ADHD Diagnosis & Management

[Therapist4Chnge]

The recent ADHD-related threads just disappeared from here and the psychiatry forum (?), so here is one that I won't delete.

RE: to "therapy" for ADHD

Therapy...no. Behavioral interventions, parent training, and skills development,..yes. These interventions most likely won't replace med interventions for true ADHD cases, but they often can help with limiting the frequency and amount of req. meds. I worked on a study back in the mid-00's involving behavioral management in the classroom, and when done consistently and w. parental training we saw positive results. We didn't look specifically at meds v non-meds, but anecdotally I found that meds helped, but the kids still needed to be "steered" in the right direction or they'd struggle just as much as non-med kids.

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[psychRA]

The recent ADHD-related threads just disappeared from here and the psychiatry forum (?), so here is one that I won't delete.

I believe the OP upgraded to a paid SDN membership so that they could delete their own threads. Kinda annoying, IMO.

 

[PikminOC]

i already had the GOLD membership...this was the first time i decided to exercise the delete
i got the gold membership as a thank you to SDN when I passed my oral board in psych a few months ago.

i read everything you posted psych RA and it means alot to me.

 

[PikminOC]

The recent ADHD-related threads just disappeared from here and the psychiatry forum (?), so here is one that I won't delete.

RE: to "therapy" for ADHD

Therapy...no. Behavioral interventions, parent training, and skills development,..yes. These interventions most likely won't replace med interventions for true ADHD cases, but they often can help with limiting the frequency and amount of req. meds. I worked on a study back in the mid-00's involving behavioral management in the classroom, and when done consistently and w. parental training we saw positive results. We didn't look specifically at meds v non-meds, but anecdotally I found that meds helped, but the kids still needed to be "steered" in the right direction or they'd struggle just as much as non-med kids.

So where can I refer my adult patients to for behavioral interventions? Or should meeting with me suffice?

 

[deleted176373]

So where can I refer my adult patients to for behavioral interventions? Or should meeting with me suffice?

Not to sound flippant, but are you skilled in providing those behavioral interventions?

If you feel the answer is yes, then perhaps that is sufficient. If you feel the answer is no or that the particular client needs additional help, then referral to another provider who specializes in behavioral interventions for ADHD might be appropriate. Giving specific advice for any client here would be inappropriate. What is important though is being able to know the limits of your competence to provide care.

If you feel you're outside that sphere, then either consult with colleagues or refer out. It's tricky to accurately self-judge your competence. Even then consulting with colleagues is always a safe bet.

Good luck!

M

 

[weeblewobble]

How much is known about ADHD/ADD in adults, and how to rule out attention issues due to those disorders (and related etiologies, I guess) versus other things like mood, substance use, Axis II, acquired injuries, etc.? From what I understand sustained attention tasks really don't cut it, but I'm not aware of better alternatives.

 

[PikminOC]

I don't feel like I can manage the behavior management so I recommend therapy for my patients regarding this.

I know my limits regarding this particular diagnosis.

 

[futureapppsy2]

I don't feel like I can manage the behavior management so I recommend therapy for my patients regarding this.

I know my limits regarding this particular diagnosis.

Then you may want to refer to a psychologist with experience in behavioral interventions for ADHD if your patients are willing and you think it could help them.

 

[PikminOC]

I do think it will help them. but some people want the meds only. i try to educate them re the meds and ask what the end point will be...they become more tolerant...and more tolderant.

 

[Doctor Eliza]

I believe the OP upgraded to a paid SDN membership so that they could delete their own threads. Kinda annoying, IMO.

Why did you do that, OP? The thread might have been helpful to others. That is the spirit of this board.

Dr. E

 

[PikminOC]

I guess im kinda paranoid with what happened on the preallo thread 'public apology'

 

[LivingOffLoans]

I do not have much expertise in this area, so when a patient presents with these concerns, I work with them realistically with what I've got. If their symptoms are interfering with work/school, I teach mindfulness stuff and do some psychoed around planning their days with a schedule. As is typical with other clients, I also provide a supportive relationship with me where they can feel understood and validated. Beyond that, when their concerns are beyond my scope of practice, I help them in locating resources where they can get the expertise they are in need of, but always leave my door open for them to come back if they feel I can be helpful.

 

[psychRA]

I do think it will help them. but some people want the meds only. i try to educate them re the meds and ask what the end point will be...they become more tolerant...and more tolderant.

