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The decision whether
to place a young child on medication for ADHD is a
decision that is often an excruciating one for
parents. In deciding whether medication is needed,
parents of young children need to consider how well
(or poorly) their child is functioning in the
important domains in their lives: school, family,
and social circle. They also need to consider
whether non-medication supports and alternatives
are effective, available, and in place. For
example, there is some research that indicates that
some parent training programs are effective in
reducing the child's behavioral symptoms, and some
accommodations and environmental supports and cues
may also help the young child function better. But
if there is a serious problem with inattention,
environmental supports and parent training usually
aren't sufficient. Some parents may understandably
wish to explore "alternative" approaches, and some
resources for information on alternative
therapies is
provided elsewhere on this site and in articles in
the ADHD
links
file.
If parents or an
adult with ADHD wish to consider medication, the
"first line" medications for treating ADHD are the
dopaminergic stimulant medications and alpha
2-adrenergic agonists. The currently prescribed
stimulant medications include methylphenidate
(Ritalin®, Metadate®,
Concerta®), dextroamphetamine
(Dexedrine®), and mixed amphetamine
salts (Adderall®). The alpha
2-adrenergic agonists include clonidine
(Catapres®) and guanfacine
(Tenex®).
The development of
longer-lasting or sustained-release stimulant
medications over the past five years has really
increased options for patients. Rather than needing
to remember to take a pill 3 or 4 times a day,
patients now have the option of taking only one
pill a day.
In the past few
years, there has been increasing use of atomoxetine
(Strattera®), a selective
norepinephrine-reuptake inhibitor. Atomoxetine is
not a stimulant, and may be preferred by those who
wish to avoid stimulant medications. Research
published to date suggests that it is an effective
treatment for ADHD, but long-term studies are not
yet available.
In general, the most
common side effects of stimulant medications are
loss of appetite and difficulty falling asleep, but
other side effects are also noted in many children
and adults such as irritability, nausea, dizziness,
stomachaches, headaches, rapid heartbeat, elevated
blood pressure, skin rashes, anxiety, drowsiness,
and social withdrawal. Rare side effects include
hallucinations and psychotic episodes, but these
side effects usually appear only at very high
doses. Most side effects disappear within a few
days or by lowering the dosage of the medication.
Because stimulant medications may lower the
threshold for seizures, in some cases, physicians
may order an EEG prior to prescribing a stimulant.
For the most part,
the medications used for children and adolescents
seem to have the same effectiveness and side effect
profile for adults. About 2/3 to 3/4 of children on
stimulant medications for ADHD show significant
improvement in school behavior and academic
functioning, and the gains also appear in the home
and community settings. There is also some evidence
that stimulant medications may help with mood
lability, temper, stress sensitivity,
disorganization, and multitasking and other kinds
of activities that many adults with ADHD find
difficult. Spencer (2004) provides a current review
of the medications used to treat ADHD in
adults.
More recently,
however, other findings appeared that raises the
issue of long-term consequences associated with
stimulant use. A study conducted by the NIH
suggests that the misdiagnosis of ADHD combined
with prescription drug use in children may lead to
a higher risk of developing depressive symptoms in
adulthood. Site visitors who would like to read an
adapted press release on this research can find it
in this external
link. The
citation of the study and an abstract can be found
here.
If "first line"
medications are not effective, there are other
medications that can be prescribed, although they
tend to be not as effective. Wender et al.
(2001)note that non-dopaminergic medications such
as tricyclic antidepressants and selective
serotonin reuptake inhibitors (SSRIs) are generally
not of benefit in treating adult ADHD in the
absence of depression or dysthymia. If there is
depression or persistent "blues" or "blahs," SSRIs
may be helpful. Spencer (2004) provides a current
review of the medications used to treat
ADHD in adults.
While there is no way
to provide a comprehensive discussion of the
complexities of treating ADHD on this web site, it
is possible to try to briefly address the major
concerns that patients, their families, and
educators often raise.
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Based on anecdotal
clinical reports in the 1970s, for many years,
there was a caution about prescribing stimulant
medications for a child who had tics or a family
history of tics. Although any one individual child
may experience a worsening of pre-existing tics,
overall, the results of controlled research
(reviewed by Dr. Kurlan in 2003) suggest that
stimulants do not increase tics in children who
have a pre-existing tic condition any more than a
placebo would, and that some children experience
tic improvement while on stimulants.
It is important to
note, however, that the non-prescribed use of
certain stimulants in high doses may induce
movement disorders or worsen tics. Misuse of
amphetamines, metamphetamines, Ecstasy, synthetic
heroin, cocaine or "crack" cocaine have the
potential to worsen tics (apart from even more
serious physical problems associated with using
illicit drugs).
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The answer to this
question depends, in part, on whether we are
talking about the core symptoms of ADHD
(inattention, hyperacitivty, and impulsivity), or
if there are other problems as well. Although a
large
and well-publicized study had
suggested that medication is more effective than
psychotherapy, and that psychotherapy didn't add
anything unless there were comorbid conditions or
social issues, other investigators have reported
that parent behavioral training, classroom
contingency management, and school-based behavioral
interventions meet the standards for being
empirically validated treatments for children with
ADHD.
A news
release that
appeared on Sept. 1 2004 is of particular note, as
it is based on Dr. Pelham's studies of behavior
therapy for ADHD. Dr. Pelham notes that when
behavior therapy is introduced prior to any
medication, children tend to need less (if
any) medication, and that the skills they
acquire may carry over into adulthood. In contrast,
when children are placed solely on medication for
ADHD, they often begin to refuse to take their
medication during their teen years, leading to
deterioration in behavior and other
problems.
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1. A
chart of medication
tradenames and generic names
is available for viewing or free download on this
site.
2.
In some cases, children with ADHD who are on
stimulant medication may, indeed, become more
active, agitated, or impulsive. Some researchers
and clinicians have suggested that if a child who
is diagnosed with ADHD has this kind of reaction to
stimulants, then they may not be truly ADHD and
may, instead, have a mood disorder such as
juvenile-onset Bipolor Disorder. The whole topic is
quite controversial, but for the most part,
stimulants generally seem to help children or
adults with ADHD "damp down."
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