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.

 

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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!

Behavior Change for the Adult with ADD

How does the adult with ADD work toward positive behavior change?

image via Flickr, Esther Gibbons

image via Flickr, Esther Gibbons

In my experience, the journey toward positive behavior change for the ADD adult begins with an experienced professional leading him through the same steps we encourage parents, teachers and childcare providers to use in managing behavior in children with ADD. That is, we help the adult with ADD to do the following:

  • Know who he is. It is important that he understand and accept his temperamental characteristics, his skills and abilities, his attentional abilities, his physical abilities, the stresses in his life, his attitudes and beliefs, and his self-esteem. He must understand which of these are changeable and which are not.
  • Set realistic expectations for himself. Based upon his understanding of his own unique profile of strengths and weaknesses, he defines behaviors are achievable for him.
  • Determine the factors contributing to an unproductive behavior and/or situation when it occurs.   In doing this, he asks himself the following questions:

◦ What is the expectation that is not being met?

◦ What are all the contributors to this failure?

◦ What role do I play in this?

◦ What role do factors outside of me play?

◦ What contributing factors are changeable and which are unchangeable or out of my control?

  • Develop a plan and put it into action. He refines the expectation as needed, and defines thoughts, actions, words and strategies that address all the factors that are under his control to maximize success at realizing the expectation, and tries it out in the real world.
  • Refine the plan when necessary. He reflects upon the success of the plan, and makes changes in the plan by modifying the expectation, the thoughts, words, action, and/or strategies.

In repeatedly guiding the adult with ADD through this sequence, the professional gives the adult progressively more responsibility. Ultimately, the adult becomes an independent problem-solver able to critically evaluate and modify his behavior in nearly any situation. In my experience, my adult patients who are open and committed to learning about themselves and how to effectively solve problems grow wise and become confident in their ability to deal with whatever is thrown their way.

How do limiting setting and use of consequences work with adults?

image via Flickr, Kaitlyn Rose

image via Flickr, Kaitlyn Rose

In adult life, limits and consequences are not generally defined in treatment or by supportive parents and teachers. Usually, it is our employer, our spouse, our friends, the police, the IRS, the bank, etc. who impose them.

Further, the limits are not always clearly defined and the consequences are often very serious. Treatment activities with the ADD adult involve clarifying the reality of the limits, defining strategies that promote success in meeting expectations, supporting and brainstorming plans when consequences do occur, and working with spouses, friends, and parents to help them allow the sometimes serious consequences to occur.


ADD/ADHD creates life challenges unique to each life stage.  Seek out care providers who have an appreciation for the challenges specific to adult expectations.  For help identifying a qualified care provider in your area, download Dr. Liden’s book, ADD/ADHD Basics 101.

Living on the ADD Edge

Why do so many people with ADD live life on the edge?

image via Flickr, Riccardo Palazzani

image via Flickr, Riccardo Palazzani

Living life on the edge: procrastinating and procrastinating only to complete the task, once again, at the eleventh hour, pushing the limits of the car’s maneuverability at 75 miles per hour, scheduling ten meetings in a five-meeting block of time, attacking the black diamond slope with beginner’s skills.

Each of these events provides the ADD individual with a “rush”—an adrenalin rush that is a consequence of the stress response. For all of us, the perception of danger sets off this response resulting in increased arousal; this allows us to hyperfocus.

By hyperfocusing in times of danger, we are more likely to save ourselves.

This series of events is clearly helpful for the ADD individual who struggles with focus otherwise.   By using the stress response, the competent individual with ADD is able to pull it all off again and again, making procrastination an art form.

The rush allows him to experience intense focus and, in this way, pull it off at 2:00 AM the morning it’s due, behind the wheel of the car, during meeting number four, and on the ski slope.

There is a rub to all this however; the stress response also results in elevated heart rate, increased blood pressure, and chronic anxiety.

The ADD individual living life on the edge thinking he has, time and time again, successfully avoided disaster in his life is actually a time bomb waiting to detonate.


