Adult ADHD-- Paul Wender, MD-- 03/10/04

ADHD in Adults Slideshow

By Paul Wender
WebMD Live Events Transcript

If you think ADHD is a childhood condition, you're only half right. More and more adults are finding out ADHD isn't something one outgrows, and many are being diagnosed for the first time in their 30s and 40s. ADHD researcher Paul Wender, MD, joined us for a grown-up look at attention deficit hyperactivity disorder. 

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live, Dr. Wender. In the last few years we have seen a rapidly growing focus on ADHD in adults, but for decades ADHD was thought of as a children's disorder and something we "outgrew." Why did it take so long to realize ADHD doesn't just go away?

Wender: It's a social phenomenon, not a psychiatric one. We published our first paper in the 1970s and published replications in the 1980s, but word did not really get out into the community until the publication of Driven to Distraction . After that, adult ADHD became the disease of the decade.

Member question: How can you tell if you have ADHD as an adult?

Wender: Well, the first issue is whether you had ADHD as a child. No one develops ADHD as an adult without having had the disorder as a child. Most adults were not diagnosed as children, and the best way to find out whether the adult had symptoms of ADHD as a child is by questioning his or her parents, or using rating scales, which retroactively evaluate a child's psychiatric status.

The major symptoms in adults we find are the following:

• Attentional difficulties.
• Hyperactivity in many, but not all patients.
• Unstable mood with people becoming reactive and depressed or, sometimes, excited to life events.
• Disorganization. People have difficulty organizing or completing tasks or planning ahead so their desk or their house or their job may be chaotic.
• Hot temper. Not all ADHD adults have a hot temper. When they do, they are not violent, but flare up and calm down quickly. This may obviously cause difficulties in relationships.
• Reduced stress tolerance, so that under pressure, people describe themselves as hassled, stressed out, or report that they become anxious, confused, depressed and have difficulty solving problems.
• Impulsivity. People often say things or do things without thinking them out first. They often interrupt others in conversation and they may spend money impulsively.

Not all ADHD adults have these symptoms, but all must have attentional difficulties. All of these symptoms occur along a continuum of severity. Normal people without ADHD have them all to some degree. Therefore, the diagnostician must make his conclusion not only on the symptoms, but also on their severity.

Moderator: You mentioned unstable mood. Are adults with ADHD often co-diagnosed with depression? Can they be treated at the same time, both with similar meds and by the same psychologist/psychiatrist?

Wender: Well, since ADHD requires treatment with medication, only physicians can prescribe it. The mood disorder is different from major or clinical depression in that it is reactive and the moods are brief. In addition, the moods are not accompanied by loss of energy or sleep difficulties, which occur in clinical depression.

Individuals with ADHD may also have a major (clinical) depression, as well, and may require medication and treatment for both conditions. The unstable mood seen in ADHD does not respond to antidepressants, although it does respond to stimulants. Similarly, of course, stimulant drugs are not effective treatment for major depression.

Member question: Many symptoms of ADHD and anxiety are similar. I have both and am currently in therapy and medication trials for the latter. Can you discuss the pitfalls of treating anxiety when ADHD is the real culprit or vice versa?

Wender: Usually the doctor should be able to determine whether the patient has ADHD, anxiety, or both. Some patients do have both. The primary long-term treatments for anxiety disorders are the antidepressants, and they will relieve anxiety to a substantial degree in about 70% of patients. They will do nothing for the ADHD that is present.

If, indeed, both are present, the doctor will want to treat one at a time. After the anxiety has been treated the doctor may want to introduce a stimulant drug. He will do so with caution, because sometimes stimulant drugs worsen anxiety, but in most instances the patient can be treated for both conditions with different medications, using stimulants for ADHD and antidepressants for anxiety.

Member question: Are the drugs Concerta and Effexor a good mix for ADD and depression?

Wender: Effexor is an effective antidepressant and is one of the drugs used to treat depression. Stimulant drugs may be used in combination to treat ADHD symptoms, which will not respond to the Effexor. Sometimes the combination raises blood pressure a little bit, so the doctor may want to follow the patient's blood pressure.

