Attention Deficit Disorder, or ADD/ADHD, is a psychological term currently applied to anyone who meets the DSM IV diagnostic criteria for impulsivity, hyperactivity and/or inattention. The diagnostic criteria are subjective and include behavior which might be caused by a wide variety of factors, ranging from brain defects to allergies to giftedness. ADD, as currently defined, is a highly subjective description, not a specific disease.
Confusion and controversy is caused by the tendency of some mental health professionals to assume that everyone diagnosed with ADD has some mysterious, irreversible brain defect. This assumption has its roots in the very first group of severely ADD people ever studied, who suffered from encephalitis, or a swelling of the brain. We also have learned that birth defects and brain injury from toxic chemicals such as lead often cause ADD. However, over the last several decades the ADD diagnostic criteria have been so broadened as to include many people with no brain defects at all. Experts in the fields of temperament and creativity have objected that perfectly healthy people are being classified as disordered. Huge numbers of these new types of people being added to the diagnostic pot have changed the way ADD is viewed in some circles, including people like Thom Hartmann, who popularized the idea of ADDers being “Hunters in a Farmer’s World”. On the other hand, many argue that such people aren’t ADD in the first place. Both may be correct. This website was started with the first viewpoint in mind (hence the title), but as time passes I find myself more likely to just say that many so-called ADD people are simply not ADD in the classic sense.
Profiles: The Diverse Face of ADD
(or the types of people who get that label, right or wrong)
Sam is an ten-year old with an IQ of 135 who gets Cs on his report card, is disruptive in class, and constantly challenges rules and procedures. He has poor handwriting, is fidgety, unorganized, impulsive, has a poor verbal memory but strong visual memory, and talks too loud and too much. He is brilliant on a computer and like to invent things. His behavior is actually perfectly normal for someone who is gifted and has an ENTP temperament (extravert-intuitive-thinking-perceiving). In school he’s bored out of his mind. He’s also a visual thinker rather than a verbal thinker, which is why he is very good at computers and picking up complex concepts. Because he is an extreme extravert, he needs to move in order to think and otherwise needs a lot of external stimulation, such as a radio on when he studies. At the same time, he can become too wound-up if overstimulated. He also has allergies to mold, dust and citrus fruits. When his allergies act up he is becomes generally more wound up, impulsive and cranky. A lack of good sleep causes the same problems. Even though he meets the diagnostic criteria of ADD, some would say he is not really ADD. Others would say he is ADD, but that ADD is a broad realm with many positives. It is not clear who is correct.
Tom is a five year old who ate paint chips containing lead when he was a toddler. The lead exposure caused permanent brain damage, and he now has an IQ of 86 and is extremely hyperactive and impulsive. He bounces from toy to toy, unable to really focus on anything for more than a few seconds. He is also very clumsy and accident prone. This is the classic case of “pure” ADD that people like Russell Barkley think about when they talk about how bad ADD is and how necessary medications are. Their mistake is in extrapolating what they know about Tom to other people such as Sam.
Sara is quiet 40-year old woman with three kids. As a child she got average grades and was not a discipline problem. Her imagination was so vivid that she daydreamed a lot and had trouble focusing on the teacher, and she was harassed by her parents for being so far away and “in the clouds”. Her entire life has been marked by disorganization and procrastination. Her IQ is 152 but she feels stupid. She loves her family but is overwhelmed by the daily routine. Sara has the rarest MBTI temperament: INFP. This temperament is associated with the best writers in history and is said to have the “soul of an artist”. She naturally focuses on her inner world and is inspired by imagination. Unfortunately, this perfectly natural temperament trait has caused her to feel different from others and to be looked down upon. She has been unable to find her niche, and she suffers from anxiety and depression, both of which cause an inability to concentrate and mental fogginess. She is also a perfectionist, a trait associated with giftedness, which is one reason she cannot seem to get started on the many artistic projects she dreams up in her head. Her natural tendency to think divergently causes her to be disorganized and her house is always a mess. She has a strong tendency to blame herself and to try and meet everyone else’s expectations, which is one reason she is so depressed. Her depression makes it even more difficult to accomplish anything, so a vicious downward cycle has left her feeling completely overwhelmed and worthless. She also has a fatty acid deficiency that became severe after her three pregnancies, which has seriously increased her depression and inability to focus.
