What Is ADD?

Excerpted from
Adult ADD: The Complete Handbook
By David B. Sudderth, M.D., Joseph Kandel, M.D.

Attention deficit disorder is a pervasive symptom complex involving inattention, impulsivity, distractibility, and hyperactivity. A number of other behavior characteristics are frequently seen in individuals suffering from this illness and will be discussed at length in chapter 3. In this chapter we will provide a detailed description of ADD's characteristics. (And in chapter 4, on differential diagnosis, we'll show you what ADD is not) We will also speculate on why another neurological disorder, Alzheimer's disease, has been widely accepted while ADD, equally valid in a scientific sense, has been widely derided by the press and even by physicians.

Historical Perspectives

In 1907, an obscure European physician named Alois Alzheimer described a case of a deceased 51-year-old woman who had developed difficulty with memory, language, and paranoid delusions during her later years. The autopsy on this woman demonstrated some peculiar, previously undescribed microscopic changes in the appearance of the woman's brain when examined under a light microscope. These changes, tangles of abnormally accumulated material, ultimately formed the basis for the diagnosis of what is known today as Alzheimer's disease. Prior to 1960, probably fewer than a hundred cases of this illness were reported in world literature. But by the mid 1990s, this disease is considered to be the fourth most common cause of death in the United States. Persons and families afflicted with this progressive, debilitating illness are viewed with the greatest sympathy by society. Alzheimer is now a household name.

Only five years before Alzheimer's report, another new disease hit the medical press. In 1902, Dr. George Still reported on a behavioral syndrome in children in the esteemed British medical journal Lancet. Still described the behavior of the children he observed in such terms as "abnormal deficits in moral control," "wanton mischievousness" and "destructiveness." (Today we would probably subdivide the group of children reported by still as children with ADD, conduct disorder (CD), and oppositional defiant disorder (ODD). While one rarely encounters the term "wanton mischievousness" in the media today, there are plenty of doubts and negative labels conveyed by reporters on ADD. Interestingly, this same doubt is virtually nonexistent when the same reporters write about Alzheimer's disease.

Why victims of these two diseases are treated in such a dissimilar manner is one of the many mysteries surrounding attention deficit disorder, which rests on as firm a scientific basis as does Alzheimer's disease.

First Treatment of ADD

The first report of effective pharmacological treatment of ADD was published in 1937 by C. Bradley, who described a group of children, ages five to thirteen, who demonstrated more organized behavior when given oral amphetamine. This medication was known to have high abuse potential among adults, who had a markedly different response to the medication, i.e., euphoric state, craving, etc. (It's important to note that adults with ADD do not experience feelings of euphoria and craving when they take amphetamines or other medications for ADD.)

At that time, it was a controversial practice to give this medication to children, when it clearly had a highly addicting effect on many people; the debate for and against the use of such stimulant medications persists to this day. The fearsome specter of a harsh and demanding society forcing small children to consume large amounts of potentially addictive or otherwise harmful medications frightened those who did not understand the positive impact of stimulants on those who need them.

Later, methylphenidate (Ritalin) became available as a treatment for ADD, as did the medication pemoline (Cylert). Many subsequent controlled studies have demonstrated that these medications are quite effective in providing symptomatic relief from the various troubling behavioral aspects of ADD.

Over the last three decades, various journal articles have suggested that some of the symptoms seen in children with attention deficit disorder persist well into adulthood. Yet it was not until 1978, in Scottsdate, Arizona, that a conference on the subject was held - a conference that attracted very little attention. Then, in the early 1980s, increasing numbers of reports in the press indicated that adult ADD was actually a genuine diagnostic entity, and in 1989 an adult ADD clinic was opened at Wayne State University in Detroit.

Seemingly overnight, adult ADD support groups appeared in many states, newsletters directed at adults with ADD began to circulate, and support groups such as the very popular CH.A.D.D. (Children and Adults with Attention Deficit Disorder) were founded.

In 1990, Dr. Alan J. Zametkin and his colleagues published an article in the prestigious New England Journal of Medicine that identified a metabolic defect in adults with attention deficit disorder. This article detailed a controlled study in which the brain's ability to utilize glucose was impaired in a person with attention deficit disorder but was normal in people without ADD. This article legitimized attention deficit disorder as a formal diagnostic entity.

Since then, many articles about attention deficit disorder in adults have been published, and in 1992 psychologist Lynn Weiss published Attention Deficit Disorder in Adults, the first book on ADD in adults for nonprofessional readers. After the publication of Weiss's book, a virtual explosion of information and interest in ADD among children and adults has dominated the print and broadcast media, but much of the media attention has been negative.

Why Was ADD Ignored for So Long?

