Four Steps to Managing ADD/ADHD Effectively with Medication

Managing ADHD Effectively with Medication | The Being Well Center's 4-Step ApproachIn our specialty practice, we have now had the opportunity to care for more than 10,000 patients with ADD/ADHD over the past 35 years. Our youngest patient is 3 years old and our oldest well into her 90’s.

We have had the unique opportunity to watch ADD/ADHD across the lifespan from early childhood to late adolescence, from young adult life to mid-adult life, and from mid-adult life to the senior years. We know of very few individuals or medical practices in the world who have had the same extensive clinical experience with ADD/ADHD and the stimulant medications as we have had.

Several years ago, Dr. Liden was asked to present a peer reviewed paper at the first International Conference on Attention Deficit Disorders in Jerusalem, Israel sponsored by the Hebrew University of Jerusalem, entitled: “TRANSACT: Toward a Standard of Care for ADD.” Our approach to diagnosis and treatment including the use of medication was the only multidisciplinary clinical program selected for presentation at this first International Conference on ADD/ADHD. We received uniformly positive feedback from other physicians attending this conference.

Since 1980, we have conducted hundreds of lectures and workshops for physicians and other health related professionals from across the country and around the world regarding ADD/ADHD and the use of medication. Dr. Liden has presented testimony to the U.S. Congressional Oversight Committee regarding the proper use of medication in ADHD. He has also sat on advisory boards for several pharmaceutical companies and has served on the board of ADDA, the national advocacy group for adults with ADD/ ADHD.

Based upon years of clinical experience and research and a review of the medical literature, we have developed a highly systematic protocol for the use of stimulants in treating patients with ADD/ADHD. The following are key features of our approach:

Managing ADHD Effectively with Medication | The Being Well Center's 4-Step ApproachStep One: A Comprehensive, Multidisciplinary Evaluation

All patients must first have a comprehensive, multidisciplinary evaluation (3 hours) that includes use of parent, child, and school questionnaires that survey the presenting concerns, efforts to address them, key life arenas where problems are appearing along with a review of the patients’ temperamental traits, readiness skills, attention and executive functioning, current and past health and mental health status, family history, attitudes, values and beliefs and a delineation of current daily routines for sleep, exercise, eating, stress management and other activities of daily living.

This is supplemented with a structured interview that probes areas of uncertainty from the questionnaire and delineates the course of the problem(s) over time.

All new patients participate in a neurodevelopmental survey of neuromaturational functioning, attention/executive functioning, expressive, receptive and pragmatic language skills, memory, problem-solving, and basic academic skills in reading, spelling, math, and written language.

All new patients undergo a targeted physical examination during which their mental status is also assessed.

At the conclusion of testing, patients/families meet with one of our medical directors to establish the ADD/ADHD diagnosis (if appropriate), identify any co-existing problems and generate a holistic profile of the individual’s strengths and weaknesses physically, emotionally, behaviorally, and educationally that helps develop a comprehensive treatment plan of which medication is only one part.

All patients receiving the ADD/ADHD diagnosis meet the DSM criteria at a minimum but also our refined criteria: chronic inattention and executive dysfunction, inattention and executive dysfunction apparent in multiple life spheres, evidence of attentional weaknesses and/or executive dysfunction on objective testing and the presence of neuromaturational delay (by history or through direct assessment using a standardized battery of “soft” neurological signs).

Managing ADHD Effectively with Medication | The Being Well Center's 4-Step ApproachStep Two: Ongoing Sessions with a Counselor

All patients who are prescribed medication must be involved with ongoing follow-up sessions with a professional counselor that are directed at improving self-awareness and self-control, establishing healthy daily routines, developing compensating strategies, and providing on-going emotional support. We never prescribe stimulant medication in isolation or as the sole mode of treatment for ADD/ADHD. We insist that our patients participate in the supportive follow- up visits on at least a monthly basis (or more frequently as needed) as a prerequisite for us to continue to write prescriptions for their ADD/ADHD medications.

