The “Myth” of ADHD?

The Myth of the ADD Myth

Review of The ADD Myth: How to Cultivate the Unique Gifts of Intense Personalities by Martha Burge (San Francisco: Conari Press, 2012)

Ms. Burge asks some provocative questions in this book, such as, “Intensity: Gift or Disorder?” While the word intensity here has a specific meaning, as described by Dr. Kazimierz Dabrowski as a particular giftedness, I appreciate her implication of how “intense” a person with ADHD can be. People with ADHD really are intense people; they feel intensely, they think intensely, they play intensely… and they fall apart intensely.

Ms. Burge, a life coach who practices in Southern California, has written this book to discuss the positive aspects of being intense in both the general and technical senses of the word. She writes compassionately about the people she has worked with who have a “deep sensitivity, a fullness of experience, a capacity for fantasy and creativity, and an intellectual curiosity” (p. xx), and who are not merely marred by attention problems.

She states that she developed her own theory of “intensities,” and then later discovered the work of Dr. Dabrowski, whose concepts described the same behaviors she had described. (See, for example, the Supporting the Emotional Needs of the Gifted (SENG) site for more information, or my blog post.) She came up with a great acronym for these different types of giftedness: SPICE. A person might be intensively Sensual, Psychomotor (Physical), Intellectual, Creative or Emotional. Generally, people who are gifted tend to be more “intense” in one of these 5 areas, and may have strong tendencies or talents in some of the other.

I want to point out that her approach may apply only to adults, and I am not sure all her ideas or suggestions can be used with children or adolescents. I have some criticisms of this book which mainly apply to how to help students function in a typical classroom setting.

A good point that she makes is that ADHD is “too common to be a disorder” (p. 18). There are many estimates of how many people have ADHD; I’ve seen research reports with 3%, 4%, 8%, 10% and even 15%. Over time, the numbers just keep creeping up. She poses a good question: “At what point do we look at a pattern of behaviors as within the normal range?” (pp. 18-19).

However, some points she makes are simply wrong. She claims that the National Institute of Mental Health (NIMH) estimates the number of people with autism is less than 1% of the population; their website states 2% (see http://www.nimh.nih.gov/news/science-news/2013/prevalence-of-parent-reported-autism.shtml). She states on p. 20 that “there are no objective tests that prove the existence of ADHD or any other psychiatric disorder,” but there are some biometric tests now for ADHD.  She skirts the issue of the efficacy of medication; she states that meditation can help most people – without using drugs. She has a section of her book, pp. 4 – 11, entitled “Medication Goes in Search of Patients” which has misleading information. She states that CHADD, Children and Adults with ADHD, was funded and founded by a big pharma company. She implies that they were set up to support giving out medications, as if all the other very helpful advice they offer is mere placebo. Yes, the pharmaceutical companies have something to gain by funding a resource like CHADD, but much of the information requires a lot of education even to understand whether or not your child has a disorder or disability. Frankly, I can’t think of anyone who would want to identify as having ADHD — how can she say that “the disorder seemed to go in search of patients” (p. 4)?

She throws in a very scary comment, that “the very same people,” i.e., doctors, who encourage parents to buy medications, are the ones who “will also tell you that stimulants are deadly” (p. 5). Hold on now! Of course abusing any substance is deadly! But death-by-overdose affects a very small percentage of patients, usually those with a pre-existing condition, and the medication is prescribed so that it will not be abused! Of course stimulants can be deadly, but so can hormone replacement therapy, aspirins, and sugary foods that lead to diabetes. It’s just not fair to scare people into ignoring a valid treatment, medication, just to serve your own pet theories. I distrust this kind of non-objectivity.

