Thursday, March 08, 2007

ADHD: The basics and the controversies

ADHD: The basics and the controversies

ADHD is the classic neuropsychiatric disorder--that is, a brain-based disorder with a primarily behavioral presentation. ADHD has a strong genetic clustering (80 percent), but its etiology is unknown. Like all other developmental disabilities, ADHD is a lifelong condition. Its manifestations and the patient's compensation to the disorder change throughout the lifespan (Wender, 1987). The basic features, impairments, and treatments, however, are very similar for both children and adults. People do not "outgrow" ADHD, just as no one outgrows any other genetic or developmental disorder. All people develop better abilities to pay attention and control impulses as they grow older. Most patients will benefit from lifelong medication, even if they have "learned to cope," because life stresses increase rather than diminish with age.

We once indulged in the wishful thinking that ADHD usually disappeared in adolescence. What we were actually seeing was the transformation of the most visible feature of bounce-off-the-wall hyperactivity into mere restlessness.

The disorder is manifested as a persistent pattern of inattention, easy distractibility and/or hyperactivity-impulsivity that is significantly more severe than that observed in persons of a comparable level of development. This inattention and/or impulsivity interfere significantly in all areas of function (school, work, social/family relationships, mood regulation, and self-esteem). In identified cases the gender ratio is 3:1, male to female, through adolescence but approaches almost 1:1 in adults.

Attention "Deficit," however, is a terrible name. Most people with ADHD report that their attention is not deficit, it is excessive. People with ADHD describe that they are drawn to all the stimuli around them equally and simultaneously. They are like jugglers who give fleeting attention to each ball in the air. Nothing gets sustained, undivided involvement.

TAKE HOME MESSAGE #1: For persons with ADHD, the ability to maintain attention and impulse control is determined by one factor-- if the task is interesting, desired, or challenging, the individual with ADHD has no problem with distractibility or impulsivity. If, on the other hand, the task is boring, it is a neurologic impossibility to stay on task. Interest and challenge only determine the ability to function, not importance. This "interest based performance" is coming to be the hallmark diagnostic symptom of the disorder and the key to successful management once medication treatment has been established.

The swings of attention can be profound from states of "zoned out" dissociation to a condition known as hyperfocus. As many as 40 percent of adolescents and adults with ADHD can enter what appears to be an altered state of consciousness while doing activities which they consider particularly intriguing. During a hyperfocus the person performs at almost 100 percent efficiency, does not notice the passage of time, does not become tired or hungry, and has virtually 100 percent comprehension and retention of what he reads.

This inconsistency of performance based on interest leaves the impression that the ability to function is under the control of the ADHD patient who is just being lazy or uncooperative. We used to use a trick question with the parents of children brought in for assessment of ADHD. We asked them what their child's favorite TV program was in the smug belief that a truly ADHD child would not sit long enough to have a favorite program. Now we understand that more than half of children and adults have the ability to become deeply and productively involved in tasks that interest and challenge them, only to fall apart when they become bored.

Many people would also like to drop the term "disorder" because ADHD seems to convey a large number of positive traits along with the distractibility and impulsivity. People with ADHD usually have much higher than average intelligence, although they commonly express frustration at not being able to demonstrate it consistently. They tend to be very creative and inventive. Sometimes this presents as being artistic, musical, or inventive, but almost always it manifests itself in intuitive problem solving. People with ADHD can often pull together the threads in complex problems to develop ingenious solutions that no one else would ever see. People with ADHD are also described as having "relentless determination" whenever they do hook into a challenge. Finally, people with ADHD tend to be affable, likable people who often have a quick and zany sense of humor. They tend to have a close, tight group of friends and family who describe them as being "high maintenance but high reward" individuals.

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