Evidence of ADD may even show up in specific areas of the brain. In 1990, Alan Zametkin, M.D., a psychiatrist at the National Institute of Mental Health (NIMH), reported startling findings about the ADD brain in the New England Journal of Medicine. Zametkin measured sugar metabolism—a major indicator of brain activity—in the brains of 30 adults who had a childhood history of ADD, along with 30 normal individuals. PET scans (positron emission tomography) allowed Zametkin to determine just how much sugar each participant's brain was absorbing, and in what regions. Sufferers of ADD absorbed less sugar in the areas of the brain that regulate impulse control, attention, and mood. Another study, by NIMH researcher David Hauser, M D., linked ADD to a rare thyroid condition called generalized resistance to thyroid hormone (GRTH) Seventy percent of individuals with GRTH suffer from ADD—an extraordinarily high correlation. Finally, recent brain scan studies have revealed both anatomical and functional differences in the brains of individuals with ADD—slight but real differences in the size of the corpus callosum (which serves as the switchboard that connects the two hemispheres of the brain), as well as differences in the size of the caudate nucleus, another switching station deep within the brain. These breakthrough studies lay the foundation for promising research, but much more work needs to be done before we may be able to use these findings to actually help us diagnose ADD. They simply point us in the direction of biology—and that pointer is powerful.
The Pivotal Moment
Nothing matters more in ADD than proper diagnosis. Even today this condition is so misunderstood that it is both missed and overdiagnosed. As the public's awareness of the disorder grows, more and more people represent themselves as experts in ADD. As one of my patients said to me, "ADD has become a growth industry" Not every self-proclaimed expert knows ADD from ABC. For instance, depression can cause someone to be distracted and inattentive (and in many cases depression and ADD even occur together). However, a constant pattern of ADD symptoms usually extends back to early childhood, while depression is usually episodic. Thyroid disease can also look very much like ADD, and only testing by a physician can rule this out. High IQ can also mask or delay the diagnosis of ADD.
If the proper care is taken, a diagnosis of ADD can be made with confidence and accuracy, even though there is no single proof-positive test. Like most disorders, ADD occurs on a wide spectrum. In severe cases an individual can barely function due to rampant disorganization or uncontrollable impulsivity, not to mention secondary symptoms such as low self-esteem or depression. Yet very mild cases of ADD can be barely noticeable, especially in a bright individual who has adapted well.
To me, the life history is the one, absolutely convincing "test," which is then supported by the criteria of the DSM-IV and by psychological testing. When someone tells me they've been called "space-shot," "daydreamer," and "out in left field" all their lives, I suspect they might have ADD. At our clinic in Concord, Massachusetts, we use an abbreviated neuropsychological battery that helps us confirm a diagnosis. The battery includes standard written tests that measure memory and logic, impulsivity, and ability to organize complex tasks. Score alone does not tell the whole story; the tester needs to watch the client to determine whether he or she becomes easily frustrated and distracted. We even include a simple motor test that measures how quickly a person can tap their finger. (Patients with ADD are very good at this; depressed patients are not.) Though these tests are helpful, they are by no means definitive. A very smart person without ADD may find these tests boring, and become distracted. On the other hand, one of the great ironies of this kind of testing is that three of the best non-medication treatments available for ADD—structure, motivation, and novelty—are actually built into the testing situation, and can temporarily camouflage ADD.
A diagnosis by itself can change a life. My own father suffered from manic-depression, and I used to wonder if I had inherited the same disorder. When I learned I had ADD, that fact alone made a huge difference to my life. Instead of thinking of myself as having a character flaw, a family legacy, or some potentially ominous "difference" between me and other people, I could see myself in terms of having a unique brain biology. This understanding freed me emotionally. In fact, I would much rather have ADD than not have it, since I love the positive qualities that go along with it—creativity, energy, and unpredictability. I have found tremendous support and goodwill in response to my acknowledging my own ADD and dyslexia. The only time talking about this diagnosis will get you in trouble is when you offer it as an excuse.
After a diagnosis of ADD, an individual and his or her family can understand and change behavior patterns that may have been a problem for many years. Treatment must be multifaceted, and includes:
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