The Best Medicine for Inattentive ADHD



THE BEST MEDICINE FOR INATTENTIVE ADD AT THE BEST BLOG OF THE WEEK!!
The best medicine for Inattentive ADHD is probably not Ritalin. Dr.  Russell Barkley, the foremost authority on ADHD, has written this about treating the inattentive subtype of ADHD:


"These children do not respond to stimulants anywhere near as well as AD/HD hyperactive, impulsive children do. Only about one in five of these children will show a sufficiently therapeutic response to maintain them on medication after an initial period of titration. Oh, you’ll find that about two-thirds of them show mild improvement, but those improvements are not enough to justify calling them clinical responders, therapeutic responders. Ninety-two percent of AD/HD children respond to stimulants. Twenty percent of these children respond to stimulants. And the dosing is different. AD/HD children tend to be better on moderate to high doses. Inattentive children, if they’re going to respond at all, it’s at very light doses, small doses. "


Many people with Inattentive ADD symptoms however, are tried on stimulant treatment.  For some people even a mild improvement is reason enough to stay on the medication.  The best medicine is always tailored to each individual but there is data that Ritalin works less well for ADHD-I  than the Adderall family of drugs. 


It would be nice, I think, to have an easy and quick reference for the medicines used to treat for Primarily Inattentive ADHD.  To better understand the treatments available, a very basic lesson in the biology of ADHD is handy.


All types of ADHD are thought to be the result of a problem with neurotransmitters in our brain. The two neurotransmitters that cause the major symptoms of ADHD are Dopamine and Epinephrine and Norepinephrine.


Simply stated, a low amount of dopamine in our brain will cause hyperactivity and impulsivity. A low amount of norepinephrine will cause lack of focus, lethargy, and mental fatigue.


Serotonin, another neurotransmitter, is secreted and depleted in tandem with dopamine and epinephrine. Low levels of serotonin make us irritable, tired, and depressed. The level of circulating serotonin is related to the levels of these other two neurotransmitters and vice versa.


All the treatments for ADHD work to optimize neurotransmitter function in the brain. The Ritalin (Methylphenidate) family works by increasing both brain dopamine and epinephrine. The Adderall (Amphetamine) family works by increasing brain norepinephrine and dopamine but this family of drugs increases dopamine by only about half as much as Methylphenidate. Strattera (atomoxetine ) works by increasing brain norepinephrine. Guanfacine (Intuniv) regulates the flow and effectiveness of neurotransmitter receptors in the brain in a way that reduces hyperactivity, improves working memory, and diminishes impulsivity, and distractibility.


So what is the best medicine for ADHD-PI? Some doctors believe that the Adderall family works better than the Ritalin family for the inattentives as the medication’s effects on norepinephrine are greater than the effects on dopamine. All stimulants can make some inattentives anxious but ADHD-PI patients seem to tolerate the amphetamines better than they tolerate the Ritalin family.


It would seem that using this very simple description, Strattera should work the best for ADHD-PI. The reality is that Strattera only works for some patients with ADHD-PI. We are not sure why this is the case. It would also seem that Intuniv would work poorly for folks with ADHD-PI as its main effect is on hyperactivity. The reality is that some doctors have found that Intuniv works well for ADHD-PI patients.


Because some folks with ADHD also have problems with depression and anxiety, antidepressants such as the tricyclics (Elavil, Norpramin, Tofranil) which work on Norepinephrine and Serotonin are sometimes prescribed. The selective serotonin reuptake inhibitors (Prozac, Paxil, Celexa) work only on serotonin and are sometimes used in conjunction with the stimulants to treat ADHD-PI with depression.


All of these medications can have side effects. The stimulants can cause weight loss, anxiety, and sleep issues. Intuniv can cause drops in blood pressure and sleepiness, Strattera can cause sexual dysfunction and has a warning for pediatric patients regarding an increased risk of agitation, irritability and suicidal thinking. Usually the medication side effects are mild or rare but when they are not, they will unfortunately dictate what treatment can be used.


