Attention-Deficit Hyperactivity Disorder

Thomas E. Brown, Ph.D., assistant clinical professor of Psychiatry at the Yale University School of Medicine and associate director of the Yale Clinic for Attention and Related Disorders, was online Tuesday, March 21, at noon ET to field questions and comments about attention-deficit hyperactivity disorder.

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Brown is the author of "Attention Deficit Disorder: The Unfocused Mind in Children and Adults," a book published by Yale University Press that presents a new science-based understanding of attention deficit disorders across the lifespan. More information is available on his Web site: drthomasebrown.com.

The transcript follows.

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Thomas E. Brown, Ph.D.: Welcome to this online conversation about ADD/ADHD (I'll be using those two terms interchangeably throughout the session). Below is a summary of some myths and facts about ADD taken from my recent book. If you would like more information about this way of looking at ADD/ADHD, please visit my Web site www.DrThomasEBrown.com

10 Myths and Facts about Attention Deficit Disorder (ADD/ADHD)

from Attention Deficit Disorder: The Unfocused Mind in Children and Adults, by Thomas E. Brown, Ph.D. Associate Director of the Yale Clinic for Attention and Related Disorders (Yale University Press, 2005)

MYTH: ADD is just a lack of willpower. Persons with ADD focus well on things that interest them; they could focus on any other tasks if they really wanted

to.

FACT: ADD looks very much like a willpower problem, but it isn't. It's essentially a chemical problem in the management systems of the brain.

MYTH: ADD is a simple problem of being hyperactive or not listening when someone is talking to you.

FACT: ADD is a complex disorder that involves impairments in focus, organization, motivation, emotional modulation, memory, and other functions of the brain's management system.

MYTH: Brains of persons with ADD are overactive and need medication to calm down.

FACT: Underactivity of the brain's management networks is typical of persons with ADD. Effective medications increase alertness and improve communication in the brain's management system.

MYTH: ADD is simply a label for behavior problems; children with ADD jut refuse to sit still and are unwilling to listen to teachers or parents.

FACT: Many with ADD have few behavior problems, Chronic inattention symptoms cause more severe and longer-lasting problems for learning and relationships for those with ADD.

MYTH: Those who have ADD as children usually outgrow it as they enter their teens.

FACT: Often ADD impairments are not very noticeable until the teen years, when more self-management is required in school and elsewhere. And ADD may be subtle, but more disabling during adolescence than in childhood.

MYTH: Unless you have been diagnosed with ADD as a child, you can't have it as an adult.

FACT: Many adults have struggled all their lives with unrecognized ADD impairments. They haven't received help because they assumed that their chronic difficulties, like depression or anxiety, were caused by other impairments that did not respond to the usual treatments.

MYTH: Everybody has the symptoms of ADD, and anyone with adequate intelligence can overcome these difficulties.

FACT: ADD affects persons of all levels of intelligence. And although everyone sometimes has symptoms of ADD, only those with chronic impairments from these symptoms warrant an ADD diagnosis.

MYTH: Someone can't have ADD and also have depression, anxiety, or other psychiatric problems.

FACT: A person with ADD is six times more likely to have another psychiatric or learning disorder than most other people. ADD usually overlaps with other disorders.

MYTH: Medications for ADD are likely to cause longer-term problems with substance abuse or other health concerns, especially when used by children.

FACT: The risks of using appropriate medications to treat ADD are minimal, whereas the risks of not using medication to treat ADD are significant. The medications used for ADD are among the best researched for any disorder.

MYTH: ADD doesn't really cause much damage to a person's life.

FACT: Untreated or inadequately treated ADD syndrome often severely impairs leaning, family life, education, work life, social interactions, and driving safely. Most of those with ADD who receive adequate treatment, however, function quite well.

For more information about this new book, visit www.DrThomasEBrown.com

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Washington, D.C.: Good morning - what kind of parenting tips would you recommend for husbands whose wives are diagnosed with ADHD and currently taking care of their first child? Thanks.

Thomas E. Brown, Ph.D.: A parent with untreated ADHD is likely to face difficult challenges in many of the complex tasks of caring for a child, particularly when scheduling and consistency are needed. If a parent is having considerable difficulty with their own ADD symptoms, it may be helpful for them to get a good evaluation and possibly treatment for themselves. This may be helpful for them, their child and their partner.

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Bangkok, Thailand: I am a very emotionally intense and empathetic person. I have been told in the past that these traits are related to my diagnosed (and treated) ADD. However, I am curious, after a number of failed relationships in which I think I may have almost "listened and understood too much"--to the point of weirding out my partners and probably making them feel the need for space--if I should aim for other ADD people who understand my emotional intensity or if I should stay away from them because we meld and create a negative synergy.

