A healthy lifestyle with particular emphasis on physical exercise, regular sleep habits and cessation of unhealthy habits (such as marijuana and excessive alcohol usage) will benefit nearly all patients with ADHD.

The medications with the longest established record of efficacy are: methylphenidate and amphetamine. These are often categorized together as “stimulant medications.” Commonly known brand names of methylphenidate and its associated compounds include Ritalin, Concerta and Focalin. The most commonly known brand names of amphetamine are Adderall, Adderall XR and Vyvanse. Approximately 70-80% of patients with ADHD will experience clinically meaningful benefits from one of the stimulants.

There is a great deal of clinical lore regarding which of the stimulants is the most effective and which side effects each is more likely to cause. However there currently is not a reliable to predict specific benefits or side effects for any particular person. Each of these medications has the same potential for beneficial effects and the same list of potential side effects, but for every patient who experiences benefits and/or minimal side effects from one of these medications, another patient will have no benefit and/or unpleasant side effects from the same medication. The best we are able to do right now as physicians is to provide patients with information on the range and liklihood of potential benefits and side effects, and then guide them through a methodical trial-and-error process of finding the most effective and best-tolerated medication.

A person’s response to the usage of an ADHD medication is not diagnostic; many people who don’t have ADHD will still find an improvement in attention and focus with the use of a stimulant medication. This is among the reasons that these medications are controlled substances. Conversely, some patients who clearly do have ADHD will not experience robust benefit from treatment with medications.

For patients who struggle in a work environment that does not suit their interests or abilities, any medication treatment will likely be of limited benefit and they may need to consider finding a career that better aligns with the particular strengths and challenges commonly found in patients with ADHD.

Other medications in common usage for ADHD are atomoxetine (Strattera), guanfacine (Intuniv) and bupropion (Wellbutrin). The primary advantage of these medications as compared to the stimulant medications is that they are not controlled substances.

Many patients with ADHD have long suffered under the impression that they just have a “character problem,”  ”just need to work harder” or are purposely “self-sabotaging,” when in fact they are working quite hard to try to manage a treatable biologic problem. There are patterns and life stories of inattention, distractibility, impulsivity and disorganization that only be coherently explained and addressed by the diagnosis of ADHD.

On the other hand, not all patients with difficulties in attention and distractibility have ADHD. The following are some of these other factors:

-Depression, anxiety, learning disabilities, substance abuse and sleep disorders can all cause similar difficulties and are not best treated with ADHD medications.

-In some cases there can be a mismatch between a person’s talents and their chosen career that can manifest as problems with focus and task completion.

-Some people attribute problems with excessive attention to detail (“hyperfocusing”) to ADHD, but there is very little research that supports this conceptualization. In these cases there is certainly a dysfunction of attention, but it is not usually best explained by a diagnosis of ADHD; the underlying biologic challenge of ADHD is usually a deficit, rather than surplus of attention. Hyperfocusing is more likely due variously to obsessive personality styles, anxiety, or to one of the many neurocognitive states that can cause difficulties for a person but that have not yet been scientifically categorized.

-There are many patients who likely have some, but not all, of the genetic makeup that it takes to have the full syndrome of ADHD. They experience attentional or organizational difficulty, but not enough whereby the can be diagnosed with the disorder. In this sense, ADHD is a “spectrum disorder,” whereby there are some people who definitively do have it,  others that definitively do not, and many people who are somewhere on the diagnostic spectrum. In this last group, patients can struggle with certain attention-related areas of their life and even though they don’t formally have ADHD, neither is another problem or disorder a better explanation for the difficulties. It is essentially a partial case of ADHD.  In these situations treatment with medications is generally not recommend as a first step in treatment; cognitive-behavioral therapy, organizational help, or finding ways to alter the working environment may be better treatment plans.

The following is a link to a recent podcast discussion regarding diagnosing ADHD:

http://dl.dropbox.com/u/27785958/IAPADHDNYTimesDiscussion.mp3

Scattered Minds: Hope and Help for Adults with ADHD by Lenard Adler

Taking Charge of Adult ADHD by Russell Barkley

ADHD in Adults: What the Science Says by Russell Barkley

Attention Deficit Disorder: The Unfocused Mind in Children and Adults by Thomas Brown

Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder by Edward Hallowell, John Ratey

Attention Deficit/Hyperactivity Disorder: A 21st Century Perspective edited by Keith McBurnett, Linda Pfiffner

Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program Client Workbook by Steven Safren

The list below is for those who wish to read some of the most informative articles that are the scientific underpinnings of such books. All of the abstracts and of some of the articles in full can be read on PubMed and Google Scholar.

