New ADHD Medication Rules
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Pub Date: 01/01/2013
Price: $14.95 USD / $15.95 CAD
Trim: 6 x 9
Format: Trade Paper
BISAC Category: Health & Fitness/Diseases/Nervous System (incl. Brain) Health & Fitness/Diseases/Alzheimer’s & Dementia
New ADHD Medication Rules deals with the over-medication, missed diagnoses and imbalanced medical treatments used today in the treatment of ADHD. Dr. Parker shows where and how these imbalances occur, provides the data and explanations for why treatment is often incorrect, and then simplifies and explains insightful methods for dealing with ADHD medications, both for medical practioners and parents of kids and adults with ADHD. Rules is based upon the latest brain science, and includes a variety of associated treatment topics that address the real complexity of ADHD medical management. The variables that effect medication effectiveness range from sleep, to breakfast, to biomedical interferences that can dramatically change the way medications burn in the body. Without Rules the possibility of missing potentially dangerous drug interactions and associated diagnostic challenges, such as depression and anxiety, adds to the greater possibility of treatment failure.
Dr Charles Parker – A writer, nationally recognized speaker, (Deep Recovery, ADHD Medication Rules, CorePsych Blog), a neuroscientist certified for SPECT brain imaging, and a practicing child and adult psychiatrist with more than 43 years of experience in clinical practice. From psychoanalysis to psychopharmacology, Parker brings a unique perspective and passion to the changes that must be made in the current diagnostic and treatment protocols for psychiatric conditions in general, and ADHD most specifically. He knows the territory not only from direct experience with active practice clients, but from those many years, since ’96, lecturing to medical colleagues on the science and applications of psychotropic meds for several pharma companies. His cutting edge interest in the dramatic advances in molecular and cellular physiology associated with effective brain function teach professionals and clients at every level about cognitive and emotional imbalance. Parker’s mission is compelling and persuasive: brain science translation into common sense packages for everyday use.
His CorePsych Blog has won numerous ADHD writing awards over the years, and set new standards for the diagnosis and treatment of Executive Function Disorders. This is his second book. Dr. Parker works and lives in Virginia Beach, Virginia.
Pills have to pass through your body before they reach your brain. The body is uniformly overlooked. What happens along that complex journey determines a drug’s effectiveness and predictability.
Unfortunately, far too many significant problems exist with Attention Deficit Hyperactivity Disorder meds because those who prescribe them don’t consider or grasp the ways drugs are absorbed and then processed in the bowel, liver or the brain itself. A patient’s diet, medical status and allergies are given only modest consideration. The interactions of multiple medications also are given short shrift. Instead, physicians often base dosages on broad –- even vague — medication formulas. Too many prescribe from statistical averages, not individual needs.
Succinctly: too many simply are not paying attention to the meds for paying attention.
What I hope to accomplish through this book is to enlighten my medical colleagues and embolden patients suffering with ADHD or symptoms masquerading as an attention or hyperactivity disorder. My intention is to arm patients, or those caring for them, with enough critical information to at least ask their doctors informed questions and challenge limited conventional thinking.
Much of the information presented here is highly scientific. Some of it is anecdotal, and the rest is clearly advocacy. It’s my firm belief, after spending decades treating those struggling with emotional and mental illnesses, that treatments should be customized based upon available science. Most importantly, physicians and patients need to partner in treatments so that medications can be adjusted correctly.
The wrong mix of drugs or prescriptions in the wrong amounts can be deadly. They can tip someone with depression into suicide. They can exacerbate, rather than alleviate, hyperactivity. The wrong blends or amounts of drugs can harm rather than heal.
ADHD diagnosis and treatment strategies are tricky to begin with. Technology has advanced to a point where it’s now possible to read the brain’s reaction to drugs and to find in the body root causes for previously unpredictable problems. Yet, too few physicians are willing or capable of employing these new assessment techniques. Treatments are not on a par with current, easily available brain science, leaving a global quandary about viable ADHD practice strategies.
ADHD medications don’t work like slap shots in a penny arcade. They must be exact with laser accuracy to hit their intended targets. Too many with ADHD are treated with cookie-cutter medication recipes and diagnoses based upon superficial behavioral appearances that overlook the complexity of the human brain. What’s missing is applied neuroscience discoveries; years of brain scan data and biomedical evidence should drive more effective diagnosis and medication delivery.
My hope is that New New ADHD Medication Rules raises awareness of better and more sophisticated approaches to treating and diagnosing ADHD.
Why Rules And Why Me?
