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NEEDS TO KNOW by Cynthia Hammer, MSW |
To obtain an ADD diagnosis:
Locate a clinician knowledgeable about ADD in adults. Start your search with the clinicians listed on the enclosed sheet or with recommendations from your family physician, your child's pediatrician, your therapist or an ADD adult. Other referral sources are the CHADD group in your area, other ADDult support groups; physician and psychologist referral services; a medical school or a learning disabilities specialist at a nearby college. As a last resort, work your way through the yellow pages: psychiatrists, neurologists, psychologists.
When you call for information, ask several questions:
- Do you diagnose ADD /ADHD? Do you accept my insurance?
- How long have you been diagnosing this disorder in adults?
- How many ADD/ADHD adults have you diagnosed in the past five years. What percent of your practice has a primary diagnosis of ADD/ ADHD?
- How familiar are you with the day to day tribulations of having ADD? (You're trying to learn if they or some one they are close to has this condition. How intimate is their understanding of ADD on a daily basis?)
- What is your treatment philosophy? (Will the clinician work with you and be open to suggestions or will he/she call all the shots. Is their treatment of ADD the same for everyone or is it individually tailored?)
- In a subtle way, learn what they do to keep current in their knowledge about adult ADD and its treatment protocols.
- How do you make a diagnosis? How many visits will it take and how much will it cost?
- How long will I have to wait for an appointment?
- Ask psychologists how they handle the medication part of treatment as psychologists do not have prescriptive authority.
- Ask physicians (and other medical personnel with prescriptive authority) what medicines they use to treat ADD/ADHD.
- Keep track of who you called and how they answered these questions.
Before your first appointment,
write down what symptoms you have. Suggest an ADD diagnosis, but not too loudly.
You are the patient after all! What the doctor says can reveal his attitude.
Listen for comments, such as, "It can't be that bad." "ADD is the
least of your problems." "You've done quite well; you can't have
ADD." or "The worst part of ADD is not the ADD itself, but the damage
that's been done to your self-esteem." If you repeatedly hear one or more
of these statements, translate this as, "I don't take ADD seriously."
Be wary of clinicians who, laughingly, tell you they "think" they have
ADD but have never sought a professional diagnosis or treatment. Again, they are
making light of the condition, not recognizing it's serious nature.
Some general considerations:
Does this clinician listen? Ask relevant questions? Respect your intelligence? Does he or she seem flexible, open-minded, interested in what you have to say? Attitude is key. Does this clinician make you feel like he, and he alone, knows what's best for you or does she seem more like a co-investigator, i.e., Let's learn together about what can be most helpful to you and how I can best help you.
Ask yourself, "Can I work with this person?" If the answer is "no," you need to look elsewhere. Even after choosing a clinician, vigilance is needed. Some clinicians verbally accept an ADD diagnosis, but do not prescribe the most accepted medications. If this occurs, ask your clinician for an explanation.
Sometimes you find a physician
who will mange only the medications with someone else handling the therapy,
counseling or coaching. This can be a good arrange-ment and often is more
economical. Occasionally, family physicians will be comfortable working with you
on medications, if someone else has made the diagnosis. For example, you could
see a psychiatrist for the diagnosis and getting stabilized on medications, then
be followed by your family physician.
Primer on Medications:
The medications used to treat ADD in adults are the same ones used to treat ADD in children. The first medicines tried are typically the stimulants: Ritalin, Dexedrine, Cylert, Desoxyn, Adderall. Some clinicians shy away from prescribing stimulants because they are controlled substances, i.e., physicians and pharmacists have extra paper work when prescribing these medications. The prescription cannot be "phoned" into a pharmacy; and it cannot be written for more than a month's supply.
Some physicians worry they will have licensing problems or FDA concerns if they prescribe stimulants or they may think you are seeking an ADD diagnosis just to obtain controlled substances. A response to this concern is the dosages at which stimulant medications are prescribed for ADD are minuscule compared to what a drug abuser would take. Commonly, people with ADD, have a reverse effect when taking stimulants. Instead of the "high" that addicts seek, ADDults feel calm. ADDults with a history of substance abuse--alcohol, marijuana and cocaine are the most common--frequently report a cessation in their desire for these substances once they are medicated for ADD.
The nationally prominent ADD clinicians believe that the earlier substance abuse was probably an inappropriate self-medication that the treated ADD adult no longer needs. Research on teen-agers with ADD taking stimulant medication shows they have a lower rate of substance abuse than their peers. Ritalin, the most commonly used medicine for ADD, has been in use for almost fifty years and is very safe when taken as directed. Dr. Hallowell says it is safer than aspirin.
Research with Ritalin over the past 50 years with children diagnosed with ADD demonstrates conclu-sively that this medicine helps most ADDers significantly reduce their ADD behaviors. (Ritalin is said to help over 70% of those diagnosed with ADD with the proviso that it be given in the right dose.)
