New York Times Syndicate
Sunday, September 14, 2003
New York Times Syndicate - September 10, 2003
Peter Richards has been teaching at the private Paideia School in Atlanta for 19 years, but it wasn't until his parents found his own 52-year-old report cards in a dusty attic that he suspected he had the same brain malady many of his pupils do: attention-deficit (hyperactivity) disorder, or ADHD.
``My report cards described lots of my students,'' says Richards, 58, leafing through a notebook of the old letters in his tiny, cramped and cluttered home office.
From fifth grade: ``Peter's very bright, but he is very distractible and distracting.''
From second grade: ``Peter discovered he could get much of the attention he wanted by clowning. He is very excitable and needs a lot of attention.''
From music: ``Peter is easily distracted, but he's calmer in shop.''
More than a half-century later, the descriptions still fit.
Encouraged by his wife, Kelly, 55, the skeptical fourth- and fifth-grade teacher visited a doctor, took a battery of tests and became one of the exploding number of adults diagnosed with the brain condition most folks associate only with children.
He's now taking Ritalin - one of several medications used to treat ADHD - and claims it's changed his life and made him more easygoing. When he's not on the drug, he says he doesn't notice a difference, but his wife and children do, claiming he's impulsive to the point of driving them bonkers.
For some time, researchers disagreed whether ADHD was a real disorder. But when a panel of experts assembled by the National Institute of Mental Health met in 1998, it issued a consensus statement acknowledging validity in the diagnosis of ADHD as a disorder with broadly accepted symptoms and behavioral characteristics.
And it's not just for kids anymore.
Experts such as Dr. Lenard Adler, professor of clinical psychiatry and neurology at New York University School of Medicine, and Dr. Ned Hallowell of Harvard Medical School estimate that 8 million to 9 million American adults have ADHD, but only a few million have been diagnosed.
Since pharmaceutical company Eli Lilly and Co. began marketing Strattera this year - the only ADHD drug approved by the FDA for adults alone - more than a million prescriptions have been filled.
Physicians wrote 295,000 prescriptions for Strattera in July, compared with 46,000 when it hit the market in January. Several million prescriptions for the half-dozen or so other ADHD drugs also were written in the same period, but there's no way to determine how many were for adults.
`Like a fog has lifted'
Still, the diagnosis is difficult and controversial because symptoms - having trouble waiting or displaying a quick temper, for example - overlap those of other mental health problems. In today's 24/7 culture, are you sure you're fidgeting from ADHD or is it because you might not be able to leave work early enough to buy milk, pick up the kids from day care and get them to soccer practice?
But ADHD adults such as Robin Kemp, 39, a poet and teacher, never have been doubters.
She can't remember when she hasn't been distracted and ``very, very hyperactive.'' Once, she says, ``I got depressed to the point of being suicidal because you wonder why you're such a screw-up. I was never able to concentrate, focus on homework, feel normal.''
Last December, she sought help and later was prescribed Strattera, and her world changed.
``It was like a light went off in my head,'' she says. ``I'm thinking I was depressed because of years of being told, `You're stupid.' I finally feel normal and do what I want. I can concentrate. It's like a fog has lifted. When I was diagnosed, I knew I wasn't this neurotic weirdo, that there was something I could do.''
Making a diagnosis
Symptoms of ADHD include inattentiveness, difficulty concentrating, memory loss, underperformance, impulsivity, a quick temper, trouble meeting deadlines, procrastination and poor planning skills.
``For the most part, ADHD has been seen as a childhood illness,'' says Dr. Chris Griffith, a psychiatrist. ``But a lot of adults have it and have learned to compensate. It goes back to early childhood. People will come in and say, `I'm about to lose my job,' or `I'm having trouble in my marriage.' ''
Internists and family doctors are considered the front line of defense for adult ADHD by the American Medical Association because most people are shy about seeing psychiatrists.
``Sometimes people will think they're depressed or anxious, but (they) probably have ADHD,'' says Dr. Marc Seltman, an Atlanta internist. ``I ask them to think when they were back in school, if they had trouble focusing, studying, reading a book and not having wandering minds. There should be no stigma. It's a chemical imbalance in the brain. But it's real, and people can be helped.''
Seltman says many of his patients have been asking him since the Strattera ads began if they might have ADHD. He does diagnose it, after extensive questioning and interviewing, but often sends patients to specialists.
