ADHD - Not Just for Kids Anymore
ADHD diagnosis in adults is on the rise. Here is one example:
It seemed that the harder he tried, the worse things got for Robert Jergen.
As a child, he was always being scolded by his parents and teachers. As an
adult, his bosses reprimanded him for missed deadlines and his attitude problem.
He got fired from jobs, drank heavily, and lost his fiancé.
But Jergen wasn't a slouch, a drunk, or intentionally obnoxious. He had a
condition called attention-deficit hyperactivity disorder (ADHD).
"I wanted to be a good kid, but I frequently did things without thinking
or without even realizing that I did them," says Jergen. Problems with
concentration continued to plague him as an adult. In college, Jergen would stay
up all night trying to finish his schoolwork. "I could not focus my
attention on the page long enough to read a paragraph. My thoughts raced round
and round in my head. It's like my mind was a pinball machine with five or six
balls smashing into each other."
ADHD is the most commonly diagnosed mental health disorder in children,
according to the American Psychiatric Association. It's often diagnosed once a
child hits preschool and is disruptive in class--unable to sit still, talking
incessantly, and having emotional outbursts. While some children see their
symptoms fade as they get older, others carry them into adolescence and
Although there is no cure for ADHD, medications and behavioral therapy can
help treat the symptoms. The Food and Drug Administration has approved two drugs
for adults, and more have been approved for use in children. But the
decision to take medication should be considered carefully and discussed with a
health professional, says Paul Andreason, M.D., a drug reviewer in the FDA's
Division of Neuropharmacological Drug Products. Some drugs used to treat ADHD
can be dangerous for adults with certain medical conditions. They also have the
potential for addiction and abuse. Adults taking medications should be closely
monitored by a physician. Children who take medications also need regular
Three Types of ADHD
Everyone has trouble sitting still sometimes, or managing time, or completing
a task. But the behavior of people with ADHD goes beyond occasional fidgeting,
disorganization, and procrastination. For them, performing tasks can be so hard
that it interferes with their ability to function at work, at home, at school,
A diagnostic manual compiled by the American Psychiatric Association
identifies three types of ADHD: inattentive, hyperactive-impulsive, and
A person with inattentive ADHD, previously known as attention-deficit
disorder (ADD), has trouble focusing on activities, organizing and finishing
tasks, and following instructions.
Children with hyperactive-impulsive ADHD are in constant motion, dashing
around touching everything in sight, and jumping on and off furniture. They
often blurt out inappropriate comments, don't wait their turn, show excessively
intense emotions, or hit others when upset. Hyperactive and impulsive adults
feel restless, are constantly "on the go," and try to do multiple
tasks at once. They are often perceived as not thinking before they act or
Individuals with the combined form of ADHD show symptoms of both inattention
Who Has It?
The National Institute of Mental Health (NIMH) estimates that between 3
percent and 5 percent of children in the United States have ADHD. This means
that in a classroom of 25 to 30 children, it is likely that at least one will
have the disorder. Three times as many boys are diagnosed with ADHD, but "girls are
getting diagnosed more and more," says Nora Galil, M.D., a psychiatrist in
private practice in Washington, D.C. The symptoms may be easier to spot in boys,
she says, who may be seen slipping from their chairs and tossing things across
the room. "You can often identify it in a short period of time because they
are so disruptive. Girls may be the ones who daydream and are not disruptive, so
it's not picked up nearly as much."
The number of adults with ADHD is unknown, and medical experts continue to
debate whether children can expect to outgrow the symptoms by the time
they reach adulthood.
Some studies have shown a significant decline in ADHD symptoms as a person
ages. Others estimate that between 30 percent and 70 percent of children with
ADHD will continue to have symptoms into adulthood.
"In adults, it's a much more elaborate disorder than in children,"
says Russell Barkley, Ph.D., a psychiatry professor at the Medical University of
South Carolina. "It's more than paying attention and controlling impulses.
The problem is developing self-regulation." This self-control affects an
adult's ability not just to do tasks, but to determine when they need to be
done, says Barkley. "You don't expect 4- or 5-year-olds to have a sense of
time and organization, but adults need goal-directed behavior--they need help in
planning for the future and remembering things that have to get done."
The Consequences of ADHD
Whether in a child or an adult, ADHD can have serious consequences. Some
studies show that children with ADHD have more emergency room visits than their
non-ADHD peers. Adolescents with ADHD are more likely to engage in risky
behavior, leading to substance abuse, sexually transmitted diseases, and teen
Adolescents and young adults are more likely to drop out of school and less
likely to enter and graduate from college, according to some studies. And adults
with ADHD are more likely to suffer from depression and anxiety, be fired from
jobs, and get divorced than non-ADHD adults.
