An Interview with Wendy Richardson
While attention deficit hyperactivity disorder (ADHD)—often called simply attention deficit disorder (ADD)—affects only about 5 percent of the general population, studies have shown that 40 to 50 percent of addicts and alcoholics have ADHD. Until about 10 years ago many alcoholics were diagnosed with a condition called post-sobriety syndrome, but recent advances in our understanding of ADHD make it much more probable that the impulsivity and inattentiveness to high-risk behaviors that often threaten sobriety may be a form of attention deficit disorder.
We turn to Wendy Richardson, author of The Link Between A.D.D. and Addiction: Getting the Help You Deserve, to help us better understand the complexities of how ADHD affects people struggling with addictions. She is a therapist and a person who has personally struggled with ADHD.
STEPS: Let’s start by talking about how attention deficit disorder is perceived by the public in general and how it is presented by the media. It seems like most of the stories I have seen are about the overdiagnosis and overmedication of kids. In addition, the condition itself is often presented as almost incapacitating. You can’t learn. You can’t sit still. How accurate is all that?
Wendy: I have a number of concerns about the role that the media plays in shaping public perceptions about ADHD. They have a powerful role, but unfortunately much of the coverage of ADHD in the popular press has reinforced a series of stereotypes and misinformation about ADHD. For example, the media has repeatedly presented ADHD as a fad even though the symptoms of this disorder have been documented since 1929 and in spite of major advances in our understanding of the neurobiological components of ADHD. The media has also repeatedly focused on the issue of overmedication. There was one news magazine that had a picture of a child on the cover. An adult was giving him a pill, and the caption was something like “Are we controlling our children with Ritalin?” The media frequently takes a profoundly skeptical position about this problem. A lot of this comes from a lack of understanding of ADHD and related disorders. Some people, even some professionals, still propagate a series of stereotypes about ADHD.
STEPS: Like what?
Wendy: Well, the typical stereotypes are that ADHD is something that a 6– to 10-year-old boy has. That people with ADHD are usually male, massively hyperactive, and completely disruptive and dysfunctional. Unfortunately, in addition to not being true, these stereotypes have some major negative consequences. For example, the stereotype ignores those people who have the inattentive type of ADHD, which means that women and girls with ADHD tend to be underdiagnosed. And, of course, the stereotypical picture of ADHD ignores ADHD in adults. The media stereotype tends to limit their focus on medication to a single drug: Ritalin. But there are many other medications used to treat ADHD.
The unfortunate consequence of negative stereotypes about medication is that many parents will not be open to considering medications as part of a comprehensive treatment plan for their children even when such medication is appropriate. That worries me. Medication can in some cases be an extremely helpful part of a comprehensive treatment program for ADHD. Medication is rarely adequate by itself. People also need help working on social, academic, occupational and relationship skills. And many need help to deal with the shame that accompanies ADHD. Finally, I suppose it is not too surprising that the media focuses on dramatic cases of ADHD rather than educating its audience about the range of intensity of the disorder.
STEPS: It strikes me as being pretty similar to the way the media deals with diabetes. Some people think—and the media consistently reinforces this image—that the treatment of diabetes is just about medication.
Wendy: Exactly. Diabetes is a useful comparison. If you have mild diabetes, diet and exercise may control it. If you have mild ADHD, you can be helped a lot by learning new social, organizational, and educational skills. But if diabetes is more severe, if the pancreas is just not producing insulin at all, then you need to have a more aggressive treatment, including medication. It’s similar with ADHD. There is a point where the neurochemical aspects of the problem become so pronounced that one needs to use medications of various kinds in order to be able to learn new skills. If you don’t address the neurochemical aspect of the problem, some people don’t have a good prognosis for a successful recovery.
STEPS: Tell me more about the range of intensity you find with ADHD. It seems to refer to quite a wide range of symptoms.
Wendy: ADHD can involve a wide range of symptoms. Not all people with ADHD exhibit the same symptoms. It is a myth, for example, that you have to be hyperactive to have ADHD. There are some people who are very active. For many adults the motor hyperactivity of childhood ADHD turns into a restlessness in the brain. They may be fidgety or physically restless yet not what we would see as hyperactive. There are also people with ADHD who have an average or a very low level of activity. For example, those with ADHD are primarily inattentive. They have difficulties focusing their attention, but they don’t have high energy levels, nor do they appear agitated or restless.
