We consider the procedure described below to be fundamentally sensible. However, these are merely thoughts from a scientific point of view, which cannot represent a therapeutic recommendation for action in individual cases.
In each case, an individually tailored therapy plan must be developed by a physician or psychotherapist.
Our presentation is not intended for self-medication, but to make medical recommendations more understandable to affected individuals and their families and to enable them to discuss the options described with the treating physician and therapist.
Official national treatment guidelines exist in America, Europe, Canada, and Germany, among others.
0. Prerequisite: Secure diagnosis¶
- Questionnaire AND tests, self-perception AND other-perception history, elementary school report cards or other reports from kindergarten and early school years
- Caution: high self-interest in testing may lead to outcome as in non-affected (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 view
- Exclude acute stress situation
- IQ test
- Exclude dominant disorders with similar symptoms
More on the topic ⇒ Differential diagnostics
- Identify comorbidities
1. Step: Psychoeducation¶
- Acquire knowledge about the causes, correlations, effects and possibilities of influence
Group experiences with other affected persons can also contribute very positively to psychoeducation
- An ADHD diagnosis is already accompanied by the realization of being different from others, in both a negative and a positive sense. This realization is often associated with great hopes for improvement of the life situation.
- The experience that other people have gone through or are going through the same thing often causes amazing relief for ADHD sufferers
- Feeling of coming home among like-minded people
- Self-esteem enhancement
- Exchange of experience
- Willingness to address the issue
2. Second step: Drug treatment¶
2.1. Treatment prioritization for ADHD with comorbidities¶
See here under 5.
2.2. ADHD symptom elimination through medication¶
⇒ Medication for ADHD - Overview
- Of those affected who would be helped by medication, only about 20 to 25% receive medication. Of those not affected, less than 1% receive medication they do not need.
- Prior to treatment with stimulants, it is recommended to
- A cardiovascular workup. to look for cardiovascular abnormalities such as
- Increased blood pressure
- Heart murmurs
- Syncope during physical exertion
- ECG is optional
- Contraindications to stimulants (most of them uncommon in childhood):
- Schizophrenia
- Severe depression
- Hyperthyroidism
- Cardiac arrhythmias
- Moderate to severe hypertension
- Angina pectoris
- Glaucoma
-
Monoamine oxidase (MAO) inhibitors
- Former hypersensitivity
- Simultaneous use
- Use within the last 2 weeks
- Caution is advised in patients with
- Motor tics
- Known drug addiction
- History of drug addiction, alcoholism, caffeine addiction
- But:
- Stimulants for ADHD can significantly reduce addictive pressure
- Alcohol and MPH at the same time do not get along at all
- Alcohol and AMP at the same time are not good, but far less bad than alcohol and MPH
- No caffeine when dosing stimulants - risk of cross effects
- Pregnancy
- Breastfeeding
- Anorexia nervosa
- History of suicidality
2.2.1. Adults: amphetamine medication before methylphenidate (test different MPH preparations if necessary) before atomoxetine before guanfacine¶
For adults, the most helpful* Prioritization of medications is
*Health insurer approvals may deviate from this
2.2.2. Children and adolescents: Methylphenidate (test different MPH preparations if necessary) before amphetamine medications before guanfacine before atomoxetine¶
In children and adolescents, the most helpful from a scientific point of view is* Prioritization of medications:
*Health insurer approvals may deviate from this
- Methylphenidate ago
- Amphetamine drugs before
- Guanfacin before
- Atomoxetine
The guidance on methylphenidate and amphetamine medications in the previous section on adults applies equally to children and adolescents.
2.2.3. Dosage principles¶
In our experience, many mistakes are made during dosing, which not only prevent an optimal effect, but often enough prevent any effect at all. Therefore, the dosage instructions should be followed very urgently,
See in detail at ⇒ Dosage of medication for ADHD
The main topics are:
2.2.3.1. No caffeine when dosing stimulants (IMPORTANT!)¶
Caffeine should be completely omitted without compromise when dosing stimulants.
