What are commonly used ADHD medications?
Most patients who have ADHD are usually quite responsive to medication. In fact, in the largest study of children being treated for ADHD, which compared medication to complex behavioral programs, results showed that medication had a significantly more positive effect than any other type of intervention. A number of different medications may be helpful, but most clinicians start with medications in the stimulant class. These include dextroamphetamine (Dexedrine) and methylphenidate (Ritalin). They come in many different forms, mostly varying in how long they last. In their shortest forms they last about four hours and in their longest acting forms they last up to about 10 12 hours. Many patients respond equally well to all types, making the delivery packaging (how long they last and how much they cost) the deciding factor for the doctor and the family. That said, most children and families prefer the convenience of the long acting form.
These medications all start working right away (in less than one hour). Once the right dose has been determined, responding children are more focused, less fidgety and impulsive, stay on task, and are generally more productive and well behaved. Children should be noticeably better on medication; however, they still may have some behavioral troubles. The goal of medication is improvement, not perfection.
Most of the side effects of stimulant medicines are mild. They include some jitteriness, occasional headaches or stomachaches. These medications all decrease appetite, less food intake, especially at lunch, and some initial weight loss is common for many children. On rare occasions this can be problematic, so doctors routinely should monitor the child’s weight and height. From time to time some children become weepy or irritable on these medications, causing the doctor to stop using the medicine causing these behaviors. The most common complaints parents have are that for many children, as the medication wears off, they have what can be best described as “rebound” symptoms. It is almost as if they have been storing the up their symptoms and they all come out at the end of the day. There are options to help with this, if they are needed. Generally the downsides of these medications are far outweighed by their benefits, making their effectiveness ratio among the highest in all of medicine. Finally all stimulants are controlled substances, with the potential for abuse, so physicians and families must take that into account in their prescription writing and their storage.
The second best medication choice for ADHD is the non-stimulant, atomoxetine (Strattera). It is the medication of choice for children who have not responded to or can’t tolerate the stimulants. Atomoxetine works quite well and although it has many of the same side effects as the stimulants (stomachaches, headaches, decreased appetite), it is slowly metabolized and lasts all day, so it doesn’t have the “rebound” problems described above. It lasts all day every day. However, unlike the stimulants, which begin having effects right away, it takes several weeks for atomoxetine to reach its full effect.
Other medications have also been shown to be effective for treating ADHD. Clonidine and Guanfacine both work to some degree. They tend to slow children down or even make them sleepy, which can often limit the usefulness of these medications. Buproprion (Welbutrin) has been successfully used in children with ADHD. This medication also treats depression and carries the full set of warnings that all antidepressants now carry when they are used in children and teens. This has decreased its popularity.
Stuart Goldman, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
Is medication necessary?
Parents often wonder if it is necessary to treat ADHD with medications, and the answer is in almost all cases, yes. In very mild cases or where there is a lot of disagreement between the parents and the teachers about medication, behavioral techniques can be tried, but the studies would indicate that these are not nearly successful by themselves when medication is not added.
Joseph Gonzalez Heydrich, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
All parents want to know if there ways to treat ADHD that don’t involve medication. I tell them that yes, there are, but that they don’t seem to have same efficacy from the studies we have in large groups of kids that medication does. Treatments that do not involve medication may work for some kids, but for large groups of kids, they don’t.
Leonard Rappaport, MD, MS, Director, Developmental Medicine Center
What are the statistics on stimulants?
It’s important to use established treatments when treating ADHD. At this point that would be starting with one of the stimulants that have FDA approval for treatment of ADHD. Stimulants will help 70 percent of the kids on the first try. If you are willing to switch between stimulants if the first does not work, approximately 90 percent of the kids respond really well to one of them. Atomoxetine is an antidepressant and it helps ADHD through a different mechanism than the stimulants. It has been not quite as good at covering the symptoms of ADHD but it has some important advantages: it’s better in terms of not promoting ticks as much and it also can be dosed so that it covers 24 hours a day, whereas the stimulants cannot do that.
Joseph Gonzalez Heydrich, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
When kids and teens have concerns
A lot of kids are very worried about taking medication and they have misconceptions about it too. I think the biggest thing is that people will think they are crazy or they are different. So we talk about that a lot. One of the nice things about the all-day effect of the stimulant is that other kids don’t have to know that they are taking a medicine. They can have it at home and it works for the entire day.
