Optimal dosage is pegged to weight. Afternoon stimulants disrupt sleep. Increase your dose every two weeks. And other falsehoods about ADHD medication that may put your treatment plan on the wrong track.
By Gina Pera
Janet recalls with a shudder the first time she took medication as a treatment for attention deficit hyperactivity disorder (ADHD). “I was glued to the sofa, unable to move for two days,” says the 37-year-old mother of two, and a marketing manager for a Silicon Valley software company. “I looked and felt like a zombie. It scared me off medication.” For Janet’s husband, the incident confirmed his long-held belief that giving ADHD medications to their 10-year-old son would be tantamount to drugging him.
When Janet later attended a local adult ADHD discussion group, she learned that some people who reported great results from taking medication said it took weeks for most patients to tolerate the dosage the doctor had prescribed her — and that many were taking half that amount.
“I should have educated myself first, instead of trusting the physician,” Janet says. “Now my husband gets upset if I talk about trying medication again. It created a wedge between us; I’m giving up higher functioning for myself and my son because of my husband’s fears.”
Janet’s experience is becoming less common. Increasingly, physicians are learning how to use medication to treat adults with ADHD, although many adults still encounter professionals whose knowledge of meds management is spotty, including psychiatrists who claim special expertise.
“You might call adult ADHD an ‘orphan’ disorder,” says Margaret Weiss, M.D., Ph.D., a preeminent ADHD clinician scientist, based in Vancouver, British Columbia. “That’s because most professionals with the expertise to recognize and treat ADHD work in child services; they are not working in adult centers or seeing adults.”
The bottom line for adults with ADHD is: Be a smart health-care consumer, and learn as much as you can about medication before you start taking it. The Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA), a coalition of ADHD experts, has created comprehensive treatment guidelines for patients, parents, and physicians. The practice guidelines, including charts of medications, are available as a free download on CADDRA.ca. My own book, Is It You, Me, or Adult A.D.D.? is another good source, as is the e-book “ADHD Treatments,” from ADDitudeMag.com.
In the meantime, if your prescribing physician makes any of the following 10 statements, share a copy of the CADDRA guidelines with her and talk things over, or find a new doctor.
1. “My adult ADHD patients do best on this stimulant medication.”
Physicians who “play favorites” with stimulant medications — the first-line treatment for ADHD — don’t have an empirical basis for doing so, and are gambling with your chances of success. Here’s why.
There are two major classes of stimulant medications: methylphenidate, or MPH (Ritalin, Focalin, Concerta, Daytrana, and others), and amphetamine, or AMP (Dexedrine, Adderall, Vyvanse, and others). The MPH class works best for some people who have been diagnosed with ADHD, but has no effect, or a negative effect, on others. The same is true for the AMP class. There is no way to predict how you will respond to each class until you try it.
Physician and ADHD specialist Patricia Quinn, M.D., suggests trying both classes of stimulants (MPH and AMP) before deciding that stimulants won’t work for you and moving on to a nonstimulant medication: “You might even try several meds within the same class before switching to another stimulant class.” For example, Ritalin LA and Concerta are both long-acting medications in the same class (MPH). Due to their different delivery mechanisms, however, each brings different results.
2. “For an adult of your height and weight, we start with this dosage.”
An optimal dosage is not related to a person’s height or weight.
3. “This is an average starting dose.”
There is no “average starting dose.” The choice depends on many factors, including:
- Your history of taking stimulant medications. Those who have taken stimulants in the past might be less response-sensitive than people who have not.
- Genetic differences — some people metabolize the medication more quickly than others.
- Co-existing conditions — anxiety or depression , for example, and their current treatments.
- ADHD symptom severity. “The brain is profoundly complex and results differ from person to person,” Weiss says.
4. “We’ll increase the dosage to 10 mg in two weeks.”
Just as a professional cannot predict which medication will work best, or at which starting dose, he also cannot predict an optimal dosage goal. The optimal dosage is identified by a method called titration: carefully increasing the dosage over time, until side effects outweigh benefits, and then dialing down to the previous dosage. The approach should always be “Start Low, Titrate Slow.”
5. “So, how’s that medication working out for you?”
Judging a medication’s effectiveness requires more than a physician asking, “How are you doing?” It requires at least two steps:
- Taking careful inventory of the challenges you face (writing them down, one by one), before you started medication
- Regularly reviewing each challenge as treatment progresses, in order to track improvement (or not), worsening symptoms, or new side effects.
