Straight Facts on ADHD and Medication (Part I)

Key Facts about ADD and Medication | The Being Well CenterAt The Being Well Center, we have developed a particular expertise in the use of medication in the treatment of ADD/ADHD. To achieve a high degree of success when it comes to medication treatment for ADD/ADHD we have found that it is commonly necessary for us to use off-label medication doses and regimens (i.e., for any medication dosage form, dosage regimen, population, or other use presently not mentioned in the FDA approved manufacturers’ marketing guidelines). Predictably this can magnify the inherent fear many patients, family members, uninformed physicians, and pharmacists have about the stimulant medications and can put us at odds with insurance companies that are increasingly restricting their formularies for ADD/ ADHD medications by imposing arbitrary quantity limits for these medications and failing to reimburse off-label uses of stimulant medications to treat ADD/ADHD.

Key Facts for Medication and ADD

Here are some key facts that combat misinformation and fear in the use of medication to treat ADD/ADHD:

  • Manufacturer labeling including dosage guidelines for Ritalin and Dexedrine, the early forerunners of the methylphenidate and amphetamine-based stimulants of today, were initially approved by the FDA many decades ago. This was at a time prior to the more rigid approval standards used today. Original documents used by the manufacturers to support their prescribing guidelines (which were ultimately approved) provided no scientific basis for the recommendations made, but rather, anecdotal feedback from a small collection of physicians who had experience prescribing the medications at that time.
  • These approved labels including manufacturer’s prescribing guidelines were subsequently grandfathered in when the United States Federal Food, Drug and Cosmetic Act (FD&C) was updated and amended. Therefore, books, clinical articles, professional society association pamphlets, drugstore/pharmacist printouts, package inserts, and other materials which use the FDA approved manufacturer’s marketing guidelines (i.e., the PDR) as the basis for their recommendations are probably the least scientifically reliable and valid pieces of information available to physicians to use in making informed decisions about stimulant medication dosages.
  • The manufacturer of a newer methylphenidate formulation, Concerta, worked out agreements with the FDA to get approval for its labeling and dosage guidelines without having to undergo extensive and expensive dosing studies provided that it adhered to dose recommendations that were equivalent to the FDA approved, yet unscientifically-determined, dosage recommendations for Ritalin. This means that the FDA approved manufacturer’s prescribing guidelines for one of the most popular medications used to treat ADHD, Concerta, are more than 50 years out of date.
  • The FDA has set a standard for medications used to treat ADD/ADHD that, to receive approval, manufacturers must demonstrate a 30% reduction in core symptomatology in blinded controlled trials in groups of individuals with and without ADD/ADHD using responses on FDA approved questionnaires or through behavior ratings from structured observations of subjects. The goal for pharmaceutical companies is to generate data to meet this standard for approval by using the lowest dose that shows group efficacy and the lack of deleterious side effects not what was the most effective dosage for individual participants. While this standard may be appropriate for manufacturers with regards to approval for marketing their products to the masses, it is out of sync with the real world realities of finding and using the most effective dosing regimens to properly treat an individual with ADD/ADHD. Most experts now agree that clinicians treating individuals with ADD/ADHD should be striving to provide 100% symptom relief (i.e., remission) throughout the entire waking day. Logically, this means that many ADD/ADHD patients might require dosages that are at variance with FDA approved manufacturer’s marketing guidelines in order to receive optimal care.
    • Once a drug is approved for use, it would be illegal for a pharmaceutical company to market it or make recommendations that are at variance with the original FDA approved guidelines even when years of clinical practice and the medical literature might suggest significant variations are warranted. Furthermore, senior management of pharmaceutical companies have told us and others that there is no incentive, in fact, significant disincentives, (i.e., exorbitant costs of conducting additional research to meet current FDA requirements and enhanced liability exposure) for them to generate more data with costly new trials to support approval of secondary indications or expanded dosages when off-label use is so common (40-60% of all prescriptions written) and sales of these products are so strong.
    • FDA approval of manufacturer’s marketing guidelines sets the parameters by which pharmaceutical companies can market their products to physicians and the public. However, they are not intended to dictate medical care. In fact, by the provisions of the FD&C Act, once a medication is approved by the FDA for marketing, physicians can prescribe it off-label for whatever conditions and at whatever dosage schedule they deem necessary to meet a given patient’s needs. In fact, off-label use of medications is an accepted and valuable part of quality care of a patient when used by physicians ethically and according to their best knowledge and judgment. Many organizations and experts have weighed in on the off-label use of medications and the consensus would appear to be that it represents good medical practice when the following pre-requisites are meet:
      1. The prescriber has experience and familiarity with the medication and the patient being treated
      2. No other alternatives are available
      3. Sound medical evidence in the published literature and/or other expert physicians support the intended use
      4. Efficacy and safety are closely monitored and documented

