Attention Deficit Disorder

by Thomas E. Brown
Yale University Press, 2005
Review by Ben Lovett on Aug 22nd 2006

Thomas Brown is already known in the Attention Deficit Hyperactivity Disorder (ADHD) world for his standardized questionnaires that people fill out to determine if they or their children have the symptoms of ADHD. In this book, Brown shows off his theoretical side, integrating research from neuroscience, pharmacology, clinical psychiatry and cognitive neuropsychology to develop a model of what he calls ''the Attention Deficit Disorder (ADD) syndrome'', a constellation of deficits in such areas as initiating tasks, persisting over time, regulating alertness and managing emotions.

If this thumbnail description of Brown's ADD syndrome does not square with what you had thought ADHD to be, you are not alone. A brief primer on official terminology: in the most recent (1994) listing of psychiatric disorders, found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), only ''ADHD'' is present. However, the symptoms required for diagnosis are divided into two areas: inattention and impulsivity/hyperactivity. If an individual only has a significant number of symptoms from the inattention list, they may be diagnosed with ''ADHD, primarily inattentive type,'' which is still referred to by many clinicians as ADD.

The inattentive subtype of ADHD, however, is not quite the syndrome that Brown discusses. He begins not with DSM-IV descriptions, but with the neuropsychological concept of ''executive functioning''. Just as an executive in a corporation plans, delegates, supervises and otherwise coordinates different tasks, certain systems in the brain do the same thing. Brown divides the various executive functions into six groups (e.g., focus, memory) and gives an overview of the research on each one. To understand Brown's ADD syndrome, think of the executive functions as a single brain system. People vary along a continuum of how effective their executive functioning system is at coordinating and monitoring tasks, and those who are at the low end of this continuum can be said to have ADD.

The first half of Brown's book is devoted to exploring the executive functions, their neural bases, and how deficits in executive functions can cause impairment in childhood, adolescence and adulthood. His points in these chapters should not be controversial, and his straightforward prose communicates complex ideas in an accessible way. More problematic is the second half of the book, which focuses on diagnosis and treatment. Since the ADD syndrome is not recognized as an official disorder, recommendations for diagnosis and treatment must either be somewhat ad hoc, or else borrowed from currently recognized psychiatric conditions, such as ADHD.

Brown chooses the latter strategy, first reviewing the typical diagnostic tools for ADHD. He points out that the clinical interview is the most important part of an ADHD assessment, and he discusses the differences between interviewing adults and children. He describes the standardized tasks and tests that can provide helpful supplementary information, and notes the advantages and disadvantages of each. Brown integrates his new ADD syndrome into clinical practice by broadening the category of ADHD, attacking purported exclusionary criteria for the disorder. For instance, the DSM-IV states that symptoms must begin before age 7, but Brown notes that children are sometimes given enough environmental support that deficits are not evident at early ages. Similarly, the DSM requires that individuals must show at least 6 of the listed symptoms, but Brown points to a study in which only 1% of adults in the general population reported experiencing 6 or more symptoms. Many would interpret this study as showing that the prevalence of ADHD is lower in adults than in children, but Brown relies on the study to argue that we should lower our symptom thresholds when diagnosing adults.

After discussing diagnostic strategies, Brown devotes an entire chapter to disorders than may accompany his ADD syndrome. It is generally agreed that individuals with ADHD experience a higher risk of developing such problems as depression, anxiety and learning disabilities, but Brown goes further, arguing that executive functioning deficits are a component of these other disorders. The chapter concludes by claiming that the ADD syndrome, as Brown describes it, is not specific to individuals who meet the criteria for ADHD; instead, ''this syndrome might be seen as a cluster of impairments that cuts across other diagnostic categories''. Brown does not shy away from the treatment implications, suggesting that ''some treatments demonstrated useful for ADHD might also be helpful for some cases of other disorders, such as depression or traumatic brain injury''.

In the last two chapters, Brown details those treatments, along with their efficacy, and the degree to which individuals with the ADD syndrome can reasonably expect their symptoms to remit. Brown's discussion of treatment options is evenhanded, relying on the now-famous MTA study (which found medication to be superior to behavioral treatment for ADHD) but also acknowledging that behavioral therapies can be useful in certain settings (e.g., schools).

Given the book's broadening of diagnostic categories, its admittance that clinically significant inattention is not specific to ADHD, and its uncritical endorsement of pharmacological treatments, the message appears to be this: some people aren't as good as the rest of us at getting things done, and if there's a big gap between what they're getting done and what they could be getting done, they have ADD syndrome, so give them medications, which will offer a good chance for symptom improvement. Given the current state of the ADHD diagnosis, filled with more contention than consensus, this may seem to be a pragmatic response. However, Brown doesn't adequately consider the downsides of this arrangement. Couldn't any apparently normal, healthy person find a life setting where they found it difficult to get things done? Is medication -- or, for that matter, behavioral therapy -- the answer, any time that someone happens to be experiencing inattention and isn't reaching what they consider to be their potential?

Brown's ''new, somewhat controversial understanding'' of these ADHD symptoms, then, should be viewed as a provocative proposal, not a careful argument that considers and deals with potential objections. For professionals and interested non-professionals, the book should contribute to a vigorous debate about foundational issues in psychopathology. The author's style and some of the information presented are clearly meant for a wider audience, but general readers should be aware that Brown's primary topic is the ADD syndrome as he describes it, not ADHD; for those seeking a general introduction to the latter condition, other volumes are available and superior.

Ben Lovett is currently a doctoral candidate in the psychology department at Syracuse University, where his research interests include learning disabilities and ADHD. For more information, see his website: http://web.syr.edu/~bjlovett/

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