Entries in ADHD (7)



Questions are sometimes raised about exceeding the maximum recommended doses of medications used to treat ADHD. I have reviewed the research studies for these medications and it is clear that the studies were to determine efficacy and were not dosing studies.  Specific doses were chosen to assess the benefit and minimize risk of side-effects.  Once efficacy was determined the study ended and there was no motivation to do further studies addressing the range of doses that were therapeutic. Thus, doses involved in efficacy studies can be mistakenly seen as being studies to determine limits of what is therapeutic. The studies could not recommend a different dose because they did not assess different [higher] doses.  Also, each person is unique and this uniqueness can include how they respond to medications with some people responding to higher doses and others to lower doses. The U.S. Food and Drug Administration recognizes this when they state “the dosing regimen [for stimulant and related medications] is adjusted according to a patient’s individual response to pharmacotherapy."

I believe that it is important to work with my patients to assess their response to medications and in collaboration with them determine an optimal dose. At times this dose may be higher than is “recommended.”  I hope that it is clearer now why this is the case and why it is necessary to prescribe higher doses for these patients.




Recently my business manager noticed that a question was raised about my prescribing Lamictal [lamotrigine] for a 9 year old girl.  I realized then that I needed to clarify why I made this choice.  I have blogged about it in the past but I felt that I needed to write about it again.

Lamotrigine was introduced as an anticonvulsant [antiseizure] medication and received negative publicity after some people who were taking it developed a very serious rash that led to a Stephens Johnson reaction resulting in the death of a few people.  It was prescribed for people with very serious and dangerous seizures and as is typical for this type of problem, the dose was maximized in a couple of days.  These people were also taking valproic acid [also an anticonvulsant] and this medication more than doubled the serum level of the Lamictal that had just been rapidly increased leading to extremely high serum levels and the serious rash.  It had also been noted that Lamictal seemed to be very effective in stabilizing moods.  The FDA [Federal Drug Administration] only allowed Lamictal to be used for moods after very extensive testing on thousands of people with the development of a titration protocol that insured that it would be tolerated without a serious rash.  It has since been prescribed and found to be safe and effective.  It is prescribed for mood swings after they have been partially stabilized and is helpful in preventing the swing into depression that plagues people with mood swings about 80% of the time.  

I began noticing that people who had been struggling with the impact of untreated attention deficit hyperactivity disorder [ADHD] were often irritable and reacted to minor situations with frustration.  This frequently continued even after their concentration and attention was improved with medication.  Then someone that I was treating who was experiencing the irritability and reactivity was prescribed Lamictal for headaches and the irritability and reactivity were significantly reduced and were elimiinated with a further titration of the dose of Lamictal.  I then began prescribing Lamictal and found it to be effective in treating the irritability and reactivity.  I would suggest that the Lamictal be continued for a year and then discontinued and there would be no return of those symptoms. I have also found that if I slowly increase the dose, Lamictal is tolerated well. Occasionally someone will develop a small rash on their arm or face and this seems related to the body adjusting to the medication and is not an allergic response.  I will reduce the dose and have a slower increase in dose and the rash goes away and does not reappear.  [The brain's need to adjust to the presence of the medication and then the absence of it is a topic for another blog].

To summarize, I have found that Lamictal is a safe and effective medication to help reduce the irritability and reactivity that can occur because of the stress of untreated ADHD.  I have wondered if these symptoms are related to the brain's attempt to reduce the demands for concentration and focusing by causing people to remove themselves from interacting with others because of the irritability and reactivity that they experience when interacting with others.  It seems to me that interacting with people requires a considerable amount of focusing and attention. What do you think?



I recently took care of an adolescent boy in the hospital who had severe anger control problems and had become suicidal.  He was hurting himself as he hit things and broke things instead of hitting people.  He also was very impulsive and driving recklessly.  He would become stuck on one thing and not be able to stop thinking about it and would then get very agitated.  He did fairly well in school [A and B student] but in talking to him he related that he had to work hard to stay focused in school and was often exhausted after school.  In addition, he always completed school work at the last minute.  He was irritable every day and would become angry even over small things, especially after he had been in school.  His daily irritability and anger outbursts alerted me to the possiblility that his irritability was due to the stress of his ADHD symptoms vs being caused by mood swings where the irritability and anger would be episodic. His anger was so intense that his primary care physician was treating him with two atypical antipsychotic medications and lorazepam.  He would be calmer for a couple of hours and then the anger would return.  I was sure that a lot of this adolescent's anger was related to his untreated ADHD.  His anger would have made his primary care physician afraid to treat his ADHD if he had recognized that he had that diagnosis.  Even though the adolescent did well in school, he struggled every day to concentrate and he procrastinated.  As I have mentioned before, everyone I have evaluated who procrastinates has ADHD or ADD.  Other people without concentration problems may try to procrastinate but the deadline pressure makes it hard for them to complete the work.  

