In our specialty practice, we have now had the opportunity to care for more than 10,000 patients with ADD/ADHD over the past 35 years. Our youngest patient is 3 years old and our oldest well into her 90’s.
We have had the unique opportunity to watch ADD/ADHD across the lifespan from early childhood to late adolescence, from young adult life to mid-adult life, and from mid-adult life to the senior years. We know of very few individuals or medical practices in the world who have had the same extensive clinical experience with ADD/ADHD and the stimulant medications as we have had.
Several years ago, Dr. Liden was asked to present a peer reviewed paper at the first International Conference on Attention Deficit Disorders in Jerusalem, Israel sponsored by the Hebrew University of Jerusalem, entitled: “TRANSACT: Toward a Standard of Care for ADD.” Our approach to diagnosis and treatment including the use of medication was the only multidisciplinary clinical program selected for presentation at this first International Conference on ADD/ADHD. We received uniformly positive feedback from other physicians attending this conference.
Since 1980, we have conducted hundreds of lectures and workshops for physicians and other health related professionals from across the country and around the world regarding ADD/ADHD and the use of medication. Dr. Liden has presented testimony to the U.S. Congressional Oversight Committee regarding the proper use of medication in ADHD. He has also sat on advisory boards for several pharmaceutical companies and has served on the board of ADDA, the national advocacy group for adults with ADD/ ADHD.
Based upon years of clinical experience and research and a review of the medical literature, we have developed a highly systematic protocol for the use of stimulants in treating patients with ADD/ADHD. The following are key features of our approach:
All patients must first have a comprehensive, multidisciplinary evaluation (3 hours) that includes use of parent, child, and school questionnaires that survey the presenting concerns, efforts to address them, key life arenas where problems are appearing along with a review of the patients’ temperamental traits, readiness skills, attention and executive functioning, current and past health and mental health status, family history, attitudes, values and beliefs and a delineation of current daily routines for sleep, exercise, eating, stress management and other activities of daily living.
This is supplemented with a structured interview that probes areas of uncertainty from the questionnaire and delineates the course of the problem(s) over time.
All new patients participate in a neurodevelopmental survey of neuromaturational functioning, attention/executive functioning, expressive, receptive and pragmatic language skills, memory, problem-solving, and basic academic skills in reading, spelling, math, and written language.
All new patients undergo a targeted physical examination during which their mental status is also assessed.
At the conclusion of testing, patients/families meet with one of our medical directors to establish the ADD/ADHD diagnosis (if appropriate), identify any co-existing problems and generate a holistic profile of the individual’s strengths and weaknesses physically, emotionally, behaviorally, and educationally that helps develop a comprehensive treatment plan of which medication is only one part.
All patients receiving the ADD/ADHD diagnosis meet the DSM criteria at a minimum but also our refined criteria: chronic inattention and executive dysfunction, inattention and executive dysfunction apparent in multiple life spheres, evidence of attentional weaknesses and/or executive dysfunction on objective testing and the presence of neuromaturational delay (by history or through direct assessment using a standardized battery of “soft” neurological signs).
All patients who are prescribed medication must be involved with ongoing follow-up sessions with a professional counselor that are directed at improving self-awareness and self-control, establishing healthy daily routines, developing compensating strategies, and providing on-going emotional support. We never prescribe stimulant medication in isolation or as the sole mode of treatment for ADD/ADHD. We insist that our patients participate in the supportive follow- up visits on at least a monthly basis (or more frequently as needed) as a prerequisite for us to continue to write prescriptions for their ADD/ADHD medications.
After the initial comprehensive evaluation, all patients for whom stimulant medication is indicated are required to go through systematic medication trial testing in our office. This involves taking a dose of medication at home and coming into the office for an appointment at a time that corresponds to when the effect of that dose should be at its peak. While in the office, they undergo objective testing of attention using the FACES, a distinctive feature analysis task we have developed, or other objective measures of attention.
Results are compared to a previous baseline performance without medication. At the time of the medication trial visit, a physical assessment including vital signs and behavioral observations are made while the patient is on the medication to monitor for any adverse effects.
In conducting these trial tests, we use a set of prescribing guidelines from the American Academy of Pediatrics (2000) based on mg of generic, short-acting methylphenidate/kg body weight/dose, not on unsubstantiated absolute dosage limits as a starting point to select the initial dose for in-office trial testing. Using this basic formula, we calculate the equivalent mg/kg ratio for other medications that are not short-acting methylphenidate (e.g., Concerta, 18 mg = 5 mg methylphenidate, b.i.d.). The Academy’s position on medication is a reflection of many clinician’s experiences and the medical literature which shows increasing positive attention benefits as one moves up in the mg/ kg ratio (i.e., .7 mg/kg dose has a greater positive effect then .3 mg/kg dose). These guidelines have been signed off by all the major professional organizations including the FDA.
