ADHD information site
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ADHD explained
Prevalence
ADHD affects children - approximately 5% rate worldwide
ADHD affects Adults - approximately 2-5% 
About 50% of children have significant reduction of ADHD symptoms by their mid-20's

Risk Factors
Biological factors
  • Genetic risk of ADHD - 70% heritability from twin studies
  • Maternal smoking and alcohol use
  • Premature birth, IVF conception, multiple births
  • Environmental toxins - organophosphate, pesticides, zinc, lead
  • Medical Conditions, such as Epilepsy, head injuries
  • Shared genetic vulnerability with Autism, depression, bipolar, schizophrenia
Environmental factors
  • Parental hostility
  • Low family income
  • Maternal deprivation
  • Long-term childhood stress
Symptoms:
1. Inattentive symptoms: 
  • making careless mistakes, 
  • difficulties with sustaining attention, 
  • difficulties with listening, 
  • difficulties following instructions, 
  • difficulties with organisation, 
  • procrastination, 
  • being easily distracted, 
  • being easily forgetful, losing things

2. Hyperactive and impulsive symptoms:
  • often fidgeting, 
  • difficulties remaining seated, 
  • feeling restless, 
  • difficulties remaining quiet, 
  • being hyperactive, 
  • talking too much, 
  • impulsive answering, 
  • difficulties turn-taking, 
  • interrupting others

Co-occurring conditions are prevalent
  • Borderline personality disorder, 34% in ADHD patients
  • Substance use disorder, 50% have ADHD
  • Eating disorder, up to 18% of patients with ED have ADHD.
  • High rates of anxiety disorder, including generalised anxiety disorder, social anxiety, OCD
  • Depression - 13-35% of people with depression have ADHD  
  • Bipolar disorder - 20% of patients with bipolar disorder have ADHD
  • Autism Spectrum Disorder - up to 85% of people with ASD have ADHD
  • Insomnia - 44% of adults with ADHD have insomnia

Aggravating factors:
  • Stress of any kind
  • Life transition: changing from Primary to High School to tertiary education, changing work or increasing responsibilities, changing homes, having children
  • Lack of sufficient sleep
  • Lack of sufficient exercise
  • Lack of adequate nutrition
  • Co-occurring mental conditions (such as depression, anxiety) and physical disorders (such as epilepsy, thyroid problems)
  • Co-occurring substance use (such as cannabis) and significant alcohol use
  • Some medications - such as mood stabiliser, antipsychotic medications, strong pain medications such as opiates
Non pharmacological:
Lifestyle Interventions: 
  • Having a Regular Routine and Schedule for the day.
  • Incorporate
    • Regular exercise to improve ADHD symptoms and effectiveness of medications,
    • Maintain a good sleep routine with going to bed and waking up,
    • Have a regular pattern of meal preparation and planning and regular meal-times,
    • Ensure you have regular social activities
    • Avoid substance use and alcohol use
    • Utilise mindfulness activities - such as guided meditation, mindfulness practices, Yoga.
Learn more about ADHD, and further strategies, with reading books on ADHD:
  • Taking Charge of Adult ADHD - available on Audible
  • A Hunter in a Farmer's World  - available on Audible
  • ADHD 2.0 - available on Audible
  • Scattered Minds  - available on Audible
  • The Adult ADHD Toolkit
  • Melissa Orlov’s books for couples.
  • Kolberg & Nadeau  - ADD Friendly Ways to Organise your Life
Brain Training: Target working memory, processing speed, and attention.
  • Brain Games: Lumosity, Elevate, BrainHQ
  • Happy Neuron website - cognitive remediation: https://www.happy-neuron.com/ 
  • Neurofeedback Therapy - utilising biofeedback principles to enhance mindfulness training.
  