    Therefore, off-label use of stimulants above or outside of the FDA approved manufacturer’s recommended dosage schedule in marketing materials by experienced healthcare providers is not only permissible, but could actually be indicated to meet certain individual patient needs when there is either justification in the medical literature or evidence that peers with similar training and experience are prescribing them in this fashion. We will provide information in this white paper that confirms that both of these criteria are met when it comes to off-label use of stimulant medications for ADD/ADHD.


    Check back later this week for more Key Facts about ADD and Medication.  Don’t miss a post! Subscribe to our blog right now! Just register your email in the upper right-hand corner of this page.  We’d love to have you with us as we discuss the truth about ADD/ADHD!

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30 days or 30 years? How Long People with ADD Should Take Medication

image via Flickr, Pink Sherbet Photography

image via Flickr, Pink Sherbet Photography

People with ADD show a great deal of variability in the length of time that they require medication as an aid to control weak attention. Because ADD is a biologically-based, constitutional problem that people do not out grow, some individuals require use of the medication for a lifetime.

Fifteen years ago, I more was more optimistic about helping individuals get to the place where they could be independent of the medication. With lots more experience, I now know that independence from medication is the exception rather than the rule.

Over the years, I have become particularly cautious about my patients’ being off medication when I know they will be behind the wheel of a car or in social situations where their decision-making has potentially serious ramifications.

When we look closely at all areas of life functioning, more than 75% of my patients continue to demonstrate a need for the aid of medication in adult life.

Pre-Requisites for Going Off ADD Medications

Some individuals do reach a point where they can “do it on their own” for varying periods of time. I have found that the key pre-requisites for a patient’s getting to this place include:

  • a firmly established balanced healthy daily routines
  • a keen awareness of what his problems are and how to control them, and
  • an ability to see at risk situations in advance and make the necessary adjustments.

My patients who are most likely to meet these pre-requisites generally have:

  • ADD that is moderate in its severity
  • a number of strengths that can be mobilized to compensate for attentional weaknesses, and
  • a history of close involvement with professionals

The Benefits of a Great Support Team

image via Flickr, Bruce McKay

image via Flickr, Bruce McKay

Additionally, my most successful patients who tackle ADD challenges without medication usually fully accept their differences, are highly motivated, and are surrounded by supportive family members, friends, teachers, and others.

The shortest period of time a person I have treated has needed the assistance of the medication has been three months. More commonly, individuals with ADD require medication for at least several years before they are able to function effectively without it at least for a brief period of time.

How We Transition Patients Off Medication

In my practice, when a patient appears to be ready for an extended trial off of medication based upon parent, spouse, teacher and other feedback, I have him stop medication for a couple of days and come into the office where we determine via testing and structured observation his readiness to discontinue the medication.

When everything suggests that he will be successful off medication, I have him remain off the medication for an additional 1-2 weeks. For the patient who is in school we notify teachers of the plan. I then have the patient come back to the office in two weeks to assess how he has performed day in and day out off of the medication. When he has done well, I see him monthly for six months, then quarterly.

Don’t Hesitate to Resume Medication When Needed!

Whenever I see signs of increased attentional problems that result in a significant life dysfunction, I resume the medication.  I’ve outlined my thoughts on a successful medication experience in 7 Keys to Successful (and Safe) Medication Treatment for ADD.


