Andrew’s life was going nowhere i. He never seemed motivated about school. Actually, he didn’t seem motivated about anything, except video games, which he played for many hours a day, often getting to bed far too late as a result. He was now starting Grade 11, and things weren’t getting any better. His parents, who were both doctors, wondered if he was depressed, but he seemed to have been like this for years, to some degree.
In his early elementary school years Andrew’s performance had been okay, though never stellar. In retrospect, he probably cruised because he was smart, the demands were low and the structure and supervision were high. In higher grades, teachers expected him to be more self-directed. Testing in Grade 3 had found him to be in the gifted range of intellectual functioning. This only made the problem feel worse in later years – he was underachieving terribly relative to his potential, just coasting along aimlessly, a sad waste of natural talent in his parents’ eyes.
It’s not that he had no intellectual interests at all. He would briefly become excited about a topic beyond the school curriculum – like the time he had watched a Steven Hawking documentary on the Discovery Channel, or when his family went on a tour of WWI battlefields in France. He would start to read up on science or history, but he would quickly lose interest. He seemed perpetually bored, lazy and lacking persistence, focus or self-discipline. He could not apply himself to long-term goals involving delayed rewards. He had recently become a fairly regular marijuana user, but probably not heavy enough to really account for his lack of motivation, and the lack of motivation had long predated this habit.
In my assessment of Andrew, he did not have enough specific and persisting depressive symptoms to meet criteria for a Major Depressive Disorder. Besides, there was no clear onset or change from his usual baseline. Rather, he seemed to have just slowly drifted into a state of increasing aimlessness and low motivation over a period of years. He did not feel a sense of hopelessness or profound pointlessness about his life and the future, but neither could he see any clear purpose for himself in life. He lacked any career goals, let alone ambition.
One thing stood out in my questioning of Andrew and his parents: he had a short attention span – especially for tasks requiring sustained effortful focus. He had a longstanding frequent tendency to zone out in class and to be more easily distracted compared with most of his peers. He would quickly become bored and restless. His parents had been aware of this, but they had always assumed that his lack of focus was the result of his lack of interest and motivation, rather than the other way round. He also lacked organizational systems for his work, despite his parents’ attempts to help him set these up. And his time management was atrocious.
Andrew had many of the typical characteristics of Attention Deficit Disorder. ADD is a diagnosis applied to children or adults with very short attention spans. It also involves relative deficits of what is referred to as executive functioning, or cognitive control (simply put: the ability to control one’s thoughts and actions – the basis of ‘will power’; these higher mental functions are closely related to, and to some degree dependent on, the ability to focus). Attention and motivation are integrally linked and mutually dependent, but it is often the case that attention is the more primary and fundamental function, influencing motivation.
Needless to say, there are very many possible explanations for lack of motivation. ADD is just one of them, albeit a fairly common one. Unfortunately and obviously, psychiatric assessment and treatment is not the answer for all unmotivated teens.
ADD is common. If we include slightly milder cases, about 5–10 per cent of the population have these characteristics. Think of ADD as one end of a normal continuum rather than a true disorder in a category distinct from normality. It’s just the way some people are—it’s part of who they are, not a ‘thing’ that they have or an illness they are afflicted by. As with most psychiatric disorders, the line separating a disorder from normality is determined (imprecisely) by the particular trait/s causing significant impairment of functioning in relation to the demands of the individual’s environment. There are evolutionary reasons for this diversity of traits in a population. Our modern environment tends to favour people who are focused, so these otherwise normal traits can be a liability in many settings.
The brains of people with ADD traits can in a sense be thought of as less internally stimulated than average brains – their brains require higher levels of external stimulation to engage them. So these people find unstimulating activities that require patient mental effort to be completely unengaging and intolerably boring. They need activities that are more stimulating, exciting, rewarding, novel or varying (video games are designed to meet these criteria). These relatively ‘under-stimulated’ brains are thought to have lower activity levels of the neurotransmitter dopamine. Dopamine plays a central role in attention and reinforcement of behaviour. When dopamine is activated in our brains by a particular stimulus or action, it is nature’s way of ‘telling’ us that something is important or good for us—it marks a stimulus as salient (noteworthy) and it reinforces an action so that it is more likely to be repeated. Dopamine activation thereby directs our attention and motivates us to persist in a behaviour. Medications that improve attention are called stimulants (caffeine is in this category). They increase dopamine activation, among other chemical effects.
I spoke with Andrew and his parents about strategies for reducing distraction, optimizing focus, improving organization, and leveraging incentives to increase his motivation. We discussed medication as an additional option, with a careful discussion of the pros and cons (side effects, risks). I was careful to emphasize that medications don’t work for everyone. Some people understandably have reservations about medications for ADD, but Andrew’s parents, being doctors, were quite interested in considering the medication options, and Andrew was willing to give it a try.
I started him on an attention stimulant medication, which he could take on days when he needed to be focused and motivated. Fortunately, he had an excellent response to the drug, and no side effects. He found school much more interesting and engaging when he was on the medication, and was much more persistent and productive on those days. He said he felt on those days like his attention “locked onto” the task at hand, and he felt a strong urge to keep doing whatever he was busy with. He even felt annoyed if he was interrupted from his task. He didn’t take the medication on days when he didn’t need to concentrate as much, because he didn’t want to feel so intense all the time.
Andrew’s marks improved impressively over the next few months. This greatly boosted his morale and his motivation more generally. There was some spill-over effect of his motivation in that he tried harder to apply himself to his work even on days when he was not on the medication, but his focus was consistently better on the days when he was on it.
I have followed Andrew for several years now. He still loves playing video games, and he still gets to bed too late at night (smoking a joint – just one, he assures me – “to settle my mind and help me sleep”). But he is close to completing a tough degree in engineering, and he is now well on the way toward achieving the clear, attainable long term career goals that he has set for himself.
iThe patient’s details have been altered to protect his anonymity. Some of the details are a composite of several patients of mine who have had similar issues.
