(editors note) This month we are fortunate to present an interview with Ron Weinstein a specialist in attention deficit disorders, learning problems and behavioral difficulties in children, adolescents and adults. Ron was diagnosed with ADHD in 1990.

There has been considerable media attention surrounding ADD/ADHD and it has been called "the disease of the '90's. Can you explain what ADD is? 

A.D.D. or Attention Deficit Disorder, also called Attention Deficit Hyperactivity Disorder (ADHD) when obvious hyperactivity is observed, is a neurobiological condition characterized by inappropriate levels of inattention, distractibility, impulsivity and restlessness or hyperactivity. All of these symptoms may not always be obvious since they can be modified either by coping mechanisms developed during childhood, by personality, intelligence and so on. 

Since everyone exhibits those behaviors from time to time, why would someone think they have ADD? 

 People who take steps toward an assessment have often spent years in various forms of psychotherapy dealing with depression, anxiety, compulsive behaviors, etc. Nothing seems to have helped. They say they have always felt 'different' and that 'something just wasn't right'. 

The symptoms you describe sound similar to a number of other disorders: depression, manic-depression, even hypoglycemia. What is the greatest distinguishing factor? 

ADD can contribute to or look like many other conditions and many of these conditions have ADD-like symptoms. This is one reason why it is very important to have a comprehensive evaluation before making a diagnosis. ADD shows itself early in life and doesn't disappear. It is not situational or episodic. Because symptoms appear in earliest childhood this is one of the best ways to differentiate ADD from other conditions which usually have a much later age of onset. It's important to get the timeline straight, so as not to confuse the effects with the cause.  

How can someone determine if they really have ADD? 

Although some may think that they can diagnose themselves by reading a book or using a checklist, the assessment of ADD, especially for adults, is not clear cut nor simple. Most importantly, an inadequate diagnosis usually leads to inadequate treatment, which usually fails. There are basic and very specific criteria that have to be met for a diagnosis of ADD. It must be comprehensive enough in order to rule out other conditions that may have 'ADD-like symptoms.'. Unfortunately, many people receive a 'diagnosis' who do not really have ADD but may exhibit similar symptoms due to childhood abuse, emotional problems, attitudes, etc.  

An assessment involves determining at what age these symptoms first presented themselves, how long they have been evident, in what situations various symptoms have been present, and whether these symptoms have been a problem. It's important to have others familiar with the individual provide additional information. Supportive material such as school and work records and psychological tests are also helpful.  

Why would someone be concerned about having ADD? 

The primary difficulty is a relative inability to inhibit behavior. In short, the usual sequence for evaluating and responding to situations is short circuited for people with ADHD. It appears from much of the research that the impulsive behavior is a way to constantly stimulate an underactive brain. Our own belief, and confirmed by many scientific studies, is that ADD is really an inability to inhibit behavior. If someone with ADD can't postpone their response to a situation, they don't have enough time to identify better ways of responding to that situation. This affects their sense of time, their ability to profit from past experiences and delay gratification, all necessary components for planning and goal setting. Someone with ADD will often inappropriately over-respond emotionally to a situation without being able to objectively evaluate the information or content. Therefore, many individuals with ADD often seek high risk situations. They often take on more than they can handle, have trouble completing projects and don't follow through on ideas. Sometimes they underachieve in school, are hot tempered and may have frequent and short-lived mood swings. Since inattention and distractibility are really the same as paying attention to everything, life becomes overwhelming.  

Why do they have a difficult time inhibiting their behavior?  

The brain contains neurotransmitters, or chemicals that are partly responsible for decreasing the level of impulsivity, which helps to increase focus, attention and concentration. When the brain is stimulated, the neurotransmitter activity level increases. Many of the studies have shown a decrease in neurotransmitter and metabolic activity in the frontal lobe of the brains of individuals with ADD when compared with individuals without ADD. This helps to explain why individuals with ADD need a constantly stimulating environment, get bored easily, act impulsively and engage in high-risk activities. 

What makes ADD incapacitating enough to take medication? 

The more important question to be asked concerns the result of not treating ADD with medication. Many people with ADD are harmed by years of living undiagnosed and misunderstood, especially when they are repeatedly told they are lazy or stupid. People who don't have ADD can't understanding how painful this can be. When someone finally becomes aware of what may have been the cause of their difficulties they often have an immediate and visceral 'gut-level' response that evokes statements like, 'Yeah, that's it'. This deeply entrenched pain is not always visible to the outside world. Our own clinical experience and numerous on-going long-term studies show that individuals with ADD are at higher risk for educational, behavioral and severe conduct problems. It seriously affects employment and interpersonal relationships. Additional risks concern the lifestyles that individuals with ADD often lead. There is often a general lack of concern for health-related behaviors such as diet and exercise. Smoking and excessive drinking are more prevalent. General risk-taking leads to higher rates of personal and motor vehicle accidents. The impulsive behavior often affects sexual conduct, putting these folks at greater risk for HIV or early pregnancy.

The continued pattern of failing to consider the consequences of acts may lead to a series of poor decisions in life, producing an erratic pattern in school, work, or personal life. The use of medication should not be an act of faith but an act based on scientific evidence. We are not aware of any medications used for ADD which deplete minerals or cause any degenerative diseases. For most people with ADD, medication has proven extremely useful. However, all medications, even aspirin, can have side-effects. While the medications prescribed for ADD are safe and have minimal side-effects, it's important to explore one's feelings about them and gather as much sound scientific information as possible. 

But aren't there professionals who think that ADD is just a myth and that those who have it are just lazy and irresponsible? 

