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An Update On Medications Used In The Treatment Of Attention Deficit Disorder
by John Ratey, M.D.
The use of medication to treat adults with Attention Deficit Disorder is a happy
intersection of neuroscience and availability of a drug to fit the supposed
problem. To the best of our knowledge the major problem in the attention system
in the brain of the person who has the diagnosis of ADHD, or of ADD without the
H, is a difference in their dopamine system. Current research shows that there
may be as many as 13 different genes that vary from the so-called normal genes
that are involved in making up what we call the attention deficits. These genes,
which are called alleles as they are alternatives to the most common variety of
gene, are mainly involved with the dopamine system. This is reflected in the
fact that there is not enough dopamine around to support the system to work in a
consistent and predictable manner.
Thus the treatment for ADHD/ADD rests on the drugs we know as those which affect
the dopamine system: the antidepressants, the stimulants, and precursors that
may boost the effectiveness of dopamine. While most neuroscientists and
neuroscience wannabes are hesitant to reduce anything to a simple equation or
catch phrase we might be on fairly firm ground in saying that attention problems
may be seen as a dopamine deficiency. Thus the job of medication is to correct
this deficit and its associated problems like anxiety, depressed and demoralized
moods, overactive startle response, and the many problems with aggression and
addictions.
The use of stimulant medications is still the easiest and most accurate route
and the one that has proven to be the most efficacious for the greatest number
of people with the diagnosis of ADHD. Contrary to popular wisdom and media
perception, they are among the safest drugs. For instance, the only longitudinal
studies to date on adolescents show that rather than being a stepping stone to
addiction, the one robust finding is that those ADHD adolescents who took
Ritalin were less likely to have a substance abuse problem at the end of their
teens and early twenties. For the adult population this is also true. Most of
the patients who are treated with stimulants do very well and have little need
to escalate the dose once the proper level has been established. In fact, given
the pain that monthly prescriptions are for both physician and patient, I am
keenly aware of the fact that most adult patients use less and less stimulant as
time goes on rather than any creep upwards in dose which some fear may be the
quick step to problems with addictions.
The stimulants are usually the first choice as I have stated because they have a
positive effect almost 90% of the time and have fewer side effects than any of
the antidepressants. We are still confined to using three types of stimulants:
methylphenidate or Ritalin, amphetamine and its brothers and sisters known to
most as Dexedrine or Adderall, and pemoline or Cylert. All these medications act
by affecting the levels of dopamine at the synapse. Some release dopamine
directly, Ritalin and Dexedrine act also to block the reuptake mechanism, and
they also act to block some of the metabolic enzymes that hang around the
synapse to gobble up loose dopamine.
Pemoline (Cylert) is a long acting medication that takes a while to get to its
therapeutic action and thus it does not have an immediate effect like Ritalin or
Dexedrine. It also has a saga attached to its use of reported deaths due to
liver failure. While the circumstances and the real incidences of the number
versus the chance effect is yet to be fully detailed, as of yet it is considered
controversial as a first line treatment and recommended only as a second line
treatment by the FDA. Abbot Pharmaceuticals, the
company that produces Cylert, has not been aggressive in countering the
complaints and perception of the risk so that its use has dropped off and Cylert
probably will continue to be a second line choice. It is unfortunate as this is
truly the only all-day stimulant we have available. Clinical experience shows
that the longer the drug acts, the better and the closer it is to producing a
normalized attention span, a predictable state of consciousness, and a stable
inner core to interact with the environment.
I quickly realized when treating patients that the longer the medication worked
the better. One of the most important therapeutic actions is to try and produce
consistency in our patients’ brain functions. We try to help them achieve a
stable mood and attention function so that they begin to realistically
anticipate that each day will be like the next. The argument that the shorter
acting compounds offer more control over the attention system seems ludicrous
since for most patients the most troubling aspect of using stimulants is the
second or third dose, which they often forget. One of the major problems in the
ADDer is the ability to remember and plan - so that the need to take another
pill at a certain time, and to be aware of the decreasing effectiveness of the
medication as it wears off, is a huge problem. Secondly, the up and down effect
of the shorter acting agents can add to the disruptive inner state that the
patient has dealt with all of his or her life. The shorter acting stimulants
thus present problems with not getting to what I see as an important goal and
benefit of any treatment - stability and predictability of attention, mood, and
behavior.
