Part I Everyone occasionally has difficulty staying still, sustaining attention, or stifling inconvenient impulses. For some people the problem is so persistent and serious, and interferes so constantly with work, friendships, and family life, that it is regarded as a psychiatric disorder. Formerly known as hyperkinesis, hyperactivity, minimal brain damage, and minimal brain dysfunction, attention deficit disorder (ADD) received its present name and description in the late 1970s. It is now the most commonly diagnosed childhood psychiatric condition, affecting about 3% of American children. Researchers have increasingly come to believe that the symptoms persist into adulthood in modified form. The problem is not, strictly speaking, a deficit of attention so much as a lack of consistent direction and control. Children with ADD are easily distracted and often seem to be daydreaming. They do not finish what they start and repeatedly make what appear to be careless mistakes. They switch haphazardly from one activity to another. Arriving on time, obeying instructions, and following rules are difficult for them. Although their intelligence is normal, in many situations they find sustained mental effort to be an insurmountable challenge. The diagnosis is usually made in the early school years, and often from observations of the child's behavior in a classroom. Many of these children are also impulsive. They seem irritable and impatient, unable to tolerate delay or frustration. They act before thinking and do not wait their turn. In conversation they interrupt, talk too much, too loud, and too fast, and blurt out whatever comes to mind. They seem to be constantly pestering parents, teachers, and other children. They cannot keep their hands to themselves, and often appear to be reckless, clumsy, and accident-prone. Physical hyperactivity is a symptom often noticed even in very young children, whose capacity for sustained attention is rarely tested by everyday life. Some of these children are difficult to hold and soothe even as infants. They run almost as soon as they can walk, climb into medicine cabinets, and rush into busy streets. Their need for movement often seems to have a driven quality. When they must remain still, they fidget and squirm, tap their feet, and shake their legs. As they grow older, they become more subdued, but their restlessness is still noticeable. Impulsiveness and hyperactivity are not required for the diagnosis of ADD, which was introduced under that name in DSM-III, the 1980 edition of the American Psychiatric Association's diagnostic manual. In DSM-III-R, published in 1987, the name was changed to attention deficit hyperactivity disorder, but the older term has been restored in DSM-IV, the 1994 edition. The disorder is now divided into three classes, depending on whether it involves mainly inattentiveness, mainly hyperactivity and impulsiveness, or both. Getting attention The diagnosis may be given chiefly because of hyperactivity and impulsiveness. Nearly 90% of children diagnosed with ADD are boys, although some studies suggest that in adults the disorder is equally common in both sexes. Boys with ADD are more likely to be hyperactive than girls. A girl who daydreams at the back of a classroom may be unhappy and failing in school, but she does not attract the attention given to a boy who is constantly talking out of turn, jumping up from his desk, and pestering other children. Children with ADD often make life difficult for themselves and everyone around them. They can easily produce chaos in a classroom or turn a family home into a battleground. Sometimes they seem to be provoking conflict just for the love of excitement. Exasperated parents and teachers may regard them as lazy, irresponsible, and arrogant; other children often find them obnoxious and avoid them. They rarely perform up to the expectations generated by the abilities they erratically display, and they almost inevitably develop a poor opinion of themselves in reaction to constant criticism and failure. Diagnosis of ADD presents many problems. One question is when a high level of physical activity or a short attention span constitutes a psychiatric disorder. Parents, teachers, and mental health professionals do not always agree. Parents and teachers may have unrealistic expectations, especially about the behavior of schoolboys. Sometimes a child who is fidgety or easily distracted simply needs a different environment - more interesting, less constraining, or smaller classes, a new way of presenting schoolwork, a less chaotic family home. There are also cultural differences that affect the behavior of children (and adults) or influence what is expected of them. ADD is diagnosed in the United States much more often than in Europe, and one especially interesting study has shown that Chinese are more likely than Americans or Japanese to find symptoms of ADD in videotapes of children's play. One of the most exasperating and frustrating features of ADD, and one reason it has been so difficult to diagnose, is the inconsistency of the symptoms. A boy may be a terror in the classroom but no trouble on the playground; his homework is excellent one week and totally neglected the next. Children with ADD can often concentrate effectively when they are intensely interested in something, and they often behave better in small groups or situations with few distractions. For these reasons, DSM-IV requires that the symptoms of ADD appear in at least two settings, such as school and home. It is difficult for a doctor or mental health professional to diagnose the disorder in an office consultation, and even laboratory tests of attention and impulsiveness are not decisive, because the symptoms often disappear when the child is with another person who is scrutinizing him closely as he confronts a novel situation or performs an interesting task. Other diagnoses Many other physical and psychiatric conditions cause symptoms that resemble those of ADD, and the disorder is associated with several other behavior problems. Some possible mimics of ADD are atypical depression, anxiety disorders, impaired speech or hearing, mild retardation, and traumatic stress reactions. A third to a half of these children have major depression or anxiety disorders. Some of them are not only distractible and impulsive but easily angered and provoked to aggression, or seemingly callous, manipulative, and egocentric. They intimidate other children, start fights, and throw tantrums. The psychiatric diagnosis that describes this behavior is conduct disorder. Many children with ADD also have learning disabilities - deficits in visual and auditory discrimination, reading, writing, or language development. The term "minimal brain dysfunction" was once used to describe this mixture of symptoms, but