ADHD (part 2)
In February’s column I discussed issues concerning the diagnosis of attention deficit hyperactivity disorder (ADHD). I would like to now focus on treatment options for children with attention deficit disorder (ADD) or ADHD. This is not meant to be an in-depth discussion but rather an overview to give you some sense of comfort when thinking or talking about this topic. Although ADD and ADHD are different entities, they are largely treated the same, and for the purposes of this column I will consider them as one.When parents first come to discuss what to do about their newly diagnosed child, they are frightened and saddened. The idea of medication that affects the brain is somehow harder to deal with than antibiotics, allergy drugs or other routine medications. Although I understand parents’ feelings about psychiatric medication, and to some degree share them, it shouldn’t be that way. Conditions affecting the personality are as real as gastroenteritis and acne. Your child is not a bad person for having ADHD any more than he or she would be for having an ear infection.
Parents frequently have heard of a number of alleged side effects of ADHD medications, most commonly that it will make their child a “zombie.” The zombie fear is widespread and is without a shred of truth. Nevertheless it is a fear that must always be addressed. Given these fears, parents often say that want to try some other form of treatment rather than Ritalin or similar medicine.
Non-mainstream treatments include herbs, chiropractic, acupuncture, homeopathy and, of course, increased discipline. Well-designed scientific studies testing the efficacy of these treatments are very few in number. I do not believe that there is any good evidence that any of these techniques are of value. I do, however, respect parents’ concerns, and I always give my stamp of approval to their trying any treatment that doesn’t clearly cause harm. I explain to parents what I have to offer, and I always leave the door open for them to return if what they wish to try doesn’t work. I also ask them to tell me about their experience with these non-mainstream techniques and promise to pass what they learn on to other parents.
So what do I have to offer? Although there has been an explosion in recent years of ADHD medications, most of them are just alternate forms of already existing products. The two main types of medications are stimulants and have been available for decades. Methylphenidate—the generic name for Ritalin, Concerta and Focalin, amongst others—is the most commonly prescribed medication. It comes as pills, liquid, sprinkleable tablets and most recently as an adhesive patch. While there are differences among these brand names, they are very closely related to each other. The second major drug group are the amphetamines, such as Adderall and Dextrostat.
Although these two groups are similar, they are different enough that some children who do not succeed on one type may do well on the other. The long-acting forms of both methylphenidate and amphetamine can be taken once daily and at maximum give about 12 hours of effect. These are not medicines that require days or weeks to exert their effects. They work as soon as the child takes them, and they exit his or her system within a day.
The two types of stimulants show similar side effects, which in the vast majority of patients are not severe enough to make parents stop treatment. Far and away the most common side effect is decreased appetite. This does not occur with everyone and is often temporary, but it can be a significant problem. Adjustments in the time of meals or adding a before-bed meal can often overcome this problem. Sleep problems are rarely a significant concern unless the medication is taken later in the day. Infrequently, there are children who seem sad or particularly moody as the medication wears off at the end of the day. Other side effects do exist but are rare and not important for this discussion.
Within the last few years a new non-stimulant medication named atomoxetine (brand name Strattera) has come on the market. Strattera claims 24-hour effectiveness, which is particularly attractive if getting ready for school is a difficult time for parent, child and school bus driver. Strattera also seems to exert some anti-anxiety effects, and so it may have a particular niche in children with ADHD and anxiety. Side effects also include decreased appetite (usually temporary), sleepiness and stomach ache. As with the stimulants, other side effects are possible but exceedingly uncommon. As opposed to the stimulants, Strattera may take as much as a month to take effect.
There are a few other medications that may be used as second- or third-line therapy, but they are used in a very small percentage of patients and are usually not as effective.
Regardless of which medication is chosen, a good physical exam is necessary, as well as a review of family health. Concerns have been raised about possible effects on the heart, but at this time the Food and Drug Administration has decided that there is insufficient evidence to link medications and heart problems.
Clearly these are medicines that require ongoing communication between the family and physician. Phone conversations can be helpful, but face-to-face meetings every several months are imperative. Ongoing feedback from teachers is also necessary to evaluate benefits or problems.
Do these medicines help, and must my child take them for life? I believe there is no question that for many children medication and behavioral techniques can change school and relationships with other children from sadness, frustration and failure to success and happiness. They don’t work for everyone, and you can always stop if you are dissatisfied. As far as duration of therapy, this is a harder issue. I think it is wise to present this as a lifelong problem but also to understand that many patients do indeed seem to outgrow the need for medication.
I have written a great deal but have only scratched the surface of the topic. As always, I would be glad to respond to any questions, and I recognize that there are controversies surrounding this subject. If you have personal concerns, I strongly recommend a discussion with your child’s doctor—and I’d recommend requesting the last appointment of the day so he or she can calmly and fully respond to all your concerns.
Dr. Alan Freshman, father of two grown boys, practices at Syracuse Pediatrics. Consult your own physician before making decisions about your family’s health care. Send e-mail to him at firstname.lastname@example.org.