Medication Treatment for ADHD

David Rabiner, Ph.D. Research Professor, Duke University

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David Rabiner, Ph.D.
Duke University

(Note: If you are looking for information on Attention Deficit Disorder (ADD) please be aware that much of what is discussed below should also be relevant. Technically, the term ADD is no longer used. Instead, children who have the inattentive symptoms of ADHD but who do not show hyperactive/impulsive symptoms are now diagnosed with ADHD, Predominantly Inattentive Type rather than with ADD. These terms mean pretty much the same thing but the latter is no longer technically correct.)

In regards to treating the core symptoms of inattention, hyperactivity, and impulsivity, it has been shown in numerous studies that stimulant medication provides significant benefit to between 70 and 80% of children with ADHD. The most commonly prescribed medications currently used to treat ADHD come from a class known as stimulant medications and include Concerta, Adderall XR, Vyvanse, Ritalin, Methylphenidate (the generic version of Ritalin). Straterra is a non-stimulant medication also approved to treat ADHD.

Although the exact mechanism by which stimulant medication works is not known, available evidence suggests that it works by correcting a biochemical condition in the brain that interferes with attention and impulse control.

"What benefits can stimulant medication produce?"

The beneficial effects of stimulant medication treatment can be dramatic. Attention to assigned class work can be improved to the extent that the child is no longer distinguishable from classmates; activity level can decline to within normal limits and impulsivity can be substantially reduced. Even associated difficulties such as disruptive behavior and peer relationship problems can sometimes show dramatic improvement. Interactions between parent and child and between the child and his or her siblings have also been shown to improve. Academically, children who respond positively to medication show clear improvements in both the quantity and quality of the work they complete. It remains to be seen, however, whether these short term changes result in long term gains in children's academic, behavioral, and social functioning.

"How long does it take stimulant medication to work?"

The effects produced by stimulant medication occur quickly, and parents and teachers often observe an improvement in the child almost right away. In contrast to older versions of stimulant medications, which tended to last for no more than 4 hours, medications prescribed today last longer, on the order of 8-12 hours.

"How extensively has the use of stimulant medication been studied?"

The efficacy and safety of stimulant medication for treating ADHD have been documented in over 150 controlled studies involving children, adolescents, and adults. This research has shown that the majority of individuals with ADHD - roughly 80% - benefit from stimulant medication. However, the degree of benefit varies and many individuals still experience difficulty with ADHD symptoms despite benefits that medication provides.

"What kinds of side effects are associated with stimulant medication?"

As with any medication, the stimulant medications commonly used in treating ADHD can produce adverse side effects in some children. These can include: sleep difficulties, stomachaches, headaches, appetite reduction, drowsiness, irritability, nervousness, and excessive staring among others. In very rare cases, stimulant medication can lead to nervous tics, hallucinations, and bizarre behavior.

The list of possible side effects can be very scary to parents considering the use of medication for their child, but it is important to emphasize that the vast majority of children with ADHD experience no adverse effects. Based on the findings from many carefully controlled studies, physicians have concluded that when properly employed stimulant medication is quite safe and the side effects are minimal. When side effects do occur they are frequently short term and generally disappear when the dosage is reduced. Despite these data, however, it is obviously important for parents to discuss their questions and concerns with their child's physician.

"But I've heard all kinds of bad things about using Ritalin?"

There are an unfortunate number of myths concerning stimulant medication that discourage many parents from considering it's use for their child. These myths are summarized in an excellent book titled Attention Deficit Disorder and Learning Disabilities: Realities, Myths, and Controversial Treatments by Barbara Ingersoll and Sam Goldstein (highly recommended) and include the following:

* Children treated with stimulant medication will become addicted to it and are more likely to abuse other drugs.

There is no data which indicates that addiction to stimulant medication is a problem or that children treated with stimulants are more likely to abuse other substances. In fact, it appears that children with ADHD who are treated with stimulants are actually less likely to abuse drugs and alcohol in adolescence

* Stimulant medication stunts growth.

The available literature indicates that ultimate height appears to be unaffected if treatment is discontinued in adolescence. However, there have been no studies of growth in children treated continually from childhood into young adulthood so caution here is warranted.

* Stimulant medication works by turning children into "zombies".

Some children do become sluggish and withdrawn when on medication, but these symptoms generally indicate that the dose is too high, or that a co-existing condition such as a mood problem has not been identified. Studies have shown an increase in prosocial behavior in ADHD children treated with stimulants, which would not be the case if it simply turned children into "zombies".

"How can I decide whether my child should receive medication?"

Although the vast majority of children with ADHD will benefit from stimulant medication, not all children need to receive it. In deciding on the use of medication for your child, the following factors may be helpful to consider:

* What other interventions have already been tried?

Some children with ADHD can have their symptoms effectively managed via other means including appropriate behavioral and educational interventions. If you are concerned about using medication with your child, make sure that non-medical interventions have been tried first. This is an important issue to discuss with your child's physician. It is important to be aware, however, that no form of treatment has been shown to be as effective as stimulant medication for the majority of children with ADHD.

* How much difficulty are my child's symptoms actually creating?

The degree of impairment in academic, social, and behavioral functioning caused by ADHD can vary substantially. If the impairment experienced by your child is on the modest side, medication can be less essential than when the impairment is great.

* What is my child's attitude towards taking medication?