Thomas E. Brown, Ph.D.: Some people with ADHD get along very well with other people most of the time, but some have difficulties such as you mention where they get too intense. If you're getting indications from friends or a partner that you're being too intense, ask them to give you some examples of how it happens.

If the examples sound like problems you have trouble controlling, you might want to check with your doctor to see if the difficulties might be helped by adjusting your medication treatment for ADD and/or whether you need to get some help from a therapist in developing better strategies.

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Richmond, Va.: Do you or your colleagues know of any studies that have been done to examine a possible connection between ADHD and the development of Alzheimer's or other dementia in later life? I often wonder if ADHD may be a precursor to Alzheimer's or if the two conditions are in any way correlated.

Thomas E. Brown, Ph.D.: Often adults with ADHD, diagnosed or not, worry that their frequent problems with short-term memory may be a sign of early Alzheimer's. I don't know of any research indicating that persons with ADHD have any greater likelihood of developing Alzheimer's than those without ADHD.

Short-term memory problems affect all of us from time to time as we get older, but adults with ADHD tend to have far more difficulty with remembering names, what they were about to say, where they have put things, what they were about to do, etc. than do those of similar age without ADD. Such problems with working memory are a central aspect of ADD and often improve (though not perfectly) with appropriate medication.

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Washington, D.C.: I have been in a committed relationship with my partner for many years now, though there are still times when I forget about her ADHD and become frustrated with her actions. Can you recommend books that might help me better understand her condition or see things from her perspective? Thank you.

Thomas E. Brown, Ph.D.: When one of two partners has ADHD, it's really important for the other partner to have a good understanding of what ADD/ADHD really is and what it isn't.

There are several books that can help with this: Hallowell has published Driven to Distraction and Delivered From Distraction. Solden has published Women With Attention Deficit Disorder and I've published Attention Deficit Disorder: The Unfocused Mind in Children and Adults.

However, reading is no substitute for conversation with your partner. You and your partner can both benefit from conversations in which you share information about both strengths and weaknesses that each of you sees in yourself and in the others.

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Washington, D.C.: If one has problems with staying-on-focus (becoming easily distracted, staying or getting organized) where does one go to seek help in coping or alleviating these behaviors? How does one seek to make it easier for others to cope with these behaviors (i.e., how can responsibilities in relationships be developed so that the strong and positive side of things can be utilized)?

Thomas E. Brown, Ph.D.: All of us have problems from time to time with staying on focus, getting organized, and doing what needs to be done when it should be done. That's human life!

What is distinctive about persons with ADD is that they have much more sustained and pervasive impairments from these problems which appear to result from inadequate willpower or lack of caring, when they actually result from problems in the dynamics of chemistry in neural networks that constitute the brain's management system.

The most effective way for a person with ADD/ADHD to alleviate their chronic ADD symptoms is to get a good evaluation from a clinician who knows what ADD/ADHD looks like and then, if the diagnosis is confirmed, get a trial of appropriate medication. This can make a significant positive difference for about 70-80% of adults with ADHD. For some the improvement in symptoms is huge, for others substantial, but not huge, and more others more modest.

However, medications for ADHD cure nothing, any more than eyeglasses cure poor vision. Appropriate medication simply alleviates ADD symptoms for the hours it is active. The critical element in medication for ADD is fine-tuning. The amount of stimulant medication that is optimal for any given individual, child or adult, has little to do with age, weight, or symptom severity. It has to do with how sensitive the person's body is to that particular medication. If you are taking medication and it's not working or is giving you significant side effects, talk with your physician to see if it can be better adjusted for you.

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Alexandria, Va.: Dear Dr.Brown, I had been diagnosed with ADHD a couple of years ago. The Doctor wanted to give me medication and I was a little reluctant to start taking medication at my age (51 at the time). After discussing this with my family my Son-In-Law made a very interesting observation, he said that I shouldn't change anything about me, this is what made me unique. I might add that I graduated HS with a C average, but I never attended College. I am an Inventor who holds a U.S. Patent, I'm very creative and I have a lot of energy. I've owned a couple of very successful businesses and live very comfortably. My question is, why must we always medicate everything!! Shouldn't we just be accepted for what we are and let well enough alone?

Thomas E. Brown, Ph.D.: Having symptoms of ADD doesn't necessarily mean that one needs to be treated with medication or anything else. The critical question is whether or not the person is significantly impaired by those ADD symptoms.

