Dr. P Discussion and Views on ADHD
ADHD
ATTENTION DEFICET HYPERACTIVITY DISORDER
Evaluation, Education, and Treatment Trial
Micro-Diagnosis and Fine Tuning
ADHD is a common diagnosis once only recognized in children , but now more and more in adults. Perhaps even more so today because of wide spread information and a multiplicity of practitioners it is still under diagnosed, over diagnosed, and misdiagnosed., therefore often not treated properly. Thus more the reason to know what it is , and what it isn’t, and how to properly treat it.
Successful treatments of uncomplicated ADHD is one of easiest, quickest, safest, treatments in modern medicine and remarkably satisfying for the patient, the parent, and the treating practitioner. At least it should be.
A super active little child, frustrating every one including himself, who cant learn, getting in constant trouble at school and home, based on lack of focus and concentration, is given the right diagnosis, and treatment. Within one hour, it is like a miracle, a new child, who can now sit still, pay attention, and thinks before they act, and a joy to be with. Yes within one hour, and with little or no negative effects, if the proper medicine at the proper dose is used, and the diagnosis is correct. No zombied out, over medicated, stoned child, just the normal child now in control and able to learn, follow direction, and well disciplined. Maybe eating a little less, as the only side effect.
Wouldn’t any one want and be happy with that result? What is the secret? It is the right diagnosis and treatment.
The basics of the approach I use will be discussed, clarified, and repeated over and over from different angles to ensure understanding. Many times I find that a misunderstanding about the basics of diagnosis and treatment are at the root cause of misdiagnosis and faulty treatment.
Besides proper evaluation and diagnosis, a scientifically based treatment trial is essential. Maximum relief is facilitated by micro diagnosis that is targeting less and less troubling symptoms and fine tuning the medication to try to eliminate them. All of this requires as much time as it takes and mutual education of doctor to patient and vice versa.
Basics, basics, basics, will be stressed over and over again. I will try to present these basics in a way that anyone can understand them.
Based on treatment response, I break ADHD into two groups based on symptoms and treatment response, Uncomplicated ADHD, and Complicated ADHD.
Uncomplicated ADHD presents with mild to moderate core symptoms, and usually responds to a stimulant medication as medicine of first choice, often alone, though there are cases that are not stimulant responsive, or there may be negative effects that outweigh the good effects.
Complicated ADHD, is complicated in two ways, one by the core symptoms being much more severe, and/or complicated by other symptoms that need medication management on their own. Complicated ADHD, usually doesn’t respond to a stimulant alone, though it may, at least initially. This initial treatment response may be a mixed blessing in that it confuses the true diagnosis, and complicates further treatment.
These other complicating symptoms, may or may not represent another diagnosis. If they do represent another diagnosis, then it needs to be determined if they are primary and thus need to be treated
first or simultaneously.
As you see things can get tricky here, and there is no substitute for further history taking and clarification of possible diagnoses, and often sequential medication treatment trials. An experienced clinician may be necessary, at least for a second opinion.
Treatment based on the proper diagnosis, can be divided into three parts:
1.Uncomplicated ADHD
2. Complicated ADHD with more severe symptoms, with no other diagnosis
3. Complicated ADHD with other diagnoses, which may be primary, further may be acute, chronic, continuous, or episodic.
Uncomplicated ADHD: Diagnosis and Treatment
The core symptoms of ADHD, according to DSM IV R are inattention , impulsivity, and hyperactivity, based on the works of Russell Barkly, I add, problems with discipline, and excitability. A useful mnemonic is I HEAD, for problems with, Impulsivity, Hyperactivity, Excitability, Attention, Discipline.
Other criterion must be met and other disorders must be ruled out before one can make the diagnosis.
According to DSM, symptoms must be inconsistent with developmental age, cause clinically significant impairment in functioning in at least two settings, such as family, community, work, school, and have been present before 7 years of age. The symptoms must persist for at least six months, with no sustained or intermittent lapses. Also the symptoms do not occur exclusively during another psychiatric disorder, or are better explained by another mental disorder.
