What Is ADD/ADHD?

Interview With Peter Jaksa, Ph.D.

MENNINGER CLINIC SEMINAR
Recorded on America Online, Online Psych Forum,  10/30/96

Guest: Peter Jaksa, PhD (DrJaksa@aol.com)

Interviewer: D. S. Bond (OLPsy1@aol.com)

OLPSYCH:  Our guest is Dr. Peter Jaksa, who is a psychologist and writes the "Ask Dr ADD" column for Online Psych. 

OLPSYCH: First question -- what is Attention Deficit Hyperactivity Disorder?

Dr JAKSA: ADD/ADHD is a diagnosable, treatable, biologically based disorder which we understand now much better than we did even 10 or 15 years ago. The primary symptoms include some combination of inattentiveness or distractibility, impulsivity, and in some people physical restlessness or hyperactive behavior.

OLPSYCH: What are some other symptoms or behaviors associated with ADD?

Dr JAKSA: Let me list some -- bear with me.

Having a LOT of difficulty sustaining attention.
Making careless mistakes, not paying attention to detail.
The child or adult with ADD often "doesn't seem to listen", seems tuned out.
Children fail to follow instructions, don't get schoolwork or chores done.
Lots and lots of difficulty with organization, keeping track of things.
Losing things often -- particularly things like supplies, homework, papers, etc.
Getting easily distracted by outside stimuli, like people talking or things going on outside the window
Forgetting to do things -- very frequently, which means things don't get done
Physical restlessness for some people, fidgeting, can't sit still, etc.
For many children, a lot of difficulty remaining seated, waiting in line, etc.
Being physically "on the go" for some people, overactive in their behavior
For children, having difficulty playing quietly or co-operating within a group
Reacting impulsively, without thinking first -- with ADHD it is often a matter of "act before you think," instead of "think before you act"!!
And also a few other things which we won't go into now.............

OLPSYCH: Yikes! But doesn't that describe most people from time to time? I can't sit still sometimes, for example.

Dr JAKSA: Certainly we all get restless or distracted at times, get disorganized, act impulsively, etc. The difference is that for most people these behaviors are relatively infrequent and relatively mild. For people who have ADHD these behaviors are pretty severe and consistent, so much so that it causes a significant degree of impairment in the person's ability to function. This can cause very real and serious problems at school, at home, on the job, in relationships, etc. If the behaviors or symptoms are not severe enough then by definition it's *not* ADHD. The severity of symptoms and degree of impairment are very real however, which is why ADHD is considered a disability under federal law.

OLPSYCH: Is there a difference between ADD and ADHD? We see both names being used and it gets confusing sometimes.

Dr JAKSA: The medical diagnosis is ADHD (Attention Deficit Hyperactivity Disorder). Some people use ADD to mean ADHD without the hyperactive component, however ADD is not an "official" medical diagnosis. Also many people use ADD as a more generic term, to mean all types of ADHD. So yes, I agree, it can get confusing sometimes!!

OLPSYCH: How common is ADHD among children and adults? Some media stories portray ADHD as being overdiagnosed, even mentioning an "epidemic" of ADHD.

Dr JAKSA: We know based on epidemiological data that ADHD occurs in 3% to 5% of children in this country. Roughly half of those children continue to have significant levels of ADHD symptoms as adults, which means perhaps 2% or 3% of the adult population has some levels of ADD/ADHD.  Is it overdiagnosed? I don't know for sure, but my guess is that it is not. We are able to diagnose it much more accurately than we did in the past which I suspect accounts for much of the increase in diagnoses of ADHD.  Dr. Russell Barkley made this point at the last CHADD conference, and I  think he's right.

OLPSYCH: Who is more likely to have ADHD?

Dr JAKSA: There are gender differences in ADHD, with males being 2 or 3 times more likely to be diagnosed than females.  That doesn't mean that ADHD is rare in girls, but boys definitely get diagnosed more often -- they tend to be more active and aggressive, disruptive. Also it definitely tends to run in families, so if a family member has ADHD you would be more likely to have it also.

OLPSYCH: Does that mean ADD is genetic?