Managing ADHD Effectively with Medication | The Being Well Center's 4-Step ApproachStep Three: Medication Trial Testing

After the initial comprehensive evaluation, all patients for whom stimulant medication is indicated are required to go through systematic medication trial testing in our office. This involves taking a dose of medication at home and coming into the office for an appointment at a time that corresponds to when the effect of that dose should be at its peak. While in the office, they undergo objective testing of attention using the FACES, a distinctive feature analysis task we have developed, or other objective measures of attention.

Results are compared to a previous baseline performance without medication. At the time of the medication trial visit, a physical assessment including vital signs and behavioral observations are made while the patient is on the medication to monitor for any adverse effects.

In conducting these trial tests, we use a set of prescribing guidelines from the American Academy of Pediatrics (2000) based on mg of generic, short-acting methylphenidate/kg body weight/dose, not on unsubstantiated absolute dosage limits as a starting point to select the initial dose for in-office trial testing. Using this basic formula, we calculate the equivalent mg/kg ratio for other medications that are not short-acting methylphenidate (e.g., Concerta, 18 mg = 5 mg methylphenidate, b.i.d.). The Academy’s position on medication is a reflection of many clinician’s experiences and the medical literature which shows increasing positive attention benefits as one moves up in the mg/ kg ratio (i.e., .7 mg/kg dose has a greater positive effect then .3 mg/kg dose). These guidelines have been signed off by all the major professional organizations including the FDA.

We inform all of our patients when the dosage we recommend via the Academy’s guidelines exceed the FDA approved manufacturer’s marketing guidelines and have them sign an informed consent.

Generally, we conduct the first trial test with a dose of the medication that falls around 0.3 mg/kg body weight with allowances made for the severity of the patient’s ADD/ADHD, his/her specific profile of attentional weaknesses, the presence of co-morbid conditions, and his/her previous experience with medication among other things. We repeat trial tests in the office until we find the lowest possible dose that gives significant positive objective benefits without adverse side effects.

Once the medication trials are complete, we have patients begin a 1-2 week clinical trial on what appears to be the optimal dose in order to assess the effectiveness of the medication in the real world and its duration of action. We may elect to begin the clinical trial with what was determined to be the “optimal dose” during the trials or we may elect to start at a lower dose and gradually titrate upwards using the “optimal dose” from the trials as a final “target.”

Three days into the clinical trial we have a brief phone follow-up with the patient or significant other to assess the initial response to the medication and identify any untoward effects that need to be addressed.

At the end of the 2-week clinical trial period, we receive feedback from patients, parents, spouses, teachers, and/or employers, as the case may be, during in-office interviews and through objective feedback forms sent to schools. We make adjustments in the medication regimen accordingly to ensure optimal coverage for the waking day and to eliminate or reduce any negative side effects.

Using this approach, the overwhelming majority of our patients take doses of the medicine that fall within the 2000 AAP Guidelines (i.e., 0.3 to 0.8 mg/kg/dose). Interestingly, many of these same doses which are within the Academy’s Guidelines fall outside the FDA approved manufacturers, non-scientifically-based marketing recommendations.

Many other specialists in the treatment of ADD/ADHD have shared with us that they have had similar experiences. For example, Dr. Til Davy from the Toronto Sick Children’s Hospital, a world class pediatric facility, has published a lead article in the Journal of Developmental and Behavioral Pediatrics, a specialty journal, describing his experience. Dr. Davy summarizes some of the key issues with stimulant dosing and states that in his experience some children with attention weaknesses require doses of Ritalin in excess of 300 mg per day and tolerate them well. He adds that there is no reason to view this as a maximum.

We are seeing an increasing number of adults with ADD/ADHD and they participate in the same structured protocol as above. In general, it has been our experience that adults with ADD/ADHD uniformly require higher absolute doses of medication compared to children though the mg/kg ratio per dose is oftentimes somewhat lower. We find that while weight can help point one in the right direction (perhaps as a reflection of brain size) it is the severity of the individual’s attentional problem that seems to have the biggest impact on determining the most appropriate dose.

