What you need to know about ADHD . . . Part 4: Medication

At the heart of the controversy and anxiety about ADHD is the use of medications to treat it.  No one, and I do mean no one likes putting children on behavioral medications.  It goes against protective parental instincts.  The idea of medicating your child’s behavior, or perhaps even your own if you have adult ADHD, is distasteful and somehow feels like giving in–like failure.  And the anxiety over medications is worsened by negative articles on the subject that routinely appear in the popular press and internet blogs.  Some criticisms are justified and some not; but these articles do not inspire confidence in using medication to treat ADHD.  But in short, when ADHD is correctly diagnosed, and when medications are correctly prescribed these medications are safe and very effective.

So, let’s break this down.  First we’ll talk about the ADHD medications, what they are and how they work, then we’ll talk about some of the controversies surrounding their use, and then we will talk about some of the strategies about them should you decide that ADHD medication is right for you or your child. 

One word of caution:  This article is intended for informational purposes only and is no substitute for careful assessment and treatment by a licensed prescriber–medical doctor or behavioral nurse practitioner.  There are many factors that prescribers will want to know when recommending a behavioral medication.  So, inform yourself, but talk to your doctor!

What are ADHD medications anyway?

There are three general types of ADHD medications:  stimulants, norepinephrine reuptake inhibitors (NRI), and antidepressants (SSRIs).  By far the most commonly prescribed and recommended treatment for ADHD are the stimulant medications.  These are amphetamine-based medications, that when taken as ordered, provide fast acting relief from the three primary symptoms of ADHD with generally minimal side effects, and without addiction potential.  The traditional form of this class of medication takes effect within 15-to-30 minutes and metabolizes out of the body in about four hours.  This means that they are relatively safe to try, because usually you’ll know if they are effective pretty much immediately.  The most well-known of these medications are Ritalin, Adderall and its generic form methylphenidate.  All of these are available in a traditional, non-time-released form.  But they are also available in a time-released form so that they stay effective for up to 12 hours.  Gone are the days of long lines of children queuing up at the nurse’s office for their noon-time dose of Ritalin.  The time-release medications decrease stigmatization and decrease the chance of missing doses.

It is counter-intuitive to give a stimulant medication to a hyperactive person, after all, wouldn’t that just make them more hyper?  Oddly, the answer is no, if they do indeed have ADHD.  No one is quite sure why the stimulant medications work, but they do indeed work and work fairly well.  They do not cure ADHD, but they help the brain overcome its limitations so that the frontal lobes are more involved with managing attention, behavioral self-control (hyperactivity/impulsivity), and improving frustration tolerance.  These medications give the ADHD adult and child the boost they need to somewhat level the playing field with their peers regarding behavior and performance at work and school.

While neuro-scientists are closing in on what exactly ADHD is (remember it’s a syndrome and has multiple causes) and why the medications work, one popular theory is that the ADHD brain is “sleepy” and that the stimulants wake it up effectively so that it can function more normally.  The average ADHD person taking Ritalin usually just feels normal–not hyper, not drugged, not buzzy, not sedated.  In fact, when I ask an ADHD child if they feel any different on medication they usually say, no they don’t, but they do notice that they don’t get into as much trouble!

The most common side effect of the stimulant medication is loss of appetite.  Children are often not hungry on the medications and will not eat a noontime meal or will pick at their food.  Parents often notice their children are very hungry in the late evening.  To compensate I recommend children be given a healthful breakfast (they should anyway) at the time they take their medication, and then be allowed to eat until satisfied later in the day, to make up for all those calories they’re using up.  Sometimes very young children need to be monitored closely when on stimulant medications so that they develop and grow normally.  Your doctor may also advise easing up on stimulant use on weekends or school holidays when behavioral medications aren’t needed as much.  Again, talk to your doctor.  But because the stimulant medications are fast acting, a day or two can be skipped and the medications will still be effective the next time they are used.  But skipping on school days is not advised because of disruptive ADHD behaviors in the classroom and with school staff.  Teachers can definitely tell when a child has not had his/her medication in the classroom!

Other medications to treat ADHD as mentioned above include Wellbutrin–a unique type of antidepressant with stimulant-like characteristics, and the SSRI type antidepressants.  There are some people that either cannot take stimulant medications for medical reasons (heart problems or seizure disorders, for example) or for whom the stimulant medications are just not effective.  Your prescriber may choose to try an SSRI instead.  One of those reasons is that the stimulant medications are a controlled medication and so their prescription is more closely regulated and monitored than other medications.  This requires more frequent patient monitoring by your prescriber, and it means more inconvenience for parents.  But the reasons to monitor these medications are well founded.  So again, if you have questions talk to your prescriber.  (By the way, the fact that stimulant medications are controlled does not make them unsafe, it means that they can be misused and sold on the street by unscrupulous people.)

