It seems that ADD is more prevalent today. Why is that?

There are many possible factors for the increased incidence of ADD. One obvious factor is that we now include inattentive or non-hyperactive ADD under the ADD umbrella. In the “old days” the incidence rates of hyperactive ADD were about 1.5%. Today incidence rates for ADD tend to run around 6%, but half of that is for the “new ADD”, i.e. inattentive ADD. Still, that would account for only part of the increase. The rest is likely due to more careful diagnosis. We look for it where we may have diagnosed a behavior problem in the past. Milder cases of ADD are more likely to be diagnosed today. I personally don’t feel there is an ADD upsurge but some see ADD as increasing in numbers and severity, possibly due to environmental factors such as pollutants, chemical additives, etc.

Is medication essential in treating ADD?

Hyperactive ADD generally requires some medication management, usually one of the stimulants. Milder cases may not require medication; they may be managed with some minor changes in the environment such as testing in a quiet area. Time management and organizational training may be sufficient. Younger children are just not mature enough to manage themselves well generally. Daily medication may be needed with these children. They simply don’t have the coping skills needed. Inattentive ADD sometimes responds well to stimulants but they often need lower doses and breaks over the weekend and vacations to minimize side effects.

How fast does medication work?

Stimulants work very fast. There often is a noticeable improvement on day one. This can alarm parents who may feel their child is being “sedated”. Usually excessive lowering of activity and energy passes after a few days or it can be avoided by reducing the dosage. Side effects generally appear quickly too. The child may be very agitated, have headaches or become angry. If this occurs you should call the doctor right away. Children who have tic disorder (sudden involuntary muscular twitches), Tourette’s syndrome (tics usually with grunts, noises, or even swearing) or seizure disorder should be cautious about stimulant medication and carefully monitored by their doctor.

What other medications are available?

You can speak with your doctor, of course. Other medications are added to stimulants to address mood and severe behavior related issues. Antihypertensive medication is often used to help decrease anxiety and anger. Mood stabilizer medication may be useful in more extreme cases. Atypical antipsychotic medication can also be used with anger management cases. Antidepressants can be useful in managing mood and anxiety. These medications may be used alone or in combination with stimulants.

What are the behavioral approaches to managing ADD?

Medication is not the only ADD treatment. Parents and adults often prefer to manage their environment and work on developing routines to manage their ADD. They need to work on cleaning and simplifying their work area. They need to work on self monitoring and self managing ADD by: setting mini-goals; self coaching; positive self reinforcement; managing setbacks; seeking help appropriately; and better time management.

Why don’t rewards and punishments work?

Rewards don’t work because they are usually tied to product, not process. Parents and teachers give some kind of reward when a task is completed. This is often difficult or impossible for the ADD child. They don’t have the skills needed to get there, or the patience to sustain the effort. Rewards just irritate them because the reward is delayed or denied. The main rewards should be at the front end of the project: positive self statements, clean work area, breaking tasks down, skipping a difficult problem (not staying stuck) after a reasonable effort, asking for help appropriately, returning to the task after a short break, identifying positive effort and outcome, filing materials at the end, cleanup, etc. Punishments don’t work because they are a reward- the child is not doing the task. They don’t work because they seem arbitrary and unfair. They don’t work because they teach the child to develop more subtle ways to avoid and undermine the work and the punishment. They don’t work most of all because they don’t teach the skills needed to complete tasks.

Should medication be taken at college?

This is an important question for parents. Many college students give their medication to others to help them “pull and all nighter”. Some sell it. Unless your child has had a history of irresponsible use of medication, I would generally urge medication use in college. The dosage and timing may have to vary a bit as their “work day” may vary greatly. Don’t forget the college student is generally likely to face far more work in a shorter period of time than the typical high school semester.

If there is no family history, is it ADD?

ADD is generally inherited although it can be caused by other factors such as birth injury, drug or alcohol use in pregnancy, premature delivery and low birth weight, head injury or very high fever. If there is no family history, you might look for ADD “masked” as something else in the family. There may be “self medication” with alcohol or drugs, delinquency or criminal behavior due to impulse control issues, significant underachievement at school or work relative to intelligence, etc. Maybe nobody thought to call it ADD or investigate it.

When should there be a referral for diagnosis and treatment?

