Wired for Wonder: Decoding ADHD

How ADHD traits challenge norms and spark creativity in a world built for structure.

What Is ADHD?

Consider these two messages — letters written to a young man from his parents. The first, when he was 16 years old in a boarding school, is from his mother:

“Your work is an insult to your intelligence.” she wrote. “If you would only trace out a plan of action for yourself and carry it out and be determined to do so, I’m sure you could accomplish anything you wish. But it is that thought­lessness of yours which is your greatest enemy.”

When he was 19, this young man graduated from the mili­tary academy at the bottom of his class with rumors flying around that he had cheated.

He had been bounced out of many schools, but his family had money and they were always able to get him back in. His father then wrote him the following:

“There are two ways of winning in an examination, one credible, the other the reverse. You have unfortunately chosen the latter method and appear to be much pleased with your success. The first extremely discreditable fea­ture of your performance was missing the infantry, for in that failure you demonstrated beyond refutation your slovenly happy-go-lucky harem-scarum style of work for which you have always been distinguished at your differ­ent schools.

“With all the advantages you had, with all the abilities which you foolishly think yourself to possess and which some of your relations claim for you, with all the efforts that have been made to make your life easy and agree­able, and your work neither oppressive or distasteful, this is the grand result that you come up among the 2nd rate and 3rd rate class who are only good for commissions in a cavalry regiment.

“I am certain that if you cannot prevent yourself from leading the idle, useless, unprofitable life you have had during your schooldays and later months, you will be­come a mere social wastrel, one of the hundreds of the public school failures, and you will degenerate into a shabby unhappy and futile existence. When that happens, you will have to bear all the blame for such misfortunes yourself.”

So wrote the parents of Winston Churchill.

Historically the way we’ve looked at people with Attention Deficit Hyperactive Disorder (ADHD) is similar to how Churchill’s parents apparently saw their son: they’re not motivated or trying hard enough, or they lack morality. There are, however, other ways to look at these people.

My first introduction to ADHD, then called ADD, came in 1978. I was Executive Director of a residential treatment facility for severely emotionally disturbed children in New Hampshire, the New England Salem Children’s Trust. Many kinds of chil­dren came through the program during the five years I ran it. Most of them had been labeled as having minimal brain damage, minimal brain dysfunction, hyperkinesis, or hyper­kinetic syndrome. Today we would label them “ADHD.”

As one means of treatment, we investigated the Feingold Diet, created by Ben Feingold, a pediatric allergist with Kaiser-Permanente in San Francisco. In 1977, he published a book called Why Your Child Is Hyperactive, and had been treating children with severe, unexplained skin rashes.

He discovered many of his young patients were allergic to specific food sub­stances, more often than not the food flavorings and colorings derived from coal tar known as salicylates. Aspirin belongs to the same family of compounds, and many of these children were also sensitive to aspirin.

Having found dozens of children with this sensitivity, Feingold developed a diet that was free of salicylates and put his young skin-rash patients on it. What happened next caught him by surprise, however: the families of these children reported that the kids, when they went on the diet, not only lost their skin rashes but also no longer exhibited hyperactive be­havior.

Feingold replicated this many times over the years, and finally concluded that if a food allergy was severe enough to cause the skin to erupt, it must also be strong enough to irri­tate the central nervous system.

Having proved this to his own satisfaction, and that of many of the other pediatricians and allergists with whom he worked, he took a next step which was largely a leap of logic and faith. If this food allergy was causing hyperactive behavior in his patients with skin disorders, might it not be possible that it was causing the same problem among those hyperactive chil­dren who didn’t have sensitive skin?

What he and subsequent researchers found out is that for a small but measurable subset of the population, this appears to be true. At the Salem Children’s Trust we did a study of the Feingold Diet with 39 children over a six-month period. For 38 children, the diet made no difference. But we had one child we could turn on and off like a light switch with salicylate. That one child also had severe psoriasis. I wrote up that incident and it was published in The Journal of Orthomolecular Psychiatry in 1980.

