It’s hard to overstate it: Please be a smart mental healthcare consumer when it comes to ADHD medical treatment.
That means not simply assuming that your prescribing physician, no matter how much ADHD expertise is professed, truly knows what’s what. Learn the basics so you can “Trust but Verify.”
For all the information flooding the Internet now about Adult ADHD, it’s still hard to find a solid overview of the medications used to treat it. So, I contacted Ted Mandelkorn, M.D. (pictured right). Had he updated the excellent handout from a lecture I’d attended years ago? Indeed he had. Even better: He gave me permission to share it with ADHD Roller Coaster readers. The first installment is below. Part II will follow shortly.
An “early adapter” of ADHD expertise and treatment, Dr. Mandelkorn is the parent of a child with ADHD and has ADHD himself. He trained in pediatrics and adolescent medicine, and he was a mental health fellow under Dr. Michael Rothenberg at the University of Washington. He has been in practice for 35 years, since 2001 at his clinic, Puget Sound Behavioral Medicine.
A PHYSICIAN’S PERSPECTIVE
Theodore Mandelkorn, MD
- WHO SHOULD TAKE MEDICATIONS, AND WHY?
- WHAT IMPROVEMENT SHOULD BE SEEN?
- WHO SHOULD PRESCRIBE MEDICATIONS?
- MEDICAL TRIALS
- WHAT IS THE CORRECT MEDICATION?
- WHAT IS THE CORRECT DOSAGE?
- WHAT ABOUT “NATURAL” THERAPIES?
Human beings are rarely created in perfect form, so we all arrive in this world with unique differences. Some differences are blessings, others are handicaps. Poor vision, for example, is a common handicapping condition that affects millions of people throughout the world. I consider poor vision a condition of “human-ness.” People can also have other medical conditions such as diabetes, asthma, thyroid conditions, ADHD, etc.—all are well recognized differences that can impair the pursuit of a normal life style if not dealt with in some manner.
ADHD is characterized by a prolonged history of inattention, impulsiveness and sometimes variable amounts of hyperactivity. It is important to emphasize that all of these symptoms are normal human characteristics. Most of us are forgetful and inattentive at times. We all at times become nervous and fidgety, and we certainly are impulsive to some degree. It is part of our “human-ness.” ADHD, therefore, is not diagnosed by the mere presence of these normal and characteristic human behaviors, but by the DEGREE to which we manifest these symptoms. ADHD individuals have an over-abundance of these normal characteristics. They have less CONTROL of these behaviors and therefore a more variable and frequently poor outcome of their day.
WHO SHOULD TAKE MEDICATIONS FOR ADHD, AND WHY?
If a person meets the clinical criteria for a diagnosis of ADHD and is not succeeding academically and/or socially up to age-appropriate expectations, medication should be a PRIMARY OPTION for therapeutic intervention. ADHD is a medical condition. Recent research out of Harvard University has documented an abnormality in the dopamine transporter system in the central nervous system of ADHD adults. This transporter system is responsible for moving neurotransmitter chemicals from the synaptic space back into the nerve cell. ADHD adults have approximately 70% more dopamine transporter than non-ADHD individuals and thus appear to have an overactive transport system.
Returning to the vision analogy, there are a number of options open to an individual who has compromised eyesight. One option is to attempt to correct the problem by wearing glasses to improve the visual acuity. Perhaps glasses will totally correct the problem or perhaps they will help only partially. After glasses are in place, we are in a position to assess what further problems are interfering with success. Then we can address these issues as well.
The opportunity to eliminate the symptoms of a medical condition partially or completely should be available to all. Many children and adults with ADHD benefit enormously from the use of medication. The medications that are in use today act as transporter blockers, thus serving to normalize this aspect of the brain chemistry. Most families who understand ADHD and its clinical manifestations prefer to try medication as a PART of their treatment plan. Over 90% of individuals with ADHD will have a positive response to one of the medical treatments.
WHAT IMPROVEMENT SHOULD BE SEEN?
In the early 1930’s, Dr. Charles Bradley noted some dramatic effects of stimulant medications on patients with behavior and learning disorders. He found that the use of stimulants “normalized” many of the systems that we use for successful living. People on medication IMPROVED their attention span, concentration, memory, motor coordination, mood, and on-task behavior. At the same time they DECREASED daydreaming, hyperactivity, immature behavior, defiance, and oppositional behavior. It was evident that medical treatment allowed intellectual capabilities that were already present to function more successfully.
When medication is used appropriately, patients notice a significant improvement in control. Objective observers should notice better control of focus, concentration, attending skills, and task completion. Many individuals are able to cope with stress and frustration more appropriately with fewer temper outbursts, less anger and better compliance. They relate and interact better with family members and friends. Less restlessness, decreased motor activity and impulsiveness are noted. ADHD individuals often complain of forgotten appointments, incomplete homework, miscopied assignments, and frequent arguments with siblings, parents, spouses, workmates, along with excessive activity and impulsive behaviors. With medication, many of these problems dramatically improve.
