Wall Street Journal (April 6, 2010)

Mind Games

Attention-Deficit Disorder Isn't Just for Kids. Why Adults Are Now Being Diagnosed, Too.

By MELINDA BECKT

How do you know you have ADHD, which experts compare to having a mind like a pinball, with thoughts flitting in multiple directions. Maybe you're just over caffeinated and overworked? And if you do have it, will there be a stigma? Should you try medication? Will it work?

Parents of children with suspected ADHD face a myriad of similar questions. But the concerns can be just as troubling for adults, whose ADHD often goes unrecognized.

An estimated 8% of U.S. children have ADHD, which is also known as ADD, for attention-deficit disorder, and some 50% of them outgrow it, according to government data. About 4.4% of U.S. adults—some 10 million people—also have ADHD and less than one-quarter of them are aware of it.

That's because while ADHD always starts in childhood, according to official diagnostic criteria, many adults with the disorder went unnoticed when they were young. And it's only been since the 1980s that therapists even recognized the disorder could persist in adults.

Even now, getting an accurate diagnosis is tricky. Some experts think that too many adults—and children—are being put on medications for ADHD, often by doctors with little experience with the disorder. Others think that many more people could benefit from ADHD drugs and behavioral therapy.

Estimated number of U.S. adults, or 4.4% of the adult population, that have ADHD. Less than one-quarter of them are aware they have the condition.

Complicating the picture further, ADHD frequently goes hand in hand with depression, anxiety and bipolar disorder, and it can be difficult to untangle which came first. "It's very common for someone to be treated for depression or anxiety for years, and have the therapist not notice the ADHD," says Mary Solanto, director of the AD/HD Center at the Mount Sinai Medical Center in New York City. But adults whose ADHD is left untreated face a high incidence of substance abuse, automobile accidents, difficultly staying employed and maintaining relationships.

That said, some adults with ADHD are highly intelligent, energetic, charismatic and creative, and are able to focus intently on a narrow range of topics that interest them. David Neeleman, the founder of JetBlue Airways, and Paul Orfalea, founder of Kinko's, have spoken out about how the disorder helped them come up with innovative ideas for their corporations, despite their having done poorly in school.

"It's amazing how successful some people are able to be despite these symptoms, and some people are totally paralyzed—there's a whole spectrum of outcomes," says Ivan K. Goldberg, a psychiatrist in New York City who co-developed a commonly used screening test.

Generally, ADHD can make life very difficult. It's thought to be an imbalance in neurotransmitters, the chemical messengers that relay signals in the brain, particularly in the frontal cortex that governs planning and impulse control. Children with the disorder, particularly boys, are likely to be hyperactive, with an intense need to move constantly, which can interfere with learning. (Girls tend to be talkative and dreamy, but they are often overlooked because they aren't as disruptive.)

Adults more typically have trouble with paying attention, focusing and prioritizing. Managing time and money are particularly difficult.

"What it really is is a disturbance of the executive functions of the brain -- it's the inability to plan things, to initiate them at the appropriate time, not to skip any of the steps and to terminate them at the appropriate time," says Dr. Goldberg. "An awful lot of these people are very bright but they can't keep it together. They keep screwing things up."

"It's extremely hard for me to sit my butt in a chair. I get fidgety. I want to get up," says Linda Hensens, 46, a medical transcriptionist in Clayton, N.C., who discovered she has ADHD when a bariatric surgeon asked about her working habits. "I'll think of the wash that needs to be done and clothes that need to be folded and dusting that needs to be done and, Oh my god, I promised my nephew I'd make a cheese cake, and I've got Easter dinner to plan. My mind is going like that all the time."

Some people with ADHD are able to compensate for their distractibility, at least for a while. Some excel in school early on but run into problems once they get to college or get a job where they have to stay organized on their own.

"I see adults with ADHD who are in medical and law school or running companies, and at some point, they hit a ceiling. Their coping mechanisms aren't effective anymore," says Peter Jaksa, a clinical psychologist who works with ADHD patients in Chicago.

Dr. Jaksa says he recognized the symptoms of ADHD in himself long after graduate school when he was working with underachieving kids. "Once you know what it is, things make sense that didn't make sense previously," he says, such as his pattern of writing every paper in college the night before it was due, with a six-pack of Dr. Pepper and a bottle of No-Doz.

