Adults With ADD Getting Long-Overdue Attention

A light bulb went off for thousands of adults who recognized themselves in the people with attention deficit disorder portrayed in the 1994 best-selling book Driven to Distraction by Edward Hallowell, M.D., and John Ratey, M.D. The authors not only publicized that adults suffer from attention deficit disorder (ADD) but went a step further by acknowledging that they had the disorder too.

Though not the first psychiatrists to recognize that adults have ADD or to write about it, Hallowell and Ratey were the first to write a comprehensive book for the public that made it to the New York Times best-seller list.

The book was read by thousands of adults who suspected that they or their spouse or a close relative had ADD, the term Hallowell and Ratey used in the book to avoid the perception that all of these adults are hyperactive. Studies have shown that disorders run in families and that about 75 percent of children with ADHD have the disorder when they become adults. Approximately 3 percent to 5 percent of the adult population have ADHD, according to the 1998 Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment by Russell Barkley, Ph.D.

“By presenting numerous case histories and lists of childhood and adult behaviors, we helped people put the different pieces of the puzzle together,” said Ratey, a clinical associate professor of psychiatry at Harvard Medical School. “The typical response from adults who realize they have ADD is ‘Eureka! Now I know why I have struggled so much.’ ”

Ratey and Hallowell have private practices in Boston. Ratey’s patients are primarily adults, while Hallowell sees both adults and children. Hallowell said that he and Ratey were perplexed by the “creative live wires” they were seeing in their practices whose behaviors seemed similar to Type A personalities or were possibly linked to hyperthyroidism. They realized that these adults had ADD, which led them to develop a list of approximately 20 criteria (see box) to facilitate the diagnosis in adults. The criteria are included in their book.

“While the definitive criteria are in the DSM, [our] list reflects the broad spectrum of traits and behaviors seen in adults with ADD,” said Hallowell.

At the top of the list is a chronic sense of underachievement, whether real or imagined. “People with ADD often have trouble reaching their potential because they can’t access their gifts,” said Ratey.

Because other symptoms include being disorganized, procrastinating, and not following through on projects, people with ADD may flounder in college or at work, leading others to conclude that they are undisciplined, lazy, or stupid. “These negative labels do more harm than the disorder itself,” contended Hallowell.

The authors dispel the myth that ADD does not exist in highly intelligent people by pointing out that such famous Americans as Albert Einstein, Thomas Jefferson, and Thomas Edison most likely had ADD.

There is a downside, however. “High-functioning successful men with ADD often have a terrible time in relationships,” said Ratey. “Relationships are a revolving door because they can’t pay attention to conversations, and they crave a lot of stimulation.”

Many adults with ADD need psychotherapy for secondary depression, anxiety, or substance abuse, said Hallowell. However, the therapist needs to structure the sessions and keep the patient focused on the topic being discussed.

“This runs contrary to psychoanalysis, where the therapist waits for the patient to say whatever comes to mind. People with ADD often are flooded with thoughts and ideas, so they may not know where to start and how to stop,” said Hallowell.

When a patient is diagnosed with ADD, it is often helpful to engage the person’s spouse or partner in therapy because “ADD doesn’t occur in a vacuum,” said Hallowell.

Not surprisingly, the non-ADD partner often has pent-up anger toward the person with ADD, which needs to be addressed in a sympathetic manner. The partner then is more receptive to learning about the disorder and can be more understanding of future problems, according to Hallowell.

He emphasized that ADD can be an asset if mastered properly. He and Ratey use a comprehensive treatment approach that includes medication, practical organizational tools, and coaching. The coaching is done, for example, by a friend or colleague who encourages the person with ADD and helps the individual stay focused on tasks or goals. Professional coaches help adults with ADD determine their goals and provide encouragement and structure to achieve them, said Ratey.

Because studies of stimulant medications have been done overwhelmingly in children, there is little information in the literature on dosing for adults. Ratey typically prescribes the higher limits of doses used for children. He emphasized, however, that there is no formula for arriving at the optimum dose.

“I have seen a football player who could not tolerate 10 mg of methylphenidate and a petite woman tolerate 50 mg of methylphenidate without a problem.”

The side effects for which clinicians should be vigilant are other medical conditions such as high blood pressure, said Ratey.

“I am excited by the latest neurobiological and genetic research on ADHD,” said Ratey.

Scientists believe that several genes play a role in ADHD, said Barkley, a professor of psychiatry and neurology at the University of Massachusetts Medical School in Worcester.

So far, sections of the DAT1 dopamine transporter gene and D4 receptor gene have been found to be overrepresented in people with ADHD. Neuroimaging studies have shown that the striatum and prefrontal cortex in the brains of adults with ADHD have high dopamine concentrations, which may be related to abnormalities in their structure and functioning, said Barkley.

His recent neuroimaging study found through using the chemical marker altropane that higher-than-normal amounts of dopamine activity exist in the striatum in adults with ADHD. That activity correlated with self-reported symptoms of inattention and hyperactivity-impulsivity, said Barkley.

“If these findings are replicated in larger studies, altropane may be useful in evaluating the beneficial mechanism of stimulant medications in ADHD,” he observed. ▪