Meet Dr. Liden, Part II

[continued from Part I]

Dr. Liden | The Being Well CenterIf I hadn’t had to live with the ramifications of Attention Deficit Disorder in my own home, I probably would have stayed with the approach [referring the management of ADD back to medical professionals with little training in ADD treatment] for a long time, thinking I was really making a difference in people’s lives.

Instead, as I faced the problem daily, I became aware of the pervasive, chronic nature of ADD and the need for a much more systematic and comprehensive treatment approach.

As a result, I left Children’s Hospital and organized a team of professionals including teachers, speech-language pathologists, psychologists, counselors, nurses, and others to begin TRANSACT Health Systems, now known as The Being Well Center.

Located near Pittsburgh, Pennsylvania, The Being Well Center provides diagnostic and treatment services for individuals with a variety of developmental, learning, and behavior problems — again, the most common being ADD.

At The Being Well Center, our initial focus was children and adolescents with these problems. However, it has become more and more apparent to us that there are large numbers of adults who continue to struggle with problems like ADD. Many of them are the parents and grandparents of the children we see. We have expanded our services to meet their needs as well.

Dr. Craig Liden | The Being Well CenterAs Senior Medical Director of The Being Well Center, I have counseled thousands of patients with ADD. I have worked with their family members. I have talked to hundreds of PTA groups and community organizations. I have conducted many in-service sessions about ADD for medical and educational professionals have supervised the expansion of our TRANSACT program to the other parts of Pennsylvania and the Eastern United States.

Through my involvement in all of these endeavors, I have become impressed with how little most people know about the common problem of ADD. Even though the same questions keep coming up, no one has provided a good resource that patients, parents, teachers, and others can use to better understand ADD. That is the rationale for my books, this blog, and our online communities on Twitter, Facebook, and LinkedIn: to provide practical, down-to-earth answers to the common questions about ADD, its assessment, and its treatment.

In putting together the answers, I have tried to combine the scientific knowledge I have gained as a researcher and teacher, the insights I have developed in working with professionals from other fields, the practical experience I have acquired in caring for more than 10,000 patients with ADD, and the hopes and fears I have experienced as a parent of a child with ADD.

Read Part I of Dr. Liden’s personal and professional 30-year journey in treating more than 10,000 individuals with ADD/ADHD.


Meet Dr. Liden, Part I

Dr. Craig Liden | The Being Well CenterI first became aware of Attention Deficit Disorder or ADD when I was a Pediatric Resident in training at the Children’s Hospital Medical Center in Boston.

When I began my rotations in the outpatient clinics, I expected to face challenging, diagnostic dilemmas involving clear-cut medical problems. Instead, I found that most of the children referred to these clinics were sent because of learning or behavior problems. I soon discovered that ADD was one of the most common reasons for these children’s difficulties.

At the time I really knew nothing about ADD.

I vaguely remembered hearing something about it during a lecture in medical school. As I tried to become more informed about Attention Deficit Disorder, I found that ADD was only superficially described in my textbooks; there was no standard reference book on the topic; and journal articles rarely agreed about what to call it, what it was, what caused it, or what to do about it.

I struggled to apply my simple cause-effect, medical model to ADD and what I got in return was frustration. So did my parents!

As a result of my frustration, I realized I could help myself to better understand and treat learning and behavior problems only with additional training in this area. I participated in a fellowship at Harvard designed to teach pediatricians how to research, teach about, and treat these problems.

During this fellowship, I began to develop an appreciation that learning and behavior problems, like ADD, are far from simple; that they are, in fact, highly complex.

I also learned that, as a physician, I have an important role to play in diagnosing and managing these problems, but that I can never do it alone. To be effective, I need to mesh my knowledge and skills with those of teachers, psychologists, speech-language pathologists, counselors, and others.

During my fellowship training, I had the opportunity to leave the hospital setting and see kids in the “real world.” While conducting research in schools, I was shocked to find that the children I had been seeing at the hospital’s clinics represented only the tip of the iceberg. More than a third of the apparently normal children I worked with demonstrated some type of problem in their learning or behavior. And attention problems were the most common.

After my fellowship, I took a faculty position in the Department of Pediatrics at the University of Pittsburgh and started a program called the Child Development Unit at the Children’s Hospital of Pittsburgh. This position gave me the opportunity to develop and research my own testing procedures for problems like ADD.

