ADD (Attention Deficit Disorder) is making news headlines today.  Some groups (consisting of physicians and medical researchers) claim it is overly diagnosed in our society, while other groups (also consisting of physicians and medical researchers) think it is still under diagnosed.  What is the answer?  Yes and yes.  There are overmedicated adolescents who primarily need better discipline and organizational skills, yet there are other adolescents who have never received counseling and/or medication that could desperately help them.  ADD is both the most over and under diagnosed condition in adolescents today!
   
What causes ADD?  We don’t know. (Reassuring isn’t it?)
What do we know?  More than we did 5 years ago.

The most important treatment is relationships.  Our goal should be to make relational events more productive for ADD people.  We know human brain growth and development is totally dependent on relationships. 

What is ADD in a sentence?  People who have trouble regulating everyday functions because they are either too intense or not intense enough (this will make more sense as we continue).  ADD is a great gift by God and when controlled and used properly can yield a successful, joyful, productive life.
Common Core Symptoms

1. Difficulty regulating focus and attention:
 ADD people are definitely capable of focus and attention, rather it is the regulation of that which causes trouble.  Focus is a very complex behavior in our brain that is coordinated and regulated by several different areas.  ADD  adolescents have problems with this coordination.  The cause can be in the brain wiring, neurotransmitter abnormalities, brain structure abnormalities, or a combination of these.  When a task is boring or repetitive ADDer’s cannot maintain focus (they under focus).  When the task is too engaging, such as visual stimuli on computer games, they often over focus.

2. Distractibility:  Our brains spend enormous energy weeding out distractions.  Two types predominate.

a.    External distractions—the hum of the lights, the noise and motion of other people, what’s going on outside the window.  Most people can put that stuff in the background and focus on one task, the speaker for instance.  ADDer’s have difficulty weeding the external out.

b.    Internal distractions—the mind thinks multiple thoughts.  ADDers often jump from subject to subject as one thought reminds them of another.  They often report lying down at night to sleep, but the mind won’t shut off.  Our mind is really amazing when you ponder that it never sleeps.  It runs 24 hours a day 7 days a week, sometimes for ninety years.  These multitudes of thoughts are a gift.  How?  CREATIVITY!  ADDers are great thinkers outside the box.  I believe all creative people have a little ADD in them!

3. Difficulty in regulating response to stimuli: This is also known as impulsivity.  ADDers act without thinking!  What is an adult’s usual response to impulsivity?  “Why did you do that?”  What is always the answer?  “I don’t know.”  They really don’t.  What is a better response?  “Remember the rule when you do such and such (i.e. talk in class) here’s the consequence.  Enforce the consequence every time.  The heart and soul of impulsivity is stimuli.  The worst times at school for ADDers are the most stimulating times such as—in the hall, recess, PE, and music class.

4.    Increased intensity of response: They laugh louder than anyone else does, get white-hot mad over little things, but also get bored very easily.  This over intensity is a great gift.  How?  ADD adolescents are the best in drama class.  This intensity makes them great drama queens.  Most good actors have some ADD.  So ADD can make you a great living.

We also see persistence and perseverance.  This means that once they get their mind set on something they won’t drop it.  If you tell Bobby we’re going to the store today, but it’s going to be a fast trip and we’re not going to buy anything extra he will most likely agree with you.  But once you get to Target he sees the exact model car that he’s always wanted.  And Target knows how to target these kids by putting these special toys at the ends of the aisle.  The scene all too often becomes an embarrassing showdown in Target because Bobby now insists on getting this car at all costs.  He refuses to take no for an answer.  Here comes the drama and the overacting as if his life will be over if not allowed to get this one car.  This is often when the “meltdown” starts that leads to Mom dragging a screaming kid out of the store.

It is actually useless to argue with ADD kids and adolescents because logic means nothing to them.  They will argue even in threat of their own life.  Here’s how you handle the matter:

“I know you don’t think this is fair, but this discussion is over.  If you say something else you will go to your room.”  If they won’t disengage you will have to.  Adults often want the last word, but don’t try to do that because it won’t happen, instead the whole matter will become more heated.

Perseverance is actually a great gift.  It makes one superb at many jobs.  Think about the persevering detective who cracks the case because he never gave up; even when logic said, “Drop it.”

5.    Difficulty in regulating response to what’s going on around them:
ADDers search out stimulating behavior.  These are teens who like to live on the edge, jump off the roof into the swimming pool, jump off a twenty-foot deck, and sadly use drugs as well.  Danger excites them.  Where we feel fear they feel exhilaration.  They also have an attraction to other ADDers.  ADDers often don’t like each other, but it’s like they have a magnet drawing them to each other.

ADDers are also attracted to a lack of structure, but they hate it.  Lack of structure makes them feel out of control.  One of the best things we can do is provide structure.  Upon experiencing it they will learn to internalize it and be empowered by the control it provides.  ADDers will do the worst in school in classes that are unstructured.

