It’s normal for parents to feel helpless and confused about the best ways to handle their child in these situations. Because kids with ADHD do not purposely decide to act up or not pay attention, traditional discipline — like spanking, yelling at, or calmly trying to reason with your son or daughter — usually doesn’t work. Fortunately there are treatment options that can help alleviate the symptoms of ADHD and arm families with the tools needed to better handle problem behaviors when they arise.

These interventions include:

• Medication
• Psychotherapy
• Or a combination of these two approaches

Medications

Used properly, medicines such as methylphenidate hydrochloride (Ritalin) and other stimulants help suppress and regulate impulsive behavior. They squelch hyperactivity, improve social interactions and help people with ADHD concentrate, enabling them to perform better in school and at work.

These medications also may help children with co-existing disorders control destructive behaviors. When used with proper medical supervision, they are considered generally safe and free of major unwanted side effects. (Some children may experience insomnia, stomachache or headache.) They rarely make children feel “high” or, on the flip side, overly sleepy or “out of it.” Although not known to be a significant problem, height and weight should be monitored with long term use of these medications. These medications are not considered addictive in children. However, they should be carefully monitored in teenagers and adults because they can be misused.

It is important to understand that these medications are not a cure-all, but they can be highly effective when used appropriately in the right dosage for each individual. In fact, as many as nine out of 10 children do better when they are taking one of the most commonly used stimulants. However, in combination with other techniques such as behavior modification or counseling, symptoms may improve even more. Researchers are currently evaluating the effectiveness of medications in combination with these other approaches to determine the best route to take.

Individuals taking any of the medications listed below should see their doctor regularly for a check-up to review the types and timing of ADHD symptoms. The benefits and potential risks of using these medications also should be discussed before the first prescription is filled.

The most commonly used stimulants are:

• methylphenidate hydrochloride (Ritalin, Ritalin SR, and Ritalin LA)
• dextroamphetamine sulfate (Dexedrine or Dextrostat)
• a dextroamphetamine/amphetamine formulation (Adderall)
• methylphenidate (Concerta)
• atomoxetine (Strattera, marketed as a “non-stimulant,” although its mechanism of action and potential side effects are essentially equivalent to the “psychostimulant” medications)

When these “front-line” medications are not effective, physicians sometimes opt to use one of the following:

• buproprion hydrochloride (Wellbutrin) — an antidepressant that has been shown to decrease hyperactivity, aggression and conduct problems.
• imipramine (Tofranil) or nortriptyline (Pamelor) — these antidepressants can improve hyperactivity and inattentiveness. They can be especially helpful in children experiencing depression or anxiety.
• clonidine hydrochloride (Catapress) — used to treat high blood pressure, clonidine also can help manage ADHD and treat conduct disorder, sleep disturbances or a tic disorder. Research has shown it decreases hyperactivity, impulsivity and distractibility, and improves interactions with peers and adults.
• guanfacine (Tenex, Inuniv) — this antihypertensive decreases fidgeting and restlessness and increases attention and a child’s ability to tolerate frustration. Tenex is the short-term preparation, while Inuniv is the long-term preparation.

Duration of treatment

On the one hand, health professionals know that attention deficit hyperactivity disorder is a chronic condition that lasts for years and sometimes for a lifetime. On the other hand, the risks and benefits of medications can change over time, so typically the treating physician and the family need to regularly re-evaluate medication use.

Unlike a short course of antibiotics, ADHD medications are intended to be taken for a longer period of time. Parents should anticipate that, for example, if the child begins taking a medication at the start of the school year, then they are generally going to be committed to working with that medication for the rest of the school year. A child’s situation may improve to where other interventions and accommodations kick in and the child can function pretty well without the medication.

Because children change as they grow — and their environments and the demands they face evolve as well — it is important for families and the treating physician to maintain an open line of communication. Problems can be encountered when a family discontinues a medication without discussing their concerns with the practitioner first.

Adults with ADHD also respond well to similar interventions, including stimulant medications. When making treatment choices, practitioners should consider the individual’s lifestyle. While these medicines can be very beneficial, side effects can occur and should be monitored. Non-stimulant medications, including the antidepressant buproprion hydrochloride (Wellbutrin), have been used. Newer reports show other antidepressants such as venlafaxine (Effexor) may be beneficial in adults as well.

Psychotherapy

Research has shown that medication alone is not always sufficient. For more than two decades, psychosocial interventions such as parent training and behavioral modifications have been used for children with ADHD. A key goal is to teach parents and educators methods that equip them to better handle problems when they arise. In this approach they learn how to reward a child for positive behaviors and how to discourage negative behaviors. This therapy also seeks to teach a child techniques that can be used to control inattention and impulsive behaviors.

Preliminary research has shown that behavior modification is also effective for children with severe oppositional problems. Such an approach may lower the number or severity of oppositional behaviors, although the underlying condition — ADHD — remains.

Some people with ADHD benefit from emotional counseling or psychotherapy. In this approach, counselors help patients deal with their emotions and learn ways to cope with their thoughts and feelings in a more general sense.

Group therapy and parenting education can help many children and their families master valuable skills or new behaviors. The goal is to help parents learn about the particular problems their children with ADHD have, and give them ways to handle those problems when they arise. Likewise, children can be taught social skills and gain exposure to the same techniques the parents are learning, easing the way for those methods to be incorporated at home.

Support groups link families or adults who share similar concerns.

Treatments to Avoid

These therapies that have not been scientifically proven to be helpful in the treatment of ADHD:

• herbal products
• restrictive or supplemental diets
• allergy treatments
• supplements
• megavitamins
• chiropractic adjustment
• perceptual motor training
• medications for inner ear problems
• yeast infection treatments
• pet therapy
• eye training
• colored glasses

What type of professionals should be sought

Most parents consult with their child’s pediatrician or family physician first. If the child mainly has symptoms of hyperactivity, impulsivity or attention problems, then these doctors are in a position to address those concerns. If the child has associated other difficulties, including anxiety, fears, depression, or motor tics, then they should be seen by a mental health specialist, such as a child psychiatrist or school psychologist. Neurologists, whose field focuses on the brain and nervous system, also diagnose ADHD.

It is important to involve the child’s teacher. Educators can lend valuable insight that helps health professionals arrive at an accurate diagnosis and plan the best treatments for that child. Teachers can convey how the child is behaving in school and help review the child’s academic progress.

Prognosis

Even though most people will never completely outgrow ADHD, a thorough assessment and treatment catered to the individual’s particular set of challenges can help them master their symptoms and lead productive, achievement-filled lives. Many believe the disorder’s characteristic behaviors can actually give these individuals a unique creative edge. People with ADHD have gone on to have successful careers in an array of occupations.

Prevention

Because researchers do not yet fully understand what causes ADHD, there are no documented strategies for preventing the disorder. However, some recent studies have indicated that smoking during pregnancy appears to be associated with an increased risk for ADHD.

These are the top 25 psychiatric medications by number of U.S. prescriptions dispensed in 2011, according to IMS Health. I’ve also provided their 2009 and 2005 ranking (you can view the 2009 list here).

To put the percent changes below into perspective, the U.S. total population rose approximately 1.6 percent from 2009 to 2011. That suggests that anything above 1.6 percent change was driven by other factors — more people seeking treatment, more pharmaceutical advertising and marketing, or some other factor.

The biggest movers and shakers on the list were Celexa — moving up 15 spots to grab the second most-prescribed psychiatric drug in 2011 — and Wellbutrin XL, moving from 22 to 13.

Drugs used to treat attention deficit hyperactivity disorder (ADHD) — generic amphetamine salts and methylphenidate — enjoyed big gains as well.

Notes:

If no percentage change is listed, we did not track it in 2005.

NA – Rank not available for this year.

* – This is not a psychiatric medication, but is often prescribed for a mental health issue.

How This Data is Derived

Information in the National Prescription Audit (NPA) is derived from IMS Health’s Xponent service, one of the most complete, national-level prescription databases in the U.S. Xponent captures roughly 70% Market Share of all prescriptions in the U.S. IMS then uses a patented projection methodology from a stratified and geographically balanced sample to represent 100% Market Share coverage of U.S. prescription activity at retail, mail service, long-term care, and managed care outlets.