The main constant is one’s ability to focus their attention where they want to focus it at a given time. Is that ability impaired? And does that impairment cause problems for them every day of their life? Does it impair them at work? In relationships? We need to focus on the attentional aspect of ADHD when making an accurate diagnosis.
If someone occasionally forgets their keys or is sometimes disorganized, that’s not necessarily ADHD. The symptoms of difficulty in focusing attention, and impulsivity with words or actions, must cause impairment and need to be consistent over time and place.
Let me use an example. Two different families take a vacation. The Smith family is very active; they have their kids in soccer and dance. They are running all over the place, hardly ever eat dinners together, and appear to be hyperactive. Yet when they go on a two-week vacation to Hawaii, they stay on one island, in one resort and mellow out. They go for hikes and can relax. The Jones family is different. Mrs. Jones has ADHD, and so do their two children. Like the Smith family, they have a very hectic life. When the Joneses head for the airport to vacation in Hawaii, they forget their tickets and have to go back home to find them. They miss their flight. When they arrive in Hawaii they don’t remember which rental car company has a car reserved for them. And on the way to the resort their son is so active that they have to stop and let him run around the pineapple fields. The next day their daughter breaks a tooth and they spend part of their vacation at the dentist. The energy, activity level and chaos in the Jones family does not change when they go on vacation. ADHD goes on vacation with them.
STEPS: I suppose just reading a list of characteristics of ADHD and recognizing that a lot of them apply to you could have some real dangers. In your book you strongly recommend against self-diagnosis.
Wendy: Absolutely. What we are looking at are characteristics that are part of normal human behavior. It’s just that in the case of ADHD these normal behaviors are taken to an extreme. Most of us will forget something now and again and will blurt something out that we wish we hadn’t. And many of us will have episodes when we have very high activity levels. We’re not talking about schizophrenia here. ADHD is not about bizarre behavior. It’s pretty normal behaviors that are on a continuum from normal to extreme. To be diagnosed as ADHD the symptoms have to be extreme enough to cause problems in daily living. And these symptoms have to be consistent over a long period of time.
I should emphasize that it is particularly difficult to diagnose alcoholics or addicts with ADHD when they are in early recovery. Many people in early recovery look like they have ADHD. Go to an AA meeting and you’ll see people who are up and down and acting quite hyper. But those may be symptoms of post–acute withdrawal and not necessarily ADHD. After a person has had a period of sobriety, if they are still unable to pay attention in meetings, unable to read The Big Book or other literature—that’s when you might start seeing symptoms of the ADHD if it’s there. It is possible to diagnose ADHD in early recovery, but it’s a tricky business and certainly not something that someone can do for themselves. There are other co-occurring conditions that accompany ADHD. These need to be sorted out and treated. A competent professional who has training and experience in this area is needed to diagnose and treat the complex composition of symptoms that can occur.
STEPS: How do you go about finding a therapist or other medical professional who has experience working with clients with ADHD?
Wendy: Word of mouth is always the best source of referrals. If you know someone who is working on ADHD issues and they speak highly of a professional they are working with, that’s a good sign. I’m not very optimistic about what you get when you respond to advertisements about some new treatment for ADHD. People who are really good in this area usually don’t need to advertise in the paper or phone book. The National Adult Attention Deficit Disorder Association maintains a list of professionals that specialize in this area. You can also get a lot of information from an organization called Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). They have local chapters in most parts of the country, and although they don’t formally refer people to professionals, you can collect information about the professional resources in your area by attending local CHADD meetings and asking questions. There is also a tremendous amount of information about ADHD on the Internet.
STEPS: One of the problems we haven’t talked about yet is that most people think of ADHD as only an impairment. But I know that some people suggest that ADHD can be a positive asset. How do you come down on that?