Around 50% of those affected experience symptoms typical of overdose (up to severe overdose) when stimulants are added to a caffeine intake that was previously tolerated without problems. In addition to a high level of shakiness, other side effects will also be drastically increased.
After successful dosing with stimulants, caffeine can be carefully added again. The difference is that those affected then know that any side effects that now occur are not the result of the stimulants
We also know reports of individual sufferers who - after years of taking stimulants - still react to even decaffeinated coffee with a slight tremor.
2.2.3.2. Slow dosing¶
- low initial dose (2.5 mg unretarded MPH / single dose or equivalent for other medications)
- at least 5 days / dose level
- Dosing increments max. 2.5 mg unret. MPH / single dose
- optimal dose is very individual
- Dose level can individually exceed “recommended maximum dose” of 60 mg / children, adolescents / day or 80 mg / adults / day (esp. fast metabolizers)
- Effect of slow dosing:
- reduces side effects
- prevents skipping the appropriate dose due to the sometimes very narrow therapeutic range
2.2.3.3. Keep dosage aid table¶
2.2.3.4. Nonresponder treatment¶
-
MPH: 30% Nonresponder
- in case of non-effect of MPH:
- Check gastric acid
- Change active ingredient
- in case of inappropriate side effects:
- change preparations first
- amazing individual side effect reactions
- Person A does not tolerate preparation A and B is fine, person B exactly the opposite: unpredictable
- Preparation alternatives e.g.:
- unretarded
- Medikinet retard / Adult
- Ritalin LA / Adult
- Concerta
- Kinecteen
- then change active ingredient
- Sequence recommendation see above 2.2.1. and 2.2.2.
-
AMP: 20 % Nonresponder
- over 40 % of those affected are helped by a change of preparation in the first 3 months
- when switching between MPH and AMP due to nonresponding, only about 10 to 15% remain who are nonresponders for both stimulant types
2.2.3.5. Ensure all-day coverage¶
-
ADHD does not end after school
- a treatment should not only establish a school ability
- Homework, social life and family life suffer quite significantly under ADHD
- unmedicated ADHD is associated with a significantly increased risk of accidents, which translates into a 9-year reduction in lifetime expectancy. Not treating this is not objectively justifiable. See the chapter on Consequences of ADHD.
- Manufacturer’s data on duration of action (rarely achieved in practice)
- unretarded MPH acts 2.5 - 3.5 hours / single dose
- 4 to 5 single doses
- hardly feasible in the long term, especially for children
- for dosing, unretarded MPH is nevertheless advantageous, as it can be regulated most finely
- half-day-retarded MPH acts 5 - 6 hours / single dose
- 2 doses + unretarded MPH for residual coverage, if necessary
- Second dose idR 50% to 75% of first dose
- all-day-retarded MPH acts for 10 - 12 hours
- Attentin (unretarded AMP) acts 5 - 6 hours
- 2 doses and, if necessary, unretarded MPH for residual coverage
- Second dose idR 50% to 75% of first dose
- L-amfetamine (Elvanse) works for approx. 10 - 12 hours
- 1 dose and unretarded MPH for residual coverage, if necessary
- Guanfacin
- Atomoxetine
- If daily coverage is not achieved
* Multiple doses taken throughout the day (up to 3 whole-day retardant doses)
* Retarded preparations can also be supplemented by non-retarded ones
- Fast metabolizers require more frequent doses / day rather than higher single doses
- in approx. 50 % of those affected, the duration of effect of stimulants is only 50 % of the manufacturer’s specification
- mostly super fast metabolizers (fast metabilizing CYP or CES1 gene variant)
- multiple dosing even of whole gestretards during the day
- Combination medication for fine-tuning / for difficult cases
- in particular:
- 50% ATX for full day treatment of emotional dysregulation
- 50 % MPH or AMP, as usually better effect on drive / concentration
- Rebound treatment
- Rebound particularly frequent with MPH
- Remedy:
- Take second dose in time for it to kick in before first dose runs out in rebound
- unretarded MPH shortly before the end of the last dose
- 1/4 to 1/3 of what would correspond to a daytime treatment dose
- Example: 20 mg half-day sustained-release MPH corresponds to 2 x 10 mg unretained MPH. Here, therefore, 2.5 to 3.5 mg unretarded MPH 30 min before the end of the last retarded dose.