What helps you hyperfocus?  Is it living “on the edge,” or have other strategies worked for you?  Dr. Liden discusses other ways to avoid the “ticking time bomb” approach in his best-selling book, Pay Attention! Answers to common questions about the diagnosis and treatment of Attention Deficit Disorder.

ADD and Temperament Extremes

Temperament Extremes | The Being Well Center

image via Flickr, Austin Kirk

Individuals with ADD seem to have a greater frequency of extreme temperamental characteristics, those inborn behavioral response patterns that shape how an individual approaches and responds to life’s events and circumstances.

The most common temperamental extremes identified in individuals with ADD appear to be high activity level, low threshold of response, high intensity of reaction, negative mood, slow adaptability, short persistence, and unpredictability of basic bodily functions such as eating, sleeping, and bowel habits.

This means that people with ADD tend demonstrate a short fuse, a low frustration tolerance, a tendency to demonstrate temper outbursts, and difficulty adjusting to change. In addition, they often seem more excitable, sensitive, cranky, and unpredictable.

Why 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.

What’s your experience with ADD and Extreme Temperaments?  Do you or a loved one fall strongly on one end or another of the temperament spectrum?  The Being Well Center follows The Being Well System, which looks beyond the symptoms of ADD/ADHD to take into account a person’s in-born temperament traits.  Treating the whole person is crucial to a successful ADD/ADHD treatment.  Talk to your doctor or care provider about your temperament traits.

5 Reasons We Know ADD is Real

I’ve heard some professionals say, “ADD is just a cover-up label for suburban parents who cannot deal with their emotionally-disturbed kids.” Some write it off as “being in vogue–the problem for this decade.” Others wonder, “If ADD is a result of an inborn physical difference, then why wasn’t it around when we were kids?

I respond strongly to this skepticism. ADD is a very real problem!

Because we are more knowledgeable, we are able to identify ADD more frequently and, thereby, it appears to be in vogue. But ADD was around when we were kids. We just weren’t aware of it.

Biologically-based attention differences are probably no more common in 2014 than they were in 1950. However, dysfunction resulting from these differences is more common because societal expectations have significantly changed over the past several decades. Many of these new demands put a high premium on the individual having efficient attentional skills in a way that was never demanded before. As a result, just as with ADD in an individual, these new societal expectations have uncovered an underlying societal problem that has probably always been there.

1.  New opportunities for our children highlight the existence of ADD

In the ‘40’s and ‘50’s, most parents worried about the basics. Nutritious food on the table and a roof overhead. Reading, writing and arithmetic. Basic health. In fact, my parents worried about whether I would survive polio or die like several of my best playmates. Thanks to amazing technological advances, today we, as parents, take these basics for granted and want much more for our children. We want our children to achieve at school, to go to college, and to get a job that is better than the one we have.

I am constantly impressed how far we will go to provide enriching opportunities and to push our children in the name of wanting them to have the chances we did not have. Often, these “chances” backfire because they require proficiency in areas, like paying attention, that some children just don’t have.

image via Flickr, woodleywonderworks

image via Flickr, woodleywonderworks

In our schools, the demand for high achievement and independent learning has filtered down to earlier and earlier grades. Curriculum content has expanded so that many teachers are overwhelmed and unprepared to introduce a wealth of new material, let alone to teach the basics to children who require some extra help.  Support services in most school districts are shrinking rather than expanding. Access to extra help is often contingent upon student failure rather than being viewed as a preventative response to minor difficulties.

It is easy to see why regular classroom teachers get frustrated when they are placed in the bind of producing high group achievement test scores to please the school board while watching 20% of their class struggle to just get by.  Without support to address these children’s needs, most teachers either become guilty or get burned-out, both of which reduce their effectiveness further.

 2.  Modern parenting styles highlight the existence of ADD

Societal attitudes about discipline and behavior management have changed radically as well. These changes have also contributed to our increased awareness of ADD–the problem that has always been there. The pendulum has swung from the rigid, authoritarian, and, frequently, punitive approach of the ’50’s to a more permissive and democratic approach in the ’70’s and ’80’s.

