Thoughts On the Medical Treatment of ADD/ADHD: A Physician's Perspective

Human beings are rarely created in perfect form, so the great majority of us arrive in this world with unique differences. Some differences are blessings; others are handicaps. Poor vision, for example, is a common handicapping condition that affects millions of people throughout the world. I consider poor vision a condition of "human-ness." People can also have other conditions such as diabetes, asthma, thyroid conditions, ADHD, etc.--all well recognized differences that can impair the pursuit of a normal life if not dealt with in some manner.

ADHD is characterized by a prolonged history of inattention, impulsiveness, and variable amounts of hyperactivity. It is important to emphasize that all of these symptoms are normal human characteristics. All of us are forgetful and inattentive at times. We all at times become nervous and fidgety, and we certainly are impulsive to some degree. It's part of our "human-ness." ADHD, then, is not diagnosed by the mere presence of these normal and characteristic human behaviors, but from the DEGREE to which we manifest these symptoms. ADHD people have an overabundance of these normal human characteristics.

WHO SHOULD TAKE MEDICATION, AND WHY?

Returning to the vision analogy, there are a number of options open to an individual who has bad eyesight. One option is to attempt to correct the problem. This could involve wearing glasses to correct the visual deficiency. Perhaps glasses can totally correct the problem, or perhaps they can only partially help. After the glasses are in place, we are in a position to assess what further problems are interfering with success. Then we can address these issues as well.

ADHD is a medical condition. Dr. Alan Zametkin has clearly demonstrated that there is something uniquely different about the metabolism of the brain affected by ADHD. If a person meets the criteria for a diagnosis of ADHD and is not succeeding academically or socially up to expectations, medication should be a PRIMARY OPTION of therapeutic intervention. The opportunity to eliminate the symptoms- toms of a medical condition partially or completely should be available to all. Many children benefit enormously from the use of medication. Many families who understand ADHD and its clinical manifestations prefer to try medication as a PART of their treatment plan. As many as 80% of individuals will show a positive response to one of the medical treatments.

Since it is impossible to determine who will respond favorably to medication, I always offer a trial of medication to each diagnosed patient. If medication will help alleviate the symptoms and does not elicit any unfavorable effects, then the patient may choose to utilize medication as one part of therapy for ADHD.

WHAT IMPROVEMENT SHOULD BE SEEN?

In the early 1930's, Dr. Charles Bradley noted some dramatic effects of stimulant medications on patients with behavior and learning disorders. He found that the use of stimulants "normalized" many of the systems that we use for successful living. People on medication IMPROVED their attention span, concentration, memory, motor coordination, mood, and on-task behavior. At the same time they DECREASED daydreaming, hyper- activity, anger, immature behavior, defiance, oppositional behavior. It was evident that medical treatment allowed intellectual capabilities that were already present to function more appropriately. When medication is used appropriately, patients notice a significant
improvement in control. Objective observers should notice better control of focus, concentration, attending skills, and task completion. Many children are able to cope with stress more appropriately, with fewer temper outbursts, less anger, and better compliance. They relate and interact better with siblings and friends. Less restlessness, motor activity and impulsiveness are noted.

It is very important to remember what medicine does and does not do. Using medication is like putting on glasses. It enables the system to function more appropriately. Glasses do not make you behave, write a term paper, or even get up in the morning. They allow your eyes to function more normally IF YOU CHOOSE to open them. YOU are still in charge of your vision. Whether you open your eyes or not, and what you choose to look at, are controlled by you. Medication allows your nervous system to send its chemical messages more efficiently, and thus allows your skills and knowledge to function more normally. Medication does not provide skills or motivation to perform. ADHD individuals often complain of forgotten appointments, incomplete homework, miscopied assignments, frequent arguments with siblings and parents, excessive activity, and impulsive behaviors. With medication, many of these problems dramatically improve. Patients successfully treated with medication typically can go to bed at night and find that most of the day went the way they had planned.

WHO SHOULD PRESCRIBE MEDICATIONS?

