7 Keys to Successful (and Safe) Medication Treatment for ADD

image via Flickr, Purple Sherbet Photography

image via Flickr, Purple Sherbet Photography

Medication is often needed to help individuals optimally manage their ADD.

Without the aide of medication, it is almost impossible for most individuals with ADD to function to the best of their abilities and take advantage of other intervention strategies.

Yet, fear of medication, much of it unfounded, stands as a major barrier for many people to even take the step to get evaluated for ADD, let alone begin treatment for it.  Based upon more than 30 years of experience with over 10,000 patients with ADD, I’ve found there are seven keys to a successful and safe experience with medication.

  1. Find the right physician.

    Successful management of ADD requires that prescribing physicians have had specific ADD training and lots of experience working with ADD and the medications used to treat it.  They should have strong communication skills, the willingness to listen to your concerns and address them in a timely manner and a commitment to providing regular long-term follow-up. Critically evaluate your physician and his/her approach before you commit to medication treatment.

  1. Get an accurate diagnosis.

    Most knowledgeable physicians follow systematic procedures to arrive at an accurate diagnosis.  This may include the use of checklists, questionnaires, structured interviews, and ideally, some objective testing of attention abilities.  It’s one thing to hear about symptoms from a patient or significant other, but actually observing the individual’s attention during testing raises the reliability and validity of a physician’s ability to diagnose ADD to a whole different level.  Objective testing helps sort out individuals who don’t really have ADD and weed out those who might be drug seeking.  It also provides a baseline that can be used to accurately judge responsiveness to medication treatment. Response to a trial of medication should never be used as a diagnostic test!

  1. Make sure someone looks at the whole you.

    Each individual with ADD has their own unique profile…different temperaments, skills, abilities, health status, life experiences, attitudes, and beliefs.  Understanding these individual differences and their potential impact on medication treatment are critical for a successful experience.  Incorporating them into the process can help you and your physician interpret and manage apparent side effects and comply with the appropriate medication regimen.  More than 70% of individuals with ADD have co-existing mental health and/or chronic medical problems, sometimes as a consequence of untreated ADD.  If these go unrecognized or untreated, they can sabotage a successful experience with medication.

  1. Participate in objective medication trial tests.

    image via Flickr, Purple Sherbet Photography

    image via Flickr, Purple Sherbet Photography

    Judging the effectiveness of a given dosage or regimen of medication by relying on informal, unstructured observations or simple checklist/behavior ratings forms is fraught with difficulties.  Some observers don’t really understand what they should be looking for or have preconceived ideas about what should or shouldn’t happen, while others may have attitudes or beliefs about medication that color their observations.  The context of where people are making their observations can also result in great variability…monitoring effectiveness in a structured classroom is very different from watching a child play with peers in the backyard or sit in front of the TV or computer.  Asking an adult with ADD “How’s it going?” is like asking the blind to lead the blind…what it takes to make accurate self-observations is good attention and that’s the very thing they don’t have!  It is far better to find the right starting dose for a particular medication by participating in serial objective tests of attention on various doses of medication beginning with the lowest one that could make a difference and advancing as needed until an optimal dose is found.  This process helps ensure that the initial starting dose that you or your child starts taking in the real world is in the right ball park.  Then, fine tuning can be done based upon targeted observations in multiple life arenas.  The right medication, dosage, and daily regimen varies greatly from individual to individual based upon their unique attentional profile, degree of their problem, and the genetically-based way they metabolize various medications.  It is not uncommon for an optimal medication regimen to exceed the drug manufacturer’s marketing guidelines.