Articles That Present an Overview of ADHD

Advances in understanding and treating ADHD. Antshel KM, Hargrave TM, et al. BMC Medicine. 2011 Jun 10;9:72.

Attention-deficit-hyperactivity disorder: an update. Dopheide JA, Pliszka SR. Pharmacotherapy. 2009 Jun;29(6):656-7

Commentary: why diagnose and treat ADHD in adults? Feifel D. Postgraduate Med. 2008 Sep;120(3):13-5.

Attention-Deficit/Hyperactivity Disorder Research: Current Status and Future Directions. Faraone SV, Biederman J. Journal of ADHD and Related Disorders. 2009;1:7–13

Updates in Attention-Deficit/ Hyperactivity Disorder: Current Concepts and Future Developments. Adler LA, Shaw D, et al. Journal of ADHD and Related Disorders. 2009;1:63–8

Attention-deficit/hyperactivity disorder in adults: evidence-based recommendations for management. Rostain AL. Postgraduate Medicine. 2008 Sep;120(3):27-38.

ADHD in Adults. Okie S. New England Journal of Medicine. 2006. Jul 16-22;(25):2637-41

Attention-deficit hyperactivity disorder. Biederman J, Faraone SV. Lancet. 2005 Jul 16-22;366(9481):237-48

Attention-deficit/hyperactivity disorder in adults. Wilens TE, Faraone SV, Biederman J. Journal of the American Medical Association. 2004 Aug 4;292(5):619-23

The epidemiology and prevalence of ADHD

The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication Kessler RC, Adler LA, et al. American Journal of Psychiatry 2006;163:716-723.

Attention-deficit/hyperactivity disorder in a diverse culture: do research and clinical findings support the notion of a cultural construct for the disorder? Rohde LA, Szobot C, et al. Biological Psychiatry. 2005 Jun 1;57(11):1436-41

The worldwide prevalence of ADHD: is it an American condition? Faraone SV, Sergeant J, et al. World Psychiatry. 2003 Jun;2(2):104-13.

The biology of ADHD

The roles of dopamine and noradrenaline in the pathophysiology and treatment of attention-deficit/hyperactivity disorder. Del Campo N, Chamberlain SR, et al. Biological Psychiatry. 2011 Jun 15;69(12):e145-57.

Neurobiology of ADHD. Tripp G, Wickens JR. Neuropharmacology. 2009 Dec;57(7-8):579-89

The Neurobiological Basis of Attention-Deficit/Hyperactivity Disorder Arnsten AF, Berridge CW, et al. Primary Psychiatry. 2009;16(7):47-54

ADHD and Medication

ADHD medications and risk of serious cardiovascular events in young and middle-aged adults. Habel LA, et al. Journal of the American Medical Association.  2011 Dec 28;306(24):2673-83.

ADHD drugs and serious cardiovascular events in children and young adults. Cooper WO et al. New England Journal of Medicine. 2011 Nov 17;365(20):1896-904.

Long-term outcomes with medications for attention-deficit hyperactivity disorder: current status of knowledge. Huang YS, Tsai MH. CNS Drugs. 2011 Jul 1;25(7):539-54.

Efficacy and safety limitations of attention-deficit hyperactivity disorder pharmacotherapy in children and adults. Wigal SB. CNS Drugs. 2009;23 Suppl 1:21-31.

ADHD and Substance Abuse

Attention deficit hyperactivity disorder and substance use disorders. Wilens TE. American Journal of Psychiatry. 2006 Dec;163(12)

The clinical dilemma of using medications in substance-abusing adolescents and adults with attention-deficit/hyperactivity disorder: what does the literature tell us? Wilens TE, Monuteaux MC, et al. Journal of Child and Adolescent Psychopharmacology 2005 Oct;15(5)

ADHD is characterized by difficulty initiating or completing tasks, sustaining attention, and controlling impulsive actions. Patients may have difficulties with organization and time management. As a result of these difficulties, ADHD can have serious negative impacts on the educational, social, and occupational lives of those who experience these symptoms.

Three types of ADHD are diagnosed:

• Combined inattentive and hyperactive-impulsive (this is the most common type, found in about 80% percent of patients).
• Predominantly inattentive (about 15%).
• Predominantly hyperactive-impulsive (about 5%)

The terminology can be confusing. Attention Deficit Disorder (ADD) is an older term for what is now called Attention-Deficit/Hyperactivity Disorder (ADHD). There is no longer any actual disorder “officially” called ADD, but some people still use ADD (or Adult ADD) to refer to the type of ADHD that is predominantly inattentive, and use ADHD (or Adult ADHD) for the type of ADHD that is predominantly hyperactive or impulsive. However, these all refer to the same disorder, and in regard to medications, the treatments are generally the same. Hyperactive symptoms often improve by adulthood, and it is for this reason that it was previously thought that patients outgrow ADHD. It is now clear, however, that inattentive symptoms usually do not resolve, though they are not always outwardly apparent if someone has structured their life in a way that avoids situations requiring extended periods of sustained focus.

