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Attention deficit disorder (ADD), termed attention deficit/hyperactivity disorder predominantly inactive by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), represents one of the two types of attention deficit hyperactivity disorder (ADHD). ADD has much in common with the other subtypes of ADHD, although it differs in having fewer, if any, symptoms of impulsiveness or hyperactivity. Instead, ADD is characterized chiefly by inattentive concentration and a deficit of sustained attention, which often manifests itself as forgetfulness, hesitation, or procrastination in patients. Untreated ADD can greatly reduce the productivity of students or workers. Studies examining the costs of illness related to ADD indicate that it averages about $15,000 per student per year for those aged 18 and under. These costs will increase as patients grow older. As a result, many schools, businesses, or other organizations, as well as individuals with ADD and their families, seek ways to respond to a diagnosis of the disorder. A market for pharmaceuticals that treat ADD has developed as a result.
The definition of ADD, the signs and symptoms used to diagnose it, the classification of patients with the disorder, and the treatment options have evolved over the years. The third edition of the DSM had identified daydreaming, drowsiness, and sluggishness as characteristics of ADD, but the DSM-IV removed these symptoms. It is difficult to define precisely how many children and adults suffer from ADD globally, in part because of differing definitions of the disorder. In the United Kingdom, for example, less than 1 percent of children are diagnosed with attention deficit or hyperactivity disorders. In the United States, by contrast, approximately 10 percent of children are diagnosed with the disorder. Many believe that 1 to 5 percent of humans have ADHD or ADD, and boys are more often diagnosed with the disorder than girls.
Some have criticized definitions of ADD and ADHD as being too centered on the behaviors of children and consequently failing to identify how the disorder is manifested in adults. ADHD has nine identified symptoms:
- Fidgeting with or tapping one’s hands or squirming in one’s seat
- Exhibiting an inability to play or engage in other activities quietly
- Leaving one’s seat in those situations where remaining seated is expected, such as in the classroom, the office or other workplace, or other situations where remaining in place is the norm
- Running or climbing about in inappropriate situations, although in adults this may be manifested by restlessness or other movements
- Blurting out answers in class before the question has been completed, completing the sentences of others, or exhibiting an inability to await one’s turn in a conversation
- Demonstrating an inability to be still for extended periods of time, as is required in restaurants or meetings, which may be perceived as being restless or difficult to keep up with by others
- Interrupting or intruding on the conversations or activities of others or using others’ property without permission
- Having difficulty waiting in line or waiting for one’s turn
Because these behaviors are disruptive in classroom or other settings, they are easily spotted and more frequently reported than the more subtle indicators of ADD.
Like ADHD, ADD has nine identified symptoms, which must be noticed by teachers, parents, or others before the process of making a diagnosis can begin. These nine symptoms are as follows:
- Failing to follow through on instructions and failing to finish schoolwork, household chores, or assignments in the workplace
- Demonstrating difficulty sustaining attention while engaged in tasks or activities, such as being unable to remain focused during lectures, while engaged in conversation, or while reading
- Overlooking or missing details while engaged in schoolwork or other tasks because of a failure to pay close attention or making careless mistakes
- Appearing unable or unwilling to listen when spoken to directly, such as when one’s mind appears to be elsewhere in the absence of obvious distractions
- Displaying an inability to follow through on instructions, starting a task but then letting it fizzle out, or failing to finish schoolwork, chores, or duties in the workplace
- Allowing extraneous stimuli to easily distract one’s attention and focus
- Avoiding or demonstrating reluctance to engage in tasks requiring sustained mental effort
- Losing or misplacing the tools, equipment, or data necessary for tasks or activities
- Exhibiting excessive forgetfulness in daily activities
For a diagnosis of ADD, children younger than 17 years must exhibit at least six of the nine inattentive symptoms, while those older than 17 years must exhibit at least five of the nine. This difference in the number of symptoms exhibited occurs because symptoms tend to dissipate as the individual grows older and a lower symptom threshold is necessary to make an accurate diagnosis. Those diagnosed with ADD are often offered a variety of treatment options, including counseling, behavior modification training, and drug therapy. If 5 percent of all children and adolescents in the United States require treatment, it could cost nearly $45 billion per year. The costs incurred as a result of ADD include increased expenditures for education, the juvenile justice system, and discipline, as well as costs due to loss of parental work.
