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.

Advertisements

I stopped my ADD medication. Now what?

image via Flickr, Kevin Dooley

image via Flickr, Kevin Dooley

What should happen when a person with ADD stops using the medication?

Since ADD is a built-in biologically based difference that the person carries with him throughout his life, it is critical that he be involved with some type of follow-up when medication is discontinued.

This follow-up should include monitoring to ensure continued progress in all life spheres, encouragement to maintain balanced healthy daily routines, reinforcement of compensatory strategies and problem solving skills, and guidance about challenges that are likely to occur in the future.

I encourage my patients to remain involved in some type of follow-up monitoring like this indefinitely. In my experience, continued follow-up also helps identify, before the bottom completely falls out, those individuals who need to resume use of the medication.


Looking for trust-worthy direction in tackling the challenges of ADD/ADHD?  Check out other posts in the Pay Attention! series that address burning questions and hot topics related to ADD.

 

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!

The ADD Adult

lifespan_adultWhat specific behaviors indicate that an adult 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 adults ages 18 and over.

Adults with ADD

  • Being irresponsible; exhibiting poor follow through
  • Changing jobs frequently
  • Having trouble with money management, characterized by excessive spending and poor budgeting
  • Making repeated careless mistakes on the job
  • Exhibiting poor communication skills that result in repeated misunderstandings
  • Being late
  • Reacting before thinking
  • Lacking a healthy daily routine
  • Having difficulty managing children
  • Being overly dependent on spouse, boss, or co-worker for supervision
  • Abusing drugs and alcohol
  • Experiencing eating disorders
  • Lacking the ability to solve problems effectively
  • Lacking the ability to prioritize things
  • Taking on projects without thinking about what is involved
  • Experiencing depression and/or anxiety

ADD Basics 101 | Dr. Craig LidenIf you just recognized someone you know (maybe yourself?) in this list, 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 next week when Dr. Liden discusses how ADD impacts sexual behaviors…

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.

How does ADD affect learning?

Check out Lisa Ling‘s frank admissions of her struggles in the classroom.  Sound familiar?

Attention plays a major role in learning since all information coming into and out of a person’s brain is filtered by attention. That is, in order to acquire a new piece of information or a skill, we must first pay attention to it. In order to show that we have mastered the information or skill, we must control our impulses, monitor our behavior, filter distractions, and concentrate for a sustained period of time on the “tests” that occur in the classroom and in the real world.

Poor attention affects both incidental and “school” learning. A person who has a weakness in attention is less able to receive all of the input from the environment–structured or unstructured–that is necessary for learning. For example, he neither sees nor hears all the steps that Mom and Dad show and tell him about cleaning his room; he misses the fact that there are actually road signs that tell where to go; and he fails to get the coach’s instructions about game strategies during practice. At school, he doesn’t listen to the teacher’s instructions; he doesn’t see the assignment written on the blackboard; he doesn’t get the meaning of the stories he reads; and he doesn’t remember the steps in long division.

ADD can also interfere with a person’s ability to demonstrate what he has learned. People with ADD may have messy rooms, dirty dishes, and poor hygiene even though they know how to clean, to do the dishes, and to care for their bodies. In school, people with ADD may fail to complete all the problems or daily worksheets, add instead of subtract on achievement tests, make careless errors on intelligence tests, reverse letters when reading or writing, and forget to capitalize and punctuate in written language tasks.

Apparent difficulties in seeing, hearing, remembering, and understanding often lead to the false conclusion that individuals with ADD have auditory or visual perceptual problems or are just less intelligent. In reality, however, they are simply not alert and not reflecting, focusing, filtering, persisting, or monitoring their behavior and their schoolwork.  Brain power only goes so far.

ADD negatively affects learning. But, it never does so alone. A person’s temperament, intellectual, and learning abilities, and language skills, among other things, interact to influence how attention affects learning. It is important to remember that ADD, as a biologically based individual difference, can occur in anyone–an individual who is gifted, learning disabled, retarded, and one who has average learning ability.

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.

ADD and Extreme Temperaments

beingwellcenter_temperamentWhy is it that so many individuals with ADD seem to have extreme temperaments?

It may be that individuals with ADD come into the world with a greater number of these temperamental extremes.

However, it is also possible that these behaviors seem to be more common in individuals with ADD because their attentional differences interfere with their awareness of and ability to control these built-in personality characteristics.

That is, it may be that extremes in temperament such as high activity level, high intensity, low threshold, negative mood, slow adaptability, and short persistence occur just as frequently in the non-ADD populations as in the ADD population.

In order to exert control over these temperamental characteristics, an individual must be aware of his extremes, monitor his behavior, and develop effective ways to keep his extremes in check. As this requires efficient monitoring, problem-solving, vigilance, and impulse control, it is likely that individuals with ADD will struggle with their temperament more frequently and as a consequence, demonstrate these characteristics more often.

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.

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.