Doug is a twenty year old college student suffering from sleep apnea triggered by allergies. Because he is always extremely tired, he has trouble concentrating and learning new things. He’s also unorganized and depressed because he’s so tired. Note that a brain scan would probably show abnormal glucose metabolism that researchers would cites as “proof” of brain damage, even though it really shows a lack of sleep and accompanying depression and anxiety. When his sleep condition is treated his “ADD” clears up.
Jessica was a very unhappy, colicky baby for her first year. She rarely slept and cried constantly. As a toddler she was hyperactive and had constant temper tantrums. In kindergarten she is simply impossible: unfocused, impulsive, and constantly getting into fights with other children. Her moods are unpredictable, and she complains of headaches. She also has a chronic stuffy nose and dark circles under her eyes. Jessica’s real problem is an allergy to wheat, milk and food colors. When her allergies are treated she becomes an entirely different child.
Ed is a successful entrepreneur who discovered he was ADD after his son was diagnosed with it. His IQ is 134. Although Ed was an underachieving “wise-ass” in school and barely made it through college, his imagination and risk-taking tendency was a key component of his later success. Ed hyperfocuses on problems until he solves them and is a workaholic. His strong tendency towards disorganization was solved by hiring competent bookkeepers and secretaries, and marrying an organized wife.
Ryan is a seven-year old boy who is naturally active and has an IQ of 120. His mother is very passive and neither one of his parents have ever disciplined him appropriately. They nag, yell and threaten, but NEVER follow up with a consequence. As a result, Ryan is a major behavior problem in school. He constantly talks when he’s not supposed to, gets into fights, and refuses to do schoolwork. When he doesn’t get his way he throws a tantrum. He lies about other kids, tattling on them to the teacher. He’s not very fidgety, he just likes to run and chase balls. He doesn’t have motor problems, and is actually pretty coordinated. Ryan is essentially a spoiled brat. He, like most kids, also has a fatty acid deficiency which exacerbates his negative behavior.
See also Readers’ Stories
There are two major types of ADD at this time (this aspect of ADD keeps evolving): ADD with hyperactivity (the traditional type of ADD) and ADD without hyperactivity (“inattentive” type). Here are the DSM IV diagnostic criteria in a condensed form:
Inattention (must meet six of the following to a degree that is “maladaptive”):
- Often fails to give close attention to details or makes mistakes in schoolwork;
- difficulty sustaining attention in tasks;
- seems not to listen;
- fails to follow instructions or finish work;
- difficulties with schoolwork or homework;
- loses things like school assignments, books, tools, etc.;
- easily distracted;
- forgetful about daily activities.
ADD with Hyperactivity (must meet six of the following to a degree that is “maladaptive”):
- fidgety in a squirmy sense;
- doesn’t stay seated;
- runs or climbs excessively (or feelings of restlessness in older children);
- difficulty playing quietly;
- often “on the go” or acts if “driven by a motor”;
- often talks excessively;
- blurts out answers to questions;
- difficulty waiting in lines or waiting turns;
- often interrupts or intrudes on others.
For a longer version of the DSM IV criteria and quotes on related MBTI temperament traits, click here.
Technically, ADD is not something you can suddenly come down with. “Symptoms” such as excessive daydreaming or hyperactivity must be present by the age of seven in two or more settings and cannot be explained by some other psychological condition such as depression or anxiety. However, there are cases of people acquiring the symptoms of ADD after experiencing brain trauma.
I will mention the “Lego Test” here. For boys in particular, some professionals say that if a child can stay highly focused and on-task when it comes to following Lego directions, then he is not actually ADD. This is, of course, not part of any official diagnostic manual and others would dispute it.
