Driven To Distraction
Adults are as scatterbrained as kids. And the disorder may be rooted in basic biology
What's "normal"? Like most mental disorders, attention disorder is a "spectrum diagnosis" with widely varying symptoms. This makes it a diagnostic challenge even for the most skilled clinicians. Is this attention problem really disabling or merely within the parameters of "normal"? "Where does the disorder begin?" asks Barkley. "It begins where impairment begins. You may have a high degree of ADD symptoms, but it just means you have a sparkling personality because there is no impairment."
Impairment for children can be poor school performance, poor relationships with peers, and difficulty in sports or clubs. Adults have far more varied and complicated arenas for both achievement and failure. "I treat an executive who is superficially extremely successful," says Lenard Adler, professor of clinical psychiatry at the New York University School of Medicine. "And yet he moves from crisis to crisis at work. His family finds him totally unavailable at home. And he has no social life outside of work. At first blush, one could look at his material success and say, `How can he have impairment?' At the same time, managing his life this way has taken a toll on everything."
Most important, however, is that the impairment is not episodic, not restricted to a single bad work experience or one year of not being able to file taxes on time. The crucial and telling component in diagnosis is a lifetime of difficulties. "The impairment of life activities is pervasive and tied to universal life activities," Barkley explains. "Activities like family functioning, developing peer relationships, occupational functioning, financial management, and having and raising children. That is what distinguishes this disorder from mere problems of living or extreme personalities."
Depending on the level of impairment, however, some of those afflicted can be very skilled at managing their problems. Perhaps the structure of grade school ensured some success, while the greater independence in middle school brought problems to the surface. One provocative study reveals that the higher the intelligence, the later the ADD diagnosis is likely to occur. Intelligent people manage to come up with a huge number of coping strategies.
Further complicating diagnosis is that 3 out of 4 adults with ADD have something else wrong with them. So the clinician must discern the disorder from other problems occurring at the same time. Mood disorders like bipolar disorder, depression, and anxiety are present in from 19 to 37 percent of the cases of adult ADD. Nancy Quinlan, for example, struggled with terrible depression before realizing she had ADD. Alcohol abuse affects 32 to 53 percent of people who have ADD, possibly because the disorder was not diagnosed in childhood and the adult has turned to self-medication. Research has shown that the more concurrent problems that appear in childhood--like dyslexia or learning disabilities--the more likely that ADD will continue into adulthood.
For clinicians, the trick is to tease out the various strands of the disorders and treat each one. Depression and anxiety are disorders that often wax and wane in their severity. ADD symptoms never abate. "A person cannot remember never being like this," says David Goodman, director of the Adult Attention Deficit Disorder Center of Maryland. "A person may be depressed for months, but they still remember what it was like not to be depressed. This makes the diagnosis the critical first step to treatment." But if someone has a host of problems--substance abuse, depression, and possible ADD--what is a clinician to do? Each disorder must be treated singly; beginning with substance abuse, then the mood disorder, then if symptoms persist, ADD.
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