ADHD
Spotlight

It’s rare for a psychiatrist to discuss openly and publicly psychiatric illness in his family.  That’s what makes the recent editorial by Dr. Jan Fawcett so impressive.*

Dr. Fawcett is a distinguished psychiatrist who specializes in depression and is the editor of a journal, Psychiatric Annals.  In the most recent issue,  January 2008,  he writes about the experiences of his son,  Craig,  who had  attention deficit hyperactivity didsorder. 

Craig’s first diagnosis was ADHD,  but after that  came drug and alcohol abuse,  depression and antisocial behavior,  failures at college,  fights, arrests,  and the diagnosis of bipolar disorder.  In the meantime  he continued suffering from ADHD:  accidents,  injuries,  losing important items,  unable  to follow through with tasks.

Somehow, Craig survived  to marry a healthy and supportive young woman. He was  responsible about his bipolar medication.   Then this last July, he was found dead in bed, his death secondary to damaged heart muscle.  “At least Craig isn’t suffering any more,”  was his dad’s first reaction.

Dr. Fawcett writes about watching Craig struggle all his life,  unable to benefit from his high intelligence,  creativity and outgoing manner.  He was always trying to help people  — and then picking the wrong people to help.

He had more to deal with than ADHD.  But it was ADHD that started the negative cascade and that persisted.  It was the  “prison that made it impossible for Craig to benefit from his intelligence,”  writes Dr. Fawcett.

If anyone thinks that  ADHD is not  “serious enough”  to justify every possible treatment effort,  and even some risk,  just ask Dr. Fawcett about his son,  Craig. 

—————————————————————————–*Fawcett D. Devastation and pain. Psychiatric Annals 38 (1):5, 2008

As an adult with ADHD you may have little ones with the same disorder, noted even before they start school. The American Academy of Child and Adolescent Psychiatry (AACAP) has just issued guidelines for treating the very little children.*

First is a careful evaluation, to be sure the symptoms are those of ADHD and not of another disorder, such as anxiety or a response to issues in the larger family, or a general medical problem. If the diagnosis is still ADHD, then the AACAP recommends behavioral and other psychological treatments before trying medication.

The next step would be a trial with methyphphenidate, Ritalin, given three times a day. The total dose would range from 7.5 to 30 mg a day,  but, as always, measuring benefits versus side effects.  Even if Ritalin helps, though, the report recommends stopping it after 6  months and reassessing the situation.

If Ritalin is unsuccessful the doctor may try one of the amphetamines — though there is less data with these meds in young children.

The next med to try would be atomoxetine (Strattera) but there is, again, little data.

Little data, little data…. the persistent problem. But these guidelines are at least a start.

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*Gleason MM, et al: Algorithm for treating ADHD in very young children. Am Acad Child Adolesc Psychiatry  46: 1532-1572,  2007

An article in yesterday’s Sunday Times  (December 9,2007) caught my eye:  “Your Child’s Disorder  May be Yours, Too,”  by Benedict Carey.  The journalist was making the point that a number of psychiatric disorders that are being diagnosed in children make their parents reflect on their life experience. Do they have the problem, too?

One of the disorders Mr. Carey writes about, entirely correctly, is attention deficit hyperactivity disorder— or, as it is always referred to in the popular press, “ADD.”  He quotes Dr. Gregory Fritz, at Bradley Hospital in Rhode  Island, saying:  ”Sometimes it is a real surprise, because the child is the first one in the family to ever get a thorough evaluation and history.  The parents are there and they begin to get the pattern.”

The article quotes an adult woman who, once her child’s ADHD was recognized, went back over her own life and found difficulties extending back to childhood. She is now getting treatment, including medication, and is doing much better.  Her story  is typical, because ADHD is highly hereditary. Once you find it in one family member it is highly likely to be in one or more other relatives.

The parent who knows he or she has the problem too may struggle with the new and unwelcome burden of the stigma that can come with having ADD. Once it’s out in the open, though,  knowledge of a parent’s difficulties may actually ease family tensions.  The youngster with the disorder can feel less guilty about being the only one with the problem.  The family may have common ground that means they can function better as a unit.  They see family patterns and issues through a whole new lens– and that may help.

A reader wrote in to ask if girls may be overlooked as having ADHD because they are not hyperactive, just daydreamers.  Absolutely!  This is a sizable problem because inattentive girls are rarely hyperactive, like boys with ADHD. Now, the occasional girl is hyperactive, too. However, most are just inattentive, unfocused—but not troublesome in the classroom. It is perfectly possible to have ADHD  “without the H”, for hyperactivity. 

Increasingly clinicians and teachers are aware of the differences in the way ADHD presents in many boys and girls. In general more girls are being diagnosed than in former times.  The absolute number of boys with ADHD does seem to be higher than in girls.  The numbers approach equality for men and for women.

It can be a shock for women, as adults, to be diagnosed as  having ADHD and then see their entire past life through a new lens. I always hope that it gives them hope, a basis for understanding their problems better.  Knowing about the disorder can lead to treatment and  to a better life.

A reader asked me for further tips about this combination of problems. 

