Attention Deficit Disorder

Attention Deficit Disorder has become a household word over the last several decades garnering the attention of parents, educators, physicians, and child care workers not to mention talk show hosts, TV programs, magazines, newspapers, and other such venues of public discussion. Is it new? Not really. Most researchers agree that Attention Deficit Disorder (ADD) has always been around, but not necessarily diagnosed, or perhaps was recognized as some other syndrome.

Whether it is occurring more or not is hard to say. Certainly the population is increasing allowing for greater hereditary transmission of the problem. What is on the rise is a growing body of research into the causes, management, and treatment of ADD that is now available to families struggling with these problems. Likewise, there is a fair amount of misinformation as well as contradictory information that is available.

What I propose to do here is to outline the basic symptoms and characteristics, causes, methods for evaluation, and strategies for the management of ADD. Since there are two major categories of ADD, I'm going to address what is known as the Inattentive Type in this article. See Understanding ADHD for a discussion of the specific concerns related to the Combined Type (more commonly called ADHD) that include not only problems related to inattention, but also hyperactivity and impulsivity.

What ADD Looks Like

The primary problem that characterizes the Inattentive Type of ADD is the inability to focus one's attention. Children with this type of ADD are unable to sustain their attention over prolonged periods of time and find themselves easily distracted by the smallest of stimuli in the environment. People talking, the sound of a car coming up the street, rain falling on the roof, a dog moving quickly in the periphery of one's vision, a stiff crease in one's pants - all of these are keenly felt by the child with ADD, and efforts to suppress them are unsuccessful. It is as though all of the sights, sounds, odors, and somatic (physical) sensations flood their sensory apparatus involuntarily without the capacity to modulate their intensity. In normal circumstances, we may be aware of a number of stimuli in our immediate surroundings, but we have some control on how much attention we wish to direct toward each of them. We can keep some things in low relief while maintaining our primary object of focus in high relief. The ADD person simply cannot do this.

Common complaints about ADD children are that they are dreamy, spaced out, forgetful, careless, unable to concentrate, disorganized and distracted. If they manage to get their homework done and in the backpack, they can't seem to turn it in when they get to school. If you send them to clean their rooms, you may come in hours later and find them sitting in the middle of the floor occupied in some activity with little to no progress made in the task at hand. If you ask what they've been doing all this time, they may not be able to tell you exactly. Perhaps they picked up one toy, placed it on the bedside table, saw something that interested them for the moment, and forgot what they were there to do.

Parents of these children become extremely frustrated with their disorganization and forgetfulness, and often peg these kids as simply lazy. To make things more confusing, there seem to be certain situations in which ADD children can be attentive. This occurs when there is the element of novelty (something new like the first week of school), a high interest value (video games), an atmosphere of intimidation (mom and dad are really mad now), or participating in a one-on-one situation with an adult (seeing the therapist, eating out with dad).

Parents often say things like, "he can sit in front of his video games for hours" or "she seems to be able to listen to music, and knows all the words to her favorite songs," and so forth. At the same time, they do poorly in school and complain about hating the work. Verbal instructions seem to go in one ear and out the other. They lose things, don't finish work, make careless mistakes, complain about the simplest distractions such as a shirt that is too scratchy against their skin.

Socially, these kids are not a behavior problem. They are cooperative and don't have particular difficulties with other children. If anything they are more often overlooked and recede into the background. They may have less interest in interacting with others and appear to hang out on the periphery, very unlike the ADHD kids that are more "in your face" and demanding of attention. Teachers like them and often their problems are not detected until later in the upper elementary years or even middle school when their difficulties with organization and forgetfulness become very noticeable.

What Causes ADD?

There is some controversy around this question, but most research points to heredity as the most common factor. ADD children very often have a parent who has similar problems. Conversations with these families usually will reveal this pattern, although it is likely that the parent's problems were never diagnosed or treated.

The largest controversy has to do with whether poor parenting can cause ADD. In the case of true ADD, it cannot. Poor parenting can greatly aggravate the problems and prevent the development of good coping mechanisms for dealing with the symptoms. In fact, one of the difficulties in making the correct diagnosis comes from our knowledge that the effects of poor parenting, dysfunctional environmental conditions, and lack of proper nurturing can create symptoms in children that mimic ADD. This is especially true in regard to the behavioral components of hyperactivity, impulsivity, and poor self-control that are the hallmark of ADHD. This is why the evaluation process is so important. We must determine the source of the problems by taking a full history and then carefully evaluating the symptoms and history against the diagnostic criteria for ADD.

Evaluation and Diagnosis

Diagnosis and evaluation is difficult because there is not a specific test for ADD. Moreover, ADD children usually do not display their symptoms at the doctor's or therapist's office, especially during the first several appointments as these situations have the quality of being novel or sometimes even intimidating. Instead, the process requires the collection of a great deal of detailed information from parents, the school, the child, and perhaps physicians or others involved in the child's life. Certain kinds of testing are also helpful. I recommend starting with an extensive interview of the parents over several appointments. At a minimum, the interview should include:

• developmental history
• history of symptoms related to attentiveness
• history of behavior and social interactions
• history of the parents' school performance and difficulties with attentiveness

Interviews with school teachers are quite helpful as well as reviewing school records, report cards, and behavior and social histories. Psychological testing can provide a baseline of information about IQ, basic developmental capacities, and tendencies toward other psychological problems, but these do not necessarily contribute much to the assessment of ADD.

