To get through each day, natures that are at all high strung, as was mine, are equipped, like motor cars, with different gears. There are mountainous, arduous days, up which one takes an infinite time to climb, and downward-sloping days which one can descend at full tilt, singing as one goes.
—Marcel Proust, In Search of Lost Time
Attention deficit disorder is defined by three major features, any two of which suffice for the diagnosis: poor attention skills, deficient impulse control, and hyperactivity.
The hallmark of ADD is an automatic, unwilled “tuning out,” a frustrating non-presence of mind. People suddenly find that they have heard nothing of what they have been listening to, saw nothing of what they were looking at, remember nothing of what they were trying to concentrate on. One misses information and directions, misplaces things, and struggles to stay abreast of conversations. Tuning out creates practical hardships, and it also interferes with one’s enjoyment of life. “A continuous and whole experience of music is unknown to me,” a high school teacher said. “My mind is off wondering after only a few chords. It is a major exercise for me even to hear one brief song through on my car radio.” There is a sense being cut off from reality, an almost disembodied separation from the physical present. “I feel like I am a human giraffe,” is how one man described it, “as if my head is floating in a different world, way above my body.”
This absence of mind is one cause of the distractibility and short attention spans which bedevil the adult or child with ADD, except around activities of high interest and motivation. There is an almost active not noticing, as if a person purposefully went out of his way to be oblivious of what is around him. I compliment my wife for a new decoration in our living room, only to be told that the very same item has been in that very same place for months or even years.
The distractibility fosters chaos. You decide to clean your room which, typically, looks like a tornado has just passed through. You pick a book off the floor and move to replace it on the shelf. As you do so, you notice that two volumes of poetry by William Carlos Williams are not stacked side by side. Forgetting the debris on the floor, you lift one of the volumes to place it beside its sibling. Turning a page, you begin to read a poem. The poem has a classical reference in it, which prompts you to consult your guide to Greek mythology; now you are lost because one reference leads to another. An hour later, your interest in classical mythology exhausted for the moment, you return to your intended task. You are hunting for the missing half of a pair of socks which has gone on furlough, perhaps permanently, when another item of clothing on the floor reminds you that you have laundry to wash before the evening. As you head downstairs, laundry hamper in arm, the telephone rings. Your plan to create order in your room is now doomed.
Completely lacking in the ADD mind is a template for order, a mental model of how order comes about. One may be able to visualize what a tidy and organized room would look like, but the mind-set of how one would get there is missing. To begin with, there is a profound reluctance to discard anything–who knows when I may need that copy of The New Yorker which has gathered dust for three years without ever being looked at? There is little space for anything. You never feel you can master the confused mess of books, papers, magazines, pieces of clothing, compact discs, letters to be answered, and sundry other objects–you only shift portions of the chaos from one corner to the next. Should you nevertheless succeed now and then, you know full well that the order is temporary. Soon you will be throwing things about again, seeking some needed item you are sure you saw recently in some obscure nook or cranny. The law of entropy rules: order is fleeting, chaos is absolute.
A relatively few people with ADD have extraordinary mechanical skills and are able to dismantle and assemble complex objects, pieces of machinery and the like, almost intuitively. Coordination difficulties affect most others, particularly in the area of fine motor control. Things are dropped, feet are stepped on, balls fly in the wrong direction. Objects piled on top of each other during clean-up are fated to come crashing down. By opening the closet door one precipitates an avalanche of books, clothes, and other items which had been gathered and arranged pell-mell, or simply thrown on top of each other in the hope that they would sort themselves out. Telephone numbers are scribbled with the digits misplaced: even if one can read what one has written, one will still get the number wrong.
