Medication is often an important ADD treatment option to consider. There is clearly a biological component to ADD, and medication is one of the biological options for treatment. Sometimes the other biological therapies discussed (supplements, neurofeedback, exercise, etc.) can replace the need for medication, but sometimes medication can be lifesaving. I think optimal brain function is the goal, not whether to be on or off medication.
Whenever medication is started or considered, it’s essential to have clear goals in mind for its use. Some examples of ADD medication treatment goals include:
Medication needs to be targeted to each individual ADD type. The wrong medication can make things worse; ineffective treatment is not innocuous. When treatments fail, individuals and families get discouraged. The discouragement leads to discontinuation of treatment. The earlier treatment is effective, the more people are willing to follow through with treatment.
Stimulants are the first-line medications for treating Type 1 and Type 2 ADD. Our current understanding of these medications is that they increase dopamine output from the basal ganglia and increase activity in the prefrontal cortex and temporal lobes. Here is a table that highlights the current available stimulant medications:
It is essential not to take stimulants with citrus juices (orange, grapefruit, lemon) or anything with citric acid in it (read the labels: citric acid is used in many things as a preservative). It tends to lessen the effect of medication. Likewise, decrease caffeine intake when taking a stimulant. Caffeine and stimulants together tend to overstimulate the nervous system.
|
Generic name |
Brand name |
Side Effects |
Notes |
|
Amphetamine and amphetamine salt combinations |
Dexedrine (regular/sustained release SR), Adderall (regular/SR), Vyvanse (SR) |
Some loss of appetite, weight loss, sleep problems, irritability, tics. Short-acting meds may need to be given frequently and have more rebound effect. Long-acting medicines are convenient but may have greater effects on appetite and sleep. |
Adderall is my personal favorite because it lasts longer than Ritalin and is gentler as it wears off. Also, the tablets are double scored. This makes it easy to quarter them and fine-tune the dose. |
|
Methylphenidate-based products |
Ritalin (regular/SR), Concerta (SR), Focalin (regular/SR), Metadaet (regular/SR), Methylin (regular/SR), Ouillivant (SR), Daytrana Patch (SR) |
Some loss of appetite, weight loss, sleep problems, irritability, tics. Short acting meds may need to be given frequently and have more rebound effect. Long-acting medicines are convenient but may have greater effects on appetite and sleep. |
Watch for rebound when it wears off with the short-acting products. |
Here is a list of common questions about stimulant medications in general.
1. What are the indications for stimulant medications?
Stimulant medications have several uses in medicine. Most commonly, they are prescribed for ADD. They are also used for narcolepsy (sudden sleep attacks); as an adjunctive treatment for depression; in chronic obesity; and to help thinking, concentration problems, and appetite problems in the elderly.
2. How can stimulant medications help?
They can improve attention span, decrease distractibility, increase ability to finish tasks, improve ability to follow directions, decrease hyperactivity and restlessness, and lessen impulsivity. Handwriting often improves with this medication. Schoolwork, homework, and overall work performance often improves significantly. Improved listening and communication skills often occur, along with a decrease in stimulation or conflict-seeking behaviors.
3. How long does the medication last? What is the usual dosage?
Ritalin and Dexedrine usually last three to four hours, but in some people they last as little as two and a half hours or as long as six hours. There are also slow-release preparations that last six to twelve hours and may help you or your child avoid taking a late morning or noontime dose. The slow-release form of Ritalin has a reputation for being somewhat erratic. For some people, it works great, for others, not so good. Often you just have to try it to see. The slow-release form of Dexedrine, Adderall, and Vyvanse seem to be somewhat more reliable.
In addition to weekday morning doses, I usually prescribe medication for my patients in the afternoon and on weekends. During those times, people with ADD still need to do work, homework, or housework and interact with other people.
Everyone is different in his or her need for medication. Some people need small doses of stimulant medication twice a day; some need it four or five times a day. Others need larger doses of stimulants. I have found that response often does not correlate with body weight or age. Trial, supervision, and observation are the keys to finding the right dose.
