ADHD treatment guide

We consider the approach described below to be fundamentally sensible. However, these are merely thoughts from a scientific point of view and cannot constitute a therapeutic recommendation for individual cases.
In each case, an individually tailored treatment plan must be drawn up by a doctor or psychotherapist.
Our presentation is not intended for self-medication, but to help people with ADHD and their families understand medical recommendations and to be able to discuss the options described with the treating doctor and therapist.

There are official national treatment guidelines in America¹, Europe², Canada³, Japan⁴ and Germany⁵, among others.

• 0. Prerequisite: reliable diagnosis
• 1. Step: Self-education and psychoeducation
  • 1.1. Self-education
  • 1.2. Psychoeducation
• 2. Second step: Drug treatment
  • 2.1. Treatment prioritization for ADHD with comorbidities
  • 2.2. ADHD symptom elimination through medication
    • 2.2.1. Choosing the right medication
    • 2.2.2. Dosing, medication adjustment
    • 2.2.3. Effect sizes of various drugs
    • 2.2.4. Goals of an optimal medication setting
  • 2.3. Many more small treatment steps
• 3. Third step: Psychotherapy
  • 3.1. Psychotherapy to reduce the symptoms
  • 3.2. Environmental interventions
• 4. Fourth step: Comorbidity and medication review
  • 4.1. Comorbidities
  • 4.2. Medication review
  • 4.3. Medication breaks
• 5. Treatment prioritization for comorbidities
  • 5.1. Prioritization according to the severity of the disorder
    • 5.1.1. Comorbidity more severe than ADHD
    • 5.1.2. ADHD more severe than comorbidity
    • 5.1.3. ADHD and comorbidity equally severe
  • 5.2. Treatment guidelines for specific comorbidities
    • 5.2.1. ADHD and depression:
    • 5.2.2. ADHD and addiction
    • 5.2.3. ADHD and anxiety

0. Prerequisite: reliable diagnosis¶

• Questionnaire AND tests, self-perception AND external perception anamnesis, primary school reports or other reports from kindergarten and early school years
  • Caution: high self-interest in tests can lead to results similar to those of non-affected persons (attention follows intrinsic control)
  • Caution: DSM and ICD require first symptoms by the age of 12, which is outside of primary school age. Barkley also assumes a first onset up to the age of 18.
    It is not appropriate to rule out a diagnosis solely on the basis of inconspicuous primary school reports. High intelligence or a high compensatory willingness to perform can make people with ADHD appear inconspicuous in elementary school. Girls are also more adapted and often do not stand out as people with ADHD.
• Family history
  • Genetic causes
  • Pregnancy and birth complications
  • Attachment disorders
  • Physical or sexual abuse
  • Psychological abuse or low-threshold psychological stress
• Complete differential diagnosis
  • Exclude deficiency symptoms
    • Blood count
      • Thyroxine (thyroid gland)
      • Zinc
      • Iron
      • Magnesium
      • B1
      • B12
      • B6
      • D3
      • Folic acid
      • Blood count not required according to other opinion⁶
  • Exclude an acute stress situation
  • IQ test
  • Exclude dominant disorders with similar symptoms
    More on the topic ⇒ Differential diagnostics
• Identify comorbidities
  • For treatment prioritization see below 5.
  • More on this at ⇒ Comorbidities in ADHD

1. Step: Self-education and psychoeducation¶

1.1. Self-education¶

Self-education through books, videos, self-help groups and forums enables individual knowledge and empowerment in dealing with ADHD.
The aim is to strengthen personal responsibility and promote a self-determined lifestyle through personal sources of information and sharing experiences in the community.

• Psychoeducation by psychiatrists, psychologists, etc.

• Read books about ADHD (several)

• Use ADxS.org as an information base

• Youtube videos from experts (lectures)

• Attend lectures (e.g. from CHADD)

• Attend self-help groups, preferably led by a professionally experienced person (e.g. at CHADD, Attention Deficit Disorder Association or The Learning Disabilities Association of America)

• Forums offer contact with other people with ADHD and help with questions, e.g. reddit/ADHD

• Even a diagnosis of ADHD is accompanied by the realization that one is different from others, in both a negative and positive sense. This realization is often associated with high hopes for an improvement in life.⁷

• The experience that other people have gone through or are going through the same thing often brings amazing relief to people with ADHD

  • Feeling of coming home among like-minded people
  • Willingness to address the topic
  • Exchange of experience
  • Strengthening self-esteem

1.2. Psychoeducation¶

Targeted knowledge transfer about ADHD under the guidance of professionals in order to positively influence the interactions, attitudes and actions of patients and caregivers.
The aim is to promote a comprehensive understanding of ADHD through professional guidance to help manage the Disorder.