2.2.3.6. Nonresponding / treatment-resistant ADHD¶
REVIEW on options for action in treatment-resistant ADHD: Cortese et al.
- Optimize stimulants
- try alternative monotherapies
- Try non-stimulants
- combined pharmacotherapy
- A combination of stimulants with non-stimulants is superior to monotherapy with only one group of agents
- Use off-label medications that have been shown to help with ADHD
- treat comorbid diseases
2.2.3.7. Development of tolerance to stimulants / habituation effects¶
REVIEW on options for action in treatment-resistant ADHD: Cortese et al.
- Development of tolerance is rather rare, but possible in some cases
-
ADHD sufferers showed significant recurrence of hyperactivity and inattention after 2 years of taking MPH when discontinued
- A meta-analysis of 87 randomized placebo-controlled double-blind trials found no evidence of habituation effects with prolonged use of:
- Methylphenidate
- Amphetamine drugs
- Atomoxetine
- α2-antagonists (guanfacine, clonidine)
- Caution: Studies on the development of tolerance to MPH in rats, which examined administration in drug dosage (10 mg/kg are not uncommon) or drug ingestion form (intravenous, rapid dopamine increase), are unlikely to be transferable to the effect of drug administration (oral / patch, slow dopamine increase); in addition, particularly high doses were often given
- higher dosage increases risk of habituation and in this respect possibly consequence of overdose
- when taken orally / patch, stimulants can always be discontinued without problems
- steady dose increase in short intervals of stimulants is not a solution
- to be distinguished from once or twice dose adjustment in the first year
- short medication vacation can help sensitive sufferers reduce tolerance buildup
- Dose lower on weekends
- Skip weekends
- break of several weeks can restore long-term effect afterwards
- Change of the active ingredient
- from MPH to AMP
- from AMP to MPH
- If the substitute is less effective, it may help to switch back after about a month. It has been reported that in many cases the tolerance disappeared after one month.
- Combination medication
- reduced stimulant content may contribute to reduced tolerance formation
2.2.3.8. Emotion loss / zombie mode: overdose or intolerance¶
A restriction of emotionality by ADHD medications need not be accepted at all. ADHD medications work properly when the affected person feels more like themselves. Any form of perceiving oneself as strange or less is a clear indication of inappropriate medication.
Stimulants dampen the limbic system. A few sufferers react particularly sensitively in this respect. In most cases, patient testing of different preparations and active ingredients helps.
More often, in our impression, an emotion restriction is the result of an overdose. In this case, restarting the dosage in the smallest possible steps should be considered. Some (albeit very few) sufferers need only a few mg of a stimulant throughout the day.
If an affected person reacts with a restriction of emotionality even with appropriately low doses of various stimulant preparations and agents, non-stimulants such as atomoxetine or guanfacine should be considered. Although these improve ADHD symptoms significantly worse than stimulants and have higher side effects, they do not dampen the limbic system.
If the effect of non-stimulants is not sufficient, e.g. because they often give less of the required drive, a comedication of non-stimulants and stimulants is possible. Since the stimulants can then be given in lower doses than with medication alone, the risk of emotion impairment is even lower.
2.2.3.9. Medication breaks¶
Many physicians recommend that their patients take a medication break of at least one week at least once a year to determine whether medication administration is still necessary. In this context, it is hardly conceivable that a state of “no longer needing” has occurred without the (previously unchanged) medication already being perceived as no longer appropriate. Normally, a decreasing “need” with no change in dosage would have to produce symptoms of overdose. We therefore suspect that cases in which those affected no longer notice any difference from the previous medicated state during the medication break are more likely to be related to reduced demands in the environment (holidays/vacation) or to a development of tolerance.
