Thirty-Five Years and 35,000 Patients Later

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Thirty-Five Years and 35,000 Patients Later
by Harold N. Levinson, M.D.

Groundbreaking work on ADD/ADHD and Related Learning and Anxiety Disorders: Their Inner-Ear/Cerebellar-Vestibular Origins, Understanding, and Treatment

Excerpted from The All-In-One Guide to™ ADD & Hyperactivity (Ages Publications)

"Two roads diverged in the woods, and I -, I took the one less traveled by, and that has made all the difference" — Robert Frost

Introduction

Most readers will probably have heard of the terms ADD/ADHD as well as about the therapeutic effects of stimulant medications such as Ritalin. However, few, if any, may have come across the unique inner-ear and related cerebellar-vestibular (CV) insights into this syndrome as initially provided within Total Concentration (1990), as well as my follow-up research. As a result, the primary aim of this chapter is to summarize my three decades of clinical research with ADHD and its related learning, mood, anxiety, and coordination disorders.

Utilizing two case presentations typical of thousands and commonsense reasoning, I will attempt to develop a comprehensive clinically-determined theory fully capable of explaining all the many and diverse symptoms and diagnostic/therapeutic facts characterizing this heretofore puzzling and complex appearing disorder. Indeed, I suspect that you all will then wonder: How could such a clear and "obvious" understanding have escaped recognition by all others — considering the many decades of combined efforts by scores of gifted researchers. Indeed, you may paradoxically also be forced to wonder: If indeed ADD/ADHD is a complex multifaceted and multidimensional learning, mood/anxiety, and balance/coordination/rhythmic syndrome, how could it have been traditionally viewed and defined as if it were only a pure and simple attention/activity impairment?

Hopefully, the following pages will enable you to fully recognize the complex portrait of ADD/ADHD as well as the explanatory benefits provided by my inner-ear/cerebellar concepts. Only by listening carefully to the following clinical descriptions of "typical" ADD/ADHD cases as well as countless others will you begin to understand how this unique theory can completely explain all the symptoms, therapies, and all the diverse data found associated with this previously mystifying syndrome.

Understanding ADD/ADHD

To meaningfully understand ADD/ADHD, one must follow a road less traveled: Listen carefully to all the varied symptoms reported by many, many patients — and then attempt to find hidden common denominators and determining mechanisms. Only by doing so will the hidden face of this complex disorder materialize. This is not only the best way to understand ADD/ADHD — it's the only way. As a result, I will now introduce two cases of mine — typical of thousands and thousands of others. Pay careful attention to all their symptoms — not only those you and I were taught to expect. In other words, follow Huxley ingeniously simple directive:

"Sit down before fact as a little child, be prepared to give up every preconceived notion, follow humbly wherever and to whatever abyss nature leads, or you shall learn nothing."

To date, most researchers took another well traveled road — and so learned nothing significantly new for their enormous and dedicated efforts. They merely recognized only those symptoms previously believed to be part of ADD/ADHD and then mistakenly attempted to define this rather complex disorder in an overly simplistic manner via a highly biased and thus tunnel vision perspective. In other words, most traditionalist experts saw only what they were looking for and then tried to define the total seen and "unseen" disorder by only 6 of the 14 parts they mistakenly believed to represent the complete portrait. Needless to say, this approach raised more questions and created more riddles than it solved.

By presenting you with typical cases, I hope to provide the vital data needed by readers to independently judge the value and validity of all my stated insights. In this way you can more objectively compare my inner-ear/CV concepts vs. those espoused by other clinicians and theorists.

Two ADD Presentations — Laurel and Joey

In the two cases that follow, I have taken the liberty of italicizing all the so-called "atypical" and previously "non-recognized"symptoms of ADD/ADHD so that they might more readily be seen and eventually integrated into the total portrait of this disorder — a portrait never before clearly understood by those following the road most traveled.