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

ADD Medications Reduce Drug Addiction Rates

image via Flickr, Alan Cleaver

image via Flickr, Alan Cleaver

Can the use of ADD/ADHD medications lead to drug addiction?

ADD medications, with the exception of Strattera, are controlled substances that can potentially be abused. This can be a source of concern because we use them in ADD individuals who are at a significantly higher risk for the development of alcoholism and drug addiction.

Interestingly, research now shows that when individuals with ADD are properly diagnosed and treated with these medications, their risk for substance use disorders is reduced to that of the general population.

I have never had a patient become addicted to one of the stimulants nor am I aware of any reports in the medical literature of someone developing addiction to a medication prescribed therapeutically for ADD.

I have had a rare patient who abused his medication, sold his medication, or was intimidated into giving his medication to a friend who wanted to crush and snort it. I would have to say that I am somewhat skeptical about what kind of “high” someone really gets from what turns out to be relatively mild stimulants.

Furthermore, when used properly, individuals do not develop a tolerance for the medications that require them to take ever-increasing dosages in order to obtain the same beneficial effects.

In fact, once the optimal dose is determined, there are only a few conditions under which a dose may need to be increased:

  • When substantial weight gain occurs in a growing child or adult, an increased dose may be necessary.
  • Similarly, refined feedback from significant others, over time, may indicate the need for further fine-tuning of the dosage level.
  • Finally, if there is a significant jump in expectations necessitating a further degree of refined attention, then a dosage increase might be necessary.

Can people with addictive disorders take these medications safely?

image via Flickr, Blake Danger Bentley

image via Flickr, Blake Danger Bentley

Interestingly enough, I have taken care of many adolescent and adult alcoholics and drug addicts who have ADD and who might not have “hit bottom” had they been involved in comprehensive treatment that included ADD medication and strategies to improve self-awareness, self-control, and problem-solving at an earlier age.

I currently use all of these medications in treating ADD individuals who have co-morbid addictive disorders, provided they participate in frequent follow-up visits to monitor their medication use.

I also insist that they are involved in counseling and a 12-step program such as Alcoholics Anonymous, Narcotics Anonymous, and Overeaters Anonymous. This careful approach has been very successful in addressing a key component to the addictive disorders of my patients. For some of them, medication use seems to be a critical factor in their success in establishing and maintaining sobriety.

Stattera does not have any abuse potential. For this reason, since it has become available, I preferentially select it as the first line of treatment in ADD patients struggling with substance use disorders.

I would not, however, hesitate to switch to one of the stimulants if I was not achieving therapeutic efficacy with Strattera.

I have learned that when they are managed properly, stimulants can be effectively and safely used in patients with addictive disorders.


Want more insights you can trust on effective ADD/ADHD treatment?  Dr. Liden shares a deeper, more clinical examination of proper use and administration of ADD/ADHD Drugs in ADD Basics 301: Rationale for Clinically Necessary Off-Label Use of Stimulant Medications in the Treatment of Attention Deficit Disorder / Attention Deficit Hyperactivity Disorder (ADD/ADHD).  Currently available as a free download ebook!

Do ADD Medications Interfere with Growth?

image via Flickr, aussiegall

image via Flickr, aussiegall

At one time it was believed that stimulant medications, used for prolonged periods of time, could interfere with growth.

In fact, it was for this reason that some physicians began recommending “drug holidays” to allow for a period of catch up growth.

However, most scientific studies suggest that medications for ADD do not significantly impact on growth. In those that have shown some impact on growth, the magnitude of the change is actually miniscule.

I monitor height and weight every three months in all patients for whom I am prescribing medication. After treating thousands of patients over many years, I have yet to see the first patient where medication treatment for ADD could be blamed for an alteration in growth.

Actually, my observations of growth patterns in children and adolescents with ADD are in sync with recent research. Many children with ADD have a relative deceleration of their growth rate as they approach and enter into puberty and tend to experience their growth spurt at a later point in puberty compared to their non-ADD peers.

Depending upon the age when ADD medication is instituted, this “normal ADD growth pattern” should be taken into account when interpreting any changes in growth rate that might occur.