As Therapist4Change mentioned earlier in the thread, one of the big problems with "therapy" for ADHD (which is actually very structured behavior management and skills training, and not what you may think of us traditional talk therapy) is that it hasn't been shown to be as effective as medication. This is especially true for adults. You can't really treat meds and therapy as equals when it comes to ADHD. If you're dealing with an adult who has done the skills training, applies those skills to the best of their ability, and is still struggling with symptoms, a meds-only approach doesn't seem unreasonable. If a patient has already gotten the maximum benefit from a particular therapy, it's unethical for us to continue it, so I don't know that it's common for someone to stay in ADHD skills training for years and years.

Can anyone confirm that tolerance is an actual problem for patients with ADHD who take meds as prescribed? Stimulants tend to have a pretty short half life, and patients are often encouraged to take "med vacations" on days when they don't need them, so I'm wondering if it's true that people automatically become more and more tolerant. I mean, other than the initial titration, you don't hear about patients having to take more and more antidepressants, or antipsychotics.

 

[PikminOC]

What happened? I think the thread delete feature (rather than just editing posts) is rather annoying for those who took the time to post in the deleted thread, although I also understand the value of having the option to squash something you posted for various reasons (which in some cases could include an entire thread).

Maybe they have another SDN membership to resurrect your thoughts. Ask the mods.

These medications are Controlled Subs Schedule 2 for a reason.

 

[PikminOC]

I wasnt trying to be an arse. The badges are new and understandably annoying. I dont know what other powers are possible but telling the mods will at least create documentation.

what is lolwut?

the schedule 2 remark was to someone else asking about the tolerance and addictiveness of amphetamines.

 

[PikminOC]

i found out waht lolwut means.

im not upper anything..just a bc psychiatrist.

im from america..i spelled arse bc i dont want to get in trouble again on sdn

tone cant be conveyed but i was really trying to get the point across that the badge thing is new and fluid.

 

[deleted176373]

These medications are Controlled Subs Schedule 2 for a reason.

Seriously... Let's look at Schedule II vs Schedule I, III, IV, etc.

Schedule I drugs are substances that "have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse."

Schedule II substances "have a high potential for abuse which may lead to severe psychological or physical dependence."

Schedule III substances "have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence."

Schedule IV substances "have a low potential for abuse relative to substances in Schedule II and III."

So, the .gov would have you believe that Xanax and Valium (schedule IV) have lower abuse potential and less addictive than Ritalin and Adderall (Schedule II). Mind you Nicotine and Alcohol aren't even scheduled drugs. Marijuana is, of course, very dangerous and only useable as a substance of abuse per .gov (and thus schedule I).

This scheduling scheme makes no sense! The idea that marijuana is more dangerous than anything on schedule IV is laughable.

During my brief stint working at an inpatient dual diagnosis ward I saw plenty of people in for Alcohol, Opiate, and Benzo dependence/abuse and never saw one person in for abuse of prescription amphetamines (not that it doesn't happen). I will be the first to admit that the rampant abuse/dependence of methamphetamine is a real problem, but methamphetamine is not Adderall or Ritalin despite all of them being stimulants. Yet all are schedule II as if they all had the same abuse potential. Ridiculous!

M

 

[deleted176373]

LOL, I am in the military and get drug tested regularly. It would be a bit unpleasant if I were to get caught abusing drugs, the military is pretty unforgiving about that. So my illegal drug use is 0.

M

 

[PikminOC]

Seriously... Let's look at Schedule II vs Schedule I, III, IV, etc.

Schedule I drugs are substances that "have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse."

Schedule II substances "have a high potential for abuse which may lead to severe psychological or physical dependence."

Schedule III substances "have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence."

Schedule IV substances "have a low potential for abuse relative to substances in Schedule II and III."

So, the .gov would have you believe that Xanax and Valium (schedule IV) have lower abuse potential and less addictive than Ritalin and Adderall (Schedule II). Mind you Nicotine and Alcohol aren't even scheduled drugs. Marijuana is, of course, very dangerous and only useable as a substance of abuse per .gov (and thus schedule I).

This scheduling scheme makes no sense! The idea that marijuana is more dangerous than anything on schedule IV is laughable.

During my brief stint working at an inpatient dual diagnosis ward I saw plenty of people in for Alcohol, Opiate, and Benzo dependence/abuse and never saw one person in for abuse of prescription amphetamines (not that it doesn't happen). I will be the first to admit that the rampant abuse/dependence of methamphetamine is a real problem, but methamphetamine is not Adderall or Ritalin despite all of them being stimulants. Yet all are schedule II as if they all had the same abuse potential. Ridiculous!

M

you've never heard of tolerance for patients on amphets for a period of time?

Since i prescribe these meds, i am very careful as the DEA monitors our scrips. If you want to prescribe too, ill bet you will be a careful prescriber.

