The challenges of adult life do not all come in the earliest adult years. Some with ADD syndrome report that they encounter problems from their executive-function impairments later, in unexpected ways. One thirty-three-year-old woman with ADD syndrome sought treatment after working successfully for ten years as an intensive care nurse in a large hospital. She had been diagnosed with ADHD during high school and had benefited from medication treatment for this throughout high school and college.
My ADHD is kicking up again. With the medicine I was taking for it during high school and college I did very well. I stopped taking it after I graduated and got into full-time nursing. I didn't seem to need it anymore. The excitement of working in the ICU kept me plenty focused. I'm good at my work and I love the challenge of caring for these really sick patients. Now things are getting bad again for me. I'm having that same frustration and feeling of helplessness and stupidity that I had for so many years before I got diagnosed.
The trouble started after I gave birth to our son three years ago; he's our second kid. We wanted two kids and they're both a lot of fun. But they're also a lot of work, and he's an especially lively handful. Since he started walking and getting into things, it has been a real struggle for me at home. My husband helps a lot and my mother-in-law provides day care for him when I work. That's all good, but the two kids together exhaust me. And then two months ago I got promoted to be nurse manager for our ICU. That's been a disaster. I can't keep up with all the work of scheduling staff, ordering supplies, and attending meetings. It's worse than it ever was for me when I was doing just direct patient care. I can't go on this way.
This woman speaks ofher ADHD "kicking up again" as though it were a recurrence of a disease that had been in remission. But ADHD is not a disease; instead it is a disorder that is closely tied to daily experiences. The woman's problem resulted from the escalating demands ofher new job as a nurse manager, along with the exhausting responsibilities of caring for her two young children. So long as she had only one child to care for and was doing only direct nursing care, she felt competent and was successful, so much so that she was offered and accepted the promotion. The trouble emerged when she was faced daily with increasing challenges to her executive functions both on the job and at home with her family.
The administrative burdens of her manager's job included setting up the work schedules for three shifts, finding coverage for nurses calling in sick, keeping track of supplies that needed to be ordered, filing required reports, representing the interests of her unit in administrative meetings, and arbitrating disputes among staff members. Unlike direct patient care, which was intensive and complex but limited to dealing with just a few patients within the limits of eight-hour shifts, this administrative position required much planning, thought, and discussion over both the short and longer terms. It required her to keep in mind countless requests, complaints, and tasks that carried over from one day to the next, sometimes over weeks and months. In short, these management tasks severely challenged this nurse's chronic executive-function impairments in organizing and prioritizing, in sustaining attention, and in utilizing working memory.
At home too this woman encountered increasing demands on her executive functions. When her son became old enough to walk, talk, and actively engage with his sister and the rest of his environment, the task of caring for him became much more demanding. He was a very lively little boy who turned out to have a fairly severe case of ADHD (this was not surprising, since parents with ADHD have a markedly elevated risk of having a child with ADHD). His energetic, sometimes wild temperament intensified the mother's already substantial job of parenting, given that the two children were only two years apart in age.
The woman's challenges at home included not just twice as many loads of laundry to fold, baths to give, and plates to prepare at each mealtime. She was also faced daily with repeated hassles between the children, each one often complaining to her about the other and persistently demanding that she resolve their dispute of the moment. Her son presented special problems with his fearless impulsivity. He required extremely close monitoring virtually every moment; often quick interventions were needed to protect him from unanticipated dangers. In addition, like many children with ADHD, her son had chronic difficulty falling asleep. This resulted in his making numerous curtain calls well past his bedtime; often it also brought two or three interruptions to her sleep each night as she was asked to calm him after a nightmare or to change wet sheets on his bed.
These and countless other demands by her children on her energy, efforts, patience, and management skills were exhausting to this mother. Some of the problems she faced at home were common to caring for any pair of young children; others were more typical of families that include a young child with severe ADHD. Even though she had support and assistance from her husband and mother-in-law, this mother felt chronically fatigued and frustrated, with an increasing feeling of incompetence at home and at work. The gap between her executive-function capacities and the expanded demands on these capacities from her family and new job had become too wide.
After his intensive interview study of life-course development in men, described earlier, Daniel Levinson similarly studied three groups of women: homemakers, women with corporate-financial careers, and women with academic careers. Levinson died just after completing the first draft of the manuscript reporting their results. His wife, Judy Levinson, a coworker in the study, completed the project and brought the book to publication in 1996. In summarizing reports from women who were attempting to balance both marriage and a demanding career, they observed:
By their late thirties most of these career women came to understand the illusory nature of the image of Superwoman who could "do it all" with grace and flair. Their self-image was more that of the Juggler, who kept many spheres in the air without dropping any or losing a step in the perpetual forward motion. While continually seeking balance, most women found it impossible to give anything like equal priority to the various components of the life structure. In general, occupation was the first priority, motherhood second, marriage a poor third, leisure and friendship a rare luxury, and with all the external tasks to be done, almost no time for the self. The women's lives were usually hectic, at times chaotic and exhausting. ... It would get better in time, they hoped, as the children grew older and the career stabilized. (p. 349)
The nurse described in this case example faced the same draining pressures that Levinson found characteristic of many career women, most of whom, presumably, did not have ADD syndrome. In her case, these pressures were intensified by the special needs of her son who suffered from ADHD, at that time untreated. The combination of these increased demands on her executive functions and her chronic impairments of ADD syndrome caused her to seek treatment.
During treatment, this nurse recognized her dilemma and clarified her priorities. She spoke most of her painful awareness that she was not providing for her children the quality of care that she wanted to give them. She said,
I'm usually doing OK at getting them the basics, but I know that I'm just not there enough for them emotionally. I'm always disorganized and frazzled and tired and too frustrated. Half the time when I lie down beside them at night to read a story, I fall asleep before they do and during the day, so much of the time I'm just too impatient. I'm not expecting to give perfection; no parent can do that. But I know they need me to be there to talk with them and to listen, to explain things to them, and to be there for them emotionally. I want to do that for them. That's an important part of my helping them to grow up. I don't want to miss out on it.
After some psychotherapy and talking at length with her husband, this woman decided that she wanted not only to resume medication treatment for her ADD syndrome, but also to resign from her manager's position and return to direct nursing care. She felt this would be more satisfying for her and that it would allow her to engage more fully in caring for her children.
Any parent's task in providing good scaffolding for a child is complex, requiring daily changes and heavy demands on executive functions. It includes anticipation, planning, and actions—doing tasks to care for the child and gradually teaching the child how to do these tasks alone. It includes modeling and explaining—showing the child in countless examples how to act and react in multiple practical and social situations of daily life. Scaffolding also includes attitudes and expectations, some overt and explicit, others more implicit and subtle, that help the child to form a personal picture of what ought to be, of what ought to be expected from one's self and others. Perhaps most important in this aspect of scaffolding is the parent's communicating to the child a sense of being cared for not only as one who is valued as a precious being, but also as one from whom certain attitudes, behaviors, and outcomes are expected—showing throughout the changes of each month and year that what this growing child feels and does each day really matters to this loving and beloved parent.
Providing this scaffolding is the process in which this nurse and mother wanted to be more fully involved. The disruption of her life that she had experienced after her promotion had created a crisis that helped her both to redefine her priorities and to find a more effective way to cope with her ADD syndrome.
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