How I Evaluate and Treat Adult ADD

The following are the steps in my evaluation and treatment process for adult ADD.  Click on any step to go directly to it.  For clinical examples, click here.

If the diagnosis is ADD, we discuss treatment options

I make sure there are no reasons why the patient should NOT take ADD medications

I discuss medication options and suggest a specific medication to treat the ADD

I tell the patient how to take the medication and give printed instructions

We make plans for the next visit and for any questions that might come up before then

Early treatment management

Long term follow up

First, I make or exclude the diagnosis of ADD

1. It generally takes me one, but sometimes two, fifty minute sessions to evaluate someone for ADD and begin treatment.  
2. To determine whether a person has ADD and help in treatment planning, I first have him or her fill out a set of questionnaires.  I then take a psychological and medical history and observe the patient's behavior during the interview.  With this information, I determine whether the person has an attention deficit and/or executive function disorder that seriously interferes with his or her work, studies, interpersonal relationships, and/or feelings of self-esteem.  (Executive function disorders are problems in a person's ability to concentrate, organize, work efficiently, and remember.  In ADD the problems largely have to do with attention and verbal memory.  However, patients with ADD are much more likely to have executive function disorders.  People with both are much more likely to have more serious educational and vocational problems.)  
3. I review the information I have obtained so far to determine whether the person's executive function problems may be caused by something other than ADD, for example a medical problem, a psychiatric problem (depression, anxiety, obsessive compulsive disorder, and others), stress, alcoholism, or a learning disorder.  If I find the person suffers from one of these, I discuss with him or her how these problems can be further evaluated and, if I am not expert in the condition, refer the patient to a specialist in that disorder.  
4. If I can find no other cause for the ADD/executive function disorder, and if the person has a life-long history of such problems, and if the symptoms are severe enough, I make the diagnosis of ADD.  If I conclude that the person does have ADD, I discuss ADD's causes, treatment, and prognosis, and answer any questions.
5. If I think medication may helpful in treating the ADD, I first decide whether a co-existing disorder should be treated first.  For example, if a person is depressed, and it is unclear whether the depression or the ADD is disrupting the person’s concentration and focus, I will usually treat the depression first, sometimes with medication, sometimes with psychotherapy.  If the depression gets better, but the concentration and focus problem persists, I usually consider adding an ADD medication.

I discuss treatment options with the patient, including medication and behavioral skills training

1. If no other conditions are present (or if they have been successfully treated), I discuss with the patient the various options for treating ADD. If I think that medication is a reasonable option, I ask whether he patient would like to explore its use.  I also may suggest behavioral skills training.  There are certain basic skills that all people with ADD need to master.  These include how to effectively use a day planner, a to-do list, a calendar, and a reminder system; how to maintain a bill paying system, how to plan and manage a project (e.g. a party, a trip), how to make and achieve goals, how to set priorities and keep to them.   Other skills are more tailored to each patient's individual needs and might include time management, managing conversations, memory aids, arriving at work on time, study skills, keeping an orderly work space, etc. 
2. If the person would like to explore the use of medication, I present the pro’s and con’s of doing so and answer any questions the  patient may have.  We then discuss any personal reasons the patient might have for not taking medication for ADD, for example, fears of addiction, concerns about personality change or dependency, etc.  If, after this discussion, they are comfortable with the notion of taking medication for ADD, we begin an exploration of what medication might be helpful for them.

If medication will be considered, I make sure there is no reason not to use medication

There are stimulant and non-stimulant medications used to treat ADD.  The stimulant medications appear to activate certain parts of the frontal lobes of the brain that are concerned with planning, organizing, and remembering.  It is also thought that they stimulate parts of the brain that filter out unnecessary stimuli like unimportant noises, visual images, and ideas.  This reduces the clutter in the executive brain and lets people function more smoothly.  

