An Interview with Ari Tuckman, PsyD, MBA, on Adult ADHD
David Van Nuys, Ph.D. Updated: Apr 15th 2010
Dr. Tuckman, a psychologist in private practice in West Chester, PA specializes in the treatment of adult ADHD (attention deficit hyperactivity disorder), characterized in children by hyperactivity, impulsivity and inattention. Most people outgrow the hyperactivity component of this disorder, but impulsivity and inattention problems may linger into adulthood, resulting in lost opportunities and poor educational, occupational and social functioning. The diagnosis is often missed in adults who are instead regarded as lazy or selfish. Functional problems associated with ADHD appear to be neurological by nature, manifesting as executive function disturbance. Aspects of executive dysfunction include impairments of prospective memory, sense of time and poor response inhibitution secondary to an impaired ability to efficiently appreciate the consequences of behavior; all types of meta-awareness which normally serve to keep people oriented regarding the responsibilities they are expected to meet. Dr. Tuckman's Integrative Treatment for Adult ADHD is comprised of four treatment componants: 1) education about the nature of deficits associated with ADHD, 2) medication (usually a stimulant) to boost executive functioning, 3) coaching (e.g., identifying distractions and removing them, and using external supports like clocks, alarms and signs to prompt behavior and stimulate awareness), and 4) psychotherapy to boost self-esteem and motivation and address mood and anxiety problems.
David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show we'll be talking with my guest, Dr. Ari Tuckman, about coping strategies for adults with ADHD. Ari Tuckman, PsyD, MBA, is the author of More Attention, Less Deficit: Success Strategies for Adults with ADHD, and Integrative Treatment for Adult ADHD: A Practical, Easy to Use Guide for Clinicians. He does a weekly podcast for adults with ADHD and those who care about them. He's a psychologist in private practice, specializing in diagnosing and treating children, teens, and adults with ADHD, anxiety, and depression. He's appeared on CNN, National Public Radio and XM Radio, and has been quoted in the Washington Post. He's the current vice-president of the Attention Deficit Disorder Association.
Now, here's the interview:
Dr. Ari Tuckman, welcome to Wise Counsel.
Ari Tuckman: My pleasure to be here.
David: Well, I appreciate the opportunity to speak with you, especially since I haven't previously done anything on the topic of ADHD. I guess you learned about this podcast through an article in the February 2010 APA Monitor that mentioned my two podcasts, Wise Counsel and Shrinkrapradio. Is that right?
Ari Tuckman: I did, and I have to say it was really nice to see an article on this topic presenting podcasts. They are such a great way to get information out there. And I think, not to pat ourselves on the back or anything, but I think as psychologists we have a lot of really good information to share with people, including the people who aren't going to walk through our door and sit down and talk to us, so podcasts are a phenomenal way to get that information out there in user-friendly little bites.
David: Well, of course I agree with you, and I also know that you have your own podcast, More Attention, Less Deficit, which is also the title of your book, and so congratulations on your podcast. I listened to one of your episodes, and you have a great voice and a very upbeat delivery.
Ari Tuckman: Well, thank you. I appreciate it. Yes, it's fun. It's a great side project, as you know so well. I think having something like this, it forces you to think a little bit because you're always kind of running at the back of your head, is this a topic that I could use for my podcast? If so, what are the connections between this and other things? So I think it forces you to be a little less intellectually lazy, or to put it more positively, to be a bit more intellectually curious and to process information a little more deeply. Yes, it's a good thing and people seem to enjoy it, so I think it's very much win/win.
David: Okay. Well, before we get into your topic, tell us a bit about your background.
Ari Tuckman: Well, I'm a psychologist in private practice in West Chester, Pennsylvania, outside of Philadelphia. And I've been in practice for 12 or 13 years. When I went to graduate school - I graduated in 1997, so it's not like that was a 100 years ago or anything - but when I graduated, I'd received virtually nothing on the topic of ADHD in adults. And as many new clinicians do, you kind of fumble around; you try to find something that might be of interest in terms of areas to specialize in, and ADHD in general and ADHD in adults, it just hit it for me.