Complications of Diagnosing ADHD in Adults

• Adult symptoms vary and are harder to diagnose than those present in children.
• It is less well known that adults can have ADHD. Those who suspect they have it may be reluctant to seek help or be unaware that they should.
• General practitioners often attribute ADHD symptoms to more commonly diagnosed disorders such as depression, bipolar disorder, anxiety disorders or common negative lifestyle issues such as poor diet. Improper diagnosis ensures that ADHD remains untreated.
• Adults with ADHD may adapt to symptoms over time. In fact, some may enjoy or feel a benefit from the energy that can define the hyperactivity part of this disorder. Those who have lived with the illness, undiagnosed, for a long time—often since childhood—may not even be aware of their own erratic behavior.

Adults with undiagnosed ADHD also exhibit a much more frequent incidence of addictive behavior than those who do not suffer from the disorder. Reasons vary, but substance abuse often is connected to a need to self-medicate untreated ADHD symptoms.

The Prevalence of Addiction in Adults with Undiagnosed ADHD

Oxford University Press, on behalf of the Medical Council on Alcohol, published an investigative research paper focusing on ADHD patients and nicotine and alcohol dependence. The findings reported, “Several studies have shown that attention-deficit/hyperactivity disorder (ADHD) represents a significant risk factor for the onset and development of addiction” (Ohlmeier et al., 2007).

Although this research focused primarily on nicotine and alcohol addiction, the rate of addiction for all substance abuse, specifically drugs with stimulant properties, is much higher for ADHD sufferers than in the general populace. Carl Sherman, PhD, explains, “A recent survey found that more than 15 percent of adults with the disorder had abused or were dependent upon alcohol or drugs during the previous year. That’s nearly triple the rate for adults without ADHD” (2007).

Often, those abusing any form of negative or illicit substances are not properly treated for the disorder or the resulting addiction — because they are unaware that they have ADHD and treatment for it is available.

Living with Undiagnosed Adult ADHD

I was not diagnosed with ADHD until age 24, so I have firsthand knowledge of the pain and difficulty that adults with ADHD face. I began to abuse stimulant drugs when I realized that they were able to slow me down — a paradoxical effect. For example, while cocaine speeds most people up, adults with undiagnosed, untreated ADHD often are slowed down. Illegal drugs affect the brain in a way similar to the medication commonly prescribed for ADHD — it is no wonder those unaware of their condition often turn to self-medication.

I abused alcohol for the same reason. It was a vicious cycle: My untreated disorder led to impulsive behavior (abusing drugs and alcohol). The relief they brought encouraged me to continue my substance abuse. This is far too common a problem among adults living with undiagnosed ADHD.

Why Is Addiction Such an Issue for Adults with Undiagnosed ADHD?

In his insightful article, “Addiction and ADHD Adults,” Carl Sherman quotes a study by Timothy Milens, MD: “In our study…only 30 percent [of participants] said they used substances to get high… Seventy percent are doing it to improve their mood, to sleep better, or for other reasons” (2007). Sherman goes on to elaborate that abuse of substances, when connected to adult ADHD, often is based on a need to self-medicate the symptoms: “…This kind of ‘self-medication’ seems especially common among individuals whose ADHD remains undiagnosed or who have been diagnosed but have never gotten treatment” (2007).

Stimulant drugs such as cocaine can provide temporary relief. Alcohol has a similar effect on the central nervous system. The medication used to treat ADHD has stimulant properties and affects the same area of the brain as stimulant drugs, though to a lesser degree. Primarily because of this, the potential for abuse among those being treated with adult ADHD, especially those who have a history of substance abuse, is difficult and requires a comprehensive approach.

Treating Adult ADHD When There is a History of Substance Abuse

Before I was prescribed medication for ADHD, I had to remain sober for a year—a reasonable amount of time. Once I was prescribed the proper medication (Concerta, a slow-release variety of Ritalin), I appreciated the ability to focus, and I found that recovering from addiction was easier, primarily because my impulsivity was lessened. Dr. Sherman also elaborated on the importance of this approach: “What’s the right way to get help? Recent studies suggest that it’s best to optimize the treatment for ADHD only after the individual has been sober for six weeks to a few months” (2007).

All stimulant-based drugs have the potential to cause addiction. For this reason, many doctors initially choose to prescribe non-stimulant medications. “Which ADHD medication is best for someone who has already battled substance abuse? For many doctors, the first choice is non-stimulant. These drugs may not be as effective as stimulants for treating certain symptoms… Other doctors choose to prescribe a stimulant…an extended-release formulation… These slow-acting meds are less likely to be abused” (Sherman, 2007).

Adults living with undiagnosed ADHD may engage in addictive behavior simply because they are medicating the primary diagnosis, which may be inaccurate. If they receive a proper diagnosis and proper treatment, they will be less likely to turn to drugs or alcohol and less likely to succumb to addiction.

Treating adult ADHD is difficult both for the primary caregiver and the patient. Because the incidence of addiction is so high among this population, treating the disorder with stimulant treatment regimens must be properly and thoroughly evaluated.

References

Ohlmeier, M.D., et al. (August 31, 2007). Nicotine and alcohol dependence in patients with comorbid attention-deficit/hyperactivity disorder (ADHD). Alcohol & Alcoholism, 42(6). Retrieved from http://alcalc.oxfordjournals.org/content/42/6/539.full.pdf

Sherman, C. Addiction and ADHD adults. ADDitude, February/March 2007. Retrieved from http://www.additudemag.com/adhd/article/print/1868.html

The reality is that it is possible to safely discontinue any medication, including psychiatric ones.

Stop your medication for the right reasons.

“Timing is everything,” according to Dr. Michael D. Banov, medical director of Northwest Behavioral Medicine and Research Center in Atlanta, and author of the book Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting. Just because someone wants to stop taking their medicine doesn’t mean they’re actually ready, he said.

There are many reasons individuals decide to stop taking medicine. For instance, they might feel better and think they don’t need treatment anymore. Their family might be pressuring them to stop, they read something about a drug that scares them, or they’re afraid that the drug will affect their personality, Banov said. Sometimes people want to stop after making major changes in their lives, such as getting a divorce, moving or changing jobs. But, according to Dr. Banov, this is actually “the worst time” to stop.

Also, some mental health conditions require taking medicine indefinitely. Ultimately, how long a person takes a psychotropic drug depends on his or her individual illness, its responses to treatment and their personal situation, according to Dr. Ross J. Baldessarini, professor of psychiatry and neuroscience at Harvard Medical School and director of the psychopharmacology program at the McLean Division of Massachusetts General Hospital. For instance, some individuals struggling with depression may take an antidepressant for nine months to a year and get better; others may need two to five years; and still others, may be “so genetically loaded for depression, that they may need to stay on them indefinitely,” Dr. Banov said.

Don’t stop your medication abruptly.

“Stopping abruptly is especially dangerous,” Baldessarini said.

Depending on the medicine, stopping abruptly or “cold turkey” can cause a variety of distressing reactions, ranging from mild to moderate early discontinuation symptoms with antidepressants, rapid return of the illness being treated, or even potentially life-threatening seizures with a high dose of benzodiazepines.

Consult your doctor before stopping any medicine, and never attempt to do it on your own.

Consider if you’ve received a thorough assessment.

A comprehensive assessment is required prior to stopping medicine. Among other indicators, your doctor needs to consider “your current clinical condition and life circumstances, your past clinical history, reasons to consider stopping versus continuing treatment, side effects and the presence of stressors and supports, as well as the dose and the length of time you’ve been taking a medicine,” Baldessarini said. You and your doctor should talk about these indicators along with how he or she plans to discontinue the drug.

There are no firm, established rules for discontinuing psychiatric medicines. However, there is one major rule of thumb: Reduce the dosage gradually whenever possible. “We still do not know for sure how long is long enough to reduce doses safely,” Baldessarini said. Still, the “slower the dose-reduction, the greater the chances of preventing return of symptoms of the illness for which treatment was started. Very slow discontinuation is especially important when a person has been taking high doses of a medicine over a long time,” he said.

Discontinuing multiple drugs is like peeling an onion, Baldessarini said. He usually leaves the most essential medicine for last. He then reduces doses of one or more optional or supplemental drugs slowly and gradually. Stopping all medicines at once is not safe.

Dealing with small final doses is tricky when dropping from a low dose to nothing. Sometimes doctors decrease the dose to one pill a day or one every two days or split the pill in half, he said. Pill-splitting can be very helpful. You can find pill splitters at your pharmacy.

Don’t expect stopping medication to be a quick process.

Gradually and safely discontinuing a drug doesn’t happen in a few days. Some drugs, including antidepressants, don’t show benefits for several weeks when they’re started; it seems best to avoid discontinuing faster than over several weeks, Banov said.

