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John Ratey, MD ADHD Article

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Foibles, Frailties and Frustration seen through the Lens of Attention

By John Ratey, MD and Andrea Miller, BS

The following case histories describe three adults with ADD who have been evaluated by Dr. Ratey. The names have been changed to insure confidentiality.

T.W. is an attractive, intelligent young man who nevertheless has spent much of his life feeling like a miserable failure. This sense was full realized when, as a teenager, he flunked out of a number of preparatory schools and by the age of eighteen was a veteran of multiple 12-step programs. Much as he tried, he could not take any interest in his classes nor attend to the teacher's presentations. As a young adult he finds his interpersonal relationships increasingly problematic because of their multidimensional demands. For him every moment is electrified and he easily becomes overwhelmed, all the more so when dealing with other people. He thus has a tendency to simplify other people into black and white, never seeing them as they really are. When he is able to see something through to completion, the results, invariably fall short of his and others' expectations; this further reduces his confidence. He never seems able to direct his focus or energy and thinks this is due to be lazy.

T.S. was a difficult child to manage, often impulsive and unproductive in school. T.S.'s mother would go to great lengths to engineer her environment so that she would have less opportunity to act out, but this only fostered her growing resentment over her mother's attempts to "force her into some kind of mold". Her teenage years were filled with a constant entourage of boys, a source of worry to her mother and a cause for teenage gossip. The boys were replaced in college by a husband and shortly thereafter, a child. The child changed T.S.'s life, giving her a purpose, a mission, a motivating force around which she could finally organize herself-until the child left for nursery school. At that time things seemed to fall apart. She became obsessed with suicidal fantasies. T.S. survived this period but still feels dissatisfied with herself, considering herself immature, a closet borderline personality, somebody who craves intensity and who is perpetually masking an internal state of chaos.

M.F. grew up in a poor, abusive family which, under her father's rule, moved often enough so that she attended eighteen different grade schools. M.F. did very poorly academically and socially even though she was not hyperactive. She has difficulty organizing her thoughts and claims that cognitive concepts are exceedingly difficult to grasp. She is very quiet and shy and does not usually advocate for herself. She describes herself as a chameleon who attempts to fit unobtrusively into her environment. She lives her life in clutter, gets distracted very easily, and feels that she could accomplish a lot if she could manage to find some free time. Self-initiation is nearly impossible for her and so she goes on and on in her life in what she calls her "droning hum," wishing all the while she should sing and shout and be joyful.

These cases represent the brief histories of three people recently seen with a diagnosis of Attention Deficit Disorder. Like many people with attention deficit problems, these adults lived much of their lives wondering what was wrong with them, ultimately attributing their failings, as others often did, to defects in character or inner psychic weakness. Their lives seemed to revolve around crisis after crisis and seldom did they feel truly successful in their endeavors.

Too often the professionals who work with adults explicitly or implicitly support the adult's belief that his or her problems stem from a lack of motivation. This occurs primarily because the professional does not recognize the problem as being one of attention. Looking at the behavioral patterns and problems of these adults through the lens of attention significantly alters the way in which one views their frailties and foibles. In addition, it offers the professional an opportunity to help the adult develop a sense of self worth as a productive person able to relate well to others.

Our experience has shown that the problems of adults who are eventually diagnosed as having attentional deficits and who seek treatment with a therapist or support group, tend to be the result of a number of common themes which often disrupt the person's enter life. They include: the adult's need for conflict and the tendency to repeat traumas, problems in initiating action, the dangers to be found in success, and an array of interpersonal problems. We will discuss briefly what we have found to be the most effective thrapeutic strategies in enabling the adult with attentional difficulties to gain a sense of self-esteem, personal effectiveness, and the opportunity to sing and shout instead of "making do in a droning hum."

The Need for Conflict and Trauma

Adults with Attention Defcit Disorder frequently experience a state of internal disorganization that may lead them to crave high intellectual charge and be either positive or negative. The exact nature of the stimulus is not as important as the need for the experience to be of high intensity. Our clinical experience indicates that the intensity of the experience organizes the individual and thus induces an inner state of calm.