And I'd like to say that, now in the year 2010, that it's a lot better in the sense that there's a lot more information out there for adults with ADHD, there are many clinicians out there who really understand all the implications of ADHA in adults, but, man, it's not better enough. It's not as good as one would hope, which is why I think this is such an important topic, because I think there's so many adults out there with ADHD who have never been diagnosed or treated for their ADHD. So I think it's, I don't know - without sounding too high and mighty - it's a little bit of a crusade in terms of this topic, to get the information out there.
David: Yes, well, let me just back you up a little bit and ask how you got into psychology in the first place.
Ari Tuckman: Well, that actually is an easy thing for me. My dad is a psychologist, so I saw what he did, and it's actually worse than that: my dad is a psychologist whose younger brother is a psychologist also, and his older brother is a psychiatrist.
Ari Tuckman: So, it's sort of the family business. I suppose I could have been a rebel and gone and become an accountant or something, but it seemed interesting to me, and I have to say I have no regrets. Not to say that I couldn't be happy doing something else too, but it's a good way to make a living.
David: Okay, well, that's a really fascinating background. When I started out, I didn't know anybody who'd been a psychologist. I'd never seen a psychologist, so it's really a different scenario than what I experienced. Well, let's get more deeply into your topic by having you start out by telling us just what is ADHD.
Ari Tuckman: Sure. Well, ADHD is the acronym for Attention Deficit Hyperactivity Disorder. Now, it used to be called ADD, Attention Deficit Disorder, and some people still call it ADD. And in a what's old is new sort of way, actually the brand new proposed changes to the Diagnostic Manual, the DSM, the official diagnostic manual - the brand new, as of just some weeks ago - one of the proposed changes is to bring back ADD as a term; that's there's going to be two diagnoses: one is ADD, and one is ADHD.
Part of the confusion is, in the current system, there's some people who have ADHD Inattentive Type. What this means is they have trouble with inattention, but they're not hyperactive, so it's confusing to say that someone who has that has ADHD, so instead they're often referred to as ADD.
So someone who struggles with inattentive symptoms of ADHD would be things like… obviously it's stuff like trouble concentrating, easily distracted; but it's also things like disorganized, poor time management, forgetful; trouble starting tasks and then if they start it, trouble finishing it, so they procrastinate a lot; losing things, stuff like that. There are also the hyperactive symptoms, which are feeling restless, being up and about, moving too much, which is very obvious in young kids, especially young boys. But hyperactive boys tend to grow into adults who are a lot less hyperactive, so in those cases, the hyperactivity sort of settles out.
But when there's also the impulsive symptoms… and, basically, the impulsive symptoms, most loosely, it's leaping without looking; so making a rash decision such as spending money on something, or signing up for something, or other kind of indiscretions. It could be saying something, blurting out, interrupting, being impatient. One example of this is adults with ADHD are more likely to impulsively quit a job or to be fired from a job, sometimes because they say something that, let's face it, is probably accurate but also not the right time and place and certainly not the way to say it, so it's not appreciated. So they say something, they shoot off at the mouth, and then they get fired for it.
It used to be thought that ADHD was just a kid thing, and by the time you hit…
David: Yes, that's the impression I had.
Ari Tuckman: Yes, and the reason is, if you're focusing on the hyperactivity, which, let's face it, is very, very obvious - as one presenter I saw said, "The school janitor can diagnose the hyperactive kids," because they make themselves known because they're running all over the place and they're bouncing around in their seat and they're poking their neighbor and they're talking to their neighbors and all of that - because that settles out, it seems as if it goes away, but the trouble with inattention and the trouble with impulsivity remains, and as an adult, that's what gets you into trouble.