Being Well CenterIn addition, I had the chance to put together a unique team approach to address these problems. Team members included social workers, psychologists, special educators, and speech-language pathologists, as well as medical staff.

Throughout my years at Children’s Hospital, I also struggled with the frustration of trying to teach medical students and residents about learning and behavior problems. Similar to the feelings that I had experienced as a Pediatric Resident, most of them hoped to diagnose simple problems that would respond to the neat technological approaches that worked so well in other areas of medicine.

Unfortunately, problems like ADD do not fit this mold.

At this stage in my professional development, I focused too intensely on the diagnosis of problems like ADD and not enough on effective treatment.

Treatment, generally, was limited to a lengthy diagnostic report to a school. These reports concluded with recommendations telling teachers how to do their job better, and they did so without considering the kinds of resources, or lack of resources, at each school.

Needless to say, such pontificators from the ivory tower of the university did not promote the cooperative working atmosphere that would be most beneficial to my patients.

I also tended to refer the management of problems like ADD back to family doctors, pediatricians, or community mental health professionals who frequently had little training or experience. Unknowingly, this approach stirred up everyone’s concern but gave little practical support or guidance about how to deal with the problems.

If I hadn’t had to live with the ramifications of ADD in my own home, I probably would have stayed with the approach for a long time, thinking I was really making a difference in people’s lives… [Read more tomorrow for Part II]

Check back tomorrow for Part II of Dr. Liden’s personal journey that has helped him become a leading international expert on the treatment and diagnosis of ADD/ADHD.

How To Pay for ADD Treatment

image via Flickr, Bill Brooks

image via Flickr, Bill Brooks

What can be done when finances interfere with pursuing proper treatment for ADD?

In many states across the United States, children diagnosed with ADD are eligible for financial assistance for medical care through the medical assistance program.

While the criteria vary from state to state, eligibility, generally, is not dependent upon family income. Certain adults with ADD may be eligible for medical assistance as well; frequently, however, employment and income criteria apply.

Medical assistance is accessed through local Department of Public Welfare or Social Security Offices.

Children and adults whose functioning is severely compromised by ADD and whose incomes (or parents’ income) fall below establish guidelines may also be eligible for Supplemental Social Security Income (SSI), financial assistance available through the Social Security Office.

In my experience, a family’s success in pursuing these kinds of aid requires lots of paperwork, patience, focus, and persistence.

The costs of treating a chronic condition like Attention Deficit Disorder can be high, but the costs of the consequences of NOT treating it are even higher!  Take a look at the cost comparison between treated and untreated ADD/ADHD.  It will give you a needed boost of energy to tackle the insurance companies or government program red tape today!

ADD or Bipolar? Why it’s hard to diagnose the difference.

image via Flickr, Matt Anderson

image via Flickr, Matt Anderson

Differentiating between Attention Deficit Disorder and Bipolar Disorder can be very challenging, particularly for the inexperienced clinician. In part, this is because these two syndromes share some common behaviors, but also because there is an overlap in the incidence of the two problems.

Research and clinical experience suggest that a many as 30% of individuals with Bipolar Disorder also have ADD and somewhere around 3.5% of people with ADD have Bipolar Disorder. Therefore, there are a number of individuals who have both ADD and Bipolar Disorder.

While there can be shared characteristics between the two syndromes, there are a few factors that can help differentiate them. ADD is a chronic problem that shows up early in childhood and manifests itself continuously throughout life. On the other hand, Bipolar Disorder is very difficult to recognize before the early teen years and when it does show up, is episodic in nature.

In my experience, more than 95% of people with ADD demonstrate markers of what I call “neuromaturational delay” such as gross or fine motor incoordination, excessive numbers of soft neurological signs, persistent articulation difficulties in childhood, or a history of bedwetting or febrile seizures. This is not the case with individuals with Bipolar Disorder.

Finally, since both problems tend to run in families, a positive family history can help point us toward the right diagnosis.

Concerned about getting the right diagnosis?  Dr. Liden‘s (free!) download ebook, ADD/ADHD Basics 101, will steer you in the direction of a clinician you can trust and give you the knowledge you need to KNOW you have the right diagnosis.  Download ADD/ADHD Basics 101 right away!


