10 Oct

I Have Trouble with Attention and Focus, What’s Wrong with My Brain? Do I have ADHD?

This is a longer Tip than usual, as it provides an in-depth understanding of what to do if you or someone you love is suffering from problems with focus and attention. It includes tips on how this condition should be comprehensively evaluated, potential causes of these symptoms other than ADHD, and stories of what was uncovered in the course of the evaluation and treatment of “Samantha” and “Jay.

If you or someone you love has been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), or believe that you or they may be suffering from this condition, our session today offers both helpful ideas and hope for improvement. Let’s begin with understanding the existential experience of the person who struggles with ADHD, which hopefully will lead to the development of empathy and compassion.

What does it feel like when one’s brain suffers from ADHD?

What does it feel like when one’s brain suffers from ADHD? Many patients with this condition feel a deep sense of frustration, anger and sadness that their brain does not work the way they wish it would – the way that other peoples’ brains work. Some have described their ADHD as “a curse.” Much as the group Pinback sings in their song “Sender”, where “acute angles divide the path that I had lost,” there is trouble staying on task, sustaining a focus, and easy distractibility; and a number of executive function challenges (including finding and executing upon a path of thought and action, then losing the path, perhaps to find it again or perhaps to lose it completely). The same may occur when attempting to write, or to speak which is emotionally upsetting at the time (“tongue tied, couldn’t talk, settle down inside”), particularly in moments fraught with the need to perform under deadline pressure, or to hold one’s ground in a tension-filled argument. It can be almost impossible to complete homework assignments and timed tests in the same time frame as others, which is humiliating and damages one’s self-esteem. Learning novel tasks, which seems easy for others, may take two or three times as long for the person afflicted with ADHD, regardless of his or her intelligence. i ii iii A number of abnormal neurobiological correlates have been found in neuroimaging studies of those suffering from ADHD.iv

Another perspective on this condition may be found in that famous song “Don’t Let Me Be Misunderstood,” by The Animals, which describes someone with good intentions, who has difficulty controlling and managing their emotions, has trouble tolerating frustration when things go wrong, and who feels misunderstood regarding their true intentions. Here the lyrics relate to the moodiness that can accompany ADHD,v when the brain won’t cooperate with carrying out one’s intentions; and the person with ADHD gets into trouble with loved ones who can’t understand why they have mood swings, irritability, anger outbursts, and are not fully “present” during conversations; and where in turn the one suffering with the condition feels deeply misunderstood. Also they may suffer from what I call “Ready… Fire… Aim” – acting impulsively before they think through or process information sufficiently. vi vii For the patient with ADHD, living in reality may feel like a “discontinuous experience,” as she or he repeatedly misses out on information and social cues in the surrounding environment.viii

When one’s speedix and efficiency of information processingx is compromised by distracting thoughts,xi xii one’s tongue may feel tied to the point of being unable to speak,xiii thoughts and behaviors may be chaotic and disorganized,xiv and feelings of anxiety xv ensue which make it difficult to settle down, which may lead to seeking out stimulation in the form of “addiction” to Web browsing (in “An Age of Distraction”)xvi xvii during homework or work assignments, risky behaviors, or substance abuse xx. Novel stressful situations, such as SATs or graduate school entry exams, medical boards or bar examinations, or promotions at work can feel extremely distressing and overwhelming.

A commonly used screening tool that rates the severity of the disorder is called the Adult ADHD – RS – IV. xxi  Psychological testing is also useful in identifying subtypes and specific areas of weakness.xxii xxiii Psychologist Dr. Marlena Wu notes that “a variety of assessment instruments can be used to assist the clinician, patient, and concerned family members in confirming whether or not ADHD is present; as well as determining relative areas of cognitive strength and weakness.” Parents in particular may wish to seek out this type of testing, as they may not want to place their children on stimulant medication in the absence of further confirmation.