I’ve witnessed medical denial all over the country. After speaking nationally to thousands of doctors, nurses and mental health professionals since first starting to practice in the 1970s, I’ve come to important conclusions: Too many don’t want to listen to the neuroscience data; too many are focused on those superficial, often counterproductive DSM 4/5 labels; too many docs hurry to prescribe ADHD meds without considering real consequences.
Regrettably, some of the most pressing medical denial and defensive, self-righteous thinking exists in otherwise sophisticated metropolitan communities with the most prestigious medical academic institutions. Ironically, some of the most intelligent and otherwise well-informed communities, such as Boston, New York City and San Francisco, shun new medical information unless it comes from their in-town provincial, group-think establishment thought leaders.
I’ve watched their responses to my presentations over the years, and repeatedly experienced their determined resistance to thoughtful investigation and improved intervention strategies. Intellectual egoism rules, serves to neglect critical thinking, and shrouds progress in wrappings of doctrinaire beliefs that don’t match biomedical brain evidence. The outcome of these blinders is that you, the patient, from New York to South Africa, suffer the consequences of ineffective or potentially dangerous treatments.
In a word, Rules arises from more than forty years of practice feedback from patients, especially when I didn’t get the meds right following the most approved protocols. I listened, and I looked for additional answers and more evidence-based approaches. Rules summarizes that learning history.
I’ve repeatedly interviewed thousands of clients who suffered for years at the hands of denial and medical innocence. After a hasty diagnostic process, too few medical providers show interest in expectations of how the meds work in the first place, or how they should work most effectively in the long run. For example, many think understanding interactions between stimulants and other medications is a waste of time and inconsequential, despite the fact that it can result in suicidal thinking.
Repeated clinical experiences provoked me to reveal to the public, specifically ADHD sufferers, the dangers and shortcomings of the status quo and its dated practices.
My hope is that Rules stimulates patients and conscientious medical practitioners to improve the consideration of treatment alternatives. ADHD dogma will be exposed and public sentiment will hopefully encourage individual challenges to the current medical establishment. By reading Rules, I hope you will become one of the informed who will ultimately pressure treatment providers to break from mainstream thinking and adapt more comprehensive ADHD diagnosis and treatment options. Let’s work together to encourage a revolution in awareness that will mandate reforms to the way medical professionals evaluate and treat this disorder.
Don’t be intimidated by the science here or the medical jargon. I will attempt to make it as clear as possible. However, some of what you will read is very technical. It’s important to understand the biological and chemical bedrock upon which Rules is based. My goal is to present comprehensive alternatives for easily workable, everyday medication management. Details matter and the ADHD details in Rules rely on applied street smarts and common sense.
On the Brighter Side
Improved ADHD medications work remarkably well and with reassuring predictability. These drugs have been studied, researched and written about more than any other children’s medications. Meds are safe when used correctly and often work well with both children and adults. Simply follow the Rules and medication outcomes will significantly improve.
ADHD treatments provide one of the best ways to understand the mix of co-existing problems so often seen with ADHD. Symptomatic treatment chasing superficial appearances often misses underlying reasons for diagnostic and treatment failures.
Side effects with ADHD meds can point the way for even better care if you understand all of the underlying conditions, not just the surface symptoms. These next examples will give you a glimpse of some of the topics covered later in more detail.
1. A ten-year-old boy with inattention and clear symptoms on a commonly used ADHD rating scale starts an immediate release medication: Adderall IR [Immediate Release]. He is given the medication in the morning, but doesn’t get a noon dose because he does not want others to know about his problems by going to the school nurse. His morning is great, but his afternoon is terrible with interruptions and misbehavior. The summary from the teachers: “The medication is not working.” The action from the doctor: Increase the morning dose to cover the afternoon time by raising the Adderall IR. Outcome: Now he is furious and wild in the morning and crashes even more furiously in the afternoon. Often the next reflex recommendation: “The medication is not working correctly – get rid of it.” My conclusion: No, it is working exactly as expected; it was, however, adjusted incorrectly. He is significantly overdosed, toxic in the morning, and still is not adequately dosed in the afternoon. Adderall IR doesn’t last more than five-to-six hours with correct dosing — dosage for more than that duration is simply too much.
2. An adult male is promoted at work, is pleased with his new responsibilities, but continues to feel increasingly overwhelmed by the complexity of “administrative problems” with colleagues. He was an outstanding performer when he had control over his work duties, but feels increasingly overwhelmed. He loses sleep, feels more inundated, fears losing his job in an uncertain economy, is given antidepressants and deteriorates dramatically. He was treated for ADHD as a child, but following this episode of reacting to the antidepressant he is quickly labeled “bipolar,” and is now regularly thinking of suicide. Antidepressants can make ADHD worse, and can make ADHD look like a mood disorder.
