Five, four, three, two, one – GO!! Or do you go on ‘one’? My son always gets a head start because he takes off on ‘one’. His sister waits for the word, ‘Go’ and is always frustrated because ‘he cheated’!! Fortunately, these two don’t race very often and when they do, my daughter actually wins because despite her delayed start, she stays focused long enough to get to the finish line. My son, well, not so much. Let’s just say that focus and concentration are not his strong suits. He is a fast runner, but his sister wins because she follows the instructions that take her straight to the finish line….
Attention Deficit Disorder (ADD) and its cousin Attention Deficit Hyperactivity Disorder (ADHD) are neurologic disorder characterized by impulsivity and lack of concentration/focus. Often identified in childhood when patients have difficulty staying seated, following/remembering instructions, and completing school work, people that suffer from ADD are often frustrated by what may seem to be a race. They can’t seem to ever win even though they are confident that they are indeed fast enough. The race that’s preventing them from winning is the one going on inside of them; they can’t seem to slow themselves down or make themselves stop. They don’t win because before they can finish this one, they’re already on to the next one….
As these and similar conditions are more frequently recognized, treatments have emerged to help improve symptoms and ultimately transform the lives of those afflicted. In previous generations, kids (and adults) that suffered from ADD/ADHD were often punished for their inability to comply. Sometimes, the punishments that resulted from a lack of understanding, patience, and compassion resulted in abuse. The world had little sympathy or tolerance for kids that couldn’t behave. As adults, these patients often underperformed due to education deficiencies and occasionally found their way into the criminal justice system often because they attempted to self-medicate or simply failed to obey laws the same way they failed to obey rules when they were in school. Fortunately, we’ve come a long way toward understanding disorders of attention and now there are effective treatments that can help those who suffer.
The medications that have shown the most efficacy and promise are stimulants. These medications primarily increase dopamine levels in the brain and central nervous system. Dopamine is known to increase attention and memory. However, it would seem counter intuitive that stimulant medications would be helpful in patients that often seem to be going too fast. How can this be?
Admittedly, the stimulant approach represents a clinical conundrum, but the efficacy is undeniable. Behavioral, nutritional, and other approaches are considered adjunctive and have not been proven to be effective in the absence of stimulants. There is a pervasive fear of stimulants that is understandable. Decreased stature and appetite along with sleep disturbances are particularly concerning especially in younger patients. Like any medication, the risks have to be weighed against the benefits. But for those most severely affected, the benefits of taking the medications far outweigh the risks of not taking them.
But still, the question remains regarding how administering stimulants can result in improved symptoms in patients that often complain of hyperactivity? The answer requires an understanding of relativity. That is, 100mph is only fast if you’re comparing it to 50mph. But if you’re comparing it to 200mph, 100mph is pretty slow. One explanation that I have used when counseling patients on ADD/ADHD stimulant medications focuses on this description. If ‘normal’ is 50mph, a person with ADD/ADHD feels like they’re going at 100mph. Stimulant medications hold a patient at 60-65mph. Therefore, if a ‘normal’ patient takes a stimulant, they feel like they’re speed has increased. However, if an ADD/ADHD patient takes a stimulant, they feel like they’ve been slowed down.
In fact, I’ve had patients on stimulants report that the stimulant actually made them sleepy!! Imagine taking Adderall and feeling like you took Ambien!! In general, the ability to slow down is welcomed and the ability to focus and concentrate enables much more rich and meaningful relationships and activities in life. And even more encouraging, is the fact that the effect is immediate. Patients don’t have to wait for weeks or months before they know the medication is working. Within a day or two, the new normal is unmistakable. When the medication is appropriately titrated, the patient is able to experience life at a manageable speed.
There are several points worth noting that come particularly into play in the adult patient dealing with ADD/ADHD. First, if the condition is first acknowledged and treated in adulthood, the patient has probably been suffering for several years and even decades. The time spent navigating a life that you have difficulty comprehending because your memory, concentration, impulse control, etc. are impaired often results in patients accumulating negative self-images, anger, depression, anxiety, criminality, and even self-injurious behaviors. These patients feel like failures and they don’t understand why? They often try really, really hard to put it all together and please their friends/family. But in the end, they fall short because they lack the requisite balance of neurotransmitters (dopamine in particular) that would be needed to sustain the acceptable performance and behaviors they strive to achieve.
The affective components, depression and anxiety, are frequently recognized and treated before the ADD/ADHD is suspected or diagnosed. This is particularly frustrating for some patients who will report improvement of depression and/or anxiety on medications indicated for these disorders, but they will note that the leveling of their affect feels ‘artificial’. A manufactured ‘happy’ or ‘calm’ that can come with these medications helps tremendously with coping, but it doesn’t begin to satisfy the patient’s desire to feel ‘normal’. Indeed, it is the experience of ‘normal’ that often causes patients to no longer need mood-stabilizing treatments.
Interestingly, after successful period of treatment with stimulants, some patients opt to stop taking them. In essence, they acquire an ability to maneuver through life’s situations in productive and socially acceptable ways. While almost all will appreciate experiencing what the illusive ‘normal’ felt like, they may also feel that something in the stimulant is ‘taking the balloons away’ as one patient put it. Again, knowing what ‘normal’ feels like is the value stimulants bring. Maintaining that feeling is a choice that patients can opt to continue, stop, or induce situationally.
Secondly, it cannot be underscored enough that stimulants can be addictive. While ‘addictive’ is also a relative concept, patients must be counseled that everyone loses focus and concentration sometimes. So called ‘normal’ people can also have occasional or even frequent problems with impulse control and memory. The sensation of slowing down to manageable speeds represents a ‘tweaking’ of the central nervous system environment, but there are more dynamics at play than dopamine levels. Trying to find the ‘perfect’ dose for all times and all situations can lead patients to ever escalating dosages. And because dopamine plays a role in other affective areas, patients may try to use stimulants to address depression or anxiety issues that would more appropriately be managed with counseling or other more targeted pharmacotherapy.
Finally, identifying and treating ADD/ADHD can be life-changing. Our experience of happiness is rooted in being able to experience our world and share that experience with others. When disorders like ADD/ADHD impair, the experience of happiness becomes far more elusive. And the ability to share experiences that you’re not even able to fully take in further isolates and frustrates the person suffering from ADD/ADHD. It’s no wonder that depression can set in and the spiral of misunderstanding descends until the damage becomes irreparable.
The race is on – a race to identify and offer hope to a group of people that may be experiencing a very unfortunate life. The race is on to lift the despair and frustration that comes with ADD/ADHD. The race is on to understand and alter the experience of a population of people who cannot understand why they don’t ever win. For so many of these patients failure comes not because they aren’t fast enough but rather because in some ways they may be too fast. The race is on – five, four, three, two….