“ADHD Is Not a Behavioral Disorder.”
Clinical psychologist Thomas Brown tells why middle-aged women suddenly develop ADHD, why brain imaging is worthless in diagnosing the condition, and why many doctors just don’t understand attention deficit.
Thomas Brown, Ph.D., sees ADHD from all sides: as a researcher, as a teacher at a medical school, and as a psychologist helping patients manage their symptoms and reclaim their lives. A clinical professor of psychiatry at the Yale University School of Medicine, Brown also writes about ADHD. His Attention Deficit Disorder: The Unfocused Mind in Children and Adults is a must-read for clinicians and patients.
Brown’s research into the brain has posited a new model for ADHD. “The old model thinks of ADHD as a behavioral disorder,” he says. “But many individuals living with ADHD never had significant behavior problems; they have difficulty focusing their attention on necessary tasks and using working memory effectively.”
ADHD is a cognitive disorder, says Brown, a developmental impairment of executive functions (EFs) — the self-management system of the brain. ADDitude caught up with Brown to get answers to a wide range of questions-yours and ours.
Has your theory of executive function impairment filtered down to family doctors who are making diagnoses and prescribing medication?
Very, very slowly. Too many doctors still think about ADHD in the old way — as a behavior problem accompanied by difficulty in paying attention. They don’t understand that “executive function” is really a broad umbrella. When patients hear the symptoms associated with EF impairment — finding it hard to get organized or to start tasks, to sustain effort to finish tasks, to hold off instead of jumping impulsively into things, to remember what was just read or heard, to manage emotions — they’ll say, “Yeah, yeah, yeah, that’s me.”
A lot of executive function impairment goes beyond the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for ADHD.
Do doctors get enough training in ADHD?
I teach in medical school, and if doctors get an hour of lecture on ADHD, that’s a lot. There are people with ADD who suffer from the fact that their doctor doesn’t have the training or experience to recognize ADD or comorbidities when they see it — or to be skilled enough to make the necessary fine-tuning of medication in order for it to be effective.
Will we find out anything new in the DSM-V, to be published in 2012, that reframes the causes or treatment of ADHD?
I’m not writing or editing it, but I’ve heard that there will be some changes — specifically in the age-of-onset criteria. For a lot of people, ADHD symptoms are invisible until after — sometimes well after — the age of seven. It’s not until adolescence, when kids are more challenged in high school or college, or in adulthood, that symptoms become apparent. I liken it to getting an EKG. When a patient lies on the table, there is a perfectly clean EKG. But when that person shovels a load of snow or plays a fast game of basketball, you may see an occlusion in his arteries. The EF impairments that are characteristic of ADD, particularly for smart people who don’t have behavior control problems, aren’t apparent until high school or later.
Can a doctor diagnose ADD in 15 minutes? And if an adult or a child receives a quick diagnosis for ADD, would you be suspicious of the doctor?
I can’t diagnose ADD in 15 minutes. If a doctor talks with you for 15 minutes and reaches for the prescription pad, alarm bells should go off. I typically spend a couple of hours with my patients in the initial interview. I ask a lot of questions and listen carefully to the answers. I get a detailed history, but I do it in a semi-structured way. What’s more, it’s not just a matter of looking for ADD. It’s important to screen for comorbid problems — because the incidence of comorbidities and ADD is quite high. The problem with the health system is that insurance companies reimburse pediatricians for only 15 minutes.
Some patients ask, even demand, that the doctor do brain imaging to nail down the diagnosis. What role does this procedure play in diagnosis?
None. ADD is not a structural problem in the brain. It’s primarily a chemical problem. There are certainly some structural differences that brain imaging shows — this part of the brain is a little smaller than normal and that part is a bit bigger. Brain imaging is a snapshot of the brain’s structure that is taken in a fraction of a second and tells you nothing about whether a patient has ADD. That’s why you need to ask questions about how the patient functions in a variety of situations at various times of the day, under different circumstances.
Are we any closer to finding out which genes are responsible for ADD?
A lot of research has been done, and there are some candidate genes, but nothing has been nailed down. The more evidence we get, the more clear it seems that there is no single, or two or three, genes responsible for ADHD. There are a whole bunch of genes, each of which controls a few of the symptoms.
Readers often ask if ADD can cause dementia or Alzheimer’s. Can it?
There is no evidence to support this claim. With ADD, we’re dealing with a problem that has to do with the chemical dynamics of dopamine and norepinephrine release at the brain’s synapses. With Alzheimer’s, the brain’s wiring is destroyed by a thick glop that accumulates on the neurons.
Don’t we need more research about adults and ADD?
The studies on adults are getting done, gradually, but we have a long way to go. We need to better understand the individual variants of ADD in adults. Some adults have big problems in school, but once they get out of school, they are able to specialize in something that they’re good at, or take a job where a secretary helps them, and they do fine. Other adults manage through school, but they don’t do well at jobs or managing a household. We’re beginning to identify the domains of impairment and to recognize that these difficulties with EFs not only affect people with academic tasks but also in their ability to maintain social relationships and to manage emotions.
Sadly, DSM-IV says nothing about this emotional component as part of the ADD syndrome. Yet it’s clear from research that emotional control is part of EF impairment (see “The Six EFs,” top left). Some adults with ADD overreact to something that is trivial, or lose it in situations where they can’t afford to lose it. These overreactions can send lives, relationships, and careers into free fall.
Women and ADHD — what are the latest findings in that area?
I see women — successful and smart — come into my office and say, “I’m afraid I have Alzheimer’s, and it scares the crap out of me. I have trouble coming up with words that used to come easily. I can’t concentrate as well as I did.” I do the evaluation, and they have ADD syndrome, but they don’t have a history of these difficulties before menopause. It makes sense, though, because estrogen is one of the primary modulators for the release of dopamine in the brain. As the estrogen level drops, as it does in menopause, the result — for some women — looks an awful lot like ADD.
Your studies show that ADDers often have high IQs, but they don’t do well in school or life. Why?
The common wisdom used to be that if you have ADD, you’re not smart, and if you are smart, you can’t have ADD. Nonsense. I did a study of 157 adults with IQs of 120 or above, the top nine percent of the population. All of them fully met diagnostic criteria for ADD, and all had significant impairment in working memory and processing speed. Many of these people weren’t recognized as having ADD problems until they were adults. They suffered a lot and often had difficulties in school before they received adequate treatment. All of them were demoralized and had given up. If they had been diagnosed earlier or had been in an environment where they were supported for their strengths and helped to recognize their limitations — not given a lot of phony happy-talk — their self-esteem would increase. Many people get put down so often that they develop defenses to protect themselves. Early diagnosis and treatment can mean so much in the arc of a person’s life.