Ritalin for all the media coverage has been the most used by most physicians but
I see it as the second line drug, because of its short action and because in my
experience it has more side effects than Dexedrine or Adderall. It seems to
affect the body more than amphetamine and gives people more muscle discomfort,
tenseness and the hibbey gibbeys. Its one advantage that is certainly intangible
is that for some it has more of a motivational edge, driving people to do their
work with a bit more intensity. But like many other aspects of medicine this is
a double-edged sword and can lead some to complain of robotic effects, lack of
flexibility, workaholic tendencies and the like. Ritalin lasts from 1 ½ to 3
hours in most people, and the SR preparation is no bargain in that it only seems
to last another hour or so. Furthermore the idea that people are getting 20 mg
of the slow release preparation is troubling as Paul Wender M.D. long ago
studied the Slow Release form and found that this 20 mg pill only gave the
equivalence of 7.5 mg of the quick release preparation.
The amphetamine compounds are longer acting, usually lasting anywhere from an
hour to two hours longer. The longer acting preparations like Dexedrine
spansules and Adderall definitely seem to work upwards of 4-6 hours for most
patients. But as with any drugs that affect the brain, there is no cookbook as
the variety in absorption, distribution, and metabolism system in each
individual makes it impossible to predict how each person will handle a given
drug. Then you have the fact that the target organ here is the brain, arguably
the most complicated structure in the universe and vastly different from one
person to another. Therefore, despite our need to reduce and control symptoms we
have to accept the fact that dosage, effectiveness, and side effects will vary
greatly. I have written that Dexedrine is "softer" than Ritalin and I
still find that to be the case. The amphetamine preparations have less side
effects, and their long acting preparations are definitely the real item. The
difference between Adderall and Dexedrine spansules in most patients is minimal.
However, there are some who have a much better response on Adderall than on long
acting Dexedrine. The reverse is also true but to a much lesser extent.
I am a big fan of using the antidepressants with patients as they have the 24
hour action that I believe is so critical. The problem is that they work less
well and in a smaller percentage of patients than the more popular stimulant
medications. First there are the tricyclics - they have been around for more
than 30 years and have proved to be invaluable and relatively safe as a
treatment for ADD and related problems. I traditionally use low doses of
desipramine (10-40 mg/day) in many adult patients as this has very low toxicity
and is effective in about 30% of patients. Joseph Biederman M.D. and colleagues
have written much about the use of desipramine, nortriptyline, and imipramine in
adults and children and have found them to be effective about 50% of the time,
though they use higher doses approaching what is recommended as treatment for
depression (150-200 mg/day).
There is controversy over the use of desipramine in children as to its side
effect on the heart's conduction system. There are a number of reports of sudden
death from cardiac arrhythmia in children using desipramine. The irritant effect
on the heart conduction pathway is reduced after adolescence. As in the case of
Cylert, if one uses statistics to look at the actual numbers of untoward
incidences of dire problems one would conclude that these drugs are not the
cause of the problem. However the availability of decent alternatives seems to
make the fears carry more weight and make the tricyclics second line treatments
in children, and for Cylert second line treatment in adults as well. These drugs
affect the norepinephrine and the dopamine system in the brain so again they act
to counter the suspected dopamine deficit.
Wellbutrin (bupropion) came out as a hoped for wonder drug that was touted as
the replacement for Ritalin. It blocks the reuptake of dopamine and should be an
effective alternative to the stimulants. It is long acting, now there is a
slow-release preparation, and it is was claimed to have fewer side effects than
the tricyclics. Unfortunately, the effectiveness that we find in the clinical
setting is not as happy as we had predicted and hoped for. It works well in
about 50% of cases but has many more side effects than any of the previously
mentioned choices. For use as an antidepressant, Wellbutrin typically is used in
doses of 300-450 mg/day. To treat ADD the dose varies greatly and I have found
that the new slow-release preparation marketed for smoking cessation (another
dopamine problem) has fewer side effects and may be easier for patients to use,
though effectiveness is still very variable.
