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Pseudo-ADD by Edward M. Hallowell, M.D. and John J. Ratey, M.D.

Excerpted from Driven to Distraction (Touchstone 1994) pp. 191-194.

Copyright Edward M. Hallowell, M.D., and John J. Ratey, M.D. Reprinted with permission.

American society tends to create ADD-like symptoms in us all. We live in an ADD-ogenic culture.

What are some of the hallmarks of American culture that are also typical of ADD? The fast pace. The sound bite. The bottom line. Short takes, quick cuts. The TV remote-control clicker. High stimulation. Restlessness. Violence. Anxiety. Ingenuity. Creativity. Speed. Present-centered, no future, no past. Disorganization. Mavericks. A mistrust of authority. Video. Going for the gusto. Making it on the run. The fast track. Whatever works. Hollywood. The stock exchange. Fads. High stim.

It is important to keep this in mind or you may start thinking that everybody you know has ADD. The disorder is culturally syntonic--that is to say, it fits right in.

It is true that the prevalence of ADD--the frequency with which it occurs in the population over a given period of time--is higher in America than it is overseas. We do not know why this is so. The British think that we overdiagnose ADD in America. Until recently, Michael Rutter, one of the leading British child psychiatrists and an expert on epidemiology, doubted that ADD, as we think of it, actually existed as a valid syndrome. He thought we were lumping other syndromes under the heading of ADD. He has since changed his mind, acknowledging that ADD does indeed exist, but he finds it in the British population at lower rates than we diagnose it here.

One possible explanation for this is that our gene pool is heavily loaded for ADD. The people who founded our country, and continued to populate it over time, were just the types of people who might have had ADD. They did not like to sit still. They had to be willing to take an enormous risk in boarding a ship and crossing the ocean, leaving their homes behind; they were action-oriented, independent, wanting to get away from the old ways and strike out on their own, ready to lose everything in search of a better life. The higher prevalence of ADD in our current society may be due to its higher prevalence among those who settled America.

Certain qualities are often associated with the American temperament. Our violent, rough-and-tumble society, our bottom-line pragmatism, our impatience, our intolerance of class distinctions, our love of intense stimulation--these qualities, which are sometimes explained by our youth as a country, may in part arise from the heavy load of ADD in our gene pool.

Since we suspect that ADD is genetically transmitted, this theory makes some sense. Although it is impossible to ascertain the prevalence of ADD in colonial Boston or Philadelphia, as you read through the lives of the adventurous souls who lived there, you can see that more than a few of them liked risk and high stimulation, balked at custom and formality, lived by innovation and invention, and rose to action rather quickly. It is dangerous to diagnose the dead, but Benjamin Franklin, for example, seems like a man with a case of ADD. Creative, impulsive, inventive, attending to many projects at a time, drawn to high stimulation through wit, politics, diplomacy, literature, science, and romance, Franklin gives us ample ground to speculate that he may have had ADD and was the happier for it.

If it is true that part of the high energy and risk-taking of our ancestors was due to ADD, then that would explain, to some extent, why our rates of ADD are higher than other people's. But even taking that into account, might we be overdiagnosing it, or might our definition of it be so broad as to be overinclusive? Frequently, people remark when they hear a description of ADD for the first time, "But doesn't everybody have that?" or, "Isn't that just a variation on normal behavior?" or "How can you call it a disorder when it's so common?"

It may seem that our cultural norms are growing closer and closer to the diagnostic criteria for ADD. Many of us, particularly those in urban areas live in an ADD-ogenic world, one that demands speed and splintering of attention to "keep up." The claims on our attention and the flow of information we are expected to process are enormous. The explosion of communications technology and our standard way of responding to its most ubiquitous form--television--provide good examples of ADD behavior. Remote-control switch in hand, we switch from station to station, taking in dozens of programs at once, catching a line here, an image there, getting the gist of the show in a millisecond, getting bored with it in a full second, blipping on to the next show, the next bit of stimulation, the next quick pick.

Because we live in a very ADD-oid culture, almost everybody can identify with the symptoms of ADD. Most people know what it feels like to be bombarded with stimuli, to be distracted by overlapping signals all the time, to have too many obligations and not enough time to meet them, to be in a chronic hurry, to be late, to tune out quickly, to get frustrated easily, to find it difficult to slow down and relax when given the chance, to miss high stimulation when it is withdrawn, to be hooked to the phone and the fax and the computer screen and the video, to live life in a whirlwind.

That is not to say, however, that most people have ADD. What they have is what we call pseudo-ADD. As we will discuss in the chapter on diagnosis, true ADD is a medical diagnosis requiring evaluation by an expert. What differentiates pseudo-ADD from true ADD, what differentiates the people who can only identify with it from those who actually have it, is a matter of duration and intensity of the symptoms.

This is true of many psychiatric diagnoses. For example, most of us know what it feels like to be paranoid. We have all felt, at one time or another, that someone is out to get us who really isn't. We have, most of us, felt suspicious and nervous, wondering: Are they watching me? Is the IRS out to get me? Is my boss setting me up? Was that joke at the meeting a veiled reference to me? That we experience moments of paranoia does not make us paranoid personalities, however. In the true paranoid personality, the paranoia besets the individual chronically and intensely. It is the intensity and duration of symptoms that differentiates the insecure person from the truly paranoid.

Similarly, we have all been depressed at one time or another. That does not mean we have suffered major depression. Most of us have gambled at some time--bought a lottery ticket or put a nickel in a slot machine-- and felt a thrill when we won. That does not make us pathological gamblers. Most people have felt a fear of heights at times, or had trouble with closed spaces, or felt frightened of snakes, but not to the extent of developing a phobia. Only if the symptoms are more intense than is normal, if they last a long while, and if they interfere with one's everyday life, only then can one entertain an actual diagnosis.

So it is with ADD. The person with true ADD experiences the symptoms most of the time and experiences them more intensely than the average person. Most important, the symptoms tend to interfere with everyday life more than for the average person.

It is important to keep true ADD separate from pseudo-ADD for the diagnosis to retain any serious meaning. If everybody who gets distracted or feels hurried or gets easily bored is diagnosed with ADD, then the diagnosis will signify nothing more than a passing fad. While pseudo-ADD may be interesting as a kind of metaphor for American culture, the true syndrome is no metaphor. It is a real, and sometimes crippling, biologically based condition that requires careful diagnosis and equally careful treatment.

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