  1. Request a regimen that provides you all day coverage.

    ADD is a neurologically-based problem that is present 24 hours per day, 7 days a week, 365 days a year.  It affects all aspects of life functioning.  As the day proceeds, the demands for efficient attention don’t decrease, they actually increase…it’s harder to pay attention during homework time, completing chores, maintaining healthy eating habits, driving a car, controlling emotional reactions, and communicating with others than it is to pay attention at school or work.  Therefore, individuals with ADD should have medication regimens that give them good attention from as close to the moment they wake up in the morning to the time they go to bed at night.  This might require using different combinations of medications: multiple doses of a short-acting medication, a long-acting combined with a short-acting, 2 doses of a long-acting or a stimulant in combination with a non-stimulant (e.g., Strattera).  It is safe to take multiple doses of these medications during the day because their effects are not additive.  More importantly, all day coverage helps reduce the serious risks that come with untreated ADD.  All day, all week coverage actually helps reduce the frequency of more common side effects such as appetite suppression and sleep disruption.

  1. Establish and maintain a Healthy Daily Routine (HDR).

    Having a balanced HDR is probably the most important thing you can do to have a positive experience with medication treatment for ADD.  Maintaining a predictable bedtime and wake time seven days a week, eating at least three meals a day, getting daily aerobic exercise, practicing some type of mind centering every day, and setting up a structure for staying on top of daily responsibilities provide an important foundation for success with medication.  Each of the elements of a balanced HDR in and of themselves helps improve aspects of your attention and your ability to regulate your behavior.  As a result, the medication doesn’t have to work so hard to get you to where you need to be, which could mean being able to use lower doses of the medications.  A balanced HDR will also help eliminate or reduce many of the more common side effects that occasionally occur with the medications used to treat ADD.  So, Get Balance!  It’s good for ADD, it minimizes side effects, makes the medication experience go more smoothly, and it’s the right thing to do for your overall health.

  1. Never use medication as the sole form of treatment.

    image via Flickr, Purple Sherbet Photography

    image via Flickr, Purple Sherbet Photography

    Relying on medication as the sole form of treatment is a setup for problems.  Dramatic things can happen when an individual with ADD starts using a proper medication regimen.  Many positive things will happen: you’ll be more alert during the day, less impulsive, less distractible, and better able to sustain your focus.  These changes may lead to increased performance at school and work, better follow through with responsibilities, greater behavior control and improved relationships with others.  However, the medication opens up a “new world”, not only the good but also a greater awareness of problem areas.  If you’re a sensitive, intense person, there may be more things to be sensitive and intense about, you may tune into areas where you have been dropping the ball, or behaviors that are problematic and irritating to others.  Therefore, having improved attention can be difficult, anxiety producing or even depressing.  Sometimes these consequences of improved self-awareness are misinterpreted as side effects of the medication.

Most individuals starting medication need support to understand and cope with this “new world” and develop new strategies to address problems with emotional regulation, independent functioning, and social/communication difficulties that they become more aware of.  Having an experienced counselor or coach to help lead you down a path to success is critical.  They can help you process your experiences, define the contributors to your problems, brainstorm new strategies to address problems, and support acceptance of who you really are.  In addition, they can help you establish and maintain the all important HDR.  Medication treatment for ADD goes much better when you walk down this new path with an experienced guide!


Dr. Craig B. Liden | The Being Well CenterCraig B. Liden, MD  is an internationally recognized expert in the diagnosis and treatment of ADD/ADHD.  Since the 1980’s, Dr. Liden has been in private practice evaluating and treating behavior and developmental issues across the life span.   He has treated more than 10,000 patients with ADD/ADHD and related co-morbidities.  Dr. Liden  has written and lectured extensively about ADD/ADHD, education, individual differences and a variety of health problems, most recently publishing Accommodations for Success: A Guide and Workbook for Creating 504 Agreements and IEP’s for Children with ADD/ADHD and ADD/ADHD Basics 101: How to Be A Good Consumer of Diagnostic and Treatment Services for ADD/ADHD.   Dr. Liden is the Founder and Medical Director of The Being Well Center located in Pittsburgh, PA.  He is available for speaking engagements, workshops, and interviews.