Laurel

Laurel's mother describes her daughter's ADHD symptoms as follows:

"Laurel, now age seven, has always been a very active, restless, and fidgety child. And she never liked or needed much sleep, even as a newborn infant. Naps were out of the question. Many nights were succeeded in lulling her to sleep only by rocking her in a swing. However, if we then tried to place her in a crib, she would invariably awaken and we'd be back to square one. Strange! But it seems she needed motion to relax sufficiently enough to sleep. As she grew slightly older, it didn't matter how early we put her to bed, or how many stories we read to her. She wouldn't or couldn't fall asleep until nine or ten at night. At times, she even rocked herself to sleep, but it was always very, very late. It's like she tried to fall asleep and couldn't. It's not like she wouldn't, as many tried to tell us.

"No matter how late she fell asleep, Laurel was up and ready to run by seven o'clock on weekdays. So it was never a case of staying up late and sleeping in late. This pattern has continued until the present day. Only recently has she begun to sleep in a little later on weekends. And that's only until around eight.

"She's never still. Even when she's asleep, some part of her body is always moving. I've questioned her pediatrician about this. All he said was, 'she is just a restless sleeper'However, watching her sleeping in motion, it seems impossible for her to be getting any rest.

"Laurel has boundless energy. As a result, she has to be involved in numerous events throughout the day. Even after a major activity which leaves her peers worn out, she wants to know (and is ready for) 'What's next?'A good word to describe her is 'scattered.' She goes from one thing to the next thing at lightning speeds. And Laurel can't stick with anything long enough to complete it. As a result, many things she does remain incomplete, disorganized, and messy. Either she is forced to race through everything, leaving her no time to finish, and/or she gets too distracted and forgets what she was just doing or thinking a moment before.

"Laurel began to show signs of unpredictable behavior as an infant. Rapidly changing mood swings emerged which included tantrums and severe acting-out behaviors. She's always been a very demanding child and requires constant attention. Where it not for our continuous supervision, Laurel and things around her — including her siblings — would rapidly deteriorate into bedlam and chaos.

'When I explained Laurel's mood swings to Dr. K., a clinical psychologist, she recommended a referral to a pediatric neurologist. Interestingly, she noted none of the mood swings that I had reported but did observe a definite restlessness about her that suggested a mild hyperactivity. The neurologist felt she probably had ADD, but not severely enough to warrant medication. However, Laurel needs something to calm her down — to help her concentrate! Besides, she was a lot calmer in his presence than in mine or even the teacher's. In fact, when I think about all his comments now logically, Laurel's functioning was minimal and her disorder was severe. In addition, the neurologist also noted a delay in her fine-motor coordination. But he didn't feel it was medically significant at this time, either. It may not have been significant to him, but it certainly affected the way Laurel read and wrote. For example, whenever she tried to read, she kept losing her place and needed a finger or a marker. And her writing was completely atrocious — unrecognizable. It's as if she had no control over the pencil or the angles and directions her writing was supposed to go. She was also accident-prone. Not only because she was active and impulsive, but because she was really, really, klutzy. When I think back over her development, it appears very easy to understand that her poor coordination corresponded with difficulties that she had with buttoning and zippering and even attempting to hold a pencil in a normal way, rather than the awkward grasp she still maintains. In any event, the neurologist suggested a sleep EEG. This turned out to be an awake EEG because the fifty milligrams of Benadryl given her did not put her to sleep. Her EEG results were normal. However, the medication calmed her down significantly and she was more alert and less distracted than ever before.

"Shortly thereafter, we took Laurel to an optometrist for vision therapy. He also noted a definite eye/hand fine-motor coordination problem as well as difficulty distinguishing right from left.

"Since Laurel started school, I have noticed definite and increasing problems with reading, writing, spelling, and organizational skills. These problems led me to read up on learning disabilities. And when I discussed all these many problems with Laurel's school psychologist, she agreed with me that Laurel was dyslexic, but did not feel the case was severe enough to be overly concerned. But I am! When I finally realized and understood the nature of all of Laurel's symptoms as well as her response to Benadryl, I decided to consult with you!

"In the meantime, we even had her fitted with colored lenses. She claimed to see the letters and words more clearly, and some decrease in reversals and word movement occurred."

