So, you or your child were just diagnosed with ADHD. Very likely, one of the recommendations for treatment is to consider an evaluation for prescription medications to manage symptoms. In fact, at my practice, when we arrive at a diagnosis of ADHD as part of a neuropsychological assessment, we will typically make the recommendation for a medication evaluation as part of the treatment approach. Some clients are reluctant to follow through with this recommendation for several reasons. We often hear clients express concern that they will become addicted to stimulant medication. Alternatively, clients also worry that they will become dependent on the medication and will not learn to manage symptoms on their own. Parents also fear that medications might have a negative impact on their young child’s development. Another concern is the potential for adverse side effects. To respond to these concerns, we turn to the research, which is quite robust. Since 1970, thousands of research studies have been conducted to explore the effects of various medication options for ADHD. This means that much is known about the medications that are commonly used to treat ADHD.
Research indicates that the most beneficial outcomes for ADHD consist of a combination of medications and therapy. According to the American Academy of Pediatrics, 80% of the children who used stimulant medications, either alone or combined with behavioral therapy, have an improvement in their symptoms and a reduction in impulsive behaviors. The majority of individuals, both children and adults, who use medication report increases in self-esteem, fewer disruptive behaviors, and improvements in their relationships. While your therapist can assist with the behavioral aspects of ADHD, such as executive functioning or social skills training, medication can be a very beneficial adjunct by improving attention and focus while reducing impulsivity and distractibility. In this instance, it provides the client with a clear window to connect with their educational or social setting and to learn and practice new skills.
The Costs of Untreated ADHD
Before we discuss the benefits of medication further, let’s take a look at the costs of untreated ADHD as individuals enter adulthood. Research findings indicate that the impact of untreated ADHD can be notable for adults. For example, adults who were diagnosed with ADHD as children tend to have lower grades, more academic difficulties, and are less likely to finish school. They tend to have more difficulty financially as well as socially. This includes more difficulty maintaining steady, consistent employment, and they tend to earn lower salaries compared to those without ADHD. Adults with ADHD tend to have a higher likelihood of sexual adjustment difficulties, sexually transmitted diseases, or unplanned pregnancies. They are also more likely to be involved in criminal activities or get into trouble with the law or others in authority. They are more likely to have driving accidents and substance use disorders. Comparatively, those individuals who are treated for their ADHD symptoms during childhood have much better outcomes and are less likely to experience educational difficulties, social challenges, legal or employment problems, driving accidents, or substance use disorders. Therefore, there is ample evidence in the research highlighting the behavioral benefits of medication treatment for individuals with ADHD.
Biological Differences in ADHD
To explore the neurological differences in those with ADHD, the brains of children and adults with ADHD have been evaluated in the research. Brain scans of children display three areas of the brain that are smaller in those with ADHD compared to neurotypical individuals. These neurobiological differences have been noted in the prefrontal cortex, which is responsible for the executive functions such as planning and organization, the fronto-striato-cerebellar projections, which are responsible for attention, focus, and ignoring distractions, and the caudate nucleus, which is responsible in part for learning and memory. Interestingly, adults who were treated with medication as children no longer had smaller areas of the brain in these regions. In fact, these brain areas were similar in size to those without ADHD. In addition, the changes in brain size were almost always accompanied by positive behavioral changes. Therefore, there is ample evidence that ADHD medication can work, not only to improve the behavioral aspects of ADHD as described above, but also at the neurobiological level to result in lasting changes into adulthood.
Who Can Prescribe Medication for ADHD?
When considering the options for medication, we recommend you work with a prescriber who has experience in mental health and behavioral disorders when exploring the pharmacological options to treat symptoms of ADHD. In many cases, a pediatrician or a general practice physician, nurse practitioner, or a physician’s assistant is able to prescribe medications and medically manage the symptoms associated with ADHD. However, if the ADHD is co-occurring with other mental health disorders or substance abuse, it may be beneficial to enlist the support of a psychiatrist. If other neurological conditions are present, a neurologist may also be involved in the medication regimen.
What Medications are Used to Treat ADHD?
There are many different medications to treat ADHD. However, they tend to fall into three categories: methlyphenidate (such as Ritalin, Concerta, Focalin and related compounds) and amphetamines (such as Adderall, Vyvanse and related compounds) comprise the two stimulant medication classes; in addition, there are a number of nonstimulant medication options. Overall, research suggests that the stimulant medications tend to be more effective as a first line approach than the non-stimulant options. Methylphenidate compounds were found to have less side effects and were better tolerated than amphetamine compounds. Thus, many prescribers will consider methylphenidate or amphetamine derivatives as an initial option for treatment given the robust impact of these medications on ADHD symptoms.
Stimulants tend to have an effect within 30 minutes, with a peak effect after two hours and then wear off within four hours, unless you or your child is prescribed an extended release or a “booster” dose. Extended release options (XR or ER), which can last approximately 8 to 12 hours, can be beneficial for children or adults to get through the school or workday. A “booster” is a short acting dose that is typically taken in the afternoon to maintain the effect for a longer period of time. We encourage you to discuss these options with your prescriber in order to find the right option for you or your child. Medications are typically available via capsule or tablet. There are also chewable tablets, orally disintegrating tablets, liquids, and skin patches in some cases for individuals who have difficulty swallowing pills, or for those that need a more precise dose. Nonstimulant medications may be considered in cases where the patient does not have a robust response to the stimulants, or when the stimulant options are resulting in adverse side effects or contraindications with other medications.
In many cases, prescribers will start at the lowest possible dose and adjust it upward in order to explore the optimal dose. Once a therapeutic response is obtained, many prescribers will recommend that you explore a slightly increased dose after symptoms have been somewhat managed to determine if there is even a better effect with a slightly higher dose. If you experience side effects at the higher dose, they will likely drop you down to the more effective dose. Ideally, the goal is to optimize symptom management with appropriate dosing. It is recommended that you continue to take your medication in the manner that is prescribed. If anxiety or irritability occur after taking the medication, the dose may need to be adjusted.
What are Some of the Side Effects?
Some of the side effects that may be experienced include sleep difficulties, changes in appetite, changes in mood (e.g., irritability, flatness or numbing), or increased anxiety or agitation. During the first month, it may be common to experience some changes in appetite, which may later normalize. This should be monitored regularly by your prescriber. Sleep difficulties can be experienced, particularly when taking a stimulant medication. For this reason, it is important to take the medication in the morning. Medication taken later in the day can greatly influence sleep. Anxiety or tics can be experienced in some cases. Tics consist of motor behaviors such as rapid eye blinking, twitches, or other repetitive behaviors that are outside of the patient’s control. Stimulants may activate or exacerbate tics. If this occurs, be sure to notify your prescriber. Discuss any side effects with your prescriber, as they may want to explore a different dose or a different medication in order to better manage your symptoms.
In summary, as you learn more about your ADHD diagnosis, it is important to recognize that there are many benefits of medication to manage the symptoms of ADHD in children, adolescents, and adults. However, we realize the process can be somewhat overwhelming and encourage you to discuss your treatment options more thoroughly with your prescriber and your therapist.
For more information on the benefits of behavioral treatment for ADHD, or to learn more about a formal assessment to evaluate the symptoms of ADHD, contact our office to meet with one of the experienced therapists at Konick and Associates.
ADHD Medication Options and Benefits for Children Webinar by Dr. Walter Karniski MD, Additude expert webinar series, podcast #438, January 19, 2023.
More information about ADHD medications can be found at Additudemag.com, along with a variety of research-based articles, webinars, and educational materials.