6.    Difficulty regulating motor activity: This is a nice way of saying hyperactivity.  There are 2 types of hyperactivity.

a.    True hyperactive—they run round and round like a dog who’s just been let out of a pen.  These represent the minority.

b.    Fidgeting—is not on purpose, but rather is an internal natural response to try and focus.  ADDers don’t like to (or possibly even can’t) do homework sitting down at a desk.  It gets too repetitive and boring to hold their attention.  They often do better with music playing in the background or stretching out on a sofa.  This sounds crazy to those of us who don’t have ADD.  ADD kids really do want to learn.  Studies find that almost all kids want to learn.

7.    Executive Function Problem: Known as “outsight” problems.  An area on the right side of our brain is dedicated to interpreting non-verbal behavior with other people.  This is often referred to as social senses or social skills.  ADDers often show abnormal activity in this part of the brain.  Many misperceive subtle non-verbal cues.  This often makes them somewhat socially inept.  One example is that ADDers often take jokes seriously and get mad.  They also don’t understand how they come across to others.  ADDers report more loneliness and depression than non-ADD people do.  Many report having only a few friends.  This can be devastating, especially as a kid.  ADD kids often unknowingly push other kids away—they can be bossy, arrogant, interruptive, tattle-tales, and too domineering.  Even if you try to tell them this they might agree with you, but they rarely perceive it and usually go right back and continue to perform the same behaviors.

This cannot be treated with medication, but rather with adults who teach structure.  This is why counseling is such an important aspect of ADD treatment.  It provides a safe environment for ADDers to open up about what they think and how they feel.  Relationship problems are often the most dangerous part of ADD.  What actually determines a lot of success and happiness in life?  Relationships!  With counseling this under active part of the brain usually catches up in maturity.

We also see constructional dyspraxia—that’s the $100 word for disorganized.  ADD brains have trouble breaking down a task into a series of small tasks.  ADDers can dream up projects all day long, they just have no idea where to start in completing them.  The devil for them is in the details.  Even projects we consider simple such as cleaning up their bedroom causes problems.  To an ADDer cleaning up your room often means rearranging the mess in the room.  So what do you do—not make them clean up the room because of their ADD?  Not at all!  This is where signs and lists are helpful that go step by step in how to clean the room.

The toughest time for ADD kids is after school until bed.  Homework is a hard time, because they are already burned out.  The amount of homework some of these schools assign is ridiculous.  Some of these kids have more studying to do at night than I did in medical school.  An ADD kid can spend hours finishing a homework project and then never give a second thought about remembering to take it to school and hand it in the next day.  You can help by reminding them of their projects and see if the teacher can collect the homework first thing in the morning before it has a chance to get lost.
BIOLOGY

    Neuropsychiatrist Daniel Amen M.D. identified 6 biologically different types of ADD with brain SPECT imaging.  CT and MRI scans show the brain’s anatomy.  SPECT scans assess the brain’s functioning.  It tells us what areas of the brain are working well, what areas are working too hard (overactive) and what areas aren’t working hard enough (underactive).

1.    Classic: This is a common pattern.  The pre-frontal cortex is underactive when trying to concentrate as compared to normal controls.  The result is poor regulation of focus (inattention and impulsiveness).  These underactive areas will actually light up with medical treatment.  One area especially where medical treatment is beneficial is allowing an ADDer to experience what normal feels like.  It’s hard to learn normal if you have never experienced it.

2.    Inattentive Type: The major feature is internal distractibility.  Girls often have this type.  It is characterized by excessive daydreaming, and even slower cognitive processing.  Schoolwork physically wears these kids out, however they are very creative.  One interesting aspect is that people with this type of ADD are usually very, very sensitive to criticism.  They get their feelings hurt and wounded very easily.  This type also has a poor internal sense of time.  If you say, “Be ready to go in fifteen minutes,” that means absolutely nothing to them.

3.    Overfocused Type: An area of the brain, the  cingulate gyrus lights up more than normal.  The cingulate gyrus is involved in obsessive-compulsive disorder (OCD).  People with very severe OCD who have failed medical treatments can have part of their cingulate gyrus removed (cingulotomy) and OCD symptoms will improve.  People with this type of ADD are overfocused, intense, rigid, and many suffer from anxiety disorders including OCD.

4.    Temporal Lobe Type: In this type parts of the temporal lobe are under active.  It can sometimes look like swiss cheese on a SPECT scan.  The temporal lobe is one of our main mood regulators.  People with this kind of ADD have poor regulation of mood.  Many of them may also have bipolar disorder.

5.    Limbic Type: In this type the limbic area lights up too much (is overactive).  The limbic system is our emotion control center.  People with this type of ADD often develop classic depression.