learning disabilities and ADD are now regarded as separate diagnoses. Critics often note the ambiguities and uncertainties in the diagnosis of ADD - the changing definitions, cultural variations, inconsistencies in the expression of symptoms, and difficulties in distinguishing them from ordinary lapses of attention or self-control. Some of these critics have suggested that the diagnosis is an adult misunderstanding or a misuse of psychiatric terminology to suppress natural liveliness. They say that ADD is merely an administrative label applied to children who, for unclear reasons, are doing badly in school or are a nuisance to their parents and teachers. Some regard its symptoms as the effect of abnormal or unsuitable environments on children with a normal variation in temperament. Most mental health professionals in the United States believe that ADD can be reliably diagnosed and treated, but a thorough evaluation is often time consuming and expensive. The requirements may include a medical examination, tests of vision, hearing, speech, IQ, and academic achievement, ratings of the child's behavior, laboratory tests of impulsiveness and attention, and, most important, interviews with parents, teachers, and the children themselves to provide a detailed history of the symptoms. Not just for kids Although ADD begins in childhood, researchers in the last 20 years have shown that it is also a disorder of adolescents and adults. The old belief that the symptoms always faded with age now seems to have been an illusion - a natural one, perhaps, because physical hyperactivity (often the most obvious sign) does subside with age, and because adults are rarely observed as closely or guided as carefully as schoolchildren. How often the symptoms persist is uncertain: estimates range from 1% of the population at age 18 and 0.3% at age 25 to figures as high as 2% of all adults. Adults with ADD are said to be impatient, restless, moody, insecure, and easily bored. They have trouble setting priorities, managing their time, meeting appointments, and keeping track of possessions. They have brief, stormy love affairs, change jobs often, and fail to fulfill what they and others regard as their potential. Perhaps more than half suffer from an anxiety disorder or chronic mild depression. As many as 25%, especially those who had conduct disorders as children, develop drug or alcohol problems or become involved in petty crime. The drug use may in part be self-medication: cocaine makes people with ADD feel less confused, and alcohol or marijuana calms them. The various symptoms of adult ADD have been misdiagnosed as bipolar disorder, obsessive-compulsive disorder, posttraumatic stress reactions, and effects of drug abuse. People with borderline personality and atypical depression score particularly high on some of the behavioral rating scales used to diagnose adult ADD. Unsurprisingly, critics of the diagnosis are especially reluctant to accept its application to adults. They say that after anxiety, depression, learning disabilities, antisocial personality, borderline personality, and drug abuse are accounted for, a person's residual restlessness, disorganization, underachievement, and dissatisfaction with life provide no justification for a psychiatric label. Some fear that adults will seek the diagnosis just to get prescriptions for the stimulant drugs that are used to treat it. (Although that has not been a serious problem so far, self-diagnosis of ADD by adults is becoming more common, and experts have felt the need to issue warnings against it.) Another difficulty is that adult ADD cannot exist without childhood ADD, but the necessary evidence is often unavailable. Memories are imperfect, and people with ADD are notoriously poor observers of their own symptoms. Parents' recollections are usually more reliable than their adult children's, but psychotherapists who treat adults usually do not talk to their patients' parents. The causes of ADD are difficult to study, because the definition has been changed so often and the symptoms are so easily confused with other disorders. Family and social circumstances and possibly traumatic stress influence the form and severity of the symptoms, but something more is almost certainly involved. At various times blame has been laid on birth complications, head injuries, food additives, food allergies, sugar, vitamin deficiencies, radiation, lead, and fluorescent lights. None of these theories is accepted today, but most experts agree that ADD is a brain disorder with a biological basis. A genetic influence is suggested by studies comparing identical with fraternal twins and by the high rates of ADD (as well as antisocial behavior and alcoholism) found in the families of children with the disorder. Several theories The brain malfunction involved may be subtle, and none of the many theories about it is well confirmed. Experts do not even agree on how hyperactivity, inattentiveness, and impulsiveness are related, or which set of symptoms is fundamental. According to one hypothesis, an impaired capacity to delay responses and inhibit behavior subjects a person with ADD to the tyranny of immediate circumstances. Other theories cite insufficient activation in the brain's reward center, the nucleus accumbens, or inadequate and inconsistent filtering by the brain's arousal mechanism, the reticular activating system (RAS). Some studies of brain blood flow and glucose metabolism using the scanning technique of positron emission tomography (PET) suggest that people with ADD consume an abnormally small amount of energy in several regions of the brain, including the frontal lobes of the cerebral cortex, which are important for planning and the control of attention. Laboratory tests do not show unusually high responsiveness to environmental stimuli in ADD, but boys with the disorder may have less tissue than average in a certain part of the corpus callosum, the band of tissue that joins the two hemispheres of the cerebral cortex. This abnormality is in a region thought to be critical to the suppression of automatic responses. Certain rare diseases may eventually provide clues to the nature of ADD. Many of the symptoms were found (and given the name "organic drivenness") in children who suffered brain damage during the influenza epidemic of 1918 or encephalitis epidemics in the 1920s . A genetic resistance to the effects of thyroid hormones runs in certain families, and the rate of ADD in those families is 10 to 15 times higher than average. The thyroid gland regulates the body's basal metabolic rate (energy consumption), and its proper functioning is necessary for normal mental development. Thyroid malfunctions are often associated with emotional disturbances, including depression.

 

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