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Neuropathology and Genetics of ADHD – 6 Part Video Series

Neuropathology and Genetics of ADHD – DNA Learning Center videos with Professor Phillip Shaw (1 to 2-minutes each)

Neuropathology of ADHD  – Three brain areas in relation to the neuropathology of ADHD: the frontal cortex, amygdala, and hippocampus.

Neuropathology of Attention  – Research indicates a pattern of right-hemisphere dominance for attention in the mature brain.

Adult ADHD – Persistence and Remission  – “Research suggests 20-25% of children with ADHD have a severe adult form, while approximately 33% show complete remission.” –  “In youth with attention deficit hyperactivity disorder (ADHD), the brain matures in a normal pattern but is delayed three years in some regions, on average, compared to youth without the disorder, an imaging study reveals. The delay in ADHD was most prominent in regions at the front of the brain’s outer mantle (cortex), important for the ability to control thinking, attention and planning. (Executive Functions) (1)

ADHD Comorbidity  – “Similarities between ADHD, oppositional defiant disorder, and conduct disorder. The boundary between these disorders is somewhat unclear.”

ADHD, DRD4, and Brain Development  – “Research links ADHD with a variant of the Dopamine RD4 gene, which is also associated with brain development.

Biochemistry of ADHD – Dopamine  – “An association between ADHD and dopamine receptors may relate to brain development.”

(1) Brain Matures a Few Years Late in ADHD, but Follows a Normal Pattern

NIH News Release- Monday, November 12, 2007

ttps://www.nih.gov/news-events/news-releases/brain-matures-few-years-late-adhd-follows-normal-pattern

6 Questions for Recognizing ADHD in Adults

This proposed version of the World Health Organization ADHD Self-Report Screening Scale is a short questionnaire designed to help people easily assess the possibility that they might have ADHD. (Researchers have revised the scale to fit the new criteria for evaluating ADHD introduced by the DSM-5 and to reflect how ADHD  presents differently in adults than in children.) FREE Printable

It’s important to keep in mind that this new questionnaire isn’t an absolute measure of whether someone has ADHD. But it can be a useful tool for assessing whether a further look is in order.

The official screener hasn’t been published yet. At this time,  “scores” would be best guesses based on the following information.

The choice of answers range from never, to rarely, sometimes, often and very often. Never is always zero, but the higher frequency answers are assigned varying points.

  1. How often do you have difficulty concentrating on what people are saying to you, even when they are speaking to you directly?
  2. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
  3. How often do you have difficulty unwinding or relaxing when you have time to yourself?
  4. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?
  5. How often do you put things off until the last minute?
  6. How often do you depend on others to keep your life in order and attend to details?

Points are given to each question according to the relative importance of the question is to diagnostic criteria. The highest score if Questions 1,2, and 3 are answered very often is 5 points. The 4th question’s top score is 2. The 5th’s highest is 4, while the final question is 3. That makes 24 points in total, with 14 points being the point at which additional evaluation is recommended.

We’ve created a FREE Printable of what we think the scale will look like based on the previous information.

 

The development of the new ADHD Screener from a 2017 APSARD conference promotional video – 13-minutes

Sources:

6 Questions for Recognizing ADHD by Neil Patterson – https://blogs.psychcentral.com/adhd-millennial/2017/04/6-questions-for-recognizing-adhd/

The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5 

Authors: Berk Ustun, MS1; Lenard A. Adler, MD2,3; Cynthia Rudin, PhD4,5; et al

http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2616166

Brief Screening Tool for Adult ADHD Released

Copy and Paste: http://www.medscape.com/viewarticle/878810?src=wnl_edit_tpal&uac=150032AY#vp_2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHO ADHD Adult Self-Report Scale

Proposed World Health organization (WHO)

ADHD Adult Self-Report Scale

     6 Questions for Recognizing ADHD in Adults    Never    Rarely     Seldom         Often     Very

   Often

   1. How often do you have difficulty concentrating on what people are saying to you, even when they are speaking to you directly?        0         1           2         4        5
    2. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?        0          1            2          4        5
    3. How often do you have difficulty unwinding or relaxing when you have time to yourself?        0           1            2          4        5
   4. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?        0           1            1           2       2
    5. How often do you put things off until the last minute?        0           1            2           3        4
    6. How often do you depend on others to keep your life in order and attend to details?        0           1            1            2         3

 The total number of available points is 24.

Recommend further testing with screening scores of 14 and above.   

For further information see:

6 Questions for Recognizing ADHD in Adults

Source:  

The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5 

Authors: Berk Ustun, MS1; Lenard A. Adler, MD2,3; Cynthia Rudin, PhD4,5; et al

http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2616166

Brief Screening Tool for Adult ADHD Released

Copy and Paste: http://www.medscape.com/viewarticle/878810?src=wnl_edit_tpal&uac=150032AY#vp_2

 

ADHD Medications: Part Two – Overview of Medications

A PHYSICIAN’S PERSPECTIVE on ADHD Medications by Theodore Mandelkorn, MD – 2011

Overview of specific ADHD Medications – Get the factsPART ONE: Therapeutic Treatment of ADHD 

PART TWO: OVERVIEW OF MEDICATIONS

It is important to note that medical treatment should always be given for the entire waking day, seven days a week.  There are few medical conditions that we do not elect to treat in the evenings, on weekends or holidays.  No one chooses to turn down their brain chemistry during his or her wakeful hours.  Therefore, all medical treatment for ADHD should last for at least 12-16 hours daily.  With this in mind, I have highlighted (***) the medications that should be preferred treatments for ADHD.

 

NON-STIMULANT MEDICATIONS

  • ATOMOXETINE, 24 HOURS (Strattera)
  • CLONIDINE, TABLETS: 4-5HOURS, PATCH: 5-6 DAYS  (Catapres)
  • GUANFACINE LONG ACTING (Intuniv)

STIMULANT MEDICATIONS:  OVERVIEW,  SAFETY PROFILE,  SIDE EFFECTS

  • METHYLPHENIDATE TABLETS, 2-4 HOURS (Ritalin)
  • DEXTRO-METHYLPHENIDATE, 4-6 HOURS (Focalin)
  • METHYLPHENIDATE SUSTAINED RELEASE, 6 HOURS (Ritalin SR20)
  • METHYLPHENIDATE LONG ACTING, 8 HOURS (Ritalin LA)
  • METHYLPHENIDATE CONTROLLED DISPENSE, 8 HOURS (Metadate CD)
  • METHYLPHENIDATE EXTENDED RELEASE, 12 HOURS (Concerta)
  • METHYLPHENIDATE TRANSDERMAL SYSTEM,  12 HOURS (Daytrana)
  • DEXTROAMPHETAMINE TABLETS, 4 HOURS (Dexedrine, Dextrostat)
  • DEXTROAMPHETAMINE SPANSULES 6 HOURS (Dexedrine)
  • AMPHETAMINE SALTS TABLETS, 6 HOURS (Adderall tablets)
  • AMPHETAMINE SALTS EXTENDED RELEASE, 12 HOURS (Adderall Xr and generic)
  • LISDEXAMFETAMINE, 12-14 HOURS (VYVANSE)

 

 

NON-STIMULANT MEDICATIONS

Guanfacine, Extended Release   (Intuniv)

This new formulation of an existing medication, guanfacine, was released by the FDA to the market in Dec.  It is an alpha 2 agonist, which will have a 24-hour effect on ADHD symptoms and may be beneficial for individuals with ADHD, particularly those with significant mood, anger, oppositional symptoms.  Preliminary results show that it is clearly beneficial for some patients without the adverse side effects often seen with other ADD medications.

 

Form:                 Pills:  1mg, 2mg, 3mg, 4mg.  Pills must be swallowed.  They must not be crushed, chewed or broken or they will loose the 24-hour effect.

Dosage:        It has a very slow rate of onset and will take 3-4 weeks to assess                        effectiveness.  The primary side effect is tiredness, lethargy, and it must be started slowly.  Suggest starting dose of 1 mg for one week, and raise by 1 mg each week to reach good therapeutic effect.  The effects do last 24 hours.

SideEffects : Lethargy, tiredness, dry mouth, constipation, dizziness,             decreased blood pressure.

Pros:                  A non-stimulant medication that appears to have a good, positive effect on ADD and oppositional symptoms that lasts 24hours with reduced side effect profile, compared to the traditional  treatments.

Cons:                A new formulation with minimal time on the market to truly assess effectiveness.

ATOMOXETINE  24 hours   (Strattera)

This is a medication for ADHD, which was released by the FDA in December 2002.  It is a non-stimulant medication, which is not abusable and can be written without Schedule II restrictions.  This is the first medication that lasts 24 hours and therefore gives full therapeutic effect throughout the day and night .Unfortunately, over the past few years, it has not performed as well as expected.  It tends to often have side effect and does not deliver as robust a response as the stimulants.

Form:                 Capsules: 10mg, 18mg, 25mg, 40mg, 60mg.

Dosage:            Weight based dose:  first four days=0.5mg/kg;  target dose (day five and after)=1.2mg/kg.  This medication must be taken with food to prevent nausea.

