What causes ADD?
The most recent models which attempt to describe what is happening in the brains of people with ADD suggest that several areas of the brain may be affected by the disorder. They include the frontal lobes, the inhibitory mechanisms of the cortex, the limbic system, and the reticular activating system. Each of these areas of the brain are associated with various functions. The frontal lobes help us to pay attention to tasks, focus concentration, make good decisions, plan ahead, learn and remember what we have learned, and behave appropriately for the situation.
The inhibitory mechanisms of the cortex keep us from being hyperactive, from saying things out of turn, and from getting mad at inappropriate times, for examples. They help us to “inhibit” our behaviors. I’ve heard it said that 70% of the brain is there to inhibit the other 30% of the brain. When the inhibitory mechanisms of the brain aren’t working as hard as they ought to, then we can see results of what are sometimes called “disinibition disorders” such as impulsive behaviors, quick temper, poor decision making, hyperactivity, and so on.
The limbic system is the base of our emotions and our highly vigilant look-out tower. If over-activated, a person might have wide mood swings, or quick temper outbursts. He might also be “over-aroused,” quick to startle, touching everything around him, hyper-vigilant. A normally functioning limbic system would provide for normal emotional changes, normal levels of energy, normal sleep routines, and normal levels of coping with stress. A dysfunctional limbic system results in problems with those areas.
The ADD/ADHD might effect one, two, or all three of these areas, resulting in several different “styles” or “profiles” of children (and adults) with ADD/ADHD.
The next questions might be, then, What causes these various systems of the brain to get out of balance? Why would they become under aroused or over aroused as the case may be? Is there one central system that controls or regulates these other systems? Be sure to stay with this line as this will be discussed in detail later.
As we mentioned earlier, the ADD/ADHD might effect one, two, or several areas of the brain, resulting in several different “styles” or “profiles” of children (and adults) with ADD/ADHD. These different profiles effect performance in these four areas: First, problems with Attention. Second, problems with a lack of Impulse Control. Third, problems with Over-activity or motor restlessness, and fourth, a problem which is not yet an "official" problem found in the diagnostic manuals, but ought to be: being easily Bored.
If the above descriptions sound like your child, then at this point you're probably asking "Will my child ever outgrow it?" Well studies seem to indicate that about 50 to 60 percent of ADD kids will outgrow most of the symptoms by the time he or she is in their 20's. The Hyperactivity may diminish in adolescence or adulthood, and may become more of a restlessness or fidgetiness and be more appropriate. The impulsivity may remain, and is often the biggest complaint of adults with the disorder. It causes a variety of problems from often interrupting others in conversations to quitting jobs for little reason and without other employment already lined up. The attentional difficulties may also persist into adulthood. It is often described as a constant “brain-fog” which makes tasks such as balancing check books and doing taxes very difficult. Gladly, most adults with ADD can find jobs where their strengths can shine, and they can be successful.
Other Important Characteristics
Other important characteristics of this disorder are:
1) That it is SEEN IN MOST SITUATIONS, not just at school, or just in the home. When the problem is seen only at home, we then would wonder if perhaps the child is depressed, or if the child is just being non-compliant with the parents;
2) That the ONSET of the symptoms occur BEFORE AGE OF SEVEN (7). Since ADD is thought to be a neurologically based disorder, we would expect that outside of acquiring its symptoms from a head injury, the individual with ADD would have been born with the disorder. Even though the disorder might not become much of a problem until the second or third grade when the school work becomes more demanding, one would expect that at least some of the symptoms were noted before the age of seven.
Concurrent problems and needs
Often the ADD child has special educational needs, though not always. Most ADD kids can be successful in the regular classroom with some help. We tend to see Lower academic achievement for I.Q. If they ought to be A students, they're getting C's instead. If they ought to be B students, they're getting D's instead. They just have a real tough time in the classroom setting. In fact, if you think about it, the classroom setting is probably the worst possible setting for these kids. There are a lot of distractions, they are told to sit still, don’t move, don’t talk, pay attention to boring worksheets, and keep on task until the work is finished. None of these things come easily to ADD kids. I've also noticed that many ADD kids "hit a wall" in school as the school year progresses. Every week they just get a little farther and farther behind, until they're so far behind that it's impossible to catch up.
Anti-social behaviors are common. About 60% of ADD kids are also oppositional or defiant. Some are even getting in trouble with the law. Impulsive-Hyperactive ADD kids are the most likely to get into trouble than are the merely inattentive kids. The inattentive kids tend to be non-compliant due to not being motivated enough to remember the things he was asked to do.
The disorder is most often recognized and referred for treatment in third grade. This is when kids hit the "academic wall." In third grade that are expected to do more and more work on their own, and they are given more homework to do as well. We also see many referrals in seventh grade, or when the child leaves Elementary school for Junior High School, with several classes and several teachers. Many ADD/ADHD kids who found ways to compensate in Elementary school are totally lost in Junior High School.