Teens and adults with ADHD have 2 to 3 times more auto accidents and twice
the number of severe accidents resulting in vehicle damage and bodily injury as
those without ADHD, according to studies done by Barkley and others. "They
have coordination deficits, less skill in maneuvering vehicles in traffic,
slower reaction time, and inattention," says Barkley.
People with ADHD often have "a huge issue of self-esteem," says
Galil. "They may have been underachievers and told 'you're so smart, why
can't you do this? You're not trying hard enough.'"
Jergen says he always tried very hard, but he couldn't focus his mind on the
task at hand. He likens it to having a song or jingle in your head for days at a
time, but "add three or four or five more thoughts to the mix and amplify
them. Spin them round and round and round in your head and make them go faster
and faster and faster until they become like an all-consuming obsession.
Everything centers on those thoughts. You can't focus on anything else. You
can't escape them."
Not a Discipline Problem
ADHD was once looked upon as a discipline and behavioral problem resulting
from bad parenting. Some suggested it was caused by high sugar intake, food
additives, excessive TV viewing, and family problems. But none of these
explanations is supported by scientific evidence.
Most scientists agree that it's a biologically based disorder of the nervous
system. Brain imaging research using a technique called magnetic resonance
imaging (MRI) has shown that differences exist between the brains of children
with and without ADHD, but the exact mechanism of brain function causing the
symptoms of ADHD is unknown. Scientists caution that MRIs used in studies are
research tools and cannot be used to diagnose ADHD in a specific person.
Recently published research suggests that ADHD tends to run in families. In
these studies, children with ADHD have, on average, at least one close relative
with ADHD. Over the years, other theories have suggested that exposure to lead
in the environment, premature birth, birth trauma, and brain injury may lead to
the development of ADHD. Some studies have shown a possible correlation between
the use of cigarettes and alcohol during pregnancy and the risk for giving birth
to a child with ADHD. For this and many other health reasons, the NIMH
recommends that women who are pregnant refrain from both cigarette and alcohol
There is no single test to determine if a person has ADHD. A specialist makes
the diagnosis by comparing a person's pattern of behavior against a set of
criteria established by the American Psychiatric Association.
"Sometimes teachers may identify a child as potentially having
ADHD," says Galil. "Parents will not always know because they organize
and structure and manage so much of the child's life, it masks what's going
Although teachers and parents may recognize some symptoms, it's important to
get a diagnosis from a health professional, ideally one with training in ADHD
and mental disorders, says the NIMH. This may be a psychiatrist, psychologist,
behavioral neurologist, or a developmental or behavioral pediatrician. More than
one health professional may be consulted to diagnose and treat ADHD, since
medical and psychological tests, medication, and counseling may be involved.
"Many health professionals believe that ADHD is over-diagnosed,"
says Andreason, and doctors need to consider the complete history of patients
before diagnosing them.
"It's a hard diagnosis to tease out, and we need to spend some time
asking questions about all areas of their life," adds Edmund Higgins, M.D.,
clinical assistant professor of family medicine and psychiatry at the Medical
University of South Carolina and a psychiatrist in private practice.
Some adults may discover they have ADHD only after their children are
diagnosed with the disorder. That's how Toni Wood found out she had it.
Wood, of Chesapeake, Va., was a hyperactive child, always getting into
trouble at school and always in the principal's office, she says. "If I was
quiet, I was sick." Throughout her school years, she had a hard time
processing information and asked a lot of questions in class. "It really
frustrated me, and everybody was looking at me and rolling their eyes. I knew I
wasn't stupid, but I was always behind."
Wood persevered, graduating from high school, serving in the U.S. Coast
Guard, and going to college. Civilian life was daunting for her after the
structured military environment where "they told you what to wear and what
to do," says Wood. She graduated from college, but continued to have
difficulty with daily activities--paying bills and completing tasks, especially
in the evening when she was most fidgety and inattentive. "I thought I was
going crazy," she says.
At age 38, Wood found out that she wasn't crazy. After both her sons were
diagnosed with ADHD, Wood's doctor diagnosed her with the condition, too. She
felt a weight being lifted off her shoulders, she says. "I'm not using ADHD
as an excuse; it's an explanation. Now I understand why."
Click here for more information on Diagnosing ADHD
Treatments for ADHD
A number of FDA-approved medications are available to help treat the symptoms
of ADHD. Some people have better results from one drug, some from another.
"But treatments need to involve a behavior modification program," says
Andreason. "Medicine is only an adjunct to behavior modification."
Children with ADHD may require emotional counseling and behavioral management
involving parents, teachers, and health professionals. Adults with ADHD may
benefit from counseling, vocational guidance, and professional coaching done by
specialists who help individuals develop coping skills and methods for
organization and time management.