Medications can be prescribed by a licensed physician only. This person may serve as a coordinator to assist with the multiple therapies often needed, such as educational advocacy, counseling, parent training, and social skill assistance. Parents and adults should look for a physician who has a special interest and knowledge in dealing with ADHD individuals.

MEDICAL TRIALS

It is necessary to establish a team for an appropriate evaluation of the medication trial. I gather information from sources who spend time with my patients. This might include parents, teachers, spouses, friends, co-workers, grandparents, tutors, piano teachers, coaches, etc. As gradually increasing dosages are administered, input is gathered from these observers. Various rating scales are available to assist in gathering factual data. However, the true assessment is whether the ADHD patient's quality of success in life has improved. For this information, I find no scale takes the place of conversations with observers.

When evaluating patients during a trial of medication, I will treat them throughout the day, seven days a week. Treating them only at school or only at work is totally inadequate. I need all involved observers, assisting in the evaluation process. Furthermore, I want to know if treatment has an effect on non- academic issues. After the trial of medication, if positive results are evident, then the family and/or the patient can make informed decisions as to when the medication is helpful. Many patients find the medication is helpful throughout all waking hours. Others may need it only during certain times of the day.

WHAT IS THE CORRECT MEDICATION?

At the present stage of medical knowledge, there is not a method of predicting which medication will be most helpful for any individual. At best, physicians can make educated decisions based on information about success rates with individual medications. In general, a large percentage of patients will respond favorably to Ritalin or Dexedrine, and one of these is usually my first choice. If one stimulant does not work effectively, the others should be tried, for experience has proven that individuals may respond quite differently to each one. Many patients respond remarkably well to imipramine or desipramine, and some physicians feel this group of medications is under used. Each family and physician must be willing to try different medications in order to determine the best and most effective therapy. This is the only way to find the appropriate treatment modality. In some patients who have multiple diagnoses such as ADHD and depression, or ADHD and oppositional-defiant disorder, or ADHD and Tourette Syndrome, combinations of drugs are being successfully utilized for treatment.

WHAT IS THE CORRECT DOSE?

If medications work, there is a best dose for each individual. Unfortunately, medical knowledge is not at a point where it can predict what the correct dose will be. This is not an unusual circumstance in medicine, however. For a person with diabetes, we must try different forms and amounts of insulin to achieve the best control of blood sugar levels. For people with high blood pressure, there are many medications that can be effective, and often a trial of multiple medications and dosages is needed to determine the best treatment. For ADHD medications, there is no magic formula. The dose cannot be determined by age, body weight, or severity of symptoms.

In fact, it appears that the correct dose is extremely individual and is not really predictable. Again, similar to people who need glasses, the kind of prescription and the thickness of the lenses is not dependent on any measurable parameter other than what you say enables you to see well. The dose of medication is determined solely by what ADHD patients need to improve their symptoms. You must be willing to experiment with carefully observed dosage changes to determine your child's correct dosage. Once the correct dosage is determined, it does not seem to change significantly with age or growth. Medication continues to work effectively through the teenage years and into adulthood if needed.

SUMMARY

Individuals with ADHD will present with a variety of well-defined symptoms and behaviors. Medication may be extremely helpful in alleviating some of these symptoms and will make the other forms of accompanying therapies much more meaningful and effective. Families must be willing to work closely with their physician to identify the correct medications and establish the best dosage levels.

MEDICATIONS: OVERVIEW

RITALIN TABLETS (methylphenidate)

