ADHD: Some Facts About Medication

Note: The following was originally posted on August 9, 2013 and updated on September 8, 2018.

Non-Amphetamine Stimulants

Amphetamine Stimulants

Nonstimulant

Antidepressants

Antihypertensives

 

Parents often ask me if I think they should use medication to help their ADHD children. I generally reply that I do not advocate either for or against medication. This is a choice that can only be made by parent and child in consultation with a trusted physician. But I do advise that before arriving at a decision, parents get the facts about ADHD medications so that their thinking can be informed by scientific research and opinion. In this spirit, I thought it might be helpful to offer a summary outlining the most frequently recommended ADHD medications, their potential benefits, and their possible side effects. As you read further, keep in mind that the medications described here should be used only with a doctor’s prescription and supervision.

 

One reason many families do decide in favor of ADHD medication is that, according to multiple scientific studies, it is their most effective option for treatment. The largest of these studies, conducted in the 1990s by the National Institutes of Mental Health, showed that a well-managed medication program helped more than 68% of ADHD school children to improve their attention and reduce their hyperactivity. The next most effective approach, school-based behavioral programs, helped approximately 55%. In the years following the NIMH study, several hundred well-controlled trials (and several hundred more that were less well controlled) documented medication success rates ranging from 70% to 90%. Other studies conducted during the past few years have suggested that even though there are significant differences among the various ADHD medications, they all appear to function in the same fundamental way: by helping certain parts of the brain be temporarily more effective in managing the chemical activity most closely associated with attention and impulse control.

Non-Amphetamine Stimulants

The medications most frequently prescribed for ADHD are variations on the stimulant methylphenidate, which was first formulated in 1944 and became widely used for attention deficit in the 1970’s. It was and still is marketed under its original brand name, Ritalin, but because the methylphenidate patent expired in 1967, it is now available (sometimes with chemical modifications) under other names that include Concerta, Focalin, Metadate, Methylin, Daytrana, and Quillivant. It is usually absorbed into the body within an hour and remains effective for 3-6 hours in its regular formulation but up to 9 hours in the ER or EX (extended release) versions. Because it has been in use for more than 60 years, methylphenidate has been evaluated by more than 250 studies, which have indicated that during the hours when it is active in kids’ systems, it helps 70-90% of them more effectively regulate their attention, impulses, and social interactions. Methylphenidate is not an amphetamine.

 

While there is little evidence that methylphenidate can result in negative long-term effects, a number of short-term side effects have been documented. Some ADHD kids, approximately 1-3%, cannot tolerate it in any dose. Others have experienced increased heart rate, blood pressure, or brain activity; decreased appetite; headaches; blurred vision; difficulty falling asleep; restlessness or anxiety; and, in rare instances, tics, depression, or erratic thinking. These effects are usually mild and tend to diminish over time. Despite the controversies and “urban myths” that have grown around its use, there is little or no scientific support for the contentions that methylphenidate is carcinogenic, damaging to the brain, or conducive to suicide. There is some evidence suggesting that in excessive doses it may become addictive, but not if used as prescribed. Because of its addictive potential, it is regulated by the U.S. Food and Drug Administration as a controlled substance.

Amphetamine Stimulants

When compounds like methylphenidate are ineffective, some doctors will prescribe an amphetamine stimulant such as Adderall, Evekeo, Dexedrine, Dextrostat, Liquadd, or Procentra. All of these contain the amphetamine salt dextroamphetamine. Adderall, for example, contains 75% dextroamphetamine and 25% levoamphetamine; Evekeo contains the same compounds in equal amounts. With Vyvanse, another frequently prescribed amphetamine, the body produces its own dextroamphetamine by converting the medication’s active ingredient, lisdextroamphetamine. Unlike methylphenidate, amphetamine compounds take several weeks to build up in the body, may not become fully effective until then, and may require several weeks to clear the bloodstream after their use is discontinued. In comparison to methylphenidate, amphetamine side effects can be more serious. These may include irregular heartbeat, high blood pressure, blurred vision, difficulty breathing or swallowing, dry mouth, constipation, diarrhea, hives, mood abnormalities, tics, seizures, shaking, nausea, fainting, and weight loss (for which dextroamphetamine is sometimes prescribed). Like methylphenidate, amphetamines can be addictive and are regulated by the FDA as controlled substances.

A Non-stimulant

Positive results have been reported for atomoxetine, a non-stimulant marketed under the brand name Strattera. It was approved by the FDA in in 2004 for use with ADHD children, but not those under the age of 6. It may require a week or more to take effect and 6-8 weeks before its results can be evaluated. Doses taken once or twice a day have been shown to improve ADHD symptoms in approximately 65% of the children studied. Unlike methylphenidate and amphetamines, atomoxetine is neither regarded as addictive nor regulated as a controlled substance. Its most common side effects in children are nausea, vomiting, dizziness, decreased appetite, fatigue, and mood swings. During clinical trials, approximately 4 children per 1000 experienced suicidal thoughts or actions, although no actual attempts or suicides occurred. A very small percent of children reported that, rather than abating, their ADHD symptoms increased.

Antidepressants

When children are depressed or unable to tolerate stimulants, antidepressants (medications used to treat depression) are sometimes prescribed for ADHD. These used include trycyclic antidepressants such as Elavil (amitriptyline), Tofranil (imipramine), and Norpramin or Pertofrane (desiprimine). They also include the atypical antidepressant Wellbutrin (buproprion). Other antidepressants such as Zoloft (sertraline hydrochloride) and Prozac (fluoxetine) are occasionally used with adolescents. Potential side effects are irregular heart rate, chest pain, numbness, headache, weakness, hallucinations, seizures, tremors, rashes, nausea, vomiting, and problems with vision, speech, or balance. In general, antidepressants are not controlled substances.

Antihypertensives

Ritalin was originally developed to treat hypertension (high blood pressure), and other antihypertensives have also been used to treat ADHD. The most common are clonidine (marketed under such brand names as Kapvay, Nexiclon, and Catapres) and guanfacine (Intuitiv, Tenex). Neither compound is a stimulant and both are believed to improve attention, reduce impulsivity, and relieve frustration. Although the two are chemically different, they share a number of possible side effects that include breathing problems, hives, irregular heart rate, insomnia, headaches, dizziness, dry mouth, constipation, and diarrhea. Clonidine may also cause confusion and drowziness. Neither clonidine nor guanfacine is regulated as a controlled substance.

 

Final Thoughts

The use of ADHD medications has sparked considerable and heated debate over the past two decades. For this reason, I have tried to base the information presented here on scientific evidence rather than opinion. There is, however, one opinion I do want to express. Some people have dismissed ADHD medications as mere “cover-ups” which do nothing more than conceal symptoms and, therefore, produce no actual or lasting change. It is true that a medication will not “cure” ADHD symptoms; it will only diminish them while it is active. But this does not mean that the medication simply hides the symptoms. It can provide a period of relief during which children can experience a greater ability to build new skills and gain new information, learning that can stay with them for many years. It is this potential for long-term gains that parents need to weigh against the potential for negative side effects in deciding whether or not to choose ADHD medication for their children.



This entry was posted in ADHD. Bookmark the permalink. Post a comment or leave a trackback: Trackback URL.