Action:               Very slow acting and will take 3-4 weeks (or more) to reach a therapeutic effect.  If the patient is already taking stimulant medications, suggest continuing them and adding the Strattera for the first 4-6 weeks, then tapering the stimulant slowly until discontinued.

Possible Side Effects:    No long-term safety information is available for this medication. Primary side effects in children include sleepiness during the day, appetite changes, and mood or personality changes. If these occur, give the dose at night or lower the dose until they improve.  Then raise dose if possible.  Adults can experience more noted effects:  transitory dry mouth and dizziness, insomnia, sleepiness and significant moodiness. Other effects in adults include possible bladder spasm, sexual dysfunction (uncommon but often result in discontinuation of medication).  Occasionally a child or adult will get very agitated.  If this occurs, discontinue the medication.

Pros:                  24-hour coverage.  Less effect on appetite than stimulants.

Cons:                Many complaints about side effects, lack of efficacy compared to stimulants.  Has not been a very satisfactory treatment for many with ADD

CLONIDINE  tablets 4-5 hours, patches 5-6 days   (Catapres)

Form:                 Patches applied to back or shoulder.  Catapres TTS-1, TTS-2, TTS-3.  Tablets .  Clonidine tablets 0.1mg, 0.2mg, and 0.3mg.

Dosage:            Very individual, usually .1-.3mg.

Action:               Works quickly.  Tablets work within 1 hour, patches within 1 day.

Effects:              Often will improve ADHD symptoms, particularly aggressive and hyperactive behaviors.  Not too helpful for focus and attention.  Decreases motor and vocal tics.  Can have a dramatic effect on oppositional defiant behavior and anger management.  Often used as one dose at night about 1½ hours before bedtime to assist with getting to sleep.

Possible Side Effects:    Major side effect is tiredness, particularly if the dose is raised too quickly.  This disappears with time.  Dizziness, dry mouth.  Some will notice increased activity, irritability.

Pros:                  Excellent delivery system if patch is used.  No pills required

Cons:                Does not usually work as well as stimulants.  Patch can cause skin irritation in many individuals and may not be tolerated.  Can affect cardiac conduction (heart rate and rhythm) in high doses and must not be left around for animals or small children to accidentally ingest.

 

STIMULANT MEDICATIONS

Some general comments can be made about stimulant medications as a class of medications.  The longer acting medications have clear advantages over the short acting medications, not only in duration of therapeutic effect throughout the day, but also in smoothness of the therapeutic effect.  It is very difficult for an individual with ADHD to remember to take multiple doses of medication during the day.  Multiple dosing increases the risk of missing doses, which results in the return of symptoms at inopportune times.  The afternoon dosing is frequently missed, causing significant difficulties.  Furthermore, each additional dose serves as an unnecessary reminder that treatment for this condition is needed and “something is wrong.”

The reason for medical treatment is to “normalize” the dayMy general rule is to always use 12-16 hour medications unless they are not effective or have intolerable side effects.  In such a case, the six or eight hour medications should be tried, because some individuals tolerate them better and find them more effective.  However, if the six or eight hour medication is used, a second dose should be given to allow patients to have the therapeutic benefit for the full day.

 

SAFETY PROFILE

The stimulant medications are one of the most studied treatments in the history of medicine.  The medications have been used extensively in children and adults over the past 50 years with no evidence to date of long-term concerning side effects.  At this time there is no conclusive evidence that use of stimulants causes any long term lasting effects on growth, although there may be some delay in height and weight gain in some individuals.

The short acting stimulants are extremely abusable and are valued highly on the street.  It is best to always use the long-acting preparations, which are not abusable to avoid the temptation of misuse and abuse.

There have been recent concerns expressed by the FDA and the press with regard to the use of stimulant medications and the risk of sudden unexpected death.  This concern was a consequence of a study done in 1999-2003 in which they looked at a large number of individuals taking stimulants and felt that there may be a slight risk.  As reported in an excellent article in the New York Times Feb 14, 2006 the apparent calculated risk of sudden unexpected death in those using amphetamines was 0.35/million (1 in 3 million) prescriptions and the risk for those on stimulants was 0.18/million (1 in 5 million) prescriptions.  There is no real evidence that this is any different from that which occurs in the normal population.  These extraordinary events of unexpected death tended to occur in individuals with congenital cardiac defects.  For this reason, the FDA issued a BLACK BOX warning to all physicians that stimulants should be used very cautiously or not at all in individuals with congenital cardiac defects.

 

COMMON SIDE EFFECTS:

The following side effects are often noted with the use of stimulants.  In general, side effects with the short-acting medications are more pronounced and bothersome than with the long-acting medications.  Thus, long acting meds are somewhat more tolerable for long-term treatment and are certainly a marked improvement for long-term therapeutic effect.

Appetite suppression:  Most will note decreased appetite during the effective hours of the medication.  This often means minimal lunch intake.  I suggest a small protein lunch such as milk, peanut butter crackers, beef or turkey jerky to get through the day.  A milkshake after school helps.  Many find their appetite returns late in the evening (around 8-9pm) when their medication wears off, and they need to be allowed to eat at that time.  If weight gain is a continued concern, I often add cyproheptadine (Periactin) 4mg, ½ tablet at breakfast and dinner.  Periactin is an antihistamine similar to Benedryl, which enhances appetite and often results in 1-2lbs-weight gain per month.  Remember that good nutrition is helpful for all, and these individuals should emphasize protein intake in their diet.

Sleep disturbance:  Many ADHD individuals will have sleep difficulties before they begin their medical treatment.  At night, their brain continues its activity and starts thinking of the day.  Using stimulant medications may either improve or worsen this problem.  In those with no prior sleep difficulty, stimulants can create significant sleep issues.  ADHD individuals do not usually have a problem with sleeping through the night (sleep disorder) but often do have problems with starting the sleep.  A clear-cut bedtime routine helps (bath or shower and then read in bed) with the elimination of caffeine, computers, computer games and television at least one hour before bedtime.  Interestingly, adding stimulant medication actually allows a percentage to sleep better at night, and this technique should be tried.  It only takes one night to see if a dose of short acting stimulant will enable sleep initiation.

Some patients, however, require more assistance.  Many patients will use a small dose of Clonidine tablets given one hour before bedtime to help with sleep initiation.  Clonidine is a mild sedative, not a sleeping pill, and it is non-addictive.  Approximately 60-90 minutes after taking the medication, a brief sleepy phase will occur that lasts about 20 minutes.  If the patient is in bed and trying to go to sleep, it is very effective.  It will NOT make someone stop playing computer games and go to bed.

Mood changes:  One of the biggest complaints about stimulants is that they can cause mood changes.  These come in a number of different forms.

Rollercoaster effect:  Short acting medications have a continuous cycling of the blood level, either rising or falling throughout the day.  This can lead to significant mood changes, particularly at the end of the four-hour cycle when the medication is wearing off.  This problem with cycling is greatly diminished with the use of eight-hour and twelve-hour medications.

Rebound effect.  Stimulants can often wear off very rapidly, and in some individuals, this can cause a rebound, a marked change in demeanor often characterized by irritability, loss of patience, and a worsening of the ADHD core symptoms.  Rebound can occur in the evening when the medication wears off and can also be evident in the morning on first arising.  The morning rebound may require an early dose of immediate release methylphenidate (MPH) prior to the administration of the long-acting dose at breakfast.  The Rebound effect is markedly reduced in frequency and severity in the long-acting stimulants.

Irritability and anxiety:  All of the stimulants have the possibility of causing a generalized irritability, and sometimes even anger, which is not tolerable over a long period of time.  They can cause anxiety and panic disorder and may aggravate existing anxiety.  Often, changing from one stimulant to another will reduce this side effect, so it is worth trying different stimulants to identify the best one for each patient.

Overdose effect:  When using the stimulants it is necessary to gradually raise the dose to find the most effective therapeutic level.  Sometimes in doing this, one gets an overdose effect.  The stimulants are incredibly safe. They have been studied for over 50 years, and there is no evidence at this time of any long-term serious complications when used appropriately for ADHD.  However, if ADHD individuals take too high a dose, they will experience an overdose effect which appears as a dulling of the personality:  They complain of being somewhat physically lethargic, subdued, dull, less conversational, less apt to laugh and be social.  By simply lowering the dose for one day, these symptoms will disappear.

Tic FormationAll of the stimulants have the possibility of temporarily causing a tic disorder or aggravating an existing one.  There is no evidence that the use of stimulant medications will cause a permanent formation of tic disorder or Tourette syndrome.  Children who already have tics (10% of children have mild tics at some point in childhood) and individuals with Tourette syndrome will find a number of different scenarios with the use of medication.  Approximately 1/3 will actually notice that the tics improve (lessen) with the use of stimulants, 1/3 will see no change at all, and 1/3 will find the tics worsen with use of stimulants.  If the stimulants are effective and tics are worse, a medication to help control the tics is usually added to the treatment.

 

METHYLPHENIDATE TABLETS  2-4 hours   (Ritalin IR)

Form:                 Short acting tablets.  Methylphenidate (MPH) 5mg, 10mg, 20mg.

