Yin and Yang of

the Bouncing Brain

Snapshot of a New Spectrum

View of Attention Differences

Prepared for a 1997 Canadian anthology, this article gives an early overview of Carla Nelson Berg's spectrum model of attention differences

[click on image to view full size]



California science and health writer Carla Nelson Berg is a longtime leader of GO MIND , the Mind-Brain Sciences Forum on CompuServe, a digital gathering place for scientists and mental health professionals, and co-leader of GO ADD , the Attention Deficit Disorder Forum, where she assisted scores of patients and interviewed dozens of specialists as a cyber "talk show host," while raising two bouncing brained offspring. This experience gave her an especially good bird's eye view of the entire spectrum of attention difficulties, while her experience as a journalist provided the tools for distilling what she learned.

"What we are calling ' ADD ' is not just about a struggle to concentrate," she reports. "It's about people who shift between extremes of under and over focusing."

Everyone with an attention deficiency has bouts of distractible inattention mixed with bursts of "hyperfocusing" where attention is so locked on it's a struggle to switch it off. What distinguishes one from the next is how much time they spend in each state, Nelson explains.

People without attention deficits are able to modulate, switching at will from one task to the next, but people with ADD cannot hold attention steady unless arousal is intense. Lacking that extra-strong "stimulus fuel" their focus fades. Yet once it is found they are also prone to over-engage, then find it hard to gear down.

In more technical terms, AD D ers require especially strong stimulation to initiate and sustain activation. As a result, they wrestle with both under and overactivity, with some being chronically sluggish and hard to turn on, while others are persistently hyper in body or mind and too turned on too much of the time, each exhibiting different sides of what Nelson also describes as an "All-or-None Attention Span."

Three Types in Nine Degrees

After more than three years of researching clinical literature and comparing thousands of first-person histories, Nelson developed a spectrum model of attention differences, previewed in her monograph, Hyperactive Hearts & Minds, a portion of which was also condensed in the ADD Forum book, Think Fast (Underwood- Miller 1996). It is a three-type model with nine degrees that shade from one to the next, changing hues as they progress in strength and length of attentiveness:

Type 1: Roving [Hypofocus]

On the under, or hypo, focusing side is the "Roving" Type 1. Prone to impulsivity and sometimes to physical hyperactivity, people who fit this "underfocusing" profile struggle to turn thinking on and sustain concentration for long. In Nelson's models, subtypes in this cluster range from a scattered "Ranger" at 1.1 to the physically hyper "Racer" at 1.3. Underthinking and overactivity are their primary obstacles. Type 2: Restless [Mixed Focus]

In the middle is a "Restless" Type 2 that blends traits from both sides, shifting between over and underthinking, frequently mixing inattention with underactivity in subtypes that range from a "Preoccupied Procrastinator" at 2.1 to an "Inconsistent Perfectionist" at 2.3. Sustaining sufficient momentum to finish all they begin is a particular problem for these in-betweeners who slide along the spectrum between distractedly scattered and overfocusing. Type 3: Relentless [Hyperfocus]

Overthinking and overactivity both combine at the other end of the spectrum where the hyperfocusing "Relentless" Type 3 resides. For this group of folks, the term "hyperfocus" is not just about getting lost in a task temporarily. Subtypes in this group range from a tenacious "Boundary Bender" at 3.1 to the all-consumed "Kamikaze" at 3.3. All of them are persistently plagued with a surplus of both mental and physical energies, awash with so many extra-intense thoughts, feelings, and sensations, they may become "overstimmed" and shut down to escape the overload.

[Note: links to illustrations are at the end of this article.]

A novel aspect of Nelson's models is that they can be used to show how attentional states change over time as engagement ebbs and flows. Each type, or "band," has 3 levels of intensity, yielding 9 "degrees" of attention difficulty. People move along this spectrum as arousal rises and falls, but some brains "bounce" more than others, she says.

Types 1 and 3 tend to be "stickers" who bounce in place, spending most of their time on the outer sides of this scale in prolonged over or under focusing, while Type 2's are "slippers" whose states shift more frequently, inattentive one moment, overattentive the next. Some of these differences may not be apparent until it is time to sustain attention to step-by-step tasks that demand patient persistence but provide low levels of feedback. This is one reason why symptoms may not be spotted until children are farther along in school.