Today’s parents are more likely to provide a detailed answer to the child’s proverbial question “Why?” than to end the discussion with “Because I said so!” In an attempt to promote self-esteem and foster creativity, many parents hesitate to set firm limits on children’s behavior or to structure their lives. Many parents are afraid to say “No.” They walk on eggshells instead. They try to control their child’s behavior with rewards rather than meaningful consequences. Many children can go with the flow and adapt to whatever management style is used.

However, the more democratic, laid-back approach places demands for self-awareness and self-control on ADD children that they are rarely equipped to meet. The resulting behavior problems in the home or school bring the ADD children into the spotlight and allow us to identify them.

 3.  Modern family units highlight the existence of ADD

image via Flickr, Marco Antonio Torres

image via Flickr, Marco Antonio Torres

The nature of the family unit has significantly changed in the past 50 years. Again, this change has forced us to become aware of the ADD population. More children are being raised in single parent homes. More and more, both parents need to hold full-time jobs outside the home. In our mobile society, Grandma no longer lives two houses away but more commonly, two hundred miles away.

All this means that the support system that previously was there to structure and bail out the child with ADD is no longer present.

Moreover, this prop has been pulled out at a time when society has placed increasing demands on children without creating increasing levels of support.

There is, for example, a shocking lack of affordable, quality childcare services across the country. As a result, many children spend countless hours alone or in the care of people who have not received basic training in child development, let alone training in working with difficult children.

In a permissive society, without supportive props, the ADD child is a set-up to misuse the increased amount of unstructured time available to him. Truancy, vandalism, and delinquency are often the outcome. And each time an individual commits such a “crime,” we have another opportunity to identify ADD.

The pace of growing up has quickened and, as a result, children are faced with increasing expectations to exercise mature social judgment. Adolescent children are placed in the position of having to make independent, adult decisions about sex, drinking, and drugs. These demands put the impulsive ADD child with poor problem-solving skills at an even greater risk for alcoholism, drug addiction, and teenage pregnancy and provide him with another chance to be in the spotlight.

4.  Our technological society highlights the existence of ADD

image via Flickr, Mervi Eskelinen

image via Flickr, Mervi Eskelinen

As our society has moved from an industrially-based to a technologically-based economy, a new set of skills and abilities are now required to make it on the job.

The highly structured, physically demanding, manual labor jobs have been replaced by white-collar positions demanding good organizational skills, effective problem-solving abilities, and independent self-monitoring.

Once again, the individual with ADD is at a disadvantage and at risk for being identified. It would not be surprising to find that individuals with ADD have a disproportionately high representation in the ranks of the unemployed.

5.  Increased stress levels highlight the existence of ADD

Finally, because of these and numerous other reasons, life’s stresses appear to be more complex and challenging than they have ever been. And if there is anything that requires us to be reflective, focused, vigilant monitors, and efficient problem-solvers, it is stress management. Without the prerequisites to meet the challenge, the individual with ADD enters into a devastating downward spiral. Marital difficulties. Money problems. Mounting anxiety and depression. Tranquilizers. Just getting by. Social isolation. Back pain. Sick days. Weight gain. Hypertension. Constant fear. Alcohol abuse. Traffic accidents. Hospitalization. Bankruptcy. Immobilization. Giving up.

ADD is Real, and We Know It.

For all these reasons and probably many more, ADD now plays a more significant and very real role in people’s lives. And, as a result, we all have the opportunity to see its impact.  When people are skeptical about the significance or even the existence of ADD, they create a barrier to overcoming a very serious, but very addressable, health disorder.  Don’t let skepticism rob you of progress toward a better, and easier, life.  ADD is a very real problem.  But it’s a problem with very real solutions.


More answers and information about ADD/ADHD can be found in Dr. Liden’s book, Pay Attention!: Answers to Common Questions About the Diagnosis and Treatment of Attention Deficit Disorder.


10,000 people living with ADD have found hope and help navigating the challenges of ADD at The Being Well Center.  No matter where you are in life, we can help, starting 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