Dosage:            Very individual.  Average 5-20mg tablets every 2-4 hours.

Action:               Immediate release (IR) MPH starts to take effect in 15 minutes, which is extremely helpful for some individuals.  Some children need an early morning dose 20 minutes BEFORE arising in the am, followed by a long-acting medication at breakfast.  Often used as a booster for evening coverage.

Possible Side Effects     See above

Pros:                  Very easy to use for short periods of coverage, such as early morning and evening.

Cons:                Must be administered frequently during the day (3-5 times/day).  Inconvenient to use at school and work.  Often causes rebound and rollercoaster effect.  Very abusable.

 

DEXTRO-METHYLPHENIDATE  4-6 hours   (Focalin)

                                                            8-12 hours (Focalin XR)

 

Focalin is an isomer product of methylphenidate.  Methylphenidate is composed of two mirror-image molecules, and it has been determined that the right-hand side of the molecule contains most of the therapeutic activity.  Therefore the left-hand side has been eliminated, giving a cleaner formulation of methylphenidate.

Form:                 Tablets:  2.5mg, 5mg, and 10mg. (Focalin)

Capsules:  5mg, 10mg, 20mg

Dosage:            The same as methylphenidate, but divide the dose by half.

Action:               The same as methylphenidate, but in some individuals up to 6 hours duration.

Possible Side Effects:    Same as MPH but possibly to a slightly less degree.

Pros:                  A cleaned up version of MPH that may last a bit longer with slightly decreased side effects.

Cons:                Same as MPH.  Very abusable.

 

METHYLPHENIDATE SUSTAINED RELEASE  6 hours   (Ritalin SR20)

Replaced by Ritalin LA.

 

METHYLPHENIDATE LONG ACTING  8 hours   (Ritalin LA)

Form:                 Capsules: 20mg, 30mg and 40mg.

Dosage:            Very individual.  Average: 20-40 mg daily or twice a day, every 8 hours.

Action:               Same as methylphenidate, but eliminates the noontime dose.

Possible Side Effects:    See above.

Pros:                  Eliminates midday dosing.  Works more smoothly than IR methylphenidate and is more effective than methylphenidate SR.

Cons:                Only works for eight hours and therefore subjects the patient to loss of focus and control in mid-afternoon.  This requires an afternoon booster to be administered.

 

METHYLPHENIDATE CONTROLLED DISPENSE  8 hours   (Metadate CD)

Form:                 Capsules: 20mg (10mg and 30mg to be available in 2003)

Dosage:            Very individual.  Average: 2-3 capsules in the am.

Action:               Same as methylphenidate.

Possible Side Effects:    See above.

Pros:                  Works more smoothly than IR methylphenidate.  Sometimes is effective when Concerta and Ritalin LA are not effective.  Not abusable.

Cons:                Works for only eight hours.  (See Ritalin LA)

 

***METHYLPHENIDATE EXTENDED RELEASE  12 hours   (Concerta)

No generic available

Form:                 12-hour long-acting tablet uses a unique delivery system that delivers a constant therapeutic level of methylphenidate for twelve full hours.  Cannot be broken or cut or delivery system is destroyed. Concerta 18mg, 27mg, 36mg, 54mg.

Dosage:            Dosage will vary as with all methylphenidate products.

Concerta 18mg = Ritalin  5mg three times a day

Concerta 27mg = Ritalin 7.5mg three times a day

Concerta 36mg = Ritalin 10mg three times a day

Concerta 54mg = Ritalin 15mg three times a day

Action:               12 hours of consistent therapy with no highs or lows throughout the day.  A few individuals will only get 8-9 hours of effective therapy and will need either a higher dose or a second dose.

Possible Side Effects:    See above.

Pros:                  Unique delivery system (an internal osmotic pump) avoids multiple dosing throughout the day.  No dosage at school.  No rebounding with missed doses.  Fewer side effects, less mood swings, and a better therapeutic response for many individuals.  No daytime dosing.  Less anxiety and worry.  Not abusable.

Cons:                Does not work for all individuals who use methylphenidate.  If ineffective, should try Ritalin LA and/or Metadate CD.  May need a short-acting booster to cover the evening hours.

 

METHYLPHENIDATE TRANSDERMAL SYSTEM  12-15 HOUR (Daytrana)

No generic available

 

The trans-dermal patch arrived on the market July of 2006 as a new and novel delivery system for methylphenidate. The patch has the medication within the adhesive layer and is thus very thin.  It works by diffusion, allowing the medication to gradually diffuse through the skin into the blood stream directly, thus avoiding the intestinal tract.  It is designed to be worn for nine hours and then removed, but will last longer if needed for evening activities.  After removal it will gradually lose effect over the next three hours, thus giving extended and controlled hours of therapy as the day dictates. The unique attribute of the patch is that the patient has complete control of when to start the patch and when to discontinue the patch.  For the first time, the patient can regulate the treatment for part or all of the day.  The medication in the patch is methylphenidate, and thus all of the above information regarding this medication applies.

 

DEXTROAMPHETAMINE TABLETS  4 hours   (Dexedrine, Dextrostat)

Form:                 Short acting tablets  5mg, 10mg.

Dosage:            Very individual.  Average 1-3 tablets each dose every 4-5 hours.

Action:               Rapid onset of action, approx. 20 min.  Lasts 4-5 hours.

Possible Side Effects:    See above.

Pros:                  Excellent safety record.  Rapid acting.  Some patients who do well on dextroamphetamine prefer the tablets to the spansules.  The rapid onset in tablet form is apparently more effective for these individuals.

Cons:                Same as MPH.  Very abusable.

 

DEXTROAMPHETAMINE SPANSULES  6 hours   (Dexedrine)

Generic available

Form:                 Long acting.  Dexedrine Spansules 5mg, 10mg, 15mg.

Dosage:            Very individual.  Average is 5-20 mg.

Action:               Very individual.  May take up to one hour to be effective.  Usually lasts 6-8 hours.  In some individuals, it may last all day.  In others, it may only last 4 hours.  Most will take twice a day, six-hour intervals

Possible Side Effects:    See above

Pros:                  Excellent safety record.  May be the best drug for some individuals.  Long-acting, smooth course of action.  May avoid lunchtime dose at school.

Cons:                Slow onset of action.  May require a short acting medication at the start of the day.  Very abusable.

 

AMPHETAMINE SALTS TABLETS  6 hours   (Adderall)

   

 

Form:                 Long acting tablets: 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 30mg.

Dosage:            Very individual, usually between 5mg and 20mg, once or twice each day.

Action:               Usually lasts 6 hours.  May be given once or twice a day depending on the length of therapeutic effect.  Duration of effect varies from person to person.

Possible Side Effects     See above.

Pros:                  Only needs to be given once or twice a day.  Often fewer side effects than the short acting medications.

Cons:                Can cause irritability in a small percentage of patients.  Very abusable.

 

***AMPHETAMINE SALTS EXTENDED RELEASE  12 hours   (Adderall XR)

Generic available April 1, 2009

Form:                 Uses a unique delivery system that delivers a constant therapeutic level of amphetamine salts for twelve full hours.  Capsules:  5mg, 10mg, 15mg, 20mg, 25mg, 30mg.

Dosage:            Very individual.  Average 15-30mg daily.

Action:               Long-acting 12-hour control of ADHD symptoms for coverage during most of the day.

Possible Side Effects:    See above.

Pros:                  Very effective.  Same as Adderall with longer duration of action.  Cannot be abused.

Cons:                May need a booster to cover the evening hours.

 

LISDEXAMFETAMINE  12-14 hours (Vyvanse)

No generic available

 

Form:                 A Pro-drug which renders this delivery system minimally abusable.  A new and novel delivery system which will deliver dextro-amphetamine smoothly over a 12-14  hour period.

Dosage:        Capsules:  30mg, 50mg, 70mg

Action:               The same as Dextroamphetamine

Side Effects:    Same as Dextroamphetamine

Pros:                  The only long-acting Dextroamphetamine on the market, and very unlikely to be abused.

Cons:                Same as stimulants

 

For the introduction to this article, please see: PART ONE: Therapeutic Treatment of ADHD 

 

For an excellent reference book regarding all of the medications that might be used for ADHD  individuals, including not only medications for ADHD but also medications for all of the associated co-morbid conditions, please refer to the following book:

 

STRAIGHT TALK ABOUT PSYCHIATRIC MEDICATIONS FOR KIDS , Revised Edition 2004

by Timothy Wilens M.D.

 

 

 

About the author:

0-ted-mandekornReprinted with permission from Theodore Mandelkorn, MD, a physician with Puget Sound Behavioral Medicine, a clinic that treats teens, children and adults with attention deficit disorder and related conditions.  For further information visit the website at http://psbmed.com,  or call 206/275-0702.

