BASIC INFORMATION ABOUT
attention deficit disorders
WHAT DOES ADD "LOOK" LIKE?
The symptoms of Attention Deficit Disorders (ADD for short) exist on a continuum. Everybody has some of these symptoms some of the time. However, individuals with ADD have more of these symptoms more of the time and to the point that it interferes with their ability to function normally in academic, work and social settings, and to their potential. (See Appendix A below)
People with ADD are often noted for their inconsistencies. One day they can "do it," and the next they cant. They can have difficulty remembering simple things yet have "steel trap" memories for complex issues. To avoid disappointment, frustration, and discouragement, don't expect their highest level of competence to be the standard. It's an unrealistic expectation of a person with ADD. What's 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 But, remember -- not all people with ADD have all of these difficulties, nor all of the time.
Because society has traditionally thought of a person with ADD as being "hyper," many children who have ADD with no hyperactivity are not being identified or treated. Individuals with ADD without hyperactivity are sometimes thought of as day-dreamers or "absent-minded professors". The non-hyperactive children with ADD most often seem to be girls (though girls can have ADD with hyperactivity, and boys can have ADD without hyperactivity).
Additionally, because of the ability of an individual with ADD to over-focus, or "hyper-focus" on something that is of great interest or highly stimulating, many untrained observers assume that this ability to concentrate negates the possibility of ADD being a concern, especially when they see children able to pay attention while working one-on-one with someone, doing something they enjoy, or who can sit and play an electronic game or watch TV for hours on end.
ADD is not a learning disability. Although ADD obviously effects the performance of a person in a school setting, it will also effect 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.
WHAT CAUSES ADD?
ADD is 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 (they do not connect or touch). This space is called a neural gap.
Since these nerve endings dont 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.
HOW IMPORTANT IS A
Very. 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.
WHAT DOES A THOROUGH
A thorough evaluation includes gathering information from a variety of sources. A thorough review of the persons 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 types and severity of ADD symptoms at home and at school, as well as types and severity of other emotional or behavior problems. 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.
WHAT IS A COMPREHENSIVE TREATMENT PROGRAM?
A thorough evaluation should provide a basis for developing an appropriate and comprehensive treatment program. Usually, medication alone is not enough. A comprehensive treatment plan needs to "wrap-around" the individual. Often teacher training, parent training, family therapy, or individual counseling are needed. It is imperative that the whole picture be "looked at" for treatment to be effective because ADD effects life at school, in the classroom, within the family, with peers and also within the person, who can have a loss of confidence and negative perceptions about himself based on past and repeated frustration, struggle or failure.
Although medication can be an important component of treating ADD, it is only one piece of a responsible treatment plan. Other equally important components of treating ADD include providing a supportive environment, teaching the person organizational skills, study skills, memory skills, time management skills, to learn how to be self-aware about how they learn best, and what kind of physical setting is the most productive for them to work in.
The learning of these skills can be a long, careful process that must be reinforced regularly until the desired skills become habituated into the persons life routine and can be done without thinking. The medication is very helpful in that it allows the person to be "available" to learn the skills that will be important for a more successful school career and toward having a happy, independent and productive adulthood.
Usually, students with ADD will require special accommodations to help them access the education a school offers, such as a place to study that suits their needs, extended time on testing, periodic one-on-one review, skill reinforcement, consistency, routine, external structure and frequent positive reinforcements from teachers, family members and other involved adults.
Because ADD symptoms are so individual, each person needs individualized accommodations. There are no "one size fits all" plans. One can think of it like eyeglasses for people who are near-sighted. Though all need glasses, each person needs a different prescription.