So I thought I understood ADD. I had supervised a study, had written it up for a journal. I thought I knew what ADD was. But apparently I didn’t.

In 1989, at the age of 12, our middle child “hit the wall” in school. Most parents of ADD children — or adults with ADD — know exactly what hitting the wall means. It’s where a child has been faking it their entire academic life, paying attention twenty percent of the time (more or less), and somehow managing to pull a rabbit out of the hat at exam time.

There are warning signs — extreme unevenness in their grades (they do spectacularly in those classes where they’ve bonded to the teacher, but poorly in those where they haven’t, regardless of how difficult the subject may be); last-minute work; constant reports of lost or missing papers and homework; a wounded expression crossing his face whenever the topic of school was brought up.

We were getting calls from his English teacher and his math teacher say­ing “You’re kid’s gonna flunk. You gotta do something.”

Frankly, the idea that he might have ADD hadn’t even oc­curred to me, although in my defense I would say first of all it had been a number of years since I’d been involved with it, and sec­ondly, all of these kids I had been working with at that point 10 years earlier were severely damaged children. So when I thought of ADD, I always thought of it in the context of severe pathology. It didn’t occur to me it might be what was going on with our son.

My wife Louise and I took him to a psychologist who special­ized in educational testing.

“Nuke him,” I said. “Give him every test you have. Rorschach, MMPI, IQ tests — everything. I want to know if he has some sort of problem or learning disability that we’ve completely overlooked. Even ask him about drug use and how life is in school — maybe there’s something going on that he’ll share with you but has been hiding from us.”

We left him with the fellow and went out to do a half-day’s errands. When we returned, the psychologist brought our son out and sat him down in an office with Louise and me on either side of him. He stood in front of us and spoke to our son.

“I can see from your tests, young man, that you’re very bright. In fact, you’re probably smarter than your IQ tests indicated, because the first thing these tests measure is a person’s ability to take a test. . . and the condition you have makes it hard for you to take tests.”

“Condition?” my son and I said at the same moment.

“Well, yes,” the man said. “You have a brain disorder called Attention Deficit Disorder, or ADD.”

My son’s eyes boggled.

“And it’s probably hereditary,” the man added, causing me to sit up and take notice.

He then went on to tell us some stories about ADD. Some of his stories were useful, but one was very counter-productive.

“It’s a little like diabetes,” he explained. “Diabetes is a fancy medical word we use to describe ‘insulin deficiency disease.’ The insulin producing cells of the pancreas die off from an autoim­mune condition or infection, leaving the body without the abil­ity to produce insulin, which is a hormone necessary for life. Without the insulin people will die, so we use daily injections to supplement their body with insulin we take from animals’ pancreases.

“Similarly, young man,” he continued, “your brain has been damaged. We don’t know how or where or when or why, but it’s not working right, and so we’re going to need to supple­ment your neurotransmitter levels with Ritalin.”

I’m not opposed to the limited use of Ritalin. When it works, it works really well; sometimes it may be the best thing for a person. But I don’t think it’s the first thing a person should try.

However, at that moment in that chair, the scientist part of me was thinking, “Hold on, wait a minute. This doesn’t make sense. There isn’t an organ in the body that is squirting Ritalin into the bloodstream all day long. ADD is not a Ritalin deficiency disease. ”

Second, and perhaps most important to me, was the fact that this explanation was devoid of an essential element. Study after study has proven that if a person has one thing in large measure he or she will be more resilient, more capable of withstanding severe trauma, will heal faster, and will even live longer if they have a fatal disease. On the other hand, without this one essential element, people die faster, heal slower, and are at greater risk of falling apart when life hits them with major prob­lems.

That one essential thing is hope.

And the ADD-as-diabetes tale was a story without hope.

