[Content]

Treating ADHD With Medications

Numbers in parenthesis refer to reference materials that are listed on a separate page.

ADHD is be the most studied disorder in child psychiatry. There are two major types of interventions, medical and non–medical.

There is no doubt that medical interventions for ADHD are effective; medications are more effective than any other intervention. Adding non–medical interventions to carefully prescribed medications doesn't work any better than medications alone. Medications are also effective when there is comorbid Oppositional Defiant Disorder, Conduct Disorder, or Anxiety Disorder. (25, 26)

Medications have side effects. Given the seriousness of ADHD by the time it is diagnosed and the safety of these medications, concern about side effects isn't a reason not to use medications. Since the risk of serious side effects is very low, and the risk of the disorder causing severe problems for the child is quite high, the balance favors using medications.

The main reason not to use medications has nothing to do with the medications themselves but with how much parents hate the idea of giving their children psychiatric drugs. I believe there are three types of parents:

Parent Attitudes Toward Medication Intervention

"If it will help, I'll do it"

The child is totally out of control and cannot get through a day of school without going to the principal's office. Their family life is on hold since every ounce of energy they have goes for caring for this child. The parent would like the child to get better instantly; this hour, if possible. The parent takes home a prescription for medication for the child on the first visit.

"I hate the idea of giving my son drugs. It would be my last choice"

The child is moderately disabled with most of the problem at school, not at home, so it doesn't seem that bad to the parents. The fact that parent is not home until about 6:00 pm every night makes it a little easier to bear, as that decreases the time needed to deal with his the son all evening. So the parents decided to try a few other non–medical things first. After two months, if things aren't better, they will try medications.

"Nothing would make me give my daughter psychiatric drugs that will affect her brain"

The child is quite disabled by ADHD, but the idea of having to give the child medications is worse than dealing with disabling ADHD. The parent tries all sorts of non–medical treatments but will never let the child take pills. The parent is hoping) that the ADHD will go away on its own. If right, the parent will feel very proud.

Frequently Asked Questions

What exactly do the medications do for ADHD?

These drugs alter the way signals are transmitted in the brain; the substances in the brain that help transmit messages. They work at different levels of the brain to alter the core symptoms of ADHD. The various drugs work on different parts of the signal transmission system. That is why sometimes one drug will work and not another

Why would anyone want to give drugs that affect the brain to children?

The main reason would be to increase the child's sustained attention so they can learn. No one would suggest trying medical treatments before the non–medical interventions are used in very mild ADHD. It is similar to diabetes in that way. If you have a type of diabetes that is not severe, your doctor may first suggest you try diet control. If that doesn't work then the doctor will consider medical treatment. If your diabetes is severe, you would start on a diet and medication right away. In other words, if ADHD is severe sometimes we use medical and non–medical treatments together from the start.

If the drug works, how will my child be different?

If the drugs work are effective the three core symptoms of ADHD (inability to pay attention, hyperactivity, and impulsiveness) are brought down to a level that is close to the average for their age group. As a result, people are usually more successful socially, academically, and have fewer family problems. Usually the child's self esteem improves as they are more successful in their performance. When these medications work right, the change can be amazing. 75 % of the children that take these medications, are indistinguishable from non–ADHD children and few of these other interventions will be needed.

What if medicine doesn't help?

Sometimes a medication won't work because the dose is not right or the medication is not the right one. Some people will not respond to one medication but they will respond to another. If the drug doesn't work it is discontinued and and the physician decides what do next. Try something else? Abandon medical treatment? Both are sometimes reasonable options.

Is it true that these drugs can have side effects?

Yes, it is. All medications have possible side effects. There are two types of side effects.

Side effects can interfere with sleep and appetite, cause depression or anger, affect the heart, cause loss of bladder control, make the hyperactivity worse, make people have tics, or cause the person to act like a zombie. Each medication will have it own specific side effects.

Are the drugs that dangerous??

Yes, if used improperly however, when used carefully according to the physician's directions they are safe.

How can that be?

Medications need to be monitored. Current medical literature advises three basic principles when prescribing psychiatric medications in children. 1) Start low, 2) Increase slow, and 3) Monitor carefully

What do you mean by "start low"?

This means that drugs are started at a lower dose than the desired level. When you have an infection, it is necessary to give people plenty of medicine right away and if there are problems then you reduce it. The problem is that high doses can cause problems and when the problems affect your mind and personality this can mean trouble for the person taking the medicine. Therefore it is best to start with the lowest dose possible; about 25% of the usual dose. Then if the child is sensitive to the drug it only causes small problems. Some children respond to drugs at very low doses, far below the usual recommendations.

