Dr. Edward Hallowell discusses Adult Attention Deficit Disorder with Canadian pollster and media pundit Allan Gregg. This interview was uploaded to Youtube on October, 2010. October just happens to be ADHD Awareness Month, so in honor of that, we are posting the video along with the full transcript of the video. Doctor Hallowell is a psychiatrist who, not unlike myself, also has ADHD and embraces both the challenges and gifts it presents. My hope is that this is both informative and encouraging to you and those you know with ADHD.
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Video Transcript of Dr. Hallowell’s Interview:
Attention Deficit Disorder is normally associated as a childhood condition, but you say this is no longer the case. You yourself were diagnosed with ADD as a young adult.Edward:
Yes, yes I’m 55 years old now. I was diagnosed in 1981 so I was what, 30 something, early thirties. I had gone through college, medical school, residency, I was doing a fellowship in child psychiatry when I heard this condition, Attention Deficit Disorder described and I had never heard of it until then and I said, “Wow. There I am.” I went through the procedure, was diagnosed. Yes indeed I have it. I didn’t really need treatment at that point but the insight simply knowing that there was a name for this collection of symptoms that I had wrestled with for my whole life was a tremendous relief.
Allan:
Now, let me make sure I understand. The reason that it’s so underdiagnosed in adulthood is, we always suspected that the symptoms disappear in children around puberty and that was the end of it, but in fact your research shows that about two thirds of children carry those symptoms on into adulthood.
Edward:
Yes, and in fact the symptoms don’t disappear during puberty, that’s one of the myths that we used to believe. I don’t quite know where that came from. It is true that some kids get over it during puberty, but what happens more often is what happened to me. I learned to compensate so well that it looked as if I didn’t have it any longer. I was still wrestling with the condition and continue to do so even this very minute. That happens to millions of adults. Now, for a good fraction of them it’s causing no problem, so no need to do anything, but for a hefty percentage it is severely holding them back in life.
Allan:
In fact, you make a point in your book that in adulthood it no longer looks like a disorder, it almost becomes a trait, a personality character.
Edward:
Exactly.
Allan:
How does it manifest itself? What are the symptoms of adult ADD?
Edward:
Let me start with the positives because people don’t usually mention them and the positives are abundant. Creativity, energy, intuition, the ability to think outside the box, tendency to be a maverick, want to do it your way, independence, persistence, tenacity, often to the point of being stubborn. All of those qualities are really good, very positive and very useful in the world.
However, they can get buried under the negatives. The negatives include: trouble getting organized, trouble staying focused, trouble staying on task, tendency to hop from topic to topic. Attention deficit is really misleading. It’s not a deficit, it’s a wandering. It’s a vectoring.
Allan:
In fact, you can be very focused for some point.
Edward:
Super focused, but maybe on the wrong thing or super focused on the right thing. You go into these state of tremendous focus. People say you don’t have ADD you can focus, that’s not true at all. You can be amazingly focused.
Allan:
When you talk about wandering, what happens? The mind all of a sudden switches to something else?
Edward:
As if the T.V. channel were changed. Just, you’re somewhere else. In the middle of a conversation, you’ll be talking to someone and suddenly you realize you’re just watching his lips move and your mind is at the ball game or the meeting you’re going to go to next or what you did last night or what you’re going to do tonight.
Allan:
Now you yourself have said that this is a very seductive diagnosis.
Edward:
Yes, yes.
Allan:
In that, once you read about all the various symptoms, virtually anyone can say, “I see myself there.” Some critics have said that this is a made up disorder. It’s a function of a fast paced life. Everyone loses concentration. What do you say to those cynics?
Edward:
Well, first of all I agree with them. You’ve got to be careful in making this diagnoses and I would caution listeners, you’d have to be comatose not to identify with some of these symptoms and living in the modern world, we are all like this some of the time. To the person who says it doesn’t exist, I’d simply tell them first of all, there’s an abundance of hard scientific evidence, brain scans, genetics that show this is a real condition. If you are very distractible, if your mind is constantly shifting and it’s causing you to underachieve in your life, that’s a disorder. That’s different from ordinary overwork frenzy, multitasking modern life.
Allan:
Lest any of our viewers think this is a trip to Hollywood, having adult ADD. There are some scary statistics in your book.
Edward:
Absolutely.
Allan:
In that, about 25% of people who have adult attention deficit disorder also have bipolar problems or manic depression. Sixty percent have drug and alcohol addiction associated with it. Why does ADD come with these other disorders or afflictions?