On the way home, my son asked, “What’s wrong with me?” I had to honestly answer that while I’d thought of myself as somewhat knowledgeable on all this stuff, I obviously didn’t know the answers. “But,” I promised him, “I intend to find out.”

The next six months were a whirlwind of research activity. I searched university FTP sites on the internet, bought every book I could find on ADD in the local bookstore, visited the Emory Medical School library to collect papers and articles on ADD, and called the psychologists, psychiatrists, and psycho­therapists I’d worked with in New Hampshire. I was collect­ing stacks and piles of paper on the topic, which gradually spread from my office to the living room to the bedroom. (Louise says I don’t have a filing system: I have a piling system.)

Basically everybody was saying what the psychologist had told my son. At its core, ADD is generally acknowledged to have three components: distractability, impulsivity, and risk-taking/ restlessness.

(If you throw in hyperactivity, you have ADHD — Attention Deficit Hyperactive Disorder — which, until recently, was considered to be “true” ADD, but is now viewed as a sepa­rate condition. ADHD is the disorder that children were believed to grow out of sometime around adolescence, but it appears that most ADHD kids simply become adults with ADD as the hyper­activity of their youth sometimes diminishes.)

Somewhere between 6 and 20 million men, women, and children in the United States were believed to have ADD at that time. Millions more indi­viduals possess many ADD-type characteristics even though they may have learned to cope so well that they don’t think of themselves as people with attention-related problems.

ADD or ADHD is not an all-or-nothing diagnosis. There appears to be a curve of behaviors and personality types, ranging from extremely-non-ADD to extremely-ADD. Although there has not yet been enough research in the field to know the shape of this curve, it probably resembles a bell curve, with the majority of “normal” individuals falling some­where in the center, showing a few ADD-like characteristics, and a minor- ADD is not an all-or-nothing diagnosis, being split up on the two extreme ends of the spectrum.

Since a large body of research indicates that ADHD is a hereditary condition, the distribution of this curve may well reflect the intermixing over the years of the genetic material of ADHD and non-ADHD individuals, blurring the edges of both types of behaviors. Placed along the spectrum of ADHD indi­viduals you will find people who typically exhibit some or all of the following characteristics:

♦  Easily distracted. ADHD people are constantly moni­toring the scene; they notice everything that’s going on, and particularly notice changes or quickly chang­ing things in their environment. (This is the reason why, for example, it’s difficult to have a conversation with ADHD people when a television is on in the room; their attention will constantly wander back to the tele­vision and its rapidly-changing inputs.)

♦  Short, but extraordinarily intense, attention span. Oddly enough, this isn’t definable in terms of minutes or hours: some tasks will bore an ADHD person in thirty seconds, other projects may hold their rapt attention for hours, days, or even months. ADHD adults often have difficulty holding a job for an extended period of time, not because they’re incompetent but because they become “bored.” Similarly, ADHD adults of­ten report multiple marriages, or “extremely intense, but short” relationships. When tested for attention span on a boring, uninteresting task, ADHD people tend to score significantly lower than others.

♦  Disorganization, accompanied by snap decisions. ADHD children and adults are often chronically disorga­nized. Their rooms are a shambles, their desks are messy, their files are incoherent; their living or working areas look like a bomb went off. This is also a common charac­teristic of non-ADHD people, possibly related to upbring­ing or culture, but something usually separates messy ADHD folks from their non-ADHD counterparts: non-ADHD people can usually find what they need in their messes, while ADHD people typically can’t find anything. An ADHD person may be working on a project when something else distracts him, and he makes the snap decision to change priorities and jump into the new project — leaving be­hind the debris from the previous project. One ADD adult commented that “the great thing about being disorga­nized is that I’m constantly making exciting discoveries. Sometimes I’ll find things I didn’t even know I’d lost!”

