There are many choices when it comes to medications for the treatment of ADHD. The two broad categories of medication include stimulants and non-stimulants. Here is some helpful information about the medications in both categories.
Stimulants
Stimulant medications are the first line of treatment for ADHD in children and adolescents. Studies have shown them to be very effective. Brain cells communicate with each other through neurotransmitters or signal proteins released from one cell that stimulates the next one. While there are many neurotransmitters the brain uses, the key neurotransmitters deficient in ADHD brains are norepinephrine and dopamine. Both are important for maintaining alertness, regulating attention, improving working memory, helping with executive functioning (organizing, planning, reasoning, problem-solving), and increasing motivation. They also help the brain control impulsive thoughts/behavior and hyperactivity. Stimulant medications "stimulate" the brain cells to produce more of these deficient neurotransmitters and slow their reabsorption, allowing for messages between brain cells to be transmitted more effectively and efficiently.
There are two major types of stimulant medication - methylphenidate and amphetamine salts. Examples of methylphenidates include Ritalin, Concerta, Metadate, Quillivant, Methylin, Daytrana, and Focalin (dexmethylphenidate), Jornay PM, Cotempla XR, Azstarys (serdexmethylphenidate/dexmethylphenidate). Examples of amphetamine salts include Adderall, Dexedrine, Procentra (dextroamphetamine), Vyvanse (lisdexamfetamine), and Adezenys (amphetamine). Response rates for both categories are similar and studies do not indicate that one is universally better than the other. However, as everyone's brain works differently, some patients may find that they respond better to one type over the other.
Stimulants come as short-acting (3-4 hours of effectiveness) and long-acting (6-12 hours of effectiveness) formulations. Short-acting stimulants are often prescribed for younger children while most school-aged children or older will require longer-lasting formulations to provide adequate coverage for school and homework hours. Sometimes a short-acting stimulant may be added on as an adjunct in the middle of the day or early afternoon if the morning medication’s effects seem to wane too quickly.
DeleteNon-Stimulants
While stimulant medication is considered first line treatment, some children and adolescents may find them to be not a good fit. This can be due to lack of sufficient response and/or side effects (see below). In such cases, a non-stimulant medication may be a better choice. Non-stimulant medications work differently from stimulants in that they increase norepinephrine activity rather than its levels. Examples include Strattera (atomoxetine), Qelbree (viloxazine), Tenex/Intuniv (guanfacine), and Kapvay (clonidine). Wellbutrin (buproprion) can also be used in some patients. It works similarly to stimulants in delaying reabsorption of both dopamine and norepinephrine, allowing for better communication between brain cells.
DeleteHow do you choose the right medication?
As mentioned above, stimulants are usually the first choice for most patients. Some considerations when choosing a stimulant medication include prior history of stimulant medication in the past (ex. if patient did not respond to one type or had significant side effects with one type, your provider may recommend trying the other type) and family history of stimulant medication use. As family members share similar genes, good response to one type of medication may increase the likelihood that your child will have a similar response.
If one stimulant medication does not seem to be a good fit, your child’s provider may recommend a trial of 2-3 more stimulants. If none of them seem to be helpful or significant side effects are experienced, a trial of a non-stimulant may be recommended.
Genetic testing for finding the “best fit” medication is being developed but current testing has not proven to be reliable or consistent. Given this, such testing is not encouraged at this time.
DeleteHow do you know what is the right dose?
There is no testing available to predict the right dose for your child. The dose is also not dependent on age, weight, or severity of his/her/their symptoms, but on your child's body's ability to absorb and break down medications. All efforts will be made to keep your child’s medication dose at the lowest effective dose with the least amount of side effects. However, if a dose is not effective, it should be gradually titrated up to a level that provides the best support for your child.
DeleteHow long do you have to wait to see if a medication is working?
Effects of stimulant medications can be seen quickly, usually within few days to a week. Given this, dose adjustments can be made fairly quickly in most patients to reach the most effective dose.
Effects of non-stimulant medications take longer to be seen, usually 4-6 weeks although some may observe benefits earlier.
DeleteCan the medications just be used as needed?
ADHD medications are usually NOT “as needed” treatment although sometimes side effects may necessitate a more irregular schedule. Breaks are certainly reasonable on weekends and vacations (see below). However, all changes should be discussed with the prescribing provider beforehand.
DeleteWhat are the possible side effects?
Side effects may vary depending on the type of medication chosen for your child. The following side effects are more commonly observed, but this is not a comprehensive list. Please keep in mind that not everyone experiences the same side effects even when taking the same medication.
Stimulants: Abdominal pain, nausea, headache, decreased appetite, sleep disturbance, anxiety/restlessness, depressed mood, worsening of motor tics
Strattera: Increased self-harm thoughts/behavior (rare)
Tenex/Intuniv: Drowsiness, fatigue, decreased blood pressure (rare)
Kapvay: Drowsiness, fatigue, decreased blood pressure (rare)
Wellbutrin: Abdominal pain, nausea, headache, constipation, dry mouth, sweating, tremors, decreased appetite, anxiety, drowsiness, anger/aggression, self-harm thoughts/behavior (rare)
DeleteWhat are additional safety issues?
ADHD medications are safe for most children and adolescents. Rare potential safety issues include the following:
Drug Interactions
It’s important to let your child’s provider know of any other medications that the patient is taking on a regular basis as some may interact with ADHD medications. Most over the counter medications, asthma inhalers, birth control pills, and acne medications can be taken concurrently with ADHD medications but it is always advisable to inform the provider if taking these or any other medications.
Increased Suicide Risk
The FDA requires that certain depression and anxiety medications carry warnings which are placed on medications with potentially dangerous side effects. In rare cases, children and teenagers taking atomoxetine (Strattera) may develop or observe increased suicidal thoughts or behavior. If this occurs, it is more likely during the first few weeks of starting the medication or when increasing doses. Given this, patients taking atomoxetine need to be monitored carefully. Parents should ask children about such thoughts/behaviors and if present, notify their doctor or prescribing provider immediately. These thoughts are reversible upon discontinuation of the medication.
DeleteAre stimulant medications addictive?
Stimulants do pose a risk for developing an addiction if used inappropriately, namely in doses higher than prescribed for prolonged periods of time. If used appropriately by the person it was prescribed to in the doses it was prescribed in, the risk is low. That is why it is important to only use these medications as prescribed and under the direction of a medical provider. Studies show that taking ADHD medications does NOT increase the overall risk of substance abuse. It actually seems to provide long term protection against developing substance abuse disorder. This likely results from children and adolescents taking ADHD medication commonly experiencing improvement in academic and social functioning, self-esteem, control of impulsive or reckless behavior, and lower rates of self-medication with drugs or alcohol.
DeleteCan breaks be taken from medications during vacation?
Absolutely. Many patients take breaks from medications during weekends and/or vacation although some find their benefit outside of the academic setting to be significant enough to continue daily, although sometimes at lower doses. Some medications need to be weaned off so please speak to the prescribing provider before making any changes.
DeleteDo ADHD medications need to be weaned off when taking breaks, switching, or stopping?
Stimulants and atomoxetine typically do not need to be weaned off when stopping. Alpha agonists usually do require a tapering off to decrease the risk of sudden increase in blood pressure. Please follow the instructions given by your provider when switching or stopping medications.
DeleteHow long do ADHD medications need to be taken for?
Duration of medication treatment will vary depending on individual patients and severity of their ADHD symptoms. It should be discussed on an individual basis with the patient’s clinician. Some children and adolescents learn to modify their study/work habits and behavior sufficiently to not need the support of medications as they grow older while others may find them to be still beneficial into adulthood.
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