Certain qualities are often associated with the American temperament. Our violent, rough-and-tumble society, our bottom-line pragmatism, our impatience, our intolerance of class distinctions, our love of intense stimulation—these qualities, which are sometimes explained by our youth as a country, may in part arise from the heavy load of ADD in our gene pool.
Since we suspect that ADD is genetically transmitted, this theory makes some sense. Although it is impossible to ascertain the prevalence of ADD in colonial Boston or Philadelphia, as you read through the lives of the adventurous souls who lived there, you can see that more than a few of them liked risk and high stimulation, balked at custom and formality, lived by innovation and invention, and rose to action rather quickly. It is dangerous to diagnose the dead, but Benjamin Franklin, for example, seems like a man with a case of ADD. Creative, impulsive, inventive, attending to many projects at a time, drawn to high stimulation through wit, politics, diplomacy, literature, science, and romance, Franklin gives us ample ground to speculate that he may have had ADD and was the happier for it.
If it is true that part of the high energy and risk-taking of our ancestors was due to ADD, then that would explain, to some extent, why our rates of ADD are higher than other people’s. But even taking that into account, might we be overdiagnosing it, or might our definition of it be so broad as to be overinclusive? Frequently, people remark when they hear a description of ADD for the first time, “But doesn’t everybody have that?” or, “Isn’t that just a variation on normal behavior?” or “How can you call it a disorder when it’s so common?”
It may seem that our cultural norms are growing closer and closer to the diagnostic criteria for ADD. Many of us, particularly those in urban areas, live in an ADD-ogenic world, one that demands speed and splintering of attention to “keep up.” The claims on our attention and the flow of information we are expected to process are enormous. The explosion of communications technology and our standard way of responding to its most ubiquitous form—television—provide good examples of ADD behavior. Remote-control switch in hand, we switch from station to station, taking in dozens of programs at once, catching a line here, an image there, getting the gist of the show in a millisecond, getting bored with it in a full second, blipping on to the next show, the next bit of stimulation, the next quick pick. In addition, now we have the constant buzz from the cyber world to add to our distraction.
Because we live in a very ADD-oid culture, almost everybody can identify with the symptoms of ADD. Most people know what it feels like to be bombarded with stimuli, to be distracted by overlapping signals all the time, to have too many obligations and not enough time to meet them, to be in a chronic hurry, to be late, to tune out quickly, to get frustrated easily, to find it difficult to slow down and relax when given the chance, to miss high stimulation when it is withdrawn, to be hooked to the phone and the fax and the computer screen and the video, to live life in a whirlwind.
That is not to say, however, that most people have ADD. What they have is what we call pseudo-ADD. As we will discuss in the chapter on diagnosis, true ADD is a medical diagnosis requiring evaluation by an expert. What differentiates pseudo-ADD from true ADD, what differentiates the people who can only identify with it from those who actually have it, is a matter of duration and intensity of the symptoms.
This is true of many psychiatric diagnoses. For example, most of us know what it feels like to be paranoid. We have all felt, at one time or another, that someone is out to get us who really isn’t. We have, most of us, felt suspicious and nervous, wondering: Are they watching me? Is the IRS out to get me? Is my boss setting me up? Was that joke at the meeting a veiled reference to me? That we experience moments of paranoia does not make us paranoid personalities, however. In the true paranoid personality, the paranoia besets the individual chronically and intensely. It is the intensity and duration of symptoms that differentiates the insecure person from the truly paranoid.
Similarly, we have all been depressed at one time or another. That does not mean we have suffered major depression. Most of us have gambled at some time—bought a lottery ticket or put a nickel in a slot machine—and felt a thrill when we won. That does not make us pathological gamblers. Most people have felt a fear of heights at times, or had trouble with closed spaces, or felt frightened of snakes, but not to the extent of developing a phobia. Only if the symptoms are more intense than is normal, if they last a long while, and if they interfere with one’s everyday life, only then can one entertain an actual diagnosis.
So it is with ADD. The person with true ADD experiences the symptoms most of the time and experiences them more intensely than the average person. Most important, the symptoms tend to interfere with everyday life more than for the average person.
It is important to keep true ADD separate from pseudo-ADD for the diagnosis to retain any serious meaning. If everybody who gets distracted or feels hurried or gets easily bored is diagnosed with ADD, then the diagnosis will signify nothing more than a passing fad. While pseudo-ADD may be interesting as a kind of metaphor for American culture, the true syndrome is no metaphor. It is a real, and sometimes crippling, biologically based condition that requires careful diagnosis and equally careful treatment.
7
How Do I Know if I Have It?
THE STEPS TOWARD DIAGNOSIS
It is arbitrary, really, where the line of diagnosis is drawn, where “normal” leaves off and ADD begins. And yet, as Edmund Burke remarked in differentiating night from day, “though there be not a clear line between them, yet no one would deny that there is a difference.”
