The diagnosis of ADHD requires a thorough assessment, and treatment involves a combination of interventions, including medication, family education, and ongoing support. Medications can improve focus and reduce impulsivity. Additional treatment is needed if a patient has a comorbid condition, such as a learning disorder, anxiety, depression, mood or conduct disorder.
Medication for ADHD should be considered when there is significant academic or social impairment, or there is a risk of accidental injury due to impulsivity or hyperactivity. Treatment for children and adults usually begins with a short-acting stimulant medication at a low dose, with slow adjustments to higher doses if necessary, or an eventual switch to extended-release preparations. Sometimes a combination of stimulant and nonstimulant medication can be effective.
In this Pocket MD podcast, neurologist Max Wiznitzer and psychiatrist Russell Schachar provide expert advice on the use of medication in the treatment of ADHD. They discuss the types of medication used to treat ADHD; when medication is needed; combined interventions; ongoing monitoring of patients; complementary approaches; and the importance of patient, family, and community education.
Max Wiznitzer, MD
Dr. Max Wiznitzer is a pediatric neurologist in the neurologic institute at Rainbow Babies and Children's Hospital in Cleveland, Ohio. He is also a professor of pediatrics and neurology at Case Western Reserve University School of Medicine.
Russell Schachar, MD, FRCPC
Dr. Russell Schachar is a practicing child and adolescent psychiatrist, a professor in the department of psychiatry at the University of Toronto, and senior scientist in the research institute at the Hospital for Sick Children in Toronto, Canada, where he holds the Toronto Dominion Bank Chair in Child and Adolescent Psychiatry. He is the head of a cognitive neurosciences laboratory that focuses on psychiatric disorders of childhood and adolescence.
Listeners will be able to:
- Explain the considerations of effective ADHD medication management.
- Describe the importance of interprofessional collaboration in treatment of ADHD.
Announcer: You are listening to Pocket MD, training on ADHD in children and adults.
Dr. Max Wiznitzer: This is a discussion of medication management in ADHD. I'm Max Wiznitzer, a child neurologist at Rainbow Babies and Children's Hospital and a developmental behavioral pediatrician with a lot of time and experience working with individuals with neurodevelopmental disabilities, including autism and ADHD. With me is Dr. Russell Schachar.
Dr. Russell Schachar: I'm a child and adolescent psychiatrist at the Hospital for Sick Children at the University of Toronto in Canada. I have a busy clinical research program at the hospital focusing on neurodevelopmental disorders of all kinds, including ADHD.
Dr. Max Wiznitzer: We're going to discuss the topic of medications for ADHD. The key message that everyone has to understand about medications is that medications can improve focus. They can reduce motor overactivity and impulsivity, but they do not teach individuals how to learn or how to behave. What do we have to do in those circumstances Dr. Schachar?
Dr. Russell Schachar: Well, the ideal treatment program for an individual with ADHD would involve, after a thorough assessment, would involve a combination of interventions, medication, psychoeducation, and familywide support—because it's a condition that it not only affects the so-called patient, but the entire family, and sometimes the community—and, more generally, and a targeted treatment aimed at any of the comorbid or associated difficulties from learning disability to social problems to problems of aggression or conduct.
Dr. Max Wiznitzer: When do you think that medication should be considered for the treatment of ADHD?
Dr. Russell Schachar: When there is substantial impairment, it should be considered. There is a debate about whether or not you should try non-drug interventions before you try drug interventions or whether you should do it the other way around. The jury is probably still out, and a little bit of the considerations that go into that have to do with the preferences and the specific nature of the family that you're dealing with. It's absolutely true that there are times when you cannot get leverage on any of the kinds of interventions that you need to put in place unless the child is medicated, because there's no opportunity for the child to regulate their behavior or for the family to find the mental energy to deal with some of the other behavioral interventions.
Equally, there are other times when possibly the family is reluctant to use medication, when it would be a perfectly legitimate to put into place non-drug interventions of various kinds.
Dr. Max Wiznitzer: One of the other areas in which medication should be considered is when the child is putting himself or herself at risk, and that risk would be at risk for physical injury, risk for social injury, in terms of peers rejecting them or not paying attention to them, or risk for academic failure. Of course, in the adult years, it would also be risk for relationship failures, as well as difficulties with employment or issues where you're getting into trouble with the authority figures because of impulsive actions related to ADHD.
