ADHD: Diagnosis or Description?

ADHD stands for Attention Deficit/Hyperactivity Disorder. It would be reasonable to assume from the name that everyone with ADHD has difficulty paying attention and staying still for any length of time. The label, however, is not accurate in this case.

Most people who have what is called ADHD can pay attention to what interests them, or to matters requiring their urgent attention, sometimes for extended periods of time. Not everyone with this "label" is hyperactive or restless, which makes the diagnostic category somewhat confusing. 

The terms "deficit" and "disorder" appear frequently in the diagnostic manual for psychiatrists and other mental health professionals, known as the DSM, currently in its fifth revision, to lend credibility to diagnostic categories through the "disease model," which is necessary for research and billing purposes. These terms do not, however, help real people to understand what they or someone close to them are dealing with. The DSM attempts to compensate for it's own deficiencies by offering three subtypes of ADHD: 1) primarily inattentive, 2) primarily hyperactive/impulsive, and 3) combined type.

A more accurate label for what most of the people with whom I meet struggle with is "Attention Regulation or Control Disorder (ARD/ACD)", which is sometimes accompanied by hyperactivity or restlessness. This name, which is my invention and not an officially recognized category, acknowledges the fact that, while it may be difficult for those with this set of traits to focus on demand, it is not impossible to do so when certain conditions (interest or urgency) exist. The presence of physical restlessness or hyperactivity is a "problem" depending upon environmental expectations. Typically difficult situations include classrooms, work meetings and cubicle settings.  

So, while our center is called ADHD Boston, we recognize the limitations of this diagnostic category. ARD or ACD Boston wouldn't get nearly as many Google hits.

Being Late

As a psychiatrist who specializes in treating ADHD, I've become accustomed to my patients arriving late for their appointments. This is common not only because of unpredictable traffic conditions, which are common, but also because many people with ADHD have difficulty with time. It seems that our "internal clocks" which keep track of the passing of time, allow us to estimate how long something will take us to do, and contribute to general time awareness are integral parts of what we refer to as executive functioning. In addition to organization, prioritization, initiation and completion of tasks, the part of the brain responsible for keeping time is either on or off for people with ADHD. It's not uncommon to become engaged in an activity, look up at the time, and be surprised at how much has gone by. Similarly, it can seem reasonable to fit in "one more thing" before leaving for an appointment, only to discover that there really wasn't enough time to get it done and be on time. 

Understandably, many people without ADHD find this annoying, or worse, offensive. Being late seems to make the statement "My time is more valuable than yours." For my patients, however, nothing could be further from the truth. They don't intend to be late. In fact, they really want to be on time, and feel guilty and ashamed when they're late. It's hard to explain chronic lateness to others, as it's easily passed off as a character deficiency. 

There are many techniques and tricks to help alleviate this problem, most of which involve "tricking yourself" into being early (which usually means on time), making a conscious effort to document how long certain things take, and externalizing your internal clock as much as possible through the use of alarms, calendars and multiple reminders. 

The most important thing to remind yourself, of course, is that it's progress, not perfection, when it comes to time.

Competence

Being good at something makes people happy. I have learned many truths over the years of practicing psychiatry, and that’s one of them. If you’re great at doing your job, get straight A’s, play a sport exceptionally, are an accomplished dancer, musician, gardener or artist, you have something to feel good about.

 

It’s not enough, however, to be competent. A second requirement, although it may seem related to ego or pride, is essential. You must also be recognized for your competence. Praise, accolades, kudos, 5 out of 5 on a job performance review – whatever form it may take – being recognized for your competence is a type of reality testing which confirms your suspicions that you are, in fact, good at what you think you’re good at.

 

This recognition need not be in the form of verbal confirmation from others. It may be simply the letter grade, points scored, increased number of clients resulting from positive word of mouth, or even applause. Different types of competence are recognized in different ways that are sometimes obvious, but can be subtle. Stand up comedians know if their audience finds them funny by the volume of laughter. A “not guilty” verdict is confirmation for the defense attorney of a job well done. Removal of an appendix, resulting in alleviation of pain and lack of infection lets the surgeon know she is competent at prolonging life and health.

 

Most of us strive for excellence in what we do, consciously or not. We might not start our day by thinking “I will improve on my skills and do my very best today,” but we do just that anyway. Problems arise when we try our hardest and the results are less than optimal. A student who studies for several hours and then gets a “C” on the test starts to doubt the connection between effort and outcome. The writer who gets his work rejected by one publisher after another might start to think his abilities are less than adequate.

 

When a person puts in what they feel is a very strong effort and the feedback is not good, competence and the ability to achieve it may be called into question. One might take such negative feedback as constructive criticism and adjust the approach taken, but only for a limited period of time. Rejection or invalidation of earnest work is sustainable by the persistent individual for varying lengths of time, and depends on the support of close friends and family, the person’s inner conviction that their ability has not yet been recognized but will be in the future, and the belief that they have a “calling” which must be pursued, regardless of recognition by others.

