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ADHD GROWS UP

Newsday, 3/16/04

ADHD GROWS UP

Increasingly, adults are relying on presciptions and coaches to get their lives in order

by Jamie Talan

As a child, Felice was always bothered by the sound of a clock ticking. It would distract her so much that she could barely concentrate on other tasks at hand. "I would miss a lot because I was paying attention to the wrong things," she said. "It was like someone always tapping on my shoulder."

And that tapper never left her side, into graduate school and beyond. Ten years ago, she was diagnosed with attention deficit hyperactivity disorder, and today, she uses a story about cookbooks to describe life before and after.

"I once had 400 or more cookbooks," said Felice, 56, who lives in Manhattan and asked that her last name not be used. "People knew I loved to cook, so everyone always gave me cookbooks." When she would move, she'd pack up all the cookbooks, even those she hadn't glanced at, "just in case."

As she was packing to move one day, she swallowed her first Ritalin pill, the classic ADHD medicine given to millions of children -- and "in one hour, I was down to 60 cookbooks," she said. "It was like bam, bam, bam. It was a huge awakening."

The past decade has seen adults increasingly diagnosed with ADHD -- especially those who came of age before teachers and therapists began identifying the disorder. They have trouble focusing on everyday tasks, agonize over work deadlines and never make them, and live amid the clutter of disorganization. And they procrastinate and underachieve.

With the diagnosis comes a look back at the lectures they've heard for decades -- that they are lazy or stupid or disorganized -- and a new understanding that brain chemistry may have played a role.

"It's the same diagnosis and the same symptoms" associated with children, said Dr. Joseph Biederman, a professor of psychiatry at Harvard Medical School and chief of the adult ADHD program there.

In adults, the inattention, distractibility and impulsivity make it hard to pay bills, complete chores at home and assignments at work. Patients complain of boredom; problems maintaining focus may contribute to a checkered work history.

Biederman believes ADHD is underdiagnosed in adults, saying that less than 20 percent of those who require treatment are getting it. (An estimated 5 percent of adults suffer from symptoms of ADHD.) He is overseeing studies that aim to better define the adult symptoms and what changes are made with treatment.

A wandering mind

Massachusetts psychiatrist Dr. Edward Hallowell realized that he suffered many of the symptoms in 1981, during his medical training. "I like to think of it as an involuntary wandering of the mind," said Hallowell, who performed well in school and was not diagnosed. Many students with ADHD, however, are not successful in school, and that can alter their life course and lead to feelings of low self-esteem. "Mentally, you are not where you're supposed to be," Hallowell said.

Interest in a diagnosis of adult ADHD followed the publication of Hallowell's 1994 bestseller, "Driven to Distraction," as well as results from the first follow-up studies of ADHD children reaching adulthood.

"Once an adult is diagnosed, the worst is over," Hallowell said in an interview. "No longer does a person think of himself as a chronic, underachieving loser. Many people learn to turn their lives around."

He offered an example of a patient: a night watchman whose IQ test score was at genius level. But the watchman had 120 jobs in one calendar year. "He'd get fired or quit," Hallowell said. Once diagnosed and treated, he returned to school and now successfully manages a plant.

Howard Abikoff of the NYU Child Study Center said that adults have problems that children never face. The impulsivity of their younger years may show up as risk-taking behavior in adulthood, he said. Their frustration can lead to problems with mood. "Their verbal impulsiveness exacts a higher social cost in adults -- both occupationally and personally," explains Russell Barkley, professor of psychiatry at the Medical University of South Carolina.

"There is also a lot of self- doubt," added Dr. John Ratey, a Harvard psychiatrist who co- wrote "Driven to Distraction" with Hallowell. While the stimulant medicines help people with ADHD focus, psychotherapy may be necessary to allow people to re-examine their lives from a different perspective.

The role of coaches

Today, ADHD coaches are available to focus on a client's external world. An ADHD coach helped Sue Rubin of Huntington organize her house so that she can find things "without tearing down the house," she said. But, she added, the disorganization returns, even with treatment.