Wendy: I think we need to be very cautious about how we talk about this issue. ADHD is clearly a disability. Being clear about the disability is important for a variety of reasons, including legal ones such as accommodations covered by the Americans with Disabilities Act (ADA). If ADHD is not a disability, greatly needed funding for its treatment may be even more scarce. At the same time, for some people with ADHD—not everyone—there is an expansiveness, a divergence in their thinking, that can be very much of an asset. The ADHD brain can be very creative. Usually, creative, successful people with ADHD need staff that help them follow through on the details of their ideas. Many of the people that I work with who have ADHD are very bright. Frequently they are extremely honest—in part because they don’t have a capacity to sensor their impulses. So you ask them a question and they tend to tell you the truth before they’ve thought of other possible responses. For me, with my years of treated ADHD, I see some wonderful assets that result from the way my brain works. But I also still struggle every day with simple things like getting a stamp on an envelope and getting it to the post office.
STEPS: In AA people sometimes talk about being a “grateful” recovering alcoholic. It is not an attempt to minimize the impairment of the addiction, but it is a recognition that some of the personality traits they have developed in recovery could not have been possible without the addiction. I suppose it is possible in the same way to get to the point where you are a “grateful” recovering person with ADHD.
Wendy: It can, of course, take a while to get to the gratitude. Most people don’t feel grateful for having ADHD or an addiction right away. But later in recovery some will experience a growing sense of gratitude for life and for the supportive community they find in recovery. I hear people say, “I’m not alone anymore, and I’ve found a relationship with a higher power.”
STEPS: It’s a bit of a trick to take the impairment seriously and at the same time not get lost in thinking that I’m just an impairment that someone found a name for.
Wendy: Exactly. Acknowledging the impairment, acknowledging that it is a disability, is important. Yet it is also extremely important to recognize that people with ADHD can adapt, accommodate and creatively manage their disability, especially with treatment.
STEPS: I have the impression that in the last few years there have been some pretty remarkable advances in our understanding of the brain chemistry involved in ADHD. I would think that it would be really helpful to know that it’s not just about behaviors but that there is a brain chemistry problem that underlies the behaviors that are characteristic of ADHD.
Wendy: Absolutely. I think that the names given to ADHD over the years suggest how our understanding has changed. Not that long ago you find ADHD referred to as “minimal brain dysfunction.” That was not a very helpful label, but it did focus appropriately on brain function as the source of the problem. Later, the medical term of preference became “hyperkinetic reaction to childhood.” I don’t see that as an improvement, because it focuses only on childhood and only on one kind of behavior. The thinking at that time was that children grew out of ADHD during puberty and that all ADHD involved hyperactivity. We now know that these are not true. After “hyperkinetic reaction to childhood” came “attention deficit hyperactivity disorder.” It’s important to remember that until recently ADHD was understood primarily as a behavioral disorder, not a neurobiological disorder. As a result, parents were frequently blamed for their children’s ADD. Parents were told that they needed to be more structured or more disciplined with their children. All of this ignored the fact that there is a huge neurochemical component.
Our understanding of the neurochemical aspects of ADHD has expanded dramatically in recent years. Several kinds of studies have shown very different patterns of brain activity in people with ADHD. It is now clear that people with ADHD have brains that function differently from people who do not have ADHD. It’s not just a behavior problem. The behavior is a symptom of a brain that functions a certain way. Some of the most exciting research on the brain chemistry that underlies ADHD is focused on the role of the neurotransmitter dopamine. This might explain why there is such a strong connection between ADHD and addictions, because all addictive substances increase the level of dopamine in the brain. So the two may be linked at a biochemical level.
STEPS: I want to talk about the connection between ADHD and addictions in a minute, but I want to follow up first on your comment about the blaming-the-parents dynamic. If ADHD is just a behavioral problem, then people are going to try to fix the problem by behaving differently. But if there is a behavioral problem and you can’t seem to change the behavior—well, that’s a setup for a lot of shame.
Wendy: That’s right. Shame is often a huge issue for people with ADHD, just as it is for people with addictions. It is extremely important to distinguish here between guilt and shame. We tend to use these words interchangeably, yet they are quite different. Guilt is what I feel when I have done something wrong. But it is something I can make amends for. If I stole money from you, I can give you the money back. Shame, on the other hand, is more a judgment about our soul. Shame is not about “I did something wrong” or “I made a mistake.” Shame is the experience that “I am a mistake.” “I am wrong.” There is something I can do about guilt. But shame is much harder because it is an internalized sense of ourselves as being so flawed that we don’t want anybody to see how bad we feel we are. What shame does is shut us off from other people. It can cut us off from God. Shame causes us to feel so unworthy that we believe nobody wants to be around us.