Both of these antidepressants can be used with the stimulants and
synergistically they may help overcome side effects and deficiencies of each of
the agents if used separately. For instance, many people experience the rebound
effect of Ritalin and Dexedrine whereby the person notices a huge return and
worsening of their symptoms as the stimulant is wearing off and being
metabolized out of the system. The addition of an antidepressant which acts
throughout the day may help cushion this rebound effect. In like manner, the
targeted use of the stimulant while the person is on the antidepressant sharpens
the attention and focusing when it is necessary.
The newer antidepressant Effexor which is used in low doses, ½ of a 37.5 mg
pill twice daily, is useful for some patients. Higher doses often leads to
unnecessary side effects, and there is a problem for some in withdrawal of the
drug when the trial is finished. Remeron, the new antidepressant on the block,
is again mainly a dopamine and norepinephrine acting agent. A problem with
Remeron is that most people cannot wake up easily if they take the medicine.
Without a doubt this is the best sleeping agent I have ever used over the years
but the dose has to be low, low, low.
In summary, we have a number of medications which are proven effective in the
treatment of Attention Deficit Disorders. There are newer medications being
developed and undergoing clinical testing, including a long acting 10-hour
formulation of methylphenidate. We should always keep in mind the huge
variability between individuals as to how they respond to a particular
medication, dosage, or drug interaction. We should also keep in mind that
medication management of ADHD is a crucial part of a comprehensive treatment
plan, but may not be enough in itself for most ADDers. Medication should be
accompanied in most cases by education, behavioral therapies which address
developing better coping skills, and ADD coaching.
About the author:
John Ratey, M.D., is an assistant professor of psychiatry at Harvard Medical
School. He practices psychiatry in the Boston area. He is the author of Shadow
Syndromes, and the co-author of Driven To Distraction and Answers To Distraction. His new book coming out in the Spring of 1999 is called The
User’s Guide To The Brain. Dr. Ratey may be reached via e-mail at jratey@tiac.net
© 1998 National Attention Deficit Disorder Association
FOCUS Archives: A select article from FOCUS, Spring 1999, the newsletter of the
ADDA.
Therapy and ADD Coaching:
Similarities, Differences, and Collaboration
by Peter Jaksa, Ph.D., and Nancy Ratey, Ed.M., ABDA, MCC
Treatment for ADD/ADHD in adults has typically been defined in terms of
medication and therapy. Coaching is emerging as another form of help that can
benefit many people with ADD. The very notion of "coaching" leaves
many people scratching their heads in confusion, however. Most health care
professionals have at best a vague idea of what coaching is, what the benefits
are for the client, or how to work with a coach in a professional collaboration.
Many physicians, some of whom are even reluctant to refer people with ADD for
testing or therapy, are not likely to recommend to their patients something as
esoteric sounding as "ADD coaching." Medication alone is seldom if
ever sufficient treatment for ADD however. Many therapists who work diligently
with their clients on emotional issues, relationship issues, and behavioral
strategies to increase productivity, are perplexed to find that the therapeutic
goals are simply not being implemented on any consistent basis. The client’s
failure to follow through may be interpreted, quite inaccurately, as
"resistance" to treatment. A working knowledge of the benefits of ADD
coaching would allow all these professionals to be more effective in treating
their ADD clients.
Current therapies incorporate many types of cognitive, behavioral, and
analytical approaches to help individuals gain insight and understanding, deal
with painful emotional problems, and overcome self-defeating beliefs and
destructive behaviors. Therapy focused on ADD behaviors typically needs to be
quite pragmatic and behaviorally oriented. As many have pointed out, the problem
with ADD is not one of desire or motivation but of follow-through and
achievement. The struggle all too often is not doing those things which the
person knows must get done! Insight by itself is practically useless if not
accompanied by a behavioral treatment plan that addresses specific problems and
provides specific strategies to deal with those problems. Even the behavior
therapies have limits when it comes to helping individuals with ADD who live in
the moment, respond to the immediate, having difficulty anticipating and looking
ahead, or simply forget what the behavioral goals were from a few days ago. This
is where effective ADD coaching can take planning, organization, pragmatism, and
accountability to another level.