We inform all of our patients when the dosage we recommend via the Academy’s guidelines exceed the FDA approved manufacturer’s marketing guidelines and have them sign an informed consent.
Generally, we conduct the first trial test with a dose of the medication that falls around 0.3 mg/kg body weight with allowances made for the severity of the patient’s ADD/ADHD, his/her specific profile of attentional weaknesses, the presence of co-morbid conditions, and his/her previous experience with medication among other things. We repeat trial tests in the office until we find the lowest possible dose that gives significant positive objective benefits without adverse side effects.
Once the medication trials are complete, we have patients begin a 1-2 week clinical trial on what appears to be the optimal dose in order to assess the effectiveness of the medication in the real world and its duration of action. We may elect to begin the clinical trial with what was determined to be the “optimal dose” during the trials or we may elect to start at a lower dose and gradually titrate upwards using the “optimal dose” from the trials as a final “target.”
Three days into the clinical trial we have a brief phone follow-up with the patient or significant other to assess the initial response to the medication and identify any untoward effects that need to be addressed.
At the end of the 2-week clinical trial period, we receive feedback from patients, parents, spouses, teachers, and/or employers, as the case may be, during in-office interviews and through objective feedback forms sent to schools. We make adjustments in the medication regimen accordingly to ensure optimal coverage for the waking day and to eliminate or reduce any negative side effects.
Using this approach, the overwhelming majority of our patients take doses of the medicine that fall within the 2000 AAP Guidelines (i.e., 0.3 to 0.8 mg/kg/dose). Interestingly, many of these same doses which are within the Academy’s Guidelines fall outside the FDA approved manufacturers, non-scientifically-based marketing recommendations.
Many other specialists in the treatment of ADD/ADHD have shared with us that they have had similar experiences. For example, Dr. Til Davy from the Toronto Sick Children’s Hospital, a world class pediatric facility, has published a lead article in the Journal of Developmental and Behavioral Pediatrics, a specialty journal, describing his experience. Dr. Davy summarizes some of the key issues with stimulant dosing and states that in his experience some children with attention weaknesses require doses of Ritalin in excess of 300 mg per day and tolerate them well. He adds that there is no reason to view this as a maximum.
We are seeing an increasing number of adults with ADD/ADHD and they participate in the same structured protocol as above. In general, it has been our experience that adults with ADD/ADHD uniformly require higher absolute doses of medication compared to children though the mg/kg ratio per dose is oftentimes somewhat lower. We find that while weight can help point one in the right direction (perhaps as a reflection of brain size) it is the severity of the individual’s attentional problem that seems to have the biggest impact on determining the most appropriate dose.
Other specialists treating ADD/ADHD adults have also found the need to use higher doses than the manufacturer’s recommendations. Dr. Daniel Amen, a nationally recognized researcher and clinician in the area of ADD/ADHD, has written to us describing his experience with medication doses and it is very similar to the one that we have experienced. Similarly, Drs. Marc and Nicolas Schwartz who see large numbers of adults with ADD/ADHD have studied optimal stimulant dosing in their private practice and have found adults require optimal doses of all stimulants that fall above FDA-approved manufacturers’ guidelines.
Once we have started patients on medication, we conduct a one-hour medication review visit every three to four months. At these visits, we re-assess attention either on or off medication
to document continued efficacy, monitor improvement and verify the need for continued use of the medicine. We also conduct an interview with the patient and significant others to monitor progress, identify problems, and respond to concerns. A targeted physical assessment including vital signs is conducted to monitor for any adverse effects. At the end of this visit, decisions are made about the medication (dosage, schedule, etc.) and the overall treatment plan is revised.
We look for every opportunity, if possible, to discontinue medication, but, not surprisingly, most of our patients seem to have significant problems which require long-term medication treatment. In carefully monitoring our patients, we have not identified any significant negative side effects with the stimulants that could be conclusively attributed to an off-label dosage/dosage regimen of medication prescribed.
We have found that most of the common side effects that occur with stimulants can be mitigated by adjusting the timing of medication, switching to another attention medication, helping patients establish and maintain balanced healthy daily routines, and providing ongoing supportive counseling in parallel with the medication.
The Cutting Edge of ADD/ADHD Management
We take our responsibility as health care providers extremely seriously and when applied to the management of ADD/ADHD, we feel that we are on the cutting edge. We have taken care to do things properly and have even submitted our approach to the State of Pennsylvania Medical Board, which found it to be in accordance with appropriate medical practice as defined by state statutes. We feel very confident and comfortable with the approach that we take with our ADD/ADHD patients.
If you’re new to Dr. Liden’s blog, you might want to Start Here to pick his brain on all topics ADD. If you’re looking for a way to get a diagnosis and treatment plan you can trust, check out The Being Well Center’s Accurate Diagnosis Determination (A.D.D.).