These SSRI type medications are generally thought to be less effective with ADHD, but there may be some good reasons your doctor may use them.  When they are more effective it may be a clue that a person has some other condition than ADHD, that mimics ADHD’s three symptoms of hyperactivity, impulsivity, and distraction.  Some of these conditions include depression, trauma, grief, autism, or simply environmental upset, such as a child experiencing the divorce of parents.  In my experience trauma and childhood depression are often overlooked in school-aged children as explanations for behavioral problems.  Also overlooked and very difficult to identify are the life-long difficulties from pre-birth substance exposure.  Children with prenatal substance exposure are often at a neurological disadvantage educationally and socially, and they may show symptoms that mimic ADHD (and may actually be ADHD).  But for some of these children ADHD stimulant medication makes their behavior worse not better, and they may need to be on sedating not stimulant medication.  Again, talk thoroughly with your doctor or mental health professional. 

Finally, children with known seizure disorders should not generally be prescribed stimulant medications as the medication may make the seizures worse.  Seizures disorders, particularly the staring type of seizures, may look a lot like ADHD, but the cause is different from typical ADHD.  Make sure your prescriber knows your child’s medical history, and that he/she screen for possible seizure activity before prescribing stimulants.

Causes for Concern in using ADHD medication are warranted.  ADHD has been over diagnosed in the past, and medications are sometimes resorted to when behavioral interventions or changing an environment may be more effective.  Medications should never be used in educational settings simply for behavioral control because they are easy.  And medication alone without behavior management or adjustments in environment and parenting techniques are highly discouraged.  Research consistently endorses that behavioral medication be combined with behavioral management, education, and counseling.  Admittedly these interventions are more complicated than simply giving a medication, but they are also very effective for the treatment of ADHD.  They tend to maximize the potential for both adults and children to be successful far more than medication alone.  Most of the concerns about ADHD medication can be addressed with careful diagnosis, with education on the syndrome, and with a few behavioral counseling appointments once the condition is identified.  Once medications are prescribed, they will need to be changed and adjusted periodically as a child (or adult) gets older. 

ADHD stimulant meds are some of the most effective medications in behavioral medicine.  They work quickly and effectively and can literally change people’s lives, improving academic and social functioning.  They are very safe when correctly prescribed and taken as ordered.  We need not fear them if they are handled with appropriate respect, with careful diagnosis, and with careful ongoing behavioral care (counseling).

Next up will be the final in my series on ADHD–behavioral interventions for ADHD: Things you can use to manage ADHD, decrease negative symptoms, and live more effectively. Stay Tuned.

What you need to know about ADHD . . . Part 3: Executive Functioning

At the heart of Attention Deficit Hyperactivity Disorder is a collection of behavior and skill deficits that neuropsychologists call Executive Functioning problems (hereafter EF).  EF problems exist in a number of neurological conditions including people with dementia, post-stroke sufferers, and closed and traumatic brain injuries.  In ADHD, EF problems are often overlooked or misunderstood because impulsive and hyperactive behaviors draw so much attention and are more immediately disruptive to other people.  But it is EF problems that cause the most long-term disruption – all the more so because they are not easily detected in ADHD.

The ability to organize thoughts, manage details, track time, plan, follow through on commitments, track life necessities, self evaluate behavior, learn from errors and mistakes, remember things, and make wise decisions/judgements are all grouped under the general heading of Executive Functioning by neuropsychologists and neuroscientist.  When EF is impaired, a person might look and sound normal in almost every way, but they just don’t seem able to manage the complexities of modern life; of school or work.  The front part of the brain, the frontal lobes, acts like the conductor of a symphony orchestra. It synchronizes all the rest of the brain to function as a whole. Like a conductor it tells some parts when to play and when to be silent, what speed to play at, what the overall piece is supposed to sound like, and when a player or section is playing out of tune. It also knows when the music is supposed to stop.  For the brain, when the conductor isn’t there, nothing functions as a whole, and each part of the brain runs on its own terms. Activities requiring “orchestrated” effort become haphazard – and it is this lack of EF that is the source of frustration for parents, spouses, and teachers.

Let’s take one single EF function – the estimation and processing of time - as an example, and you will begin to understand what the ADHD sufferer is up against.  Your ability to sense the flow of time is an EF function.  Most of us, by the time we are adults, have developed the ability to estimate how long things take.  And we have the ability estimate how much time has passed while doing a particular activity. We aren’t precise with these estimates, but we’re accurate enough to function. But the ADHD person is at a great loss in their ability to estimate time. Some tasks seem to fly by for them, when in reality they may have taken hours. Other tasks seem to go on forever, when in fact it’s only been a moment or two.  This ability to estimate time is so automatic with us that we don’t even realize we do it.  So the parents of an ADHD child expect their children to have developed this ability by their mid-teens when they may not have it at all.