So, when you look at some of the outcome data, it's just painfully, painfully clear that adults with ADHD are struggling a lot more than folks without. And it's things even down to little nitty gritties like credit scores, blood cholesterol levels, driving records; but then other stuff like unplanned pregnancies, graduation rate from college, annual income. I mean, across the board, folks with ADHD, especially untreated ADHD, struggle much more than most other people - more than folks who are anxious, more than folks who are depressed, more than many folks with bipolar disorder. So it's not a trivial kind of thing. This is big stuff, that these folks are really having a much harder time with things than, frankly, they should have to.
David: Okay, well, that covers a lot of ground. It was very fascinating to me because I guess I am one of those who had the impression that it was primarily a problem with kids and primarily with boys and that they grew out of it, but as a result of reading through the book, a copy of which you sent me - a very excellent book - I see that I was wrong about that, as you've just said. You know, it's so easy, as I hear you talk about it, to see myself in much of what you've said, and I think that's one of the issues here, is that self diagnosis is difficult and may be erroneous, and also you talk about official diagnostic criteria versus unofficial diagnostic criteria, so take us through some of those issues.
Ari Tuckman: Sure. Well, the official diagnostic criteria are the ones that come out of the official, what's called the DSM, the Diagnostic and Statistical Manual. And the problem with the DSM criteria is they're really better descriptors of ADHD in kids than they are in adults. But some of the criteria in terms of inattention would be trouble maintaining attention: so being easily distracted; being disorganized in terms of tasks or activities or losing things; being forgetful, things of that sort. And then some of the unofficial ones - and this is where there's a little bit of a rip - but like the 10 question Cosmo quiz "Do you have ADHD? Take our quiz and find out," the problem is that there are many, many things that can make someone forgetful, including just a bad night's sleep; so what we're shooting for is a more nuanced approach, so more than that.
So, some things that I'll ask in terms of unofficial criteria are… like to get at the hyperactive symptoms, one thing I'll often ask is, "Do you watch movies? Do you go to the movie theater, or do you tend to watch movies at home?" And someone who has those hyperactive symptoms will probably say, "You know what? I hate going to the movies. I don't like sitting for two hours. I don't like feeling trapped in. I want to get up and walk around." So instead, they don't go to the theater; they'll watch movies at home: they get up, they go to the bathroom, they get something to eat, they check their email. They're doing other things rather than just sitting and watching.
David: Yes, interesting.
Ari Tuckman: Another example would be a lot of folks with ADHD don't read books; so instead, they'll flip through magazines, they'll read web pages, stuff like that. When they do read… there's a lot of attention required in reading, a lot of concentration, so what they find is that they don't retain what they read, that their attention goes in and out while they're reading. So one of the questions I'll ask is, "When you read, how good are you at remembering what you've read?" And the folks with ADHD will say, first of all, "I don't really read unless I have to," often; and if they do read, they'll say, "Yes, I don't remember what I read. I get to the bottom of the page and I have no idea what I just read;" that their attention has blinked and gone away while their eyeballs are moving across the page.
David: Yes, but again, that's an experience that I would think that many of us can relate to, and you recommend against self diagnosis for that reason, right?
Ari Tuckman: Yes, and unfortunately that's one of the problems with ADHD - and this isn't limited to ADHD - but one of the problems is the symptoms of ADHD… let's face it, we all have our moments, and we all forget things sometimes. We're all sometimes disorganized. We all sometimes lose things or have trouble paying attention, but that doesn't make ADHD; that's just normal life and imperfection. Now, it's the same sort of thing in terms of depression - we all have our moments when we're down; or anxiety - we all have our moments when we worry about stuff.
But what we do is, as a profession, we draw a line at some point. We make a cutoff and say, okay, the top 5% or the lowest 5% or whatever there, the people who cross that line, that counts as whatever diagnosis, and all the other 95%, that's just normal human variability. And as much as on the one hand it's easy for critics to knock that, there's a lot to be… this takes place in terms of physical medicine, with high blood pressure.
