ADHD: Treatment Overview
by Leslie E. Packer, PhD
This article last updated January 2009
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. Some resources for information on alternative therapies is provided elsewhere on this site, with the following caution: before you waste time, money, and hope on any therapy, research it carefully and do not just rely on the seller’s claims of “research-proven.” The same holds true for claims that brain scans can predict response to treatment or guide treatment: the science does not currently support such claims (cf, Zametkin et al., 2005), despite what its proponents might claim.
The current medical assessment and treatment practice parameters are the 2007 guidelines. They are available online in full-text format (pdf) for those site visitors who would like to read them. The parameters include one particular recommendation that I am not sure I agree with: that if there may be a learning problem, first treat the ADHD for two months and then decide whether to test if learning problems persist. The logic behind this is that if the learning problems were due (solely) to inattention, treatment should resolve the problem or clear improvement will be noted. Keeping in mind that practice parameters are not always based on actual research and based on my experiences, I would prefer schools to conduct the educational evaluation immediately and not wait — and possible risk losing — two months’ of education. At the very least, it would enable schools to start implementing accommodations so that if the student is frustrated, some of the frustration would be reduced. If treatment appears to be working, a re-evaluation will indicate whether the medication is having any influence on the learning problem or if accommodations and interventions continue to be needed.
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. Whether any benefits of medications persist, even when children stay on medications, is contentious. Recent research that followed up on children enrolled in the MTA study raises some doubts about the long-term effectiveness of medication treatment (cf, Molina, Hinshaw, et al., 2009). Most healthcare professionals would describe medication as the first line of treatment for ADHD although they acknowledge the importance and potential value of other approaches such as parent training, environmental modifications, and peer interventions.
The medications used to treat ADHD are pretty much the same for children and adults, although the doses are usually much lower for adults. The “first line” medications are the stimulant medications, alpha 2-adrenergic agonists, and atomoxetine (Strattera), a norepinephrine reuptake inhibitor that is not a stimulant. The currently prescribed stimulant medications include methylphenidate in various formulations [e.g., Ritalin®, patch form (Daytrana®), Metadate®, Concerta®], dextroamphetamine (Dexedrine®), dexmethylphenidate hydrochloride (Focalin XR®) and mixed amphetamine salts (Adderall®). In 2007, lisdexamfetamine dimesylate (Vyvanse®) received FDA approval for use in children aged 6-12. The alpha 2-adrenergic agonists include clonidine (Catapres®) and guanfacine (Tenex®). Not all of these medications are FDA-approved for use in treating ADHD in children, adults, or both. Some medications that are used off-label (i.e., without FDA approval for the treatment of the diagnosis) are approved by the FDA for other diagnoses in adults, including bupropion. The information on this page should not be viewed as treatment advice or recommendation and is presented only for informational purposes.
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. One longstanding concern for parents has been whether stimulants delay growth in height and weight. Available research suggests that stimulants do delay growth, although the effect may lessen over time. As Faraone, Biederman, and their colleagues (2008) suggest, it is possible that it is ADHD itself that is associated with growth retardation and careful quantitative research is needed, although there is sufficient evidence to suggest that parents need to consider the possibility that use of stimulants may stunt growth. Stimulants have also been reported to induce manic episodes in some patients with Bipolar Disorder (Wingo & Ghaemi, 2008). Of particular concern is the issue of whether stimulants are associated with cardiac events, and parents and adults with ADHD are reminded that is important to be an informed consumer about medications (pdf). In 2007, Winterstein et al. (2007) published an article in Pediatrics on the results of a review of cases over a 10-year period. Based on their data, they concluded that “Stimulants were associated with an increase in cardiac emergency department visits. More evidence is needed that addresses the long-term risk/benefit of the various treatment options and the effect of other cardiac risk factors and comedications.” Their full report is available here (pdf). A more recent report by Gould et al. (2009) also reports a significant association between stimulant use and sudden death. Such studies understandably raise the level of concern parents have about putting their children on these medications. Atomoxetine has its own adverse effects profile, and has been linked to severe liver problems in some cases.
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 some of the other major concerns that patients, their families, and educators often raise.
Why Give a Stimulant to Someone Who is Hyperactive?
This question has perplexed many parents and educators, but the answer is that stimulant medications generally don’t make people with ADHD more hyperactive.2 Although the following is an oversimplification, it may help you understand what happens:
Assume that an individual with ADHD appears hyperactive because the pathways in the brain that “put on the brakes” are underactive. Stimulant medications increase the levels of neurochemicals involved in these “brakes” (although the precise mechanisms are not well understood and this is a simplification). When the stimulant medication is taken, these neurotransmitter levels now rise (or are stimulated up to) normal levels, and the individual will now approach having the “brakes” and inhibitory controls that their non-ADHD peers have. The net affect of boosting (stimulating) their neurochemical levels is that their ability to inhibit responding is now raised to “normal” levels.
Do Stimulants Worsen Tics or Tourette’s Syndrome?
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 and Erenberg in 2005) suggest that stimulants generally do not increase tics in children who have a pre-existing tic condition any more than a placebo would. Careful monitoring of the child or teen as well as dose reductions will reveal whether any tic increases are likely due to the natural waxing of tics or are medication-related. That said, it is important to note 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).
Because of the concern that stimulants might induce or worsen tics as well as concerns over other side effects, alternatives to stimulants for those with history of tics or vulnerability to tics are often prescribed. But as a case report by Sears and Patel (2008) involving the use of atomoxetine (Strattera®) shows, even non-stimulant medications may be associated with problems in individual cases.
IS MEDICATION ENOUGH?
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 [cf, Fabiano et al. (2008); Pelham & Fabiano (2008), Fabiano, Pelham, et al. (2009)].
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.
In a follow-up to the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder, investigators looked at children who had been in the medication treatment condition. The advantage of medication alone or in combination with behavior therapy compared to behavior therapy alone decreased, starting 14 months after treatment ended. After three years, 45-71% of the children in the original medication treatment group were still on medication, but there was no advantage over behavior therapy alone by the third year of treatment. It appeared that some children did continue to improve with continued treatment, but a subset did not. A press release from the NIMH issued in 2007 summarizes the complex follow-up data, including data that treatment had not normalized the risks of substance abuse or delinquency; treating children and teens for one year was not sufficient to prevent the emergence of some problems.
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.”