You Can Stop the ADHD Medication
Let’s Move Past Guessing Into Solid Evidence And Start Working By Downloading These Predictable Solutions!
by Dr. Charles Parker
After many, many years of reworking these concepts and specific medication strategies these ADHD Medication Rules are, very simply, game changing tactics to correct the mess that currently exists using stimulant meds to treat ADHD throughout the country.
So what’s the big problem? The problem is at once simple and complex:
The simple: We are treating thinking – without thinking about thinking!
The complex: New brain science is overlooked, meds are used capriciously, and dangerous outcomes occur everyday… on top of the simple fact that literally thousands of folks are simply not treated or diagnosed correctly – leaving them frustrated with the medical system and the ADHD diagnosis in the first place.
But finger pointing is not my theme, teamwork is. The last chapter details specifics on how to work with your doc. The problem lies not with “the system,” but with the new medical facts. The solution is about working together more effectively – in the context of new brain and body science. But be forewarned: many don’t know about these new initiatives because the science is so far ahead of everyday practice.
I am but one of the many docs who didn’t understand the practice points detailed in Rules – even though I have worked for years learning and teaching the psychopharmacology nationally – and then chasing down neuroscience evidence for ADHD with SPECT brain imaging.
The science has just blown past us, and now it’s time to retrench with the basics rather than living in the cloud of imprecision associated with the current diagnostic codes and the amorphous treatment strategies based upon those superficial appearances.
This book is for patients, – and professionals will also appreciate the common sense approach to logical next steps in the evolution of treatment for ADHD. I am completely against polarized thinking, do not take the position “I am right and you are wrong,” but rather seek to correctly evolve the treatment process for the millions who seek the best ADHD care. Rules is about making “best practices” better, not creating new polemics. Improved, precise strategies will result in more predictable outcomes.
Why waste more time and money repeating the same counterproductive ADHD medication strategies that simply don’t work as you would think they should?
Rules will improve your overall ADHD understanding of all the details, including the most important issues of diagnostic targets and medication specificity.
Let’s pay attention by paying attention to these new ADHD Medication Rules, and think more carefully, more specifically about thinking. The subsequent stimulant medication results will render a more positive prognosis.
The Guarantee: And if you don’t think Rules significantly contributes to your treatment protocols through an improved understanding of ADHD, you can ask for a full refund, no questions asked.
Become a part of the community that understands what’s going on with new insights into ADHD and applied neuroscience. Last time I checked the mind was connected with the body.
See you in the ADHD Rules Book!
Here are some key excerpts from the book:
The 10 Biggest Problems with ADHD Medications.
Problem #1: Overlooking Targets – Beyond Diagnostic Labels
Let’s start with the basics. ADHD diagnostic labels currently focus almost entirely on the surface, the description, the appearance of ADHD. Hyperactive, Inattentive and Combined are topical, veneer descriptions enduring from years ago, now an ancient time, when we had no scientifically validated measuring tools to look at the biological activity of each person’s brain.
Please take a moment to understand this point: I am not suggesting that we rush out and throw away descriptive diagnostic tools and insights – to categorically replace them with only functional measures. (So often new science comes down to an ‘either/or’ disagreement, when the real solution is more ‘yes/and.’No) Nor am I suggesting that everyone needs a SPECT brain scan for informed diagnosis. I am emphatically saying that functional brain imaging evidence, and comprehensive neurophysiologic inquiries do dramatically change our medication treatment protocols.
Remember how the brain actually works, static labels only show what it looks like from the outside. First consider this brief review [many more details in ADHD Medication Rules] of these three functional ADHD targets/presentations. While you’re reading about these three consider how often these subsets are completely overlooked:
I. Acting ADHD: Acting Without Thinking
II. Thinking ADHD: Thinking Without Acting
III. Avoidant ADHD: Not Thinking and Not Acting
Some Medication Solutions Discussed In Detail in Rules:
1. ADHD is best treated with stimulant medications, not SSRIs, – certainly not tricyclic antidepressants such as desipramine.
2. SSRIs will aggravate ADHD, and increase impulsivity.
3. Phobias and cognitive anxiety, if secondary to ADHD, will respond poorly to the national standard of treatment for OCD: SSRIs
4. Context for ADHD9 is important; ADHD is most frequently not a 24×7 diagnosis. Doing well with video games does not rule out ADHD.