It is this last diagnostic criterion, the other disorders, especially other psychiatric disorders, that I find is the one that is not seriously evaluated and considered in enough depth historically and developmentally that leads to diagnostic confusion, the wrong diagnosis, and therefore the wrong short term and long term treatment.
Closely related to the other diagnosis problem, is the criterion the presentation should be sustained with no intermittent lapses, again not closely followed. Though there are fluctuations in functioning based on the core symptoms, ADHD is not episodic, it doesn’t come and go, wax and wane, get much better or much worse from base line, and when it does there are often apparent factors to explain the changes. ADHD is always in the background and it is chronic, that is the core problems can last a life time, with varying impairment.
Perhaps as crucial as the diagnostic criterion, the treatment response should also sustained once the right medication and dose is found, not intermittent with relapses.
Uncomplicated if it means nothing else means not complicated by other psychiatric or medical disorders, including, medication and or drug and alcohol induced. These other disorders must be ruled out, and if not ruled out, provisionally considered if treatment is to be adequate, appropriate and successful.
Before treatment begins there must be both a ruling in process and a ruling out process, one must know what to include, and what to exclude.
This process in medicine is called formulating a differential diagnosis.
There are many ADHD look "alikes" especially mood and anxiety disorders, physical disorders that manifest with ADHD symptoms, like recurrent Ear infections, Thyroid disease and Sleep Apnea, Drug and Alcohol, and medication induced disorders, like medications used for seizures.
Another area often overlooked or not considered seriously enough as a cause or making ADHD symptoms worse is environmental factors, like too much general stress at home, at school, at work,, in relationships, and specific stresses like neglect, abuse, and other traumatic events.
One must rule in the symptoms that make the disorder and simultaneously rule out look alike syndromes hat represent another diagnosis, and thus perhaps another all together another mediation approach, or no medical approach as may occur in specific learning disorders, that require educational interventions not medication.
Some of this ruling in and ruling out can be done by almost anyone if they have the right information, others require an experienced practitioner, some one who sees a lot of ADHD and its look alikes and has much experience in actual hands on treatment.
Simple screening tools, like the a general mental health symptom screening test that I use in my office practice can help.
The logic behind using these screening tool, or taking more extensive history, is simply to see if there are more symptoms, behaviors, problems, than the core symptoms of ADHD, if there are they need to be further evaluated and often treated first, or carefully simultaneously.
What are the core symptoms, and what needs to be ruled out?
The diagnosis is clearly made if one follows the DSM , my interpretation follows and will be further clarified by fictional case examples.
The core problems are 1. In paying attention, sustaining attention, and shifting attention or focus. 2. Impulsivity that that may be social, cognitive, or behavioral, that is not thinking of the consequences before you act, talk, or think. 3. Hyperactivity, which me be quite overt, like always on the go, cant sit still, or just an inner sense of restlessness, or a preference not to be seated or still. 4. Excitability, or a short fuse, overly emotional but this mood component should not dominate the picture .
5. Discipline issues, such as ADHD related , not other diagnosis related ODD, that is oppositional defiant problems, and not learning from life experiences, and making the same social, behavioral and cognitive, mistakes over again and again.
These core symptoms would occur more in situations, where the individual under usual circumstances may normally have problems with focus or attention, where factors such as [4M’s] bad Motivation [ video game vs. math home work], wrong Milieu or setting[ sitting in front of the TV vs. classroom], negative Mood [ sad, mad, bored vs. happy and excited], and little Meaningfulness of the situation play more of a part.
For example, a student is very interested in math, it turns him on, thus puts him in the right mood, he finds the class room a completive arena, thus the setting or milieu is conducive and helpful, this is becomes meaningful, and he’s motivated to succeed. Otherwise this young man is very unfocused, can hardly stay seated for his other subjects, talks out of turn, and without the right medication is failing everything else.
