Timmy’s parents are right, partially. Timmy can do things that he is interested in, but he has trouble with jobs that require more sustained effort. It’s not because he doesn’t care; it’s because, more than most other people, he needs to find something interesting for it to hold his attention.

Timmy searches for stimulation. That often gets him into trouble because he doesn’t pay attention when he’s supposed to. He turns to look out of the classroom window when he should be listening to the teacher. He gets up out of his seat during the middle of a lesson. He annoys other children when they are trying to listen or do their work. Although medical scientists do not know exactly what causes AD/HD, I can tell you what I think it is, just as I explained it to Timmy’s parents.

What Causes AD/HD?

Most child psychiatrists, including myself, do not believe the root cause of AD/HD is psychological. We believe an abnormality in the body’s nervous system produces the disorder. As I told Timmy’s parents. This is only a hypothesis, and no one really knows what causes AD/HD. But the "nervous system" hypothesis has considerable explanatory value, and I believe something like it does operate in AD/HD.

I describe AD/HD as a kind of barrier to the nervous system—an "invisible shield" that prevents normal levels of stimulation from getting through. It is as if Timmy had a thick layer around his nervous system: normal levels of stimulation don’t penetrate it. Just as nature hates a vacuum, so, too, the nervous system hates sensory deprivation. So if Timmy doesn’t get stimulation, he will seek it out. This would explain Timmy’s excessive need or, perhaps better put, his thirst for any stimulating information or event. He looks out the classroom window not because he’s lazy or wants to annoy his teacher or his parents but because he’s looking for something to hold his interest. He simply finds school work and chores too boring. Timmy wants to do well. He wants to make his parents proud of him. But he just can’t seem to do this, because of his excessive need for stimulation.

Making the Diagnosis

Not all children or adults with inattention have AD/HD. For example, inattention can result from low IQ or when kids with high intelligence are placed in academically unchallenging environments. Some rebellious children resist tasks that require self-application simply because of an unwillingness to conform to others’ demands. Certain medications (for example, bronchodilators or isoniazid) can cause inattention, hyperactivity, or impulsivity. So, how do we make the diagnosis?

I explained to Timmy’s parents that AD/HD represents a specific disorder. And because problems may appear to be AD/HD, we need to be careful not to label people with the diagnosis recklessly. AD/HD has a "shape", "color", and "feel". An accurate diagnosis can usually be made when someone has at least 6 of nine symptoms from either one of the following lists (Symptoms listed here are based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washigton, DC: American Psychiatric Association; 1994):

AD/HD, inattentive type

1. failing to give close attention to details or making careless mistakes
2. difficulty sustaining attention in tasks or play activities
3. not seeming to listen when spoken to directly
4. not following through on instructions and failing to finish schoolwork, chores, or duties
5. difficulty organizing tasks and activities
6. reluctance to engage in tasks that require sustained mental effort
7. losing things (toys, school assignments, pencils, books, or tools)
8. being easily distracted by extraneous stimuli
9. being forgetful

1. fidgeting
2. being unable to remain seated in the classroom or in other situations in which remaining seated is expected
3. running or climbing excessively
4. difficulty playing or engaging in leisure activities quietly
5. being "on the go" as if "driven by a motor"
6. talking excessively
7. blurting out answers before questions have been completed
8. difficulty awaiting one’s turn
9. interrupting or intruding on others

Many individuals with AD/HD have at least six symptoms of inattention and at least six symptoms of hyperactivity-impulsivity. We then give them the diagnosis of AD/HD, combined type.

Timmy’s parents asked me about a "test" for AD/HD. I told them we make the diagnosis on the basis of history and clinical observation. Psychological testing and neurological examinations provide no significant value in establishing the diagnosis of AD/HD. They, in fact, contribute little but additional costs to the diagnosis and treatment. Neurological evaluation may, however, be used to rule out other neurological disorders. Though the frequency of neurologic "soft signs" (mild neurologic abnormalities) is greater among children with AD/HD, their presence does not confirm or rule out a diagnosis of AD/HD since neuropsychological abnormalities are also found in a fraction of normal children. And psychological testing, although not diagnostically helpful, can detect the possible coexistence of learning disabilities.