Frances Johnson, Advanced Practice Nurse
Sometimes a kid doesn’t notice a difference in his or her behavior, which is the best of all worlds, because that means he or she is having no side effects. The child just notices that things are happening to him or her differently. For example, a younger kid may get invited to his or her first birthday party after starting medication because before he or she was too disruptive and no parent wanted the kid around. The kid isn’t aware that he or she is different, just that he or she is being treated differently by others.
Leonard Rappaport, MD, MS, Director, Developmental Medicine Center
If an adolescent tells you he or she no longer wants to take his or her medication, I think it’s the clinician’s role to figure out why. If it is because of a side effect, we can often change the medication and get rid of the side effect. If they are in denial that anything is going on, sometimes you have to stop medication on a trial basis and see if other people notice behavioral changes, collect data on it, and let the patient make a decision on it.
Leonard Rappaport, MD, MS, Director, Developmental Medicine Center
When parents have concerns
I think the bottom line is that no parent wants to have their child on psychotropic medicine. I think that also includes the stimulant medicines which we’re using as our first choice for the treatment of ADHD. So there’s a lot of education initially with the parent about the effect of the medicine, what the side effects are, and we are pretty up front about what we know and don’t know about the medicines. I think at that point it’s pretty important to establish the relationship so that parents are comfortable. If there is something they feel is an adverse effect from the medicine they can call up and check it out.
Frances Johnson, Advanced Practice Nurse
There is never any pressure to put a child on a medicine immediately. Sometimes I have parents come for a couple of visits before they feel comfortable. Often the stimulants are a medicine that we know pretty much right away if they are going to work. They are also a kind of medicine that is excreted from the body once the effect for that that day is over. It’s reassuring for parents to know that they can stop the medication one day and there is no carry over effect from one day to the next. It’s really meeting the parent where they are at and trying to give them all the information we have available according to what they need.
Frances Johnson, Advanced Practice Nurse
There is the natural concern for the family and for the patient about the possibility of unintentionally getting addicted to the stimulant medication. I have not seen a patient yet, though, who I have discovered is abusing his or her medication. That might be in part because of the way that we prescribe and monitor our patients. Our patients need to check in with our services at least three times a year. If they ask us for a refill for more than six months or if we haven’t seen them in six months we don’t give the refill– they need to come back and see us. That way we can monitor their vital signs, like blood pressure and heart rate. We can also monitor their academic progress, get feedback from their teachers and their parents, and make sure the patient is doing OK. In older adolescents or patients that we believe are at higher risk for abusing stimulants, we use stimulant preparations that are time released and thus less likely to produce euphoria if abuse is attempted.
Alcy Torres, MD, Pediatric Neurologist
Medication can makes a positive difference
Preschoolers will respond to medication treatment, but it has to be done more carefully, with more monitoring, and perhaps with lower doses. Often we leave the mediation for more severe cases to see if the preschooler will outgrow some of the symptoms of ADHD. With older adolescents and college students you have to balance the efficacy of the stimulants with the risk of them abusing it, or giving it to their friends, or selling it. That risk is much less with the longer acting sustained release stimulants, but it still needs to be thought about, and why it’s important for the parents to be monitoring and administrating medication for adolescents.
Joseph Gonzalez Heydrich, MD, Senior Associate in Psychiatry, Child and Adolescent Psychiatrist
What we look for when we treat ADHD with medication is a remarkable positive response. We seek a remarkable positive response with essentially no negatives– that’s the objective. If there is a subtle positive response, then it’s probably not a response at all. If everyone scratches their heads during a trial of medicine and says “it seems a little better,” that’s not a positive response. That means the medicine, for one reason or another, is not working. Either it is not the correct diagnosis, or it’s not the right dosage of medicine, or it’s not the right medicine.
Leonard Rappaport, MD, MS, Director, Developmental Medicine Center
There are families who are very receptive to medication, and there are other families who are reluctant to try it. I think how you feel about medication largely depends on what your experience with your medical care has been like prior to discussing the possibility of medication– I think that has a lot of influence on it. There are parents who after getting educated about the medicines, reading websites, and having their questions answered by their child’s doctor, become more confident. Then there are others who need more reinforcement. I think the most influential factor is whether or not medicine can make a positive difference in the child’s life. I see parents who were initially reluctant and then they come back for a follow up visit and then they say, “What a remarkable difference! This is another kid!” They actually convince you that what you are doing is right. It is so dramatic– the grades that were failing now become As or Bs and the kids are on honor roll; I think that that is very positive.