 

People with ADHD are constantly confronted by the disconnect between their innate ability and what they are able to manifest in reality. Although they have great ideas and can visualize in their mind’s eye the completed product, they are often unable to see their vision through to fruition. This results in frustration, discouragement and eventually doubt regarding their true capabilities. Ultimately, low self esteem and depression can result, leading to the cessation of attempts to demonstrate competence

This is why the recognition of and treatment for ADHD is essential. Children are especially vulnerable to negative feedback in the face of solid effort. Adults, having endured years of rejection and failure, become slowly traumatized by their experiences and often choose “safe” occupations which do not challenge them, but offer the solace of competence in the absence of self nullifying criticism and defeat.

 

We all start out in life with an innocent, if perhaps naïve belief that if we try hard enough, we can accomplish anything we set our minds to. Nurturing this belief is the job of parents, teachers and coaches entrusted with fragile emotions and limitless potential. With just enough encouragement and praise, persistence and confidence is solidified, leading to competence and recognition thereof. Every person deserves no less, but sadly, not everyone receives these minimal prerequisites.

 

If we all try to create conditions in which our own sense of competence includes mentoring and instilling this feeling in others, we can “pay it forward,” ensuring the continuance of confidence.

 

Brain Pattern Recognition Software

No matter what your profession, you use your brain’s pattern recognition capabilities to quickly assess and identify problems. Once you’ve diagnosed the problem, this neural network, unique to your brain, will point to possible solutions. Whether you’re an auto mechanic, investment banker, attorney or IT manager, the information patterns presented by challenges you encounter register unconsciously throughout each day, manifesting in the efficiency with which you perform your job.

 

The same can be said for physicians and other health care professionals. We listen to patients tell their story, pay attention to facial expressions and mannerisms, rank issues in the order determined by their emphasis, calculate the probability that various diagnoses fit the pattern, and eventually recommend a treatment plan.

 

“Practicing medicine” is an accurate description of what doctors do. The more time we spend with patients trying to identify patterns and solutions, the more chances we have to be mistaken or correct. The more we learn from treatment failures, the less likely we are to repeat such errors. On the other hand, when we accurately identify a pattern which leads to effective treatment recommendations, the probability of future success increases.

 

With this in mind, I frequently tell patients that whatever they have to say is important. As I listen and observe, an intangible “vibe” is created by the words, tone of voice, expressed emotions and body language. Over time, a pattern emerges which, although unique to the individual, indicates the most likely diagnosis and hence, the most effective treatment.

 

When it comes to ADHD, symptoms tend to be consistent. Inattention, procrastination, disorganization, impulsivity, restlessness, inability to complete tasks, inaccurate sense of time passing, hyper-focus and difficulty staying in the moment are, to varying degrees, usually present in those who meet the diagnostic criteria. Underlying personality, work ethic, ambition, frustration and the recognition that more can be accomplished can all affect treatment outcomes.

 

Coexisting depression, anxiety or bipolar disorder are frequently present in those with ADHD, resulting in different symptom patterns. The degree to which these conditions may be causing impairment and whether they are primary or secondary to ADHD symptoms is key to formulating an effective treatment plan. Because symptoms overlap, accurate pattern recognition is crucial.

 

As you go through each day, try to observe when you engage in pattern recognition. When the problem and solution seem obvious to you, but not to others, chances are good that you unconsciously ticked through a “differential diagnosis,” quickly arrived at the most effective “treatment plan,” and went on to the next issue at hand. As you become fully aware of the pattern recognition software in your brain, you’ll be able to access and use it consciously, resulting in more effective and efficient problem solving.

Welcome

Welcome

This is my first attempt at blogging, and I’m pretty excited about it. We have a new website as well, and we’re hoping to interact more with those of you who take the time to look over the site. My intention is to answer questions that are asked of me, either by email, form submission or in person on a daily or weekly basis, and to write about subjects of interest to the ADHD community.

ADHD and Relationships

ADHD and Relationships

In early childhood, our ability to pick up on social cues is dependent upon the degree to which we devote our attention to noticing these cues. When an environment full of stimulation and often confusing information is thrust upon us, we tend to focus on that which is most urgent and pressing. If attention is limited, some things will go unnoticed. If our ability to filter out extraneous stimuli is lacking, we assign equal importance to everything that gets through, making it impossible to prioritize and process information.

ADHD and Priorities: Making a List, Checking it Once

ADHD and Priorities: Making a List, Checking it Once

When you have a lot of important things to do, it may seem impossible to prioritize. In fact, when everything on your list is a high priority, you may feel paralyzed, unable to make the choice of what to tackle first. This, of course, feels very bad indeed. So many tasks to check off that list, but no progress made.

How to Turn Overwhelming Circumstances Upside Down

How to Turn Overwhelming Circumstances Upside Down

Microsoft Word provides me with four definitions of the word overwhelm: 1. overpower somebody emotionally, 2. provide somebody with a huge amount, 3. overcome somebody physically, and 4. surge over somebody or something. A quick online search reveals the original meaning, dating back to the 14th century, was “to turn upside down, to overthrow,” which I much prefer, as it implies conquest and action.