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.

© 2006 Ben Lovett

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/

Categories: ChildhoodDisorders, General