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!

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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.

 

How does ADD affect learning?

Check out Lisa Ling‘s frank admissions of her struggles in the classroom.  Sound familiar?

Attention plays a major role in learning since all information coming into and out of a person’s brain is filtered by attention. That is, in order to acquire a new piece of information or a skill, we must first pay attention to it. In order to show that we have mastered the information or skill, we must control our impulses, monitor our behavior, filter distractions, and concentrate for a sustained period of time on the “tests” that occur in the classroom and in the real world.

Poor attention affects both incidental and “school” learning. A person who has a weakness in attention is less able to receive all of the input from the environment–structured or unstructured–that is necessary for learning. For example, he neither sees nor hears all the steps that Mom and Dad show and tell him about cleaning his room; he misses the fact that there are actually road signs that tell where to go; and he fails to get the coach’s instructions about game strategies during practice. At school, he doesn’t listen to the teacher’s instructions; he doesn’t see the assignment written on the blackboard; he doesn’t get the meaning of the stories he reads; and he doesn’t remember the steps in long division.

ADD can also interfere with a person’s ability to demonstrate what he has learned. People with ADD may have messy rooms, dirty dishes, and poor hygiene even though they know how to clean, to do the dishes, and to care for their bodies. In school, people with ADD may fail to complete all the problems or daily worksheets, add instead of subtract on achievement tests, make careless errors on intelligence tests, reverse letters when reading or writing, and forget to capitalize and punctuate in written language tasks.

Apparent difficulties in seeing, hearing, remembering, and understanding often lead to the false conclusion that individuals with ADD have auditory or visual perceptual problems or are just less intelligent. In reality, however, they are simply not alert and not reflecting, focusing, filtering, persisting, or monitoring their behavior and their schoolwork.  Brain power only goes so far.

ADD negatively affects learning. But, it never does so alone. A person’s temperament, intellectual, and learning abilities, and language skills, among other things, interact to influence how attention affects learning. It is important to remember that ADD, as a biologically based individual difference, can occur in anyone–an individual who is gifted, learning disabled, retarded, and one who has average learning ability.

Catch up on previous posts in the Pay Attention series.

Patients of all shapes, ages, and sizes come to The Being Well Center and Dr. Craig Liden for diagnoses and treatment plans they can trust. Can we help you too? Visit The Being Well Center for more information about Dr. Liden’s services.

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.

ADD? Why can he concentrate on some things but not others?

Being Well Center | ADD and ConcentrationIf a person has ADD, why can he concentrate on some things but not on others?

At the right place, at the right time, and under the right circumstances, a person with ADD can pay attention. Generally, when this occurs, the individual is highly motivated and has strengths in the skills required to participate successfully in the task at hand.

Sometimes, the intrinsic characteristics of the object or event to which a person with ADD is trying to pay attention are so powerful that they act as magnets that draw out every ounce of attention. Television, the computer, and hand-held electronic games are the most common examples of such seductive magnets in everyday life. Paying attention to TV is a relatively passive act when compared to paying attention to Mom’s lecture about how to behave with the babysitter or the science teacher’s complex description of a chemical reaction.

Sometimes apparently efficient attention in a person with ADD is deceptive. He has simply learned to act attentive. His eyes and ears may be open and his head may be nodding acknowledgement, but he is not tuning in to the fine details of what is happening; in this way, he often misses the richness of the experience. It is only through formal assessment that we can determine the extent to which a person has really paid attention.

Catch up on previous posts in the Pay Attention series.

Patients of all shapes, ages, and sizes come to The Being Well Center and Dr. Craig Liden for diagnoses and treatment plans they can trust. Can we help you too? Visit The Being Well Center for more information about Dr. Liden’s services.

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.

Do people have ADD from birth?

ADD Basics FamilyAs we continue laying out the truth about ADD/ADHD, we turn to some of the most common, burning questions my patients, friends, family, and colleagues most commonly ask me.  The answers to these questions form a critical foundation to understanding the truth about Attention Deficit Disorder.

If people are born with ADD, why don’t problems show up right after birth?

ADD becomes apparent only when the inborn attentional differences interfere with the individual’s ability to meet expectations in the environment. Depending upon the severity of a person’s attentional differences, his temperament, the status of other skills and abilities, and the specific nature of environmental expectations, ADD can crop up at any point along the life span from infancy to old age. Let’s take a look at how this can happen.