2. Second step: Drug treatment¶

2.1. Treatment prioritization for ADHD with comorbidities¶

See under 5.

2.2. ADHD symptom elimination through medication¶

2.2.1. Choosing the right medication¶

See also Choice of medication for ADHD or ADHD with comorbidity

2.2.2. Dosing, medication adjustment¶

In our experience, many mistakes are made when dosing, which not only prevent an optimal effect, but often enough prevent any effect at all. It is therefore particularly important to follow the dosage instructions,
See in detail at ⇒ Dosing of medication for ADHD

2.2.3. Effect sizes of various drugs¶

• Effect size at optimum setting:
  • Amphetamine drugs: 1.1-1.5
  • Methylphenidate: 1.0-1.3
  • Guanfacine: 0.8
  • Atomoxetine: 0.65

See in detail at ⇒ Effect size of different forms of treatment for ADHD

2.2.4. Goals of an optimal medication setting¶

• Enable experience of what life without ADHD can be and feel like (enables people with ADHD to define intrinsic goals for non-drug therapy)
• Establish therapeutic ability (bring attention and concentration to the level required for learning more functional modes of action)
  • Increased treatability with dopaminergic ADHD medications, as dopamine increases or restores neuroplasticity⁸
  • Growth hormones, which are required for neuroplasticity (learning), are reduced in ADHD. Stimulants increase the levels of growth hormones.
• The aim is not to completely eliminate all ADHD symptoms **
  • People with ADHD differ from those without ADHD only in the number of symptoms that occur frequently. Non-affected people also have some symptoms frequently.
  • Individual prominent symptoms should be treated as singularly as possible (e.g. impulsivity with very low doses of SSRIs, aggressiveness with low doses of antipsychotics) instead of trying to treat them with ADHD medication, as this would result in too much broad intervention
• Do not underestimate emotional dysregulation
  • Stimulants allow adequate functionality during the day and prevent breakdowns and comorbidities in the medium term. See under Consequences of ADHD.
  • In the case of emotional dysregulation that is not sufficiently improved by stimulants, the non-stimulants atomoxetine or guanfacine (usually as co-medication with stimulants), which are effective throughout the day, can help. People with ADHD should also be given the opportunity to have an appropriate social life in the evenings - because of the quality of life on the one hand and the protective effect on the other. It is also important to protect any children from the emotional imbalance of parents.

2.3. Many more small treatment steps¶

The points mentioned here should always be taken into account when treating ADHD, as they can usually make a further helpful contribution without having any significant side effects. The points do not represent alternatives, but should all be taken into account.
However, their Effect size (even in combination with all other options) is significantly lower than the relevant medications mentioned above. If it were otherwise, the reports of successful treatment without the relevant medication would be legendary. Newcomers to this topic can find information in forums for those affected, such as ⇒ ADHD forum of ADxS.org
For more information on the Effect size of non-pharmacological forms of treatment for ADHD, see ⇒ Effect size of different forms of treatment for ADHD