There are a number of what's called "rating scales" that can be helpful. A short list would include the Achenback Child Behavior Checklist (CBCL), Behavior Assessment System for Children (BASC), Conners Rating Scales-Revised (CRS-R), ADD-H Comprehensive Teacher/Parent Rating Scales (ACTeRS) and the Attention Deficit Disorder Evaluation Scale (ADDES) series. For evaluators, Russell Barkley's Home and School Situations Questionnaires are good devices for gathering pertinent information from parents and teachers. These use a rating scale to be applied to a series of questions that target ADD symptoms.

The bottom line in making a diagnosis of ADD is to carefully collect and review all of the information listed above, as well as spend adequate time with the family and child for observation and discussion. It is necessary to rule out other possibilities such as specific learning disabilities and processing problems, depression and anxiety disorders, or reactions to social stress either at home or school. All of these may be present along with ADD and their careful evaluation is necessary. ADD children can develop depression and anxiety over time, especially as their self-esteem is challenged due to their inability to perform and the negative reactions of others in this regard. Treatment for these problems often accompanies the treatment for ADD.

Intervention Strategies

Once the diagnosis of ADD has been made, it is then necessary to develop a comprehensive plan for treatment and monitoring. The plan should include the following four elements: education and counseling, behavior management, medication evaluation, and monitoring. Let's take them one at a time.

Education and Counseling

Children and parents both will be able to deal with the symptoms of ADD more effectively if they know as much as they can about the disorder, how it manifests, and especially how it effects both the individual and the family. A counselor is very important in this part of the process, and can serve as the person that oversees the process of education as well as monitors how the family is dealing with problems as they go along. The specific issues the counselor can address are helping the parents to devise an effective behavior management plan, repairing negative perceptions about the child, treatment of depression and anxiety symptoms that may have developed among any or all of the family members, and monitoring progress.

Counseling may also be necessary to deal with marital distress that has arisen in trying to cope with an ADD child. This is especially true for children diagnosed with the Combined Type of ADD where behavior problems related to hyperactivity and impulsivity are more prevalent.

Behavior Management

The diagnosis of ADD does not mean that irresponsible behavior is to be excused. Rather it assists the child and family with understanding that different kinds of strategies may be necessary to help the ADD child function well. For example, ADD children often do much better with written instructions, timed chores, extra positive reinforcement, more one-on-one interaction, and structured activity. They may also need some training in self-cueing to help them deal with forgetfulness. Another good technique is to break tasks into smaller components such as listing out each step of a single chore.

A counselor can help parents and children (especially teens) devise the various strategies that will work, as well as monitor their effectiveness in order to revise them as necessary. At the same time, limit setting is necessary and needs to be reinforced as usual, but with the understanding of the child's capacities. ADD children need to get the message that they can learn to successfully cope with their problems by identifying and understanding what they are, and then learning how to compensate for them.

Medication Evaluation

The most common and popular treatment strategy is the use of stimulant medication. Stimulant medications (Ritalin, Dexedrine, Adderall) can be quite helpful in increasing the ability to focus, but it is very important to have a full picture of the exact nature of the problems and their sources before plunging into this avenue of intervention. It is not advisable to put children on stimulant medication unless we are sure of the diagnosis, and sometimes depending on the types of problems that are prominent, other types of medications are indicated.

In particular, children who are having greater problems with anxiety and depression along with ADD symptoms may do well on a regimen of what are known as the tricyclic antidepressants (Tofranil, Norpramin, Pamelor). Sometimes both stimulants and antidepressants are taken at the same time so that the symptoms of anxiety and depression are alleviated while the ability to focus is also enhanced.

Why Stimulants Work

ADD seems to correlate with problems in the prefrontal areas of the brain. The prefrontal cortex is associated with the ability to focus and attend as well as self-regulate behavior and impulses. This area of the brain is underactive in people with ADD, and has a low level of dopamine functioning. Stimulants enhance dopamine functioning which in turn enhances the ability to focus and regulate behavior. Stimulants are particularly effective with the Combined Type of ADD, and often quite effective with Inattentive Type. They can be contraindicated when anxiety and a tendency toward over-focusing are present. In these cases SSRI antidepressants (Prozac) can be helpful.

A word of caution is to be sure that a thorough evaluation as described above has been completed if medication is to be considered. Prescribing medication on the basis of a 15 to 30 minute assessment by a physician without all of the other information is not advisable. Nor is medication treatment without counseling and education a good strategy. Learning to cope with and compensate for the problems associated with ADD has equal if not more importance than simply the alleviation of attention related problems.

Is Medication Necessary?

No, not always. Behavior management programs that are constructed to cater to the specific problems related to ADD can greatly improve the functioning of these children, often without medication. The decision to use medication depends on the severity of the problems, the effectiveness of other intervention strategies, and a clear understanding of other problems that may be contributing to the child's overall functioning. Sometimes the treatment of anxiety and depression along with the development of an effective behavioral program is enough to increase the ADD child's experience of success enough so that attention related problems can adequately be compensated for without medication. For others, medication is necessary for even the mundane day to day activities such as getting dressed, brushing one's teeth, or getting to school. Each child needs to be evaluated from the perspective of his or her own individual characteristics and needs, family situation, and best overall strategies for creating successes.

Monitoring

Monitoring should take place throughout the process of evaluation and treatment. Regular appointments with the counselor, school personnel, and physician prescribing medication are necessary. In addition, regular feedback between the parents with each other, and the parents and child are also helpful in staying on top of problems as they occur. Keep in mind that regular, positive interaction with the ADD child is very important to enhance and preserve the parent-child relationship, and should always outweigh time spent in dealing with problems.