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Dear Dr. Debug:
I have noticed a lot of articles in the last few months about childhood and adult Attention Deficit Disorder (ADD). There seems to be a lot of controversy about whether the symptoms of ADD are caused by a neurological deficit or by learned thinking patterns. A recent study showed a relationship between large amounts of early childhood television viewing and later childhood symptoms indicating ADD. I would be interested in your thoughts about ADD. -- Signed: Curious About Attention Deficit Disorder.
Historically, ADD in children has received the most attention because of the challenges that hyperactive, impulsive children caused for school systems. ADD is divided into two categories -- a hyperactive type and what I call a "day-dreamer" type. I don't use the term Attention-Deficit/Hyperactivity Disorder (ADHD) even though that is the "official" name for the condition because ADHD gives the impression that hyperactivity must be present to make the diagnosis.
It used to be thought that children with ADD grew out of it, but it became evident that what they tended to grow out of was the hyperactive component. Many children with ADD became adults with untreated ADD. Many were never diagnosed during their school years because they weren't causing problems (the day-dreamer type). They often experienced failures in higher education and had lifestyles of rapidly changing jobs, poor work skills, and difficult relationships. Due to frequent failures, adults with ADD often get depressed and experience chronic low self-esteem.
Here are a few signs of ADD: (1) Inattention and memory problems -- losing or forgetting things, being absent-minded, not finishing things, misjudging time, trouble getting started ("procrastination"); (2) Hyperactivity and restlessness; and, (3) Impulsivity and emotional instability -- saying things without thinking first, interrupting others, easily frustrated and angered, unpredictable moods, driving recklessly. ADD seems to be distributed equally between women and men. It is important to note that all conditions have degrees of expression, so there is mild, moderate, and severe ADD.
We do not yet have the ability to directly study the living, human brain at the microscopic level, so we do not yet know the precise causes of ADD symptoms. Research points toward a deficit of the neurotransmitter norepinephrine in the prefrontal cortex of the brain. A well-functioning prefrontal cortex is crucial to judgment, organization, attention span, planning, impulse control, problem solving, critical thinking, forward thinking, and empathy.
To help people understand the probable biological deficit in ADD, I use a very simplified explanation I call the "bridges-out" concept. The brain is made up of billions of little pieces of road (nerve cells). The pieces of road are connected by bridges (chemicals called neurotransmitters). In the human brain, there are no long roads without bridges. So, if a lot of bridges are out (low neurotransmitter levels), there are fewer roads available for transporting data. When there are only a few roads for information to travel on, much information does not get processed properly. People with ADD symptoms can be very good at single-tasking, but generally do not multi-task very well.
All medications that help with ADD symptoms do similar things -- they increase certain neurotransmitters in the prefrontal cortex. In effect, they put more bridges back into operation creating more usable roads for information processing. If people with normal levels of neurotransmitters take these medications, all they may get are side-effects. There are no "processing" advantages to increasing neurotransmitter levels to above normal. Unfortunately, these medications do not permanently repair the brain, but just add a missing component.
Not all people with ADD have difficulties and problems. There are people who, because of their particular circumstances, intelligence level, or support system, do very well. They may be very creative and energetic, and accomplish a lot. However, in those people who are experiencing mostly the downside of ADD, I recommend a thorough evaluation and a treatment plan.
With respect to the question of whether the diagnosis of ADD and treatment with medication is being over-utilized in children, it is my opinion that it is. In fact, I feel that medication for all mental health conditions is over-utilized in the United States. We are a society enamored by "quick-fix" solutions and so-called "cost-effectiveness." Mental health treatment based on learning new skills and mindsets is under-utilized.
The study that you note about early childhood television viewing and later childhood indicators for ADD is a very important reminder to us that obtaining skills such as focusing, problem solving, and having patience may be learned or not learned. Although ADD appears to have a genetic influence, we often under-estimate how powerful early learning experiences can be. If learning has something to do with establishing certain pathways in the brain for processing certain information (sometimes called the "pathways of least resistance"), then it makes sense that a medium such as television might be teaching distraction rather than focus, entertainment rather than problem solving, and impatience rather than patience. -- Best wishes, Dr. Debug.
Ron Sterling, M.D. (Dr. Debug) is an award-winning psychiatrist in Seattle, Washington. He has been writing for newspapers and magazines since 1998 on subjects ranging from good manners to senior mental health. He hosts and maintains the well-known Internet mental health center, DearShrink.com. The Doctor Debug column is dedicated to assisting with the "debugging of malfunctioning elements in our own personal programming."
Adult Attention Deficit Disorder
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