• Vitamins and minerals
  Determine blood values and dose to upper limit values or above. More on this at* ⇒ Vitamins, minerals, dietary supplements for ADHD*
  • Vitamin D3
    • October to May essential in Germany
    • Very important for ADHD and essential for depression. Prescribing serotonergic or noradrenergic antidepressants (which, in our opinion, have considerably stronger side effects than ADHD medication) without first checking the D3 level is, in our opinion, malpractice (except in cases of severe depression)
  • Zinc
  • Magnesium
  • Iron
  • B12
  • B 6
• Omega-3/omega-6 fatty acids
• Sleep problems
  • Treat offensively
  • Avoid benzodiazepines and SSRIs. If necessary, trimipramine, amitriptyline or trazodone (low doses in each case)
  • Melatonin (immediate release, particularly helpful for ADHD)
  • Light therapy
  • Find out more at ⇒ Sleep problems with ADHD
• Initiate drug treatment for mild remaining comorbidities only after analyzing the effects of the ADHD medication (usually after approx. 6 months)
• Test for and rule out food intolerances
  • Effect size with existing intolerance and consistent avoidance: 0.25
  • Find out more at * ⇒ Nutrition and diet for ADHD*
• Test and rule out allergies
• Testing and treating chronic low-threshold inflammation (very difficult)
  • Inflammatory problems in ADHD can be an indication of problems with the adenosine balance, which strongly influences dopamine
  • More on this at * ⇒ Endurance sports, fitness training in the article Non-drug treatment methods*
• Lots of sports and exercise⁹
  • Endurance exercise has a significant Effect size in reducing the symptoms of ADHD (and other mental health problems such as depression)
    • Effect size of weight training, on the other hand, is lower
  • Sport must be fun if it is to be practiced sustainably
  • Endurance sport
    • Increases stress resistance, shuts down stress systems (for 24 - 48 hours)
    • Effect size in the optimum case (e.g. 5 x 1 hour / week) up to 0.7
  • Find out more at ⇒ Sleep problems with ADHD
• Healthy diet
  • Avoid sugar¹⁰
  • Avoid bad fats (saturated fatty acids, trans fats; e.g. frying fat)⁹
  • Plenty of antioxidant foods (vegetables, fruit)⁹
    • Helps to reduce antioxidant stress

3. Third step: Psychotherapy¶

3.1. Psychotherapy to reduce the symptoms¶

The form of therapy chosen is only of minor importance here (exception: mindfulness-based therapies are more suitable than cognitive therapies, depth psychology therapies are only useful for dealing with unpleasant experiences and psychoanalysis is generally unsuitable for ADHD). It is much more important that the patient feels very comfortable with the therapist and that they feel very well looked after and accepted. This in no way means a cuddly therapy in which the therapist only tells the patient what they want to hear, but positive acceptance and a basis of trust, which are the indispensable foundations for successful therapy. Without these minimum requirements, even the best form of therapy and the most experienced therapist will be useless. Therefore, a great deal of patience is required when choosing the right therapist.
It is also important that it is not about a single therapeutic measure, but that as many therapeutic measures are taken until a satisfactory condition is achieved.

In all therapy measures, it must be ensured that the therapist is familiar with all ADHD symptoms relevant to treatment. Even today, doctors and therapists are often still under the fatal misconception that ADHD is limited to the diagnosis-relevant symptoms of DSM or ICD. Therapists who do not want to accept the original symptoms of ADHD beyond DSM / ICD as such should be avoided. Otherwise, there is a real danger that the person with ADHD will be blamed for behaviors that actually stem from ADHD itself. This can cause further deterioration for the person with ADHD instead of improvement.

Suitable types of therapy can include

• Mindfulness-based (behavioral) therapy (MBCT) to improve self-awareness, to improve self-control over symptoms and to learn and practice mindfulness-based stress reduction (MBSR) and stress reduction techniques (e.g. 8-week intensive MBCT + MBSR courses)
  In ADHD-HI in particular, the vicious circle of inability to recover should be broken, which helps to maintain the continuous operation of the HPA axis.
• Neurofeedback for long-term improvement of autonomic control (6 months to 2 years)
  • SMR training to improve impulse control and combat sleep problems
  • Theta beta training to improve the regulation of activation
  • SCT training to reduce overactivation or increase underactivation
  • A combination of theta beta training or Z-score training and SCP training (simultaneously or consecutively) seems to be particularly recommended
• If necessary, cognitive behavioral therapy for self-esteem problems, social behavior problems. Here ⇒ Rejection sensitivity: fear of rejection and criticism as a specific ADHD symptom note. Cortisolergic stress arises in particular in subjectively self-esteem-threatening situations.
• If necessary, depth psychological therapy for the treatment of serious experiences/experiences
• Trauma therapy (EMDR) for traumatic experiences, if necessary
• For children up to 6 or 10 years: parent-centered therapy; child-centered therapy ineffective.

