Attention Deficit Disorder©
Jeffrey Tate, MD
Certified American Board of Psychiatry and Neurology
Clinical Assistant Professor, UA Medical School
Do you or a loved-one have any of these types of problems?
• A child cannot keep his mind on 20 minutes of homework. It takes
her over an hour to complete the assignment.
• A child cannot remain quietly attentive in class for 30 minutes. He repeatedly interrupts verbally or physically.
•A college student cannot pay attention to a lecture or a textbook. His mind wanders off to his own daydreams.
• A saleswoman cannot overcome feelings of boredom while trying to finish paperwork for her job. She rushes through, not doing it very well.
• A high school student repeatedly puts off major assignments until the very last minute.
• A housewife cannot keep her home or her checkbook organized; she feels constantly overwhelmed by things to do.
Each of these persons suffers with ADD, a common disorder found in both children and adults. Recent research indicates that about one in twelve Americans suffer from ADD. Fortunately, modern treatment is safe and very effective.
Unfortunately, there has been much confusion and incorrect information about ADD in the media. This report is intended to provide you an accurate understanding of ADD, its causes and treatment.
Common Symptoms of ADD
The only essential symptom in ADD is difficulty sustaining attention on tasks that are important but not entertaining. Also, any of the following symptoms may be present in persons with ADD:
• Quick boredom that is very severe and even painful
• Difficulty listening well (daydreams during class lecture; inattentive during conversations)
• Poor memory for non-entertaining tasks (forgets to turn in completed homework; forgets two of three items on a to-do list)
• Puts off tasks to the last minute
• Starts many projects, but leaves many unfinished
• Poor memory of what was read (cannot answer questions at the end of the chapter)
• Poor impulse control (speaks or acts quickly without thinking through the consequences)
• Impatience and intolerance of waiting
• Irritability and angry outbursts
• Brief, sudden "mood swings;" gets overly excited, or overly "down"
• Fidgety, restless, hyperactive Few persons with ADD have all these symptoms; most have three or four that have been present since childhood.
In addition to the symptoms above, there are often (though not always) social, occupational and emotional complications of ADD. These include:
• Difficulty maintaining relationships (with schoolmates, marriages, friendships) due to impulsive, aggressive, and intrusive
behaviors
• Difficulty with authorities (with teachers, police, and managers) due to oppositional or thrill-seeking misbehavior
• Poor school and career performance due to forgetfulness, boredom, tardiness,procrastination, inability to be organized (see our page on School Problems)
• Depression (see our page on Clinical Depression)
• Low self-esteem
• Anxiety, tension and nervousness (see our page on Anxiety Disorders)
Doctors once thought that all persons outgrow ADD before age 20. We now know that most persons continue to have symptoms of ADD all their lives, though the symptoms may lessen with age.
Hyperactivity and ADD
"Hyperactivity," which means a person cannot "sit still" to a normal degree, may or may not be present in a person with ADD. The hyperactivity symptoms may be very mild or very severe. In order of mild to severe, hyperactive symptoms include:
• Nearly constant foot and leg movements when sitting
• Pencil tapping during meetings and conversations
• Frequent squirming in chair or desk
• Talking too much, too loudly, interrupting
• Running when should walk
• Unable to sit through a class, church service, or movie
ADD children with severe hyperactivity are referred for treatment much more often. They disrupt the home and classroom, making their problem more noticeable and intolerable to adults.
Usually, hyperactivity symptoms improve with age. The attention problems usually do not improve as much.
ADD children without hyperactivity, unfortunately, usually are not referred for treatment. Because they generally are not very disruptive, they are merely labeled as under-achievers, absent-minded, lazy, or stupid. As a result they are often life-long under-achievers.
What is Normal and What is ADD?
There has been much fear that "normal" persons, especially children, would be labeled as ADD and medicated. But research has shown that when experts make the diagnosis, this is not a problem. In fact, the National Institute of Health, which is the federal government's medical research agency, recently concluded that--with expert evaluation--ADD can be as well diagnosed, as well understood, and as well treated as any other medical condition.
The American Psychiatric Association has set clear and definite criteria a person must meet in order to be diagnosed with ADD. When these criteria are followed, the diagnosis is very accurate.
"Normal" attention span is controlled by at least two factors: (1) a task's entertainment value or intrinsic interest, and (2) a task's importance.
Either factor should allow our attention and concentration to be maintained for sufficient time to complete a task that is appropriate for our age and IQ.
So, a task that has low entertainment value or intrinsic interest say balancing your check book or doing 30 minutes of math homework or writing a term paper should nevertheless hold your attention long enough to start and complete the task simply because it is important.
The person with ADD is unable to give sustained attention to tasks that are important but are not entertaining or interesting. This is the primary difference between "normal" and ADD.
When evaluating an adult, we must be sure that the attention problems began in childhood. ADD does not develop newly in adulthood; it develops in childhood, and can continue into adulthood-and it may cause more problems as you get older. Attention problems that begin in adulthood are usually due to some other problem.
The Causes of ADD
ADD is usually an inherited chemical problem in the executive function circuits in the brain. Persons with ADD are four times more likely to have a parent or sibling with ADD (though the parent probably was never diagnosed). If a parent has ADD each child has a 50% chance of having ADD.
The problem in the executive function circuits seems to be low functioning of a biochemical called dopamine that transmits information in that circuit.