Other specialists treating ADD/ADHD adults have also found the need to use higher doses than the manufacturer’s recommendations. Dr. Daniel Amen, a nationally recognized researcher and clinician in the area of ADD/ADHD, has written to us describing his experience with medication doses and it is very similar to the one that we have experienced. Similarly, Drs. Marc and Nicolas Schwartz who see large numbers of adults with ADD/ADHD have studied optimal stimulant dosing in their private practice and have found adults require optimal doses of all stimulants that fall above FDA-approved manufacturers’ guidelines.

Managing ADHD Effectively with Medication | The Being Well Center's 4-Step ApproachStep Four: Medication Review Visits

Once we have started patients on medication, we conduct a one-hour medication review visit every three to four months. At these visits, we re-assess attention either on or off medication
to document continued efficacy, monitor improvement and verify the need for continued use of the medicine. We also conduct an interview with the patient and significant others to monitor progress, identify problems, and respond to concerns. A targeted physical assessment including vital signs is conducted to monitor for any adverse effects. At the end of this visit, decisions are made about the medication (dosage, schedule, etc.) and the overall treatment plan is revised.

We look for every opportunity, if possible, to discontinue medication, but, not surprisingly, most of our patients seem to have significant problems which require long-term medication treatment. In carefully monitoring our patients, we have not identified any significant negative side effects with the stimulants that could be conclusively attributed to an off-label dosage/dosage regimen of medication prescribed.

We have found that most of the common side effects that occur with stimulants can be mitigated by adjusting the timing of medication, switching to another attention medication, helping patients establish and maintain balanced healthy daily routines, and providing ongoing supportive counseling in parallel with the medication.

The Cutting Edge of ADD/ADHD Management

We take our responsibility as health care providers extremely seriously and when applied to the management of ADD/ADHD, we feel that we are on the cutting edge. We have taken care to do things properly and have even submitted our approach to the State of Pennsylvania Medical Board, which found it to be in accordance with appropriate medical practice as defined by state statutes. We feel very confident and comfortable with the approach that we take with our ADD/ADHD patients.


If you’re new to Dr. Liden’s blog, you might want to Start Here to pick his brain on all topics ADD.  If you’re looking for a way to get a diagnosis and treatment plan you can trust, check out The Being Well Center’s Accurate Diagnosis Determination (A.D.D.).

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A Proven Formula for Success with ADHD and Medication

image via Flickr | Purple Sherbet Photography

image via Flickr | Purple Sherbet Photography

ADD/ADHD has been a provocative topic in lay and professional communities for decades: What is it? Does it really exist? What causes it? How is it diagnosed? Is it over-diagnosed? Is it really a significant health issue? Why are so many people being diagnosed with it?

A key driver behind many of these questions is the fact that effective treatment of ADD/ADHD more often than not necessitates the use of controlled substances to treat a problem that just does not seem that serious to many individuals.

The front-line medications for ADD/ADHD, the methylphenidate and amphetamine based stimulants, provoke strong feelings, namely, worry and fear in most patients and, unfortunately, in many professionals involved in their care.

Because of these fears, some well founded and some not, many patients with legitimate concerns go undiagnosed while others do not get treated or are treated with sub-therapeutic dosage regimens. As a result, their short and long term outcomes are not optimal and the chances of developing significant secondary co-morbidities increase.

Over the past 35 years, in our ADD/ADHD specialty practice in Pittsburgh and at various satellite locations, we have diagnosed and successfully treated more than 10,000 patients (greater then a 90% success rate).

Being Well Center | Success with Medication and ADDWe have accomplished this high degree of success by rigidly adhering to a comprehensive, multidisciplinary approach that is individualized to the needs of each patient. We have created systematic evidence-based protocols which we have refined by consistently applying them to our patients and continuously assessing their efficacy and cost effectiveness/efficiency.

