Could it be an attention disorder?

The mention of attention deficit hyperactivity disorder (ADHD) usually brings to mind young boys who can't sit still in class. That's because most cases of ADHD are diagnosed in childhood, and in boys more often than in girls. But half of children with ADHD become adults with ADHD--and many cases aren't even identified until adulthood, when more women than men are diagnosed for the first time.

What is ADHD?
ADHD is a neurobiological disorder characterized by inattentiveness, hyperactivity, and impulsiveness. Its cause isn't entirely clear, but it may be partly genetic. It has a strong hereditary component--one out of four siblings of a person with ADHD also has ADHD--and there's preliminary evidence that certain genes are involved.

MRI images show that adults with and without ADHD use different parts of their brains to accomplish the same tasks. For example, in adults with ADHD, the frontal lobes are less active in many situations. These brain regions are responsible for what's called executive function--that is, planning, problem solving, organization, and self-regulation.

Adults with ADHD have problems at work, at school, and in social settings (see "What does ADHD look like in adults?" page 3). They may forget details of projects or find it difficult to sit through a long dinner party, for example. They may make impulsive decisions that endanger themselves and others, such as driving drunk. ADHD is also associated with higher stress levels, marital problems, substance abuse, and underemployment.

Identifying ADHD in an adult is complicated because several other disorders have similar symptoms and can either disguise ADHD or cause a person to be misdiagnosed as having ADHD. These include depression and anxiety, schizophrenia, thyroid disease, seizure disorders, sleep problems, allergies, substance abuse, and learning disabilities.

People don't suddenly acquire ADHD as adults. The symptoms are present in childhood, but especially in girls, often go unrecognized.

ADHD in women
According to Cheryl Weinstein, Ph.D., director of the Center for Cognitive Remediation at Boston's Beth Israel Deaconess Medical Center, girls are underdiagnosed because they try harder to compensate for their symptoms, perhaps to avoid being labeled "bad." They may have worked hard to stay organized or relied on a parent to help fit the pieces of their lives together. Girls' ADHD may also escape notice because their primary symptoms--shyness and inattentiveness -- are less disruptive than the hyperactivity more typical of boys.

When women with ADHD become parents themselves, have stressful jobs, or both, they can no longer get by on their marginal coping skills. Their ADHD may also contribute to health problems." Many women with ADHD work longer hours than their peers to get the same amount of work done," says Dr. Weinstein. "They don't exercise or follow their health regimens because they don't feel they have time to fit them in. They have problems with impulse control, so they may eat too much and gain weight, which can lead to conditions like diabetes and sleep apnea."

Because estrogen receptors are found throughout the brain--including areas responsible for skills such as organizing and prioritizing--some experts suspect that the loss of estrogen at menopause exacerbates ADHD. But more research is needed to prove a connection between hormones and ADHD.

Who can help?
A good place to start is your primary care doctor. She or he may refer you to a neurologist, a psychiatrist or psychologist, or a neuropsychologist, who specializes in testing for learning disabilities. You may also find referrals through support groups hosted by organizations that specialize in ADHD (see "Selected resources").

No matter what type of doctor you see, a comprehensive exam should include a complete medical history and questions about your physical, emotional, and mental symptoms. Your clinician will want to interview a significant person in your life, such as your spouse, a parent, or a sibling. The clinician will also be interested in your recollections of childhood attention problems. Clues may come from school report cards or the accounts of family members.

You may be referred for a neuropsychological evaluation, which tests memory, attention, language, visual, and executive functions as well as reading, math, and writing skills. Keep in mind that testing is expensive and may not be covered by insurance.

The only way to know for sure if you have ADHD is to be evaluated by a qualified professional. But if you're concerned and would like to know more about the symptoms, consider taking a self-assessment test. One devised by researchers at the New York University School of Medicine is available online at www.med.nyu.edu/Psych/training/adhd.html or by calling 800-411-4209 toll free.

What helps?
Treatment usually includes medication and some form of supportive therapy. Only one drug, atomoxetine, is FDA-approved for adult ADHD. But many of the same medications that children take also help adults. All of these drugs fall into two classes: stimulants and antidepressants (see the medications chart on page 2).

Behavioral therapy hasn't been as well studied, but most doctors believe it's valuable. "Medications prime your attention, and then you need someone to help you to find your strengths and develop strategies to work around your weaknesses," explains Dr. Weinstein. For example, behavioral therapy can help someone set realistic daily goals and find ways to achieve them.

People with ADHD sometimes feel bad about themselves or are anxious or depressed. Talking with a psychotherapist or behavior therapist can help them cope with upsetting thoughts and learn to accept themselves.

What can I do about ADHD?
Here are some strategies that ADHD patients learn at the Center for Cognitive Remediation:

• Buy a notebook you can fit into your bag or purse. In it, keep a calendar in which you write down all your appointments and everything you need to do. Check the notebook several times a day and always put it in the same place when you go home.

• Write down anything people say that you need to act on or remember. Don't be afraid to ask people to repeat.

• Set aside specific times for tasks such as paying bills, doing laundry, cleaning, exercising, and relaxing.

• Set up a system to keep organized. Before you go to bed, place everything you'll need to take with you the next day--papers, purse, backpack or briefcase, and umbrella--in an assigned area just for you.

• Consider hiring a professional organizer to help with your projects and materials. A doctor who specializes in ADHD may be able to refer you to someone in your area.

Medications to treat ADHD in adults
Stimulants
• methylphenidate (Ritalin, Concerta, others)

• dextroamphetamine (Dexedrine)

• amphetamine with dextroamphetamine (Adderall)

Comments
Can cause decreased appetite, insomnia, headache, and nervousness or agitation. May be addictive.

Antidepressants
• atomoxetine(*) (Strattera)

• desipramine (Norpramin, Pertofrane)

• imipramine (Tofranil)

• bupropion (Wellbutrin)

• venlafaxine (Effexor)

Comments
Antidepressants may be particularly helpful for patients with both ADHD and depression. Side effects vary from drug to drug, but may include sleep problems, drowsiness, dry mouth, dizziness, nausea, and constipation.

(*) Atomoxetine is the only drug specifically approved for adult ADHD and is the usual first line of treatment.

What does ADHD look like in adults?
ADHD is not a matter of being a little disorganized or distracted. Its symptoms are persistent and can ruin personal relationships and careers. Adults with ADHD:

• often act without thinking and talk without listening

• procrastinate, make careless mistakes, and abandon unfinished projects

• are easily bored and disorganized

• are constantly late for appointments and too impatient to sit through meetings or stand in line

• often tune out conversations or interrupt others, blurting out whatever is on their minds

• may be reckless and disasterprone in driving or conducting romances

• often fail to find or keep jobs worthy of their talents

Selected resources
Children and Adults with
Attention-Deficit/Hyperactivity
Disorder (CHADD)
800-233-4050 (toll free)
www.chadd.org

National Center for Gender
Issues and ADHD
202-966-1561
www.ncgiadd.org

Women with Attention Deficit
Disorder, by Sari Solden, M.S.,
MFCC (Underwood Books, 1995).

Driven to Distraction, by Edward
M. Hallowell and John J. Ratey
(Touchstone Books, 1995)

For more resources,
visit our Web site:
www.health.harvard.edu/Women

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