"We see people from all of the professions who have managed to succeed despite the limitations, but they have often done it at significant cost," says Dr. Solanto. "They don't have time to enjoy life. They don't get their work done in the course of a day. They have to stay late after hours, or they are doing without sleep, frantically trying to meet deadlines. It ultimately takes a toll on their wellbeing and a toll on the people around them."

Do You Have Adult ADHD?

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While that sounds like many people who are simply driven or trying to do too much in an uncertain economy, experts say it may be ADHD when it interferes with the basics of life. "The magic word is impairment," says Dr. Jaksa. "Everyone gets distracted. Who's not late occasionally? But if you are chronically late, you lose your job and maybe your friends as well."

"I was a textbook case," says Ali Bauman, a 38-year-old writer in Chicago. "I had a messy bedroom and a string of minor car accidents that I could never explain. I couldn't keep the house clean, pay bills, get things done on time. It wasn't that I didn't want to do it, I just wasn't capable of doing it."

As with other psychiatric conditions, there is no blood test or brain scan that can diagnose ADHD. Experts say people who suspect they have it should have a thorough evaluation, ideally with a psychologist or psychiatrist who specializes in the disorder, looking at how they functioned in early childhood, in school and social settings and personal relationships. A screening test can help determine if you should see a mental-health professional, but shouldn't be used for diagnosis.

Once ADHD is diagnosed, most experts recommend treatment with both medication and behavioral therapy.

As counterintuitive as it may seem to give stimulants to people who can't sit down, drugs such as Ritalin, Adderall, Concerta and Vyvanse increase neurotransmitters in parts of the brain that help people focus and control impulses. "They wake up the parts of the brain that are sluggish, so they regulate the brain at a more normal level," Dr. Jaksa says.

There are some concerns that stimulant medications can be abused by people who don't need them. Dr. Goldberg notes that drugs for ADHD can make anybody focus better. But for people with true ADHD, they bring significantly more mental clarity. "My brain felt like it was screwed on more tightly. Everything came into focus. I could be active and do things with my life," Ms. Bauman says.

There also have been concerns that such medications could make some people with ADHD lose their creative edge. But, says Dr. Jaksa, "In my experience, that only happens when the dosage is too high, or it's not the right medicine." He also recommends at least 30 minutes a day of vigorous exercise, which can also increase neurotransmitters.

While medication can help ADHD sufferers focus better, behavioral therapy can teach them what to focus on, how to schedule their lives and set priorities.

Dr. Solanto developed a 12-week program to help people with ADHD learn to manage time, break down daunting tasks into manageable steps and keep themselves organized. One mantra of the program is: "If it's not in the planner, it doesn't exist," says Dr. Solanto. In a study of 88 patients published last month in the American Journal of Psychiatry, they found that those who participated in the program improved significantly more than those who received more standard supportive therapy.

ADHD coaching services provide some of the same lessons, for anywhere from $60 to $300 an hour. "People contact me when they're sick of themselves. They keep repeating the same patterns and can't get a grip on how to change it," says Nancy Ratey, a Boston-based coach who has ADHD herself. She designs individual strategies to help clients meet their responsibilities, which could run the gamut from hiring an administrative assistant to programming their cellphones to ring every hour to make sure they are staying on schedule. "There's nothing worse than an ADHD boss," who keeps saying "this is urgent," "no, this is urgent," she says.

Many ADHD sufferers learn their own tricks to stay organized.

"I buy socks in only one color so I don't confuse them," says Ms. Bauman. "I use one purse a week and my keys stay in there." And because she gets overwhelmed wandering around the grocery store, Ms. Bauman says she's begun ordering groceries online to save time.

Besides learning such organizing skills, many people with ADHD say the biggest challenge is learning not to let the disorder erode their self-confidence, and not to blame themselves for shortcomings.

"There's a huge incidence of depression with ADHD because you are continually failing in the eyes of others, not reaching your potential. People recognize you are smart, and you can't find your niche," says Rob Cahill, 38, an ADHD sufferer who works in social service agency in New York.

Still, Mr. Cahill says that understanding his disorder has helped him empathize with the social-service clients he serves. "The ADHD is a gift in some ways, it's just sometimes hard to recognize."