Many patients are referred for “recalcitrant ADHD” or otherwise unmitigated conditions of behavioral inhibition and/or disruptiveness. ADD is a real condition and appears to have a genetic and also learned component. Nevertheless there are many causes for impairment of attention: they include fatigue, malnourishment, emotional upset, and noxious distraction.
Other terms for ADD include minimal brain dysfunction, minimal brain damage, hyperkinetic reaction of childhood, and mental restlessness.
In general, ADD is much more than a deficit of attention. Sometimes it is considered from the point of view of “executive dysfunction” because so many aspects of mature neurological function are impacted by the condition. Here, we tend to think of ADD as an example of “frontal lobe disorder”.
If ADD (with or without hyperactivity) does not respond well to stimulants, an in-depth evaluation is appropriate. Stimulants are a good “probe” for uncomplicated ADD – basic measures of attention and concentration/error inhibition will improve when the patient is taking an appropriate dose of stimulant.
Here, we consider non-response to stimulant to be an indication of mis-diagnosis or co-morbidity. Sometimes the diagnosis is just plain wrong – the patient actually has OCD or mood disorder. Other times there are co-morbidities such as post-concussion syndrome or substance misuse or psychiatric illness that occur along with ADD. Sometimes we find early dementia.
Finding the right diagnosis is the key. Here we utilize functional brain measurement by SPECT scan, or EEG/QEEG. Often we obtain educational or neuropsychological testing. Once we understand & ameliorate brain function, habilitation and remediation are more likely to give the right results.