Supplements: 
  • Fish oil 3g daily, or Flaxseed (vegan)
  • Turmeric 1.5g daily
  • Gingko Biloba 40mg three times a day
  • Korean Red Ginseng 3mg daily
 
Supports with school or work:
  • Written instead of verbal instructions
  • Flexible working hours
  • Regular meetings to keep on track
  • Turning camera off during virtual meetings
  • Specific desk assigned rather than hot-desking
  • Focus on tasks completed, rather than hours spent
  • Software to record and transcribe meetings
  • Flexibility to work from home
  • Map of buildings of work
  • Clear and specific instructions
  • Working in quiet space
  • Extended deadlines when things get too much
  • Fidget toys during work or meetings
  • Working alone over group projects
  • Internal fake deadlines to add urgency
  • Sensory or quiet room in the workplace
  • Noise-cancelling earphones or headphones
  • Rocking stool
  • Starting earlier or later to avoid rush hour
  • Sitting-standing desk
  • Walking meetings to reframe eye contact and feel more relaxed
  • Closed caption on virtual meetings
  • Messaging before calling to warn what you want to speak about
  • Agenda in advance of all meetings
  • Sending written minutes and action points after all meeting 

Learning accommodations: 
  • Chunking related information in small packets of information - and make sure you understand what is being learned.
  • Repeated learning three times to ensure it sticks.
  • Use visual aides or auditory learning aides if they help.
  • Use reminders or prompts to recall information, such as cheat-sheets, post-it notes, to-do lists.
  • Allow additional time to process information.
Addressing comorbid conditions:

Professional supports 
Treatment Priority
Medications
Medications:
You will still have to do a large amount of work to undo all the coping mechanisms that you have developed over the years to contend with your poor attention and impulsivity.  Medications can level the neurologic playing field so that your efforts to solve your problems can now succeed. Pills don’t give skills. Your life will be the same as it was before you started taking medicine for your ADHD.

Stimulants 
  • Examples: Methylphenidate (Ritalin, Concerta), Dexamfetamine, Lisdexamfetamine (Vyvanse).
  • Significant response (approximately 70%)  and fast response time, to most symptoms of ADHD, both the inattentive symptoms and hyperactive symptoms.
  • They are considered drugs with potential for abuse and addiction, so there are a lot of rules and exclusion criteria that dictate the use of them.
  • They have a lot of common side effects, some include: loss of appetite, loss of weight, sleep disturbance, headaches, blurred vision, dry mouth, nausea, constipation/diarrhoea, agitation, anxiety, increased heart rate and blood pressure, emotional numbing, sexual dysfunction, constricted blood vessels to fingers/toes.
  • They have some serious side effects: worsening anxiety, depression, suicidality, psychosis, palpitation, dizziness, chest pain and/or tightness, shortness of breath.
  • Risks of Long-Term risks are not quite clear yet, but there is some evidence it may increase the risk of cardiovascular conditions such as hypertension and arterial disease and heart failure; and may reduce risk of depression and suicide, but may increase risk of psychosis.
  • Most people with ADHD who take stimulants do not get “high”.  When an individual’s therapeutic dosage is exceeded, most people complain of being confused, sedated, and “dopey”.  Consequently, there is a very low potential for abuse of these medications by people with demonstrable ADHD.
  • Further information on Methylphenidate (Ritalin, Concerta):   https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2010-CMI-04824-3&d=20230910172310101 
  • Further information on Dexamfetamine: https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2017-CMI-01668-1 
  • Further information on Lisdexamfetamine (Vyvanse): https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2013-CMI-02070-1 

As part of the initiation assessment of prescribing stimulants:
  • The treating doctor will need to access SafeScript - an online script monitoring system, to check on the use of other controlled substances with the stimulant.
  • Completion of a psychiatric assessment, psychometric testing, and collateral information (informant report or school reports)
  • There will be a pre-screening investigations for stimulant treatment, such as blood tests, an ECG due to potential cardiac side effects, and urine drug screen, given the nature of the stimulants being a controlled substance.
  • Exclusion criteria include: As per clinical guidelines and the state-based regulatory guidelines: 
  • Active psychiatric illness, including: acute depressive episode or overwhelming anxiety, and no recent substance use of any kind in the preceding 3 months
  • Lifetime history: of psychosis (having hallucinations or delusions) or alcohol and other substance use dependence, or treatment for substance use disorder or intravenous substance use, or age older than 70 years.
  • If any of the exclusion criteria apply, then a second opinion from another psychiatrist will be needed and prior approval will be required from the state-based Authority before being able to prescribe the stimulant medication.