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 differentiated use 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.

Our sense is that appropriate treatment of ADD/ADHD with proper dosing of medication is going to emerge as a significant health care issue.

Success with ADD and Medication | The Being Well CenterWe are eager to work with others to resolve this important health care problem. We are confident that if we work together we can come up with a more appropriate set of guidelines for the use of stimulant medications in the treatment of ADD/ADHD so that these individuals can receive a higher quality of medical care and better long-term outcomes.

We believe that cost effective and efficient management of a common problem like ADD/ADHD, such as we provide with our approach, can be a cornerstone to reducing overall health care costs.


Find more honest answers and resources you can trust at TRANShealth Inc, a non-profit organization that imagines a future where accurate diagnosis and effective treatment for ADD is the norm. TRANShealth seeks to educate, inform, guide, and cheerlead individuals pursuing a path to overcome the challenges of ADD/ADHD.

Attention Deficit Disorder in the Laundromat

image via Flickr, David Goehring

image via Flickr, David Goehring

While the experience I’m about to share occurred 15 years ago, but I remember it like it was yesterday. Its message is as valid today as it was when I was blessed to have had my Laundromat experience.

As Divine Order would have it, I found myself in a laundromat two weeks ago. My plans were to run inside, quickly place my clothing in the washing machine, run to the grocery store, return to the laundromat, place my clothing in the dryer, swing by the hardware store, return to laundromat, and scurry home with my clean clothes in basket.

This, however, was not my destiny.

Rather, I spend two hours at the laundromat that night listening to a story — an all too-true story that I want to share. I hope that it will illustrate the painful truth of my reflections, the serious impact ADD has on the quality of life, and the tremendous need that we must all work to meet.

This is the story of the woman who proctors the events that occur in this laundromat. She watches the people. She cleans the washers. She wipes the tables. She sweeps the floor. And she talks…

 

She works at the laundromat part-time.

She’s been divorced twice.

Her 10-year-old son has a hard time in school.

He struggled for a long time–was held back a grade and was recently placed in the LD classroom.

He has a problem controlling his behavior.

She says she has a real hard time with him.

She says he is always getting in trouble.

He recently started a fire in the boy’s bathroom at school.

He’s been diagnosed as having ADD.

She’s on welfare.

She uses the medical assistance card for health care.

She has other children.

Her son’s father is an alcoholic— she’s certain he has ADD, too.

Her mom left home when she was very young.

Her dad was abusive.

She says that she doesn’t feel that she experienced a lot of love when she was growing up.

She says she’s depressed.

She sees a psychiatrist weekly.

She says she’s been diagnosed as being depressed as a result of a chemical imbalance.

She takes a new drug for her chemical imbalance.

She says that she really doesn’t believe her depression is because of a chemical imbalance.

She thinks she’s depressed because her life is a disaster.

She says her work at the laundromat is the only thing that keeps her going — gets her out and doing something.

But she worries about how bad things get at home when she’s not there.

She has no consistent childcare for her children.

She has seen many counselors.

She says her current psychiatrist wonders why her son does the things he does.

Over the years, she’s been given many different reasons for her son’s behavior: he just wants her attention, he’s emotionally disturbed, he’s reacting to her depression.

She doesn’t know what to think.

She makes sure every day, as her kids go off to school, to say “I love you very much” so that they’ll know no matter what, they’re loved.

She laughs and says she really thinks she has ADD, too.

She doesn’t know what to do about it.

Her son was recently in the psychiatric ward of a local hospital for six weeks.

She says he isn’t much different since coming home from the hospital.

The hospital bill was $38,000.

She didn’t have to pay for any of it.

She says that our tax money paid for all of it.

She’s grateful for that.

She doesn’t know how other people ever get any help.

She thinks that people on welfare get the best medical care in the country.

She says she has a friend who works in the welfare office; he can’t afford to get help for his daughter who has the same problems.