Such a break in medication should always be weighed against the background of the increased risk of accidents during this time.
Children with eating problems or growth issues may benefit from a break in medication for several weeks during the vacations to build up weight reserves for the upcoming school season or to catch up on length growth (which, if affected at all, is usually only delayed by MPH).
2.2.4. Effect sizes of different drugs¶
- Effect strength at optimum setting:
- Amphetamine drugs: 1.1-1.5
- Methylphenidate: 1.0-1.3
- Guanfacine: 0.8
- Atomoxetine: 0.65
2.2.5. Goals of an optimal medication setting¶
- Enable experience of what life without ADHD can be and feel like (allows sufferers to intrinsically define goals for non-drug therapy)
- Establish therapy capability (bring attention and concentration to the level required for learning more functional ways of acting)
- Increasing treatability with dopaminergic ADHD medications, as dopamine increases or restores neuroplasticity
- In ADHD, growth hormones, which are necessary for neuroplasticity (learning), are decreased. Stimulants increase the levels of growth hormones.
- The goal is not to completely eliminate all ADHD symptoms **
-
ADHD sufferers differ from non-affected people only in the number of symptoms they have frequently. Non-affected people also have some symptoms frequently.
- Single prominent symptoms should be treated as singularly as possible (e.g. impulsivity with lowest doses of SSRI, aggressiveness with low doses of antipsychotics) instead of trying to treat them with ADHD medications, as this would result in too much broad intervention
2.3. Many other small treatment steps¶
The points mentioned here should always be considered in ADHD treatment, as they can usually make a further helpful contribution without showing significant side effects. The points do not represent alternatives, but should all be considered.
However, their effect strength (even in combination of all possibilities) is considerably lower than the above-mentioned relevant drugs. If it were otherwise, the reports of successful treatment without the relevant drugs would be legend. Newcomers to this topic can obtain information from affected person forums, such as the ⇒ ADHD forum of ADxS.org
- Vitamins and minerals
Determine blood values and dose to upper limits or above. More on this at* ⇒ Vitamins, minerals, dietary supplements for ADHD*
- Vitamin D3
- October to May essential in Germany
- Very important in ADHD, essential in depression. Prescribing serotonergic or noradrenergic antidepressants (which in our opinion have considerably stronger side effects than ADHD drugs) without first checking the D3 level is, in our opinion, malpractice (except in 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 (each at low doses)
- Melatonin (unretarded, especially helpful in ADHD)
- Light therapy
- See more at ⇒ Sleep problems with ADHD
- Initiate drug treatment of mild remaining comorbidities, if possible, only after analyzing the impact of ADHD medications (usually after about 6 months)
- Test and exclude food intolerances
- Test and exclude allergies
- Test and treat chronic low-threshold inflammation (very difficult)
- Lots of sports and exercise
- Endurance exercise has a significant effect size in reducing the symptomatology of ADHD (and other mental health problems such as depression)
- Effect strength of weight training, on the other hand, is lower
- Sport must be fun for it to be practiced sustainably
- Endurance sports
- Increases stress resistance, shuts down stress systems (for 24 - 48 hours)
- Effect size in the optimal case (e.g. 5 x 1 hour / week) up to 0.7
- See more at ⇒ Sleep problems in ADHD
- Healthy diet
- Avoid sugar
- Avoid bad fats (saturated fatty acids, trans fats; e.g. deep-frying fat)
- Abundant antioxidant foods (vegetables, fruits)
- Helps to reduce antioxidant stress
3. Third step: psychotherapy¶
3.1. Psychotherapy to reduce symptoms¶
Here, it is only insignificantly important which form of therapy is chosen (exception: mindfulness-based therapies are better suited than cognitive therapies, depth psychological therapies are only of use for unpleasant experiences that need to be worked through, and psychoanalysis is fundamentally unsuitable for ADHD). It is much more important that the patient feels very comfortable and accepted by the therapist. This does not at all mean a cuddly therapy, where the therapist would only tell the patient what the patient wanted to hear, but the positive acceptance and the basis of trust, which are the indispensable foundations for a successful therapy. Without these minimum conditions, the best form of therapy and the greatest experience of the person treating the patient will be useless. Therefore, a great deal of patience is required here in the selection of the appropriate therapist.
