Laura J. Martin, MD
When Amanda, 30, was diagnosed with ADHD five years ago, she began to understand the risk-taking that had marked her teens and twenties: the drug abuse, binge drinking, and casual sex with numerous men who had flirted with her in bars.
She couldn’t put the brakes on those intensely exciting experiences, but she also despaired that her life was out of control. “Before I was diagnosed, I was depressed a lot because I just didn’t understand what was wrong,” says the Baltimore resident, whose last name is being withheld to protect her identity.
Not every adult with ADHD engages in thrill-seeking or risky behavior. But like Amanda, many are driven to danger by impulsivity or hyperactivity -- hallmark symptoms of ADHD -- combined with a high need for stimulation and a diminished ability to grasp consequences.
As a result, they may begin courting problems early. According to the National Institute of Mental Health, in the first few years of driving, teens with ADHD are involved in nearly four times as many car accidents as peers without the disorder -- and those accidents are more likely to cause injury. Teens with ADHD also get three times as many speeding tickets.
Furthermore, in one study of adolescents, more than 50% of teens diagnosed with ADHD contracted a sexually transmitted disease, says George Keepers, MD, chair of psychiatry at Oregon Health and Science University and director of the OHSU Adult Attention Deficit Disorder Clinic. Teens with ADHD also accounted for almost all of the pregnancies that occurred during the study. “You can see that there’s a tremendous amount of risky behavior that goes with the diagnosis,” Keepers says.
Risk taking may extend into adulthood in the form of substance abuse, physical fights, habitual gambling, jumping headlong into online relationships with strangers, and other perilous or even life-threatening actions.
How might ADHD be at fault? The disorder impairs the brain’s executive functions, Keepers says, “where we form judgments, where we predict the future, where we try to conform our actions to tasks that will lead us to success, rather than to failure.”
But there’s hope when people learn that their high-risk behavior stems from ADHD. “Their likelihood of avoiding risky behaviors is very much related to whether they’re treated,” Keepers says.
For Amanda, undiagnosed ADHD turned her school years into an ordeal. She couldn’t focus on textbooks or lectures because of inattentiveness, so she played on teachers’ sympathies to get better grades. “I sort of manipulated my entire way through school,” she says. “I literally passed by the seat of my pants.”
When she graduated from high school, she was unprepared for community college or the work world, she says. “I just felt like I couldn’t buckle down and focus on anything in my life.”
She continued to live at home. But to her parents’ chagrin, the reckless behavior, which had started with drugs in high school, began to escalate. After a romantic breakup in her mid-twenties, Amanda turned to binge drinking to cope with her distress.
“I was really destroying myself,” she says. “For a long time, I lived by this motto, ‘If you’re going to be a bear, be a grizzly’ -- all or nothing. I didn’t start anything slowly. I started binge drinking right from the get-go.”
Drinking became a gateway to multiple encounters, some involving unprotected sex. “I’d just go to any random bar by myself. One drink would turn into two, two would turn into four, four would turn into seven,” she says. “The next thing I know, I’m so intoxicated I can barely drive, and I was hooking up with strangers and not remembering what I had done the night before.”
All the while, her finances suffered, too. “I was making really bad decisions and I couldn’t save any money. Any dime that I got, I would spend it on something -- didn’t matter what. I would go on these random shopping sprees even if I didn’t have money. I acquired all this debt and couldn’t figure out how to pay it off.”
Did she ever consider the future? “I never once really thought about the consequences,” she says. “It was like, ‘This is just what I want to do... and I don’t care who it affects.’”
Why do some people with ADHD have a “hunger for intense stimulation,” as psychiatrist Edward M. Hallowell, MD, describes in his book Driven to Distraction?
Thrill or danger may focus the distracted or inattentive mind in a way similar to that of ADHD stimulant medications: by enhancing the release of adrenaline, Hallowell writes. “Hence, such behavior may constitute a form of self-medication.”
The idea makes sense to Amanda. “Especially when I was a mortgage processor, I was so bored. It was the same thing over and over again every day. Going out at night and binge-drinking -- that was my excitement. I got to have honeymoon scenes with a different guy every night,” she says.
“At the time, it feels great. Then you always wake up the next day and you regret it. You don’t feel so good and you’re hung over and it’s awful,” she says. “I guess with my ADHD, I just would forget that... and it starts all over again.”