3.2. Environmental interventions¶

• Eliminate stressors
• Optimal design of the working and learning environment, e.g.
  • Eliminate superfluous stimuli
  • Enable sufficient arousal
• Discussions with relationship partners to create mutual understanding
  • Systemic therapy (family therapy, parent therapy) if necessary to change ingrained problem patterns
• Focusing your life and career on things that really interest you
  • More on this at ⇒ Motivational problems with ADHD.

4. Fourth step: Comorbidity and medication review¶

4.1. Comorbidities¶

• After 9 to 12 months of ADHD treatment, check the continued existence of comorbidities
• If necessary, specific drug treatment (note interactions, e.g. caution with SSRIs)
• If necessary, choose specific ADHD medication that also has a positive effect on comorbid disorders

  • Atomoxetine acts noradrenergic and dopaminergic on PFC and striatum, stimulants noradrenergic and dopaminergic only on striatum.
    ⇒ Atomoxetine for ADHD Atomoxetine is reported to be beneficial for severe ADHD-I or SCT.

  • Note the problems of serotonin reuptake inhibitors in ADHD-I.
    ⇒ Notes on serotonin reuptake inhibitors (SSRIs) in ADHD

  • In ADHD with bipolar Disorder:
    Whether ADHD medications (especially for bipolar 1) can have a mood destabilizing effect is controversial. In contrast: Barkley¹¹
    It is recommended to treat Bipolar Disorder first and then treat ADHD (see above).

4.2. Medication review¶

• After completing the non-drug therapy measures (regularly, e.g. annually), check whether medication is still necessary
  • Adjustment if necessary
  • Reduction if necessary
  • Termination, if applicable
• Regular physical check-up when administering medication
• Dosage: trying to eliminate all ADHD symptoms through medication would be malpractice. Non-affected people have 9 out of 32 symptoms (of the total symptom list ⇒ Total symptom list according to manifestations) frequently, people with ADHD have 26 out of 32 symptoms frequently. Trying to completely eliminate even the “healthy” 9 symptoms would inevitably lead to an overdose.

We have witnessed amazing changes in people with ADHD as a result of medication and therapeutic measures, with the quality of life improving immensely within just one year in some cases.
The changes were particularly impressive in those people with ADHD who persistently and consistently took every opportunity to improve. Barely any of the people with ADHD found all the forms of therapy they tried to be useful. In our opinion, the most successful people with ADHD were those who did not expect any particular measure to be successful, but who consistently tried one measure after another until a satisfactory condition was achieved. Once one therapeutic measure was completed, the next one followed, but only as much at a time as was manageable.

4.3. Medication breaks¶

Many doctors recommend that their patients take a medication break of at least one week at least once a year to determine whether medication is still required. It is barely conceivable that a state of “no longer needing” has occurred without the (previously unchanged) medication no longer being perceived as appropriate. Normally, a decreasing “need” at a constant dosage should cause symptoms of an overdose. We therefore suspect that cases in which people with ADHD no longer notice any difference to their previous medicated state during the medication break are more likely to be related to reduced demands in the environment (vacation/holiday) or to the development of tolerance.

Such a break from medication should always be weighed up against the background of the increased risk of accidents during this time.

Children with eating problems or growth problems can benefit from a break of several weeks during the vacations to build up weight reserves for the coming school term or to catch up on length growth (which, if impaired at all, is usually only delayed by MPH).¹²

5. Treatment prioritization for comorbidities¶

5.1. Prioritization according to the severity of the disorder¶

In principle, the clinically more severe disease or the disease that is most important to the person with ADHD should be treated first in accordance with the guidelines.¹³

5.1.1. Comorbidity more severe than ADHD¶

• Primary treatment of comorbidity
• E.g. severe depression, bipolar 1,¹⁴¹⁵ addiction, psychosis, severe anxiety
• For depression, anxiety and addiction at the same time as parallel treatment of the usually causative ADHD.¹⁶
• Comorbid anxiety with ADHD may require specialized treatment.¹⁶

5.1.2. ADHD more severe than comorbidity¶

• Primary treatment of ADHD as the leading Disorder.¹⁴
• Mild emotional dysregulation, mood swings, mild impulsivity or aggression, mild anxiety disorders or dysphoria (especially dysphoria with inactivity) are improved by ADHD treatment.¹⁷¹⁵¹⁸

5.1.3. ADHD and comorbidity equally severe¶

If in doubt, we would prefer ADHD treatment.
Treating ADHD can significantly reduce the symptoms of comorbidities - and even eliminate them.¹⁹
We also believe that taking into account the side effects of the medication, so that the treatment with the fewest side effects is preferred, should usually lead to ADHD treatment being prioritized.