Like many others with ADD, I have little ability to form three dimensional mental representations or to divine the spatial relationships of things, no matter how well explained. When in a novel I come to a physical description of, say, a room with a desk here, a bed there, a window, a night stand, my mind’s eye just glazes over. I can’t configure it in my imagination. Asking for directions in the street, the person with ADD loses track by the time his informant is half-way through her first sentence. Fortunately, he has perfected the art of nodding. Ashamed to admit his lack of comprehension and knowing the futility of asking for clarifications which he would grasp with no greater success, he gives a masterful impersonation of one who understands. Then he heads off, entrusting himself to good fortune. “When there is a fifty per cent possibility of choosing the wrong turn, I will do so about seventy-five per cent of the time,” one of my ADD patients said. The deficient visual-spatial sense works synergistically with the distractibility. Our hapless friend order just doesn’t stand a chance.
The distractibility in ADD is not consistent. Many parents and teachers are misled: to some activities a child may be able devote, if anything, a compulsive, hyperconcentrated attention. But hyperfocusing which exludes awareness of one’s environment is also poor attention regulation. Too, often hyperfocusing involves what may be described as passive attention, as in watching television or playing video games. Passive attention permits the mind to cruise on automatic without requiring the brain to expend effortful energy. Active attention, in which the mind is fully engaged and the brain has to perform work, is mustered only in special circumstances of high motivation. Active attention is a capacity the ADD brain lacks whenever organized work must to be done, or when attention needs to be directed towards something of low interest.
A facility for focusing when one is interested in something does not rule out ADD, but to be able to focus the person with ADD needs a much higher level of motivation than do other people. Ignorance of this fact has led many doctors to miss the diagnosis. “Indeed, the characteristic of our patient,” wrote a psychiatrist of a college lecturer I had diagnosed with attention deficit disorder but whose GP wanted a second opinion, “is that he is able to focus his attention on something that he is really interested in, which for patients afflicted with ADD is very difficult.” That is not what is very difficult. What can be immobilizingly difficult is to arouse the brain’s motivational apparatus in the absence of personal interest.
ADD is situational: in the same individual its expression may vary greatly from one circumstance to another. There are certain classes, for example, in which the ADD child may perform remarkably well, while in others she is scattered, unproductive, and perhaps disruptive. Teachers may conclude that the child is wilfully deciding when, or when not, to buckle down and work diligently. Many children with ADD are subjected to overt disapproval and public shaming in the classroom for behaviours they do not consciously choose. These children are not purposively inattentive or disobedient. There are emotional and neurophysiological forces at play that do the actual deciding for them. We shall examine them in due course.
The second nearly ubiquitous characteristic of ADD is impulsiveness of word or deed, with poorly-controlled emotional reactivity. The adult or child with ADD can barely restrain himself from interrupting others, finds it a torture awaiting his turn in all manner of activities, and will often act or speak impulsively as if aforethought had never been invented. The consequences are predictably negative. One is forever trying to shut the barn door after the horse has bolted. “I want to control myself,” a 33-year old man said at his first visit to my office, “but my mind won’t let me.” The impulsiveness may express itself as impulse buying, the purchase of unneeded items on a sudden whim without regard for cost or consequence. “Impulse buying?”, another man exclaimed during our first interview. “If I had the money I would impulse buy the whole world.”
Hyperactivity is the third salient characteristic of ADD. Classically it is expressed by trouble keeping physically still, but it may also be present in forms not readily obvious to the observer. Some fidgetiness will likely be apparent–toes or fingers tapping, thighs pumping, nails being chewed, teeth biting the inside of the mouth. The hyperactivity may also take the form of excessive talking. In a minority of cases, especially in girls, hyperactivity may be absent altogether. They may go through school inattentive and absent minded but, as they cause no trouble, they are “passed through” from grade to grade. While the finding of hyperactivity is not required for the diagnosis of ADD, it can be quite dramatic for some patients. “The only thing that ever slowed me down was the police siren when I was caught speeding, ” said a twenty-seven year old woman.
