Sit Down and Pay Attention
A record number of children and adults are being diagnosed with ADHD. Is it hype or science?
Watching a TV commercial one evening, Bill Sappenfield sat up and took notice. The announcer reeled off symptoms for attention deficit hyperactivity disorder (ADHD) — leaving projects unfinished, becoming easily frustrated or bored, speaking without thinking, not listening to conversations — and the 54-year-old operations vice president said, “That is me!”
His wife, Mona, and their daughters, Jessica and Jacquelyn, had witnessed those symptoms in Sappenfield for years. Jacquelyn, 17, had told her mother that he acted a lot like the boys she knew who'd been diagnosed with ADHD. "He'd go on rants, jump up and leave something he was working on. He just had no attention span," says Jacquelyn. "And his office — it looked like Hurricane Katrina hit there instead of New Orleans."
"His behavior was totally changing a lot of relationships with friends and business partners," adds Mona, who with her husband runs Mona's Spa and Laser Center. "He couldn't stay focused and that became a real handicap. I think he's probably been this way all the years I've known him. I wasn't aware of specific symptoms for ADHD, I just thought a lot of times he could use a chill pill," she smiles. "But if you suspect that someone in your family needs medication to feel better and make the whole family feel better — and it's someone you've known and loved for 24 years — you want to help."
At Mona's urging, Sappenfield visited his family physician, who prescribed the generic form of Adderall, one of a variety of psychostimulant-based drugs that treat ADHD. His wife and daughter noticed a difference in about a week. Says Jacquelyn, "He's more calm and reasonable, and willing to listen. He's doing the things he loves to do, like fishing. And he's taking a Spanish class for when we go to Mexico. Before, he'd get frustrated and just quit."
Sappenfield believes the medication is "doing the job" for him. "We're getting a lot of negative things out of our lives we weren't able to do before," he says. "We're tying up loose ends and moving forward. I'm very glad I got help."
"Just a handle we put on bad behavior?"
As an individual with ADHD (a category which includes the subclassification attention deficit disorder, or ADD), Sappenfield is not alone. According to a 2006 federally funded survey, an estimated 4.5 percent of American adults struggle with its symptoms (see sidebar on page 68), as do 3 to 5 percent of children. With the U.S. population at 300 million, that comes to at least 9 million individuals who get lost in conversation; who are distracted in class by a tapping pencil; who go to the store for milk and come home with oranges; who annoy others with boisterous, "in your face" behavior; who fail a test or lose a job because — as more than one person has described it — there's too much traffic in their heads.
It's a disorder we've heard a lot about since 1980, when the American Psychiatric Association classified it as a medical condition that causes specific behavioral problems. But its symptoms were first clinically observed in the early 1900s by British pediatrician G.F. Still, who described the conduct in children as a "defect of moral control" but who believed it had a medical cause. In 1937, doctors found that amphetamines could reduce hyperactive and impulsive behaviors, and in 1956, Ritalin, the most common psychostimulant medication, was introduced. Since then, and especially over the past 25 years, ADHD has become a household acronym, with some people questioning, as Mona Sappenfield wondered, "Is ADHD just a handle we put on bad behavior?"
Not according to medical research being done all over the country.
Dr. Jerry Heston, a local child and adolescent psychiatrist, explains that ADHD is a neurodevelopmental disorder with a physical basis that results in a shortage of the neurotransmitter dopamine. "It's not just a reaction to something, like depression can be," says Heston. Sophisticated PET scans show that ADHD children and adults have lower functioning primarily in the frontal areas of the brain, especially the executive center, which controls organization, focus, sequencing, logic, and sense of time.
Though its cause is still unknown, experts believe ADHD has a genetic correlation, which means that if one child in a family has ADHD, there's a strong chance that another child, as well as one or both parents, has it too. Besides its genetic base, other less common possible causes are head injuries, lead poisoning, or a mother who drank alcohol or smoked during pregnancy.
"Why are you giving my child speed?"
The primary treatment for ADHD comes in the form of stimulants, usually dextroamphetamine or methylphenidate. Richard Luscomb, a psychologist who works with children and adults, says, "People may ask their doctor, 'Why are you giving my child speed?' I think what has thrown off the lay public is that these medicines are called psychostimulants, and they wonder why a hyperactive person would need a stimulant.
"But an ADHD patient is not overstimulated," continues Luscomb. "What's happening is, their brain is not filtering well; the governing center of the brain is not getting enough energy because it's not producing enough dopamine. I explain it to a kid sometimes using a 100-watt light bulb. I'll dim it and say, 'It's not getting enough electricity.' So when we give the patient the psychostimulant, it powers up the executive center by releasing more dopamine."
According to Medco Health Solutions, a prescription drug benefit management company, consumption of psychostimulants is skyrocketing. Between 2000 and 2005, the percentage of Americans ages 20 to 44 taking the medications increased 139 percent. Though the increase was less significant for children, at 52 percent, they're still the majority of psychostimulant consumers. Most are now taking long-acting medications, given in the morning before school. For those who don't respond to stimulants, antidepressants may be administered. And one nonstimulant drug is now available: Strattera, which was FDA approved in 2002.