5.2. Treatment guidelines for specific comorbidities¶

5.2.1. ADHD and depression:¶

• Note the difference between dysphoria / severe depression in ADHD
  ⇒ Depression and dysphoria in ADHD
• Always check D3 blood levels and thyroid hormones before taking antidepressants for moderate or mild depression
• Summary of the Texas Children’s Medication Algorithm for ADHD-HI and MDD by Burleson Daviss (2018) Moodiness in ADHD - A Clinicians Guide, p. 99 (modified)^{2122 23}
  • Impairment from ADHD-HI worse than from MDD:
    • Start of stimulant monotherapy according to the ADHD-HI algorithm.
      • If thereupon:
      • ADHD-HI, but does not address depression:
        Add SSRIs for the treatment of depression
      • ADHD-HI and depression remain the same:
        Switch to a new class of stimulants
        • From MPH to AMP or from AMP to MPH
          • Unlike MPH, amphetamine medications also have a mild antidepressant effect and therefore have an advantage over MPH in cases of comorbid depression. ⇒ Amphetamine medication for ADHD
        • If MPH and AMP are unsuccessful:
          • Change to Guanfacin
        • If Guanfacin is also unsuccessful:
          • Switch to atomoxetine
      • Exacerbate ADHD-HI and/or depression:
        Switch to SSRI²⁴²⁵
  • Impairment from MDD worse than from ADHD-HI²⁴ or suicidal thoughts/suicidal behavior²²:
    • Start of SSRI monotherapy²⁴
      • If thereupon
        • Depression, but does not address ADHD-HI:
          Add stimulants for the treatment of ADHD-HI
        • Depression remains the same or worsens:
          Switch to another SSRI
      • If thereupon
        • Depression, but not ADHD-HI:
          Add stimulant to treat ADHD-HI.
        • Depression remains the same or worsens:
          Switch to non-SSRI antidepressant, e.g.
          • Bupropion¹⁴
          • If bupropion is unsuccessful:
            Nortriptyline, desipramine or venlafaxine¹⁴

5.2.2. ADHD and addiction¶

• Addiction or alcohol abuse should be stabilized first, but can be treated at the same time as ADHD.¹⁷ In particular, there is no longer any reason to withhold stimulants as ADHD medication from addicts and treat them solely with atomoxetine, which is significantly less effective and has considerably more side effects.²⁶

5.2.3. ADHD and anxiety¶

In our experience, people with ADHD with a comorbid anxiety disorder or high anxiety levels often experience more severe side effects when taking medication. This is not a consequence of a particular effect or increased side effect risks of ADHD medication in comorbid anxiety²⁷, but a consequence of the anxiety itself. Anxiety causes a focus of attention on possible side effects, while an optimistic mindset directs attention to possible positive effects of the medication. This is also known from the treatment of chronic pain.
Therefore, practitioners should consider at least temporarily administering anxiety-relieving medication to people with ADHD with high anxiety levels before or during dosing.
We have repeatedly experienced in the forum that dosing is particularly difficult for people with ADHD and fails more often, partly because the person with ADHD finds it much more difficult to maintain the many slow increases in dose required to find the appropriate dose. Each increase in dose is a new and special challenge for an anxiety sufferer.
Persons with ADHD with comorbid anxiety also titrated placebo to lower target doses than people with ADHD without anxiety²⁸

ADHD medication can have an anxiety-relieving effect once it has been dosed correctly.²⁹³⁰

It is reported that nervousness or anxiety occur significantly more frequently with AMP drugs than with MPH drugs.³¹

Remedy:

• Reduce dose
• Switch to a long-acting preparation
• During dosing
  • Dose for one week. Side effects often disappear after a few days.
  • Consider increasing the dose as an option. Often enough, side effects do not occur with a higher dose.
• Switch to non-stimulants