Also its important to know that ADD and I.Q. are two different things. ADD is not related to I.Q. Some parents are convinced that if their child has ADD it means that they are retarded. On the other hand, other parents say, "I've heard that ADD kids are really very, very bright. I think my child must have ADD." as if they wanted to wear a button that said, "my child is smarter than your child because he has ADD." Well, that's ridiculous. Some ADD kids are below average I.Q., some are even retarded. Some ADD kids are above average I.Q., and some are even quite brilliant. But the awful truth for a parent to hear is that most kids are AVERAGE I.Q., that's why they call it "average." And most ADD kids have average I.Q. as well.
Attention, impulsivity, hyperactivity
What do we mean by problems with ATTENTION?
When we talk about attention, we are talking about two different kinds of abilities: The ability to focus on a specific task put in front of us to do, such as school work, and the ability to pay attention in a more global sense to the world around us, to be able to pay attention to the buzz of the lights overhead, and the touch of the clothes on your skin, and the children playing outside of the classroom. These are two different kinds of attention.
One Definition of "Paying Attention" is - “Sustaining and selecting to the right cue.” One part of that definition is that the child has to pick the right thing to pay attention to. That’s the “selecting” part of the definition. A better word might be "Filtering." The brain is supposed to filter out distractions, or stimuli which compete for our attention, but might not be important. Many children with attentional problems pay attention to everything in the world around them equally, such as giving equal time to the touch of the clothes on their skin, the buzz of the lights overhead, the kids outside the classroom, and the math worksheet in front of them. This, of course, is a problem if he needs to be paying attention to the math worksheet.
Many Children with Attention Disorders have trouble concentrating on the specific task in front of them, especially if they are working on something like school work or chores that are only moderately interesting, or not interesting at all. These kids have to be very motivated, very excited, very interested in what they're doing in order to pay attention.
That's not my kid, watch him play Nintendo... Now, you might be thinking, "This is not my kid. I have a kid who could play Nintendo, and be so focused that the house could burn down around him, and he'd never notice." Well, that could be. A lot of these kids could do just exactly that. Nintendo is interesting, its challenging, its fun, they get immediate feedback, they could be playing the Nintendo for hours. But just put a math worksheet in front of them and see how different that it. They have a terrible time paying attention to something that's not interesting or that's not motivating, which accounts for about 85% of school work, and about 100% of chores.
Part of the problem with attention that these kids can have is a lack of FLEXIBILITY with attention. A person without ADD has the ability to shift from the kind of attention that is focused on a specific task at hand to the kind of attention that is global many times in just a few seconds. At will we can shift from reading our book to scanning the room to know where our kids are and what they are doing, and then very quickly return to focusing on our reading. We have Flexibility in our ability to focus. We can shift from specific focus to global focus at will and very quickly. Individuals with ADD do not have this same Flexibility of focus. They have a very difficult time shifting from a global focus, such as they might have at recess or lunch break, to a specific focus that would be required when they return to the classroom to study math and work on the math worksheet in front of them. This is why they could play Nintendo, be really focused on that task, and not notice the house burning down around them.
"Space-Cadets" but not "Hyper"
A second type of attentional problem is sustaining attention to the task. We may call this attention span. Many children may be able to focus attention to the correct task, but then can’t sustain it for very long. Their “attention span” is very short for their age. Unless kept highly motivated, these children have a very hard time staying focused long enough to finish the work that they start. They are often seen as fidgety, easily distracted, and “day-dreamers.” These are the people who may start five different projects, but fail to finish any of them. They may begin to clean their rooms, but after a short time become distracted by their toys or baseball cards and forget all about the job that they are supposed to be working on.
A note about children with attentional problems: Often children as described above are not impulsive or hyperactive. They just appear to be “space-cadets,” unfocused, or lazy. Children with only the attentional problems tend to be females, and they are the least likely Attention Deficit Disorder subgroup to receive any help for their condition. Kids who are just inattentive, or space-cadets, are often seen failing to pay close attention to details, or having trouble keeping their minds focused on a task, especially with school work or chores. They often don’t seem to be listening. They are often disorganized. They often will try to get out of doing their homework because it is just such a boring task. They are the kids that will spend two hours to complete a 20 minute homework assignment, and then fail to turn it in to the teacher the next day because they have lost it in their back pack or sent it to the Bermuda triangle of homework assignments.
Next, let’s discuss IMPULSIVITY.
Impulsivity is found in two areas: Behaviorally and Cognitively. Behavioral impulsivity would include what you do. People with behavioral impulsivity don't stop and think first before they act. No matter how many times you tell this kid, "stop and think first," the next time the situation comes up, he may well do the same impulsive thing again. They aren't learning from their past mistakes. Their learning threshold is very high, and if you don't excite them, or motivate them enough to get them above that learning threshold, they don't learn, and they make the same the same mistake again and again.
These are kids who act without thinking first, cut in line, can't wait their turn in line or in a game, blurt out answers in class, speak when they're supposed to be quiet, maybe show aggressive behaviors, are often a little too loud, sometimes fights, and often have poor social skills, which of course is the death socially for teenagers with ADD. They impulsively say the wrong thing at the wrong time. They can get one date, but they can’t get the second date because they might impulsively blurt out something and then say, "Why did I say that?" The other teens are asking, "Who is this guy?" and often begin to avoid him. Also, sometimes these kids fail to learn those subtle social cues that everybody else has learned, and so they're socially awkward and often don't know why.
