Life in Overdrive
By CLAUDIA WALLIS |
Dusty Nash, an angelic-looking blond child of seven, awoke at 5 one recent morning in his Chicago home and proceeded to throw a fit. He wailed. He kicked. Every muscle in his 50-lb. body flew in furious motion. Finally, after about 30 minutes, Dusty pulled himself together sufficiently to head downstairs for breakfast. While his mother bustled about the kitchen, the hyperkinetic child pulled a box of Kix cereal from the cupboard and sat on a chair.
But sitting still was not in the cards this morning. After grabbing some cereal with his hands, he began kicking the box, scattering little round corn puffs across the room. Next he turned his attention to the TV set, or rather, the table supporting it. The table was covered with a checkerboard Con-Tact paper, and Dusty began peeling it off. Then he became intrigued with the spilled cereal and started stomping it to bits. At this point his mother interceded. In a firm but calm voice she told her son to get the stand-up dust pan and broom and clean up the mess. Dusty got out the dust pan but forgot the rest of the order. Within seconds he was dismantling the plastic dust pan, piece by piece. His next project: grabbing three rolls of toilet paper from the bathroom and unraveling them around the house.
It was only 7:30, and his mother Kyle Nash, who teaches a medical-school course on death and dying, was already feeling half dead from exhaustion. Dusty was to see his doctors that day at 4, and they had asked her not to give the boy the drug he usually takes to control his hyperactivity and attention problems, a condition known as attention deficit hyperactivity disorder (ADHD). It was going to be a very long day without help from Ritalin.
Karenne Bloomgarden remembers such days all too well. The peppy, 43-year-old entrepreneur and gym teacher was a disaster as a child growing up in New Jersey. "I did very poorly in school," she recalls. Her teachers and parents were constantly on her case for rowdy behavior. "They just felt I was being bad -- too loud, too physical, too everything." A rebellious tomboy with few friends, she saw a psychologist at age 10, "but nobody came up with a diagnosis." As a teenager she began prescribing her own medication: marijuana, Valium and, later, cocaine. ,
The athletic Bloomgarden managed to get into college, but she admits that she cheated her way to a diploma. "I would study and study, and I wouldn't remember a thing. I really felt it was my fault." After graduating, she did fine in physically active jobs but was flustered with administrative work. Then, four years ago, a doctor put a label on her troubles: ADHD. "It's been such a weight off my shoulders," says Bloomgarden, who takes both the stimulant Ritalin and the antidepressant Zoloft to improve her concentration. "I had 38 years of thinking I was a bad person. Now I'm rewriting the tapes of who I thought I was to who I really am."
Fifteen years ago, no one had ever heard of attention deficit hyperactivity disorder. Today it is the most common behavioral disorder in American children, the subject of thousands of studies and symposiums and no small degree of controversy. Experts on ADHD say it afflicts as many as 3 1/2 million American youngsters, or up to 5% of those under 18. It is two to three times as likely to be diagnosed in boys as in girls. The disorder has replaced what used to be popularly called "hyperactivity," and it includes a broader collection of symptoms. ADHD has three main hallmarks: extreme distractibility, an almost reckless impulsiveness and, in some but not all cases, a knee-jiggling, toe-tapping hyperactivity that makes sitting still all but impossible. (Without hyperactivity, the disorder is called attention deficit disorder, or ADD.)
For children with ADHD, a ticking clock or sounds and sights caught through a window can drown out a teacher's voice, although an intriguing project can absorb them for hours. Such children act before thinking; they blurt out answers in class. They enrage peers with an inability to wait their turn or play by the rules. These are the kids no one wants at a birthday party.
Ten years ago, doctors believed that the symptoms of ADHD faded with maturity. Now it is one of the fastest-growing diagnostic categories for adults. One-third to two-thirds of ADHD kids continue to have symptoms as adults, says psychiatrist Paul Wender, director of the adult ADHD clinic at the University of Utah School of Medicine. Many adults respond to the diagnosis with relief -- a sense that "at last my problem has a name and it's not my fault." As more people are diagnosed, the use of Ritalin (or its generic equivalent, methylphenidate), the drug of choice for ADHD, has surged: prescriptions are up more than 390% in just four years.
