He was dynamic, outgoing, and enormously entertaining.

He was creative, full of ideas, and energetic.

And he was one of the most frustrating people you would ever care to be around.

About whom do I speak? A bright, charming man with Attention Deficit Hyperactivity Disorder.

ADHD is more complicated than you might think. Although there is much written about it, I want to cover a few of the things that can be missed about the condition. But first, let me explain the name and define it.

There are three types of ADHD (Attention Deficit Hyperactivity Disorder):

• 1. ADHD, Predominantly Inattentive Type. This used to be called ADD, but technically speaking, sufficient inattentiveness is considered a category of ADHD, even though little hyperactivity may be present. These are the folks who seem to be listening, but are lost in space; easily taken away by a tune, a sound, or an idea; the people who miss the details and forget the assignments.

• 2. ADHD, Predominantly Hyperactive-impulsive Type. This is what most people think of when they hear or read the four letter acronym ADHD. People with this diagnosis are characteristically talkative, active, intrusive; a bundle of unmanaged, impulsive activity.

• 3. ADHD, Combined Type (meaning it includes the symptoms typical of the first two categories); too many balls in the air, for sure.

What about the man I mentioned at the top; a person who had the “combined type” of ADHD?

He had lots of energy and ideas, so people found him engaging. But it wasn’t a very productive sort of energy. He would begin things, but not complete them. He was disorganized — losing keys and papers, and forgetting appointments. He promised to do things, but couldn’t be relied upon to do them as quickly or as well as expected, if at all.

This man (let’s call him A.T.) went nowhere fast; very fast. A.T. looked liked the “Energizer Bunny,” but mostly traveled in circles.

He tended to over commit himself, taking on more tasks than he could handle effectively, chronically underestimating what he could accomplish in the time available. A.T. was routinely late for appointments, and made decisions quickly, without fully considering the longer term consequences of his actions. Bored easily, distracted more easily, and prone to procrastination, he knew that he wasn’t what others hoped for and expected. Although he was full of promise, his reputation was that of someone who was a thoughtless, irresponsible underachiever — an individual who needed minding.

Employers were disappointed, co-workers were frustrated by A.T., and his spouse was driven just a little crazy, feeling that she couldn’t depend on her partner. She’d married someone who was exciting, only to find that the excitement he produced was more of the “Oh, no!” kind that made her sweat when she discovered he was late to pay a bill or pick up the kids. Not surprisingly, she started to see him as just another one of the kids, as their partnership turned into more of a “disapproving mother/resentful child” relationship than either of them wanted.

Before I tell you about A.T.’s treatment, let me say a few things that might not automatically come to mind about the condition and its consequences:

1. Hyperactive/impulsive ADHD individuals can sometimes look like they are world beaters, but mostly beat themselves; indeed, they are often chronic underachievers. If you are planning on forming a working group or partnership with such a person, don’t be fooled by a positive first impression of excitement and energy. You will almost certainly be disappointed down the road.

2. ADHD, even today, is sometimes not detected in schools. There are several reasons:

• The inattentive form of this condition may well produce school failure, but not misbehavior. Inattentive children are often quiet and relatively well-behaved, unlike their hyperactive-impulsive counterparts.
• School personnel may incorrectly attribute ADHD-like behavior to laziness or oppositionality. Moreover, school systems, even when they do formal evaluations, are frequently reluctant to identify problems that require additional resources and personnel, which they are hard-pressed to provide given their limited funds.
• An ADHD child who is bright can compensate (to some extent) for his attentional problems by relying on his excellent intellectual abilities, at least for a while. Eventually, however, many of these children (as they age and school begins to demand more of them) find out that advanced intelligence is no longer sufficient to permit success.
• There is no single standard measure that reliably identifies ADHD. Evaluators commonly use some combination of paper and pencil tests, clinical judgment, and attentional measurements. Intelligence (IQ) and neuropsychological tests can easily miss some of the most clinically obvious cases of this condition.

3. The fact that ADHD children are able to become “hyperfocused” on things like computer games or other tasks that they find especially interesting, does not invalidate the diagnosis of ADHD. Indeed, this sort of selective attention is seen fairly often.

Some researchers believe that those games provide rewarding stimulation in the form of frequently changing images, sounds, and challenges; as well as the success of achieving points or increasing levels of success, thus “capturing” the attention and imagination of the ADHD youngster. By comparison, the real world school room seems boring. Recommendation? Limit your child’s screen time, even in front of regular TV shows.

