Attention Deficit Disorder (ADD) is a neurological condition that affects learning and behavior. It affects approximately 5 – 10% of our population. It develops in childhood, and usually is not grown out of. ADD is characterized by persistent and excessive problems in which a child is unable to focus and pay attention, or conversely displays hyperactive and impulsive behavior. Some of the top characteristics of ADD are: attention difficulties, distractibility, hyperactivity, impulsivity, attention-demanding behavior, school difficulties, and learning disorders. It is extremely difficult to describe the characteristics of children with ADD. The key to the characteristics is the intensity, the persistence, and the pattering of these symptoms.
People with ADD are often noted for their inconsistencies. One day they can “do it,” and the next they cannot. They can have difficulty remembering simple things yet have “steel trap” memories for complex issues. To avoid disappointment, frustration, and discouragement, do not expect their highest level of competence to be the standard. What is normal is that they will be inconsistent. Typically, they have problems with following through on instructions, paying attention appropriately to what they need to attend to, seem not to listen, be disorganized, have poor handwriting, miss details, have trouble starting tasks or with tasks that require planning or long-term effort, appear to be easily distracted, or forgetful. In addition, some people with ADD can be fidgety, verbally impulsive, unable to wait their turn, and act on impulse regardless of consequences.
However, it is important to remember not all people with ADD have all of these difficulties, nor all of the time. Although ADD obviously affects the performance of a person in a school setting, it will also affect other domains of life, which can include relationships with others, running a home, keeping track of finances, and organizing, planning, and managing most areas of ones life.
ADD is considered to be a neurobiological disorder. The most recent research shows that the symptoms of ADD are caused by a chemical imbalance in the brain. To understand how this disorder interferes with ones ability to focus, sustain attention, and with memory formation and retrieval, it is important to understand how the brain communicates information.
Each brain cell has one axon, the part of the cell that sends messages to other cells; and many dendrites, the part that receives messages from other cells. There is a space between the axon and the next brain cell called a neural gap. Since these nerve endings do not actually touch, special chemicals called neurotransmitters carry (transmit) the message from the end of the axon to the dendrites that will receive it. With ADD there is a flaw in the way the brain manages the neurotransmitter production, storage or flow, causing imbalances. There is either not enough of them, or the levels are not regulated, swinging wildly from high to low.
When diagnosing ADD, a thorough evaluation is very important. In order for an individual to be diagnosed with ADD, comprehensive evaluations must be administered that include a complete individual and family history, ability tests, achievement tests, and the collection of observations from people who are close to the person who is being assessed. It is also extremely important to have an assessment that is individualized and designed to uncover co-existing conditions, such as learning disabilities and behavior, mood or anxiety disorders (depression, generalized anxiety, obsessive-compulsive disorder, oppositional defiant disorder, etc.), or any other problem that could be causing symptoms that look similar to the symptoms of ADD.
A thorough evaluation includes gathering information from a variety of sources. A thorough review of the person’s medical, academic and family history is essential. In the case of a child this is done through a detailed, structured interview with the parents. Behavior rating scales should be filled out by parents and teachers to provide information on the types and severity of ADD symptoms and other emotional or behavior problems at home and at school. Depression, anxiety and other emotional disorders are tested through a comprehensive psychological screening. Intellectual and achievement testing is used to help screen for and then assess learning problems, and areas of strength and greatest struggle.
For decades, stimulant medications have been used to treat the symptoms of ADD. For many people, these medicines dramatically reduce their hyperactivity and improve their ability to focus, work, and learn. The medications may also improve physical coordination, such as handwriting and ability in sports. Recent research by National Institute of Mental Health (NIMH) suggests that these medicines may also help those with an accompanying conduct disorder to control their impulsive, destructive behaviors.