As the numbers have grown, ADHD awareness has become an industry, a passion, an almost messianic movement. An advocacy and support group called CHADD (Children and Adults with Attention Deficit Disorders) has exploded from its founding in 1987 to 28,000 members in 48 states. Information bulletin boards and support groups for adults have sprung up on CompuServe, Prodigy and America Online. Numerous popular books have been published on the subject. There are summer camps designed to help ADHD kids, videos and children's books with titles like Jumpin' Johnny Get Back to Work! and, of course, therapists, tutors and workshops offering their services to the increasingly self-aware ADHD community.
It is a community that views itself with some pride. Popular books and lectures about ADHD often point out positive aspects of the condition. Adults see themselves as creative; their impulsiveness can be viewed as spontaneity; hyperactivity gives them enormous energy and drive; even their distractibility has the virtue of making them alert to changes in the environment. "Kids with ADHD are wild, funny, effervescent. They have a love of life. The rest of us sometimes envy them," says psychologist Russell Barkley of the University of Massachusetts Medical Center. "ADHD adults," he notes, "can be incredibly successful. Sometimes being impulsive means being decisive." Many ADHD adults gravitate into creative fields or work that provides an outlet for emotions, says Barkley. "In our clinic we saw an adult poet who couldn't write poetry when she was on Ritalin. ADHD people make good salespeople. They're lousy at desk jobs."
In an attempt to promote the positive side of ADHD, some CHADD chapters circulate lists of illustrious figures who, they contend, probably suffered from the disorder: the messy and disorganized Ben Franklin, the wildly impulsive and distractible Winston Churchill. For reasons that are less clear, these lists also include folks like Socrates, Isaac Newton, Leonardo da Vinci -- almost any genius of note. (At least two doctors interviewed for this story suggested that the sometimes scattered Bill Clinton belongs on the list.)
However creative they may be, people with ADHD don't function particularly well in standard schools and typical office jobs. Increasingly, parents and lobby groups are demanding that accommodations be made. About half the kids diagnosed with ADHD receive help from special-education teachers in their schools, in some cases because they also have other learning disabilities. Where schools have failed to provide services, parents have sometimes sued. In one notable case that went to the U.S. Supreme Court last year, parents argued -- successfully -- that since the public school denied their child special education, the district must pay for her to attend private school. Another accommodation requested with increasing frequency: permission to take college- entrance exams without a time limit. Part of what motivates parents to fight for special services is frightening research showing that without proper care, kids with ADHD have an extremely high risk not only of failing at school but also of becoming drug abusers, alcoholics and lawbreakers.
Adults with ADHD are beginning to seek special treatment. Under the 1990 Americans with Disabilities Act, they can insist upon help in the workplace. Usually the interventions are quite modest: an office door or white-noise machine to reduce distractions, or longer deadlines on assignments. Another legal trend that concerns even ADHD advocates: the disorder is being raised as a defense in criminal cases. Psychologist Barkley says he knows of 55 such instances in the U.S., all in the past 10 years. ADHD was cited as a mitigating factor by the attorney for Michael Fay, the 19-year-old American who was charged with vandalism and caned in Singapore.