During this titration phase, experts recommend talking with your physician weekly. In-office visits should take place every three to four weeks, to review side effects, physical health, patient and family well-being, and other therapies, when indicated.
Many experts and patients report that not enough physicians closely monitor medications used in adults. “It’s critically important to do, but the utter paucity of clinicians doing it is shocking,” says psychologist Stephen Hinshaw, Ph.D., a leading ADD/ADHD researcher and professor of psychology at the University of California, Berkeley. “You can’t notice small improvements or side effects without a monitoring sheet.”
Weiss recommends using rating scales that measure a broad range of symptoms and functioning; in other words, a metric for tracking how you’re doing in life. The Weiss Functional Impairment rating scale is a good place to start. Having a tangible method for observing change makes the target concrete and keeps it in focus.
6. “You should see a huge improvement in symptoms right away.”
Research tells us a lot about overall stimulant efficacy, but we cannot tell how it will affect any particular individual. That’s because clinical trials are:
- Conducted in controlled settings
- Done with patients who have no co-existing conditions (a rarity among adults with ADD/ADHD)
- Very brief in duration (usually ending before side effects can develop).
The potential positive effects of medical treatment for ADD/ADHD shouldn’t be oversold, Weiss warns. “It’s true that some symptoms may improve dramatically in days, or even in hours. But it is important to wait to judge the full effect of the medication, because it can take some time for all the data to accrue.”
As you face challenging situations in your life, you can gauge how your responses differ from those in the past. “It can also take time to notice the differences in how people are reacting to you, or to evaluate changes in how efficient or how much better you’ve become at your job,” she says.
Weiss offers these guidelines:
- Symptoms tend to get better within weeks.
- Functioning improves within months.
- Developmental changes happen over years. For example, the individual who never had a friend can now make and keep them. An adult who could not keep a job can now hold onto one for a year.
7. “If the stimulant disrupts your sleep, we will have to switch you to a nonstimulant.”
The causes of sleep problems among adults with ADD/ADHD are multi-faceted, and poorly understood by most physicians. Increasingly, research is pointing to neurophysiological differences in circadian rhythm, the inner biological clock that tells us when to go to sleep. Yet there are other ADHD-related obstacles to sleep, such as being unable to “put the brakes on” a chatty brain.
In evaluating a stimulant’s apparent adverse effect on sleep, it’s important to pay attention to timing. Perhaps sleep problems are caused by the rebound from the medication’s wearing off. In that case, you should try taking the medication earlier in the day. Some people with ADD/ADHD sleep better on a stimulant; such medications stop “brain noise” and increase focus on going to sleep and staying asleep.
8. “Sure, continue consuming caffeine, if you like.”
Many adults with ADD/ADHD have lifelong love affairs with coffee or caffeinated sodas. Yet caffeine may exacerbate the effect of stimulant medications, creating anxiety and heart palpitations. You can’t determine what’s causing these side effects — the stimulant or the caffeine — unless you gradually wean yourself off caffeine before starting stimulants. (Try to do it a few days in advance, though, so that you don’t mistake a headache due to caffeine deprivation for a medication side effect.)
“Some people can tolerate stimulants and still have some caffeine,” Weiss says. “For others, caffeine interferes by creating or exacerbating side effects, making it impossible to increase the stimulant to therapeutic doses.”
9. “If you have high blood pressure, you can’t take stimulants.”
An adult should have a thorough physical before starting any new medication, and adults with ADD/ADHD should have their blood pressure and heart rate checked before beginning, and periodically during, treatment.
However, Weiss dashes the common myth that hypertension precludes taking ADD/ADHD medication: “I would say that it is never a contraindication. You treat the hypertension first. And, in fact, there are medications for ADD/ADHD that lower blood pressure.” These include generic guanfacine and its longer-acting brand-name formulation, Intuniv, which can lower both systolic and diastolic blood pressure. These medications are often used as an alternative to, or in conjunction with, stimulants.
10. “If you think that the stimulant has stopped working for you, maybe we should try something else.”
Perhaps the stimulant stopped working for any of several neurobiological reasons. Or could you have forgotten what life was like before you started taking the stimulant?
Adults who are diagnosed with ADD/ADHD later in life typically develop the habit of paying attention only to the exciting or new. After a few weeks of experiencing the “novelty” of improved symptoms, it’s easy to forget how far you’ve come. This is another reason for keeping written records of baseline symptoms and of the progress you’ve made. It’s the only way to know if the med is doing its job.