Some Interesting Questions

Is Laurel's ADD/ADHD atypical — in that it is mixed or compounded with typical dyslexic/LD symptoms affecting reading, writing, spelling, direction, as well as balance/ coordination/organization signs? Is it an accident that Benadryl, an antihistamine with inner-ear-enhancing potency, calmed Laurel down while enhancing her alertness and minimizing her distractibility — an effect often expected from stimulants?

Joey

Perhaps the description of another "obvious" child with ADHD named Joey might help clarify both the expected and unexpected symptoms characterizing this disorder. As you will soon understand, any valid and reliable definition of ADHD must include all of its symptoms — the typically recognized as well as the typically unrecognized. As before, I will italicize and thus highlight only the reported typically unrecognized dyslexic, mood/anxiety and balance/coordination/rhythmic difficulties found to be part and parcel of this syndrome.

Joey is a six-year old who was brought to me by his father for "extreme restlessness and distractibility." He seemed foggy and preoccupied and found it difficult to maintain eye contact. In fact, he appeared unable to concentrate when looking and thinking or speaking at the same time. School discipline and restraints bothered him no end. Indeed, the only times he was quiet were when he periodically came home spent or burned-out. When he was controlled at school, he was wild at home. And no two days were the same, although the overall pattern was similar. Sometimes he would bounce around from hyper- to underactive in the same day. Most of the time, these variations would occur at intervals of several days.

Joey was short and stocky — strong, but clumsy. As a result he found it difficult to run off his energy without tripping or falling. Speech functioning was delayed and evidence of articulation problems were still apparent. In fact, he was too impatient and lacked the persistence to complete sentences and thoughts. Were it not for an intelligent glint in his eyes and facial expression, one might have thought Joey's IQ to be below average, especially as he also evidenced severe learning disabilities in school affecting reading, writing, spelling, math, memory, grammar, and sense of direction and time.

Although Joey's mother was greatly concerned about his impaired overall functioning, his father seemed quite confident — even overconfident. "I used to be just like him, perhaps worse. And now I'm practicing urology. The only thing different about me was that I was never fearful. Joey is fearful of heights — he was always that way, since he was an infant. Bouncing him up and down terrified him. And he would even get motion sick, too! Stairs terrify him, especially going down. Sometimes he just slides his way from step to step on his backside. And see-through steps are the worst for him. The same is true with escalators. He panics going down them. And his nights have been terrible since infancy. He has had night terrors since birth. And sometimes I think he is afraid of strangers and has day terrors as well.

Some Additional Clinical Considerations

Are the dyslexia/LD, speech, anxiety and balance/coordination, psychosomatic (motion-sickness) symptoms characterizing Joey's ADD/ADHD part and parcel of one overall syndrome caused by one common denominator?, or are those separately named "disorders" or groups of symptoms linked to ADHD by chance and thus derived from separate origins?

The Total ADD/ADHD Syndrome

The neurophysiological examination of more than 30,000 children and adults like Laurel and Joey have revealed that:

More than 96% of children and adults with ADD/ADHD examined neurophysiologically indicate balance/coordination/rhythmic signs and symptoms diagnostic of only inner-ear/CV dysfunction.
Over 90% of individuals with typical symptoms of ADD/ADHD also evidence associated dyslexic/LD, mood/anxiety as well as balance/coordination/rhythmic and psychosomatic (headaches, dizziness, motion-sickness, tinnitus [ear buzzing]) symptoms.
Over 90% of patients referred with a primary diagnosis of dyslexia/LD or Anxiety Disorder manifest significant degrees of overlapping or associated symptoms of ADD/ADHD and balance/coordination/rhythmic disturbances.
Only inner-ear/CV mechanisms can explain all the signs and symptoms characterizing ADD/ADHD, dyslexia/LD, mood/anxiety, psychosomatic and balance/coordination/rhythmic disorders.
Last but not least, all the stimulant medications helpful for ADD/ADHD and all the anti-anxiety/antidepressant medications were shown by NASA-related research to have antimotion-sickness potency. Since the antimotion-sickness antihistamines were shown by my research to be helpful for all the dyslexia/LD, psychosomatic and balance/coordination/rhythmic symptoms as well as for ADD/ADHD and mood/anxiety disorders — it appears reasonable to view all these diverse groups of medications as inner-ear/CV-enhancers.

