Attention Deficit Disorder

Attention Deficit Disorder is a complex condition that is not well understood at the present time by many clinicians and the general public. New information is being discovered rapidly however. Dr. Amen is one of the pioneers in this field and this article is meant to summarize his work.

Attention Deficit Disorder (ADD) and Attention Deficit Disorder with Hyperactivity (ADHD) occur as a result of neurological dysfunction in the prefrontal cortex of the brain. This is the newest part of our tri-brain system in evolutionary terms. It is the part of our brain that performs executive functions. The functions of this brain deal with 1) attention span, 2) perseverance, 3) judgment, 4) organization, 5) impulse control, 6) self-monitoring and supervision, 7) problem solving, 8) critical thinking, 9) forward thinking, 10) learning from experience, 11) ability to feel and express emotions, 12) interaction with the limbic system, and 13) empathy.

Whenever there is a problem with this part of the brain, a number of skills that many human beings take for granted would not be available in any optimal way. The following are problems that develop when the prefrontal cortex is affected. 1) Short attention span, 2) distractibility, 3) lack of perseverance, 4) impulse control problems, 5) hyperactivity, 6) chronic lateness and poor time management, 7) disorganization, 8) procrastination, 9) unavailability of emotions, 10) misperceptions, 11) poor judgment, 12) trouble learning from experience, 13) short-term memory loss, and 14) social and test anxiety.

The exact neurological problem with ADD is unknown at this time. However SPECT scans, single photon emission computed tomography, which measures cerebral blood flow and metabolic activity patterns, has noted that when someone with ADD concentrates, their prefrontal lobe activity decreases significantly. This essentially means that under stress and concentration someone with these disorders cannot bring to bear their full cognitive capacity.

It is theorized that our usual ability to screen out and attend to stimuli of our choice is impaired with these individuals. I like to think of it as going to the mall during the summer. It is too bright and there are too many people around, but it is not overwhelming.  However, at Christmas time after a couple of hours at the mall people are so over-stimulated that it is hard to find the car. People with ADD feel this way almost all the time.

There are five recommended courses of treatment for someone with ADD or ADHD. Physicians often give an antidepressant such as Wellbutrin and Strattera, which tends to calm the limbic system and increase dopamine, a neurotransmitter. In my experience as a therapist, this can be helpful but stimulants, the second course, seem to do a better job. Stimulants given in small doses, so the mood alteration is minimal, act in a paradoxical manner. This means that instead of accelerating a person they help to focus and calm them while still allowing the prefrontal lobe to remain active. They also seem to increase dopamine. This neurotransmitter is negatively affected with people suffering from ADD. The third regimen, a combination of an anti-depressant and a stimulant, seems to work best for most people suffering from most forms of ADD. The fourth treatment consists of teaching relaxation, stress-management, organizational, and socializing skills. This should always be included as part of treatment whether or not medication is used.

Another form of treatment is the naturopathic approach. Due to my background I cannot adequately discuss this method, and as yet am not sufficiently familiar with the treatment to be able to measure its efficacy. At the present time, supplements, vitamins and chiropractic care seem to be effective as an adjunct to stimulants.

There are numerous misconceptions about Attention Deficit Disorder and a lot of emotional fervor about the diagnosis. It reminds me of the debate over Prozac several years ago or whether or not Alcoholism is a disease or a moral defect. It is understandable that people worry about giving young children a mood-altering drug. However, any time medication is considered as an approach, the physician needs to carefully assess both the costs the benefits and the severity of the problem. Most medication difficulties with ADD result from mismanagement. When the appropriate amount of medication is used with ADD the benefits are immense and the cost is minimal. A person’s life changes dramatically for the better. It is as if for the first time a person can think clearly and their self-esteem soars.

There is still a tendency in this country to feel that people need to pull themselves up by the bootstraps regardless of the severity of the problem. They are often blamed for their own illness. This happens a lot with ADD.

