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Ask the Mental Health Expert Archives 2001-2004

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ADD Development

Q. Is it possible to not exhibit symptoms of Attention Deficit Disorder (ADD) in childhood and then have nearly all the symptoms manifest as a teenager?

I had an excellent memory as a child, nearly photographic. At age fourteen I was in a car accident. I had a concussion and broken bones. About a year later, I started getting ADD-type symptoms. I am 29 years old now and still have nearly all the symptoms of ADD (without hyperactivity).

I have seen a therapist once, she told me that it cannot be ADD because the symptoms were not present prior to age 7. I thought I had read that the onset may occur with trauma, in adolescence. Is that true?

A. The prevailing teaching (or dogma?) on ADHD (Attention Deficit Hyperactivity Disorder) is that it virtually always makes itself known prior to the age of 7. This criterion, in fact, must be fulfilled in order to receive a diagnosis of ADHD under the rules of DSM-IV, psychiatry's diagnostic bible.There are some research studies that clearly do support this view (e.g., see Willoughby et al, J Am Acad Child Adolesc Psychiatry. 2000 Dec;39(12):1512-9.)

On the other hand, not all clinicians believe this, and some retrospective data suggest a few cases in which ADHD may have a late onset--perhaps in the teenage years (see, e.g., Hesslinger et al, Psychiatry Res. 2003 Aug 1;119(3):217-23).

All that said, your history of a concussion may be the critical issue here. There is no question that after suffering a concussion or traumatic brain injury (TBI), some individuals will show ongoing and sometimes chronic problems with attention, mental processing speed, and other cognitive problems of varying severity.

For example, Chan (J Clin Exp Neuropsychol. 2002 Dec;24(8):1081-93) found that in a sample of 92 patients with postconcussive complaints and 86 normal controls, patients with persisting postconcussive complaints demonstrated a general deficit in attentional performance as compared with the normal controls.

These patterns still persisted when measures of emotional disturbance were controlled. By DSM-IV criteria, most such individuals probably would not be given the diagnosis of ADHD, though the text is a bit ambiguous on this point if symptoms begin prior to age 7.

In practical terms, you may want to consider discussing your problem with a neuropsychiatrist who has special expertise in the area of TBI. There may be both medications and cognitive training techniques that could improve your attention to some degree.

December 2003

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