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ADHD treatment guide

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ADHD treatment guide

We consider the approach described below to be fundamentally sensible. However, these are merely thoughts from a scientific point of view and cannot constitute a therapeutic recommendation for individual cases.
In each case, an individually tailored treatment plan must be drawn up by a doctor or psychotherapist.
Our presentation is not intended for self-medication, but to make medical recommendations easier to understand for those affected and their families and to enable them to discuss the options described with the doctor and therapist treating them.

There are official national treatment guidelines in America1, Europe2, Canada3, Japan4 and Germany5, among others.

0. Prerequisite: reliable diagnosis

  • Questionnaire AND tests, self-perception AND external perception anamnesis, primary school reports or other reports from kindergarten and early school years
    • Caution: high self-interest in tests can lead to results similar to those of non-affected persons (attention follows intrinsic control)
  • Family history
    • Genetic causes
    • Pregnancy and birth complications
    • Attachment disorders
    • Physical or sexual abuse
    • Psychological abuse or low-threshold psychological stress
  • Complete differential diagnosis
    • Exclude deficiency symptoms
      • Blood count
        • Thyroxine (thyroid gland)
        • Zinc
        • Iron
        • Magnesium
        • B1
        • B12
        • B6
        • D3
        • Folic acid
        • Blood count not required according to other opinion6
    • Exclude an acute stress situation
    • IQ test
    • Exclude dominant disorders with similar symptoms
      More on the topic Differential diagnostics
  • Identify comorbidities

1. Step: Self-education and psychoeducation

1.1. Self-education

Self-education through books, videos, self-help groups and forums enables individual knowledge and empowerment in dealing with ADHD.
The aim is to strengthen personal responsibility and promote a self-determined lifestyle through personal sources of information and sharing experiences in the community.

  • Psychoeducation by psychiatrists, psychologists, etc.

  • Read books about ADHD (several)

  • Use ADxS.org as an information base

  • Youtube videos from experts (lectures)

  • Attend lectures (e.g. from CHADD)

  • Attend self-help groups, preferably led by a professionally experienced person (e.g. at CHADD, Attention Deficit Disorder Association or The Learning Disabilities Association of America)

  • Forums offer contact with other sufferers and help with questions, e.g. reddit/ADHD

  • Even a diagnosis of ADHD is accompanied by the realization that one is different from others, in both a negative and positive sense. This realization is often associated with high hopes for an improvement in life.7

  • The experience that other people have gone through or are going through the same thing often brings astonishing relief to ADHD sufferers

    • Feeling of coming home among like-minded people
    • Willingness to address the topic
    • Exchange of experience
    • Strengthening self-esteem

1.2. Psychoeducation

Targeted knowledge transfer about ADHD under the guidance of professionals in order to positively influence the interactions, attitudes and actions of patients and caregivers.
The aim is to promote a comprehensive understanding of ADHD through professional guidance to help manage the disorder.

2. Second step: Drug treatment

2.1. Treatment prioritization for ADHD with comorbidities

See under 5.

2.2. ADHD symptom elimination through medication

2.2.1. Choosing the right medication

See also Choice of medication for ADHD or ADHD with comorbidity

2.2.2. Dosing, medication adjustment

In our experience, many mistakes are made when dosing, which not only prevent an optimal effect, but often enough prevent any effect at all. It is therefore particularly important to follow the dosage instructions,
See in detail at Dosing of medication for ADHD

2.2.3. Effect strengths of various medications
  • Effect strength with optimum setting:
    • Amphetamine drugs: 1.1-1.5
    • Methylphenidate: 1.0-1.3
    • Guanfacine: 0.8
    • Atomoxetine: 0.65

See in detail at Effect size of different forms of ADHD treatment

2.2.4. Goals of an optimal medication setting
  • Enable experience of what life without ADHD can be and feel like (enables those affected to define intrinsic goals for non-drug therapy)
  • Establish therapeutic ability (bring attention and concentration to the level required for learning more functional modes of action)
    • Increased treatability with dopaminergic ADHD medication, as dopamine increases or restores neuroplasticity8
    • Growth hormones, which are required for neuroplasticity (learning), are reduced in ADHD. Stimulants increase the levels of growth hormones.
  • The aim is not to completely eliminate all ADHD symptoms **
    • ADHD sufferers differ from non-affected people only in the number of frequently occurring symptoms. Non-affected people also have some symptoms frequently.
    • Individual prominent symptoms should be treated as singularly as possible (e.g. impulsivity with very low doses of SSRIs, aggressiveness with low doses of antipsychotics) instead of trying to treat them with ADHD medication, as this would result in too broad an intervention

