Is it ADHD or an Anxiety Disorders?

When you are having some sort of difficulty and you go to get help, the primary goal of the clinician is to figure out the underlying problem or diagnosis. This is not any different when the topic is ADHD, yet figuring out the problem accurately has significant implications when it comes time to provide treatment. Many children and adults have difficulties focusing and paying attention. It is crucial to undersand that not every child or adult who squirms or gets distracted has ADHD. At times, both children and adults are readily tried on medications without taking the time to figure out the underlying problem that is causing the symptoms. At times it is perfetly normal to be distracted, have difficulty focusing or to be forgetful. Of course these are three symptoms of someone who might potentially have ADHD, but they could also be just normal.

My primary concern in this article is in differentiating between anxiety and ADHD because both syndromes can mimic each other and there are sometimes challenges in differentiating between the two. It is not uncommon in my practice to see someone for consultation because none of the ADHD medications have helped them so they are looking for the next medication option. This is where there is a tremendous value in getting a thorough diagnostic evaluation to figure out some of the potential reasons for the lack of efficacy of the medications as welll as to confirm the diagnosis.

Anxiety by itself can cause someone to be fidgety, unfocused, easily distracted, forgetful, disorganized, etc... Once again these are some of the hallmark symptoms of ADHD; however they also tend to show up when there is an underlying anxiety disorder. One of the ways to differentiate between the two syndromes is that the aforementioned symptoms tend to be most prominently exhibited in an episodic manner or in a cyclical manner in anxiety. In those who have ADHD, their symptoms tend to be persistent across settings and tend to be consistent over time. The nature of anxiety is that it breeds worries, fears, nervousness, obsessions, compulsions and avoidance behaviors while those with ADHD tend to be impulsive. It is totally possible to suffer from both syndromes which can complicate matters when it comes to treatment. Since both of these syndromes can be so similar, yet have very different treatments, it is imperative to get a thorough evaluation prior to initiating any treatment.

Combining medications for ADHD

It had become common for both children and adults to take more than one medication in the treatment of ADHD. It is prudent to remember that the more medications one takes, the higher the risk for drug-drug interactions as well as potential negative side effects. At this point, there is a limited amount of published research data on combination treatment. Despite the limited data to back up the practice, the strategy of using more than one medication continues to become more popular.

The most common scenario where combining medications is considered is when one medication is partially effective and there is still a need for improvement and increasing the dose is not an option because negative side effects have already occurred at the higher dose. It is much more prudent to do a medication trial with another medication before adding a second medication. There are many times where changing the medication results in improved effectiveness. Sometimes, that might mean going back to a medication that has been tried in the past.

It is essential that there is a discussion with the prescribing physician about realistic expectations regarding the potential benefit of medication treatment. Unrealistic expectations can lead to mutliple medications and unnecessary high doses. The approach to combination treatment needs to be the same as making any other medical decision. There need to be a clear undertanding of the goal of treatment; evaluating the potential benefit versus the potential risk of the treament being considered, exploring alternative options; and finally recognizing the potential risks of not utilizing that treatment option. These 4 essential points must be considered and discussed with the prescribing physician before combination treatment is initiated.

See Making the Connection: A Parent's Guide to Medication in ADHD (www.adhdparents.com)

Larry's Story- An adult with untreated ADHD

Larry is a fourty-three year old real estate agent who lives alone. He has three children from two different marriages. He has held many different jobs in sales. He briefly attended a community college, but never received a degree. Everyone who meets Larry likes him, but all of his employers perceive him to be irresponsible and careless. Both of his marriages ended due to financial strains and his inconsistent job history. There have been three episodes of depression. In his mid twenties, Larry had difficulties with excessive alcohol use, and briefly lost his drivers license due to a DWI charge. His parents and teachers always thought him to be smart, but accused him of being "lazy". Larry was eventually accurately diagnosed with ADHD. He finally received treatment and readily admits that his life is finally stable for the first time.
Larry's story is a great example of some of the potential consequences of not treating ADHD. Whenever a medical decision is being made, it is vital to understand the risks of not treating the condition. This is also true for ADHD.

(Adapted from Making the Connection: A Parent's Guide to Medication in ADHD- p 17-19)

Bupropion/ Wellbutrin for ADHD

One of my patients yesterday asked me about Bupropion (Brand is Wellbutrin) for treating ADHD. Bupropion is primarily an antidepressant that is sometimes used in the treatment of ADHD. Its actual benefit in treating ADHD symptoms is mild especially for symptoms such as impulsivity and hyperactivity. The data in children and adolscents is minimal in comparison to other medications. There is a clear need for more research on this drug. For people who have a history of substance abuse or depression along with the ADHD, it can be a safe first alternative. (See Making the Connection- A Parent's Guide to Medication in ADHD- pages 81-82)

Can you do a brain scan to diagnose ADHD?

(Adapted from Making the Connection- A Parent's Guide to Medication in ADHD)

The field of psychiatry is always searching for a conclusive diagnostic test to aid physicians in diagnosing the various mental conditions. Unfortunately this test doesn't currently exist for any psychiatric illness and ADHD is not any different. Brain scans are used frequently in research studies. Research has shown that children with ADHD have smaller brain volumes in specific parts of the brain (frontal lobes, white matter, and cerbellum). These are only research studies and cannot and should not be used to diagnose ADHD in a specific child or teenager.

Does Sugar cause ADHD?

I meet many parents who wonder whether their children's sugar intake is causing ADHD. Currently, there is no research evidence that this is the case. There are studies that have compared kids on sugar and off of sugar. These studies show that there is no link between sugar in kids and attention or behavior problems. However, parents need to exercise common sense and good judgment. There are many legitimate reasons to limit your children's sugar intake such as good nutrition. Unfortuantely limiting sugar intake does not result in an amelioration of ADHD symptoms.

What is the best ADHD medication?

There are many different medications on the market that are used to treat ADHD. The two classes are the stimulants and the non-stimulants. The stimulants (such as methylphenidate, mixed amphetamine salts, etc...) are still considered the most potentially beneficial medications in the treatment of ADHD symptoms. However, the nonstimulant Atomexetine can be potentially beneficial. The potential benefit of the different stimulants is the same. One stimulant is not better than another. Each person has a unique response to a given medication, so for some people there is one medication that works better than another. This can only be evaluated for each person.