4. How will the doctor monitor the medication?
In my practice, I initially see patients every couple of weeks until we find the right medication and dosage. During appointments I ask about progress (at home, school, and work) and check for any side effects of the medication. I’ll keep a check on weight and height and occasionally check blood pressure. In addition, I often ask teachers to fill out follow-up rating scales to see the effectiveness of the medication. For adults, I often ask that their spouses come to the appointments so that I can get another opinion on the patients’ progress.
5. What side effects can these medications have?
Any medication can have side effects, including allergies to the medication (usually exhibited by a rash). Because each patient is different, it is important to work together with your physician to find the best medication with the least amount of side effects. The following list may not include rare or unusual side effects. Talk to your doctor if you or your child experiences anything different after starting the medication.
Common Side Effects
As the medication wears off, there may be a rebound effect where the hyperactivity or moodiness becomes worse than before the medication was started. Dosage adjustment usually helps rebound.
Lack of appetite. Encourage a good breakfast, and afternoon and evening snacks; give medication after meals, rather than before. Some children and teens become hungry near bedtime. Unfortunately, some parents think that the child’s hunger is no more than a manipulative ploy to stay up later, and they engage the child or teen in a battle. The medication really does affect appetite. If the child or teen is hungry later on and they did not have much to eat at dinner, it is often a good idea to give them a late evening meal or snack. For some people, a lack of appetite is a significant problem and the medication may need to be changed or adjusted. Some of my patients use nutritional supplements to make sure they get enough calories and nutrients.
Trouble falling asleep. Some people experience insomnia. If they do, I either give them a lower dose in the late afternoon or eliminate the last dose. In cases where there are problems when the last dose is eliminated, I may try giving a small dose of the stimulant right before bedtime. This works especially well for the hyperactive group. The medication settles them down so that they can go to sleep. Typically I will try this on a Friday night the first time to make sure it doesn’t keep someone up all night. For insomnia, I often recommend a concoction of 6 ounces of warm milk with a tablespoon of vanilla and a tablespoon of sugar or honey. This seems to have a nice sedating effect for many people. I also use melatonin or our Restful Sleep preparation.
Headaches or stomachaches. Patients may complain of headaches or stomachaches. These typically go away after several weeks. Acetaminophen or ibuprofen can be helpful for the headaches; taking the medication with food often decreases the stomach problems.
Irritability, crankiness, crying, emotional sensitivity, staring into space, loss of interest in friends. Some patients experience moodiness and minor personality changes. These side effects often go away in a week or two. If they don’t, the medication often needs to be changed. Sometimes Wellbutrin or Strattera is a good option when this occurs.
Less Common Side Effects
Tics. Some patients develop tics (such as eye blinking, throat clearing, head jerking) on the medication. If that happens, it is important to discuss it with your doctor. Sometimes the tics go away on their own; sometimes higher doses of the medication may improve the tics; and sometimes the medication has to be stopped. If the stimulant is very helpful, I might add another medication (such as clonidine) along with the stimulant to help with the tics.
A complicating factor with tics is that a high percentage of patients with tic disorders, such as Gilles de la Tourette’s Syndrome (manifested by having both motor and vocal tics), have ADD. Sometimes it is hard to know if the medication caused the tics or if the tics were already present but worsened by the medication.
Slowed growth. There used to be a concern about stimulants stunting growth, but the long-term studies show that even though they may slow growth for a period of about a year, in the long run children usually catch up to where they should be.
Rapid pulse or increased blood pressure. If a patient notices chest pain or a heart flutter, it is important to notify the physician.
Nervous habits. Picking at the skin, stuttering, and hair pulling can sometimes occur with these medications.
Keep in mind that the side effects of having untreated ADD are usually worse that those caused by the medication.
6. What could happen if this medication is stopped suddenly?
There are no medical problems due to stopping the medication suddenly. A few people may experience irritability, moodiness, trouble sleeping, or increased hyperactivity for a few days if they have been on daily medication for a long time. Often it is better to stop the medication gradually over time (a week or so).