But in some people, these medications can also stimulate the heart and activate a person so much that he or she may feel jittery or have difficulty sleeping.  Some people have none of these side effects, even on high doses, but some have them even with fairly low doses.  It is currently impossible to predict any individual's response so careful trial and error with any medication not taken before is usually the best approach.

1. If the patient wishes to try medication for ADD, I take the patient’s blood pressure and pulse.  I do this to be sure that there are no obvious cardiac abnormalities that may make it unwise for them to take medication for their ADD.  I also record their pressure so if they do start taking medication, I can see if it is affecting their heart and blood pressure.  Some  people develop a slight increase in pressure and pulse while taking medication.  Uncommonly, some people have a more serious increase in pressure, the medication must be stopped.  (I have treated had some overweight patients with high blood pressure who lost weight while taking a stimulant medication and as a result had their pressure return to normal.)
2. If blood pressure and pulse are normal, I review whether the patient has taken medication for ADD in the past and with what effect.  If they (or a blood relative) has achieved a good response from a particular medication, I am likely to prescribe that medication again. 
3. I describe and discuss the non-medication treatments for ADD which might be tried instead of, or along with, medications. 
4. I explain that in my experience one medication or another helps about 80% of adults with ADD and that any one medication has about a two-thirds chance of helping.  With the stimulant medications, it is clear within a week or two (sometimes within a day or two) whether the medication will help.  However, with the non-stimulant medications, it may take three to six week to be certain whether they do or don't work.
5. I inform the patient that if the first medication we try does not work, we can try others.  If no one medication works alone, we may try a combination of medications.  Since it can take up to six weeks to be sure that one medication will not work, it may take three months or longer to find the right dose or combination.  Patience and perseverance may be required.

I Suggest a Specific Medication

1. If the patient, with this information, would like to start treatment with medication, I suggest a specific medication for the patient to take.  Until recently this had been Adderall, but I have found that Vyvanse offers two major benefits over Adderall.  It lasts longer, typically ten to twelve hours, and its effect remain fairly constant throughout that period.  (It is difficult to maintain a steady effect with the short acting medications as each dose lasts only 3 to 4 hours, and sometimes the effects of long acting Adderall varies over the course of a day.)  I have changed many patients from Adderall to Vyvanse with very good results.  Almost all have preferred the Vyvanse.   (For more information about Vyvanse, click here.)
2. If a patient is taking brand name Adderall, after the proper dosage is established I may switch to a generic if the patient does not need (or cannot afford) a long acting compound.  My next choice of a stimulant is methylphenidate (Ritalin, Concerta, Focalin and others.)  I will use these if the patient had trouble sleeping or gets too jittery while taking Adderall.  It causes some patients to get irritable., especially as it wears off.  My next choice is Dexedrine: its long acting form seems to last only 4 to 6 hours.
3. My second line treatment for ADD is Strattera and rarely Wellbutrin, Effexor, or Provigil.  These are generally not as effective as the first line treatments, but for a few people, Strattera works better than the stimulants (Vyvanse, Adderall, Ritalin, etc).  I use second line treatments only when the first line medications have not worked or when it appears that depression and anxiety may be contributing to the ADD symptoms, since the second line medications all have anti-depressant and anti-anxiety effects.  The Eli Lilly company has mailed a "black box" warning to physicians that two patients (of over a million) taking Strattera developed severe liver problems.  Fortunately neither of them required transplantation.  Patients taking Strattera should be aware of the early symptoms of liver damage such as jaundice, pain inside the right lower rib cage (where the liver is), flu like symptoms, and dark urine. (For information from the manufacturer, go to Strattera.com.) If you are being treated with Strattera, consult your physician about this development to get more information and to determine what course of action to take. 

