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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The Prognosis for ADD

image via Flickr, by Ginny

image via Flickr, by Ginny

What is the prognosis when ADD is treated appropriately?

The prognosis of ADD is highly variable depending upon a multiplicity of factors. The individual’s temperament. His language skills. His intelligence. His basic academic skills. The profile and severity of attention weakness. His physical characteristics. The integrity of his nervous system. The presence of illness. Stresses in his life. His attitudes and beliefs. His self esteem. His motivation. The expectations set for him. The profile of strengths, weaknesses, and temperamental characteristics of people in his life….

For each individual, the mix of these factors is a little bit different. And for any given individual, the mix is constantly changing. This is what makes ADD such a challenge.

When all these factors are taken into account and appropriate, comprehensive treatments are put into place, the prognosis for ADD is good but guarded.

That is, the ADD individual can be helped to function successfully academically and on the job; he can have meaningful social relationships; and he can function independently.

However, as long as he continues to take on life’s challenges, there is always the possibility that the problems associated with ADD will resurface. But this really is no different from what we all face in our own personal quest for self-development.


There is no magic pill or quick fix for Attention Deficit Disorder.  That’s why Dr. Liden has dedicated over 30 years of his life to diagnosing and treating the disorder, following his patients through many life stages and challenges, helping them achieve success and independence through it all.  His collected wisdom is shared here on the BWC blog and in a number of books.  He also serves as Senior Medical Director of The Being Well Center, which offers Long Distance Services and an affordable Accurate Diagnosis Determination.

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.

 

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 and Sex

How does ADD impact sexual behavior and functioning?

Over the years, behind the closed door of my office, I have heard hundreds of unusual stories regarding my patients’ sexual activities. I have come to appreciate that, while the topic is often emotionally loaded, the behaviors are generally completely understandable when put into the context of ADD.

ertterdownloadsA certain amount of body exploration and sexual experimentation is normal for all children; in young children with ADD this exploration and experimentation can seem extreme because we see it. Young ADD children often lack that inner voice that says, “Keep your hands out of your pants when others are around” or “Do not touch other kids’ private body parts” or “Don’t draw that in school.”  While other children may have the same impulses, they usually have enough self-control and social monitoring to think first and, in this way, stay out of trouble with their sexual thoughts and feelings.

As children get older it is normal for them to be sexually curious. Oftentimes, older children and adolescents with ADD impulsively act on their curiosity. Then, as a consequence of their poor monitoring and decision-making, they get caught doing something that seems bizarre or perverted to others. The number of older children and adolescents in our practice who have been caught looking at, taking, or even wearing mom’s lingerie, exploring pornographic websites on the computer, using (and running up huge bills) on phone sex hotlines, or sending pornographic photos of themselves to someone they met on the Internet is astonishing. In my experience, upon taking the time to debrief the events with my patients, clearly these behaviors are not signs of perversion or serious mental health problems but rather normal sexual interest in the absence of good self-control.

We all know that in adolescence, sexual exploration continues, and that its consequences can be very serious. Premature experimentation or early sexual involvement can lead to unplanned pregnancy, sexually transmitted diseases, and serious legal trouble. Adolescents with ADD who are struggling with a low self-esteem and lack of acceptance by peers can too easily become involved in sexual relationships to feel good and be accepted never thinking about the potential consequences. In my experience, impulsive kids who struggle in reading the social signals often finds themselves caught up in the heat of the moment and have no idea how to get out.   Many of my ADD adults share with me their scary versions of this story still feeling the regret and guilt.

Dr. Craig Liden | ADD and SexI have found that adults with ADD often struggle with relationships and sexual activities as much as the adolescents do. Impulsivity frequently leads the adult with ADD to jump into relationships and sexual intimacy too quickly. At first, this intimacy feel good; it blots out the pain of loneliness that often accompanies adult ADD. But this quick, feel-good approach to sexuality commonly contributes to promiscuity, addictive involvement in pornography, and risky sexual behavior in the ADD population. In fact, individuals with ADD have been found to have a four times greater risk of acquiring a sexually transmitted disease than the general population.

ADD can also have a significant impact on sexual functioning in “normal” adult relationships as well. It is easy to imagine how the ADD adult with low arousal who finds himself particularly exhausted at the end of the day often has no interest or energy for sex. Many of my patients who have experienced chronic stress as a result managing their weak attention day in and day out struggle with the spectrum of sexual dysfunctions that occur in people who are depressed and anxious — decreased libido, difficulty with arousal, and an inability to reach an orgasm.

Apart from these sexual difficulties, it is not uncommon for the ADD individual’s poor communication and listening skills to interfere with intimacy and, in turn interfere with the quality of his sexual relationships. In my discussions with spouses of ADD individuals, complaints about self-centeredness in the bedroom are the norm.


We’re talking tricky topics this week on the Being Well Center blog.  Check in for discussions about ADD and drug abuse and ADD and chronic health problems.


Our current blog series is excerpted from Dr. Liden’s best-selling book, Pay Attention!: Answers to Common Questions About the Diagnosis and Treatment of Attention Deficit Disorder.

first photo credit: Patricia Mellin via photopin cc

second photo credit:.Andi. via photopin cc

The ADD Preschooler

lifespan_preschoolWhat specific behaviors indicate that a preschooler might have ADD?

Efficient attention is required for success in all areas of life. As an ever-present filter between the individual’s external and internal worlds, it screens all incoming and outgoing information to and from the brain. In this way, attention has a profound influence on how an individual experiences events and behaves in all life spheres: school, job, home, and neighborhood. It interacts with other skills and abilities to shape the quality of social interactions, school/job performance, and independent functioning. Therefore, behaviors that suggest attentional difficulty can appear in any area of a person’s life. The following behaviors identify some of the more common red flags that might signal ADD in children ages three to six years old.

