve at a much higher level. They're able to communicate more clearly and organize more effectively.

It's the direct result of what lack of focus can do vs. what proper focus can do. And most people are just not aware of how incredibly damaging being unable to pay attention can be. And the key is that it's "unable" as opposed to "unwilling." But what the spouse, the teacher or the employer often thinks is that it's unwillingness.

Does ADD affect children and adults in fundamentally different ways?

No, the same symptoms -- distractibility, impulsivity and restlessness -- that same triad is present in both children and adults. Though one difference is that the lives of adults are different from those of children. It can be a less obvious problem for adults because adults are allowed to do what they're good at, and they're not forced to do what they're bad at. Whereas kids are forced to do both what they're good at and what they're bad at. We ask kids to be good at everything, but adults don't have to be.

Of course, the longer you live with undiagnosed ADD, the more likely it is that you'll come under the influence of secondary problems like anxiety and depression. If you feel chronically frustrated, that's depressing and anxious-making. That's more of a problem in adults.

What did you mean when you wrote that in the world of ADD "landing is learned in midair"?

The person with ADD typically puts off studying, understanding or learning a new skill until it's a crisis, and they're about to crash to the ground. Only then do they pull out their book or instruction manual or get ready for a presentation. Amazingly enough, they're often able to pull it off, but there are those times they don't, and they crash. It's horribly damaging to a student's life or an adult's career or someone's marriage if someone is always trying to produce results at the last minute.

But there are professions in which that type of behavior can help you succeed.

Some professions are filled with ADD. Journalism is a hotbed. So is advertising and the stock market. Anything that involves creativity, risk, excitement, you'll find a lot of ADD people. Hollywood is ADD heaven. Actors and everyone out there thinks they have it. It's because it's high stimulation -- the structure is changing all the time and it's an adventure. Entrepreneurship of any sort is a great profession for people with ADD. A lot of doctors have ADD, a lot of trial attorneys, a lot of people in sales.

The careers that are bad for people with ADD are those that put a high premium on conformity, punctuality, doing what you're told, repetition and organization. A mid-level executive in an insurance company is going to be in ADD hell. Probably a mid-level executive anywhere would be.

If possible, it's best for people with ADD to be self-employed. If you're a writer, be freelance, but have a wonderful assistant who has attention surplus disease. Some people are just born better organizers.

In the book, you write about a number of the social costs caused by undiagnosed ADD.

The prisons are just full of people with ADD. The stats are hard to get because prisons won't let you go in and do testing, but people estimate that well over 50 percent of the prison population has undiagnosed ADD or an undiagnosed language-based disability. In other words, they can't put feelings into words and they're impulsive. Add that to poverty and drugs and alcohol and you have a criminal. That and being male, because 95 percent of the prison population is male, which is such a staggering statistic. Men have such a hard time dealing with aggression. And dealing with feelings in any way except being more aggressive.

Is ADD an American phenomenon? It hasn't been diagnosed as frequently in any other country.

We have more diagnoses, but not more people that have it. The epidemiological studies in places as far away as Indonesia show roughly the same prevalence rates, roughly 5 percent of the population. The reason we diagnose more is because we've led the world in ADD research and educating the general public.

It also has to do with the type of people that originally came to America. I think our gene pool is loaded for ADD. Those who colonized the country tended to be the mavericks, the people who didn't want to sit still, those who wanted to set off on their own. Our country was built by people like that.

I don't like these lists people trot out all the time speculating which historical figures might have had ADD -- Edison and Einstein and others. But certainly there have been people who fit an ADD profile. Obviously I haven't met them, so I can't diagnose them, but ADD traits are very much in the American grain. I mean, if you read a description of the early colonists, it's like an ADD hall of fame. Benjamin Franklin -- if he didn't have it I'd be amazed. The positive qualities of innovation, thinking outside the box, trying to get a lot done, all of that is very much in our gene pool.