Essential Elements Of Coaching
What exactly is ADD coaching? At present the parameters of this emerging field,
which is a specialty area within the broader field of personal and professional
coaching, are still being defined. In a nutshell, coaching involves an ongoing
relationship between a coach and client that is very goal-driven, structured,
and focused on helping the clients actively create practical strategies to
accomplish specific goals and also develop general skills to be more effective
in their daily lives. The coaching relationship is highly individualized, focus
on the particular needs of the client, and might encompass many areas of the
client’s life: work, exercise, nutrition, stress management, social and
recreational needs, and so on. Unlike therapy, where the professional brings a
particular orientation and set of therapeutic skills to apply to the problems at
hand, the coach and coaching client mutually agree on what approach might work
best for the particular client. As in therapy, a coaching relationship is safe,
respectful, and supportive for the client, never coercive or punitive. A coach
helps the client understand how ADD impacts behavior, rallies the client’s
motivation and active involvement in making changes, and elicits creative
strategies to serve the needs of the client.
Very specific goal setting, planning, and strategies for organization and
managing time are put into place early in the coaching process. The coach takes
an active role in terms of offering suggestions, keeping in mind that goal
completion is paramount along with skill building. Although there is no set
model, contact between coach and client typically takes place a number of times
during the week to allow for monitoring and encourage accountability on the
client’s part. A weekly meeting of 30 to 60 minutes, conducted in person or by
phone, is supplemented by shorter phone calls and even e-mail messages to report
on progress.
The coach takes on a very pragmatic, hands-on approach. He or she may
collaborate with a professional organizer who goes into the client’s home or
office to help the person better organize and use physical space. Any ADDer who
has lived with clutter and disorganization can appreciate the value of that!
Coaches may help clients organize working areas, living areas, set up storage
and filing systems, even organize bedroom closets. Setting priorities, clearly
defining goals, and allocating time on a weekly planner for each required
activity is a basic strategy that almost all ADDers benefit from. Keeping on top
of one’s schedule to the point that routines get established takes time and
lots of effort. Again, having contact with a trusted ally several times during
the week helps the client remember and follow through on planned activities.
This is helpful for most people, but crucial for ADDers.
Similarities Between Coaching and Therapy
A therapist and a coach each establish a helping relationship with a client,
with the general goal of helping the client to grow and to live a better life.
The working relationships must be supportive, respectful of the client’s needs, and free of manipulation or
abuse. Confidentiality must be respected
within the therapeutic or coaching relationship. Both therapist and coach get to
know the client over time, help them assess priorities and goals, and help the
client pursue those goals. Both approaches require a client who is open to
change and willing to make changes in how things are done.
Both coaching and therapy deal with feelings and beliefs to some degree, but at
very different levels. A therapist commonly helps the client work through very
painful feelings and negative or self-defeating beliefs and behaviors. A coach
does not get involved with emotional, cognitive, or behavioral problems of
clinical intensity (depression, anxiety disorders, personality disorders,
addictions, etc.) but must refer the person to a therapist to help deal with
these issues. Feelings do play a part in the coaching relationship however, and
may involve frustrations, fears of failure, avoidance behavior, and loss of
confidence. These feelings can be dealt with in the course of the coaching, in
terms of what motivates the client’s behavior and helps or hinders goal
achievement. The client’s experience of overcoming past obstacles to success,
and piling up a series of successes, may in itself produce some benefits in
terms of heightened self-esteem and a reduction in stress, anxiety, and worry.
Certainly these may be viewed as therapeutic benefits even though the intent was
not to provide therapy.
Some Essential Differences
Therapy is by nature a mode of "treatment," involving the application
of therapeutic techniques and remedies to relieve problems related to a disorder
that fits within DSM-IV diagnostic categories, as well as to deal with problems
of daily living. Licensed therapists earn an advanced degree in a formal
training program, and must pass a licensing exam in their state.
Coaching is based more on a holistic or "wellness" model, intended to
improve daily functioning and well-being for individuals without significant
psychological impairment. This places coaching more in the realm of an
educational process as opposed to a treatment process. There are no training
programs for coaches in colleges or universities, no formal degrees, and no
oversight by state licensing boards.
Coaching has limited benefit, and may be very inappropriate, for individuals
with significant emotional or psychological problems. If those problems are
evident at the start of coaching, or develop later on during the coaching
process, the coach will refer the client to a therapist. This requires that a
well trained coach has a general knowledge of psychopathology and is able to
recognize when he or she is faced with a problem for which coaching is not
appropriate. A close working relationship with a therapist helps to clarify
diagnostic issues.
