Letters from Maine

The 'ADHD Adult' Dilemma



Back in the Dark Ages, before Al Gore invented the Internet, there were hyperactive children. The most troublesome were sedated with tranquilizers, but eventually a counterintuitive discovery resulted in a more humane and successful management with amphetamines.

“Hyperactivity” morphed into a family of “attention-deficit hyperactivity disorders” when it became apparent that there were children whose minds jumped from distraction to distraction while their bodies remained relatively stationary.

In the 1980s most of us told parents that their children's attention-deficit hyperactivity disorder symptoms would abate during puberty so that medication could be discontinued. Of course, this prediction proved to be wrong in many cases.

In fact, some physicians and mental health workers began labeling previously undiagnosed adults as having ADHD and treating them with stimulants.

Should we pediatricians interpret this growing population of amphetamine-popping “ADHD adults” as an embarrassing diagnostic oversight and gear ourselves for a massive class-action suit by an entire generation of distracted and impulsive 30- or 40-somethings?

Do “ADHD adults” exist, and are we to blame?

Let me tell you what I think. It is pretty obvious to almost everyone who has watched a child mature that the attention span of a 15-year-old is significantly longer than that of a 15-month-old.

This is true even for those children whose nervous systems' chemical and structural arrangement makes it more difficult to pay attention.

And, it shouldn't surprise us that someone who was diagnosed as having ADHD as a child might remain on the distractible side of the bell-shaped curve of adults.

But, if our management of ADHD has been more comprehensive than simply writing Ritalin prescriptions, most of our patients should not require medication by the time they leave our practices.

It is unreasonable to ask educators and parents to adapt every child's environment to match his/her individual personality and learning style.

In the case of ADHD, stimulant medication can ease that round peg-square hole fit while we adults are helping the children find topics, activities, environments, and vocations that will keep their interest long enough to allow them to experience success. We can hope that medication will buy us some time while we wait for the natural process of maturity to come to our rescue. But, hoping isn't enough.

The educational process should include thoughtful and creative planning of curricula and learning spaces. Vocational experiences such as job shadowing and social skills coaching should be considered. Of course, these observations apply to any child whose learning style and capabilities are out of the mainstream. And certainly it doesn't happen enough.

Now, what about the 40-year-old college graduate who shows up in the internist's office complaining that he is having trouble concentrating, that he needs three cups of coffee just to get through the first hour at work, and that he never feels fulfilled in anything he does because he is always jumping from one thing to another? He's already taken a 10-question test that he found in a magazine and discovered that he has all the symptoms of adult ADHD.

Well, he got through college with prescription stimulants, so I think you and I can figure we are off the hook for a missed diagnosis. We can only hope that his internist understands that distractibility and impulsiveness can be symptoms of sleep deprivation and depression as well as the result of family and social turmoil.

It may be that this unfortunate guy has simply found himself with the wrong job and/or the wrong spouse. It's very possible that some stimulants stronger than his three morning cups of coffee will make him feel better for a while, but I suspect in the long run things won't improve without a broader approach.

We pediatricians know that just because Ritalin seems to improve some of the symptoms, it doesn't mean that our young patient has ADHD. In my opinion, if you need Ritalin to do your job, you need a new job.

There may be a few adult patients with “true” ADHD today who have escaped detection, but I can't imagine that anyone in the next generation will reach the age of 30 without a day care provider, teacher, or well-meaning aunt suggesting, “You should ask the doctor if he has ADHD.”

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