If you’ve been taking a medicine for years, Banov recommended reducing the dose, stepwise, over at least six weeks. While this may be a conservative practice, he said that “sometimes, you might not detect a change for a few weeks, but later, problems may arise.” Discontinuation symptoms usually occur within days of stopping a medicine, but relapse of the illness being treated can be delayed for weeks after initially feeling well.

In bipolar disorder, Baldessarini and his research team found years ago that the rate of discontinuing ongoing treatment determines the risk and timing of relapse, he said. Initially, their research found that risk for relapse after discontinuing lithium was reduced by one half or more when slow dose-reduction over several weeks was compared to abrupt discontinuation (Baldessarini et al., 2006). Gradual discontinuation of antipsychotic drugs also resulted in lower risk of relapse in schizophrenia (Viguera et al., 1997). In a recent study, he and his colleagues found that stopping an antidepressant abruptly or only over several days resulted in a much greater risk for depression or panic than gradual discontinuation over two weeks or more (Baldessarini et al., 2010).

If you’re switching from one medicine to another, you can be more aggressive than when discontinuing altogether, Banov said. Usually you switch drugs because of ineffectiveness or side effects, and commonly a new drug is introduced as the previous one is gradually removed. This way, there’s little concern about either withdrawal symptoms or relapse, assuming that both drugs have similar effects or belong to the same class, he said. If you’re switching classes, it’s usual to “cross-taper” the medicines: You take both drugs for a while, and then, the doctor reduces the dose of one and ups the dose of the other.

Your doctor may prescribe another medication.

If you’re taking a relatively short-acting antidepressant, such as paroxetine (Paxil) or venlafaxine (Effexor), and you experience bothersome symptoms, “your doctor may prescribe a long-acting antidepressant such as Prozac for a time, and then gradually discontinue the long-acting drug to limit risk of discomfort of withdrawing,” Baldessarini said. “The principal byproduct of the metabolism of fluoxetine has an extraordinarily long half-life or duration of action,” he said, and can take weeks to leave your system.

This method is not well established for discontinuing other classes of psychotropic drugs, including antipsychotics and mood stabilizers, so the best option usually is to “discontinue such drugs gradually, with close clinical monitoring by your doctor,” Dr. Baldessarini said.

It is important for physicians to be aware of side effects from real world experience as well as information supplied by drug companies. A team from Quintiles Inc., the drug company consultants based in Falls Church, Va., looked at patient-reported side effects of ADHD drugs. The drugs covered were amphetamine and dextroamphetamine (Dexedrine); atomoxetine (Strattera); dexmethylphenidate (Focalin); lisdexamfetamine (Vyvanse); and methylphenidate (Concerta, Ritalin).

Results showed that 48 percent of the 325 patients surveyed reported at least one side effect, most often loss of appetite, sleep problems, and mood swings. Differences between the drugs in terms of side effects were thought to be minor. About a fifth (21 percent) of the side effects were considered “very bothersome” or “extremely bothersome,” but only 20 percent of patients mentioned the side effects to their physicians.

The rate of side effects appeared similar for drugs that stimulate the central nervous system and nonstimulant drugs. However, mood disturbances were more common on stimulants, whereas nausea and gastrointestinal problems were more common on nonstimulants.

Researcher Dr. Sharon B. Wigal commented that drug treatment of ADHD typically brings significant therapeutic benefits. But “also evident is the associated pattern of relatively common adverse events that may impact, and even impair, short- and long-term outcomes.”

She explains that side effects can vary by the age of the patient, with preschoolers often having stronger side effects. Most side effects settle down in a couple of weeks, or with a reduction in dose or change in timing. In fact, many are dose-dependent, she says. Nevertheless, they are often the reason why patients stop treatment.

A 2003 investigation into physicians’ perceptions of ADHD drugs found that “the stimulant drug side effects of decreased appetite or weight loss, sleep disruption, and exacerbation of anxiety were a concern for 32 percent, 50 percent, and 22 per of physicians, respectively.”

About 38 percent of the 365 physicians who completed the survey said they would prefer to prescribe a nonstimulant than a stimulant medication. The researchers state, “While many physicians consider the side effects of the stimulants easily managed, others are concerned about prescribing stimulants because of their side effects.” They add that, “The majority of physicians would prefer to prescribe a noncontrolled medication without abuse potential instead of a controlled medication to treat children or adolescents with ADHD.”

Physicians were more likely to believe that side effects are easily managed if they were child and adolescent psychiatrists, which suggests that those who have more experience in treating children and adolescents with attention deficit disorder are more confident in managing stimulant side effects.

Longer-acting drug formulations used once daily are often preferred, to avoid the need to take medication during the daytime, and to minimize side effects. Lisdexamfetamine, sold as Vyvanse, is a new amphetamine which has been shown to work for up to ten hours in children and adults with ADHD. It has a side effect profile similar to other longer-acting amphetamine drugs.

Dr. Brian J. Cowles from the Albany College of Pharmacy and Health Sciences, Vermont, believes that owing to its unique composition, lisdexamfetamine “may lead to a possible reduction of abuse potential.” He says that side effects linked to lisdexamfetamine include decreased appetite, insomnia, irritability, weight decrease, headache, and upper abdominal pain. These tend to occur most at the start of treatment, or following an increase in dose.

A further study confirmed that over 95 percent of side effects occurrences for all doses of lisdexamfetamine are mild or moderate. But nine percent of the 272 children in the study discontinued treatment due to the drug’s side effects.

Research has also looked at the long-term side effects of ADHD medications. A 2007 review examined the evidence and found possible links to appetite and growth, both height and weight. Loss of appetite has been reported in up to 60 percent of children on stimulant drugs. Two major reviews examined all the available data and both concluded that stimulants may be associated with a reduction in expected height gain, at least in the first three years of treatment.

But Dr. Willemijn M. Meijer of the PHARMO Institute in Utrecht, The Netherlands, says the deficits in height and weight “do not appear to be a clinical concern for most children treated with stimulants.” He adds that, “The importance of good nutrition should be pointed out to parents.”

Fears have also been raised about potential long-term effects of stimulant drugs on the heart and on the child’s developing brain. But the available data on these outcomes is limited, so the true effects are still unknown. So far, long-term studies have been inconclusive or contained methodological flaws, so further information is needed. Drugs used to treat attention deficit disorder are generally considered safe and effective.

References

Cascade, E., Kalali, A. H. and Wigal, S. B. Real-World Data on: Attention Deficit Hyperactivity Disorder Medication Side Effects. Psychiatry (Edgmont), Vol. 4, April 2010, pp. 13-15.

Stockl, K. M. et al. Physician perceptions of the use of medications for attention deficit hyperactivity disorder. Journal of Managed Care Pharmacy, Vol. 9, September-October 2003, pp. 416-23.

Cowles, B. J. Update on the management of attention-deficit/hyperactivity disorder in children and adults: patient considerations and the role of lisdexamfetamine. Therapeutics and Clinical Risk Management, Vol. 5, 2009, pp. 943-48.

Domnitei, D. and Madaan, V. New and extended-action treatments in the management of ADHD: a critical appraisal of lisdexamfetamine in adults and children. Neuropsychiatrtric Disease and Treatment, Vol. 6, May 25, 2010, pp. 273-79.

McDonagh, M. S. et al. Drug Class Review on Pharmacologic Treatments for ADHD: Final Report. Portland Oregon Health & Science University, December 2007.

Meijer, W. M. et al. Current issues around the pharmacotherapy of ADHD in children and adults. Pharmacy World and Science, Vol. 31, October 2009, pp. 509-16.

This student (I’ll call her Eva) is home schooling due to chronic fatigue syndrome. On top of that, she’s got attention deficit disorder (also known as ADD or attention deficit hyperactivity disorder, ADHD). Yet here she is, for two hours now and counting, totally absorbed in a very complex and detailed discussion of political and economic dynamics between world powers after World War I.

You would think that we tutors see a lot of ADHD in our line of work.

We certainly have enough students with that diagnosis. Probably a third of the kids I work with take attention-regulating medications (Concerta seems to be the most common).

So I guess the ADHD is there. But I don’t feel like I see it a lot. After decades of working one-on-one with students and naturally engaging with them on their level, ADHD is simply not a part of my day-to-day tutoring interaction. Perhaps I’m just so inured to it, so automatically flexible and accommodating toward all sorts of learning styles and needs, that ADHD doesn’t hit my internal radar anymore. Or maybe students don’t exhibit their ADHD when they’re engrossed in material at their level.