Considering all the above insights, it appears reasonable to assume and even conclude that ADD/ADHD and related learning and mood/anxiety disorders are part and parcel of one syndrome resulting from one and the same inner-ear/CV dysfunction. Clearly, the diverse overlapping symptoms characterizing individuals and groups with ADD/ADHD will depend on the specific pattern and degree of primary CV mechanisms impaired, their secondary connections to various CNS processors (i.e., frontal lobe, parietal lobe, occipital lobe, mood and anxiety centers, etc.), as well as the ability for CNS compensation.

In summary, the total ADD/ADHD syndrome was found to comprise an additional group of hundreds of typically unrecognized symptoms affecting 13 major areas of non-concentration/activity dysfunctioning. These dysfunctioning groups include: Reading, Writing, Spelling, Mathematics, Memory, Direction, Time, Speech, Grammar, Balance and coordination, Phobias and related mental and behavioral disorders, Psychosomatics, Self-esteem and body image.

The Traditionally Recognized and Accepted Symptoms and Definition of ADD/ADHD

For the typically recognized symptoms of ADD/ADHD, readers are referred to the DSM IV manual, Attention-Deficit/Hyperactivity Disorder (pgs. 78-95), as well as the footnoted content at the end of this chapter.* According to the DSM IV criteria, a diagnosis of Attention-Deficit/Hyperactivity Disorder is made statistically: One must have 6 or more of 14 attention deficit symptoms lasting more than 6 months and/or 6 or more of 14hyperactivity-impulsivity symptoms dating back before age 7.

A New Classification of ADD

Although the DSM IV definition of Attention-Deficit/Hyperactivity Disorder has significant research value insofar as the need for standardization to facilitate comparison of diverse data derived from similar samples, it has major clinical drawbacks. Thus, for example, as any clinician knows, just about all medical disorders occur in mild, moderate, severe, and even compensated (clinically unrecognizable) forms. And ADHD is no exception to this rule. According to my clinical experience, individuals may have only 1,2,3,4, etc. symptoms — and still have ADHD, irregardless of the DSM IV criteria. Indeed, the prior DSM III version required 8 of 14 symptoms for a "sanctioned" definition. I have little doubt that future DSM changes will recognize the above stated clinical reality. Moreover, the response to medications of individuals with ADHD having "6 or more symptoms" and "less than 6 symptoms" are identical — clearly suggesting that the DSM IV statistically determined diagnostic cut-off is "artificial" and deprives the vast majority with this disorder of an accurate diagnosis and meaningful treatment.

Since similar appearing and even overlapping symptoms of ADD and hyperactivity may stem from differing origins, it seemed reasonable to devise a diagnostic classification based on determining mechanisms rather than merely the number of symptoms present. As a result of such a classification, each unique determining mechanism and corresponding symptom can be specifically isolated and more effectively treated. By contrast, the DSM IV "diagnosis by the numbers" masks any such clarification, since all the differing underlying mechanisms and corresponding overlapping symptoms are statistically lumped together and appear as if one.

Eventually my research efforts recognized four primary and one secondary types of concentration disorders (CD) based on mechanisms of origin rather than on descriptions of the symptomatic fall-out. According to this new classification:

Type I CD is due to realistic emotional trauma.
Type II CD is due to unconscious neurotic conflicts.
Type III CD, or ADD, is due to primary neurophysiological and/or neurotransmitter dysfunction of the cerebellar-vestibular system (CVS), or inner-ear, as well as interconnected circuits of the alerting and concentration modular centers.
Type IV CD, or ADD, is due to a primary non-CVS neurophysiological and/or neurotransmitter dysfunction of the reticular activating and concentration modulating systems of the brain, perhaps with secondary or associated involvement of higher centers as well as the inner-ear. This disorder may account for those with extremely severe and pervasive symptoms and tends to have a poorer prognosis than Type III ADD.
Type V²CD is due to the secondary effects of "energy drain" resulting from a variety of conditions such as anemia, metabolic, or chemical disturbances.