Dr. Russell Schachar: You're absolutely correct, I would say. I think one of the underappreciated features of ADHD is the risk, the attendant risk for physical injury. One in five children with concussion have premorbid ADHD, which is a substantial increase in risk. In other words, ADHD is all by itself, a risk for accidental injury that can lead to other consequences. In the preschool years, that's also true for burns, that children with ADHD in the preschool years are at increased risk for burns. These are all aspects of the kind of impairment that lead families to come for, bring their child for an assessment and have to be taken into consideration when you're weighing up what kinds of interventions to offer.
Dr. Max Wiznitzer: You mentioned that the families require psychoeducation. We know that one of the good sources of education in the United States is the national advocacy group for ADHD, which is CHADD, which can be found at www.CHADD.org, C-H-A-D-D, as well as their information arm, the National Resource Center on ADHD, which can also be accessed at www.help4adhd.org. One of the things that we always have to do is we have to make sure our patients and their families are informed consumers because we get improved compliance in those circumstances.
Dr. Russell Schachar: Absolutely. Having a child with any kind of problem is a difficult experience for people. It is not what you imagine when you have children; you imagine that your child will be perfect in every way and not be a problem in any way. Then it turns out that you have difficulties, and it's an extremely lonely process. It creates a great deal of stress within a family, between siblings, between parents, and a terrific antidote for that is to reach out to other individuals who have similar issues to get quality information that gives you hope and a better picture of the condition that you're dealing with. That goes a long way to dispelling some of the despair and loneliness and distress that families feel.
Similarly, children, as they get older, at least some of them begin to wonder more about why they are a little different. You hear in your office, children will say, "I don't know, doc, I'm smarter than those other kids, but they get great marks and I don't, and I feel terrible," and you can't possibly find enough time in your office if you're a child psychiatrist or developmental pediatrician or a family doctor to provide the kind of psychoeducational input that those children need and those families need. CHADD is a fabulous resource for all of that. We really encourage our families to reach out.
Dr. Max Wiznitzer: We know that the medication options that we have fall basically into three major groups: the stimulant medications, the alpha agonists, and as a general category, the antidepressants. If you're going to basically choose a medication for a child, which group do you tend to first gravitate towards?
Dr. Russell Schachar: Well, the collective experience is that one starts with stimulant medication, either dextroamphetamine or methylphenidate in one of its preparations, and these days, it's usually a long-acting preparation, which precludes the need to give a second dose of medication during the middle of the day. The details of how each of these work in terms of the time course, their onset and duration are somewhat different and important to know, but in general, almost always, practitioners will start with a stimulant medication.
Dr. Max Wiznitzer: Well, my experience has been that I usually will start with a short-acting stimulant medication, simply to make sure that, number one, we can compare behaviors during the day, see how they do in the morning compared to the afternoon. If they have an adverse reaction to it, it does not last the entire day. Parents seem to be more open at times to approaching it that way, and then moving towards a long-acting preparation after that time. From your standpoint, are all the long-acting preparations actually identical or can some people do better with one type of long-acting medication compared to the other?
Dr. Russell Schachar: It really does look like some people do better with one long-acting preparation or the other. It is not quite clear why that should be. There are subtle differences between the medications, which we won't go into in detail here. If you start with, say, a controlled release version of methylphenidate, and try several of them and you're not getting the right response with one and you go to the next, you can often get a better response by switching to a controlled-release version of dextroamphetamine and vice versa. Some people prefer to start with dextroamphetamine and switch to methylphenidate.
It's not possible at this point, to know, to predict with any degree of certainty, who will benefit from which of those two classes of medication, and for the most part, the children respond pretty much the same way. But in actual clinical practice, you do find you're more successful with one preparation than with another.
Dr. Max Wiznitzer: What percentage of children with ADHD ultimately would respond to one or the other stimulant medications?
Dr. Russell Schachar: I believe it's in the order of 70% of individuals would respond.
Dr. Max Wiznitzer: For those who don't show response, what other medication options are available?
Dr. Russell Schachar: Well, there are nonstimulant medications. Usually the algorithms take you to atomoxetine, which is an oral adrenergic re-uptake inhibitor. It's widely used. It has apparently, in head-to-head comparisons with stimulant medication, a lower effect size, but there are many children who benefit from a atomoxetine who wouldn't benefit from a stimulant medication.
Dr. Max Wiznitzer: Besides atomoxetine, are there other options?
Dr. Russell Schachar: Yes. Guanfacine is also available.
Dr. Max Wiznitzer: How about clonidine?