True ADHD with hyperactivity is rather easy to diagnose. However, only in the last ten years was ADD inattentive type recognized. This diagnosis is hard to spot and often is characterized by a general spacyness and inability to track conversations. It also used to be common knowledge that children were the only ones to suffer from this disorder and that once they became 14 they grew out of it. What is more common is that in the normal course of experimentation with drugs and alcohol a person with this disorder finds amphetamines and becomes addicted to them. Almost the right drug, wrong dose! Most people do not grow out of the disease. Interestingly enough, even with hard-core Methadrine addicts, if they are put on a small dose of Adderall, 20- 30 mg. of sustained release 1-2 times a day, they thrive and it does not reactivate the addictive process.

Dr. Daniel G. Amen is one of the acknowledged leaders in the field for the study of Attention Deficit Disorder. He has expanded the classifications of this condition within the last two years from the standard two types of Hyperactive and Inattentive by adding four more distinct types of ADD. He has done this by exhaustive research and has been aided by the SPECT scan, which is a sophisticated brain scanning tool that measures and clearly shows what part of the brain is most active. What is most impressive about his work is that he stresses the need for a multi-treatment approach. This includes attention to diet, exercise, vitamins, supplements, traditional psychotropic drugs, and behavioral techniques.

In “Healing ADD” Dr. Amen lists the six types of ADD as 1) Classic hyperactive, 2) Inattentive, 3) Over focused, 4) Temporal, 5) Limbic, and 6) Ring of Fire. Each of these types has much in common, but also differences in symptoms and treatment.

All of the types of ADD have as their primary feature periodic impairment of the prefrontal cortex of the brain and dopamine involvement. Classic ADD is characterized by both hyperactivity and inattentiveness. It is usually quite easy to treat by a combination of a high protein diet, aerobic exercise, a stimulant such as Adderall or Ritalin, and possibly the supplement of L-Tyrosine. Often an anti-depressant is used as well.

Inattentive ADD lacks the hyperactivity, but people who suffer from it have a difficult time focusing and are often very scattered. As with the classic type the prefrontal cortex is involved. The treatment for inattentive ADD is usually exactly the same as the classic type.

Overfocused ADD exhibits the same problems and symptoms of prefrontal cortex as with classic and inattentive ADD, but the difference is that the sufferer of over focused often cannot break away from a thought or behavior. This is because the cingulate system of the brain is overactive and often locks a person into self-destructive, negative, or repetitive behavior. Often a stimulant will cause temper problems if used alone. Therefore, it is usually helpful to have the person take an anti-depressant first and only later to add the stimulant. Another possible treatment is to use St. Johns Wort, a natural herbal anti-depressant, but it is important not to use both a traditional and an herbal anti-depressant at the same time. The other forms of treatment such as diet and exercise is the same as the first two types of ADD.

Temporal ADD is still characterized by problems with the prefrontal cortex, but the temporal area of the brain is often affected. This could be from a previous head injury, but not necessarily. All the symptoms remain the same, but often extreme bouts of anger are also included.  The treatment for this type is usually a stimulant and an anti-convulsant such as Depecote. All other treatment is the same except the following supplements can be used: GABA, Ginkgo Biloba, or Vitamin E.

Limbic ADD is when the limbic area of the brain is also affected in addition to the prefrontal cortex. This type of ADD has the symptoms of inattentive ADD, but a significant amount of depression is also present. A stimulant and an anti-depressant are indicated. Aerobic exercise is needed, but often a complex carbohydrate and protein mixed diet is indicated. The following supplements are used:  SAMe or L-tyrosine.

Ring of Fire ADD is a very disorganized and severe form of ADD that is a combination of all the other types. The entire brain is lit up on a SPECT scan. In addition to the standard treatment of a stimulant and an anti-depressant, an anti-psychotic like Respiridal is often called for. Dietary and exercise treatment is the same as in inattentive type. The following supplements are possibly needed: GABA or Omega-3. Other supplements that have been found helpful with ADD in general are Zinc, Flax seed oil, and Serephos.

Attention Deficit Disorder is a neurological dysfunction that has no known cure at the present time. However, the good news is that effective treatment is available and following the protocol can improve how a person feels and functions more dramatically than many psychiatric conditions. What I find so attractive about the work of Dr. Amen is that he treats the whole person. He stresses the need for appropriate psychotropic medication, but also believes that a clinician needs to pay attention to diet, exercise, and behavioral strategies to fully address ADD.

© 2003 Jef Gazley, M.S., LMFT www.asktheinternettherapist.com

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