As a result of this classification, all patients and all symptoms can be clearly defined in terms of their specific and even overlapping origins. Now all symptoms, depending on their respective origin, can be more effectively treated. In other words, all concentration-related symptoms can be more easily understood — the mild, the severe, and even the transient and reversible normal Freudian-like slips of functioning that periodically affect us all. Needless to say, a similar classification holds true for hyperactivity and impulsivity as well.

Explaining All the Symptoms — Ten Simple Mechanisms

In order to readily explain all the typically recognized and previously unrecognized symptoms comprising the total ADD/ADHD syndrome, I was led to condense all the many and varied inner-ear/CV mechanisms so that ten might be used for explanatory purposes.

The inner-ear acts like a guided-missile computer system — guiding our eyes, hands, feet, and various mental and physical functions in space and time.
The inner-ear system also acts like the vertical and horizontal holds on a television set. It fine-tunes all motor (voluntary and involuntary) responses leaving the brain and all sensory responses coming into the brain.
The inner-ear is also a three-dimensional compass system. It reflexively tells us spatial relationships such as right and left, up and down, and front and back.
The inner-ear also serves as a timing mechanism, setting rhythms to motor tasks.
The inner-ear also acts as a dynamic filter — significantly blocking-out maladaptive sensory-motor and mental backgrounds.
Integration of sensory-motor functioning is also inner-ear related.
The inner-ear, via its connection to various mood, anxiety, motor-energy, and autonomic nervous system centers of the brain, modulates these and various other functions.
The inner-ear serves as a gyroscope for the brain.
The inner-ear processes tone and gravity signals.
The inner-ear was also assumed to facilitate the processing of starting and stopping functions.

Because these mechanisms are thoroughly discussed in my other works (Total Concentration [1990], Phobia Free [1986], Smart But Feeling Dumb [Revised 1994], A Scientific Watergate — Dyslexia [1994]), I will merely use three of them here to highlight their explanatory capabilities: Inhibition, Filtering, Modulation (Fine Tuning).

Hyperactivity/Impulsivity — can be explained if we merely assume an impaired inhibitory or braking mechanism. Thus, for example, a difficulty in properly braking the activity center of the CNS may lead to abnormalities varying from hypoactivity to hyperactivity and variable fluctuations thereof. Similarly, difficulties with controlling or inhibiting action — mental and/or physical — will lead to impulsive verbal and/or motor events.
Distractibility — can be explained by a dysfunctioning in background filtering for visual, acoustic, tactile, smell, and even internal physical and mental/emotional stimuli. It's as if there were "holes" in our filtering system and so in leaked excessive internal and/or external stimuli that otherwise would have been screened-out.
Impaired Concentration — results when signal scrambling or impaired fine-tuning and modulation of sensory-input signals trigger secondary processing difficulties and avoidance; or when improper modulation of the reticular activating system results in faulty arousal which is too little, inconsistent and/or too persistent — the latter contributing to overfocusing, perseveration of thoughts and actions, as well as insomnia and other sleep disturbances.

Diagnosing CV Dysfunction — and Type III or CV-Determined ADD/ADHD

Because over 90% of individuals manifesting symptoms of ADD/ADHD evidence CV dysfunction, testing is aimed at highlighting or diagnosing this neurophysiologically determined difficulty. Since the CV testing techniques are discussed in my other works, I will list them here. These tests include: Optokinetic Tests, Electronystagmography (ENG), Neurological Testing, Posturography (Balance) Testing, and Bender Gestalt & Goodenough Figure Drawings.

For a diagnosis of CV-based or Type III ADD/ADHD to be made, both CV signs and symptoms and determining mechanisms must be present. As noted, various contributing or types of ADD mechanisms may co-exist — and thus their differentiation and selective treatment are essential. Once again, these specifics may be found within the pages of Total Concentration (1990).