Many professionals still feel that way about alcoholics and other addicted persons. Unfortunately, there are some people who use the diagnosis as an excuse and explanation for their struggles. ADD should never be used as an excuse. In order for any of us to grow, we need to constantly work on ourselves. However, many ADD characteristics such as impulsivity or restlessness are part of the inherent personality of the ADD individual. 'Working hard' to control these behaviors often leads to other frustrations.  

What are some examples of the positive types of behavior we might see in someone who has ADD? 

We like to turn what might be considered 'disabilities' into 'abilities'. People with ADD tend to think creatively and can often see relationships between things that others can't. They are usually the 'big picture' people. They are often bright, intuitive, full of new ideas and plans and able to respond quickly to situations. Since they are always scanning the environment, they have great powers of observation. With an on-going need for immediate gratification, they are very incentive-oriented. 

Do you think that ADD underlies many cases of substance and spousal abuse and other types of addictive behavior? 

The constant need for stimulation or 'newness' is manifested in many ways. Engaging in high-risk behaviors such as promiscuous sex, gambling, excessive eating, dangerous sports or uncontrollable raging stimulate the brain and increase the neurotransmitter activity. 

Many people with ADD have experienced chemical addictions, especially to cocaine. Many cocaine users report that they feel 'normal' and 'focused' when using and don't experience the high others report. Of course, this depends upon how it's ingested and how much is used. Similarly, for someone whose mind is constantly racing, alcohol and/or marijuana helps with relaxation. But these drugs can cause problems. 

Have there been many scientific studies undertaken on ADD? 

There are numerous valid and reliable physiological, neurological and genetic studies being conducted at major universities and medical centers throughout the U.S. Over the past three years alone, there have been over 350 articles published in the most prestigious and respected medical journals. Some of these studies are funded by the National Institutes of Health. 

What are the implications of these studies? 

Most of the neurological studies have concentrated on the frontal lobe of the brain, which is responsible for what are considered the 'executive' functions including planning, organizing and the ability to focus. In order to perform these functions, we need to be able to inhibit our behavior for a long enough time to accomplish these tasks. For non-ADD individuals, this process includes many steps including evaluating the situation, evaluating the options and weighing the potential consequences. This is very difficult for individuals with ADD whose ability to inhibit their behavior is compromised. 

Is there any evidence that food or environmental allergies are causing this? 

From our experience and through numerous controlled scientific studies, it has been repeatedly shown that there is no relationship between allergic disorders, foods (including sugar) and ADD. Elimination diets or allergy-related diets have consistently failed to support this approach as helpful to the general population of individuals with ADD. Although there may be a very small percentage of individuals with a known history of allergies or sensitivity to sugar who show moderate benefit, the behavioral improvement is quite minimal. If someone believes that the ADD symptoms and behaviors are caused by food or allergies, it makes no sense to try to convince them otherwise.  

What kinds of medication are usually prescribed? 

There are two classes of medication which are useful, safe and in both cases, act by increasing neurotransmitter activity in the frontal lobe. Depending on the symptoms, they can be used individually or together. Stimulant medications such as Ritalin, Dexedrine and Cylert are used to decrease distractibility by increasing focus and concentration. The general misconception is that this type of medication is used to control hyperactivity. However, the decrease in observable hyperactivity is actually the result of increased ability to concentrate. Certain antidepressants are very useful for ADD individuals who are extremely impulsive. They help to even out their mood swings, reduce the short fuse and allow them to 'think before acting'. In any case, each individual is unique and the medications need to be monitored to determine their effectiveness. If someone is an alcoholic or has been a substance abuser, can the same medications be used? Aren't they addictive? In many cases, untreated ADD can lead to self-medication with alcohol and other drugs. There are certain types of medications which can be used safely in cases where relapse is a fear, but the medications used for ADD are not addictive.  

I've heard that some people feel that after a while their meds don't work? 

Medication alone is not the answer to overcoming the difficulties encountered throughout a lifetime of untreated ADD. When someone says 'the meds don't work', it's usually the individual who has stopped working. 

Are there homeopathic, natural or herbal preparations that can be used? 

Successful treatment of ADD requires specifically dealing with the problems of inattention, impulsivity, hyperactivity and poor motivation. The further the treatment gets away from these performance points, the less effective the treatment becomes. Non-medication treatments including herbal remedies, dietary additions and elimination diets, vitamin and mineral supplements, biofeedback and acupuncture have been reported to be clearly ineffective. Occasionally, some may help reduce specific symptoms to a minor degree. Rarely do any of them produce lasting results. We believe that proper nutrition, exercise and a healthy lifestyle is important for everyone. However, to date there is no empirical evidence that any homeopathic or herbal preparations can decrease or eliminate the symptoms of ADD. However, if individuals take an herbal remedy and feel that it improves their memory, for example - that's great! But that doesn't negate the importance of taking the proper medications. Our concern is that someone will look for the 'magic' cure. 

Can someone just take the meds when they feel they 'need' them?  

Medicating in this way is no different from using alcohol or drugs to change your state of mind. Do diabetics only take insulin when they 'need it'? 

Do you have any comments concerning what to look for when seeking an assessment? 

Beware of anyone who is too quick to make a diagnosis after one visit, or prescribes medication "to see what happens'. Since ADD affects all aspects of an individual's life there are many kinds of professionals who can conduct an assessment. The letters behind the name don't tell you who can play the game. Unfortunately there are too few professionals who have the ability and the experience of working with individuals and families with ADD.

So is there hope that someone with ADD can live a fulfilling life? 

Yes, we see miracles happen every day. We've worked with people between the ages of 3 and 73 whose lives have been profoundly affected by ADD. They have been able to significantly change their lives for the better through a combination of careful assessment, proper counseling and guidance and appropriate medical treatment.  © 1996 R.S. Weinstein