Many of those who treat ADHD see the recognition of the problem as a humane breakthrough: finally we will stop blaming kids for behavior they cannot control. But some are worried that the disorder is being embraced with too much gusto. "A lot of people are jumping on the bandwagon," complains psychologist Mark Stein, director of a special ADHD clinic at the University of Chicago. "Parents are putting pressure on health professionals to make the diagnosis." The allure of ADHD is that it is "a label of forgiveness," says Robert Reid, an assistant professor in the department of special education at the University of Nebraska in Lincoln. "The kid's problems are not his parents' fault, not the teacher's fault, not the kid's fault. It's better to say this kid has ADHD than to say this kid drives everybody up the wall." For adults, the diagnosis may provide an excuse for personal or professional failures, observes Richard Bromfield, a psychologist at Harvard Medical School. "Some people like to say, 'The biological devil made me do it.' "
A DISORDER WITH A PAST
Other than the name itself, there is nothing new about this suddenly ubiquitous disorder. The world has always had its share of obstreperous kids, and it has generally treated them as behavior problems rather than patients. Most of the world still does so: European nations like France and England report one-tenth the U.S. rate of ADHD. In Japan the disorder has barely been studied.
The medical record on ADHD is said to have begun in 1902, when British pediatrician George Still published an account of 20 children in his practice who were "passionate," defiant, spiteful and lacking "inhibitory volition." Still made the then radical suggestion that bad parenting was not to blame; instead he suspected a subtle brain injury. This theory gained greater credence in the years following the 1917-18 epidemic of viral encephalitis, when doctors observed that the infection left some children with impaired attention, memory and control over their impulses. In the 1940s and '50s, the same constellation of symptoms was called minimal brain damage and, later, minimal brain dysfunction. In 1937 a Rhode Island pediatrician reported that giving stimulants called amphetamines to children with these symptoms had the unexpected effect of calming them down. By the mid-1970s, Ritalin had become the most prescribed drug for what was eventually termed, in 1987, attention deficit hyperactivity disorder.
Nobody fully understands how Ritalin and other stimulants work, nor do doctors have a very precise picture of the physiology of ADHD. Researchers generally suspect a defect in the frontal lobes of the brain, which regulate behavior. This region is rich in the neurotransmitters dopamine and norepinephrine, which are influenced by drugs like Ritalin. But the lack of a more specific explanation has led some psychologists to question whether ADHD is truly a disorder at all or merely a set of characteristics that tend to cluster together. Just because something responds to a drug doesn't mean it is a sickness.
ADHD researchers counter the skeptics by pointing to a growing body of biological clues. For instance, several studies have found that people with ADHD have decreased blood flow and lower levels of electrical activity in the frontal lobes than normal adults and children. In 1990 Dr. Alan Zametkin at the National Institute of Mental Health found that in PET scans, adults with ADD showed slightly lower rates of metabolism in areas of the brain's cortex known to be involved in the control of attention, impulses and motor activity.
Zametkin's study was hailed as the long-awaited proof of the biological basis of ADD, though Zametkin himself is quite cautious. A newer study used another tool -- magnetic resonance imaging -- to compare the brains of 18 ADHD boys with those of other children and found several "very subtle" but "striking" anatomical differences, says co-author Judith Rapoport, chief of the child psychiatry branch at NIMH. Says Zametkin: "I'm absolutely convinced that this disorder has a biological basis, but just what it is we cannot yet say."
What researchers do say with great certainty is that the condition is inherited. External factors such as birth injuries and maternal alcohol or tobacco consumption may play a role in less than 10% of cases. Suspicions that a diet high in sugar might cause hyperactivity have been discounted. But the influence of genes is unmistakable. Barkley estimates that 40% of adhd kids have a parent who has the trait and 35% have a sibling with the problem; if the sibling is an identical twin, the chances rise to between 80% and 92%.
Interest in the genetics of ADHD is enormous. In Australia a vast trial involving 3,400 pairs of twins between the ages of 4 and 12 is examining the incidence of ADHD and other behavioral difficulties. At NIMH, Zametkin's group is recruiting 200 families who have at least two members with ADHD. The hope: to identify genes for the disorder. It is worth noting, though, that even if such genes are found, this may not settle the debate about ADHD. After all, it is just as likely that researchers will someday discover a gene for a hot temper, which also runs in families. But that doesn't mean that having a short fuse is a disease requiring medical intervention.