Theories of ADD/ADHD

To date, there are almost as many theories of ADD/ADHD as there are experts (including the theory that this disorder does not exist as a clinical entity). As with the diverse theories of dyslexia and anxiety disorders, the value and validity of any conceptualization rests entirely on its ability to encompass and explain all other theories, as well as all the data and variations characterizing the corresponding disorder, while leading to new and unexpected discoveries.

Since the CV system is a fine tuner, filter, inhibitor, etc. to the brain, it can readily explain all the concentration/distractibility/activity symptoms characterizing ADD/ADHD as well as the associated dyslexic/LD, and mood/anxiety and balance/coordination/rhythmic symptoms and all their variations. By virtue of differences in degrees of signal-scrambling and compensation — it is even easy for the CV theory to explain the "non-existent" theory of ADD/ADHD.

Before leaving this topic here, I will quickly note how CV-determined poor eye and hand coordination can explain the typical visual fixation and tracking reading and dysgraphic writing symptoms characterizing dyslexics. And the reported speech-based slurring, articulation, stuttering...symptoms can be similarly understood. Additionally, poor CV-determined balance and coordination can readily explain fears of falling and height phobias whereas inner-ear impaired motion processing may trigger fears of moving elevators, escalators, trains, planes, buses and even walking.

Treatment

By understanding the specific CV-related mechanisms triggering all the many and varied symptoms characterizing ADD/ADHD, it is now possible to obtain a greater than 75-85% success rate by using only CV-enhancing medications. As is well known, the CV-enhancing stimulant medications tend to significantly improve the typically recognized concentration/activity sector of the total ADD/ADHD portrait and panorama. By contrast, the CV-enhancing antimotion-sickness antihistamines and nutrients tend to more significantly improve the "typically unrecognized" dyslexic/LD sector. Since both groups of medications have synergistic and overlapping effects, the combined use of these differently named CV-enhancing medication groups offers most patients the best possible chance of the best medication-based improvements.

Having treated more than 30,000 children and adults over the past three decades, I can assure all readers that this type of medical treatment can work well — and without risk. However, one must know how to properly "drive" the medication program, just as one needs to know how to safely drive a car, boat, plane, etc. By using very small doses and avoiding all side effects, we can reduce the negative risks to almost zero, while obtaining rapid and often dramatic improvements in a wide range of all the symptoms characterizing this previously mystifying disorder. By contrast, the risk of non-treatment is significant.

Since a wide range of anti-anxiety and antidepressant medications were also shown by NASA-related research to be CV-enhancers, it is no wonder that these and other groups of medications can often be helpful "team mates." Moreover, by facilitating normal and even above average signal transmission and processing, it is possible for a wide range of nutrients to further maximize the benefits this type of therapy can offer.

Clearly, the greater one's comprehension of the mechanisms determining ADD/ADHD, the more flexibility a clinician has in designing and utilizing overlapping helpful non-medical treatment modalities. Thus behavior modification, biofeedback, various nutritional supplements, and avoidance of neurotoxic substances, etc. can be significantly helpful — especially when combined with the previously described medical approach. One can often assume that most reported helpful therapies — help. Our aim as therapists is to discern clinically how and how much each therapy works so that the best possible combined or "team approach" can be developed and implemented per patient.

New and Unexpected Discoveries

As noted above, a valid theory invariably leads to new and unique insights. Accordingly, my research led me to recognize that the inner-ear/CV system often plays a hidden co-existing minor role in such major disorders as mental retardation, cerebral palsy, autism, pervasive developmental delay, schizophrenia, etc. Thus by treating the CV component mixed-in the above disorders with CV-enhancers, there often results significant improvement — although the primary cause and effect of the major impairment persists. Needless to say, any improvement in a major disorder — however minor — is significant, especially to suffering individuals and all those interested in helping them.

Summary

The aim of this chapter was to provide readers with new and unique insights into the inner-ear/CV basis of ADD/ADHD and related learning/mood/anxiety disorders. Since this content is highly summarized, it was only possible to skim its surface. Were each of the subtitles properly expanded, then you would more readily grasp the diagnostic/therapeutic benefits of the CV-based formulations of ADD/ADHD vs. those contained within DSM IV and most other texts. Indeed, the CV concepts of ADD/ADHD are sufficient to include and integrate all the traditional and even non-traditional ideas and reported data while formulating a scientifically holistic and meaningful treatment program — ensuring that each and every individual with ADD/ADHD can maximize their potential and achievement.

