The fact is that when Ritalin and the other medications used in the treatment of ADD are used properly, they are very safe indeed, and can be as dramatically effective as the right pair of eyeglasses can be for nearsightedness. But many people never get to the point where they rationally weigh the evidence and make a decision based on the facts. Instead, they abruptly decide against medication as if they were casting a vote against sin and evil, and in so doing subject themselves, or their children, to unnecessary pain and frustration. It would be like the nearsighted person deciding that glasses were bad, a kind of vice or unnecessary crutch, and that he should be able to get by by squinting harder.
Although medication does not always work, when it does work, it works wonders. To decide against it on an informed basis is fine, but to decide against it for irrational reasons is a mistake. The information that follows is offered in the hope that the decision-making is as informed as possible.
Not much has changed in the seventeen years since the original publication of Driven to Distraction, not in medications for ADD nor, for that matter, in all psychopharmacology. Finding new effective medications for the brain has been a struggle, and we are still waiting for the breakthrough drugs that will help with brain-based problems.
Today, as in the past, we have two main classes of medication that are approved by the FDA in the treatment of ADD: the stimulants and the antidepressants. The same medications are used in both children and adults. For both children and adults with correctly diagnosed ADD, some medication will be effective about 80 percent of the time. Finding the right medication and the right dosage can take several months of trial and error, as we still do not (as yet) have a way of predicting what medication in what dosage will help a given individual. It is worth being patient and not giving up too soon, as often an increase in dosage or a change in medication will make a dramatic difference.
When medication is effective, it can help the individual focus better, sustain effort over a longer period of time, reduce anxiety and frustration, reduce irritability and mood swings, increase efficiency by enhancing concentration as well as reducing time lost in distraction, and increase impulse control. These primary effects may lead to secondary effects of increased confidence, sense of well-being, and self-esteem.
The medication does not always work, and even when it does work, sometimes it must be discontinued due to intolerable side effects. In these cases, the nonmedication forms of treatment can still produce significant therapeutic gains.
First, let’s consider the stimulants, the most common of which is Ritalin (generic name, methylphenidate). Each dose of short-acting Ritalin lasts between two to four hours. Therefore, short-acting Ritalin is given in divided doses throughout the day. The usual dosing schedule is as follows: first dose with breakfast, second dose four hours later or with lunch, and third dose about four or five o’clock in the afternoon. This routine may be varied according to one’s individual schedule. The main point is to have the medication on board when you need to be focused, and to space each dose by about four hours.
However, one big improvement in these medications has been the recent development of effective long-acting forms. Before the introduction of Concerta in 2000, the long-acting and generic preparations of methylphenidate were not very useful. But pharmaceutical companies have stepped up with better generic varieties as well as true long-acting brands. There is Ritalin LA (a better version of Ritalin SR), Methylin, Metadate, and a generic methylphenidate that works much better than the older versions. We also have Focalin and Focalin XR, which is the d-isomer of methylphenidate and is a bit stronger and a bit longer lasting than the traditional Ritalin.
These newer drugs are particularly helpful for children who might often forget to take their noon dose or don’t want to be seen going to the school nurse for medication. In the past, children who have had this concern have been prescribed the slow-release forms of methylphenidates, such as Concerta, Ritalin LA, Methylin, Ritalin SR, or Metadate CD. These claim to last eight hours. However, in many cases the slow-release forms do not work as long as they claim.
Dexedrine, another stimulant and a popular alternative to Ritalin, has now shown up in multiple forms as treatment for ADD. Adderall—the first of what I call “Old Drugs in New Bottles”—was renamed from the drug Obetrol, one of the diet drugs of the 1960s, and has made quite an impact on the field. It also comes in the form of an effective long-acting Adderall XR. In addition, there is an effective all-day preparation called Vyvanse, which is a purer form of amphetamine than Adderall.
As their name implies, the stimulants act on neurotransmitters to activate or stimulate the central nervous system. In ADD, this has the effect of helping the individual to focus or attend more fully than before. They also can have a mood-leveling effect.
A few things the stimulants do not do should be mentioned to clear up common misconceptions. They do not “drug up” or cloud the sensorium of the individual taking them. They are not addictive in the doses prescribed for ADD. They do not always take away the creativity or “special something” so many people with ADD possess.
However, there may be side effects. Using Ritalin as an example, the most common side effects are appetite suppression and sleep loss. Blood pressure may also be elevated. These side effects are dose-related and may be avoided by lowering the dose. There may be some nausea and headaches at the outset of therapy; these usually pass within a few days. In addition, as the medication wears off, the individual may feel a letdown or change of mood. One can usually accommodate to this by changing the amount or timing of the dose. One may also feel jittery or nervous on Ritalin, while still getting therapeutic benefits. Sometimes the addition of a low dose of a medication called a beta-blocker, such as nadolol, can remove this jitteriness.
