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DHD can follow its victims into adulthood, when the disorder can be especially hard to detect
By Kate Shatzkin
The Timonium woman, now 39, was relieved. "Just knowing there is really something there that needs to be addressed, needs to be released, you can forgive yourself for your shortcomings," she said. But more than a decade after researchers began to acknowledge that the disorder now commonly known as ADHD - for attention deficit hyperactivity disorder - can affect adults as well as children, many go through life without diagnosis or treatment, studies show.
Doctors used to believe that ADHD was a disease of childhood, outgrown by the late teens. But in one-half to two-thirds of cases, symptoms persist into adulthood. A New York University School of Medicine study estimated in 2003 that the disorder affected 8 million to 9 million U.S. adults, but that only a quarter of them had sought help for its symptoms. Even fewer had been properly diagnosed with ADHD.
Part of the reason, ADHD experts say, is that many primary-care physicians - and even psychiatrists - don't know how to recognize the problem. Some are still skeptical that adults can have ADHD. "Physicians have not been trained on this disorder," said Dr. David Goodman, director of the Adult Attention Deficit Disorder Center of Maryland and an assistant professor of psychiatry at the Johns Hopkins University School of Medicine.
The New York study found that nearly half of 400 primary-care physicians surveyed said they did not feel confident in diagnosing ADHD in adults. Just 34 percent reported being "very knowledgeable" or "extremely knowledgeable" about the disorder.
That's not so surprising, because there's still no consensus on exactly what symptoms and impairments qualify for the diagnosis, said Jeanette Wasserstein, an assistant clinical professor of psychiatry at Mount Sinai School of Medicine in New York City. "We don't have definitive neuropsychological tests, although we're getting ever closer," Wasserstein said. "It remains the state of the clinical art."
The cost for adults
For adults, the fallout from untreated ADHD can be failed relationships, lost jobs and the enduring feeling that they don't fit in. Others have adapted so well that their symptoms are barely noticeable to the casual observer. Part of the problem is that ADHD symptoms in adults - distractibility, impulsiveness, forgetfulness - can mirror those of other conditions like anxiety, depression and bipolar disorder.
Medication prescribed for those problems "helps take the edge off, but it doesn't touch the ADD," said Carol Robbins, a clinical psychologist in Annapolis and Silver Spring. Even physical conditions, from head injuries to lead poisoning to seizure disorders, can mimic ADHD, Wasserstein writes in a coming issue of the Journal of Clinical Psychology.
There's a push to help frontline doctors recognize the disorder, said Mary Frank, a physician who practices near San Francisco and is president of the American Academy of Family Physicians. The California chapter of the group has a goal of educating 3,000 family doctors this year about how to recognize the disorder - initially through simple questions.
Frank said she has about two patients a month who come in suspecting they have the disorder; about a third really do. But she's had trouble referring them to local psychiatrists - as some insurance companies demand - because they aren't taking new patients. "It's very important that family care doctors know they can diagnose and treat this in their own practice," Frank said.
Some experts say ADHD in adults is not only real, it's costly. A recent study by a Harvard psychiatry professor concluded that adult ADHD is responsible for an estimated $77 billion in lost household income in the United States each year. The disorder runs in families. Children with ADHD have a 40 percent chance of having a parent who suffers from it, Goodman said.
Most experts agree on one central feature of ADHD in adults: Its symptoms must also have been present in childhood. Unlike their children, many of today's adults didn't know they had ADHD back then. Marla Fowler of Westminster didn't recognize the signs for a long time, even though she struggled in school and in life. As an adult, she chose jobs that kept her moving, like working on film crews. At 33, after moving to Maryland from California, she took to the Internet to find out "why I was always switching around and moving around." She went to a psychologist who specialized in ADHD, and the diagnosis didn't take long. Four years later, Fowler said, she can now concentrate on her studies - she's getting a master's degree in social work - with the help of medication. Before going out, she used to have to come back in at least four times to retrieve things she'd forgotten. "Yesterday I came in once, and I was ecstatic," she said.
Subtler signs in women
The disorder can be even harder to diagnose in women, whose symptoms may be more subtle. For years, Kerch McConlogue of Baltimore had no idea that she had it. But after a psychiatrist asked how her concentration was, "I thought about it and I thought, I don't do anything that takes longer than 20 minutes," said McConlogue, 52.
When Suzanne Strutt of Timonium initially sought help for ADHD about 10 years ago, she went first to a highly regarded internist. She says he told her he "didn't believe in ADHD" and put her on Prozac. The antidepressant didn't help. It took her another couple of years for a psychiatrist to identify Strutt's problem. The writer and editor has done well on medications, but because of some side effects, now takes them only when she needs to be very focused. Strutt, 59, is a board member of the Greater Baltimore chapter of Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD).
Majerowicz, the Timonium mother, said her diagnosis - and treatment with Concerta, the same medication her daughter takes - turned her life around. The once-a-day drug, one of several medications like Ritalin, controls ADHD symptoms by stimulating the central nervous system. She said she was able to focus well enough to start her own interior design company. "It's just such an awesome feeling to know you're working to your potential," she said.
But some say there can be a downside to ADHD treatment in adults. Lara Honos-Webb worries that, for some, treatment for ADHD can actually be harmful. In her new book, The Gift of ADHD, she writes that ADHD "symptoms" can just as easily be viewed as positive, and that the real harm, especially for children, is in labeling the condition a disorder. The same can be said for adults, said Honos-Webb, a clinical psychologist and assistant professor in the counseling psychology program at Santa Clara University in California. While some see them as spacy and hyperactive, adults with ADHD can be highly creative and exuberant, she said.
Witness David Neeleman, the founder of the airline JetBlue, who invented the electronic ticket - and freely admits to having the disorder. "Maybe if they gave themselves permission to indulge their imagination, they would come up with a great business idea," Honos-Webb said. "You may actually be squelching some of these gifts by using the medications." Wasserstein, the Mount Sinai professor, said some adult patients stop taking their medication when they want to let creative thoughts flow. "But even those people will go back on the medication to execute," she said. Without medicine, "you have a billion great ideas, but you can't write the paper," she said.