I give my patient instructions on how to take the medication and provide printed instructions

1. I tell the patient when to take the medication, what foods or other medications might affect its metabolism, what side effects are typical, what side effects should prompt the patient to call me, and what drug interactions to avoid.  With the patient, I draw up a list of  “target symptoms” for which the medication is being prescribed.  I discuss how to (and how not to) judge whether the medication is working. I discuss what changes to look for when starting the medication or increasing the dose.
2. I give the patient a print-out of the side effects of the medication prescribed and of the dosing schedule.
3. If I have prescribe a controlled medication like Vyvanse, Adderall, Ritalin, or Dexedrine, I explain the issues regarding  prescriptions and refills for controlled medications. (Some of these differ from state to state but all require written, not called in, prescriptions and refills.)
4. I review my policies (which had been outlined by my secretary before the patient’s first session) regarding refills, cancelled or missed appointments, reaching me with urgent problems, payment arrangements for sessions and for reports for schools or lawyers that may be requested.
5. I ask if the patient has any questions about the treatment plan and answer them.
6. I give the patient a prescription for the prescribed medication.  If they will be paying for their medication out of pocket, I give them a list of prices for ADD medications charged by various pharmacies in the local area.  (In some cases, these differ significantly from pharmacy to pharmacy.)

We make plans for the next visit

1. I give the patient instructions to call me in a week or so to report on his/her progress and to call sooner if there are any problems.
2. I give the patient an appointment to see me in about two weeks.  I have the patient write down the appointment time or give him/her an appointment card, since forgetfulness about appointment times is common in ADD.  I arrange to have my secretary call the patient the day before the scheduled appointment with a reminder.
3. If the patient is taking a stimulant medication, I have the patient start the medication at a low dose and slowly increase it every three days or so until he/she achieves a satisfactory response or it is found not helpful.  During the time the patient is slowly increasing the dose, I remain in contact by visit or phone every week or two.  I encourage the patient call me between sessions if there is a pressing question.
4. I have the patient complete a chart scoring how effective the medication is being on an hour-by-hour basis throughout the day.  This helps me adjust the timing of doses throughout the day.

Early treatment management

1. We meet as scheduled and, if a positive response has been obtained, I make any necessary adjustments in the dosing and timing of the medication, and deal with any side effects. 
2. I check to be sure there have been no significant change in blood pressure or pulse.
3. Most patients respond adequately to a dose of stimulants of between 15 mg and 50 mg per day but some require less or considerably more.  Most people find doses above this uncomfortable and are very unlikely to take more than they need.
4. If the patient has not had a satisfactory response to 60 mg per day and has no disturbing side effects, I discuss the risks and benefits of further increases, pointing out that higher doses have not been approved by the FDA but have been found helpful in many cases.  I discuss the fact that many clinical specialists suggest a maximum dose per day of between 3/4 mg and 1 mg per pound of body weight (e.g. 120 to 160 mg per day for a 160 pound person.)   I also discuss the fact that higher doses are more often associated with more side effects, including increases in blood pressure.  If trying a higher dose is acceptable to the patient, I slowly increase the dose, stopping the increase when an optimal response has been achieved or if there are unacceptable side effects.  If the response is not satisfactory at the maximum dose, I stop the medication and consider starting another.
5. Once a satisfactory response has been achieved, I meet with the patient in two to four weeks to make any further adjustments.  It may take as long as six weeks to be sure a medication works satisfactorily at a particular dose, and three or four medications may need to be tried to find one that works best.
6. The management of treatment sessions for patients with ADD is very important.  Patients' distractibility and lack of focus can make sessions disorganized and run over-time if not handled properly.  I think you will find it helpful to read the page on this site, ADD and Psychotherapy, even if you not doing psychotherapy with the patient.  It contains a number of helpful suggestions about how to manage treatment disruptive behaviors that are often seen in patients with ADD.

Follow up sessions

1. If there are no other psychiatric or therapy issues that need addressing, I schedule appointments no more ofen than every three months or so to check on the patient’s psychological and medical condition, on his or her response to the medication, to make sure the medication is being taken as prescribed, and to make any necessary adjustments in the dosing.  I give patients a questionnaire to fill out before the next session (see below).  This is not necessary but it can save time and allow you to pace your sessions rather than finding yourself having to deal with unanticipated issues just as the session is about to end.

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