ADD is NOT the same as Hyperactivity

image via Flickr, Carolyn Tiry

image via Flickr, Carolyn Tiry

Hyperactivity is one of the many labels that have been used over the years to describe individuals who demonstrate the characteristics of ADD. Other labels that have been applied to this same grouping of individuals include hyperkinesis, Minimal Brain Dysfunction (MBD), dyslexia, and learning disability.

The use of so many diverse terms to describe the same or similar behaviors has contributed to much of the confusion that surrounds ADD.

In fact, today many use the term ADHD or Attention Deficit Hyperactivity Disorder to describe all ADD individuals. They go on to break ADHD into several subtypes: primarily hyperactive, primarily inattentive, and combined type. I don’t embrace these labels and distinctions for several important reasons.

Don’t Perpetuate the Hyperactive Myth

First, holding onto the ‘hyperactive’ label perpetuates the myth in the minds of many lay and professional people that one must be hyperactive in order to have ADD. Clearly, this is not the case, since the majority of individuals with ADD demonstrate either a normal or a low activity level!

Hyperactivity is NOT a Core Characteristic of Attention Deficit Disorder!

Secondly, I don’t believe that hyperactivity is a core characteristic of the ADD syndrome. My observations over the years are that individuals with ADD show “hyperactive” behavior for two reasons, both grounded in underlying attention difficulties.

image via Flickr, Dana

image via Flickr, Dana

Some individuals with ADD demonstrate fidgetiness and motoric overactivity because they have underlying problems with low arousal and need extra movement such as squirming in their chair, bouncing their leg, or tapping their fingers to keep them awake.  Interestingly, these unconscious attempts to maintain arousal frequently disappear quickly when these individuals take one of the ADD medications that wakes them up.

Other ADD individuals appear to be “hyperactive” because their attentional weaknesses preclude efficient self-control of a temperamentally-based high activity level.

I have seen this in my own family. My older son got his mother’s weak attention and my high activity level. His impulsivity, distractibility, and poor self-monitoring coupled with his high activity level lead to his bouncing off the wall, numerous careless accidents, and disturbing out of his seat behavior. On the other hand, my high activity level has never been as problem for me. When it is coupled with my strong attention, I have been able to “put a method to my madness” to accomplish many things.

Real World People Don’t Fit Into Neat Little Boxes

I appreciate that categorization systems like DSM (Diagnostic and Statistic Manual) that split ADD into various subtypes (e.g., Hyperactive) may serve a purpose in defining a pool of research subjects or to clarify communication between professional. However, my experience in the real world is that individuals don’t fit into such neat little boxes defined by narrow criteria.

When all is said and done, what matters most when it comes to ADD are the five key characteristics of inattention. After this, every individual with ADD is unique: some hyperactive, some underactive, some intense, some very sensitive, some gifted, some retarded. What we see on the outside is the result of how the core characteristics mix with other traits, abilities, and characteristics.

Craig 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 publishingAccommodations 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.

The Truth About ADD Medication and Suicide

image via Flickr, Pedro Ribeiro Simões

image via Flickr, Pedro Ribeiro Simões

Attention Deficit Disorder medications do not appear to be a direct cause of depression or violent behavior.

However, the use of medication in individuals with ADD can unmask over-sensitivity, extreme intensity, or a low frustration tolerance that had been hidden by weak attention.

As these characteristics are uncovered in an individual with poor self-control and ineffective problem solving, they may make the person slightly more prone to violent outbursts or self-destructive acts. This is another reason that a person who is treated with medication for ADD must be followed closely and provided with strategies for more effective problem solving and self-control.

Moreover, some people with ADD seek help because they are overwhelmed by life and have become sad, depressed, and even suicidal.

Others can present with a history of violent temper outbursts often the outgrowth of poor self-control of impulsivity, intensity, and a low frustration tolerance.

Oftentimes, attempts to manage these behaviors with other medications such as antidepressants have been only partially effective.

For these two groups of people, accurately diagnosing and instituting proper medication use, coupled with other treatments can help them dramatically turn their lives around. In my experience, persistence of extreme dysfunctional behaviors in the face of proper medication and appropriate treatment suggests a need for more intensive psychiatric intervention.