Pay Attention!  5 Things You Need to Know (but don’t) About ADD/ADHD

Dr. Craig Liden | The Being Well Center

Based on my observations and studies treating ADD for the past 30 years, it’s fair to say that ADD touches upward of 20% of our population.  More than ever, we need to understand this often misunderstood, misaligned disorder.

People who are treating their ADD are living and thriving.  Let’s make the path to accurate diagnosis and effective treatment plans clear for all.

5 Things Everyone Should Know About ADD/ADHD:

1.    Attention Deficit Disorder is very common in adults. It is suspected that 1 in 25 adults has ADD.  However, only half have been properly diagnosed and less than a quarter are being properly treated.

2.    Untreated adult ADD can result in many chronic issues: obesity, chronic bowel problems, addiction disorders, depression/anxiety, and college failure, not to mention failed relationships, accidents, or poor job performance.  Properly diagnosing and treating ADD could have a huge impact on our society and health care system.

3.    Proper treatment of ADD with medication and counseling always starts with a comprehensive, diagnostic evaluation that includes objective testing, feedback from various members of the patient’s life, and a look at the whole person.

4.    Risks associated with correct medication use are minimal compared to the risks of untreated ADD.  Medication is often necessary but never sufficient and should always be paired with supportive counseling.  Stimulant medications used to treat ADD are generally very safe and are not addictive.

5.    The preferred name for ADD/ADHD is ADD since “Hyperactivity” is only one of many symptoms of ADD patients and shows up in less than 10% of those diagnosed.

Dr. Craig Liden is the Founder and Medical Director of The Being Well Center, an ADD/ADHD diagnostic and treatment center in Pittsburgh, PA that has helped more than 10,000 people worldwide living with ADD.

TRANShealth Inc. is sponsoring a free download of Dr. Liden’s book, ADD/ADHD Basics 101, in which Dr. Liden gives 10 steps to securing a diagnosis and treatment plan you can trust. 

 

Succeed in the Workplace in Spite of ADD

Are there jobs that are particularly good for the ADD adult?

image via Flickr, Nana B Agyei

image via Flickr, Nana B Agyei

It may seem that the presence of certain ADD traits make the ADD adult better suited for some jobs than others. However, we can find successful ADD adults in almost all jobs and all kinds of work.

Each person with ADD has a unique set of strengths and weaknesses that work together in a complex way to create ‘fits’ in world of work.

It is simplistic to think that an individual’s attentional characteristics, in isolation, should influence his career choice over the careful consideration of all parts of who he is.

What can an adult with ADD do in the workplace when ADD is interfering with job performance?

ADD can interfere with job performance in countless ways. Productivity problems, poor performance reviews, or probationary status may be indications that attention weaknesses are negatively impacting in the workplace.

When this occurs, the adult with ADD may invoke the Americans with Disabilities Act (ADA). Under this law, employers may be required to make accommodations that allow the person with a disability to be successful on the job.

In my experience, calling upon the ADA should be done cautiously and only when employment is at risk. When, upon considering the risks involved in sharing personal medical information with an employer, the adult with ADD chooses to invoke the ADA, he may begin by discussing with his employer, his disability, its impact upon job performance, and his request for accommodations.

When the request for accommodations are “reasonable” and will not cause the employer “undue hardship” or alter the job basic requirements, the employer is required to make those or similar accommodations.


Don’t miss our prior discussion about when and how much to share with your employer about ADD!

Behavior Change for the Adult with ADD

How does the adult with ADD work toward positive behavior change?

image via Flickr, Esther Gibbons

image via Flickr, Esther Gibbons

In my experience, the journey toward positive behavior change for the ADD adult begins with an experienced professional leading him through the same steps we encourage parents, teachers and childcare providers to use in managing behavior in children with ADD. That is, we help the adult with ADD to do the following:

  • Know who he is. It is important that he understand and accept his temperamental characteristics, his skills and abilities, his attentional abilities, his physical abilities, the stresses in his life, his attitudes and beliefs, and his self-esteem. He must understand which of these are changeable and which are not.
  • Set realistic expectations for himself. Based upon his understanding of his own unique profile of strengths and weaknesses, he defines behaviors are achievable for him.
  • Determine the factors contributing to an unproductive behavior and/or situation when it occurs.   In doing this, he asks himself the following questions:

◦ What is the expectation that is not being met?