She says her son has been on Ritalin for a while.

When he was in the hospital there was in increase in his dose.

She doesn’t understand why.

She doesn’t really know what ADD is.

She doesn’t know what’s going to happen to her son.

She says she’s frightened for him.

Weekly, he sees a psychiatrist whom she says she met one time for 10 minutes.

She doesn’t know what the psychiatrist talks with him about.

He used to see a different psychiatrist.

She didn’t know what they talked about either.

She says she feels that she’s learned a lot about life from her experiences.

She’s at a loss for how to turn her life around.

Meanwhile, she says she’ll continue to do her best with what’s been offered.

 

At 8 o’clock, the laundromat closed, but I am sure her story goes on and on. Don’t trick yourself into thinking that this is just the story of a welfare mother in a laundromat.

If you have an open ear and an accepting attitude, I have learned that you can hear a similar story from your neighbor, your cousin, your hairdresser, you minister, your grocer, and even from your doctor.


What is your life story with ADD/ADHD?  We’re listening…

The Greatest Challenge of Being an ADD Doctor

Dr. Craig Liden | The Being Well CenterThere are many things that clinicians, healthcare professionals, and educators can do to help the individual with ADD and his family to improve the quality of their lives. The satisfaction of participating in this process is unbelievable.

However, the biggest challenge of working with Attention Deficit Disorder is that it is so unpredictable. Just when we think that, together, we have made it over the hump–that now it’s licked–invariably (maybe it’s next week, maybe it’s next month, or maybe it is in a year or so) the bottom falls out again. A new expectation comes along and the road for the person with ADD gets bumpy again.

While we all can intellectually appreciate that ADD is a chronic, biologically-based difference that results in recurrent dysfunction, it is a whole different thing for professionals to accept this emotionally.

It is common for professionals to experience a sense of failure and feel disappointed when significant problems resurface in a patient after a sustained period of apparent normal functioning.

In addition to grappling with his own emotions, the clinician must face the challenge of supporting the ADD individual and his family in their coming to grips with the chronic nature of ADD. This can be particularly difficult when what everyone really wants is a simple, easy answer.

Finally, with the persistence of the problem, inevitably comes the guilt on the part of parents, teachers, and clinicians who think, “if only I had…”


Are you a doctor, clinician, educator or parent who has thought, “If only I had…”?  

Want the inside scoop and honest answers about other ADD topics?  Start here for some of our most popular posts, or go right ahead and buy a copy of Dr. Liden’s bestseller, Pay Attention!

 

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.

ADD or Bipolar? Why it’s hard to diagnose the difference.

image via Flickr, Matt Anderson

image via Flickr, Matt Anderson

Differentiating between Attention Deficit Disorder and Bipolar Disorder can be very challenging, particularly for the inexperienced clinician. In part, this is because these two syndromes share some common behaviors, but also because there is an overlap in the incidence of the two problems.

Research and clinical experience suggest that a many as 30% of individuals with Bipolar Disorder also have ADD and somewhere around 3.5% of people with ADD have Bipolar Disorder. Therefore, there are a number of individuals who have both ADD and Bipolar Disorder.

While there can be shared characteristics between the two syndromes, there are a few factors that can help differentiate them. ADD is a chronic problem that shows up early in childhood and manifests itself continuously throughout life. On the other hand, Bipolar Disorder is very difficult to recognize before the early teen years and when it does show up, is episodic in nature.

In my experience, more than 95% of people with ADD demonstrate markers of what I call “neuromaturational delay” such as gross or fine motor incoordination, excessive numbers of soft neurological signs, persistent articulation difficulties in childhood, or a history of bedwetting or febrile seizures. This is not the case with individuals with Bipolar Disorder.

Finally, since both problems tend to run in families, a positive family history can help point us toward the right diagnosis.