♦  Distortions of time-sense. Most non-ADHD people de­scribe time as a fairly consistent and linear flow. ADHD individuals, on the other hand, have an exaggerated sense of urgency when they’re on a task, and an exaggerated sense of boredom when they feel they have nothing to do. This sense of boredom sometimes leads to the in­creased consumption of substances such as alcohol and drugs, which alter the perception of time, whereas the sense of fast-time when on a project often leads to chronic impatience. This elastic sense of time also causes many ADD adults to describe emotional highs and lows as hav­ing a profound impact on them. The lows, particularly, may seem as if they’ll last forever, whereas the highs are often perceived as flashing by.

♦ Difficulty following directions. This has tradition­ally been considered a subset of the ADHD person’s char­acteristic of not being able to focus on something they consider boring, meaningless, or unimportant. While receiving directions, conventional wisdom has it that ADHD people are often monitoring their environment as well, noticing other things, thinking of other things, and, in general, not paying attention. In other words, ADHD people frequently have difficulty following direc­tions, because the directions weren’t fully received and understood in the first place.

♦  Exhibit occasional symptoms of depression, or daydream more than others. ADHD individuals who are relatively self-aware about the issues of sugar and food metabolism often report that depression or tired­ness follows a meal or the consumption of sugary foods. This reaction may be related to differences in glucose (sugar) metabolism between ADHD and non-ADHD people.

Another possibility is that ADHD people are simply bored more often by the lack of challenges presented by our schools, jobs, and culture, and this boredom translates for some people into depression.

♦  Take risks. ADHD individuals seem to have strong swings of emotion and conviction, and make faster de­cisions than non-ADHD types. While this trait often leads to disaster, it also means that ADHD individuals are fre­quently the spark plugs of our society, the shakers and movers, the people who bring about revolution and change. ADHD expert Dr. Edna Copeland, in a 1992 At­lanta speech, referenced a study which indicates that about half of all entrepreneurs test out as being ADHD.

Evidence is strong that many of our Founding Fathers were also ADHD. If they hadn’t been, the United States of America might never have come into being. ADHD risk-takers may have predominated in the early Americas be­cause those were the people best suited to undertake the voyage to this continent and face the unknown.

♦  Easily frustrated and impatient. To “not suffer fools gladly” is a classic ADD characteristic. While oth­ers may beat around the bush, searching for diplomacy, an ADD individual is most often direct, to the point, and can’t understand how or why such bluntness might give offense. When things aren’t working out, “Do Something!” becomes the ADD person’s rallying cry — even if the something is sloppy or mistaken.

What the Experts Say

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IVr) published by the American Psy­chiatric Association has substantially expanded its criteria for ADHD. If you are interested in the only “official” methods for diagnosing ADHD or ADD in children or adults, you can find the DSM-IVr at your local library or bookstore.

Most likely, if you were to look at the American Psychiatric Association’s criteria for ADHD, you would see bits of yourself and others. While numerous books and therapists offer elabo­rate (and sometimes expensive) tests for ADHD/ADD, it’s im­portant to remember that, according to the American Psy­chiatric Association, the only true diagnostic standard is to “hit” on their specified criteria. While elaborate and time-consuming tests may be interesting, and may provide useful insights into other facets of personality, none is officially rec­ognized by the American Psychiatric Association, which is the final arbiter of these matters in the United States.

The Hallowell-Ratey Criteria

In 1992, psychiatrists Edward M. Hallowell and John J. Ratey developed, through years of clinical practice, study, and obser­vation, their own set of criteria for spotting probable ADHD, particularly in adults. While this isn’t an “official” set of diag­nostic criteria, since its first appearance in their book Driven to Distraction it has become one of the more common stan­dards against which both lay people and clinicians measure the probability of a person having ADHD.

According to Hallowell and Ratey, ADHD may be present when we see a chronic disturbance in which at least twelve of the following criteria are present (quoted with the kind permission of the authors):

A sense of underachievement, of not meeting one’s goals (regardless of how much one has actually ac­complished). We put this symptom first because it is the most common reason an adult seeks help. “I just can’t get my act together” is the frequent refrain. The person may be highly accom­plished by objective standards, or may be floundering, stuck with a sense of being lost in a maze, unable to capitalize on innate potential.