"I was bright and spacey," said Rubin, 50. She had worked as a speech pathologist and, later, pharmaceutical saleswoman -- and said because she didn't work in an office, she was able to hide her disorganization. "It worked to my benefit. I had to think of my feet to compensate for my lack of organization." Nancy Ratey, from Massachusetts, called on her ADHD experience to become a coach. Her husband, the Harvard psychiatrist, liked to call her a "hired nag."

And that is sometimes how it feels to people on the other end of an ADHD coach. "We call our clients once a week and discuss their goals and what they hope to accomplish," says Andrea Yellinek, a coach who lives in Bayside. She assesses where clients are breaking down in their goals and sets up a structure.

"One man I work with would wait until 1 p.m. to write a report that was due for a 3 p.m. meeting," Ratey said, adding that people must want to change their lifelong patterns to improve.

Sari Solden, an ADHD therapist in Ann Arbor, Mich., and author of "Journeys Through ADDulthood," believes that medicines and coaching are the first steps. She tries to help people develop their strengths, and not focus on deficits.

"Adults with ADHD have a confused self-image," Solden said. "They have failed in some things and were very successful in other things, and that is a confusing way to grow up."

NYU's Abikoff said many new techniques, including coaching, have not been rigorously tested. "While the coaching business makes sense, there are no controlled clinical trials to suggest it does or doesn't work," he said. "But ultimately, we should know what is going on when we deliver these treatments."

Picking the brain

Once scientists began peering into the brain and unraveling biological circuits, it became clear the brain's prefrontal cortex worked like an executive secretary to help people focus, organize, manage time and direct behavior. Children, and more recently adults, with ADHD have been found to have subtle differences in the frontal lobe. Barkley, of the Medical University of South Carolina, explains that normal functioning of the prefrontal cortex permits people to organize lives across time. He likens it to a symphony conductor who organizes various instruments in an orchestra: Each person must perform in a timely manner to make beautiful music. By contrast, the ADHD brain's executive system is disorganized and prone to disruption. Essentially, the conductor is out to lunch.

Most of the medications used to treat ADHD work on a specific brain chemical called dopamine. It controls movement, behavior and emotion. It is also the chemical that reinforces pleasurable experiences, and scientists suspect that it helps make tasks seem more interesting.

Ritalin was the first on the scene, developed in the late '50s, but today, there are many other stimulants in a variety of strengths. Some can be taken once a day and work for 12 hours, others are swallowed two to three times a day. Last year, Strattera, an Eli Lilly drug, became the first federally approved medicine for adults with ADHD. It's also the first nonstimulant and works on a brain chemical called norepinephrine involved in attention and executive function. It affects dopamine through a feedback loop. These medicines can have mild to moderate side effects.

Cognitive therapy is also useful in helping people cope with the symptoms and the impact of the condition on their lives.

The medical treatment of ADHD was discovered by accident in 1937, the year amphetamines were discovered. Dr. William Bradley, a psychiatrist from Rhode Island, used them to treat headaches among teenagers living at a residential center for youngsters with conduct disorders. They didn't get rid of the headaches, but the teachers reported that the boys' unruly behavior was improved.

Attention deficit hyperactivity disorder wasn't officially coined until the 1960s. Problems paying attention were also observed in these children, mostly boys, but this was blamed on their inability to sit still and focus. For decades, teachers handpicked these children and recommended therapy for what was then considered a childhood behavioral disorder that they would outgrow.

Medicines were usually stopped once the children hit adolescence based on beliefs that they would outgrow the problem, and that stimulants produced the opposite effect in teenagers as it did in younger children. As it turned out, both of these beliefs were wrong.

Studies conducted by Rachel Klein, who was working at Long Island Jewish Medical Center in the 1980s and is now at the NYU Child Study Center, hinted that half of ADHD children carried their symptoms into adulthood. The finding was considered radical.

Robert Tudisco, 39, a lawyer in White Plains, sought help five years ago. But not for ADHD. He wanted advice on how to get his son to pick up after himself when he had the same problem. "A lot of my prediagnosed life makes sense now," he said. "It explains why I succeeded at certain things, and why I failed at others." He now runs support groups through an ADHD organization and has redirected his practice to help adults with work problems triggered by ADHD symptoms.

Copyright 2004, Newsday, Inc.

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