There is no exclusion for behavior caused by giftedness, normal temperament diversity, allergies or fatty acid deficiencies. If you meet the criteria, then you are ADD, even if your behavior is the result of having an IQ of 175 and being confined to a dull school. Behavior cannot be caused by some other psychological condition, however, such as depression or anxiety.
Background and History: ADD was first identified and studied in the early 1900’s, although it wasn’t called ADD back then. After World War I, researchers noted that children who had contracted encephalitis displayed a high incidence of hyperactivity, impulsivity, and conduct disorders. And in the 1940’s, some soldiers who had experienced brain injuries were found to have behavioral disorders.1 It seemed clear that brain damage could cause hyperactivity. Other forms of brain insult have since been identified as causes of hyperactivity, including exposure to lead and other environmental toxins, as well as fetal exposure to drugs and alcohol.
Once brain damage was identified as a cause of hyperactivity in certain patients, researchers assumed that all hyperactivity was caused by brain damage, even when no brain damage could be identified. That’s why ADD was once called “minimal brain dysfunction.” This is an important point to understand. It is because of this early association of brain injury and hyperactivity that ADD traits are still assumed by many to reflect a brain disorder. Researchers made a giant leap in logic: Because brain injury can lead to hyperactivity, they believed that all hyperactivity was caused by brain injury. We now know this is not true. In fact, hyperactivity is also associated with giftedness, but obviously we cannot say that all hyperactive children are gifted any more than we can say all hyperactive children have suffered brain injury.
More recent studies have shown that ADD is largely genetic. That is, it runs in families. This has lead some ADD researchers, notably Russell Barkley, to assume that our population is experiencing large scale random genetic mutations, a rather ridiculous notion for anyone familiar with population genetics. Anytime more than one percent of the population carries a gene, geneticists rule out random mutations under the belief that the gene has been actively selected for. For example, the gene-based disease sickle cell anemia has been found to help a population by providing resistance to malaria.
In the 1990’s a growing number of ADD experts began to view ADD not so much as a disorder, but instead a natural condition which leaves ADDers at a disadvantage in some common modern settings, and many positive attributes became associated with ADD, such as creativity, enthusiasm and entrepreneurial tendencies. This is probably due in part to the ever expanding world of ADDers. A few decades ago only the most dysfunctional hyperactive kids were identified as “disordered” and these kids were more likely to suffer from actual brain injury. Today, the diagnostic criteria are so broad that millions of children in the U.S. are getting the label. Any underachiever who doesn’t seem to pay attention in school or who has trouble handing in finished homework is fair game for a diagnosis. I spoke to one teenager who was diagnosed ADD even though her grade point average had never been below a 3.85 (taking Ritalin allowed her to achieve a 4.0). I also spoke to a psychiatrist who routinely prescribed Ritalin to “C” students in an effort to improve their grade point average.
How common is ADD?
The figure for ADD is typically given as 3-5 percent of the population. The real figure is unknown and estimates vary between 1 and 20 percent or even more. This is largely because the diagnostic criteria are so subjective: What is considered “clinically significant impairment” to one person might seem more like normal childhood behavior to someone else. For example, in one English survey, only 0.09 percent of the children were found to be ADD. But in an Israeli study, 28 percent of children were rated hyperactive by their teachers. And in one U.S. study, teachers rated 50 percent of boys as restless, 43 percent of boys as having “short attention spans” and 43 percent of boys as “inattentive to what others say.” 2
Diagnoses and medication rates can vary greatly within the U.S. Gretchen Lefever, a pediatric psychologist who became concerned when she was suddenly inundated with ADD referrals, studied 30,000 grade-school students in two Virginia school districts. Her findings, which were published in “The American Journal of Public Health”, showed that 17% of white boys in the region were given medication for ADD while at school. Other rates were 9% for African-American boys, 7% for white girls, and 3% for African-American girls.3
Is ADD Real?