◦ What are all the contributors to this failure?

◦ What role do I play in this?

◦ What role do factors outside of me play?

◦ What contributing factors are changeable and which are unchangeable or out of my control?

  • Develop a plan and put it into action. He refines the expectation as needed, and defines thoughts, actions, words and strategies that address all the factors that are under his control to maximize success at realizing the expectation, and tries it out in the real world.
  • Refine the plan when necessary. He reflects upon the success of the plan, and makes changes in the plan by modifying the expectation, the thoughts, words, action, and/or strategies.

In repeatedly guiding the adult with ADD through this sequence, the professional gives the adult progressively more responsibility. Ultimately, the adult becomes an independent problem-solver able to critically evaluate and modify his behavior in nearly any situation. In my experience, my adult patients who are open and committed to learning about themselves and how to effectively solve problems grow wise and become confident in their ability to deal with whatever is thrown their way.

How do limiting setting and use of consequences work with adults?

image via Flickr, Kaitlyn Rose

image via Flickr, Kaitlyn Rose

In adult life, limits and consequences are not generally defined in treatment or by supportive parents and teachers. Usually, it is our employer, our spouse, our friends, the police, the IRS, the bank, etc. who impose them.

Further, the limits are not always clearly defined and the consequences are often very serious. Treatment activities with the ADD adult involve clarifying the reality of the limits, defining strategies that promote success in meeting expectations, supporting and brainstorming plans when consequences do occur, and working with spouses, friends, and parents to help them allow the sometimes serious consequences to occur.


ADD/ADHD creates life challenges unique to each life stage.  Seek out care providers who have an appreciation for the challenges specific to adult expectations.  For help identifying a qualified care provider in your area, download Dr. Liden’s book, ADD/ADHD Basics 101.

Positive Rewards Backfire for Kids with ADD

Do reward systems work with children who have ADD?

In a word, no.

While the use of rewards may produce positive short-term improvement in behavior and are helpful in making kids feel good, they generally fail to result in long-term change.

image via Flickr, Lars Plougmann

image via Flickr, Lars Plougmann

In order for a person to change his behavior, he must stop and think before he acts. Initially, a reward may be attractive enough to motivate the ADD child to think before acting. As time goes on, however, he inevitably becomes bored with the reward; it loses its meaning and must be made more and more appealing in order to result in continued positive behavior.

From what I have seen in my patients, parents who rely on rewards to ensure appropriate behavior have to be very rich because very soon they cannot get the child’s attention with anything less than a new pony or some similar extravagance!

One of the biggest problems with the use of rewards as a technique of behavior modification is that it encourages the pattern of “I won’t do this unless I get what I want.” Without a “carrot,” the child does not behave appropriately. The real world does not work this way. We don’t have bosses who give us raises for making it to work on time, spouses who give us jewelry for making the bed, or friends who send us flowers for showing up for dinner on the right night. Rather in the real world, negative consequences occur when we fail to meet the expectations of daily living.

Some people are drawn toward the use of rewards and positive reinforcement as a means to build the low self-esteem that too often ADD children experience. In our enthusiasm to give these children a boost, we fail to appropriate that self-esteem does not come from a pat on the back, a new toy, or a dollar bill. Rather, self-esteem is an inside job–it develops from within when we face problems head on and make it through to the other side intact (even if we are stumbling), ready to face the next challenge that comes along.

Isn’t there any role for positive rewards in the management of ADD?

