Down by the old
(Not the new, but the old)
(Not the river, but the stream)
Where I first
(Not the second, but the first)
(Not me, but you)
With your eyes
(Not your ears, but your eyes)
(Not green, but blue)
Dressed in gingham
(Not plaid, but gingham)
(Not three, but too)
It was then
(Not now, but then)
(Not old, but knew)
That I loved
(Not hated, but loved)
(Not false, but true)
You were sixteen
(Not seventeen, but sixteen)
My village queen,
(Not the king, but the queen)
Down by the old
(Not the new, but the old)
(Not the river, but the stream).
Down By the Old Mill Stream, by Tell Taylor *
ADHD: Fact or fiction?
Ritalin and other ADHD meds: Dangerous fad or helpful tool?
Good – now that we’ve gotten the drama out of the way, let’s get down to actually talking about ADD, not agonizing over how many Adderalls can dance on the head of a pin, which is what much of the ‘discussion’ about ADD has been for decades. I remember a time when I was on the phone with a consulting psychiatrist, and suggested that he evaluate our shared patient for ADD and appropriate meds. After an ominous silence, he sneered, “You change your tune right now, young man, or I’m hanging up this phone.” Change my tune? I said, “How about, Down By the Old Mill Stream?” Sure enough, he hung up. Oh well, I doubt that he could have done justice to the all-important second-lead patter that makes that song any fun at all (see above). And really, as someone wise once said (I’m pretty sure it was either Rumi or Art Linkletter), any psychiatrist who doesn’t even offer to sing second lead on Down By the Old Mill Stream is, well, not even worth the paper his prescription pad is printed on. Then again, perhaps the poor thing was just suffering from social anxiety or stage fright and needed a little encouragement to get out there and vocalize. Or maybe all that talk of ADD scared him off because he couldn’t relate to being mentally disorganized. Well, as Ned Hallowell once said at a lecture I attended, some people suffer from Attention Surplus Disorder (ASD), and that kills all the fun of being off-the-wall.
Now, where was I again? Oh yeah – ADD. Unfortunately, this is one of those disorders that carries special stigmas and complications along with it, since all kinds of mythology about it has passed into popular culture, to the misfortune of anyone who has it. It became ‘good copy’, and provocative, adorning the covers of Time, Newsweek, and any other rag that thought it could make a buck by fanning the flames of controversy and scaring the public. It was denigrated as an ‘excuse’ for students who could not do their homework, an unethical bonanza for doctors who prescribed medications for it, and a cop-out for anyone who was disorganized, scattered or had difficulty concentrating and staying on task. People were told if they just ate the right things, it would miraculously go away. They were assured, and scolded, that it was caused by food additives, too much sugar, too much TV, video games, not enough exercise, and any other handy shibboleth that hucksters of all kinds could think up.
The net result: people who have it are often ashamed and confused; they feel inferior to ‘regular’ people, and wonder:
What’s wrong with me? Why can’t I read a book like other people, or get through a movie, or pay attention in class, and why can’t I stop jumping around all the time? Why do I get so many parking tickets, and why can’t I pay them on time, pay my bills, or even find my bills? Why can’t I finish a term paper, or start studying before the last minute? Why does my room look like a federal disaster area, why am I always forgetting everything, why do I always make everyone mad, why am I always late? I don’t think I’m a bad person, but what’s wrong with me? Am I stupid, lazy, emotionally disturbed or what?
Thank goodness, in recent years ADHD (the new, ‘approved’ name, doubtless thought up by people with Attention Surplus Disorder) has become less of a religious cult and more of an actual working diagnosis. The Americans with Disabilities Act helped – now anyone with a legitimate diagnosis of ADHD can have extra time to complete tests, for example. Why? Because they’re stupid, lazy and emotionally disturbed? No, because they in fact have a brain function disorder that can actually be seen on functional brain scans (SPECT; PET). As Dr. Daniel Amen and many others have shown repeatedly for years, it can be demonstrated that, when many people with ADHD are asked for example to do math problems in their heads, activity in their frontal cortex actually can slow down, rather than speed up, as in ‘normal’ people. What does this mean? It means that when confronted with certain kinds of problems in ‘real life’, such as academic ones, many people with ADHD actually can’t “think straight”, regardless of their IQ. It means they may ‘space out’ when contemplating starting a term paper, instead of making and carrying out plans to begin the paper. I have heard this phrase countless times:
I can’t trust myself.