Some people have argued that there is no such thing as ADD. Upon reading their arguments I have found that what most of them are actually saying is that ADD is not a singular “disease”, but rather a collection of behaviors or “symptoms” caused by a wide range of problems. So, to some extent, it’s really a matter of semantics. They compare a diagnosis of ADD to that of a diagnosis of “fever.” Imagine going to the doctor with a temperature and being told you have been diagnosed with a disease called “Fever,” and that all you can do is take aspirin to lower it. You might question the wisdom of such a simplistic approach and wonder why the doctor doesn’t look for the CAUSE of the fever. Doctors rarely look for the cause of ADD behaviors. Instead, they assume such behaviors are due to some mysterious brain defect that for some odd reason a huge number of people seem to have.
Opponents of this simplistic approach argue that the concept of ADD as a singular and discreet disease is a complete fabrication. They do NOT argue that ADD behaviors are simply caused by lack of discipline or are figments of people’s imagination. They believe people should be seen as individuals, and their specific problems treated as symptoms. The actual “condition” causing the behavior could range from brain damage to giftedness to allergies, and “treatment” would similarly range from stimulant medication to alternative education to allergy shots, depending on the root of problem.
How is ADD Diagnosed?
ADD should be diagnosed by a psychologist or psychiatrist who is knowledgeable about ADD as well as giftedness and creativity. Avoid diagnosis by a pediatrician, since pediatricians as a group are far more likely to simply prescribe medications without properly assessing the child. Psychiatrists and neurologists are far more likely to prescribe medications before acquiring a total picture of the patient.
Adults, especially those with the non-hyperactive form of ADD, may have trouble finding a practitioner knowledgeable in ADD, since until recently ADD was considered a childhood condition. Women with ADD are often told they suffer from depression and are prescribed antidepressants which do not work.
Ask the practitioner what his or her ADD assessment entails. A good assessment typically runs several hours and will include tests for IQ and creativity. Avoid anyone who simply asks a few question and then prescribes medication to “see what happens.” Most people do better and feel better on stimulants, even those without ADD, so this is a very bad approach for a professional to follow. For additional information and a checklist for children see my page called Children: Diagnosis, “Treatment” and Alternatives.
Common Misconceptions About ADD
1. Many people assume ADDers cannot pay attention. This is completely false. In fact, ADDers are known to “hyperfocus” on anything which captures their attention, to the point where it is difficult to get their attention. It is true, however, that a higher degree of interest is necessary before the ADDer can pay attention. ADDers do not tune-out or daydream on purpose or to be rude. Some people have likened it to having an on-off switch in the brain. Interest is needed to activate or “turn on” the brain, after which the ADDer can pay attention. If there is no interest, then the brain is “off” and the ADDer is likely to do something to try and get it back on. This can include sensation seeking, daydreaming, or becoming immersed in something the ADDer finds very interesting. It can also include disruptive behavior. This might be nature’s way of making sure that some people are always on the lookout for something new and interesting – these are our explorers and discoverers. Ritalin and other stimulants appear to work by artificially stimulating the brain, allowing the ADDer to tolerate a duller setting than they could otherwise function well in (e.g. schools).
2. Someone can be ADD and not be hyperactive. Some ADDers, especially girls, are quiet daydreamers.
3. Oppositional behavior is often confused with ADD. ADD in itself does NOT directly cause oppositional behavior. It can, however, indirectly result in anger and oppositional behavior if the ADDer is chronically mistreated, for example, by parents and teachers who continually blame the child for not “performing” like other children. Such children may give up trying to please their parents and instead misbehave out of frustration and anger. Otherwise, ADD kids are often described as enthusiastic and affectionate by understanding parents. In addition, some people reacting to foods may become hostile as well as hyperactive while they are reacting to the food.
4. You cannot tell if someone is ADD by their response to stimulants. Most people perform better and feel better when given stimulants, including those who are not ADD. That’s why so many people drink coffee.
How Do ADD Brains Differ from Average Brains?
