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A Lifetime of Distractions

by : Harvard Health Publications

Although we usually think of attention deficit/hyperactivity disorder (ADHD) as a problem affecting squirmy schoolchildren, it can be a lifelong disorder, an unwelcome and unruly childhood companion that can follow you all the way to old age. Brain imaging studies are finding distinctive patterns of neural activity in ADHD adults that match those in ADHD children. Family studies of parents and close relatives of ADHD children turn up statistically significant numbers of ADHD adults.

Studies of twins (identical and fraternal) reared in the same home environment have shown ADHD to have the highest heritability of any psychiatric disorder. It has nearly twice the heritability of asthma and three times that of breast cancer. Genetic studies of ADHD "carriers" have zeroed in on a number of genes involved in the regulation of dopamine, norepinephrine, serotonin, and other neurotransmitters. No one expects to find a single ADHD gene, but further research into the complex molecular biology that underlies memory, attention, and how we make up our minds could sharpen drug treatments for ADHD — and uncover new ones.

Top 10 symptoms of patient-suspected adult ADHD

• Poor concentration

• General disorganization

• Tendency not to finish projects

• Inattention

• Poor school performance

• Problems with time management

• Difficulty controlling temper

• Impulsive behavior

• Problems with anxiety

• Difficulty functioning at work

Source: Archives of Internal Medicine, June 14, 2004.

In the meantime, studies have shown that the same stimulant drugs used to treat childhood ADHD are safe and effective for adult ADHD. Atomoxetine (Strattera), the first non-stimulant approved by the FDA for treatment of ADHD, is also the first ADHD drug officially approved for use in adults as well as children.

The prevalence of ADHD remains a major controversy. The low-ball estimate is that 1% of adult Americans are ADHD-afflicted, but some experts say it’s as much as 6%, which would work out to about 10 million people. On the other hand, another study came up with a figure of only 0.5% among 40-year-olds. Disputes over these statistics reflect deeper questions. Does untreated ADHD explain unhappy lives filled with crime, drugs, and underachievement? Or is this another case of medicalizing a more diffuse problem?

What does it look like?

Perhaps the clearest picture of adult ADHD comes from studies of people originally diagnosed with ADHD in grade school and followed by researchers through adolescence and young adulthood. These studies vary widely in their estimates of ADHD prevalence, remission rates, and relationship to other psychiatric disorders. But over all, they show a high percentage — 80% in several studies —of ADHD children growing into ADHD adolescents. Such individuals have continual trouble in school, at home, on the job, with the law in general, and with substance abuse in particular. Compared with control groups, ADHD adolescents are more likely to smoke, to drop out of school, to get fired, to have bad driving records, and to have difficulties with sexual relationships.

"There’s a great deal of continuity from the child to the adult form," says Russell Barkley, a researcher at the Medical University of South Carolina. "We’re not seeing anything that suggests a qualitative change in the disorder. What’s changing for adults is the broadening scope of impact. Adults have more things they’ve got to do. We’re especially seeing problems with time, with self-control, and with planning for the future and being able to persist toward goals. In adults, these are major problems."

Poor time management is a particularly treacherous area. As Barkley observes, "With a five-year-old, time management isn’t relevant. With a 30-year-old, it’s highly relevant. You can lose your job over that. You can lose a relationship over it."

Medications for ADHD

• Stimulants. Methylphenidate (pronounced meth-il-FEN-i-date) is the standby drug. It’s better known by one of the brand names it’s sold under, Ritalin, but is also available as a generic. Methylphenidate also comes in formulations that are intermediate-acting (Metadate ER, Methylin ER, Ritalin SR) and long acting (Metadate CD, Concerta, Ritalin LA). Dexmethylphenidate (Focalin) is a formulation of methylphenidate that is theoretically more potent and more readily absorbed than the older versions. A popular alternative to methylphenidate is a mixture of amphetamines sold under the brand name Adderall and, in a longer-acting formulation, Adderall XR. A distant third choice is dextroamphetamine (Dexedrine, DextroStat).

• Tricyclic antidepressants. They’re an option if the stimulants prove ineffective or intolerable. Desipramine (Norpramin), nortriptyline (Aventyl, Pamelor), and imipramine (Tofranil) are the ones most commonly prescribed.

• Atomoxetine (Strattera). This drug is a selective norepinephrine reuptake inhibitor, not a stimulant. It takes several days to build up to an effective level, but then continues without the hill-and-valley effects of methylphenidate and other stimulants.

In short-term trials, the stimulants seem to help 70%–80% of children, adolescents, and adults. When the drugs work, they increase attention span and suppress impulsiveness and frantic motion. But individual results vary widely. Some patients report a bounceback of symptoms or just plain grouchiness as the medication loses steam. The slower, timed-release formulations may get around that.

Another drawback is that the FDA classifies all stimulants as controlled substances. That means a written prescription is required for each month’s supply, and many doctors require regular return office visits before writing prescriptions. It’s a good practice because of the potential for abuse, but it adds to the cost of treatment. The timed-release versions add to the bill because they’re expensive. Atomoxetine, on the other hand, is not a controlled substance, so prescriptions can include multiple refills.