If there is one disorder in psychiatry, that is mostly neurological, or pure brain chemistry problem, more based on biology, and less on traditional mental health issues it is ADHD, uncomplicated by other psychiatric disorders. Because of this strong biological basis, medication treatment is often fixes most of not all of the problems, and little other treatment may be necessary, except some education for the patient and the family.
To have this good outcome with uncomplicated ADHD one must be sure that is what one is treating, by ruling out other disorders, and evaluating the severity of the symptoms.
First rule in the core symptoms, and then rule out the other disorders, the look alikes and those presentation with the severe symptoms than may not respond to simpler medication approaches which is usually a stimulant medication.
If this is done a stimulant medication many times by itself will correct the underlying brain chemistry problems that is believed to be the basis of the uncomplicated ADHD syndrome.
What are the major rule outs or ADHD look alikes? And What about the severity issues?
Extensive discussion about other diagnoses cant be discussed in this review, but I will attempt to give you a thumb nail outline of the highlights of the major pretenders.
Mood and anxiety disorders, especially a mood problem resembling a Bipolar disturbance or and agitated Unipolar type , and severe anxiety disorders, especially based on abuse, neglect, trauma especially of more subtle nature like a less obvious PTSD or Post Traumatic Stress Disorder and Attachment type disorders again the more subtle ones, should be on the top of ones list.
Less common but still near the top of ones list should be a thinking disorder, often mild and developing, similar to Schizophrenia.
It can not be stressed to many times or too empathically that uncomplicated ADHD should be relatively free of significant mood, anxiety and thinking disturbance, and less so of significant behavioral disturbance as seen in extreme aggressive and other impulse disorders and Antisocial and Conduct disorders.
What this means practically on a level anyone should understand, is that if the patient presents with too much, too frequent, too intense, too distressing and impairing mood swings, emotionality, rage attacks, fears, worries, inhibitions, rituals, sleep disturbance, illogical rapid thinking off on tangents, defects in conscience, impulse control and socialization leading to antisocial,/ conduct that is criminal/delinquent behaviors it is not likely uncomplicated ADHD and will not usually or for long respond to the usual medication approach, that is a stimulant medication.
If these other complicating factors are present usually a different and more complicated medication approach is needed.
Simply put if there are a lot of mood and anxiety symptoms present together with ADHD symptoms, then medicine that work more specifically for mood and anxiety are needed as the first line of therapy or together with ADHD medication. If this is not done the diagnostic-treatment-response cycle can get all messed up, and confuses both the treatment and diagnosis.
An example of this which is quite common is confusing a bipolar type of mood disorder with ADHD symptoms with uncomplicated ADHD because they share symptoms. In a sense a mood disorder
in the Bipolar Spectrum has an ADHD syndrome built in, and this may or may not be a separate disorder. The differential diagnosis of these two disorders can be difficult, and will be furthered discussed in the section on Complicated ADHD syndromes.
This point of wrong diagnosis and wrong treatment is so important I shall discuss it over and over to make the point over and over.
For the sake of illustrating the issue simply, a Bipolar Spectrum mood disorder besides having problems with mood shown by irritability, excitably, sadness, other defining symptoms include, distractibility, thoughtlessness or impulsivity, and a high activity level, that is over activity, sleep difficulties, grandiosity that is having big ideas, fast thinking, and very fast speech. One can see that the first three problems the distractibility, impulsivity, and over activity are core symptoms of ADHD, if one only focus on these, or has only found these symptoms in ones history taking, it is easy to conclude the person has ADHD, and start an ADHD medication.
Because of non specific responses of certain medications such as stimulants they may be initially helpful, which further confuses the picture, therapeutically and diagnostically. Stimulants the first line treatment for ADHD non specifically will treat the distractibility, impulsivity and hyperactivity in this ADHD look a like, which really has the diagnostic flavor more of a Bipolar Mood disorder, and like a patch on a inner tube may temporarily fix the problem, but like a patch may blow under enough pressure.
