Warnings about possible side effects of prescription medications are updated frequently. To stay abreast of recent warnings that may have been issued on your child's medication, visit the Food and Drug Administration's drug-safety index website, and ask your pharmacist for an update each time you refill the prescription.
By Shashank V. Joshi, M.D.,FAAP
If your child has been diagnosed with attention deficit hyperactivity disorder (ADHD) and you are considering giving him medication to manage the symptoms, here is some advice for you from a pediatrician/child psychiatrist.
Along with a thoughtful and thorough evaluation, most parents want information. What do you want to learn about medication and its effects? Remember, it's important to feel comfortable with your child's medical practitioner, so ask yourself:
To prepare for each appointment, write down your questions ahead of time and leave space under each one to fill in the answers.
While behavioral interventions can be very helpful, medication therapy is almost always recommended for kids who are diagnosed with ADHD. Medication therapy (sometimes referred to as pharmacotherapy) includes more than simple "medication management"; patients and their families should feel that their doctor is really listening to them in order to best understand and manage their concerns (and not simply refilling prescriptions), even though your appointment time with the doctor may be limited.
Eighty years of clinical experience have taught us that, by far, the most effective medicines for the treatment of ADHD are from the class called psychostimulants, which includes two major types: methylphenidates (MPH) and amphetamines (AMPH). (A third type, pemoline, has fallen out of favor over the past 5 to 10 years due to concerns about severe liver side effects.) These medicines are called "psychostimulants" because they "stimulate" certain areas of the brain which are responsible for focus, concentration, and impulse control.
MPH preparations include medicines such as Ritalin®, Methylin®, Focalin®, Metadate®, and Concerta®. There is no evidence that one preparation is any better than another, and most prescriptions are based on the preference of the practitioner or the patient. There are, however, some differences to be aware of, especially regarding how a specific formulation works throughout the day. Concerta®, Metadate-CD®, Focalin XR®, and Ritalin-LA® all have the advantage of being once-daily preparations, and one dose may last from 8 to 12 hours. The latter three of those just listed may be taken apart and sprinkled on food if a child has trouble swallowing pills. Metadate-CD and Concerta release most of its medicine in the latter morning and afternoon, whereas Ritalin-LA releases about 50% in the morning and 50% in the afternoon. The other (shorter acting) MPH preparations require dosing two or three times a day, as they are effective for shorter periods of time (three to four hours). Methylin is available in chewable tablet and liquid forms. Your doctor can tell you more about the specific reasons a particular medicine would be best for your child. In April 2006, a methylphenidate patch called Daytrana® was approved by the U.S. Food and Drug Administation (FDA) as a second line treatment (to be tried only if medication by mouth is ineffective). The patch, which is changed daily, may last up to 12 hours and can be cut for dosing modifications.
AMPH preparations include Dexedrine®, Adderall®, and Adderall-XR®. The latter is designed to last around 10 hours and can be usually be given in one dose in the morning. It can also be taken apart and sprinkled on food, if necessary. In February 2007, a new version of amphetamine, Vyvanse® (lisdexamfetamine mesylate), was approved by the FDA. This medicine is called a "prodrug", because it is inactive until metabolized in the body. It may last 8 to 10 hours and has been shown to have a lower abuse potential than its sister compound, amphetamine.
Strattera® (atomoxetine) is a non-stimulant agent approved by the FDA for treating ADHD in adults, teens, and children ages 6 and older. Although Strattera® and psychostimulants are comparable in some efficacy studies, stimulants are still considered first-line treatment for ADHD. However, Strattera® may be especially helpful to patients who cannot tolerate stimulants due to specific side effects (such as tics), and for those who had an unsatisfactory response to stimulants. Strattera® might also be considered first-line by families who don't want their children treated with stimulant medicines.
Other medicines with scientific evidence to support effectiveness include antidepressants, such as Wellbutrin® (bupropion), Effexor® (venlafaxine), and Tofranil® (imipramine), and antihypertensives, such as Catapres® (clonidine), or Tenex® (guanfacine).