Some anatomical differences have been found in the brains of persons with ADD, and there may be an "attention center" in the brain that is not working well in persons with ADD.
While inherited genetics is the most common cause of ADD, head injury can be a rare cause of ADD. Lead poisoning also may be a rare cause of ADD. Fetal exposure to street drugs, alcohol, or maternal smoking during pregnancy may be a cause of some cases of ADD. Scientific studies, however, have shown that sugar and food additives have no effect on ADD. Likewise, it's been found that problems during childbirth do not cause ADD.
Diagnosing ADD
Many parents have wondered why ADD is diagnosed more than when they were children. There are at least three reasons:
1. In only the past ten years we are able to diagnose ADD without hyperactivity. Before, these persons were simply labeled as absent minded.
2. Mild ADD causes more problems nowadays than it did 25 years ago. The demands for good attention and concentration in school and at work are much higher in our modern "information age" where so much must be learned so quickly. As a result, more persons are seeking help for mild ADD.
3. The number of ADD persons is probably higher due to the greater frequency of smoking during pregnancy compared to 30 years ago when many fewer women smoked. (Now, as many women as men smoke.)
The American Psychiatric Association has set clear and definite criteria a person must meet in order to be diagnosed with ADD. When these criteria are followed, the diagnosis is very accurate. The US National Institute of Health (NIH) recently reviewed the diagnosis and treatment of ADD and concluded that it is as reliable a diagnosis as most medical conditions.
A good history of the person's behavior and development is usually adequate to make a precise diagnosis of ADD. This history may be obtained from the patient, parent, spouse, or a teacher. Most of the time, this information will be sufficient to decide whether the person has ADD without further testing.
Occasionally, special tests are used to help make the diagnosis in confusing cases. While these tests can help make the diagnosis, they cannot provide certainty one way or the other. The history of the person's behavior and observations in the office are more important.
CAT scans, MRI scans, EEGs, and other special neurological tests have not yet proven helpful in diagnosing ADD.
Treatment of ADD
The treatment of ADD has been controversial: Should medications be used? Will behavior modification work? Will medications lead to addiction? Let's address these issues by looking at the currently accepted medical treatment of ADD.
Medication
Since ADD is a neurochemical disorder affecting brain dopamine, we know this dopamine problem must be corrected to correct the symptoms of ADD. For most persons with ADD, behavioral treatments cannot work until the dopamine deficiency is corrected. Correcting the dopamine deficiency requires special medications. Recently, the American Academy of Pediatics has said that medication will be needed in almost all cases of ADD.
Several medications have been found to improve ADD. The best known is Ritalin, which has been used since the 1930s. There have been fears that Ritalin would lead to short stature, drug addiction, and even an over-drugged "zombie" state. Scientific studies have shown that-when properly prescribed-none of these problems need happen.
In fact, children with ADD who are treated with Ritalin are less likely to develop drug abuse problems. A recent study of over one thousand children taking these medications for up to ten years concluded that long-term treatment with these medications is safe in children.
In recent years newer medications, including Adderall and Concerta, have become the preferred medication among ADD specialists. Adderall and Concerta increase the brain dopamine level, improving the executive function circuits in the brain. These medications are effective in relieving ADD symptoms in about 93 percent of patients.
Studies indicate that medication treatment can improve
all of the symptoms of ADD:
• Attention and concentration are improved
• Procrastination is reduced
• Impulsive feelings are reduced
• Aggression is reduced, both verbal and physical
• Reading retention improves
• Fidgeting and hyperactivity are reduced
• Social relationships are improved
• Memory improves
• Sleep often improves
• Grades and work performance improve
There is evidence that treatment also improves self-esteem and reduces depression and anxiety.
Other medications such as Cylert, Dexadrine, Wellbutrin, imipramine, clonidine, and Effexor are commonly used to treat ADD as well. Which medication is best for a particular individual is determined by a physician in discussion with the patient or parents.
Counseling
Studies indicate that individual therapy or counseling of the person with ADD, when used alone without medication does not lastingly improve the ADD symptoms. The dopamine deficiency must first be corrected, and for that a medication is required. However, counseling can be a very important part of the complete treatment of the person with ADD. Counseling can:
• Reduce depression
• Improve self-esteem
• Improve parenting skills
• Improve marital relationships
• Improve problem-solving skills
• Improve social skills
• Improve work and organizational skills
When to Seek Treatment for ADD
Attention Deficit Disorder is very common in the United States. At least 7 percent of the population suffers from this disorder. If you or a loved-one repeatedly have difficulty starting or completing important tasks an evaluation should be sought. Untreated, ADD has a corrosive effect on performance, relationships, mood, and self-esteem.
In school children an evaluation for ADD should be obtained when:
• There are prolonged school behavior problems
• There are prolonged periods of low grades
• The grade point average is slowly falling over the months or years
There are signs of serious stress due to the school workload. Signs of stress include prolonged:
• Headache
• Stomach ache
• Insomnia
• Depression
• Excessive worry
• School avoidance
Fortunately, treatment for ADD is readily available and affordable. Medications and counseling can relieve most of the symptoms and improve school, occupational, family, and social functioning. Treating ADD need not be expensive-no costly blood tests are required, and psychological tests are usually not needed. After a medication is working well, medication checkups are only needed every three to six months.
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