TRICKY DIAGNOSIS
In the absence of any biological test, diagnosing ADHD is a rather inexact proposition. In most cases, it is a teacher who initiates the process by informing parents that their child is daydreaming in class, failing to complete assignments or driving everyone crazy with thoughtless behavior. "The problem is that the parent then goes to the family doctor, who writes a prescription for Ritalin and doesn't stop to think of the other possibilities," says child psychiatrist Larry Silver of Georgetown University Medical Center. To make a careful diagnosis, Silver argues, one must eliminate other explanations for the symptoms.
The most common cause, he points out, is anxiety. A child who is worried about a problem at home or some other matter "can look hyperactive and distractible." Depression can also cause ADHD-like behavior. "A third cause is another form of neurological dysfunction, like a learning disorder," says Silver. "The child starts doodling because he didn't understand the teacher's instructions." All this is made more complicated by the fact that some kids -- and adults -- with ADHD also suffer from depression and other problems. To distinguish these symptoms from ADHD, doctors usually rely on interviews with parents and teachers, behavior-ratings scales and psychological tests, which can cost from $500 to $3,000, depending on the thoroughness of the testing. Insurance coverage is spotty.
Among the most important clues doctors look for is whether the child's problems can be linked to some specific experience or time or whether they have been present almost from birth. "You don't suddenly get ADD," says Wade Horn, a child psychologist and former executive director of CHADD. Taking a careful history is therefore vital.
For kids who are hyperactive, the pattern is unmistakable, says Dr. Bruce Roseman, a pediatric neurologist with several offices in the New York City area, who has ADHD himself. "You say to the mother, 'What kind of personality did the child have as a baby? Was he active, alert? Was he colicky?' She'll say, 'He wouldn't stop -- waaah, waaah, waaah!' You ask, 'When did he start to walk?' One mother said to me, 'Walk? My son didn't walk. He got his pilot's license at one year of age. His feet haven't touched the ground since.' You ask, 'Mrs. Smith, how about the terrible twos?' She'll start to cry, 'You mean the terrible twos, threes, fours, the awful fives, the horrendous sixes, the God-awful eights, the divorced nines, the I-want-to-die tens!' "
Diagnosing those with ADD without hyperactivity can be trickier. Such kids are often described as daydreamers, space cases. They are not disruptive or antsy. But, says Roseman, "they sit in front of a book and for 45 minutes, nothing happens." Many girls with ADD fit this model; they are often misunderstood or overlooked.
Christy Rade, who will be entering the ninth grade in West Des Moines, Iowa, is fairly typical. Before she was diagnosed with ADD in the third grade, Christy's teacher described her to her parents as a "dizzy blond and a space cadet." "Teachers used to get fed up with me," recalls Christy, who now takes Ritalin and gets some extra support from her teachers. "Everyone thought I was purposely not paying attention." According to her mother Julie Doy, people at Christy's school were familiar with hyperactivity but not ADD. "She didn't have behavior problems. She was the kind of kid who could fall through the cracks, and did."
Most experts say ADHD is a lifelong condition but by late adolescence many people can compensate for their impulsiveness and disorganization. They may channel hyperactivity into sports. In other cases, the symptoms still wreak havoc, says UCLA psychiatrist Walid Shekim. "Patients cannot settle on a career. They cannot keep a job. They procrastinate a lot. They are the kind of people who would tell their boss to take this job and shove it before they've found another job."
Doctors diagnose adults with methods similar to those used with children. Patients are sometimes asked to dig up old report cards for clues to their childhood behavior -- an essential indicator. Many adults seek help only after one of their children is diagnosed. Such was the case with Chuck Pearson of Birmingham, Michigan, who was diagnosed three years ago, at 54. Pearson had struggled for decades in what might be the worst possible career for someone with ADD: accounting. In the first 12 years of his marriage, he was fired from 15 jobs. "I was frightened," says Zoe, his wife of 35 years. "We had two small children, a mortgage. Bill collectors were calling perpetually. We almost lost the house." Chuck admits he had trouble focusing on details, completing tasks and judging how long an assignment would take. He was so distracted behind the wheel that he lost his license for a year after getting 14 traffic tickets. Unwittingly, Pearson began medicating himself: "In my mid-30s, I would drink 30 to 40 cups of coffee a day. The caffeine helped." After he was diagnosed, the Pearsons founded the Adult Attention Deficit Foundation, a clearinghouse for information about add; he hopes to spare others some of his own regret: "I had a deep and abiding sadness over the life I could have given my family if I had been treated effectively."