5. Remember: Many with personality/character presentations often do suffer with ADHD – avoidance and thinking often look too much like “personality problems.”
Problem #2: Neglecting the Evidence of Metabolic Rate:
Don’t worry; this *metabolic rate* thing will be easy. Think burn rate: fast or slow burn. Fast burn rates require much more medication to correct the symptom picture, and slow burn rates require much less medication. Slow burn rates can create unpredictable toxicity, even with “average” doses. Think about it: Fast burn is like pine wood on a fire, slow burns like an oak Yule log. Fast needs more meds, slow rates need lower doses. Many are simply not paying attention to the way medications burn, or the body biologic factors that effect the burn rate of ADHD meds.
Age, weight, body size, gender, do not consistently effect the burn rate. Autism, brain injury,10 Asperger’s, and a wide variety of other metabolic variables often do effect the burn rate, and become far more indicative of sensitivity to medications than those previous markers – often creating a very slow burn rate. Remember that slow burn rate will almost always show a relative toxicity, resulting in unwanted side effects, even at even low doses. ADHD meds will become far too stimulating, and just won’t work right.
Knowing burn rate, understanding the underlying metabolic challenges, will make medication adjustments far more predictable.
The Therapeutic Window
One of the easiest ways to evaluate burn rate is through considering objective assessments of The Therapeutic Window.Effective medication management works best with a workable window, with explicit sides, a top, and a bottom. I have outlined The Window on one page in Rules for easy reference and further distribution. The Therapeutic Window will help keep all of your medical team on target as they assess treatment objectives and medication predictability.
Problem #3: Multiple Diagnoses, Emotional Baggage, and ADHD
Multiple diagnoses, and the biologic complexity associated with ADHD is far more common than simple, unadorned ADHD. Miss this key point and you miss most of the action. The key medical word describing multiple diagnoses for ADHD matters is “comorbidity.‟ The importance of multiple diagnoses are several: using the right medications for the specific diagnosis, correctly organizing several medications with multiple diagnoses, and understanding the differences of each mediation’s possible side effects.
When ADHD presents with comorbid bipolar and depression, medications require a specific protocol:
1. First the mood stabilization.
2. Then the antidepressant - and
3. Then the ADHD stimulant medication – all carefully detailed in Rules.
Most frequently seen in the office: Depression and anxiety treatable with SSRIs, associated with comorbid ADHD. Complex situations such as these often suffer from multiple neurotransmitter challenges. I use and recommend neurotransmitter biomarker testing in all complex presentations. Biologic evidence provides more predictable outcomes.
1. Treat comorbid conditions in the correct order.
2. Multiple diagnoses require carefully adjusted multiple medications.
3. Complex presentations require more metabolic review and a better look at neurotransmitter precursors [paid by most insurances].
4. Watch carefully for side effects that might reveal any of these comorbid conditions below.
5. Untreated depression combined with ADHD stimulant meds can look remarkably bipolar.
6. Each psychiatric medication requires its own titration strategy, – has it’s own characteristic burn rate/metabolic signature. Stimulants require the most careful attention.
Problem #4: Overlooking Depression with ADHD
Depression with ADHD requires special focus. If depression is overlooked with ADHD, the stimulant medications can significantly aggravate suicidal thinking and intent. Do I have your attention? This topic alone is the reason for the associated details in the Rules – you and yours will benefit from Rules because I go over this topic.
Look for this important pharmacologic dynamic: Think of a seesaw. On one end of the board sits serotonin, the neurotransmitter that mainly effects depression and anxiety – and on the other end sits dopamine, the primary neurotransmitter for ADHD.
If the patient suffers from both conditions, the seesaw is lowered on both sides forming the shape of the roof of a house. Both neurotransmitters are down in number. Serotonin associated with the depression is down/diminished on the left; dopamine with ADHD symptoms is down/diminished on the right.
Correct either one individually, bring either one up toward a level horizon, and the consequence for the other, because they are connected on the seesaw, is to bring the opposite side further down. Treat only the ADHD with coexisting depression, and the depression worsens; treat depression without recognizing the ADHD, and the PFC looses control as the ADHD mushrooms.
