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ADD, ADHD Q & A with Dr. David Hung

Is there a difference between ADD and ADHD?
In theory, yes. In reality, no, because the terms are so vage and overlapping that many clinicians use them interchangeably.

Is the definition of ADD/ADHD clear?
Yes, the definition is in fact quite stringent. The problem is the term covers too many symptoms, even though each symptom is clearly described.

DSM-IV defines three types of ADHD: ADHD-Predominantly Inattentive Type, ADHD-Predominantly Hyperactive-Impulsive Type, or both (Combined). Each types has 9 symptoms and a child must have at least 6 of the 9 in order to be diagnosed as either ADHD-Predominantly Inattentive or ADHD-Predominantly Hyperactive-Impulsive, and at least 12 symptomes for the Combined type. In reality,clinicians tend to use less than the minimum required symptoms to diagnose, resulting in over-inclusions. The actual definition is broad and covers so many symptoms that two ADD persons could behave very dissimilarly and require very different treatments . Also because the term covers so many symptoms, some of them are bound to be overlapped with other diagnoses, forming comorbidity. As a result, many children carry multiple diagnoses (ADD and pervasive auditory processing deficiency, ADHD and Oppositional Defiance Disorder, etc.)

A second problem is that although the definitions are clear, the diagnosing by clinicians is often loose. So there is a discrepancy between defining the pathology in the book and actually diagnosing the pathology. Much trial and tribulation and frustration have resulted from these diagnoses.

Are the symptoms clearly defined?
No. Although DSM-IV describes the symptoms (behaviors) quite clearly, the actual definition of each can vary between clinicians. There are no objective and logical ways to define the symptoms. For example:

*How much should a person forget before he is deemed 'forgetful'? Three times a day? Or 30 times a day?
*And exactly what is meant by forgetful? Three minutes after the event? Or three days after the event?
*What type of attention is crucial in ADD? Is it attention to all school tasks? Or attention to math or to writing?
*In what setting does the deficit occur? Are there attention deficits while watching TV or playing video games? Or only in the classroom? Or only in a specific class with a particular teacher?
*How ‘hyper’ should a child be before he is hyperactive? I have seen the ADHD diagnosis given to a boy just because he talked out in class too much. One can go on and on....

The broad definition allows clinicians to use the term in different ways. As a result, you can have 10 children bearing the ADHD label but showing different symptoms. The clinician's bias or logical reasoning skills are the calling shots in making the diagnosis.

Is the diagnosis of ADD/ADHD subject to cultural influence?
Yes. As a Social Phenomenon the prevalence of ADD/ADHD is to a large extent the result of cultural, social and life-style changes. Just think back 25 years ago, there were much less requirement for in-seat activities. We used to be more physically involved - playing in the filed, catching birds, climbing trees, driving a tractor or a lawn mower, etc. A kid used to be happy spending half a day jumping rope, climbing tress, or trying to catch fish in a stream. Even the old one-room, non-graded country school had more physical activities and less seat work than our present school. Indeed, many of the so called ADD/ADHD kids would have had no problems learning and fitting in in years back . If there were seated, quiet times (I don’t mean lounging on the couch watching TV, which contributes significantly to the ‘inability’ to sit up straight in class), they used to entice more attention and stamina from the child. Remember not too long ago many kids used to collect and appreciate rare stamps, or practice (not dabble) on the piano? We used to have to concentrate in order to ‘hear’ the ball game on radio, and visualize the scenes at the same time. Persisting and focusing on activities were a must in the olden days. But the same kids nowadays probably wouldn’t touch a piano or look at tiny stamps.

How is ADHD a by-product of the modern world?
The modern world has 'progressed' to a life style that tends to produce children (and adults) who are reluctant to attend to details and are accustomed to a whole host of technological gadgets that instantaneously entertain -- playing electronic games, surfing the Internet, watching MTV, flipping TV channels on the remote control, or talking on cell phone. The modern child can flip TV channels the second he doesn’t like the look or the sound. Movies for teens have to be fast moving and loud in oreder to hold their attention.. He can go through videogames in a flash. If he loses a game, he can always hit the re-try button again, and again, without much planning or forethought, until he hits it right. If we missed a sequence in a ball game on TV, there is always the instant replay. So who has the need to focus and attend carefully? Who has the patience to read books, play chess, collect stamps or practice on the violin? The need to imagine and focus on any activity is diminishing rapidly. In other words, children can now afford to be, and often times train themselves to be, careless, impatient and non-focused.

Is the ADD problem getting worse?
Yes and no.
No in the sense that our children's brain is no different from previous generations'. There is no fundamental change of physiology.
Yes in the sense that ADHD is a by-product of the developed world, just as obesity or lung cancer.

Ironically, the working world of industrial societies is going to the other direction - requiring more sustained seat-work and focused attention, from designing computer programs, analyzing stocks, to flying airplanes. It’s like many of us who are tone-deaf were suddenly thrust into a world that required playing music to survive. Tone-deafness in such a world would be treated as pathological and a serious ‘learning disability’. In reality, the modern-day child's inability to focuse and contemplate while doing seat work and intellectual tasks, and the schools' reemphasis of the 3 R’s accentuate the problem. Thus many children who would have functioned fine before are now labeled ADD or ADHD.

Is there a boy/girl difference?
Yes. Girls will ‘naturally’adjust to the demands of focused seatwork more easily. Right now it's 50-50, but by the year 2010, there will be more females graduating from college than male.

How do children labeled ADD/ADHD fare?
The ADD/ADHD child (usually a boy) is often disruptive, oppositional to adults or peers, or shows no interest learning in the classroom (the problem gets noticed more at school first than in the home). Many ADHD children are put on psychotropic medication. Still many others have gotten seemingly sophisticated treatments, causing tremendous expenses and time, and yet continue to fare poorly and worse, develop a sense of despair and stigma about the 'disease'.

What types of treatment are available?
A whole host of expensive treatments exists, among them sophisticated apparatuses to activate the left brain and drugs to the child. Tremendous anxiety and energy are expended by parents and often, sadly, to no result. What is first needed is a label-free, behavioral evaluation of the symptoms. Then design a behavioral treatment/trraining program for the symptoms. Indeed, behavior therapy has remained most promising in the long run.

What are the symptoms to be considered in behavior therapy?
* poor or fluctuating school grades and academic performance,
* frequent ‘forgetfulness’ (of homework, test dates, for example),
* losing things or homework or school materials,
* excessive physical movement and fidgetness,
* adult dependence - does not focus and work unless being prompted or 'nagged',
* impulsiveness, and disruptiveness,
* low frustration tolerance, bad temper

What are the possible causes to be evaluated in behavior therapy?
The above symptoms are often caused by some of the following factors:
* inapporiate school curriculum, teaching levels and/or materials,
* inapporiate classroom structure,
* inadequate achievement level, especially in math, writing and critical reasoning skills,
* the child's unique learning style, study habit, life style, energy level, interest, social activities,
* the presence of specific learning disability, dyslexia, auditory or visual processing problems, intellectual deficits, etc.,
* family condition and dynamics - sibling conflict, parental disagreements, divorce, etc..

What is behavioral treatment?
Ultimately, there is only one kind of treatment worthy of undertaking - that it creates visible improvement on the behavioral symptoms, regardless of the diagnosis. We maintain that motivation, discipline, family dynamics, life style and previous learning history of the child have a lot to do with the problems of ADHD. The key is to have a thorough, logical analysis of the problem, the settings and the consequences, then design invidualized exercises for the child and provide re-structuring programs for the family. See also Focusing Therapy.