 

ADHD Medications: A Physician’s Perspective

 By Theodore Mandelkorn, MD – 2011

ADHD is a medical condition. Medication is a PRIMARY OPTION for therapeutic intervention.ADHD Medications: PART ONE

  • INTRODUCTION
  • WHO SHOULD TAKE MEDICATIONS, AND WHY?
  • WHAT IMPROVEMENT SHOULD BE SEEN?
  • WHO SHOULD PRESCRIBE MEDICATIONS?
  • MEDICAL TRIALS
  • WHAT IS THE CORRECT MEDICATION?
  • WHAT IS THE CORRECT DOSAGE?
  • WHAT ABOUT “NATURAL” THERAPIES?
  • SUMMARY

 

PART TWO: OVERVIEW OF ADHD MEDICATIONS 

 

INTRODUCTION

Human beings are rarely created in perfect form, so we all arrive in this world with unique differences.  Some differences are blessings, others are handicaps.  Poor vision, for example, is a common handicapping condition that affects millions of people throughout the world.  I consider poor vision a condition of “human-ness.”  People can also have other medical conditions such as diabetes, asthma, thyroid conditions, ADHD, etc.—all are well-recognized differences that can impair the pursuit of a normal lifestyle if not dealt with in some manner.

 

ADHD is characterized by a prolonged history of inattention, impulsiveness and sometimes variable amounts of hyperactivity.  It is important to emphasize that all of these symptoms are normal human characteristics.  Most of us are forgetful and inattentive at times.  We all at times become nervous and fidgety, and we certainly are impulsive to some degree.  It is part of our “human-ness.”  ADHD, therefore, is not diagnosed by the mere presence of these normal and characteristic human behaviors, but by the DEGREE to which we manifest these symptoms.  ADHD individuals have an over-abundance of these normal characteristics.  They have less CONTROL of these behaviors and therefore a more variable and frequently poor outcome of their day.

WHO SHOULD TAKE MEDICATIONS, AND WHY?

If a person meets the clinical criteria for a diagnosis of ADHD and is not succeeding academically and/or socially up to age-appropriate expectations, medication should be a PRIMARY OPTION for therapeutic intervention.  ADHD is a medical condition.  Recent research out of Harvard University has documented an abnormality in the dopamine transporter system in the central nervous system of ADHD adults.  (1)  This transporter system is responsible for moving neurotransmitter chemicals from the synaptic space back into the nerve cell.  ADHD adults have approximately 70% more dopamine transporter than non-ADHD individuals and thus appear to have an overactive transport system.

 

Returning to the vision analogy, there are a number of options open to an individual who has compromised eyesight.  One option is to attempt to correct the problem by wearing glasses to improve the visual acuity.  Perhaps glasses will totally correct the problem or perhaps they will help only partially.  After glasses are in place, we are in a position to assess what further problems are interfering with success.  Then we can address these issues as well.

 

The opportunity to eliminate the symptoms of a medical condition partially or completely should be available to all.  Many children and adults with ADHD benefit enormously from the use of medication. The medications that are in use today act as transporter blockers, thus serving to normalize this aspect of the brain chemistry.  Most families who understand ADHD and its clinical manifestations prefer to try medication as a PART of their treatment plan.  Over 90% of individuals with ADHD will have a positive response to one of the medical treatments.

WHAT IMPROVEMENT SHOULD BE SEEN?

In the early 1930’s, Dr. Charles Bradley noted some dramatic effects of stimulant medications on patients with behavior and learning disorders.  He found that the use of stimulants “normalized” many of the systems that we use for successful living.  People on medication IMPROVED their attention span, concentration, memory, motor coordination, mood, and on-task behavior.  At the same time, they DECREASED daydreaming, hyperactivity, immature behavior, defiance, and oppositional behavior.  It was evident that medical treatment allowed intellectual capabilities that were already present to function more successfully. (2, 3)

 

When medication is used appropriately, patients notice a significant improvement in control.  Objective observers should notice better control of focus, concentration, attending skills, and task completion.  Many individuals are able to cope with stress and frustration more appropriately with fewer temper outbursts, less anger and better compliance.  They relate and interact better with family members and friends.  You should see less restlessness as well as decreased motor activity and impulsiveness. ADHD individuals often complain of forgotten appointments, incomplete homework, miscopied assignments, and frequent arguments with siblings, parents, spouses, workmates, along with excessive activity and impulsive behaviors.  With medication, many of these problems dramatically improve.

 

It is very important to remember what medicine does and does not do.  Using medication is like putting on glasses.  It enables the system to function more appropriately.  Glasses do not MAKE you behave, write a term paper or even get up in the morning.  They allow your eyes to function more normally IF YOU CHOOSE to open them.  You, the individual, are still in charge of your vision.  Whether you open your eyes or not, and what you choose to look at, are controlled by you.  Medication allows your nervous system to send its chemical messages more efficiently, and thus allows your skills and knowledge to function more normally.  Medication does not provide skills or motivation to perform.  Patients successfully treated with medications typically can go to bed at night and find that most of the day went the way they had planned.

WHO SHOULD PRESCRIBE MEDICATIONS?

Licensed physicians, physician’s assistants or nurse practitioners can prescribe medications. This person may serve as a coordinator to assist with the multiple therapies often needed, such as educational advocacy, counseling, parent training and social skill assistance.  Parents should look for a physician who has a special interest and knowledge in dealing with ADHD individuals.  This professional should be skilled in working closely with families to try the many and varied medical treatments that are available until the correct therapeutic response is attained.  Members of CH.A.D.D chapters are an excellent resource for referrals to appropriate professionals. (Editors note: See Find a Provider for other referral options.)

MEDICAL TRIALS

It is necessary to establish a team of observers to appropriately evaluate a medication trial.  Gather information from sources that spend time with the patients.  This might include significant others, parents, teachers, grandparents, tutors, piano teachers, coaches, etc.  As gradually increasing dosages are administered, feedback is gathered from these observers.  Various ADHD rating scales are available to assist in gathering factual data.  The most important assessment, however, is dependent on whether the ADHD patient’s quality of success in life has improved.  For this information, I find no scale takes the place of conversations with patient and family members.

 

When evaluating patients during a trial of medication, it is important to maintain treatment throughout the waking day, seven days a week.  Treating them only at school or in the workplace is totally inadequate.  I need all involved observers, especially parents and/or significant others, assisting in the evaluation process.  Furthermore, I want to know if treatment has an effect on non-academic issues.  Recent studies have found that treatment is necessary for most ADHD individuals throughout the full day, thus allowing full development not only of academic or work skills, but also the all-important social skills that are utilized with friends and family.  After the trial of medication, if positive results are evident, then the family and the patient can make informed decisions as to when the medication is helpful.  Most patients need the medication throughout the day and evening.

WHAT IS THE CORRECT MEDICATION?

At the present stage of medical knowledge, there is no method of predicting which medication will be most helpful for any individual.  At best, physicians can make educated decisions based on information about success rates with individual medications.  Over 80% of ADHD individuals will respond favorably to the stimulant medications, methylphenidate and amphetamines.  Both of these categories of medications may need trials to assess which is best.  If one stimulant does not work, the others should be tried, for experience has proven that individuals may respond quite differently to each one.  Other alternative medications are available including the non-stimulant medications for ADHD.  Experience has shown that the non-stimulants are not as effective as the stimulants, but they more be better tolerated by some.  Each family and physician must be willing to try different medications in order to determine the best and most effective therapy.  This is the only way to find the appropriate medical treatment.  In some children who have multiple diagnoses such as ADHD and depression, or ADHD and anxiety, or ADHD and Tourette syndrome, combinations of medications are being successfully utilized for treatment.

WHAT IS THE CORRECT DOSAGE?

If stimulant medications work, there is an optimal dose for each individual.  Unfortunately, medical knowledge is not at a point where it can predict what the correct medication or dose will be.  This is not an unusual circumstance in medicine, however.  For a person with diabetes, for example, we must try different forms and amounts of insulin to achieve the best control of blood sugar levels. For people with high blood pressure, there are many medications that can be effective, and often a trial of multiple medications and dosages is necessary to determine the best treatment.  For stimulant medications, there is no magic formula.  The dose cannot be determined by age, body weight or severity of symptoms.  In fact, it appears that the correct dose is extremely individual and is not at all predictable.  Again, similar to people who need glasses, the kind of prescription and the thickness of the lenses are not dependent on any measurable parameter other than what the individuals say enables them to see well.  The dose of medication is determined solely by what ADHD patients need to most effectively reduce their symptoms.  One must be willing to experiment with carefully observed dosage changes to determine the correct dosage.  The appropriate dosage does not seem to change very much with age or growth.  Medication continues to work effectively through the teenage years and through adulthood.

With the non-stimulants, the dosage at the present time is calculated according to weight.  These are the only medications for ADHD for which this is true.

WHAT ABOUT “NATURAL” THERAPIES?

At this time, there is no evidence that natural therapies are therapeutic.  There are many anecdotes about various “magical” cures for ADHD, but none have been found to be valid.  Remember:  multiple anecdotes do not mean proof.     Natural therapies such as grape seed extract, blue algae, biofeedback, magnets, megavitamins, diet, and other “natural products” have not yet shown any lasting therapeutic benefit.  At this time traditional medical therapy is the most effective treatment for ADHD.  This is quite similar to other medical treatments such as insulin, THE best form of treatment for Type 1 diabetes, or thyroid pills THE best therapy for an inactive thyroid gland.  Furthermore, natural health food treatments are not regulated by the government and are therefore highly suspect for contamination.  Please be cautious when experimenting with alternative therapies on your family members.

