Childhood Disorders 657
Because the sets of symptoms vary, clinicians fi nd it useful to classify ADHDinto different types. The hyperactive/impulsive type is associated with disruptive
behaviors, accidents, and rejection by peers, whereas the inattentive type of ADHD
is associated with academic problems that are typical of defi cits in executive func-
tions: diffi culty remembering a sequence of behaviors, monitoring and shifting the
direction of attention, organizing material to be memorized, and inhibiting interfer-
ence during recall. A third group of patients, with the combined type, has symptoms
of each of the other two types.
However, symptoms may change over time; as some children get older, the par-ticular set of symptoms they exhibit can shift, most frequently from hyperactive/
impulsive to the combined type (Lahey et al., 2005). Children with ADHD often
have little tolerance for frustration, as was true of Edward Hallowell in Case 14.7;
such children tend to have temper outbursts, changeable moods, and symptoms of
depression. Once properly diagnosed and treated, such symptoms often decrease.
Problems with attention are likely to become more severe when sustained atten-tion is necessary or when a task is thought to be boring, which is what happened to
Javier. Various factors (psychological and social) can reduce symptoms, including:
- frequent rewards for appropriate behavior;
- close supervision;
- being in a new situation or setting;
- doing something interesting; and
- having someone else’s undivided attention.
In contrast, symptoms are likely to become more severe in group settings, where the
individual receives less attention or rewards.
Socially, people with ADHD may initiate frequent shifts in the topic of a conver-sation, either because they are not paying consistent attention to the conversation
or they are not following implicit social rules: Those with symptoms of hyperactiv-
ity may talk so much that others can’t get a word in edgewise, or they may inappro-
priately start conversations. These symptoms can make peer relationships diffi cult.
CASE 14.7 • FROM THE INSIDE: Attention Defi cit/Hyperactivity Disorder
Attention-defi cit disorder (ADD) was the term used in the third edition of the DSM. In his
book Driven to Distraction: Recognizing and Coping with Attention Defi cit Disorder from
Childhood Through Adulthood, psychiatrist Edward Hallowell recounts what happened
when he learned about the disorder:
I discovered I had ADD when I was thirty-one years old, near the end of my training in child
psychiatry at the Massachusetts Mental Health Center in Boston. As my teacher in neuropsy-
chiatry began to describe ADD in a series of morning lectures during a steamy Boston sum-
mer, I had one of the great “Aha!” experiences of my life.
“There are some children,” she said, “who chronically daydream. They are often very
bright, but they have trouble attending to any one topic for very long. They are full of energy
and have trouble staying put. They can be quite impulsive in saying or doing whatever comes
to mind, and they fi nd distractions impossible to resist.”
So there’s a name for what I am! I thought to myself with relief and mounting excitement.
There’s a term for it, a diagnosis, an actual condition, when all along I’d thought I was just
slightly daft.... I wasn’t all the names I’d been called in grade school—“a daydreamer,” “lazy,”
“an underachiever,” “a spaceshot”—and I didn’t have some repressed unconscious confl ict
that made me impatient and action-oriented.
What I had was an inherited neurological syndrome characterized by easy distractibility,
low tolerance for frustration or boredom, a greater-than-average tendency to say or do what-
ever came to mind... and a predilection for situations of high intensity. Most of all, I had a
name for the overfl ow of energy I so often felt—the highly charged, psyched-up feeling that
infused many of my waking hours in both formative and frustrating ways.
(Hallowell & Ratey, 1994, pp. ix–x)