I decided to treat this adolescent's ADHD even with his severe anger problems. He responded rapidly with improved concentration and significantly improved anger control.  He said that he felt "calmer" and more "even" without the irritable reaction to minor stresses.  He still was reacting to some stresses that had been very intense for him.  Because of the degree of anger that was still occuring, I decided to treat him with Depakote ER [vs Lamictal] as he needed more rapid help with the anger. His improved concentration abilities and lowered irritability helped him to learn DBT coping skills that are taught as part of the treatment program on the Copestone Adolescent Inpatient Program.

I have previously blogged about the importance of diagnosing and then treating ADHD in adolescents [or children or adults] who are irritable every day as this will significantly lower their irritability.  I wanted to write about the above adolescent because even with severe anger control problems, treating the ADHD is critical to helping the adolescent gain control of their anger. 



Jason Fletcher from the Yale School of Public Health published a study showing some of the economic impact of childhood ADD/ADHD on the adult labor market.  Using data from the National Longitudinal Study of Adolescent Health, Dr. Fletcher shows that employment is reduced by 10-14%, earnings are reduced by one third and the need for public assistance is increased by 15% for adults who were diagnosed with ADD/ADHD as children.  There was also an indication that the earilier the diagnosis the greater the impact. Dr. Fletcher believes that treatment of ADD/ADHD can lesson the impact on employment and other negative effects of childhood ADD/ADHD.

Related to the question if treatment of ADD/ADHD will reduce negative outcomes as adults, Lichensteinet al., in the November 22, 2012 issue of the New England Journal of Medicine published findings indicating that treatment of ADD/ADHD can lower the rates of criminal behavior.  These findings held up looking at the pooled data and if looked at on an individual basis.  The authors believe that this shows that treatment of ADD/ADHD lowers the risk of criminal behavior and likely lowers the risk of other negative outcomes from untreated ADD/ADHD such as the employment rate as discussed above.

An epidemiologic study of ADD/ADHD by Costello and Angold out of Duke University and published in the Archives of General Psychiatry in 1996, using children from western North Carolina, showed that ADD/ADHD was underdiagnosed and undertreated.  This would seem to underscore the importance of identifying children who have ADD/ADHD and providing effective treatment in order to prevent negative outcomes as adults, including lower employment and criminal behavior.



A number of behaviors that are frequently found associated with people who have ADHD, seem to be coping strategies.  Thus these behaviors help to reduce stress associated with ADHD even though they may appear to be symptoms of the disorder and a part of the problem.

One behavior is procrastination.  Deadline pressure seems to help someone with ADHD to complete a task. It appears that the brain of someone with ADHD. has to use energy that is usually reserved for emergencies or novel learning activities to concentrate and focus.  Their brain is reluctant to do this and it seems that deadline pressure convinces their brain to use this energy to focus at least for a limited period of time. That may be why people with ADHD are more successful using procrastination to complete tasks than other people are.

Another behavior is irritability.  Irritability occurs around people and may be held in check and not revealed to others.  The irritability is not part of mood problems and seems to serve to remove someone with ADHD from the presence of others.  This reduces stress as interacting with people requires a lot of concentration and attention.  

An additional behavior is a tendency to interrupt others.  This "impulsive behavior" is necessary to pass on some information that the person with ADHD will very likely not be able to remember if they wait until it is their turn during the conversation.

Additionally, people with ADHD have to use a different part of their brain to concentratea and the energy used to concentrate is depleted rapidly.  Thus later in the  day, when the child with ADHD is with their family or the adult with ADHD is with their significant other or spouse and/or children, the person with ADHD will have very little concentration left and will likely be quite irritable if they have to interact with others or they will isolate themselves from others.

Obviously, the above coping strategies frequently leads to stress in relationships, unhappiness and feelings of being a failure.  

These coping strategies are not necessary [but may persist] after medication treatment has begun along with cognitive and behavioral strategies.  Thus treatment can relieve a lot of stress that the person with ADHD experiences before treatment.