Treatment for ADHD
Numerous medications are available to treat ADHD, including antidepressants (especially those in the tricyclic family); stimulants in the methylphenidate and amphetamine family; medications traditionally used to lower blood pressure, such as guanfacine and clonidine; and “Noradrenergic reuptake inhibitors” such as atomoxetine. These medications can be helpful in abating symptoms for the right patient with the right set of symptoms. It is important to note that some medications work best for certain subtypes of ADHD, and all medications are associated with risks and possible benefits. Since not all medications are safe or effective for every individual, it is important to complete a thorough evaluation with a psychiatrist or psychiatric nurse practitioner before starting ADHD treatment.
ADHD medications have different properties and mechanisms of action, with some modulating dopamine (DA) and/or norepinephrine (NE) release and absorption in some parts of the brain much more aggressively than others. The range of available medications comes in handy, as not all individuals with ADHD present in the same way or experience the same level of neurotransmitter deregulation. Thus, affected individuals benefit most when they are prescribed the right medications for their individual needs. Finding the right dose is also essential, as inattention, impulsivity, and inefficient information processing can be caused not only by too little DA and/or NE in the prefrontal cortex, but also from too much. I call this the “goldilocks syndrome.” This means that giving someone an ADHD medication that is too strong or a dose that is too high can worsen symptoms or cause them to feel devoid of energy and motivation. Overly medicated individuals often feel more disorganized and either restless and anxious or devoid of personality because the medication decreased their hyperactivity symptoms to the point of making them overly unreactive. Finding the right medication and the right dose for each individual can only be accomplished when the prescribing practitioner explores the patient’s history and symptoms to determine which parts of the brain are affected and which neurotransmitter imbalances are at play. The practitioner will also review the patient’s medical diagnoses and current medications to avoid possible interactions. Then the patient and provider take the time to monitor specific symptoms together, as a medication is introduced, and dosage is incrementally adjusted.
With amphetamines discovered in 1887, dextroamphetamine in the 1920s, and methylphenidate in 1954, and Amphetamine mixed salts in 1960, stimulants are among the most frequently studied drugs in psychiatry, with over 350 studies completed in the last several years (Prince J. Child Adolesc Psychiatr Clin N Amer, 2006 January 15 (1) 13-50).
The list of possible adverse drug reactions and side effects for stimulants can be frightening to say the least, ranging from dehydration and growth suppression of 1 cm per year to cardiac disease and sudden death. However, it is important to note that if taken at the right dose, stimulants have been found to only minimally affect height, and that children who suffer from decreased growth while taking the medication may be able to “catch up” thereafter (MTA Cooperative Group. Pediatrics 2004; 113: 762-769). The most dangerous potential adverse drug reactions are very unlikely to occur in persons with no history of heart disease, fainting, palpitations, chest discomfort, dizziness, or of family history of sudden cardiac death before the age of 30. The rate of sudden death cases in healthy children without cardiac issues taking stimulants has been demonstrated to be the same as for children not taking stimulants (Vitiello B, 459). It goes without saying that patients who experience exertional chest pain or unexplained syncope during treatment should stop intake of stimulant medication and complete a cardiac evaluation. Typically, people diagnosed with advanced arteriosclerosis, symptomatic cardiovascular disease, glaucoma, seizure disorders, uncontrolled hypertension, or pheochromocytoma should not take stimulant medications. However, in the case of seizure disorders and glaucoma, exceptions can be made with careful monitoring and treatment planning.
Common side effects of stimulants include increased blood pressure and heartrate, headaches, stomachaches and decreased appetite, insomnia (especially with the extended release formulations), anxiety and irritability, depression, decreased circulation in the fingers and toes (predisposing people to frostbite), and tics. Potential side effects should be monitored during the course of treatment, as they may indicate a need to change medications or decrease the dosage.
Fact or fiction? Common questions about stimulants:
- Are stimulants addictive when used as prescribed? They must be crushed and inhaled or injected to be addictive. For individuals likely to crush and inhale or inject stimulant medications, lisdexamfetamine dimesylate (brand name: Vyvanse) may be a good treatment option, as it must pass through the gut to become active; inhaling or injecting it would not cause a person to feel high.
- Do stimulants trigger aggressive, assaultive behavior? Stimulants most often decrease temper tantrums/aggression by increasing organization of thought and thus decreasing anxiety and frustration.
- Do stimulants increase the likelihood of seizures? Yes, but only at very high doses or when combined with other medications that may increase the risk for seizures.
- Do stimulants cause Tourette Syndrome? Less than 3% of patients who take stimulants develop tics. Among individuals with Tourette Syndrome, 30% experience an increase in tics with intake of certain stimulants; however, 35% experience a decrease in tics. Careful selection of stimulant medication can significantly benefit these patients, as stimulants such as dextroamphetamine (brand name: Dexedrin) are less likely to cause tics than others (e.g., methylphenidate products).