In the United States, an estimated 4.4 percent of adults ages 18-44,xxiv 4 percent of children ages 4-8, and 9.7 percent of children ages 9-17xxv experience symptoms and some disability from ADHD. As such, this condition is one of the most common of all psychiatric disorders. The good news is that ADHD is associated with an exceptional response rate to treatment.xxvi

Research has established that ADHD is a neurobiological condition with a likely genetic component

Research has established that ADHD is a neurobiological condition with a likely genetic component.xxvii xxviii Critical circuits in the frontal cortex of the brainxxix responsible for sustained attention, organization, planning, and various other executive functions are not functioning properly. The speed and efficiency of information processing is inconsistent, and compromised.xxx These circuits mainly rely upon two neurotransmitters to function (dopamine and nor-epinephrine), and most medications used to treat ADHD increase the availability of one or both of these two transmitters.xxxi Additional treatments typically include education, cognitive/behavioral techniques that establish various routinesxxxii of daily living, and cardiovascular fitness exercise. Exercise activates the frontal cortexxxxiii in all age groups, and increases levels of both dopamine and nor-epinephrinexxxiv to improve ADHD symptoms (we will cover this in more detail in our next session).

Because these patients are frequently distracted by wandering thoughts, excessive daydreaming, and external motion and sounds in the environment when trying to focus on a task, they miss out on a number of important events going on around them, and struggle harder to learn new information. This has nothing to do with their level of intelligence, as I have treated many outstanding students, executives, and professionals with ADHD. These highly capable individuals have become overwhelmed and emotionally depleted from the challenge of processing increasing volumes of information. Certain information from the environment therefore never “gets inside” their brain, and is unavailable to be processed, particularly when their “supply” of information processing is exceeded by the “demand” to process information while at school or in the workplace.

A useful analogy to assist in explaining this experience is to imagine for a moment that your computer suffers from ADHD. As a result, an average of one out of every ten keystrokes that you type on the keyboard never register in the computer – that portion of the data never gets entered. In addition, the keystroke data that is “dropped” on the way in is random and unpredictable. The computer then inconsistently processes the information that has been entered – at times with the latest Intel Core i7-5960X Extreme Edition chip, and at other times with an Intel 386 microprocessor designed 20 years ago. The end result is that this computer could run Windows 95 just fine, but what about Windows 10?

For simpler processing tasks this computer would function pretty well, but as processing complexity increased, it would begin to function poorly, if at all. How well would the computer function with its varying processors that are commanded to process incomplete information? What would the work product (for example the text or financial information you have created), look like when displayed or printed out? If you use your imagination, you can picture the result.

What are some of the behavioral manifestations of ADHD?

What are some of the behavioral manifestations of ADHD? As Eric Burdon sings about in “Don’t Let Me Be Misunderstood,” those suffering from ADHD may be more prone to mood swings, swinging from a carefree, joyful, enthusiastic, spontaneous, and even entertaining self to another side filled with worry, anger and impulsivity. Related behaviors can include poor frustration tolerance, irritability, difficulty waiting in lines or when stalled in traffic, restlessness, agitation, fidgeting, difficulty sitting still, and having a “short fuse.”xxxvi xxxvii

If you or someone you love suffers from these symptoms, how do they originate? What’s behind these self-sabotaging behaviors that are not intended? An underlying clue relates to how challenging it can become to maintain stable positive self-worthxxxviii xxxix when one’s brain functions so inconsistently, and the speed and efficiency of processing external information and internal thoughts is so variable and unreliable. While our brains may function in certain respects like a computer, a machine lacks a heart. Having ADHD is not just cognitively challenging, it is emotionally painful, as learning new material becomes more of a struggle and takes longer than it does for others, social cues are missed, distractibility is interpreted as a “lack of interest” or “rudeness” by others, and self-esteem is diminished over time.

Anxiety, mood swings, and depression may set in. Patients with ADHD are more likely to develop a major depressive disorder, significant anxiety disorder, or substance abuse problem than the general population.xl xli Social development is slower and more challengingxlii due to missed social cuesxliii xliv and delayed brain maturation.xlv Symptoms may be masked by high intelligencexlvi and a strong work ethic, which provide for a temporary “work around” the ADHD processing deficits. But as the complexity of life increases at certain transition points (for example moving from middle school to high school; taking standardized tests such as the SAT, LSAT, medical boards or bar examination; or receiving a significant promotion at work) the attentional system may become overwhelmed, emotional symptoms become more pronounced, and psychiatric care becomes necessary.