Dr. David Kube heads the pediatric department at the University of Tennessee Boling Center for Development Disorders. He says psychostimulant use is rising because more children — including those as young as 5 years old — are being diagnosed with ADHD. "I don't think there's really an increase in people having it, I think it's something that hasn't been recognized. And we're picking up a lot more girls who probably didn't get evaluated because they didn't have behavior problems as much as boys do. They have academic problems, caused by the inattention and distractibility. That's a big group," says Kube. "Besides that, we used to stop the meds after middle school or high school because hyperactivity went away. Now we see the need for treatment longer."
"More wrongly diagnosed than overdiagnosed."
For all these people being dosed with Ritalin, Adderall, Concerta, and other psychostimulants, what are the side effects? Studies show that appetite loss is the most common, while insomnia, nausea, headaches, and other effects are also reported. "In some children, moodiness or irritability can occur," say Kube. "If that happens, their dosage may need to be adjusted. The medication should not change their personality; it should curb their boisterous behavior."
Some ADHD patients taking psychostimulants report feeling less friendly and sociable and resist taking the medication, "We can tailor it so they'll take it at school, but we give them a break from it on weekends," says Heston. "But if they've got church, soccer, or some activity where good behavior is required, it saves everyone a lot of grief if they go on and take it."
As for long-term side effects, the National Institute of Mental Health is conducting a longitudinal study that examines factors ranging from changes in height to drug addiction in people taking psychostimulants; to date, no definitive effects have been reported, but the study is ongoing.
Heston believes in looking at the effect of not treating children: "ADHD has ramifications that affect a lot of things in life. I do contract work at the Youth Development Center, which is sort of a juvenile jail. The common story there is, 'Yeah, I was on that medication when I was 6 or 7.' And they got off it because of side effects or they couldn't afford it. Now they're in trouble, dealing with impulsive behavior 24/7."
In addition to concern about overmedication, some professionals and lay people believe ADHD is overdiagnosed — or as one physician said, "It's kind of in vogue to say you have it." Heston acknowledges "there may be some element of that but I think it's underdiagnosed in some communities. At [a private school], a kid with mild symptoms makes Bs and Cs, and with the medicine he makes straight As. Whereas if I went to [a school in a low-income area] where kids are failing, I think it's possibly undiagnosed. So there's a disparity." He and others also emphasize the importance of recognizing conditions that can mimic ADHD, such as thyroid conditions and depression. Says Luscomb: "I think it's more often wrongly diagnosed than overdiagnosed."
"Not just a bad kid."
As a child gets older, he or she will likely outgrow the hyperactivity of ADHD, but about 60 percent of children will continue to struggle as adults with disorganization. Heston offers a silver lining: "The level of severity may decrease. And the brain can also be changed by learning how to get around the problem. The goal is to mature, to learn coping ways — not for kids to stay on medication all their lives."
Luscomb offers anecdotal evidence that's also promising: "We're finding that when we treat ADHD aggressively over a long period of time during brain growth development, a lot of these kids don't need treatment as adults, and that somewhere in mid- to late-college, if we take them off the medicine, they function as if they're still on it."
In addition to medication, experts recommend behavioral counseling. "It's important to educate and train the parents about providing structure and making expectations clear," says Heston. "Parents say, 'Our other child got through fine, but with Johnny we have to be much more on target, stay on him a lot.' So they should set a schedule for Johnny, and understand that he's going to be more active, and that he's not just a 'bad kid.' Some children who are in trouble a lot or have learning difficulties may develop depression, so counseling could help their self-esteem if not their ability to concentrate."
"A child with ADHD can really stress the whole system," adds Luscomb. "Parents may give a child a three-point command: I want you to go upstairs, grab your coat, and turn off the light. Well, they go upstairs and that's the last you hear of them. So there's yelling back and forth, and the parents are afraid to answer the phone during the day because they know it's going to be the school. So behavioral counseling with children and parents is important."
"Hitting a brick wall."
Sandy Wright is a professional organizer whose husband and two children have ADHD. With a background as a corporate trainer for Holiday Inns, she has coached employees in productivity and now works with ADHD children and adults. Describing her work with a 6-year-old assigned to do a mobile book report, she says, "Procrastination is the biggest factor holding him back because he can't pare the project down to something manageable. So I sit down with him and we list the 10 steps he'll need to take over the next 16 days before the report is due. We plot that out so he's not overwhelmed by the project's size and scope."
Working with an adult, Wright taught a woman how to use a software calendar/task manager. "First we decided if she was a morning or afternoon person," says Wright. "She was peaking in the afternoon, so from 4:15 to 4:30 each afternoon, we decided she should prioritize and list what she needed to do the next day. Some people need visual and tactile stimuli — like a piece of paper with certain tasks color-coded. The main idea is to break the task down into parts."