2.3. Many more small treatment steps

The points mentioned here should always be taken into account when treating ADHD, as they can usually make a further helpful contribution without having any significant side effects. The points do not represent alternatives, but should all be taken into account.
However, their strength of effect (even in combination of all possibilities) is considerably lower than the relevant medications mentioned above. If it were otherwise, the reports of successful treatment without the relevant medication would be legendary. Newcomers to this topic can find information in forums for those affected, such as ADHD forum from ADxS.org
For more information on the effect size of non-drug treatments for ADHD, see Effect size of different forms of treatment for ADHD

  • Vitamins and minerals
    Determine blood values and dose to upper limit values or above. More on this at* ⇒ Vitamins, minerals, dietary supplements for ADHD*
    • Vitamin D3
      • October to May essential in Germany
      • Is very important for ADHD and essential for depression. Prescribing serotonergic or noradrenergic antidepressants (which, in our opinion, have considerably stronger side effects than ADHD medication) without first checking the D3 level is, in our opinion, malpractice (except in cases of severe depression)
    • Zinc
    • Magnesium
    • Iron
    • B12
    • B 6
  • Omega-3/omega-6 fatty acids
  • Sleep problems
    • Treat offensively
    • Avoid benzodiazepines and SSRIs. If necessary, trimipramine, amitriptyline or trazodone (low doses in each case)
    • Melatonin (unretarded, particularly helpful for ADHD)
    • Light therapy
    • Find out more at Sleep problems with ADHD
  • Initiate drug treatment for mild remaining comorbidities only after analyzing the effect of the ADHD medication (usually after approx. 6 months)
  • Test for and rule out food intolerances
  • Test and rule out allergies
  • Testing and treating chronic low-threshold inflammation (very difficult)
  • Lots of sport and exercise9
    • Endurance exercise has a significant effect on reducing the symptoms of ADHD (and other mental health problems such as depression)
      • Strength of effect of weight training, on the other hand, is lower
    • Sport must be fun if it is to be practiced sustainably
    • Endurance sport
      • Increases stress resistance, shuts down stress systems (for 24 - 48 hours)
      • Effect size in the optimum case (e.g. 5 x 1 hour / week) up to 0.7
    • Find out more at Sleep problems with ADHD
  • Healthy diet
    • Avoid sugar10
    • Avoid bad fats (saturated fatty acids, trans fats; e.g. frying fat)9
    • Plenty of antioxidant foods (vegetables, fruit)9
      • Helps to reduce antioxidant stress

3. Third step: Psychotherapy

3.1. Psychotherapy to reduce the symptoms

The type of therapy chosen is only of minor importance here (exception: mindfulness-based therapies are more suitable than cognitive therapies, depth psychology therapies are only useful for dealing with unpleasant experiences and psychoanalysis is generally unsuitable for ADHD). It is much more important that the patient feels very comfortable with the therapist and that they feel very well looked after and accepted. This in no way means a cuddly therapy in which the therapist only tells the patient what they want to hear, but positive acceptance and a basis of trust, which are the indispensable foundations for successful therapy. Without these minimum requirements, even the best form of therapy and the most experienced therapist will be useless. A great deal of patience is therefore required when choosing the right therapist.
It is also important that it is not about a single therapeutic measure, but that as many therapeutic measures are taken until a satisfactory condition is achieved.

In all therapy measures, it must be ensured that the therapist is familiar with all ADHD symptoms relevant to treatment. Even today, doctors and therapists are often still under the fatal misconception that ADHD is limited to the diagnosis-relevant symptoms of the DSM or ICD. Therapists who do not want to accept the original symptoms of ADHD that go beyond DSM / ICD as such should be avoided. Otherwise there is a real danger that the affected person will be assigned responsibility for behaviors that actually stem from ADHD itself. This can lead to further deterioration for the affected person instead of improvement.

Suitable types of therapy can include

  • Mindfulness-based (behavioral) therapy (MBCT) to improve self-awareness, to improve self-control over symptoms and to learn and practice mindfulness-based stress reduction (MBSR) and stress reduction techniques (e.g. 8-week intensive MBCT + MBSR courses)
    In ADHD-HI in particular, the vicious circle of inability to recover should be broken, which helps to maintain the continuous operation of the HPA axis.
  • Neurofeedback for long-term improvement of autonomic control (6 months to 2 years)
    • SMR training to improve impulse control and combat sleep problems
    • Theta beta training to improve the regulation of activation
    • SCT training to reduce overactivation or increase underactivation
    • A combination of theta beta training or Z-score training and SCP training (simultaneously or consecutively) seems to be particularly recommended
  • If necessary, cognitive behavioral therapy for self-esteem problems, social behavior problems. Here Rejection sensitivity: fear of rejection and criticism as a specific ADHD symptom note. Cortisol stress arises in particular in subjectively self-esteem-threatening situations.
  • If necessary, depth psychological therapy for the treatment of serious experiences/experiences
  • Trauma therapy (EMDR) for traumatic experiences, if necessary
  • For children up to 6 or 10 years: parent-centered therapy; child-centered therapy ineffective.