Dr JAKSA: Yes, very much so. It's important for everyone to keep this biological perspective in mind, in terms of understanding and treating ADHD. Too often people with ADHD are blamed for their symptoms and accused of not caring, being lazy, or having some character defect, etc. These accusations are unfair and also can hurt self-esteem tremendously.

OLPSYCH:  So then ADD cannot be caused by bad parenting or poor teachers?

Dr JAKSA: Absolutely not! This is an important point, so let me say it again: absolutely not!!!!
It is grossly unfair and misleading to blame parents or teachers for the ADHD symptoms and behaviors. Good parenting and good teaching can make a big difference in how well the ADHD behaviors are managed however, and how well a child with ADHD learns to cope with the symptoms. Sometimes medication is also necessary.

OLPSYCH: Without getting too technical, what is the biology of ADHD?

Dr JAKSA: What medical research has shown is that in people with ADHD there is an area in the brain involving the frontal lobe and basal ganglia, which is underactive. These areas of the brain are responsible for inhibiting or controlling impulsive and disruptive behavior. Interestingly, what some medications such as the stimulant medications do is to normalize functioning in these areas of the brain, meaning, roughly speaking, that with medication those areas are working at the same rate of speed as the rest of the brain. These are rough generalizations, but based on the research findings that I've seen this is what happens with ADHD at the biological level. We've still got a long ways to go to fully understand the biology of ADHD though. 

OLPSYCH: How is ADD diagnosed and who is qualified to diagnose it? I know I am not.

Dr JAKSA: ADHD should be diagnosed only by a qualified health professional who is experienced in working with ADD/ADHD. This person may be a psychologist, psychiatrist, pediatrician, neurologist, clinical social worker, etc. -- however it is very important that the individual be knowledgeable about ADHD and preferably have some experience working with people with ADHD. A comprehensive evaluation should involve a thorough medical and developmental history, behavior rating forms which can give a better indication of type and severity of symptoms, and when necessary screening for learning problems or emotional problems which can complicate the ADHD related problems. It is common for people with ADHD to present with what are called co-morbid conditions, for example depression, anxiety disorders, substance abuse, or learning problems, and these should be at least screened for.

OLPSYCH: Someone in our audience has asked, what are the most common types of treatments for ADD?

Dr JAKSA: The most effective treatment is a combination of medication (when necessary) and behavior therapy or counseling to work on learning coping skills and to work on any emotional issues that are also causing problems. For many adults an ADD "coach" can be very helpful, someone to be a combination advisor and cheerleader.  There are people across the country who are getting training to be ADD coaches, but we still don't have enough of them I don't believe.

OLPSYCH: What role does therapy play? You mentioned emotional issues.

Dr JAKSA: It is quite common to see children, and adults too, with ADD/ADHD experience a history of frustration and underachievement, which leads to loss of confidence, a sense of insecurity or inferiority, sometimes depression, anxiety disorders, etc. Some extremely bright people with ADHD go through life basically "spinning their wheels" and being unable to achieve their goals. Therapy can help a great deal in dealing with these kinds of problems.

OLPSYCH: Do children with ADD usually need special help at school?

Dr JAKSA: Sometimes, sometimes not. When there are academic or behavioral problems at school, often the school needs to provide extra services or make reasonable accommodations for the child with ADHD.

OLPSYCH: What are reasonable accommodations.

Dr JAKSA: That depends on the needs of the particular child. Accommodations such as preferential seating (for example in front of class), help with organizational skills and social skills training, reducing the workload if necessary, giving more time for certain tasks, providing the opportunity for untimed tests, providing a note-taker, and providing more one-to-one help when necessary.

OLPSYCH: Well, some people would say these accommodations give the students with ADHD an unfair advantage.

Dr JAKSA: Actually, they don't. The accommodations are simply a means to help the student overcome their ADHD symptoms.  It levels the playing field, nothing else.   For example it takes a student with ADHD longer to go through a list of problems -- if you're a teacher giving a test, are you interested in testing how fast the student can complete those problems, or testing how much knowledge the student has? If you're testing for knowledge and not speed, then the untimed test for the student with ADHD makes sense and is fair.

OLPSYCH: Are learning disabilities common with ADD?

