That which caused us trial shall yield triumph; and that which made our heart ache shall fill us with gladness.  The only true happiness is to learn, to advance, and to improve; which would not happen unless we have com­menced with error, ignorance, and imperfection. We must pass through the darkness to reach the light.

 

- Albert Pike

                           

 

INTRODUCTION

 

Attention Deficit Disorder (ADD) is a mental dis­order.  A “mental disorder” is a

 

collection of symptoms . . . that causes an in­divid­ual distress, disability, or the increased risk of suffering pain, disability, death, or the loss of free­dom [Morrison, p. 8].

 

Specifically, ADD is a neurobiological mental dis­or­der characterized by signifi­cant levels of inatten­tion, hyperac­tivity and impulsivity. ADD is a loosely used term. Publica­tions with “ADD” in the title mostly describe a dis­order called, "At­tention Deficit Disor­der with Hyperactivity" (ADD/+H)—a term from the Diagnos­tic and Statis­tical Manual of Mental Dis­orders, Third Edition (DSM-III) pub­lished in 1980. The second ADD subtype listed in the DSM-III is "Attention Defi­cit Disorder without Hyperactivity" (ADD/-H). To con­fuse matters, many thera­pists use “ADD” to denote the latter subtype exclu­sively.

“Atten­tion-Defi­cit/Hyperactivity Disorder” (ADHD) replaced the term, Attention Deficit Disorder, in the updated DSM-IV (1994). Many professionals, how­ever, con­tinue to use the older term, “ADD.” (Note:  this author frequently uses the term “ADD” throughout the book.) 

There are three types of ADHD:  Predominantly Inat­tentive Type, Combined Type and Hyperactive-Impul­sive Type.

 

Inattentive Type (ADHD-I)

 

My disorder, ADD/-H,[1] is pretty much synony­mous with what is now called the "Predomi­nantly In­attentive Type" of ADHD in the American Psychiatric Asso­ciation's DSM-IV.  The diagnosis requires that an in­dividual exhibit at least six of nine inattentive symptoms for six months or longer (see list of symp­toms be­low). The symptoms must cause a significant impairment, be evident be­fore the age of seven years, and be present in two or more domains of a person's life (for example, family, work or classroom).

The DSM-IV inattentive symptoms, paraphrased be­low, specify that a person often has difficulty with:

 

     Inattentive Symptoms

 

1.    Paying accurate attention

2.    Maintaining attention when doing tasks

3.    Listening when others are talking

4.    Following through with instructions and as­sign­ments

5.    Organizing life and work

6.    Participating in tasks that require mental ex­er­tion

7.    Losing things required for task completion

8.    Being distracted by stimuli in the environ­ment

9.    Forgetting things          

 

Combined Type (ADHD-C)

 

ADHD-C (or ADD/+H) is the most common type of ADHD.  It includes all three categories of symp­toms: inat­tention, hyper­activity and impulsivity.  The diagno­sis requires the pres­ence of at least six of nine behaviors in the inattentive cate­gory (above) and a minimum of six of nine combined hyperactive-impul­sive symptoms that occur often (see below):

 

Hyperactive Symptoms

             

1.    Fidgeting

2.    Not being able to sit when expected

3.    Feeling restless (adolescents and adults)

4.    Being too loud during leisure time

5.    Being "on the go"

6.    Talking too much

 

     Impulsive Symptoms

             

7.    Answering before questions are finished

8.    Problem waiting one's turn

9.    Interrupting conversations

 

Hyperactive-Impulsive Type (ADHD-HI)

 

A diagnosis of ADHD-HI requires a person to have a minimum of six hyperac­tive-impulsive symptoms with less than six inattentive symptoms.  This is largely an artificial cate­gory added to the DSM-IV.  It primarily describes the dis­order in young children who have not yet entered school. (DSM-IV inattentive symptoms are mostly descriptive of a school experi­ence.)   As these children en­ter school, this diagnosis will likely change to ADHD-C.

When an adolescent or adult formerly met the minimum number of criteria for ADHD in childhood, and he or she continues to have symptoms, but cur­rently has fewer than the number required for diag­nosis (six), then symptoms are said to be "in partial remission."

Murphy and Barkley (1996) studied 720 adults be­tween 17 and 84 years old to develop norms for a new rating scale, the ADHD Behavior Checklist for Adults.[2]  They found that symptoms tend to decrease over time, and thus they recom­mend reducing the num­ber of symptoms re­quired for an ADHD di­agno­sis (six or more) depending on a person's age range: 17-29, 30-49 and 50+.  For exam­ple, their diagnostic cutoff (+1.5 standard deviations) for total inattentive symp­toms of persons between 17-29 years of age is only four.

 

The Incidence of ADD

             

About 80% or more of people with ADD have it because of the genetic trans­mission of neurobiologi­cal traits. Other causes of ADD-like behaviors in­clude anxiety, Bipolar Dis­order, cerebral palsy, de­pression, epilepsy, Fetal Alcohol Syndrome/Effects, Fragile X Syndrome, head trauma, lead poisoning, mental re­tardation, Posttraumatic Stress Dis­order, Reactive Attachment Disorder and thy­roid problems.        