There has been increasing interest in adults with attention deficit problems in both the popular press as well as the psychiatric literature. Some of this results from a greater awareness that the attentional deficits of childhood often persist into adulthood;xlvii while other aspects relate to a pervasive anxiety over the need to perform at ever higher levels in the workplace, given the Great Recession and its attendant job loss and painfully slow recovery.xlviii xlix

Symptoms such as trouble sustaining attention, being easily distracted by internal or external stimuli, trouble staying on task, jumping from one task to another without completion, procrastination, problems with organization, difficulty focusing and executing on tasks particularly when they are boring, fidgeting, frequently being in motion, and interrupting others while they are speaking, are among the hallmarks of classic adult attention deficit disorder.l

There are four major areas of dysfunction under which most symptoms and behaviors of ADHD can be grouped. These include executive function (for example trouble organizing, planning, following through on the plan, good time management), attention (inability to sustain a focus particularly when bored, easy distractibility, difficulty staying on task), arousal level (people with ADHD tend to be under aroused, and may crave stimulation as they focus better with a higher arousal level), and behavioral (for example fidgeting, restlessness, impulsivity, anger outbursts).li lii liii

However, a note of caution is in order, given the risk that “Adult ADHD” may become over-diagnosed, and stimulants may become over-prescribed, much in the same fashion as childhood ADHD.liv It is important to recognize that there are many causes of disrupted attention in adults that bring about symptoms similar to adult ADHD, but have differing origins and treatments. A careful diagnostic assessment is in order.

Attentional problems can result from a number of conditions

Attentional problems can result from a number of conditions including: anxiety disorders, ranging from OCD to recurring panic attacks; certain prescription and non-prescription medications; vitamins, supplements and nutriceuticals; concussion and/or whiplash injuries; alcohol abuse; use of marijuana and other mood-altering drugs; sleep apnea syndrome; thyroid disorders and other hormonal or metabolic disorders; lead, or other heavy metal intoxication; overexposure to pesticides; vitamin deficiencies; mood disorders; petit mal or complex partial seizures; early stage dementia, or other conditions.

As we have pointed out in other Weekly Tips, the optimal approach to determine a correct diagnosis and treatment plan is called the biopsychosocial model.lv Only through a careful history of potential biological, psychological, and social/environmental factors can the various contributors to attentional problems in adults be delineated and addressed. Sometimes it is helpful to bring in a spouse or significant other to listen to their perspective regarding symptoms. For example, they may have noticed staring spells that sometimes characterize a type of epilepsy such as petit mal or complex partial seizures.

Ultimately, the correct diagnosis and initiation of successful treatment can end years of frustration, demoralization, despair, and anxiety over these attentional problems and their destructive effects on self- esteem, and important outside relationships; and one’s relationship with oneself. A new chapter may begin, characterized by greater personal fulfillment, and a richer awareness of a life that was previously unobserved.

Samantha’s Story

Samantha is 41 years old, and arrived for her first session along with her younger brother and her parents, all of whom were very concerned about her and wanted her to “get treatment for her ADHD.” She had been diagnosed with Adult ADHD, predominantly inattentive type, and was suffering from symptoms including trouble sustaining a focus, being easily distracted, severe procrastination, trouble with organization, messiness, and impulsively moving from job-to-job. In addition she had complained of ten years of depression and chronic low self-esteem. Her life was complicated by the fact that she was recently divorced and had sole custody of her two young sons, and her ex-husband owed her six months of child support that he refused to pay. Despite a court order for him to pay up, including provisions to garnish his wages, because he was self-employed as a CPA he was able to avoid payment for long periods of time, which not infrequently placed Samantha and her children in financial peril.

She was an attractive woman yet looked unkempt, and on examination appeared confused, and rambled in her speech. She appeared to be quite overwhelmed by life, and fortunately her parents were helping to support her financially and emotionally until she could improve. She was also very close to her brother, and was able to confide in him about pretty much anything. He loved her very much, and despite his being two years younger, was very protective toward her, and “had her back.”

In taking a careful history from each of them, it was apparent that Samantha had indeed manifested symptoms of the inattentive type of ADHD as a child, where she was a shy, dreamy kid whose backpack and desk were quite disorganized, and who procrastinated around homework assignments, and with whom teachers frequently commented that she was “not working up to her potential.” Samantha exclaimed, with a great deal of emotional pain, “My brain has never worked the way I wanted it to, and recently it has been working even worse than before. I feel scared that something is really wrong with me.”