Edward:
Well, it’s genetic and I think the core issue is what I call the itch. The itch at the core of ADD. The itch you can’t scratch. In chemical terms it’s a relative depletion of dopamine, which is a neurotransmitter associated with pleasure.
Allan:
Right.
Edward:
People with addictions, people with bipolar disorder, people with ADD, people with mood problems all tend to have trouble generating pleasure at an ordinary level so they resort to extraordinary means. Whether it’s becoming manic, in the case of bipolar disorder or abusing substances in the case of the addict or in the case of ADD seeking high stimulating situations of extreme engagement in order to get the adrenaline pumping, which in term, leads to dopamine. Substance abuse, violent behavior…the jails, for example are full of people with undiagnosed ADD, adaptive methods of scratching.
Find a creative outlet. When you hook yourself up to a creative outlet. For David Neeleman, it was JetBlue. He started an airline. For myself, it’s writing books. For an entrepreneur, it’s starting a business. Those are creative outlets and that is a marvelous way of harnessing the energy of ADD. On a more mundane level, physical exercise is tremendously helpful in treating ADD, of scratching the itch.
Allan:
This again, triggers the release of dopamine.
Edward:
Exactly, exactly.
Allan:
I want to come back to those, but first, diagnosis is difficult, is it not? Why?
Edward:
Again, difficult in whose hand? Difficult in my hands? No. Difficult in the hands of a primary care physician? Yes.
Allan:
So first, they’re not qualified?
Edward:
Nothing against them, I’m incompetent at diagnosing cancer. So you do what you’re good at. In the hands of an ADHD specialist it’s not that hard. What people need to know is there’s not a proof-positive test for ADD/ADHD. If we had that then diagnosis would be easy. You’d just go get a brain scan.
Allan:
It’s not like diabetes.
Edward:
Exactly or a tumor where you can see it on the scan. We rely on the history, so you have to take a very careful history. Teasing out various factors, but if you do that, the diagnosis will emerge quite clearly and in addition you will identify what else is going on, the positives which I think you really need to bring front and center, as well as the other conditions you’ve mentioned. Bipolar may also be present. You may have a problem with substance abuse. You may have a problem with depression. You may have a problem with anxiety disorders. You may have an associated learning disability as I do. I also have dyslexia. You want to get a complete diagnosis that includes the identification of your talents and strengths, but also enumerates the coexisting conditions so you can have a complete treatment plan.
Allan:
There is some scanning technology though. Is there some quantitative electroencephalogram (QEEG), I think that’s one.
Edward:
Yes, yes yes,
Allan:
What does this do? This looks at the brainwaves?
Edward:
The QEEG for short, is a variation on the EEG, the brainwave that’s a diagnostic tool. It’s not a proof positive and then we have various scans. Most of them are still research tools. The MRI at the top of the list has shown us anatomical differences in certain regions of the brain in ADD. This has not become standardized to the point of it being a diagnostic test, but there’s a statistical significance to these scans taking in aggregacy.
Allan:
I see.
Edward:
We can say there’s a difference in the ADD brain and the non ADD brain, but not able yet to use it as a diagnostic test. I think if we’re ever going to get a proof positive diagnostic test it’s going to come from this dopamine that I was talking about earlier. A test that measures dopamine receptors and the dopamine transporter molecule. That may be the first real biological test we’ll have for ADD as well as propensity towards addiction.
Allan:
It’s a big business. Two billion dollars now, the pharmaceutical industry has a vested interest in convincing people that they have ADD. In fact, some of the pharmaceutical companies are giving people six questions to ask yourself and if you answer positively for four, rush to a doctor. I mean, what do you think of that?
Edward:
Well, I think, I have two ways of thinking about it. On the one hand it’s very good that we’re educating the public and as long as you do rush to the doctor and let the doctor be the gatekeeper I think that’s fine. If you rush to the pharmacy, in other words, if you rush to take the pill, then it’s a big, big problem. I think that’s where you have to be careful. It’s fine with me if drug companies promote this diagnosis, advertise and tell people about it as long as the consumer goes to the doctor.
Allan:
The doctor is the gatekeeper.
Edward:
The doctor is an informed and educated gatekeeper. Unfortunately, too often that doesn’t happen. The consumer rushes the doctor, the doctor gives them a prescription. They short circuit the diagnoses and the person ends up taking the wrong medication or thinking that medication alone is the treatment for this condition. That’s woefully inadequate. It’s a big problem.
