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WebMD Medical News,
12/19/03
ADULT ADHD: MORE CONTROVERSY, TREATMENTS
An increasing number of adults are discovering that ADHD is not just a
problem for children.
by Dulce Zamora
For 12 years, Melydia Clewell Beagles was a successful TV news anchor in
Chattanooga, Tenn. Her cool demeanor in front of the camera, however, only
masked the confusion and frustration she regularly experienced within.
"For most of my life, I felt as if everybody else got a joke that I didn't
get," says the 35-year-old. "I thought, 'Why can everybody else get their
housework done, and I can't get mine done? Why can everyone else
accomplish as much as they do in a day, and I can't? Why do other people
need to have something explained to them only once, and sometimes I need
it five or six times?'"
To make matters worse, Beagles' personal life was a mess. Her marriage
failed, she was overextended on credit during most of her 20s, and had
been in a car accident at least 18 times. Plus, her relationships suffered
because she would often snap at people.
It wasn't until a psychiatrist diagnosed her with attention deficit
hyperactivity disorder (ADHD) that things began to turn around. After
taking a stimulant for the condition, Beagles says she felt like a
different person.
"I had a clearer mind and a grip on my emotions," says Beagles, noting how
she now has enough energy to fulfill her daily commitments and to work on
her self-esteem.
Beagles is one of an increasing number of adults who discover that ADHD is
not just a problem for children.
Nationwide, between 3% and 6% of kids have ADHD, and about half become
grownups with the disorder, says Mitchell Clionsky, PhD, president of the
ADD Center of Western Massachusetts. The statistics vary slightly on how
many people have ADHD, but there seems to be no question among medical
professionals that the ailment affects adults.
Although many experts have long suspected the adult factor, there now
seems to be more public attention on the matter.
In the last year, the FDA approved a new drug called Strattera for the
treatment of ADHD. It was the first medicine officially authorized for use
in adults as well as children. (Prior to this, doctors often treated
adults with drugs approved for children.)
Eli Lilly and Co., the manufacturer of Strattera, then started a marketing
campaign to make people more aware of adult ADHD. TV commercials presented
the symptoms of the disorder, which include trouble staying attentive,
hyperactivity, and impulsivity. Lilly is a WebMD sponsor.
The campaign has arguably fueled the debate over whether ADHD is a
legitimate medical condition and has renewed concerns about people being
misdiagnosed or needlessly medicated.
The Controversy
There are health professionals who, while not questioning the validity of
ADHD as a medical disorder, believe there may be problems associated with
it.
ADHD is "grossly overdiagnosed," says Carl Tischler, PhD, a diplomate of
the American Board of Professional Psychology. He says it's easy to point
to the disorder because the symptoms, such as attention and concentration
problems, are common. Plus, the drugs are usually effective in treating
symptoms, he says, but that does not necessarily mean the real problem has
been addressed.
Attention and concentration problems can stem from other things, explains
Tischler, including other mental health conditions such as depression or
anxiety, and life situations such as bad relationships, poor sleep
patterns, or difficulty around the holidays.
In addition to the problem of over- or misdiagnosing, critics say
medications may be handed out too fast.
"I think that this phenomenon of school teachers essentially having drugs
in their desk drawer for Johnny, Alan, and Jerry...has gotten out of
control," says Lewis P. Lipsitt, PhD, professor emeritus of psychology,
medical science, and human development at Brown University. "We've gone
overboard in medicalizing or biologizing behavioral problems."
Lipsitt says ADHD has often become an excuse for bad behavior, regardless
of the root of the problem.
Yet despite their criticisms, both Lipsitt and Tischler still recognize
ADHD as a real neurological condition that affects some adults and kids.
The Science
There, in fact, appears to be agreement in the medical community that the
disorder is a legitimate one. The condition is not only recognized by the
American Psychological Association and the American Psychiatric
Association, but also by the American Medical Association, the American
Academy of Pediatrics, the National Institutes of Health, the U.S. Surgeon
General, and the CDC.
Dozens of international, independent health professionals also signed a
consensus statement in January 2002 stating that there is no controversy
in the scientific community over whether ADHD is a real condition. The
statement reads: "In fact, there is no such disagreement -- at least no
more so than there is over whether smoking causes cancer, for example, or
whether a virus causes HIV/AIDS."
