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MANAGING MEDICATIONS
10 ADHD Medication Fallacies Even Doctors Believe
Optimal dosage is pegged to weight. A ernoon stimulants disrupt sleep. Adderall causes high blood
pressure. And other falsehoods about ADHD medication that may put your treatment plan at risk.
BY GINA PERA
Janet recalls with a shudder the rst time she took medication as a treatment for attention de cit
hyperactivity disorder (ADHD or ADD). “I was glued to the sofa, unable to move for two days,” says the
37-year-old mother of two, and a marketing manager for a Silicon Valley software company. “I looked
and felt like a zombie. It scared me o ADHD medication.”
When Janet later attended a local adult ADHD discussion group, she learned that some people who
reported great results from taking medication said it took weeks for most patients to tolerate the Adderall
dosage the doctor had prescribed her — and that many were taking half that amount. “I should have
educated myself rst, instead of trusting the physician,” Janet says.
Janet’s experience is becoming less common. Increasingly, physicians are learning how to use medication
to treat adults with ADHD, although many adults still encounter professionals who make serious
medication mistakes like those listed below, including psychiatrists who claim special expertise.
“You might call adult ADHD an ‘orphan’ disorder,” says Margaret Weiss, M.D., Ph.D., a preeminent
ADHD clinician scientist, based in Vancouver, British Columbia. “That’s because most professionals with
the expertise to recognize and treat ADHD work in child services; they are not working in adult centers or
seeing adults.”
The bottom line for adults with ADHD is: Be a smart health-care consumer, and learn as much as you can
about ADHD medication before you start taking it. The Canadian Attention De cit Hyperactivity Disorder
Resource Alliance (CADDRA), a coalition of ADHD experts, has created comprehensive treatment
guidelines for patients, parents, and physicians. The practice guidelines, including charts of medications,
are available as a free download on CADDRA.ca. My own book, Is It You, Me, or Adult A.D.D.? Stopping the
Roller Coaster When Someone You Love Has Attention De cit Disorder is another good source.
In the meantime, if your prescribing physician makes any of the following 10 statements, share a copy of
the CADDRA guidelines with her and talk things over, or nd a new doctor.
[Self-Test: ADHD Myth or ADHD Reality? Check the Facts About ADHD]
1. “My adult ADHD patients do best on this stimulant
medication.”
Physicians who “play favorites” with stimulant medications — the rst-line treatment for ADHD —
don’t have an empirical basis for doing so, and are gambling with your chances of success. Here’s why.
There are two major classes of stimulant medications: methylphenidate, or MPH (Ritalin, Focalin,
Concerta, Daytrana, and others), and amphetamine, or AMP (Dexedrine, Adderall, Vyvanse, and others).
The MPH class works best for some people who have been diagnosed with ADHD, but has no e ect, or a
negative e ect, on others. The same is true for the AMP class. There is no way to predict how you will
respond to each class until you try it.
Physician and ADHD specialist Patricia Quinn, M.D., suggests trying both classes of stimulants (MPH and
AMP) before deciding that stimulants won’t work for you and moving on to a nonstimulant medication:
“You might even try several meds within the same class before switching to another stimulant class.” For
example, Ritalin LA and Concerta are both long-acting medications in the same class (MPH). Due to their
di erent delivery mechanisms, however, each brings di erent results.
2. “For an adult of your height and weight, we start with this
dosage.”
An optimal dosage of ADHD medication is not related to a person’s height or weight.
[Free Download: 7 Myths About ADHD… Debunked!]
3. “This is an average starting dose for adults with ADHD.”
There is no “average starting dose.” The choice depends on many factors, including:
Your history of taking stimulant medications. Those who have taken stimulants in the past might
be less response-sensitive than people who have not.
Genetic di erences — some people metabolize the medication more quickly than others.
Co-existing conditions — anxiety or a mood disorder, for example, and their current treatments.
ADHD symptom severity. “The brain is profoundly complex and results di er from person to
person,” Weiss says.
4. “We’ll increase the dosage to 10 mg in two weeks.”
Just as a professional cannot predict which medication will work best, or at which starting dose, he also
cannot predict an optimal dosage goal. The optimal dosage is identi ed by a method called titration:
carefully increasing the dosage over time, until side e ects outweigh bene ts, and then dialing down to
the previous dosage. The approach should always be “Start Low, Titrate Slow.”
5. “So, how’s that ADHD medication working out for you?”
Judging a medication’s e ectiveness requires more than a physician asking, “How are you doing?” It
requires at least two steps:
Taking careful inventory of the challenges you face (writing them down, one by one), before you
started medication
Regularly reviewing each challenge as treatment progresses, in order to track improvement (or
not), worsening symptoms, or new side e ects.