Okay, great, we can measure your blood pressure and get numbers, but there's some sort of consensus out there in the field that says, okay, this number over that number, from that point up, that is high blood pressure and deserves treatment. But if you think about it, the number that qualifies now for high blood pressure is not the same as it was 20 years ago because research has found that there's damage done at a lower blood pressure number than we thought it was 20 years ago.
So, even there, there's subjectivity involved, and I think that's part of the problem; that if you whip through a quick symptom checklist or a self-report, it's very easy to say, "Sure, I do that. Oh, yeah, I do that. I do that." The difference is the matter of degree in the sense that, if the question is do you lose your keys, anyone can say, well, yes, occasionally. But the difference is people with ADHD lose things on a much more consistent basis, and it's not one of those things of like, "Oh, I lost my keys. Oh, there they are in the living room" - 30 seconds of looking and you find it. For folks with ADHD, they lose their keys and they're gone forever, or they turn up in the refrigerator because they were putting groceries away and they put it down on the shelf and then they put something on top of the keys.
So folks with ADHD have much more suffering for it, and to a point where they're getting written up at work for showing up late when they can't find their keys. Now, probably most of us can't say that. Those without ADHD can't say, "Yes, I've gotten written up at work for lateness because I couldn't find my keys." So that's what separates ADHD from just the regular old "I got too much on my mind" sort of a thing.
David: Well, in your book, you go through some specific areas where adults with ADHD are challenged, and I'd like to step you through some of those. The first one is what you refer to as "executive functioning." So what do you mean by executive functioning, and what are some examples of that?
Ari Tuckman: Well, executive functions are… you know, there's fads in psychology like everything else, and executive functions are definitely one of the fads that's hot right now. Essentially, what the executive functions are is they're our highest level brain processing functions. So what they enable us to do is to make good choices in a complex world, or to navigate the complexities of this world that we live in. So, if you think about amoebas for example, there's a stimulus and there's a direct response; there's not a whole lot in between. As humans, we have the ability to sort through all sorts of different stimuli coming at us from outside, as well as all sorts of stimuli that we generate inside our own heads.
So we're sitting in class as a high school student, let's say, and listening to the teacher through some kid dropping a pencil behind us, through somebody walking down the hallway. It's a nice day, so we're looking out. That girl sitting in front of us, boy, is she cute, and look at the dress she's wearing. We're thinking inside our own head, "I wonder what I should do this weekend," "I have that test in English next period; I wonder if I studied enough." So there's all of this stuff going on. What the executive functions enable us to do is, hopefully, to sort through it all and make good choices about what we're doing.
Now, this a very moment by moment sort of thing, and one example of the executive functions is what's called perspective memory, or another way of putting it is remembering to remember. And that's stuff like when I get home tonight, I have to remember to call so-and-so about something, or I have to remember to bring my computer charger home with me when I leave tonight because I'm going to need it tomorrow morning, or five minutes from now, I need to remember to, I don't know, check my email or something. So it's that carrying a memory from this moment into the future, and as adults, man, there's a lot of perspective memory going on.
We all have to-do lists, but you can't write every single thing down, so some of that has to be kept inside your head. Folks with ADHD have less consistent perspective memory, so it's "Hey, honey, can you pick up a gallon of milk on the way home?" "Yes, absolutely. I will do that." And they mean it when they say it. The trouble is, as they're driving home, their brain doesn't trigger them "bring the milk." So instead of pulling off to the supermarket on their way home, they just drive straight on in. They walk in the door, and their spouse says, "You get the milk?" And they go, "Oh," because their perspective memory failed them.
So perspective memory's one example of one of the executive functions. Also another example would be what's called the sense of time; in other words, that sense of what time is it now. How long have I been doing what I'm doing? How much longer do I have until I need to change and do something else? How long will this take? Just all of that kind of managing time in all its complexities.
