Are we over-diagnosing ADHD or ADD? It seems to be that way given the high percentages reported and the reaction of the public that this diagnosis has simply become another bin to drop people into and provide a label with all kinds of problems.
What actually is the Hyperactive and Combined subtype? What are these disorders and what do they really mean?
We believe that they represent the presence of ADD (Inattentive Type) and the combination of another disorder or the presence of an acquired attention problem that is not a genetic disorder. Here is why.
Disorders that typically create hyperactive symptoms:
- Restless Legs Syndrome
- Sleep Apnea
- Sleep Deprivation
- Brain Injury
- Post Traumatic Stress Disorder
- Type A Personality
- Oppositional Defiant Disorder
Anxiety is a generalized state of edginess, nervousness, and worry that can result in a child or adult continually moving or playing with some type of object. Children and adults tend to move their knee up and down when seated. The ADD child is described as restless due to hands or feet often locked in motion, playing with various gadgets or things on their desk (paper clips to balancing pencils, gnawing on erasers, sucking on their clothing). Anxiety tends to be present in the family history, anxiety is modeled in the behavior of the parent. Anxiety can present as overactive symptoms and an inability to sit still. Anxious people can become impulsive, acting without thinking. They can rush through tasks they feel uncomfortable with. Anxiety can create disorganization as materials are flung about in an effort to complete the task. Anxious individuals are typically described as fidgety.
Hyperthyroidism is a condition that can result in behavioral symptoms of mania as well as hyperactivity. We had a child many years ago who was in for ADD testing. She presented with rather extreme symptoms of bouncing all over the room, unable to stop herself from getting up mid-sentence to walk around, talking in a loud voice as she interrupted conversation. Discussion with her primary care physician and referral to a specialist resulted in the diagnosis of hyperthyroidism. When she was treated all of these symptoms disappeared.
Restless Legs Syndrome is a condition that becomes worse with rest, creepy, crawly and tingly sensations present the urge to move to relieve the discomfort. It becomes worse at night. Children who have growing pains have similar symptoms, their legs ache and hurt. Growing pains may be a precursor signaling the likelihood of later development of RLS. They relieve the discomfort by walking around and cannot sit still. Even when sitting their legs seem to be uncontrollably moving. Individuals diagnosed with RLS have been found to be at risk for ADD and vice versa, proven in recent research studies. Poor sleep at night due to leg pain can create daytime distractibility and restlessness. When preoccupied by their legs, they may find it difficult to remain focused or to attend in class, acting impulsively at times and certainly unable to sit still.
Sleep Apnea, Insomnia and Sleep Deprivation can create daytime sleepiness. Daytime sleepiness in children is different from symptoms seen in adults. Children become more active rather than tired. Sleepy children can easily appear as hyperactive, moving continually. They will appear rather restless, skipping and hopping and jumping rather than walking. Sleepy individuals are more moody, easily frustrated and irritable, reactive in their emotions to ongoing daily events. They will tend to be less patient, unable to wait for their turn, unconcerned about the consequences of their behavior.
Brain Injury is a well known causal factor to result in problems with executive reasoning affecting both behavior as well as thinking processes. This population is well known to demonstrate symptoms of impulsivity, disregard of the consequences of their behavior, unaware of the impact of they have upon those around them. They have difficulty following any routine due to selective attention issues, becoming drawn to anything novel in their environment. This can result in actual movement from one object to another or continual switching of topics in conversation. There is difficulty inhibiting responses or behavior in general, thus they act before thinking. Behavior and emotional reactions are unbridled. Without the capacity to damp down emotions, frustration is easily shown, behavior quickly escalates out of control and out of proportion to the precipitating event. They do not think they should have to follow rules; they may not remember the rules or be able to sequentially comprehend behavior rule combinations.
Post Traumatic Stress Disorder is a disorder caused by some type of traumatic event that creates documented changes in the brain. The brain areas identified in recent research include the executive reasoning processes. Behavior is typically associated with problems of executive reasoning; impulsivity, disregard of consequences, emotional reactivity, failure to abide by rules, unappreciated of those around them, often not keeping agreements or promises made.
Type A Personality, Oppositional Defiant Disorder are disorders that present symptoms of being behaviorally out of control, disregarding needs and wants of those around them, defiant with authority and so on. Symptoms are that of being stubborn, resistant to change, non-responsive to punishment, determined to have things their own way, based upon the belief that they know more and are correct in their thinking. They do not follow rules or adjust their behavior. They maintain the leadership role and take directions from no one other than themselves. Type A personalities by nature are fast talking, fast moving, extreme in their reactions, easily frustrated, impulsive and impatient. They pace rather than stroll. There is a diminished wait time capacity and they can easily “blow up” if kept waiting for too long.
Listed below are symptoms from a self-report measure for the subtypes of Hyperactivity and Combined Subtype. As you read them you will see that any of the disorders discussed above could result in one or many of these symptoms:
- Nervous and high strung
- Refuses to follow requests made by parents
- Grabs things from others
- Interrupts others while talking
- Impulsive, unable to wait his turn, reacts without thinking
- Easily frustrated
- Begins tasks prior to completion of teacher directions
- Intrudes upon others
- Easily angered annoyed or upset
- Ignores consequences of his behavior
- Cannot follow rules of game
- Fidgety behavior
- Disorganized with possessions
- Changes from one uncompleted activity to another without finishing the first activity
- Rushes through chores or tasks with little or no regard for quality
- Begins tasks prior to completion of teacher’s directions
- Cannot adjust behavior to expectations of different situations
- Makes excessive noise
- Runs in the house, does not sit appropriately on furniture
- Nervous when things do not go the right way
- Fails to follow a routine
- Hops, skips, jumps when moving instead of walking
- Handles objects; twirls pencils, plays with things in the desk, repeatedly sharpens pencils
- Talks beyond what is expected or at inappropriate times
- Does not wait appropriately for assistance from instructor
- Demonstrates inappropriate behavior when moving in a group
- Acts as if driven by a motor
- Excessive activity
- Cannot sit still even if told to do so over and over
- Cannot maintain appropriate position while seated in the car
- Runs in a shopping mall or wide area
- Cannot restrain the need to continually move
- Always playing with some type of object or thing if not moving
- Rushed speech, talks fast
- Flits through a room
- Cannot wait for their turn in a game
- Extremely short attention span
Take home message
Is there really a Combined or Hyperactive subtype related to ADD/ADHD or is the problem the combination of attention symptoms and an additional disorder? When a child or adult is labeled with Combined or Hyperactive subtype, there is no further search for the possibility of an additional disorder that could be affecting their brain or their quality of life. Further we limit the accuracy of the diagnosis and the ability to provide treatment based upon accurate diagnosis. Treating for an attention problem is not going to fix a brain or sleep problem and treatment is different for emotional disorders.