Parents with children who have ADD often want to know if the condition will continue when the child grows up. Some individuals report that they have no evidence of the problem after reaching adulthood. Others continue to be affected. Approximately 4% of adults have a diagnosis of ADD. The condition was not identified as a diagnosis 30 years ago; therefore it was not recognized until adulthood in some older generations. It is now believed that at least half of children with ADD carry their problems with them into adult life.
Adult attention deficit disorder has attracted attention over the past several years, with publication of books such as Driven to Distraction and ADD in the Workplace. In an adult work and family environment, hyperactivity is less of an issue. ADD in adults usually becomes translated into more subtle forms such as restlessness or impulsive actions–blurting out an angry or rude comment at an inappropriate time. It is also less evident in adults because they do not exhibit the same capacity for displaying the feelings of hyperactivity and disruption.
To some degree, all of these traits are common in healthy adults as well as persons with other mental disorders such as anxiety, depression, substance abuse, bipolar disorder and borderline personality disorder. Symptoms are also similar to those for hyperthyroidism, obstructive sleep apnea, lead toxicity, head injury and certain types of seizures. As a result, diagnosing adult ADD is difficult and should ideally be done by a specialist–a psychiatrist, psychologist, neurologist or pediatrician. The list of symptoms are most certainly not exclusive of ADD, thus assessment by a trained professional is essential. From 30 to 50 percent of self-diagnosed (or loved ones) reports turn out to be something other than ADD–most typically depression.
Starts in Early Childhood
By definition, attention deficit disorder never has an adult onset. Diagnosis requires that symptoms were noted at least by age 7 and persisted since that time, even if the disorder was never detected. And, like any mental illness, ADD is diagnosed only if it causes dysfunction severe enough to interfere with effective social, family and job life.
The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) defines three subtypes of attention deficit disorder: predominantly hyperactive, predominantly inattentive and a mixture of the two. It’s believed that many girls and both male and female adults have the predominantly inattentive form that may never get diagnosed or even noticed during childhood because it doesn’t include hyperactivity. The ratio of males to females with ADD is 10:1 among children but only 2:1 among adults.
Symptoms fall into three classes:
Distractibility: difficulty sustaining attention, not listening when spoken to, failing to follow instructions, forgetfulness, difficulty getting organized, ignoring details and making careless mistakes.
Hyperactivity: fidgeting and squirming, restlessness, easily bored, difficulty engaging in quiet activities such as watching a movie or playing cards.
Poor impulse control: impatience, difficulty waiting in line, tendency to interrupt others, starts projects without proper planning or preparation, tendency to react quickly without thinking of the outcome.
Diagnosis usually requires at least six of these symptoms noted persistently in more than one environment since early childhood. Adults usually don’t exhibit all three types of symptoms, and in 90 percent of adults the most prominent symptom is inattention.
The above symptoms can be as disabling on the job, of course, as they are in a school setting. ADD is actually recognized as a disability under the Americans with Disabilities Act. Compared with other disabilities, however, accommodation can be fairly easy: flexible schedules, reduction of distractions and use of personal digital assistants or other memory aids.
Many adults find comfort in simply knowing there is an explanation for the symptoms. Treatment is usually the same as that for children–stimulant medications combined with education and self-management strategies. The disorder may be caused by an imbalance in neurotransmitters. Stimulants work by increasing the availability of dopamine and norepinephrine, brain chemicals that play an important role in attention and concentration. Some of the effective options for treatment include Ritalin, Adderall, Concerta, Dexedrine, and Metadate. The medications differ mainly by their course of action over time. Side effects include sleep problems, appetite suppression and weight loss.
For some patients, antidepressants may also be helpful–either by themselves or in conjunction with stimulants. Bupropion (Wellbutrin) is a popular choice because it is an antidepressant with some of the effects of a stimulant. Persons with ADD, and particularly adults, are likely to have co-existing problems such as depression or substance abuse that must be treated first. Doctors are reluctant, for example, to prescribe a controlled substance such as Ritalin for a patient with a history of substance abuse. In a person with bipolar disorder, a stimulant might bring on a manic episode.
Most patients note a remarkable improvement fairly quickly after starting medication, but they usually need to learn new habits as well and develop strategies to compensate for their illness. A person with attention deficit disorder tends to get bogged down in details and may lack a sense of priority. Lists, calendars, personal digital assistants and computerized schedules are often helpful. As papers pile up on the desk, it’s easy to lose track of phone messages and miss appointments. Most patients also do better with less clutter on the desk.
Deadlines and external structure can help maintain focus and concentration. Nevertheless, ADD patients also may benefit from flexibility in scheduling–being allowed to come to work early or stay late to accomplish certain tasks when there are fewer distractions and noise. If all of this sounds familiar, it should. Nearly everyone suffers from some of these symptoms to some degree some of the time. And nearly everyone benefits from self-management strategies. Persons with attention deficit disorder, however, have experienced disabling problems for many years and need more than a resolve to “get organized.” With a good diagnosis and treatment, they can be happier and more productive.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director, Richmond Apothecaries, Inc.
1/14/2010