Member question: If I suspect that I have ADHD, where is the best place to start to get help?

Wender: The very best place to get help is from a psychiatrist who has experience with treating ADHD in adults. Since the diagnosis is relatively recent, psychiatrists have varying experience in treating it, but more are becoming expert. A physician must treat the patient at first, since clearly the most effective treatment is medication and only physicians may prescribe it.

Member question: I was diagnosed with ADHD in my early 30s. When I look back I realize most of the signs were there as a child, but because I wasn't bouncing off the walls I don't think anyone ever thought of me as ADHD. But I was (and still do) constantly jiggling my feet and legs, tapping my fingers, and singing repetitive nonsense songs or phrases. Are those "quieter" versions of hyperactivity?

Wender: Yes, they are. Many ADHD adults who would have qualified for a diagnosis of ADHD combine type, that is inattention and hyperactivity and impulsivity, become, when adults, jigglers, foot tappers, and knee swingers. They also report they do not like sitting at a desk and try to get up as frequently as possible. While they were ignored in childhood is problematic. Twenty years ago much fewer children were diagnosed with hyperactivity or ADD.

Member question: Dr. Wender, how is ADD affected by a woman's menstrual cycle. I am unbearable during this time. Is there anything I can do to ease the moodiness slightly?

Wender: Nothing is known about how the symptoms of ADHD change during the menstrual cycle. However, it is well recognized that many women without ADHD develop irritability and depression premenstrually and these women frequently respond to treatment with SSRIs.

Member question: How does one tell the difference between bipolar disorder and ADD?

Wender: Bipolar disorder is being diagnosed with increasing frequency, and the largest change is the increased frequency of diagnosis in childhood. The symptoms of bipolar disorder and ADHD are very different. ADHD patients do not have prolonged downs with the full symptoms of clinical depression and they do not have the highs seen in bipolar disorder. The treatments for bipolar disorder, lithium and the anticonvulsants, are ineffectual in treating ADHD.

Member question: As someone recently diagnosed with ADHD I'm both relieved and wary. I hope I can now be a better listener and less forgetful and more likely to actually finish the projects I start, but I don't necessarily want to lose the spontaneity and creativity and other aspects of my personality that I think are positive attributes of my particular brain wiring. Yet it seems to be 'rid' of ADHD, my goal would be to become predictable, even-keeled, and less 'enthusiastic' (as I like to call it). Where does the ADHD end and I begin? Will I not be me anymore if I adhere to a drug and talk therapy treatment?

Wender: If you take medication you will be a changed you. That is just the way a depressive is when she takes antidepressant medication. In general, stimulant medicine does not decrease creativity and spontaneity, it rather decreases going off in different directions. What the patient has to do is weigh the benefits and deficits of the treatment. The treatment is immediately effective, that is the first day you take the medication the symptoms are going to respond, if they are going to do so. As the dose of medication is changed to control symptoms he or she can decide whether medication has eliminated parts of their personality they wish to keep.

Of course, one is not compelled to take stimulant medication every day of one's life. One can discontinue it and determine the costs and benefits of being without it. One possibility is to take it some of the time and not others.

What is very important for the ADHD person to know is that, in general, she is not aware of how her behavior appears to others. The reason she is unaware is that she has had these symptoms her entire life. When she takes or stops taking stimulant medication she should obtain feedback from someone close, such as a partner, to determine their perceptions of the changes with medication. Others may notice desirable changes that are at first not 'observed by the patient.

Member question: Is ADHD something to be cured or managed? 

Wender: Treatment for ADHD controls the symptoms but does not cure the disorder. Treatment of ADHD in this respect is like the treatment of depression. Antidepressants only control symptoms; they do not cure depression. The big difference between the two disorders is ADHD is life-long, while depression frequently diminishes and disappears for long periods of time and treatment can then be discontinued.

Member question: What strategies or suggestions do you have for helping NEWLY diagnosed loved-ones? They are 20- and 21-year-old 'children.' Both were given meds by a medical doctor, one forgets to take meds and the other is hesitant to take full dosage as he doesn't want to run out, and has no health insurance. As they no longer live at home I am not sure what type of support to offer.

