What is ADD?

Attention Deficit Disorder, or ADD/ADHD, is a psychologicalterm currently applied to anyone who meets the DSM IV diagnostic criteria for impulsivity,hyperactivity and/or inattention.  The diagnostic criteria are subjective and includebehavior which might be caused by a wide variety of factors, ranging from brain defects toallergies to giftedness.  ADD, as currently defined, is a highly subjective description,not a specificdisease. 

Confusion and controversy is caused by thetendency of some mental health professionals to assume that everyonediagnosed with ADD has some mysterious, irreversible brain defect.  This assumptionhas its roots in the very first group of severely ADD people ever studied,who suffered from encephalitis, or a swelling of the brain.  We alsohave learned that birth defects and brain injury from toxic chemicalssuch as lead often cause ADD.  However,over the last several decades the ADD diagnostic criteria have been sobroadened as to include many people with no brain defects at all. Experts inthe fields of temperament and creativity have objected that perfectlyhealthy people are being classified as disordered.  Huge numbers of these new types of people beingadded to the diagnostic pot have changed the way ADD is viewed in somecircles, including people like Thom Hartmann, who popularized the idea of ADDers being "Huntersin a Farmer's World".  On the other hand, many argue that such peoplearen't ADD in the first place.  Both may be correct.  This websitewas started with the first viewpoint in mind (hence the title), but as time passes I find myselfmore likely to just say that many so-called ADD people are simply notADD 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 thistime (this aspect of ADD keeps evolving): ADD with hyperactivity (the traditional type ofADD) and ADD without hyperactivity ("inattentive" type). Here are the DSM IVdiagnostic criteria in a condensed form:

Inattention (must meet six of thefollowing 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;
• unorganized;
• 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 ofthe 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 onrelated MBTI temperament traits, click here. 

Technically, ADD is not something you can suddenly comedown with.  "Symptoms" such as excessive daydreaming or hyperactivity mustbe present by the age of seven in two or more settings and cannot be explained by someother psychological condition such as depression or anxiety.  However, there arecases of people acquiring the symptoms of ADD after experiencing brain trauma.

I will mention the "LegoTest" here.  For boys in particular, some professionals say that if achild can stay highly focused and on-task when it comes to following Legodirections, then he is not actually ADD.  This is, of course, not partof 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 thecriteria, then you are ADD, even if your behavior is the result of having an IQ of 175 andbeing confined to a dull school.  Behavior cannot be caused by some otherpsychological 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 ADDback then.   After World War I, researchers noted that children who had contractedencephalitis displayed a high incidence of hyperactivity, impulsivity, and conductdisorders.  And in the 1940's, some soldiers who had experienced brain injuries werefound to have behavioral disorders.¹   It seemed clear that braindamage could cause hyperactivity.  Other forms of brain insult have since beenidentified as causes of hyperactivity, including exposure to lead and other environmentaltoxins, as well as fetal exposure to drugs and alcohol.

Once brain damage was identified as a cause ofhyperactivity in certain patients, researchers assumed that all hyperactivity wascaused by brain damage, even when no brain damage could be identified.  That's whyADD was once called "minimal brain dysfunction."  This is an importantpoint to understand.  It is because of this early association of brain injury andhyperactivity 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 nowknow 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 cansay all hyperactive children have suffered brain injury.

More recent studies have shown that ADD is largelygenetic.  That is, it runs in families.  This has lead some ADD researchers,notably Russell Barkley, to assume that our population is experiencing large scale randomgenetic mutations, a rather ridiculous notion for anyone familiar with populationgenetics.   Anytime more than one percent of the population carries a gene,geneticists rule out random mutations under the belief that the gene has been activelyselected for.  For example, the gene-based disease sickle cell anemia has been foundto help a population by providing resistance to malaria.

In the 1990's a growing number of ADD experts began to viewADD not so much as a disorder, but instead a natural condition which leaves ADDers at adisadvantage in some common modern settings, and many positive attributes becameassociated with ADD, such as creativity, enthusiasm and entrepreneurial tendencies. This is probably due in part to the ever expanding world of ADDers.  A few decadesago only the most dysfunctional hyperactive kids were identified as "disordered"and these kids were more likely to suffer from actual brain injury. Today, the diagnosticcriteria 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 handingin finished homework is fair game for a diagnosis.  I spoke to one teenager who wasdiagnosed ADD even though her grade point average had never been below a 3.85 (takingRitalin allowed her to achieve a 4.0).    I also spoke to a psychiatrist whoroutinely prescribed Ritalin to "C" students in an effort to improve their gradepoint average.