There is a logical set of steps that lead to a diagnosis of ADD. The key to it is the history, one’s own recollection of one’s life, confirmed and amplified (particularly in diagnosing ADD in a child) by the observations of those close to one: parents, spouse, teacher, sibling, friend. There is no definitive test for ADD, no blood test or electroencephalogram reading, or CAT scan or PET scan or X-ray, no pathognomonic neurological finding or psychological testing score.
It is important to underline this point: the diagnosis of ADD is based first and foremost on the individual’s history or life story. The most important step in determining whether one has ADD is sitting down and talking to somebody who is knowledgeable in the field. The most important “test” in making the diagnosis of ADD is the taking of the individual’s history. This is old-fashioned medicine, not high-tech. This is a doctor talking to a patient, asking questions, listening to answers, drawing conclusions based upon getting to know the patient well. These days we often don’t respect or trust anything medical that doesn’t depend upon fancy technology. Yet the diagnosis of ADD depends absolutely upon the simplest of all medical procedures: the taking of a history. This is the most powerful (and, ironically, the least expensive) tool we have in making a diagnosis. Your doctor should be sure to trust it and use it before ordering complex, expensive, and sometimes unnecessary tests.
The logical steps toward diagnosis proceed as follows:
1. You Seek Help
Something happens to lead you to look for help. In children this is usually academic underachievement or disruptive behavior. In adults the inability to “get one’s act together,” chronic disorganization or procrastination, underachievement professionally, trouble staying close in a relationship, chronic anxiety or depression, substance abuse, gambling, or chronic distractibility are the leading reasons one seeks help. Most adults who have ADD do not suspect they have it. They just feel that something is amiss in some unnameable way. Many are being treated for some condition other than ADD, the ADD lying masked and undetected.
2. Review Your History
The first step in the diagnostic process is for you to find a physician knowledgeable in the field of ADD and to sit down with him or her and go over your life story. If after reviewing your history your physician decides (1) that you have the symptoms of ADD, (2) you have had them since childhood, (3) you have the symptoms to a much
greater degree than your peers of the same mental age, and (4) there is no other diagnosis that can explain your symptoms, then a presumptive diagnosis of ADD can be made.
You should keep in mind a few points concerning your history. First of all, it is best if at least two people relate the history. People with ADD are notoriously poor self-observers. The history will be much more reliable if another person is present to corroborate, enlarge upon, or give a different point of view on what you say. In the case of children, the history should be taken from the child, from parents, and from schoolteachers’ written or telephoned reports. With adults, the history should be taken from the individual in question as well as his or her spouse, or a friend or relative. If available, documents from past school and college experience can contribute to the history as well.
In reviewing your history, your physician will want to know about the following ten areas. It will make your first visit more efficient and productive if you go over these in your mind beforehand:
a. Family history. In your parents, grandparents, or extended family, is there any history of ADD or hyperactivity (not likely, since the diagnosis was not made frequently a generation ago, but if it was, it is highly significant)? Any history of related disorders such as depression, manic-depressive illness, alcoholism or other substance abuse, antisocial behavior, or dyslexia or other learning disabilities? If you are adopted, that itself is a significant finding, as ADD is much higher among the adopted than among the general population.
b. Pregnancy and birth history. Were there risk factors such as maternal drug use during pregnancy (including cigarettes and heavy alcohol use), inadequate health care during pregnancy, any trauma or oxygen deprivation during birth, any illness during the period just after birth?
c. Medical and physical factors. Your doctor will take a standard medical history, asking about past illnesses, surgeries, injuries, and so forth. There will also be questions about what medications you currently take, as well as about your use of alcohol, tobacco, cocaine, marijuana, and other drugs. A sexual history should also be included. People with ADD often have a variety of sexual problems, most commonly hyposexuality or hypersexuality.
Your physician will ask about certain specific physical factors that are often associated with ADD, including left-handedness or ambidextrousness, frequent ear infections in childhood, upper respiratory infections or other illnesses as a child, allergies, sleep disturbances, especially great difficulty in falling asleep, or frequently waking up during the night or trouble getting up in the morning, awkwardness or clumsiness or poor hand-eye coordination, bed-wetting as a child, accident-proneness as a child, or high frequency of somatic complaints as a child.
d. Review what is called your “developmental history.” At what age did you walk, talk, learn to read, etc? There are often erratic developmental patterns in people with ADD. They will have been advanced in some areas and delayed in others.
e. School history. How did you feel about school? What was it like for you? This is a key question in your history. Many people with ADD point to school as the first place they realized anything was different about them. Were you slow to learn to read, to write? Did you have trouble with organization, promptness, impulsivity? Were teacher comments full of statements such as “If only Johnny could sit still and pay attention …” or, “Johnny could do so much better if only he would buckle down …” or “Johnny is more interested in socializing than studying …”? Was underachievement a pattern? Was performance inconsistent, erratic?
