ADHD Medication is Key to College Success

image via Flickr, CollegeDegrees360

image via Flickr, CollegeDegrees360

When students arrive on campus, the demands for efficient attention and self management skills (that is executive functioning) immediately soar . . . challenging academics, consistent study habits, maintenance of healthy daily routines for sleep, eating and exercise, money management, and more complex social decision making.

Meeting college demands is particularly challenging for students with ADD/ADHD and for the overwhelming majority of them, this means having the aid of a medication regimen that provides benefits throughout the whole day.

An all-day medication regimen is a key to college success

We’ve learned from our experience in our Confidence@College program that college is a bad time to try to “fly on my own” and go without medication treatment.

In fact, in our C@C patient population, we have found that acceptance of the need for medication and compliance with an appropriate all-day medication regimen is near the top of the list of factors that contribute our 81% success rate.

For some ADD/ADHD individuals who have been able to get by without medication in the past, entrance into college with its increased demands means having to seriously consider the use of medication for the first time.

For others who have been able to get by with a medication regimen geared to get them through the school day, it means revising their regimen to provide coverage into the evening hours.  And for others, it means committing to taking the medication 7 days a week!

Don’t let an improper use or lack of medication keep you or your student from success at college!

A specific, individualized success plan leads to college success

At The Being Well Center, patients who enroll in our Confidence@College program always start with a Discovery Session where we identify the key problem areas and survey the whole person so we can pinpoint the barriers to success and uncover strengths we can mobilize to meet these new challenges.

We then develop an individualized Success Plan.  When medication is a part of the success plan we conduct systematic medication trial testing using objective testing procedures to find the right medication and a treatment regimen that provides efficient attention throughout the waking day.

Before students arrive on campus we brainstorm with them and their parents how they are going to get their medication and how to securely store it.  We go over the logistics of when they will take the medication based upon their weekly schedule.  In addition, we review the dangers of diversion of the medication and make sure we have a mechanism in place to closely track the quantity of medication we provide them.

Follow-up support at school leads to college success

Once students are on campus, we use innovative technologies and support from our staff through our GuideU video counseling sessions to ensure the student complies with the medication regimen and maintains healthy daily routines, the foundation for a successful medication experience.  We identify signs of sub-therapeutic treatment and possible side effects quickly and our medical staff fine tunes the treatment regimen as needed.

We’re there to ensure success during the whole college experience not just in the classroom, library or study carrel.  We make sure our patients are aware of the importance of taking the medication during evening hours and weekends where social activities provide high risk challenges for un-medicated ADD/ADHD students.

Avoid “unmedicated” fun consequences

Impulsivity, poor self awareness, weak self monitoring and ineffective problem solving can lead to social decisions that can be disastrous . . . alcohol intoxication, substance abuse, unprotected sex leading to unplanned pregnancy or STD, or illegal activities.  One night of un-medicated “fun” can lead to expulsion from school and life-long consequences.

Compliance with the right medication regime leads to college success

If you’re at the top of your game, college can be an exciting and enriching experience intellectually, developmentally, and socially, and can provide you with what it takes to independently fulfill your dreams and aspirations through life.  Compliance with the right medication regimen helps this become a reality for students with ADD/ADHD!


Be confident with your child’s success at college . . . call us at the BWC and set up an appointment to participate in our Confidence@College program.  We’ll make sure your child has all the tools, including an optimal medication regimen if needed, to succeed at college.

Confidence@College | The Being Well Center

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.).

Straight Facts on ADHD and Medication (Part 2)

Straight Facts on ADD Medication Part 2 | The Being Well CenterIn Part 1, we explored the essential key facts of ADD/ADHD and the unfounded fears surrounding medication treatment.  Today, we dig deeper into physician application of medication and why more, not less, medication, may be best for your situation.

State-of-the-art care may require more, not less, medication

State of the art care for Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ ADHD) frequently requires doses/dosage regimens of stimulant medications that are at variance with FDA approved manufacturer’s guidelines (i.e., off-label).

