"I'd like to start by reviewing some facts about ADD. ADD has been medically described since 1902. There is little agreement about what causes it, how to diagnose it and how to treat it. According to some studies, ADD affects as many as 10 million Americans, many of them adults, and approximately 4 percent of school-age children. Males are more likely to exhibit associated hyperactivity (attention-deficit/hyperactivity disorder, or AD/HD); that hyperactivity may help explain why three times as many males as females have been diagnosed with ADD. Depending on whose statistics you believe, about 80 percent of children and 50 percent of adults improve with medications.
"Now, some myths. Myth: ADD disappears during puberty. Myth: Physical hyperactivity must be present to confirm an AD/HD diagnosis. Myth: Positive response to medication is confirmation of diagnosis. Myth: Distractibility is responsive to will. Myth: ADD can be prevented with good prenatal care. Myth: Good parenting can prevent much of the acting out in ADD children. Myth: By extension, poor parenting is responsible for behavior problems in ADD children. Myth: Parents who medicate their children are trying to make their own lives easier. Myth: ADD medication removes will and creativity.
"The defining feature of ADD, as the name indicates, is a problem with 'attending,' which may be defined as focusing selectively on an intended stimulus, sustaining that focus and shifting it at will. The following characteristics are the result of disordered attending: difficulty focusing attention; poor organization and task completion; low stress tolerance; hyperactivity; impulsivity; mood swings; difficulty with time management; trouble with transitions; and perfectionism, or black-and-white thinking.
"ADD has been medically described for almost 100 years as minimal brain damage (MBD), hyperkinetic reaction of childhood (HRC), attention-deficit disorder (ADD) and, most recently, attention-deficit/hyperactivity disorder (AD/HD). The consistent recognition of ADD began when the first amphetamine studies were published in l988, just as child psychiatry really differentiated itself from its origins in adult psychiatry.
"Motor hyperactivity dominated early thinking about ADD, both because it was such a dramatic problem and because it seemed to respond so markedly to the use of stimulants. But because motor hyperactivity tends to lessen with age, the idea that ADD was primarily a childhood disorder--outgrown when the hyperactivity was no longer overt--became popular, fanned by ADD's placement in the child psychiatry section of the Diagnostic and Statistical Manual (DSM). We now know that ADD persists beyond childhood and that overt symptoms of hyperactivity are not necessarily present in every ADDer. ADDers can appear 'driven' or 'dreamy/spacey,' hyperactive or inattentive, or a combination of both.
"Although everyone gets distracted sometimes, an ADD diagnosis is one of degree and persistence. An individual must present symptoms severe enough to be clearly maladaptive and inconsistent with his or her developmental level and to have caused some evident impairments since childhood in at least two settings (for instance, at home and at work or school). There is no blood test, CT scan or other fully researched quantitative measure of ADD, so diagnosis relies heavily on anecdotal evidence. We know the disorder only by the prevalence, persistence and degree of disability caused by its presenting symptoms.
"The efficacy of Ritalin in treating ADD may seem surprising given that Ritalin is a stimulant medication. If ADDers seem overstimulated, why would a stimulant calm them down? The answer seems to be that some neurons are working overtime while others are underfunctioning in a person with ADD. Stimulating the latter actually brings about a balance.
"Contrary to the long-standing misconception, stimulants work exactly the same way on an ADDer's brain as on anybody else's--they stimulate specific neurons, causing them to secrete neurotransmitters (chemical messengers that brain cells use to communicate). The symptoms of ADD are caused by a need for stimulation in exactly those sites where stimulant medications such as Ritalin work.
"Thanks to the work of Alan Zametkin of the National Institute of Mental Health and his associates, published in 1990, and the ongoing work of ADD doctors such as Daniel Amen (author of Windows into the ADD Mind), we are beginning to gain insight into which areas of the brain are not functioning normally when ADDers attempt to concentrate on certain types of tasks. ADDers exhibit underfunctioning in the prefrontal cortex, the area of the brain that secretes many of the neurotransmitters signaling the brain to pay attention to specific stimuli and to ignore others. There is much less activity in the brain of an ADDer in those areas responsible for filtering and focusing, compared with the brain of a non-ADDer attempting the same tasks.
"The problem is compounded by the marvelous way our brain adapts to injury: when one area of the brain becomes incapacitated, new neural networks are formed in other areas to take on tasks formerly accomplished with the aid of the now injured area. Brain activity scans show that there is much more going on outside the prefrontal cortex of ADDers than in the brains of normally functioning individuals attempting the same tasks. So we ADDers, with disabled brain areas for filtering and focusing, have more stimulation from the rest of the brain than our non-ADD counterparts, who do have filters. No wonder we get distracted and a little short-tempered at the effort required to manage the informational and sensory overload!
"When the neurons in the prefrontal cortex are stimulated with medications, stimulant foods, certain 'natural' remedies (or the naturally occurring adrenaline that accompanies waiting until the last minute to attempt to do a project), the neurons produce their chemical messengers in greater supply. A non-ADDer with a normally functioning prefrontal cortex experiences an excess of these neurotransmitters and feels 'speeded up' as a result. An ADDer (having an underfunctioning prefrontal cortex) experiences a state similar to the one non-ADDers live with most of the time, and the rest of the brain stops overcompensating. Freed of the excess activity in the rest of the brain and with a sudden ability to focus, the ADDer feels calmer than before and so may appear to slow down.
"Just as no two stroke victims have identical brain injuries or compensation responses, no two ADDers have brains that underfunction and overcompensate in the same way--which is why some stroke victims recover lost functions over time when others don't, and why stimulants have different rates of effectiveness on different ADDers. And in the same way that glasses on a nearsighted child do not produce the miracle of literacy all by themselves, stimulant medications merely make the ADDer available for learning; they do not deliver the learning. There are no magic bullets, and none of us escapes the fact that living is a 'hands-on' experience. It does make a difference, however, when those 'hands' are functioning optimally.