Point of View


Point of View

A VAST Difference: Depathologizing ADHD

By Ryan Howes

March/April 2020


The ADHD diagnosis has gotten a lot of negative attention in recent years: in classrooms, the media, around dinner tables, and yes, in the offices of clinicians across our field. Some think the disorder is overdiagnosed, or fueled by Big Pharma to get our kids hooked on meds. Others maintain it’s a symptom of a generation of children who weren’t taught to focus and are hooked on ever-distracting screens. In recent years, it’s been said to be an easy excuse for adults who aren’t organized enough to show up on time.

According to psychiatrist Edward (Ned) Hallowell, New York Times bestselling author of several books, including the seminal Driven to Distraction, not only are these perceptions false, but so is the very notion of ADHD as a disorder. A Harvard Medical School faculty member for 21 years and the founder of The Hallowell Centers in Boston, New York City, San Francisco, and Seattle, he believes that rather than a curse, an ADHD diagnosis can be a blessing. Once people understand it, they can learn to control and focus their brain to significantly improve their life.

I caught up with Hallowell last fall for a very focused conversation on how he’d like to turn the way most people think about ADHD on its head.

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Ryan Howes: How did you first become interested in studying ADHD?

Hallowell: In 1981, when I was doing my residency in child psychiatry, I attended a lecture by Elsie Freeman on a condition I’d never heard of. It was called ADD then, attention deficit disorder. Sitting in on that lecture was one of the great aha! moments of my life. Wow, I thought, that must be what I have! It explains so much! But it wasn’t long before I realized that the medical model we were presented with didn’t include the whole story. The symptoms fit me, but I knew from personal experience that a whole lot of good stuff comes with the condition.

I wanted to learn as much as I could, but back then, people were pretty skeptical about ADD. Was it real, or just an excuse? So I spent that decade collecting information, not from books, but from patients. They were my textbook. Then in 1994, I wrote Driven to Distraction. I thought it would sell maybe 10,000 copies, but that book has now sold over 2 million copies. It really put the condition on the map and gave so many people the chance to learn about it and understand it well beyond the stereotype of hyperactive little boys running around and bumping into things.

RH: You’ve said that you grew up in something you call a WASP Triad. What is that?

Hallowell: It’s a combination of alcoholism, mental illness, and politeness. Those are my forebears, my family.

RH: In your conceptualization of ADHD, are you using a primarily genetic model, or does growing up in the WASP Triad have something to contribute?

Hallowell: Well, upbringing always contributes something; there’s no doubt about that. It’s always a combination of nature and nurture, genes and life experience. But as far as the condition itself—what I think of as a trait—it’s genetic. You inherit the genes that contribute to it. In fact, it’s one of the most heritable conditions in all of the behavioral sciences. And it’s genetically related to bipolar disorder, which my dad had.

RH: I haven’t heard that before. What’s the connection between ADHD and bipolar disorder?

Hallowell: Genetically, you often find upstream in people with ADHD a history of either bipolar or major affective disorders. They’re cousins in a way. If you think about it, they share a lot. ADHD is a question of controlling high energy, mania being the extreme version of that. I describe it to people as having a Ferrari engine for a brain with bicycle brakes. I’m a brake specialist, so I tell the kids I work with, “Don’t worry, we’ll work together to strengthen your brakes, so you can win races and become a champion.”

RH: That changes the narrative quite a bit from pathology to a potential strength.

Hallowell: Yes, ADHD is a combination of distractibility, impulsivity, and restlessness. It’s power without control, but when you take each one of those negatives and turn it on its head, you get a positive. The flip side of distractibility is curiosity, which is a tremendously powerful force. The flip side of impulsivity is creativity. What is creativity but impulsivity gone right? You don’t plan for creative ideas; they just pop. They come with disinhibition. So they depend on having brakes that aren’t too strong. Then hyperactivity, when you get to be my age—I just turned 70—it’s called energy.