You need to tell your prescribing physician about any other medicines you’re taking, especially anything for high blood pressure or thyroid problems.

As an ADHD adult, you also need to recognize that ADHD adults are notorious for self-medicating, especially with tobacco, alcohol, and caffeine, but also with other drugs. Once you get some help with your ADHD, you may find that you start to work on a drug or alcohol problem that has gotten out of hand.

On the other hand, researchers have noted differences between the childhood and the adult profiles of ADHD. For example, children diagnosed with ADHD are overwhelmingly boys, but studies of adults have found that the gender difference is less pronounced. Are girls less likely to exhibit the hyperactive-impulsive "boys-will-be-boys" behavior that gets a teacher’s attention? Or do more boys grow out of the condition so that the gender ratio in adults is more even? No one knows for sure.

Childhood ADHD is divided into three categories: primarily inattentive, primarily hyperactive-impulsive, and a combination of the two. What these variants "grow into" in adults is an open question. Most experts agree that pure hyperactive behavior usually diminishes with maturity: Few ADHD adults are completely unable to stay in their seats. Yet many ADHD adults are restless fidgeters and pacers. The picture of adult ADHD is clouded by the question of psychiatric "comorbidities" — other disorders that are distinct from ADHD but can complicate the condition. Young ADHD adults generally have higher rates of antisocial personality, anxiety, depression, and substance abuse.

How is it diagnosed?

After a thorough physical exam to rule out other problems, clinicians question patients using standardized lists of ADHD symptoms to come up with a score on severity and persistence. The results are assessed in the context of a developmental, psychiatric, and family psychiatric history, including the patient’s prenatal, childhood, and school history. Clinicians can also draw on an assessment of the patient’s behavior by family members or on a patient’s reporting of childhood experiences. The reliability of retrospective self-reporting is a point of contention. Some studies suggest that it leads to underdiagnosis; others, to overdiagnosis.

Experts agree that there’s no such thing as adult-onset ADHD. According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a childhood history of ADHD symptoms, whether they were recognized, treated, or ignored at the time, is essential for a diagnosis of adult ADHD. But establishing a childhood history is easier said than done. If you were born before about 1965, you’re probably too old to have grade-school records that use a label like hyperactive. Over-40 hyperactives belong to the "runs with scissors" generation. Children with attention problems were often just thought of as lazy or daydreamers. A study of about 850 adults with ADHD published in the Archives of Internal Medicine earlier in 2004 found that only a quarter of them had been diagnosed with the condition as children or teenagers.

Psychiatry itself has muddied the waters by switching its labels. ADHD has supplanted attention deficit disorder and another diagnosis called "minimal brain dysfunction." The definition of ADHD has evolved from emphasizing hyperactive behavior to recognizing more complex neurological deficits involving the brain’s executive functions. Under newer definitions, non-hyperactive adults are more likely to pass the diagnostic threshold for ADHD, thus raising the overall prevalence.

Happy endings

Salvatore Mannuzza and Rachel Klein of the New York University Child Study Center, who conducted widely cited research on ADHD children aging into ADHD young adults, point out that statistics don’t tell the full ADHD story. Yes, their studies, like others, show trouble with jobs, education, and self-esteem. But nearly all of their subjects were gainfully employed. Some had achieved higher-level degrees and admission to medical school. Adult ADHD may be a lifelong disorder for some, Mannuzza and Klein conclude, but they can go on to achieve educational and vocational goals just like anyone else. ADHD precludes nothing.

What you should do if you have ADHD

Get evaluated. You need a clinician with experience in diagnosing adult ADHD. Most primary and family care specialists are used to treating or referring children, not adults, for ADHD. You may need to ask for a referral to a mental health clinician who knows adult ADHD. Find out if there’s an ADHD support group or organization active in your area. A good place to start is www.chadd.org, a national support and advocacy group for adults and children with ADHD.

Get medication. Medication is usually the treatment of first resort for ADHD (see above). Medications help but don’t cure the condition. For many adults, medication lessens the disorder’s internal noise and outward chaos, helping them to gain some sense of self-control.

Get educated. There is a large, and largely helpful, body of literature on adult ADHD. Edward Hallowell and John Ratey’s Driven To Distraction comes highly recommended. For more titles and additional information, try the National Institute of Mental Health (www.nimh.nih.gov/healthinformation/adhdmenu.cfm).

Get organized. Get a calendar — a large one. Get a personal organizer, electronic or otherwise. Build schedules and routines. Set up a "launch pad" near the door for keys, wallets, glasses, briefcases, and backpacks. Get a book about getting organized around your ADHD.

Get counseling. Adult ADHD can put tremendous strain on a marriage, a relationship, or an entire family. If your ADHD is driving you crazy, imagine what it’s doing to your spouse or your children. Many adults discover that they have ADHD only after a child is diagnosed with the condition. This is serious. You need to talk about it.

Get moving. Exercise is good for almost everything that ails you. For ADHD adults, it’s a healthy way to burn off excess energy, for example, before sitting down to work. Being an ADHD adult, you can’t just vaguely plan on working out or perhaps going to a dance class. You need to put it down in ink as part of your weekly schedule. Routine and habit are adult ADHD’s best friends.

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