The bipolar disorder has to be dealt with first.  You need to find a psychiatrist, preferably one who specializes in mood disorders. You are likely to need medicine. The most popular ones today are “mood stabilizers.”  There are several of these and the doctor will discuss the plusses and minuses.   Of course I can’t prescribe for you, just give you ideas of what to expect. None of the medicines work instantly; they can take weeks.  Often treatment will involve taking a combination of medications.

Once your mood is stabler, then attention can turn to your ADHD. Most clinicians want you to be doing stably well for several months before trying the ADHD meds.  The stimulants especially can disturb your mood, so caution is indicated.

There are organizations that help people with Bipolar Disorder, especially the National DMDA and DRADA, which are both on the web. Books by Raymond DePaulo, Kay Redfield Jamison, and Fred Goodwin are also helpful.  Good luck with it.  The good news is that bipolar disorder is often found in highly intelligent and creative persons who, with good treatment, can lead very productive lives.

It’s no surprise theat in families where children have ADHD that there are greater problems functioning smoothly as a system. Parents struggle more with these youngsters— and when one or both parents have the disorder the  confusion and impact is even greater.  Formal studies of such families document the greater problems that parents have being good parents when one or more children have ADHD.  Such parents struggle not to be more controlling and more negative when their children are untreated for the disorder.

In one recent such study, researchers were heartened by the results of treating ADHD children with medication. They  found, over the course of three months, when the child with ADHD did have such treatment, that family function improved significantly. Not only was the family function level higher but parents were less depressed.  In addition to being less depressed mothers were less anxious.  The total family improved in terms of being more empathic and functioning responsibly.*

These changes seem to make common sense. However, there is always skepticism about the effectiveness of treatment for psychiatric disorders, particularly about the results of using medicines for ADHD.  Does this study show  a transformation in family life after ADHD children take medicine? No.  An improvement? Yes. 

Now it would be interesting to see a similar study of families where the parent is the one with the ADHD. I’ll report that one if I find it!

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*Gustaffson P, et al: Improvement in family function with treatment of childhood ADHD.  J Attention Disorders, October, 2007.

Friends are a great resource in life. They’re almost like family members who we make family members by choice and natural affinity, not simply blood ties. Adults with ADHD need and enjoy friends, as do any of us. However, their ADHD may  make it harder to make and to keep friends.

Sustaining conversation with others may be tough for the person with ADHD. If you are distracted easily it’s hard to be a good listener.  ADHD adults may tend to interrupt the conversation or blurt out something that is on their mind.  What they are thinking, though  may or may not be where the group talk is going.  If their social radar is poor, which means that they are bad at picking up nonverbal signals from other persons, the ADHD adult may miss feedback which would help them modify their behavior.  Maintaining friendships means planning, remembering, contacting, and regularly staying in touch with friends.  Many adults with ADHD don’t realize this.

Knowing more about what is expected, staying consciously aware of such issues, can help the ADHD adult form and maintain friendships. In some areas there are group therapies which are natural learning settings for such patients to understand their interpersonal issues better and find new ways of relating.

Of course, there are plusses to ADHD as well as minuses. Many ADHD adults have a pleasing spontaneity and liveliness and sense of humor which other persons find appealing.   They can be quick-witted and creative.  In friendships as in other aspects of life, success depends on knowing and building on your strengths.

Many adults with ADHD find medication makes a big difference  for the better in their life.  Even if it helps them focus and concentrate, however,  as one patient told me,  “I still have to tell my brain what to do!”  That often means supplementing medication with other supports and systems.

Some of my patients are  already in networks at work and at home which provide them with structure and supportive elements.  These free them up to do what they do best.  “Other people”  take up the slack. 

Many other patients don’t have the luxury of supportive or people-rich environments. They need to do more of this themselves. They structure their life with Day-Timer schedule books, or use PDAs such as PalmPilots or Blackberries to keep track of their schedule. Computers can be programmed to remind people of appointments.  As humble a help as wearing a wristwatch can make a big difference in keeping to a schedule!

A book I often recommend is called ADD-Friendly Ways to Organize Your Life, by Nadeau and Kilborg.  More than one patient has told me the book saved their career. 

So keep on looking for effective ways that “tell your brain what to do!”

The current estimate is that 4.4% of the adult population of the United States have attention deficit hyperactivity disorder.  There have not been that many studies of adults with ADHD; children with the disorder have been more carefully and fully investigated. However, more than one study of adults has now confirmed that percentage, called the prevalence of a disorder.

4.4% is not a large percentage–but it is a large number of people.  The most recent careful studies suggest, in addition, that a relatively small proportion of adults with ADHD have been diagnosed or treated for the disorder.  In fact, the estimates are that 75% of adults with ADHD have not been diagnosed.  Even more, an estimated 89%, have still not been treated.*

Remember too that ADHD in adults rarely presents by itself. There are usually coexisting symptoms of anxiety or mood disorders or substance abuse.  So we have  a long way to go before we successfully address the burden of unnecessary suffering in this group of people.  Bringing attention to their plight is a main aim of this blog.  Treatment exists for improving all of these conditions.

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*Adler L, Morrill M, Maya E et al: Issues in the treatment and diagnosis of adult ADHD iby primary carer physicians. Presented at the International Congress of the Collegium Internationale NeuroPsychopharmacologicum, July 9-13,2006, Chicago, Ill.