PERSONALITY OR PATHOLOGY? While Chuck Pearson's problems were extreme, many if not all adults have trouble at times sticking with boring tasks, setting priorities and keeping their minds on what they are doing. The furious pace of society, the strain on families, the lack of community support can make anyone feel beset by ADD. "I personally think we are living in a society that is so out of control that we say, 'Give me a stimulant so I can cope.' " says Charlotte Tomaino, a clinical neuropsychologist in White Plains, New York. As word of ADHD spreads, swarms of adults are seeking the diagnosis as an explanation for their troubles. "So many really have symptoms that began in adulthood and reflected depression or other problems," says psychiatrist Silver. In their best-selling new book, Driven to Distraction, Edward Hallowell and John Ratey suggest that American life is "ADD-ogenic": "American society tends to create ADD-like symptoms in us all. The fast pace. The sound bite. The quick cuts. The TV remote-control clicker. It is important to keep this in mind, or you may start thinking that everybody you know has ADD."
And that is the conundrum. How do you draw the line between a spontaneous, high-energy person who is feeling overwhelmed by the details of life and someone afflicted with a neurological disorder? Where is the boundary between personality and pathology? Even an expert in the field like the University of Chicago's Mark Stein admits, "We need to find more precise ways of diagnosing it than just saying you have these symptoms." Barkley also concedes the vagueness. The traits that constitute ADHD "are personality characteristics," he agrees. But it becomes pathology, he says, when the traits are so extreme that they interfere with people's lives.
THE RISKS
There is no question that ADHD can disrupt lives. Kids with the disorder frequently have few friends. Their parents may be ostracized by neighbors and relatives, who blame them for failing to control the child. "I've got criticism of my parenting skills from strangers," says the mother of a hyperactive boy in New Jersey. "When you're out in public, you're always on guard. Whenever I'd hear a child cry, I'd turn to see if it was because of Jeremy."
School can be a shattering experience for such kids. Frequently reprimanded and tuned out, they lose any sense of self-worth and fall ever further behind in their work. More than a quarter are held back a grade; about a third fail to graduate from high school. ADHD kids are also prone to accidents, says neurologist Roseman. "These are the kids I'm going to see in the emergency room this summer. They rode their bicycle right into the street and didn't look. They jumped off the deck and forgot it was high."
But the psychological injuries are often greater. By ages five to seven, says Barkley, half to two-thirds are hostile and defiant. By ages 10 to 12, they run the risk of developing what psychologists call "conduct disorder" -- lying, stealing, running away from home and ultimately getting into trouble with the law. As adults, says Barkley, 25% to 30% will experience substance- abuse problems, mostly with depressants like marijuana and alcohol. One study of hyperactive boys found that 40% had been arrested at least once by age 18 -- and these were kids who had been treated with stimulant medication; among those who had been treated with the drug plus other measures, the rate was 20% -- still very high.
It is an article of faith among ADHD researchers that the right interventions can prevent such dreadful outcomes. "If you can have an impact with these kids, you can change whether they go to jail or to Harvard Law School," says psychologist James Swanson at the University of California at Irvine, who co-authored the study of arrest histories. And yet, despite decades of research, no one is certain exactly what the optimal intervention should be.
