Attention Deficit-Hyperactivity Disorder
	ave you noticed how limited the range of behaviors is of young children. Regardless of the underlying cause, children almost universally behave disruptively and inattentively. Take for example an anxious child with separation anxiety, she worries about her parents and is impatient and fidgety in class. A depressed child may be disruptive because depression in young children very often presents as irritable mood and inattention. An angry and defiant child might fight with others and ignore teacher's directions. And children with Learning Disabilities, language disorders, or English as a second language might be disruptive and inattentive because they are "bored". As we can see, disruptive and inattentive behavior is not specific to a particular disorder. These are merely symptoms of many different underlying problems that cause children to act in this manner. The universal descriptive diagnosis for this behavior is Attention-deficit Disorder (and for the last nine years Attention-deficit Hyperactivity Disorder) embodying problems of inattention, impulsivity and hyperactivity.
	Attention-Deficit, is it a disease? The name of the Attention-Deficit Disorder (ADD) is really a misnomer and implies a deficit in attention. However, many children with this disorder focus perfectly fine on subjects of their own choosing (such as watching TV and playing Nintendo). The problem resides in an inability to regulate (i.e. initiate, maintain, and shift) attention to cognitively challenging tasks of someone else's choosing. I am often asked how a child with Attention-Deficit Hyperactivity Disorder can pay attention so well to video games, TV programs, Lego's, etc. They seem to have no difficulty paying attention when doing these fun things that they like. They are attracted to activities which require less persistent cognitive effort and offer an immediate gratification. They concentrate first on things they like and push aside unpleasant chores. Attentional difficulties for these children present themselves in specific tasks and not for any given general task. How can we pick out inattentive children from the group. Let me use an analogy. In order to identify children with muscle weakness out of a sample of one hundred, one would not ask them to pick up a pencil twenty times. The task so easy won't help to discriminate between the weak and the strong. Rather, asking them to lift 30 pound dumb-bell 10 times will be a more meaningful test. The task used to identify children with deficit of attention is school work. In child's life schools are the most demanding of concentration: hours of sustained attention on cognitively difficult material. So school work becomes the discriminator of who has attentional deficits. Attention is also affected by a number of medical problems (seizure disorders, headaches, prescription drugs, etc.), and by psychiatric/psychological issues (depression, bipolar disorder, anxiety, obsessive thoughts), as well as environmental/situational conditions. Sustained, directed attention is probably the weakest neuropsychological function of the brain and gives out in stressful situations in contrast with other faculties such as long term memory or motor skills, which stay firm.
	Impulsiveness Young children are neurologically immature. Children are impulsive; they act before thinking. They see, they do; they think, they talk. Their frustration tolerance is low, and there is no barrier separating feelings (anger or joy) from action (hitting or laughing). They take no time to consider consequences. In a biological sense, maturation is a development of inhibitory system or the ability to suppress and meter immediate impulses and emotions. Maturity comes with age, both conventionally and neurologically. The part of their brain responsible for slowing down before taking action is not fully developed yet. Young children are expected to "grow up" and develop some of these social and self-controlling skills by the time they go to school at 5 to 6 years of age. This happens for most children, but not for all. Many youngsters are still very impulsive and inattentive when school starts and are often given a label of ADD. Teachers complain and you begin to worry about your child. As children grow older, the process of self-evaluation improves. Development of impulse control takes place in the prefrontal lobes of the brain together with the control of emotional expressions. This area is also responsible for analytical thinking, problem solving, estimation skills, prioritizing. It develops throughout childhood and adolescence and reaches its complete maturity sometime in twenties, behind all other parts of the brain. Many children just naturally grow out of ADD as they grow older.
	Hyperactivity In the past Attention-Deficit Disorder was named a hyperkinetic syndrome (it is still the name used in Europe) because hyperactivity, or excessive mobility, was considered the hallmark of the disease. Hyperactivity is secondary to poor focusing and impulse control. Until Paul Wender, M.D. identified deficit of attention as the core problem, many believed that the condition did not extend beyond early teens. Indeed, by early teens hyperactive children learned to control external motor behavior and, although still inattentive, were not as fidgety as before. External gross motor movements got substituted with feeling of internal tension, impatience, and fine motor movements, such as finger tapping. Impulsiveness and attentional difficulties did not go away, however, until much later.
	Too much or too little, both cause problems Most of the regulated physiological functions are dimensional. Extreme parameters are not supported by nature. Again by analogy, consider vision; it is equally debilitating to have nearsightedness as it is to have farsightedness. Both conditions interfere with good vision; both require correction. This is also true for high and low blood pressure, high and low blood sugar or any other function. Regulation of attention is no exception. There are two extremes of attention; underfocusing and overfocusing. Underfocusing occurs when attention shifts rapidly and with the slightest cue, never stays on one subject for any length of time, and always seeks novel stimuli. Children in this state are "busy bees", are always on the go, climb and run excessively and can be described as "bouncing off the walls." Another extreme, overfocusing, refers to attention that is "locked" in one position. These Children are in dream world, and have difficulties shifting to a new activity. They are often perfectionists, stubborn and socially awkward. In our daily adult life, we have to be flexible to function in both modes (as we use both near accommodation and far accommodation for our vision). When we write reports or balance our checkbooks, we have to overfocus and block out distractions. When we cross a dark parking lot or drive on freeway, we underfocus and are mindful of potential dangers that may be coming from many directions. Most of the time, attention of a mature individual is in the mid-position. That is not how it works for young children with Attention-deficit Disorder. They are mostly swaying from one extreme to the other, and because of their relatively weak regulatory system, they move unpredictably.
	Attention-deficit Disorder is not a disease in the same sense as diabetes or cancer. It is the name of a collection of symptoms. I regard majority of cases of Attention-deficit Disorder as developmental delays in areas of concentration and impulse control. Developmental variations have always been around. Human neurobiology has not undergone fundamental changes over the last 10,000 years. Physical endurance was the most important survival trait for the last century. Today, it is cognitive strength which hold the keys to success. In the course of this century, education became universal. In the last 40 years, children have been expected to do schoolwork six to seven hours a day, five days a week, for up to thirteen years. Until recently, education was very limited in time and depth. Advanced education was elitist and often individual. Universal educational came with a price. Many new skills became important: ability to sit still for a long time, follow the rules and pay attention. Two percent of students (two standard deviations off the mean) don't have these skills ready when expected, and a few percent more have other problems that strain timely development and functioning of focusing and impulse control. The overwhelming number of Attention-deficit Disorder cases seen today are side effects of the expectations and pressures of today's life. However since the label is now given so liberally, the real examination of the other underlying reasons if often not done. There are many ways to treat this modern disease and I will review some treatment modalities in the future as I update this page.   ©Michael Levin, M.D.