The loquacious hyperverbality of many children with ADD is notorious. One Grade Two little boy was called “talk bird” by his classmates, so incessant was his chatter. His parents, too, were often after him to be quiet. It’s as if such a child is saying “I am cut off from people. My anxiety is that if I don’t work overtime to establish contact with them, I will be left alone. I only know to do this through my words. I know no other way.” Some adults with ADD have told me that they speak so quickly in part because so many words and phrases tumble into their minds that they fear forgetting the most important ones unless they release them at a fast rate.
The individual with ADD experiences the mind as a perpetual motion machine. “I have a mind like a butterfly,” a fifty-seven year old woman said. An intense aversion to boredom, an abhorrence of it, seizes hold as soon as there is no ready focus of activity, distraction, or attention. One experiences an unremitting lack of stillness internally–a constant background static in the brain, a ceaseless “white noise, ” as Harvard psychiatrist Dr. John Ratey has put it. There is a merciless pressure in one’s mind impelling one on, without necessarily any specific aim or direction. As long ago as 1934 an article in The New England Journal of Medicine identified a distressing driven quality to some people’s lives, which the authors called “organic drivenness.” I, for one, have rarely had a moment’s relaxation without the immediate and troubling feeling that I ought to be doing something else instead. Like father like son. At the age of eight or nine my son said to me once that “I always think I should be doing something but I don’t know what it is. ” The oldest person to whom I have prescribed a stimulant was an eighty-five year old woman who, on taking Ritalin, was able to sit still more than fifteen minutes for what was literally the very first time in her life.
The restlessness coexists with long periods of procrastination. The threat of failure or the promise of reward has to be immediate for the motivation apparatus to be turned on. Without the rousing adrenalin rush of racing against time inertia prevails. Not once in high-school or university did I begin an assignment or essay before the eve of the day it was due. In that era of manual typewriters my rough copies had to serve simultaneously as final copies. They resembled academic tossed salad: sheet upon sheet pasted over by pieces of paper with hastily scribbled corrections. On the other hand, when there is something one wants neither patience nor procrastination exist. One has to do it, get it, have it, experience it, immediately.
Frequent and frustrating memory lapses punctuate every day in the life of the person with ADD. A close friend of mine, Brian, has attention deficit disorder. He also has a dog. They take each other for walks every day. As Brian puts on his coat, hat, and boots the dog lies under the kitchen table, waiting. Brian leaves the house, the dog doesn’t move. The dog will not move until Brian has come back into the house for the third time for key, wallet, or whatever other items he has forgotten to take the first two times. “My master may take some perverse pleasure in this bizarre in-and-out-and-in ritual,” the hound probably says to himself, “but call me a bird dog if I’ll follow his example.” The dog has learned from experience, which is more than can be said for his owner.
My most recent memory failure, as I write this, occurred four days ago. I showed up at Ben Gurion Airport in Tel Aviv, all packed and ready for the flight home to Vancouver. I was pleased with myself for getting somewhere on time for a change. At the airline counter the ticket agent looked at my travel documents. Lines of puzzlement spread across her face. “But your flight is booked for tomorrow,” she finally said. Perhaps I was unconsciously trying to compensate for all the other occasions that saw me perilously late getting to airports.
I am often asked how with such traits it was possible for me to get through the grind of medical school. The general answer is that there are many people who seem to be high achievers despite their ADD. ADD can blight various aspects of one’s life. The apparent professional success of the workaholic can mask serious problems in other areas. It is also true with ADD, as with everything else, that there are degrees of it, with wide variations from one end of the range to the other.
Although I had planned to become a doctor all my life, I did not enter medical school until the age of twenty-eight, after several detours. In my early twenties I had gradually scaled down my academic ambitions because I could not get myself to work at my studies consistently. One memorable day in second year I walked into the examination room, bleary eyed, having read five Shakespeare plays between midnight and seven o’clock in the morning. Unfortunately, I had got the dates wrong–this particular examination was not in Shakespeare, but in European literature. So it went, term after term. In third year I dropped out altogether. In medical school I had a rough time of it for the first two years when the emphasis was on basic sciences, taught in excruciating detail. Even then I invariably began my exam preparations late the previous evening. I found it easier to become motivated and engaged as the courses become more practical and people-oriented in the higher years. And, challenging as it can be, medical school does present one with consecutive deadlines, exams to pass, hoops to jump through. It is less a long-term project than an extended series of short-term ones.