And for a lot of folks with ADHD, they don't manage their time well because they don't have an internal clock that tells them, okay, I've got 20 minutes to surf the web, and then I got to get up and get dressed and go to work. So here I am at 20 minutes, 10 minutes, 15 minutes, 20 minutes, and half an hour, 40 minutes, 50 minutes - oh, my God, now I'm late. They miss… their brain doesn't set the alarm that says, bingo, it's been about 20 minutes; check the clock; oh, my God, it's time to get going.
Ari Tuckman: So they miss those transition points, or they underestimate how long something will take: "Oh, I can continue surfing the web. It's only going to take me 10 minutes to take a shower and grab some coffee." Well, it's not 10 minutes; it's 20 minutes; so underestimating, and then they wind up running late as a result of it.
David: Yes, now, I had some people in my family - I won't say who - who seemed to have some of those time management issues, but they don't have the rest of the checklist, so I guess to really come up with the diagnosis you have to have more than one of these sorts of issues. There's another area of challenge that you talk about in the book that you refer to as "response inhibition," and I guess this probably refers to the impulsiveness that you mentioned earlier. Say a little bit about that.
Ari Tuckman: Sure. Just kind of defining terms: impulsivity is… basically, what it means is doing something without taking the time to think through the consequences. If I buy this new HDTV on sale, will I have enough money at the end of the month? I don't know, let's see. Hmm, what big bills do I have? I got the credit card; how much did we spend on that last month? What other expenses are coming up? Do I have any reason to think that I'm going to have less money coming in? In other words, all this processing ideally would go on before someone pulls the trigger on buying a new TV. Or saying something that… and this is that moment by moment "is this the right thing to say": has the person I'm talking to, have they come to a natural stopping point where now it's my turn to speak? As opposed to getting caught up in an idea and blurting it out.
So, response inhibition is that function in the brain, that part of the brain, that enables us to create that gap between stimulus and response. And folks with ADHD are not as reliably able to do that, so they tend to do a lot more leaping without looking, which tends to create a lot of moments of "Why did you…whatever." Why did you say that? Why did you buy the TV? Why did you click on that link and spend 20 minutes on YouTube when you knew you had to leave in five minutes? Things like that.
You know, it's not about desire; it's not about motivation; it's not about passive-aggressive or any of that stuff. It can look like it, so the person who, instead of going to that meeting at work, winds up tooling around on the Internet, it can look like they're being passive-aggressive against their boss, or they don't care about their job, or they're just sort of, I don't know, self-absorbed, or whatever. But that assumes that they stopped long enough to think about it and then made that choice.
David: This sounds like it shades into another one of the challenge areas that you discuss, which is emotional self-control.
Ari Tuckman: Right, yes, that a lot of folks with ADHD tend to get caught up in whatever they're feeling in that moment; that that tends to drive their actions more. Now, sometimes this is described as them being spontaneous, and the little joke I have is when you do something on the spur of the moment and it works out okay or well, then it's called being spontaneous. When you do something on the spur of the moment and it blows up on you, then it's called being irresponsible or foolish.
And that's part of the trouble, is that for a lot of folks with ADHD, they have a hard time living their intentions. You know, they have good intentions: they wanted to get to that meeting on time. They understand why it's important, so you don't need to explain that to them. And yet somehow that idea of "I got to leave in five minutes for that important meeting" gets lost in the heat of the moment, especially if they get caught up in something else. So they make choices that seem to be bad choices, but it's not like they're stopping, considering their options, and then choosing it. They're off to the races before they've had time to really think about it.
And one of the implications of that… well, there's a couple of implications. One of them is lecturing people with ADHD doesn't tell them anything they don't already know. They know all of these things; they just can't reliably do it. So that's number one, is lecturing just makes them feel bad about themselves and probably hate the lecturer. But the other is that, since lecturing doesn't work, the better alternative is to set things up ahead of time so they're more likely to do what they're supposed to; in other words, don't count on that response inhibition, that ability to stop and think through their options.
