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.

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Sleepy Students at Risk for College Failure

Attention in College Students | The Being Well CenterWhen we think about ADD/ADHD in a college student, we can easily imagine how impulsivity, distractibility, short attention span, problems with following through with directions, poor organizational skills, weak task/time management and procrastination, can wreak havoc on her success.

What may not come to mind, however, is one of the most common attentional weaknesses that contribute to college failure – low arousal level.

So what is Low Arousal level anyway?

Well, at a very basic level, we must maintain a certain level of alertness in order to pay attention and regulate our behavior.  Arousal level refers to how awake and alert we are at any point in time.  

Based upon our clinical experience with thousands of patients, we have found that many individuals with ADD/ADHD have a low arousal level; they are not alert and sufficiently awake to pay optimal attention.

This statement can be confusing to some people who presume that because some individuals with ADD/ADHD are “hyperactive” that they are hyperaroused when, in reality, the opposite is probably true!

The Low Arousal Student Profile

A student with low arousal level can demonstrate a wide range of behaviors.  She may become fatigued during mundane activities (like listening to lecture or completing a 60-page reading assignment), yawn excessively, have a glazed look in her eyes, or actually fall asleep at her desk.

Commonly, ADD/ADHD students blame these behaviors on the task, the subject matter or the professor . . . “too boring.”

Can Low Arousal Look Like Hyperactivity?

On the other hand, some ADD/ADHD students who are under-aroused demonstrate “hyperactivity” ranging from leg bouncing, wiggling in the chair, fidgeting, aimlessly playing with materials, and stretching or actually getting out of their seat and wandering around.

Our clinical experience suggests that these “hyperactive behaviors” are actually unconscious attempts by the ADD/ADHD student to self-stimulate herself in order to increase or sustain her arousal in a learning (or should we say “boring”) situation.

Underlying Conditions Can Magnify Low Arousal

Other conditions or co-morbidities can magnify an ADD/ADHD student’s struggle with alertness or arousal including sleep deprivation, obstructive sleep apnea, iron deficiency anemia, poor nutritional habits (like skipping meals, pigging out, or self medicating with carbohydrates), depression and certain temperamental extremes (such as low frustration tolerance or short persistence) to name a few.  All of these conditions are very common in students with ADD/ADHD.  Sometimes these conditions even mimic ADD/ADHD in students who don’t have the diagnosis.

Medication Can Fix Low Arousal

Commonly, low arousal can signal the possible need for medication treatment in a student with ADD/ADHD.

In those students already taking medication, it can indicate the need to refine the dosage level (generally it means there is a need for more) or dosage regimen (adding medication dosage(s) to provide all-day coverage into the evening when most students study and read those “boring” text books!)

Healthy Daily Routines Can Fix Low Arousal

At the very least, the tendency toward low arousal suggests the need to establish and maintain healthy daily routines for sleeping, eating, exercise and relaxation.

It should be obvious that unmanaged low arousal can be a major risk factor for college failure.  Dealing with it means getting a comprehensive evaluation to determine all the possible contributors and then developing a targeted, individual treatment plan to address each contributing factor.  That’s what we do at the BWC!  Contact us today so we can help your child “wake up” and start experiencing the success he or she is capable of!

If any of this resonated with you, take the next step to pinpoint if Low Arousal is throwing roadblocks in your path to college success.  Click here to download our Confidence@College success screeners for a quick, easy, and free quiz.

3 Ways to Have a Positive Experience with ADD Medication

image via Flicker, Nan Palmero

image via Flicker, Nan Palmero

1. Participate in a Comprehensive Evaluation

There are many things an individual can do to increase the likelihood he will have a positive experience with medication. First, and perhaps most critical, it is important that the individual has participated in a comprehensive evaluation before starting medication and has a treatment plan in place that addresses not only ADD but also any co-morbid problems.

Failure to properly identify and manage any co-morbid conditions is one of the most common reasons people don’t do well with these medications.

He should also seek out a physician and other professionals with a significant amount of experience with treating ADD in children, adolescents, and adults to implement the treatment plan; the quality, value, and wisdom of the support, direction, and feedback an experienced clinician provides can help an individual through even the most difficult adjustments to medication.