As this medication patch begins to leak, the presenting symptoms will re occur, and so the doctor, increases the medication and it may temporarily help again. This cycle can repeat itself over and over, until either the side effects of the medication become to great and you cant increase it any further, and or the stimulant in higher doses may actually on the biochemical level worsen all symptoms, as it is causing more and more negative effects such as decreased appetite, insomnia, irritability, emotional liability, or a zombied out, emotionally numbed out, the practitioner not aware of this keeps increasing the medication, and the cycle continues, in a kind of therapeutic tolerance which in reality shouldn’t occur. to the medication.
To add insult to injury, the stimulant medication which for uncomplicated ADHD would fix the moodiness and irritability associated with it, in the case of this mood disorder, may initially help thus mask the underling core symptom which is the mood issue, only to make it worse, and continue to hide it, thus confusing the diagnostic picture, and delaying proper therapy, and along the way may give the stimulant a bad name as the side effects predominate more and more. Thus ruining the reputation of a good medicine that if used for the right problem would cause little or no problems.
This complicated scenario which happens frequently can be avoided by proper diagnosis, education of the patient and or parent,, and appropriate treatment trials, following sound basic pharmacological principals that should be know both to the practitioner and the patient and their family, and re assessment of the evaluation-diagnosis,-treatment response cycle.
Let us assume one has followed the diagnostic criterion for ruling in ADHD, and further assume one has ruled out other diagnosis, these are two very big assumptions. You have further concluded the symptoms are not severe or extreme. Your working diagnosis is ADHD of the uncomplicated type. Now a treatment trial is in order.
The treatment trial like having a working diagnosis should be undertaken provisionally realizing it represents another scientific cycle of data gathering, evaluation, forming a working theory, testing the theory with a treatment, which depending on the response, gives us new data, and the cycle should repeat it self. All of this a continuing opportunity to educate the practitioner and the patient.
The treatment should be considered a trial, and one doesn’t know what to do next until one sees the treatment trial response. Also the trial helps clarifies the diagnostic process.
The treatment trial in Uncomplicated ADHD should usually begin with stimulant medication, unless there are medical contra indications, that is good reason why one shouldn’t. The good should far out weigh the bad, and first of all do no harm. Stimulants are the treatment of choice, the gold standard, a treatment that has stood the test of time, going back to the late 1930’s. A treatment so good, safe, effective little has changed in 70 years. What has change over the years is not the actual medicine so much but the delivery systems, taking oral medication that worked 3 to 5 hours and making formulations that now last approximately 8 to 12 hours, and a trans dermal, patch system that can last up to 24 hours.
There are other medicines that may help, such as certain antidepressant medications, medicines used for blood pressure, other psychiatric medications, when stimulants for what ever reason are not the first choice.
What all these medications have in common is their proposed method of action on brain chemistry that fits with the theoretical model of the defects in ADHD, which are primarily believed to be dopamine and less so norepinephine. Simply put not enough of these chemicals stay between the nerve cells in the brain so one can initially pay attention , get focused, and stay focused and continue to concentrate, with out over or under concentrating. This is believed to be the primary deficit in Attention Deficit Disorder, regardless of the subtype.
Whatever the proposed mechanism of action, stimulant medication are extremely effective and safe for uncomplicated ADHD. Usually within 30 minutes, once the right dose and medication is found, to one hour the effects are evident, with improvement of the core symptoms of concentration, impulsivity, and over activity, and less emotionality. Concomitantly one can then see improvement in compliance and learning both socially, experientially and academically. People start learning from experience, make less of the same mistakes over, and over, their grades go up, work output improves in quality and quantity, and they make less social mistakes due to impulsivity.
All stimulants are based on properties of the amphetamine molecule, and can be divided into amphetamine based, like Adderal and Dexedrine, or methylphenidate based, that is Ritalin, Metadate, Concerta ,Focalin, Daytrana transdermal patch. All are equally effective in studies thought individuals may have different responses , good and bad , based on their own unique brain chemistry. It is often wise if one gets a negative effect , or less then optimal effect with one product or formulation to do a trial with another.