I suggest that the “functional deficit rule” might apply to the question. When the child or adult is significantly underachieving in their life, that should be a reason for referral. I would add emotion or behavior management problems are strong indicators for referral. The child often communicates their discomfort indirectly with headaches, need to go to the bathroom, anger issues. They may not say they have an attention problem. Their emotion and behavior problems tell you they are stressed.

What should we expect from school?

If a parent suspects ADD issues are creating problems for their child, they should conference with the teacher as early as possible in the school year. There should be good knowledge regarding possible problems after the first 6 weeks. Waiting until mid year may delay testing and changes in the educational plan until the next academic year. A meeting with the school psychologist, teacher, principal and other specialists (e.g. reading, occupational therapy) is usually the next step. Some observations in the classroom, teacher and parent ratings and testing may be next. Testing by a school psychologist is often done. However, this may only involve rating scales completed by the teacher and parent, or it may only involve a general IQ test or a few achievement tests. If the evaluation seems insufficient, it probably is. Parents should push for a thorough assessment that will answer questions about attention problems and as well as academic skills. Finally, if there seems to be a significant problem a formal committee meeting is set up to develop an educational plan. Accommodations usually include preferential seating up front and extended testing time in a quiet area. Many children also need assignments broken down into smaller segments with frequent checking by the teacher. They may need help with note taking. They may be behind in basic skills and therefore will need extra remediation assistance to develop reading, writing or math skills.

How can a parent advocate without being adversarial?

Parents are often frustrated with delays in testing, shortened versions of testing, acceptance of mediocre or average work, delays in implementing special services, and failure to implement the educational plan consistently. Schools have limited budgets and competing interests which need to be balanced. Your child is not the only child with needs. Teachers also can be distracted by behavior problems which elicit their immediate attention, rather than addressing the underlying problems. If your child is defiant and angry, they’ll deal with that at school, not the ADD. It’s easy to get into an adversarial state with school staff, but that takes a lot of time and energy. The school has plenty of time and the rules and regulations give them plenty of power. It’s best if you take a strategy of frequent, regular meetings with key players, keep copious notes and copies of e mails and letters, communicate concerns in writing for the record, set specific goals and dates for examining progress, assign accountability, and stay focused on the ADD issue.

How do I handle a teenager who says he doesn’t need medication or extra help?

Start with respect. Inquire about the thinking and feelings that underlie that desire. Often the child has a good point. There may be some side effects to medication that are subtle, such as “flattening” of their mood and affect. They may have a sense of stigma with the diagnosis. They may honestly feel they can handle things without medication. They may simply want to assert some control over their lives. Perhaps a trial period without medication can be arranged with some objective goals set such as good school attendance, no lateness, grades maintained, no detentions, etc. At the end of the agreed time period, you both can review how it has gone. There may be a desire to self correct. I would urge parents to ask for and get an answer about how the child intends to correct the problem. The child needs to accept responsibility and work out a specific correction plan, not just “I’ll try harder”.

What career paths fit the ADD adult?

There is no right answer but hyperactive ADD adults tend to work in skilled trades or sales. Many develop their own business. Generally work that allows them to use their high energy level, requires some risk taking, and offers some novelty and change are acceptable. For non-hyperactive ADD, there may be a preference for structure and a steady but not intense flow of work. Investigative or scientific work may fit. Technician or engineering may be acceptable. ADD does not limit anyone. The ADD adult can work successfully in any field provided they develop coping skills or delegate aspects of their job that are a weakness.

Besides the attention problems are there any other problems ADD individuals face?

There appears to be a much higher risk of anxiety disorder in untreated ADD adults. There also is a much greater depression rate. Many also experience physical symptoms of protracted stress such as GIRD. Some grind their teeth at night. It stands to reason that years of frustration and failure experiences might wear you down! Often adults present emotional and behavioral problems initially, but on closer inspection they have had a lifetime of underachievement and frustration. For many, addressing the ADD issues helps out considerably in these various problem areas.

Should adults consider stimulant medication or any medication?