Concerned about getting the right diagnosis?  Dr. Liden‘s (free!) download ebook, ADD/ADHD Basics 101, will steer you in the direction of a clinician you can trust and give you the knowledge you need to KNOW you have the right diagnosis.  Download ADD/ADHD Basics 101 right away!

 

ADD is NOT the same as Hyperactivity

image via Flickr, Carolyn Tiry

image via Flickr, Carolyn Tiry

Hyperactivity is one of the many labels that have been used over the years to describe individuals who demonstrate the characteristics of ADD. Other labels that have been applied to this same grouping of individuals include hyperkinesis, Minimal Brain Dysfunction (MBD), dyslexia, and learning disability.

The use of so many diverse terms to describe the same or similar behaviors has contributed to much of the confusion that surrounds ADD.

In fact, today many use the term ADHD or Attention Deficit Hyperactivity Disorder to describe all ADD individuals. They go on to break ADHD into several subtypes: primarily hyperactive, primarily inattentive, and combined type. I don’t embrace these labels and distinctions for several important reasons.

Don’t Perpetuate the Hyperactive Myth

First, holding onto the ‘hyperactive’ label perpetuates the myth in the minds of many lay and professional people that one must be hyperactive in order to have ADD. Clearly, this is not the case, since the majority of individuals with ADD demonstrate either a normal or a low activity level!

Hyperactivity is NOT a Core Characteristic of Attention Deficit Disorder!

Secondly, I don’t believe that hyperactivity is a core characteristic of the ADD syndrome. My observations over the years are that individuals with ADD show “hyperactive” behavior for two reasons, both grounded in underlying attention difficulties.

image via Flickr, Dana

image via Flickr, Dana

Some individuals with ADD demonstrate fidgetiness and motoric overactivity because they have underlying problems with low arousal and need extra movement such as squirming in their chair, bouncing their leg, or tapping their fingers to keep them awake.  Interestingly, these unconscious attempts to maintain arousal frequently disappear quickly when these individuals take one of the ADD medications that wakes them up.

Other ADD individuals appear to be “hyperactive” because their attentional weaknesses preclude efficient self-control of a temperamentally-based high activity level.

I have seen this in my own family. My older son got his mother’s weak attention and my high activity level. His impulsivity, distractibility, and poor self-monitoring coupled with his high activity level lead to his bouncing off the wall, numerous careless accidents, and disturbing out of his seat behavior. On the other hand, my high activity level has never been as problem for me. When it is coupled with my strong attention, I have been able to “put a method to my madness” to accomplish many things.

Real World People Don’t Fit Into Neat Little Boxes

I appreciate that categorization systems like DSM (Diagnostic and Statistic Manual) that split ADD into various subtypes (e.g., Hyperactive) may serve a purpose in defining a pool of research subjects or to clarify communication between professional. However, my experience in the real world is that individuals don’t fit into such neat little boxes defined by narrow criteria.

When all is said and done, what matters most when it comes to ADD are the five key characteristics of inattention. After this, every individual with ADD is unique: some hyperactive, some underactive, some intense, some very sensitive, some gifted, some retarded. What we see on the outside is the result of how the core characteristics mix with other traits, abilities, and characteristics.


Craig B. Liden, MD  is an internationally recognized expert in the diagnosis and treatment of ADD/ADHD.  Since the 1980’s, Dr. Liden has been in private practice evaluating and treating behavior and developmental issues across the life span.   He has treated more than 10,000 patients with ADD/ADHD and related co-morbidities.  Dr. Liden  has written and lectured extensively about ADD/ADHD, education, individual differences and a variety of health problems, most recently publishingAccommodations for Success: A Guide and Workbook for Creating 504 Agreements and IEP’s for Children with ADD/ADHD and ADD/ADHD Basics 101: How to Be A Good Consumer of Diagnostic and Treatment Services for ADD/ADHD.   Dr. Liden is the Founder and Medical Director of The Being Well Center located in Pittsburgh, PA.  He is available for speaking engagements, workshops, and interviews.