SUMMARY

Individuals with ADHD present with a variety of well-defined symptoms and behaviors.  Medication may be extremely helpful in alleviating some of these symptoms and will allow the other therapeutic modalities to be much more successful.  Families must be willing to work closely with their physician to identify the correct medications and establish the best dosage levels.

 

 

References:

  1. Dougherty, D.D. Dopamine transporter density in patients with ADHD. Lancet 1999; 354: 2132.
  2. Bradley, C. The behavior of children receiving Benzedrine. Am J Psychiatry 1939; 99: 577-585.
  3. Bradley, C. Benzedrine and Dexedrine in the treatment of children’s behavior disorders. Pediatrics 1950; 5: 24-37.

 

NEXT POST: PART II, AN OVERVIEW OF THE SPECIFIC MEDICATIONS USED TO TREAT ADHD

 

 

Resources:

For an excellent reference book regarding all of the medications that might be used for ADHD  individuals, including not only medications for ADHD but also medications for all of the associated co-morbid conditions, please refer to the following book:

 

STRAIGHT TALK ABOUT PSYCHIATRIC MEDICATIONS FOR KIDS , Revised Edition 2004

by Timothy Wilens M.D.

 

Suggested Reading:

 

  1. DRIVEN TO DISTRACTION  by Ned Hallowell, MD
  2. DAREDEVILS AND DAYDREAMERS by Barbara Ingersoll
  3. UNDERSTANDING GIRLS WITH ADHD by Kathleen Nadeau and Patricia Quinn
  4. UNDERSTANDING WOMAN WITH ADHD by Kathleen Nadeau and Patricia Quinn
  5. TEENAGERS WITH ADHD by Chris Dendy
  6. IS IT YOU, ME OR ADHD by Gina Pera (For couples where one has ADHD and the other does not)

 

0-ted-mandekornAbout the author:

Reprinted with permission of Theodore Mandelkorn, MD, a physician with Puget Sound Behavioral Medicine, a clinic that treats teens, children, and adults with attention deficit disorder and related conditions.  For further information visit the website at http://psbmed.com,  or call 206/275-0702.

 

 

The ADD Journey

Living successfully with ADHD. Help for the road ahead.by Cynthia Hammer, M.S.W.

Stage I: “The Journey Begins” (Discovery and Diagnosis)

Relief: “Finally, an explanation!

For many adults, discovering they have ADD, usually by reading an article, a book or seeing something on television, is a very emotional moment. People at this point in time are usually very excited. They want to talk. They want to tell their story. They want to be understood now that they are starting to understand themselves. Most want to immediately seek a professional diagnosis so they can move forward with treatment.

Stage II: “Wandering in the Wilderness” (Increasing Awareness)

This stage is marked by a variety of feelings and questions.

  • Denial: “How do I know this is a valid disorder?”
  • Flickering Optimism: “Maybe there is hope.”
  • Fear, anxiety, and more anxiety: “What if I follow through with treatment, but nothing changes? All that effort and for what?” Another failure?” “Is medication safe? If I use it, will I have to take it for the rest of my life?”
  • Grief, Anger, and Resentment: “Why wasn’t this diagnosed and treated sooner?”

Stage III: “Up and Over the Mountain Top” (Restructuring)

At this stage, the ADDult no longer puts his energy into “What might have been ….” She moves forward with her life, focusing on what works and minimizing the impact of what does not. Some ADDults go to bed in Stage II and wake up in Stage III. It is hard to predict when or why the transition occurs, but it does, and it feels good! In Stage III, ADDults feel less shame about their disorder. They feel more empowered and more comfortable with telling others about their condition. Stage III involves:

  • Accepting: “I’m ready to let go of the past. I want to get on with my life.”
  • Delegating; Using Strategies and Accommodations: “Could some else more easily do this task?” “What strategies can I use, what accommodations can I request to accomplish my goals?”

Stage IV: “Enjoying the Peaceful Valley”(Self-Acceptance)

Along your journey you have enjoyed the occasional oasis…the moments when you recognize and praise yourself for new behaviors, small accomplishments, and completed tasks. You note where you started and how far you have come. The journey has been difficult, (and often you wanted to quit or turn back), but you realized you were making progress toward your destination. By noting the oases along the way, you confirm for yourself that you are traveling in the right direction, on the right road and keep you nourished for continued travel.

Eventually, you reach a point in your journey when you are traveling light. You no longer carry baggage from your past. You are a seasoned traveler, good at figuring out how to pass through this rough landscape. You are confident in your abilities and strong in your knowledge of having survived. You know your journey will get easier–that you will even start to enjoy it. You continue to journey, but now you travel without needing guides and fellow travelers. You journey down the open road of life, sometimes skipping, sometimes trudging, sometimes limping, but now there is usually a song in your heart, a twinkle in your eye, and a smile on your face. It is good to notice another oasis just ahead. Your journey of life has become the adventure you have always looked for.

Everyone on an ADD JOURNEY needs guides and fellow travelers to show the way and provide support when we weaken and falter. Our guides and fellow travelers provide the six essentials of multi-modal ADD treatment.

  1. Diagnosis
  2. Education
  3. Support
  4. Medication
  5. Counseling
  6. Coaching

Just as the wise backpacker carries the ten essentials when out trekking, the journeying ADDult needs to have the ADD treatment essentials at hand. Whether or not all treatments get used during the journey depends on the traveler. Some need to employ all treatments; others, only a few. Below is a chart showing which Guide or Fellow Traveler is most suitable for each stage of the journey

TREATMENT GUIDE/FELLOW TRAVELER STAGE
Diagnosis Psychologist, Psychiatrist, Counselor or Primary Care Physician I
Education and Support Education and Support Groups Self-education Self-Help Groups Friends and Family I and II,
I and II,
II and III
Medication (and/or Alternative Treatments) Psychiatrist, Primary Care Physician (and/or Alternative Health Care Providers) II, III, and IV
Counseling (and Therapy Groups) Counselor, Psychologist or
Psychiatrist
II and III
Coaching Professional Coach or Coaching Partner III

WHO ARE YOUR GUIDES FOR STAGES I AND II?

Psychiatrists are medical doctors who specialize in helping people with mental health problems. Their training includes medical school and usually a three-year postgraduate residency. One advantage of their training is that it enables them to understand, use, and prescribe medications. With respect to ADHD, this is a definite advantage, since ADD treatment usually includes medication. In addition to psychiatrists, other medical doctors along with physician assistants and some nurse practitioners have prescriptive authority. However, none of them do psychological testing.

Sometimes psychological testing is recommended–not to make the ADD diagnosis–but to gain other information on the person’s functioning. Only psychologists do this kind of testing. So, at times, an adult seeking an ADD diagnosis may see several different professionals. Some adults see several experts for another reason. They cannot find a knowledgeable helper. Sadly, many mental health professionals are not knowledgeable about adult ADD. They may look at it as either a “made up” or an over-diagnosed problem. Since mental health professionals are not used to working with adult ADD patients, it is likely that they may believe another problem is dominant.

Professionals in any field tend to “see” only what they know. If they don’t know or understand something, they can’t see or treat it. For example, the psychologist may see your problem mainly as depression or anxiety (especially if you are a woman), not recognizing the ADD as the underlying concern. How you feel about your life because of your untreated ADD may cause you to be depressed or anxious. ADD may be your primary problem, but other problems may need treatment as well.

In evaluating a mental health professional’s knowledge about ADD in adults, many of the following questions could be asked. Most of these questions could also be asked of ADD counselors and ADD coaches.

  1. Do you accept my insurance? Do you diagnose ADD/ADHD?
  2. How long have you been diagnosing this disorder in adults?
  3. How many ADD/ADHD adults have you diagnosed in the past five years. What percent of your practice has a primary diagnosis of ADD/ ADHD?
  4. How familiar are you with the day to day tribulations of having ADD? (You’re trying to learn if they or someone they are close to has this condition. How intimate is their understanding of ADD on a daily basis?)
  5. What is your treatment philosophy? (Will the clinician work with you and be open to suggestions or will he/she call all the shots. Is their treatment of ADD the same for everyone or is it individually tailored?)
  6. In a subtle way, learn what they do to keep current in their knowledge about adult ADD and its treatment protocols.
  7. How do you make a diagnosis? How many visits will it take and how much will it cost?
  8. How long will I have to wait for an appointment?
  9. Ask psychologists how they handle the medication part of treatment.
  10. Ask physicians (and other medical personnel with prescriptive authority) what medicines they use to treat ADD/ADHD.

YOUR GUIDES FOR STAGES II AND III – Therapists and Coaches

Counselors/Therapists: Often, after being diagnosed with ADD, it is a good idea to find a therapist with you whom you can work. Many times adults with ADD have become so mired in negative feelings about themselves that the first thing they need to do is to face these feelings directly and learn how to let them go. Besides dealing with the ADD symptoms themselves, there may be depression, anxiety, or other problems that need to be addressed.