Memorize this one. Spread the word. Tell your friends.
1. Always check for different signs of depression, – both thinking/cognitive and feeling/affective depression. All depression is not just feeling down.
2. Cognitive depression shows as apathy, indifference, attitude, and silence - disconnected. “Guy depression” looks like negative frustration, is often still depression, and beyond gender.
3. Watch for both sides of the seesaw in any clinical evaluation and any clinical history. In adults: a long history of poor response to antidepressants with cognitive confusion after a few days [often ADHD], and with children: the hard crash in the PM when the stimulant dose wears off [often depression]. If you look, you will see it.
4. Don’t mix Paxil or Prozac with either AMP or MPH as they both interact significantly with both medication families, most especially with AMPs, by plugging the 2D6 pipeline. With mismanaged care and an uninformed emphasis on primitive generic antidepressants, drug interactions abound. Dangerous interactions will most likely become an unpleasant surprise months down the line, if not watched carefully, - another medication challenge with potentially catastrophic consequences.
5. In Rules I cover these drug interaction issues in detail – and they remain overlooked by most practitioners even today – even though I have been pointing them out to national audiences for more than 14 years.
Problem #5: Overlooking Bipolar with ADHD
The current wastebasket diagnosis for many with these misunderstood brain function, diagnostic, and pharmacologic issues is bipolar disorder [BPD]. Talk about diagnosis by appearance! The new tongue-in-cheek diagnostic axiom: “If your mood swings, it’s bipolar.” And, yes, in some cases, it is. But often, BPD is simply overdiagnosed.
In far too many presentations of ADHD with mood swings the bipolar diagnosis is too hastily thrown into the mix. Often the mood swing complexity, the underlying biomedical causes, are simply overlooked. Just because you have mood swings doesn’t make you bipolar [thus, according to many, subject to no stimulants] – and only the heavy, weight gaining, side effect ridden tranquilizers indicated for treating bipolar disorder are recommended.
Often missed are significant challenges with drug interactions, immune system dysregulation, and hormone imbalances – to say nothing of completely ignoring issues of burn rate mentioned above and detailed in Rules.
Consider these bipolar proactive solutions:
1. Bipolar mood swings do not exclude, as some indicate, the possibility of using antidepressants or stimulants. Some academics disagree, but those in the trenches frequently use both mood stabilizers and stimulants, as well as antidepressants as indicated.
2. Use the treatment priorities outlined in Problem #2 above when considering treatment of comorbid BPD and ADHD.
3. Titrate [adjust dosages for] stimulant drugs far more carefully, adjusting dosage over longer periods. No rapid stimulant additions. We cannot prevent all mood swings, but stabilization with stimulants, if indicated, can significantly contribute to overall emotional stabilization.
4. Look carefully in the childhood history for signs of ongoing unmanageable cognitive abundance. ADHD moods often show a contrite self-reflection – bipolar less so.
5. If mood disordered, always review carefully for substance abuse. Warn others about substance abuse; street drugs with the combination of ADHD and bipolar can create havoc. With stimulant use: at first you feel smart and bulletproof, then you become stupid, and dangerous to yourself.
6. If large mood swings are present, attempt to differentiate and investigate head injury, brain trauma with functional brain imaging such as SPECT.17 Often MRI and CT scans don’t show serious functional brain impairment.
Problem #6: Overlooking Brain Injury with ADHD
At first blush, ADHD diagnosis seems quite simple; just make the focus and attention diagnosis with various testing tools, watch for comorbid diagnostic issues, and start ADHD medications. But overlooked Traumatic Brain Injury [TBI] can completely unwind the treatment process. If you miss TBI, stimulant medications can create massive difficulties from psychosis, to physical destructiveness, to aggravation of substance abuse problems.
Oftentimes individuals who suffer with injury simply don’t recall the event, and often only with SPECT brain scans in hand do they remember the entire injury – so careful questioning is in order.
One very interesting person in my office simply could not remember injury, until I repeatedly questioned him about various possibilities. After a pregnant pause in the interview he asked, “Does getting struck by lightning count?” They thought he was dead for 10 minutes. And remember, you don’t have to be completely knocked out to suffer a brain injury – whiplash alone can create an injury process.