ADD/-H reportedly afflicts about 1.4% of boys and 1.3% of girls in the general population—percent­ages that remain relatively constant over time (Szat­mari, Offord and Boyle, 1989).  The incidence of ADD/+H is higher, between 3 - 5%.  Hy­peractive traits are not as constant over time and may dimin­ish or disappear with age.  Between 22% and 32% of people with ADD will out­grow the disor­der by adult­hood (M. Fischer, 1997).

             

Differences in ADD/-H & ADD/+H Personalities

           

Russell Barkley contends that ADHD-I (aka ADD\-H) may not be a true subtype of ADHD and could be a separate disorder (Barkley, 1996; Barkley 1997a).  The inattention problems of ADD/-H and ADD/+H seem to be qualitatively different.  People with ADD/-H have problems with selec­tive attention, whereas those with ADD/+H have difficulty with persistence and sustained attention.  ADD/-H is less under­stood than ADD/+H.  The research literature on the former disorder is quite meager.

Researchers report that people with ADD/-H, in contrast to those who are hy­peractive, tend to be le­thar­gic and withdrawn.  They have more difficulties with per­ceptual-motor speed and proc­essing (Barkley, Grodzinsky and DuPaul, 1992), are more likely to be depressed and anxious, have fewer con­duct problems and are more ac­cepted by their peers than those with ADD/+H (Lahey and Carlson, 1991; Stanford and Hynd, 1994).

People with ADD/-H are more docile, obedient and polite than those with ADD/+H (Taylor, 1995). Com­pared to their hyperactive peers, they are more re­spectful of boundaries and limits; they hold feel­ings in and suffer in silence; they are shy wallflow­ers, in­clined to be humble and self-critical; they bond sat­isfacto­rily with others, but may be moderately un­popular.  (This profile characterized me as a child.)

Both ADD groups have a higher rate of learning dis­abili­ties than the general population (up to 30% ver­sus 7% - 15%). Individuals with ADD/-H tend to be un­derachievers in mathematics (Morgan et al., 1996).  Sixty percent of ADD/-H subjects in one small sam­ple had comorbid diag­noses of develop­mental arith­metic or reading disorders (Hynd et al., 1991).

Pharmacological responses to stimulant medica­tions, like Ritalin (methyl­phenidate), are slightly dif­ferent for the two groups.  Barkley and his associates re­port that methyl­phenidate is less effective in treating individuals with ADD/-H.  They found that 76% of ADD/-H subjects responded clinically to the drug, com­pared with a re­sponse rate of 95% for the ADD/+H group.  As a group, children with ADD/-H tended to respond best to lower doses of the medica­tion (5 mg) twice daily, while children with ADD/+H responded better to moderate or high doses (10 - 15 mg) twice daily (Barkley, DuPaul and McMurray, 1991).

 

Other ADD Subtypes

 

Daniel Amen (1999) proposes three additional ADD sub­types not found in the DSM-IV based on his brain imag­ing studies using SPECT scans (Single Photon Emission Com­puter Tomography).  They are Limbic ADD, Overfocused ADD, and Temporal Lobe ADD.  All show diminished pre­frontal cortex activity.  Each type may have symptoms of inattention, hyper­activ­ity and/or impulsivity, plus the following char­acter­istics: 

 

1.    Limbic ADD (increased limbic system activ­ity)

 

·        Mood problems, irritability

·        Automatic Negative Thoughts (ANTs)

·        Sleep problems

·        Lethargy

·        Social isolation

·        Self-esteem problems

 

2.    Overfocused ADD (increased anterior cingu­late gyrus activity)

 

·        Attention shifting problem

·        Over worry

·        Stuck on thoughts or behaviors

·        Argumentative/oppositional

·        Grudge holding

 

3.    Temporal Lobe ADD (increased or decreased tem­poral lobe activity)

 

·        Mood problems

·        Aggressive

·        Mild paranoia

·        Anxiety

·        Somatic problems (headaches, abdomi­nal pain)

·        Visual or auditory illusions

·        Learning problems (e.g., reading, audi­tory processing)

 

Other ADD Criteria

 

The DSM-IV criteria mostly describe the mani­festa­tions of childhood ADHD.  Hallowell and Ratey's Suggested Diag­nostic Criteria for Attention-Deficit Hy­perac­tivity Disorder in Adults (1994a, pp. 73-76) give a more complete picture of adult symptoms.  (These criteria are discussed in this book under Diagnosing My ADD Symptoms.)

Some authors suggest that ADD, despite its status as a disorder, correlates with positive traits such as creativ­ity and a high degree of intelligence (see Hart­mann, 1993; Hallowell & Ratey, 1994a).  These claims are largely anec­dotal.  Ex­perienced mental health professionals know that not all chil­dren with ADD have high IQs or are creative, and not all grow up to be successful.  Some experience emo­tional and learning problems that go undiag­nosed and un­treated. With early identification and treat­ment, however, more children with severe symptoms can grow up to be happy, productive adults and achieve fuller potentials.

Next, I examine descriptions of historical per­spectives about the etiology of ADD in the next chapter.

 

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