The disorganization, emptiness, and boredom (in the form of lack of directedness) that follows the resolution of conflict and trauma can lead again to the internal state that adults with ADD find intolerable. Consequently, there is a need for new and perhaps even more compelling conflict and repetition of old traumas as the individual seeks to organize experience. The formal mechanism behind this cycle might best be grasped by briefly examining the way in which people typically process and make snese of their experience. Information is taken in from the environment through the limbic system, which regulates mood, memory, and arousal. The limbic system classifies and sorts the information along emotional and perceptual lines, and then transfers the data to individual data banks comprised of similar information, thus making it likely that the appropriate memory store is chosen based upon its affective quality. Morton Reiser, who has described the process in more detail, terms the individual stores of related information, "affect-laden nodal neural nets."

It may be that the person with attentional deficits has only a few big "pots" in which to store experience. The affective quality that defines the "pot" is that of intensity, excitement, and thrills, as opposed to the more differentiated categories of love, joy, sadness, remorse, etc. Whether the lack of highly differentiated, cognitive-affective structures is primary to the attentional deficit or caused by it might not matter as much as how that structure comes to guide and govern the person's experience. The need for high stimulation becomes "hardwired" into the individual's brain and the individual is then prompted to continually seek it out-internally from old traumas, or externally through conflict and new traumas. In other words, pathways in the brain become fixed around the high stimulus "recipe," thus mandating that the individual attemtp to assemble the appropriate ingredients, the least desirable of which are boredome and emptiness.

Such a view is very valuable when evaluating and interpreting the experiences of ADD adults. It was earlier described that T.S. suffered a severe depression when her child left home to attend nursery school. In fact the constant care required by an extremely dependant child is a highly stimulating activity, and the loss of the child to nursery school deprived T.S. of the object around which she had come to orgainze her experience. Becasue the recipe mandated by T.S.'s intensity pot included high stimulation, regardless of the type, her new orgainzer very quickly and ingeniously became her suicidal fantasy. In order to function in a healthy and productive manner, T.S. would need to find more constuctive ways to orgainze herself. This approach toward addressing her suicidal fantasy in in stark contrast to her own analysis and determination that the existence of the fantasy was evidence of her "borderline" personality.

Problems in Initiating Action and the Dangers of Sucess

The notion of failure has often become a life theme for adults with attention problems, especially those whose disorder went unrecognized and therefore untreated during childhood and adolescence. Distractibility, h yperactivity, impulsivity, and the frequent inability to learn from past experience (due, perhaps, to the failure to attend to relevant cues from the enviornment) have all interfered with the individual's ability to accomplish any number of life's important tasks. As a result the adult has internalized an image of failure that manifests itself whenever he/she is called on to begin anything new.

The repeated image of failure and the sonstant fear that all will not come out as planned eventually causes the adult to avoid beginning the new project, the new job, the new school, or the new relationship. This difficulty in initiating action further complicated by the individual's ability to become easily distracted from his or her particular plan, and also, by the individual's belief that his control rests somewhere outside of himself.

T.W. becomes so unnerved when a situation requires a course of action that each successive step toward completion becomes magnified andoverwhelming. The normal sequence of behavior-outcome-consquences (which he imagines will be failure) becomes compressed and his entire sense of continutiy and sequence is disrutped. It is as if each of life's moments is falling one upon the other so that any feeling of furture is lost. Thus, he panics. The nature of this experience leads him to avoid the panic. Sadly, he comes to see himself as lazy.