- Can stimulants trigger mania? Stimulants are at lower risk of triggering manic episodes than most antidepressant medications.
- Does the use of stimulants increase risk of substance abuse? ADHD is associated with an increased risk of substance abuse and cigarette smoking, as nicotine can improve concentration through its effects on the brain. Some recreational drugs can increase DA levels in the brain and thus decrease anxiety, restlessness and feelings of sadness. Several studies have examined whether or not stimulant use can trigger or worsen drug abuse, and the consensus is that when used properly, they do not (Humphreys K, 2013). In fact, it is now believed that in adolescents/teens, the proper use of stimulants to treat ADHD decreases the risk of drug abuse.
Although utilizing stimulants that trigger increased DA and NE in the brain is the gold standard for treating ADHD, not all patients fit the profile of having both low levels of NE and DA. For instance, patients diagnosed with conduct disorder, oppositional defiant disorder, psychotic disorders and/or bipolar affective disorder are thought to have too much DA activation in some prefrontal circuits, while patients experiencing tics may have too much DA activation in their striatum. These patients may benefit from medications that will decrease DA in these parts of the brain while increasing DA in parts of the brain where this neurotransmitter is too low.
Here are a few more reasons why a psychiatrist or psychiatric nurse practitioner may not choose stimulants as a first line treatment for ADHD:
- The patient doesn’t want to take a stimulant or the patient or provider would like to try medications that are milder and/or have a decreased risk of causing side effects.
- There is a history of substance or alcohol abuse, or a strong family history of substance abuse, as most stimulants can be abused if crushed and inhaled or injected. Preferred treatment options would include using medications less likely to increase DA and produce euphoric feelings. If the person is experiencing co-morbid alcohol abuse, Strattera may be favored in this scenario, as it has the added benefit of potentially decreasing heavy drinking.
- The patient has a poor appetite, weighs little, or has a history of behaviors reflecting possible anorexia, as stimulants are known to decrease appetite
- The practitioner wants to decrease the risk of stunting a child’s growth (approximately 1cm/year)
- The patient presents with a predominant hyperactivity/impulsivity type of ADHD, rather than a combined type of ADHD, for which other medications may be safer and more effective.
- The patient presents with a predominantly inattentive profile (formerly known as ADD) and has never tried Strattera.
- The patient is suffering from cardiac issues.
- The patient is on sedative medications and/or opioids, which may be interfering with concentration, so the provider recommends decreasing these medications before taking ADHD medication to determine if it would solve the problem.
- The patient has an oppositional defiant disorder or conduct disorder for which other medications, better known to decrease argumentativeness, violence, disobedience and temper tantrums can first be tried.
- The patient is trying to quit smoking and would benefit from a medication that also helps smoking cessation, such as Wellbutrin.
- The patient has a condition for which the use of stimulants is contraindicated.
- The patient is pregnant.
- The patient is experiencing another mental health disorder that may be exacerbating poor concentration, impulsivity or hyperactivity.
Non-Pharmacological Treatment of ADHD: How to Train the Brain
There are many strategies that can help people with ADHD. Here are a few to try:
- Exercising for 20 to 90 minutes in the morning to vent off excess energy and decrease feelings of hyperactivity, anxiety, or restlessness during the day (Medina et al. 2010).
- Putting things away in designated and strategic places (e.g., putting your car keys in the fridge to remember your lunch for work the next day).
- Using numbered “to do” lists and reminders on your phone.
- Engaging in activities that increase focus and memory, such as trying to memorize telephone numbers or playing specialized brain games.
- Avoiding bright and/or busy environments to avoid feeling overstimulated.
- Building extra time into your schedule to avoid being late.
- Deconstructing big tasks with deadlines into smaller tasks with multiple deadlines to finish projects on time.
- Starting Cognitive Behavioral Skill Training with a qualified therapist, or EEG biofeedback, which utilizes video games to consciously change brain waves to frequencies that are better suited to improve concentration to complete particular tasks (Blum et al. 2008).
In addition, parents can help children better cope with ADHD by:
- Issuing clear commands.
- Establishing house rules and time-out procedures.
- Using role play to practice handling difficult situation.
- Being consistent with demands and in setting limits.
- Developing a reward point system to help reinforce good habits (ADHD conference 2017).
Accommodations for People with ADHD
ADHD is recognized as a disability under federal legislation (the Rehabilitation Act of 1973; the Americans with Disabilities Act; and the Individuals with Disabilities Education Act). Many accommodations can be incorporated into school settings and in the workplace to help individuals thrive in these environments (Blum et al. 2008). Teachers can be taught strategies to better attract and keep their students’ attention, such as issuing daily report cards and using different modes to communicate information in more stimulating ways (e.g., videos and song). Students can be given accommodations such as extra time on tests, tutoring, and front-row seating; fidget toys and yoga balls can help a student who is fidgety or restless.