 Non Stimulants
  • Wide range of different drug classes: antidepressants, alpha agonists, weak stimulants, antipsychotic medications, dementia medications
    • Examples: Atomoxetine, bupropion, venlafaxine, amitriptyline, clonidine, guanfacine, modafinil, armodafinil, aripiprazole, brexpiprazole, memantine, donepezil
  • Less response (approximately 50%), and slower response time (a few weeks), to most symptoms of ADHD, with some selective use.
  • They are not considered drugs of abuse, so there are less exclusionary rules with them. They are not PBS-listed for Adults diagnosed with ADHD after 18 years of age, which will impact on cost. There is no requirements for long-term psychiatric reviews, if people are stable on them long-term.
  • They have common side effects, which differ based on the drug class, but less of the serious side effects compared to the stimulants.
    • Atomoxetine: headache, blurred vision, dizziness, constipation, reduction of appetite, insomnia. (Cost: $23 per 28 tablets of 10mg; $43 per 28 tablets of 40mg). Dose range: 10mg to start, to 40mg - 100mg a day.
    • Bupropion: headache, blurred vision, dizziness, constipation, works as an antidepressant as well, though not as effective for anxiety symptoms. (Cost: $61 per 30 tablets of 150mg) Dose range: 150mg a day to 300mg a day
    • Clonidine: reduced heart rate and blood pressure, dizziness. Specifically helpful for night-time with reducing racing thoughts and hyperactivity to improve sleep. (Cost: $21 per 100 tablets of 100mcg) Dose range: 50 microgram to 200 microgram a day.
    • Guanfacine: similar to clonidine, though usually better tolerated. Can be expensive without PBS subsidy. (Cost: $61 per 28 tablets; $29 with PBS subsidy). Dose range: 1mg a day to 4mg a day 
    • Modafinil: similar to stimulants, loss of appetite, loss of weight, sleep disturbance, headaches, blurred vision, dry mouth, nausea, constipation/diarrhoea, agitation, anxiety, increased heart rate and blood pressure. (Cost: $102 per 60 tablets of 100mg). Dose range: 100mg a day to 200mg a day. 
    • Aripiprazole: sense of restlessness, occasionally sedating and causing weight gain. Preferred for people with a history of psychosis or bipolar disorder. (Cost: $61 per 30 tablets). Dose range: 5mg a day to 20mg a day.
    • Memantine: reduced heart rate, gastrointestinal upset. (Cost: $40 per 56 tablets)
General Principles of selecting medication treatment: 
  1. What is the Level of functional impairment and needs, and does it exceed what behavioural and environmental modification can accommodate/compensate for, such that medication is required?
  2. On balance, is stimulants contraindicated, and if not, is it going to be more effective and within reasonable range of risk? Is non-stimulant treatment preferred?
  3. If stimulants, has there been past response to previous trials of stimulants? If so, then can consider re-trialing past treatment, if there has been a reasonable response and tolerability. If no previous trials, then generally for adolescents, trial methylphenidate (Ritalin); and for Adults, trial dexamfetamine/Vyvanse.
  4. Short-Acting or Long-Acting stimulant:
    • Short-Acting: generally last 3-4 hours, require multiple doses, and provide more control, and easier to change doses, but disadvantages include requiring system and being able to recall taking it multiple times a day, and higher potential for crashes.
    • Long-Acting: generally last 8-12 hours, once daily dosing, and more consistent action over the day, with less ease of changing doses.
  5. Select starting dose, based on medication and formulation.
    • Short-Acting generally half tablet twice a day, then increase
    • Long-Acting generally a low dose to initiate.
 
Stimulants
  • Dexamfetamine
    • 5mg tablets, 100 tablets each box, dose range maximum of 8 tablets a day. 
    • Cost is $11 per 100 tablets.
    • Short-acting - 3-4 hours 
    • Consider initiating at 2.5mg morning and midday (twice a day), then going up to 5mg twice a day if tolerated. Most people generally take 5mg twice a day to 10mg twice a day.
  • Vyvanse
    • dose range from 20mg to 70mg, 30 tablets each box, dose range maximum of 70mg a day.  
    • Cost is $29 per 30 tablets.
    • Long-acting - 8-12 hours 
    • Consider initiating 20-30mg a day, then increase dependent on response and tolerance. Most people generally take 30-50mg a day.
 