M.F. also avoids initiating action. In contrast to those who have attention deficits with hyperactivity, M.F.'s condition (ADD without H) increases h er tendency to avoid exploring the environment. It also makes her even more dependent upon external sources to gain a feeling of control. She is very shy and cannot advocate for herself. (It is worth noting that advocation for the self could be considered a form of self-initiation.) Her partner of many years structures much of her time and activity. Any interruption from her partner while she is engaged in an activity causes her to "lose her stride" and become enraged. Her feelings of rage immediately send her into a state of near paralysis because of her inability to advocate for herself and because of her belief that the control for action actually rests in her partner.

Ironically , achieving success holds its own type of danger for those ADD adults who have the ability to see a project (or crisis) through to the end. The reason for this is as complex as it is simple-accomplishments lead to a sense of completion. This poses a threat to the individual because closure and the loss of the project or crisis is accompanied by the loss of goal-directedness. Thus the ADD adult becomes trapped in a terrible bind: one cannot finish what one cannot even begin, and one does not wish to begin what cannot be finished.

Probelms with Intimacy: "How can I be Heart to Heart when I can't even be eye to eye?"

Perhaps the biggest reason why previously undiagnosed adults with attention deficits seek treatment is their chronic failure to form healthy intimate relationships. One reason may be that ADD characteristics, such as physical jumpiness and the constant need for intense and/or mulitple sources of stimuli, make it nearly impossible for the adult to sustain the emotional and cognitive contact that intimate relationships demand. Even a firm desire to commit to a relationship often is not enough to prevent the adult from becoming bored, distracted, or discuraged within the relationship.

Intimacy in relationships can also be difficult to achieve because the nature of the attention deficit proves very hard on the partner. The partner can feel undervalued due to both the distractibility of the ADD adult and the tnedency of that adult to throw existing energy into activites other than the relationship in repeated attempts to achieve order. Also, the distractibility and impulsivity of the ADD adult can lead him or her to underract or overreact to the requests, needs, and problems of the partner. The ADD adult may be aware of these inappropriate reactions but frequently can do nothing to correct the situation. One adult we know described the experience of overreacting as a "freight train" that could not be stopped.

The repeated failures in intimate relationship may prompt the ADD adult to develop an attitude toward intimacy that further hinders the possibility of achieving it. Intimate relationships become associated with situational demands that the ADD adult finds impossible to meet. A self-fulfilling prophecy is created where the individual expects failures in intimacy, defensively determines that he or she does not want or need intimacy, develops avoidance strategies pertaining to relationships with others (such as emotional withdrawal) and then experiences even greater difficulty in achieving intimacy. The end result of the process offers yet another opportunity to berate oneself over one's inabilities.

The Social Paradox of ADD: Asocial Behavior and the Fear of Being Alone.

In addition to difficulties in achieving intimate, one-to-one relationships with others, ADD adults face difficulties i being effective in the wider social world. Such difficulties can be subtle, yet still impair the quality of the adult's experiences. Some ADD adults have reported a history of antisocial behavior such as cheating while some feel they do not know how to treat people properly. Others, like T.W., engage in self-destructive and/or risk-taking behaviors that very often involve substance abuse. Still others report that they feel like they are morally corrupt. We believe that such antisocial behavior tems from the adult's feelings of being bad, of constantly falling short of personal and interpersonal expectations, of failing again and again. The interplay between the feelings of "badness" and inner chaos prompts many adults to "act out," not unlike a child's acting out, but with the understated skill and complexity of an adult. The acting out behaviors elicit negative reinforcement from others, and another self-fulfilling prophecy is established.

A major reason why some individuals are not diagnosed with ADD until they are adults is because, as children, they did not exhibit overtly antisocial or hyperactive behaviors. Very often this is due to their intelligence, talents, skills, and/or the advantage of a structured enviornment, all of which may have allowed them to compensate for their disorder.

Paradoxically, most adults with attention problems cannot tlerate being alone despite their occasional disregard for other people or their inability to get along socially. Being alone can be most difficult because ADD adults feel empty and lacking if they are not focused or driven by a stimulus. As we know, this may prompt them to seek or create conflict or trauma. Thus, for many, it becomes imperative to avoid being alone.