Treatment

Risks of Not Treating

Many people do not appreciate how serious a disorder AD/HD can be. AD/HD prevents kids like Timmy from being able to focus attention on academic work; the frequent results are significant academic underachievement and poor self-esteem. Furthermore, the impulsivity, short attention span, and overactivity often make the child’s behavior unacceptable to peers, resulting in poor socialization and rejection by others because they often find it too difficult to be with someone with AD/HD. In late adolescence and in more serious cases, antisocial behavior and an increased risk of developing drug and alcohol abuse can follow—partly because of the increased impulsivity of AD/HD and partly because the individual is simply not happy.

Using Stimulants to Treat AD/HD

The fact that medicines such as Ritalin or Dexedrine can help people with AD/HD is itself both interesting and instructive. Stimulants are the most effective medications for the disorder. Stimulants? Intuitively, we might think that, if we were going to use a medication to help a hyperactive child, we would want to use a tranquilizer, not a stimulant. We might expect a stimulant to make the condition worse since the child is already "hyper." The clinical fact, however, is that tranquilizers make kids and adults with AD/HD more "hyper"; and stimulants make them better. How can we explain this curiosity?

Again, the idea of the "invisible shield" around the nervous system might explain this unexpected finding. A tranquilizer tranquilizes Timmy and "thickens" this barrier, allowing even less stimulation to get through. As a result, Timmy feels an even greater craving for stimulation, and he might become hyperactive or more distractible. Perhaps then, stimulants work for AD/HD because they don’t tranquilize. Instead they stimulate the nervous system, leaving Timmy less "thirsty" for outside stimulation and better able to focus his attention.

Of all children and adults diagnosed with AD/HD, 50% to 70% respond to treatment with stimulants with significant clinical benefit. Their improvement can be profound and is often not appreciated by those unfamiliar with the treatment responsiveness of AD/HD. These medications often result in functioning at a level better than any the patient has ever experienced before.

Children and adults with AD/HD are not "drugged" into compliant, complacent behavior. Numerous studies report stimulants that improve all of the core symptoms of AD/HD (the hyperactivity, inattention, and impulsivity). Treated with stimulants, people with AD/HD are alert and responsive and have at their disposal greater options for skilled adaptive behavior and greater flexibility for behavioral choices. Left untreated, they are distracted, impulsive, disorganized, too easily overwhelmed by stresses, and hot tempered.

Behavior Management

Behavior management can be extremely important. It is essential to understand, however, that medication is the only intervention that will actually reduce the individual’s symptoms. Without medication, only the environment - not the individual - can be changed. Behavior management means changing the environment so that the inattentive and impulsive individual can function better.

Parent Training for Behavior Management

Sometimes quite helpful, behavior management can be taught to parents in order to enable them to more effectively manage the child’s day-to-day behavior. Altogether, however, it should be remembered that behavior management is a way of helping parents cope with but not change the underlying behavioral dysfunction caused by AD/HD. Behavior management techniques involve a decreased emphasis on blaming the individual and increased emphasis on changing the child’s environment in order that the individual function better. Only medication can change the central symptoms of the disorder.

General Principles of AD/HD Behavior Management

• AD/HD is a biological deficit in persistence of effort, attention, and inhibition. AD/HD individuals typically also exhibit a reduced sensitivity to behavioral consequences. These characteristics are not the result of laziness or moral weakness.

• Give immediate and frequent feedback. Occasional praise a few times a day works for normal children and adolescents, but AD/HD individuals require frequent feedback. The adult may find this tiring, but frequency is necessary in order to change patterns of behavior that have developed in the AD/HD individual over time. Adults need to remember to look for behavior for which to give feedback. Children are much less influenced by general rules than by immediate consequences. Positive feedback may take the form of praise or material rewards, but it should be clear, specific, and occur as close to the moment of the behavior as possible.

• Use nonverbal rewards. For the AD/HD individual verbal praise is rarely sufficiently potent by itself. The addition of physical affection, privileges, and material rewards increases the effectiveness of positive feedback.