1. With TBI, brain injury, treatment is not a one trick pony. Always provide more interventions than just stimulant medications. Stimulants will help somewhat, but the underlying reality, as it is with all of these brain dysregulations, is restoring the brain, helping it re-grow, and form new neural pathways. We want to support the neuroplasticity, the neurophysiology, the neurotransmitters, the nutrition – everything.
2. Use low dose stimulants for TBI carefully, focusing on the Therapeutic Window, and the specific targets of cognitive dysfunction, not primarily for the depression or moods. Use that Window as a guide regarding DOE, but start ADHD medications, if indicated, at less than ½ of a small child’s dose with TBI.
3. Consider neurofeedback,19 the positive results in the literature, with my colleagues, and in our office have been significant.
4. HBOT, Hyperbaric Oxygen Therapy, has proven extremely helpful to press healing oxygen into the brain cells.
5. In these complex presentations, no single intervention can cover the entire complexity for neuronal recovery.
Problem #7: Overlooking the Therapeutic Window
Dosing strategies require specific oversight. The Therapeutic Window can effectively keep all eyes on this productive process with medication adjustments.
Correct functional diagnosis sets the target; the Therapeutic Window sets how you get there.
Finding that Window sounds complicated at first, but it’s easy, and the benefits are clearly measurable. If medications are correctly adjusted, the patient lives right inside that Therapeutic Window with little or no side effects: They don’t go out the top, nor do they bump on the bottom – they float in the air, right inside that important window. Simply stated: The Window Top correlates with too much, the Bottom with too little, and the sides, the DOE, help add that burn rate, additional perspective. The sweet spot is there in between all of these edges.
The simple objective: think inside of this box, and you’ll actually be thinking outside of the box.
The Therapeutic Window
Represents the body’s ability to metabolize the medication effectively. If you simply pay attention to these simple details the possibility of the most common two problems with dosing ADHD medications are almost naturally corrected.
Consider these easy 7 tips on finding the Therapeutic Window.
1. The Problem with Stimulant Meds: The fundamental difference with stimulant medications: they don’t last all day – thus the problem with timing. Every medication, each body is built different metabolically, each with a different size pipeline, using different pipelines, and different kinds of speeds – thus the problems with dosage. Cookie cutter dosing strategies create significant problems.
2. The Custom Job – Beyond Genetics: The Therapeutic Window is specific for each individual adult or child, not based on your mother, father, sister, brother, or great aunt’s experience with medications in general or stimulants specifically. Yes, some families manifest medication sensitivities that may appear genetically related, but don’t necessary exclude a low-dose, careful trial.
3. The Top is Toxic: The dosage is too high, and side effects occur, such as feeling overfocused, agitated, or stoned. If your sleep is significantly disturbed, or your appetite is gone, either the dose of the medications or the medication itself may be incorrect. Always identify dosage carefully from the moment you begin. Start low, go slow, and don‟t increase more than weekly or every other week. See the Breakfast section in Rules for more specific help.
4. The Bottom Doesn’t Work: Start low at the outset, and dose upward to find the specific range/accuracy markers. Vyvanse often needs little titration – it remains quite stable in dosage over time, and characteristically provides a more cognitive, less anxious clarity to executive function. AMP products require a bit more attention to keep within the Window, but show better efficacy. MPH products appear more forgiving, but still need specific adjustments. Vyvanse, due to its unique prodrug metabolic pattern, is both more predictably effective and more forgiving, although it isn‟t for everyone.
5. Sides Show the Duration of Effectiveness – DOE: Measure the hours exactly: The AM side: when did you take it, and the other, PM side – when did it quit working? Each stimulant medication lasts only a specific duration. If you are below that expected duration, you are under-dosed. If you go past that expected DOE, you are on too much.
6. Drug Interactions: Non-stimulant drugs can clog the system, and cause unpredictable problems if they are ignored. This caution involves drugs that interact with the stimulants, especially some antidepressants.
7. Denial of The Therapeutic Window: If you don’t consider it, if you don’t know it’s there, you simply cannot target it. If you don’t target the Window specifics, you are either trying to shoot geese at night, or simply throwing cans of paint at the barn door, then declaring it painted. Without clear visualization of the target, without paying attention to the details and the edges, initial positive results become predictably negative over time. Stability over time is predictable with consistent parameters.