For the remaining skeptics, Russell Barkley, PhD, professor of psychiatry
at the Medical University of South Carolina, points to more than 4,000
studies on children with ADHD. The studies on adults are not as numerous,
but he says they show that up to 5% of them have the disorder.
There are also scientific advances that show ADHD as a clear medical
problem, says Barkley. "We've identified at least 2 or 3 genes that
contribute to this disorder," he says. "We now have a number of studies
that repeatedly document areas of the brain that are not as well-developed
in people with this disorder."
The research is ongoing, and some of it may be preliminary, but it is
reportedly promising in identifying and treating people with ADHD.
The Drugs
Many doctors regard medication as the most effective treatment for ADHD.
Andrew Adesman, MD, of the board of directors for Children and Adults With
Attention-Deficit/Hyperactivity Disorder (CHADD), says stimulants such as
Ritalin, Concerta, Metadate, and Adderall seem to work best. "Eighty
percent of kids respond well with stimulants," he says.
For adults, response rate is 70%, says Terry Matlen, MSW, of the board of
directors for the Attention Deficit Disorder Association (ADDA).
Options for people who don't do well on stimulants include Strattera and
Cylert. Yet many clinicians don't use these drugs as a first-line defense
against ADHD, says Adesman.
Strattera is still new, and there's not a lot of information about it, he
says. And Cylert is associated with liver problems.
Strattera is the first nonstimulant drug to be approved for ADHD for
treating both children and adults. Strattera was approved in November
2002, and by October 2003, 2 million prescriptions had been written for
Strattera, according to Lilly.
Some doctors prescribe the antidepressant Wellbutrin for ADHD,
particularly for people who have bad side effects with stimulants. But,
again, it is not used as a first line of defense. Stimulants are usually
on top of the list in treating the disorder.
Other Treatments
Psychotherapist Lew Mills works with adults with ADHD, but he struggles
with the disorder himself. So do his 18-year-old daughter and 10-year-old
son.
Mills finds organizing big, long-term projects hard to do, which is why he
says he does well in his profession. At the end of a session, he can put a
piece of work down and move on to something else.
His daughter often has trouble regulating her emotions and dealing with
people. His son struggles with academics.
ADHD has affected Mills and his children in various ways, and they have
dealt with the disorder in different ways as well. All of them have found
medication to be helpful, but Mills has followed advice in self-help books
to keep his life as simple as possible. His daughter has Mills to help
guide her in dealing with life issues, and his son has attended a school
that accommodates different learning styles.
The Mills family has experienced firsthand what doctors know about
patients with ADHD: that the disorder affects everyone uniquely, and
different treatments work for different people.
Besides drugs, treatments for ADHD include cognitive behavioral therapy,
psychotherapy, life coaching, self-management classes, exercise, and
meditation.
Experts do not agree on the effectiveness of these options for ADHD. Some
doctors believe one or a combination of them might help supplement drug
therapy. Yet many seem to agree that it's important to be careful about
what treatment a patient chooses.
"If it's too good to be true, then it probably is," says Matlen,
particularly pointing out herbal treatments. She says they're not
scientifically proven to be effective.
The Future
Although plenty of attention has gone into the controversy over ADHD's
legitimacy and concerns with overmedication, the ADDA says the real
problem is that so few people with the disorder have been diagnosed with
it.
"What we're seeing is a tremendous amount of people who are either missed
entirely or misdiagnosed (with anxiety, depression, or substance abuse),"
says Matlen. Because they are not treated properly, she says many folks
become more anxious and depressed.
While different groups debate over legitimacy, overdiagnoses,
misdiagnoses, and missed cases, the research continues on ways to better
identify and treat the condition.
The NIH has funded studies on PET scans, MRI imaging of ADHD brains, and
on cognitive behavioral therapy (CBT).
Pharmaceutical companies are also working on more nonstimulant drugs that
will help with ADHD symptoms. Targacept is working on 2 man-made compounds
(TC-5231 and TC-1734) that will hit the receptors in the brain that are
usually affected when people take in nicotine. The receptors reportedly
have a role in memory, attention, and learning.
Targacept notes that their compounds are not nicotine and have nothing to
do with cigarette smoking.
Though other treatments are being researched, experts say nothing appears
to be immediately promising.
In the meantime, people diagnosed with and treated for ADHD live day by
day the best they can with today's resources. And contrary to popular
belief, many of them even lead successful professional lives, as with
Beagles and Mills.
"ADD has benefits," says Beagles. "I'm glad I have the ability to handle a
lot of things at one time."
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