Difficulty getting organized. Organization is a major problem for most adults with ADD. Without the structure of school, without parents around to get things organized for him or her, the adult may stagger under the organizational demand of everyday life. The sup­posed “little things” may mount up to create huge obstacles. For want of the proverbial nail — a missed appointment, a lost check, a forgotten deadline — their kingdom may be lost.

Chronic procrastination or trouble beginning a task. Often, due to their fears that they won’t do it right, they put it off, and off, which, of course, only adds to the anxi­ety around the task.

Many projects going simultaneously; trouble with follow-through. A corollary of #3. As one task is put off, another is taken up. By the end of the day, week, or year, countless projects have been undertaken, while few have found completion.

Tendency to say what comes to mind without nec­essarily considering the timing or appropriateness of the remark. Like the child with ADD in the classroom, the adult with ADD gets carried away in enthusiasm. An idea comes and it must be spoken; tact or guile yields to childlike exuberance.

A restive search for high stimulation. The adult with ADD is always on the lookout for some­thing novel, something engaging, something in the out­side world that can catch up with the whirlwind that’s rush­ing inside.

A tendency to be easily bored. A corollary of #6. Boredom surrounds the adult with ADD like a sinkhole, ever ready to drain off energy and leave the individual hungry for more stimulation. This can easily be misinterpreted as a lack of interest; actu­ally it is a relative inability to sustain interest over time. As much as the person cares, his battery pack runs low quickly.

Easy distractibility, trouble focusing attention, ten­dency to tune out or drift away in the middle of a page or a conversation, often coupled with an ability to hyperfocus at times. The hallmark symptom of ADD. The “tuning out” is quite involuntary. It happens when the person isn’t looking, so to speak, and the next thing you know, he or she isn’t there. An often extraordinary ability to hyperfocus is also usu­ally present, emphasizing the fact that this is a syndrome not of attention deficit but of attention inconsistency.

Often creative, intuitive, highly intelligent. Not a symptom, but a trait deserving of mention. Adults with ADD often have unusually creative minds. In the midst of their disorganization and distractibility, they show flashes of brilliance. Capturing this “special something” is one of the goals of treatment.

Trouble in going through established channels, fol­lowing proper procedure. Contrary to how it often appears, this is not due to some unresolved problem with authority figures. Rather, it is a manifestation of boredom and frustration: boredom with routine ways of doing things and excitement around novel approaches, and frustration with being unable to do things the way they’re supposed to be done.

Impatient; low tolerance for frustration. Frustration of any sort reminds the adult with ADD of all the failures in the past. “Oh, no,” he thinks, “here we go again.” So he gets angry or withdraws. The impatience has to do with the need for stimulation and can lead others to think of the individual as immature or insatiable.

Impulsive. Either verbally or in action, as in impulsive spending of money, changing plans, enacting new schemes or career plans, and the like. This is one of the more dangerous of the adult symptoms, or, depending on the impulse, one of the more advantageous.

Tendency to worry needlessly, endlessly; tendency to scan the horizon looking for something to worry about alternating with inattention to or disregard for actual dangers. Worry is what attention turns into when it isn’t focused on some task.

Sense of impending doom, insecurity, alternating with high-risk-taking. This symptom is related to both the tendency to worry needlessly and the tendency to be impulsive.

Mood swings, depression, especially when disen­gaged from a person or a project. Adults with ADD, more than children, are given to unstable moods. Much of this is due to their experience of frustra­tion and/or failure, while some of it is due to the biology of the disorder.

Restlessness. One usually does not see in an adult the full-blown hyper­activity one may see in a child. Instead one sees what looks like “nervous energy:” pacing, drumming of fingers, shift­ing position while sitting, leaving a table or room frequently, feeling edgy while at rest.

