With 28+ stimulant medications for the treatment of ADHD, there are many choices. The good news is there are many options, unfortunately this leads to confusion for the prescriber. A panel of national experts discussed topics on ADHD and I offered information on a basic concept to thoughtful choose medications. This information is useful for prescribers and patients who choose to understand the sequence of medication trials after the first one doesn’t work, doesn’t last long enough, or has side effects.
This segment is a portion of the longer discussion on ADHD topics by the panel. You can view other segments at HCPLive.
Better information for better treatment. Thank you for your interest.
Dr. David W. Goodman was video interviewed by Vox.com on misdiagnosis of ADHD as a counterpoint to Dr. Allen Francis, psychiatrist, who believes ADHD is overdiagnosed. The video is excellently edited and very engaging. While it is easy to say ADHD is overdiagnosed because of the extensive media coverage, it is not overdiagnosis. The basis for my opinion lies in the research facts: 4.5% of US adults ages 18-44 are believed to have ADHD, a diagnosis whose basis is the persistence of symptoms since childhood of which 75% were never diagnosed as children. Of the adults with ADHD in the U.S., only 25% have been treated in the last year. With the prevalence rate of ADHD internationally ranges from approximately 2-10%, appallingly few adults outside of the U.S. are identified and treated.
Setting aside those adults who are accurately diagnosed with a comprehensive evaluation, there are patients who are given the diagnosis of ADHD and don’t have it. Inadequate clinician training, little time spent obtaining the history, and strong patient demand for ADHD can lead to misdiagnosis. These patients who do not have ADHD should not be placed on stimulant medication. More often, primary care clinicians are prescribing short-acting stimulants which can be abused, misused, and sold/given away to friends/customers.
SOME FACTS:
65% of all stimulants prescribed in the U.S. are prescribed primary care clinicians; 55% of all stimulants prescribed are short-acting; four international guidelines for the diagnosis and treatment of ADHD recommend long-acting stimulants as first line medication, not short-acting.
Well, that’s enough science for today. I provide this information so that if you are in a conversation about this topic, you are armed with meaningful data, beyond opinion.
As I have said before in my blogs, let science be the designated driver on the highway of opinions.
If you’re reading this blog, you are one of the millions of people who now use the Internet to gain information on medical issues. In a recent survey of consumers, this is where people are looking for medical information.
Most accessed online resources:
53% web M.D.
22% Wikipedia
19% health magazines and websites
16% advocacy group websites
12% YouTube
10% Facebook
10% blocks
9% Pharma company websites
(results from third annual national consumer survey by Makovsky Health and Kelton, 2014)
I would like to take this opportunity to direct your attention to the attitude magazine website that has a large number of webinars from noted academic and professional experts in ADHD. For many with ADHD it’s often easier to watch a video on a specific ADHD topic then to read a book. While many with ADHD can sit and read for extended periods of time, it always struck me as odd that clinicians referred patients to books knowing their ability to sustain attention would be limited, especially in the evening when it medication affect us dwindled.
Explore the webinars on this site as a can be extremely helpful. On this blog site, I will continue to direct my patients in readers to reliable sources of information and clinical insights from my practice not available elsewhere.
Anticipating over 300 attendees, the 13th Annual ADHD Conference for parents, teachers, professionals and adults with ADHD on Saturday, February 22, 2014 from 8:00am to 1:00pm will feature several expert speakers. West Chester University is just outside Philadelphia. Below is the program of speakers and topics.
Marie Paxon, program coordinator, invited me to present on the science of diagnosis and treatment of ADHD in adolescents and adults. If you reside in the area, please consider attending because it is a great way to learn a great deal about ADHD quickly and network with people with ADHD and those who offer guidance and treatment. See you there.