A good therapist can help you develop practical ways to deal with your daily life based on your own problems and circumstances. You will develop insights into how your ADD symptoms have interacted throughout your life, which is likely to help you understand why your life has taken a certain direction. It is our belief that a good therapist will educate you thoroughly about ADD.

Individual therapy is the most likely choice because most people prefer the privacy of a one-to-one relationship with a mental health professional. In individual therapy you and your therapist talk about your particular problems and develop ways in which you can deal with them more effectively. You will probably see your therapist once each week, although the schedule may later change. Visits usually last about forty-five to fifty minutes. After the initial screening is completed, you and the therapist will spend your visits talking about specific challenges, developing coping strategies, sharing new insights, and whatever concerns are on your mind.

The therapy will vary according to the therapist’s orientation. For example, one therapist may help you listen to your negative thoughts and get you to actively challenge them. This method is central to cognitive therapy. Another therapist may help you develop strategies for actively confronting and, hopefully, overcoming the ADD symptoms that make your life less than optimal. Often you will gain insight as therapy proceeds. You may have misunderstood your ADD and thought that you were just “lazy, crazy, and stupid.” You may have many misconceptions that you built up over the years that you can now interpret in the light of your new understanding of ADD.

This does not in any way release you from doing the necessary work to get your life in order. Yes, you will develop insights. But you will also need to work at developing skills you have never had before.

A good therapist will teach the ADD adult to acknowledge the importance of small steps in making progress. Often people don’t continue along the road of self-improvement because they don’t acknowledge their small steps of Progress. The person with ADD often expects a difficult problem to be solved rapidly. “I want it yesterday.” If it can’t be solved soon, the person gets frustrated and gives up. The adult with ADD who learns the value of taking small but positive steps toward a goal learns a very valuable lesson. The good therapist keeps the client on track and helps the client maintain a positive perspective.

Coaches can be therapists, although coaching is not therapy. Coaches can also be another ADD adult, a friend or someone in your family. ADD coaching focuses on practical issues confronting the ADD adult, such as organization, managing time and setting and reaching goals. Coaching could help ADD adults to develop routines and daily habits which will simplify and make their lives more manageable. Some coaches are very forceful and offer lots of suggestions while others prefer coaches who mostly listen and then offer ideas.

A coaching relationship could last any length of time, but a typical relationship lasts at least six months. Sometimes coaching is done in person, one hour a week. It can be done over the phone, 10-15 minutes a day, or even done through e-mail. Hiring a trained person to be your coach is called professional coaching while getting someone else to work with you is called peer or partner coaching.

A coach works with you to improve your results and your successes. A coach will:

  1. help you set better goals and then reach those goals
  2. ask you to do more than you would have done on your own
  3. get you to focus your efforts better to produce results more quickly
  4. provide you with the tools, support, and structure to accomplish more

How does coaching differ from consulting? …therapy? ….sports coaching? …Having a best friend?

Coaching is a form of consulting as coaches provide advice and expertise in achieving personal change and excellence. However, unlike the consultant who offers advice and leaves, a coach stays to help implement the recommended changes, making sure they really happen and ensuring that the client reaches his goals in a lasting way.

In most therapies, patients or clients work on “issues,” reflect on their past experiences and try to understand the psychodynamic causes of their behaviors. Coaching focuses only on the here and now, looking at the problems in the present needing solutions. In this way, it is like solution-focuses therapy. Coaches work with their clients to gain something, such as new skills, not to lose something, such as unhealthy thought patterns. The focus is on achieving personal and professional goals that give clients the lives they want.

Professional coaching includes several principles from sports coaching, like teamwork, going for the goal, and being your best. Unlike sports coaching, professional coaching is non-competitive. You develop your own way to achieve your goals. There is not one best way to do it. It is not focused on outdoing someone else. It is focused on strengthening the client’s skills, such as a trainer might do.

Having a best friend is always wonderful, but you might not trust your best friend to advise you on the most important aspects of your life and/or business. A best friend might not be able or willing to provide the consistency in monitoring and feedback that coaching demands. The relationship with your coach has some elements of a good friendship in that a close relationship evolves. The coach knows when to be tender or tough with you, is willing to tell you the truth, and keeps your best interests foremost in the relationship.

“A coach is your partner in achieving professional goals, your champion during a turnaround, your trainer in communication and life skills, your sounding board when making choices, your motivator when strong actions are called for, your unconditional support when you take a hit, your mentor in personal development, your co-designer when developing an extraordinary project, your beacon during stormy times, your wake-up call if you don’t hear your own, and most importantly: Your coach is your partner in living the life you know you’re ready for, personally and professionally.” —Thomas Leonard, President of Coach University

People hire coaches because they want more to their life; they want to grow as individuals, and they want to make achieving their goals easier. When using a coach, people take themselves and their goals more seriously. They immediately start taking more effective and focused actions. They stop focusing on thoughts and behaviors that drag them down. They create a forward momentum to their lives and they set better goals for themselves than they would have without a coach.

COACH SELECTION RECOMMENDATIONS

Rapport is very important. Your relationship with your coach is important to your professional and personal growth. The effective coaching relationship is an effective model for all your other relationships: inspiring, supporting, challenging and productive. Choose someone you will be able to relate to very well.

Experience in your field is less important, although knowledge of A.D.D. is important. Coaching technology works for a wide variety of people, professions, and situations. A coach with experience in your personal or professional situation may understand you more quickly. However, much of your work with a coach will involve encouraging you to use and develop your personal skills and your expanding network. Therefore, the specific business experience of your coach is not as important as you might think. Coaching technology works independently of the business or professional environment.

Location is normally not important. While some coaches do offer on-site coaching, it is normally not necessary nor efficient. You will get the same or better results with telephone coaching at a fraction of your investment with on-site coaching.

Interview more than one coach before you decide. Most coaches are happy to speak with you for several minutes in order to get to know you and your situation. You can use this time as an opportunity to gather information and an impression about the coach’s style. Compare two or three coaches and select the one who seems most helpful to you. Trust yourself to know what you need.

Ask the prospective coach good questions. Great coaches are willing to answer your questions directly and forthrightly. Consider asking questions about their depth of experience, qualifications, skills, and practice. For example:

  1. “How many clients have you coached, and how many are presently active clients?”
  2. “What is your specialty and how long have you been practicing in that specialty?”
  3. “What is your knowledge of Attention Deficit Disorder? (expand this to be lots of questions–modify those suggested earlier for evaluating a mental health professional’s knowledge of ADD)”
  4. “How many clients have you had with A.D.D.?” What percentage of your clientele has this diagnosis?”
  5. “What qualifies you to coach people in my situation and how many people with my concerns have you coached?”
  6. “How do you typically work with a client?”
  7. “What are the names and numbers of some of your clients so that I may ask about your coaching?”
  8. “How long do clients usually work with you?”
  9. “What are your fees?”

RESOURCES

Find Treatment and Support for ADHD

Find an ADHD coach

The inspiration for this article and some of the information on the journey, its stages, (stage IV is my addition), guides and fellow travelers came from a self-published booklet, “Coaching Partners,” by Lisa F. Poast

Material on therapy and therapists was adapted from  Do You Have Attention Deficit Disorder? by Lawrence Thomas, Ph.D. It is published by Dell Books

Information on coaching was obtained from the International Coaching Federation.

*About the author

0 1 CynthiaHammerEarlyCynthia Hammer, MSW, ACSW, an adult with ADHD and the parent of three sons, two with ADHD. At age 49, she learned that she had ADHD and realized she knew very little about the disorder. Cynthia founded ADD Resources in 1994 and went on to become a nationally recognized advocate for the understanding of ADHD among both those who have it and those who treated it.  Cynthia is now retired and lives in Tacoma with her husband.

Original Source https://web.archive.org/web/20040207085617/http://www.addresources.org/newsletter_sample.php#journey

(Image courtesy of Stuart Miles/ FreeDigitalPhoto.net) Modified on Canva 

Treatment for ADHD and Addiction

New treatments combine medication for ADHD, drug detox and therapy.

by Trey Dyer

About 4.4 percent of American adults — 10 million people — have ADHD. And roughly 8 million children have been diagnosed with the disease, making it one the most commonly occurring mental health disorders in the United States.

 

The rate of co-occurring substance use disorders is high among those with ADHD. Individuals with this diagnosis are 2.5 times more likely to develop a substance use disorder. A study by researchers at Massachusetts General Hospital found that 15 to 25 percent of adults who have a substance use disorder also have ADHD.

 

For co-occurring ADHD and substance abuse disorders, the best treatment programs combine medical treatment for ADHD, drug detox and therapy that addresses both disorders. Additionally, proper ADHD treatment during childhood can prevent further development of the disorder that may lead to a substance use disorder during adulthood.