What do you mean by "go slow"?

ADHD is not an acute illness. Less than 10% of the people with this disorder need to be treated very quickly. Most people have had it for years; consequently, there is no need to increase the dose quickly. By going slowly it is easier to identify and manage any side effects. It is easier to find the lowest effective dose with this method. What is "monitor carefully"?

Each of the medications has specific side effects that need to be monitored regularly. Some common ones are monitoring weight, muscle "twitches" or tics, depression, blood pressure and pulse, and making sure parents know what the side effects are of the different medications. In this way, if there is a problem, it can be identified early and avoid serious consequences.

How often does my child have to see the physician for follow up?

The physician will determine with the parents the frequency of monitoring visits. It may include verbal contact in a few days to monitor initial doses; then likely an office visit before the month has ended. Once it is known if the medication is effective and there are no side effects most kids are seen only three or four times a year.

How long does my child have to take medicine?

If there is a big benefit with minimal side effects, it is common to have children take the medication throughout the school year. In the summer some physicians have the child go off the medicine to see what happens while others have them remain on the medication. If they are doing well on medicines, the only way you can tell if they still need the medicine is to see them off of it. If they seem to be no different off the drug, some physicians have them start school off the medicine. If there are signs during the summer or at school of relapse, then the child restarts the medicine.

What drugs are used?

The medical treatment depends on a few things. Most physician's want to use the drug that is easiest to use, least expensive, and most effective. It is the presence or absence of these comorbidities that determine which drug is likely to be the most effective. This means certain medicines will work and others will not. The first choice of drugs for ADHD is the stimulants. The other drugs are all second choice and usually reserved for children who do not respond to the stimulant drugs.

Monitoring

Some drugs need more monitoring than others. Some drugs require blood tests; others require blood tests and EKGs; or the heart rate and blood pressure to be monitored. The drugs requiring the least amount of monitoring are the stimulants (Ritalin, Concerta, ADDerall and Dexedrine.) Tricyclics (a classification of drugs) require blood tests and EKGs to determine the right dose. Clonidine requires blood pressure and pulse checks.

Number of dosages per day

Some drugs have to be administered three times a day or more. That means someone has to be very attentive to getting the drug in the child at school and usually after school too. Very few children will reliably take their own medicine. Some children really object to having to go someplace at school and afterwards to get their medicines. The drugs that need to be given three times a day are short acting Ritalin and short acting Dexedrine (not Dexedrine Spansules).(editor's note: there are now longer–acting medicines that need to be taken only once or twice a day.)

Cost

Overall, these are not expensive drugs; costs run less than $100.00 a month depending on the pharmacy.

In Summary

There is no perfect drug. Below the description of each drug is a chart that summarizes all of this information. No one can predict which drug will work in a child and which will not; nor which drug will cause side effects in a child and which will not.

Stimulants Are the Most Commonly Used Medications for ADHD

The stimulants include Ritalin and Concerta (both methylphenidate), Dexedrine, ADDerall and Dexedrine Spansules (dextroamphetamine). Often one drug in this group will work for a person while another will not. They all have the same side effects but some people will tolerate one drug far better than another. 90% of children with ADHD will respond to one of the stimulants. There is more data to support the effectiveness of stimulants as a treatment in ADHD than for any other medical treatment in medicine!

Stimulants in Special Populations

Preschool

In some circumstances, drugs are used in this age group. Usually, it is because the child's behavior is so disruptive that the child cannot attend a structured preschool program. It is important for children with severe ADHD to attend preschool as it can be very helpful in building their social skills.

Stimulant medications are safe in this age group. However, there tend to be more side effects. In recent studies of preschoolers with ADHD and other common comorbid conditions 45% had side effects. There was not much problem with sleep and appetite, but with mood changes, irritability, and withdrawal. (20) Overall, when used carefully, these drugs can be helpful in many preschoolers with severe ADHD (7). The doses need to be increased over time and are usually close to 1mg/kg. Overall, about 75% of children in this age group respond to medications.(32)

Teenagers

Stimulant drugs are very effective in this group. The biggest problem is that medications require multiple dosages a day. A short acting drug like Ritalin or Dexedrine tablets would have to be given three times a day. This is hard to remember, even if you do not have ADHD. The first line choice is drugs that can be given once or at most twice a day. Obviously, if drug abuse is a problem short–acting stimulants are not used: [It is harder to abuse the long acting stimulants as they are formulated not to create a "rush"].