4. Although many people are hesitant to take medication, ADHD is a diagnostic category that is especially responsive to psychotropic medication. Hundreds of studies support the effectiveness of such treatment for about 85% of children with this condition according to Russell Barkley’s authoritative 2006 book Attention-Deficit Hyperactivity Disorder. In a 2007 paper by Elliot and Kelly — “ADHD medications: an overview” published in the journal Attention — the authors state that “No medicine available to psychiatrists produces a more rapid and dramatic effect more safely than the proper dose of a stimulant to a patient with ADHD.”

5. If medication does work, it will likely be needed on a continuing basis, not as a temporary fix. The irony is that stimulant medication, which will cause internal agitation in those who are not suffering from ADHD, actually permits the person with the condition to focus more and become less prone to the hyperactivity/impulsivity that had been a problem.

6. ADHD is correlated with a greater risk of developing a Conduct Disorder, typically characterized by antisocial misbehavior and defiance of authority. Not surprisingly, such individuals often abuse alcohol or drugs (not only as an act of rebellion, but also as a self-medication designed to calm their hyperactive state). Adolescents and adults who have ADHD are thought to make up at least 25% of the population of prisons according to Barkley.

In all these examples, the impulsive, ill-considered behavior that is typical of ADHD takes a fearful toll. Such individuals are easily bored, requiring intense and novel reinforcement (rewards) to motivate them, and are prone to “sensation-seeking” — looking for extreme excitement that their condition seems to make them crave. Indeed, one patient of mine reported driving at speeds approaching 100 MPH on city streets simply for the feeling it produced in him. Nor did he think he was at much risk (or putting others at much risk) in doing so, thus demonstrating the poor judgment characteristic of those with the hyperactive-impulsive form of ADHD, as well as their tendency to disregard rules and authority figures.

7. While many general medical practitioners (GPs) can prescribe medication for ADHD quite well, some are hesitant to do so, sometimes due to lack of training or inexperience with this particular diagnosis. Cautious GPs will prescribe psychotropic medication, but are prone to giving doses that are too small. It is generally best to see a psychiatrist in such cases; that is, someone who specializes in the prescription of medication for psychiatric disorders.

8. The frustration that ADHD produces in school children can make them give up (and eventually drop out), believing that nothing they can do will make any difference in their performance. Some of them will become avoidant of academic or other work tasks because they believe that they will fail, thus producing a self-fulfilling prophecy. Many will get angry at the teachers, bosses, and parents who so often are reminding them of their inadequacies. Thus, ADHD fuels other behaviors that make a good life difficult.

What happened to our friend A.T?

You’d think it was simply a matter of telling him of the benefits of medication, wouldn’t you?

Not so fast.

He was one of those folks who was uncomfortable with the “idea” of having to be reliant on medicine. He told me that he didn’t “believe” in medication, as if it was a matter of religious faith.

A.T. was also quite narcissistic; in denial concerning his own responsibility for the things that went wrong in his life. Similarly, he had no trouble blaming others including bosses and wives. Not to mention that he drank too much and didn’t acknowledge that it was a problem. Indeed, he had only come into treatment at his spouse’s insistence.

One of the challenges of psychotherapy is the fact that few people fit “pure” diagnostic types. Instead, one must be aware of all the complicating factors that can make effective therapy difficult. This man’s narcissism, denial, and alcohol abuse certainly created just such complications.

Had A.T. been more motivated and self-aware, less prone to denying the misery he was creating around him, a cognitive-behavioral (CBT) approach to his ADHD could well have helped, even if he chose not to take medication.

CBT programs include formal guidance in planning and organizational skills, assistance in problem solving and decision-making, help in reducing the number of distractions in the environment, practice in new thinking skills, training in ways to reduce procrastination, and advice to help you cope with failure. Homework is required between sessions.

The program described by Steven Safren and his associates in the work book Mastering Your Adult ADHD, developed by psychologists at Massachusetts General Hospital and Harvard University, was able to produce significant improvement in about 50% of those patients who continued to have clear problems even after being treated with medication.

So, if you have ADHD, medication and CBT provide reasons for optimism that things can get better.

Just don’t drop the ball!

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The top image is the Carbon Cycle created by the U.S. Government Department of the Interior. The one that follows is the Tux Crystal Linus Award by Nevit Dilmen. The next photo was created by Thomas Pusch and is called Scolded By Mama. The fourth picture is of Two Men Playing a Computer Game by Love Krittaya. Finally, a picture of a Geode  by Whitsoft Development. All are sourced from Wikimedia Commons.