Allan:
The implications for treatment when you have ADD associated with other disorders, especially medical treatment, does this complicate matters tremendously?
Edward:
Yes, but it’s not insurmountable. If you go to see a specialist who knows what he or she is doing, these are very treatable conditions. Essentially, the treatment doesn’t just bring you to an even the playing field, it allows the assets to predominate. As I see it, the goal and treatment of ADD, as well as bipolar, as well as depression is not just to eliminate the downside, but to capitalize on the upside. That’s the part that I think is new about my book and my approach. I’m saying it’s not just a matter of taking care of what’s wrong, it’s looking for what’s right and promoting it.
Allan:
Can the treatment of things like bipolar actually make the ADD worse?
Edward:
Sure. Depending on how you go about doing it. If you mismanage the treatment, you can make part of it better and part of it worse. There is a lot of skill involved in treating these conditions, but like flying an airplane: there’s a lot of skill involved, but a lot of people can learn how to do it.
Allan:
Sure.
Edward:
It’s not impossible to learn how to do it.
Allan:
Conversely, I guess, if you have no treatment, the prospect of succumbing to alcoholism for example becomes even that much greater because that desire, that itch as you say, is there and is being unattended.
Edward:
Absolutely. In the addicted population there’s a heavy predominance of people with undiagnosed ADD, bipolar disorder and depression.
Allan:
Not only is it hard to detect adult ADD, but I understand with children, especially preteens, 10-12 is especially difficult. Why is that?
Edward:
Well, in childhood the symptoms of ADD are normal.
Allan:
Right.
Edward:
You know, all kids are distracted and buzzery. How do you separate the normal boy from ADD? The same thing even with girls and now we realize that hyperactivity does not have to be part of this diagnosis.
Allan:
Yeah we always thought that ADD was also a boy disease or boy disorder.
Edward:
Exactly and we now know girls have it and women have it. The reason we miss them is they weren’t hyperactive at all.
Allan:
Right.
Edward:
They weren’t overturning chairs and desks, they were sitting in the back of the room quietly day dreaming. The teacher thought of them as slow or shy, but if you ask the girl, what’s it like to be in the classroom she says, “It’s fine. I’m almost never there.” She’s got her own world and the woman the same thing. The woman, if you asked her, this woman who’s been dismissed as a dingbat or dismissed as spacy or dismissed as not very bright. If you sit down and talk to her she’ll say, “I have such trouble staying focused, that’s why I’m forgetful, that’s why I underachieve, that’s why…” and she’ll tear up and say, “I know I’m smarter than everyone thinks I am.”
Allan:
Right.
Edward:
This is so poignant, but it’s also so gratifying because then I can give a diagnosis and offer a treatment plan and this woman who has sold herself short or the world has sold her short…she can suddenly achieve at the level that her brain really entitles her to achieve at.
Allan:
Right. I’m also surprised to learn that this is a problem that can run in the family.
Edward:
Yes.
Allan:
Not that it was genetically based, but in one family you have can the entire group with ADD. I understand of your three children, two have ADD as well.
Edward:
My 15 year old Lucy has it, my middle child Jack has it and our youngest Tucker, who’s nine, doesn’t have it but he wishes he did. Which shows you how we regard it in the family. My wife Sue doesn’t have it, but she thinks its contagious.
Allan:
Now, the single most agonizing, I think decision, when someone discovers they or their children have ADD is to medicate or not to medicate. What’s your position generally on this?
Edward:
Sometimes people ask me do I believe in Ritalin? My response is it’s not a religious principle. This is a medication. If you use Ritalin or the other stimulants properly, it can be dramatically effective and very safe. What most people don’t realize is that stimulant medication has been around since 1937. It was first used to treat this condition in 1937, so we have about 70 years of experience in prescribing stimulant medication. That’s a lot of clinical experience.
Allan:
Let me just interrupt there for one second though. Having said that, my understanding is that most people were taken off medication once they reached the teens.
Edward:
Right.
Allan:
The notion of lifelong use of this is still fairly murky. Is that right?
Edward:
Correct, but what we have though is a lot of experience with people taking it three to five years. What we don’t have is experience of people taking it 25 years. You have to do the risk-benefit analysis. What are the side effects of not taking the medication? That’s a question people don’t usually ask.
Allan:
Right, of course.
Edward:
If you look at the kids who take it and you look at the adults who take it and who benefit from it, they won’t give that up. They were struggling beforehand. The benefit they get from it is as pronounced as the benefit someone who’s near-sighted gets from wearing eyeglasses. The side effects of not taking the medication in their cases is severe.