This is where the medical model falls short, because it only talks about the problematic side and leaves out all the positives: creativity, imagination, curiosity, energy, entrepreneurialism. So what I’ve done is changed the name from ADHD to VAST: Variable Attention Stimulus Trait. The point is much more than semantic: the deficit disorder model is simply inaccurate. This is not a deficit of attention at all. It’s an abundance of attention. The problem is controlling it. The deficit model makes it sound like a form of dementia, which it certainly is not. Some of the most famously successful people in the world have this condition. Calling it a disorder is just flat out wrong, and hyperactivity usually isn’t present in adults. So the word attention is right, but deficit, hyperactivity, disorder are wrong.

I’m under no illusion. I don’t think the creators of the DSM will throw out the ADHD label, but I’m hoping to give the general population a term that they can live with—and appreciate. What kid wants to be told he has Attention Deficit Hyperactivity Disorder, let alone what adult? It’s pathologizing, stigmatizing, which does no one any favors. It scares a lot of people away from getting diagnosed. And if they do get diagnosed, it conveys shame and fear.

RH: So you’re a brake specialist. What does that look like?

Hallowell: Another analogy I use is that ADHD is like Niagara Falls. Until you build a hydroelectric plant, it’s just a lot of noise and mist. But when you build that hydroelectric plant, you can light up the state of New York.

RH: How does someone start to build a hydroelectric plant or put on the brakes when they’re dealing with ADHD, or VAST?

Hallowell: It begins with education, with reframing. It also begins with wanting to understand it. Once you get someone interested, and take away the fear and the “I’m wrong” parts of it, then you can make it your own and say, “How do I want to work with this?” For adults, it’s about marrying the right person and finding the right job. For children, it’s about finding where they can plug in their brain so it lights up.

In other words, it’s about the finding the right places for people to thrive, which involves trial and error. But there are a number of interventions that are helpful. Physical exercise helps a lot, as do sleep, nutrition, coaching, and understanding the components of executive functioning. The most common intervention is medication, which works about 80 percent of the time. An 80 percent track record is pretty good, and when medication does work, it’s a godsend. By itself, though, it’s not nearly enough. You still need to have a comprehensive plan.

RH: My adult clients usually know when they’re depressed, when they’re anxious, but I often encounter clients who say, “I’ve spent my entire life dealing with these symptoms, and I didn’t even know it was ADHD.” Is that common?

Hallowell: It’s a crying shame that even now therapists and people in the medical profession miss it all the time. Of course many people who have this condition don’t know they have it—that’s the only life they’ve known. So they think, “Well, that’s just normal that I forget things, overlook things, see things other people don’t, come up with new ideas and forget them. That’s just the way I am.” Then someone like me comes along and says, “No, there’s a word for this. There’s a tremendous upside to it, but there’s also a tremendous downside. And here’s the good news: we can really help you.”

The flip side of impulsivity is creativity. What is creativity but impulsivity gone right?

Treating adults is so much fun because it’s like you give new life. I have people all the time telling me, “You’ve changed my life forever.” It’s a good news diagnosis. Things can only get better once you name it, and you can get the tools to help with it. I love my specialty! Unlike a lot of people who work in mental health, I can say that I love what I do because my clients almost always improve—and often dramatically.

RH: The talk among therapists within the last 20 years or so has been that ADHD is overdiagnosed, especially among children. People blame everyone from greedy drug companies to parents and teachers who’d rather medicate rather than discipline. Is there any validity to that?

Hallowell: Sure. It’s both overdiagnosed and underdiagnosed. Some people don’t “believe” in it, or dismiss it as being overdiagnosed. It’s amazing how many people get caught up in the hot-button topic without really having a clue about what the condition is about. In that way, it becomes sort of politicized.

Yeah, there are places where people angling for higher SAT scores or some other kind of accommodation try to get the diagnosis, and medication gets handed out too easily. Although the misuse of medication is a major concern, much more damaging is when it’s present and not diagnosed. The people I see most often with it are adult women, where almost invariably they get diagnosed with depression or anxiety or both, and get put on an SSRI, which just doesn’t help at all. In those cases, missing the diagnosis, making the wrong diagnosis, and giving the wrong treatment will cost these women the new life they could otherwise have. So, to me, the big challenge remains educating the medical, psychological, and teaching professions as to what this condition actually is, what it looks like, and then giving proper treatment when it’s warranted.