 

The risk for substance abuse is often higher for people with ADHD. Compared to the general population, people with ADHD are:

  • Three times more likely to develop a nicotine use disorder
  • Two times more likely to develop an alcohol use disorder
  • Two times more likely to develop a cocaine use disorder
  • 5 times more likely to develop a marijuana use disorder

 

Research shows that those with ADHD may have lower levels of dopamine — the brain chemical responsible for reward-seeking behavior — and turn to substance abuse or other dopamine-releasing behaviors as a result.

 

Despite the increased risks, those with co-occurring ADHD and substance use disorders are not doomed to struggle with addiction their entire lives. Many rehab centers offer specialized programs for co-occurring disorders that focus on treating the separate disorders concurrently, giving patients a realistic chance of reaching recovery and living a healthy life.

Treatment for Co-Occurring ADHD and Substance Use Disorder

 

Treatment for co-occurring mental health and substance use disorders is most effective when the disorders are treated simultaneously. Addressing them at the same time is preferred to treating them one at a time, which was the generally held practice in the past.
Medication is the most common form of treatment for ADHD, and with proper use, it can greatly benefit those with co-occurring ADHD and substance use disorders. Stimulant and nonstimulant medications can be effective in treating individuals with ADHD with or without a co-occurring substance use disorder. The most common types of medications used to treat ADHD are stimulants.

Stimulant Medications

A study by researchers at Massachusetts General Hospital examining the results of six long-term studies found that stimulant treatment for ADHD during youth leads to reduced risk of developing a substance use disorder during adolescence and adulthood.

 

The two most common stimulants used to treat ADHD are methylphenidate and analogs of amphetamine.

 

Amphetamine medications activate the reward pathway and trigger the release of dopamine in the brain, bringing balance to dopamine levels among those with ADHD. This can help alleviate drug cravings.

 

According to researchers at Columbia University, clinical trials of Ritalin (methylphenidate) have also been effective in reducing symptoms of ADHD and substance use disorder when combined with relapse prevention therapy. The drug has a relatively low risk of abuse under proper medical supervision.

 

Methylphenidate has been used for decades to treat ADHD and has shown to be effective for children and adults. Uncontrolled trials of methylphenidate have shown to have a positive impact in reducing symptoms of ADHD and cocaine use disorders, according to researchers at Columbia University.

 

Nonstimulant Medications

 

Some nonstimulant medications can be used to treat ADHD and may present an alternative to stimulants. While stimulants have a higher abuse potential, nonstimulants are often seen as a less effective treatment option.

 

Atomoxetine is a selective norepinephrine reuptake inhibitor that can be used to treat ADHD. It affects those with ADHD similarly to stimulants, but in a more gradual manner. With no known abuse potential, atomoxetine is an attractive alternative to stimulant medications.
Tricyclic antidepressants have also been used to treat ADHD. However, they are generally less effective than stimulants in treating ADHD.

Problems with Medication Treatment

 

Research from Massachusetts General Hospital shows medications that are effective in treating adult ADHD may be effective for adults with ADHD and co-occurring substance use disorders, but the medical benefits of the medications are hindered if an individual is actively abusing substances.

 

Challenges of treating patients with a substance use disorder include:

 

  • Patients may not take medications reliably.
  • Patients may require higher doses in order for a medication to be effective.
  • The presence of other substances in a patient’s system may make the therapeutic effects of a medication less effective.

Individuals actively engaging in substance abuse are more difficult to treat with medication, with or without a co-occurring disorder.

 

Alcohol and ADHD Medications

 

ADHD medications are associated with high risks when used concurrently with alcohol. Adderall is a medication of particular concern because it is commonly abused by college students who participate in binge drinking culture at parties, bars and nightclubs.

Individuals who abuse Adderall and alcohol together find that the depressant alcohol effects are lessened by the stimulant properties of Adderall, allowing them to drink more for longer periods of time.

Abuse of Adderall or other ADHD medications while drinking may cause people to consume hazardous amounts of alcohol. ADHD medications that block the depressant effects of alcohol may cause individuals to ignore signals from their bodies that they have had enough to drink, which can lead to dangerous health concerns such as alcohol poisoning.

It is crucial for people to consult their doctor about alcohol use while taking any type of ADHD medication.

 

About the Author: Trey Dyer is a writer for DrugRehab.com. Trey is passionate about breaking the stigma associated with drug addiction in the United States. When Trey is not writing, he can be found fly fishing, playing soccer or cooking BBQ.

 

Sources:

 

Adler, L. et al. (2005, March). Long-term, open-label study of the safety and efficacy of atomoxetine in adults with attention-deficit/hyperactivity disorder: an interim analysis. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15766294

Columbia University. (n.d.). Adderall: Health risks when combined with alcohol? Retrieved from http://goaskalice.columbia.edu/answered-questions/adderall-health-risks-when-combined-alcohol

Levin, F. et al. (1998, June). Methylphenidate treatment for cocaine abusers with adult attention-deficit/hyperactivity disorder: a pilot study. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9671342

Mariani, J. & Levin, F. (2007). Treatment Strategies for Co-Occurring ADHD and Substance Use Disorders. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676785/

Michelson, D. et al. (2003, January 15). Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12547466

National Institute on Drug Abuse. (2010). Comorbidity: Addiction and Other Mental Illnesses. Retrieved from https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf\

Somoza, E. (2004). An open-label pilot study of methylphenidate in the treatment of cocaine dependent patients with adult attention deficit/hyperactivity disorder. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15077842

Sottile, L. (2015, October 20). The Disturbing Relationship Between Addiction and ADHD. Retrieved from http://www.vice.com/read/the-disturbing-relationship-between-addiction-and-adhd-511

Wilens, T. et al. (2003, January). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12509574

 

“Image courtesy of stock photos/FreeDigtalPhoto.net” Modified on Canva

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My Emotional Journey with ADHD

“I am all that I was, and now I have the potential to be even more.”by Cynthia Hammer, MSW, ACSW – Founder of the non-profit ADD Resources

It Seemed So Easy for Others

Are wondering if you might have ADHD? Will it be immediately clear to you that you have ADHD so you’re able to set about getting diagnosed and treated? Is it the eureka moment that we so often hear about?  Can it be as simple as a parent takes their child in to be diagnosed for ADHD, recognizes it in themselves,  bursts into tears, is diagnosed and treated, and experiences a dramatic improvement in their life?

It Took Me Years

This was not my journey of awareness and acceptance of having ADHD. It took me over a year after learning about ADHD to realize I had this disorder and another year in treatment to develop a positive attitude. For any of you who may be reluctant to start your journey, I assure you that learning to accept and manage your ADHD will bring you more satisfaction and contentment with your life than you have ever experienced.

I Was So Sure It Was the Fault of My Poor Parenting

Although my brother and nephew were diagnosed with ADHD years ago, no bells went off in my head when we started to have problems with two of our children. Russell Barkley, Ph.D, says 40% of children diagnosed with ADHD have a parent with the same disorder while Ted Mandelkorn, MD, says that over 90% of those diagnosed with ADHD have a relative somewhere in the immediate or extended family who also has the condition. I knew there was a familial connection to the condition but thought what our children were exhibiting was plain, old-fashioned misbehavior. If we could only parent better, they would behave better.

And So It Went

Off and on I had read library books about ADHD. Sometimes I would think it described one or another of my sons, but then again, it did not sound quite like them. So it went for several years. Then my husband heard a pediatrician talk on ADHD. He came home convinced it described one son. We took him to be diagnosed and started him in treatment. After a year of attending treatment sessions with my son, along with more reading and attending CHADD meetings, I tentatively told the pediatrician treating my son that I thought I had ADHD as well and he readily agreed!

My Denial Pushed Back Help

The prime reason it took so long to help my children and myself is denial. No one wants to admit there is something the matter. They don’t want to have any impairment. They don’t want to be different from normal people. The condition is called a disorder, such a hopeless sounding label. My relatives with ADHD were having major problems in their lives. I was reluctant to associate my children with the same condition. Wasn’t this consigning them to a bleak future? Wouldn’t it be more hopeful to keep working on better parenting skills than to say they had this disorder? I thought ADHD was a handicapping condition that would be diagnosed and that would be it. I focused on denying the disorder, instead of on how treatment could bring benefit and improvement.

Accepting the Diagnosis for Others But Not for Me

After accepting the diagnosis and treatment for my sons, why did it take so long to see the condition in myself? Denial, along with two other factors, was at work. ADHD is difficult to self-identify because of its complexity and the lack of clarity in the description of the symptoms. One author would stress certain features or describe them in a way that I could relate to. I would say, “Yes, that’s me!” Another author would describe other features and it wouldn’t sound like me! I should have paid more attention to the wording that introduces a list of characteristics, where it says, for example, “will demonstrate 8 of the following 20 characteristics.” I didn’t need to have all the characteristics to have the condition, but the characteristics had to be of a degree and pervasiveness that they caused significant turmoil in my life.