It is further important that it is not a matter of a single therapeutic measure, but that as long and as many therapeutic measures take place until a satisfactory condition has been reached.
In all therapy measures, it must be ensured that the therapist knows all ADHD symptoms relevant to treatment. Often enough, doctors and therapists are still subject to the fatal error that ADHD is limited to the diagnosis-relevant symptoms of DSM or ICD. Therapists who do not want to accept the original symptoms of ADHD beyond DSM / ICD as such should be avoided. Otherwise, there is a concrete danger that the affected person will be assigned responsibility for behaviors that in reality stem from ADHD itself. Such a thing can cause further deterioration for the affected person instead of improvement.
Appropriate types of therapy may 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)
Especially in ADHD-HI, the vicious cycle of inability to recover should be broken, which helps maintain the continuous operation of the HPA axis.
- Neurofeedback for long-term improvement of self-control (6 months to 2 years)
-
SMR training to improve impulse control and against sleep problems
- Theta-beta training to improve the regulation of activation
-
SCT training to reduce overactivation or increase underactivation
- Especially recommendable seems to be a combination of Theta-Beta-Training or Z-Score-Training and SCP-Training (simultaneously or consecutively)
- 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 notice. Cortisolergic stress arises especially in subjectively self-esteem-threatening situations.
- If necessary, depth psychological therapy for the treatment of serious experiences / experiences
- If necessary, trauma therapy (EMDR) for traumatic experiences
- For children up to 6 or 10 years of age: parent-centered therapy; child-centered therapy ineffective.
3.2. Environment Interventions¶
- Eliminate stressors
- Optimal design of the working and learning environment, e.g.
- Eliminate superfluous stimuli
- Enable sufficient arousal
- Discussions with relationship persons to create mutual understanding
- If necessary, systemic therapy (family therapy, parent therapy) to change ingrained problem patterns
- Life and career focus on things that really matter
4. Fourth step: comorbidities and medications review¶
4.1. Comorbidities¶
- After 9 to 12 months of ADHD treatment, check for persistence of comorbidities
- Specific drug treatment if necessary (note interactions, e.g. caution with SSRIs)
- If necessary, select specific ADHD medications that also have a positive effect on comorbid disorders
-
Atomoxetine acts noradrenergically and dopaminergically on PFC and striatum, stimulants noradrenergically and dopaminergically on striatum only.
⇒ Atomoxetine in ADHD Atomoxetine is reported to be beneficial in severe ADHD-I or SCT.
-
Note problem with serotonin reuptake inhibitors in ADHD-I.
⇒ Comments on serotonin reuptake inhibitors (SSRIs) in ADHD
-
In ADHD with bipolar disorder:
Whether ADHD medications (especially for bipolar 1) can have a mood-destabilizing effect is controversial. In contrast: Barkley
It is recommended to treat Bipolar Disorder first and then ADHD (see above).
4.2. Drug Review¶
- After completion of non-drug therapy measures (regularly, e.g. annually), check whether medication is still required
- Adjustment if necessary
- Reduction if necessary
- Termination if necessary
- Regular physical check-up when medication is administered
- Dosage: to attempt to eliminate all ADHD symptoms through medication would be malpractice. Unaffected individuals have 9 of 32 symptoms (of the total symptom list ⇒ Symptom total list according to manifestations) frequently; affected persons have 26 of 32 symptoms frequently. To try to completely eliminate even the “healthy” 9 symptoms would inevitably lead to overdose.
