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Attention deficit disorder (ADD) is not only for children. About 8 to 9 million American adults, and as many women as men, have ADD. There are three types: hyperactive/impulsive, inattentive and combined hyperactive/impulsive/inattentive. For years, the criterion for diagnosing ADD in adults was the same as for children: at least six symptoms of inattention and hyperactivity/impulsivity in two or more settings (work and at home, for example) to a point where those symptoms impair your daily life.
But that’s changing. Today, as more adults seek help for ADD symptoms and as more research is done exclusively on adults, doctors are refining their ideas about how ADD differs in adults and children. Here, Thomas E. Brown, Ph.D., associate director of the Yale Clinic for Attention and Related Disorders at Yale University School of Medicine and author of Attention Deficit Disorder: The Unfocused Mind in Children and Adults, helps to clarify what adult ADD is -- and is not.
Q: How does ADD differ between adults and children?
A: Children are more likely to have the hyperactivity symptoms of ADD than adults are. Even adults who were hyper when they were kids usually are not that hyper as adults. Also, the ratio of ADD changes from about three to one boys to girls, to about one to one men to women. That suggests that there are a lot of girls who have these difficulties, but they don’t cause enough trouble for other people when they’re in school, and so often diagnosis waits until adulthood, when they reach a point where they can identify the problem and seek help for themselves.
Q: Can ADD begin in adulthood?
A: The classical notion is that ADD begins in childhood -- that you’re born with it. One of the criteria for diagnosing ADD has always been that symptoms should have been recognizable by age 7, but that’s nonsense. There are no data behind it. In a lot of people, you don’t see any problems until a child starts middle school or high school and has multiple teachers. In some people, the symptoms don’t really appear until they’re living on their own for the first time.
In some women, symptoms may not arise until midlife. I’ve seen doctors, lawyers and other highly successful, well-educated women who have no ADD symptoms most of their lives, and when they hit their mid-40s to early 50s and are in perimenopause, they suddenly experience an unprecedented difficulty with keeping track of things, organizing things, remembering things and a whole syndrome that looks an awful lot like ADD occurring at midlife. Estrogen is one of the chemical modulators for the release of dopamine in the brain, and it happens to be the neurotransmitter that is most important for the functions affected by ADD. When estrogen levels drop in menopause, in some women that causes a substantial drop in their ability to exercise these executive functions that worked very well up until then.
Q: What do neurotransmitters have to do with ADD?
A: People often say, “ADD is a chemical imbalance in the brain,” which makes it sound as though there’s not enough salt in the soup. That’s not it at all. ADD is a breakdown in communication in the brain. There are 100 billion tiny neurons (nerve cells) in the human brain, and they have to communicate, to transmit messages from one neuron to another. The brain makes 50 different neurotransmitter chemicals to help carry those messages. The neurotransmitters most affected in people who have ADD are dopamine and norepinephrine. If you have ADD, your brain makes those chemicals the same way everybody else’s brain does. It just does not release and reload them effectively. ADD involves chronic failures in communication from neuron to neuron.
Q: Does that mean people with ADD can’t focus well on anything?
A: No. Two conditions can change the chemistry of the brain instantly: when you’re really interested in something, and when you are really scared. In both cases, there’s an increase in the release of those neurotransmitters -- and people with ADD can function as well as anyone else in those instances. Where people with ADD have trouble is the day-to-day routine stuff of which most of life is made up.
Q: How is thinking about ADD evolving?
A: We have switched from thinking about ADD as primarily a behavior problem to thinking of it as a problem of the development of the management system of the brain, what are called the “executive functions.” Those executive functions include your ability to get organized and get started on things; being able to prioritize tasks; being able to focus on something you need to, but then switch focus when you need to; to stay alert and sustain effort on things over a long time; to manage emotions so that you don’t get too flooded with worry or annoyance or other feelings; and being able to utilize working memory so that you can, for example, keep track of conversations and remember something you’ve read or heard.
Q: What are common misconceptions about ADD?
A: People think that to have ADD you have to be hyper and behave badly, or that people with ADD simply aren’t as smart as people who don’t have ADD. There is no truth to those beliefs. I have studied people with very high IQs who have ADD, and there are many people with ADD who have never had behavior problems, but do have problems getting organized, getting started on stuff, being able to stay focused or being able to keep one thing in mind while doing something else.
Q: Are people who have ADD more creative or talented than people who don’t?
A: That’s another myth. There’s a little romanticizing that happens when people talk about ADD. Some people with ADD are amazingly talented and successful, but a lot of them also have a difficult time delivering the goods. What we do see is that every single person with ADD has at least one or two activities in which they can focus very well and have no trouble with these executive functions that they’re having so much trouble with in almost everything else. A patient said to me once, “Having ADD is like having erectile dysfunction of the mind. If the task you’re trying to do is something that turns you on, you can perform. If the task doesn’t turn you on, you can’t get it up, and you can’t perform.” It’s not a matter of willpower. When you have ADD, it doesn’t matter how much you say to yourself, “I really ought to,” or, “I should.” You can’t make it happen.
Q: How do medicines for ADD work?
A: After those neurotransmitters are released to carry a message from one neuron to another, what hasn’t been used up of the chemical gets sucked back into the sending cell. In people with ADD, their brains suck it back in too fast. The medicine slows down that “suck it back in” function by fractions of a second, but it means you get a better connection. In addition to slowing down the suck-it-back-in function, some medicines also help the brain to release a little more of the chemical in the first place. The medicine does not put more chemicals in the brain; it helps the brain’s chemicals carry the messages from one neuron to another more effectively.
Q: How can adults who think they might have ADD find a doctor who is qualified to evaluate and diagnose them?
A: Some primary care doctors are up to date on ADD in adults. Others are not, but may be able to refer you to an expert in your area. Children and Adults with Attention Deficit/Hyperactivity Disorder[(www.chadd.org] (CHADD) is a national organization with local chapters around the country, and their meetings and website are a good place to get information about resources and doctors in your area. If you live in or near a city with a teaching hospital, call up and ask, “Is there a clinic for adults with ADHD?” The Attention Deficit Disorder Association also has a physician referral service on their website. Diagnosis should include a physical exam to rule out medical problems, a thorough medical history and initial interview, use of adult ADD screening tests or questionnaires and screening for other mental health issues in addition to ADD.
Q: Can adult ADD be cured?
A: Once diagnosed, most people with ADD can be successfully treated and their symptoms can improve. The medications help about eight out of 10 people who take them. Other strategies, including behavior therapy to improve organization and time-management skills, and good health habits like having a regular sleep schedule, eating well and exercising all can help adults with ADD to function better. Some adults with ADD also have coexisting problems such as anxiety or substance abuse issues. When those problems are addressed and treated, often the ADD symptoms improve, too.