It is important for people to understand that ADD is a real disability that effects all aspects of a person's life, (though it does not need to be handicapping). It is important for people involved with individuals with ADD understand that they usually have to put forth enormous effort to produce close to the same results as people who do not have ADD. Additionally, there are now brain studies that show that when someone with ADD is told to "just try harder" and does, the result can be anxiety and a brain that actually starts to shut down its primary executive functions. The ADD brain works even less efficiently under stress than the brain of a person without ADD. What that means of course is that for many people the ADD symptoms will get even worse during times of high stress. This is a good scientific example of why people with ADD can perform better in testing situations when the pressure of time limits is removed.
Certainly, no one would tell a person who has a physical disability to just use some self-discipline and try harder to get around on their own! Rather, they would be supported by providing a wheelchair and a ramp in order to give equal access to a workplace, school setting or other services. Nor can one make a paraplegic walk by applying discipline. Similarly, one cant make a person with a biologically-based lack of self-control do better by simply disciplining them.
Individuals with ADD must be accommodated. It's not equitable to expect a person with a disability to compete with non-disabled peers by simply applying self-control to be like people without disabilities. Telling a person with ADD if they just tried harder and had more self-control they could remember, pay attention, be more organized, etc. without providing a supportive infrastructure is the same as ordering a physically disabled person to get up and walk. In this case accommodation is not made with a wheelchair or a ramp, but rather by developing support systems and accommodations that allow the person to do what they are capable of doing and meet the demands of the school or work setting.
Therapists, educators, and physicians routinely teach children that ADHD is a challenge, not an excuse. Medication corrects their underlying chemical imbalance, giving them a fair chance to learn, develop compensatory strategies, and face the challenges of growing up to become productive citizens. Accommodations for the disabled, as mandated by federal and state laws, are not ways of excusing people from meeting societys responsibilities, but rather make it possible for them to compete on a leveled playing field.
HOW DOES STIMULANT
Stimulant medication acts as a sort of "gate-keeper" in the brain which helps the brain to better regulate the manufacture, storage and flow of its own neurotransmitters when needed by the brain.
Ritalin (methylphenidate) is the most commonly prescribed of the psycho-stimulant medications used for ADD. Others that are commonly prescribed are Dexedrine, and now Adderall. About 95% of the people who have ADD and take a stimulant medication obtain benefit. There are a rare few that receive no benefit from any stimulant medications and who do have "real" ADD.
Stimulant medications were first given to children with ADD symptoms in 1937, and have been extensively researched and studied since then. In fact, the largest body of research that exists for any medication for pediatric use is for stimulant medications.
Rapid-acting Ritalin starts to work within 15-20 minutes. It lasts about 3-5 hours (depending on the metabolism of the person). Ritalin is water-soluble, which means that there are no traces of the medicine left in the system once it has stopped providing beneficial effect. Because of this fact, people who are prescribed Ritalin need to re-administer it every 3-4 hours to maintain a therapeutic level. Ritalin is not physically addicting because of the quick absorption and depletion, and because of the relatively small doses prescribed for Attention Deficit Disorder.
Generally, the beneficial effects of Ritalin will peak about 2 hours after taking it followed by a lessening of benefits until the medicine is out of ones system. To ameliorate this "falling off" many individuals do best when they slightly overlap their doses. After one gets to know their own response to their medication and can determine when the medicine is out of their system, a dose overlap is often recommended.
Dexedrine Spansules and Adderall are slower releasing medications that provide a longer "window of benefit" for many people. Though the length of time someone with ADD will receive benefit from one of these slower acting medications varies from individual to individual, one can expect an effective therapeutic level to last approximately 5-8 hours per dose. For a variety of reasons, teenagers often do better with one of these medications.
Because the degree of symptoms of ADD are as individual as each person, the proper medication, therapeutic dosage amounts and optimal medication schedules vary from individual to individual. Body weight has no bearing on the therapeutic dose, though body weight is often used as a guideline when a medication trial is started. Typical dosage amounts of regular Ritalin are 40-80mg a day, given in three to four doses, though each persons needs can vary widely. Dexedrine Spansules and Adderall dosage amounts are generally from about 10-30mg a day, given in one or two doses. Though dosage amounts are important, the timing of the daily medication schedule can be just as important to achieving positive results.