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Did My Personality Change, or Did I Just Take ADD Medication?

image via Flickr, Wewiorka Wagner

image via Flickr, Wewiorka Wagner

Do ADD/ADHD medications cause personality changes?

It is not uncommon to see new and different behaviors in the individuals starting ADD/ADHD medications. However, ADD medications are not really mood altering or personality changing drugs.

Commonly, upon beginning medication, most individuals report feeling more aware of what is going on around them. As a result of this increased awareness, some people, understandably, become sad or depressed as they, for the first time, tune into the mess that ADD has caused in their lives: failure in school, social isolation, financial difficulty, marital problems, etc.

For some individuals, this new appreciation of reality can be overwhelming. Without effective problem-solving skills, they often have no mechanism to make things better. Without adequate support, feelings of sadness can intensify and turn into depression.

Hitting Bottom Motivates Change

It can be disconcerting to parents, teachers, spouses, and friends to watch from the sidelines while someone they love goes through this period of “being down.” It is important to keep in mind that this hitting bottom can be a source of motivation for change provided that parents, teachers, spouses, doctors, counselors, and others are supportive and provide guidance. 

The significant behavioral and personality changes that can accompany the use of these medications can be misinterpreted when we fail to appreciate the powerful impact of weak attention.

“Tuned Out” Masks True Personality

The untreated ADD individual often misses many of the things that cause most of us to respond emotionally. When he fails to show an outward response (because he has failed to tune into the event), we make assumptions about his temperament or personality. The possibility that he has not tuned into the event does not usually enter into the equation.

image via Flickr, Jim Larrison

image via Flickr, Jim Larrison

Enhanced awareness often uncovers temperamental characteristics that may have always been present in the ADD person.

For example, the seemingly outgoing, happy-go-lucky child may suddenly become subdued and fearful; the easy-going child may suddenly appear to be more strong-willed, and the insensitive spouse starts crying for no apparent reason.

Uncover the Underlying Traits

None of these changes represent alterations of personality, rather, the uncovering of underlying traits such as low threshold, high intensity of response, slow adaptability, or withdrawal response to new situations that were always there. Prior to medication, these life events and circumstances that provide opportunities to understand an individual’s personality went unnoticed.

Such effects of medications are sometimes mistakenly seen as negative side effects of medication and parents or the ADD individual may choose to discontinue the medication rather than take the opportunity to work on controlling these intrinsic temperamental traits.

 Switch Medications if Temperament Issues Persist

In some cases, the enhanced manifestation of these temperamental characteristics can be so profound that it interferes with the individual’s learning better self-control.

In such circumstances, I have found it is wise to switch to a different medication.

In my experience, this more frequently occurs with the stimulants. I have rarely felt it necessary to switch from the non-stimulant, Strattera, in response to a patient’s struggles with his temperament.

It suffices to say there can be great individual variability among individuals and medications when it comes to the apparent impact on personality.


Dr. Liden and The Being Well Center believe strongly in treating the Whole Person.  That means we believe there’s a lot more to dealing with ADD/ADHD than just getting the medication right.  You might find our post on Temperament helpful in providing more guidance on personality.  Or browse the various topics in our popular Pay Attention! series.  We’re here to help you untangle the tricky problems present with ADD/ADHD, one knot at a time.  

 

What Happens After ADD/ADHD Medication?

What actually happens when a person starts taking ADD/ADHD medications?

At a most basic level, ADD/ADHD medications work to increase an individual’s arousal level to some greater or lesser degree. In addition to becoming more alert, he becomes more reflective, less distractible, and better able to focus and sustain his concentration for longer periods of time. He begins to tune in to the impact of his behavior and the quality of his performance.

image via Flickr, devinf

image via Flickr, devinf

As a result of these improvements in attention, the person’s overall awareness of himself improves; he begins to think – to use that little voice in his head. This, in turn, makes for improved self-control and more effective problem-solving.