I like to believe that the latter is at least partially true. Certainly, as I observe Matt and Eva bantering away (it’s Matt, now, who’s looking a little bit tired, while Eva keeps asking eager questions and making connections), I don’t imagine anyone could watch this lesson and imagine that Eva has unmedicated ADHD.

Now, it’s true that I’ve seen Eva’s eyes glaze over a few times during this marathon history lesson. Matt had to take a few detours to explain some very technical detail or another, something hard even for me to understand (the differences between communism, socialism, and fascism, for example). They’ve been going for about an hour and a half at this point, and Eva looks a bit dazed and tuned out. I wonder if this is where Matt will lose her and the lesson will be over.

But, no. Eva suddenly perks up, shakes her head as if shaking away the fog, and pitches right back in with another question. Forty-five minutes later, it’s Matt who cries uncle. He’s worn out, whereas Eva, attention deficit disorder notwithstanding, would have happily kept on discussing the intricacies of world war politics, economics and social dynamics.

I was eager to discuss the topic of ADHD with Matt and compare notes.

In general, because we’re tutors, focused on one student at a time, Matt and I don’t experience ADHD as a learning problem. We can roll with the needs and interests of the individual student, instead of having to shoehorn a lesson into a classroom framework or a limited amount of time.

As Matt points out, ADHD has no impact on a person’s overall intelligence, ability, or talent; this is why ADHD warrants extra time on standardized tests such as the SAT with no penalty. To him, it seems to produce a different kind of intelligence.

Matt reports that some of his fellow students who have attention deficit disorder have issues focusing on any single subject for an “acceptable” length of time, but these same students may have a surprising amount of general knowledge. Instead of learning well from a “specialized” high school history class which spends 45 minutes to an hour discussing European history, ADHD students Matt’s worked with have shown a remarkable ability to jump easily from history, to physics, to mathematics, to English, with comparatively little fatigue. Writing a single 5-page paper on a single topic may be difficult, but five 1-page papers on different subjects may come easily.

And then there’s Eva, who can keep going on a single subject that interests her, for hours! What kind of ADHD is this? Yes, she’s highly distractible under certain conditions, but capable of intense and sustained focus under others. Discussing these different students makes me notice that not all ADHD is the same, that this debatable concept is even less clear than I had thought.

Matt also points out that in a world such as ours, with ever-increasing access to dense and difficult information, with ever more rapid change and upheaval, we may want to pause and evaluate what skills will be truly beneficial to individuals and society as a whole. People who are better at jumping from topic to topic, at branching across subjects and making connections, may find their skills highly valuable in the very near future. So, certainly, will be people like Eva, who can delve deeply into a single topic, to the exclusion of others.

Both Matt and I are thinking more now about the positive aspects of ADHD, and appreciating our students and their unique skills even more.

His new girlfriend isn’t so sure. She thinks she could fall in love with him but he’s driving her crazy. “Why can’t he even sit through a movie without fidgeting or getting up to get a snack or to straighten something he notices is out of order, or just to walk around the couch?” She wishes he would just settle down! Please! She’s gone on the web to see if she can make sense of his distractibility and agitation. Aha! The symptom list for ADHD is a perfect match. “Maybe you should see your doctor for some medicine,” she told him. “Maybe then we would be able to have a quiet dinner out. It would be wonderful to have a conversation that stayed on topic for more than a few minutes.”

That was six months ago. Much has happened since. Tony was fortunate. He liked his girlfriend enough to want to please her, so he did ask his doctor whether something could be done to help him be more relaxed. Rather than jump to conclusions based on Tony’s report of his behaviors and his girlfriend’s certainty that he had ADHD, his doctor took the opportunity to do a long-overdue physical exam and to run some tests. The result? A diagnosis of thyroid hormone resistance. Appropriate treatment followed.

Oh, Tony will always take pride in being a bit driven. But he is now able to concentrate. He doesn’t lose his keys or misplace files every day. Best of all, he is able to pay attention to his girlfriend — and his clients — in a way that they experience as more respectful and caring.

Adult ADHD is often underdiagnosed. Although as many as 8 million American adults have it, it has often been missed. For many years, it was thought that children with ADHD outgrew it. Sometimes being unable to control one’s behavior or focus one’s thoughts was seen as an issue of immaturity or refusal to grow up and get with the program. And sometimes the symptoms were seen simply as an eccentric and scattered personality type.

Over the last decade, though, the public has become more aware that ADHD often is carried into adulthood, and medical and mental health professionals have become more sophisticated in making the diagnosis. The result has been the classic pendulum swing, with patients coming in having diagnosed themselves with ADHD and requesting (sometimes even demanding) Adderall or Ritalin to help manage it. Doctors who are under pressure to see four patients an hour don’t always take the time to do a thorough workup and sometimes acquiesce rather than argue with an insistent patient. A consequence is that at least some of the time, people are being treated for ADHD while a perhaps more serious condition goes unrecognized.

The truth is that there are at least a dozen disorders and diseases that share the same symptoms as ADHD. Sleep disorders, mental illnesses like anxiety, depression, and bipolar disorder, neurological conditions like absence seizures or a brain tumor, and even allergies can account for hyperactivity, difficulties with short-term memory, and lack of focus. Medications, whether prescribed or over-the-counter, can produce unexpected or unrecognized side effects of agitation or problems with concentration. And sometimes what looks like ADHD is the way a person is compensating for undiagnosed learning disabilities.

If you or someone you care about passes an online test for ADHD, by all means take the symptom list seriously. But don’t accept the diagnosis as fact without first consulting your doctor to determine whether there is a medical or medication-related explanation. Proper diagnosis is the only way to ensure that symptoms get properly treated.

Obesity — an excessive amount of body fat — can lead to serious health problems, such as high blood pressure. In its most recent update, the American Heart Foundation found that 23.4 million children between the ages of 2 and 19 are overweight or obese. Of those 23.4 million children, 12.3 million are male and 11.1 million are female. The American Heart Foundation adds that 12 million of those children are considered obese; 6.4 million are males and 5.6 million are females. The NIH adds that “over the last two decades, this number [of overweight children] has increased by more than 50 percent and the number of ‘extremely’ overweight children has nearly doubled.”

Pagoto et al. (2009) found that children who have ADHD symptoms into adulthood have higher overweight and obesity rates that patients who only had ADHD symptoms during childhood. The study defined normal weight as a body mass index (BMI) of 24.9 kg/m2 and under; overweight as a BMI between 25.0 kg/m2 and 30.0 kg/m2; and obese as a BMI of 30.0 kg/m2 and greater. In patients who had ADHD only during childhood, 42.4 percent had a normal weight, 33.9 percent were overweight and 23.7 percent were obese. In patients who were diagnosed as children and continued to have symptoms into adulthood, 36.8 percent had a normal weight, 33.9 percent were overweight and 29.4 were obese.

Dopamine Link to ADHD and Obesity

Different studies have hypothesized about the link between obesity and ADHD. One hypothesis is that dopamine comes into play in both conditions, thus linking them together. Researchers Benjamin Charles Campbell and Dan Eisenberg (2007) note that dopamine levels in the brain increase when food is present, even if the person does not eat it. Dopamine is linked to the reward system, causing a person to feel happy when there is an increase in levels. By activating the dopaminergic pathways, eating becomes a pleasurable task.

Those with attention deficit disorder, in turn, have lower dopamine levels, particularly in the prefrontal cortex. Dopamine levels affect working memory, resulting in problems sustaining attention during a task. The authors note that “this switch in attention may be associated with a phasic increase in dopamine reinforcing the reward from novelty.” Thus, any action that increases the dopamine levels, such as eating, will be appealing for those with ADHD. The authors add that certain factors with ADHD can prevent the patient from only eating until full. For example, the poor inhibition control can contribute to overeating. Because of the satisfaction that comes from eating, those with ADHD may use food to self-medicate and increase dopamine levels. The overeating can lead to obesity if not monitored.

Obesity Risk with ADHD Medication

Treating ADHD without medication also may contribute to overweight in children. Waring and Lapane (2008) found that those with ADHD who do not use medications are 1.5 times more likely to be overweight than those with ADHD who take medications for the disorder. The study, which interviewed 5,680 children with ADHD, found that only 57.2 percent of those with ADHD took medications. The authors note that those who take attention deficit disorder medication are 1.6 times more likely to be underweight than those who do not take medication. This trend may be due to the side effects of stimulants, which the NIH states are the primary drug for ADHD. These side effects include weight loss and a reduced appetite.