All of us appreciate a positive comment acknowledging our behavior, praise for succeeding at a new task, and simple expressions of affection.  This is certainly true for children, adolescents, and adults with ADD.

These positives can be especially important when the ADD individual is struggling with the impact attention weaknesses have on his life.

It is important for us to actively look for opportunities to give praise, a pat on the back, a little reward, and lots of cheerleading to the ADD individual for new behaviors, successes after struggles, and valiant attempts at difficult tasks.

These positives are valued as spontaneous expressions of feelings and thoughts. It is my experience, however, that when they become a negotiating tool or a method to coerce the ADD individual into good behavior, their value is lost.


Dr. Liden shares even more tips on effective responses to ADD/ADHD in his bestselling book, Pay Attention!

 

Get Help for ADD in School

School Success for ADD | The Being Well Center

image via Flickr, Jekino Educatie

There are two ways that students with ADD may receive support and accommodations in school. When ADD severely impacts upon learning and academic performance, the child may be eligible for Special Educational services through IEP law.

When a parent believes a child is struggling academically, the first step is to express his concerns to the building principal or guidance counselor. I always recommend that the parent put his concerns and a formal request for a thorough evaluation in writing addressed to the principal. In my experience, it is important that the parent keep a copy of all written documents for himself; creating a paper trail may be critical in insuring future educational accommodations for the child.

After a formal evaluation by qualified school personnel, the child with ADD may meet the criteria for being identified as learning disabled, emotionally disturbed or “other health impaired” and therefore qualify for special education services. At that point, parents and school personnel work together to define in writing an Individualized Educational Plan (IEP) to meet the unique educational needs of the child.

Section 504 of the Rehabilitation Act of 1973 states that any institution receiving federal fund must make accommodations for people with recognized disabilities. Because ADD is such a recognized disability, children with ADD are eligible for accommodations in any federally funded school.

Accommodations in school include allotment of extra time to complete tasks and tests, use of teacher signed assignment book, preferential seating and increased frequency of feedback to parents.

The first step in pursuing accommodations under Section 504 is for the parent to express his concerns and accommodations request verbally and in writing to the principal, guidance counselor, or, in college, the disabilities services office. As the appropriate accommodations are defined, it is important that they be formalized in writing; this ensures compliance, accountability, and future accommodations.

Are there other services available for the ADD child who experiences difficulties despite the usual interventions?

image via Flickr, Bart Everson

image via Flickr, Bart Everson

When ADD severely compromises the child’s functioning at home and school despite intervention, he may be eligible for Wrap-Around or Therapeutic Staff Support (TSS) services through the county or state mental health department.

These services assume different names and forms across the country and are dependent upon the unique needs of the child. For some children, the service involves access to a trained support person in the home to help with behavior management and independent functioning. For others, it involves having a support person accompany the child to each of his classes to facilitate his meeting school expectations.

While it varies from state to state, access to these kinds of services generally require the child be assigned a mental health or medical assistance case manager and to participate in additional comprehensive testing. I recommend to parents whose child can benefit from these services to begin the process by contacting the county or state mental health office.


Accommodations for Success | Dr. LidenIf you’re ready to secure educational support for your child, you will find Dr. Liden’s book, Accommodations for Success, invaluable.  Dr. Liden walks you through every step necessary to get the customized support you need for your child to achieve and succeed.

The Major Goals to Reach in ADD Treatment

What are the primary goals in working with the ADD individual?

 

image via Flickr, Steve Betts

image via Flickr, Steve Betts

Since ADD is the result of a built-in biological difference, it cannot be cured.

However, life can be made better for the individual with ADD.

While it is unrealistic to think that we can eliminate all the manifestations of the problem, it is possible to help the ADD individual be successful in life despite his attention weaknesses. His success requires that he develop improved self-awareness, better control of his impulsivity, inattention, and behavior, and become a more responsible life problem-solver.

When this occurs, the individual with ADD not only experiences an improved quality of life, but he minimizes the likelihood of his experiencing, in the future, the various social, emotional, and health dysfunctions for which he is at risk.