Alcy Torres, MD, Pediatric Neurologist
One of the wonderful things about this stimulant medicine is that we can tell pretty much right away whether they are going to help the symptoms or not. And often there is a very dramatic improvement. I’ve had parents who don’t even tell the school whose son or daughter is started on the stimulant and the teacher will send glowing reports about how much of the behavior has improved in this student. The kids are not as distracted; they are more focused. Sometimes there are less behavioral difficulties in class, less clowning around, less disruption in the classroom. The medicines can make a significant difference.
Frances Johnson, Advanced Practice Nurse
When parents are reluctant to try medication, I usually explore the nature of their concerns and take these concerns seriously. I explain that they can always ask any questions they or their child might have and that the well-being of their child is my highest priority. I consider the pros and cons of medication with parents (and older children) and explore how the child’s overall frustration and difficulty might be decreased on medication. I suggest parents talk with themselves and take time in making a decision, and that if their child seems to have adverse reactions, the medication can always be stopped. I also explain that medication is not a substitute for other interventions at home and at school. I also share my general optimism that medication can often make a large difference to kids with ADHD.
Barbara Burr, MD, Pediatric Psychiatrist
Concerns about abuse and the importance of using a specialist
The possibility of medication abuse is present not only for those patients who have ADHD but for everyone in general. For those patients who have ADHD, we know that the chances of developing true substance abuse disorders are higher if their ADHD is not treated.
Alcy Torres, MD, Pediatric Neurologist
I see them every week at first. I might have someone start on a stimulant medicine and then I’ll see them in two weeks to see, because I’m starting them on a low dose so I am basically tapering it up. I want to start the low dose because I don’t want them to have a lot of side effects because it can really turn kids off.
Frances Johnson, Advanced Practice Nurse
When I have seen over-medication or too much medication, it is often because it has been poorly monitored. We need to make sure that parents and their prescribing physician have a good working relationship so that they can collaborate effectively. It is important that the child is constantly being monitored, so that side effects are being evaluated and progress or lack thereof is noted.
Eugene D’Angelo, PhD, Chief, Division of Psychology
Sometimes, particularly in very busy pediatric practices, pediatricians try to be helpful to parents who are desperate to help their child who is acting out. These physicians give them medication to try and they will be speaking with the parents over the telephone, sometimes increasing it without further evaluation. I remind pediatricians that they wouldn’t start somebody on a cardiac medication without having a comprehensive cardiac workup completed. I feel similarly about evaluation of ADHD or any other concerning behavioral problem. Because of the problems with access to mental health services, it can take months before a pediatrician can make a referral and the child is seen, and meanwhile the parent and child are suffering. I appreciate the dilemma of the pediatrician it’s not sloppy practice to prescribe after a brief office practice– they are trying to be pragmatic and helpful– but it’s important for them to recognize that it is not the best of practices.
Eugene D’Angelo, PhD, Chief, Division of Psychology
Concerns about side effects
Appetite decrease is a big side effect, so we monitor weight. We get a baseline weight when the kids start on the medicine and then I weigh them every visit to see if they are losing weight or not. Some kids do lose weight on it and that’s a problem. We often have to encourage healthy snacks at night when the medicine has worn off. Sometimes kids can have an upset stomach, or a headache, or feel anxious. Starting them at a low dose often will help that. As they are getting used to the medicine we often make some adjustments; for example I encourage them to start eating a little breakfast before they take their medicine. That way, they are eating breakfast before the medicine takes effect so it’s not decreasing their appetites during that time and it’s making it a little less harsh on their stomachs. They often will have the biggest appetite decreases at lunch time and then it’s wearing off by supper time. Often they eat reasonable suppers and then they may need to have a healthy snack at night if they aren’t maintaining their weight. I often caution parents to watch for worsening mood because for some kids it can cause mood difficulties. Kids who are vulnerable can get increased irritability rages and that has happened for some kids, so we monitor for that. If there are blood pressure issues we monitor for that because it does have the potential to raise the blood pressure a little bit. I have some kids on my case load who have blood pressure problems already, so I coordinate with their other treaters around the hypertension issues which also makes it a little bit more tricky.
Frances Johnson, Advanced Practice Nurse