It is very important to remember what medicine does and does not do. Using medication is like putting on glasses. It enables the system to function more appropriately. Glasses do not MAKE you behave, write a term paper or even get up in to morning. They allow your eyes to function more normally IF YOU CHOOSE to open them. You, the individual, are still in charge of your vision. Whether you open your eyes or not, and what you choose to look at, are controlled by you. Medication allows your nervous system to send its chemical messages more efficiently, and thus allows your skills and knowledge to function more normally. Medication does not provide skills or motivation to perform. Patients successfully treated with medications typically can go to bed at night and find that most of the day went the way they had planned.
WHO SHOULD PRESCRIBE MEDICATIONS?
Licensed physicians, physician’s assistants or nurse practitioners can prescribe medications. This person may serve as a coordinator to assist with the multiple therapies often needed, such as educational advocacy, counseling, parent training and social skill assistance. Parents should look for a physician who has a special interest and knowledge in dealing with ADHD individuals. This professional should be skilled in working closely with families to try the many and varied medical treatments that are available until the correct therapeutic response is attained. Members of CHADD chapters are an excellent resource for referrals to appropriate professionals.
It is necessary to establish a team of observers to appropriately evaluate a medication trial. Gather information from sources that spend time with the patients. This might include significant others, parents, teachers, grandparents, tutors, piano teachers, coaches, etc. As gradually increasing dosages are administered, input is gathered from these observers. Various ADHD rating scales are available to assist in gathering factual data. The most important assessment, however, is dependent on whether the ADHD patient’s quality of success in life has improved. For this information, I find no scale takes the place of conversations with patient and family members.
When evaluating patients during a trial of medication, it is important to maintain treatment throughout the waking day, seven days a week. Treating them only at school or in the workplace is totally inadequate. I need all involved observers, especially parents and/or significant others, assisting in the evaluation process. Furthermore, I want to know if treatment has an effect on non-academic issues. Recent studies have found that treatment is necessary for most ADHD individuals throughout the full day, thus allowing full development not only of academic or work skills, but also the all-important social skills that are utilized with friends and family. After the trial of medication, if positive results are evident, then the family and the patient can make informed decisions as to when the medication is helpful. Most patients need the medication throughout the day and evening.
WHAT IS THE CORRECT MEDICATION?
At the present stage of medical knowledge, there is no method of predicting which medication will be most helpful for any individual. At best, physicians can make educated decisions based on information about success rates with individual medications. Over 80% of ADHD individuals will respond favorably to the stimulant medications: methylphenidate and amphetamines. Both of these categories of medications may need trials to assess which is best. If one stimulant does not work, the others should be tried, for experience has proven that individuals may respond quite differently to each one. Another alternative medication is atomoxetine (Strattera), a non-stimulant medication for ADHD that was approved by the FDA in December 2002. Each family and physician must be willing to try different medications in order to determine the best and most effective therapy. This is the only way to find the appropriate medical treatment. In some children who have multiple diagnoses such as ADHD and depression, or ADHD and anxiety, or ADHD and Tourette syndrome, combinations of medications are being successfully utilized for treatment.
WHAT IS THE CORRECT DOSAGE?
If stimulant medications work, there is a best dose for each individual. Unfortunately, medical knowledge is not at a point where it can predict what the correct medication or dose will be. This is not an unusual circumstance in medicine, however. For a person with diabetes, for example, we must try different forms and amounts of insulin to achieve the best control of blood sugar levels. For people with high blood pressure, there are many medications that can be effective, and often a trial of multiple medications and dosages is necessary to determine the best treatment. For stimulant medications, there is no magic formula. The dose cannot be determined by age, body weight or severity of symptoms. In fact, it appears that the correct dose is extremely individual and is not at all predictable. Again, similar to people who need glasses, the kind of prescription and the thickness of the lenses are not dependent on any measurable parameter other than what the individuals say enables them to see well. The dose of medication is determined solely by what ADHD patients need to most effectively reduce their symptoms. One must be willing to experiment with carefully observed dosage changes to determine the correct dosage. The appropriate dosage does not seem to change very much with age or growth. Medication continues to work effectively through the teenage years and through adulthood.
For atomoxetine, the dosage at the present time is calculated according to weight. This is the only medication for ADHD for which this is true.
WHAT ABOUT “NATURAL” THERAPIES?
At this time, there is no evidence that natural therapies are therapeutic. There are many anecdotes about various “magical” cures for ADHD, but none have been found to be valid. Remember: multiple anecdotes do not mean proof. Natural therapies such as grape seed extract, blue algae, biofeedback, magnets, megavitamins, diet, and other “natural products” have not yet shown any lasting therapeutic benefit. At this time traditional medical therapy is the most effective treatment for ADHD. This is quite similar to other medical treatments such as insulin, THE best form of treatment for Type 1 diabetes, or thyroid pills THE best therapy for inactive thyroid gland. Furthermore, natural health food treatments are not regulated by the government and are therefore highly suspect for contamination. Please be cautious when experimenting with alternative therapies on your family members.
Individuals with ADHD with present with a variety of well-defined symptoms and behaviors. Medication may be extremely helpful in alleviating some of these symptoms and will allow the other therapeutic modalities to be much more successful. Families must be willing to work closely with their physician to identify the correct medications and establish the best dosage levels.
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