The Decision to Medicate

Is the Zombie Effect Real? Stimulant Tolerance? Top ADHD Medication Concerns & Answers

Saying yes to medication is a complicated and nuanced decision for parents. But in most cases, medication is the best tool in the ADHD treatment box, especially in combination with cognitive behavioral therapy. Here, learn about the top concerns and challenges associated with stimulant medication use among kids and teens — and get expert guidance.

Boy with ADHD seeking treatment help

What Is the Best ADHD Treatment?

Integrative ADHD treatment — combining stimulant medication with directive cognitive behavioral therapy — has been accepted as the gold standard of ADHD treatment for decades. Despite this, the popular press still questions the inclusion of medication as equal with therapy, leaving many parents somewhere between bewildered and opposed to using it with their kids.

Every week, we receive intake requests from young (and not so young) adults who note something like, “My parents knew I had problems in school, but they didn’t believe in diagnosis or medication” or “I was tested in fourth grade and they said I had ADHD, but my parents thought I was just immature.” Others admit, “We knew I had ADHD and I took medication for it until I was 14, but I didn’t like taking it so I stopped.” Each request comes from someone having a really hard time in work, school, or relationships.

Should I Medicate My Child for ADHD?

One of the biggest critiques of medication management for ADHD is reserved for the treatment of minors. Skeptics ask, “Aren’t we just treating kids for being kids?” or worry that children are too young to make the choice, or will suffer long-term consequences. Some people are just plain upset by the idea that prescribers give kids “speed” and claim that it calms them down. Others fear the Zombie Effect — that stimulants turn playful children and teens into robotic, Stepford Children, overriding their natural personalities.

The problem with this perspective is simple: Your child either has ADHD or he does not. If he does have it, he is either impaired, or not. And if he is impaired, talk therapy or supplements or nutrition or exercise or discipline isn’t going to resolve that.

It’s OK to try those things for a reasonable time, and if the symptoms are more manageable, you can declare your child ADHD-free. But if the symptoms persist, and you don’t treat your child’s neurological condition, he will grow up having missed critical learning, both academic and social, that other kids have. And that is the definition of “being behind” in school and in life.

[Free Download: A Parent’s Guide to ADHD Medications]

ADHD Medication: Addressing Stimulant Tolerance

The longitudinal Multimodal Treatment of ADHD study found that some children who use stimulants for years end up no better off than their peers who didn’t take medication. Nobody seems to understand how this makes sense. People who need to be on stimulants nearly always have a love-hate relationship with them, so nobody is going to stay on them if they aren’t benefitting. We think that the problem identified in the MTA study is that of stimulant tolerance, a rarely discussed topic that seems oddly controversial among prescribers.

Simply put, the more you take stimulant medication, the less effective it is. The less effective it is, the more you want a dosage increase. The more you increase the dosage, the more tolerant your body becomes, and (you guessed it) the less effective the medication becomes. Eventually, you hit a ceiling, where you can go no higher, and often that ceiling is well past the maximum recommended dose. To anyone who has taken stimulants for more than six months, this idea isn’t controversial. It’s obvious. We believe this is why, after taking thousands of doses of stimulant, the MTA kids ended up in the same spot as their non-medicated peers.

Fortunately, there’s a good workaround for tolerance — taking regular stimulant breaks, as our prescribers recommend at our clinic. These breaks last not for a day or a weekend, but for about two weeks every four months. We suggest this be done under supervision, but we’ve found many prescribers who don’t know about, recognize, or believe in tolerance. Parents may have to be persistent to get them on board. Adhering to this strategic approach changes every aspect of a teen or young adult’s relationship to medication, their satisfaction using it, and the efficacy it has in their lives.

ADHD Medication Side Effects

ADHD medication is not all sunlight and roses, just take the pill and you’ll be fine. There are three problems that maximize side effects and minimize benefit. The first is starting your child’s ADHD treatment journey at the primary care physician’s office. We love our PCPs, but they aren’t optimal prescribers. They aren’t paid to sit down for an hour or two or three and get to know you, your history, and your experiences. Specialized mental health providers are.

[Free Download: The Ultimate Guide to ADHD Medication]

The second problem is that even some mental health providers don’t use standardized assessments, like the Conners, Barkley, or Brown scales to make their initial evaluation. These scales aren’t simply checklists of symptoms. They’re “norm-referenced,” meaning they’re given to subjects known to have ADHD and to those known not to have it. The results are used to pick out the diagnosable kids from the non-diagnosable ones. There are test forms for teens, parents, and teachers to complete. You should not consider treating your child’s ADHD without completing them, along with having a good one- to three-hour interview.

The final obstacle is the common disconnect between the therapist/evaluator and the medication provider. When we say, “integrative treatment,” we mean that the prescriber and therapist either work in the same office or staff cases regularly, so they can give each other feedback. If you’ve struggled to find a practice that operates this way, we offer some tips in our book to help you along.

When things go wrong with ADHD medication management in teens and young adults, the problem is usually in the system of deployment, not in the medication itself.


How to Help Teens Ease into Medication

Problematize. To accept treatment, teens need to feel ADHD as problematic, as a pain in their life that limits and controls them. This requires matching a formula that considers what they value, how much energy they exert to enact those values, and whether they attribute achievement to their own striving or to a sense of entitlement. Too many parents normalize their children’s struggles to make them feel better, when they should, in a kind but direct way, problematize and propose solutions.

Build a prescribing relationship. There must be a meaningful relationship between the client and the prescriber/therapist team. Teens and young adults need to feel like they aren’t just a member of that team, but its leader. They need to trust providers to take them seriously, speak to them like peers, and to be genuinely interested in solving the problem.

Emphasize consent. Teens will only respond to treatments to which they have given full and informed consent. We won’t see anyone from middle school or up if she does not agree to be seen. This increases compliance dramatically.

Parents also have consent. Your child may decline medication, but if that affects his performance in school or leaves him dependent on you and living in the basement, you are free to support good decisions and extinguish bad ones through behavioral modification. Make deals with your child to incentivize success in life, and link that to taking medication. This seems harsh to many parents, but it works.

Best ADHD Treatment for Kids & Teens: Next Steps

Wes Crenshaw, Ph.D., is co-author of the new book, ADD and Zombies: Fearless Medication Management for ADD and ADHD.


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