One of the strengths of Twelve Steps programs is that both shame and guilt are dealt with. In Steps 4 and 5 we make an inventory of our lives and then admit to God, ourselves and another person the exact nature of our wrongs. These are steps that help reduce shame. Doing a fifth step with another person can powerfully dissolve feelings of shame. Telling your flaws and secrets to someone and not being rejected is a powerful experience. Going to meetings and telling your story and finding that you are not alone is also a powerful antidote to shame and isolation. Later on, in Steps 8 and 9, we work on guilt. We identify people we have harmed, become willing to make amends to them, and then, if it will not result in additional harm, we actually make amends to those we have harmed. These steps are very helpful in dealing with guilt.
ADHD groups, whether Twelve Steps–based or not, can have much the same effect for people with ADHD. Talking with each other helps to dissolve the shame. Many people experience the same effect when they attend events or conferences about ADHD. Being with other people who struggle with the same things we struggle with is really an essential part of the recovery process.
STEPS: Tell me more about the particular kinds of shame associated with ADHD.
Wendy: Shame comes from many different places. Shame related to ADHD tends to be that internalized sense that I am stupid, dumb and lazy. Kids with ADHD know early on that they think differently. And when you think differently, oftentimes it feels like your thinking is wrong. I know that from my own experience in school. For example, I would solve math problems differently. I had a math exam in school, and I just wrote the answers down. I got an F even though the answers were right, because I didn’t show the steps I took to get to the answer. So I talked with the teacher and took the exam a second time and again received an F. This time the teacher said, “Well, you showed your work and the answers are correct, but you didn’t solve the problem the way I taught you to solve the problem.” Because I thought differently, because I took a different path to get to the same result, I was “wrong.” You can imagine how easily these experiences can add to a person’s shame. And you can also imagine how much worse this would be if a person with ADHD also had a learning disability. It would be very easy to internalize the messages I’m stupid, I’m lazy, I just don’t care. Those are the kinds of labels that are often used to describe kids who struggle with ADHD.
The other word that’s used is potential. You hear “Mary isn’t working up to her potential” or “Jimmy is a very smart boy, but he just isn’t living up to his potential.” That word can trigger feelings of shame. It’s as if people are saying, “You could do better, but you just don’t want to.”
It is the internalization of these kinds of shaming messages that leads us to create an inner panel of critical voices. When we make a mistake, that inner Board of Critics will immediately say, Oh, you stupid idiot! You always do this kind of thing. You never remember. Many of us have shaming voices, and it takes work to identify these voices, their sources and the core beliefs we have about ourselves that these voices reinforce.
STEPS: It’s like having a very distorted mirror. Having ADHD means that the feedback you get from your environment is untrustworthy.
Wendy: Yes. When I do trainings I have a picture I show that I took in Yosemite. It is a picture of a mountain reflected in a lake. The top part of the picture, the real mountain, is overexposed, so you can’t see it very well. But the reflection of the mountain in the lake is perfectly exposed and beautiful. Often when a person comes to me for counseling about ADHD issues, it’s as though they can only see the top part of the picture. They see themselves as washed out, stupid, uncreative, isolated. Yet I see the bottom half of the picture. Shame can take a warm, loving, creative, talented person and make them think that they are completely worthless. So a critical part of the recovery process for people with ADHD is getting a more accurate mirror to use in life.
STEPS: Let’s get back to the connection between ADHD and addictions, which is the main focus of your book. Is it that people with ADHD are predisposed to addictions? Or is it that people with ADHD self-medicate to treat the symptoms of their ADHD? What’s the connection?
Wendy: There is a variety of connections. You named two of them. Some people have a genetic predisposition for ADHD and addiction. Researchers have found defects in specific areas of genes that help the brain produce and utilize dopamine. There are also people with ADHD who are trying to increase dopamine levels in their brain. They may have no idea that all addictive substances increase dopamine levels. Since people with ADHD are already deficient in dopamine utilization, they may be more motivated than people who don’t have ADHD to use dopamine-increasing drugs.
STEPS: It does seem that addicts of any kind who are in recovery have a difficult dilemma to face when it comes to choosing to take medication. There is a unique set of fears and questions about the meaning of sobriety and stuff like that. What kind of advice do you give people who are struggling with those questions?