Her prior psychiatrist had prescribed Adderall and Zoloft, and yet not only was she not improving, it appeared she was getting worse. Her parents and brother noted that Samantha’s symptoms of depression had been changing over the past two years since Adderall and Zoloft were prescribed for her. She had become more moody and irritable, with frequent mood swings. At times she would spend far too much money, would go on “cleaning binges” in the house where she would stay up all night, would speak very rapidly and appear to have too much energy.

Samantha described that her thoughts were always racing, and that at the times where she had great amounts of energy she also felt depressed and suicidal. She was also scared that her memory function was declining, and both she and her family members described increasing confusion and forgetfulness around even simple tasks. It appeared to me that while she had suffered from childhood ADHD, her symptom picture as an adult had devolved from one of depression and ADHD to what looked more like a Bipolar 2 Disorder with rapid cycling, and much of the time she was in a “mixed episode”lvi simultaneously experiencing symptoms of both depression and hypomania.

At the conclusion of her first session I shared with Samantha and her family some of the basic principles of the biopsychosocial model of understanding in saying, “This is a complicated picture, and not simply ADHD. Samantha, there are many possible causes of disrupted attention, including ADHD, mood and anxiety disorders, and a number of other physical causes. I promise you that we will get to the bottom of what is causing your problems, but that means we first need to establish the correct diagnosis. Are you and your family open to looking at a number of the possible physical causes of how you are feeling? It means that I won’t be prescribing something new for you today. We would wait until we have more information, so as not to rush to judgment on the best way to help you.” Samantha and her brother and parents all agreed with this approach.

I ordered a complete physical examination and blood work to rule out infectious, toxic, metabolic and endocrine causes of her condition (these tests look at hormone and vitamin levels, kidney and liver functions, inflammation, substance abuse, hidden infectious disease such as Lyme, heavy metal toxicity, and other possible physical causes). In her case the physical exam and blood testing were completely normal. The conclusion was that the Adderall and the Zoloft were triggering what is called medication-induced bipolar disorderlviii lix which had developed over time into her mixed mood state. “Samantha, it is your medication that is worsening your condition, and we need to take you off it. How do you feel about this idea?” Both she and her family agreed, as instinctively they had all felt that the medications were making her worse.

We agreed to progressively wean her off the Zoloft and the Adderall, and began prescribing gradually increasing doses of Lamictal (lamotrigine) a medication that has both mood stabilizing and antidepressant effects;lx lxi and she would begin weekly psychotherapy sessions with me. Once she was stabilized on the correct dose of Lamictal, we agreed to look at adding back in a medication to treat her ADHD, and find one that hopefully was not mood destabilizing.

At the beginning of treatment her confusion and memory problems were so pronounced that she would show up late for appointments, and at times forgot them altogether so we would speak by telephone instead. In these early sessions Samantha appeared disheveled and would ramble on in a disorganized fashion, and remained anxious and depressed. Her mental confusion then began to clear somewhat, and her mood lifted and began to stabilize after about a month of treatment, during which time we met for supportive therapy and were gradually increasing the dose of her Lamictal to a therapeutic blood level.

In the sessions I established an empathic rapport with her around the challenges of raising two young children (who reportedly were well behaved and doing great in school) along with an unreliable and hostile ex-husband. I gave her practical advice about how to build routines to organize her household and carry out daily housekeeping duties, and as her mental function cleared we also began to explore possible next career moves. She had really been beaten down by life and by her emotional illness, and it was important to give her a bit of a boost in morale and not just depend upon the medication to lift her spirits and improve her attentional functioning. And so I said to her, “Samantha, I have had a chance to observe you in the waiting room with your two sons. Your love and devotion for them just radiates out from you. You are so patient with them when they express their questions and concerns that it is really impressive watching you in action. It is so hard to be a single mom, I really admire your dedication and tenacity. You don’t get angry or give up and give in to them even when they are whining or behaving in ways that are irritating and annoying. You exhibit so many traits that serve you well in your family life, and these will greatly assist you in recovering your health through our work together.”

Once the Lamictal and psychotherapy had fully stabilized her mood and lifted her depression, we initiated treatment of her ADHD with Vyvanse, a long acting medication that is chemically related to Adderall. We proceeded to increase the dose of Vyvanse very slowly to watch for possible mood destabilizing effects, but fortunately none emerged as the Lamictal was at a therapeutic blood level and protected her against further mood swings. While the Vyvanse helped her improve her focus and attention, and provided increased mobilization and initiative, she continued to complain of forgetfulness and confusion.