6.    Ring of Fire: No, this is not the Johnny Cash type, but rather includes some elements of all the above.  The name is derived from the way it looks on a SPECT scan.

GENETICS

    Genetically there are several conditions that live near ADD:

• Learning disorders—particularly the ability to decode letters—reading disabilities
• Anxiety disorders—40% of ADDers report periods of significant anxiety.  Type II & III have up to 70% concordance for anxiety disorders.
• Mood disorders—Mainly depression and bipolar disorder
• Grooming behaviors—Some ADDers pick their skin with their fingernails until they create sores.  Many others bite on their fingernails down to the quick.  These behaviors are extremely difficult to extinguish.  They are now thought to be genetically related.  The almost always improve with age and eventually go away.

TREATMENT

    All things are a tool in treatment—again fostering relationships is the most important.

1.    Structure, Structure, Structure: This means predictability and consistency.  Don’t try to correct every behavior—you will drive yourself and your child crazy.  But be consistent on the ones you do go after.  Make sure they know what the consequences are and then make sure the consequences happen.  Always be thinking of ways you can tighten structure in an ADDers life.

Our brain’s physical development peaks at about age 18.  That is why the best tennis players are often teenagers.  Learning ability peaks 16-20 years.  This is why it is important to be able to focus in high school and college.  What we call wisdom ability or networking ability is not complete until about age 25.  This means that no matter how physically gifted or smart a young person is the will often make foolish life decisions until about age 25.  Car rental companies actually discovered this first that is why they won’t rent a car to someone no matter how good the driving record until they are 25.

2. Hastening wisdom development: Two things in particular hasten wisdom development in ADDers.

a.    Mentors: adults who invest in a child or adolescent’s life make a huge difference.  In the teen years it is often best if these adults are not the adolescent’s parents.  Our culture like no other has separated adult and teen culture.  Adults have in essence said, “You teens go have your own culture, listen to your own music, watch your own TV shows, wear your own clothes, and don’t bother us.”  Teens however, need direction and guidance from adults in their lives.  Sadly the only adult guidance many kids get is TV.  Coaches play a huge role in teenagers’ lives.

b.    Natural consequences: (not punitive) Allow natural consequences to happen.  The worst thing is when parents want to bail their kids out of all trouble and use the excuse because they are ADD.

3.Three things that can impede wisdom development:

a.    Alcohol: It can permanently disrupt this whole process.  Add alcohol to someone who already seeks danger and you have a deadly combination.

b.    Marijuana: New research shows that marijuana damages young brains much more than old brains

c.    Nicotine: ADD teens often use it to relieve anxiety.  It is extremely addictive.  Our country is on a big campaign to lower teen smoking.  The main motivator is emphasizing the bad health effects smoking creates.  This doesn’t resonate too well with ADDers, because remember I said earlier they are not swayed too much by logic.

  4.  Medications: Medications help the prefrontal cortex to make enough neurotransmitter to regulate attention.  Medicine is often a great tool allowing an ADDer to experience what focus really is.  The drawback is that medicine usually only works for a limited time.  No medication is a magic bullet and no medication works 100% of the time.  I’m asked a lot if meds can squash creativity.  No the meds won’t, but sometimes side effects can flatten mood and mask creativity.  The creativity is still there when you take the med away.

5.  Diets: The Feingold diet, which was popular in the early 1970’s then fell out of favor has seen a resurgence, especially among Christian groups.  It emphasizes cutting out high sugar foods and foods with dyes and certain additives.  Studies have shown that the diet substantially helped only about 5-10% of kids.  It is a hard diet to follow, it cuts out over 300 foods, many of them are kids favorites.  This diet is especially hard on the kid who has to watch all of the other family members eat whatever they want.  The diets are still more popular in Europe than America.


Vitamin B6 and magnesium also help brain function.  Omega 3 fatty definitely helps.  So do to the amino acids L-tyrosine and GABA.  Physical exercise helps greatly, especially to dissipate hyperactivity.  Limited exposure to TV and computers also helps.

    ADDers usually have strong IQ’s with variability in skills, but all the knowledge in the world is pretty useless if you can’t organize.  It is important that ADDers know both their strengths and weaknesses and how to use them.  This country has millions of people who only know their weaknesses.  Who are these people?  These are the perpetual victims in our society.  To them the awfulness of ADD is a great excuse not to succeed, not even try.  Sadly, each day our society is becoming more accepting of this.  There are also millions of people who know only their strengths.  These are the arrogant.  They perpetuate the deadly myth that is prevalent in our society today that one should grow up and be good at everything.  This sets young people up for failure.
 
Again the number one tool in ADD is relationships.  That is why I am adamant about ADD patients being involved in counseling and not just medication treatment.  ADD people are smart, creative, and charismatic, but they must learn how to organize.  Always remind the ADD person of this and they can go far.