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Questions persist about ADD diagnosis in adults
Research supports medication and counseling
Although recognized as a legitimate illness for more than a decade, many health care providers still refuse to acknowledge attention-deficit disorder (ADD) as an affliction affecting adults, say behavioral health experts.
Recent articles in The New York Times magazine1 and The Wall Street Journal2 have helped raise public awareness of the condition, some say. But at the same time, critics of the ad campaign for the treatment drug, Strattera, and producers of the MTV "True Life" reality show episode "I’m On Adderall" have given voice to a widespread fear that the diagnosis is just an attempt to medicalize immature behavior, and that treatment with medication can lead to stimulant addiction.
"There are a lot of doctors who don’t realize that ADD exists in adults. They think it is only an illness that affects children — and even then, they think it is only hyperactive little boys," says Edward Hallowell, MD, a Massachusetts psychiatrist and author of the 1994 bestseller Driven to Distraction, a book on ADD in adults. "My book did a lot to put adult ADD on the map, but even then a lot of folks still said, This is just nonsense — people just need discipline, and people need to shape up.’ It has taken a long time to demonstrate with magnetic resonance imaging [MRI] studies and medication and genetic screening that this is a real brain difference."
MRI studies of hyperactive adolescents and adults diagnosed with ADD have shown diminished functioning in the prefrontal lobe of the brain, which controls executive functions like memory, sense of time, impulse control, and the filtering out of stimuli not related to the task at hand, adds Carol Gignoux, a Boston-based certified counselor and executive coach who specializes in working with adults with ADD.
In the late ’60s and early ’70s, when ADD was first becoming known as a condition affecting children, many experts in the field believed it was something that people outgrew. However, by the late ’70s, the psychiatric community began to realize that some adults also suffered.
The problem, say both Gignoux and Hallowell, is that ADD doesn’t always look the same in one person and the next. And adults often have learned ways to self-medicate or modify their behavior to a certain extent.
"It is an interesting disability, and people hit the wall at different times," says Gignoux. "Their life is just a certain way, and then it becomes really difficult when they are asked to do some things at a higher level than they had been. And suddenly, they can’t function. Most people with ADD had it as a child, but it always takes different forms and different degrees."
Although published estimates put the incidence of ADD in the general population at 3% to 4%, Gignoux says she and others believe it actually is much higher. "I believe at least three out of every 10 workers in the work force has ADD," she says. "There are problems with the reporting of figures for this disease in particular because of the stigma. Often people with ADD don’t understand what they have, they don’t know where to turn to get help, and there are really no resources in the workplace."
Gignoux takes some issue with articles like the piece in The New York Times magazine because she fears they will do more harm than good.
While the article may be the avenue by which some realize there is a name and treatment for what they have, they also continue the stigma that adults with ADD are extremely difficult to employ and cannot function well in a structured environment, she says.
"The article cited the most extreme and difficult cases, when really most people with ADD are not faced with those levels of challenges," she says. "Some are, but it is not to say that it’s this huge problem out there for employers."
People with ADD do very well when they are accurately diagnosed and put on appropriate medication, combined with therapy and work coaching, she says. "Basically, what they need is a mentor or coach, they need someone to teach them the behaviors and strategies and work with them," she says. "There are medications that make you more receptive toward the things you need to do in life, but it doesn’t teach how to change your behavior."
Time management is particularly difficult for people with ADD because they often don’t sense time passing in the same way that non-ADD people do, she adds.
One of her strategies in executive coaching is to work with clients in the use of tools like day planners and other schedule aids and strategies to help them manage their time.
One person, for example, has learned that he must check his e-mail only once a day because he was so easily distracted by being on the computer.
Other people might need a different alarm clock or more than one alarm clock to get them going on time in the mornings. "The point is that we can learn strategies that help us function, and once the person with ADD learns them, they have them forever, they are fine," she says.
The key symptoms of ADD — restlessness, impulsivity, and an inability to focus — do sound as though they could describe almost anyone at different times and certain circumstances. And making an accurate diagnosis is not a simple task, says Hallowell.
"You need someone who will take an appropriate history and ask the right questions," he notes. "The real tool still is a good history. If you have someone who knows what they are doing and you sit down and tell your story, ADD just pops right out."
"What clinicians should look for is unexplained underachievement — someone underachieving socially or professionally for reasons that no one can explain," he continues. An example is a person with an advanced degree and high grades throughout school who then, inexplicably, cannot hold a job.
"Then, the physician should explore whether the person has trouble sustaining attention by asking questions like, Do you have trouble when the interesting part of the job is over? Do you have trouble managing time? Do you seek out high stimulation situations in order to focus?’"
It is then important to make the appropriate referrals for follow-up counseling and therapy, he says. People with ADD are often misdiagnosed with depression or bipolar disorder, or, in the other extreme, are told they are simply stupid, lazy, or unskilled.
"It is not just men. A lot of women are misdiagnosed as depressed, or spacey, or ditsy — these pejorative kinds of adjectives — and they are frustrated because they don’t know why," he explains. "They are thrilled to discover that they have a condition. It is wonderful to see them get the diagnosis, and then turn it all around. They go from long periods of underachievement to really solid lives."
Is ADD a disorder or a personality?
While acknowledging that people with ADD need help to function productively in modern society, both Hallowell and Gignoux say they are reluctant to categorize ADD as a "disorder" in the traditional sense.
Some have even wondered whether modern society has created this disorder by insisting everyone adhere to a regimented, extremely time-focused existence. In previous centuries, for example, people who did not do well in structured environments had more options for employment than they do now. And in other cultures, time and rigid adherence to schedule are not as highly valued as in the Western industrialized countries.
Many business tycoons, inventors, and innovators in other fields are known to have or have had attention-deficit disorder, and many people with ADD tend to be highly creative and energetic when properly motivated, Gignoux says.
Are they trying engineer a uniform human personality? "That has been a whole other controversy," says Hallowell. "Are we trying to medicate the Tom Sawyers of the world out of existence? The way I see it is that it is not a disorder so much as it is a trait — a way of being. There are a lot of assets that go along with this condition. People with ADD tend to be creative, energetic, and better able to think outside the box."
Inventor Thomas Edison is just one of the famous people known to have had attention-deficit disorder.
"We have to show corporate America that, without a lot of modifications and extra expenses, how easy it is [to] support these folks," Gignoux says. "These folks are also the Thomas Edisons of the world. They are the main contributors to our world in terms of coming up with new ideas and solutions, so we shouldn’t throw the baby out with the bath water. We need to find ways to understand."
1. Belkin L. Office Messes. The New York Times magazine, July 18, 2004.
2. Maher K. Time management strategies help professionals with ADD. The Wall Street Journal, March 3, 2004.