by Carole Jackson
I saw a TV commercial showing a business meeting with one attendee clearly agitated and unable to focus on the events at hand. Then the narrator says that maybe this person has a disorder -- adult ADD (attention deficit disorder). But, come on... everyone gets distracted during meetings when speakers drone on, after a late night, or on any Friday afternoon. Why, then, adult ADD? Is it yet another opportunity to control human behavior with medication? For decades, most people have "known" that children outgrow ADD in their teen or early adult years. Maybe... or do they just learn to manage it better?
I discussed this question with J. Russell Ramsay, PhD, assistant professor of psychology in psychiatry at the School of Medicine, University of Pennsylvania, in Philadelphia. He is also the associate director of its adult ADD treatment and research program. Dr. Ramsay told me that contrary to previous assumptions, researchers have found that from 50% to 75% of children with ADD continue to "experience significant problems from the disorder" when they reach adulthood. It is not possible to "catch" ADD as an adult, so adult sufferers have had it their whole lives. Professionals and others missed this for so long because the criteria used to determine ADD in children aren't appropriate for evaluating adults, nor do grown-ups display symptoms in the same way as kids. In particular, he says, adults mature out of the hyperactive element. Few grown-ups feel the need to climb over sofas, he adds, as a result of learned behavior modification and probably brain maturation. However, other symptoms of ADD, especially a persistent sense of mental restlessness, inattention and distractibility, remain throughout a lifetime if untreated. A man I know came to mind when Dr. Ramsay and I talked -- a doctor in his 40s who discovered when he had his children tested and diagnosed for ADD that he, too, had the disorder. He says that despite his success, he had always carried around a sense of doom, a fear that he couldn't repeat past achievements, that this time he wouldn't be able to do it. That fear, says Dr. Ramsay, is common among adults with ADD.
In some ways adults with ADD suffer even more than children do because life's expectations are now so much greater. Spouses and children, to say nothing of coworkers and bosses, often depend on the person for maintaining structure and organization. Furthermore, adults do not have a support network of parents and teachers reminding them what needs to be done and helping pave the way to completing responsibilities. Because adult life is faster paced, these people fall behind at a more rapid clip -- and the consequences are greater. Studies have shown that adults with ADD change jobs and get divorced more frequently... they are poorer drivers... and at higher risk for substance abuse. This group also tends toward depression and anxiety -- understandable given the life problems many face -- and they are often heavy smokers, in part, observes Dr. Ramsay, because nicotine is known to stimulate areas of the brain that control planning, foresight and attention.
Experts estimate that 8 to 10 million adult Americans have ADD to one degree or another. While childhood ADD affects many more boys than girls, among adults it is gender balanced. Some speculate that this is because female children are less likely to have the hyperactive aspect of the disorder. Consequently, teachers and parents usually don't recognize ADD in little Maggie or Emily, sitting quietly at their desks but unable to focus on what the teacher is saying, whereas Justin, climbing over his desk, is a prime suspect for the disorder.
HOW TO TEST FOR ADULT ADD
I asked Dr. Ramsay what should prompt a person to go for testing and diagnosis of ADD as an adult. He explains that having ADD is far beyond a bad day here and there. These people chronically feel they are not living up to their realistic potential, and they underperform at work and at home. They are disorganized and can't pay attention even when they are highly motivated to do so. It is not possible to develop ADD as an adult, and so a person with it would have a clear pattern of many symptoms and resultant problems from childhood to the present. Additionally, in adults with ADD, there are frequently accompanying conditions such as depression, anxiety and substance abuse. In fact, another red flag alert of possible ADD is if people sought out and followed treatment for these other problems and despite adherence, did not find success. If ADD is at the core of a problem, the ADD will have to be addressed before the other conditions resolve, says Dr. Ramsay.
TREATMENT OPTIONS -- MAINSTREAM MEDICINE
According to Dr. Ramsay, treatment for adult ADD begins with medication because of its neurologically driven symptoms. (Note: Naturopathic practitioners raise the question of whether ADD is simply a neurological disorder, or there are dietary or environmental influences. More on this below.) Currently three types of medications have FDA approval for treating adult ADD, the intent of which is to help the individual focus better. These are dexmethylphenidate hydrochloride (Focalin), amphetamine-dextoamphetamine (Adderall) and atomoxetine (Strattera). Unlike the other two, Strattera is a nonstimulant and particularly helpful for people who have anxiety as an accompanying condition. Doctors also can prescribe other drugs, including methylphenidate (Ritalin), that are FDA approved for children, though Ritalin is prone to risks and side effects.