So one example of this, just one out of a million, but one example: I had a client who, for work, spent a lot of time on the computer, and he had espn.com as his homepage, which was the worst thing he could have done, because he goes to look something up, espn.com pops up; he says, "Oh, hey, watching the Redskins - draft picks coming up. Let's see." Click, and then away he goes for 15 minutes seeing what the Redskins are doing, and not actually doing the work stuff. So one of the strategies that we used is you got to set something else for your homepage, because as soon as that homepage pops up in your face, it's too tempting, it's too hard, to not click off onto that, rather than do the other thing that you should be doing. It's the whole idea of "lead me not into temptation."
David: Yes, that's fascinating. That begins to get into the whole area of treatment and how you work with people in terms of… I guess you're teaching skills; you're coaching, and not doing the lecturing/blaming that tends to happen.
Ari Tuckman: Right. Yes, and I have this four-part treatment model that I wrote about in my first book for clinicians, Integrative Treatment for Adult ADHD, and then I wrote from a different angle in the More Attention, Less Deficit book, which is meant for the adults of ADHD themselves or their family members.
So, first part of the treatment model is education, just plain old learning about ADHD. And the reason why it's important is, for a lot of these folks who struggled so hard to accomplish what they've accomplished, have had so many of these setbacks of things blowing up in their face and not really having good explanations for why, just learning that this is like a neurology thing - this is not a bad intentions thing; this is not about bad character or anything like that; this is just neurology - I think it can be really liberating. Now, with knowledge comes responsibility, so if you know it's ADHD, then you have a responsibility to take that information and do something with it to make your life better, and that gets into the next three.
So, second part of this four-part treatment model is medication. I'm a psychologist; I don't write prescriptions. Generally I like to talk to people rather than solve stuff through pills, but I got to say, meds are pretty good for ADHD. They help response inhibition; they help the other executive functions; they just make it easier for folks with ADHD to do what they're supposed to do. It just takes some of that automatic stuff and makes it a little bit more conscious and intentional, so that meds are an important part of the treatment model.
Third part is what I call coaching. Now, coaching means different things to different people. When I say coaching, I mean coaching for ADHD folks which is specific, practical strategies to be more organized, manage your time better, choose priorities, follow those priorities, things like that; so my guy with espn.com, or the guy I saw this morning, who always has trouble getting out the door on time and getting to work on time and is being written up for it. I mean, two more write-ups and he's gone. He's losing his job for being 5 or 15 minutes late. So what are some strategies to use, based on understanding ADHD, that help them get out the door more reliably?
Now, this goes beyond the obvious stuff of, well, just leave earlier, which is, to be blunt, it's kind of worthless advice. They know they should leave earlier. If they could do it, they would have. So the coaching strategy is to break it down a little bit. So instead of saying, well, just leave at 8:30, say, all right, if you need to leave at 8:30, that means you got to be in the kitchen by 8:15; that means you got to be in the bathroom by 8 o'clock; that means your alarm has to go off at 10 of 8:00, for example; and then putting those times up in each of those places. So, on the bathroom mirror, put a post-it note that says, "8:00 to 8:15," and then in the kitchen, put a post-it note that says "8:15 to 8:30." They could even take it a step further, where you set little alarms in each of these places because, if you remember, we talked about poor sense of time, that you just kind of float through the morning and not have a clear sense of "in my progression of getting from the bed to the front door, where am I in that flow of time: how much time do I have left, how long will these things take?" So by breaking it out like this, it puts it into smaller pieces of time that are more easy to manage inside his head.
So that's the coaching piece, and then the fourth part of the model is therapy, which is helping them feel better about themselves. And there's a book out there, kind of an older book - I have to say I'm not crazy about the contents of the book, but the title is absolutely brilliant - which is You Mean I'm Not Lazy, Stupid, or Crazy? And what's so brilliant about that title is that, if you don't have ADHD as an explanation for the troubles that you're having, that's what you're left with - lazy, stupid, or crazy - because why in the world else are you doing these things that you're doing? You keep getting yourself into trouble. Why?