3.2. Environmental interventions

  • Eliminate stressors
  • Optimal design of the working and learning environment, e.g.
    • Eliminate superfluous stimuli
    • Enable sufficient arousal
  • Discussions with relationship partners to create mutual understanding
    • Systemic therapy (family therapy, parent therapy) if necessary to change ingrained problem patterns
  • Focusing your life and career on things that really interest you

4. Fourth step: Comorbidity and medication review

4.1. Comorbidities

  • After 9 to 12 months of ADHD treatment, check the continued existence of comorbidities
  • If necessary, specific drug treatment (note interactions, e.g. caution with SSRIs)
  • If necessary, choose specific ADHD medication that also has a positive effect on comorbid disorders
    • Atomoxetine acts noradrenergic and dopaminergic on PFC and striatum, stimulants noradrenergic and dopaminergic only on striatum.
      Atomoxetine for ADHD Atomoxetine is reported to be beneficial for severe ADHD-I or SCT.

    • Note the problems of serotonin reuptake inhibitors in ADHD-I.
      Notes on serotonin reuptake inhibitors (SSRIs) for ADHD

    • For ADHD with bipolar disorder:
      Whether ADHD medication (especially for bipolar 1) can have a mood destabilizing effect is controversial. In contrast: Barkley11
      It is recommended to treat the bipolar disorder first and then treat ADHD (see above).

4.2. Medication review

  • After completing the non-drug therapy measures (regularly, e.g. annually), check whether medication is still necessary
    • Adjustment if necessary
    • Reduction if necessary
    • Termination, if applicable
  • Regular physical check-up when administering medication
  • Dosage: trying to eliminate all ADHD symptoms through medication would be malpractice. Non-affected people have 9 out of 32 symptoms (of the total symptom list ⇒ Total symptom list according to manifestations) frequently, sufferers have 26 out of 32 symptoms frequently. Trying to completely eliminate even the “healthy” 9 symptoms would inevitably lead to an overdose.

We have witnessed astonishing changes in those affected as a result of medication and therapeutic measures, with the quality of life improving immensely within just one year in some cases.
The changes were particularly impressive in those patients who patiently and consistently took advantage of every opportunity to improve. Hardly any of those affected found all the forms of therapy they tried to be useful. In our opinion, the most successful patients were those who did not expect individual measures to be successful, but who consistently tried one measure after another until a satisfactory condition was achieved. Once one therapeutic measure was completed, the next one followed, but only as much at a time as was manageable.

4.3. Medication breaks

Many doctors recommend that their patients take a medication break of at least one week at least once a year to determine whether medication is still required. It is hardly conceivable that a state of “no longer needing” has occurred without the (previously unchanged) medication no longer being perceived as appropriate. Normally, a decreasing “need” at a constant dosage should cause symptoms of an overdose. We therefore assume that cases in which those affected no longer notice any difference to the previous medicated state during the medication break are more likely to be related to reduced demands in the environment (vacation/holiday) or to the development of tolerance.

Such a break from medication should always be weighed up against the background of the increased risk of accidents during this time.

Children with eating problems or growth problems can benefit from a break of several weeks during the vacations to build up weight reserves for the coming school term or to catch up on length growth (which, if impaired at all, is usually only delayed by MPH).12

5. Treatment prioritization for comorbidities

5.1. Prioritization according to the severity of the disorder

5.1.1. Comorbidity more serious than ADHD

  • Primary treatment of comorbidity
  • E.g. severe depression, bipolar 1,1314 addiction, psychosis, severe anxiety
  • For depression, anxiety and addiction at the same time as parallel treatment of the usually causative ADHD.15
  • Comorbid anxiety with ADHD may require specialized treatment.15

5.1.2. ADHD more severe than comorbidity

  • Primary treatment of ADHD as the leading disorder.13
  • Mild emotional dysregulation, mood swings, mild impulsivity or aggression, mild anxiety disorders or dysphoria (especially dysphoria with inactivity) are improved by ADHD treatment.161417

5.1.3. ADHD and comorbidity equally severe

If in doubt, we would prefer ADHD treatment.
Treating ADHD can significantly reduce the symptoms of comorbidities - and even eliminate them.18
In our opinion, taking into account the side effects of the medication, so that the treatment with the fewest side effects is preferred, should also usually lead to ADHD treatment being prioritized.