 

[psychRA]

Well congrats. So you are a closet advocate for trannies, because I guarantee that won't fly in military, but maybe that is why you are being so cautious... Regardless, not trying to be a "dick", and I do think status quo is there to be challenged. But psych field embraces status quo as though it is necessarily correct, which is false assumption as well. And as I said, just because you are in military doesn't mean you aren't smoking those blunts and f------ dat a---, even if it does make it more difficult. Best regards.

Edited my reply.

To GroverPsychMD - I'm wondering whether there's actual data to back the idea that people who are prescribed stimulants inevitably end up having to take "more and more." I have several friends and family members with ADHD, and they've been on stable doses of a stimulant for years. They haven't needed increasingly larger doses to get the same therapeutic effect. My brother, for example, is a law student in his 30's and is on the same dose of Ritalin that he was taking at age 14. Granted, that's anecdotal experience, but it seems to contradict the idea that everyone who takes them develops a tolerance.

 

[erg923]

Hmmm. I think embracing a little more of the "status quo" (in terms of your behavior and attitude during intellectual discourse) that you seem to disdain will actually be NECESSARY if you want to continue to learn from your fellow students and elders in this forum, AND if you want to actually enter and be successful within this profession.

 

[deleted176373]

you've never heard of tolerance for patients on amphets for a period of time?

Since i prescribe these meds, i am very careful as the DEA monitors our scrips. If you want to prescribe too, ill bet you will be a careful prescriber.

Yes, but what makes Adderall worthy of schedule II and Xanax/Valium schedule IV? Worse yet, haven't you heard of alcohol tolerance... not scheduled at all!

My point had little to do with conservatively prescribing any drugs, but rather that there wasn't a really good reason for Adderall for being on schedule II when other substances are just as risky or even more risky.

That was my point, DEA scheduling is arbitrary at best. You are absolutely correct, I too, would be conservative if I had prescription writing privileges.

M

 

[beingintherapy]

Yes, but what makes Adderall worthy of schedule II and Xanax/Valium schedule IV? Worse yet, haven't you heard of alcohol tolerance... not scheduled at all!

My point had little to do with conservatively prescribing any drugs, but rather that there wasn't a really good reason for Adderall for being on schedule II when other substances are just as risky or even more risky.

That was my point, DEA scheduling is arbitrary at best. You are absolutely correct, I too, would be conservative if I had prescription writing privileges.

M

Dopamine receptors are implicated in ADHD/amphets. There's a risk of receptor burnout and rx onset parkinsons-like symptoms.

 

[cara susanna]

I actually just talked to my relative, who is a medical fellow, about this topic. He thinks that one day we'll find out about harmful long-term effects of ADHD meds and they'll be taken off the market.

That's probably an extreme view, but I found it interesting.

 

[PikminOC]

I actually just talked to my relative, who is a medical fellow, about this topic. He thinks that one day we'll find out about harmful long-term effects of ADHD meds and they'll be taken off the market.

That's probably an extreme view, but I found it interesting.

thats funny bc i just read on another medical site regarding the neurotoxicity of stimulants

 

[MBellows]

The recent ADHD-related threads just disappeared from here and the psychiatry forum (?), so here is one that I won't delete.

RE: to "therapy" for ADHD

Therapy...no. Behavioral interventions, parent training, and skills development,..yes. These interventions most likely won't replace med interventions for true ADHD cases, but they often can help with limiting the frequency and amount of req. meds. I worked on a study back in the mid-00's involving behavioral management in the classroom, and when done consistently and w. parental training we saw positive results. We didn't look specifically at meds v non-meds, but anecdotally I found that meds helped, but the kids still needed to be "steered" in the right direction or they'd struggle just as much as non-med kids.

Have you looked into any of the research on neurofeedback training for people with ADHD?

 

[cara susanna]

thats funny bc i just read on another medical site regarding the neurotoxicity of stimulants

Very interesting. Do you have a link that you'd be willing to share?

 

[PikminOC]

I tried to post it on here, but apparently i cant post it on sdn (it blocks the name of the site) . Please pm me and I will get it to you.

I PMed you cara sussanna

 

[PikminOC]

Any more discussion? I think neurofeedback is a great intervention for many psychiatric illnesses.

I sent my link to a few of you.

 

[Therapist4Chnge]

Have you looked into any of the research on neurofeedback training for people with ADHD?

I haven't. Any citations you'd recommend?

 

[MBellows]

I haven't. Any citations you'd recommend?

I haven't done a lot of reading on it yet, but here's a limited (somewhat old) position paper on the subject. http://www.tandfonline.com/doi/full/10.1080/10874201003773880