Jergen has developed his own coping strategies, and daily exercise is an
important one. "When my mind is in a fog, I get on the treadmill and break
a sweat, the fog parts, and I can concentrate," he says. He's also set up
his office environment with special lighting and soft music to help him relax
People with ADHD may be hyperactive, but, surprisingly, they are often
prescribed a stimulant to help treat the symptoms. Stimulants can improve
alertness and attention without making the hyperactivity worse.
FDA-approved stimulants for children ages 6 and older include products
containing various forms of methylphenidate, amphetamine, and methamphetamine.
In August 2004, the extended-release form of the stimulant Adderall (Adderall
XR), previously approved to treat children with ADHD, was also approved to treat
adults with ADHD. An extended-release form of a drug works in the body over a
longer time than an immediate-release form, allowing the medication to be taken
Adderall or other stimulants should not be taken by people with certain
conditions, including hyperthyroidism, glaucoma, moderate-to-severe
hypertension, other heart-related conditions, or a history of drug abuse. Some
common side effects of stimulants are insomnia, decreased appetite, and
increased anxiety or irritability. Children who take stimulants may grow and
gain weight more slowly, and growth should be monitored by their pediatricians.
Because stimulant medicines have a high potential for abuse, the U.S. Drug
Enforcement Administration has placed stringent controls on them. For example,
the DEA requires special licenses to manufacture, distribute, and prescribe
these controlled substances, and prescription refills aren't allowed.
One other drug, Strattera (atomoxetine), is FDA-approved for use in adults
with ADHD as well as in adolescents and children ages 6 and older. Strattera is
not classified as a stimulant and does not seem to have a potential for abuse.
It is not classified as a controlled substance, so it can be prescribed with
refills. Strattera increases the levels of the neurotransmitter norepinephrine
in the brain, whereas the stimulants work primarily on the neurotransmitter
dopamine. Strattera may take three or four weeks for its full effectiveness to
kick in; stimulants can have a nearly immediate effect in some patients.
Strattera causes an increase in heart rate and blood pressure and should be
used with caution in people with hypertension or heart-related conditions. In
clinical studies, the most common side effects of Strattera in adults were dry
mouth, headache, insomnia, nausea, decreased appetite, and constipation. In
children and adolescents, common side effects were stomachache, headache, and
decreased appetite. Like stimulants, Strattera may slow weight gain and growth
in children, and these measures should be monitored by a pediatrician.
Click here for more information on ADHD Treatment Options
Galil, who treats both children and adults with ADHD, says she doesn't use
medications as frequently in adults. Parents bring children to her because
they're not doing well at school or their behavior is disruptive, she says, but
adults who haven't been diagnosed as children often "have found ways to
cope without medication for years." Sometimes, she'll prescribe a stimulant
as needed for specific tasks, such as for an events planner who was
"marvelous at events with a headset on and 4,000 people around her, putting
out a fire a minute," but didn't do well sitting back at the home office
doing paperwork. So she'd take medication on a day that she needed to spend time
"With children, it's different," says Galil. "They often
benefit from medication seven days a week. Adults, by and large, don't want to
be on medication all the time." But with diagnosis and treatment,
"some who never finished college or graduate school now have the tools to
go back and finish."
Wood is one of these. Since she's been on medication, she went back to
college and earned a second degree. "I saw such a difference," she
says. "College was so much easier" and so were routine household
tasks, like paying bills. Wood is now an ADHD coach, helping other people cope
with the disorder.
Once he was diagnosed with ADHD at age 24, Jergen said it took about two years
of trying different medications and dosages to find out what worked best for
him. Like Wood, he found that tasks became easier for him. He got his doctorate
in special education, published five books in two years, and became an associate
professor at the University of Wisconsin-Oshkosh. "I have a lot of energy
and I don't sleep a lot," says Jergen, who recounts his experiences with
ADHD in his book, The Little Monster: Growing Up With ADHD. Jergen
urges parents of children with ADHD to help them use the energy to be productive
instead of making them slow down.
After 10 years of taking various stimulants, antidepressants, and mood
stabilizers, Jergen went off medications in 2002 because of their sexual side
effects and the development of a vocal tic that caused him to make involuntary
noises. He continues teaching and writing, recently got married, and says,
"My life is just fantastic."
"I'm still hyperactive, impulsive, and inattentive," adds Jergen.
"If I were an air traffic controller, planes would be crashing." But
Jergen, known as a dynamic speaker, says he's in his element in front of a
Drug Risks and Precautions
Public health officials are concerned that stimulants may be inappropriately
prescribed for some adults with ADHD. "Stimulants do work, but we know that
they increase blood pressure and pulse rate," says Andreason, which could
lead to strokes and heart attacks. "These drugs are very strongly labeled
for their risk to the cardiovascular system," he adds.