f. Home history. Where younger children are concerned, the physician will ask about behavior at key times of day, such as when getting dressed in the morning, leaving for school, eating dinner with the family, making the transition from one activity to another, getting to sleep at night and getting up in the morning. In diagnosing adolescents and adults the questions will likely be about such topics as the appearance of their desks, any mess piles about house or study, and the general level of disorganization or impending chaos. There might also be questions about the number of high-stimulation gadgets owned (i.e., computers, stereos, CDs, fax machines, answering machines, video recorders, exercise machines, video games, televisions, intercoms, satellite dishes, and portable or car phones), and about length of time spent interacting with family as opposed to going from project to project or sleeping.
g. College and other educational experience. Do you recall themes of underachievement or special struggles? Any formally diagnosed learning disabilities?
h. Job history. Have you seen a pattern of underachievement, trouble with bosses, frequent job changes, or trouble with deadlines and procrastination? Do you have a tendency to be a maverick at work? Are you particularly innovative or creative? Are you a hard worker? Is saying or doing the wrong thing at the wrong time a recurring problem?
i. Interpersonal history. Have you experienced trouble staying connected, either in a conversation or in a long-term relationship? Do you particularly like people? Have you had a tendency to be misunderstood interpersonally, your inattentiveness often being mistaken for indifference?
j. Before your first visit with a professional, compare your history (or your child’s) with the defining lists of symptoms in Tables I and II and the Utah Criteria.
The formal diagnostic criteria for ADD in children, as set forth in the standard psychiatric manual, DSM-III-R (Diagnostic and Statistical Manual, third edition, revised), are summarized in Table I.
The above criteria cover children. These criteria have been statistically assessed—that is to say, they have been tested against other criteria and with various groups of children to ascertain which factors are most discriminating in diagnosing ADD. These criteria are included in the diagnostic manual of psychiatry.
As yet, we do not have formal, statistically validated criteria for the diagnosis of ADD in adults. It is only fairly recently that the syndrome has even been recognized in the adult population. However, based upon our clinical experience with hundreds of adults with ADD, we set forth the criteria in Table II for making the diagnosis of ADD in adults (this is an abbreviated version of the symptoms discussed in chapter 3).
In addition to the criteria above, also rate yourself using Paul Wender’s Utah Criteria. (These are referred to as the Utah Criteria because Wender is professor of psychiatry at the University of Utah School of Medicine.)
Whatever diagnostic criteria one refers to, it cannot be stressed too firmly how important it is not to diagnose oneself. While the information and examples presented here may lead you to suspect that you or your child or a relative has ADD, an evaluation by a physician to confirm the diagnosis and to rule out other conditions is essential.
3. Consider All Possibilities
In making the diagnosis, your physician must also rule out other conditions that can look like ADD as well as look for conditions that may occur with ADD. Often the diagnosis of ADD is missed because the ADD is masked by some coexisting condition such as substance abuse, depression, or anxiety. At other times the diagnosis is made incorrectly when some medical condition such as hyperthyroidism is causing the symptoms.
Table IV lists some of the conditions that may resemble ADD and need to be ruled out in making the diagnosis, and some of the conditions that may accompany or mask ADD. While you may not know the exact nature of all the diagnoses in the list, it can be used as a point of reference to ask your doctor about.
Most of these require an evaluation by a physician. Certain blood tests may need to be ordered, such as thyroid-function tests, or other kinds of medical diagnostic tests may be indicated, such as an electroencephalogram. These are not always indicated, however. Your physician will determine if they are.
Although a full discussion of what physicians call the differential diagnosis—the complete list of possibilities that must be considered before confirming one diagnosis—would require more medical knowledge than this book presumes, a few remarks should be made.
* * *
TABL
E I
DIAGNOSTIC CRITERIA FOR ATTENTION-DEFICIT HYPERACTIVITY DISORDER IN CHILDREN
(according to DSM-III-R)
NOTE: Consider a criterion met only if the behavior is considerably more frequent than that of most people of the same mental age.
A. A disturbance of at least six months during which at least eight of the following are present:
1. Often fidgets with hands or feet or squirms in seat (in adolescents [or adults] may be limited to subjective feelings of restlessness).
2. Has difficulty remaining in seat when required to do so.
3. Is easily distracted by extraneous stimuli.
4. Has difficulty awaiting turn in games or group situations.
5. Often blurts out answers to questions before they have been completed.
6. Has difficulty following through on instructions from others.
7. Has difficulty sustaining attention in tasks or play activities.
8. Often shifts from one uncompleted activity to another.
9. Has difficulty playing quietly.
10. Often talks excessively.
11. Often interrupts or intrudes on others.
12. Often does not seem to listen to what is being said to him or her.
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