Questions About Abusing Stimulants

The stimulant medications are closely related to certain drugs of abuse. If you crush Ritalin (methylphenidate) and smoke it you can get high and large doses of Dexedrine by mouth can be addictive. Some people try to combine these drugs with other street drugs to get high and as a result these stimulant medications do have "street value".

Will my child get addicted to Ritalin or Dexedrine?

No, the only situation that can lead to addiction is when a confirmed drug abuser is allowed unlimited access to these drugs.

If my child uses Ritalin or Dexedrine now, will s/he be more likely to use street drugs and alcohol later?

No, in fact evidence suggests the reverse is true. Teenagers with ADHD who are treated with stimulants are less likely to end up abusing drugs than teenagers with ADHD who do not take stimulants. It seems like stimulants might actually protect children from drug abuse.

My son has ADHD but also abuses drugs when he can get them. Is it safe for him to take stimulants?

Maybe. The usual approach is to make sure people are clean with urine drug screens and then make sure that they do not have access to the supply of medication.

Stimulants

Short Acting Stimulants

These are drugs that last 3–4 hours per dose and have to be given 2–3 times a day to work. They used to be the standard drugs for ADHD. Now they are only used in special circumstances such as

• A preschooler who is too small for the long acting pills. The drugs are given by weight, sometimes the smallest long acting size is still too big.
• A child can't swallow the long acting pills. The short acting pills can be crushed, but not the long acting ones.
• An add–on to another ADHD drug such as Welbutrin.
• The child has a more effective response on this type of stimulant.

Ritalin

Ritalin (methylphenidate)—It is confusing, as there are three drugs which all have the same chemical in them, but with different names. The chemical is Methylphenidate. The three pills are called Ritalin, Ritalin SR, and Concerta.

This is certainly the most frequently used drug for ADHD. It is a cousin of speed. Unless you are a confirmed drug addict, you will not get high on this drug unless you crush it up and try to smoke it. When taken as a pill, it will not make you high, so it is not addictive. It requires no special monitoring. They are easy to crush can be given in anything sticky for children who cannot swallow pills. It is usually given at breakfast, lunch, and after school.

Dexedrine

This is the oldest drug used for ADHD. The tablets last about 6 hours at the most. That means two or three doses a day. There are some children who will respond to short acting Dexedrine and nothing else. In fact, they might respond to short acting Dexedrine but not to Dexedrine Spansules.

Long–Acting Stimulants

This is the first choice for stimulant treatment in most children with ADHD. There are two drugs in the category that last about 12 hours. There is another older drug, Ritalin SR, which lasts 6–7 hours.

Dexedrine Spansules

The Spansules are tiny pills in a capsule (like a cold capsule) and last about 12 hours.

Ritalin SR

At one time this was the state of the art for stimulants in ADHD. The slow release Ritalin can be given once a day and it works for about 8 hours, but not 12.

Concerta (long acting Methylphenidate)

This pill is different and actually releases the drug in such a way that it is just as effective as Ritalin tablets three times a day, but with only one dose. The side effects are the same as with the short–acting Ritalin. Theoretically, there should be fewer mood swings as the drug wears off. (36) Cost: This drug is more expensive than the other stimulants.

(Editor's note: ADDeral XR is also a long acting stimulant. For more information on the medicines used to treat ADHD, read the free article at this website ADHD Medications: Adderall, Concerta, Dexedrine, Focalin, Metadate, Ritalin, Strattera and More)

How Do You Give These Drugs?

I start with a dose that is quite low and watch the child for a few days. One of three things will happen:

1. Absolutely nothing—then we increase the dosage
2. A little improvement and no side effects—then we increase the dosage.
3. Lots of side effects—stop the drug and consider something else.

The child's behavior is monitored after each dose increase. It is important to find a dose that will control the symptoms and not cause a lot of side effects.

Once a drug is effective there is no guarantee that the dosage is going to stay the same. In fact, over 70% of children have to have their dosages adjusted over the span of a year.