Allan:
Well you aren’t on medication, your children are.
Edward:
Well, I am on medication. There it is.
Allan:
How do you determine, again given the difficulty of some of the diagnosis, how do you determine who’s going to benefit from medication and who really isn’t?
Edward:
First of all, you take a careful history and make a diagnosis. Then once you’ve made your diagnosis the statistics are 80% of those who have ADD will benefit.
Allan:
Are going to benefit.
Edward:
Of those, a sizable fraction don’t want to take any medication. I am certainly one who honors that. One of the reasons in my book I have many chapters devoted to non-medication treatments for ADD is because there was a lot of people that just don’t want to take any medication and that’s fine. I give them the medical facts about the safety of the medication and let them make their own decision. In my own children’s case, they have benefited tremendously from medication, but they also receive the non-medication treatments as well and that comprehensive treatment program it’s the golden treatment.
Allan:
Total package.
Edward:
It’s the best way to go.
Allan:
What about the other side? I mean there are reports that up to 50% of kids who are on Ritalin really don’t have ADD and this is being used often just to suppress normal rambunctiousness in children, it’s like a teacher’s aid.
Edward:
Yeah, again the data do not bear out.
Allan:
They don’t?
Edward:
Not at all.
Allan:
Urban legend? Old wives tale?
Edward:
It’s part of this, and again I don’t understand it, but it’s part of this tremendous desire to denigrate these medications. Now, I’m certainly not here to promote them. In my book…
Allan:
No, that’s why we have you on the show.
Edward:
I go to great length to talk about non-medication approaches, but for some reason there is this tremendous amount of stuff written about how bad these meds are, when in fact, the data support how useful they are. If you add up the number of prescriptions written for stimulant medication and measure it against the number of people who have ADD, you’re not getting 50% more prescriptions than people who have ADD. People just pull these figures out of thin air. “Fifty percent are overprescribed. Where does that come from? How did you get your data sir? I don’t know. It’s 50% though. It’s out there. I’ve seen it.”
Allan:
Yeah, “it’s out there.”
Edward:
Exactly. That is not to say it doesn’t get overprescribed, it does, I know it does. I see people who are taking stimulant medication who shouldn’t be taking it. I think what’s happening is what I call “pseudo ADD”. There are a lot of kids who don’t have enough, what I call connectedness in their lives, they don’t have family dinner. They don’t have adult supervision. They’re watching too much T.V., playing too many video games. You put kids in that kind of a soup of not enough human connectedness and supervision, too much stimulation with video, they’ll look as if they have ADD. They’ll be distractful, impulsive and restless. To put them on medication is a great mistake. You’re medicating something that should not be medicated. What those kids need is more human connectedness. What they need is more supervision. What they need is more time playing outside, having family dinner, getting a pet, spending time with grandma, turning off the television, turning off the video.
Allan:
Let’s talk about some of those things because a big part of the book deals with the non-medical treatment of ADD and how to bring out the talents of people who have ADD. One of the most important things you point out too, is finding something you’re good at.
Edward:
Absolutely.
Allan:
Mastering that thing you’re good at and getting recognition for that mastery: this is part of your five-point program. Why is this so important?
Edward:
Well, what you build a lifetime on is developed talents and strengths, not remediated weaknesses. I think we in the medical profession have made a big mistake when it comes to mental health and focusing in on what’s going wrong instead of focusing in first on what might be made right, because what you’re going to build a lifetime on are talents and strengths that you develop. Not weaknesses that you remediate. Now, I’m not saying don’t remediate the weaknesses, yes you need to do that, but what I want us to do, start doing front and center, because a lot of these folks come in, adults come in saying, “I don’t think I’m really good at anything” and we have to go searching, but in everyone you can find the hint of a talent. The flicker of an interest and we need to identify that and then start to promote it. As you promote that, as someone goes gee, “You mean I can do this? I might be good at this? This cooking interest I have, I could actually work at a restaurant or…?”
Allan:
What benefit does that have?
Edward:
Well, as you get better at something, as you gain what I call mastery, self-esteem builds, confidence builds and furthermore, motivation builds. A lot of these. We tend to want to do more of what we’re getting better at.
Allan:
That helps with everyone. How does that help someone with ADD?
