There are a number of behavioral, dietary and lifestyle treatments for ADHD, which should be considered before or even along with medication, but for this section let us focus on medication treatment for ADHD.
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The mainstay of medications for ADHD are the psychostimulants. The most well-known of these is methylphenidate (Ritalin) and its derivatives, such as Concerta and Focalin. There is also another line of psychostimulant medications derived from Dexedrine, such as Adderall or Vyvanse. All of these psychostimulants have similar effects. Their main mechanism of action appears to be increasing dopamine and norepinephrine availability to the frontal lobe and other regions of the brain. This has the effect of increasing the ability of the frontal lobe especially to do its job of executive functioning.
There has been a great deal of research demonstrating that these medications are effective, at least in the short term. They generally significantly improve ADHD symptoms in about 70 to 75 percent of children who take them. They can make a dramatic difference in the school, home and social performance of children with ADHD.
One might ask, then, why not give every child with ADHD a trial of these medications. There are two reasons. First, there a number of side-effects associated with medication use. I will not discuss all of them in detail, but they include appetite suppression, sleep problems, growth delay, tics, headaches, anxiety, depression, irritability and aggression. One to three percent of those taking psychostimulants will experience hallucinations. These medicines can also produce personality changes that are harder to define. I often will hear parents say “he is just not himself” or “she’s lost her joy.”
Another interesting fact is that the few long-term studies that have been done with these medications have failed to show any long-term benefit. The most well-known of these is the MTA study, in which more than 500 children were given either medication, medication and behavioral treatment, behavioral treatment only or community care. After one year, both medication groups produced superior results. However, the children were followed for another two years, although the randomized part of the study was over, and by three years there was no difference in ADHD symptoms between those taking medication and those who were not taking medication. A second study beginning with preschoolers had similar results. The reasons for this are not well understood, but it certainly casts doubt upon using medication as the sole treatment for ADHD.
In fact, in November of 2015, the Cochrane Review, a very highly respected group of researchers who periodically review the quality of the evidence for medications and other treatments, expressed significant reservations about how good the evidence is for the efficacy of methylphenidate in particular. They stated the following:
“At the moment, the quality of the available evidence means that we cannot say for sure whether taking methylphenidate will improve the lives of children and adolescents with ADHD.”
They suggested the need for better long-term trials to assess if there were serious long-term effects and also suggested larger randomized trials of nonpharmacologic treatments.
There are two other types of medication that can be effective for ADHD, at least in short-term studies. The first is atomoxetine, or Strattera, which is not a stimulant. It is a medication that increases the amount of norepinephrine in the prefrontal cortex of the frontal lobe. It is more similar to the antidepressants than to the stimulants. It can be effective, especially for those who do not tolerate stimulants, but has its own set of possible side effects.
Finally guanfacine, or its long-acting form Intuniv, is a derivative of a blood pressure medication called clonidine. It is an alpha-2 agonist and seems to also improve the function of the prefrontal cortex. It is often effective for decreasing intermittent explosive impulsivity and can be used with psychostimulants as well as by itself. The most common side effect of this medication is fatigue, and this may limit its effectiveness in some children.
One last topic concerning medication is the question of whether the psychostimulants are addictive. Because they are stimulants, many people compare them to methamphetamines or cocaine. However there is no evidence that these medications, used as prescribed, are physically or psychologically addictive in that sense. When many of the children I treat reach high-school age, they begin refusing to take medication. This behavior is hardly typical of addictive drugs like methamphetamine. On the other hand, the psychostimulants do have a significant potential for abuse. They can be misused, either by overdosing or snorting through the nose, and when used in this way can be very dangerous. Some stimulants, as well as Strattera or Intuniv, have less abuse potential and may be indicated when there is risk of abuse.