No one fully understands what role Ritalin or other stimulants play, but research conclusively demonstrates that these stimulants make most of us with ADD function better. (from mild improvement to significant improvement). We are assured, by our physicians and the FDA, that the stimulants are not harmful to us in the doses prescribed.
ADD is a neurochemical disorder. People with ADD lack one or more chemicals (still to be determined) in our brain in the right quantities in the right places at the right times. We may have these desired chemicals sometimes in the amounts and places we need, but not always, and not at our choosing-- i.e. that's why we have variable performance. When our brain chemicals are not flowing normally, (i.e. as they flow in people without ADD) we are very ADD.
Dr. Daniel Amen, M.D. of Fairfield, CA,. says that the brains of those with ADD/ADHD benefit from stimulants as they cause more blood flow (which is healthy) to our frontal lobes than they would otherwise receive. It is commonly believed by clinicians treating ADD that a greater harm--emotionally and socially--occurs to those with untreated with ADD, than any possible harm from the medications. Unfortunately, this knowledge is not accepted by the public, and the media often adds to the public's fear of the medicines used to treat ADD.
Some clinicians continue to increase the medicine's dose until there's a desired effect or too many undesirable side effects, such as jitteriness, stomachaches or head-aches, that do not subside after a few weeks. Some clinicians use Zantac or Pepto-Bismal to help patients who experience stomach-ache to help them through an adjustment period.
If, after trying the stimulant medications at various dosages the desired effect is not achieved, then certain anti-depressants such as imipramine, desipramine and nortriptyline along with Wellbutrin and perhaps Effexor are tried. If none of these work for you, your physician might try other medicines, or combinations of medicines. Proper dose levels are determined on a case-by-case basis, not by weightor age.
How do you determine if the medicine is working, if you are taking the best medicine for you, at the best dose and on the best dosing schedule?
Thomas Phelan, Ph.D. suggests all patients try a second or even third stimulant. Individuals may respond quite differently to each one. He will start with, say, Ritalin,and note what is the best result the patient achieves and at what dose. He'll then have the patient try dexedrine or ADDerall or Cylert , again observing the best result at what dose. After this, he and the patient jointly decide which medicine at what dose is best for long-term usage. The point is, you may be "treated" for ADD, but without some comparisons with other medicines used for ADD, you may not be taking the one that will work best for you.
This is why it is very important to work with a clinician knowledgeable about ADD who is willing to work "with you;" not dictate to you. You need a clinician who is aware of what changes medicines can bring about in an ADDer's ability to function and who knows it's not a disorder where one medicine or one dosing schedule suits all. In turn, you, the patient, need to learn what changes to watch for in your functioning when you take medicine. Sometimes you might need another person in your life to note these changes, as ADDers can be poor self-observers.
What are some specific changes to look for when taking medicine?
When medicated you may be able to stay involved in a conversation or finish a taskbefore moving on to something else or you may remember to do something that you needed to do. You may find your social interactions more relaxed and that others seemto enjoy being with you more.
Dr. Theodore Mandelkorn of Seattle says that ADDers on (proper) "medication IMPROVE their attention span, concentration, memory, motor coordination, mood,and on-task behavior. At the same time they DECREASE daydreaming, hyperactivity, anger, immature behavior, defiance, and oppositional behavior. Medical treatment allows intellectual capabilities that were already present to function more appropriately.
When medication is used appropriately, patients notice a significant improvement in control. Objective observers notice better control of focus, concentration, attending skills, and task completion. Many are able to cope with stress more appropriately, with fewer temper outbursts, less anger, and better compliance. They relate and interact better with family members and friends. Less restlessness and impulsiveness are noted."
He goes on to say, "It is very important to remember what medicine does and does notdo. Using medication is like putting on glasses. It enables the system to function more appropriately. Glasses do not make you behave, write a term paper, or even get up in the morning. They allow your eyes to function more normally IF YOU CHOOSE to open them. YOU are still in charge of your vision. Whether you open your eyes or not, and what you choose to look at, are controlled by you. Medication allows your nervous system to send its chemical messages more efficiently, and thus allows your skills and knowledge to function more normally. Medication does not provide skills or motivation to perform.
ADDers often complain of forgotten appointments, incomplete work, mistakes in written work, frequent arguments with family members or co-workers, excessive activity, and impulsive behaviors. With medication, many of these problems dramatically improve. Patients successfully treated with medication typically can go to bed at night and find that most of the day went the way they had planned."