She calls meditation “the drug to end all drugs” (p. 52). Her approach to helping her adult clients includes meditation, mindfulness, and understanding some intellectual constructs, such as “the internal map of reality” (p. 46). It has been my experience to witness people with ADHD to be able to relax and focus only after they have taken medication to regulate their brains. I agree that meditation is wonderful and that developing a sense of your “inner voice” is an essential part of growing up and healing. But I do not think it is fair to tacitly discredit the use of medication. Some people can’t get to the state of being able to meditate until after they medicate. As with most conditions, every person is somewhere on the spectrum … some people have an “intense” case of ADHD, and many of those people when undiagnosed turn to drugs and alcohol to soothe or self-medicate – leading to an unproductive life of addiction and substance abuse.

As Burge points out, many people choose not to meditate, or believe they can’t meditate, because it takes too long – and a pill is a lot more convenient. I would ask her and all the anti-medication people out there – please leave room for both. If you can succeed without medication, great. But if you are a child or a young adult who is failing in school, you may be limiting your future choices if you can’t perform tasks that require focus, concentration and completion. There are minimum requirements to get into college, and we all know that earning a college degree is one of the most predictable ways to be financially secure as an adult.

While I respect a parent’s desire not to give medication to his or her child, I hope that parent is able to provide the time and energy to support that child – including sitting with them during a daily meditation period – to teach them how to utilize the non-medication tools of meditation, visualization, deep breathing, stretching, and developing an inner voice. My experience is that most 10-year-old boys who have ADHD – it’s not a myth – do not have the self awareness yet to benefit from this kind of training. Yet, they struggle and suffer and lose their self-esteem as they watch, mystified, their grades plummet and the respect of their teachers and peers diminish. That can cause permanent damage.

I used to think that ADHD was a myth, too. “We never heard of it when I was a kid in school!” Then, I walked into an elementary school classroom, where I hadn’t been in over 35 years, and saw a young man sitting backwards on a chair, his torso hanging over the back of the chair, his shoes off, as he attempted to work on a piece of paper with a pencil. He was not a myth. His disability was real. He didn’t want to be that way; he didn’t know why he felt like he was crawling out of his skin when forced to sit properly. He just couldn’t pay attention because he was physically – and yes, to use Dabrowski’s term, sensually – out of balance.

Cognitive Behavioral Therapy (CBT) for ADHD

A great book on the effectiveness of cognitive-behavioral therapy, or CBT, for people who have ADHD has just been released in paperback. While it is intended for therapists who want to help people with ADHD to build skills in executive functioning, the first half of the book presents evidence about the areas in life where working adults may struggle and fail, in spite of being talented, articulate and hard-working. It’s called Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction by Mary V. Solanto. She is a psychiatrist at the Mount Sinai School of Medicine in New York City. I’ve taken some important definitions and descriptions from this book which hopefully will shed light on behaviors (usually negative) that you may observe in yourself or your children.

Personally, I am very impressed with the quality of the writing in this book, both by Solanto and her other contributors. She provides evidence of the success of such a program, whether or not the person with ADHD is taking medication or not. She focuses on the challenges that adults face, those adults who did not “grow out of” ADHD (which is estimated to be about half of the population who has ADHD as children – about 8% of the population). I wish there were more programs here in the Los Angeles area which used this approach. While some mental health facilities offer classes on CBT (such as Kaiser Permanente), they do not gear it to the challenges faced by people with ADHD.

“Insufficiency of Medication as a Comprehensive Treatment for ADHD”

Even with medication – which is not effective for all patients with ADHD – there are skills and behaviors which were never learned as children that the medication cannot “teach” the person how to do (pp. 13 – 14). Mainly these are the executive functions or the ability to self-manage: organizing, planning, self-monitoring, accessing working memory, utilizing self-inhibition, shifting/ transitioning attention from one task to another, etc. (p. 14). This lack of executive functions is developmental – many of these skills eventually do “stick” but usually about 2 – 3 years behind their peers. This delay may be caused by a physical difference in the brain. “Structural and functional neuroimaging studies both in adults (Seidman, Valera & Bush, 2004) and in children (Seidman, Valera & Makris, 2005) have revealed deficits in the volume and activation of regions of the prefrontal cortex known to subserve these executive functions” (p. 15).