Form: Short acting tablets administered by mouth. Ritalin 5 mg, 10 mg, 20 mg Dosage: Very individual. Average 5 mg - 20 mg every 4 hours. I prescribe 5 mg to start and raise by 5 mg every 4-5 days with close observation until correct dose is achieved. Duration of Action: Rapid acting Ritalin starts to work in 15-20 minutes, which is extremely helpful for the child who has trouble starting his day, Some children will need medication 20 minutes BEFORE time to get up. It will last about 3'/24 hours, and so the effective dosage will need to be repeated every 31/2-4 hours to maintain positive effects during the waking hours. By virtue of its short action, Ritalin is discontinued every night and must be restarted each morning. Effects: Ritalin is one of the best and most dependable medications for treatment of ADHD symptoms. It specifically improves concentration, memory, and control of frustration and anger. Possible Side Effects: Moderate appetite suppression, mild sleep disturbances, transient weight loss, irritability, motor ties may occur if dose is too high (will disappear on lower dose). (Patients with Tourette Syndrome -- if Ritalin makes ties worse, discontinue. In some Tourette patients, ties decrease on stimulants.) Overdose effects with stimulants: depression, lethargy, "loss of spark." If this occurs, lower the dose. Pros: Excellent safety record. Very easy to use and evaluate. Very specific control of medication timing. Most dramatic improvement for many individuals. May be used with most other commonly used medications. Cons: Must be administered frequently during the day. Inconvenient to use at school. May experience moderate rebound reaction -- anger, frustration, temper when medication wears off. Possible roller coaster effect during the day as medication level fluctuates.

RITALIN SR 20 (methylphenidate sustained release)

Form: Long acting tablets administered by mouth. Ritalin SR 20. Dosage: Very individual. Two to three tablets may be needed. I use it primarily in conjunction with regular Ritalin to smooth out peaks and valleys and prevent rebound. I give 1/2-1 tablet of Ritalin SR 20 with each dose of regular Ritalin. Duration of Action: Long acting, about 6-8 hours. BE AWARE -- although called SR20 it actually appears to release only 5-7 mg of medication (not 20 mg) over 6-8 hours. Effects: Same as Ritalin tablets. Possible Side Effects: Same as Ritalin. Pros: Excellent safety record. May be most effective when used in conjunction with regular Ritalin. Tends to smooth out the peaks and valleys of regular tablets. Given with regular Ritalin 15-20 minutes before the child gets out of bed in the morning, it will prolong the positive effect of regular Ritalin to five hours (the lunch hour). Cons: Does not always work in a predictable fashion, and sometimes not at all.

DEXEDRINE SPANSULES (dextroamphetamine)

Form: Long acting, administered by mouth, Dexedrine Spansules 5, 10, 15 mg. Dosage: Very individual: Average is 5-20 mg. Duration of Action: Very individual. May take 1-2 hours to be effective. Usually lasts 6-8 hours. In some it may be effective all day. In others it may only last four hours. Effects: Same as Ritalin. Possible Side Effects: Same as Ritalin. Pros: Excellent safety record. May be the best drug for some individuals: longer acting, smoother course of action. May avoid lunch time dose at school. Cons: Slow onset of action. Remember, it takes 1-2 hours to work and may require a short-acting dose at first in the AM to start the day.

DEXEDRINE TABLETS (dextroamphetamine)

Form: Short-acting tablets administered by mouth. Dexedrine tablets 5 mg. Dosage: Very individual: Average 1-3 tablets each dose. Duration of Action: Rapid onset of action 20-30 minutes. Lasts 4 hours. Effects: Same as Ritalin. Possible Side Effects: Same as Ritalin Pros: Excellent safety record. Rapid acting. Some patients who do well on Dexedrine prefer the tablets over the Spansules. The more rapid rate of onset is apparently more effective for these individuals. Cons: Same as Ritalin.

CYLERT (pemoline)

Form: Long-acting tablets administered by mouth. Cylert 37.5, 75 mg. Dosage: Very individual. Duration of Action: Slow onset of action, thought to be a medication that will last all day, but in most cases lasts 6-8 hours. Effects: Same as Ritalin Possible Side Effects: Same as Ritalin. However, has been known to cause mild liver damage. Pros: Long acting, may eliminate lunch dose. Cons: Not as safe as the other stimulants. Would only use if other stimulants are not effective. Should NEVER be first drug of choice. Has caused hepatitis and death. Must do liver function blood test every six months.