2. Stick with the Medication for a “Fair Chance” period

image via Flickr, Luz Adriana Villa

image via Flickr, Luz Adriana Villa

Secondly, it is important for the individual to stick with the medication and give it a “fair chance.” It is not unusual for it to take several weeks or in the case of Strattera, a month or more for everything to settle down and the individual to start to reap the benefits of improved attention.

While patience is not usually a virtue of individuals with ADD, this is one place where working extra hard to persist can pay big dividends.

3. Maintain a Healthy Daily Routine

Finally, in my experience, establishing and maintaining what I call a healthy daily routine (HDR), is the single most important thing an ADD individual can do to have a positive experience with medication.

My staff and I put a lot of energy into helping our patients establish a good HDR consisting of the following:

  • Going to bed and waking up at approximately the same time every day
  • Getting an adequate amount of sleep; for adults this means approximately 7 or 8 hours and for children even more depending upon their age
  • Eating three meals a day at predictable times
  • Eating a balance of foods from all of the food groups
  • Drinking adequate amounts of water ― for adults about 8 glasses a day
  • Getting approximately 30 minutes of aerobic exercise each day
  • Participating in a mentally challenging activity other than work or school each day
  • Taking time to participate in 15 to 20 minutes of a mind-centering activity (meditation, yoga, prayer, etc.) each day
  • Spending time with family and friends each day
  • Taking care of daily responsibilities: health, finances, home and work
image via Flickr, Dr. Abdullah Naser

image via Flickr, Dr. Abdullah Naser

The components of a HDR may seem so obvious, yet for many people – with or without ADD – establishing and maintaining a healthy lifestyle is very difficult. Over the years, I have seen the tremendous benefit of including these simple activities into daily life.

My patients who are committed to and consistent in their routines, time and time again, are successful with medication use and experience significant improvement in their daily functioning. My patients who are not are more likely to have problems with the medication and, often, do not experience the tremendous benefits others experience with medication.

When individuals embrace and maintain a good HDR, their medication works better, they experience fewer side effects, and they lead healthier, happier, and more productive lives.

A balanced HDR is so critical to a positive experience with treatment for ADD that I learned long ago to make it the first thing I ask about when an patient says things are not going well. I am almost always rewarded. When one of my patients who had been doing well complains that the medication does not seem to be working as effectively or that an unpleasant side effect has suddenly emerged, it invariably turns out that some element of his HDR has gone awry and things snowballed from there. My experience is that getting his HDR back on track oftentimes boosts the effectiveness of the medication and eliminates nagging side effects.

Keep the Goals of ADD Medication Treatment in Mind

image via Flickr, devinf

image via Flickr, devinf

There are three key goals in using medication to treat ADD.

First is to improve the individual’s attentional status. Specifically, we want the individual to experience increased arousal, improved focus, decreased distractibility, improved monitoring, and a longer attention span.

Secondly, the medication should enable the ADD individual to take advantage of the other therapies that are important in addressing all his needs. That is, we want the medication to make the individual more available to treatments that teach new skills and behaviors, provide compensatory strategies, and address co-morbid conditions.

Finally, and most importantly, the medication should assist the ADD individual to function efficiently and effectively in all life spheres throughout the whole day.


Tap into more of Dr. Liden’s expertise in the safe and effective use of medication to treat ADD/ADHD in his free ebook, ADD/ADHD Basics 3o1.

 

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!

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.

Losing Sleep Over ADD?

How does ADD impact sleep?

image via Flickr, Vic

image via Flickr, Vic

In our practice, about 70% of people with ADD come to us with sleep problems—trouble getting to sleep, staying asleep, or waking up in the morning. This makes all the sense in the world—as a key feature of ADD is low arousal, it falls to reason that an event that involves arousal in the day will play a role in the sleep-wake cycle at night.

Some of my patients who have trouble falling asleep at night experience wakefulness, in part, because they are unable to turn off their minds; as they lay in bed, distractibility keeps their minds active, moving from one thought, worry, or plan to another never quieting sufficiently to shift into the sleep mode. Others seem to struggle with getting to sleep as a consequence of a second wind: they come home wiped out; they zone in front of the television until 10:00 PM; get a surge of energy, act on it and find it tough to come down to sleep when they try.