Wender: One can offer support to another person only if that other person wants that help. If he or she is willing to accept it, one can then give advice with regard to the condition, or better yet, make sure the person who is being treated is educated about the disorder.

As a psychiatrist I do not just give medication to ADHD adults, I spend a long time explaining to them and their partner what the symptoms of the disorder are, what medication may or may not do, and what further help may be useful after they receive maximum benefit from medication. I want to re-emphasize that educating the patient is an essential component in treating the ADHD adult.

Member question: I've never spoken with a psychiatrist before, how do I go about finding one with experience treating ADHD?

Wender: You can call the state psychiatric association or you can contact the department of psychiatry at a nearby medical school. This is sometimes helpful because they sometimes have doctors who specialize in treating adults with ADHD.

Member question: I have been on Adderall for a year and a half, since being diagnosed with adult ADHD. I was seeing a counselor, but we both agreed I had made great progress and only needed to see him when I felt the need. But I'm wondering if I should stay on the Adderall forever, or like the counselor, will there be a day when I don't need it?

Wender: ADHD, so far as we know, does not diminish substantially with age. That means to control symptoms patients must remain on their medication. The most effective medications are clearly stimulant drugs, and patients must remain on them as long as they want the symptoms controlled.

Member question: I have adult ADHD and my husband and I are trying to get pregnant. Is there anything I can take that will not affect a fetus? I was on Strattera and loved it but there isn't enough info to know if it would be bad. 

Wender: Strattera is very similar to trycyclic antidepressants. There is considerable evidence about their relative safety during pregnancy. I personally do not know of the effects of stimulant drugs on the fetus, but since they affect the developing brain I would be strongly inclined to discontinue stimulant medication during pregnancy.

Member question: If a child has ADHD, is it likely that one of his parents has ADHD? Should parents be screened if a child is diagnosed?

Wender: ADHD is genetic, and in many instances one of the ADHD child's parents will have ADHD. If either one of the parents is having psychological problems it would be a good idea for them to receive an evaluation to determine if they, too, have ADHD. Frequently, parents with ADHD have more difficulty dealing with an ADHD child and it may be of benefit to their child as well as to themselves.

Member question: What about someone with just ADD, without the hyperactivity? Do the stimulant drugs work for them?

Wender: This condition is called ADHD Primarily Inattentive Type.
Stimulant drugs do seem to work for people with primarily attentional problems. These patients have not been studied with multiple symptoms, so we do not know if those with purely inattentive type respond as well to stimulant drugs.

The important thing is that a drug trial does not take much time and is not expensive and the patient with ADHD Primarily Inattentive Type should receive a trial with stimulant medication to see if she will benefit.

Member question: My adopted son has ADHD. Both his parents were drugs addicts. Could this have caused his ADHD? Would his treatment be different?

Wender: Many people who are drug addicts do have ADHD, so it is quite possible that the child inherited ADHD from his parents. If his biological mother was taking drugs during pregnancy that may have affected the child's development and may have contributed to ADHD symptoms. In either case the treatment for the child is the same as for any other child with ADHD.

Member question: Why do people with ADHD have difficulty sustaining friendships?

Wender: ADHD's problems contribute to people's problems in relationships. If they are inattentive they do not listen to what the other person says and the person complains they are not listened to. People with ADHD may interrupt people, which the other person finds upsetting. Also, as I mentioned, many ADHD patients have shifting moods. Lastly, those patients with a hot temper obviously produce friction with others.

Moderator: Do you have any final words for us, Dr. Wender?

Wender: My book is called Attention-Deficit Hyperactivity Disorder in Children and Adults , and it offers explanations about the disorder and discussions about how parents can manage the disorder. In addition it discusses the symptoms of ADHD in adults, how patients may recognize it, and what the best course of treatment is. It is sometimes difficult to find in bookstores, but is available easily online through Amazon and Border's.

Moderator: Thanks to Paul Wender, MD, for sharing his expertise with us today. For more information on attention deficit, pick up Dr. Wender's book, ADHD: Attention-Deficit Hyperactivity Disorder in Children and Adults .

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