Why Hyperactivity is Not ADD

Self report measures that assess the Hyperactive subtype of ADHD indicate the following symptoms:

• Nervous and high strung
• 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

ANXIETY CAN MIMIC HYPERACTIVITY

Anxiety is a generalized substrate of edginess, nervousness, and worry that can increase to symptoms of panic to the point that it feels like you are having a heart attack. Anxiety easily leads to avoidance of a fearful situation or stimulus and procrastination of doing things that are feared. For the ADD child or adult this means avoiding paperwork or the things that we do not feel as competent about. Anxiety increases if we think about it more and more. There is a tendency to become perfectionistic and compulsive about the things we can change, which increases when we feel more stressed and out of control. For example, cleaning the house when you have invited people over and you have a million other things to do as well before they come.

Attention Deficit Disorder (ADD) children tend to be highly anxious, generally growing up with a genetic anxiety disorder that runs through the family. Consequently, children grow up with anxiety in the household; this anxiety is modeled through their parents and manifests in the child’s own internal anxiety. An anxious child appears to be restless; moves around a lot, plays with various gadgets and toys (from paper clips to anything that is available, balancing pencils, etc.); they may gnaw through erasers, chew on fingernails or suck through the collar of their jacket. Their hands and feet seem to be in a continual form of movement. In contrast, child with hyperactivity issues moves uncontrollably, running, loud, unable to attend to simple things for even a few minutes. An anxious child can attend for longer periods of times and is not wild and uncontrollable in their actions. When grown this anxiety continues to be evidenced in much the same manner; the fiddling does not stop even though the objects change and the method is different. Generally, there are more individuals diagnosed with ADD without hyperactivity when this misdiagnosis of Attention Deficit Hyperactivity Disorder (ADHD) hyperactivity is not applied.

WITH TIME ANXIETY AND FAILURE LEADS TO DEPRESSION

People who are anxious and upset develop the tendency to feel sad over the things they cannot fix, the things they have no control over, and basically their own inability to effect change in their day-to-day life. Following these feelings tends to be the notion that everyone around them has an easier life, that learning is not as hard, that others can accomplish the same tasks with less effort. The idea that no one struggles as much as they do.

Depression can manifest itself as either anger or sadness depending upon the personality type or gender.

Males generally tend to react with anger before they allow themselves to cry. Women tend to cry before they are able to show anger. Societal values and how men and women believe they need to present themselves in public undoubtedly impact these tendencies. Depression in any form means predicting the worst, expecting bad things to happen, not expecting good things to occur and life is experienced as a series of adverse events.

PERIODIC LIMB MOVEMENTS, RESTLESS LEGS SYNDROME, INSOMNIA, SLEEP APNEA

If children do not get restorative sleep at night or they have insufficient sleep or sleep deprivation, daytime symptoms can easily mimic hyperactivity. By remaining active during the day children can remain awake. Periodic limb movements disorder (PLMD), restless legs syndrome (RLS), insomnia, and sleep apnea can cause sleep deprivation and/or a lack of restorative sleep, thus creating daytime sleepiness. In order to stay awake, children move around a lot, shift often in their seat, fidget, and play with anything in their vicinity. These behaviors can lead to an inaccurate observation of hyperactivity. New research is identifying a substantial overlap between Attention Deficit Hyperactivity Disorder (ADHD) and RLS and PLMD in sleep. Recent studies are identifying the overlap between sleep apnea and ADHD. In some cases treatment of the sleep apnea is resulting in cessation of ADHD symptoms. While this is not an often occurrence what does happen regularly is the presence of significantly diminished overactive symptoms following treatment that in some cases warrant a reconsideration of treatment with medication.

A person affected by RLS or PLMD experiences discomfort to varying degrees in their limbs and finds it difficult to sit down or to remain seated because they get relief by walking or moving around. This becomes worse during certain periods of the developmental cycle, especially if the individual is going through a growth period such as adolescence. When preoccupied by the feeling in their legs, it becomes difficult to remain in their seat and they will walk around the classroom or the staff meeting, hop, skip, or jump as opposed to walking, and have difficulty following a routine especially if it means sitting down, generally appearing highly restless.