There is great controversy surrounding the stimulant most commonly used to treat ADD, Methylphenidate, more commonly known as Ritalin. Ritalin was first synthesized in 1955 and began to be used in the 1970’s. Ritalin is a methylphenidate; from the family of drugs know as central nervous system stimulants. It’s on set of action is 30 minutes and its duration of action is 3 to 5 hours. Doctors are uncertain how Ritalin works in the body. It affects the balance of chemicals in the brain.
Recent research indicates that it affects the balance of Serotonin working with Dopamine in the brain. Serotonin is a naturally occurring chemical in the brain. Serotonin appears to inhibit behavior and activity. The Dopamine dramatically reduces hyperactivity and improves the ability to focus, work, and consequently, learn. Even though Ritalin is the preferred choice of medication, there are severe side effects for taking it. The most common side effects of Ritalin are loss of appetite, loss of sleep, nervousness, dizziness, drowsiness, headache, nausea, and stomach pain.
There are two modalities of treatment that specifically target symptoms of ADD. One uses medication and the other is a non-medical treatment with psychosocial interventions. The combination of these treatments is called multimodality treatment. Psychostimulants are the most widely used medications for the management of ADD symptoms. At least 70% to 80% of children and adults with ADD respond positively to psychostimulant medications, which have been used to treat the cognitive and behavioral symptoms of ADD for more than 50 years. Stimulant drugs, such as Ritalin, Dexedrine, and Aderall when used with medical supervision, are usually considered quite safe. Although they can be addictive to teenagers and adults if misused, these medications are not addictive in children. They seldom make children “high” or edgy. Nor do they sedate the child. Rather, the stimulants help children control their hyperactivity, inattention, and other behaviors.
Different doctors use the medications in slightly different ways. Ritalin and Dexedrine come in short-term tablets that last about 3 hours, as well as longer-term preparations that last through the school day. The short-term dose is often more practical for children who need medication only during the school day or for special situations, like attending church or a prom, or studying for an important exam.
As useful as these drugs are, Ritalin and the other stimulants have sparked a great deal of controversy. Most doctors feel the potential side effects should be carefully weighed against the benefits before prescribing the drugs. While on these medications, some children may lose weight, have less appetite, and temporarily grow more slowly. Others may have problems falling asleep. Other doctors say if they carefully watch the child’s height, weight, and overall development, the benefits of medication far outweigh the potential side effects. Side effects that do occur can often be handled by reducing the dosage. However, doctors recommend that patients be taken off a medication now and then to see if it is still necessary. They recommend temporarily stopping the drug during school breaks and vacations, when focused attention and calm behavior are usually not as crucial; this precaution is referred to as a “drug holiday.” Drug therapy is a highly effective means of treating disorders, including ADD.
For those not comfortable with drug therapy there are other means of treating ADD, such as behavior therapy. This is especially effective for children. For example, children with ADD need structure and routine. They should be helped to make schedules and break assignments down into small tasks to be performed one at a time. It may be necessary to ask them repeatedly what they have just done, how they might have acted differently, and why others react as they do.
Especially when young, these children often respond well to strict application of clear and consistent rules. In school, they may be helped by close monitoring, quiet study areas, short study periods broken by activity (including permission to leave the classroom occasionally), and brief directions often repeated. They can be taught how to use flashcards, outlines, and underlining. Timed tests should be avoided as much as possible. Other children in the classroom may show more tolerance if the problem is explained to them in terms they can understand. When combined, drug and behavior therapies can be highly effective when treating Attention Deficit Disorder.
Like many disorders, ADD is disruptive and if left untreated it inhibits the proper functioning in society and of one’s daily activities. At this time there is no cure for ADD, but much more is now known about effectively coping with and managing this persistent and troubling developmental disorder. Hopefully, the day is not far off when genetic testing for ADD may become available and more specialized medications may be designed to counter the specific genetic deficits of those who suffer from it.
Larry J. Seidman : Harvard Medical School at Massachusetts General Hospital
Douglas, V.I. & Peter, K.G. 1979: Attention and the development of cognitive
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