So understanding that it's ADHD helps them feel better about themselves, and then as a result, I think they're more likely to then apply themselves more actively and effectively with these new strategies. For a lot of them, they've gone to this pessimistic mindset of: "I get all fired up; I find some new strategy; I try it; it works for a little while, and then it stops working when the enthusiasm burns away. So why should I bother trying anything?" So that's the therapy side, is to get them activated again; give them some well-founded sense of optimism that, if I apply myself, it can actually work out well this time; address all the anxiety and depression that's so common among adults with undiagnosed ADHD; and just help them really perform at their best.
So those are the four parts: education, medication, coaching, and therapy; and they're all important in their own way.
David: Now, in the medication area, what are some of the medications that seem to be effective? I know we've heard of Ritalin and have the impression that these people are often put on some kind of speed. Is that in fact what you're talking about, or is it something different?
Ari Tuckman: Actually, it is. Ironically, it's one of the things that doesn't make sense, that someone who's hyper, you put them on a stimulant and they become less hyper. Intuitively, it's backwards, but the reason why the stimulants work is they increase activity in the part of the brain that's responsible for that response inhibition, that ability to create a gap between stimulus and response. So by increasing that activity, it helps folks with ADHD be more planful and more mindful and more intentional about what they do and when they do it. So that's what the meds do.
Now, the funny thing is, in the field of ADHD, the big advances for meds have really not been that big. We've had Ritalin since the '50s. Ritalin is great except it only lasts about four or five hours, so you got to take it two or three times a day, which is a bit of challenge to remember. So instead of old Ritalin, we now have Concerta or something called Focalin XR or a patch called Daytrana that is literally the same Ritalin that's been around since the '50s, just in a pill that makes it last 8 to 12 hours, or a patch that makes it last 8 to 12 hours. Or we have Adderall, which has been around since the '80s; which, plain Adderall is good, but once again, it only lasts about five or six hours, which makes… you know, most of us have to be functional for more than five or six hours in a day. So, instead of Adderall now, we have Adderall XR, or a cousin of Adderall called Vyvanse, which lasts that same 8 to 10 to maybe 12 hours.
So, someone with ADHD, they take the stimulant in the morning, it lasts for most of the day, and then by the end of the night, it's gone and they start over tomorrow. So, generally speaking, the stimulants, they're very effective. They're pretty straightforward to get right; not too bad on the side effects, at least compared to some other meds out there; and, I don't know, they tend to work. Plain and simple, they tend to work.
David: Okay, well, you said that you coached people to understand that they're dealing with a neurological issue. What do we know about what's going on in the brain for people with ADHD?
Ari Tuckman: Well, ADHD primarily affects the frontal lobes, which is the part of the brain right behind our forehead that is, evolutionarily speaking, it's the most advanced; it's the latest developing part. It's what separates us from monkeys and cats and dogs and lizards and the other animals; that we have more frontal lobe than these other organisms do. So, it's primarily the frontal lobes. There's a handful of genes thus far that have been identified as being involved with ADHD. There's probably a few more that they'll find; that it's not a simple "one gene, yes or no" kind of a thing; it's that there's a number of genes involved. And the neurotransmitters that are affected are primarily dopamine with a little bit of norepinephrine.
Now, the implication of this is a lot of folks with ADHD are also… they wind up becoming anxious or depressed, partly because of the struggles that they're having - being anxious and depressed in those situations is sort of good judgment. So they're anxious and depressed. They might be put on Prozac or Paxil or Zoloft - one of the antidepressants that affect serotonin.
Now, those can be helpful for anxiety and depression, but because they don't address or because they don't have any affect on dopamine or on norepinephrine, a pound of Prozac does absolutely nothing for ADHD. So, as a result, these folks see some partial benefit, but they don't really get the kind of benefit one might hope. So that's why the stimulants, which affect primarily norepinephrine, or some of the non-stimulant medications that are out there like Strattera or Intuniv, or there's an antidepressant called Wellbutrin, they primarily affect norepinephrine, so they have then some benefit for ADHD, but often not as much as the stimulants do.
