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April 2001
ATTENTION DEFICIT HYPERACTIVITY DISORDER: A MORE PRECISE DESCRIPTION
By Alan M. Solomon, Ph.D.

Attention Deficit Hyperactivity Disorder is a real clinical phenomenon. A previous article on our website, therapyinla.com, provided evidence to substantiate that fact. (See "Attention Deficit Disorder: Myth or Reality" September, 1998 article.) ADHD affects 5-10% of all children, is correlated with differences in brain structure compared to a non-ADHD population, and manifests as behavioral difficulties in attention/focus, levels of activity, and self-control. There are often additional difficulties with behavior, social relationships, emotional issues, and academic functioning. More precise measurements are now available which have begun to identify more complicated versions of ADHD, allowing clinicians to develop more targeted, comprehensive, and sophisticated interventions as well.

In fact, over the last decade or so, Dr. Daniel Amen, a psychiatrist in Northern California, has been measuring brain activity in children and adults with ADHD, using the latest in brain scan technology available. He has been able to identify six subtypes of ADHD overall, four more types in addition to the two "classic" types of ADD with hyperactivity and ADD without hyperactivity. A short description follows for each of the six subtypes. Types three to six include ADD behaviors of type one or two, but also show additional serious difficulties.

Type 1: Classic ADD

Restlessness, hyperactivity, constant motion, troubles sitting still, talkative, impulsive behavior, lack of thinking ahead (see previous article on ADHD).

Type 2: Inattentive ADD

Short attention span (especially about routine matters), distractibility, disorganization, procrastination, poor follow-through/task completion (see previous article on ADD).

Type 3: Overfocused ADD

Worrying, holds grudges, stuck on thoughts, stuck on behaviors, addictive behaviors, oppositional/argumentative.

This is the kind of child who worries about things turning out exactly as he anticipates or wishes, gets extremely upset when his wishes are not satisfied, and then may argue intensely and without end to "get his way". He may engage in ritualistic behaviors that must be followed, or else intense upset occurs. This child lacks flexibility in his thinking, has great difficulty shifting his attention away from whatever is his current focus, and is often unable to see options, to go with the flow, or to cooperate with others in situations. There are often other family members with similar characteristics of being overfocused. This can also be thought of as Obsessive-Compulsive ADD.

Type 4: Limbic ADD

Sad, moody, irritable, negative thoughts, low motivation, sleep/appetite problems, social isolation, finds little pleasure.

The limbic system is the part of the brain responsible for emotions, basic drives for food, sleep, comfort, and sex, and for motivation to work and perform. Difficulties in this area often develop into depressive symptoms, which for children may manifest as irritability/anger more than the sadness/low energy seen in adults. This might be thought of as Depressive ADD.

Type 5: Temporal Lobe ADD

Inattentive/spacey/confused, emotional instability, memory problems, periodic intense anxiety, periodic outbursts of aggressive behavior seemingly triggered by small events or intense angry criticisms directed at himself for failures and frustrations, overly sensitive to criticism and slights by others, frequent headaches and/or stomachaches, learning difficulties, and serious misperceptions/distortions of people and situations.

This kind of child struggles greatly to read social cues, understand facial expressions, and appreciate tone of voice. He may not "get the message" in social situations unless it is spelled out clearly, in bold letters, repeatedly, and then may make the same mistake the next time in the same or similar situation. His misperceptions may be very dramatic, such that typical teasing/joking/"messing with each other" that kids engage in may be felt to be severe personal attacks, which prompt intense retaliations. He may also not appreciate the impact of his own behavior, failing to see how he may be provoking/irritating to others. Learning difficulties may involve auditory and/or visual processing deficits - the kind of learning disabilities that can be assessed with standard testing instruments. This kind of ADD may be thought of as Explosive ADD.

Type 6: Ring of Fire ADD

A ring of overactivity in the brain scan image which surrounds most of the brain is the source of the name for this type of ADD. It is characterized by too many thoughts, very hyper behavior, very hyper verbal expressiveness, a hypersensitivity to light, sound, taste, or touch. This child is often easily distracted, aggressive, oppositional, and moody. His thoughts may "race" with overly grand ideas and expectations. The changes in behavior observed in this child may occur on a cyclical basis. This is ADD with Bipolar features, often a manic quality that is difficult to manage. Dr. Amen suggests different interventions for each subtype of ADD. He suggests other interventions in addition to medication.

Type 1: Classic ADD

Stimulant medication (Ritalin, Adderall, etc.), a diet with more protein and less carbohydrates, intense aerobic exercise.

Type 2: Inattentive ADD

Stimulant medication, perhaps stimulating antidepressants (Welbutrin, for example), a diet with more protein and less carbohydrates, intense aerobic exercise.

Type 3: Overfocused ADD

An antidepressant that has a dual focus on two brain transmitters (seratonin and dopamine) (Effexor, for example), and/or an antidepressant that enhances seratonin (Prozac, Zoloft, Paxil, or others, for example). A stimulant medication may need to be added. A diet with less protein and increased complex carbohydrates will help, along with intense aerobic exercise.

Type 4: Limbic ADD

An antidepressant that is also stimulating (Effexor or Welbutrin, for example), with a stimulant medication could be added; a balanced diet, and intense exercise.

Type 5: Temporal Lobe ADD

Anticonvulsant medication (Neurontin, Depakote for example), a stimulant could be added; a diet with more protein and less simple carbohydrates.

Type 6: Ring of Fire ADD

Anticonvulsant medication (Neurontin, Depakote for example, a stimulant medication could be added; sometimes some of the newer, different anti-psychotic medications may help (Risperdal, or Zyprexa); a diet with more protein and less simple carbohydrates.

There are several typical lifestyle choices that worsen ADD significantly. Television viewing and/or videogames in large amounts make ADD much worse, probably because these activities deplete the brain of chemicals needed for attention/focus, self-control, and social-emotional interactions. A lack of exercise, too many simple carbohydrates (high sugar content), and caffeine also negatively impact ADD. Nicotine worsens ADD.

As discussed in the previous article, professional help with an experienced psychologist is essential which may include counseling for the individual with ADD, counseling for parents and family members, social training groups with peers, adjustments in school programming (which may require advocacy with school district officials), additional educational help on a more individual basis, and involvement in support groups for the parents. A thorough evaluation by a psychologist before any intervention is attempted is strongly recommended. Medication efforts under the care of a psychiatrist with expertise and experience in treating ADD (rather than a family physician or pediatrician) is also preferable, to insure that more skilled and sensitively attuned adjustments can be made in any medication that is being used.

Dr. Amen's clinic in Northern California can be reached at (707) 429-7181, or, online at www.amenclinic.com. A wide range of reading materials can be ordered at MindWorks Press at the same phone number, or online at www.mindworkspress.com.

Dr. Solomon is a psychotherapist in practice in Los Angeles. He is a member of the Independent Psychotherapy Network.

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