It is not uncommon for my patients with ADD to experience nighttime wake ups. For some of these individual’s this is actually related to sleep apnea—periods of cessation of breathing during sleep. Research suggests that sleep apnea occurs in the ADD population more frequently than in the general population; it is likely that this is a function of a higher incidence of obesity in people with ADD and obesity is a key contributor to sleep apnea. Many of my patients do not suffer from sleep apnea but still more often wake up during the night. My understanding of this is a function of a less than good sleep-wake cycle in ADD population.

Probably, one of the hallmarks of ADD is trouble waking up in the morning. While this is particularly difficult for those who get their second wind at night and don’t fall off to sleep until very late, it is also experience by ADD individuals who have had the benefit of eight hours of sleep. Again, it is likely that this is a result of the disorder arousal system in the ADD population.

Apart from its being a drag, sleep difficulties are a serious problem for the ADD individual; we know that sleep deprivation on top of an arousal problem only intensifies his impulsivity, distractibility, poor monitoring, and weak vigilance.


Don’t fight those sleepless nights alone!  A thoughtful doctor or therapist can help you tackle the challenges of ADD and restful sleep.  For help finding the right care provider, Dr. Liden offers a step-by-step guide to finding a diagnosis and treatment plan you can trust to succeed: ADD/ADHD Basics 101

Follow Up Care for ADD Medication

How often should an individual with ADD be checked once he starts medication?

image via Flickr, Kate Ter Haar

image via Flickr, Kate Ter Haar

Once the proper medication regimen has been established and the initial adjustment phase is over, my bias is that ADD individuals should participate in follow-up with a clinician at least monthly until all areas of his dysfunction are resolved or stabilized. This can be with a physician who performs brief med-checks and probes patient compliance with all parts of the treatment plan.

Alternatively, follow-up can be with a counselor, ADD coach, tutor, or other professional implementing the treatment plan and communicating to the physician about progress, persistent problems, and observed or reported medication side effects.

Regardless of the frequency of these follow-up visits, I see all of my patients for whom I am prescribing medication every three months for a more comprehensive medication review visit.

Include the Parent or Spouse

I strongly encourage both parents or the spouse to attend these visits with the ADD child or adult. At these appointments, I check height, weight, blood pressure, and heart rate and perform a targeted physical exam when there are specific health concerns. Each patient also participates in a brief reassessment of his attention using specific tests that I have developed. Sometimes we reassess attention on the current dosage of medication to document its current effectiveness. Other times, we assess attention of medication to document continuing need.

I always meet with the ADD individual to directly observe his functioning and to hear his perspective about how he is performing in each major life sphere — school, work, social involvements, home life, and daily routines and responsibilities. I also probe to be certain he is taking the medication as directed and check his perceptions regarding efficacy, side effects, or other problem areas. I then meet with his parents or spouse to discuss the same areas. As ADD individuals are notoriously inaccurate in monitoring their own performance or behavior, another person’s perspective is always helpful.

At the conclusion of these visits, I give my feedback about the progress the individual is making . . . sometimes followed by a hug or pat on the back and sometimes with a kick in the rear! Together we decide whether to keep the medication regimen the same, discontinue it, or to make changes.

Anticipate the Future and Stay in Touch

image via Flickr, in transition

image via Flickr, in transition

This visit also provides me with an opportunity to provide anticipatory guidance about problems that are likely to emerge in the near future as the expectations in the individual’s life change. When appropriate, I also share my treatment recommendations with the other professionals who are working with the individual.

As individuals continue in treatment, do well, and remain stable for a long period of time, occasionally, these visits out to occur twice a year rather than quarterly.

However, this is rare; I have learned over the years that a lot can happen in an ADD individual’s life in three months, let alone six months, that can head him in the wrong direction.

More often than not, the ADD individual is not fully aware of a change in direction or has used ineffective problem solving that complicated matters rather than solved a problem. I prefer more contact rather than less when it comes to management of ADD and so do most of my patients.


Catch up on all of the discussion topics 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.