Dr. Liden’s clinic, The Being Well Center, offers free resources for people working through the challenges of living with ADD and its related co-morbidities.  Don’t miss the BWC resources page for free downloads and ideas that could help you or a friend today.


The Truth About ADD Medication and Hypertension

image via Flickr, liviana1992

image via Flickr, liviana1992

ADD/ADHD stimulant medications and Strattera have been studied extensively and both have been found to cause slight, but clinically insignificant changes in blood pressure and heart rate in children and adults.

Any increase in heart rate or blood pressure that does occur tends to diminish as the medication is used over time.

Therefore, there is no need to routinely screen heart rate, blood pressure, or EKG’s before using any of these medications.

In my experience, the ADD medications can also be safely used with all of the medications currently used to treat hypertension.

However, some so-called beta-blockers can cause fatigue and sleepiness, which may aggravate ADD symptoms. If this occurs, either a switch in anti-hypertensives or an adjustment of the ADD medication may be necessary.

I have seen many adults with ADD who were hypertensive and receiving anti-hypertensive treatment at the time they were diagnosed with ADD.

Interestingly, when we instituted medication and other supportive treatment, they began eating better, exercising more, losing weight, and handling stress more effectively and soon had normal blood pressure with no need for anti-hypertensive medication.

For further insight into the clinical truth of ADD/ADHD medication, don’t miss Dr. Liden’s (free) download PDF of his book, ADD/ADHD Basics 301.  More honest discussion about the hot topics surrounding Attention Deficit Disorder can be found in our Pay Attention! blog series.

The Truth About ADD Medication and Tics

image via Flickr, Scarleth Marie

image via Flickr, Scarleth Marie

Twitches, tics, or tic-like behaviors are very common in individuals with ADD even before the use of medication.

When treatment is started with one of the stimulant medications, it is my experience that these behaviors decrease or stop in many individuals, stay the same in some and, occasionally, become worse in others.

The reason for these different responses is unclear. In many people, it appears that the aide of stimulant medication reduces tics by helping the individual to function more effectively and behave more appropriately. This, in turn, serves to reduce the underlying stress and anxiety that were the driving forces behind the tics.

In others, the reverse seems to be true. The increased awareness that comes with medication treatment leads to heightened anxiety and the emergence of or increase in tics.

There is no predictable effect from stimulant to stimulant regarding their impact on tics.

That is, for a given individual, tics may appear or increase with one stimulant medication and not with another.

Because Strattera has a different mechanism of action, it really has no potential to increase or cause tics to emerge. For this reason, Strattera may become the medication of choice in patients with a history of tics, twitches, or Tourette Syndrome unless other factors point to a need for a stimulant. In several of my patients with tics, the institution of Strattera either stopped or greatly reduced tic behavior.

For further insight into the clinical truth of ADD/ADHD medication, don’t miss Dr. Liden’s (free) download PDF of his book, ADD/ADHD Basics 301.  More honest discussion about the hot topics surrounding Attention Deficit Disorder can be found in our Pay Attention! blog series.

The Truth About ADD Medication and Seizures

image via Flickr, r. nial bradshaw

image via Flickr, r. nial bradshaw

It was once believed that ADD/ADHD medications could lower the threshold for having seizures in individuals who have underlying seizure disorders.

Careful research and lots of clinical experience has shown this is not the case. With the exception of the second-line ADD medication, Wellbutrin, which can lower seizure threshold, it has been my experience that all of these medications can be used safely in individuals with a seizure disorder. The presence of a seizure disorder should not be a contraindication to medication use.

Furthermore, the ADD medications do not interfere with the effectiveness of any of the anticonvulsants. However, some of the anticonvulsant medications can lower an individual’s arousal level and, thereby, exacerbate ADD symptoms.

Occasionally, when arousal is a problem, physician managing the seizure disorder may be able to switch to a different anticonvulsant that has less associated sedation. If this is not possible, then the increased attentional weaknesses that can accompany the use of anticonvulsant therapy need to be managed by modifying the ADD medication regimen.

For further insight into the clinical truth of ADD/ADHD medication, don’t miss Dr. Liden’s (free) download PDF of his book, ADD/ADHD Basics 301.  More honest discussion about the hot topics surrounding Attention Deficit Disorder can be found in our Pay Attention! blog series.