1. Start medication by looking for duration of effectiveness [DOE] and side effects.
2. Know/teach the DOE for every medication you use, noted above.
3. Begin at the outset to ask every member, especially children and adolescents, who often are not consulted, to provide input regarding the Therapeutic Window. Feedback with The Therapeutic Window encourages self-mastery, self-esteem, and precise solutions.
4. Use The Therapeutic Window as a guidepost, not an absolute path.
Problem #8: Overlooking The Protein Breakfast
“Who cares about breakfast? It’s a great thought, but who has the time?” And if you want to look good, it’s an easy diet thing, an irresistible meal to skip. “Hey, I’m doing OK without it, why bother? Pop-Tarts and cereal will do it, no problem – I’m always in a rush in the morning.”
The best brain reason for eating a protein breakfast is simple: neurotransmitter precursors.20 Yes, neurotransmitters do carry the messages, but if you don’t have sufficient neurotransmitters, you can’t manipulate them to work better. This is basic.
So how do you grow your neurotransmitter resources? Protein breakfast fuels the fire. Details matter, and are discussed in an entire Breakfast chapter in Rules.
1. Start at the beginning of stimulant medication treatment with a focus on breakfast proteins, especially with “picky eaters.”
2. Bring the child into the discussion of food choices and work hard to create alternative palate options that include forms of protein.
3. Medication improvements have been reported with protein doses as low as 8 Gm, such as those found in protein breakfast drinks. My own recommendation is to use higher doses of protein, cleaner doses with fewer sugars, such as found in breakfasts with eggs, protein powder on cereals, and protein bars [many have 20+ Gm of protein]. Smaller children obviously require less.
4. Best strategy for breakfast at school: some protein [a shake or protein drink?] given at home, before the medication, then the school breakfast.
Problem #9: Overlooking Sleep
Sleep may appear to be the easiest of problems to correct, but it is often the hardest. The sleep experts say we need 8.25 total average hours to defrag the fragmented brain – but, as I often say to the irritated adolescents, I won’t hold you to that .25! Insufficient sleep will almost always generate more unpredictable outcomes.
If you open Systems Utilities on your PC, you know it takes quite awhile to defrag your desktop, and so it is with your brain. Interestingly, and quite unexpectedly, correcting the ADHD problem with stimulants will often completely correct sleep challenges. Sleep is a far more complex issue than commonly appreciated and directly effects ADHD symptom proliferation. Sleep patterns to measure from the outset of medical intervention are:
Total Average Hours – TAH
Begin sleep assessment by doing the TAH math. You know the target is 8.25 hrs, and less than that will bring problems. Do you have trouble is falling asleep, staying asleep, or awakening too early in the morning?
Practice Sleep Hygiene
Yeah, I laughed at the phrase “Sleep Hygiene” too when I first heard it, but, listen up, it works. In a short summary like this, we cannot cover all the nuances of sleep hygiene. Suffice it to say that:
a. Sleep time should be consistent
b. No eating or watching TV from the bed
c. No caffeinated beverages in the PM
d. Exercise earlier in the day
e. Watch that stimulant medications don‟t create sleep problems
Identify and Treat Comorbid Conditions That Effect Sleep
Depression, mood disorder, bipolar illness, immune dysfunction, stress, brain injury, estrogen dominance [e.g. polycystic ovaries], are just a few of the many comorbid conditions which require their own targeted treatment.
1. Consider specific pharmaceutical sleep medications for a prompt response.
2. Melatonin is an easy, over-the-counter starting point.
3. The inhibitory neurotransmitters L-Taurine 500-1000 mg, and L-Theanine 100-200 mg are also over-the-counter and may prove helpful with out prescriptions. Testing will tell you specifically what is needed.
4. Clonidine at low doses is sedative, not addictive, and often can be used as needed at the 0.1 mg dose for sleep.
5. Consider sleep apnea evaluation if indicated, even in children, as sleep apnea will significantly contribute to poor medication responses treating ADHD.
Problem #10: Overlooking The Significance of Medical Teamwork
Don‟t just sit on the bench [and privately complain] with your medical team during the stimulant medication game. Medical team play is essential to recovery. First, understand the easy, basic medication details, then, discover how to use simple medication rules to help manage your care for the long term. When you understand the simple guidelines in this review, your cooperation will make you become a valuable team member.