Depression in ADHD, for example, can also be determined by the intensity of unpleasant conflicts that are also caused by ADHD symptoms.19

5.2. Treatment guidelines for specific comorbidities

5.2.1. ADHD and depression:

  • Note the difference between dysphoria / severe depression in ADHD
    Depression and dysphoria in ADHD
  • Always check D3 blood levels and thyroid hormones before taking antidepressants for moderate or mild depression
  • Summary of the Texas Children’s Medication Algorithm for ADHD-HI and MDD according to Burleson Daviss (2018) Moodiness in ADHD - A Clinicians Guide, p. 99 (modified)2021 22
    • Impairment from ADHD-HI worse than from MDD:
      • Start of stimulant monotherapy according to the ADHD-HI algorithm.
        • If thereupon:
        • ADHD-HI, but does not address depression:
          Add SSRIs for the treatment of depression
        • ADHD-HI and depression remain the same:
          Change to a new class of stimulants
          • From MPH to AMP or from AMP to MPH
            • Unlike MPH, amphetamine medications also have a mild antidepressant effect and therefore have an advantage over MPH in cases of comorbid depression. Amphetamine medication for ADHD
          • If MPH and AMP are unsuccessful:
            • Change to Guanfacin
          • If Guanfacin is also unsuccessful:
            • Switch to atomoxetine
        • Exacerbate ADHD-HI and/or depression:
          Switch to SSRI2324
    • Impairment from MDD worse than from ADHD-HI23 or suicidal thoughts/suicidal behavior21:
      • Start of SSRI monotherapy23
        • If thereupon
          • Depression, but does not address ADHD-HI:
            Add stimulants for the treatment of ADHD-HI
          • Depression remains the same or worsens:
            Switch to another SSRI
        • If thereupon
          • Depression, but not ADHD-HI:
            Add stimulant to treat ADHD-HI.
          • Depression remains the same or worsens:
            Switch to non-SSRI antidepressant, e.g.
            • Bupropion13
            • If bupropion is unsuccessful:
              Nortriptyline, desipramine or venlafaxine13

5.2.2. ADHD and addiction

  • Addiction or alcohol abuse should be stabilized first, but can be treated at the same time as ADHD.16 In particular, there is no longer any reason to withhold stimulants as ADHD medication from addicts and treat them solely with atomoxetine, which is significantly less effective and has considerably more side effects.25

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  20. Pliszka, Crismon, Hughes, Corners, Emslie, Jensen, McCRACKEN, Swanson, Lopez (2006):TEXAS CONSENSUS CONFERENCE PANEL ON PHARMACOTHERAPY OF CHILDHOOD ATTENTION DEFICIT HYPERACTIVITY DISORDER. The Texas Children’s Medication Algorithm Project: revision of the algorithm for pharmacotherapy of attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2006 Jun;45(6):642-657. doi: 10.1097/01.chi.0000215326.51175.eb. PMID: 16721314.

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  25. Kooij, Bijlenga, Salerno, Jaeschke, Bitter, Balázs, Thome, Dom, Kasper, Filipe, Stes, Mohr, Leppämäki, Brugué, Bobes, Mccarthy, Richarte, Philipsen, Pehlivanidis, Niemela, Styr, Semerci, Bolea-Alamanac, Edvinsson, Baeyens, Wynchank, Sobanski, Philipsen, McNicholas, Caci, Mihailescu, Manor, Dobrescu, Krause, Fayyad, Ramos-Quiroga, Foeken, Rad, Adamou, Ohlmeier, Fitzgerald, Gill, Lensing, Mukaddes, Brudkiewicz, Gustafsson, Tania, Oswald, Carpentier, De Rossi, Delorme, Simoska, Pallanti, Young, Bejerot, Lehtonen, Kustow, Müller-Sedgwick, Hirvikoski, Pironti, Ginsberg, Félegeházy, Garcia-Portilla, Asherson (2018): Updated European Consensus Statement on diagnosis and treatment of adult ADHD, European Psychiatrie, European Psychiatry 56 (2019) 14–34, http://dx.doi.org/10.1016/j.eurpsy.2018.11.001, Seite 22, 7.4.1.

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