"Patients with hypertension shouldn't be getting stimulants," says
Kate Gelperin, M.D., a medical officer in the FDA's Office of Drug Safety.
"If your blood pressure is on the high side, these drugs are not for
you." About one-third of U.S. adults have high blood pressure, according to
a study published in the October 2004 issue of Hypertension, a journal
of the American Heart Association.
Raymond Woosley, M.D., Ph.D., a clinical pharmacologist and vice president
for health sciences at the University of Arizona, says, "There are a lot of
people who don't know they have hypertension or heart disease. In many people,
the first symptom of heart disease is sudden death." Woosley advises adults
with ADHD who are prescribed stimulants to "make sure their doctor is fully
informed of their total medical condition and get a complete medical workup to
make sure they're not at risk."
Even those without hypertension who take stimulants may be at risk, says
Gelperin. "It's not known whether adults who take stimulants over long
periods of time may have an increased risk of sudden death, stroke, or heart
attack," she says, "although we do know that people who take an
overdose of stimulants experience these adverse effects."
Woosley also recommends that parents get their children checked by a
qualified pediatrician before giving them stimulants for ADHD. Parents should
not insist on a stimulant for their child based on the positive experience of a
friend's child who is taking the stimulant or because a teacher suggests it, he
says. A child should be examined by a doctor and diagnosed with ADHD before
being placed on a stimulant. "A stimulant given to a child with ADHD can
help to normalize them," he says, "but if given to someone who doesn't
have the right diagnosis, it can make them worse." Once prescribed a
stimulant, a child's blood pressure and heart rate should be monitored closely
until the dosage is stabilized, and then yearly, says Woosley, since the way the
body responds to medication is highly variable and may change over time.
Research has shown that people with ADHD who take stimulants in the form and
dosage prescribed do not appear to be at as great a risk for addiction as
previously feared. However, when stimulants are abused, the consequences can be
extremely dangerous--even deadly. According to the National Institute on Drug
Abuse, taking high doses of a stimulant can cause an irregular heartbeat,
dangerously high body temperatures, and heart failure or lethal seizures.
"The FDA has received many reports over the years describing serious
adverse effects, including death, associated with stimulant abuse or
overdose," says Gelperin.
"Some people will like the effects of the stimulants--either performance
enhancement or the euphoria--and will want to be diagnosed as having ADHD,"
says Higgins. "Where I get concerned is when college students or even
professionals come to me and say, 'I have trouble with attention.' Everyone has
trouble with attention at some point--particularly with boring tasks." We
need to separate patients with some symptoms of ADHD from those who have a
genuine disorder, he says.
Higgins is also troubled by parents who take their child's stimulant or
someone else's and claim they feel better. "Stimulants are basically
'speed,'" he says, "and most people will be more productive with them.
That doesn't mean they have a disorder."
Higgins says that, in his practice, he reserves stimulants for people who
have severe impairment, for whom Strattera doesn't work, and who are not at risk
for substance abuse.
How is ADHD Diagnosed?
According to the American Psychiatric Association, a person is diagnosed with
- they often have either six inattention symptoms or six hyperactivity and
- symptoms continue for at least six months and are more frequent and severe
- symptoms cause significant damage to social, academic, or work functioning
- some damage to functioning occurs in at least two settings, such as home,
work, or school
- some damaging symptoms occurred before age 7
- the symptoms are not due to another disorder.
- does not pay close attention to details or makes careless mistakes
- has trouble keeping attention on activities
- does not seem to listen when spoken to directly
- does not follow through on instructions and fails to finish tasks
- has difficulty organizing tasks and activities
- avoids, dislikes, or is reluctant to do tasks requiring sustained mental
- loses things necessary to do tasks or activities
- is easily distracted
- is forgetful in daily activities.
Hyperactivity or impulsiveness symptoms
- fidgets with hands or feet or squirms in seat
- leaves seat at times when remaining seated is expected
- feels restless, or, in a child, inappropriately runs about or climbs
- has difficulty taking part in leisure activities or playing quietly
- is "on the go" or acts as if "driven by a motor"
- talks excessively
- blurts out answers before questions have been completed
- has difficulty awaiting turn
- interrupts conversations or intrudes on others' activities.
What's It Like Having ADHD?
"... It's like being super-charged all the time. You get one idea and
you have to act on it, and then, what do you know, but you've got another idea
before you've finished up with the first one, and so you go for that one, but of
course a third idea intercepts the second, and you just have to follow that one,
and pretty soon people are calling you disorganized and impulsive and all sorts
of impolite words that miss the point completely. Because you're trying really
hard. It's just that you have all these invisible vectors pulling you this way
and that, which makes it really hard to stay on task."
Edward M. Hallowell, M.D., (c) 1992, used by permission. Hallowell is a
psychiatrist in Sudbury, Mass., who has ADHD.