Side Effects of Stimulants and Their Management

Sleep

Many children with ADHD have insomnia. Sometimes, the stimulants actually improve sleep. A child may be able to go to sleep, but awaken a few hours later. More commonly, the child just can't fall asleep. This is serious for a number of reasons. First, the child will become sleep deprived leading to irritability, poor concentration, and fatigue. Second, since most parents do not go to sleep before their children the parents are sleep deprived with the same problems as the child. This is a not a good combination! If it is a mild sleep problem, sometimes attending to sleep hygiene or developing good sleep habits will do the trick. Actions such as—an earlier bedtime, eating or avoiding certain foods, no TV or computer, quiet activities in the evening and no naps—sometimes will do the trick. What to do depends on how well the child is doing on the drug at that particular dose. The key is to do something. Sleep deprivation will undo every successful intervention you have made.

Appetite

The stimulants can reduce a person's appetite. Often a child will not be quite as hungry on one of these drugs. Other children are finally able to sit down long enough to eat something and actually gain weight. Problematic weight gain is very rare, but weight loss is common. I weigh children regularly who are taking these drugs. Some children will eat no breakfast, lunch or afternoon meal but not lose weight because they spend their evenings eating. Children may have other complaints such as stomachache. Food supplements like Ensure, Boost and instant breakfast may help. If this has been tried and a child is still losing weight, it doesn't matter how well they are doing. It is time to stop that particular drug.

"Rebound"

The short–acting drugs can cause rebound. When the drug wears off the child does not return to his usual severity of ADHD but to a much worse state. He may stay this way for 1–3 hours before becoming his usual self. For example, a child takes Ritalin at breakfast and at lunch with great results. The drug wears off right after school, and the child behaves like are a monster until evening. If rebound is severe something has got to be done; no matter how well the child might be doing in school. It is better to be consistently "hyper" than Dr. Jekyll at school and Mr. Hyde at home. Sometimes, you can get around a rebound effect by giving a small dose of the shortþacting drug (usually Ritalin) in the afternoon.

Unwanted psychiatric signs and symptoms

30–50% of children may have, to one degree or another, unwanted psychiatric signs and symptoms on stimulants. These are all reversible when you stop the drug. Everyone involved in the medical care of children with ADHD needs to be watchful for these. It is important to remember that even if this happens with one stimulant, it does not necessarily mean it is going to happen with a different stimulant.

• Decreased activity—some children will become very, very still on these stimulants, especially in the first few hours after they take them. Often, they are perfectly behaved, but are taking in next to nothing. This is usually due to the dose being too high, but can happen at low doses in susceptible people.
• Increased hyperactivity—some children will actually become more hyperactive, not less, with these drugs.
• Mood changes—occasionally, these drugs will make a person sad, angry, or very easily upset. Irritability is also possible. The child appears to cry at the drop of the hat. Less commonly a child will become giddy and actually seem high.
• Language—occasionally, a child who has a problem with speaking or understanding may go backwards on one of these drugs and speak even less than usual.
• Movements and compulsions—occasionally these drugs will make people have what appear to be nervous tics as in Tourette's syndrome. At times, these can be compulsive, such as new onset of nail biting, licking the hand, or having to touch certain things.

The possibility of the above things happening to a child who is already having psychiatric problems is often scary to contemplate as a parent. It is another reason to start low, go slow and monitor carefully. These unwanted psychiatric signs and symptoms are reversible. Most children do not have side effects that affect the mind.

Other mild side effects

There are sometimes some mild nuisance side effects of the stimulants. Occasionally a mild headache, abdominal pain, and other mild physical symptoms are reported by children taking these drugs and go away with time. Most research has found that this type of side effect is as common in children treated with placebo as with an actual stimulant drug.

Long–term side effects

The truth is there aren't any long–term side effects. Occasionally, there is a report that these drugs will do something bad to a person if taken for years it isn't true. If a child is tolerating the drug wel it isn't going to do something down the line. This is very clear from the research. These drugs have been carefully studied for at least thirty years.

Side effects at school

The side effects of the stimulant medications are rarely seen by the school. Studies have shown that while teachers are good at determining how effective a drug is, they are not accurate in noting side effects (29). As a result, it is not uncommon for teachers to be more enthusiastic about medical treatment or suggesting that the dose of the medication be increased.