Waring and Lapane’s results correspond to the dopaminergic pathway findings. If those with ADHD tend to overeat, the side effects of the stimulants would discourage that. Another factor is the mechanism of the drug. The National Institute on Drug Abuse (NIDA) states that stimulants, like amphetamines and methylphenidate, increase dopamine levels in the brain, thus reducing ADHD symptoms. Therefore, if dopamine levels are not managed, those with ADHD may overeat to increase satisfaction levels, which can lead to obesity.

References

Charles, Benjamin C. and Dan Eisenberg. Obesity, Attention Deficit-Hyperactivity Disorder and the Dopaminergic Reward System. Collegium Antropologicum, March 2007 (PDF).

Pagoto, Sherry L. et al. Association Between Adult Attention Deficit/Hyperactivity Disorder and Obesity in the US Population (PDF). Epidemiology, March 2009.

Waring, Molly E. and Kate L. LaPane. Overweight in Children and Adolescents in Relation to Attention-Deficit/Hyperactivity Disorder: Results From a National Sample. Pediatrics, Vol. 122, No. 1: July 2008.

Overweight and Obesity—Statistics; 2009 Update (PDF)

Attention Deficit Hyperactivity Disorder (ADHD)

Weight Problems in Children

Stimulant ADHD Medications – Methylphenidate and Amphetamines

In the early stages of a relationship, people with ADHD may talk too much or find themselves unable to follow the conversation. They may also misread social cues. A person with attention deficit disorder may have shifts in energy, making it hard for their partner to keep up with. Those with poor impulse control may come on too strong, and it can be particularly difficult to manage a relationship at times of stress.

In a relationship, the non-ADHD partner can find that they have to carry out all the planning, cleaning, organizing, bill paying and other responsibilities such as family commitments and arriving on time, as well as diffusing awkward situations caused by blunt comments or actions. One’s partner may struggle to help the person with ADHD find the most suitable treatment, and to deal with side effects and the cost of regular medication.

The major symptoms of attention deficit disorder — forgetfulness, inattentiveness, difficulty completing tasks and impulsivity — can all cause issues in a relationship. These can become even more complicated if children are involved. Adults with ADHD may find it difficult to remain attentive during conversations. They may be forgetful, failing to pay bills or keep the home safe for children, and miss important birthdays or anniversaries. The partner can feel hurt as a result, even if they realize it’s due to the ADHD.

Impulsive behavior can lead to reckless, irresponsible actions and overreaction to small problems. This can cause major misunderstandings and arguments that quickly spiral out of control. Adults with ADHD may also have built up emotional defenses resulting from years of not being understood, believed or trusted. When these defenses are not recognized or resolved, they can trigger anxiety and anger.

A study by Dr. Klaus Minde of McGill University in Montreal, Canada, looked at the family relationships of 33 adults with attention deficit disorder. His team found that married adults with ADHD had “poorer overall marital adjustment and more family dysfunction.” The researchers say, “The findings in this study underscore the need for assessments and treatments to address marital and family functioning of adults with ADHD.”

The same team also looked at the impact on the children of these ADHD adults. They report, “Family and marital functions were impaired in ADHD families regardless of the gender of the affected parent. Children without attention deficit disorder from families with one psychiatrically healthy parent did well, while the behavior of children with ADHD was always poor and not associated with parental mental health.” They highlight the important influence of the non-ADHD parent.

To help manage the obstacles that will arise and maintain a workable relationship, both partners need to understand the differences in their perception and communication styles. Acknowledging and accepting differences helps the adult with ADHD to feel respected, then the process of successfully negotiating those issues or behaviors becomes easier.

Expressing negative feelings like resentment or anger is important, yet it’s often difficult when one or both partners have a hard time listening without interrupting. One approach sometimes recommended is for each partner to write down how they feel, what’s bothering them or what’s working well. Since this is not done face-to-face, neither partner can interrupt, be distracted, or make impulsive judgments.

Another tool which can help gain clarity is making a list of each partner’s top priorities, both day-to-day and long-term. This can reveal possible causes of tension. Working together to overcome such obstacles helps build mutual trust and clarity.

Some other practical strategies that may help include: shopping lists and lists of daily responsibilities, a calendar of important dates, routines to simplify housework as much as possible, planning projects and outings in advance. If repeated financial or legal problems occur, the non-ADHD partner may choose to take responsibility, as long as resentment does not arise. Computers and cell phones can be used to set reminders for tasks that need doing.

Research shows that relationship problems are less likely if the person with ADHD has the condition under contrhttp://psychcentral.com/lib/wp-admin/post-new.phpol. Several medications are available and their pros and cons are widely discussed on the many ADHD websites. But drugs alone might prove insufficient. There is only so much medication can do so it may be a good idea to speak to a psychologist experienced in attention deficit disorder. Counseling or cognitive behavioral therapy are useful for some sufferers.

Other approaches are group therapy, family therapy, coaching, tutoring, physical exercise, proper rest, and adequate nutrition. ADHD and partner-focused peer support groups can also help. Marriage or couples counseling could also resolve problems that have arisen in the relationship as a result of attention deficit hyperactivity disorder.

References

Eakin, L. et al. The marital and family functioning of adults with ADHD and their spouses. Journal of Attention Disorders, Vol. 8, 2004. pp. 1-10.

Minde, K. et al. The psychosocial functioning of children and spouses of adults with ADHD. Journal of Child Psychology and Psychiatry, Vol. 44, May 2003, pp. 637-46.

Attention Deficit Disorder Association

Attention Deficit Disorder Resources

ADHD/ADD Online Resources (UK-based)

A great deal of research has investigated the possible role of caffeine in ADHD. Caffeine is a psychoactive stimulant drug, which can increase alertness and reduce drowsiness. Coffee, tea, soft drinks and chocolate all contain caffeine and are consumed around the world. Approximately 90 percent of adults in North America consume caffeine daily.

It is widely believed that caffeine boosts attention in normal adults, but research results are unclear. Some studies find better performance on memory tasks; others find that caffeine aids concentration but impairs short-term memory. There is also a general belief that caffeine makes people more anxious and hinders sleep. Caffeine withdrawal may trigger headache, fatigue, irritability and nervousness.

As it is a stimulant, caffeine has been investigated as a potential treatment for attention deficit disorder. Its use as a therapy is not widespread because it was found in research studies to be less efficient than other stimulants. But experts writing in 2008 suggest the doses were too low to have a consistent effect. They say that if caffeine proves useful, it “would represent a qualitative increment over the traditional repeated use of psychostimulants, which can have severe side effects if repeatedly used in children.”

Anecdotal evidence suggests that many individuals are already using caffeine to self-medicate ADHD in themselves or their children. Many sufferers find it has the opposite effect than it does in other people: instead of making them more active and stimulated, it actually has more of a “calm-down” effect, and encourages sleep.

The effectiveness of coffee in calming ADHD children has become a great discussion point on websites and forums. Many adults with ADHD also turn to coffee. In fact, some can’t do without it; caffeine’s stimulating effect helps them focus and stay on task.

A similar outcome has been found in animals. A 2005 study of rats with hyperactivity, impulsivity, poor attention, and deficits in learning and memory found a significant improvement in test results when caffeine was administered to the rats beforehand.

The researchers, from the Federal University of Santa Catarina in Brazil, explain that these rats are “considered to be a suitable genetic model for the study of ADHD, since they display hyperactivity, impulsivity, poorly sustained attention, and deficits in learning and memory processes.”

The rats received a dose of caffeine 30 minutes before training, immediately after training, or 30 minutes before a test session in a water maze. These rats needed significantly more training sessions to learn the maze than ordinary rats, but then performed similarly in the test session 48 hours later.

Pre-training caffeine improved the learning deficit in the “ADHD” rats, but had no effect on the other rats. Caffeine given post-training made no difference to either group. “These results demonstrate a selective learning deficit which can be attenuated by pre-training administration of caffeine,” say the researchers.

Caffeine certainly appears to be beneficial for some adults and children with ADHD. But just because it is easily accessible without a prescription, it is still a drug and this does not guarantee a lack of side effects. Overconsumption can be dangerous, especially when consumed on a regular basis over a long period of time. Consuming sugar alongside caffeine in coffee, tea, cola or chocolate may exacerbate attention deficit disorder symptoms.

What’s more, the effects of caffeine are likely to be more short-lived than those from conventional medication, and may diminish over time, as habitual intake can lead to increased tolerance.