How common is ADD?

The figure for ADD is typically given as 3-5 percent of thepopulation.  The real figure is unknown and estimates vary between 1 and 20 percentor even more.  This is largely because the diagnostic criteria are so subjective:What is considered "clinically significant impairment" to one person might seemmore like normal childhood behavior to someone else.  For example, in one Englishsurvey, only 0.09 percent of the children were found to be ADD.   But in an Israelistudy, 28 percent of children were rated hyperactive by their teachers.  And in oneU.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 whatothers say." ²

^{Diagnoses and medication rates can vary greatly within theU.S.  Gretchen Lefever, a pediatric psychologist who became concerned when she wassuddenly inundated with ADD referrals, studied 30,000 grade-school students in twoVirginia school districts.  Her findings, which were published in "The AmericanJournal of Public Health", showed that 17% of white boys in the region were givenmedication 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 nosuch thing as ADD.  Upon reading their arguments I have found that what most of themare actually saying is that ADD is not a singular "disease", but rather acollection of behaviors or "symptoms" caused by a wide range of problems.So, tosome extent, it's really a matter of semantics. They compare a diagnosis of ADD to that ofa diagnosis of "fever."  Imagine going to the doctor with a temperature andbeing told you have been diagnosed with a disease called "Fever," and that allyou can do is take aspirin to lower it.  You might question the wisdom of such asimplistic 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 behaviorsare due to some mysterious brain defect that for some odd reason a huge number of peopleseem to have. 

Opponents of this simplistic approach arguethat the concept of ADD as a singular and discreet disease is a completefabrication.  They do NOT argue that ADD behaviors are simply caused by lack ofdiscipline or are figments of people's imagination. They believe people should be seen asindividuals, and their specific problems treated as symptoms.  The actual"condition" causing the behavior could range from brain damage to giftedness toallergies, and "treatment" would similarly range from stimulant medication toalternative education to allergy shots, depending on the root of problem.

How is ADD Diagnosed?

ADD should be diagnosed by a psychologist or psychiatristwho is knowledgeable about ADD as well as giftedness and creativity.  Avoid diagnosisby a pediatrician, since pediatricians as a group are far more likely to simply prescribemedications without properly assessing the child.  Psychiatrists and neurologists arefar more likely to prescribe medications before acquiring a total picture of the patient.

Adults, especially those with the non-hyperactive form ofADD, may have trouble finding a practitioner knowledgeable in ADD, since until recentlyADD was considered a childhood condition.   Women with ADD are often told theysuffer from depression and are prescribed antidepressants which do not work. 

Ask the practitioner what his or her ADD assessmententails.  A good assessment typically runs several hours and will include tests forIQ and creativity.  Avoid anyone who simply asks a few question and then prescribesmedication to "see what happens."  Most people do better and feelbetter on stimulants, even those without ADD, so this is a very bad approach for aprofessional to follow.  For additional information and a  checklist forchildren see my page called Children: Diagnosis, "Treatment" and Alternatives.

Common Misconceptions About ADD

1.  Many people assume ADDers cannot payattention.  This is completely false.  In fact, ADDers are known to"hyperfocus" on anything which captures their attention, to the point where itis difficult to get their attention.   It is true, however, that a higher degree ofinterest is necessary before the ADDer can pay attention.  ADDers do not tune-out ordaydream on purpose or to be rude.   Some people have likened it to having an on-offswitch in the brain.  Interest is needed to activate or "turn on" thebrain, after which the ADDer can pay attention.  If there is no interest, then thebrain is "off" and the ADDer is likely to do something to try and get it backon.  This can include sensation seeking, daydreaming, or becoming immersed insomething the ADDer finds very interesting. It can also include disruptive behavior. Thismight be nature's way of making sure that some people are always on the lookout forsomething new and interesting - these are our explorers and discoverers.  Ritalin andother stimulants appear to work by artificially stimulating the brain, allowing the ADDerto tolerate a duller setting than they could otherwise function well in (e.g.schools). 