A common complaint of such parents is that their children seem to take forever to get ready in the morning.  Or they may miss important school assignments because they don’t really know what day it is.  They may be able to spend hours playing a video game – because it is so immersive, but 5 minutes with a book feels like an eternity.  Adults with ADHD are notorious in my practice for missing appointments and coming in late – they just don’t have that internal clock helping them through the complexities of modern life.  They miss bills, deadlines, are late with permission slips, and they forget promises.  They are plagued with late fees, lost opportunities, and low productivity all because that part of the brain that tracks the flow of time isn’t working for them.

The ADHD sufferer needs help with EF tasks, whether or not others in their life think “they should have gotten this down by now.”  Lapses in EF behavior are not laziness, willful disobedience, being inconsiderate, or lack of effort. They are missing some basic cognitive abilities that the rest of the world takes for granted.  So the first two steps in compensating for weak EF are understanding and compassion.  Once these two are applied behavioral supports and environmental changes can be put in place to help the ADHD sufferer compensate for weak executive functioning. 

I have two more entries in this overview of ADHD and both have to do with treatment – next up: What you need to know about ADHD medications . . .Stay tuned.

Here are some useful links to more information about Executive Functioning.

Wikipedia entry on Executive Functioning

An Educators Guide to ADHD and LD:  Executive Functioning

What you need to know about ADHD . . . Part 2: Diagnosis

ADHD is a behavioral syndrome, which makes accurate diagnosis problematic.  ADHD has multiple causes which all effect the function of the front lobes of the brain, but with different manifestations.  I am frequently asked to assist parents, teachers, pediatricians, and occasionally adult patients to assist in determining if someone truly has ADHD or some other behavioral problem.  The challenge of diagnosis is made more difficult because there is no medical test for ADHD.  There are some psychological tests that can be helpful, but no specific “test” for ADHD. Rather, these tests assess the cognitive functioning or simply describe the behavioral traits via a check list completed by a teacher or parent. So how do you diagnose ADHD? Diagnosis is accomplished through careful observation, description of behavior, and by ruling out situational influences that may produce ADHD behavior but resolve once they are eliminated (poor sleep for example). 

If the person in question is a child I will often encourage his or her parents to become familiar with common ADHD symptoms so they can be in a better position to report back on the behaviors they observe – training them to see the whole pattern of behavior, not just one or two behaviors that may be bothersome. The parent's observations, combined with those of a trained and experienced psychologist produces the most accurate diagnosis. Usually this process works well not only because ADHD behavior is fairly predictable, but because the reactions and behavior patterns of the parents of ADHD children are also predictable: they are frustrated, fatigued, and feel at their wit's end! If needed, IQ and achievement testing can be included to provide a more complete diagnosis process and to assess for learning problems that often accompany ADHD.   

Let's take a closer look at the three main symptom categories of ADHD 

Hyperactivity. It is usually very clear when a person is hyperactive. Hyperactive children (and adults) have great difficulty sitting still – they are only able to do so with great effort.  When in my office they move constantly, are up out of their seat, roam around the room, unplug equipment, explore things without asking (open desk drawers etc.), and show no respect for normal interpersonal boundaries. Sometimes the parent of the child is embarrassed by this behavior and sometimes they’ve long since given up trying to manage it.  If the person is able to stay seated, they are constantly fidgeting – tapping on things, chewing on their clothing, and touching anything within their reach.  If you ask them to stop, they might be able to stop for a very short time but then they go right back to touching, tapping, moving, fidgeting, and wandering.  This hyperactivity is not generally willful behavior – the frontal lobes of their brains are not able to send “cease and desist” commands to the motor centers of their brains to enable stillness.  At school they are often in trouble for being out of their seat or wandering out of the classroom without permission.  ADHD people aren’t hyperactive all the time, just most of the time. They love playing action video games because it’s one of few places where their hyperactive behavior is rewarded. 

Impulsivity.  When a person exhibits impulsivity, they act before they think.  If an idea goes flying through their mind they act on it before the frontal lobe has a chance to stop the action or assess its appropriateness. Remember that the frontal lobes are not supplying any control to the other parts of the brain, so the impulsive person just . . . acts.  They do not censure their words, they do not stop themselves from offensive actions, and they tend to blurt out whatever random thing floats up. We all have these thoughts and impulses, but most of us know better than to say them or to act on them because our frontal lobes stop us. The impulsive person is disinhibited.  Poor impulse control causes the most problems in social settings, since many of these impulsive behaviors are socially inappropriate:  aggression, rude or mean comments, sexually suggestive behavior, grabbing things without asking (often interpreted as stealing – which it may or may not be), pushing, shoving, and getting angry at the mildest provocation. When parents see these impulsive behaviors they almost universally ask their child, "Why?" “Why did you just hit your brother!?”  They almost get the answer back, “I didn’t!” or “I don’t know.” And, believe it or not, the child may be being honest; they really don’t know why they do the things they do.  Impulsive behaviors are not usually conscious choices – not in the way most of us experience acts of will.  It is frontal lobe action that give us the feeling of “I” or of choice. The frontal lobe is just not intervening when the behavior is impulsive, so asking why is usually not helpful.    