She never came down with a sexually transmitted disease, she says. “It’s almost mind-boggling that I haven’t.”
But she got a huge wake-up call: an unplanned pregnancy that ended in an emotionally wrenching abortion.
After that crisis, Amanda knew that she had to confront the risk-taking head-on, she says.
Her psychiatrist, David W. Goodman, MD, has treated her with ADHD medication, as well as a drug for alcoholism. Goodman is director of the Adult Attention Deficit Disorder Center of Maryland and an assistant professor at Johns Hopkins University School of Medicine.
For patients, it’s important to treat not only the ADHD, but any accompanying psychiatric problems, including mood disorders, anxiety disorders, and substance or alcohol abuse, Goodman says. That’s because treating ADHD alone won’t necessarily curb a drug or drinking problem, he says.
But combining ADHD and other psychiatric treatments often works well to reduce high-risk behaviors, Goodman says -- if patients follow the plan. “You have to get people who are motivated to stay in treatment consistently, take medication consistently, and appear at their therapy sessions consistently.”
Besides medication, counseling can provide concrete and practical help to reduce risk-taking. Even with medication, “You still have to learn how to behave in some different ways,” says Lew Mills, PhD, MFT, a therapist in San Diego who counsels adults with ADHD.
Mills works with some clients to avoid red-hot situations in which they might lose impulse control. For example, if a man with ADHD habitually gets into bar fights, it’s useless to counsel him not to swing at someone who insults him. “At that point, it’s too late,” Mills says.
Instead, Mills will help the man find ways to steer clear of danger, perhaps by controlling how much he drinks or choosing not to visit rowdy bars. “There’s some chain of events that leads them to that calamity that they have to break earlier,” Mills says.
A reputable ADHD coach can also offer useful strategies. But expertise varies widely, so check credentials carefully, experts say.
One ADHD coach, Jodi Sleeper-Triplett, MCC, SCAC, has worked with hundreds of teens and adults. She also wrote the book, Empowering Youth with ADHD. She has seen people in their thirties and forties express remorse for the relationship, job, or financial ruins that happened before they were diagnosed.
“There’s a lot that we can do in a safe space of coaching, with no judgment,” Sleeper-Triplett says. She says coaches can help ADHD clients weigh decisions and consequences, set goals, and build the “skills to get from point A to point B.”
Coaching is also forward-looking, she says. “We’re not delving back into the emotional, therapeutic past. The fact that someone is reaching out and saying, ‘I really didn’t do a good job up to now,’ -- OK, let’s start with today and see where we can go.”
Amanda is looking to the future, too. “When I started on medication, my parents saw the change in me,” she says.
With ADHD medication, her focus and organization have improved, she says. After her morning dose kicks in, “I literally pop out of bed and I'm ready to go. I’m ready to start my day and get my tasks completed,” she says -- whether it’s doing laundry, hitting the gym, feeding a friend’s cat, or getting ready for work.
Although she has faced struggles and setbacks, she’s pleased that her life has finally turned in the right direction, she says. After a succession of jobs -- veterinary technician, mortgage processor, club promoter, massage therapist -- Amanda is now steadily employed at a restaurant.
Soon, she’ll move out of her parents’ house, but she’ll still have some structure. She’s moving in with a 54-year-old family friend who will hold her to “rules of the house,” she says.
Now that she’s better able to control her impulsivity, Amanda no longer binge-drinks or seeks hookups in bars, she says. “After that pregnancy, I can’t binge drink. I can’t be that risky anymore, and I don’t ever want to go through that again.”
Recently, she tried a new approach: She joined an online dating service. “What came out of all this is that I finally realized that I do want a relationship,’ she says. “I do want to be with just one person.”
SOURCES:Amanda [last name withheld], ADHD patient, Baltimore.George Keepers, MD, chair of psychiatry, Oregon Health and Science University; director, OHSU Adult Attention Deficit Disorder Clinic.David W. Goodman, director, Adult Attention Deficit Disorder Center of Maryland; assistant professor, Johns Hopkins University School of Medicine.Lew Mills, PhD, MFT, therapist, San Diego.Jodi Sleeper-Triplett, MCC, SCAC, ADHD coach, author, Empowering Youth with ADHD.National Institute of Mental Health: “Attention Deficit Hyperactivity Disorder”.Driven to Distraction, Edward M. Hallowell, MD, and John J. Ratey, MD. Pantheon Books, 1994.
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