In conclusion, I hope this chapter serves as a catalyst for all individuals — especially therapists — interested in understanding and helping patients with this previously mystifying and oversimplified disorder. Clearly, a synergy is created when all disciplines can be united under a common theoretical format. Hopefully, this CV-based content will facilitate this synergy.

Bibliography

A Space Saver — Since most of this chapter's insights were uniquely derived, and until recently considered controversial, I will merely highlight a few of my own works — containing vital other references — as well as recent studies independently verifying my cerebellar formulations:

A. My Pertinent References

Total Concentration (Evans, 1990)
Smart But Feeling Dumb (Warner, 1984, Revised 1994)
The Discovery of Cerebellar-Vestibular Syndromes and Therapies — A Solution to the Riddle Dyslexia (Springer-Verlag, 1980; Stonebridge, Revised 2000)

B. Recent Independently Validating References

Attentional activation of the cerebellum independent of motor involvement. From Science, March 28, 1997: Magnetic resonance imaging was used to demonstrate that the cerebellum is involved in diverse cognitive and noncognitive neurobehavioral systems, with attention and motor systems each activating distinct cerebellar regions. (G. Allen, et al, San Diego State University, Joint Doctoral Program in Clinical Psychology, San Diego).

Cerebellum in attention-deficit hyperactivity disorder: a morphometric MRI study. From Neurology, April, 1998: Clinical, neuroanatomic, and functional brain-imaging studies suggest a role for the cerebellum in cognitive functions, including attention. It was found that a cerebello-thalamo-prefrontal circuit dysfunction may contribute to deficits encountered in ADHD. (P.C. Berquin, et al, CHU Hopital Nord, Service de Pediatrie 1, Amiens, France).

The human cerebro-cerebellar-system: its computing, cognitive, and language skills. From Behavioral Brain Research, Volume 44, 1991: Results of a study suggested that the cerebellum contributes to the learning of cognitive and language skills, as well as its acknowledged traditional role in motor functions. (Henrietta Leiner et al, Channing House, Palo Alto, CA and Robert S. Dow Neurological Sciences Institute, Portland, OR).

Abnormal visual-vestibular interaction and smooth pursuit tracking in psychosis: Implications for cerebellar involvement. From Journal of Psychiatry and Neuroscience, March 1991: Findings suggest that cerebellar dysfunction may contribute to irregularities in smooth pursuit tracking and fixation suppression found in psychotic patients. (P.M. Cooper, et al, School of Psychology, University of Ottawa, Ontario).

Cerebellum implicated in sensory acquisition and discrimination rather than motor control. From Science, April 26, 1996: Magnetic resonance imaging suggests that the cerebellum may be active during motor, perceptual, and cognitive performance. (J.H. Gao, et al, University of Texas Health Science Center, Research Imaging Center, Medical School, San Antonio).

Cerebellar size and cognition: correlations with IQ, verbal memory and motor dexterity. From Neuropsychiatry, Neuropsychology and Behavioral Neurology, January, 1997: Results indicate that the cerebellum contributes to cognition as well as volume significantly correlated with the ability to retain already encoded information — verbal and fine motor skills. (S. Paradiso, et al, University of Iowa College of Medicine, Department of Psychiatry, Iowa City).

The cerebellar cognitive affective syndrome. From Brain, April, 1998: In a neuroimaging study of patients with cerebellar diseases, researchers found impairments of verbal fluency, abstract reasoning and working memory; spatial cognition; inappropriate personality and behavior; and language deficits such as agrammatism and dysprosodia. (J.D. Schmahmann, et al, Department of Neurology, Massachusetts General Hospital, Boston).

Does the cerebellum contribute to cognitive aspects of speech production? A functional magnetic resonance imaging (fMRI) study in humans. From Neuroscience Letters, May 15, 1998: Positron emission tomography studies suggest a contribution of the lateral aspects of the right cerebellar hemisphere to higher-level (cognitive) aspects of speech production. (H. Ackermann, et al, University of Tubigen, Department of Neurology, Germany).