An adult with ADD looks back on his life to see plans never fully realized and intentions unfulfilled strewn about the landscape like abandoned casualties on a long march. “I am a person of permanent potential,” one patient said. Surges of initial enthusiasm quickly ebb. People report unfinished retainer walls begun over a decade ago, semi-constructed boats taking up garage space year after year, courses entered and quit in languages, in woodworking, in music, in art and in sundry other subjects, books half-read, business ventures forsaken, stories or poetry not written–many, many roads not travelled.
Social skills are also an issue. Something about ADD hinders one’s capacity to recognize interpersonal boundaries. Although some ADD children shrink away from being touched, in early childhood most of them literally climb all over adults and generally exhibit an almost insatiable desire for physical and emotional contact. They approach other children with a naive and unrequited openness, to which rebuffs are often the response. Impaired in their abilities to read social cues, they may be ostracized by their peers. For parents it is heartbreaking to witness their child’s exclusion from school ground games, birthday parties, sleepovers, Valentine card exchanges.
While generally the case, poor social skills are not universal. There is a type of ADD child who is socially adept and wildly popular. In my experience such success hides a lack of confidence in important areas of functioning and masks a very fragile self-esteem, although this may not emerge until these children grow into their late teens or early twenties.
Adults may be perceived as aloof and arrogant or tiresomely talkative and boorish. Many are recognizable by their compulsive joking, their pressured, rapid-fire speech, by their seemingly random and aimless hopping from one topic to the next, and by their inability to express an idea without exhausting the English vocabulary. “I have never finished a thought in my life,” one young man lamented. Men and women with ADD have about them an almost palpable intensity to which other people respond with unease and instinctive withdrawal. “It’s as if I was from Mars and everyone else was from earth,” one forty-year old woman said. Or, as another put it, “everyone else seems to belong to some nice persons’ club, only I am excluded.” This sense of being always on the outside looking in, of somehow missing the point, is pervasive. At social events I tend to gravitate to the periphery, conscious of a feeling that somehow I cannot enter into the spirit of things. I observe people talking to each other, people I may know quite well, acutely aware that I have nothing to say to anyone. Social conversation has always been a mystery to me. I have at times looked at people engaged in animated talk and wished that I was invisible so that I could overhear them–not to eavesdrop, only to find out once and for all exactly what there is to talk about. My patients with ADD tell me much the same thing about their experience. “I don’t know how to make small talk, or I’m afraid of saying something stupid,” a twenty-six year old woman said. And the truth is, when the ADD adult does join conversations, she often finds herself bored by the minute attention others devote to subjects that to her seem to skim only the surface of life.
To interview adults with attention deficit disorder is often to traverse a minefield booby-trapped with jokes. Unexpected turns of phrase and consciously absurd associations pepper life histories which, in themselves, are often not much to laugh about. “Thank God it’s only ADD,” said one man after I confirmed his diagnosis. “I always used to think I was one crouton short of a Caesar salad.” Children with ADD often act the part of the class clown.
The moods of the ADD child are as capricious as the weather patterns El Nino has loosed upon the world. Happy smiles are transformed into frowns of displeasure or grimaces of despair in a matter of moments. Events awaited with joyful anticipation and begun with exuberant energy often end in bitter disappointment and a sulking, accusatory withdrawal. The emotional states of adults with attention deficit disorder are also up and down without apparent rhyme or reason. Good days and bad days follow each other according to some mysterious calendar written who knows where and by whom.
The common theme on all days, good or bad, is a gnawing sense of having missed out on something important in life.