RH: Do the symptoms mimic anxiety and depression, or are anxiety and depression a result of ADHD?

Hallowell: Anxiety and depression can occur in the wake of ADHD. You’re depressed because you’re not doing as well as you know you could, and you’re anxious because you’re wondering what you’re going to overlook or forget next. Often, if you put them on a stimulant medication, suddenly they start doing better. The depression goes away, and they start feeling more in control, so the anxiety goes way.

RH: You run a summer adventure family camp. What does that look like?

Hallowell: It’s just a week, but it’s a wonderful week on Lake Michigan. It’s for parents and their kids who have ADHD. I meet with the parents in the morning for three hours to give them tools and knowledge, and a team of gifted teachers facilitate experiential learning opportunities with the kids. The kids don’t know they’re learning executive function skills, but they are. They go canoeing, cook a meal, and go to a farm in the morning, and then in the afternoon they all get to play in a beautiful place and make friends with each other. The parents benefit not only from what they get from me, but from each other. There’s a tremendous amount of bonding, sharing, and realizing that we’re all in this together. There’s a lot of tears and a lot of laughter.

RH: Video games seem to be a focal point for kids with high levels of ADHD, or VAST. There’s so much stimuli, but they can just lock in and be there for hours, right?

Hallowell: People with ADHD are always looking to focus, and there are adaptive ways to find that and maladaptive ways. The combination of novelty stimulation and motivation creates focus; video games are perfect for that. They’re exciting, structured, motivating, and interactive, which makes them addictive. The whole dopamine circuitry kicks in. I’m not opposed to video games or screens in general, but what I really champion is learning moderation. The abstinence model, which is often invoked in addiction treatment, isn’t practical in today’s world because you have to be able to use a screen.

RH: What’s the future for treatment of ADHD?

Hallowell: We need to spread the word about the nonpathology of ADHD, and I think as far as treatment goes, it’ll be in the direction of exercise and brain games. I think medication will be used a lot less when we’ve effected these other interventions. A new treatment I’m using involves stimulating the cerebellum through physical exercise, which in turn stimulates the frontal lobe. It’s really promising. I think that’s going to be the direction the treatment takes.

RH: What would you say to generalist therapists who don’t necessarily specialize in ADHD?

Hallowell: I’d tell them that if they learn more about ADHD, they’ll find a pleasant new addition to their practice. They’ll love treating it because they’ll see improvement. After all, we’re all in this field to help people, right?

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Ryan Howes, PhD, ABPP, is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. Contact: rhowes@mindspring.com.

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Tuesday, April 7, 2020 11:16:58 PM | posted by Mercy Carbonell
Dear Ryan, Thank you so much for your interview with Ned Hallowell. I know Ned briefly because he is an alum of the secondary school where I teach English/coach, Phillips Exeter Academy. He returned recently to give an Assembly & speak with Faculty/Staff. It was his framing/reframing & certain ways he spoke of ADHD that allowed me to go & get tested for what I have suspected I have been living with for 51 years. Perhaps what I most appreciate in your interview & within Ned's work is the shift from a condition that should be pathologized/negative to one that has celebratory qualities. I would not be the teacher, artist, athlete, coach, thinker, friend I am today if I many in my midst had not chosen to honor my creativity as it emerges. As a dear friend wrote to me recently, "Plans that never amount to anything and ideas that trail off are how Mercy expresses love for the things that excite her." And I let out a long exhale and burst into tears at his capacity to honor my mind. My hope is that Ned's work/reframing & your interview/Work will allow so many to thrive, to feel celebrated rather than depleted, to stretch their gifts into creative realms that can allow others to feel their humanity. Your Interview is a beautiful pulse into what is possible. Thank you ~ Mercy Carbonell she/her/hers Instructor in English, Phillips Exeter Academy