A condition known as caffeinism can be triggered when caffeine is consumed in large amounts over an extended period of time. Caffeinism causes nervousness, irritability, anxiety, tremulousness, muscle twitching, insomnia, headaches and heart palpitations. A high intake over time can also lead to peptic ulcers and other gastrointestinal problems.

Caffeine use for ADHD should always be discussed with a physician and may not preclude the need for other medication or therapy.

References

Lesk, V. E. and Womble, S. P. Caffeine, priming, and tip of the tongue: evidence for plasticity in the phonological system. Behavioral Neuroscience, Vol. 118, 2004, pp. 453-61.

Cunha, R. A. et al. Potential therapeutic interest of adenosine A2A receptors in psychiatric disorders. Current Pharmaceutical Design, Vol. 14, 2008, pp. 1512-24.

Caffeine As An Alternative ADHD Treatment

Prediger, R. D. et al. Caffeine improves spatial learning deficits in an animal model of attention deficit hyperactivity disorder (ADHD) – the spontaneously hypertensive rat (SHR). The International Journal of Neuropsychopharmacology, Vol. 8, December 2005, pp. 583-94.

From her work in primary care settings, Risa Weisberg, Ph.D, assistant professor (research) and co-director of the Brown University Program for Anxiety Research at Alpert Medical School, has seen “firsthand how a great many patients accept a prescription from their provider without asking many questions about it, or often, without even knowing for what symptoms/disorder it is being prescribed.”

Such a scenario can stall or sabotage your treatment. Confused, you’re likely left with tons of questions, unaware of what you’re taking and how it’s supposed to help. You may be feeling helpless — a spectator in your own recovery — and hopeless, if the medication doesn’t seem to work or has bad side effects. Your doctor likely is clueless about your real concerns, not having all the information to guide his or her decision-making process.

But you don’t have to feel like a powerless bystander, on the outskirts of your own treatment. In order to become a sharp self-advocate, you just need some information. Here’s some hints for for taking medication safely and effectively. At the end, you’ll also find a basic glossary of common medication-related terms.

1. Haven’t picked a physician yet? Do your homework and conduct an interview. Before you decide on a doctor, whether it’s a primary care physician or a psychiatrist, ask some questions about qualifications and see if he or she is a good fit for you. Questions to get you started: Where did you go to school and do your training? Do you specialize in a specific mental illness? Do you have hospital privileges? Here’s a list of excellent questions to ask a psychiatrist during and after your first appointment. They focus on bipolar disorder, but you can easily adapt them to any disorder.

2. Ask the doctor about your diagnosis. You have the right to know precisely what you’re diagnosed with and how the doctor came to that conclusion. Making a diagnosis doesn’t happen in a 5-minute interview. You want to make sure that the doctor conducted a thorough evaluation. Did the doctor get your medical and mental health history? Did you complete a standardized test? Did the doctor ask about your symptoms and recent experiences?

3. Seek out psychotherapy. Medication isn’t your only option. Depending on the disorder, you may only need psychotherapy or you may take medication and see a therapist. Psychotherapy provides lasting benefits, whereas a medication’s effects stop as soon as you stop taking it. Cognitive-behavioral therapy effectively treats depression, anxiety disorders and bipolar disorder. To find a therapist, you can ask your doctor for a recommendation, browse the Web or check with universities and medical schools. Be sure the therapist specializes in your mental illness. For advice on finding a good therapist, check out this eBook.

Some Web sources for finding a therapist:

• Psych Central’s therapist finder
• The Association for Behavioral and Cognitive Therapy for CBT-trained therapists
• Children and Adults with Attention Deficit/Hyperactivity Disorder
• Anxiety Disorders Association of America
• National Eating Disorder Association

4. Before taking the medication, ask specifics. Peter Roy-Byrne, M.D., professor and chief of psychiatry at the University of Washington at Harborview Medical Center, and Michael R. Liebowitz, M.D., professor of clinical psychiatry at Columbia University and managing director of The Medical Research Network, suggest asking:

• How will I know if this medication is working?
• What are the side effects, and what do I do if I experience them?
• When will the medication start to work?
• How long will I have to take it?
• If I take it for X amount of time, what’s the likelihood of reducing symptoms?
• What are the dose requirements?
• Will you be monitoring me throughout the course of this medication?
• When will you talk to me next?

The Agency for Healthcare Research and Quality has a basic handout with more questions. Here’s a thorough list if your child is taking medication, which you can easily revise for your situation.

5. Unsure about medication? Explore why. Are you on the fence because of potential side effects, the stigma of having a disorder or taking medication, a bad past experience, fears of addiction or uncertainty about the validity of your diagnosis? Talk to the doctor about your concerns before making the decision to take or refuse the medication.

But knowing what treatments are effective and how to find them can seem just as overwhelming as the diagnosis. Here’s a clear-cut look at managing ADHD, from evaluation to treatment.

Common Misconceptions

• ADHD is over-diagnosed. “It really depends on the community; ADHD can be over-diagnosed in some communities and under-diagnosed in others,” said Arthur L. Robin, Ph.D, licensed psychologist and chief of psychology at the Children’s Hospital of Michigan. For instance, ADHD may be under-diagnosed in an inner city where no one talks about it, but over-diagnosed in an affluent suburban area, where parents are more aware of ADHD and may think their child has the condition if he or she isn’t doing well in school.

• Inattention, distractibility and impulsivity are character flaws. ADHD is a neurobiological disorder, and these “character flaws” are symptoms.
• You can will yourself out of ADHD. “The fact is, and research backs this, that the harder one tries, the worse the symptoms seem to get,” Matlen said.
• Children outgrow ADHD. “What people typically outgrow is the hyperactive part of ADHD. What remains is the inattentive and impulsive parts of the disorder which can cause impairments in academic, personal and occupational arenas,” said Adelaide Robb, M.D., associate professor of psychiatry and pediatrics at the Children’s National Medical Center in Washington, DC.

Diagnosis

“The best antidote to under-diagnosis and over-diagnosis is an appropriate evaluation,” Robin said. Pediatricians, who are at the frontline, don’t have the time necessary to conduct a comprehensive evaluation, so they may jump to conclusions and prescribe medication, he said. To avoid this, ask your pediatrician to help you find a mental health professional. Also, note that ADHD symptoms must occur across settings, including at school and home. Adults can ask their primary care physicians for a referral.

According to Robin, an appropriate evaluation entails: systematically reviewing ADHD symptoms from the DSM-IV with parents; getting input from teachers, who complete standardized rating scales; conducting a thorough interview with parents and children; and ruling out alternative explanations. To rule out learning disabilities or low cognitive ability, the practitioner administers an IQ and achievement test.

For diagnosis in adults see here.

Steps to Successful Treatment

1. “Be thankful. ADHD is a condition that can be managed effectively when it is recognized and understood,” said Peter Jaksa, clinical psychologist and director of ADHD Centers in Chicago.
2. Educate yourself about ADHD. Whether it’s you or your child, become an authority on ADHD. Read online resources (e.g., Psych Central, Attention Deficit Disorder Association, Children and Adults with Attention Deficit/Hyperactivity Disorder); attend conferences ; and seek support groups.

   For parents, learn about how ADHD affects your child “in school, socially and at home”; what parenting techniques work for kids with ADHD; and your child’s educational rights, Matlen said. For adults, understand your ADHD brain by cataloguing how ADHD impacts your daily functioning, Robin said. For some, the biggest impact is on organization, ability to follow through, short-term memory and attention to details, he said. Does ADHD interfere with work, intimate relationships, parenting your kids?

3. Talk to professionals about treatment options. Choose professionals who regularly see people with ADHD. Look at your treatment options as “tools in a tool chest to be used as needed across your life,” Robin said. These tools typically include medication, cognitive-behavioral therapy (CBT) and organizational strategies—an effective combination for treating ADHD.
4. Become an advocate. “Parents are the most important and strongest advocates” for their kids, Jaksa said. Help kids “understand that they aren’t ‘dumb’—that their brains are simply wired differently,” Matlen said. “Meet with your child’s teachers before school starts to inform them about your child’s history and “discuss strategies that would be helpful for your child,” Jaksa said. If your child doesn’t have an Individualized Education Plan (IEP), talk to the principal and school psychologist about doing the evaluation, he said. Don’t be afraid to ask how therapy is going, Robin said. If it doesn’t seem successful, seek another therapist.