Some researchers frame this as “a fundamental deficit in inhibitory control” (Barkley, Murphy & Bush, 2001; Nigg, 2006) – whether it is to stop an automatic impulse in a given situation, or to “prevent interference from extraneous stimuli.”  Russell Barkley is a well-known proponent of this description of ADHD: “Inadequate inhibitory control results in a a proneness to respond to immediate external or internal stimuli, and is manifested cognitively as poor working memory, distractibility, failure to carry tasks through to completion, inattention to detail, and ‘careless’ errors. Tasks that are lengthy, multistep, or inherently challenging will be particularly vulnerable to disruption. Inadequate working memory may result in difficulties in monitoring and adjusting current behavior so as to maximize timely progress toward overarching goals” (p. 15).

Another area that medication does not help someone suffering from ADHD is an insensitivity to reinforcement. That is, consequences of current behaviors simply don’t enter their minds. This has been described as having an “elevated reward threshold in ADHD” (p. 16). Another way of looking at this is having a “steeper delayed reinforcement gradient” (p. 16). This means that people with ADHD can’t be satisfied sticking to an unpleasant task with the knowledge that “it will matter later when you apply to college” or “this could help you get a job promotion later.”

An unfortunate word is used medically to describe someone who suffers from two or more disorders simultaneously: “comorbid.” Some practitioners now use the word “co-occuring” which makes more sense and is less… morbid. It is quite common for people with ADHD to develop anxiety or depression, caused by years of failure and underachievement. “Adults with ADHD complete fewer years of education, have higher rates of unemployment… and higher rates of marital separation and divorce. In addition, adults with ADHD have higher rates of substance and alcohol abuse disorders (18%) as well as increased rates of anxiety (51%) and depression (32%; Kessler et al., 2006), and adult women with ADHD are at greater risk for eating disorders (Biederman et al., 2010). (pp. 8 – 9).

All of these symptoms and outcomes are probably well-known to you already, as a parent with a child with ADHD. There is hope, of course, in several types of treatments, starting with medications that help the neurotransmitters in the brain focus better and longer.

CBT is a treatment that is psycho-social; that is, it is information that is taught to individuals who seek to change their behaviors. A person with ADHD may not have that “inner voice” that warns them to keep their mouths shut during a sensitive conversation, or to look at a long-term outcome, or to consider at least three bids before deciding on a contractor. CBT helps people become aware of the specific types of situations that can get them into trouble, then to identify what they normally think and do in those situations, and then to think and do something different – in order to achieve a different (positive) outcome.

CBT is founded on the work of Aaron Beck, Albert Ellis, and others (p. 20). The program described by Solanto in this book has key ingredients to help people make changes in their behaviors:

• Explicit skills training
  • Time management: how to use a planner
  • Time management: how to prioritize activities
  • Organization: how to use the space around you for your work – placement of tools and other materials needed on a daily basis
• Development of Compensatory Strategies
  • Setting up a work environment to minimize distracters
  • Setting a timer to get work done
  • Maximizing important external prompts, like post-it notes or an electronic calendar
• Generalizing positive statements/maxims
  • Use of Take-Home Exercise activities that the person can do by himself
  • Frequent repetition of positive statements so that they will automatically start popping up in the person’s consciousness (development of that “inner voice”), such as “Out of sight, out of mind,” and “Getting started is the hardest part.”

There are many more ideas presented in this book about how to accomplish this “brain training,” including a complete 12-week training manual written for therapists to take a group of participants through these ideas and give them specific and practical tools to change their behaviors.

Hopefully with such a well-written guide now available in paperback (just published in 2013; I received my copy on September 12, 2013), we will see more utilization of this healthy therapy, CBT.

UPDATE 9-16-13: I received a message from the author, Dr. Mary Solanto, who recommended contacting the Association of Cognitive and Behavioral Therapies at www.abct.org to find a cognitive-behavioral therapist in your area. He or she can use this book as a guide to address the specific needs of people with ADHD — building executive functions.