The Lilly ad, which mentions neither the drug nor the company, depicts a woman at a business meeting whose mind is spinning so fast she can't concentrate. The message is that her job performance is being affected by her inability to focus.
The ad refers viewers to a Web site, where they see ``Eli Lilly'' for the first time (www.adultadd.com). It has a six-question quiz that includes questions like ``Do you have difficulty getting things in order?'' and whether you're distracted by noise.
Recently, public doubts about ADHD in adults led more than 100 scientists worldwide to issue a manifesto denouncing attempts to have it labeled as ``myth, fraud or benign.''
Dr. Arthur Caplan, chairman of the Department of Ethics at the University of Pennsylvania Medical School, says that while ADHD is a serious condition, he wonders if drug companies may be pushing ``self-generated diseases'' to sell new medicines to people who don't have problems but who can be led to believe they might by savvy marketing campaigns.
``Germany or other countries don't have anything close to the rates we do in children or adults,'' Caplan continues. ``Either we suffer from a bizarre geographic condition or our doctors are more prone to find it. I think it reflects more aggressive marketing because of the incentive by drug companies to find conditions that require chronic treatment.''
Lilly spokesman David Schaffer says Caplan's claim is ``ridiculous'' and that the company, to stay competitive, needs to formulate drugs that work, and ``Strattera has been shown by independent scientists to be very effective.''
Lilly senior scientist Calvin Sumner helped develop the drug and echoes Schaffer's comments. Sumner says repeated tests, reviewed by peers, have shown Strattera to be ``highly effective'' in blocking symptoms of adult ADHD.
Genetics plays role
Scientists such as Adler and Hallowell, who have devoted their careers to the study of ADHD, strongly disagree that more people are being diagnosed because of drug company marketing. They contend ADHD is underdiagnosed.
``Everybody accepts ADHD in childhood, and it doesn't make sense that it goes away in adults,'' Adler says. ``There's no doubt it's genetically loaded. . . . If you have a child with ADHD, you or your spouse have a 40 (percent) to 50 percent chance of having ADHD. We know some of the neurochemistry of the disorder. ADHD is not bad parenting, it's genetics.
``This is not a disorder we are creating in the U.S. We know that if you're adult and spend an hour writing notes to yourself to make sure you do things during the day, this can be a significant impairment.
``I've known executives whose annual reviews would read like an ADHD checklist. This is not normal aging.''
Says Dr. Rick Winer, a psychiatrist:
``It's become a significant part of my practice. The most common opening line I hear is, `My son or daughter was recently diagnosed with ADHD, and he or she reminds me of me.' ''
Benefits of research
While ADHD is often treated with Ritalin, Strattera and other drugs, some treatments involve therapy without medication or a combination of both. Children, for instance, may be coached on behavioral therapies that involve rewards for desired behaviors.
Megan Brightwell, 27, a family therapist, takes no medications yet but is grateful that so much research is being done on ADHD that she no longer feels ``like the Lone Ranger,'' as she always did in her youth.
Debbie Woodie, 42, finally was diagnosed by a psychiatrist last year. The mortgage banker bounced from task to task but never got anything done.
``I never thought ADHD was an adult problem,'' Woodie says.
Desperate, she researched ADHD online, went to a psychiatrist and began taking Concerta, a stimulant like Ritalin.
``I noticed a difference right away,'' she says. ``It works. My memory is better. I know it is a chemical imbalance. And I'm doing a lot better.''
Researchers stress that screening tests need to be taken before a diagnosis is made, such as the comprehensive one at www.med.nyu.edu/Psych/training/adhdscreen18.pdf, which asks 18 questions. In addition, the experts agree, no diagnosis should be made without a thorough examination and background interview by a physician, psychiatrist or psychologist.
Family sees difference
Richards, the Paideia teacher who is taking Ritalin, says he can't tell whether his brain has less activity when he's on medication.
But he says his wife can. She ``gets all over me'' when he skips taking it for a few days, Richards says.
``His whole family can tell the difference,'' says Kelly Richards. ``He's not as impatient on the medicine, less impulsive. He doesn't say the first thing that's on his mind without pausing to think of the consequences.''
His wife and daughter Kennesaw, who also has ADHD, say his medicine makes him less impulsive, less likely to lose his temper.
He says it ``keeps the beasts at bay.'' Then he adds philosophically: ``But I see some real evolutionary advantages to it. Certainly in Paleolithic times, the ones who survived probably had ADHD. They were the ones who'd hear the sound of the saber-tooth(ed) tigers.''
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