Typically, individuals with ADD appear to be normal at birth. As children, they are minimally, if at all, delayed in meeting major milestones of accomplishment such as walking and talking. They generally reach school age with only minor problems in controlling their behavior and interacting with peers. The first grade classroom is often the first place where specific expectations for paying attention occur. As a result, the entry into school is one of the more common times when ADD first shows up. Other key transition points in the individual’s life where expectations for increased efficiency of attention can lead to the emergence of ADD include the following:

  • Movement to the upper elementary grades where time constraints are imposed and increased demands are placed on children to function independently
  • Movement to junior/senior high school where more refined organizational and study skills are required
  • Movement to college where fewer supports are available and the ability to function independently is essential
  • Movement into a new home away from parents where there are no supports and the ability to function independently is even more critical
  • Marrying or cohabiting with a partner where functioning impacts upon the quality of life of another person and demands for efficient problem-solving are high
  • Becoming a parent where responsibilities for keeping it all together, all the time is essential

Individuals with ADD who have strengths in other areas (e.g., strong language skills, a charming personality, intellectual giftedness) can go a long time in life without being identified as having a problem. I have seen many children go through elementary school with A’s and B’s only to have the bottom fall out upon entry to middle school or junior high school. In these circumstances, careful probing of the educational history of these children often reveals evidence of attentional weaknesses that have either been overcome with sheer brain power or been overlooked by parents and teachers because these subtle weaknesses hadn’t really led to failure.

While failure to meet increasing school demands is a very common way for ADD to be uncovered, it can also happen as a result of failure to meet increasing demands for independent functioning, social interaction, or problem-solving at home, in childcare, in the neighborhood, or on the job.

Meet Michael

Michael is a good example of this. He is a 10-year-old boy who has always done very well, academically and socially. He has learned new concepts quickly, has shown a gift for memorizing facts, has been easy to get along with, and has always been a great conversationalist.

Until two months ago, he had also functioned very well at home. At that time, however, his mother got a new job that meant she was no longer able to be with Michael after school. And, despite all of her attempts, she had been unable to find someone who would stay with Michael until her new workday ended. So, for the first time, Michael was on his own everyday from 3:00 p.m. to 6:00 p.m.

The new expectation for him was “keep yourself busy and stay out of trouble for three unsupervised, unstructured hours.” This new demand uncovered Michael’s impulsivity, distractibility, and lack of ability to think through the ramifications of his behavior. He broke a living room lamp by rough housing in “off-limits territory”; he burned a hole in the new family room couch while “fooling around” with a butane lighter; and he soaked the bathroom carpet when he ran to answer the telephone, forgetting to first turn off the faucet.

Without his mom around to help him structure his time, to remind him of the house rules, and to watch over his activities, Michael had become dysfunctional.

Meet Emma

Emma’s story is similar. She is a 22-year first year elementary school teacher who has just married. Emma is gifted, kind, funny, sensitive, and very hardworking. Until now she has done well in almost every sphere of her life, but she has never been asked to establish her own home, to share finances, nights, and laundry with someone else, to complete daily lesson plans for five subjects, to effectively manage thirty fifth-grade children for six hours every day, and to negotiate unclear work politics all at the same time.

Emma is a mess. Despite her intelligence, her hard work, her sense of humor and her likeability, she is not experiencing success anywhere in her life.

Catch up on previous posts in the Pay Attention series.

Patients of all shapes, ages, and sizes come to The Being Well Center and Dr. Craig Liden for diagnoses and treatment plans they can trust. Can we help you too? Visit The Being Well Center for more information about Dr. Liden’s services.

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.

Jeff is a great kid! He just forgets.

Do you recognize these people?

bwc_lifespan

Annie, age 35

Annie is an attractive mother of three.  To look at her you would never guess what a disaster every area of her life has been since college.  As a young teacher, she never developed lesson plans and couldn’t control her classes.  She wanted to do something else but didn’t feel she had the skills.  Instead, she started a family.  As a homemaker, she rarely cooks a meal, struggles to pick up the house before her husband gets home from work, and has 45 half-done projects.  She manages the family finances–writes the checks, but forgets to mail them.  Her relationship with her husband is poor, and she feels guilty about not meeting her children’s needs.  She’s depressed, and her self-esteem is in the pits.

Adam, age 19

In high school, Adam was the class clown; everyone liked him.  Now, he goes to college because “that’s what everybody does!”  With the distractions of college life–being away from home for the first time, fraternity parties, weekend football games, and wild roommates–he is no longer able to get by on his quick mind and entertaining personality.  By the end of his first semester, he is on academic probation.  Despite this warning, threats by his parents, and all his good intentions, at the end of the second semester, Adam is asked not to return next fall.

Jeff, age 11

Jeff is a great kid!  He just forgets.  He forgets what his homework is.  He forgets to bring home the science book to study for tomorrow’s unit test.  He forgets to bring home his instrument for band practice.  He forgets to hang up his coat, to put his shoes away, and to throw his dirty clothes in the hamper.  He forgets to take out the garbage and to feed the dog.  He forgets to brush his teeth, to tuck his shirt in, and to make his bed.  If Mom wasn’t there to nag him, he’d probably forget everything–but still, he is a great kid.