  • Ritalin
    • 10mg tablets, 100 tablets each box, dose range maximum of 10 tablets a day.
    • Cost is $18 per 100 tablets.
    • Short-acting - 3-4 hours 
    • Consider initiating at 5mg morning and midday (twice a day), then going up to 10mg twice a day if tolerated. Most people generally take 10mg twice a day to 20mg twice a day.
    • Ritalin LA - 8 hours, now on PBS for adults diagnosed with ADHD after 18 years of age.  Cost is $29 per 30 tablets.
  • Concerta
    • not on PBS for adults diagnosed over 18 years old.  Cost is $48 per 30 tablets, and $29 with PBS subsidy.
    • dose range from 18mg to 72mg, 30 tablets each box, dose range maximum of 108mg a day
    • Long-acting - 8-12 hours 
    • Consider initiating with short-acting Ritalin, before converting over to equivalent dose of Concerta. 

Precautions on using stimulants:
  • Take stimulants with food to reduce side effects.
  • In the first few hours after a dose:
    • Avoid any acidic, natural or artificial juices, soft drinks, foil-packed bars, vitamin fortified cereals
    • Avoid or be cautious drinking caffeine, as this can make people agitated.
    • Avoid alcohol, as people can become affected by alcohol much more significantly.
  • You can take breaks from it, such as on weekends or holidays if not required.
  • Be cautious with certain medications: caffeine, decongestant, nicotine, oral or injected steroids, asthma inhalers when having active asthma.
  • Some people find increased benefit having a high-protein diet.
 
Monitoring stimulant trial:
  • While starting at a low dose, monitor for:
    • response (i.e. reduction of symptoms, such as improved concentration, reduced procrastination, "clarity" of thinking, improved organisation of thought, reduced jitteriness or activity, improved ease of sleeping), and if there is any gradual reduction of improvement in the first few weeks
    • duration of response,
    • "crash" when wearing off (feeling tired, sleepy, generally lasting a few hours)
    • Any other side effects, and if there is any improvement
    • If there are any serious side effects, such as depression, suicidality, psychosis, palpitation, dizziness, chest pain and/or tightness, shortness of breath, then cease it straight away.
    • If there is any missed doses, or "drug holidays", monitor for withdrawal symptoms (similar to a prolonged crash), which can last from half a day to a few days.
  • When to increase:
    • Generally when there is no response, and no side effects
    • When feeling sleepy and tired at a lower dose
    • When there has been response, which has reduced to levels where there are ongoing functional impairment, i.e. not being able to get work done, still being frustrated as much as before starting medications.
    • And do not increase dose more than what has been agreed upon with your treating doctor, and generally increase a dose by a small amount every week or two if needed.
  • Ensure you follow up at regular intervals with your treating doctor until the medication regime has been stabilised.
  • Please note: a medical review is necessary for any changes to medication doses that has not been previously discussed, or changes to medications, or renewal of scripts
  • The aim of treatment dose is for functional improvement, not necessarily symptom improvement.
  • The subsequent period of medication titration is to review response and tolerability and titrate medication to an appropriate dose, to a stable medication regime. After this, if there is a period of stability and it becomes clear that people have reached their "stable" dose, there is sometimes an option to transfer prescription to their regular GP, with a few caveats: GP has to be happy to prescribe and undertake the registration process, no further changes to medication doses can be undertaken, and there will still be a need for periodic reviews with a psychiatrist.
Withdrawal:
  • When people stop taking medications, some people have withdrawal syndrome, where they feel tired and sleepy and sluggish. This can last from half a day, up to a few days, and less commonly, up to a few weeks. 
  • When changing from stimulants at a high dose, to reduce the risk of withdrawals, you can reduce the dose of stimulants gradually over a few weeks, before changing to try the new medications.
Crashes:
  • Short-acting: If taking short-acting stimulants, crashes can be managed by adding on a low-dose of short-acting stimulants towards the end of the duration of action
  • Long-acting: If taking long-acting stimulants, crashes can be managed by adding on low-dose of short-acting stimulants, or using the long-act stimulants across two time points to slow down the crash, for example taking half the dose at the usual time, and taking the second half of the dose 2 hours later.