ADHD and the Brain: Knowledge Matters Speakers
Marilyn B. Benoit, M.D. is a child and adolescent psychiatrist. She is senior vice president of Clinical and Professional Affairs and chief clinical officer at Devereux. She is a past president of the American Academy of Child and Adolescent Psychiatry. Dr. Benoit has served on the faculties of Howard and George Washington Universities and is a clinical associate professor of psychiatry at Georgetown University Medical Center, from which she received the Vicennial Silver Medal of Honor for 20 years of distinguished service.
David W. Goodman, M.D. is assistant professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. He is also director of the Adult Attention Deficit Disorder Center of Maryland in Lutherville and medical director of Suburban Psychiatric Associates, LLC. Dr. Goodman is the author of The Black Book of ADHD.
Marjorie Johnson, LCSW, PCC is a licensed clinical social worker and certified coach who provides leadership and career coaching, training, and counseling. She specializes in helping students and professionals with ADHD. Ms. Johnson serves on Chester County/Main Line CHADD’s Professional Advisory Board and is a professional member of ADDA (Attention Deficit Disorder Association.). She is past president of the International Coaching Federation-Philadelphia chapter and was named the 2011 Small Business Person of the Year by the Exton Chamber of Commerce (PA).
Jesse D. Matthews, Psy.D. is a licensed psychologist and has worked with individuals with ADHD for a number of years. He is in private practice at The Center for Psychological Services in Paoli and Ardmore and also works at Holcomb Behavioral Health Systems, a community mental health organization. He evaluates adolescents for substance abuse at the Chester County Youth Center in West Chester and does substance abuse evaluations and treatment in an outpatient program in Kennett Square. Dr. Matthews is an adjunct professor at Immaculata University. Previously, Dr. Matthews worked for six years as a counselor at Hill Top Preparatory School, and he facilitated the Chester County/Main Line CHADD teen ADHD support group for two years.
Joan M. Polka, Ph.D. is a psychologist in the Counseling Center at West Chester University assigned full time to the Act 101 portion of the Academic Development Program (a developmental education opportunity for underprepared first-time college students). She is also co-chair of Chester County/Main Line CHADD’s Adult Program and was the 2011 CHADD Educator of the Year.
Martin Patwell, Ed.D. is director of the Office of Special Services for Students with Disabilities at West Chester University. He has also been the director of evaluation clinic at Landmark School. He has presented “Trends and Issues in Disabilities in Higher Education” at Jiangxi University, Nanchung, China. He is also a consultant to The College Board, Inc.
Preeti Singh, M.S. is the associate director of the Twardowski Career Development Center at West Chester University.
Sharon Watson, M.S. is assistant director of West Chester University’s Office of Services for Students with Disabilities. She has over 20 years of experience working with students with learning differences, mental health, and physical disabilities.
8:30 a.m. Welcome
Chester County/Main Line CHADD and West Chester University
West Chester University
Earl F. Sykes Student Union
110 West Rosedale Avenue
West Chester, PA 19383
8:45 –9:15 a.m.
ADHD Across the Lifespan
Marilyn Benoit, M.D.
Research has proven that ADHD does not end with childhood. Over the course of a lifetime, the scenarios change, but the struggles might not. What does ADHD look like at each stage of life and what is the impact? This fast-paced-but-thorough presentation will help attendees learn more about this complex disorder and will provide a summary of current treatment and management options. Don’t miss this valuable session to gain a better understanding of childhood, teen, and adult ADHD.
9:15 –10:30 a.m.
ADHD and the Brain – What You Need to Know About Treatment and Management
David W. Goodman, M.D.
Those with ADHD express frustration with the disorder’s symptoms: trouble focusing, procrastination, forgetfulness, and difficulty filtering out distractions. Some people have a slower processing speed and others struggle with impulsivity. To make things even more complex, many people with ADHD will have a co-occurring condition like learning disabilities, anxiety, depression, or autism. The good news is that treatment is available, and there are strategies to counteract these challenges. Dr. Goodman will provide an overview of medications and pro-social treatments for ADHD and discuss common co-occurring conditions in this valuable presentation. Children and adults report that they receive unhelpful advice like “try harder,” “start applying yourself,” and “pull yourself up by your bootstraps.” Attend this session to learn about evidence-based treatments for ADHD and how they make a difference.
