ADHD: Some Facts About Medication

This blog was originally posted on August 9, 2013 and updated on October 19, 2018.

Parents of ADHD kids often ask what I think about using medication to treat their children’s symptoms. I usually reply that I am agnostic about pharmaceuticals – that I advocate neither for nor against them. What I do urge is that before arriving at a decision, parents get the facts about ADHD medications by speaking with their doctors and doing some internet research. In this spirit, I thought it might be helpful to offer a brief description of the most frequently recommended ADHD medications, their potential benefits, and their possible side effects.

Based on multiple scientific studies, medication is currently recognized as the most effective form of treatment for ADHD. The largest such study, one conducted in the 1990s by the National Institutes of Health, showed that a well-managed medication program helped more than 68% of ADHD school children to improve their attention and reduce their impulsivity. Nearly three hundred subsequent trials have documented medication success rates ranging from 70% to 90%, and all of the meds approved by the Food and Drug Administration for treatment of ADHD were shown to be significantly more effective than no medication. School-based behavioral programs have proven approximately 55% effective and mental health counseling about 40%. To a lesser degree, other treatments such as exercise, neurofeedback, and mindfulness practice have been found effective.

Among the medications approved by the FDA for treating ADHD, the great majority are stimulants. All of these rely on one of two active ingredients, methylphenidate or amphetamine, and all work in the same basic way: by stimulating certain parts of the brain to increase their efficiency in processing dopamine and/or norepinephrine, the neurotransmitters that help us regulate the three attributes most often associated with ADHD: attention, impulsivity, and executive functioning.

Methylphenidate is the “grand daddy” of all ADHD medications. It was was first formulated in 1944 and first used for attention deficit in the 1950’s. This compound was and still is marketed under its original brand name, Ritalin. Since1967 when the methylphenidate patent expired, it has also become available (often with chemical modifications or enhancements) under other names that include Concerta, Focalin, Metadate, Methylin, Daytrana, Aptensio, Quillivant, and Quillichew. Most of these deliver methylphenidate in the form of a capsule or pill. Daytrana utilizes a transdermal patch and Quillichew a cherry-flavored chewable tablet.

Methylphenidate usually becomes active within an hour and remains effective for 3-6 hours in its regular formulation but up to 9 hours in extended release versions. Over its 60-year history it has been evaluated in more than 200 research trials and analytical studies, which have consistently found it helpful to some degree with most ADHD kids. Many of them require a booster in the afternoon to focus on homework.

While there is little evidence that methylphenidate presents any long term risks, a number of short-term side effects have been documented. Some ADHD children, approximately 1-3%, cannot tolerate it in any dose. Others may experience increased heart rate, blood pressure, or brain activity; decreased appetite or sleep; headaches; blurred vision; restlessness or anxiety; and, in rare instances, tics, depression, or erratic thinking. These effects are usually mild, tend to diminish over time, and cease shortly after the medication wears off. Despite the “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 potential for abuse, it is regulated by the FDA as a Schedule 2 controlled substance.

The following methylphenidate medications are approved by the FDA for the treatment of childhood ADHD: Aptensio, Concerta, Cotempla, Daytrana, Focalin, Metadate, Methlyn, Quillivant, and Ritalin.

Amphetamine Stimulants
In recent years, it has become increasingly common for doctors to treat ADHD with amphetamine stimulants, most of which are based on the amphetamine salt dextroamphetamine. For example Adderall, the most frequently prescribed amphetamine, is compounded of 75% dextroamphetamine and 25% of another amphetamine salt, levoamphetamine. A variant, Evekeo, contains these same compounds but in a 50-50 ratio; a relatively new medication, Mydayis, mixes dextroamphetamine with three other amphetamine salts. With Vyvanse, an increasingly popular formulation, the body produces its own dextroamphetamine by processing the medication’s active ingredient, lisdextroamphetamine. Amphetamine stimulants are usually taken in the morning and remain active until early or mid-afternoon. Boosters are sometimes prescribed.

Unlike methylphenidate, amphetamine compounds can 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 with methylphenidate, the side effects of amphetamines can be more serious. These may include irregular heartbeat, high blood pressure, blurred vision, difficulty breathing or swallowing, dry mouth, constipation, diarrhea, hives, tics, seizures, shaking, nausea, fainting, and weight loss (for which dextroamphetamine is sometimes prescribed). Late in the day when the effect of an amphetamine begins to decrease, some young people experience 1-2 hours of mood disruption in the form of irritability, anxiety, or sadness. Like methylphenidate, amphetamines can be addictive and are regulated by the FDA as Schedule 2 controlled substances.

The following amphetamine medications are FDA-approved for treating childhood ADHD: Adderall, Adderall XR, Dexedrine, Dexedrine Spansule, Evekeo, Vyvanse, Mydayis.

A Non-stimulant
Positive results have been reported for atomoxetine, a non-stimulant originally marketed under the brand name Strattera and now available as a generic. In 2002 it was approved 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, although to a lesser degree than stimulants. Unlike methylphenidate and amphetamines, atomoxetine is not considered addictive nor is it regulated as a controlled substance. Its most common side effects are nausea, vomiting, dizziness, decreased appetite, fatigue, and mood swings. During clinical trials, approximately 0.4% of the participating children experienced suicidal thoughts or gestures, although no actual attempts or suicides were reported. A very small percent of children reported that, rather than abating, their ADHD symptoms increased.

Strattera and generic atomoxetine have been approved by the FDA for treating childhood ADHD.

Ritalin was originally developed to treat hypertension (high blood pressure), and other anti-hypertensives have also been used to treat ADHD. The most common are clonidine (marketed under such brand names as Nexiclon, Kapvay, and Catapres) and guanfacine (Intuniv, 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 drowsiness. Neither clonidine nor guanfacine is considered addictive or regulated as a controlled substance.

Intuniv and Kapvay are approved by the FDA for treatment of childhood ADHD. Nexiclon, Tenex, and Catapres are prescribed off-label, which means they are FDA-approved for treating other conditions but not yet for ADHD.

When children are unable to tolerate stimulants or have been diagnosed with both ADHD and depression, antidepressant medications are sometimes prescribed. These include trycyclic antidepressants such as Elavil (amitriptyline), Tofranil (imipramine), and Norpramin or Pertofrane (desiprimine). They also include the atypical antidepressant Wellbutrin (buproprion). Selective serotonin reuptake inhibitors such as Prozac (fluoxetine) and Zoloft (sertraline hydrochloride) are also prescribed for depressed adolescents who also have ADHD. Potential side effects of antidepressants 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.

Antidepressants are prescribed off-label for the treatment of childhood ADHD.