What are the main goals in working with the parents of a child with ADD?

One of the primary goals in working with parents is to help them accept ADD in their child.

This is a major challenge–accepting that their child is not perfect is a struggle for all parents!

For the parents of a child with ADD, the struggle is magnified by the fact that the child looks so normal on the outside and, on occasion, he can pull it all together. Lack of parental acceptance is the most frequent barrier to successful treatment.

Other critical treatment goals include:

  • helping parents to set appropriate expectations
  • to state the limits for behavior clearly
  • to appropriately structure the environment
  • to give feedback
  • to provide effective consequences for inappropriate behavior
  • and to reinforce self-awareness and self-control.

Finally, parents need help to find the middle ground between being harsh disciplinarians and being overprotective.

In setting goals for working with parents, it is important that professionals recognize parents’ desperate need for support–their children are tough to live with hour after hour, day after day.


Looking for clear answers and dependable support for ADD?  Dr. Liden’s best-selling book, Pay Attention, offers clarity and inspiration based on his 30 years experience diagnosing and treating more than 10,000 individuals living with ADD/ADHD.  Reader Margi S. comments, “I have read many books on ADD. Your book discussed many issues with quite a sensitive, matter of fact, confident presentation. I feel that teachers and parents would see the ADD child through different eyes if they read your perspective.”

Why ADD/ADHD is Frequently Misdiagnosed

image via Flickr, Raul Hernandez Gonzalez

image via Flickr, Raul Hernandez Gonzalez

The ways that ADD shows itself are highly variable from person to person depending upon an individual’s age, unique personality characteristics, profile of strengths and weaknesses, and the stresses and demands place upon him.  Differences in any one of these areas combine with the characteristics of ADD to produce an unlimited variety of problem behaviors.

For example, the preschooler with ADD who is strong-willed, sensitive, and intense may be labeled as a behavior management problem; the school-age child with ADD, who has difficulty organizing his thoughts into words and following directions and has problems with phonetics may be diagnosed as language disordered; the adolescent with ADD who is defiant and unkempt and whose grades are suddenly slipping with the new academic demands may be suspected of abusing drugs and alcohol; and the adult with ADD who is shy, socially withdrawn, overweight, and has a low self-esteem may be seen as being depressed.

Because of our limitations as observers of human behavior, we tend to judge the book by its cover. Our snap judgments often interfere with responsibly looking below the surface to investigate the possible role of ADD in these problems.

Our suspicions regarding the cause of a problem naturally influence to whom we go for help. Commonly, this means we seek help from a single professional who has expertise in the area in which we think the problem lies. This increases the possibility of misdiagnoses in several ways.

Even good clinicians’ approaches to problems are colored by their disciplinary bias and training; that is, they generally find what they are looking for. The psychiatrist makes a psychiatric diagnosis; the neurologist makes a neurological diagnosis; and the school psychologist makes an educational diagnosis. Furthermore, depending upon their training and experience, many clinicians may not even consider the possibility of ADD.

All of this serves to reinforce the need for a comprehensive, systematic, team approach to evaluating all behavior, learning, social, life performance, and chronic health problems.

The fact that there is no definitive test for ADD further complicates diagnosis. While there is some general agreement, there are not universally accepted diagnostic criteria for ADD. This means that making the diagnosis of ADD requires qualitative data interpretation and decision-making. Unless it is highly systematic, such qualitative diagnostic techniques are susceptible to multiple sources of error. Pediatricians, family practitioners, and other health-related professionals who have received training in transdisciplinary approaches to diagnosis and treatment are uniquely qualified to conduct effective team evaluations.


How do you know if your chosen health care provider is qualified to diagnose ADD/ADHD accurately?  Dr. Liden gives you a series of criteria and key questions to ask when seeking an accurate diagnosis for ADD in ADD Basics 101.