10:45 –11:30 a.m.
ADHD and Social Interactions
Jesse Matthews, Psy.D.
Social interactions can consist of anything from a casual conversation with an acquaintance to daily communication with loved ones. This can present challenges for both children and adults with ADHD. Those with ADHD may feel isolated and disconnected from others. They may find that executive function challenges can cause them to misinterpret social cues, which are usually unspoken or vague. The invisible challenges of impulsivity, forgetfulness, and an inability to regulate emotions can have a negative effect on forming and maintaining friendships. Fortunately, new information and strategies are available through the field of social learning and social cognition. Attend this session to learn more about this exciting topic and how to apply it to everyday life.
• Facilitated activity: Mindfulness Meditation and ADHD
Marjorie Johnson, LCSW
Mindfulness meditation is a way to calm the mind and relax the body while increasing the ability to sustain attention and manage distractibility. Hear about compelling research and daily applications of mindfulness meditation. Practice it to experience the deep relaxation it generates.
11:45 a.m. –1:00 p.m.
Becoming Successful in College and Early Career
ADHD and Career Success
Preeti Singh
Career development is a life-long process, involving decision making, self-awareness, exploration, preparation, and experience. What tools are available to help students successfully navigate this territory? This brief presentation will provide an overview of resources and strategies.
WCU Student Panel
Sharon Watson, facilitator
Current students at West Chester University who have “been there, done that” tell it like it is. Their transitions, challenges, and routes to where they are today provide a look at what real students face in college.
• Facilitated activity: ADD and Loving It?!
This video blends humor, hope, and science to dispel the myths about adult ADHD. Comedian Patrick McKenna seeks a diagnosis for adult ADHD and learns the facts from an impressive array of experts. Funny, moving, and transformative, this fascinating documentary will hold you spellbound!
All ADHD medications that are FDA approved to treat adults have designated maximum daily doses. It is important to understand how these daily maximum doses are determined in order to consider higher doses beyond these thresholds. The FDA receives the clinical registration trial research and it makes a determination of maximum daily dose based on the presented data. If, for example, a clinical trial had a maximum dose of 50 mg a day then the FDA will only approve the drug with a maximum daily dose of 50 mg. An example of this is Vyvanse where the trial looked at 30 mg, 50 mg and 70 mg a day. Maximum daily dose approved is 70 mg.
In some cases where the clinical trial evaluated several doses, the FDA may only approve a maximum dose in the middle dose range from the trial because the higher dose didn’t demonstrate a statistically significant difference in effect. Case in point, Concerta maximum daily dose in the package information is 72 mg, although the U.S. adult trial went to 108 mg a day. However the trial protocols are not designed to answer the question “If you don’t respond to 72 mg a day, will you respond to 108 mg a day”.
Where am I going with this? I have several patients at what would be considered as very high doses of stimulant medication-methylphenidate 400 mg a day, Vyvanse 200 mg a day. Unsafe? Well neither patient complains of problematic side effects for which they would stop the medication. Also, blood pressure and pulse are in normal range. We got to these doses because lower doses didn’t have any effect until we went higher. In each of these cases, I have ordered stimulant blood levels to see if blood levels were too high. In fact, in each case the levels were lower that what was expected by mathematical extrapolation.
The point? There are a group of ADHD adults who are very fast metabolizers who will only respond to very high stimulant doses. Since most of the metabolism of amphetamines and methylphenidate occurs outside the liver, I’m not sure obtaining a liver P450 enzyme profile to determine metabolism will be useful.
If you have ADHD and have not responded to appropriate stimulant doses, then consider seeing an ADHD adult psychiatrist who has experience and comfort with this dosing concept. That’s what true expert clinicians are for.
