The Decision to Medicate

Top 10 Questions About ADHD Medications for Children…Answered!

Before considering ADHD medication for your child, you want to know how they work, what risks exist, and what dosages and frequencies are normal. Here, experts answer these and other frequently asked questions about treating your child’s attention deficit disorder.

Questions and Answers About ADHD Medications for Children
Questions and Answers About ADHD Medications for Children

1. How can I tell if my child really needs ADHD medications?

Experts agree that ADHD medications for children should be considered when symptoms interfere with social, emotional, or academic life. Behavioral therapy and other non-drug treatments can be helpful for controlling ADHD symptoms, but, in most cases, experts say, these approaches are not powerful enough to replace medication.

“If your child has been diagnosed with ADHD and is struggling, he probably needs medication,” says Stephen Copps, M.D., an ADHD specialist in Macon, Georgia. “Medication is the cornerstone of therapy. It’s appropriate for most children with diagnosable ADHD. It is not a last resort.”

Of course, it’s essential that your child’s diagnosis of ADHD is a reliable one. ADHD-like symptoms can be caused by a range of disorders, including anxiety, depression, and obsessive-compulsive disorder. In some cases, a child’s symptoms arise from the frustration associated with having to struggle with a learning disorder.

Make sure the doctor uses the diagnostic criteria spelled out in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM-V. The doctor should get input from your child’s teacher as well as from you, his parents.

2 Are the medications safe?

The stimulants commonly prescribed for ADHD are considered among the safest of all psychiatric medications. “The risks of using these medications are very low,” says William W. Dodson, M.D., a Denver-based psychiatrist who specializes in ADHD. “The risks involved in not treating ADHD are very high. These include academic failure, social problems, car accidents, and drug addiction.”

As with many prescription drugs, of course, stimulants can interact dangerously with certain other medications. Be sure to alert the doctor about any other medications your child takes.

A 2004 study indicated that, between 1999 and 2003, 19 children died while taking either methylphenidate or amphetamine, the two most commonly prescribed stimulants. The FDA concluded that the number of deaths was no greater than would have been expected, given the large number of kids taking these medications. In addition, five of the children who died had a structural heart defect.


To Medicate, or Not to Medicate — That’s the Question


“People who have existing cardiac problems are already at risk for sudden death, and it’s not clear that these medicines increase that risk,” says Timothy Wilens, M.D., associate professor of psychiatry at Harvard Medical School in Boston. “If taking a stimulant does raise their risk, it is estimated to be about the same as what it would be if the person was physically active in sports.” Nonetheless, the FDA recently decided to require a label warning that these medications should not be taken by any child who has such a heart defect.

Your child’s doctor should check for heart palpitations, irregular heartbeat, and fainting spells, as well as a family history of sudden cardiac death or irregular heartbeat, when giving your child a physical exam. If any of these factors are present, the patient — whether child or adult — should be evaluated by a cardiologist before taking a stimulant. In general, there is no need for apparently healthy kids to undergo an electrocardiogram or any other high-tech-and high-cost-diagnostic procedure before starting stimulant medication.

3. What about side effects?

Stimulants can cause a range of side effects, notably appetite suppression and weight loss. But these effects tend to be transient, recent studies suggest. “Eighty percent of children who take stimulants experience some appetite suppression, but this side effect usually goes away on its own within six months,” says Dr. Copps. Giving children a big meal after their medication has worn off may be enough to compensate.

Stimulants can also cause headaches or lead to difficulty falling asleep. Lowering the dosage or switching to another drug may ease these problems.

In rare cases, children taking a stimulant experience visual or tactile hallucinations, or develop a tic, such as blinking uncontrollably.

No one should have to tolerate side effects,” says Larry Silver, M.D., clinical professor of psychiatry at Georgetown Medical Center in Washington, D.C. “After all, the problem can usually be solved with a simple adjustment to the medication’s dosage or schedule.”

4. Will medication stunt my child’s growth?

Researchers continue to debate whether stimulants have any long-term effect on a child’s height and weight. “There seems to be a subtle effect in the first year or two,” says Dr. Wilens. “Children may be about one to three pounds lighter, and one-quarter to one-half inch shorter, than they would have been had they not taken the medication. However, long-term studies show that, even if kids do drop height and weight initially, they tend to rebound to their normal growth patterns about three years out.”

Each time a child goes in for a checkup and a new prescription, the doctor should check his height and weight.