Dr JAKSA: Roughly 30% of individuals with ADD/ADHD also have some type of learning disability. These individuals in particular need an early and accurate diagnosis, comprehensive educational testing, and educational accommodations when necessary.

OLPSYCH: Medication for ADD can be a touchy subject. Many people are scared of using medication in the treatment of ADD. Should they be?

Dr JAKSA: No, not in my opinion. When used appropriately medications for ADHD present no more problems than any other types of medications. Unfortunately there has been some media hysteria around the use of medication, particularly Ritalin, which has scared many parents needlessly.  Medications such as Ritalin and Dexedrine have been used for over 40 years and researched extensively. 

OLPSYCH: What are some of the fears you hear from parents of kids with ADD, or adults with ADD?

Dr JAKSA: That somehow using medication will turn the child into a "zombie" or "robot", in effect change their personality. This should NEVER happen if the proper medication at the proper dosage is being used. The prescribing physician and the parents need to monitor for any side effects, and typically these can be controlled by adjusting dosage or timing of administration. Other common fears are that medication will stunt growth, lead to drug addiction later on, or cause the person to be dependent on medication as adults. There is no factual basis for these fears, based on research evidence and clinical experience in working with people with ADD/ADHD. 

OLPSYCH:  What about the fear of drug abuse with Ritalin?

Dr JAKSA:  Again, the research evidence and clinical experience simply does not support that, that ADD medications lead to drug abuse. Do some people abuse medications such as Ritalin?  Yes - some will.  I like to bring up a point made beautifully by Dr. Stephen Copps, however.  Kids abuse all kinds of things, from alcohol to glue to gasoline fumes.  What are we going to do, abolish glue and gasoline?  Of course not. If substance abuse is a problem then it should be treated as a substance abuse problem, not a problem of ADD medication.

OLPSYCH: Any advice for parents on dealing with ADHD behavior at home?

Dr JAKSA: Sure....do we have a couple days??

OLPSYCH: What kinds of challenges does an ADHD child present for parents?

Dr JAKSA: Well, consider that many kids with ADHD are extremely active, don't listen well, get very emotional very quickly, get bored easily and can be very demanding, and have poor impulse control. Consider also that they tend to seek out exciting and stimulating activities, and hate the mundane everyday activities which parents consider "responsibilities".

OLPSYCH: Like homework and chores?

Dr JAKSA: Exactly!

OLPSYCH: How about reviewing the top 10 rules for parents, then we'll take some questions?

Dr JAKSA: A long time ago Dr. Russell Barkley formulated his Ten Golden Rules for parents of kids with ADD........let me paraphrase them real quickly.

Dr JAKSA: Make the rules specific and clear....post them in writing

Dr JAKSA: Use rewards that are powerful and meaningful to the child

Dr JAKSA: Give feedback often...let them know how they're doing often!

Dr JAKSA: Help them anticipate and plan for what's coming up

Dr JAKSA: Expect that they will have good days and bad days

Dr JAKSA: Use positives and praise more than negatives.....or punishments

Dr JAKSA: Keep in mind that we are dealing with a biological problem....not a
character defect!

OLPSYCH: Good advice!

Dr JAKSA: As Dr. Sam Goldstein once said, "act - don't yak!" --  don't talk too much, respond with behavior

Dr JAKSA: Maintain a sense of humor........be patient!

Dr JAKSA: And finally forgive your child and yourself.........you're all in
it together, and trying your best!

OLPSYCH: Thanks! Why don't we take a few questions. Let's try not to
overwhelm our guest!

Dr JAKSA: Those are some pretty good rules to live by!

 
Slip111: I think that these are great rules for all parents and children.
Humane, sensitive, thoughtful.

Abdill: When a person has trouble starting and staying on a project (on medication)
what do you suggest?

Dr JAKSA: The medication may not be as effective as it needs to be perhaps. Also it might help to take breaks at times, work in smaller segments of time and plan out what you're going to do better.

MGreene: Is having trouble organizing thoughts and making speeches a symptom?

OLPSYCH: You mean like speeches at work or on the job?

Dr JAKSA: Yes, that's common but not necessarily due just to ADD. That could also be due to anxiety for example.