7. How long will the medication be needed?
There is no way to know how long a person may need to take the medication. The patient, doctor, parent, teacher, and spouse need to work together to find out what is right for each person. Sometimes the medication is only needed for a few years, sometimes it is needed for many years.
8. Does this medication interact with other medications?
It is a good idea to check with your doctor before mixing any prescription medications. Make sure he or she knows every medication—including over-the-counter preparations and dietary supplements—that you are taking. When stimulants are used with tricyclic antidepressants, an occasional side effect may occur, such as confusion, irritability, hallucinations, or emotional outbursts. Sometimes, however, combining stimulants with antidepressants can be a powerfully positive combination. I have done this in many patients without bad effects, but remember, everyone is different.
It is not a good idea to combine stimulants with nasal decongestants (such as medications that contain pseudoephedrine or related medications), because rapid pulse or high blood pressure may develop. If nasal decongestion is severe, it is better to use a nasal spray.
Many patients with ADD may become cranky or more hyperactive on antihistamines, such as Benadryl. If medicine for allergies is needed, ask for one of the antihistamines that does not enter the brain, such as Hismanal. Check with the pharmacist before taking over-the-counter medication with stimulants.
9. Does this medication stop working at puberty?
Not usually. For most people it continues to work into adulthood. If it does lose its effectiveness, the dose may need to be increased; alternately, switching to another stimulant may be helpful. However, for the vast majority of people with ADD, medication does not stop working at puberty.
10. Why does this medication require a special prescription? (This information varies from state to state)
Stimulants sometimes require special prescriptions for controlled substances that must be filled within a certain period of time. Some adults have been known to abuse stimulants, so caution is always advised. In my experience, children who are adequately treated for ADD have a lower percentage of drug abuse as teenagers and adults than those kids with ADD who were never treated with medication.
11. What if my child or I have problems remembering to take the medication?
Remembering to take medication three times a day can be difficult, even for people who do not have ADD. Forgetfulness is a common symptom of ADD, and when the medication has worn off, the person is fully ADD again. If forgetfulness is a chronic problem, don’t assign blame or be upset. Look for solutions. Here are two I recommend: try switching to a slow release form of the medication, or get an alarm system (such as a digital watch that has five alarms) to help you remember.
12. What about the negative news media reports on these medications?
It is critical to get your medical information from your doctor, not solely from the media that often reports only sensational findings. Many people have erroneous ideas about stimulant medication. If you hear things that worry you, check with your doctor before making any decisions.
For a period of a year, I kept a log of comments my patients told me after I started them on stimulant medication for Type 1 and 2 ADD. Here is a brief sample from the log.
“I experienced an increased awareness of the world around me. I saw the hills for the first time when driving to work. I saw the bay when I crossed over the bridge. I actually noticed the color of the sky!”
“A dramatic difference! I am really amazed.”
“I experienced a 180-degree difference in my attitude.”
“I left your office a skeptic. I came back converted.”
“My husband said he doesn’t have a knot in his stomach anymore.”
“I look at my children and say ‘Aren’t they cute,’ rather than complaining about them.”
“I could enjoy the moment. My thoughts are calmer, quieter, easier to live with.”
“I could sit and watch a movie for the first time in my life.”
“I am able to handle situations where I used to be hysterical. I am able to see when I’m starting to overreact.”
“The lens on my life is much clearer.”
“I was tremendously overscheduled. No sane person would do that!”
“It amazes me that a little yellow pill [5 milligrams of Ritalin] can take me from wanting to jump off the bridge to loving my husband and enjoying my children.”
“It is like being given sight!”
“I’m not running at train-wreck speed.”
“For the first time I felt in charge of my life.”
“I’m better able to keep things in perspective.”
“I used to think I was stupid. It seemed everyone else could do more things than me. I’m starting to believe that there may be intelligent life in my body.”
“My appetite is more normal.”
“I sleep much better. Can you believe I’m taking a stimulant and it calms me down?”
“I’m out of the damned black hole I was in.”
“I used to be the kind of person who would go walking by myself in downtown Detroit at 2 A.M. Now on the medication I would never do something so stupid. Before, I just wouldn’t think about the consequences.”