Although the exact mechanism is unknown, a number of associated neurochemical abnormalities have been observed, and considerable evidence suggests that the disorder has a strong genetic component and a biological underpinning; the pathophysiology includes dysfunction in both norepinephrine and dopamine activity, particularly in the frontal cortex.

Patients with ADHD are twice as likely to have problems with substance abuse as those without ADHD. The reasons for this are numerous and vary for each person, and usually include genetic risk factors. It is also often the case that patients with ADHD are more impulsive in most regards, including with the ability to modulate substance usage. However, even when patients feel that their substance usage is related to their ADHD, substance use disorders are best addressed and treated as problems in their own right; treatment of ADHD does not by itself seem to reduce rates of substance abuse.

Some forms of substance abuse, particularly regular marijuana usage, can present with symptoms similar to ADHD. Chronic cannabis usage is associated with neurocognitive effects that include deficits in attention and working memory, slowed mental processing and difficulties with decision making and impulsivity. These deficits have been documented to last at least several weeks past the last time of marijuana usage. Some patients report that they use marijuana or other substances to self-medicate their attentional difficulties. Given what is known about the effects of cannabis on cognition, it is difficult to postulate a physiologic mechanism whereby marijuana could treat a primary attentional deficit.

For these reasons, the ongoing usage of substances, particularly marijuana or stimulants (such as methamphetamine or cocaine), makes it quite difficult to have diagnostic clarity prior to beginning treatment. Those substances also make it challenging to assess the true benefits of a medication once ADHD treatment has been initiated, since ADHD medications are known to be of limited benefit while there is ongoing substance usage.

In all cases it is recommended that patients be off all substances of potential abuse before starting medication treatment for ADHD.

If you think you may have ADHD but are still using excessive alcohol, marijuana or other drugs, I would be glad to provide you with some referrals to help you try to address your substance use before trying to treat your attentional difficulties.

There is quite a large medical literature on this topic. I list some examples here for those interested in reading deeper into the topic:

Neuropsychological deficits associated with cannabis use in young adults. Grant JE, Chamberlain SR, et al. Drug and Alcohol Dependence. 2011 Sep 13.

Adolescent substance abuse: the effects of alcohol and marijuana on neuropsychological performance. Thoma RJ, Monnig MA, et al. Alcohol Clinical and Experimental Research. 2011 Jan;35(1)

Chronic cannabis users show altered neurophysiological functioning on Stroop task conflict resolution. Battisti RA, Roodenrys S, et al. Psychopharmacology. 2010 Dec;212(4):613-24.

Executive function deficits in short-term abstinent cannabis users. McHale S, Hunt N. Human Psychopharmacology. 2008 Jul;23(5)

The influence of marijuana use on neurocognitive functioning in adolescents. Schweinsburg AD, Brown SA, et al.  Drug Abuse Reviews. 2008 Jan;1(1)

The relationship between non-acute adolescent cannabis use and cognition. Harvey MA, Sellman JD, et al. Drug and Alcohol Reviews. 2007 May;26(3)

Neuropsychological deficits in long-term frequent cannabis users. Messinis L, Kyprianidou A, et al. Neurology. 2006 Mar 14;66(5)

Attributes of long-term heavy cannabis users: a case-control study. Gruber AJ, Pope HG, et al. Psychological Medicine. 2003 Nov;33(8)

Cognitive measures in long-term cannabis users. Pope HG Jr, Gruber AJ, et al. Journal of Clinical Pharmacology. 2002 Nov;42(11 Suppl)

Dose-related neurocognitive effects of marijuana use. Bolla KI, Brown K, et al.Neurology. 2002 Nov 12;59(9)

I am not part of any insurance network and do not accept insurance reimbursement as a form of payment. Patients are expected to pay at the time of appointments.

If you have a health insurance policy that provides coverage for some or all of your treatment (this is most often called “PPO out of network coverage”), payment is expected at the time of services and then you will request reimbursement directly from your insurance company. I do provide itemized receipts to assist you with this process.

CANCELLATION POLICY AND MISSED APPOINTMENTS

Patients are expected to pay in full for any session that is missed or cancelled less than 48 hours ahead of time.