We can discuss it, debate it, pontificate on it and pulverize the subject into the ground and still not come to any conclusions on the matter. Discussing Attention Deficit Disorder (ADD), like politics, tends to raise blood pressures, and lose friends. The child struggling in school, who daydreams, and fails to keep up with his peers is likely to be labeled a “slacker,” called incorrigible and even unredeemable, or put on stimulant medicines in the fervent hope this will “drive the devil from him.” In Victorian times, that ailment we now call ADD was thought to be evidence of moral turpitude, requiring a priest to perform an exorcism, more than any physician’s intervention. It is even referenced in the Bible. The remedy there was that the child be brought to the edge of the village and left on his own with the implication being a wild animal would whisk him away in the still night thus alleviating the turmoil of dealing further with him from the lives of the villagers. For many, ADD treatment now is not much better. Our understanding of its causes, and the way we have come to characterize it, leave many wondering whether such a condition even exists.
It does. But as often happens in medicine, when no easily identifiable biologic markers are recognized, we are left with conjecture, which slips to opinion, ultimately corrupted by biases without basis in any fact. And therefore ADD just doesn’t seem to add up to much of anything. One of the main faults I believe is the fact we call it a disorder at all. It really isn’t, and shouldn’t be viewed as such. Maybe it would help to monetize this vague concept of attention. Let’s say each of us is given $100 worth of attention to use as we see fit. Some among us are able to invest all that attention in one task, whether it’s a book they are reading for pleasure, or solving math problems by way of review in preparation for an upcoming exam. Most of us, however, would likely expend only so much on an immediate task, maybe as little as we can to “get the job done,” while we spend a little bit on the TV program on in the background, and a little bit on a conversation with the brother in law helping with the chore with which we are tasked. Multitasking. But if we’re doing ten different things and alotting only $10 worth of attention from our hundred dollars of attention on each task without considering the actual cost required, we can begin to slip into problems. Whether it’s work, or school, or home, lack of attention to one detail may be costly.
But yet there is a survival value to being a little less than attentive to one task, so that we may be vigilant to potential dangers. An obvious example might be investing all our attention on a book, say War and Peace, as we read it peaceably in the woods, caught up in the writing and the story and completely unaware of the bear sneaking up behind us. In an evolutionary sense, attention deficit, or better, hyper vigilance, assured survival in an agrarian society. Attention to detail, “focus,” especially in school age children, mattered once the children were brought in from working the fields and suddenly kept seated in a classroom eight hours a day.
As mentioned there is no biologic marker to say definitely one has ADD. Unlike diabetes there is no elevation of a certain compound or chemical which proves it. We use rating scales, which may be problematic. A teacher’s assessment, or a parent’s assessment may differ one from the other only so much. The Diagnostic and Statistical Manual offers some guidance, but not much. But when assessment and rating scales vary widely between observers, consider another diagnosis. ADD may be co-morbid with another condition which needs to be addressed first, or exclusively. The decision to initiate therapy with medications is not taken lightly. Nor should medication, whether in an adult or child, ever be initiated without consideration to ongoing monitoring, and with specific target goals planned out beforehand.
So ADD doesn’t always add up. In fact it more often divides us.