If there is not significant impairment in school or work, in family or social relationships, or in doing what you need to do from day to day, you probably don't want or need treatment. None of us is ever going to be perfect!

However, there are many children, adolescents and adults, including some adults well past the mid century point, who suffer considerably from ADD impairments. For them, medication may offer relief from a lot of unnecessary suffering and frustration.

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Colorado Springs, Colo.: Is the ability to just walk away from a relationship suddenly characteristic of someone with ADHD or ADD?

Same question for someone who seems intensely interested one day but then backs off the next and then "wash rinse repeat" immediately or is this more of a fear of intimacy thing?

Thomas E. Brown, Ph.D.: Many people with and without ADD/ADHD are puzzled by their tendency to suddenly feel that they want to walk away from a relationship, even when the precipitant for that feeling seems pretty insignificant, at least in retrospect. This may result from repeatedly getting into relationships with people who are not a good fit for you, or from one's own fears of making a commitment, or from a variety of other internal or external pressures.

However, many people with ADD report that they have chronic problems with giving up too quickly in their relationships with others, impulsively walking away, literally or figuratively, rather then trying to work things out together. This may be a variant of their continually needing to change the channel on TV, always looking for something else that might be more interesting.

Sometimes it is only after a long line of aborted relationships, perhaps with a couple of divorces included, that the person realizes that there is no potential partner out there who is always going to meet our expectations. Often this is matched with belated awareness that there are some persistent problems in oneself that may sometimes be difficult for any partner. Such problems are not unique to persons with ADHD! Developing and sustaining a mutually satisfying relationship is always an ongoing process and the result inevitably includes a mix of satisfactions and frustrations.

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Washington, D.C.: Hi Dr. Brown, Thanks very much for having the chat. Are there any studies or other empirical evidence of a child "outgrowing" their ADD? That is, with or without treatment, a child that once presented ADD symptoms no longer presents such symptoms now that they are older. I understand that ADD is thought to be caused by a brain chemical imbalance, but I wondered if the imbalance or at least symptoms indicative of the imbalance may go away after a number of years.

Thomas E. Brown, Ph.D.: Some preschoolers fully meet diagnostic criteria for ADHD and then, over a few years, develop so they catch up with their age mates in their ability to exercise appropriate self-management. About 20-30% of those diagnosed with ADHD in early childhood seem to outgrow the disorder as they get older, even without treatment.

However, it's usually not possible to tell in advance who will and will not outgrow their ADD symptoms. Delaying treatment may cause the child (and family) to suffer considerably in ways that may be hard to compensate for later. If a child is having significant impairment from ADD symptoms, it usually makes sense to get a careful evaluation and treatment. This should then be reviewed on an ongoing basis, at least once a year, to see if continuing treatment is needed.

For most of those with ADD/ADHD, the most difficult times are from junior high through the first few years after high school. That is the time when one is faced with the widest range of tasks to do with the least opportunity to get out from under the ones that one is not very good at.

If one is lucky, after that time one can find a niche and specialize in doing tasks that will earn a living while using one's skills and avoiding those things that are too tough to do. Many people with ADD who have really struggled in school do much better when they get out of school, into a job that fits their abilities and interests, especially if they can get a good secretary!

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Minneapolis, Minn.: How does one diagnose ADD? You say it is "essentially a chemical imbalance", does this mean there is something to measure?

Do you believe some of the children have been misdiagnosed? (I believe my step-son falls into this category.) What impact does medication have on these kids?

Thomas E. Brown, Ph.D.: There is no single test that can adequately diagnose ADHD. There is no imaging study of the brain, no blood test, no rating scale, no neuropsychological test that can, in itself, reliably determine such a diagnosis. The most effective way to assess for this complex disorder of the brain's management system is a comprehensive clinical interview with a clinician who can recognize ADD in its variety of forms and who can differentiate it from other problems that may accompany the ADD and/or may look like ADD when then problem is really something else.

We can't measure the chemical problems in the brain directly because it is not a problem of "too much salt in the soup." The problem is at the level of the countless connection points where critical neurons interface with one another. For those with ADHD, one of both of the two specific chemicals that operate the brain's management system are not released effectively or are taken back up too quickly at these countless points of connection. The process occurs in widespread areas within milliseconds. We don't have technology to measure this for clinical purposes. Our best tool is to get a good history of the person's strengths and problems in everyday life. With that, the diagnosis can be reliably made.

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Thomas E. Brown, Ph.D.: The time we have for this discussion is now up. Sorry I wasn't able to respond to all of the many questions submitted. If you want more information, please check the Web sites at chadd.org and add.org and/or my Web site DrThomasEBrown.com. Thanks very much for your interest.

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