There are generally few side-effects from the commonly used stimulant medications. These are usually mild and short-term. The most common is a reduction of appetite, which can be regulated by taking the medication just after eating (not before).
WHAT ABOUT DIET, SLEEP
AND TEENAGERS WITH ADD?
One of the most common side-effects of stimulant medications can be a reduction in appetite. Many people with ADD are simply not hungry at set meal times while the medication is in their system. It is important for these individuals to have snacks available that are high in protein and complex carbohydrates. Many people with ADD rarely sit down and eat a complete meal, but rather will need to eat several small servings throughout the day. Research shows that all students have increased performance after a meal high in protein and complex carbohydrates such as peanut butter on wheat toast. Making these snacks available for teens and for students with ADD is even more important because of their often irregular or poor eating habits.
SLEEP. . . Many people with ADD have always had a hard time getting to sleep. Some individuals who take stimulant medications find that they have a harder time getting to sleep. Paradoxically, others find that the medicine helps them to sleep faster and better. This is a good example of how "individual" ADD and a persons response to medication can be. Problems with sleep can usually be addressed by making adjustments to the time of the last dose of medicine, and by establishing a solid routine around bedtime to allow for a "shifting of gears" from day-time activity to rest and sleep.
For teenagers with ADD, in particular, sleep can become a serious problem. For them, ADD creates the equivalent of a sleep disorder because of their extreme difficulty getting to sleep and rousing, especially when waking to an early school schedule. These students must have compensatory sleep whenever possible. In extreme situations their doctor may prescribe either a small dose of an anti-depressant such as Prozac; or of Clonidine, an anti-hypertensive that has properties that also help block norepinephrine -- another neurotransmitter that can effect a person's ability to settle down and go to sleep.
One does not outgrow ADD, though a person can learn to master strategies to effectively compensate. It is now understood that ADD is a lifespan disability and inherited (genetically passed from one generation to the next).
The child who has hyperactivity may begin to look like he is out-growing the ADD because the symptoms of hyperactivity can diminish at puberty. The symptoms of ADD seem to change at this age. They appear to become more internalized, or "socialized." This does not mean that the struggle of coping with the ADD has disappeared, or that the person doesnt need accommodations or should discontinue treatment.
About half of the children who are diagnosed with ADD do develop a large enough inventory of effective skills that they are able to compensate quite well as adults without medication. About half of the children who are diagnosed with ADD do continue to require medication, work that is stimulating, a structured environment, and workplace accommodations to work at full potential when adults.
Note: Based on clinical
criteria, only those with significant symptoms, as compared to the norm, can be diagnosed
with Attention Deficit Disorders. In other words, when one has been diagnosed with
Attention Deficit Disorders, based on a full and comprehensive evaluation, the symptoms of
ADD are significant enough that they cause impairment; treatment and accommodations
DSM-IV Criteria for the diagnosis of ADD requires that: A) six or more
symptoms of inattention have persisted for at least six months to a degree that is
maladaptive and inconsistent with developmental level, OR six (or more) symptoms of
hyperactivity-impulsivity have persisted for at least six months to a degree that is
maladaptive and inconsistent with developmental level; B) Some hyperactive-impulsive or
inattentive symptoms that caused impairment were present before age seven years; C) some
impairment from the symptoms is present in two or more settings (e.g., at school [or work]
and at home; and D) there must be clear evidence of significant impairment in social,
academic or occupational functioning.
*Based on scientific research, the expected percentage of people who have clinically significant symptoms of Attention Deficit Disorders should be about 5 - 8% of the general population. According to studies, however, less than half of those individuals have received appropriate diagnoses. Of those who are diagnosed few are receiving necessary recommended and appropriate multi-modal treatment.
Prepared by Rebecca Chapman Booth
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