With improved attention, the next step in treatment is cognitive behavioral therapy (CBT), says Dr. Ramsay. He explains that while medication improves symptoms, people often need to address behavioral patterns they developed over time, for instance, approaching problems in the same way over and over in spite of never achieving good results. Furthermore, having untreated ADD frequently creates highly negative thinking and fear of taking on challenges, he says. In CBT, people learn to examine their negative beliefs and the way they have influenced them. They then explore new behaviors that have positive outcomes and build confidence. The usual CBT therapy takes place over six months, in once-a-week sessions. The goal is for people to learn the means of becoming their own therapists. Once people have learned new strategies and how to better analyze and make decisions, they are in a position to incorporate additional new tools including better ways to structure their time and environment.
NATUROPATHIC TREATMENT OPTIONS
While mainstream doctors insist their treatment methods are effective, some sufferers of ADD think otherwise when it comes to dealing with side effects of the medications. Hence, many seek out nonpharmaceutical options or set up a team approach with their naturopathic and allopathic doctors working together on a treatment protocol.
I spoke with nutritionist Susan Weiner, RD, MS, who specializes in treating ADD in both adults and children. Not surprisingly, her first advice concerns diet. Although it is ideal to work with a nutritionist knowledgeable in this area, she says there are general guidelines for everyone. The first step is to carefully observe your current eating patterns. Weiner says that people with ADD are nearly always impulsive about their food choices and they tend to eat a lot of simple carbohydrates (cookies, candies and the like). But to keep the edginess that is part of the disorder under control you must keep blood sugar levels as steady as possible, not too high and not too low.
The first rule is to correct your current diet with a planned approach to eating. Follow the general rules for a healthful diet -- protein, many fruits and vegetables and whole grains -- and eliminate most if not all sugar-loaded foods. Have three meals each day and if needed, Weiner advises a mid-morning and an afternoon snack. For healthful snacking, carry non-perishable, portable low-glycemic index foods, such as almonds, walnuts or chopped vegetables (which should be in your refrigerator at all times to combat hunger attacks).
To be sure you are getting a wide range of antioxidants, fiber and other nutrients from fruits and vegetables, Weiner recommends choosing a different color each day to focus on, for example, oranges, squash, papaya and cantaloupe on your "orange day." You may find having a cup of caffeinated coffee each morning beneficial because as a stimulant, it often eases ADD symptoms. But don't go overboard, she warns, by making coffee a constant companion.
Weiner also recommends exercise of all types. Aerobic exercise is especially good because it helps bring fidgeting under control and raises mood-enhancing endorphins. But she particularly likes yoga for adults with ADD because, she says, it is a great way to reduce anxiety and relax. However, one important caveat -- it is critical to master the proper breathing patterns and technique for yoga because otherwise it increases rather than decreases restlessness. She advises working with a good instructor until your breathing technique becomes automatic.
Finally, Weiner advises a regular intake of omega-3 fatty acids, available in cold-water fish such as salmon and tuna, dark green vegetables, walnuts and flaxseeds. However, eat fish just twice a week (because of mercury concern), but take an omega-3 fish oil supplement every day. General recommendations are for 1,000 mg a day of an oil that contains both DHA and EPA. It's best to work with an ND to determine if any other supplements or herbal products would also be helpful in individual cases.
Anyone who suspects ADD should take a six-item mini questionnaire adapted from a longer one developed by the World Health Organization -- go to "recognizing ADD" at www.adultadd.com. If your responses indicate a potential problem, Dr. Ramsay says to locate a specialist who will do a full evaluation, a process that takes two to three hours. Part of this will be an investigation of childhood problems and behaviors, including school records or report cards that likely have teachers' notes to the effect of "trying, but not working to potential." Finding a specialist who is knowledgeable about adult ADD can be difficult, he says, because training isn't widely available. Check with major medical centers, such as the University of Pennsylvania and Duke, both of which have ADD treatment and research centers. There are also clinics and doctors who treat adult ADD. Do ask, though, if they are trained in adult ADD, because it is not the same as childhood ADD and requires specialized training. You can find more information at www.chadd.org and www.add.org.
Having a chronic condition such as adult ADD can create great pain for both an individual and his/her family. Fortunately, awareness of this continued challenge for some is growing and there are many treatment options available that can help make the world a kinder, gentler place for those with adult ADD.
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