About 60 percent of Wright's adult clients seek her out at the desperation point. "Usually one of two things has happened," she says. "The person himself realizes he's hitting a brick wall and he's ready to take action. A man may realize he's spending too much money because he doesn't have a sense of how much he has, and it's impacting his financial status. Or a mother is not getting her kids' papers signed and returned, so it's affecting the whole family. In other situations, someone else is the impetus for their calling me. A wife has said, 'I'm leaving you if you don't shape up.' Or an employer has said, 'I'm firing you if you don't perform.'"
Companies sometimes hire Wright to work with people who they know can do excellent work but are missing deadlines and not producing up to speed. When Wright talks to the employee, she'll realize they're not planning their day or compartmentalizing certain tasks. "They're always in catch-up mode rather than keep-up mode," she says. "In a conversation, one sentence will send their mind off on a tangent and they'll be lost. If they can't stay focused, if they can't get to places on time, or can't deliver products, they're perceived as incompetent. So I try to help."
"Adult ADHD is real."
Wright learned a lot about adult ADHD through her husband. "One day he was driving and I was talking and I looked over and I could tell he wasn't listening, so I interjected, 'Well, then, the elephant came right out of the tree but its ears kept it from falling.' My husband didn't blink." She gradually learned that he was hyperfocusing, a common mechanism used by adults and children with ADHD. "That helped him stay in the moment and get the task done he needed to do."
According to Luscomb, people who use hyperfocusing — concentrating intently on a single thought or task — can "outperform many other folks. The thing is," he adds, "it wears them out, they lose their peripheral side. They wait till the last minute to turn the mechanism on, then they work like crazy, and are rewarded by getting the project done." So they keep doing it that way — procrastinating, then hyperfocusing — instead of seeking help.
Luscomb, who sees both children and adults, notes how diagnosis and treatment for the disorder has changed over the years:
"When I was in training between 1975 and 1980, we were still being taught that we could only diagnose ADHD between ages 6 to 12. Past age 12, we had to change the diagnosis to oppositional disorder or something else. That theory has been shot out of the water.
"In the early '80s," he continues, "we were treating adults undercover because people didn't want to believe they were really ADHD. Now there's more understanding and acceptance and less stigma."
"Adult ADHD is real," he adds. "It affects jobs, communications, social life, marriages. In couples therapy, the wife might say that her husband swears he told her something, but he never did. ADHDs will have a conversation in their head and remember it as if they actually had it." Others, he says, are always late for meetings, haven't read a book all the way through in years, and "many of them got through college on the seven-year plan, going from school to school."
When an adult does see a professional, it may first be with his child. Heston describes a common scenario: "The kid is brought in for ADHD evaluation and one of the parents, more often the husband, might say, 'You know, I think I had this growing up.' Some tell me they're still having trouble keeping a job so they think the medicine might help them."
It's essential to remember that, with ADHD, symptoms must have been occurring for a long period of time. "It's not just something that comes up, when a person thinks, 'Oh, I'm distracted, I must have ADHD.' That's not how it works," says Heston.
Luscomb sees a similar scenario. "Most adults come in because they know it runs in families. When discussing their child, they'll say, 'I was just like that.'" That's a good thing, he adds, because it enhances the parent's understanding of what the child is going through.
But in working with the adult, he doesn't leap to the conclusion that a parent has ADHD. First, he performs a differential diagnosis, ruling out other possible problems. Then he asks questions about middle school, high school, college, to see how long the patient has been experiencing symptoms, and often "risk flags will come up."
Besides a checklist of symptoms, Luscomb also performs a cognitive memory assessment to see if the patient has problems related to attention and concentration, and a learning test to evaluate the patient's global and visual memory. "I like to have baseline data, to measure change, to be sure we've isolated the issue," he explains. As for medication, "you don't want to treat depression, or a deteriorating brain condition, or a thyroid disorder with ADHD medications. If the patient is medicated, we want to ask if it's helping his symptoms, such as improving short-term auditory memory. I don't think it's a good idea to just shoot in the dark and say, 'Let's try this medication.'"
"Brilliant, creative go-getters."
Whether you or your child has ADHD, experts stress that the disorder has its positive aspects.
Says Kube: "It's more easily treated than other problems we handle and one of the most researched. Also, studies show that adults who were treated for ADHD as children are a lot less likely to become involved in drugs and alcohol, have fewer auto accidents and more stable relationships, are more likely to be employed, and avoid legal troubles. If people with ADHD can get organized and learn to follow through on projects, they can get a lot of things done."
Luscomb takes the positive side to a higher level. "The thing to remember about ADHD adults, a lot of them are CEOs, brilliant, hyperfocusing, and creative. They're our go-getters," he says. "Many famous people are thought to have had ADHD, including Einstein. That's why I tell parents, don't get upset about your ADHD children. Yes, it's frustrating when they do their homework but don't turn it in, or go in the shower and forget to come out because they lose a sense of time. In a few years, those same kids may be running huge companies or creating great art. So never despair."
For more information, experts recommend Driven to Distraction by Edward Hallowell, and the website CHADD.org.