Prescriptions
  • Scripts for stimulants are strictly regulated and controlled.
  • They expire 6 months after the date of prescription of the script, even if there are any repeats still available.
  • You have to return to the same chemist for any repeat scripts.
  • There is an interval period between each script - i.e. you have to wait the set interval period from using the first script before you can pick up the next repeat.
Titrating Vyvanse
  • There is a method to titrate (slowly increase) Vyvanse if this has been discussed. 
  • The Vyvanse capsules can be opened, and the granules can be dissolved in water. 
  • Dissolve the granules in the capsule in the equivalent (to millilitres) volume of water. For example, if you are using a 30mg capsule, dissolve the granules into 30mL of water, if you are using a 50mg capsule, dissolve the granules into 50mL of water.  
  • This will result in each millilitre approximating 1mg, and you can then measure out the dose you intend to take. For example, if you intend to take 20mg, drink 20mL. If you intend to take 40mg, drink 40mL.
  • The rest of the volume of dissolved medication can be saved for later dosing or discarded.
  • Generally you can commence at Vyvanse 20mg once daily, and then increase by 10mg every few days if tolerated. 

Titrating Vyvanse
Special Populations
Psychosis
The risk of psychosis in the general population is 0.2-0.4% on these stimulants.

There is a 30% risk of psychosis for people with a history of psychotic disorder, on therapeutic doses of stimulants.
If there are significant risk factors, such as a strong family history of psychosis, the risk is up to 30% (generally around 15%).

Medications that would be better used for ADHD in people vulnerable to psychosis include atomoxetine, guanfacine, or aripiprazole/brexpiprazole.

Bipolar Disorder
There is a 3-fold increased risk of hypo/manic episodes (9%) with stimulants, over the baseline one-year incident rate of 3%. This risk is mitigated associated with stimulants if there is a therapeutic dose of mood stabiliser (lithium or valproate, possibly lamotrigine) or antipsychotic medication (olanzapine, risperidone, aripiprazole).

In people with a history of psychotic symptoms associated with a depression or manic episode, there may be a risk of psychosis from the use of stimulants.There is a risk of manic episodes from the use of atomoxetine, bupropion and other antidepressants.

If a person has a history of bipolar disorder with previous psychotic symptoms, the safest option is aripiprazole or brexpiprazole.

Depression
There may be a risk of depressive episodes with stimulants, although there is also evidence of good response to bipolar and unipolar depression with the use of stimulant treatment. 
Pregnancy
Pregnancy
 Baseline risk for major malformations is 3%
 Risk is up to 5% if include developmental and other problems not be evident in 1st year of life

Risks of untreated ADHD:
> Higher rates of unplanned pregnancies- especially in teens - (15.2% vs 2.8%)
>  Exacerbation of co-existent mood disorders
 > Substance abuse/ self-medication
 > Disrupted employment/education/relationships
 > Accidents
 
Risks of Medications:
> Early pregnancy ADHD medication use was more commonly reported by mothers of infants/fetuses with
­- gastroschisis (crude odds ratio [cOR]: 2.9, 95% confidence interval [CI] = [1.2, 6.9])
­- omphalocele (cOR: 4.0, 95% CI = [1.2, 13.6])
- transverse limb deficiency (cOR: 3.3, 95% CI = [1.1, 9.6])
> The adjusted relative risks for methylphenidate were 1.11 (95% CI, 0.91-1.35) for any malformation and 1.28 (95% CI, 0.94-1.74) for cardiac malformations
> No increased risks were observed for amphetamines: 1.05 (95% CI, 0.93-1.19) for any malformations and 0.96 (95% CI, 0.78-1.19) for cardiac malformations
>  Danish database study reported a statistically significant modafinil use odds ratio of about 3 for major malformations based on 6 live-born infants with malformations among 43 exposed

Summary: 
Dexamphetamine may be safer option in pregnancy, but preferably not in the first trimester.

Breastfeeding
> Some women able to cease stimulants during BF if on maternity leave and not working
> Others find ongoing/increasing need for medications, due to sleep deprivation, or mood disorder

Dexamfetamine:
> In medically prescribed doses, evidence suggests that  that dexamphetamine does not adversely affect breastfed infant
> Effects of dexamphetamine in milk on long-term neurodevelopment has not been well studied

Ritalin:
> In doses prescribed for medical indications, limited evidence indicates that methylphenidate levels in milk are very low and not detectable in infant serum
> Effects of methylphenidate in milk on infant neurodevelopment have not been well studied

Summary: 
> Both stimulants may be safe to use in breastfeeding, and Ritalin may have less passage into the milk compared to Dexamfetamine.
Pregnancy and medications
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