Imagine living with this:
Just when you need your brain to ‘ramp up’ and get going, it shuts down and you can’t think straight. You are talking to someone about something sensitive, and suddenly you blurt out something inappropriate. You are talking to someone and suddenly you notice they have a glazed look in their eyes, because (you suddenly realize) you have been rambling tangentially about everything under the sun for the last five minutes.
You are sitting in class, being quiet and facing front. Suddenly, everybody is getting out paper and pen, preparing to do something important – why? You realize you have been spacing out for the last five minutes, though you thought you were attending to the teacher’s every word.
You vow to start working on your taxes early this time, but first you’re going to allow yourself just a few minutes of watching your favorite TV program. You even set the timer on your iPhone for fifteen minutes, to make sure you don’t forget. You ‘come to’ two and a half hours later, wondering what the hell happened. You realize you set the timer for 8:00 AM instead of PM, your wife is yelling at you because you promised to put the dishes in the dishwasher and feed the dog, and when you finally do get to work on the taxes, you can’t find the paper bag where you put all the receipts for the past year.
Your life becomes a constant storm of forgetting, failures, disappointing others, embarrassment, inability to trust yourself, and wondering, “What have I done now?”
What am I supposed to do again? It’s on that list somewhere. Where is that damn list anyway – the new one, not the one that got lost somewhere in the car last week. Where’s that phone number – you know, the one of that guy I was supposed to call to explain why I was late with the information he wanted, the information about – oh, what was it again?
This – this storm of forgetfulness, this barrage of unfinished business, this litany of people mad at you, this is your life. So what do you do? You develop compensatory mechanisms to help you get through it, things most people wouldn’t understand, things that are private, alone. Most all of these mechanisms are developed ‘in house’ by people who are alone, ashamed, confused, frustrated – they are not well-known principles that are taught in school by anyone, but Rube Goldberg devices of the mind, that help you get through time, that help you survive. Things like:
Getting high on marijuana or alcohol (“Thank god – for a few minutes or hours I can forget all my problems, slow down a little, appreciate the moment, and not feel bad about myself”.) Of course, it ends up not only worsening the problems (because, though you may feel better for the short term, you have just put off real life that much longer, making returning to real life more difficult, requiring more dope and more booze), but now you have a problem with dope and booze on top of your ADD problems. And now everyone’s mad at you for that, too, requiring more dope and booze to ‘deal’ with it all. And on and on.
Becoming adept at excuse-making. This is a whole internal subculture unto itself, including developing a persona where you laugh at yourself for others’ benefit (while hurting inside), saying things like, “There goes Old Faithful again – every hour on the hour, I have to forget something important,” or “They say I was dropped on my head a lot as a baby.” You spend inordinate amounts of time trying to think up plausible excuses for things undone, things forgotten, things you “didn’t have time for”, although secretly you know that you wasted ten times as much time avoiding the task as you would have spent actually doing it.
Lying to others about “what happened”, and what’s worse, lying to yourself. Eventually, you begin to believe your own lies and excuses and blaming, until they all run together and you can’t tell them apart anymore.
Saying to yourself, “Fuck it – I don’t care. I’ll just be a rebel and go my own way, and damn the consequences. ‘Their’ world is all fucked up anyway – I don’t want to be a part of it. Bunch of compulsive, anal, neat freaks and perfectionists anyway. Who the hell needs it?”
All around you, you see people doing well, doing what they are supposed to be doing, paying their bills on time, their taxes on time, not being terrified because they might be pulled over for an expired car registration and brake lights that don’t work. They’re getting raises, promotions, and everyone isn’t mad at them. Somehow, they seem able to do things right, do things on time, take care of business. How do they do it? Are they better than you? Smarter than you? They don’t blurt things out, or embarrass themselves, or have to lie to live, or have to remember their lies so they all match up.
What’s wrong with me, anyway?
This is when those who seek therapy, seek therapy. If they are young, it most likely involves school performance, “not working up to potential”, and comes complete with disappointed, angry, frustrated parents who also wonder what they did wrong to produce this obstinate, maddening low achiever.
If they are adults, they come in trailing a stream of sabotaged opportunities, missed deadlines, legal troubles, and wrecked relationships. Nowadays, most will add, parenthetically, after they’ve listed their ‘real’ problems, “Oh, and I’m pretty sure I have ADD, too,” as if they are reporting, for the sake of completeness, that in addition to cancer, they also have dandruff.