My conclusion: He does suffer from ADHD, which is aggravated by the change of context at work, and can be quickly corrected with proper medication management. Adult psychiatrists are often suspicious and misinformed about adult ADHD treatment because many lack the basic training for ADHD diagnosis and medication management.
3. A wealthy technology consultant is suicidal, feels that he is demented, and, at age forty five, fears he may suffer from an early onset of Alzheimer’s. He has been treated by several psychiatrists over the years, suffers with ADHD and depression, and comes to the office for a second opinion after having been diagnosed with “brain injury” by the initial SPECT imaging consultants. He is on Prozac and Adderall, and his SPECT brain images look like brain Swiss cheese. My conclusion: Brain injury is not the problem – he is demented from a common drug-drug interaction with Adderall and Prozac. Prozac interacts by building up the Adderall, through blocking the Adderall breakdown. He is simply toxic, and needs different doses of new medications. His ADHD, anger and depression are treatable through correcting the inappropriate mix of medications. His SPECT consultants missed the drug interaction and mistook the diminished functioning as brain injury.
4. An apparently healthy adolescent girl, attractive and outgoing, cannot seem to find the correct dosage of stimulant medication. As she has grown older her periods are worse than ever, prompting a start on birth control. The stimulants are either too weak to correct her attention issues, or too strong and make her overwhelmingly anxious. She skips breakfast, sleeps only about six hours on average, and, quite surprisingly, has bowel movements only two times a week.
My conclusion: After careful review she shows many characteristics of a narrow Therapeutic Window encouraged by multiple metabolic issues associated with Polycystic Ovarian Syndrome, gluten sensitivity, and delayed bowel transit time, all of which significantly interfere with stimulant medications. Sleep, nutrition, neurotransmitter challenges, hormone dysregulation and significant metabolic slowing all contribute to unpredictable outcomes with ADHD medications. ADHD medications simply can’t be adjusted correctly without understanding and correcting each underlying biologic-based metabolic, burn rate variable.
The bottom line: medication management using stimulants can be achieved by paying more attention to the associated medication effects so often found with ADHD problems. If you don’t look, you simply can’t see. If you do look, recognizing these remarkably simple patterns will make ADHD medication management much more predictable.
We must start paying closer attention to both the person and his reaction to stimulant medications. And this bears repeating: remember, misusing stimulants can result in severe consequences, including suicide.
Too many with ADHD suffer the consequences of physician errors in dosing strategies, missed diagnosis and confusion over treatment objectives. Much of the bad rap, the pervasive stigma, associated with the diagnosis and treatment of ADHD is based upon failures to identify these many problems.
It’s quite paradoxical that ADHD, one of the most common psychiatric conditions, is pervasively misidentified and mismanaged. Many patients justifiably complain. Regrettably, they too often conclude that the treatment process is useless, or they remain frustrated for years with problematic or inadequate treatment.
Far too often, ADHD patients find themselves not only misunderstood by their family, but also lost in a sea of medication confusion within the medical community. Lacking obvious and specific rules to address the complexity of their symptoms, many feel they must rely on vague intuition or the advice of gossip. In fact, the meds often appear so unpredictable that many, at first, seriously doubt the stimulant medication choice, the medication dosage, and the underlying ADHD diagnosis from the outset. Too often it seems like nothing works, no matter what interventions physicians offer.
In the courtroom, hearsay evidence is inadmissible. When it comes to medical strategies, however, “hearsay” forms the bulk of how a condition is judged and treated. They act upon something mentioned casually by a friend, or something heard in a brief news report. In our new Twitter world, hearsay is becoming a mainstay. When it comes to ADHD treatment, everyone is an expert, and unreliable gossip sets the standard of care. Unfortunately, some health care professionals also plug into this pattern of gossip. Speculation rules far too often, even in the treatment community.
The truth is, current practices typically make little operational sense to patients or many professionals. Translating ADHD medication theory into effective what-you-do-in-the-office, step-by-step guidelines remains downright elusive. Even the most informed observer recognizes that no rule book exists that sets clear treatment options, clear objectives, and specific outcome measures.
Treating ADHD without first establishing targeted outcome expectations is like playing basketball without hoops; there’s a lot of running around with no goal. Often treatment appears as a “maybe,” an afterthought, with casual consideration.
New, more brain-physiology-precise ADHD guideposts remove much of the guesswork. I have found such testing more precise than psychological testing, which can muddle ADHD diagnosis, burdening a medical team with uncertainty because their own psychological criteria remain uncertain.
Why is there so much denial regarding precise use of stimulant medications, and how have we become collectively so inattentive to the details for correctly dosing stimulant medications? It’s all about training, perspective, and the evolution of measurement tools based upon brain and body biologic processes.