Wendy: Well, it varies. AA puts out a wonderful little pamphlet called “The AA Member’s Guide to Medications & Other Drugs.” It was printed in 1984. Let me read just one paragraph to you:
Just as it is wrong to support any alcoholic to become readdicted to any drug, it is equally wrong to deprive any alcoholic of medication which can alleviate or control other disabling physical and/or emotional problems.
Often when I work with people in recovery I’ll have their sponsor come in with them. We’ll talk about the fear that many addicts have about taking psychostimulant medications for ADHD. Some people think it’s the same as taking speed. I’ll talk about the differences between prescribed medication and street drugs. First, with prescribed medication you know what the quality of the medication is. If you are taking 10 mg of Adderall, you know it’s 10 mg of Adderall. If you are taking it as prescribed, you are taking it by mouth. You are not grinding it up or making it water soluble to snort or inject. You are taking the amount prescribed at the prescribed times. You’re not taking more because you want to stay up late. You are not getting high. When medication is taken as part of a comprehensive treatment program that seriously addresses both ADHD and addiction, the potential for abuse is low. You just don’t give someone in recovery a hundred Dexedrine pills and say “See you in a month.” I have seen very little abuse of medication for ADHD when it is part of a comprehensive treatment program.
The big mountain to climb over for many alcoholics and addicts is the question, What do I say in meetings? Usually I suggest that people consider not talking about taking medication for ADHD in meetings unless they feel comfortable. There may be members who will criticize you for your choice. During the past decade there has been tremendous growth and increased understanding in AA about the role of medication to treat ADHD and other conditions. [But] you can still hear someone at a meeting say, “You don’t take nothing no matter what.”
STEPS: It can really hurt when the people you expect to be most helpful—like other people in recovery—are not helpful. Which reminds me, I wanted to ask you about ADHD at church. Most of the institutions in the Christian community are organized basically around educational models. We have lots of lectures (sermons) and classes (Sunday school classes). I suppose that people with ADHD can be expected to have the same kinds of problems at most churches that they have with most schools.
Wendy: Yes, indeed. I think that one of the primary components of spirituality is being able to pay attention. We need to pay attention to ourselves and to what we are hearing from God, whether in prayer or meditation. If you can’t pay attention it can make it very difficult to have a sense of connection with a power greater than yourself, or God. Let me put it this way: People with ADHD are often success deprived. They don’t sit right. They don’t read right. They don’t stand in line right, and they don’t write right. If they have the same kind of experiences in Sunday School, they will bring this deprivation and the shame connected with it into church as adults. It shouldn’t surprise any of us that people with ADHD have difficulties with the typical church service.
STEPS: So you can wind up feeling not just defective, but spiritually defective as well.
Wendy: Absolutely. It is shame that has the potential of severing my connection with God. I call it a Higher Power outage. That’s what happens. If I’m having a shame attack, I can lose the connection to my power source.
STEPS: How would you do church in a way that is helpful to people with ADHD?
Wendy: There are many things you could do. The first thing that comes to mind is to do lots of singing and standing up and sitting down. And participatory activities of all kinds, such as hugging or greeting the person sitting next to you. The Reverend at the church I attend (whose name happens to be Bill Wilson) uses short stories, metaphors and humor in his lessons.
STEPS: So the bottom line is that a diagnosis of ADHD isn’t the end of the world, is it? It can be the beginning of some positive changes.
Wendy: I am extremely hopeful about the treatment of both ADHD and addiction. Once people get an accurate diagnosis and treatment, it can be as though they finally found a missing piece of the puzzle. People who have been trying to stay clean and sober, but who have been living a miserable life because of their restlessness and impulsive actions, may find long-term sobriety for the first time. When the ADHD piece is put into place, it gives people a context for understanding their behavior. It also reduces shame, and it contributes to a radically increased quality of sobriety. That’s important because when we are living in a quality sobriety rather than a desperate sobriety we are much less likely to relapse.
Wendy Richardson (MA, MFT, CAS) is a therapist with a private practice in Soquel, California. She is the author of The Link between ADHD and Addictions: Getting the Help You Deserve (Pinon Press, 1997).