This perspective is significant to the ADD adult's history but, unfortunately, is overlooked by many clinicians who interpret the adult's behavior in some rather unflattering and possibly damaging ways. For example, T.S's seven or eight boyfriends, although typical of adolescent girls with ADD, might be viewed by the clinical "establishment" as a narcissistic need to have gratifying objects to give her the abundance of love that she apparently needed. In reality she reports that she couldn't have cared less about their affections. It was the constant activity associated with having the boys around that she needed and craved. When presented with the idea that these boys were just a source of stimulus for her, she enthusiastically agreed. But this idea had never been presented to her before and therefore she had been viewing her behavior in much more negative terms. Although she has managed to become quite successful in her chosen career and has maintained some important relationships, her journey would have been much easier if she had been offered a look at her behavior through the lens of attention.

The Treatment of Adults with ADD: A New Way for a New Day

Our hope here has been to describe some common themes that become superimposed over the ADD adult's attempts to find satisfaction in life so that these themes may be addressed in treatment or in a support group. Many of the problematic behaviors discussed here (to the extent that they have become scripts that guide and govern the individual's perceptions and responses) can be unlearned or altered once the individual recognizes that many of his frustrations stem from neuropsychological causes rather than from failures in character, morals, or ability. Thus, psychoeducation becomes key to adults with attention deficits.

A common complaint of the adults in treatment is their sense of being immature, childlike, and lagging behind peers in their achievement of life tasks. This is not surprising if we consider that growth and maturity are the result of the continual integration of emotion and experience. The immaturity described by the ADD adult can be thought of as a lack in the number of available recipes that the indivicual has at his or her disposal, a lack of differentiated, generalized memories that have emotional attachments applied and that equip the individual with a wide repertoire of expectations, discriminating experiences, and response behaviors. It could be said that the sense of chaos that disrupts the adult's lexperience of self, achievement, and well-being might very well be the sensation of being lost on many levels in the intensity bracket that dominates his or her processing, storage, and retrieval of experience. Thus the holding enviornment of therapy, a support group, or other treatment mode must help foster new neural growth, i.e., new neural nets, new dimmensions of feeling and thingking that do not rely on intensity and that do not hold exclusively negative self images.

A practical and immediate way to begin such a provess of relearning is to offer support and assistance to the adult by helping him structure and order his or her enviornment. This might include helping the adult with planning and orgainzation skills such as using external tools e.g., date books, to maintain a sense of control. Also, encourage the adult to include highly stimulating activities, such as dancing or skiing, in his schedule so that the need for stimulation can be channeled constructively.

Additionally, we believe that is it sometimes necssary, and often extremely helpful, to start the adult on a medication that can quiet the inner sense of chaos, lessen the distractibility, and help him focus. Most often we recommend desipramine, methylphenidate (Ritalin) or amphetamines with the beta blockers, buspirone, bluoxetine, or clonidine as possible adjuncts. These sometimes provide an immediate relief to the individual and can facilitate the acquisition of new cognitive-affective structures as the adult's chaos and confusion diminishes.

Such has been the case for T.W. who was started on Norpramine after his consult and who sat down on the first day of the medication to complete an eight page paper for school. Previously this would have been a nearly impossible task. He reports that he is enjoying his classes now, is procrastinating less, and is finally keeping his apartment neat and organized. If he has a free moment he translates it into positvie action , and the panic related to self-initiation has subsided. He can get through a strong impluse now and look at it; it's as if he can freeze-frame his moments instead of being bombarded by them. He feels solid and balanced, with an equilibrium inside of himself on which he can count. In fact, he threw out two bottles of Vodka that he had been storing, "just in case" for almost five years. Although it may take some time for him to truly change the patterns he has established for himself, he says that for the first time in his life, he feels "normal."

John Ratey is Director of Research, Medfield State Hospital, and Assistant Professor of Psychiatry, Harvard Medical School. Andrea Miller is a research associate at Medfield State Hospital


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