If continually sleepy or sleep deprived, the person may become highly irritable, emotionally reactive or easily annoyed and upset at the slightest thing. They would naturally be less patient, more impulsive in their thoughts and behaviors, ignoring consequences of their behavior because they are tired and no longer care about anything except wanting to sleep. During quiet periods when more prone to go to sleep, they may talk to others to remain awake and alert and move about appearing highly restless due to the nature of the activity.

BIPOLAR DISORDER

The highs and lows of bipolar disorder can easily look like overactivity, especially in the manic state. When in the manic phase of this cycling disorder, individuals can easily appear hyperactive. Bipolar disorder is often cited as a correlated disorder accompanying hyperactivity. The problem is identifying what bipolar really is. Too often after completing a full psychological evaluation, individuals who presented with the diagnosis of bipolar based upon outwardly displayed symptoms were not diagnosed with this disorder once the evaluation was completed. Brain injuries, seizure disorders, and sleep-related breathing disorders manifest frontal lobe symptoms that can easily present with the expansiveness and grandiosity of the bipolar disorder.

When in the true manic phase the person cannot sit down, becomes highly impulsive, cannot refrain from blurting things out at inappropriate times, and simply cannot contain themselves in any manner. They are unable to adjust their behavior to any situation. They cannot contain themselves from impulsive actions and reactions. These symptoms do not singularly differentiate a psychiatric disorder from a disorder affecting the brain.

TRAUMATIC BRAIN INJURY, POST-TRAUMATIC STRESS DISORDER, BIRTH TRAUMA

Injury to the brain, as well as disorders specifically affecting the frontal processes, will easily present with symptoms of impulsivity as well as hyperactivity. Deficits of selective attention (related to deficient frontal processes) will tend to result in the individual selecting everything in their environment to pay attention to. As a result, they find everything novel as stimulating and thus, tend to run from one novel stimulus to the next. The younger children are, the more overly active or hyperactive that they will outwardly appear and often more behavioral problems are equally present.

Deficits of selective attention, specifically related to impaired frontal functioning, results in a child who often cannot control their overactivity or impulsive response pattern. Parental threats or promises of discipline are insufficient to stop behaviors related to impaired brain processes.

When the frontal processes are injured, symptoms related to lack of inhibition, selective attention, and perseveration predominate, creating the boy who calls across the gym informing one of the girls that she has hairy legs. Symptoms typical to both hyperactivity and brain injury overlap in the descriptions of the child who cannot sit still, remains unresponsive to adult discipline, cannot engage in a conversation due to continual distractibility that includes focusing on everything around them.

The boy in history who is preoccupied with last night’s television show and interrupts the teacher to ask a question about South Park or begins to talk about a scene from a recent movie as a totally unrelated topic to the history discussion presents with classic symptoms characteristic of frontal lobe impairment as well as descriptors of hyperactivity.

Post Traumatic Stress Disorder

Children appear hyperacitvty appears in the form of extremely poor eye contact and difficulty listening someone is talking. The primary complaint of distractibility results in increased stress subsequent to the tendency to continually lose things or to have difficulty organizing tasks to get anything accomplished. Individuals are forgetful in daily activities, tend to interrupt others in fear of forgetting what they wanted to say, and blame others in fear of being blamed and ultimately physically harmed as a result. It is well known that traumatized individuals will come after someone in fear, anticipating that they will be harmed and learning to attack first. They may immediately become defensive as a self protective mechanism. My experience is that the presence of emotional trauma can create a whole different persona or personality from who the person was prior to the trauma occurring in their life. A person who has been traumatized tends to become hypervigilant, ever alert to avoid problems. Blame is typically placed upon others in effort to avoid punishment that is likely to be harsh and well beyond the action. In this manner the presence of trauma in a person’s life can create a personality that while looking like hyperactivity as we behaviorally know it, is truly incorporated to address real fears associated with the life they are living.