Cognitively, these are kids who will make a Multiple number of guesses in a short period of time. On a matching task, or if you give them multiple choices orally, you'll see them guess for the right answer very quickly, "it's this one, no, its this one, no, wait, its this one," until finally you step it and when he guesses right, you'll say, "that's it!" which of course just reinforces his guessing. These kids have very limited problem solving strategies. They don't stop and look and the problem and then say, "Well, I could do it this way first, then do that, then I'll be done." They don't do that. They usually just start the task and then let trial and error take its course.
Now remember, being fast is not a problem. Some have pointed out that "fast and accurate is good." It's fast and inaccurate that is a problem. Impulsive kids are often seen interrupting others in conversations, or blurting out answers in class. They often have trouble waiting their turn in games, or have trouble lining up at school. They just don’t wait... or think... before they act.
What is HYPERACTIVITY?
First of all, not all of the kids with this disorder are hyperactive. Perhaps as many as two out of three are, but perhaps as few as only 50%. So, that means that as many as 35 to 50% of kids with ADD are not hyperactive. Most of the kids that we see in our private practice setting are hyperactive kids, because they get in the most trouble. Their parents are usually pulling their hair out and saying, "We've got to get this child some help." The sad truth is that if a parent is going to spring for money to get treatment for his kid, that kid's usually got to get in trouble. So that's why we see the hyperactive kids the most in treatment.
What do we mean by "hyperactivity"? Well if you have a child who is hyperactive, you need no explanation. He's the one running across the ceiling. But for the rest of you, this is what I mean. These are kids that act as if they are driven by a motor. They "go." You wind them up in the morning and they "go" until they're finally exhausted, and then they go to sleep, maybe. Some of these sleep pretty well during the night, and some of them hardly need sleep at all. Three hours of sleep and they're up and ready to go.
Each child is different, each child is unique, even if they have the same disorder. One definition of hyperactivity is "high levels of non-goal directed motor activity." A child with high levels of motor activity which is always directed at a goal may not be hyperactive. He may be a future professional athlete or rocket scientist. It's the kid who bounces from one activity to another in a manner inappropriate for their age that is our concern.
Hyperactivity is often seen as the child being “over aroused.” There is a part of your brain that is constantly scanning the environment to see if there are any changes in that environment. If anything has changed, then that part of the brain asks the question, “Is this new thing in the environment good or bad? Is it something good to eat, or is it going to eat me? How should I feel about this new thing? Should I like it, or be afraid or it?” In many kids who are hyperactive this part of the brain is overly sensitive, and the kids are seen as startling easily, overreacting to things, touching everything around them, and being very edgy. They never seem to be able to just relax. Some of these kids also have a very quick temper, a short fuse. They are sometimes explosive. They often lose friends because of their intensity and temper, and they often seem to run over people like a tornado.
But as we have said, a lot of ADD kids are not hyperactive. And the kids who are not hyperactive tend to be girls, and they tend to sit in the back of the classroom and just quietly get C's and D's when everyone knows they should be getting A's and B's. They're the one's being labeled as "lazy" and at the parent conferences the parents are told, "He or she could do better if they'd just try harder."
Also as we've said, these kids are BORED EASILY.
If the subject is interesting, then he's OK. If it’s only moderately interesting, or not at all, then he can't sustain his motivation levels, or his attention to task. Although it’s not in the literature, nor in the diagnostic criteria, this aspect of being easily bored is the most common element that I’ve seen with these children. Since most of the work from school is boring, and since everything to do with chores at home is boring, these kids can have a very difficult time growing up.
If the above descriptions sound like your child, then at this point you're probably asking "Will my child ever outgrow it?" Well studies seem to indicate that about 50 percent to 60 percent of ADD kids will outgrow most of the symptoms by the time he or she is in their 20's. The Hyperactivity may diminish in adolescence or adulthood, and may become more of a restlessness or fidgetiness and be more appropriate. The impulsivity may remain, and is often the biggest complaint of adults with the disorder. It causes a variety of problems from often interrupting others in conversations to quitting jobs for little reason and without other employment already lined up. The attentional difficulties may also persist into adulthood. It is often described as a constant “brain-fog” which makes tasks such as balancing check books and doing taxes very difficult. Gladly, most adults with ADD can find jobs where their strengths can shine, and they can be successful.
We should also acknowledge that for many ADD will turn out to be the ticket for disaster in their lives. About half of all individuals with ADD will also develop problems with society, with authority, with the rules of life. These individuals will average about two felony arrests before the age of 20 unless they are properly treated as a child. One study suggests that about half of all men in prison in the state of California carried the diagnoses of ADD and Conduct Disorder as children, but went untreated, either because the families denied that there was a problem, or didn’t have the financial resources for treatment, or because they just didn’t know what to do about the problem.
It is extremely important that all children with ADD, whether the inattentive space-cadets or the impulsive hyperactive children, it’s important that all children with ADD receive the help that they need. These children need to tools to help them to be successful.