TOFRANIL and NORPRAMINE (imipramine and desipramine)

Form: Tablets administered by mouth. 10, 25, 50, and 100 mg tablets. Dosage: Very individual. I start with a low dose 10-25 mg, and raise slowly as needed. Duration of Action: Variable. Often has a 24-hour effect, and therefore can be administered at night. Some patients prefer to split the dose and take every 12 hours. Effects: Often relatively low doses can improve ADHD symptoms within a few days, but may take 1-3 weeks for full effect. Higher doses may improve depression symptoms and mood swings, which are often seen in ADHD individuals. Possible Side Effects: Nervousness, sleep problems, tiredness, and upset stomach, dizziness, dry mouth, unusually fast heart rate. May affect conduction time of the heart, leading to irregular heart rate. May affect blood count (rare). Pros: Often works when stimulant medications are not helpful, and may be the drug of choice for many individuals. Prolonged duration eliminates school dose. Smoother course of action. Often helps with mood swings and depression. May be used in conjunction with stimulant medications. Cons: Can affect the heart conduction rate, therefore requires an EKG prior to the medication trial and after treatment level has been established. Can affect the blood count, therefore requires a complete blood count with all illnesses. Need to be careful when taking other medications. Consult doctor for list of medications to avoid. Medication needs to be increased and decreased gradually. Should not start and stop abruptly.

CLONIDINE (catapres)

Form: Patches applied to back of shoulder. Catapres TTS-1, TTS-2, TTS-3 (expensive). Tablets administered by mouth. Catapres tablets--1 mg., 2 mg., 3 mg. (low price) Duration of Action: Patches will last 5-6 days. Tablets are short acting, last 4-6 hours. Effects: Often will improve ADHD symptoms, although not always as dramatically as Ritalin. Decreases facial and vocal ties in Tourette Syndrome. Often has a dramatic positive effect on oppositional defiant behavior and anger management. Possible Side Effects: Major side effect is tiredness, particularly if raised too quickly. Will normally disappear with time. Some patients may notice dizziness, dry mouth. Some will notice increased activity, irritability, conduct disorder and should discontinue the medication. Pros: Excellent delivery system if patch is used. No pills required. Frequent positive effect on oppositional defiant behavior, and obsessive compulsive behavior. Does not effect sleep or appetite. Positive effect on tic behavior. Cons: Does not usually work as well as Ritalin for ADHD symptoms. Patch causes skin irritation in many and cannot be tolerated.

ADDERALL (four amphetamine salts)

Form: Long-acting tablets: 10 mg and 20 mg Dosage: Very individual, usually between 5 mg and 20 mg, once or twice a day Duration of Action: Usually last 6-12 hours. May be given once or twice a day, depending on length of therapeutic effect. Duration of effect varies from person to person. Effects: Same as Ritalin Possible Side Effects: Less affect on sleep, appetite, growth and rebound. No roller coaster effect. Pros: Only needs to be given once or twice a day, often fewer side effects. Very nice medication when effective. Cons: Does not work well for everybody. Relatively new on the market and not much clinical experience at this time.

WELLBUTRIN (bupropion hcl)

Form: 75 mg (yellow-gold) 100 mg (red) Dosage: 75-300 mg daily (average) in three divided doses Duration of Action: Long acting medication (half-life of 24 hours) Effects: A few studies suggest improvement in ADHD. In general, not as good as stimulants. Very helpful in conjunction with stimulants for depression. Possible Side Effects: Can cause seizures (1/4000) if dose STARTED too rapidly. Raise dose slowly. Cannot use if seizure disorder is present. May cause dry mouth, anorexia, rash, sweating, tremors, tinnitus Pros: Very good medication to use for treatment of depression Cons: Very little evidence that it is helpful for ADHD. Studies are still in progress.

WELLBUTRIN SR (bupropion hcl long-acting)

Form: 100 mg (blue) 150 mg (purple) Dosage: 100-150 mg twice a day Duration of Action: Effective for over 24 hours Effects, Possible Side Effect, Pros, Cons: Same as Wellbutrin

Dr. Mandelkorn trained in pediatrics and adolescent medicine and was a mental health fellow under Dr. Michael Rothenberg. An adult with ADHD who has a son with ADHD, Dr. Mandelkorn specializes in the diagnosis and treatment of ADHD in children and adolescents. He maintains a private practice in Mercer Island, Washington. His ADHD clinic presently follows over 600 children with ADHD. Dr. Mandelkorn lectures nationwide about management.

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