Lack of Self-Awareness Made It So Hard

The other factor that makes self-identification difficult is related to an ADHD characteristic, a  lack of self-awareness. For example, I could feel I had offended a coworker, but I had no insight or understanding of how or why. I was too fearful of what they might say to ask them. ADHDers do not realize how they come across to others. (This is why it is helpful to have outside evaluations of your behaviors from people closely associated with you.) In many ways, people with ADHD delude themselves that they are doing just fine; it’s the others that they work with or associate with who have the problems. ADHDers always have good reasons to justify why they did something the way they did, and they do not understand why others might have a problem with that.

My Son Helped

My lack of self-awareness made me unable to examine my own actions and say to myself, “This is typical ADHD behavior.” However, I was able to look at my son’s troublesome behaviors and recognize that I did similar things. What he did (or did not do) that annoyed me were things that I did! As I analyzed my son’s annoying behaviors, I began to have some understanding of how I annoyed and frustrated others.

My Supervisor Helped

Another factor in my developing awareness was my supervisor. Her grandson recently had been diagnosed with ADHD, and she had read about the condition. She knew my two children had been diagnosed, and we sometimes would share information. During my annual evaluation, she brought up some points about my work that could use improvement, e.g., my inability to be a team player; my penchant for getting excited about a new project, but dropping it when only partly finished, blithely expecting someone to finish it because I had moved on to other things; and my not prioritizing my work so that the most important things got done. She said I was a mixed bag and that made it hard to evaluate me. I did some things very, very well and other things inadequately. I recognized these behavior patterns as common to ADHD. When I mentioned that I thought I might have ADHD (again my tentativeness), she said she thought so too.

Treatment Brought Me Relief

After getting diagnosed by a knowledgeable physician, I entered treatment, and like the condition itself, my emotions became very complicated. Of course, I felt relief, mentally saying over and over again, “So that explains it!” After starting on medicine, I immediately noticed improvements in my functioning and relationships. The education and counseling I received helped me learn which behaviors were related to ADHD, and I instituted techniques for managing or minimizing their disruptive influence. So it surprised me, when almost a year after being diagnosed, I blurted out, “I’ve been in a grieving process.” I hadn’t been aware of feeling this way until the words came out of my mouth.

Yet, I Grieved for the Loss of My Individuality

Why is there grief! I have two explanations. To accept the diagnosis and treatment, I had a loss in my self-image. Prior to knowing I had ADHD, I knew I was an individual. I did some things, maybe many things, differently than others, but I had a pride in most of my characteristics and abilities. Now I was learning that those characteristics that made me special are a disorder. Even though I had not seen the connection, my special characteristics had made my life more difficult than it is for normal people.

I Felt Disabled, Ashamed and Embarrassed

I felt like a disabled person. As I became more aware of how I came across to others, I felt shame and embarrassment. There was something the matter with me. Others could see it. Often they were reacting negatively to me because of how I acted. Even though part of me could see that my relationships were improving because of treatment, another part of me withdrew from relationships. I felt awkward and self-conscious, feeling that I was less than others.

I Grieved for the Life I’d Lost

The second reason for grief was a realization that my whole life had been less than it could have been. If only someone had only known about my ADHD years ago…. If only I had been diagnosed and treated years earlier…. Much in my life would have been better. These thoughts kept going through my mind. I reflected on the inappropriate actions I had taken, the people I had offended, the mistakes I had made. I felt ADD was accountable for all that had been bad in my life.

I Found Others Who Were Angry Instead

Many ADD adults, in addition to grief, experience anger as they recall their life experiences. They have so many unhappy memories of being demeaned, berated, and made to feel inadequate. Now they wonder why no one knew there was something wrong. They wonder why they weren’t treated with more kindness, patience, understanding, and love. It would have made such a difference!

Now, I Am All That I Was and More

With treatment, both grief and anger subside and resolve. I came to realize that knowing I have ADHD did not make me a new person. I stayed the person I was, my unique, special self. Only now I can better control the kind of person I am, and I am better at perceiving how I come across to others so I can adjust my behavior accordingly. Knowing about my ADHD and getting treatment for it did not make me less, as I initially thought. I am all that I was, and now I have the potential to be even more. In this context, I like to think of the American advertising slogan, New and Improved. While I am not a new model, I am an improved one! Life is a continuing adventure.

*About the Author

0 1 CynthiaHammerEarlyCynthia Hammer, MSW, ACSW, an adult with ADHD and the parent of three sons, two with ADHD. At age 49, she learned that she had ADHD and realized she knew very little about the disorder. Cynthia founded ADD Resources in 1994 and went on to become a nationally recognized advocate for the understanding of ADHD among both those who have it and those who treated it.  Cynthia is now retired and lives in Tacoma with her husband.

 

“Photo courtesy of Vlado-Free Digital Photo.net” – Modified on Canva

 

 

 

Washington Nonprofit and State Organizations

Washington Nonprofit and State Organizations for ADHD concerns

Support and Information      Find a provider          Parenting Classes    

 Educational Issues     Low income Help

 

Support and Information 

ADHD and Mental Health Nonprofits

 Parent Support groups Puget Sound area – CHADD – Children and Adults with ADHD

ADHD information and Support   ADD freeSources

NAMI  is the National Alliance on Mental Illness, the nation’s largest grassroots mental health. They work to raise awareness and provide essential and free referral, support, education, and outreach surrounding mental illness.

NAMI Washington has 23 NAMI affiliates  

NAMI – Greater Seattle

 

 Find a Provider

Learning Disabilities Association of Washington (LDAWA) provides a referral service to connect individuals – parents, children, teens, adults, and professionals – with resources throughout the Puget Sound. Learning Disabilities Association of Washington is a state affiliate of the Learning Disabilities Association of America.  New Online Directory

Call 211 to locate appropriate treatment and agencies. There’s also a website if you want to search for  yourself. ADHD, Learning Disabilities or Parenting classes yield good results. Washington Information Network – 211

Washington State ADHD Treatment Providers – Note: ADD freeSources does not endorse or recommend any provider or services listed. Nor should not being on the list affect your choice of provider. Most of these were chosen because they were associated with ADD Resources or local CHADD groups at some time.

Ark Institute of Learning in Tacoma assists students with a variety of learning challenges including; dyslexia, language disorder,  nonverbal learning disorder/visual-spatial processing disorder, dyscalculia, dysgraphia, specific learning disorder or disability, and attention issues. Provides assessments, training, and support – – Nonprofit, but services are billed at a regular rate.

Parenting Classes

CHADD’s  Parent to Parent Training – 14 hour Webinar Course

Puget Sound Parenting Calendar  → http://www.psasadler.org/calendar.pdf from the Puget Sound Adlerian Society (Give it a minute to load) Copy and paste URL

 

Catholic Community Services of Western Washington

Services and locations

Low-cost Parenting classes and counseling available at some locations

 

Education Issues Washington State

Washington P.A.V.E. Parent resource detailing the rights of children with disabilities to a free and appropriate education. 1-800-572-7368.

  • Parent training Centers – Statewide Parent Training Information Center (PTI) is a federally funded program that provides training, resources, and support for parents in Washington State whose children have special learning needs, individuals with disabilities, professionals – anyone interested in people with disabilities. Staff and volunteers work with you one-to-one or provide workshops on various aspects of obtaining appropriate services in the public school system.
  • Conducts workshops for parents and others on laws governing special education, testing and assessment, IEP’s, communication, 504 plans and other topics as needed.
  • Staff assists parents individually to increase skills in working with their children’s teachers, therapists, and other team members to obtain appropriate educational services.
  • Has volunteer community liaisons who assist parents.
  • Provides information about resources and specialists in your community.
  • Has information about resources and laws in Washington and other states.
  • Office of the Education Ombudsman is an agency within the Governor’s Office created to help elementary and secondary public school students and families in Washington understand how the public school system works, how to find education-related resources and how to resolve conflict with schools. This organization is independent and neutral and not a part of the state public education system.

Staff  Seattle office-Toll-free: 1-866-297-2597
Phone interpreter services available
Fax: 206-729-3251
OEOinfo@gov.wa.gov

 

Low Income Help

Diagnosis and Treatment for Children

Catholic Community Services in Whatcom and Skagit Counties offers specialized ADHD assessment, counseling, and case coordination for children of families with low income. Treatment includes collaboration regarding medication evaluation and management with primary care physicians, psychiatrists, and community clinicians. The clinic also provides parent education, behavior management classes, school consultation, and parent/teacher education.

Child Development Clinic – University of Washington has been operating since 1965 and serves approximately 200 children each year. Each child visits the clinic one to three times during the year and is served by multiple clinicians at each visit. About 80% of clients seen at this clinic are less than nine years of age. Over 50% of children served are insured by Medicaid.

Clients are diagnosed with an array of developmental disabilities including intellectual disability, autism spectrum disorders, motor disabilities, learning disabilities, behavioral disorders, communication disorders, and attention-deficit hyperactivity disorder.

 

Catholic Community Services of Western Washington

Services and locations

Low cost Parenting classes and counseling available at some locations

 

Hope Sparks – Tin Can Alley in downtown Tacoma

Offers core behavioral health programs – Counseling, parent education and family support

 

Please help complete these resources. These are what I had saved in my files from 3 years ago with updated links.  Leave a comment if you know of other organizations and services that pertain to ADHD.