• Rewarding is not the same as bribing or spoiling. Bribery (or spoiling) is giving an incentive to someone for not doing something he or she shouldn’t. Rewarding is giving an incentive for desirable behavior.

• Start with rewards before punishments. First, redefine the problem behavior into a desirable alternative. Then reward it consistently for a week or two before beginning any punishment for undesirable behavior. Punishment, if necessary, should be mild and very selective—only for a specific negative behavior, not for everything that is offensive. The ratio should be 3 rewards (positive feedback) for every punishment (negative feedback).

• Maintain perspective. Remember, you are dealing with an individual who in many ways is handicapped. Forgive both yourself and your child when inevitable failures occur. But don’t give up.

Overcoming Codependency

  Codependency has become a buzzword of our time, and as with all buzzwords that acquire a certain cultural currency, the vital concepts behind it can sometimes be undermined with time. In the case of this particular buzzword, however, we cannot afford to let its meaning slip away. Codependency is one of our most destructive psychological habits, and, unfortunately, one of the most prevalent

What is codependency?
Contrary to what many people think, codependency does not only refer to dependent relationships that involve substance abuse. Its connotations are far broader. Someone who is codependent is one who has let another's behavior or feelings affect them in a way that interferes with work, creativity, other relationships and personal growth. Alternately, the word codependency also refers to people who are preoccupied with controlling other people's behaviors and feelings. In either case, whether a person is excessively swayed by another, or excessively dominant, the result is an inability to feel balanced, whole, and empowered.

Distorted and damaged self-esteem is the root of codependency.
When we feel healthy and whole, we understand that we cannot control other people's feelings, ideas, or behaviors. We make decisions that are best for us, and others are afforded this same right and responsibility.

However this healthy perspective is undermined when the sense of Self is damaged through frank emotional and physical abuse, through experiences that did not validate our point of view, or when our basic need for love, understanding, and empathy were not met by those who took care of us. Walking through life with a distorted sense of Self is like seeing life through a foggy pair of eyeglasses. We cannot see the outside world clearly because our own ability to register and navigate healthy choices and ideas is impaired or undermined by past experience.

Jane's story
Jane M's story is an example of patients' testimony revealed in individual and group therapy.

Jane arrived at group therapy because she did not understand why she was not excelling in her career, and why she chose relationships in which she always functioned as the caretaker and fixer. She complained of vague symptoms of headache, stomachache, and fatigue in which there was no clear medical explanation, diagnosis, or treatments that helped. Through a series of weekly sessions and through feedback from her group, she began to realize that she was recreating patterns from her past that affected her inner sense of well being and her relationships.

Jane grew up with parents who were alcoholics. Aside from the difficult memories of intoxicated caregivers, Jane remembered that she evolved into the "family rescuer". She cared for her parents without understanding that they were responsible for their own behaviors and feelings, and became a surrogate parent to her brother. In essence, she took upon herself the difficult burdens of her parents and brother by thinking that she caused or was responsible for their actions and feelings. "If I did more for them, I thought I would be loved more." All of this resulted in an undeveloped sense of self-esteem for Jane. Because she was so focused on keeping the family together, she neglected her own needs and wants, and lost her own identity. As an adult, she found that she was trying to please everyone at work and at home, at the expense of her own feelings and inner growth.

Through courageous and patient attempts to pursue therapy, Jane realized that the only one that she could be responsible for was herself. This was not a selfish attitude (which is what she previously thought) but, rather, a healthy one, since she was creating proper boundaries that were never learned. She also recognized how much of her personal time, energy and concentration was spent trying to correct, challenge, and cure her significant others' problems over the years, including a fraught relationship with an alcoholic boyfriend. Despite her efforts, she was frustrated because she was not receiving balanced love and nurturing in return.