Disclosing Your Diagnosis

“People with ADHD should treat their personal ADHD information like any other kind — think about who should know and what that information could do, both in a positive or potentially negative way,” Matlen said. Telling loved ones may help them better understand what’s been going on and allow them to be helpful and supportive, she said. If loved ones don’t seem to understand, “give them articles, books and websites where they can learn more,” Matlen said.
At work, Sandy Maynard, M.S., an ADHD coach who operates Catalyst Coaching, advises against disclosing your diagnosis. Instead, identify “what you need to perform better” and ask for it, she said. A boss will rarely refuse a reasonable accommodation.

ADHD also affects approximately 4 percent of adults, according to the National Institute of Mental Health. These adults have problems with organization, time management, sustaining their attention, completing tasks and controlling their emotions. They can miss deadlines, speak without thinking, get easily distracted, misplace items and have trouble remembering things. Similar to children, symptoms in adults can vary — some adults might be especially gregarious while others withdraw and isolate themselves.

For both kids and adults, these symptoms create problems at school, work and in relationships. Though ADHD can make daily life difficult, it’s effectively treated with medication and psychotherapy. If you think you or a loved one has ADHD, see a mental health professional for a comprehensive evaluation.

What Are the Risk Factors and Causes of ADHD?

Like other psychological disorders, ADHD is caused by a multitude of factors, including the following.

• Genetics: Studies show that ADHD runs in families with greater frequency than in the general population. Twin studies have attributed about 80 percent of ADHD to genes (see Faraone, 2004), though estimates vary. Researchers also have explored the contribution of specific genes. A recent large-scale study demonstrated that many genes are involved in ADHD (see genetic determinants of ADHD). Since many symptoms make up the disorder, that would seem to make sense.
• Environment: The maternal environment might increase the risk for ADHD, including smoking during pregnancy (in an already genetically susceptible child), low birth weight and mom’s mental health. Some research has found that preschool children exposed to high levels of lead might be vulnerable to ADHD (Braun, Kahn, Froehlich, Auinger & Lanphea, 2006). Also, ADHD seems to be associated with traumatic events, such as emotional or physical abuse (see Banerjee, Middleton & Faraone, 2007).
• Food additives: The hypothesis that food additives increase ADHD risk has been a controversial one. A recent study found that drinking beverages with food additives increased hyperactivity in children without ADHD (see here and here).
• Brain injury: Head trauma can cause ADHD-like symptoms, though only a small percentage of children with ADHD have experienced brain injury, according to the National Institute of Mental Health (NIMH). Also, a recent study disputes this hypothesis.

Symptoms of ADHD

Inattention

• Misses details and makes careless mistakes
• Is unable to organize tasks and activities
• Has difficulty following through on instructions and completing assignments
• Gets bored with a task after only several minutes
• Doesn’t seem to listen when spoken to
• Is easily distracted
• Often loses toys, school supplies or anything necessary for a particular task
• Is often forgetful
• Avoids, dislikes or hesitates to participate in activities that require continuous mental effort (e.g., homework)

Hyperactivity

• Fidgets or squirms in seat
• Leaves his or her seat when it isn’t appropriate
• Runs or climbs when it isn’t appropriate (in adults, this might be restlessness)
• Frequently has difficulty playing or participating in activities quietly
• Often acts like he or she is “on the go” or “driven by a motor”
• Talks excessively

Impulsivity

• Blurts out answers before questions are completed
• Has a tough time awaiting his or her turn
• Interrupts others (e.g., disrupts a conversation or game)

Issues with Adult Diagnosis

The criteria for diagnosing children with ADHD are reliable. However, since they were originally created with children in mind, they may be inappropriate for diagnosing adults.

Many symptoms adults commonly experience, including procrastination, poor motivation and time management problems, are excluded from the criteria are excluded from the criteria (see Davidson, 2008). Also, it can be difficult to distinguish ADHD from other psychological disorders, including depression, bipolar disorder and generalized anxiety.

What Are the Different Types of ADHD?

• Predominantly Inattentive Type: A prevalent diagnosis among adults, this type shows six or more symptoms from the inattention category and fewer than six symptoms from the hyperactive-impulsive (but individuals can exhibit some of these symptoms).
• Predominantly Hyperactive-Impulsive Type: These individuals show six or more symptoms from the hyperactive-impulsive category and fewer than six symptoms from the inattention type (but some of these symptoms can be present).
• Combined Type: Common in children, this type exhibits six or more symptoms of the inattentive type along with six or more symptoms from the hyperactive-impulsive type.

How Is ADHD Diagnosed?

A trained mental health professional, such as a psychologist, psychiatrist or therapist, can accurately diagnose ADHD. This is done with a face-to-face clinical interview. The practitioner will take a comprehensive history, including current and past symptoms, medical conditions, co-existing psychological disorders and family history. When diagnosing children, the practitioner will gather information from parents and teachers. (See here for details).

What Treatments Exist for ADHD?

Both children and adults with ADHD are treated with psychotherapy, medication or both.

What Kinds of Medications Are Used for ADHD?

Both stimulants and nonstimulants are prescribed to treat ADHD, helping to improve academic, occupational and social functioning. Medication is available in either a short-acting dose (which lasts for about four hours) or a long-acting dose (which lasts about 12 hours).

Contrary to their name, stimulants actually calm patients and are used as the first line of treatment. They help control hyperactivity, impulsivity and inattention, improving an individual’s ability to concentrate, learn, follow instructions and interact with others.

There are two primary types of stimulants—methylphenidate-based (Ritalin, Concerta, Metadate) and amphetamine-based (Adderall, Dexedrine).

Studies have shown that these medications are safe. Side effects may include trouble sleeping, loss of appetite and anxiety. Because of this, stimulants might not be appropriate for someone who already has anxiety.

There are several concerns with prescribing stimulants for children:

1. Stunted growth. Though there might be subtle effects, it seems stimulants don’t affect one’s ultimate height and weight, according to a recent review (Faraone, Biederman, Morley & Spencer, 2008). The authors did note that doctors should still monitor children’s height.
2. Addiction and future drug abuse. Many parents also worry their kids will become addicted to stimulants and develop drug abuse problems. However, a great deal of research has found that taking stimulants does not increase an individual’s risk for substance abuse (see Biederman, Monuteaux, Spencer, Wilens, MacPherson & Faraone, 2008). Interestingly, some research has even shown protective effects—children who respond well to stimulants are at lower risk for alcohol and substance-related problems. (This might not be true for adults).
3. Heart problems. Rare, but fatal cardiac complications may occur in children with underlying heart disease. For this reason, the American Heart Association has recommended that all children with ADHD have cardiovascular screenings before they’re prescribed stimulants. For details, read here and here).
4. Nonstimulants. Atomoxetine (Strattera) was the first and so far only nonstimulant medication to receive approval to treat childhood ADHD. It also was the first ADHD medication approved for adults.

   Strattera lasts 24 hours as opposed to the four- or 12-hour effects of other stimulants. Its side effects also include insomnia and loss of appetite, though this is more common with stimulants.

   The FDA has required that Strattera be sold with a black box warning about suicidal risk; it might increase children’s and teens’ suicidal thinking and behavior.

5. Medication concerns for adults. All of the above medications also are prescribed to adults with ADHD. However, because of the high risk for abuse, there is controversy over prescribing stimulants to adults with a history of substance abuse — prevalent among adults with ADHD, reports ADDitude.

Psychotherapy

Psychotherapy is a significant component of ADHD treatment, because it teaches both children and adults the skills they need to succeed. In addition to therapy, many adults with ADHD work with a coach, who helps them get organized and develop and achieve their goals as well as providing valuable feedback and support. For more details on ADD coaches see here and here.

Behavior therapy is just as it sounds: It helps promote appropriate behavior (e.g., doing one’s homework) and decrease problem behavior (e.g., acting out in class). The therapist, parents and teachers establish rewards and consequences to promote positive behaviors.

Cognitive-behavioral therapy helps adults identify negative thoughts and behaviors and change them. In addition, individuals learn how to overcome everyday struggles, including problems with organization and time management.

Social skills training teaches both adults and children how to interact appropriately with others and build healthy relationships. Individuals with ADHD tend to have difficulty understanding social cues (e.g., facial expressions; body language) and might come off as inattentive or offensive.

What Do I Do Next?

If you think you have or a loved one has ADHD, you’ve already accomplished your first step: educating yourself about the disorder. For more detailed information, check out our ADHD guide and complete an ADHD questionnaire. Adults can read a first-hand account of life with ADHD here.

To receive a comprehensive clinical assessment, see a mental health professional or check with your primary care physician or community mental health clinic. Remember that ADHD can be successfully managed, so it’s essential to get evaluated as soon as possible.

