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.

Understanding Temperament: Activity Level

image via Flickr by David Dodge

image via Flickr by David Dodge

A key goal in effective treatment for Attention Deficit Disorder should be to understand our temperament and the temperament of the children we live and work with. We need to critically consider how any extreme temperamental traits might be contributing to problems in performance, behavior, or social interaction.

In our experience, understanding the concept of temperament and applying that knowledge to ourselves as parents and teachers and to those around us helps us to better understand behavior…struggles, failures, and successes.

Understanding ACTIVITY LEVEL

Activity Level refers to the amount of activity from high to low that we engage in throughout our day.

Some of us are always moving and physically active; others of us are more sedentary and spend most of our time engaged in quiet activities.

The child with a high activity level is likely to be in his element in gym class and playing tag during recess and to have more difficulty staying settled during quiet seated activities; on the other hand, the child with a low activity level might prefer sitting and drawing or reading during free time rather than going outside to play an active game.

Temperament Traits and ADHD | The Being Well Center | Free PrintableUpcoming blog posts will discuss the other 9 Temperamental Traits that make you and your child unique.  Follow along with this Being Well Center | Temperament Worksheet designed to help you pinpoint where your child’s temperament trait falls on the continuum.

Don’t forget to follow us on Facebook and join a community of people interested in getting the facts straight with compassionate support for ADD/ADHD!

Straight Facts on ADHD and Medication (Part I)

Key Facts about ADD and Medication | The Being Well CenterAt The Being Well Center, 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 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.

Key Facts for Medication and ADD

Here are some key facts that combat misinformation and fear in the use of medication to treat ADD/ADHD:

  • Manufacturer labeling including dosage guidelines for Ritalin and Dexedrine, the early forerunners of the methylphenidate and amphetamine-based stimulants of today, were initially approved by the FDA many decades ago. This was at a time prior to the more rigid approval standards used today. Original documents used by the manufacturers to support their prescribing guidelines (which were ultimately approved) provided no scientific basis for the recommendations made, but rather, anecdotal feedback from a small collection of physicians who had experience prescribing the medications at that time.
  • These approved labels including manufacturer’s prescribing guidelines were subsequently grandfathered in when the United States Federal Food, Drug and Cosmetic Act (FD&C) was updated and amended. Therefore, books, clinical articles, professional society association pamphlets, drugstore/pharmacist printouts, package inserts, and other materials which use the FDA approved manufacturer’s marketing guidelines (i.e., the PDR) as the basis for their recommendations are probably the least scientifically reliable and valid pieces of information available to physicians to use in making informed decisions about stimulant medication dosages.
  • The manufacturer of a newer methylphenidate formulation, Concerta, worked out agreements with the FDA to get approval for its labeling and dosage guidelines without having to undergo extensive and expensive dosing studies provided that it adhered to dose recommendations that were equivalent to the FDA approved, yet unscientifically-determined, dosage recommendations for Ritalin. This means that the FDA approved manufacturer’s prescribing guidelines for one of the most popular medications used to treat ADHD, Concerta, are more than 50 years out of date.
  • The FDA has set a standard for medications used to treat ADD/ADHD that, to receive approval, manufacturers must demonstrate a 30% reduction in core symptomatology in blinded controlled trials in groups of individuals with and without ADD/ADHD using responses on FDA approved questionnaires or through behavior ratings from structured observations of subjects. The goal for pharmaceutical companies is to generate data to meet this standard for approval by using the lowest dose that shows group efficacy and the lack of deleterious side effects not what was the most effective dosage for individual participants. While this standard may be appropriate for manufacturers with regards to approval for marketing their products to the masses, it is out of sync with the real world realities of finding and using the most effective dosing regimens to properly treat an individual with ADD/ADHD. Most experts now agree that clinicians treating individuals with ADD/ADHD should be striving to provide 100% symptom relief (i.e., remission) throughout the entire waking day. Logically, this means that many ADD/ADHD patients might require dosages that are at variance with FDA approved manufacturer’s marketing guidelines in order to receive optimal care.
    • Once a drug is approved for use, it would be illegal for a pharmaceutical company to market it or make recommendations that are at variance with the original FDA approved guidelines even when years of clinical practice and the medical literature might suggest significant variations are warranted. Furthermore, senior management of pharmaceutical companies have told us and others that there is no incentive, in fact, significant disincentives, (i.e., exorbitant costs of conducting additional research to meet current FDA requirements and enhanced liability exposure) for them to generate more data with costly new trials to support approval of secondary indications or expanded dosages when off-label use is so common (40-60% of all prescriptions written) and sales of these products are so strong.
    • FDA approval of manufacturer’s marketing guidelines sets the parameters by which pharmaceutical companies can market their products to physicians and the public. However, they are not intended to dictate medical care. In fact, by the provisions of the FD&C Act, once a medication is approved by the FDA for marketing, physicians can prescribe it off-label for whatever conditions and at whatever dosage schedule they deem necessary to meet a given patient’s needs. In fact, off-label use of medications is an accepted and valuable part of quality care of a patient when used by physicians ethically and according to their best knowledge and judgment. Many organizations and experts have weighed in on the off-label use of medications and the consensus would appear to be that it represents good medical practice when the following pre-requisites are meet:
      1. The prescriber has experience and familiarity with the medication and the patient being treated
      2. No other alternatives are available
      3. Sound medical evidence in the published literature and/or other expert physicians support the intended use
      4. Efficacy and safety are closely monitored and documented

    Therefore, off-label use of stimulants above or outside of the FDA approved manufacturer’s recommended dosage schedule in marketing materials by experienced healthcare providers is not only permissible, but could actually be indicated to meet certain individual patient needs when there is either justification in the medical literature or evidence that peers with similar training and experience are prescribing them in this fashion. We will provide information in this white paper that confirms that both of these criteria are met when it comes to off-label use of stimulant medications for ADD/ADHD.

    Check back later this week for more Key Facts about ADD and Medication.  Don’t miss a post! Subscribe to our blog right now! Just register your email in the upper right-hand corner of this page.  We’d love to have you with us as we discuss the truth about ADD/ADHD!

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.

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.


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!


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 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.

The Truth About ADD Medication and Seizures

image via Flickr, r. nial bradshaw

image via Flickr, r. nial bradshaw

It was once believed that ADD/ADHD medications could lower the threshold for having seizures in individuals who have underlying seizure disorders.

Careful research and lots of clinical experience has shown this is not the case. With the exception of the second-line ADD medication, Wellbutrin, which can lower seizure threshold, it has been my experience that all of these medications can be used safely in individuals with a seizure disorder. The presence of a seizure disorder should not be a contraindication to medication use.

Furthermore, the ADD medications do not interfere with the effectiveness of any of the anticonvulsants. However, some of the anticonvulsant medications can lower an individual’s arousal level and, thereby, exacerbate ADD symptoms.

Occasionally, when arousal is a problem, physician managing the seizure disorder may be able to switch to a different anticonvulsant that has less associated sedation. If this is not possible, then the increased attentional weaknesses that can accompany the use of anticonvulsant therapy need to be managed by modifying the ADD medication regimen.

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.


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.