ADHD medication: What you should know

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.

Visiting the doctor

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:

• Is it easy to ask the doctor questions and get answers I understand?
• Does the doctor spend adequate time spent addressing my concerns, or do I feel rushed?
• Were all my questions answered?
• How often will I need to bring my child to an office appointment?
• Do I have a way to reach the doctor between visits?

To prepare for each appointment, write down your questions ahead of time and leave space under each one to fill in the answers.

Considering medication

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.