Edward:
It helps absolutely with everyone. It’s just that people with ADD tend not to be doing it because they tend to be frustrated, they tend to be underachieving, but yes indeed this is a plan for everybody. The five steps I outline in the book are (1.) connect, (2.) play, (3.) practice, (4.) mastery, (5.) recognition. There’s a whole chapter about that. That is a way of developing everyone’s talents. Yes indeed. That’s why I recommend it to everybody. Managers in business, parents, teachers in schools, coaches, if you want to bring out the best in someone, that’s what you need to do. It’s just that it’s particularly relevant to the ADD population because notoriously they have not had the best brought out in them. They’ve had the worst brought out in them.
Allan:
You also write not just about the dos to help people with ADD, but the don’ts. We’ve talked already about how exercise can be very, very helpful, but conversely, one of the worst things you say you can do, especially to the child, is give them a detention that takes away their play. What happens then?
Edward:
When you give a detention period to a child, it’s like…what’s an analogy? It’s like giving a diabetic a candy bar. You’re doing precisely the worst thing. What these kids need to do is not sit still, what they need to do is go out and run around.
Allan:
Give them an errand as a task.
Edward:
Absolutely. If you want them to have a penalty, have them run laps or go pick up the school grounds, but have physical exercise on a daily basis. These kids and grownups really need physical exercise and when they get it, they tend to be focused, they tend to be calmer. When they don’t get it, it’s paradoxical. They tend to spill over. They tend to get really antsy and agitated and the more you tell them to sit still, the more impossible it is for them to do it.
Allan:
Shut off the T.V. and no video games for the day. Why?
Edward:
I’m not saying don’t give them any T.V. and video, but limit it because there’s something about the interaction with T.V. and video we don’t understand exactly what it is that is unsettling. It leads the mind to states of instability as well as low creativity. These kids tend to get antsy, distracted and not terribly interesting the more T.V. and video they consume. It’s essentially intellectually empty. It’s stimulating.
Allan:
Yeah, because that’s what you would think at first. You have hand eye coordination going on, visuals.
Edward:
Big deal, hand eye coordination. It is stimulating, but it is intellectually empty, yeah. There are no ideas in it.
Allan:
Diet. Things like omega-3 fatty acids. Very, very good?
Edward:
Yeah, very important. We’ve always known that food mattered, but we haven’t known exactly what to prescribe and I have a chapter on what, some of it is obvious like eat a balanced diet, try to stay away from additives. There’s good evidence that junk food is bad for you in general and particularly bad for your ADD. Then a specific intervention, eat a diet rich in antioxidants as well as take omega-3 fatty acid as a supplement. The supplement, I suggest is fish oil because it’s very rich.
Allan:
Well sardines, salmon.
Edward:
Well, you have to eat an awful lot of sardines and salmon. I think you ought to get a bottle of fish oil.
Allan:
A supplement.
Edward:
Yeah, just like grandmother used to give us castor oil, she was on the right track. Now make sure it’s high grade fish oil because if you don’t get the top of the line you might get contaminants like mercury and other poisons.
Allan:
What advice do you give to someone who has either a spouse or a child with ADD? What’s the principle advice that you offer them?
Edward:
Learn about it. Learn about it because as you learn about it, you’ll learn how to manage it. Don’t despair, don’t think of this as a curse.
Allan:
Or a prison sentence or something.
Edward:
At all. Think of it as a gift. But it’s a gift that’s difficult to unwrap. What my book tries to do is help you unwrap it so the gift can emerge, because it looks at first like a curse. It looks at first like, “My gosh”, this person just can’t get their act together. This kid can’t put his clothes on in the morning, can’t get his homework organized, can’t sit still at the table, can’t go to a party without causing a problem, can’t go on vacation without being so disruptive. This adult is just a chronic loser. This adult just loses jobs, breaks up in relationships, drinks too much, gets into arguments and what a waste of potential. He’s got so much going for him and he never will make any use of it. Okay, it looks like a curse, but I promise you, embedded in that there is a gift. If you learn how to take care of the downside, if you learn how to get focused, if you learn how to get organized and in the case of adults, if you find ways of delegating and compensating and capitalizing on your strengths, the gifts can be unwrapped and that is the whole point of my writing this book.
Allan:
I’ve got a magic wand here. I can get rid of your ADD, do you want me to use it or not?
Edward:
Absolutely, not.
Allan:
Honest? Honest as truth?
Edward:
I wouldn’t, as God is my witness, I would not trade it for the world nor would I trade it in my children.
Allan:
Edward Hallowell, I want to thank you very much for joining me, it’s been a real pleasure.
Edward:
Thank you.