|
EPSTEIN QUARTERLY
Updated October, 2003
 Email this article to a friend
INTRODUCTION
Today it is an accepted fact that ADD can continue from childhood into the adult years.
But twenty years ago this fact was barely an idea on the horizon. The first person to
recognize that ADD could be present in adults was Paul Wender, M.D., and his research
yielded new insights and opened a new era for adults struggling with the condition.
Since then much attention has been paid to ADD in adults, and many books tapes and
lectures are now available. While there is a good deal of lengthy material available, this
edition of the Epstein Quarterly will give an overview both as a summary and as a source
for the many ADD adults who lack the attention span to read full length books.
SYMPTOMS
Following are the usual symptoms, first as a list and then in a descriptive paragraph:
Attention problems as shown by easy distractibility, an inability
to keep one's mind on the job and forgetfulness.
Restlessness, at times hyperactivity, with an inability to relax,
always being "on the go."
Lack of organization, often with an inability to complete tasks.
The individual reports a lack of organization at the job, in running the household or with
schoolwork. Tasks frequently are not completed, and there is disorganization in
activities, problem-solving and organizing time.
Impulsivity: Decisions made hastily, without reflection, often to
the disadvantage of the individual.
Mood Swings: There are shifts from normal to down to mildly up.
The moods usually last a few hours. When down, there is a feeling of being bored or
discontent.
Explosive temper, easily provoked, with short-lived outbursts.
The ADD adult is generally restless and always distractible. There can be moodiness
with quick changes from a normal to a down mood and back again. Occasionally there are
explosive outbursts which are short-lived for the ADD adult, but often devastating to
everyone else in the room. Disorganization affects work, study and daily activities and
impulsivity can lead to action without thinking.
The Racing Mind is also a symptom to note. The racing mind never stops thinking and
jumps from one thought to another. A patient described it by saying "my mind is like
rapidly changing TV channels, except someone else has the controls." This is very
disconcerting to the individual, who probably has no idea that it is related to ADD.
CASES
While ADD adults have certain common characteristics, the individuals can be very
different. Following are two cases in point:
Richard came to see me after his child had been diagnosed with ADD. He reported that he
had an excellent executive position, but struggled to complete his work. He could not keep
focused on a task or a conversation. He was unable to organize his work, having piles of
paper on his desk. It was hard to get things done because procrastination was a way of
life. He was often moody and occasionally had brief but devastating explosive episodes.
Because of his short attention span he did not reads anything but short articles. He felt
that his distractibility and failure to complete tasks put a great strain on his marriage.
In addition, he was sure that his advancement at work had been adversely affected by his
symptoms.
Richard fits the diagnosis of Attention Deficit Hyperactive Disorder, Inattentive Type.
Len presented a different history and picture. He had been hyperactive as a child. He
was aggressive and presented a problem to school and family. IQ was tested and was 115. He
could not focus his attention, was in trouble, and soon gave up on school. By age 16 he
was drinking heavily and had dropped out of school. He had a series of good jobs, but he
could not hold any because he could not concentrate, was easily frustrated, and said and
did things that led to his being fired.
His diagnosis is Attention Deficit Hyperactive Disorder, Hyperactive/Inattentive Type.
As you can see, the cases show that there is a marked difference in types of ADD and
the result on the individual. One person may have a characteristic that is very severe,
while another ADD adult may not have it at all. However, all types of ADD are serious and
need to be treated.
THE EARLY YEARS
Since ADD is a condition that exists from birth, when diagnosing ADD in adults it is
important to demonstrate the existence of some signs in the early years. Because the child
with the hyperactive form is no problem to spot, this type of ADD has usually been
identified in kindergarten or first grade. The disruptive and sometimes aggressive nature
of the behavior created a problem child, and so identification was made and help followed.
The inattentive type of ADD is a different situation. Remember that prior to 1980 the
condition was unknown. Therefore, very few inattentive adults have ever been thought of as
ADD. Nevertheless, we have to demonstrate the existence of ADD symptoms in the early
years. Some of the key words we hear are: daydreaming, underachieving, and not working up
to potential. Organization problems, procrastination, and low frustration tolerance are
often part of the child and adolescent years and help define the existence of early
symptoms.
EVALUATING THE "PROBLEM"
Though common characteristics exist in ADD, we must evaluate each in terms of its
impact on the individual and his or her quality of life. For example, being disorganized
may mean only losing the car keys or it may mean a serious inability to handle paperwork,
complete tasks, pay bills, or keep the household going.
When it comes to distractibility, the hallmark of an Attention Deficit Disorder, the
inability to pay attention while on the phone, drifting off in meetings, and starting new
projects without completing the old can be disastrous for the business person. The way
his/her spouse and family suffer must also be understood. For example, perhaps he/she does
not listen when spoken to. This is often perceived as not caring, especially by children.