Distractibility. The third major symptom is distractibility or poor attention span.  Almost everyone has seen Dug the talking dog in Pixar’s film Up! Dug's classic "squirrel!" outburst is a perfect example (and now a universal joke) about distractibility.  People with ADHD have a very difficult time staying focused on tasks that require effort at attention.  Sometimes their attention span lasts only a second or less. This puts them at a huge disadvantage for academic tasks and in obtaining instructions.  In the classroom they may well be 30 to 60 seconds behind what the teacher is saying because their thoughts keep ping-ponging around.  If the teacher gives verbal instructions they are very likely to miss some or all of it.  When parents ask their child, "Do you have any homework?" they may say “no” either because they are exhausted from trying to track such details, or because they truly never heard the assignment. Distractibility makes reading pure drudgery. It takes someone with ADHD five times longer to read a paragraph, and maybe longer still to retain it. They rush through homework, skimming over the top and getting things wrong even when they know it. Then they forget to put the homework in their bag even if they do complete it and so have nothing to turn in the next day. ADHD children usually get poor grades – not because they cannot learn, but because they simply need more help in managing the receiving and turning in of assignments and help in staying focused long enough to complete them.   

One additional complication of poor attention is that ADHD sufferers have notoriously bad organizational skills. In the first article I hinted at executive functioning as being a core issue in ADHD. Executive functioning includes all the skills we use in navigating daily life and in ADHD executive functioning is often broken.This deficit is closely linked to distractibility and impulsivity.  But it’s so important that I’ll dedicate my entire next article to the subject.  Stay tuned . . . 

What you need to know about ADHD . . . Part 1

ADHD or Attention Deficit Hyperactivity Disorder is a behavioral syndrome that affects three primary areas of functioning:  hyperactivity, impulse control, and attention.  ADHD involves the frontal lobe of the brain – the area that affects behaviors in these three domains.  It is a syndrome, which means these symptoms tend to happen together with no single specific cause.  The brain and ADHD are each complex, so that it is almost impossible to isolate a single cause of ADHD in any individual.  However some of most often suspected causes include: mild closed brain injury (falls, concussions, etc.), chemical injury to the brain such as exposure to drugs or environmental toxins during critical stages of brain development, brief lapses of oxygen (anoxia) that injures the brain, and inheritance or DNA vulnerabilities.  The injuries that cause ADHD are subtle and rarely observed at the time they occur.  The three behavioral symptoms only show up later and so we rarely associate them to the causes.  Since some of those causes are unobservable, there is no clear or definitive answer to “What caused this.” 

The brain is astoundingly complex, and this is particularly true of the frontal lobe – the area implicated in ADHD.  This part of the brain is the “master conductor” that tells the other parts of the brain what to do, when to do them, when not to do them, what to attend to, when to quiet down, and when to remain silent. It is the part of the brain we most closely associate with our will or with that sense of “I” when we initiate actions.  ADHD may be due to an injury to the frontal lobe directly, or it may be damage to some of the millions of nerve fibers going in and out of the frontal lobe which communicate with the rest of the brain.  Or it may be that the brain chemistry affecting the frontal lobes is not quite right.  Whatever the specific cause, most research points to frontal lobe problems as the “place” where ADHD happens. 

Because of this frontal lobe complexity, there are many individual differences in the behavior of people diagnosed with ADHD.  Some show extreme hyperactivity, and some exhibit none at all. Some have varying degrees of ability to focus. while some cannot sustain attention for more than a second or two.  Some can hyper-focus when very interested in something, but cannot break off from this hyper-focus when their attention is needed elsewhere.  Some have very poor short-term memory, while others are less forgetful. Some have very poor self-management and organizational skills (what psychologists call executive functioning) and some are less plagued with this problem. And any or all of these symptoms may come and go, influenced by fatigue or poor sleep.  Because of this variability, some erroneously conclude, “there’s no such thing” as ADHD. Or they’ll say, “I don’t believe in ADHD” as though it is a matter of faith. But the ADHD syndrome is very real and very disruptive to the lives of those who have it and to their loved ones working to raise or support them.

Check back for the next article on how ADHD is diagnosed, and helpful information on the behaviors and symptoms associated with ADHD. 

-Dr. Mark Dobbs