During this titration phase, experts recommend talking with your physician weekly and using an ADHD
medication tracking log like this. In-o ce visits should take place every three to four weeks, to review
side e ects, physical health, patient and family well-being, and other therapies, when indicated.
Many experts and patients report that not enough physicians closely monitor medications used in adults.
“It’s critically important to do, but the utter paucity of clinicians doing it is shocking,” says psychologist
Stephen Hinshaw, Ph.D., a leading ADHD researcher and professor of psychology at the University of
California, Berkeley. “You can’t notice small improvements or side e ects without a monitoring sheet.”
Weiss recommends using rating scales that measure a broad range of symptoms and functioning; in other
words, a metric for tracking how you’re doing in life. The Weiss Functional Impairment rating scale is a
good place to start. Having a tangible method for observing change makes the target concrete and keeps
it in focus.
6. “You should see a huge improvement in ADHD symptoms right
away.”
Research tells us a lot about overall stimulant e cacy, but we cannot tell how it will a ect any particular
individual. That’s because clinical trials are:
Conducted in controlled settings
Done with patients who have no co-existing conditions (a rarity among adults with ADHD)
Very brief in duration (usually ending before side e ects can develop).
The potential positive e ects of medical treatment for ADHD shouldn’t be oversold, Weiss warns. “It’s
true that some symptoms may improve dramatically in days, or even in hours. But it is important to wait
to judge the full e ect of the medication, because it can take some time for all the data to accrue.”
As you face challenging situations in your life, you can gauge how your responses di er from those in the
past. “It can also take time to notice the di erences in how people are reacting to you, or to evaluate
changes in how e cient or how much better you’ve become at your job,” she says.
Weiss o ers these guidelines:
Symptoms tend to get better within weeks.
Functioning improves within months.
Developmental changes happen over years. For example, the individual who never had a friend can
now make and keep them. An adult who could not keep a job can now hold onto one for a year.
7. “If the stimulant disrupts your sleep, we will have to switch
you to a nonstimulant.”
The causes of sleep problems among adults with ADHD are multi-faceted, and poorly understood by most
physicians. Increasingly, research is pointing to neurophysiological di erences in circadian rhythm, the
inner biological clock that tells us when to go to sleep. Yet there are other ADHD-related obstacles to
sleep, such as being unable to “put the brakes on” a chatty brain.
In evaluating a stimulant’s apparent adverse e ect on sleep, it’s important to pay attention to timing.
Perhaps sleep problems are caused by the rebound from the medication’s wearing o . In that case, you
should try taking the medication earlier in the day. Some people with ADHD sleep better on a stimulant;
such medications stop “brain noise” and increase focus on going to sleep and staying asleep.
8. “Sure, continue consuming ca eine, if you like.”
Many adults with ADHD have lifelong love a airs with co ee or ca einated sodas. Yet ca eine may
exacerbate the e ect of stimulant medications, creating anxiety and heart palpitations. You can’t
determine what’s causing these side e ects — the stimulant or the ca eine — unless you gradually wean
yourself o ca eine before starting stimulants. (Try to do it a few days in advance, though, so that you
don’t mistake a headache due to ca eine deprivation for a medication side e ect.)
“Some people can tolerate stimulants and still have some ca eine,” Weiss says. “For others, ca eine
interferes by creating or exacerbating side e ects, making it impossible to increase the stimulant to
therapeutic doses.”
9. “Adderall and high blood pressure are linked.”
An adult should have a thorough physical before starting any new medication, and adults with ADHD
should have their blood pressure and heart rate checked before beginning, and periodically during,
treatment.
However, Weiss dashes the common myth that hypertension precludes taking ADHD medication: “I
would say that it is never a contraindication. You treat the hypertension rst. And, in fact, there are
medications for ADHD that lower blood pressure.” These include generic guanfacine and its longer-
acting brand-name formulation, Intuniv, which can lower both systolic and diastolic blood pressure.
These medications are often used as an alternative to, or in conjunction with, stimulants.
10. “If you think that the stimulant has stopped working for you,
maybe we should try something else.”
Perhaps the stimulant stopped working for any of several neurobiological reasons. Or could you have
forgotten what life was like before you started taking the stimulant?
Adults who are diagnosed with ADHD later in life typically develop the habit of paying attention only to
the exciting or new. After a few weeks of experiencing the “novelty” of improved symptoms, it’s easy to
forget how far you’ve come. This is another reason for keeping written records of baseline symptoms and
of the progress you’ve made. It’s the only way to know if the med is doing its job.
[The Ultimate Guide to ADHD Medication]
Updated on June 17, 2019
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