Tendency toward addictive behavior. The addiction may be to a substance such as alcohol or cocaine, or to an activity, such as gambling, or shopping, or eating, or overwork.

Chronic problems with self-esteem. These are the direct and unhappy result of years of condi­tioning: years of being told one is a klutz, a space-shot, an underachiever, lazy, weird, different, out of it, and the like. Years of frustration, failure, or of just not getting it right do lead to problems with self-esteem. What is impressive is how resilient most adults are, despite all setbacks.

Inaccurate self-observation. People with ADD are poor self-observers. They do not accu­rately gauge the impact they have on other people. This can often lead to big misunderstandings and deeply hurt feelings.

Family history of ADD or manic-depressive illness or depression or substance abuse or other disorders of impulse control or mood. Since ADD is genetically transmitted and related to the other conditions mentioned, it is not uncommon (but not necessary) to find such a family history.

In addition to requiring 12 out of 20 hits on this test, Drs. Hallowell and Ratey add that these characteristics must in­clude a childhood history of similar behaviors and not be ex­plainable by other medical or psychiatric conditions.

The DSM says a psychiatric diagnosis isn’t warranted un­less something’s wrong — unless there’s some significant im­pairment of a major life function. My friend and editor, Dave deBronkart, found that he meets the criteria for ADHD on the above tests. When he told an ADHD expert that he was quite successful in his life nonetheless, the unfortunate response was, “You probably have something wrong with you and don’t even know it.”

Conditions that May Mimic ADHD, and Vice Versa

Several conditions may mimic certain characteristics of ADD, causing an inaccurate diagnosis. These include:

♦  Anxiety disorders. ADHD may cause anxiety when people find themselves in school, life, or work situa­tions with which they cannot cope. ADHD differs from anxiety disorders in that latter disorder is usually epi­sodic, whereas ADHD is continual and lifelong. If anxi­ety comes and goes, it’s probably not ADHD.

♦  Depression. ADHD may also cause depression, and sometimes depression causes a high level of distractability that’s diagnosed as ADHD. Depression, however, is also usually episodic. When depressed patients are given Ritalin or other stimulant drugs, which seem to help with ADHD patients, depressed patients will often experience a short-term “high” followed by an even more severe rebound-depression.

♦  Manic-Depressive Illness. Manic-depression, or bi­polar disorder, is not often diagnosed as ADHD because the classic symptoms of manic-depressive illness are so severe. One day a person is renting a ballroom in a hotel to entertain all his friends; the next day he’s suicidal. Yet ADHD is often misdiagnosed as manic-depressive ill­ness. A visit to any adult ADHD support group usually produces several first-person stories of ADHD adults who were given lithium or some other inappropriate drug because their ADHD was misdiagnosed as manic-depres­sive illness.

♦  Seasonal Affective Disorder. This recently discov­ered condition appears to be related to a deficiency of sunlight exposure during the winter months and is most prevalent in northern latitudes. Seasonal affective dis­order (SAD) symptoms include depression, lethargy, and a lack of concentration during the winter months. It’s historically cyclical, predictable, and is currently treated by shining a certain spectrum and brightness of light on a person for a few minutes or hours at a particular time each day, tricking the body into thinking that the longer days of spring and summer have arrived. Sea­sonal affective disorder is sometimes misdiagnosed as ADHD, and vice versa, but seasonality is its hallmark trait.

Two additional conditions, Fetal Alcohol Syndrome (FAS) and Central Auditory Processing Disorder (CAPD) should also be noted here, because there is nothing in the DSM-IV to exclude a diagnosis of ADD in these children.

Hopefully, this rather comprehensive roundup of ADD and ADHD, along with its history, is helpful to you. There are many articles here on HuntersInAFarmer’sWorld that speak to both diagnosing ADHD and finding ways through it with success. Next week I’ll look at several.