Some people would say that besides the most obvious cases, ADD is diagnosed too frequently. For example, in her recent book "Home Alone America," Mary Eberstadt wrote about diagnosing children that the current criteria "cast as pathological a great many other children who have what could be called the now-you-see-it, now-you-don't variety" of ADD. There's the same sort of perception with adult diagnosis as well.

I think what those people worry about is that the diagnosis is being used as an excuse, and it should never be used as an excuse. It's not an excuse to get out of taking responsibilities, it's an explanation to help you take responsibility more effectively. And it shouldn't become a political issue, and it veers dangerously toward that all the time.

People will ask me, "Do you believe in Ritalin?" and I'll say, "It's not a religious or political principle, it's a medication, for goodness' sakes." It's not a matter of "Do you believe in ADD?" It's brain science. It's a diagnosis made to help people, to advance knowledge, to help people learn better. I feel very strongly and passionately committed to keeping it away from the rhetoricians who want to turn it into an article of faith or belief. If we keep it in the realm of reason we can make use of what we know and not get lost in the quagmire of political and religious debate.

Why does it get politicized like that?

We unwittingly approach conditions of the mind differently from conditions of the body. There's a sort of unspoken bias that when it comes to the mind you're not supposed to even talk about it let alone intervene using medication or other formal treatment. It's the same sort of bias mental health professionals face all the time. It's been around forever.

But again, don't play up the bias. That's what always bugs me about the media; they want to talk about bias and prejudice, but that's just a footnote. I mean, I love the press, don't get me wrong, I wouldn't be talking to you if I didn't, but for some reason the media always wants to write about the problems and biases and conflicts. I guess it's sexier that way, but the big story ought to be that we've identified an issue and we're developing strategies for dealing with it. Whether it's ADD in a classroom or pseudo-ADD in the workplace, this is a really common issue that affects tens of millions of people, and we're developing guidelines for helping people to deal with it. And that's really good news.

OK, let's finish up with sex, then. There's a section of your book devoted to ADD and sex. Usually, those two things aren't really discussed together.

The sex part is very interesting and I'm quite certain nobody has written about this. I just learned about it by treating so many adults with ADD. There are a few common patterns.

One is couples who almost never make love. And they think, Oh God, I guess we're losing interest in each other, but that's not really the case. It's a scheduling problem. If you think of ADD, one of the biggest problems is showing up in the right place at the right time. And what happens with these couples is that the ADD person will stay up until all hours of night on the computer, so the two are never awake and in bed at the same time. A simple behavioral prescription often works: Pick a night, any night, and show up in bed at 10 o'clock, naked, and see what happens. You might end up just watching "Law and Order," but you might end up making love, and most of the time that's what happens.

Another sexual issue is that women who have undiagnosed ADD have trouble reaching orgasm. They might blame it too much on a Catholic upbringing or something like that, but that's not the problem. It's that they can't focus long enough. Especially for women, sustained focus is essential for an orgasm, and it's not going to happen if you're lying there and wondering about the kids' doctors appointments the next day. Medication can make a huge difference by helping them focus. Those have been some of my most grateful patients.

A third problem is when men essentially use sexuality as a form of self-medication, and they become sex addicts, or whatever you want to call it. It can happen with women, too, but it's mostly men. And they think, I'm a bad person, and that sort of thing, but in reality it's undiagnosed ADD, and when they get the ADD treated they're able to stop compulsive sexualizing.

The ADD person looks for high stimulation and that can be found in any number of different ways. Drug abuse is one way, gambling is another way, risk-taking behaviors like driving a hundred miles per hour down the highway is another way. But you can also get that same high stimulation in healthier ways. Physical activity, entrepreneurial endeavors, those are good ways. The goal is not to get rid of the desire to seek the high stimulation, but to find adaptive ways of doing it.

Christopher Dreher

Christopher Dreher is a writer living in Plymouth, Massachusetts.

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