Some researchers believe that once we have mapped the genetic issues involved in ADHD, we will be able to tailor individual treatments for everyone with ADHD. I am not holding by breath. The neurotransmitter action in the brain is complex. None of the neurotransmitters work independently. The variety of symptoms in ADHD are also interrelated and complex.


Given the individual and unique symptom manifestation of ADHD, and the differences in the occurrence and tolerance of medication side effects, the treatment of Inattentive ADD will always be, to some extent, a process of individual trial and error.  What is the best treatment for Inattentive ADHD?  I guess the best answer is, it depends.

25 comments:

  1. Hi,

    Just ran across your site today and have enjoyed the articles I've read.

    I just wanted to point out that Wellbutrin actually works on Norepinephrine and dopamine, not seratonin reuptake.

    :-)

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  2. I've been reading your site and I have a question regarding your artical. I'll give some information about my situation before I ask my question. I'm almost 20 years old and recently found out I have ADHD-PI. The medican I'm using is Dexedrine SR, and my question would Strattera be better? Now if your wondering why wouldn't just ask my docter, well I've been on the medication for almost two months now and It works, however, there will be random periods last from a few days to a week where the I burnout sooner leaving me with a headache and the feeling inattentive for most of the day. I've asked my docter, and tells not to worry it is just a small side effect.
    If you have any insight for me, would you please email me at gh3ttotriggerz@live.ca
    thank you

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  3. Sorry that's gh3ttotriggerz@live.com

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  4. My daughter is ADHD-PI with ODD tendencies. She has been on Strattera for little over a year. Some improvements were seen however she continued to struggle in school and her ODD was adding so much stress to the family. Through testing, we ruled out learning disabilities, Dyslexia, and auditory processing disorder. About 5 weeks ago, she started Intuniv with great results!!! I am convinced that the Intuniv is helping in the Prefontal Cortex, which is the control center for executive functions. I feel that my daughter's educational issues are directly related to poor executive functions and thus, Intuniv is helping the part of the brain responsible for excutive functions. I'm hoping to wean her off Strattera to see if Intuniv alone is the answer. Also, our home life is so much better due to my daughter's defiance being under control.

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  5. I am so glad that the Intuniv is working well!! I know how disruptive ODD can be to a household. Tess

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  6. Hi,
    Epinephrine and norepinephrine are NOT the same thing!!!!

    "The two neurotransmitters that cause the major symptoms of ADHD are Dopamine and Epinephrine (norepinephrine)."

    How am I supposed to see you as a reliable source when you say things like that? I really want to like this blog, but that is an unacceptable error. (I'm a junior in college, majoring in neurobio.)

    I wish you well,
    Jessica

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  7. Jessica,

    I did not mean to make it sound like they were the same thing. The parenthesis should say "norepinephrine plays a role as well" instead of just "norepinephrine". That was sloppy writing and I will correct it.

    Thanks so much for pointing out that writing it like that made it sound like I thought they were the same thing. Inattentive people almost always need an editor in life. Someone to cross 'T's and dot the 'i's and I do much better work when someone checks over what I have written.

    Thanks again for your editing help! Tess

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  8. Thanks for your reply! :)
    Jessica

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  9. DISCLAIMER: THIS DOES NOT APPLY TO CHILDREN

    When I take medication (as needed), I usually alternate Focalin XR and Vyvanse at 3 months intervals. These are taken 3 days a week at most along with Omega 3s, Tyrosine, B-complex, Multi-vitamin/multi-mineral. This medication schedule has allowed me to remain at the same dosage for years.

    If one is foolish enough to follow the advise of "experts" like Barkley (i.e. take medicine daily w/o supplementation), they would require a continual escalation in dosage of stimulant medication as they deplete their brain's neurotransmitters and DAT concentrations.

    Again, this is just for adults. I am not judging or pushing my beliefs on anyone, but I strongly disagree with giving such substances to children (as do most actual ADHD experts).

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  10. I think medicating children for ADHD should be the last resort and that parents should exhaust other measures before turning to medication.