Further Reading

Attention Deficit Disorder Association
ADDvance
National Institute of Mental Health
National Resource Center of ADHD
ADDitude
Helpguide, Rotary Club of Santa Monica

ADHD is a neurological condition characterized by inattention, hyperactivity and impulsivity. Three subtypes of ADHD generally are recognized by professionals:

• hyperactive-impulsive (the child does not show significant inattention)
• inattentive (the child does not show significant hyperactive-impulsive behavior — previously called ADD); and
• combined (the child who displays both inattentive and hyperactive-impulsive behavior).

Children who are anxious or depressed, are sensitive to sugar, or are sleep-deprived also may display attention problems, poor impulse control and hyperactivity. In the July/August 2003 issue of Psychology Today, a Brown University study suggests “sleep deprivation in normal children can lead to symptoms of attention-deficit hyperactivity disorder (ADHD).”

Researchers found that several days of sleep deprivation resulted in the development of ADHD symptoms, and that children’s hyperactivity levels escalated with each additional night of poor sleep. The sleep deprivation may be due to sleep apnea, allergies, asthma, circadian rhythm disorder or restless legs syndrome. Not only are children at serious risk of being misdiagnosed as ADHD, if their sleep or health problem remains undetected, their health can be jeopardized.

Research shows a clear link between sleep and school performance but many teachers and schools are slow to get the message. Teachers often are unaware that a lack of sleep is keeping many of their students from being able to concentrate at school and jump to the conclusion that a child has a learning problem or ADHD. Sleep deprivation generally is overlooked by school psychologists who fail to take it into account when making their assessments.

Sleep problems associated with ADHD include:

• Difficulty relaxing and falling asleep
• Restless legs syndrome
• Sensory processing deficits (may be overly sensitive to stimulation, sounds, light, clothing, blankets)
• Motor restlessness
• Night awakenings
• Bed wetting
• Snoring
• Sleep apnea

Children with ADHD usually respond well to relaxation techniques practiced at least twice a day. Adequate exercise also is important.

If you suspect that medication is interfering with your child’s sleep, meet with your physician to discuss adjusting it. Be aware that stimulant medications such as Cylert, Ritalin, Dexedrine and Adderall may make it difficult for a child to fall asleep at night, especially if they’re taken in the late afternoon.

Dubbed “The Dream Maker” by People magazine, Patti Teel is a former teacher and the author of The Floppy Sleep Game Book, which gives parents techniques to help their children relax, deal with stress, or fall asleep. Visit Patti online at www.pattiteel.com to subscribe to her free newsletter.

Drugs for Depression

Although the Phase III pipeline of drugs for the treatment of depression is deep, including several compounds with new mechanisms of actions, none is expected to be approved in 2009. Pristiq (desvenlafaxine, the major metabolite of venlafaxine), Wyeth’s follow- up to Effexor (venlafaxine), was approved for depression in adults by the FDA in March and could gain ground in the clinic next year.

AstraZeneca submitted an sNDA in May for Seroquel XR for the treatment of generalized anxiety disorder, which was the first submission of an atypical antipsychotic medication for this indication. In February, the company submitted an sNDA for Seroquel XR for the treatment of depression.

In September, LaboPharm submitted an NDA for DDS-04A for the treatment of depression. This compound is the well-known antidepressant trazodone a 5-HT2 receptor antagonist, formulated for once-daily administration. The NDA was based on data from five pharmacokinetic studies and a North American study that included more than 400 patients.

New drugs on the horizon for late 2009/2010 U.S. approval include Valdoxan (agomelatine), which is in development by Novartis and Servier, and Saredutant (SR 48968), a Sanofi-Aventis compound. Valdoxan, which has a novel mechanism of action—melatonin (MT1 and MT2) receptor agonist and 5-HT2C receptor antagonist—and an attractive side-effects profile (i.e., no sexual dysfunction or weight gain), is anticipated.

Novartis is currently conducting four large-scale Phase III trials in the United States, all of which are scheduled to complete in 2009. A U.S. NDA might be submitted in 2009. Saredutant, a neurokinin-2 (NK2) receptor blocker, is well tolerated but has produced mixed results in long-term Phase III trials. Sanofi-Aventis will decide on regulatory submissions based on the results of two ongoing trials assessing saredutant in combination with escitalopram and paroxetine, which are scheduled for completion in the first half of 2009.

Drugs for Bipolar Disorder

Longer-acting injectable and oral formulations of approved atypical antipsychotic medications are the focus of late-stage drug development for bipolar disorder.

Janssen is currently marketing Risperdal Consta, a long-acting, injectable formulation of risperidone for the treatment of schizophrenia. The drug was developed by combining risperidone with the Alkermes’ Medisorb delivery system to maintain a therapeutic drug concentration when administered once every two weeks.

In 2008, Janssen submitted two supplemental New Drug Applications (sNDA) for bipolar indications. An sNDA submitted in April seeks approval for adjunctive maintenance treatment to delay the occurrence of mood episodes in patients with frequently relapsing bipolar disorder. A July sNDA submission looks to indicate Risperdal Consta as monotherapy for the maintenance treatment of bipolar I disorder to delay the time to occurrence of mood episodes in adults.

Another long-acting atypical antipsychotic, AstraZeneca’s Seroquel XR (quetiapine extended-release tablets), was approved in October 2008 for acute treatment of depressive episodes associated with bipolar disorder and manic and mixed episodes associated with bipolar I disorder, as well as maintenance treatment of bipolar I disorder as adjunctive therapy to lithium or divalproex.

Drugs for Schizophrenia

Late-stage drug development for schizophrenia includes a new injectable formulation of an approved atypical antipsychotic and two new drug candidates with atypical antipsychotic mechanisms of action.

Janssen developed an injectable formulation of its antipsychotic, Invega (paliperidone extended-release) by combining it with Elan’s NanoCrystal technology to enable administration by intramuscular injection on a once-monthly schedule. In October 2007, the company submitted an NDA for the treatment of schizophrenia and prevention of symptom recurrence. In August 2008, the FDA requested additional data before approving the NDA, but did not require any additional studies. Janssen is currently evaluating the FDA response and will work with the agency to resolve outstanding questions. Potential advantages of Invega over Risperdal Consta include reduced dosing frequency (once monthly vs. once every two weeks) and no need for refrigeration.

In September, Lundbeck’s NDA submission seeking approval for Serdolect (sertindole) for the treatment of schizophrenia was accepted for review by the FDA. Serdolect is a new-generation atypical antipsychotic. It exhibits a higher level of limbic-selective increased dopaminergic activity than other atypical agents, which may contribute to an attractive extrapyramidal side-effect profile. Serdolect has been launched in Europe, South and Central America, Asia and the Middle East and has been administered to more than 70,000 patients.

Schering-Plough’s NDA submission for its new 5-HT2A- and D2 receptor antagonist Saphris (asenapine) was accepted by the FDA in November 2007 and is undergoing a standard review. Saphris is a fast-dissolving, sublingual tablet acquired by Schering-Plough when it combined with Organon BioSciences earlier in November 2007. The NDA seeks approval for schizophrenia and acute or mixed episodes associated with bipolar I disorder. In November 2008, top-line Phase III clinical trial results demonstrated the efficacy of Saphris in long-term schizophrenia relapse prevention. Approval and launch in 2009 are possible.

Drugs for Attention Deficit Disorder (ADHD)

A new drug with a nonstimulant mechanism of action may be approved in 2009 for the treatment of attention-deficit/hyperactivity disorder (ADHD). Intuniv (guanfacine extended-release tablets) is a selective alpha2A-agonist in development by Shire for the once-daily treatment of ADHD. The company submitted an NDA for monotherapy for the treatment of ADHD symptoms throughout the day in children aged 6 to 17 years and received an approvable letter from the FDA in June 2007. The FDA requested additional information, and the company has been conducting additional clinical work related to the drug’s label.

Immediate-release guanfacine, a medication used to treat high blood pressure, also is used off-label in ADHD.

Anticipated advantages of Intuniv over guanfacine include FDA approval specifically for ADHD and maintenance of blood concentration in the therapeutic range, which is problematic with immediate-release formulations. Another potential advantage: Intuniv is not a controlled substance, and is not associated with any known mechanisms for potential abuse or dependence.

An estimated 30% of children with ADHD cannot tolerate stimulant drugs or do not benefit from currently available ADHD medications. Intuniv also might have applications in combination with stimulant drugs to reduce aggression and insomnia associated with stimulants and adult patients. Shire hopes to gain FDA approval and launch Intuniv in the second half of 2009.