Treatment And Prognosis
Although a variety of treatment options exist for those diagnosed with ADD, these therapies often do not cure ADD. Indeed, when medication is used to treat ADD, it ameliorates the symptoms of the condition, but if the treatment stops, the symptoms will return. As a result, some prefer behavior modification therapy as it tends to provide the patient with the tools needed to deal with the disorder. In addition, some believe that ADD is sometimes “outgrown” as patients mature, with symptoms declining in severity or disappearing completely.
Pharmaceutical treatment of ADD is attractive because it ameliorates or masks the symptoms of the disorder, permitting patients to go about their daily lives with fewer impediments. Some of the more popular pharmaceuticals used to treat those diagnosed with ADD are Adderall, Ritalin, and Strattera. Adderall, or amphetamine-mixed salts, is a fast-acting stimulant produced in both short-and long-acting formulations. Adderall induces reuptake inhibition of dopamine and norepinephrine while also increasing the incidence of the release of these neurotransmitters into the synaptic cleft. Because Adderall is often better tolerated in patients than methylphenidates (e.g., Ritalin) and since it has a better cardiovascular disease profile than other options, Adderall is often the first drug prescribed to those with ADD, especially adults with the disorder.
Ritalin is a fast-acting methylphenidate, produced in both short-and long-acting formulations. Ritalin produces dopamine reuptake inhibition and also works to a lesser extent to encourage norepinephrine reuptake inhibition. Ritalin has been demonstrated to be well tolerated by most patients, including adults, in the short term. Because Ritalin can cause significant increases in blood pressure, however, and since few long-term studies have been conducted regarding its long-term effects on adults, it is used less frequently with adults with ADD than other options.
Strattera is the brand name for atomoxetine, a slow and long-acting stimulant. Strattera works chiefly as a norepinephrine reuptake inhibitor, and to a lesser extent as a dopamine reuptake inhibitor. Although prescribed for those with ADHD, Strattera seems to be especially effective for those with ADD. Strattera is especially useful when prescribed for adults who do not obtain sufficient vigilant concentration response from Adderall or who suffer too many side effects from other drugs. A variety of other alternative therapies for treating ADD exist, including histaminergic and cholinergic medications, but these have a much smaller research base than other treatment options.
Children who have been diagnosed with ADD are at greater risk of academic failure, early withdrawal from school, or other problems than those who do not have ADD. The reasons for these problems are several. Parents and teachers often make incorrect assumptions about the attitudes, behaviors, and work ethics of children with ADD, providing them with plentiful and incorrect negative feedback for their efforts. Children with ADD are often branded as lazy, careless, irresponsible, immature, and unconcerned about their academic success. Children with ADD may also develop a sense of fear when faced with structured assignments or planned work despite an inherent love of learning. Diagnoses of ADD have increased dramatically over the past 25 years, from approximately 600,000 children prescribed medication for ADD in 1990 to nearly 3.6 million today. While many estimate that approximately 5 percent of American youth have ADD, nearly 15 percent of high school children in the United States have been diagnosed with this condition. This overdiagnosis results in expenditure of nearly $100 billion annually for unnecessary treatment and other expenses. Shortages of certain popular ADD medications may also be linked to the overdiagnosis of the condition.
The symptoms of ADD are less overt in adults. This is because adults are able to make cognitive adjustments to control ADD symptoms. It also seems likely that over time, adults are able to develop coping skills that minimize the effect of inattentiveness symptoms, which allows them to compensate for problems and be more successful in academic or workplace settings. Inattentive individuals often come to understand that they are somehow internally different from their peers. The continuous negative feedback that many such individuals have received often becomes internalized, creating a negative self-image that in turn becomes self-reinforcing. Employers, academic institutions, and the individuals themselves have an interest in correcting this, as a poor self-image can create numerous and severe problems related to the maintenance of healthy peer relationships, success at workplace tasks, and success in training initiatives.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Publishing, 2013.
- Brown, Thomas Attention Deficit Disorder: The Unfocused Mind in Children and Adults. New Haven, CT: Yale University Press, 2005.
- Hallowell, Edward and John J. Ratey. Driven to Distraction: Recognizing and Coping With Attention Deficit Disorder From Childhood Through Adulthood. New York: Anchor Books, 2011.