There are ongoing clinical trials to study the effectiveness of other medications such as Provigil® (modafinil) and certain naturopathic remedies, such as very long chain (omega-3) fatty acid supplementation. Most practitioners will discuss all options with you, but learn everything you can about medications to treat ADHD and generate your own questions prior to your appointment with the doctor.
Medication side effects are usually transient and minimal. Your child's practitioner will go over specific side effects, depending on what is prescribed. In general, stimulants are known to cause headache, stomachache, small increases in blood pressure and pulse, appetite suppression, and sleep difficulties. Less common side effects include irritability, mood changes, unmasking of tics, and slowing of the speed of growth in height. All of these are responsive to simple interventions, such as giving the dose with food, lowering the dose, changing its timing, or switching to another medicine.
Recently, the FDA has included new warnings regarding the use of Strattera (atomoxetine) — it has, on rare occasions, been associated with suicidal thinking in teenagers — and also for psychostimulants (they have a rare association with severe cardiac side effects and sudden death, primarily for children with a history of certain pre-existing heart problems).
The FDA link regarding drug safety information for patients and families can be found at here.
How you talk to your child about medication depends, in large part, on your child's developmental stage. Younger children (5 to 7 years old) need reassurance they're not "bad" kids. They need to know their parents understand that they're trying really hard to behave, pay attention in class, or stay in their seat. The medicine will make it easier for them to succeed because it allows them to make good choices and be in control of their behavior and attention, rather than being controlled by their behavior.
Older school-aged and preteen children (8 to 12 years old) also need constant reminders about, and attention to, things they can do well, rather than having their parents dwell on their difficulties. Medical analogies can be helpful, like, "You know how getting eyeglasses helped you [or your friend or your cousin] a lot with schoolwork? That's sort of how this medicine is supposed to help too."
Teens need to know it's not "all about the pill." When their grades turn around, they did it; the medication simply allowed them to focus long enough to actually get the work done. The teen still had to do the homework or finish the paper. Meds can't take tests! Emphasize that you, he, the doctor, and his teachers are all on the same team, trying to help him succeed.
Just as it's usually not a good idea to keep family secrets, keeping school personnel in the dark about your child's ADHD is generally not helpful either. While it may be difficult to secure appropriate accommodations at certain schools, most schools do want to support their students. Your child's practitioner, school psychologist, or counselor may have some practical classroom suggestions. Work with your child's teacher to create a special "signal" (e.g., a gentle squeeze on the shoulder, or an opportunity to do a special errand) when it's time to go to the office or nurse's station to take midday medication. Once-daily preparations make these kinds of arrangements unnecessary, but for those who respond better to shorter-acting agents, it's crucial for maintaining confidentiality.
Again, your child's doctor will go over the specifics, depending on the medicine used. I encourage all patients to take all medicines seven days a week, at least for the first month. This allows parents to observe any changes during the weekends. If the team decides that taking the medication is not necessary on the weekends, so be it. However, this rule only applies to the psychostimulants. All other psychotropic medications need to be taken each and every day unless the doctor tells you otherwise.
Be sure to pick your words carefully when praising your child's behavior or setting limits. "Wow, you're having a great day today. You must have taken your meds!" is a somewhat backhanded compliment. Better to say, "Wow, you're trying really hard today. Nice job of paying attention, (or cleaning your room, sticking with a hard assignment, or staying in your seat"). Without overdoing it, publicly praise as much as possible to bolster self-esteem and focus on your child's strengths. Be generous with the small but significant non-verbal cues of life — a pat on the back here, a high-five there. You're spending a lot of time, effort, and spirit seeking treatment for the problem; just don't forget to nurture what's good about your child!!
In general, most children and teens do not outgrow their ADHD, so medications may be helpful over the entire lifespan. However, depending on the specific type of ADHD (i.e., inattentive, hyperactive/impulsive, or combined), interventions may need to be adjusted over time. Teens and adults are capable of developing cognitive strategies that were not possible for them as children, which may lead to successful management of their ADHD, and which may lessen or eliminate the need for medication.