5. There are so many different drugs. How does the doctor know which to prescribe?

There is no evidence that any particular medication is best. “Treatment of ADHD should begin with an oral stimulant, either an amphetamine or a methylphenidate-based formulation,” reports the November 2006 issue of Treatment Guidelines, a highly respected newsletter for physicians about prescription drugs. “None of these drugs is inherently more effective than another… The choice of a specific drug should be based on its rapidity of onset, duration of action, and effectiveness in a given patient.”

Most children with ADHD do very well on one of the methylphenidate-based (Ritalin, Metadate, or Concerta) or amphetamine-based (found in Adderall and Dexedrine) drugs. If one med doesn’t seem to work — or if it works only at an extremely high dosage — the doctor may prescribe another drug.

6. How long do the medications last?

The short-acting forms of methylphenidate, amphetamine, and mixed amphetamine salts last about four hours. Each also comes in an eight-hour form, and methylphenidate comes in a 12-hour form. The recently introduced methylphenidate skin patch works for up to 12 hours. It’s critical that your child be “on” medication whenever hyperactivity, inattention, or impulsivity threatens to interfere with important activities. (That goes for sports and other after-school activities, as well as classroom time.)

7. What options are available for children who have trouble swallowing pills?

Methylphenidate is available in liquid and chewable forms, as well as in pill form. It’s also possible to get stimulants in capsules, which can be opened and the contents sprinkled on food. Another option is the methylphenidate skin patch.

8. How will the doctor determine the correct dosage?

The correct dosage of a stimulant is determined not by the child’s weight or age, but according to how efficiently his body metabolizes the medication. Thus, a seven-year-old who tips the scale at 50 pounds might need a dosage higher than the one that works for a 200-pound adult.

Most doctors start with a very low dosage of a particular stimulant, and then raise it every week or two until the benefits level off, or side effects become a problem (feedback from parents and teachers is very important). Then the previous dosage is usually deemed to be the best one for that patient.

Some doctors alternate methylphenidate and amphetamine, to see which is preferable. “I always have my patients try both types of stimulant medication, because people tend to prefer one over the other,” says Dr. Dodson.

9. I understand that stimulants don’t work for some kids. Is that true?

Yes. Some children don’t respond to stimulants. Others respond but are unable to tolerate the side effects. What’s more, stimulants may be inappropriate for children who take inhaled steroids for asthma, or anyone who has bipolar disorder, a history of drug addiction, seizure disorder, or an eye condition known as narrow-angle glaucoma. And, of course, kids with certain heart conditions should not take stimulants.

For these children, doctors sometimes prescribe the non-stimulant medication atomoxetine (Strattera). Recent reports suggest, however, that this mediation is not especially effective for some children with ADHD. Its side effects include nausea, vomiting, and dizziness, and some reports suggest that the drug can affect the liver and heart.

Tricyclic antidepressants, such as imipramine (Tofranil) and desipramine (Norpramin), or the antidepressant bupropion (Welbutrin), can help alleviate hyperactivity and inattention, although these meds tend to be less effective against impulsivity. In this case, blood pressure drugs like clonidine (Catapres) or guanfacine (Tenex) can be helpful.

10. I’ve heard that some parents allow their children to go off medication at times — for example, during weekends or over the summer. Are “drug holidays” a good idea?

Some experts, including Dr. Copps, are dubious of this practice. “One-third to half of your child’s education occurs outside of school,” he says. “If he can’t pay attention, he can’t learn.”

Dr. Silver says parents often tell him that their child does not need meds at home because they can “handle” these behaviors there. In response, he says, “I ask if they spend a lot of time telling their child to ‘sit still,’ ‘stop jumping on the couch,’ ‘leave your sister alone,’ and ‘stop interrupting me when I’m on the phone.’ If the answer is ‘yes,’ I tell them, ‘You may be living with these behaviors, but you’re not tolerating them. Think about what you’re doing to your child’s self-esteem.'”

On the other hand, children who have used a stimulant successfully for some time might be given a brief trial off the drug, to see if it is still necessary. This should be done only when school is out — and only with a doctor’s supervision.

“About 50 percent of kids with ADHD need medication into adulthood, and about half just get better with time,” says Dr. Wilens. “By tapering the medication off and then letting the child go without it for a couple of weeks, we can see if changes in therapy are needed.”


Helpful Books for Treating Kids with ADHD

Straight Talk about Psychiatric Medications for Kids, by Timothy E. Wilens, M.D.

The ADHD Book, by Beth Ann Hill, with James Van Haren, M.D.

The Mislabeled Child, by Brock Eide, M.D., and Fernette Eide, M.D.

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