Often people think of "focus" as holding a camera still and adjusting the lens for a clear picture of an unmoving object. That is not the meaning of focus in the title of this book. Rather, focus refers here to a complex, dynamic process of selecting and engaging what is important to notice, to do, to remember, moment to moment. Much as a careful driver focuses on the task of driving a car in heavy traffic by actively looking ahead while also checking mirrors, observing road signs, braking, and so on (all while monitoring dashboard gauges, keeping in mind the speed limit and destination, and ignoring the temptation to look too long at interesting sights), a person employs this very active, rapidly shifting, repeatedly readjusted deployment of attention and memory as the "focus" needed to plan and control ongoing activity. Such focus is extremely difficult for the 7 to 10 percent of the world's population who suffer from a syndrome of cognitive impairments currently known as attention deficit disorder (ADD) or attention-deficit hyperactivity disorder (ADHD).
"Syndrome" is a term that describes a cluster of symptoms that tend to appear together. For example, nasal congestion, sore throat, headache, fatigue, and fever often appear together as a syndrome commonly referred to as a "cold." One single cause or a variety of different causes might lead to one common syndrome.
In this book, the term "ADD syndrome" is used to refer to a cluster of impairments in the management system of the mind. The DSM-IV, the diagnostic manual of the American Psychiatric Association, describes currently accepted diagnostic criteria for attention-deficit hyperactivity disorder (ADHD). The concept of ADD syndrome introduced in this book is not intended to be a new diagnosis, replacing existing diagnostic categories. I am simply proposing a new way of looking at these impairments, of which many, but not all, are encompassed in current diagnostic criteria for ADHD. Other labels have been proposed for this cluster of impairments: "Attention Deficit Disorder," "Executive Dysfunction," "Minimal Brain Dysfunction," "Regulatory Control Disorder," and "Dysexecutive Syndrome," to name a few. The concept of ADD syndrome described here includes many impairments described by these various labels, impairments that often appear together and tend to respond to similar treatments.
Compared to others of the same age and developmental level, persons with ADD syndrome tend often to have an "unfocused mind" not only for driving, but also for many other important tasks of daily life. This does not mean that persons with ADD syndrome are never able to focus adequately. Nor does it mean that those without ADD syndrome are always well focused. ADD syndrome is not like pregnancy, an all-or-nothing status with no in-between. It is more like depression. Every person feels sad sometimes, but a person is not diagnosed and treated for depression simply because he feels unhappy for a few days or even a few weeks. It is only when depressive symptoms are persistent and significantly impairing that the diagnosis of depression is appropriately made. Similarly, persons with ADD syndrome are not constantly unfocused, but they are much more persistently and pervasively impaired in these cognitive functions than most other people.
My purpose in writing this book is to describe more adequately the complex ADD syndrome as it occurs in children, adolescents, and adults. My understanding of ADD syndrome is not universally accepted. Some researchers prefer less cognitive, more behavioral models to describe this disorder. In these pages the reader will find a new, somewhat controver sial understanding of ADD syndrome, including how it can be recognized and how it can be treated effectively.
Sometimes an effective treatment for a disorder is discovered by accident, before there is a full understanding of what is being treated or why the treatment works. An effective treatment for ADD syndrome was accidentally discovered in 1937 by Charles Bradley, a Rhode Island physician who was seeking a medication to alleviate severe post-spinal-tap headaches in behavior-disordered children he was studying. The amphetamine compound he tried was not helpful for the headaches, but teachers reported dramatic, though short-lived, improvement in the children's learning, motivation, and behavior while they were on this medication. Gradually this treatment gained wider use for hyperactive children with disruptive behavior problems.
Our understanding of what would later be called ADD syndrome expanded significantly during the 1970s when researchers noticed that hyperactive children tend also to have chronic problems with inattention that, like problems with hyperactivity, improve in response to stimulant treatment. In 1980 the American Psychiatric Association first used the term "attention deficit disorder" as an official diagnosis. At that time they recognized chronic impairment of attention, with or without hyperactive behavior problems, as a psychiatric disorder. The 1980 version of the diagnostic manual also noted that although this disorder usually originates during childhood, impairments to attention sometimes persist into adulthood. A 1987 revision of the manual changed the name of this condition to Attention-Deficit/Hyperactivity Disorder; since that time the official name has continued to bind inattention to hyperactive behavior problems, largely neglecting the independent importance of the syndrome's cognitive impairments.
Over the past decade, specific medicines have proven safe and very useful to many children, adolescents, and adults throughout the world who suffer from ADD syndrome. Yet very little has been published to explain in understandable terms the complex nature of attention and the wide variety of these chronic cognitive problems associated with ADHD.
In this book, I emphasize the crippling effects of chronic inattention problems on development and functioning throughout the lifespan. I also suggest that the current diagnosis of ADHD encompasses only part of a much wider range of cognitive impairments that are often responsive to medication treatment. And I propose that a cluster of cognitive impairments associated with ADHD, here called ADD syndrome, affects not only those diagnosed with ADHD, but also many people with a wide variety of other conditions, some of whom might benefit from treatments used for ADHD.
Like most clinicians of my generation and, unfortunately, many of the current generation, I learned very little about impairments to attention during my professional training. We were taught to recognize little children, mostly boys, who were extremely hyperactive and often responded to treatment with stimulant medications. And we were told that these hyperactive children often had difficulty paying attention to their teachers and parents. But our education about attention problems generally stopped there.
In the ensuing thirty years of clinical work, I have learned much more about the complex nature of attention. The impetus for most of this learning came from my patients: children, adolescents, and adults struggling with learning, working, social relationships, and family life. As they described to me the wide variety of their chronic problems with inattention, I began to appreciate the complexity of attention and its crucial importance in everyday life. Indeed, by describing the wide range of cognitive functions that improve when treatment is effective, these patients have helped me see the interconnectedness of the attentional networks of the mind.
Although this book is built on a clinical understanding of patients with problems of inattention, it also incorporates information from current research in psychology, psychiatry, and neuroscience. By integrating recent findings in these rapidly changing fields with the clinical study of how inattention affects patients day by day, we can better understand previously mysterious processes within the brain—and better support patients with symptoms of ADHD.
Many people of all ages continue to suffer needlessly from chronic impairments of attentional functions. I hope through this book to share my understanding, acquired over years of clinical experience and research, that many of these complex impairments are treatable. I want to challenge common misunderstandings of ADD syndrome and to advocate for those who suffer from the disorder. In addressing ADD syndrome, we have an important opportunity both to relieve widespread suffering and to learn more about the vast, fascinating complexities of the human brain's attention and management systems.
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