He came in to discuss testing because he wanted medications as treatment for adult attention deficit disorder (ADD).
George has been my patient since I first met him in the new born nursery 26 years ago. Married with two pre-school children, he has worked doing computer graphics in a local family owned print shop. I see the rest of the family (including his children, wife and parents) regularly, but he has been in only sporadically for acute visits and several physicals. He is on no medications and his problem list only mentions an appendectomy and a family history of diabetes.
“So, George, my nurse tells me you are concerned you may have ADD and wonder if medication would help. What can you tell me about what’s been going on?”
It seemed that George’s wife had been complaining that he was not ‘doing his share’ around the house. For example, he was supposed to clean up and organize the attic over the winter. He purchased some shelves and plastic bins and spent an afternoon cleaning up and took a pickup load to the dump, but since then had only spent a couple hours and the project had remained unfinished for several months. He volunteers to do errands, but then either doesn’t follow through, or goes shopping but purchases the wrong brands or sizes, or only some of what is on the list. When he is supposed to bring the kids places, he always seems to be late and forget some key pieces, like their snacks or extra diapers. At work he noted that he sometimes forgets to check and refill the ink cartridges before a print run and rarely remembers to do paper inventory at the end of the week.
A friend he bowls with said this sounded like his son’s ADD, which had responded well toAdderall. George had gone on line and read the book Driven to Distraction (lent to him by his bowling buddy) and had decided that “I pretty much am the person they describe.” Specifically, he noted that he was disorganized, tended to procrastinate, preferred watching TV to doing chores, got frustrated easily, was down on himself for being unproductive, and wanted to be more like his wife ‘who can go shopping without a grocery list and remember everything.’
Some probing revealed that he can work for hours without problems on his pickup truck, that he is never late for his bowling events, and never forgets any of his bowling equipment. His appetite and sleep patterns were normal. He was not a smoker and did not use alcohol or drugs. Looking back in his chart with him, we noted that he was a B student all the way through school, and had done fine with sports (hockey and baseball).
As we sat and reviewed this, I pointed out that problems with impulsivity or distractibility impairing attention or focus were notably absent from his list of symptoms, making the diagnosis of ADD quite improbable. I suggested gently that this was more consistent with intention deficit disorder than attention deficit disorder, that it was most likely related to a combination of problems with motivation and organizational skills, and that medication was very unlikely to be useful. I offered him two approaches to consider:
- See a psychologist to do some more formal neuropsychological testing to look at cognitive strengths and weaknesses and help him develop coping skills.
- Hire a ‘life coach’ to help him with motivation and organization.
After some negotiation with his insurance company, he had formal neuropsychological testing which showed him to be of above average intelligence and with normal cognitive and processing skills, but with a tendency to externalize responsibility. The psych evaluation suggested some structural changes: working with his wife and work supervisor to make prioritized lists for the week, structuring his work day to make repetitive tasks more automatic, and - at the top of the list - get a life coach for ongoing support.
Last I heard, he and his wife were meeting with his life coach every 3 weeks and things were going well.