Other, far-less-frequent side effects of Ritalin include the development of an involuntary muscle twitch, or what is called Tourette’s Syndrome; growth suppression in children (for which there is a compensatory spurt in growth when the medication is discontinued); alteration in blood count or other blood chemistries (which normalize upon discontinuation of the medication); or feelings of jitteriness or general unpleasantness, which also pass upon discontinuation of the medication. These side effects are very rare. In general, Ritalin is an extremely safe medication when given under proper supervision.
One can take generic preparations or the brand names. In our experience the brand-name drugs work better than the generic alternatives.
The therapeutic dose varies from individual to individual and does so for every medication. A typical dose for Ritalin would be 10 milligrams (mg) three times a day. One usually starts at 5 mg twice a day to see if the medication is going to be well tolerated. After a few days it can be increased to 10 mg twice a day, then on to three times a day. One can continue to increase the dose until either side effects appear—appetite suppression or sleep loss or other side effects—or until a therapeutic benefit is achieved and target symptoms are relieved.
Sometimes the medication simply does not work no matter what the dose. Other times one gives up too soon, not reaching a high-enough dose to achieve a therapeutic effect. One can increase the dose until side effects occur, but when side effects do occur the dose should be lowered or the medication stopped. If the medication is stopped, one can try another stimulant or another class of medication. It should be borne in mind that if one stimulant does not work, another stimulant may.
A common reason for the medication not to work is giving up too soon on it. Often it takes weeks, even months, to find the right dosage and the right dosing schedule. Sometimes a low dose will work, but only if it is given at the right time. Sometimes a small increase in dose will make a great difference. Sometimes the addition of another medication will allow the first medication to work better. This can be a tedious process, like trying on many pairs of shoes until you find the right fit. But it is well worth the effort.
Often the person taking the medication will not
be aware if it is working. However, teachers, friends, spouse, or boss may notice dramatic improvement in focusing and productivity. Therefore, the assessment of efficacy should include reports from at least one other person in addition to the person taking the medication. In children, behavioral checklists filled out by the classroom teacher can be particularly helpful. In adults, the assessment is somewhat less formal, but it should be equally objective.
Of the antidepressants used to treat ADD, Strattera, Wellbutrin, and Norpramin are the most commonly used. Strattera is the newest of this group and has achieved much popularity, though it often has the uncomfortable side effects of nausea and fatigue. Although they are completely different substances, chemically, than the stimulants, they often have a similar effect upon the target symptoms of ADD. Sometimes, when a stimulant does not work, this group will, and vice versa.
There are several advantages of antidepressants over Ritalin and the other stimulants. First, they often can be given in a single daily dosage, thus avoiding the need to remember to take a pill several times a day. (Trying to remember to take medication for ADD brings up a kind of Catch-22: How are you supposed to remember to take the medication that is supposed to help you remember to take your medication?) Second, they do not produce the jagged peaks and valleys some people experience on Ritalin. They are often smoother, evener in their action. Third, they are not controlled substances and so there can be greater flexibility in prescribing.
Several other medications have been found to be helpful in childhood and adult ADD. These include tricyclics such as Tofranil, as well as other medications such as Clonidine, Cymbalta, Prozac, and others. Therefore, if the stimulants or Strattera, Wellbutrin, and Norpramin do not work, there are other medications one can try.
In addition, there are various medications that can be useful adjunctively, either to treat side effects or to improve the effect of the primary medication. We have already mentioned the usefulness of the beta-blockers, specifically nadolol at a dose of 20 mg per day, to treat the jitteriness or anxiety that is sometimes associated with the stimulants, particularly Ritalin. Recently Intuniv, another old pill with a new name—the former antihypertensive drug guanficine, or Tenex—has also been approved for treatment of ADD medication symptoms.
There are several other medications worth mentioning. Many women who have ADD feel that their symptoms get much worse when they are premenstrual. As one of our patients has commented, “I do okay on the medication for most of the month … but when I’m juggling twelve balls in the air to get something done, and then PMS arrives, it makes it impossible to continue to function very well.”
No scientific evidence linking a proneness to PMS with ADD has been offered. But many of our female patients report unusually severe PMS symptoms. It might be a common accompanying problem. It can restrict a woman’s attempts to deal with her ADD and can make any existing anxiety, depression, or mood swings much worse. The addition of serotonin-active drugs like buspirone, fluoxetine, or sertraline (BuSpar, Prozac, or Zoloft) to the treatment regimen can make a great difference to the woman with ADD. These medications can alleviate the typical PMS symptoms and re-regulate the neuroendocrine imbalance wreaking havoc on an already unbalanced system.