Practically the medication works by helping the person slow down stop and concentrate and slow down stop and think, regardless of proposed mechanism of action. Practically the stimulants still stimulate, but they stimulate the brakes in the brain, and not the gas pedal. In a non ADHD person both the brakes and gas pedal would be stimulated and thus the development of tolerance and possible addiction, and many undesirable side effects. The ADHD brain in all most all cases dose not develop tolerance and if anything addiction is less likely. The ADHD brain develops hardly any undesirable negative effects especially of psychiatric nature, such as over stimulation, agitation, nervousness, elation, rebound depression, dysomnias, if the right medicine is chosen at the right dose.
What medicine do you choose and how is the dose regulated and adjusted?
ADHD is 24 hour a day 7 day a week problem so choosing a stimulant preparation that has a long duration of action may be your first choice. Three oral preparations have up to 12 hours duration , Adderal XR, Concerta, and Focalin XR, and the transdermal preparation the patch Daytrana was tested to last at least 12 hours but likely can last much longer maybe even 24 hours though not tested to do so.
The obvious advantage of these preparations is that once a day dosing in the morning is often sufficient, thus no need to remember to take a second dose, or in the case of a child having the school nurse ad mister a dose in the school setting. There is enough stigma and problems with compliance with ADHD without adding fuel to the fire by making the dosing more complicated than it need be or having other people who may not understand the problem and its treatment in control of medication administration.
There are a few shorter acting preparations, Dexedrine Spansule, Metadate CD, and Ritalin LA lasting about 8 hours. The short acting tablet forms of Focalin, Dexedrine, and Adderal, lasting about 4 to 6 hrs, and short acting methylphenidate or Ritalin lasting as little as 3 to 4 hours.
How is it adjusted? I refer you to section on general principals of medication management but to summarize and specifics you may need know about ADHD medication will follow.
Regardless of the medication a schedule should be initiated starting at a lowest dose of one of the longer acting medication and slowly increasing the dose as the patient tolerates. The reason to start low is twofold, one allow the brain to get used to the medication in a sense so there are little to no side effects , and too find low end responders. Low end responders are people who have good results with lower than expected doses of medication. If one starts a usual dose it may already be too high.
Depending on the practice and judgment of the prescriber the medication can be increased every few days or weekly depending on the response. In most cases there is no reason to go slower than that, because the effects of the medication are almost immediate, within an hour, and last only as long as the medication is designed to last about 4 to 12 hours.
The medication should be increased in steps until the optimal effect is achieved and the medicine is lasting the appropriate length of time. Within 30 minutes to 1 hour after the right dose is given one should see improved concentration, less impulsivity, and less hyperactivity up to 12 hours, or the expected length of duration of the medication with no or minimal side effects.
In a few days to a week the patient or the parent of the patient should be able to tell if concentration, activity level , impulsivity, excitability, and emotionality, is better , worse , or the same.
The negative effects or side effect at all points of the trial should be at he nuisance level and never be intolerable. If they are either the schedule is too fast, or it is the wrong medicine, wrong dose, or the wrong diagnosis. The treatment response should be neutral or helpful, and the negative effects should never outweigh the positive effects.
If the medication isn’t working or the negative effects are too great after adjustment of dosing either it is a case of ADHD that is not stimulant responsive, or it is not uncomplicated ADHD. The medicine should be stopped and the patient needs to be reevaluated.
Distress associated with the treatment should not be worse than that associated with the disorder.
In almost all cases of uncomplicated ADHD properly diagnosed , the treatment should fit like a hand and glove, a lock and a key, if it doesn’t something is wrong, and a re evaluation is needed.