Physicians have a long history of assuring parents that various problems will be "outgrown" as the patient approaches adulthood, and ADD was no exception. Although it is true that most children do typically outgrow some conditions such as bed-wetting and petit mal seizures, other disease states are not outgrown. Another explanation for this delay in the recognition of ADD is unquestionably related to adaptation and compensation by the patient. Adult attention deficit disorder patients frequently have developed various strategies for dealing with their problems which enable them to support themselves and "get by."

Also, many other conditions are frequently seen in patients with ADD or may be a consequence of the ADD. As a result, this other condition may dominate the patient's overall disability while the ADD component is less obvious to the treating physician. Thus, if a person was depressed and also had ADD, it was more likely that the depression would be diagnosed rather than the ADD.

Furthermore, medical knowledge races ahead at atomic velocities while medical practice proceeds in accordance with its own internal pocket watch.

Another relevant factor is that an increasingly involved and educated lay public has largely imposed its own timekeeping strategies on doctors, often pressuring them into taking positions and responding faster with regard to accepting an illness than with the wait-and-see positions many doctors have taken in the past.

ADD: What's in a Name?

Attention deficit disorder has gone through various terminology rites of passage before reaching its current nomenclature. The term minimal brain damage/dysfunction (MBD) was current at one point, as was hyperkinetic reaction of childhood (HRC). Attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) are the terms used by most authorities today. This terminology is far from perfect, and we predict that these names will be replaced in the near future, as a more precise understanding of this disorder is achieved and its various subgroups are identified.

In this book, we will use the terms attention deficit disorder and ADD rather than ADHD because many of our readers will have ADD but will not experience hyperactivity as a major problem - or a problem at all.

Primary Symptoms of ADD

Below we list and briefly describe the most commonly experienced primary symptoms of attention deficit disorder. If you don't see yourself in all of these, understand that each person with ADD is different and exhibits different symptoms and different degrees of symptoms (mild, moderate, and severe). Also, the problems that one person has may be no obstacle for another person with ADD. Although symptoms among people with ADD vary, most exhibit the symptoms of impulsivity and inattention, while others exhibit hyperactivity. We'll discuss these symptoms and others in this section.

Impulsivity

Impulsivity, or impulsiveness, appears to be one of the features of ADD which changes very little throughout the course of an ADDer's life. This uncritical, seemingly reflexive tendency to respond to various external stimuli can be the most disabling and even dangerous feature of adult attention deficit disorder.

Impulsiveness in children is often overlooked by adults and is sometimes even viewed as "cute." In the adult world, however, this type of behavior is poorly tolerated and rarely goes unpunished. Impulsive behavior can ruin you financially, cause you to lose your job and your family, or even saddle you with a fatal sexually transmitted disease.

One of our patients, Steven J., reported some difficulties at work, which allowed him the "privilege" of changing jobs twenty times in one year. (Note: all names have been changed in our anecdotes about people with ADD.)

The longest job I've ever had lasted six months and I would have been fired long before that if people knew what I was actually doing. I tend to annoy people immensely by blurting out whatever comes into my mind and constantly interrupting people around me. My boss would give me one job but I would get bogged down in one part of the task or altogether start on something new. Every time I began a new job I thought of ten other things that I should be doing at the same time. This often led to my not being able to accomplish the task set before me during the course of the day, leaving me with ambitious but totally unrealistic plans of finishing at home.

Invariably I would go home, grab something to eat, check my mail, "relax on the computer," make a few phone calls, and by then it was midnight and 1 was too tired to even think about the work, which, by the way, I had left in my car. Although I replayed this script over and over again, I was equally surprised every time. The next day I would take my unfinished work back into the office, make my excuses and do it all over again.

Steven brings up several difficult issues facing the ADDer, including verbal "impetuosity." A person with ADD is faced with an urgent need to express ideas "before they get away" from him. He (and others like him) seems to lack mental filing cabinets where information can be stored and retrieved at will. This unquestionably is one reason an ADDer is pressured to relieve himself of his thoughts and ideas.

As noted elsewhere in this book, individuals with ADD often have unique insights and creative impulses that "evaporate" if not mediated to other individuals, written down, or otherwise put on "hard copy." The concept of "inspiration preservation," our phrase for saving your creative ideas, will be discussed elsewhere in this book, and we'll suggest various strategies to avoid losing creative ideas.

Individuals with ADD can be virtual "verbal howitzers" firing in a semirandom, absolutely automatic manner at anyone, hostile and friendly. Spouses and children are often the objects of ill-conceived remarks that are generated and executed before the ADDer has really contemplated the consequences of these remarks. Close friends and family members of individuals with this particularly annoying tendency can learn to accept this to a certain degree. Spouses often report being socially embarrassed by the involuntary verbal outbursts of someone with this disorder. The other side of this coin is that individuals with ADD are often very quick with witty repartee or anecdotes.

ADD-related impulsivity can also lead to financial catastrophes.