Or on the home front, is the ADD wife having trouble completing her chores so that she
can then spend time in activities she would prefer? Or, worse, does disorganization and
distractibility combine so that appointments are missed, the house never organized, and
the children's requirements almost overwhelming?
These are brief descriptions of very common findings. Once the ADD adult understands
ADD's symptoms and their effects, methods can be developed to deal with the problems, and
as a result, improve the quality of life.
TREATMENT WITH MEDICATION
The most useful and effective treatment approach is with medication. This does not mean
that other programs are unnecessary, and this will be discussed shortly. However,
medication may make a successful outcome much more likely.
The medications most frequently used fall into either the stimulant or antidepressant
groups. With adults, as with children, the stimulants seem best. Side effects are mild and
can include sleep problems, restlessness, dry mouth, and rarely, fatigue. Occasionally the
stimulants can cause a rapid pulse. Therefore, if an individual is over 40, I ask that
they have a check up with their family doctor unless there was a check up within the
previous year.
If there is any problem with pulse rate or blood pressure, I always work together with
the family doctor. Medication can be used, but we need to follow the pulse and blood
pressure somewhat more closely than usual.
Following is a brief description of the medications:
Dexedrine
Dexedrine is often my first choice with adults. This is because it seems to last longer
than the Ritalin and because it comes in several long-acting forms that may be convenient
for the patient. I start with 5 mg. of Dexedrine three times daily, and then evaluate the
effectiveness after about a week of use. Usually the dose or frequency needs to be
adjusted. At times, the primary side effect of sleep difficulties makes it hard to use. If
a long-acting preparation is indicated, I may try a Dexedrine Spansule or Adderall, a more
slowly metabolized Dexedrine preparation.
Methylphenidate
Methylphenidate is often known by the brand name Ritalin. It is the most frequently
used medication for the treatment of ADD. It is effective and comes in 5 mg., 10 mg. and
20 mg. tablets. There is an infrequently used Ritalin, 20 mg. SR, which acts somewhat
longer than the regular Ritalin. However, it is often unpredictable in its action.
A new entry into the medication arena is Concerta. This is a 12-hour release tablet and
has many possible benefits. It became available in October 2000 and will be an important
medication as times goes on.
Wellbutrin
This is a medication that is safe and easy to use. It is helpful for some but not all
of those with ADD, and much less specific in its use. It is taken twice a day, every day.
It can be used alone or in conjunction with a stimulant.
Effexor
This is a medication primarily used for depression or anxiety. It has occasionally been
helpful for those who did not respond to the other medications.
ADDITIONAL APPROACHES
Medications limit or remove the distractibility, improves the attention span and
increases the ability to organize. The ADD adult feels calmer, more focused, and in
control of his/her life.
Now we are in a good position to review the specific problems and work on solutions.
One point of attack is through reading. With the help of medication, some can use books to
help them learn how to improve functioning. Many need to work out specific methods such as
a Franklin Planner or similar organizer. In my office I've added an organizational
specialist who goes to the home or place of business to work out organizational systems.
Whatever is done, it is important to remember that it takes time and often is not easy.
However, the results can be excellent and of great help to the ADD adult and his/her
family.
ART'S STORY (Reprinted from Volume 7, Number 1)
So many readers told me how this story resembled their life that I thought I would
reprint part of it. Art was working on his Ph.D. Here is how he described a chore.
"I started to empty the dishwasher, but as I opened the door I noticed a screw was
loose. So I went downstairs to get a screwdriver. On my workbench was my truck headlight
which needed to be repaired. I tried but couldn't, so I got in my car and drove 30 minutes
to the parts store that carried the light my car required. I got the part, installed the
light, and drove home. At that time I remembered the dishwasher, got a screwdriver,
tightened the screw and emptied the dishwasher." Time elapsed: Three hours.
CONCLUSION
The ADD adult may have struggled for years, never knowing they had this condition. We
now have a great deal of knowledge about the symptoms of the condition and things that can
be done to help. Nevertheless, we have a long way to go in the area of diagnosis and
treatment. I look forward to significant progress in the years ahead.
Following are several books on the subject of ADD in adults. These and others are
available from the Connecticut Association for Learning Disabilities, 203-838-5010. The
books are not listed in any particular order.
1. Woman with Attention Deficit Disorder by Sara Solden
2. You Mean I'm Not Lazy Stupid or Crazy by Kelly and Peggy Ramundo
3. Out of the Fog - Treatment Options and Coping Strategies for Adult ADD by Kevin
Murphy
4. ADD on the Job by Lynn Weiss, Ph.D.
5. Driven to Distraction by Hallowell and Ratey
6. The Hyperactive Child, Adolescent, and Adult - ADD Through the Lifespan by Paul
Wender, M.D.
7. Adventures in Fast Forward - Life, Love and Work for the ADD Adult by Kathleen
Nadeau
|