“Now I can give talks in front of groups. Before, my mind would always go blank. I organized my life around not speaking in public. Now my brain feels calmer, clearer.”
“I feel like I think everyone else feels.”
“I’m not as intimidated by others like I used to be.”
“My husband may not be as happy as before I was on medication. Now I can think and he doesn’t win all of the arguments. I’m going to have to retrain him to not always expect to get his way.”
“I’m not losing my temper.”
“It’s like waking up after being asleep your whole life.”
“Night and day!”
“I feel totally in control of my life.”
“Six months ago there was no way I would drive on L.A. Freeways. Now I can drive on them no problem.”
“I can’t stand useless confrontation when I used to thrive on it!”
When stimulant medications do not appear to work for Type 1 or 2 ADD I may try a medication such as Strattera, Provigil, Wellbutrin (the stimulating antidepressant medication listed under Type 5 Limbic ADD), or one of several blood pressure medications, such as clonidine or guanfacine. The blood pressure medications have been found to be helpful for hyperactivity, aggressiveness, and impulsivity. They are not usually helpful with the attentional symptoms. Mixing them with a stimulant medication can produce excellent results.
Clonidine and guanfacine are also used as primary treatments for tic disorders such as Gilles de la Tourette’s Syndrome. When I use clonidine in addition to a stimulant medication I will order a screening EKG. There have been several reports that this combination may cause problems, even though personally I have found it to be an effective, safe combination. These medications have also been used to treat insomnia, which is very common in ADD.
Type 3 (Overfocused) ADD is most likely due to a deficiency of both serotonin and dopamine. Medication interventions need to be targeted at enhancing both of these neurotransmitters. If one neurotransmitter is enhanced by itself it may make this type worse. For example, when stimulant medications are given to people with Type 3 (Overfocused) ADD, they often become overstimulated and stuck on certain issues. In addition, they tend to be anxious and worried. Serotonin medications by themselves (such as Prozac or Zoloft) tend to help with the overfocus but eventually cause more problems with focus and motivation. A balance is needed.
Effexor, Pristique, and Cymbalta are my first drugs of choice for Type 3 (Overfocused) ADD. They increase serotonin (helping to shift attention) and norepinephrine and dopamine (stimulating neurotransmitters). Often they can be used alone without the need for a stimulant medication. When these medications are ineffective or not well-tolerated I often prescribe an SSRI (selective serotonin reuptake inhibitor). These medications only increase serotonin availability in the brain so I often need to add a stimulant medication like Adderall to fully treat this type of ADD.
In our experience, people who have temporal lobe problems may experience an increase in angry or aggressive feelings on serotonin enhancing medications and even supplements. Therefore, we are careful to screen for these before placing someone on these medications. If there are side effects on any medication, it is important to contact your doctor and discuss them. Unlike stimulants, these may take several weeks to a month to be effective and even three to four months to see the best benefit.
The medications used to treat Type 4 (Temporal Lobe) ADD are classified as anticonvulsant medications. We have seen that they are good at stabilizing temporal lobe activity and they tend to significantly help symptoms of aggression, mood instability, headaches, and in some cases learning problems. Treating Type 4 ADD often involves combining them with a stimulant medication. Even though these medications are classified as anticonvulsant or antiseizure medications, we are not saying that Type 4 patients have a seizure disorder. Rather, they have dysfunction in a part of the brain commonly associated with seizures. In treating ADD, we often use much lower doses than used to combat seizures. Sometimes even very small doses are all that is necessary. Anticonvulsants strive to enhance the neurotransmitter, GABA, which has a calming or inhibitory effect on nerve cells. In the last twenty years, psychiatry has come around to using these medications for many different conditions. Anticonvulsants are almost equally prescribed by psychiatrists and neurologists.
Typically, I tend to prescribe Neurontin for anxiety, irritability, and pain; Lamictal for resistant depression; and Depakote or Tegretol for aggression.