Although there is as yet no definitive answer to this question. As a group, ADDers MAY have less activity in certain parts of their brain while they are asked to perform tedious math problems or other dull exercises. (I’ve yet to see any researcher examine what ADD brains look like while engaged in something they find interesting.) I say MAY because the quality of research has been generally poor and misleading. For example, in one highly publicized study that showed less brain activity in ADD children, all of the children on the study had abruptly been removed from Ritalin 24 hours before the test. It is possible that their brains had adjusted physically to the Ritalin and were in a state of withdrawal during the test. I find it interesting that when a different study showed brain differences in people who use methamphetamine (speed), the researchers concluded that the speed had damaged their brains. Yet when Ritalin users brains were examined, the researchers assumed that the brain differences were due to ADD.
When reading studies that purport to explain ADD brain difference, bear in mind that:
1) In most studies, the ADDers studied are SEVERELY dysfunctional and are therefore NOT representative of the typical child who is routinely diagnosed with ADD.
2) Most of the people studied for ADD also have depression and/or anxiety. Both of these conditions significantly impact how the brain performs, so the results may indicate more about depression and anxiety than about ADD.
3) Many children studied also have learning disorders, so the brain differences found may be due to their learning disorders, and not to ADD. Again, the data is confused.
4) Successful ADDers are excluded from study, because no one is really interested in them.
5) The medication that the children had been taking for ADD may have caused brain differences.
6) Some brain differences may be temporary and subject to environmental influences. Glucose activity is impacted by diet and metabolism. Dopamine activity is also impacted by diet. Even thoughts have a powerful impact on the brain: Brain scans of obsessive-compulsive folks before and after psychoanalysis showed that training people to think differently actually changed their brain scan. Brains may also change temporarily when someone is having an allergic reaction. Doris Rapp, M.D. documented alterations in EEG tests while children were challenged with allergens. The EEG results corresponded with dramatic behavior changes in the children, including hyperactivity. (Source: Is this Your Child? Discovering and Treating Unrecognized Allergies in Children and Adults by Doris Rapp).
7) The brain is very poorly understood and there is no good data pool for normally functioning people. In other words, scientists have no idea at what point normal brain diversity ends and abnormalities start because they haven’t studied very many normal brains. Instead, they typically study a very small control group. The control group only demonstrate what is average, not what is perhaps unusual but otherwise normal. Einstein had some very unusual brain differences which could have been interpreted as either defects or differences depending on the bias of the researcher (his overall brain size was average).
Dopamine: The neurotransmitter dopamine has been implicated in ADD. Dopamine is the “feel good” chemical in the brain which is responsible for our ability to concentrate as well as our feelings of happiness. Just about all mood-altering drugs work on dopamine, including alcohol, cigarettes, caffeine, heroin, and cocaine, as do stimulant medications for ADD. Dopamine activity increases naturally in response to mental or physical stimulation (this is nature’s way of getting us off our butts), which is why ADDers can focus much better after exercise or during an emergency. In fact, it is said that many of the people involved in emergency response are ADD, such as firemen and ER physicians.
It is quite possible that some people are born with reduced levels of dopamine activity. People born with less dopamine may unknowingly spend much of their lives looking for ways to boost dopamine, either in positive ways like being highly active, inventive or competitive, or in negative ways by being reckless, gambling, or taking drugs. Another possibility is that lifestyles affect dopamine activity. For example, the brains of children raised on high levels of stimulation (e.g. by watching Cartoon Network and playing video games all day) might “adapt” physically so that high-stimulation becomes a requirement. Finally, general nutrition is important. Researchers have demonstrated a correlation of ADD and fatty acid deficiency. Fatty acids are used to build receptors for neurotransmitters like dopamine as well as neural synapses formed while learning new things.
1. A Parent’s Guide to Attention Deficit Disorders by Lisa J. Bain, 1991, Children’s Hospital of Philadelphia.
2. The Myth of the A.D.D. Child, by Thomas Armstrong, Ph.D., 1997
3. “Study Suggests Doctors Overprescribing Ritalin”, CNN Report, Aired August 31, 1999.