If depression coexists with ADD, as it often does, antidepressant medication can be quite helpful, in addition to the medication for ADD. Ritalin, by itself, has a mildly antidepressant effect. The addition of Norpramin, or one of the serotonin-active medications such as Prozac or Zoloft can help treat the depressive symptoms while the stimulant treats the symptoms of ADD. One should not usually start the antidepressant at the same time one starts the stimulant. This is because the individual’s depression often disappears as the symptoms of ADD go away. However, if the depression persists, an antidepressant medication may help.
Rage outbursts, tantrums, and even violent behavior sometimes accompany ADD. There are a variety of medications that can treat these symptoms. The mood-stabilizing medications lithium, valproic acid (Depakote), and carbamazepine (Tegretol) all may help control these outbursts. The beta-blockers nadolol (Corgard) and propranolol (Inderal) can also reduce explosiveness.
If obsessive-compulsive disorder occurs with ADD, the addition of clomipramine (Anafranil) can treat the obsessional symptoms.
The medications used in the treatment of ADD are summarized in the following table:
There are emotional issues that underlie the taking of medication, particularly in children, but in adults as well. Many people recoil at the thought of taking medication for their brains, or their children’s brains. It conjures up images of thought control or serious mental illness. It is important to discuss these fears or preconceptions as openly as possible.
The taking of medication for ADD should not be an act of faith but an act of science. Sometimes people ask, “Do you believe in medication as part of the treatment of ADD?” as if medication were a religious principle. We neither believe in it nor disbelieve in it for all people. Rather, we approach it rationally. For most people who have ADD, medication has proven to be extremely useful. For some it has proven to be ineffective. For a very few it has proven to be harmful. If the diagnosis of ADD is carefully made, the best research data we have states that a trial of medication is indicated. However, it might not work.
Before starting the medication it is useful to explore all one’s feelings about it, in addition to getting as much scientific information about it as possible. There are many misconceptions and much misinformation about the medications involved in treating ADD.
A few last points about medication must be stressed. Medication is not the whole treatment for ADD. It is a useful and powerful adjunct, but it should never be regarded as the complete treatment. Medication should always be monitored by a physician. One should never take medication without feeling comfortable doing so. Spend time preparing yourself to take the medication—talking about it, getting questions answered—before you start, and your chances of success will be greatly improved.
Practical Tips on the Management and Treatment of ADD
This section offers short, encapsulated bits of advice on how to deal with ADD, practical tips that aim to assist in the day-to-day coping with life with ADD. These tips are culled from our years of experience in working with individuals with ADD, hearing their problems and complaints, and learning from the solutions they devised.
As you read through the following suggestions, you will probably find that you use many of them already; you will find that some of them are obvious or apply to everybody, with or without ADD; you will find that some of them seem irrelevant to your situation; and you will find, we hope, that some of them are new and quite helpful.
A word of caution should be added. Often when people read these tips for the first time, they become excited about incorporating them into their lives right away. After an initial burst of enthusiasm and improvement, however, they find that the old habits associated with their ADD start to creep back into their lives, and they find that the tips, although “correct,” are hard to follow consistently. As one patient said, “If I could follow the tips, then I wouldn’t need to follow them, because I wouldn’t have ADD in the first place.” Or as another patient said, “I have my days when I can follow the tips and days when I can’t. It’s like the old heartbeat, up and down.”
It is important, therefore, to keep in mind that the tips are only one part of a treatment program. Very few people with ADD can implement these tips consistently on their own. They need help, either from what we call a “coach,” or from a group, or from a therapist, or from some other external source. Do not feel intimidated or disheartened if at first you have trouble putting all these tips to work for you in your life. It will take time, it will require hard work, and it will require encouragement (and forgiveness) from the outside world. But with these considerations in mind, the tips can offer solid, practical help.
FIFTY TIPS ON THE MANAGEMENT OF ADULT ATTENTION DEFICIT DISORDER
> INSIGHT AND EDUCATION
1. Be sure of the diagnosis. Make sure you’re working with a professional who really understands ADD and has excluded related or similar conditions, such as anxiety states, agitated depression, hyperthyroidism, manic-depressive illness, or obsessive-compulsive disorder.
2. Educate yourself. Perhaps the single most powerful treatment for ADD is understanding ADD in the first place. Read books. Talk with professionals. Talk with other adults who have ADD. These may be found through ADD support groups or local or national ADD organizations like CHADD. You’ll be able to design your own treatment to fit your own version of ADD.
3. Choose a coach. It is useful for you to have a coach or some person near to you to keep after you, but always with humor. Your coach can help you get organized, stay on task, give you encouragement, or remind you to get back to work. Friend, colleague, or therapist (it is possible, but risky, for your coach to be your spouse), a coach is someone who stays on you to get things done, exhorts you as coaches do, keeps tabs on you, and in general stands in your corner. A coach can be tremendously helpful in treating ADD.
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