Do take a personal moment at the outset to discuss with your medical team this precise medication management process. It will help set the stage for further improved communication. Having spoken to many hundreds of docs over many years about these issues, I can assure you that most will appreciate your insight and perceptions.
Why You Should Now Read ADHD Medication Rules
Let’s make this next step completely uncomplicated. If you read this paper, if you appreciated the helpful, condensed points I’ve made here, you will love Rules.
- Rules is without a doubt the most easily understandable, most easily available,
- and most useful book currently available that tells you specifically how to use
- ADHD medications correctly.
- Rules is downloadable in pdf and carries all the easily available hot links for
- even further reading and resource downloading.
- A casual search of Amazon will confirm that no medical author provides specific
- solutions for these pervasive ADHD Medication problems specifically written for
- the public.
- Reading Rules will confirm that no medical author has identified or is even
- thinking as deeply about these many ADHD medication challenges, and the
- associated lifelong downstream effects of these abundant misunderstandings.
- Rules is designed to bring medical professionals together with these solutions,
- not to incite polemics or overly simplify the complexity of ADHD diagnosis and
- treatment. One chapter is devoted to working on these issues with your medical
- Rules will make you an informed ADHD medication consumer wherever you
- are, and provides solutions that can contribute to the resolution of frustration
- and confusion with ADHD medications for years to come.
- The current ADHD diagnostic labels need serious revision, and far more details
- about those suggested revisions are contained in the over 170 pages of Rules.
The most important reason I wrote Rules is because I’ve seen so much suffering from inattention to the ADHD diagnosis and medication details – and the details aren’t that hard to understand. You only have to see one person who tried suicide on a missed ADHD diagnosis or an obvious ADHD medication drug interaction to become immensely passionate about preventable problems, predictable solutions, and predictable brain science.
I wrote Rules to save you significant money, time, and most importantly, heartbreak with treatment failure. I hate to see the many who suffer with multiple visits and medications, often over many years, that either work ineffectively, or simply don’t work at all. Rules is my serious attempt, after 40+ years of the most comprehensive training and experience available in the country,21 to share with you just-exactly-how-to-get-ADHD-meds-right.
You will appreciate, and probably already know, one of my favorite axioms from the days when I set up and ran addiction treatment programs: “The true definition of insanity is repeating the same thing, expecting different results.” Thousands are awash in medication repetition without targets, medication trajectory awareness or specific ADHD treatment strategies.
The everyday details from Rules have worked for me and my medial teams for many years, and helped us provide answers for second opinion consults from clients all over the country and the world. I don’t profess to get every medication intervention right on the front end every time, but almost always get it right over time with these new and often overlooked biomedical assessments. Functional brain science changes the game. Everyday we treat numerous folks who have bounced hard with other less insightful treatment strategies.
If you are interested in the how, the specific street applications for the best use of ADHD medications, and want to become the most informed consumer for you and your family, do download Rules and drop a comment at CorePsych Blog as other’s have about how Rules works for you.
Table of Contents for Rules
Section I: First Things First
Beginning Treatment, First Identify Target Objectives
Overview ———————————————————————- 11
1. Right Drugs For The Right Diagnosis —————————19
2. How to Get Past Outward Appearances ———————- 30
3. Acting ADHD: Acting Without Thinking ———————– 35
4. Thinking ADHD: Thinking Without Acting ———————38
5. Avoiding ADHD: Not Thinking And Not Acting —————53
6. Measure Metabolism: The Burn Rate —————————64
7. Depression & Anxiety: ADHD Confusion ———————-84
8. Furious Minds: Bipolar And ADHD ——————————99
9. Unpredictable: Brain Injury And ADHD ———————–108
Section II: Monitoring Medication Progress
Improved Structural Grids for Medication Management
10. Shoot For Your Therapeutic Window ———————–122
11. Breakfast Matters ————————————————–137
12. Sleep For Brain Defrag ——————————————-150
13. Managing With Your Medical Team ————————-161
Thanks for taking the time to join me in this brief review of the evolving science for treatment of ADHD presentations with stimulant medications. I do hope these remarks will help you, your family, and your clients more successfully address some of the challenges seen with ADHD medications.