American Professional Society for ADHD and Related Disorders (APSARD) is an organization founded by a national and international group of experts in ADHD treatment and research. The annual meeting, “ADHD Advances: Challenges and Opportunities” being held September 27 – 28, 2013 at the Hyatt Regency Washington on Capitol Hill in Washington, DC brings together these experts and other professionals interested in learning and advancing their skills. The presentations are the cutting edge research, treatment options, and technology developments to further our understanding of ADHD and the co-existing psychiatric and medical disorders. Information and discussions extend beyond U.S. research to include Canadian, European and Middle East research and treatments.
I am honored to be invited to present a 60 minute workshop on the “Choice and Optimal Dosing of Medications for Adults with ADHD” with my co-presenter Dr. Janet Standard, a psychiatric Advanced Practice Nurse at the NYU Health Services.
The conference is open to professionals in the health care field and registration is available now. . this link, you can browse the conference agenda, location, and hotel accommodations. This is a top-level, relatively small conference that allows all participants to engage and exchange thoughts and ideas. If you are in the field of ADHD, this is a conference not to miss. See you there.
Don’t miss this extra-ordinary conference on ADHD. CHADD has an annual conference open to patients and family, the general public, and professionals. The conference is held in a different location around the country. This year it is in our backyard in Washington, DC.
I’m honored to be invited to present a 3 hour lecture on “Treatment Options for Treating ADHD in Adults” with my colleague and friend, Dr. Anthony Rostain from the University of Pennsylvania.
This conference gives attendees the opportunity to speak with national and international experts, authors, researchers, and educators in the ADHD field. There is an enormous amount of information and resources available thereby making it a cost and time-effective way to gather “all you need to know about ADHD but were afraid to ask”. LOL
Also, for people who are new to ADHD, you’ll be assured that you are not alone. Imagine hundreds of people with ADHD that you can share experiences and helpful approaches.
I’m encouraging my interested patients and families to attend. I know that successful treatment progresses faster with educated patients and families. Hope to see you there.
As a follow-up to my blog on the new brain EEG “test” for diagnosing ADHD in children, a 2013 meta-analysis ( a review of all studies) research publication reviewed the individual studies on the use of EEG in children with ADHD. The NEBA study was included. The leader author of this study, Dr. M Arns at the University of The Netherlands concludes that EEG testing for ADHD is not a clinically useful test at this time. He explains his thoughts in a very recent piece for CHADD on their website.
Although the theta/beta wave ratio is different in ADHD children, there is too broad a range in this patient population to make the EEG test useful.
So, as I mentioned in my previous blog, be cautious if someone recommends this test “as a helpful way to make an accurate diagnosis.” As I have said before, let science be the designated driver on the highway of opinions.
With the increasing shortage of ADHD stimulant medications, Maryland Public Television invited me to a live interview by Jeff Salkin on Direct Connection with Jeff Salkin on January 30, 2012 Monday at 7:30 pm. I had been invited on his show a few years ago about adults with ADHD.
I will discuss the possible explanations for these shortages in addition to the large picture of drug shortages across all medication categories. As is frequently the case, there is no one cause. I hope to lay out the explanations. More importantly, I’ll offer suggestions to work around these shortages for you and your family members.
Join us this Monday night. I want to thank my patients who have offered their stories about the impact of the shortages.
Because of my recognized expertise in ADHD, I’m honored to have been invited to speak as a featured quest on Maryland Public Television’s program, Direct Connection with Jeff Salkin on January 30, 2012 Monday at 7:30 pm.
I will be addressing the stimulant shortage over the past several months-possible causes, the routes of manufacturing medications, the distribution of medications across the country, the sporadic availability of these medications, suggestions to physicians and patients on how to avoid shortages or alternative medications when shortages occur.
This problem now plagues those patients and family who use these medications in order to function at their highest level. The absence of medication may severely compromise ones ability to perform consistently thus increasing anxiety.
Join us and listen to my commentary and suggestions.