Dr. Gross in Santa Clara, CA suggests asking if the medication you are taking is significantly helping with these concerns:
 | Academic underachieving and
inattentiveness
| Hyperactivity or troublesome
fidgeting
| Verbal and/or behavioral
impulsivity (blurting out, interrupting others, acting before thinking)
| Difficulty falling asleep at night
| Trouble coming awake (not getting
out of bed) in the morning
| Excessive irritability with-out
cause and/or easy frustration
| Bedwetting or primary nocturnal
enuresis
| Dyslexia with spatial or verbal
reversals
| Episodic explosiveness, emotional
outbursts, or temper tantrums
| Unexplained and persistent
emotional negativity | |
Finding the right clinician and the right medication can take time, but those who persist are well-rewarded for their efforts. Good luck with your search.
Primer on therapy/counseling
Selecting a good therapist to help you with the pyscho-social treatments for your ADD can be difficult. How can you make the best choice? How will you evaluate your choice? Which kind of therapist to choose? Will expense be a factor? What your medical insurance pays for can limit your choices, although being diagnosed and treated for your ADD will probably be the best spent money in your life.
Psychiatrists are medical
doctors (M.D.s) who receive special training in psychiatry.
Note that only M. D.s, physician
assistants (PAs) and certain nurse practitioners can prescribe medications.
Psychologists (Ph.D.) have doctorate degrees in psychology while social workers
(MSWs, ACSWs or CSWs) and marriage and family counselors (MFTs or CMFTs) have
master degrees in their respective disciplines. Other counselors may have
Master's Degree in Counseling (MA) and related fields. In addition, they may
have specialized training in Chemical Dependency (CDCC), or Mental Health (MHC).-
Verify that they are both licensed by the state and certified, which demonstrates a higher level of training, by their professional organization or by the state. If you do not understand their titles, ask for clarification. No professional or ethical therapist should mind being asked about their educational or professional back-grounds.
While it is not possible to say one kind of training is superior to another when choosinga mental health provider, a good rule of thumb is to go with a therapist you can afford.You are not going to be helping yourself if you go into deep financial debt trying to get outof deep emotional pain. Most therapy sessions last about an hour and the cost ranges from $50 to $125/hr, with some clinicians offering sliding scale.
Plan to briefly interview one or more
therapists on the phone before you set-up an initial appointment. Ask about
their training and background. Describe the kinds of issues you want help with.
Make absolutely
sure that the therapist is familiar with ADD in adults.
(use the same questions asked when
finding someone to diagnose you for ADD, see page 1).
They should be knowledgeable about ADD and its manifestations so they can help educate you and help you realize your difficulties in life were the result of subtle neurological deficits in the brain, not character defects or moral shortcomings.
Therapists for ADD adults should be more directive than is typical in a "therapeutic relationship." ADDults often talk and talk with-out achieving insight or direction from their "ventilating." They need structure and guidance to stay focused, to stay on topic, to get the most benefit from their therapy
If you find a therapist that seems good via the phone, set up a longer, in-person, interview. Some therapists provide an initial half hour session at half their regular rate. Others expect you to devote a full hour to getting acquainted and seeing if you can work together.
Pay attention to your feelings during this initial session. It's important that you find someone who makes you feel comfortable and who gently challenges you to explore your inner life and past experiences. It is important to find someone who respects your individuality and your opinions, and who you feel you can trust 100%. If you feel the need to lie or withhold important information from your therapist, you are not going to get any real help.
When you find a therapist you like, plan to give therapy about six sessions before deciding whether or not to go on with it. It usually takes that long to uncover areas of concern and begin to identify your issues.
Most good therapists work with their clients to develop treatment goals. When these are formalized and written down, it ensures that you and your therapist are on the same "track" and working on the same problems. Also, by occasionally reviewing the goals, you can chart your progress (or lack thereof) in therapy and work with your therapist to change therapy if need be.
Six months to a year of counseling is often needed to work through most problems. For ADDults, this can be faster. After dealing with an issue, people with ADD are generally ready to move on. We tend not to dwell on the past; to not be reflective. You should feel that going to the therapist is helping you and that you are improving. Watch out for therapists who want to continue therapy when you feel ready to end it. They may need to "help" you more than you need to be helped.
Many ADDults don't require intensive long-term therapy to get their lives on track and to improve their self-esteem and confidence if they don't have a lot of life-time baggage that needs to be worked through. Often, medication, learning about what ADD is and is not, putting good coping skills in place, exercising regularly and taking good care of them- selves, along with belonging to an ADD support group, even via the computer, are enough. Sometimes, instead of therapy, ADDults only need "coaching." They benefit by having someone who regularly checks in with them to see how things are going; someone who helps the ADDult develop and carry out strategies that will work for him in achieving his goals.
After you stop therapy, it may take a few months or longer before you fully integrate the knowledge you gained in counseling into your daily life. That's to be expected: Good things--like new, healthy behavior--always take time to develop.