Non–Stimulant First Line Drugs

Bupropion (Welbutrin)

This drug has been available in the USA for about 10 years. It is used primarily as an antidepressant. However, it affects the same chemicals in the brain (dopamine and norepinephrine) that the drugs for ADHD effect. As a result, it has been tried in ADHD in children and adults. There are only a few studies of this drug in children. However, all of them have found it to be effective. In the one study which compared it to Ritalin, it was found to be almost, but not quite, as effective as Ritalin. (3) It has been used in children who have Conduct Disorder, substance abuse problems and Attention Deficit Hyperactivity Disorder, and it has been found to be helpful. (15) It comes in a slow release form, which means there is no need for a middle of the day dose. Since this drug is also an antidepressant, it is a first line choice if a child has both depression and ADHD. It is also a good choice if people have had problems with depression from stimulants. A recent study has shown that children with depression and ADHD treated with Bupropion (Welbutrin) responded quite well to the medicine. Depression improved in 88% of the children and ADHD in 63% of the children. In 58% of the children, the drug helped both the ADHD and the depression. (31)

Side effects—Rashes are common; one out of six children will get a rash which usually resolves over 3–4 days. Nausea and vomiting can occur. About 1/3 of children will lose a little weight. Less common side effects include irritability, sleep problems, and headaches.

Second Line Drugs

All of the medications below involve more risk. That is, in rare cases, people can have serious side effects. This means that there is additional monitoring required.

Why do you use these drugs?

1. Because the drugs above have not worked.
2. Because the risk of ADHD is far greater than the risk of the medication.

ADHD is not always a mild disorder. People with ADHD sometimes engage in very risky behaviors. These are risky to themselves and to others. ADHD can totally demoralize a child and put them at significant risk for depression. The risk of substance abuse related accidents, motor vehicle accidents, demoralization, other psychiatric disorders and even suicide is not that small.

If you look at a group of children with ADHD that go to see a pediatric psychiatrist and then see how they are doing four years later, 51% will have required tutoring, 34% will have repeated a grade, 15% will be in special classes, and 16% will have been diagnosed with a learning disability. Compared to children without ADHD, they will be 10 times more likely to have manic–depressive disorder, 8 times more likely to have depression, and 4 times more likely to have major anxiety problems. (1)

The risk of serious problems with the drugs below is on the order of 1 in 10,000 or less. To put that in perspective, your chance of being killed in a car accident on the way to school is .7 in 10,000. Compared to the risks of ADHD, most people would say the risks of these medications are worth taking.

You need to learn about how these medications are monitored and what the risk is and then, with your physician, decide what to do.

Clonidine (Catapress, Dixarit)

This drug was originally developed for treating blood pressure in children. It is safe abd useful for a lot of medical problems. Indications for Clonidine are: tics, severe ADHD, severe aggression, sleep disturbances in ADHD, detoxifying heroin addicts, menopausal flushing, and autism. The good thing about this medicine is that it never aggravates tics and it works in very aggressive kids who never sleep. A recent study showed that when added to a stimulant, children with ADHD and ODD or CD had a noticeable improvement in their ODD and CD symptoms, but not their ADHD symptoms. They also had with few side effects. (35) The medicine is safe for pre–schoolers.

Tricyclics

This is a classification of medications which were the first drugs used for depression in adults. One of them, imipramine, has been used for years with children who wet the bed. These medicines work in a slightly different part of the brain. They work very well in children who are depressed or anxious. They do not wear off over the day, and they do not usually worsen tics. They can be given it at breakfast and bedtime.

I heard of somebody who was taking two drugs at the same time. Why would they do that?

Attention Deficit Hyperactivity Disorder is sometimes so severe that one drug won't control it. There are certain cases where it is necessary to use two drugs to control Attention Deficit Hyperactivity Disorder. This requires even more monitoring and an even more careful approach.

The Bottom Line

Drugs can be very beneficial. They all have side effects. If used carefully, they can be lifesavers; if not, a nightmare.

Alternative Medicine Treatments

There are quite a number of substances that are supposed to help ADHD which are "natural" such as vitamins, herbs, minerals, and other plant products. They are usually advertised as being very safe and effective. For the most part, they are safe. There are few side effects with these agents. On the other hand, there is not the same kind of research data on natural treatments that is found with medical treatments.

---

Dr. Jim Chandler is originally from Minneapolis, Minnesota. He graduated from the University of Minnesota Medical School in 1983 then moved to Iowa City, Iowa for a residency in psychiatry. He now lives and works in Yarmouth, Nova Scotia where he practices both pediatric and adult psychiatry. This information on ADHD is from a series of pamphlets Dr. Chandler wrote to provide accurate, unbiased information on common pediatric psychiatric disorders.

• Experience Membership
• Update Your Profile
• Make a Donation
• Listen to Podcasts