Yes. Adults benefit from medication management of ADD. They tend to feel they don’t need it for various reasons. They simply may be used to ADD, like a person who develops a hearing loss or vision problems. They may have adjusted their life to ADD and they may not recognize a problem in the attention area even exists. They may avoid jobs and delegate tasks that require attention to detail to others, including delegating to their spouse. They may have developed elaborate coping mechanisms to deal with the ADD. For adults who cope pretty well, medication should not be on the table. But for those who have significant functional deficits in their professional and personal life, medication may greatly improve the quality of life.

Do you recommend discussing ADD with you employer?

Generally I do not suggest that. Due to poor understanding of ADD employers may often assume one of two extreme views. They may see the employee as seeking an excuse for their problems on the job. After all, this is one handicap that doesn’t show! If you were in a wheel chair, everyone understands and accepts the handicap. They may even go overboard to help. The employer may also see the ADD employee as seriously deficient and likely to have ongoing problems. Can we trust that employee to follow through? I generally suggest that the ADD adult advocate for the conditions that will help him or her work to their potential. For example, “I work best when …”; “It would help me do my work if …”, etc. You can ask for the time, the resources, the space, the assistance- that will help you do your job.

What if the employer won’t or can’t give you what you need?

You may have to move on. You can’t work in a place that doesn’t allow for individual differences and doesn’t provide support to the employee that is reasonable. I would rather see you move on your own terms than be punished continuously and finally fired. Of course, you may want that job badly enough to get the help you need on your own. I have known adults that have hired a typist to prepare their dictated notes and reports. Some adults may decide to bring paperwork home. Some may purchase lighting, filing cabinets, noise cancellation devices, etc. that make their office space more workable. In the end, you have to be able to be successful at your job or it will end sooner or later, probably badly.

Are there any ways to control how you actually think? Can you learn to focus?

In my counseling with children and adults I have increasingly focused on helping the ADD child or adult learn to think before acting. It is difficult but not impossible. Before any transition, most people stop and think, “Do I have everything?, What will I need next? Do I have enough time to do that?” etc. Most people quickly run checklists in their mind. ADD folks often don’t even ask these questions. It’s not automatic. They need to work at pausing and thinking for a moment before acting. It sounds like a small point but it can be very helpful. You can be organized and high functioning, but there has to be a moment of planning.

What about time management training?

ADD children and adults are terrible time managers. They generally grossly underestimate the time needed for a task, then quit in frustration if they find it too difficult. Non ADD children and adults tend to run quickly through the steps of a task in their mind. They see the problem more accurately. Adults and even young children can learn to break down a task into its parts and estimate time needed for each part. They need to learn to do their work in short bursts, setting a specific goal each time (e.g. I will read 5 pages in 10 minutes, I will do 5 math problems in 15 minutes, etc.) We all work better with self imposed, reasonable goals. It’s our competitive nature. It’s also important that the child or adult learn to be increasingly self reliant in their work rather than being pressured or nagged by others

What about the workspace clutter? What can be done?

Clutter is a big problem for ADD individuals. Simplify, simplify, simplify. Like the covered wagons crossing the Rockies, throw it out if it’s not essential. The desk, walls, floor- all need to be clean and relatively distraction free. A few pictures or one poster may be enough. A clean, clutter free environment invites attention and efficient work. Having brightly colored storage bins or folders for specific material is helpful. Fewer cloths in the drawers or closet helps. Fewer toys helps. A countdown alarm is often useful to keep the work moving. Music in the background can help some children and adults. It can be background noise that blocks other conversation or noise outside the room. Work with the child or your spouse to simplify. A fresh coat of paint and indirect lighting helps the focus too. Overhead lighting tends to be glaring and shines on everything. A desk or floor lamp brings your focus in, not out.

What is the future of ADD?

That’s hard to tell. We will continue to see vast improvements in our understanding about how the brain works in the coming years. I don’t expect any miracle cure with medication. ADD is simply too complex and it involves too many systems within the brain to lend itself to a medication cure. The stimulants are still the gold standard for medication with hyperactive children and adults. Pharmaceutical companies are increasing the length of action gradually and that will continue. The next generation of stimulants will last 15 hours or more, not the current 10 to 12 hours. Employers will be more likely to accommodate to the needs of the ADD worker as acceptance and understanding gradually grows. Our views of ADD are still primitive and I expect there will be a change in the terms used to describe attention problems and better research on the types of ADD. We aren’t going to make much progress by lumping them all ADD problems together and trying to treat them all with a single approach.