ADHD Medications

What’s the best ADHD medication for my child?

This is a situation where “one size doesn’t fit all,” and we have to avoid that temptation. When we think about medication for ADHD, most of us probably immediately think of an amphetamine—particularly Adderall. While that drug might be indicated for your child, there are a lot of factors that should go into making that choice. Not taking the time to consider these can result in treatment failure, adverse reactions, and compounded frustration. Let’s take a look at how we should go about making the important decision of whether to start a medication, which one it should be, and at what dose.

Before any prescription is written, your physician should gather a detailed patient and family history regarding the presence of any cardiovascular disease. This should be followed by a focused cardiovascular physical exam, along with your child’s baseline height, weight, blood pressure, and heart rate. This is important since the stimulants used with ADHD can an increase in blood pressure and heart rate. We want to be sure this isn’t going to cause an unnecessary complication. In addition, the presence of potential medication side effects should be explored before any medicine is started. It will be important to know which is the cart and which is the horse, should any of these reactions occur. These include, among other things, sleep disturbances, abdominal pain, changes in appetite, headaches, and tics. (Tics are sudden, repetitive movements or involuntary sounds, such as eye blinking, shoulder shrugging, facial grimacing, or throat clearing. They can at times be a side effect of ADHD medications, but more often the medications are unmasking a preexisting problem. That’s why it’s important to explore these things ahead of time.) If your child is an adolescent, there should be a thorough assessment for any existing or potential for substance use or abuse.

Once we’ve done these things, it’s important to make sure you and your child (if age appropriate) understand the purpose of treatment with medications, how they work, what problems to look for, and what to expect. If there has been no history of appetite problems, tics, or sleeping disorders, these specifically need to be discussed as possibilities and addressed should they arise. This is the time to ask questions—a lot of them. Make sure you get the answers you need.

When the decision to start medication has been made, understand that it will usually take between one to three months to determine the best medication, dosage, and frequency of administration for your child. Keeping that in mind will help avoid frustration during this adjustment/titrating phase, especially with the need for frequent follow-ups—maybe weekly for a while.

Remember, “one size doesn’t fit all,” and to help drive that point home, here are some things that need to be taken into account before a medication is selected:

• What’s the duration of desired medication coverage? Short-acting stimulants last about four hours, so what are we trying to “cover?” Is that enough time? Does the window need to be extended to midafternoon or early evening?
• What time of day are your child’s target symptoms the worst?
• Can they swallow pills or capsules?
• Can/should the medication be given at school?
• Are there preexisting problems, such as tics, headaches, etc?
• What are the potential side effects of a particular medication?
• Does your child have a history/potential for substance abuse or is there someone in your home with that potential?
• What about the cost of the drug? In general, short-acting stimulants are much less expensive than the longer acting ones, and generics less expensive than brand-names. While generics work just as well as brand-names, they’re not always available in the same dosages, making their use more problematic at times.

While there are several classes of medications to choose from for treating ADHD, most experts will recommend the use of a stimulant, including amphetamines (Ritalin, Adderall), methylphenidate (Metadate) or, lisdexamfetamine (Vyvance). This choice of using a stimulant is based on a rapid onset of action and a long track record of safety and success. We’re going to limit our discussion of ADHD medications to the use of these stimulants.

Let’s start with the rapid/short-acting forms. These should be the initial choice in children less than six years of age, mainly because they are more sensitive to higher doses of these medicines, and longer acting preparations don’t come in the smaller doses they require. Effects from the medicine can be seen within as little as 30 minutes, with a peak effect between 2 or 3 hours. This is important to know, since timing is everything here. This is another question to ask your physician and to keep in mind as you monitor your child’s day and needs.

Intermediate or long-acting drugs are generally used with children who require a duration of action longer than four hours, or in whom giving medicine every four hours poses a problem. They make it easier to be sure your child gets the coverage they need and improve adherence to the treatment plan. Another advantage is that they are less likely to be abused, since they don’t have the immediate “pop” of the short-acting forms. They’re going to be more expensive though, so we need to keep that in mind. As a general rule, you won’t see an effect for a couple of hours and it will be more gradual than the rapid-acting, with the peak happening around 7 hours.

It’s perfectly acceptable—maybe preferable—to combine a long-acting drug in the morning with a short-acting one in the afternoon, to give extended coverage when needed. Again, this all depends on your child, the setting, and their needs.

In the beginning, it’s all about adjustments and titration, with the goal being to find the optimal dose at which target outcomes can be achieved with minimal or no side effects. Here are some points to keep in mind:

• These drugs are not weight-based (such as an antibiotic for a five-year-old), since every child’s metabolism is different and the way they handle these medications will differ.
• It’s helpful to start these medicines on a weekend so you’ll be able to observe the initial response and watch for any side effects.
• All of these stimulant medications should be started at the lowest possible dose and increased gradually as needed (usually every three to seven days). We want to see an improvement of about fifty percent in the core symptoms (without the development of side effects) and this can be apparent in as little as 30 to 40 minutes after the drug is given.
• High-fat meals can delay the onset of some of these drugs, and even increase the peak concentrations.
• If the drug needs to be stopped, it’s perfectly safe to do so at once—“cold turkey.” There’s no need to gradually taper this medication.

So what are the side effects we should be looking for?

These are powerful medications, and while very effective and safe, they can produce some unwanted reactions.

• Decreased appetite and weight loss. If this happens, it’s not a reason to stop the medication. Try giving it at or after a meal and make sure your child has access to calorie-dense but nutritious foods.
• Poor growth. A “drug holiday” might be tried if this happens, but should be based on a series of measurements and use of growth charts. Your physician can help with that.
• Sleep disorders. This might come in the form of nightmares and insomnia. The best initial approach is to insure your child has a good sleep routine and environment (dark, cool, quiet).
• Make sure your child is getting plenty of fluids, and during one of these episodes, take their pulse and write it down.
• We mentioned those earlier, and if they should start or worsen while on the medication, the dose may need to be lowered or stopped altogether.
• This is something that occurs as the medication is wearing off in the afternoon or evening. The problem symptoms return, and may even be worse. Here’s where a longer-acting form can be used, or adding a rapid/short-acting medicine to cover the problem time period.
• Moodiness, in addition to increased activity, sadness, or irritability is common with short-acting drugs as they wear off. Again, a longer-acting form might help, or adding a short-acting one in the evening.

Sounds complicated, but with the understanding of a couple of key points—peak effects, coverage, combining short and long-acting drugs—there should be a successful medication regimen for your child. And if one stimulant does not give us the desired response, at least fifty percent of the time a different one will. The same is true with side effects. We might see the development of a tic or insomnia with one drug, but not with another. Don’t give up, and learn all you can. And make sure your physician is experienced in the treatment of ADHD and is aware of these concerns and options. A good idea is to go to your child’s first visit with a list of the behaviors you want to see addressed, the problems your child is having at home and at school, and the times of day/week that are the most difficult.

Now the good news. If your child has been correctly diagnosed as having ADHD, and the correct medication/dosing/timing has been selected, the response rate to this treatment approximates 70%– in some studies even more. That’s a huge number, and cause for optimism and hope. This not only includes improvement in the core symptoms of ADHD, but also in the relationship between you and your child. That’s what we’re trying to accomplish, isn’t it? But it has to be done thoughtfully, carefully, and with patience.