Dr. Liden’s Prescription for Success with ADHD

Dr. Liden presented this past weekend at the Annual International Conference on ADD/ADHD.

As part of the weekend, Dr. Liden appeared on WWL-TV4 News in New Orleans, sharing his insights on why he believes we need more medication for ADD/ADHD.  Watch as he outlines the responsible use of stimulant medications in treating Attention Deficit Disorder and shares how he responsibly and clinically prescribes medication as part of the treatment plans at The Being Well Center.

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!

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.


Don’t miss other answers to tricky questions about ADD/ADHD Medication!  Sign up to receive Dr. Liden’s latest blog posts by entering your email address at the top of this page.

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