These types of residual cognitive problems can accompany bipolar disorder as well as treatment resistant depression, and may not respond to conventional medication management and psychotherapy. Some patients’ cognitive impairment responds to a combination of Buspirone plus Melatonin.lxii But in Samantha’s case given her history of rapid mood swings, to address these lingering functional deficits we began a trial of Namenda (memantine), a medication used to treat Alzheimer’s disease, which has recently shown much promise in improving mood stabilization and cognitive functioning in bipolar patients.lxiii lxiv lxv The Namenda began to improve Samantha’s memory function and organization.

She developed a to-do list in a spiral notebook that she kept in her purse, and actually began to show up early for each therapy session! At the time of this writing she had brightened considerably and she and her family were feeling hopeful. We had created a “rehabilitation roadmap” whereby she would progressively take on increasing work responsibility moving from part-time to full-time employment as a customer service representative, and gradually wean herself off parental support. This had begun to restore her self-respect as she became more self-sufficient.

In Samantha’s case her attentional problems were partly a result of her longstanding ADHD, but also were caused by her mood disorder, and by the medications she had been taking which had worsened both her mood stability and her cognitive functioning. The great news is that just a few weeks ago she was awarded a full-time position at work, and as a result is now poised to assume greater responsibility and independence in her life. She was absolutely beaming as she reported this news to me, and we high-fived each other at the end of the session.

Jay’s Story

As Eric Burden sings other lyrics from “Don’t Let Me Be Misunderstood,” they speak to a kind of edginess that is taken out on the woman he loves, and yet he doesn’t mean to unload his problems on her. This certainly describes my 49-year-old patient Jay, who is president of a charitable foundation devoted to providing solutions to world hunger, and who sought out help because of problems with anger outbursts, which had worsened over the past several years. These included shouting at motorists, and provocative public encounters that at times almost resulted in physical altercations. In addition, Jay had become angrier at home with his wife and children, which placed a strain on his marriage and family life, which had previously been very satisfying. He described having trouble focusing on his work, being increasingly distracted, and feeling like his mind just wasn’t working properly anymore.

Jay wondered if he was showing early signs of Alzheimer’s disease and felt scared that something was really wrong with his brain. He’d had mild problems with concentration over the years, and wasn’t the most organized executive he’d ever met, yet he had managed to feel effective until recently.

His outbursts had followed a series of major life events for this talented executive that had taken place over the past five years; he had lost both of his parents, his youngest daughter had gone off to college, and his foundation was facing unique challenges that demanded greater organizational leadership and executive function demands than ever before. With the continuing sizable growth of the association that had resulted from his successful stewardship, Jay felt increasingly overwhelmed and out of control, which was eroding his confidence and making him feel less effective.

Deep feelings of inadequacy began to surface, and he began to feel like a bit of a fraud, and feared that his employees would find out that he had no idea what he was doing much of the time. At the conclusion of our first session, mindful of other powerful men who I had treated who had “hit a wall” at work having previously functioned quite well, and using what I had learned in my personal psychoanalysis about my own father’s struggles (in retrospect, my father had definitely suffered from ADHD), I said to Jay, “Over the course of your adult life you have been accruing increasing levels of power and prestige, yet perhaps have been feeling more and more helpless. Therein lies a paradox that might be worthy of exploring together. Clearly you have achieved great outward success, yet have also sustained a series of losses in recent years. As well there may be something biological going on that is adding to your distress. If you choose to work with me, we will explore all of these issues over time. What do you think of this approach?” Jay agreed that he would like to work with me, and so we began.

During the course of evaluating the underlying causes of his anger outbursts, it became apparent that he had a history of some childhood learning difficulties, which had been largely overcome by his innate intelligence and hard work, but had left within him a legacy of humiliation given his growing up in a family of high achievers. His father in particular was an extremely driven and highly accomplished businessman, and had expected and demanded “great things” from his son, getting furious with Jay as a child when he’d mistakenly interpreted Jay’s learning problems as “laziness and willfulness,” and “not respecting the value of hard work.”

Jay’s learning difficulties included trouble sustaining attention, being easily distracted, and clowning around in class; messiness with his backpack, desk and bedroom; and procrastinating around homework assignments that were “boring.” Completing these assignments took him much longer than his peers, which deepened his feelings of humiliation. Not infrequently, when called upon to answer a question by a teacher, Jay would be unable to answer as he hadn’t heard the question in the first place. His mind had been wandering elsewhere or he had been daydreaming. His teachers not infrequently commented that Jay “didn’t work up to his ability.”