When The Three R's Go To School

When it comes to sustain attention in class, the underfocused Type 1 may be the hardest to engage with lectures and books. Rovers often seek their stimulation through bodily sensations, craving intense experience (if not also risky adventure) as a way of heightening feeling. Frequently they will also be kinetic-style learners who benefit from direct hands-on activities where they can observe cause and effect for themselves. Testing may also reveal overlapping learning difficulties such as dyslexia, dysgraphia, or CAPD (central auditory processing disorder) and/or issues with sequencing and multi-tasking, although these issues may be masked and hard to detect on standard tests in children with high IQs who have learned how to compensate.

Relentless Type 3's, at the opposite pole, are quite often hypersensitive, quick to react and hard to detach once "hooked". Their distractions flow from a swirling flood of thoughts and acute sensations that can keep them absorbed in a "noisy" internal world or obsessively focused on what's in front of them. Accordingly, they may need coaching about how to attend less intently. Overlapping aspects of NBD s, i.e. neurobehavioral disorders, such as the tics of Tourette's Syndrome ( TS) or the perserverating of Obsessive- Compulsive Disorder ( OCD ), are often - but not always - seen in the Type 3, sometimes again in tandem with learning difficulties. Children with non-verbal learning disorders or traits from the autistic spectrum may also exhibit a Type 3 attention difficulty. Threads of stronger affective disorders, such as bipolar, are also sometimes seen in this cluster, although bipolar remains a complex and difficult diagnosis to make in childhood.

The Restless Type 2 blends paler tones of the highs and lows from both poles in a paradoxical mix that may be confusing both to themselves and to others. For example they may be underactive physically yet overactive mentally, dreamily roaming far and wide but mostly inside their own minds. Or, at the other end of the Type 2 band, they may resemble their Type 3 cousins, with hypersensitive feelings that add anxiety to erratic attention, persistently distracted by internal chatter. Either shade may be a puzzling blend of strong potential and uneven productivity.

Imaginative lessons, avoidance of too much rote, plus flexible pacing to accommodate waxing and waning energies can help all of the types keep their focus raised and attentions engaged, Nelson suggests.

Connecting Comorbidities

Aspects of depression or anxiety are sometimes seen alongside attention difficulties, particularly in adulthood and especially in the more highly focused Types 2 and 3. As noted above, the Type 3 may also exhibit traits from the autistic spectrum or aspects of bipolar disorder. Medication is not always appropriate, especially in milder cases, but when prescribing becomes complex, it may take a specialist who is especially skilled in the biological side of psychiatry to tease out these overlapping, or "comorbid," conditions and prescribe accordingly.

Type 1 patients often report being helped by standard doses of stimulants such as Ritalin and Dexedrine, but Types 2 and 3 sometimes report paradoxical effects with stimulants being either too sedating or too agitating. Sometimes this is resolved by lowering or raising the dose beyond the standard levels, or by combining it with a second drug, such as an antidepressant, or by substituting another medication for the stimulant. [Note: This article was written before widespread adoptiont of next generation stimulants and new forms of antidepressants that selectively target neurotransmitters such as noraderenaline.} In all events, patients should be prepared for trial and error while the proper drug and dosage is found, and they should not be reluctant to query their doctors if any prescription does not appear to be working well.

Brain chemistry can vary widely from person to person, even those of a similar age with similar symptoms. This is also the reason why, Nelson notes, the spectrum of attention difficulty contains so many hues.

Separate or Subdivide?

With such a broad spectrum, one has to ask if it even makes sense to call it all " ADD ". Might it be better to split all these symptoms into separate conditions with different names?

When it comes to popular use of the term ADD , "If I could wave a wand," Nelson says with a smile, "I'd frame it as a spectrum of 'Attention Difficulties' - emphasis on the plural - to make more space for different types and degrees of intensity. But then, I'd vote to subdivide rather than separate."

There is a growing body of evidence to suggest key aspects of attention difficulties may stem from different "settings" at the same neurotransmitter sites or on the same genes, which may be why we see more than one shade in the same families. There is also a well-established support community providing welcome assistance across this whole spectrum to both adults and children.

"If we split this community based on their differences," Nelson notes,"we risk losing sight of what unites them all in the end: all of them know how it feels to cope with an All-or-None attention span."