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>Over-focused ADD

June 7, 2011

>Hope has an intake evaluation for ADHD management coming up in a few weeks so I’ve been reading to come up to speed. ADHD also runs in my family so I’m interested. The book on the top of my pile today is Daniel G. Amen’s Healing ADD, which  I found four years ago when Hope was two and I first wondered if she had ADHD.

Amen discusses 6 different forms ADD takes based on brain imaging scans which correlate neurological under- and over-activity in the brain with behavioral characteristics. Why split so many hairs with an ADD/ADHD diagnosis? In Amen’s clinical experience, each of the six types responds differently to a broad range of therapeutic intervention, which is logical if each has a different neurological basis.

Four of Amen’s six types are forms most people would identify with ADD. Two are surprising because they don’t closely fit the stereotype of ADHD: one distinguished by explosive anger and aggression, and one characterized by over-focus and anxiety. (Anxiety is a characteristic of several forms of ADHD.) This post is about that last form, the one Amen calls Type 3, Over-focused ADHD.

Mercy has anxious tendencies and is highly focused (kind of like me, even though we are not biologically related). I am not concluding that she has Type 3 ADHD. But because of my natural interest in anxiety in children I found Amen’s Type 3 interesting as a reason some kids might display anxious tendencies.

According to Amen, (who removes the “H” for “hyperactivity” from ADHD because it can be misleading: some people with ADD, Attention Deficit Disorder, are not hyperactive) the hallmark characteristics in Type 3 ADD are: excessive or senseless worrying; opposition and argumentation; tendency to perseverate (get stuck) on negative thoughts; tendency toward compulsive behaviors; tendency to hold grudges; highly focused –shifting attention from subject to subject is hard; has difficulties seeing options in any situation; tendency to hold on to own opinion and not listen to others; can get locked into a course of action good or bad; is controlling and orderly and gets upset if things are not done a specific way; is criticized by others for worrying too much. (Healing ADHD, p. 101)

To differentiate this diagnosis from anxiety disorders like OCD (obsessive compulsive disorders) Amen emphasizes that in Type 3, these tendencies overlay the core characteristics of ADD like distractibility, trouble with organization, poor follow through and poor  “internal supervision” (p. 110) –generally indicators of executive functioning deficits.

It is fascinating to follow Type 3 through Amen’s later chapters on intervention strategies –everything from supplements to diet to medication to biofeedback and behavioral coaching –because the interventions that help Type 3 are not the same as the other 5 types. That is a strength of this book from a reader’s perspective: his discussion of the 6 distinct types early in the book makes it easy to narrow it down to one or two types to follow through the rest of the book, ignoring the types that don’t apply.

His discussion of nutrition is brief, but concludes (without mentioning gluten) that people with all the types (with the exception of Type 3) generally feel better on a high protein/low carb diet because of how simple carbohydrates act on brain chemistry. Amen acknowledges that medication is a cornerstone of the treatment plan for many people with ADD and discusses which types respond best to which meds. But I like how he stretches outside that box to say that in his clinical experience, meds alone may be disappointing; the best treatment is holistic.

Last, a personal observation. Hope has two diagnoses: ARND (on the FASD spectrum) and ADHD. While she’s always been high-energy, her preschool teachers told me they did not think she had ADHD because, in their experience, those kids were “bouncing off the walls” and were almost always boys. Hope fit neither stereotype of a child with ADHD. Yet the more I read about ADHD, the more I think: It is the ADHD behaviors that have been so hard to live with all along. In other words, my impression has been that we were seeing the FASD, when the even bigger issue undermining the peace on our family maybe has been ADHD (rooted in FASD).

Why is that important? Only 60-70% of those who have FASD also have ADHD. In my very informal, unscientific sample of moms I know who have kids with PAE (prenatal exposure to alcohol), those kids with untreated ADHD behaviors bring us to the end of rope –to the point of seeking an FASD evaluation –much quicker than kids with PAE but who do not show signs of ADHD.

So it is much harder for moms whose kids are in that 30-40% who do not have ADHD to look at their kids and recognize other signs of FASD. Unfortunately, the FASD literature is dominated by kids who have both FASD and ADHD, and by affected children with lower IQs. That leaves me wondering how many families are struggling with the knowledge of PAE in academically bright kids with challenging behaviors who don’t measure up to the FASD poster child who also has ADHD?

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