COrla45: Can too high a dose of Ritalin actually increase hyperactivity?

Dr JAKSA: Not that I know of........often a too high dosage will produce sedation. Bring that up with your physician please.

Rhonda5: Can you have a disability that makes you have SO much trouble with getting lost along with ADD?

Dr JAKSA: Rhonda.....yes! Possibly a nonverbal learning disability.  ADD in itself makes getting lost easier though.

MGreene: Is desipramine another drug effective in treating ADD?

Dr JAKSA: Desipramine is an antidepressant medication that works well for some...not others.  Please bring up medication questions with your physician.

COrla45: Why does Ritalin appear to work some days and not do anything other times?

Dr JAKSA: Good question....people just respond that way sometimes.....also some days the ADD symptoms are just worse.  People have "good" days and "bad" days, particularly kids with ADD.

Slip111: Anger and ADHD please?

Dr JAKSA: People with ADD tend to be more emotional in general.......also have a shorter fuse, anger easily.

JAKNEFE: As a teacher and a mom, what book would help me to identify and help young ones?

Dr JAKSA: I like Russell Barkley's TAKING CHARGE OF ADHD, particularly for parents.   Lots of good books out there on ADD though.

MGreene: Is it common for patients with ADD to develop addictions or
obsessive behaviors?

Dr JAKSA: ADDers tend to be more prone to substance abuse, for a lot of reasons I believe........another complicated topic. Some people try to self-medicate with alcohol or other drugs, which is always a bad idea by the way.

Frogpl: How does depression, anger and ADHD seem to become so interwoven
and difficult to treat?

Dr JAKSA: That is a great question, but a complicated one........with frustration, underachievement, loss of self-esteem and hope, it can lead to depressive feelings.

Kit6: Are children with ADD and low self esteem issues more likely to try to kill themselves?

Dr JAKSA: Suicide? No.

RHofm: Any research on ADD kids who were intervened with early & substance abuse?

Dr JAKSA: If ADHD is treated early and well, many problems can be prevented.

OLPSYCH: That's good to hear!

Ntb7: What is early?

Dr JAKSA: Early can be as young as four or five....as soon as problem behaviors develop.

AirAlert: Dr Jaksa are you referring to medication or behavior intervention or simply good parenting?

Dr JAKSA: Whatever helps! All of the above, AirAlert.

OSurr: With out letting the social bias that it's illegal affect the answer, how does cannabis affect ADD?

OLPSYCH: OSurr, I think like it effects everything else. Not good for you.

Dr JAKSA: Marijuana will likely make the ADD symptoms worse, and cause MORE problems.

Sing440: Is it common for ADD patients to be either hyper-focused or "out of it"? I'm like that. When I'm at work, doing a task, I have such tunnel vision - I don't know what's going on around me. There could be a robbery and I'd miss it!

Dr JAKSA: Hyperfocusing is common at times, yes.  Being distracted is probably more common, but ADD can cause both at different times. 

Ntb7: Have many ADD children tried homeschooling? Less distractions yet not
as structured?

Dr JAKSA: The effectiveness of homeschooling depends on the child....some do better with it, others not. Most kids with ADD don't need home schooling though.

JAKNEFE: How about homeopathy ? What about environmental factors as a cause?

Dr JAKSA:  I'm not aware of homeopathy providing effective treatment for ADD. Environmental factors as a cause? Of some ADD-like symptoms perhaps. Things which effect the brain in childhood can cause ADD or symptoms which are similar to ADD -- some examples are lead poisoning, encephalitis which is a brain infection, or severe head injury.

OLPSYCH: Friends, THANKS! Let's give Dr Jaksa a big round of applause!!!!

MGreene: Thanks a lot!

Jesmos: BIG ROUND

Cath: ::::::Applause::::::::

Frogpla: thanks!

Dr JAKSA: Thank you all........my pleasure!

For further information:

Peter Jaksa Ph.D. may be reached via e-mail address: DrJaksa@aol.com   or phone (847) 405-0220

Online Psych is accessible via America Online (keyword: Online Psych)

(c) 1998 Peter Jaksa, Ph.D.