2. Someone can be ADD and not be hyperactive.  SomeADDers, 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 chronicallymistreated, for example, by parents and teachers who continually blame the child for not"performing" like other children.   Such children may give uptrying to please their parents and instead misbehave out of frustration and anger.Otherwise, ADD kids are often described as enthusiastic and affectionate by understandingparents.  In addition, some people reacting to foods may become hostile as well ashyperactive while they are reacting to the food. 

4. You cannot tell if someone is ADD by their response tostimulants.  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 AverageBrains?

Although there is as yet no definitive answer to thisquestion.  As a group, ADDers MAY have less activity in certain parts of their brainwhile they are asked to perform tedious math problems or other dull exercises.  (I'veyet to see any researcher examine what ADD brains look like while engaged in somethingthey find interesting.)  I say MAY because the quality of research has been generallypoor and misleading.  For example, in one highly publicized study that showed lessbrain activity in ADD children, all of the children on the study had abruptly been removedfrom Ritalin 24 hours before the test.  It is possible that their brains had adjustedphysically to the Ritalin and were in a state of withdrawal during the test.  I findit interesting that when a different study showed brain differences in people who usemethamphetamine (speed), the researchers concluded that the speed had damaged theirbrains. Yet when Ritalin users brains were examined, the researchers assumed that thebrain differences were due to ADD. 

When reading studies that purport to explain ADD braindifference, bear in mind that:

1) In most studies, the ADDers studied are SEVERELYdysfunctional and are therefore NOT representative of the typical child who is routinelydiagnosed with ADD. 

2) Most of the people studied for ADD also have depressionand/or anxiety.  Both of these conditions significantly impact how the brainperforms, so the results may indicate more about depression and anxiety than about ADD.

3) Many children studied also have learning disorders, sothe 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 noone is really interested in them.

5) The medication that the children had been taking for ADDmay have caused brain differences.

6) Some brain differences may be temporary and subject toenvironmental influences.  Glucose activity is impacted by diet and metabolism.  Dopamine activity is also impacted by diet.  Even thoughts have a powerfulimpact on the brain: Brain scans of  obsessive-compulsive folks before and afterpsychoanalysis showed that training people to think differently actually changed theirbrain scan. Brains may also change temporarily when someone is having an allergicreaction.  Doris Rapp, M.D. documented alterations in EEG tests while children werechallenged with allergens.  The EEG results corresponded with dramatic behaviorchanges in the children, including hyperactivity. (Source: Is this Your Child? Discoveringand Treating Unrecognized Allergies in Children and Adults by Doris Rapp).

7) The brain is very poorly understood and there is no gooddata pool for normally functioning people. In other words, scientists have no idea at whatpoint normal brain diversity ends and abnormalities start because they haven't studiedvery 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 butotherwise normal.  Einstein had some very unusual brain differences which could havebeen interpreted as either defects or differences depending on the bias of the researcher(his overall brain size was average).

Dopamine: The neurotransmitter dopaminehas been implicated in ADD.  Dopamine is the "feel good" chemical in thebrain which is responsible for our ability to concentrate as well as our feelings ofhappiness.  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 (thisis nature's way of getting us off our butts), which is why ADDers can focus much betterafter exercise or during an emergency. In fact, it is said that many of the peopleinvolved in emergency response are ADD, such as firemen and ER physicians.

It is quite possible that some people are born with reducedlevels of dopamine activity.   People born with less dopamine may unknowinglyspend much of their lives looking for ways to boost dopamine, either in positive ways likebeing highly active, inventive or competitive, or in negative ways by being reckless,gambling, or taking drugs.  Another possibility is that lifestyles affect dopamineactivity. 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, generalnutrition is important.  Researchers have demonstrated a correlation of ADD and fattyacid deficiency.  Fatty acids are used to build receptors for neurotransmitters likedopamine as well as neural synapses formed while learning new things.

1.  A Parent's Guide to Attention DeficitDisorders by Lisa J. Bain, 1991, Children's Hospital of Philadelphia.

2. The Myth of the A.D.D. Child, by ThomasArmstrong, Ph.D., 1997

3. "Study Suggests Doctors OverprescribingRitalin", CNN Report, Aired August 31, 1999.