Coaching is more flexible. Much of the work may be done over the phone, since
the emotional component of therapy that requires in-person meetings is not an
issue with coaching. A coach in Boston may work with a client in Denver and
never meet in person, yet the coaching can be very effective. The exception to
this is when the coach works with children or adolescents, who do require
in-person meetings. A coach-client contact may involve a five minute phone
update, or an e-mail confirmation that a goal was accomplished. A coach is able
to take a more holistic approach that takes into consideration any issue which
effects daily living: productivity, the work and home environment, diet,
exercise programs, managing time, basic financial management (are the bills
getting paid?), sleep, and so on.
A very practical consideration for many people is that therapy is covered by
health insurance, whereas coaching is not. Many coaches charge fees that are
similar to what therapists charge.
When Collaboration Is The Solution
There are instances when it is in the client’s best interests for a coach to
refer the client for therapy, for a therapist to refer the client for coaching,
and for coach and therapist to both work with the client in a collaborative and
cooperative manner. As noted above, a coach will refer a client for therapy if
the client is experiencing significant emotional problems related to depression,
anxiety disorders, issues of abuse or trauma, personality disorders, angry or
violent outbursts, rapid mood swings, addictions, and other such problems.
Therapy may also be indicated during periods when outside life factors interfere
with the client’s ability to function and more psychological support is needed, for example during a
divorce, separation, death in the family, serious illness, and so on.
As more and more awareness grows about the sometimes pervasive effects of ADD on
the personal and professional lives of individuals, many therapists consider
other approaches that help with managing ADD. Regular exercise is known to
produce significant benefits. The services of a professional organizer can be
very helpful with structuring the work and home environment to reduce clutter
and reduce disorganization. Many therapists are referring to coaches so that
they can help the client clear the behavioral "clutter" and allow the
therapist to focus more on core therapeutic issues.
A therapist might consider referring a client to a coach for a number of reasons. When a client has difficulty following through on the goals set in
therapy and the problem is not getting resolved in therapy, a coach can help
therapy be more productive. The coach is able to provide more frequent contact
with the client, set up more structure in the client’s life to help address
the therapeutic goals, and improve follow-through. Coaching can also be very
helpful when the client needs to learn specific skills such as creating time
lines, setting up more structures, and can benefit from the increased
accountability that comes from frequent coach-client contacts. When a coach and
therapist are both working with a client they need to maintain regular contact
to monitor progress and ongoing problems. They must also work together to keep
the boundaries clear, making sure that coaching issues are handled by the coach,
and therapy issues by the therapist.
Some therapists have incorporated limited coaching techniques into their
practice to better help the client with ADD. Some example might be to keep lists
of issues to be worked on, give written homework assignments, and ask the client
to check in during the week to report on progress and follow-through. It is more
common for therapists to go into the coaching realm or use coaching tools, but
this is not reciprocal. Coaches are not qualified, nor can legally adopt
therapeutic tools or techniques in their coaching, unless the coach becomes a
licensed therapist. The most useful combination of techniques occurs when the
therapist and coach are separate individuals and have a solid, complementary
working relationship. Both need a clear understanding of the goals each will
pursue in working with a client.
About the authors:
Peter Jaksa, Ph.D., is a Clinical Psychologist in private practice in Deerfield,
IL. He is President of ADDA. He is the author of 25 Stupid Mistakes Parents Make
(Lowell House Press/NTC Contemporary, 1999). Dr. Jaksa may be reached at
e-mail address: DrJaksa@aol.com
Nancy Ratey, Ed.M., ABDA, MCC holds a master’s degree in administration
planning and social policy from the Harvard Graduate School of Education, is a
Master Certified Coach and is the Immediate Past President of ADDA. As
co-founder of the AD/HD coaching field, Nancy is widely recognized as the leader
of on-going efforts to develop and advance the coaching profession. She is
frequently featured in the media, lectures nationally and internationally,
writes extensively on coaching including co-authoring 2 books and, contributing
chapters on coaching to many other texts. Known for her high energy and
directedness, Nancy branded “Strategic Life Coaching” to reflect her own
unique style and philosophy towards coaching. This method of coaching is geared
towards high achieving senior executives and professionals with AD/HD. Nancy
lives in Wellesley, MA with her husband and 3 dogs.
For information and
resources please visit: www.nancyratey.com
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