Preschooler (Three to Six Years)

  • Failing to take turns during play activities
  • Not sharing during play
  • Not being aware of dangerous situations (e.g., crossing the street)
  • Switching from one activity to another
  • Not being able to sit at the table until the family has finished
  • Not being able to maintain concentration in learning activities
  • Failing to sit still to read a story or to put together a puzzle
  • Not seeming to hear
  • Impulsively hitting, pushing, or biting others
  • Being fearless and reckless during play
  • Being asked to leave preschool/daycare
  • Struggling to control emotional reactions
  • Wandering off

If your response to this list is “Uh-oh.  Now what?”,  go to ADDBasics.org and download Dr. Liden’s free guide, ADD Basics 101. In 10 clear steps, Dr. Liden will guide you to an accurate, trustworthy diagnosis and outline what you should look for in an effective treatment plan.

Check back tomorrow for red flags in School Age children’s behavior…

Catch up on previous posts in the Pay Attention series.

Our current blog series is excerpted from Dr. Liden’s best-selling book, Pay Attention!: Answers to Common Questions About the Diagnosis and Treatment of Attention Deficit Disorder.

Do people have ADD from birth?

ADD Basics FamilyAs we continue laying out the truth about ADD/ADHD, we turn to some of the most common, burning questions my patients, friends, family, and colleagues most commonly ask me.  The answers to these questions form a critical foundation to understanding the truth about Attention Deficit Disorder.

If people are born with ADD, why don’t problems show up right after birth?

ADD becomes apparent only when the inborn attentional differences interfere with the individual’s ability to meet expectations in the environment. Depending upon the severity of a person’s attentional differences, his temperament, the status of other skills and abilities, and the specific nature of environmental expectations, ADD can crop up at any point along the life span from infancy to old age. Let’s take a look at how this can happen.

Typically, individuals with ADD appear to be normal at birth. As children, they are minimally, if at all, delayed in meeting major milestones of accomplishment such as walking and talking. They generally reach school age with only minor problems in controlling their behavior and interacting with peers. The first grade classroom is often the first place where specific expectations for paying attention occur. As a result, the entry into school is one of the more common times when ADD first shows up. Other key transition points in the individual’s life where expectations for increased efficiency of attention can lead to the emergence of ADD include the following:

  • Movement to the upper elementary grades where time constraints are imposed and increased demands are placed on children to function independently
  • Movement to junior/senior high school where more refined organizational and study skills are required
  • Movement to college where fewer supports are available and the ability to function independently is essential
  • Movement into a new home away from parents where there are no supports and the ability to function independently is even more critical
  • Marrying or cohabiting with a partner where functioning impacts upon the quality of life of another person and demands for efficient problem-solving are high
  • Becoming a parent where responsibilities for keeping it all together, all the time is essential

Individuals with ADD who have strengths in other areas (e.g., strong language skills, a charming personality, intellectual giftedness) can go a long time in life without being identified as having a problem. I have seen many children go through elementary school with A’s and B’s only to have the bottom fall out upon entry to middle school or junior high school. In these circumstances, careful probing of the educational history of these children often reveals evidence of attentional weaknesses that have either been overcome with sheer brain power or been overlooked by parents and teachers because these subtle weaknesses hadn’t really led to failure.

While failure to meet increasing school demands is a very common way for ADD to be uncovered, it can also happen as a result of failure to meet increasing demands for independent functioning, social interaction, or problem-solving at home, in childcare, in the neighborhood, or on the job.

Meet Michael

Michael is a good example of this. He is a 10-year-old boy who has always done very well, academically and socially. He has learned new concepts quickly, has shown a gift for memorizing facts, has been easy to get along with, and has always been a great conversationalist.

Until two months ago, he had also functioned very well at home. At that time, however, his mother got a new job that meant she was no longer able to be with Michael after school. And, despite all of her attempts, she had been unable to find someone who would stay with Michael until her new workday ended. So, for the first time, Michael was on his own everyday from 3:00 p.m. to 6:00 p.m.

The new expectation for him was “keep yourself busy and stay out of trouble for three unsupervised, unstructured hours.” This new demand uncovered Michael’s impulsivity, distractibility, and lack of ability to think through the ramifications of his behavior. He broke a living room lamp by rough housing in “off-limits territory”; he burned a hole in the new family room couch while “fooling around” with a butane lighter; and he soaked the bathroom carpet when he ran to answer the telephone, forgetting to first turn off the faucet.

Without his mom around to help him structure his time, to remind him of the house rules, and to watch over his activities, Michael had become dysfunctional.

Meet Emma

Emma’s story is similar. She is a 22-year first year elementary school teacher who has just married. Emma is gifted, kind, funny, sensitive, and very hardworking. Until now she has done well in almost every sphere of her life, but she has never been asked to establish her own home, to share finances, nights, and laundry with someone else, to complete daily lesson plans for five subjects, to effectively manage thirty fifth-grade children for six hours every day, and to negotiate unclear work politics all at the same time.

Emma is a mess. Despite her intelligence, her hard work, her sense of humor and her likeability, she is not experiencing success anywhere in her life.

Catch up on previous posts in the Pay Attention series.

Patients of all shapes, ages, and sizes come to The Being Well Center and Dr. Craig Liden for diagnoses and treatment plans they can trust. Can we help you too? Visit The Being Well Center for more information about Dr. Liden’s services.

Our current blog series is excerpted from Dr. Liden’s best-selling book, Pay Attention!: Answers to Common Questions About the Diagnosis and Treatment of Attention Deficit Disorder.