David: Okay, well, I'm impressed by the knowledge and compassion that you bring to this area, and I'm wondering if, as we wind down here, if there's anything else that you'd like to say.
Ari Tuckman: Well, I guess a few things. One of them is I hope that the clinicians who are listening really pay some serious attention to ADHD in adults because, even though… you know, in the general population, if you pull a hundred people, random people, off the street, about 5% of them or 4-5% of them will have ADHD; but if you look at the clinical population, in other words, the people who come into therapists' offices like you and me - whether they come in for anxiety, depression, work issues, marital stuff, whatever - anywhere from 1 in 5 to 1 in 10 will also turn out to have ADHD. So, indeed they are depressed, but 1 in 10 of the folks who come in for depression also have ADHD. So if you miss the ADHD piece of it, and you only focus on the other part, you're not going to be as effective as you would like to be. Now, to the non-clinicians out there in your listenership: if their struggling with anxiety or depression or whatever, and they're not getting the benefit they might hope, ADHD might be one explanation to take a look at.
The other thing I'd like to say is, as disabling as ADHD can be when it's undiagnosed and untreated in the sense of how big an effect it can have on someone's life, man, it's also really treatable. Not that anyone's life becomes perfect, but at this point in time, we've got some really good techniques and really good interventions to help folks with ADHD do better in their lives. And I think education's really important. For those with ADHD or who have family members with ADHD, the more they learn, the better off they are. So whether it's my book or podcast or somebody else's or book or podcast, go out there and learn because the more you learn, the better off you're going to be.
David: Okay, now, speaking of your book, More Attention, Less Deficit, is that available on Amazon.com and other such sites?
Ari Tuckman: It is. It's available all over the place. It also newly became available on the Amazon Kindle as well.
David: Oh, that's great.
Ari Tuckman: Yes, and then I also have… Actually, I believe so strong in the executive functions as being just crucial to understanding ADHD, I've actually put a free pdf of the first chapter of my book More Attention, Less Deficit, which covers executive functions, I've actually put that on my website adultadhdbook.com, so if they go there and click on the More Attention, Less Deficit cover, it'll bring them to the homepage for that book, and scroll down a little bit, and you'll find… it'll say "free sample." It's that important.
I wish I could say it was my good idea to make the executive functions the first chapter in the book, but that was actually my publisher's good idea, but at least I was smart enough to recognize it was a great idea, and I ran with it.
David: That means you have good executive functioning.
Ari Tuckman: Exactly, exactly.
David: Hey, Dr. Ari Tuckman, I want to thank you for being my guest today on Wise Counsel.
Ari Tuckman: Well, my pleasure. This is fantastic. I appreciate the opportunity.
David: I hope you found this conversation with Dr. Ari Tuckman both informative and interesting. His book, More Attention, Less Deficit: Success Strategies for Adults with ADHD, is both comprehensive and very readable. I would say it's an excellent resource for adults with ADHD and their loved ones. For more information about Dr. Tuckman's books, podcast, and upcoming presentations, you can check out his website at http://adultadhdbook.com.
You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.
If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.
Gifted and misdiagnosed - Douglas Eby - Apr 20th 2010
Thanks for a fascinating and informative overview. Are you familiar with James T. Webb, Ph.D.? He is author of the book Misdiagnosis and Dual Diagnoses of Gifted Children and Adults, and writes in his earlier article (link below) Mis-Diagnosis and Dual Diagnosis of Gifted Children, "Many gifted and talented children (and adults) are being mis-diagnosed by psychologists, psychiatrists, pediatricians, and other health care professionals. The most common mis-diagnoses are: Attention Deficit Hyperactivity Disorder (ADHD)… (etc)." Does Dr. Tuckman have any perspective on this sort of misdiagnosis?