Though most people do better on a longer acting agent, there are exceptions to that rule. The shorter action preparations the ones that last 3 to 6 hours, tend to cause more side effects, and compliance problems because of needing dosing every 3 to 6 hours. However the very peaks and valleys that these shorter acting medication have that result in negative effects, in others perhaps 5% of the population, are actually helpful to these individuals.
As with all unexpected or less common medication effects re evaluation after treatment response is the only way to know this, though family history may give a clue.
Stimulants have been traditionally only be used during the day for a few reasons, in some people the interfere with sleep and appetite, also some believer that the person only needs the medication for school or work, and not in the evening. However ADHD is a 24 hour 7 day a week problem in most people, and many people can benefit from dosing that would last all day and all night.
For example a child who has trouble settling down in the evening due to ADHD, and not other causes, thus has trouble falling asleep. Also this same child may have restless fragmented sleep all night, occasionally accompanied by night mares, bed wetting, and in the morning may be very hard to wake up. Once up this child may be so active, and defiant that getting the morning dose of medication in the child may be very difficult and near impossible. What is just described is not an uncommon scenario. If all of this is due to the same brain chemistry, that is causing ADHD, and its symptoms during the day, that are very medication responsive, it would make sense that using the medication around the clock would be logical and helpful. Why would one use other medications , one for sleep and nightmares, another for bedwetting, if one would do the job? What does one do? One does a medication trial in the evening to see what response one gets. For example if the child is on 20mg of some 12hour preparation at 7 am before school, one would give the same med at 7pm, thus giving 24 hr coverage, with resolution of the above problems. The solution for multiple problems that at first seem not to be related may be just this simple.
Another option for the ADHD person, who cant wind down, and has trouble falling asleep, is the use of medications called clonidine or guanfaciene that were originally developed for lowering blood pressure, but their action in the brain is to modulate norepinephine one of chemicals believed to be involved with ADHD, and yet can be tire ring or sedating, thus is ideal for initiating sleep, clonidine lasting about 4 hours, and guanfaciene lasting about 8 hours, thus more useful for maintaining sleep.
Occasionally clonidine or guanfaciene can be used during the day, to help with hyperactivity and impulsivity, and they may have a use for the worried anxious person who may also have motor tics or twitches, however these meds may have little direct effect on concentration so their use as first line or the primary medication for ADHD combined type may be quite limited. Also they are limited by safety issues, they can be lethal in overdose, and can be quite sedating and tire ring .
The use of antidepressants as first line treatment is limited by their effectiveness and their safety and side effect profile, the exception may be buproprion or Welbutrin, which on the biochemical level seems to work very much like a stimulant, working on both norepinephine and dopamine.
Amoxatene or Strattera, which works only on the norepinephine component in my hands has been much less effective, and has other side effects and metabolic concerns.
Side effects of medication, perhaps better called non therapeutic effects, need to be clarified and understood. What might be a negative effect for one might be therapeutic for someone else.
For the most part negative effects of the stimulants tend to be mild and transient, and the most common are decreased appetite, some trouble with initiating sleep, mild stomach and headache usually relieved if taken with food. A more troubling side effect is emotional lability or irritability, because it is a psychiatric side effect.
In general psychiatric side effects that is effects that may effect mood, emotions, thinking, perception, behavior require more attention and intervention especially fine tuning of the medication and the diagnostic process. This is essential to ensure diagnostic and therapeutic accuracy and compliance and a long term good out come.
Irritability or excessive emotionally is such an effect, and may represent many things in the ADHD person who is getting stimulant treatment.
1. It can be a symptom of ADHD thus more medication may be needed.
2. It can be an negative effect of the class of medicine, and less is needed.
3. It can be a negative effect of a specific med not class and new med in same class is tried
4. It can be symptom of an underlying mood disorder that needs its own med treatment
5. It may be a underlying trait like in some ODD, and this not medicine related
I am a firm believer that in modern psychiatric medication management if properly done, with the micro diagnosis as described above with the target of irritability as an example, and resultant fine tuning of the medication, most of the bad press and notoriety of psychiatric medication could be eliminated.