TREATMENT
The best-known therapy for ADHD remains stimulant drugs. Though Ritalin is the most popular choice, some patients do better with Dexedrine or Cylert or even certain antidepressants. About 70% of kids respond to stimulants. In the correct dosage, these uppers surprisingly "make people slow down," says Swanson. "They make you focus your attention and apply more effort to whatever you're supposed to do." Ritalin kicks in within 30 minutes to an hour after being taken, but its effects last only about three hours. Most kids take a dose at breakfast and another at lunchtime to get them through a school day.
When drug therapy works, says Utah's Wender, "it is one of the most dramatic effects in psychiatry." Roseman tells how one first-grader came into his office after trying Ritalin and announced, "I know how it works." "You do?" asked the doctor. "Yes," the child replied. "It cleaned out my ears. Now I can hear the teacher." A third-grader told Roseman that Ritalin had enabled him to play basketball. "Now when I get the ball, I turn around, I go down to the end of the room, and if I look up, there's a net there. I never used to see the net, because there was too much screaming."
For adults, the results can be just as striking. "Helen," a 43-year-old | mother of three in northern Virginia, began taking the drug after being diagnosed with ADD in 1983. "The very first day, I noticed a difference," she marvels. For the first time ever, "I was able to sit down and listen to what my husband had done at work. Shortly after, I was able to sit in bed and read while my husband watched TV."
Given such outcomes, doctors can be tempted to throw a little Ritalin at any problem. Some even use it as a diagnostic tool, believing -- wrongly -- that if the child's concentration improves with Ritalin, then he or she must have add. In fact, you don't have to have an attention problem to get a boost from Ritalin. By the late 1980s, over-prescription became a big issue, raised in large measure by the Church of Scientology, which opposes psychiatry in general and launched a vigorous campaign against Ritalin. After a brief decline fostered by the scare, the drug is now hot once again. Swanson has heard of some classrooms where 20% to 30% of the boys are on Ritalin. "That's just ridiculous!"' he says.
Ritalin use varies from state to state, town to town, depending largely on the attitude of the doctors and local schools. Idaho is the No. 1 consumer of the drug. A study of Ritalin consumption in Michigan, which ranks just behind Idaho, found that use ranged from less than 1% of boys in one county to as high as 10% in another, with no correlation to affluence.
Patients who are taking Ritalin must be closely monitored, since the drug can cause loss of appetite, insomnia and occasionally tics. Doctors often recommend "drug holidays" during school vacations. Medication is frequently combined with other treatments, including psychotherapy, special education and cognitive training, although the benefits of such expensive measures are unclear. "We really haven't known which treatment to use for which child and how to combine treatments," says Dr. Peter Jensen, chief of nimh's Child and Adolescent Disorders Research Branch. His group has embarked on a study involving 600 children in six cities. By 1998 they hope to have learned how medication alone compares to medication with psychological intervention and other approaches.
BEYOND DRUGS
A rough consensus has emerged among ADHD specialists that whether or not drugs are used, it is best to teach kids -- often through behavior modification -- how to gain more control over their impulses and restless energy. Also recommended is training in the fine art of being organized: establishing a predictable schedule of activities, learning to use a date book, assigning a location for possessions at school and at home. This takes considerable effort on the part of teachers and parents as well as the kids themselves. Praise, most agree, is vitally important.
Within the classroom "some simple, practical things work well," says Reid. Let hyperactive kids move around. Give them stand-up desks, for instance. "I've seen kids who from the chest up were very diligently working on a math problem, but from the chest down, they're dancing like Fred Astaire." To minimize distractions, ADHD kids should sit very close to the teacher and be permitted to take important tests in a quiet area. "Unfortunately," Reid observes, "not many teachers are trained in behavior management. It is a historic shortfall in American education."
In Irvine, California, James Swanson has tried to create the ideal setting for teaching kids with ADHD. The Child Development Center, an elementary school that serves 45 kids with the disorder, is a kind of experiment in progress. The emphasis is on behavior modification: throughout the day students earn points -- and are relentlessly cheered on -- for good behavior. High scorers are rewarded with special privileges at the end of the day, but each morning kids start afresh with another shot at the rewards. Special classes also drill in social skills: sharing, being a good sport, ignoring annoyances rather than striking out in anger. Only 35% of the kids at the center are on stimulant drugs, less than half the national rate for ADHD kids.