How these dramatic changes in attention actually affect individuals with ADD varies considerably depending upon their underlying temperament, status of their skills and abilities, and the circumstances of their lives. For the majority of individuals, at least initially, this can be an awe inspiring experience similar to that which I went through when I first got my glasses: “Wow, there are leaves on the trees.” I was obsessed for several days with looking at people’s faces, enthralled with the features I had not noticed for years and I rejoiced that I really didn’t need to buy a new TV . . . the picture was sharp and clear!

I have had many individuals express this same type of wonderment about their new world when starting medication. Some voraciously read for hours at a time, some started obsessively cleaning the house, some marveled at their ability to think clearly, and some talked incessantly sharing ideas that had been bottled up for years.

On the other hand, for some, the honeymoon is short lived. That’s because everything that happens when someone starts paying attention for the first time is not necessarily positive. For a child, this might mean a sudden realization that he is flunking at school, is behind the 8-ball at home, and that others have been laughing at him, not with him. Similarly, with an adult, it can be devastating for her to tune into the fact that she has $40,000 in credit card debt, is 50 pounds overweight, and is in a relationship based on need, not love.

Such sudden realizations of the circumstances of life and ADD’s impact can precipitate the emergence of new problems like depression and anxiety, which require support, management and, sometimes, other medical treatments. This is one of the key reasons I believe the medications should never be used by themselves, but always in combination with other supportive therapies.


Dr. Liden is the Founder and Medical Director of The Being Well Center, located in Pittsburgh, PA.  For more of his 30-years’-expertise insights into effective treatment of ADD, download ADD/ADHD Basics 101.  Join our discussion on the 7 Keys to Successful (and Safe) Medication Treatment

5 Ways to Remember to Take ADD/ADHD Medication

5 Ways to Remember ADD Medication | The Being Well Center

image via Flickr, Tim Pierce

1.  Depend on Grown-up Support Already in Place

Remembering to take medication every day or multiple times during the day can be a challenge for anyone and is even more so for the individual with ADD. When treating young children, it is not generally a big issue because parents, teachers, and school nurses take on the responsibility of giving the medication.

2.  Medicate Parents First

The exception is when one or both parents also have ADD and then forgetting to have their children take the medication becomes another symptom of untreated ADD. This is one of the reasons I prefer to diagnose and treat the parents first when a parent-child combo comes to my office for help.

3.  Give Adolescents FULL Responsibility

As children get older and move into adolescence and adulthood, assuming full responsibility for remembering to take the medication needs to be a top priority. I often encourage parents to use responsible taking of the medication as a “ticket of admission” to other important big life privileges like driving a car or going out with friends. In fact, my words to my own son were: “If I can’t trust you to take the medication without reminders, then how can I trust you to make the difficult right decisions out in the world?”

4.  Develop an Established Daily Routine

image via Flickr, Santiago Nicolau

image via Flickr, Santiago Nicolau

The single most important tool in remembering to take medication is helping the ADD individual to develop an established daily routine for sleeping, eating, exercise, and other activities of daily living. In the context of a structured daily routine, it becomes easy to find times to consistently take medication. For example, a three-times-a-day medication regimen of short-acting stimulants can be tied to mealtimes. A once-a-day medication like Strattera can always be taken with breakfast or dinner. The most difficult medication administration schedules to structure are the twice-a-day regimen required for the long-acting stimulants. The key again is to try to tie taking the medication into another regularly occurring activity.

One suggestion often made to ADD individuals is to use devices such as timers, watches, or pill containers with timers and buzzers. In theory, these tools should work, but our experience has been that they often become just one more thing to deal with, lose, or forget. Ultimately, the successful use of these tools is also dependent on the establishment of a structured daily routine – to set the timer, fill the container, etc. So, we put the focus on the establishment of a daily routine.

5.  Commit to Using Medication

Finally, when it comes to consistently taking the medication, it is critical that the individual is truly committed to the use of medication. Sometimes what appears to be a problem remembering to take medication is really a problem with acceptance of the ADD diagnosis and the need to take medication in order to function effectively and behave appropriately. Under such circumstances, support with acceptance is more important than any reminder system.


What tips, tricks, reminders, or advice help you remember your ADD/ADHD medication?