So, the first thing we talk about is that ADHD isn’t just something “else” you have, in addition to your real problems: it is a primary problem, that affects the entire range and scope of your life, from school, to work, to relationships, to your personality, and most importantly, your self-esteem, your dreams and your hopes. This is BIG, and it needs to be dealt with, if not first, then soon. We talk about how ADD is not a moral disorder, and not a genetic propensity to being a lazy slob, a liar and a procrastinator. It is not caused by having a deprived childhood, though of course it interacts with whatever emotional problems, and whatever other disabilities, are on board. It is not about being stupid, though high intelligence can mask it until later in school, perhaps college, grad school or beyond, or whatever point ‘real’ mental work is required, work that you can’t just toss off at the last minute.
We talk about self-image, which by this time is usually down in “Loser/Failure” territory. Most people seem to operate on the implicit assumption that they, along with everyone else, have “free choice” in what they do. Much later, after a lot of therapy, most of them look back and see that they were in fact hobbled by emotional wounds and damaging assumptions, and that they were irrationally harsh on themselves, holding themselves to standards they couldn’t possibly have reached, operating as they were with both hands tied behind their backs. But when they begin, waving the ‘free choice’ banner, they have no other option but to see themselves, personally, as the reason for their failures – what in AA they call “character defects” (much to my disagreement).
They want to know:
Why can’t I get it together, like everyone else does? Lots of people have problems, and worse backgrounds than me, but they seem to be able to function, and live up to their potential. Why not me?
Why not you? Because your brain isn’t working right. And because your brain isn’t working right, you’ve developed a chip on your shoulder, resistance to doing the things you can’t do as well as you ‘should’ (schoolwork, sitting still, paying attention, reading, being patient about anything), and the belief, on some level, that you’re some kind of a second-class citizen who’s born to fail, or at least disappoint. So we often start with education – reading (though of course reading is hard sometimes) books like Driven to Distraction, by Edward Hallowell, books by Daniel Amen, that show graphically the functional deficits in performance based on actual brain scans, and describe the subtypes of ADD that are suggested by these studies, and also books that take a creative, even refreshingly radical view of ADD, books like Attention Deficit Disorder, by Thom Hartmann (it used to be called Hunter in a Farmer’s World !), the parent of an ADD child, who developed a theory that in the early days of human existence, the ADD brain was actually MORE suited to survival in a hunter-gatherer society, when an active, ever-changing approach to interaction with the natural world was required in order to recognize possible prey and move boldly towards risk and taking chances in obtaining it.
We discuss possible medications that can help, and also the resistance to such help: “I shouldn’t need that”; “Pills are just a crutch”; “I’m not that bad”; “It’ll make me a zombie”. We talk about how the proper medications, far from making them a ‘zombie’, can make them feel like “That’s more like it – now I feel like myself; now I can use my brain, instead of fighting it all the time.”
No, “pills” are not the entire answer, and sometimes they are not part of the answer at all, but they can often provide a dramatic shift in the ability to utilize what the person has – to get the car on the road, instead of being up on blocks, which is how it feels to many ADD sufferers.
We also talk about ways to keep ‘to do’ lists that work – lately, there are several ‘apps’ for cell phones that are remarkably good at helping people organize their lives, not only keeping tasks in order, but reminding people of upcoming needs, and helping them keep track of elapsed time. A young patient of mine says his app is like having a “smart valet” – there to help him address the tasks of life, without judgment or blame.
And what is the outcome of all this? Well, I’ll just say that there is nothing more meaningful than having someone who was angry and resentful, disillusioned with the whole idea of doing anything with their life, feeling like a total failure, sit before me and say, with tears in his eyes:
I’m not stupid, after all – I’m not lazy, and I’m not a bum. I can do things. I just have to give my brain some help, and when I do, I can accomplish all kinds of things. I’m not afraid anymore of what’s going to come out of my mouth, and of what I’m going to do next. I don’t wake up in the morning dreading remembering what I did, or didn’t do, yesterday. I don’t have to make up excuses and lies to cover my screw-ups. Do you have any idea what it’s like to be able to trust yourself again?
Turns out there’s a lot more at stake in treating ADD than proper mental functioning.
The real treasure at the end of all the work?
* Song published by Tell Taylor in 1910. He wrote it in 1908, but his friends tried to persuade him not to publish it, as they felt it had ‘no commercial value’. Whoops – it became one of the most popular songs of the early twentieth century, sold four million copies in sheet music, and is still a staple of campfires and barbershop quartets, a hundred years later. The moral? If it feels true to you, go with it. Self-respect.
Note: All clinical vignettes herein are significantly altered to protect patient confidentiality and privacy.