Lack of training and experience about ADD/ADHD and its pervasive nature, limited experience with the medications used to treat it, and a misunderstanding/ misinterpretation of the intent of the FDA approved guidelines promotes fear of off-label use of stimulant medications in patients and many professionals.

As a result, many patients who could greatly benefit from proper treatment receive sub-therapeutic dosage regimens or no treatment at all.

The medical literature provides ample support for the safe use of off-label doses/dosage regimens of stimulants in children and adults with ADD/ADHD when tailored to a patient’s individual needs. A national survey of family physicians, pediatricians, developmental pediatricians, and child/adult psychiatrists has shown that greater than 45% have prescribed stimulant mediations for ADD/ADHD off-label.

Technically speaking: Digging into the medical literature supporting off-label regimens

In general, the medical literature demonstrates that for most patients there is a linear dose-response curve with regards to stimulant medications. This means the higher the dose the greater the response. Other patients show no response at lower doses but require substantially more robust doses before they show any positive benefits.

These differences in medication responsiveness appear to reflect genetically-based individual differences in factors that affect how an individual metabolizes these drugs. We now have genetic testing that can facilitate a better understanding of why certain patients appear to be outliers when it comes to medication effectiveness and adverse effects.

Straight Facts on ADHD Medication | The Being Well CenterTherefore, in the presence of continued dysfunction in an ADD/ADHD individual, medication can legitimately be increased to the point that all day clinical efficacy is achieved or side effects become intolerable or unmanageable.

In our experience, this later issue is oftentimes very complicated. Clearly, the ADD/ADHD field could benefit from much more research into the use of medication and dosage levels in particular.

We feel that the major limitation of current medical literature is the significant heterogeneity of the ADD/ADHD population in terms of the degree of their problem and profile of underlying attentional weaknesses and executive dysfunctions along with the presence of individual differences in temperament and/or co-morbid conditions that have not been accounted for in study designs.

For supporting resource articles, click here (see page 10 of ADD/ADHD Basics 301).

A National Survey of Physicians Concurs

We have conducted a national survey of physicians regarding their prescribing practices with regards to ADD/ADHD. We obtained randomized samples (including geographic area) of membership lists from the American Academy of Family Practitioners (AAFP), the American Academy of Pediatrics (AAP), the American Psychiatric Association (APA), the Society of Developmental and Behavioral Pediatrics (SDBP), and the American Academy of Child and Adolescent Psychiatry (AACAP). Each physician was asked to complete a detailed questionnaire designed by a research psychologist with a strong background in marketing surveys.

ADD/ADHD Basics 301Results indicate that approximately 45% of all physicians responding had used stimulants in treating ADD/ ADHD at dosages greater than the FDA approved manufacturer’s marketing guidelines. Furthermore, as training and experience with ADD/ADHD increases, the percentage of physicians using higher doses increases (see tables on page 13 of ADD/ADHD Basics 301).

Our interpretation would be that as physicians get more training and more experience with ADD/ADHD, they come to recognize that it is frequently necessary to exceed FDA approved manufacturer’s marketing guidelines for stimulants in order to properly manage their patients in all life spheres throughout the working day.

Medication in Context of Multi-Modal Treatment

By using a systematic protocol that involves a comprehensive multidisciplinary assessment to first establish a valid ADD/ADHD diagnosis and identify related co-morbidities, objective in-office medication trial testing, and ongoing supportive counseling, we have safely incorporated off-label dosing regimens of stimulant mediations when needed to help our ADD/ADHD patients function effectively in all life spheres.

Read More:

5 Things You Need to Know About ADD/ADHD

7 Keys to Successful ADD/ADHD Medication Treatment

A Proven Formula for Success with ADD/ADHD Medication

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.

The Truth About ADD Medication and Suicide

image via Flickr, Pedro Ribeiro Simões

image via Flickr, Pedro Ribeiro Simões

Attention Deficit Disorder medications do not appear to be a direct cause of depression or violent behavior.