Do you recognize Justin, Karen, or Lisa?
Do you recognize Melissa, Mark, or Betty?
Do you recognize Tina, Doug, or John?

These are my patients.  You may have recognized your son or daughter, your spouse, your parents, even yourself.  I’ve come to appreciate how ADD can look quite different across the lifespan, depending on circumstances, temperament, and expectations.  For some people, managing a home and family brings the conflict with ADD to a head.  For others, it’s the high expectations (and failures) at college.  Still others struggle in the smaller ways, like chronically forgetting homework.

Our current blog series is here to help you sort through the challenges of identifying and treating ADD / ADHD.  You might find there are a number of things you don’t know about ADD (but should).  You might find that you recognize my patients.  If you’re seeking answers, you’re always welcome at The Being Well Center, or you can download my free e-book, ADD Basics 101, in which I guide you through 10 clear steps to securing a diagnosis and treatment plan you can trust.

Patients of all shapes, ages, and sizes come to The Being Well Center and Dr. Craig Liden for diagnoses and treatment plans they can trust. Can we help you too? Visit The Being Well Center for more information about Dr. Liden’s services.

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.

School’s Out

School’s out for summer!

No more pencils…

No more books…

No more teacher’s dirty looks…

But for your child with ADHD, maybe the dirty looks from other kids continue and the social isolation he felt all school year only intensifies as he spends hour after hour in front of a screen during the long hot days of summer.  For many ADHD children and teenagers, negotiating the subtleties of establishing and maintaining meaningful relationships is as challenging as any subject at school.  At school, teaching occurs!  And most of what is taught it pretty concrete…even the most abstract academic concepts are more black-and-white than the process of establishing and maintaining meaningful relationships.

Early in their development, children play together, at first side-by-side and then, cooperatively.  This works for toddlers and preschoolers.  As children get older, their use of language as a social tool becomes more and more critical in relating to others.  By the time our children are in their early teens, initiating and sustaining conversations is at the core of all of their meaningful relationships. Making this transition is often tremendously challenging for the child with ADHD, and as result he/she is often left feeling lonely and on the periphery.

What makes the art of conversation so challenging for many ADHD children and teens (and yes, even adults), is that mastery requires that we all follow the many unwritten rules of conversation.  It is important to appreciate that other than when we say to our kids, “Hey look at me when you are talking” and “Don’t interrupt me when I am talking,” we do not  teach our children these rules.  They learn them indirectly through observation and accurate interpretation of the subtle feedback that comes their way when they break a rule in conversation…and we know that observing, reflecting, and checking themselves are inherent weaknesses for people with ADHD.  As a result, often, ADHD children and teens are unaware of the rules and struggle with the primary vehicle for relating to the people in their world.

 

Rules for Conversation

  • Maintain eye contact with your conversational partner
  • Take turns
  • Pick topics that are interesting to your conversational partner
  • Stay on topic
  • Give verbal and nonverbal signs that you are listening and interested
  • Carry your share of the conversation
  • Do not monologue
  • Stay connected to the content of what your partner just said
  • Request clarification when you don’t understand what your partner said
  • Change topics in a bridging sort of way or alert your conversational partner of a change
  • Use a more formal style of talking with conversational partners who are less familiar or in positions of authority

 

Summer is a great time for our ADHD kids to improve their conversational skills.  At The Being Well Center,  I work with kids of all ages, individually and then in groups to help them clearly know and master the application of all of the rules to become more confident and competent as conversationalists.  The progress they make is tangible and exciting for them.  If your ADHD child or teen struggles to initiate and sustain meaningful conversations and you are interested in promoting these skills, reach out to us…I would welcome the opportunity to help!  Or find a good Speech-Language Therapist to help.  Be a good consumer and be certain she has a passion for pragmatic language and a commitment to making it real…transferable to your child’s real world.  In my experience, talking about it and playing pragmatic language games yield little change in the real world.  Rather, focused, engaging, and practical pragmatic language activities will give your ADHD child or teen the tools for a lifetime of conversation.

What do you plan to do this summer to keep your ADHD child building social and conversational skills?

Jane Reck is a speech-language therapist who graduated from the University of Pittsburgh and Syracuse University summa cum laude.  Jane has more than 25 years of clinical experience as a case coordinator and speech-language therapist on The Being Well Center’s multidisciplinary health care team providing treatment to clients of all ages.  She has participated in the care of hundreds of patients with ADD/ADHD and has trained and supervised professionals from a variety of disciplines in how to use The Being Well System.  She has helped lead the establishment and management of transdisciplinary health care programs in the United States and Central America.