Pay Your Attention:What Causes Attention Disorders
THE CAUSE(S) OF ATTENTION DISORDERS
The term, ADHD, is really a misnomer. It's not really a disorder. By definition, a disorder has certain characteristic symptoms (signs and behaviors that are "abnormal"), a predictable natural history (what happens over time without treatment), and a common underlying cause ("etiology"). Treatment, if any, is directed to modify the symptoms or alter the underlying cause of the disorder.
Instead, ADHD is a symptom complex, and the diagnosis is based on the presence of a sufficient number and severity of the symptoms that are listed in the current diagnostic handbook (DSM IV) that clinicians use. However, this exact complex of symptoms has many very different causes (etiologies) that have different natural histories, and respond to very different treatments.
There are many possible causes of attention problems, including:
a) it's normal, age appropriate behavior that is mislabeled; most of the overly active, difficult-to-manage children don't have ADHD;
Case illustration: Sue was a very intelligent, active, intrusive, and somewhat "bossy" six years old girl who was a "management" problem at home and in school. She always wanted to do it herself and didn’t "listen well". Her parents tended to be inconsistent in their behavior management attempts and to be easily irritated by her. Her teacher was boringly repetitive and pedantic. Sue didn’t have ADHD- she was what Linda Budd called "active alert". Perfectly normal. Things improved considerably with some behavior management counseling for the parents and consultation with the teacher.
Note: Linda Budd’s books on the active alert child are very, very helpful even if the child does have ADHD.
b) any number of general medical problems (such as anemia, hyperthyroidism, chronic ear infections, and dietary inclusions/sensitivities;
Clinical comment: Dietary sensitivities do exist although they are not very common. One of our studies done some years ago revealed that only one of twenty children whose ADHD symptoms reportedly "responded" to dietary management did, indeed, respond sufficiently to changes of diet.
c) many medications (such as anticonvulsants, antihistamines, and psychodepressants that sedate or slow the brain);
Comment: Since these medications are often necessary for the general well being of the person, it’s important to use the lowest effective dose to minimize side effects.
d) toxic conditions (drug induced or an illness);
e) sensory deficits (like undetected hearing and visual impairments) and sensory hypersensitivities;
Comment: The clinician needs to consider all of these potential problems when evaluating attention.
f) neurological problems other than ADHD, such as visual and/or auditory distractibility, sleep disturbances (including narcolepsy), epilepsy, "acquired/traumatic" or Traumatic Brain Injury (TBI);
Case illustration: A successful professional was seriously injured in an auto accident in which close relatives were killed. He was evaluated by teams of professionals, and, although he'd had a severe concussion, there was no sign of brain damage or memory impairment. His recovery was slow but steady with many surgeries, medications, and rehabilitation interventions. Several years later, he was telling a friend, a psychologist, that in spite of grief counseling, he remained "depressed"- he felt preoccupied and was distractible, frequently off task, disorganized, and easily bored. These are symptoms of depression, and they are also symptoms of ADHD, inattentive type. When his friend referred him for an ADHD assessment, it was discovered that the evaluation obtained after the accident did not include a T.O.V.A. even though brain injuries can cause ADHD. It turned out that he did have traumatic ADHD, and his symptoms responded to treatment.
g) family style and (dis)organization (including social and cultural factors);
h) lack of school readiness, different learning style, and low motivation;
Comment: Some individuals learn best with a "hands on" experience rather than hearing or reading about it.
i) stress (including emotional trauma and inappropriate demands);
j) intellectual impairment and precocity;
k) learning disabilities;
l) other psychiatric conditions including abuse/post traumatic stress disorder, psychosis, bipolar or obsessive-compulsive disorders, autism, Tourette, depression, and anxiety;
Comment: A multi-faceted clinical evaluation is needed to determine whether one or more of these conditions exist with or without ADHD.
m) substance use, abuse, and withdrawal (including caffeine and nicotine);
Comment: Substance use and abuse are common in untreated individuals with ADHD, and the co-existence of ADHD makes the treatment of substance abuse more difficult. Although it seems counterintuitive to treat a substrance abuser with ADHD with low doses of psychostimulants (See 13 below), it’s the most effective treatment.
n) behavior disorder including oppositional/defiant;
Case illustration: Jack was six years old when seen by his family physician because of hyperactivity, impulsivity, stealing, and temper tantrums at home and at school where he was not progressing academically. Assuming that Jack had ADHD, combined type, the doctor prescribed 10 mg of methylphenidate (a psychostimulant). Jack initially appeared to be less hyperactive and impulsive. The dosage was increased to 20 mg with minimal improvement and some increase in irritability and sleep disturbance. Jack was subsequently seen for a psychological evaluation and was diagnosed and successfully treated for a behavior (conduct) disorder without medication.
o) and, finally, the neurological disorder of attention or ADHD
To complicate matters even further- these causes are not mutually exclusive. An individual with the ADHD symptom complex could very well have more that one cause co-existing (co-morbidity) and needing more than one treatment modality. Prime examples would low self-esteem and depression. In addition, there can be a genetic component as well since a percentage of individuals with ADHD have close relatives with it also.
Sometimes co-morbid problems, like low self-esteem, are so prominent that the clinician may not recognize the underlying attention disorder. This is often the case in children with the Inattentive Type of ADHD and in adults when ADHD wasn't diagnosed in childhood.
So, it's very important that the clinician carefully considers all of the possible causes of the symptom complex without leaping to a conclusion and prescribing a treatment. Selecting a diagnostician is not an easy task- you want someone who has the necessary expertise. An excellent source of information is The TOVA Company that maintains an up to date directory of clinicians who specialize in the diagnosis and treatment of attention disorders, including ADHD. For free recommendations of clinicians in a particular geographical area, please call 1.800.REF.TOVA (800.733.8082).
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