We have witnessed astonishing changes in patients as a result of medicinal and therapeutic measures, and in some cases the quality of life has improved immensely within just one year.
The changes were particularly impressive in those affected who, with patience and consistency, took advantage of every opportunity that presented itself for improvement. For hardly any of the patients, all the perceived forms of therapy proved to be useful. According to our perception, those affected were particularly successful who did not expect a certain success from individual measures, but who consistently tried one measure after the other until a satisfactory condition was reached. Once one therapeutic measure was completed, the next one followed, but only as much at a time as was easily manageable.
5. Treatment prioritization for comorbidities¶
5.1. Prioritization according to the severity of the disturbance pattern¶
5.1.1. Comorbidity more severe than ADHD¶
- Primary treatment of comorbidity
- E.g. major depression, bipolar 1, addiction, psychosis, severe anxiety
- For depression, anxiety and addiction at the same time under parallel treatment of the mostly causative ADHD.
- Specialized treatment may be needed for comorbid anxiety with ADHD.
5.1.2. ADHD more severe than comorbidity¶
- Primary treatment of ADHD as a leading disorder.
- Mild emotional dysregulation, mood swings, mild impulsivity or aggressiveness, mild anxiety disorders, or dysphoria (especially dysphoria with inactivity) are improved with ADHD treatment.
5.1.3. ADHD and comorbidity equally severe¶
When in doubt, we would prefer ADHD treatment.
Treatment for ADHD can significantly reduce symptoms of comorbidities - even eliminating them.
We also believe that consideration of the side effects of medications, so that the treatment with the fewest side effects is preferred, should usually lead to prioritization of ADHD treatment.
Depression in ADHD, for example, may also be determined by the intensity of unpleasant conflicts co-occurring with ADHD symptoms.
5.2. Treatment guidelines for specific comorbidities¶
5.2.1. ADHD and depression:¶
- Note difference dysphoria / major depression in ADHD
⇒ Depression and dysphoria in ADHD
- Always check D3 blood levels and thyroid hormones before antidepressant administration for moderate or mild depression
- Summary of the Texas Children’s Medication Algorithm for ADHD-HI and MDD by Burleson Daviss (2018) Moodiness in ADHD - A Clinicians Guide, p. 99 (modified)
- Impairment from ADHD-HI worse than from MDD:
- Start stimulant monotherapy according to ADHD-HI algorithm.
- When thereupon:
-
ADHD-HI, but does not address depression:
Add SSRI for the treatment of depression
-
ADHD-HI and depression remain the same:
Change to a new stimulant class
- From MPH to AMP or from AMP to MPH
- Amphetamine medications, unlike MPH, have concomitant mild antidepressant effects and therefore have an advantage over MPH for comorbid depression…. ⇒ Amphetamine medication in ADHD
- If MPH and AMP unsuccessful:
- If guanfacine also unsuccessful:
-
ADHD-HI and/or depression exacerbation:
Switch to SSRI
- Impairment from MDD worse than from ADHD-HI or suicidal ideation/suicidal behavior:
- Start SSRI monotherapy
- When thereupon
- Depression, but does not address ADHD-HI:
Add stimulants to treat ADHD-HI
- Depression stays the same or gets worse:
Switch to another SSRI
- When thereupon
- Depression but does not address ADHD-HI:
Add stimulant to treat ADHD-HI.
- Depression stays the same or gets worse:
Switch to non-SSRI antidepressant, eg.
- Bupropion
- If bupropion unsuccessful:
Nortriptyline, desipramine, or venlafaxine
5.2.2. ADHD and addiction¶
- Addiction or alcohol abuse should be stabilized first, but can be treated simultaneously with ADHD. In particular, there is no longer any reason to withhold stimulants as ADHD medications from addicts and to treat them solely with atomoxetine, which is significantly less effective and has considerably more side effects.