    I have a son that was treated with OT, vision therapy, movement therapy, cerebellar stimulation, behavioral therapy, cogntive therapy, auditory processing therapy, social skills training and psychotherapy and was still unable to curb his impulses (which sometimes resulted in dangerous consequences for himself and or others). His self esteem was in the gutter because he did NOT want to behave this way. He has been helped by the stimulants and he is now on only 10 mg of Adderall a day.

    Stimulants for children are a last resort but sometimes, unfortunately (and there is not a parent worth their salt who is happy about this fact), they are indicated.

    Pete, lets agree to disagree on this one. As always, I greatly appreciate your input.

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  11. Please don't feel the need to explain yourself Tess. My only opinion of you is one which is purely positive and I choose to focus on your intention as a loving mother who's trying her best to handle a challenging situation. I would have considered myself fortunate to have been blessed with such a mother - because let me tell you sister, I was not.

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  12. Thinking of mothers who do not dodge bullets, step in front of busses or in the words of a popular song, catch a grenade, for their children makes me want to cry. I am fortunate that my mother did all those things for me because, among other things, she taught me how to do this for my children. Thanks for your support. Tess

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  13. I noticed that missing from the list of treatment options was elimination diets. In light of recent studies linking food additives to ADD/ADHD behavior, it seems like there should be some mention of them in deference to parents who for what ever reasons don't want to use stimulant medications. One program which has been around since the 1970s is Feingold (feingold.org). It eliminates synthetic/artificial colors (dye), flavorings, sweeteners, fragrances and the petroleum based preservatives BHA, BHT, TBHQ and possibly some foods.

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  14. In the post labeled 'ADHD Diet Recommendations', I talk about elimination diets. It is up in the left hand column where it says, "Where to Find Information On".

    I did not include it in this post because I thought it made sense to put that info in the diet post.

    Thanks for your comment!

    Tess

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  15. I'm 10 days into a trial of Bupropion (Wellbutrin) and it's already having a really positive effect on my clarity of thought, mood and anxiety. I feel much better on it than on dexamphetamine, and although I can choose to combine the two I am finding that on the Buproprion my need for dexamphetamine is greatly reduced.

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  16. Tess, curious and appreciate your toughts on Vyvanse? My son (8) has been diagnosed with ADHD (non hyper) and defnitely started as a help. He curretly is taking the lowest dose available, as the next ant up for him made him really zone out). He consistently has little concept of time, task completions and although quite focused (hyper focused) at times, excellent in math and reading, completing tasks is something that isn't happening without someone behind him. So, finding your blog on Inattentive ADHD has offered me a potential answer to my concerns. Maybe it's not behavior? Concerned abou t the Vyvanse and how to speak more to his physician about my son, because his higher IQ is "coverng up" his real challenges that cause him and our fmaily frustration. His (seems like) inability to hear, respond and complete tasks or recall these tasks, yet he can completely recite a book he just read or give an excellent narration on the players names and their stats for a football team. Thankful to find your blog and apprecaite your research or feedback. MOWEG

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    Replies
    1. Wow, I have a 11 year old daughter and I have to say, I could have wrote your post. My daughter was diagnosed a couple years ago with ADHD (non hyper) and now, that she is in 5th grade, we are at the point, where she struggles so much that we are considering trying some medication. The difficult part is, what medication will be the right one for her . We are a military family and never seem to get to see the same doctor more than twice. So your post helped me out a lot. Thank you!