It is very important to discuss the rational for using medication with the child. The child needs to know why it is being suggested and how it can be helpful. This is especially true for older children and adolescents, who may have concerns about being teased should their peers find out that they are taking medicine. If children have strong objections to taking medication, these should be discussed and understood. Should these objections persist, using medication may not be productive.

* Will objective information about the effects of medication be provided?

In my opinion, this is critical. Despite the well documented benefits of stimulant medication, as many as 20-30% of children do not experience significant benefits. In addition, many parents are surprised to learn that when children with ADHD receive only a placebo (i.e. medication that appears to be the real thing but is not), teachers frequently report significant improvement in the child's behavior. This means that some children may receive stimulant medication for a sustained period even though they derive no objective benefit from it.

What causes this placebo effect? No one knows for sure, but when teachers are aware that a child has started medication, it is difficult for them to provide an objective, unbiased account of the child's behavior. Some children may also do better when they believe they are receiving medication that is supposed to help. This can make it difficult for parents and physicians to get objective information to use in making decisions about long term medication use.

"So how do I know for sure that the medication I really helping my child?"

Despite the placebo effect noted above, there are many children for whom the response is so dramatic that it seems impossible to attribute the improvement to a simple placebo response. Studies have found, however, that sometimes the improvement reported when a child is eceiving placebo can also be quite dramatic. In addition, determining the optimum dose for a child in the absence of receiving objective feedback is also difficult.

Fortunately, it is not hard to conduct a careful trial that provides more objective information about a child's response to medication. This is accomplished by having the child receive different medications doses as well as a placebo over a 3-4 week period. For example, in a 4 week trial, the child receives a low, medium, and higher dose for one week each, and a placebo for one week. At the end of each week, the child's teacher completes ratings of the child's behavior and academic performance. Because neither the child nor the teacher know what the child was receiving each week during the trial, the teacher's ratings provide more objective information. By comparing the ratings made each week one can determine whether:

* medication was clearly superior to placebo;

* what dose produced the optimal response;

* whether any adverse side effects were observed (sometimes children report what appear to be side effects when they are only getting a placebo);

* what problems with behavior and academics may remain even if medication clearly helped, and which need to be targeted via other means.

This simple procedure provides more reliable and objective information that can be used to decide about the benefits of ongoing medication use. Unfortunately, many physicians do not use this relatively simple procedure and rely on anecdotal reports from teachers and parents to base medication decision on.

"How often do most children need to take medication?"

Long acting stimulant medications like Concerta, Adderall XR and Vyanse typically work for 8-12 hours. Therefore, children generally do not need to take more than one dose a day before school. Depending on each child's individual response and situation, however, an additional dose - perhaps of a shorter acting stimulant - may also be prescribed by a child's physician to assist with homework and behavior in the evenings.

"Do children with ADHD need to take medication on weekends and over vacations?"

This depends. For children whose symptoms are relatively mild, medication during the school day may be all they require. Unfortunately, some children have more severe forms of the disorder and have difficulty behaving appropriately in a much wider variety of settings. For example, some children with ADHD may struggle in any type of peer activity without medication. Other children may be unable to complete their homework without the help of medication. Thesechildren may benefit from receiving medication outside of school hours. This is an important issue that needs to be discussed with your child's doctor.

"For how long do children with ADHD need to take medication?"

The best answer to this question is that a child should take medication for only as long as it is helpful and necessary. For some children with ADHD, symptoms seem to dissipate as they get older to the point where continued use of medication is no longer necessary. Many other children will continue to struggle with ADHD symptoms into adolescence and young adulthood, however. These individuals may benefit from receiving medication during many years of their development. Because the need for stimulant medication may change over time, most experts recommend that this issue should be re-evaluated on an annual basis. In addition, the effectiveness of medication a child is receiving needs to carefully evaluated on a regular basis.

"What other kinds of medication are used to treat children with ADHD?"

Straterra is a non-stimulant medication that has been approved by the FDA as a treatment for ADHD in children and adults. This would be the most commonly prescribed non-stimulant medication. Many physicians choose to begin treatment by trying one of the stimulants, however.

SUMMARY AND CONCLUSIONS

* Stimulant medication can provide significant benefits to the majority of children with ADHD.

In addition to reducing the core ADHD symptoms of inattention, hyperactivity, and impulsivity, it can also enhance academic performance, reduce disruptive and aggressive behavior, and improve relationships with peers and family members.

* The improvements resulting from stimulant medication are based primarily on the results of short term studies.

More data on the long term effectiveness of this form of treatment is required. A recently completed study, however, does provide evidence of sustained benefits over a 15 month period.

* Even though a child may benefit from stimulant medication, there can often be remaining academic and/or behavioral difficulties that need to be addressed by other forms of intervention.

For many children with ADHD, stimulant medication will be only one component of an overall treatment plan.

* Most children do not experience any prolonged adverse side effects from taking stimulant medication.

This medication is believed to be safe for consistent use over many years, and no adverse long term side effects have been reported in the literature. It is very important, however, for parents to discuss their questions and concerns with their physician and pharmacist.

* Because many children with ADHD may appear to improve when given only a placebo, it is important to use an objective procedure to determine medication effectiveness.

Anecdotal reports from teaches who know a child is receiving medication may be unreliable.

* A child's response to medication can change over time.

Children's need for medication can also change. Re-evaluating these issues on a periodic basis is important.

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