Employers may be asked to try to provide quieter work environments for employees where distractions are less present, to provide employees with to do lists to help prioritization and organization, step by step protocols to help decrease mistakes made by inattention, and extra training time.
Docosahexaenoic acid (DHA) is an omega-3 fatty acid that is a main component of the brain’s cerebral cortex (Bradbury, J. 2011). Several studies have demonstrated that DHA supports the creation and healthy development of brain cells, facilitates brain cell communication, and increases the brain’s resilience against potentially damaging processes (Swanson et al. 2007). Conversely, omega-3 deficiencies have been found to alter DA regulation and increase inattention and hyperactivity (Agostoni C et al. 2017). Research also suggests that taking omega 3 supplements as an adjunctive treatment for ADHD can boost the efficacy prescribed ADHD medications and thus decrease the need for higher doses (Bloch et al 2014; Derbyshire E, 2017). The nutritional supplement Vyarin may help facilitate the absorption of omega 3 fatty acids; preliminary studies indicate notable improvements in ADHD symptom presentation in children who take it (include a reference for this statement).
The omega-6 fatty acid, gamma linolenic acid (GLA), is also important for brain health, as it helps with the creation of arachidonic acid (ARA), which is a substance that allows for other important substances used by the brain to be created (Agostoni C et al. 2017). However, the excessive consumption of omega-6 fatty acids in the modern Western diet can displace DHA omega-3 from membrane phospholipids, preventing proper absorption of omega-3 fatty acids (Bradburry, J 2011). For this reason, people with ADHD are discouraged from taking omega-6 supplements. Omega 6 can be found in sunflower and pumpkin seeds, popcorn, corn tortilla chips, most potato chips and foods prepared with sunflower, grapeseed, palm, corn and/or linseed oil.
Melatonin is helpful for children with sleep-onset insomnia (Bloch et al 2014) and for many adults with ADHD, for which falling asleep is a problem.
Zinc and magnesium deficiencies can lead to difficulties with DA regulation, potentially causing problems with concentration, impulse control, and hyperactivity. A healthy diet aimed at reducing the risk of these deficiencies may help. Supplementation with over-the-counter medications is not encouraged, as an overdose of zinc and magnesium can cause serious and potentially fatal health issues (Bloch et al 2014, Blum et al. 2008).
Are There Advantages to Having ADHD?
During prehistoric times, it may have been useful to have hyperactive tendencies for hunting and impulsive tendencies that helped scare away dangerous animals — or compelled humans to run away from them. It is not difficult to imagine how being hypersensitive to stimuli may have been an adaptive mechanism favored by evolution. This sensitivity would have helped individuals to quickly notice approaching threats and shift attention from one task to another, thus facilitating the juggling of berry picking, baby watching, fire tending, and predator alertness (ADHD Thomas J Weigel MD, Conference 2017).
To this day, individuals with ADHD are known to be creative, intellectually curious, out-of-the box thinkers who can adapt quickly to various situations — and multitask effectively. They often excel in the arts and sciences. It is likely that these qualities contributed to the successes of many famous people throughout history who are known to have or who have been strongly suspected of having ADHD, including U.S. President Abraham Lincoln; Microsoft founder Bill Gates; architect Frank Lloyd Wright; founder of the Ford motor company, Henry Ford; physicist Sir Isaac Newton; theoretical physicist Albert Einstein; journalist Lisa Ling; NBA star Michael Jordan; Virgin founder Richard Branson; poet Robert Frost; philosopher Socrates, inventor Thomas Edison; painter Vincent Van Gogh; actress Whoopi Goldberg; and authors Mark Twain, Agatha Christie, Katherine Ellison, and Virginia Woolf.
Helpful books for parents:
SOS Help for Parents: A practical Guide for Handling Common Everyday Behavior Problems by Lynn Clark, PhD
Playful Parenting by Lawrence J Cohen, PhD (audiobook)
Check out the first two parts of this series:
About the Center of Excellence in Co-Occurring Medicine:
The Center of Excellence in Co-Occurring Medicine is an outpatient clinic in Beaverton, Oregon, that offers expert, compassionate psychiatric care and substance abuse treatment.
About Esther Gabrielle Rosengarten, PMHNP-BC:
Ms. Rosengarten is Director of Clinical Operations at the Center of Excellence in Co-Occurring Medicine. She is a Psychiatric and Mental Health Nurse Practitioner with a long history of leadership in behavioral health and clinical practice, which reflects a deep commitment to the well-being of her patients. Prior to joining the Center of Excellence, Ms. Rosengarten served as Chief of Behavioral Health at Harvard Vanguard Medical Associates in the greater Boston area.