Our Shared Past Medical Perspective
In 1969, when I started training in Philadelphia, the two essential questions all psychiatric residents were instructed to ask every new patient were, “What are your dreams?” and, “What are your fantasies?” Our highly regarded psychoanalytic instructors in those days were simply not interested in biology and often opposed medical interventions. They were even against talking too much with the patients because you might interfere with the transference. This remarkable bias against biological understanding remains alive and well in consultation practices across the US even today.
Why? Psychiatrist’s back then did not have access to adequate measurements. The tools to evaluate brain function simply did not exist for street practitioners. Without laboratory measurements for brain activity, specifically the way the brain and body actually work together, the standard of care was not based upon biological evidence and relied, instead, on psychological explanations.
In those days, it was like dealing with microbes without benefit of a microscope. You don’t think about looking for what you can’t see.
Brain and Body Science Changed
the Treatment Game
ADHD treatment is at a crucial crossroads. We can now see more brain activity markers than ever before. Science is taking us down dramatically different diagnostic paths. Those following the scientific trail find themselves in a growing controversy about standards of ADHD medical care. The public, medical research teams and the media now hotly debate the subject of correct ADHD treatment.
Brain science has yielded so much new information that many providers are scrambling to try to keep up with data regarding functional brain activity, nutrition, and the great variety of treatment options available for the ADHD spectrum of difficulties.
On the other hand, when treating ADHD in the office, many others attempt to navigate the direct effects of challenged brain function without specific maps or a compass. Most psychological tests and questionnaires don’t provide specific medication treatment markers that can be used in everyday office management. And, more importantly, psychological testing itself often overlooks specific functional brain challenges that result in ADHD symptoms.
We need more dynamic, more applicable, measurable markers for every office visit, for every medication check, that serve both patients and practitioners.
Patients need an uncomplicated method by which they can easily report progress. Patient involvement in care must become much more participatory, more highly refined at every medication check. A recent study regarding topics discussed during medication checks showed that only one minute of an average sixteen minute office visit was spent discussing medication effectiveness. An essential, yet frequently overlooked example question: “Exactly how long does that stimulant medication actually work?” One unstructured office visit every one-to-three months will not provide the answer.
Research clearly shows that we aren’t on target in the office. Static diagnostic labels based upon appearances don’t adequately address moving mind dynamics. We plainly aren’t thinking about the way the brain is working, the way it actually functions cognitively, as observed in the office. We aren’t thinking about thinking.
Brain and Body Science Evolve
Those old psychological questions about dreams and fantasies remain useful in specific circumstances, but the prevailing medical focus is now on developing measurable biologic evidence, beyond dreams and imagination. New biological inquiries about metabolic dysfunction become imperative, because body metabolism, including hormonal function, immune dysfunction and the body’s rate of metabolism, all directly affect brain function: measurable unbalanced behaviors in thinking, feeling and acting. You probably already knew that; but what you likely didn’t know is that measurement tools such as laboratory and imagining methods have significantly improved.
You can see the manifestations of unbalanced brain function in the office and in the street any day, but only laboratory tools will reveal specifics about the biological occurrences that send those unbalanced signals and result in changes with brain activity — now measurable on a cellular level.
If we can now identify and then measure thinking, feeling and acting behaviors that associate with specific brain functions, and then relate them to specific brainwork, why are we still using superficial terms and measures that document appearances in the office as the ADHD standard of care? Terms such as “hyperactive and inattentive” are observations and descriptions of behavior, not statements about real brain function. These outdated terms work as markers only for the least informed, and then inadequately if the patient begins treatment with stimulant medication. Those diagnostic targets are simply too vague.
New Brain Maps Do Change the Treatment Process
Patients must become familiar with these completely different levels of thinking with their respective medical consultants. Rules shows you how to effectively participate in your own treatment.
Our work together must better identify specific treatment targets, provide improved clinical diagnostic measurements, create measurements easy to use during brief medication checks, and identify specific medication actions and interactions. The devil is in those details, and we’re too often collectively lost without them.
Think of the ADHD treatment game we have been using in the past as Golf ADHD, and this new game, with different rules, as Tennis ADHD. Golf ADHD is not a bad game; it simply is insufficient in many cases to deal with the new biologically based feedback loops we will be outlining in these next chapters. Golf ADHD Rules may work for the most uncomplicated presentations, while Tennis ADHD Rules apply with any additional complexity, with nuanced problems that don’t respond to ordinary care. These new perspectives aren’t to discard past ADHD labels, only to suggest future treatment protocols based upon greater precision available with the new brain and body science.
Let’s get started with a different game.