As a teenager he had joined a gang of older boys that actively vandalized local schools and merchants, and, given his charismatic personality and innate leadership skills, Jay eventually became the gang’s leader. He recalled that for several years he felt angry at the whole world and got a kick out of destroying property that belonged to others. Despite his angry lawbreaking behaviors, deficits in attention and executive function, and a mediocre school performance; through hard work and persistence he had completed college and “just squeaked by” in graduate school where he attained an MBA.

Jay’s lackluster academic career was more than made up for by a strong passion for his work, an intense drive to help make the world a better place, a warm and charming leadership style, and a keen ability to motivate and inspire others. As a result he had risen to the pinnacle of his profession in the world of not-for-profit organizations, and his foundation had tripled in size and was nationally renowned for its work at the time he began to see me.

After reviewing his history, and performing a standardized screening questionnaire, I said to him, “Jay, you are suffering from ADHD, a condition with which you were born. It helps to explain much of what you struggled with as a child, which resulted in your feeling humiliated in class, and at home in confrontations with your father. He had expected so much more from you than you could possibly deliver given the constraints that this condition had placed upon your functioning in class, in completing homework assignments, and with respect to your chores at home. In spite of your ADHD you have achieved remarkable success, which is a tribute to your character, resilience, and work ethic.

“However, the increasing demands of your position in recent years have overwhelmed your ability to process information, serving to recreate those feelings of humiliation and helplessness that you experienced long ago. We can treat this condition with medication, analyze your workflow to help you develop better routines to manage workplace demands, and also help you come to terms with the intense feelings that are undermining your relationships at home and at work.”

We initiated psychotherapy and medication treatment, and I recommended changes to his work environment to improve his focus and organization. The first medication prescribed was Adderall XR, which assisted him in significantly improving his focus and being free from distractibility. Unfortunately it would wear off sooner than he desired, as Jay would frequently need to work into the evenings and he desired medication coverage through this period of time. As a result we substituted Vyvanse for the Adderall to achieve a longer duration of action. Neither the Adderall nor the Vyvanse helped him with his difficulties in planning, organizing, working memory, and following through (all executive function deficits), and an ongoing tendency to misplace important items. Strattera (atomoxetine) was added to further boost activity in the norepinephrine circuits, which then had a major positive impact in improving his executive functioning abilities to organize his life, and in reducing some of his anxiety.lxvi

Jay then replaced his executive assistant with one who was more talented and better able to assist him in organizing his daily routine. He was encouraged to use a smart phone calendar and its alarm function, and to create a digital to-do list on the phone, all of which synced with his laptop and his assistant’s PC. He adopted these tools which helped to make him a more effective executive. His wife Karen was invited in for several sessions along with him – first to explain the diagnosis and treatment plan and then to engage her help in developing routines for Jay at home to make their life together less stressful. She had become increasingly troubled by his anger outbursts, frequent interruptions while she was speaking, and his impulsivity when driving the car.

During the course of his therapy Jay was able to grieve his parents’ deaths, and come to terms with his anger over their prolonged period of ill health, and the sense of helplessness it had engendered in him. On one such occasion I said to him, “Jay, as a business executive you are accustomed to taking rapid action to solve thorny problems, and have always strived to find a solution that enables your organization and you to move on successfully. While this driven ‘can do’ style works well in the business world, it does not work so well with the human heart. You never took the necessary time out to grieve the deaths of your parents, and perhaps now is the time.” Reluctantly, and against the grain of his action-oriented personality, Jay began to express his feelings of sadness and anger over helplessly watching his parents grow old and enfeebled. He had just felt so powerless and bereft at the time, yet had buried these feelings by throwing himself ever more forcefully into his work.

He also expressed his sadness and anger over his younger daughter moving on to college, and the emotional consequences of the empty nest syndrome in him and his wife, and its effect on their marriage now that his favorite era in their lives together had come to an end. Jay was able to grieve another huge disappointment in his life, when his older daughter first repudiated his religious background, and later became engaged to a young man of a different faith, and converted to his religion.