Injury to the brain affecting the frontal processes produces an individual who does not have the brain capacity to restrict their behavior, so they cannot be patient, they cannot restrain their impulsivity, they cannot stay on task or they cannot avoid blurting out what they think at the wrong time and in the wrong place. They have to have their own way because they cannot shift sets, and become stuck in their thoughts. They cannot comprehend the give and take of relationships (therefore they do not keep agreements or appreciate the efforts of others, ignore rules and do not feel guilty). They are easily frustrated, easily angered, easily annoyed, with no capacity to damp down their emotions which are frequently overly reactive and out of control and not commensurate with the situation. As such, they become overly excited and cannot follow the rules of the game. Finally, the feedback loop of sound is not present, so they are loud, far louder than the situation demands and while easily upset if others are loud, they remain unaware of their own loudness.

Socially, these children do not share very well, they become stuck on certain objects and will not give them up, and they tend to bully other children, becoming highly demanding and manipulative to get their way. Without a social conscience in place, they have difficulty apologizing for their mistakes, feeling guilty when they have done something wrong, and they are difficult to reach with punishment, generally nonresponsive and seemingly immune to discipline.

HYPERTHYROID

When hyperthyroidism is active, the person can develop manic qualities that will appear as overly active. I had a child who came in with those huge ‘‘bug eyes’’ and I evaluated her for ADD. While displaying clear-cut symptoms (albeit mild, and none of her testing scores fell below average limits) of ADD, she also demonstrated frontal deficits that made little sense given her history and the absence of any birth or subsequent causal factors that would be related to a brain injury. I suggested to the parents to wait for a confirmed diagnosis of ADD prior to ruling out thyroid issues. She ultimately was diagnosed with a hyperthyroid condition that was rather significant; significant enough to clinically present as a feasible and probable causal factor. Once the thyroid condition was stabilized, which took several months, reevaluation still revealed the clear-cut pattern of a long-term genetic ADD disorder, although her scores did not fall below average limits and her functioning in the classroom did not suggest the need for medication.

TYPE A PERSONALITY AND ALCOHOLIC PERSONALITY

The behavior of these two types of personalities can present as an individual who is hyperactive, always on the go, always moving. Individuals given the descriptor of type A personality tend to appear hyperactive simply because they are fast paced, fast talking and fast thinking; which are the behavioral indices that we have come to see as ADHD. We typically associate any type of extremes or fast pace with hyperactivity. If on a tight schedule, type A personalities can become overly frustrated, impulsive, and highly impatient. Lack of time and feeling overwhelmed changes their persona, brings out the worst, and they seem more hyperactive by the minute. This may negate the following of a routine, the wait for things to happen; such as for the waitress to come to the table or the teacher to come to their desk. With a diminished wait time capacity, they get up to find the teacher or to track down the waitress if they need to leave the restaurant.

People with either or both of these personality types do not always comply with rules if they feel they are not correct or not appropriate for the situation. Feeling superior to others or used to the leadership role, they do not work well in group situations, taking over and becoming demanding and/or controlling. They do not follow rules, believing they know a better shortcut or a better way and attempt to convince the group of this. They tend to become judgmental; judging their superiors or the teacher in the classroom or the authority figure, requesting rules to be changed, ‘‘just this one time.’’ They do not believe that consequences will actually affect them, which they have the power to move around the situation, to move around the rule that has been made and so on. They do not adjust their behavior to specific situations if they feel that it does not require that. For example: ‘‘So, you are in the library talking, there is no one else around who cares?’’

Type A or alcoholic personalities tend to be more extreme thinkers, thinking they are right about something and refusing to back down on a point or to concede an error. If they are rigid thinkers then perseveration or getting stuck may occur, thus promoting black and white thinking and negating consideration of any alternative response. When illness affects these individuals, such as cardiovascular disease or sleep apnea, these symptoms can become more pronounced.