Treating ADHD with Medication

Note: The information presented below is based on research that has been reported in both medical and psychology journals. Although this information is believed to be accurate, it is not intended to substitute for discussions with a physician.

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 medication used to treat ADHD is Concerta, although a number of other stimulant medications are also used including Ritalin, Adderall, and Dexedrine. 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. The beneficial effects of stimulant medication vary in length depending on the child and the type of stimulant, (i.e. Adderall, Dexedrine, and Concerta last longer than Ritalin) but are generally gone within 3-8 hours. For this reason, children often require several doses during the day.

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. Despite this impressive body of empirical support for stimulant treatment, several cautions need to be kept in mind. These include the following:

• The majority of these studies were conducted with school age children and the available evidence with other age groups is much more limited. Few studies have been conducted with preschoolers and results with this age group have been less positive. Adolescents have also been studied less frequently, although the studies which have been conducted have generally reported a robust response to stimulants in this age group. Very few controlled studies on using stimulant medication to treat ADHD in adults have been reported. Results with adults have been variable, but the majority appear to benefit.
• Over 80% of studies done prior to 1997 examined the efficacy of methylphenidate (the generic name for Ritalin).
• Few well controlled studies on other types of stimulant medication such as Dexedrine, Concerta, and Adderall have been conducted. To date, however, there is little evidence of differential effectiveness for different stimulants.
• Almost all studies are very brief—not more than a few weeks duration at most.
• Despite the impressive short term benefits that have been documented, the magnitude of long term benefits resulting from stimulant medication treatment have not yet been clearly documented. A recent completed study in Sweden, however, demonstrated sustained benefits from medication over a 15 month period. Although there are no known long term adverse effects of taking stimulant medication, some scientists feel that this is an area that requires additional study.
• Most studies have been restricted to Caucasian males. Much less is known about the efficacy and safety of stimulant medication with females and with minorities. To date, however, there is no reason to expect substantially different results in these populations. In fact, a recently published study testing stimulant medication in girls with ADHD found it to be every bit as effecitve as in boys.

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.

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.

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 four-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?

Because the effects of stimulant medication generally wears off within 3-8 hours, two doses per day—one before school and one at mid–day —is quite common. Some children are able to get by with only a single administration per day, while some may require a third dose to help with after school activities and homework.(Editor's note: with some of the newer, long acting stimulants, children may only need 1-2 doses/day.)

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?

Tricyclic Antidepressants are also used in treating individuals with ADHD and the effectiveness and safety of these compounds has also been studied fairly extensively. Medications in this class of compounds include Imipramine, Desipramine, Amitriptyline, Nortriptyline, and Clomipramine. In a review article published in the April, 1996 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, it was reported that 29 studies evaluating the safety and efficacy of treating ADHD in children, adolescents, and adults.

Nine of these studies reported robust response rates, meaning that at least 50% of the subjects receiving the medication showed significant improvement. Eighteen of the studies reported a moderate response rate, meaning improvement was observed in between 30-50% of subjects. (Editor's Note: Strattera is a non-stimulant medication that has also been used recently to treat ADHD with success.)

In some cases, physicians may also provide other anti-depressants to treat ADHD including fluoxetine (i.e. Prozac), and bupropion (i.e. Wellbutrin). Although there is some evidence that these medications can be helpful in treating ADHD, there have been few controlled studies on their efficacy have been conducted to date.

Why would antidepressants be prescribed rather than stimulants?

In the vast majority of cases where medication is felt to be an appropriate part of a comprehensive treatment plan for ADHD, stimulant medication (generally methylphenidate) will be the drug of choice. Although most children with ADHD will be helped by stimulants, it is not possible to predict what the response for an individual child will be. If one type of stimulant is not effective, and an appropriate range of doses have been tried, it is quite possible that a different stimulant will be helpful.

Antidepressants would generally be tried if:

• Stimulant medication was not effective—before giving up on stimulants, physicians may try several different types
• Even though stimulant medication reduced ADHD symptoms, there were adverse side effects that were severe enough that the child could not continue taking it.
• There is a clear indication of a co–occurring mood or anxiety disorder in addition to ADHD - there is some evidence in the literature that when these additional difficulties are present, stimulant medication may be less effective than antidepressants.

What about using dietary changes to help with ADHD?

The idea that ADHD symptoms reflected allergic reactions to food additives was popularized by Dr. Ben Feingold, a pediatrician and allergist. Dr. Feingold speculated that reactions to certain types of food additives accounted for approximately half the cases of ADHD. He also reported that when children with ADHD were placed on his prescribed diet, 50% showed such dramatic improvement that they were able to discontinue stimulant medication.

Although this would be wonderful, the data to support such a claim is lacking. In fact, as early as 1986, a review of the studies on the relationship between children's diet and their behavior failed to find support for any causal association between food additives and behavioral disturbance.

Now, although there is no evidence to suggest that dietary factors are responsible for ADHD symptoms in a large percentage of children, a panel convened by the National Institue of Health did conclude that there may be a small group of children who respond negatively to certain food additives. Thus, even though there is no documented relationship between food additives and ADHD symptoms overall, that does not mean it may not occur with individual children. This is thus a factor that parents may wish to consider, although the odds that an ADHD child's symptoms can be successfully treated by dietary changes would appear to be quite small.

What about the use of natural remedies to treat ADHD?

Over the years, a number of natural remedies to treat ADHD have been touted. In fact, you can find many so proposed natural cures on the Web by searching for information on ADHD with any of the available search engines. Currently, Pycnogenol and St. John's Wort are two natural remedies that are frequently touted.

If you look closely at the evidence provided by proponents of these products, you will find that they are essentially anecdotal reports and testimonials. This is a real problem, because in many cases, the apparent benefits reported by individuals may represent nothing more than a placebo effect. To my knowledge, there is not a single controlled study of such treatments that has been conducted.

Does that mean that these treatments do not work? Not necessarily. It does mean, however, that compelling scientific evidence for their effectiveness has not yet been provided.

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. Note: These conclusions are based on studies that have been done primarily with Caucasian, school age boys. Less evidence on medication effectiveness for girls, minorities, and adolescents is available. At this point, however, there is no clear reason to expect any significant differences.

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.

Tricyclic antidepressants, along with some more recently developed antidepressants (i.e. Strattera and Wellbutrin) have also been shown to be helpful in treating ADHD symptoms.

They will generally be used as a second line treatment if stimulant medications are not successful, if stimulnat medications produce unfavorable side effects, or if the child has concurrent symptoms orf anxiety or depression.

Dietary changes and natural remedies lack scientific evidence of effectiveness in treating ADHD.

Available data indicates that only a small minority of children with ADHD symptoms may benefit from dietary changes. To date, no controlled studies demonstrating the benefits of various natural remedies are available.

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Dr. David Rabiner is a child psychologist and Senior Research Scientist at Duke University.and produces a monthly online newsletter, Attention Research Update, that helps parents, professionals, and educators keep informed about new research on ADHD. To sign up for a free subscription, please visit http://www.helpforadd.com.