At the heart of the controversy and anxiety about ADHD is the use of medications to treat it. No one, and I do mean no one likes putting children on behavioral medications. It goes against protective parental instincts. The idea of medicating your child’s behavior, or perhaps even your own if you have adult ADHD, is distasteful and somehow feels like giving in–like failure. And the anxiety over medications is worsened by negative articles on the subject that routinely appear in the popular press and internet blogs. Some criticisms are justified and some not; but these articles do not inspire confidence in using medication to treat ADHD. But in short, when ADHD is correctly diagnosed, and when medications are correctly prescribed these medications are safe and very effective.
So, let’s break this down. First we’ll talk about the ADHD medications, what they are and how they work, then we’ll talk about some of the controversies surrounding their use, and then we will talk about some of the strategies about them should you decide that ADHD medication is right for you or your child.
One word of caution: This article is intended for informational purposes only and is no substitute for careful assessment and treatment by a licensed prescriber–medical doctor or behavioral nurse practitioner. There are many factors that prescribers will want to know when recommending a behavioral medication. So, inform yourself, but talk to your doctor!
What are ADHD medications anyway?
There are three general types of ADHD medications: stimulants, norepinephrine reuptake inhibitors (NRI), and antidepressants (SSRIs). By far the most commonly prescribed and recommended treatment for ADHD are the stimulant medications. These are amphetamine-based medications, that when taken as ordered, provide fast acting relief from the three primary symptoms of ADHD with generally minimal side effects, and without addiction potential. The traditional form of this class of medication takes effect within 15-to-30 minutes and metabolizes out of the body in about four hours. This means that they are relatively safe to try, because usually you’ll know if they are effective pretty much immediately. The most well-known of these medications are Ritalin, Adderall and its generic form methylphenidate. All of these are available in a traditional, non-time-released form. But they are also available in a time-released form so that they stay effective for up to 12 hours. Gone are the days of long lines of children queuing up at the nurse’s office for their noon-time dose of Ritalin. The time-release medications decrease stigmatization and decrease the chance of missing doses.
It is counter-intuitive to give a stimulant medication to a hyperactive person, after all, wouldn’t that just make them more hyper? Oddly, the answer is no, if they do indeed have ADHD. No one is quite sure why the stimulant medications work, but they do indeed work and work fairly well. They do not cure ADHD, but they help the brain overcome its limitations so that the frontal lobes are more involved with managing attention, behavioral self-control (hyperactivity/impulsivity), and improving frustration tolerance. These medications give the ADHD adult and child the boost they need to somewhat level the playing field with their peers regarding behavior and performance at work and school.
While neuro-scientists are closing in on what exactly ADHD is (remember it’s a syndrome and has multiple causes) and why the medications work, one popular theory is that the ADHD brain is “sleepy” and that the stimulants wake it up effectively so that it can function more normally. The average ADHD person taking Ritalin usually just feels normal–not hyper, not drugged, not buzzy, not sedated. In fact, when I ask an ADHD child if they feel any different on medication they usually say, no they don’t, but they do notice that they don’t get into as much trouble!
The most common side effect of the stimulant medication is loss of appetite. Children are often not hungry on the medications and will not eat a noontime meal or will pick at their food. Parents often notice their children are very hungry in the late evening. To compensate I recommend children be given a healthful breakfast (they should anyway) at the time they take their medication, and then be allowed to eat until satisfied later in the day, to make up for all those calories they’re using up. Sometimes very young children need to be monitored closely when on stimulant medications so that they develop and grow normally. Your doctor may also advise easing up on stimulant use on weekends or school holidays when behavioral medications aren’t needed as much. Again, talk to your doctor. But because the stimulant medications are fast acting, a day or two can be skipped and the medications will still be effective the next time they are used. But skipping on school days is not advised because of disruptive ADHD behaviors in the classroom and with school staff. Teachers can definitely tell when a child has not had his/her medication in the classroom!
Other medications to treat ADHD as mentioned above include Wellbutrin–a unique type of antidepressant with stimulant-like characteristics, and the SSRI type antidepressants. There are some people that either cannot take stimulant medications for medical reasons (heart problems or seizure disorders, for example) or for whom the stimulant medications are just not effective. Your prescriber may choose to try an SSRI instead. One of those reasons is that the stimulant medications are a controlled medication and so their prescription is more closely regulated and monitored than other medications. This requires more frequent patient monitoring by your prescriber, and it means more inconvenience for parents. But the reasons to monitor these medications are well founded. So again, if you have questions talk to your prescriber. (By the way, the fact that stimulant medications are controlled does not make them unsafe, it means that they can be misused and sold on the street by unscrupulous people.)
These SSRI type medications are generally thought to be less effective with ADHD, but there may be some good reasons your doctor may use them. When they are more effective it may be a clue that a person has some other condition than ADHD, that mimics ADHD’s three symptoms of hyperactivity, impulsivity, and distraction. Some of these conditions include depression, trauma, grief, autism, or simply environmental upset, such as a child experiencing the divorce of parents. In my experience trauma and childhood depression are often overlooked in school-aged children as explanations for behavioral problems. Also overlooked and very difficult to identify are the life-long difficulties from pre-birth substance exposure. Children with prenatal substance exposure are often at a neurological disadvantage educationally and socially, and they may show symptoms that mimic ADHD (and may actually be ADHD). But for some of these children ADHD stimulant medication makes their behavior worse not better, and they may need to be on sedating not stimulant medication. Again, talk thoroughly with your doctor or mental health professional.
Finally, children with known seizure disorders should not generally be prescribed stimulant medications as the medication may make the seizures worse. Seizures disorders, particularly the staring type of seizures, may look a lot like ADHD, but the cause is different from typical ADHD. Make sure your prescriber knows your child’s medical history, and that he/she screen for possible seizure activity before prescribing stimulants.
Causes for Concern in using ADHD medication are warranted. ADHD has been over diagnosed in the past, and medications are sometimes resorted to when behavioral interventions or changing an environment may be more effective. Medications should never be used in educational settings simply for behavioral control because they are easy. And medication alone without behavior management or adjustments in environment and parenting techniques are highly discouraged. Research consistently endorses that behavioral medication be combined with behavioral management, education, and counseling. Admittedly these interventions are more complicated than simply giving a medication, but they are also very effective for the treatment of ADHD. They tend to maximize the potential for both adults and children to be successful far more than medication alone. Most of the concerns about ADHD medication can be addressed with careful diagnosis, with education on the syndrome, and with a few behavioral counseling appointments once the condition is identified. Once medications are prescribed, they will need to be changed and adjusted periodically as a child (or adult) gets older.
ADHD stimulant meds are some of the most effective medications in behavioral medicine. They work quickly and effectively and can literally change people’s lives, improving academic and social functioning. They are very safe when correctly prescribed and taken as ordered. We need not fear them if they are handled with appropriate respect, with careful diagnosis, and with careful ongoing behavioral care (counseling).
Next up will be the final in my series on ADHD–behavioral interventions for ADHD: Things you can use to manage ADHD, decrease negative symptoms, and live more effectively. Stay Tuned.