Optimal Treatment of ADHD

The best outcome for individuals with ADHD includes a combined treatment of therapies and once-a-day medication, according to David W. Goodman, MD, assistant professor of psychiatry and behavioral sciences at John Hopkins University School of Medicine and Director of the Adult Attention Deficit Disorder Center of Maryland. Dr. Goodman provides a helpful pneumonic for remembering the important aspects of treatment – DEEP.

D - Diagnosis

Diagnosis is the first step in the treatment process. Once an individual is diagnosed, he can begin to make changes in his life through education, environmental changes, pharmacotherapy and psychotherapy.

E - Education

An important part of treatment is gaining knowledge and an understanding about what ADHD is – and what it is not. Medical research validates the fact that ADHD is a neurological condition. It is not a function of poor character, low IQ, poor motivation or bad parenting. This information relieves individuals of the burden of being self-critical and feeling lazy or stupid.

E - Environmental Change

An individual with ADHD can benefit from structuring and implementing organizational techniques to his daily environment - the household, work space, etc. Click on Tips for Organizing the ADHD Household and Strategies for Success in the Workplace to learn more.

P - Pharmacotherapy and Psychotherapy

Pharmacotherapy, or medication, is an important part of the treatment process. Stimulants are the most commonly used drugs to treat ADD/ADHD in adults and children. These medicines can improve attention span and concentration, as well as decrease hyperactivity, restlessness and impulsivity. The stimulants are broken down into two categories – methylphenidates and amphetamines. There is also a non-stimulant medication approved for treating ADHD called Strattera (generic name: Atomoxetine).

Once-A-Day Medicines

There are an increasing number of medication preparations, including immediate release, extended release and long acting forms. Dr. Goodman typically prescribes once-a-day medicine that is taken in the morning and lasts up to 12 hours. If a medicine is taken at the same time every morning it is much easier to maintain compliance with treatment. Dosages are less likely to be missed or taken at the incorrect times.

The main problem with the immediate release meds are that they only last approximately 3 hours and must be administered 3 to 4 times daily for adults. While the immediate release medications are effective, some children and adults experience a type of roller coaster effect. When the medicine is taken and increases in the individual’s blood stream, he may experience a period of feeling tense, anxious or irritable. As the medicine wears off three hours later, the individual often experiences a loss of energy or a feeling of general “blah-ness.”

These up and down effects that occur every 3 hours -- upon taking the meds and upon the meds wearing off – may even make a person feel that the side effects are worse than the improvements. Not to mention that these effects occur with each administration. When meds are taken 3 to 4 times a day, this can be quite problematic.

Dr. Goodman notes that adult patients, who were diagnosed with ADHD as children, often return to treatment as adults after a period of time being off medication. Typically, when these patients were children, meds were discontinued by the parents or as a teen or young adult these patients simply chose to stop. As adults, they come to Dr. Goodman when they are struggling with ADD/ADHD issues and in need of help. Sometimes these patients express concerns about medication because of their past experiences.

Dr. Goodman explains to them that there are newer preparations of medicines that prevent the up-and-down feelings and uses a helpful analogy to explain the difference.

Person A and person B travel from New York to Los Angeles.
Person A takes a direct flight from NY to LA.
Person B has to stop in Chicago, then make another connection in Phoenix, and finally arrive in LA.
Both will arrive, but who will feel better overall?
Person A’s day will be more balanced and as a result he will feel less tired.

Person A took a once-daily medication, while person B took it three times a day. This is the difference most people will feel taking once-a-day, long acting medications.

Dr. Goodman notes that ADHD medicines work quickly. Individuals should notice a definite improvement within a few days. Focus is better. One is able to stay on task for longer. Things don’t take so long to complete. Many patients remark that they are amazed by how much more productive they are in the day.

Psychotherapy

Self-image is often a huge issue for those who have struggled with ADHD. People may come to believe that they are not capable of doing any more than they are currently doing. If they have experienced repeated failures or rejections, they may feel they simply aren’t capable beings. It is easy to become self-critical and negative about the future – as a result these individuals aren’t able to realize their great potential.

Psychotherapy is the other important “P” in the pneumonic outlining treatment approaches. Through psychotherapy an individual can regain their self-esteem, improve their self image, gain a better understanding of feelings, and make structural changes to improve the quality of their life.

With the reduction of ADHD symptoms with medication, the person's daily functioning improves. Self-confidence grows from consistent performance which then further increases the confidence to pursue a goal. Success begets success and the person blossoms. One’s entire outlook is improved with each success.

_Source:

David W. Goodman, MD. Interview/personal correspondence. 06 March 08.