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  17. A very biased article, indeed. Many vegans all over the world raise healthy children. However, there is no denying that all parents have a responsibility for the health and well-being of their child: to provide whatever nourishment is necessary for that child to thrive and to seek medical help when there is a problem. Allowing a child to die this way is reprehensible. Ignorance and/or adherence to dietary restrictions are no excuse. These parents were extremely unfit to take care of this child no matter what their diet.
    Properly balancing the diet and taking the advice of a dietitian if required will help in maintaining a healthy body. I feeling changes too fast. tribulus terrestris

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  18. Umm all I have to say is WOW! Albert smith what child are you talking about? And really? Have you ever stuggled through life with a child who has ADD-I on a daily basis. Mine was undiagnosed until I was 17. I was the first and only child for 9 years and bc of my dad's job we basically moved every year. Even though he was never home I was fortunate enough to have a stay at home mom. We weren't well off enough to afford the luxury of cable and the internet wasn't around back then. Life was hell when it came to homework. My mom and I would fight everynight for 5 hours over homework. It wasn't until after my sister came along that my mom began to wonder if something was wrong because she could see the difference in my non-ADD sister. NOBODY had any idea that there was anything wrong with me prior to this. Qualification has nothing to do with your dietetic bs. How dare you lay such judgement on people like my mother who was right there struggling with me side by side 5 hours every night for 12 years! It is evident sir that you are in fact a self righteous biggot! There are people out there that a little extra DHA and Omega's help yes. But there are plenty others who need more than just a little supplementation and therapy. Those who actually need medicine to correct that imbalence and THOSE are the people this article was written for. So unless you have something constuctive to say maybe you should concentrate on learning some healthy humility. Thanks.

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  23. Hi, I think some posts aren't actually about this blog. See the posts from later dates. They seem to be about something different or add's. They all have links.
    But om a more interesting note: I appriciate your advocacy and consideration for your mother and other parents. I imagine it must be a very lonely and seemingly endless quest for parents to find out what is happening with their child. I'm curious to know how you ar doing now. Are you taking any of the mentioned drugs? Are you in college, already working or doing something completly different? I was diagnosed in 1982 at the age of 4. Then it was called Minimal Brain Distruction(MBD), later they changed in Disfunction. The name is, in any way, a misnomer! In those days, at least here in Europe, institutionalisation was a more common thing then now for good reason. And with the fact that my mother was mentallly pretty unstable, I didn't stand a change. So there I went to live in a home with kids with all different kinds of problems. And the thing with these kinds of homes is that you enter with your own little set of problems, but a sort of crosscontamination takes place. So after a year they find even more reasons for you being there..... So thirteen years later, being almost eighteen, they let me loose into the world..... Now I was not only diagnosed with ADHD, but I could add, two personality disorders and a PTSS to the list. It took more then ten years to get things in place and perspective: I really had a misguided view of the world. I refused therapy for a long time. I mean I wasn't about to trust another liing soul with a psychiatic title again. But in 2004 I could no longer deny that my inability to hold a job, finish any form of education and the massive burn-out I was in the middle of, had anything to do with the past. As the phrase, that I relally like says: You can clean your house obsessively, but if something is rotting in the celler it keeps on smelling! Then I was re-diagnosed with Attentive ADD, which is a better fitting coat I must say. And now, ten years on and seven years of therapy, I'm doing it on my own. I'm a resident speaker at our regonal ADHD & Autism centre. Afterwards I meet a lot of people and I've nottice that my story gives a perspective of time. How far we already have come. Specially when it comes to diagnosing and the ecknowledging the differences between forms of attention and hyperactive disorders. And of course the way people with AD(H)D and their loved ones are guided(I don't like the word treatment in this, it suggest that it can or needs to be cured) I'm using Dexamphetamine after trying Ritalin for a while. It's not jet the perfect fit but with time and the old "trail and error" approach it will get there. My main goal is to let people see that besides the obvious challenges people with AD(H)D have some many extraordinary talents and are often very creative. Let's put atleast as much emphasis on those qualities as we do on the challenges. I have great respect for all of you who are searching and struggeling to find the right way to meet these challenges!! And for those kids, teenagers and there parents here is my advice: Let go of any conventions and follow your childs and/or your own intuition!!! This is what has worked for me and I hope it will work for you. Remember that a lot of what is written and what has become convention was done by or ment for the average. Good grace what a story..... well, if it helpes one person...

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  24. Sorry this was ment as a comment to the anonymous post on the 19th of february...

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