However, the use of medication in individuals with ADD can unmask over-sensitivity, extreme intensity, or a low frustration tolerance that had been hidden by weak attention.

As these characteristics are uncovered in an individual with poor self-control and ineffective problem solving, they may make the person slightly more prone to violent outbursts or self-destructive acts. This is another reason that a person who is treated with medication for ADD must be followed closely and provided with strategies for more effective problem solving and self-control.

Moreover, some people with ADD seek help because they are overwhelmed by life and have become sad, depressed, and even suicidal.

Others can present with a history of violent temper outbursts often the outgrowth of poor self-control of impulsivity, intensity, and a low frustration tolerance.

Oftentimes, attempts to manage these behaviors with other medications such as antidepressants have been only partially effective.

For these two groups of people, accurately diagnosing and instituting proper medication use, coupled with other treatments can help them dramatically turn their lives around. In my experience, persistence of extreme dysfunctional behaviors in the face of proper medication and appropriate treatment suggests a need for more intensive psychiatric intervention.


Dr. Liden’s clinic, The Being Well Center, offers free resources for people working through the challenges of living with ADD and its related co-morbidities.  Don’t miss the BWC resources page for free downloads and ideas that could help you or a friend today.

 

The Truth About ADD Medication and Hypertension

image via Flickr, liviana1992

image via Flickr, liviana1992

ADD/ADHD stimulant medications and Strattera have been studied extensively and both have been found to cause slight, but clinically insignificant changes in blood pressure and heart rate in children and adults.

Any increase in heart rate or blood pressure that does occur tends to diminish as the medication is used over time.

Therefore, there is no need to routinely screen heart rate, blood pressure, or EKG’s before using any of these medications.

In my experience, the ADD medications can also be safely used with all of the medications currently used to treat hypertension.

However, some so-called beta-blockers can cause fatigue and sleepiness, which may aggravate ADD symptoms. If this occurs, either a switch in anti-hypertensives or an adjustment of the ADD medication may be necessary.

I have seen many adults with ADD who were hypertensive and receiving anti-hypertensive treatment at the time they were diagnosed with ADD.

Interestingly, when we instituted medication and other supportive treatment, they began eating better, exercising more, losing weight, and handling stress more effectively and soon had normal blood pressure with no need for anti-hypertensive medication.


For further insight into the clinical truth of ADD/ADHD medication, don’t miss Dr. Liden’s (free) download PDF of his book, ADD/ADHD Basics 301.  More honest discussion about the hot topics surrounding Attention Deficit Disorder can be found in our Pay Attention! blog series.

The Truth About ADD Medication and Tics

image via Flickr, Scarleth Marie

image via Flickr, Scarleth Marie

Twitches, tics, or tic-like behaviors are very common in individuals with ADD even before the use of medication.

When treatment is started with one of the stimulant medications, it is my experience that these behaviors decrease or stop in many individuals, stay the same in some and, occasionally, become worse in others.

The reason for these different responses is unclear. In many people, it appears that the aide of stimulant medication reduces tics by helping the individual to function more effectively and behave more appropriately. This, in turn, serves to reduce the underlying stress and anxiety that were the driving forces behind the tics.

In others, the reverse seems to be true. The increased awareness that comes with medication treatment leads to heightened anxiety and the emergence of or increase in tics.

There is no predictable effect from stimulant to stimulant regarding their impact on tics.

That is, for a given individual, tics may appear or increase with one stimulant medication and not with another.

Because Strattera has a different mechanism of action, it really has no potential to increase or cause tics to emerge. For this reason, Strattera may become the medication of choice in patients with a history of tics, twitches, or Tourette Syndrome unless other factors point to a need for a stimulant. In several of my patients with tics, the institution of Strattera either stopped or greatly reduced tic behavior.


For further insight into the clinical truth of ADD/ADHD medication, don’t miss Dr. Liden’s (free) download PDF of his book, ADD/ADHD Basics 301.  More honest discussion about the hot topics surrounding Attention Deficit Disorder can be found in our Pay Attention! blog series.