ADHD: Not just a childhood disease

When people hear the term attention-deficit/hyperactivity disorder, or ADHD, they typically envision unruly schoolchildren – usually boys – who can’t sit still or finish their homework. But as a study in the June 14, 2004 issue of the Archives of Internal Medicine points out, ADHD, characterized by impulsivity and difficulty focusing, affects both sexes and does not necessarily go away when those children become adults. The study further indicates that the disorder is often missed because only 25 percent of adult participants with ADHD had been diagnosed during childhood or adolescence.

Studies estimate that between four to five percent of adults have ADHD, but until the late 1970s, experts believed the difficult-to-diagnose disorder resolved after childhood, so adults with ADHD were – and often still are – overlooked. The disorder, especially if untreated, can impede professional achievement, disrupt social relationships, and promote risky behaviors.

Is It Hereditary?

New 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 psychological 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, nor-epinephrine, serotonin, and other neurotransmitters.

What Does It Look Like?

In one research, people who went to their doctors suspecting they had ADHD have many of the symptoms characteristic of the disorder: poor concentration, general disorganization, the tendency to leave projects unfinished, and inattentiveness (please see table).

Childhood ADHD is now divided into three categories: primarily inattentive, primarily hyperactive-impulsive, and a combination of the two. What these variants "grow into" adults is an open question. Most experts agree that pure hyperactive behavior usually diminishes with maturity: Few ADHD adults are restless fidgeters and pacers. The picture of adult ADHD is clouded by the question of "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 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.

For now, experts agree that there’s no such thing as adult-onset ADHD. According to the American Psychiatric Association’s latest 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.

The criteria for the diagnosis of ADHD, however, have been a point of contention among various experts. Psychiatry itself has muddled the waters by switching its labels. ADHD has supplemented attention deficit disorder (ADD) and another diagnosis called "minimal brain dysfunction" (MBD). The definition of ADHD has evolved from emphasizing hyperactive behavior to recognizing more complex neurological deficits involving the brain’s executive functions – that is, planning, problem solving, organization, and self-regulation.

What Helps?

Treatment usually includes medication and some form of supportive therapy. Only one drug, atomoxetine (Strattera), is FDA-approved for adult ADHD. But many of the same medications that children take also help adults.

Behavioral therapy hasn’t been as well-studied, but most doctors believe it’s valuable. "Medications prime your attention, and then you need someone to help you to find strengths and develop strategies to work around your weaknesses," explains Cheryl Weinstein, PhD, director of the Center for Cognitive Rehabilitation at Boston’s Beth Israel Deaconess Medical Center. For example, behavioral therapy can help someone set realistic daily goals and find ways to achieve them.

What Can I Do About Adhd?

Here are some strategies that experts recommend for those with ADHD:

• Get evaluated. You need a clinician with experience in diagnosing adult ADHD. Most primary and family care specialists are used to treating and 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 for information is www.chadd.org, the website of the Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) organization – a support and advocacy group for adults and children with ADHD.

• Get medication. Medication is usually the treatment of first resort for ADHD. 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 helpful body of literature on adult ADHD. Edward M. Hallowell and John J. Ratey’s Driven to Distraction (Touchstone Books, 1995) comes highly recommended. For more titles and additional information, try the US National Institute of Mental Health at 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. Write down anything people say that you need to act on or remember. Set aside specific times for tasks such as paying bills, cleaning, exercising, and relaxing. Set up a system to keep organized. Before you go to bed, place everything you’ll need to take with you the next day – papers, purse, backpack or briefcase – in an assigned area just for you.

• 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.

• Get moving. Exercise is good for almost everything that ails you. For ADHD adults, it’s a healthy way to burn excess energy, for example, before sitting down to work.

Happy Ending

Salvatore Manuzza and Rachel Klein of New York University, 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 higher-level degrees and admission to medical school. Adult ADHD may be a lifelong disorder for some, Manuzza and Klein concluded, but they can go on to achieve educational and vocational goals just like anyone else. ADHD precludes nothing.