In addition to anticonvulsants, I often use memory-enhancing medication for people with temporal lobe problems. Memory problems are very common in this ADD type. Donepezil (Aricept) is a medication indicated for Alzheimer’s disease that works by increasing the amounts of acetylcholine in the brain. Acetylcholine is a neurotransmitter that is known to be involved in laying down new memories. I have seen this medication be very helpful for many patients with Type 4 (Temporal Lobe) ADD. One woman wrote me that after she took Aricept it was like going from 4 megabytes of RAM in her head to 128 megabytes. In addition, Piracetam, a medication that is difficult to obtain in the U.S., but not in Europe or Canada, has been shown in a number of studies to help memory. A number of my patients through the years have written away for it and found it beneficial without side effects. Mark, a seventeen-year-old patient with learning disabilities stemming from memory problems, was placed on Piracetam. In three weeks he noticed that he felt that he was mentally clearer and his memory was better. His school performance improvement has lasted for the three years that he has taken Piracetam.
Wellbutrin is my favorite medication for Type 5 (Limbic) ADD. Researchers think it works by increasing dopamine. It has also been found to be effective in helping people stop smoking. When Wellbutrin was first released in the United States, a number of people developed seizures on it. It was then pulled from the market in the early 1980s. The manufacturer figured out the dosage pattern was wrong and the FDA allowed them to rerelease it with a different dosage regimen. Do not take more than 150 milligrams at a time of the regular release preparation or 300 milligrams of the slow release preparation. Imipramine is another option for this type. I also use it for anxiety disorders and bedwetting.
I typically start with supplements for this type, usually a combination of GABA, 5HTP and L-tyrosine. If I prescribe medication I typically start with one of the anticonvulsants listed under Type 4 ADD, and may add a stimulant medication later on. Stimulants by themselves often make this type worse. When used alone, serotonergic medication also seem to make this type worse. If the anticonvulsants do not seem to work, I may very cautiously use one of the novel antipsychotic medications, such as Risperdal. Often the dosages of the anticonvulsants or antipsychotic medications are much smaller than needed for seizure disorders or psychotic illnesses. In selected cases, the antipsychotic medications can be very effective. Some of my teenage patients have been kept out of the hospital or residential treatment centers using these medications. However, one of the problems with these medications is weight gain. I have a number of patients who have gained twenty to thirty pounds in less than a year. The amazing response to the medication is the only reason I persisted with the medication. The anticonvulsant Topamax is known to promote weight loss in some patients and I have used it successfully in some of my Ring of Fire patients. The blood pressure medicines guanfacine and clonidine can also be helpful. These tend to calm overall hyperactivity seen in this type.
For this type I like to presbribe the tricyclic antidepressants imipramine or desipramine, both of which have been shown to be helpful for anxiety symptoms, depression, and ADD. I have also successfully used Neurontin plus a stimulant to help this group.
Sometimes a combination of medications is needed to obtain the full therapeutic effect. I particularly like the combination of stimulants and antiobsessive medications for children of alcoholics. Sometimes a person may have three or four different subtypes of ADD and may be on a sophisticated combination of medications. If that is the case for you, I recommend an evaluation by a specialist in the field.
REMEMBER:
The goal needs to be the best functioning, not to be off medication!
Many people have the misguided belief that it is better if they only take a “little bit” of the medication. Often this attitude causes the medication to be ineffective. I give patients the following metaphor:
When a person goes to the eye doctor because he or she is having trouble seeing, they want a prescription for the glasses that will help them see the best. They don’t ask for “just a little bit of a lens.” They want to see clearly!
So it is with ADD: Everyone is different in the quantity of medication they require to function at their best. For some people, it is 5 milligrams of Adderall one to two times a day. For others, it is 20 milligrams of Adderall three times a day. Everyone is different.
Many of my patients are rightfully concerned about the side effects of medication for ADD, as they should be. It is also important to ask yourself about the side effects of not being effectively treated. Given all we know about the poor outcomes of people who have never been treated or only received ineffective treatment for ADD, it is worth asking. My bias is to start with supplements if possible, but when they are only partially effective or ineffective, medications are worth considering.