Dysfunctional cortico-cerebellar circuits cause "cognitive dysmetria" in schizophrenia. From Neuroreport, June 1, 1998: Studies made point to a dysfunctional corticocerebellar circuit leading to poorly coordinated mental activity ("cognitive dysmetria"), which could explain the broad range of schizophrenic symptoms. (A.K. Wiser, et al, University of Iowa, College of medicine, Mental Health Clinical Research Center, Iowa City).

Metabolic abnormalities in developmental dyslexia detected by 1H magnetic resonance spectroscopy. From The Lancet, June 20, 1998: Using proton magnetic resonance spectroscopy, this study led to the conclusion that the cerebellum is involved in dyslexia. (Caroline Rae, PhD, et al, University of Sydney, Australia and University of Oxford, UK).

Association of abnormal cerebellar activation with motor learning difficulties in dyslexic adults. From The Lancet, May 15, 1999: A study found lower brain activation in dyslexic adults undertaking tasks known normally to involve cerebellar activation. (R.I. Nicolson, PhD, et al, University of Sheffield, the MRC Cyclotron Unit at Hammersmith Hospital and the Institute of Neurology, UK).

Physiological and behavioral effects of an antivertigo antihistamine in adults. From Perceptual and Motor Skills, Volume 88, 1999: A study found physiological support for the use of an antimotion sickness antihistamine to improve cognitive-related performance with obvious implications in treating learning-disordered children. (J.L. Lauter, PhD, et al, University of Oklahoma Health Sciences Center, OK).

Cerebellar Deficiency Model of Dyslexia Upheld. From Clinical Psychiatry News, January 2000: A study showed that dyslexic adults failed to learn an associative type of eye blink conditioning learning that is controlled by the cerebellum. (Joan M. Coffin, PhD, King's College, PA).

Rational dosages of nutrients have a prolonged effect on learning disabilities. From Alternative Therapeutic Health Medicine, May 2000: A study on the effects of certain nutrients on children with learning disabilities showed significant academic and behavioral improvements within a few weeks of treatment with nutrient supplements. (R.M. Carlton, et al, Stonybrook University Medical School, New York).

The role of the cerebellum in cognition and behavior: a selective review. From Journal of Neuropsychiatry and Clinical Neuroscience, Spring 2000: A study on the role of the cerebellum in cognition and behavior, highlighted cognitive deficits and personality changes associated with cerebellar disease. (Rapoport, M., et al, Dept. of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Canada).

**The DSM IV* Diagnostic Criteria**

I would like to include the typically recognized ADD/ADHD symptoms included within the DSM IV here so that readers may clearly understand the symptoms needed for a traditionally accepted definition.

Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

Either 1) or 2)
1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
  1. Inattention
    1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
    2. Often has difficulty sustaining attention in tasks or play activities.
    3. Often does not seem to listen when spoken to directly.
    4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (due to oppositional behavior or failure to understand instructions).
    5. Often has difficulty organizing tasks and activities.
    6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
    7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools).
    8. Is often easily distracted by extraneous stimuli.
    9. Is often forgetful in daily activities
2. Six (or more) of the following symptoms of hyperactivity-impulsivity have been persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.
  1. Hyperactivity
    1. Often fidgets with hands or feet or squirms in seat.
    2. Often leaves seat in classroom or in other situations in which remaining seated is expected.
    3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
    4. Often has difficulty playing or engaging in leisure activities quietly.
    5. Is often "on the go" or often acts as if "driven by a motor."
    6. Often talks excessively.
  2. Impulsivity
    1. Often blurts out answers before questions have been completed.
    2. Often has difficulty awaiting turn.
    3. Often interrupts or intrudes on others (e.g., butts into conversations or games).
Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning
The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months.

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 I not met for the past 6 months.

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past months

314.90 Attention-Deficit/Hyperactivity Disorder, Not Otherwise Specified: This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.

Coding note:
For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.