Elsewhere around the country, enterprising parents have struggled to find their own answers to attention deficit. Bonnie and Neil Fell of Skokie, Illinois, have three sons, all of whom have been diagnosed with ADD. They have "required more structure and consistency than other kids," says Bonnie. "We had to break down activities into clear time slots." To help their sons, who take Ritalin, the Fells have employed tutors, psychotherapists and a speech and language specialist. None of this comes cheap: they estimate their current annual ADD-related expenses at $15,000. "Our goal is to get them through school with their self-esteem intact," says Bonnie.
The efforts seem to be paying off. Dan, the eldest at 15, has become an outgoing A student, a wrestling star and a writer for the school paper. "ADD gives you energy and creativity," he says. "I've learned to cope. I've become strong." On the other hand, he is acutely aware of his disability. "What people don't realize is that I have to work harder than everyone else. I start studying for finals a month before other people do."
COPING
Adults can also train themselves to compensate for ADHD. Therapists working with them typically emphasize organizational skills, time management, stress reduction and ways to monitor their own distractibility and stay focused.
In her office in White Plains, Tomaino has a miniature Zen garden, a meditative sculpture and all sorts of other items to help tense patients relax. Since many people with ADHD also have learning disabilities, she tests each patient and then often uses computer programs to strengthen weak areas. But most important is helping people define their goals and take orderly steps to reach them. Whether working with a stockbroker or a homemaker, she says, "I teach adults basic rewards and goals. For instance, you can't go out to lunch until you've cleaned the kitchen."
Tomaino tells of one very hyperactive and articulate young man who got all the way through college without incident, thanks in good measure to a large and tolerant extended family. Then he flunked out of law school three times. Diagnosed with ADHD, the patient took stock of his goals and decided to enter the family restaurant business, where, Tomaino says, he is a raging success. "ADHD was a deficit if he wanted to be a lawyer, but it's an advantage in the restaurant business. He gets to go around to meet and greet."
For neurologist Roseman, the same thing is true. With 11 offices in four states, he is perpetually on the go. "I'm at rest in motion," says the doctor. "I surround myself with partners who provide the structure. My practice allows me to be creative." Roseman has accountants to do the bookkeeping. He starts his day at 6:30 with a hike and doesn't slow down until midnight. "Thank God for my add," he says. But, he admits, "had I listened to all the negative things that people said when I was growing up, I'd probably be digging ditches in Idaho."
LESSONS
Whether ADHD is a brain disorder or simply a personality type, the degree to which it is a handicap depends not only on the severity of the traits but also on one's environment. The right school, job or home situation can make all the difference. The lessons of ADHD are truisms. All kids do not learn in the same way. Nor are all adults suitable for the same line of work.
Unfortunately, American society seems to have evolved into a one-size-fits- all system. Schools can resemble factories: put the kids on the assembly line, plug in the right components and send 'em out the door. Everyone is supposed to go to college; there is virtually no other route to success. In other times and in other places, there have been alternatives: apprenticeships, settling a new land, starting a business out of the garage, going to sea. In a conformist society, it becomes necessary to medicate some people to make them fit in.
This is not to deny that some people genuinely need Ritalin, just as others need tranquilizers or insulin. But surely an epidemic of attention deficit disorder is a warning to us all. Children need individual supervision. Many of them need more structure than the average helter-skelter household provides. They need a more consistent approach to discipline and schools that tailor teaching to their individual learning styles. Adults too could use a society that's more flexible in its expectations, more accommodating to differences. Most of all, we all need to slow down. And pay attention.
With reporting by Hannah Bloch/New York, Wendy Cole/Chicago and James Willwerth/Irvine