Then his daughter and future son-in-law decided that they would be married on a beach in Bermuda, instead of the storied hotel that he and his wife had dreamed of for her ever since she was a young girl. He had celebrated many holidays with his family there, and he had long wished to walk her down the aisle at this special place.

His heart was broken, and I thought about how best to help it heal. I recalled how it had felt when our oldest daughter attended graduate school here in D.C., and when her college sweetheart moved here to be with her I got really excited, and was convinced that they would settle here for the remainder of their adult lives. Then, her boyfriend decided to pursue a once-in-a-lifetime entrepreneurial opportunity, and the two of them moved to New York City. I felt sad, yet it was an easy train ride to go and visit with them. Then the little startup that her boyfriend had joined was acquired by a Bay area behemoth, and they got engaged, moved to San Francisco, and then got married. My heart was broken, and yet I felt so happy for them as they launched their life together.

Feeling like Jay was a kindred spirit I said to him, “Jay, I am reminded of how Steve Martin felt in that wonderful movie, ‘Father of the Bride.’ The wedding itself was the easy part, but coming to terms emotionally with his daughter getting married was the hard part. It raises so many issues that are important for us to discuss – how you feel about your little girl growing up and moving on with her fiancé; what it feels like for you to be growing older and facing mortality, while the two of them are just launching their life together; seeing them so happy and deeply in love, with you being married to Karen for all of these years and how that relationship can feel troubled or stale at times; what it means for your daughter to assert herself and be different from you, and to shatter your longstanding dreams regarding where she would be married. You likely have deep feelings about all of these issues. Let’s explore them.”

And so, while Jay was initially furious with his daughter over these choices in her life, through talking about the issues that I raised, and others that emerged, he was able to eventually let go of his anger toward her and the attendant feelings of betrayal, express his sadness and other feelings about this momentous life stage event, and move on to begin to love his new son-in-law.

Jay eventually became aware of his anger toward his father as well, who had been a demanding perfectionist – and in many ways was the opposite of his son – meticulous in organization and focus, but lacking Jay’s passion and creativity. Through the process of grieving and letting go in the context of a supportive and empathetic psychotherapy Jay felt less burdened, and the substantial resolution of his ADHD symptoms provided by the medications had increased his confidence, and helped him to feel more in control of his life, reducing his feelings of being constantly overwhelmed.

Over time Jay became significantly more satisfied with his life, and more effective as a leader. He began to grow his senior leadership team by hiring in some extremely talented individuals with strong organizational skills, and was able to take the activities of his foundation to other countries to work toward ending hunger there. He began to be able to laugh at situations that used to provoke his angry outbursts, and experienced more joy. While he was able to give up most of his road rage, the challenging traffic patterns and fierce roadway congestion in the Washington, D.C. region prevented him from fully letting go of his anger outbursts at other motorists. At least now he kept the windows of his car closed when he shouted at them!

A Plan of Treatment

If you believe that you, your partner, or child may have ADHD it is important that an expert in this condition conducts an evaluation and recommends a plan of treatment. Once treatment is underway, there are additional ways to help. There are a variety of treatment options that were mentioned above including medication, cognitive behavioral therapy (CBT- which can also be a form of “ADHD Coaching”), and environmental manipulations including the provision of accommodations at work and at school. The CBT therapy may involve analyzing the daily activities and required tasks, looking for the bottlenecks and roadblocks that interfere with achieving better results, and then designing, testing and implementing routines which, when practiced over and over again, can become embedded into daily life to improve effectiveness and efficiency. If you are the parent of a child or adolescent with ADHD, it is best that someone else designs the routines and then supports your child in the implementation. If you take on this role, you may worsen your child’s preexisting oppositional and defiant behavior, and struggles with your authority.

You can be more effective in helping your loved one by being supportive and encouraging around the routines that they have learned, and provide reminders for them to use the routines they have learned if they begin to feel frustrated or upset with a cognitive challenge. If you are providing instructions or a list of items to take care of, put them in writing. Establish a location within your home that is fixed and inviolable for items such as eyeglasses, wallet, mobile telephone, and keys. Encourage daily cardio fitness exercise as this increases levels of dopamine and norepinephrine in the brain, providing a kind of natural stimulant-like effect.

In a future Weekly Tip we will talk in more detail about how “exercise is medicine” for ADHD. If you or someone you love has an attentional disorder, I look forward to deepening your understanding.

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