Over time, the fog upon Jane's eyeglasses began to lift.
Her distorted sense of Self gave way to a new wholeness, vitality and freedom as she allowed herself to release intense, negative emotions arising from inner mistrust, guilt, rage, shame and blame. She reworked destructive patterns in her childhood of trying to rescue and fix her own caretakers, which prevented her from accepting herself and her limitations in helping others. She created new boundaries through a healthier sense of Self, and set limits with relatives, friends, and intimate partners on what she would and would not do by owning her own life and placing the responsibility of their problems upon themselves. She recognized that she had to recreate love, acceptance, and understanding in her present life through new creative projects and activities that she never received or had the opportunity for in her childhood.

As a result, Jane switched careers into a high paying job and found a partner who was understanding and nurturing. Her physical complaints gradually subsided; she even found new life in aerobics and yoga as part of her own well-being and spiritual quest.

Four trouble spots
Like Jane, those suffering from a feeling of distorted Self must contemplate whether four major areas correspond to their own life experience.

Low self-esteem
Low self-esteem is defined as: ongoing inadequate feelings; difficulties accepting praise; constant self-judgment and criticism; ongoing feelings of guilt, worthlessness, shame; fear of rejection; and severe reactions to criticism. These all point in the direction of a low self-worth that may have deep rooted origins and require inner healing.

Difficulty setting boundaries
Injury to the Self contributes to the difficulty in managing where our needs begin and another person's ends. In a household in which fear and mistrust rule, our sense of Self shuts down. What results is isolation and withdrawal from how we truly feel. Repression and denial cover our own knowing of how to give and receive. If boundaries remain distorted, healthy needs are not met and there is imbalance in managing the needs of others. Rescuing and fixing others at the expense of our own well-being is one form of this, the extreme form is to caretake and enable those who are abusing alcohol and other substances to continue their destructive activities.

Problems meeting individual needs and wants
When Self is damaged through constant undermining of our own sense of trust and what is right for us, there is great difficulty in navigating our own needs and desires. Many suffering from this are fearful and judge themselves for seeking and finding their own highest and best in life. Until Self is healed, there is the ongoing struggle of not feeling "good enough" to create health and balance. Or, there is too much giving or withholding from others. The meter for understanding our own ability to choose and create health is in the quality of relationships, creativity, job satisfaction, as well as how we create our own personal space that is right for us. The central question to always ask is, "how peaceful and content are we, when we are alone with ourselves?"

Difficulties in creating balanced living
Highs and lows, ups and downs, extremes in behaviors, and difficulties finding time for one's Self are all signs that require inner contemplation. For example, if you are a workaholic, is there a history of abuse or of being undervalued or unappreciated, so that there is something to prove? If there is reckless spending or chaotic relationships, is that a recreation from experiences with past caretakers? If there is neglect of creativity is that disavowing our need for balance in work and play? All are seeking happiness; one needs to perform one's own healing work to elicit the motives and conflicts that prevent time for recreation, career, and our own inner spiritual development.

Recovery
Ongoing consistent recovery work is key. As Jane experienced over time, consistent practice and intervention goes a long way in healing the distorted Self. Below are some avenues to explore.

Regular individual and group psychotherapy provide an outlet to ventilate feelings, confront resistances, open up and discuss difficult family patterns and their present day effect, and to work through old wounds through feedback of other members as well as the therapist.

Structured programs such as Alanon, Alateen, and Codependents Anonymous all work to keep the focus on the individual and to dissect what role each person plays in contributing to the distorted sense of Self. The consistent and ongoing group support gradually allows those who have been abused, misunderstood, undervalued or unappreciated to create a new sense of empowerment and forward movement in their lives. These groups enhance self-esteem, help people to recreate and relearn healthy boundaries, validate personal needs that were unmet in the formidable years, and attempt to help members develop a sense of well-being for themselves.

Spiritual growth and development in whatever form or path for those open to this aspect allows free flow of creativity and accesses and enhances the healing process. Allowing and exploring the essence of the human condition in any form creates new hope and a sense of connection to life that was perhaps distorted and disrupted over time.

The miracle of the Self is that it is adaptable, malleable and that it can be healed. The disease of codependency can therefore be transformed to the healthy approach of co-creation with others in the world to lead a more fulfilling life. The eyeglasses become clear and finally the world can be seen as it really is.