I cannot overstate it: We must be smart mental healthcare consumers. Especially when it comes to ADHD medical treatment.
That means not assuming that your prescribing physician truly knows what’s what. No matter how “confident” that physician acts. No matter how much ADHD expertise he or she proclaims.
Learn the basics so you can “Trust but Verify.” That is the goal of this ADHD Roller Coaster’s ADHD Medications Guide, Part I and Part II.
Information on Adult ADHD floods the Internet. Yet, it’s still hard to find a solid overview of the medications used to treat it. So, I contacted Seattle-based Ted Mandelkorn, M.D.. 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.
I posted this ADHD Medication Guide in 2010 and will try to update any critical changes since that time [in brackets].
PLEASE NOTE (March 2021): My online training will cover medications in depth. Be sure to subscribe to this blog to be notified when it’s online!
An “early adapter” of ADHD expertise and treatment, Dr. Mandelkorn is the parent of a child with ADHD. He also 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. Thank you, Dr. Mandelkorn!
Post I Overview
The next post, Part II, covers medications; this post covers:
- WHO SHOULD TAKE MEDICATIONS, AND WHY?
- WHAT IMPROVEMENT SHOULD WE SEE?
- 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. 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, and ADHD. All these conditions indicate well-recognized differences that can impair pursuing 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?
Let’s say 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 documents 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. Thus, they appear to have an overactive transport system.
Returning to the vision analogy, an individual with compromised eyesight has numerous options. One option is to try wearing glasses . Perhaps glasses will totally correct the problem. Perhaps they will help only partially. It’s only after eyeglasses are in place, however, that we can 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 We See?
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.
Children 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. Medical treatment allowed intellectual capabilities that were already present to function more successfully.
[Gina notes: I detail Dr. Bradley’s surprising, unintentional discovery in my book, Is It You, Me, or Adult A.D.D.? Stopping The Roller Coaster When Someone You Love Has Attention Deficit Hyperactivity Disorder]
When medication is used appropriately, patients notice a significant improvement in control:
- Better control of focus, concentration, attending skills, and task completion
- Coping better with stress and frustration
- Relating and interacting better with family members and others
- Less restlessness, decreased motor activity and impulsiveness
Please 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.
Similarly, medication allows your nervous system to send its chemical messages more efficiently. In turn, this 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.
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 individuals and families to try the many and varied medical treatments that are available until the correct therapeutic response is attained.
Conducting Medical Trials
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, adult siblings, teachers, grandparents, tutors, piano teachers, coaches, and others.. As gradually increasing dosages are administered, input is gathered from these observers. Various ADHD rating scales 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. This allows 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?
Currently, 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. 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. Some individuals 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 example, for a person with:
- Diabetes, we must try different forms and amounts of insulin to achieve the best control of blood sugar levels.
- 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.
- ADHD taking 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, this is 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.
Similarly, 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.
We encounter endless anecdotes about “magical” cures for ADHD. Yet, none have been found to be valid. Remember: Multiple anecdotes do not constitute meaningful data.
Items such as grape seed extract, blue algae, biofeedback, magnets, megavitamins, diet, and other “natural products” have yet to show any lasting therapeutic benefit.
Currently, traditional medical therapy is the most effective treatment for ADHD. This is quite similar to other medical treatments such as insulin, which is the single best form of treatment for Type 1 diabetes, or thyroid pills are 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. As such, they 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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