3 Ways to Have a Positive Experience with ADD Medication

image via Flicker, Nan Palmero

image via Flicker, Nan Palmero

1. Participate in a Comprehensive Evaluation

There are many things an individual can do to increase the likelihood he will have a positive experience with medication. First, and perhaps most critical, it is important that the individual has participated in a comprehensive evaluation before starting medication and has a treatment plan in place that addresses not only ADD but also any co-morbid problems.

Failure to properly identify and manage any co-morbid conditions is one of the most common reasons people don’t do well with these medications.

He should also seek out a physician and other professionals with a significant amount of experience with treating ADD in children, adolescents, and adults to implement the treatment plan; the quality, value, and wisdom of the support, direction, and feedback an experienced clinician provides can help an individual through even the most difficult adjustments to medication.

2. Stick with the Medication for a “Fair Chance” period

image via Flickr, Luz Adriana Villa

image via Flickr, Luz Adriana Villa

Secondly, it is important for the individual to stick with the medication and give it a “fair chance.” It is not unusual for it to take several weeks or in the case of Strattera, a month or more for everything to settle down and the individual to start to reap the benefits of improved attention.

While patience is not usually a virtue of individuals with ADD, this is one place where working extra hard to persist can pay big dividends.

3. Maintain a Healthy Daily Routine

Finally, in my experience, establishing and maintaining what I call a healthy daily routine (HDR), is the single most important thing an ADD individual can do to have a positive experience with medication.

My staff and I put a lot of energy into helping our patients establish a good HDR consisting of the following:

  • Going to bed and waking up at approximately the same time every day
  • Getting an adequate amount of sleep; for adults this means approximately 7 or 8 hours and for children even more depending upon their age
  • Eating three meals a day at predictable times
  • Eating a balance of foods from all of the food groups
  • Drinking adequate amounts of water ― for adults about 8 glasses a day
  • Getting approximately 30 minutes of aerobic exercise each day
  • Participating in a mentally challenging activity other than work or school each day
  • Taking time to participate in 15 to 20 minutes of a mind-centering activity (meditation, yoga, prayer, etc.) each day
  • Spending time with family and friends each day
  • Taking care of daily responsibilities: health, finances, home and work
image via Flickr, Dr. Abdullah Naser

image via Flickr, Dr. Abdullah Naser

The components of a HDR may seem so obvious, yet for many people – with or without ADD – establishing and maintaining a healthy lifestyle is very difficult. Over the years, I have seen the tremendous benefit of including these simple activities into daily life.

My patients who are committed to and consistent in their routines, time and time again, are successful with medication use and experience significant improvement in their daily functioning. My patients who are not are more likely to have problems with the medication and, often, do not experience the tremendous benefits others experience with medication.

When individuals embrace and maintain a good HDR, their medication works better, they experience fewer side effects, and they lead healthier, happier, and more productive lives.

A balanced HDR is so critical to a positive experience with treatment for ADD that I learned long ago to make it the first thing I ask about when an patient says things are not going well. I am almost always rewarded. When one of my patients who had been doing well complains that the medication does not seem to be working as effectively or that an unpleasant side effect has suddenly emerged, it invariably turns out that some element of his HDR has gone awry and things snowballed from there. My experience is that getting his HDR back on track oftentimes boosts the effectiveness of the medication and eliminates nagging side effects.

Keep the Goals of ADD Medication Treatment in Mind

image via Flickr, devinf

image via Flickr, devinf

There are three key goals in using medication to treat ADD.

First is to improve the individual’s attentional status. Specifically, we want the individual to experience increased arousal, improved focus, decreased distractibility, improved monitoring, and a longer attention span.

Secondly, the medication should enable the ADD individual to take advantage of the other therapies that are important in addressing all his needs. That is, we want the medication to make the individual more available to treatments that teach new skills and behaviors, provide compensatory strategies, and address co-morbid conditions.

Finally, and most importantly, the medication should assist the ADD individual to function efficiently and effectively in all life spheres throughout the whole day.

Tap into more of Dr. Liden’s expertise in the safe and effective use of medication to treat ADD/ADHD in his free ebook, ADD/ADHD Basics 3o1.