Dr. Russell Schachar: Clonidine, well, clonidine is about as old as I am. It's not a first-line treatment for ADHD, and in part, because of some of the cognitive and blood pressure effects that are associated with it. In fact, in our clinic, it's rarely used, but has been used with good effect in some individuals.
Dr. Max Wiznitzer: In addition to that, there is some literature telling us that combination therapy can be helpful. For instance, a stimulant medication with a nonstimulant. There are publications about combining a stimulant with atomoxetine, combining stimulant with an alpha agonist and getting an improved effect where either one doesn't seem to be working as well.
Dr. Russell Schachar: Yes. A good practice would suggest that if committed to helping a child get better, you may have to work through all the individual drugs that are available, plus some of the combinations. It is also true that, over time, sometimes revisiting a medication that previously didn't work well will generate a good effect later on. One of the key take-home messages to people who are beginning think about working in this population is that there is no really simple treatment for ADHD. Drug treatment isn't a write-a-prescription-and-see-somebody-in-a-year kind of proposition. Proper stimulant medication needs to be sculpted, monitored along with adverse effects, which we would probably come to in a moment, and altered as needed. There is definitely no one-size-fits-all-and-forever.
Dr. Max Wiznitzer: One of the other things that's always important to remember, as you pointed out, is follow up, making sure that we know how they're doing. The usual recommendation is to follow up with the individuals in about one month, within one month after you started the medication and the follow up does not have to be necessarily face-to-face. It could be telephone, and with the new technologies we have, it could be telemedicine if there are distance issues that are involved. But now, let's move on to one of the things that you did mention, which was adverse effects. We know any treatment we have always has the potential for an adverse effect. What are the common adverse effects that you come across in the population when we treat them with these medications?
Dr. Russell Schachar: With stimulants, it's headaches, stomachaches, trouble with falling to sleep, and loss of appetite. Of those four, headaches and stomachaches tend to dissipate really quickly in the course of treatment. It's important to alert at least the family of those effects, because they may be quite agitated when they occur, and persistence for several days will often overcome those symptoms.
Loss of appetite for some children can be a persistent issue, which needs to be managed all by itself. We can perhaps come back to that. Difficulty falling to sleep is often dose-related, unlike appetite loss, which is often not dose-related, but sleep needs to be monitored, just like appetite. Because of that, it's important to monitor heighten and weight as well.
Dr. Max Wiznitzer: For our listeners, we have to remember that while the medications can interfere with sleep, in the majority of children, the sleep disorder or sleep disturbance predates the use of any of the medications that we use.
Dr. Russell Schachar: Predate and be a consequence of the medication, I would say. Interestingly enough, there are some individuals who actually sleep better when on stimulant medication, in part because their day has gone better. They are less agitated and they have a more calm evening routine. For all of those reasons, they could well have an easier time falling to sleep and staying asleep.
Dr. Max Wiznitzer: For atomoxetine, people have reported that you can get an allergic reaction, a rash, but very rarely, you can have a liver problems that can occur as a consequence. More commonly, unlike the stimulant medications, atomoxetine will make some children tired, and that may preclude the use of this medication or may need for the dose to be changed from once daily to a twice daily dose at a lower dose for each one. In addition, for the alpha agonists, guanfacine itself in some children, besides making them tired, can make some children irritable, and—something that's really not reported in the package label—increases appetite in some children so they actually gain weight. It's something that people just have to be attuned to and pay attention in order to monitor it. It's one of those things, if you ask the questions, you'll get the answer. As it's been shown with studies of adverse reactions, if you don't ask about an adverse reaction, many times you're not told about it.
Dr. Russell Schachar: Correct. Some people advocate not to ask, because then you don't hear about them, but in typical clinical practice, you should alert your families and the child to the kinds of symptoms that they might experience so that they understand that these are not life-threatening and can be managed by you through care.
Dr. Max Wiznitzer: You mentioned before the potential effects on growth. Can you expand on that a bit?
Dr. Russell Schachar: There's increasing evidence that, especially with prolonged use of stimulant medication and especially at higher doses and without breaks, that there is an effect on overall height and possibly weight. As you said, early on, it's important for families to know that there's not an effective treatment in medicine that doesn't have an adverse effect, only a potential adverse effect. Ineffective treatments have no adverse effects in medicine. It's important that parents know, patients know, what those risks are and that it's very reassuring to them that you monitor their height and weight and their other vitals, like pulse and blood pressure as well as you go along. They see that you've been that you're attentive to these kinds of issues, and if there were any issues about them falling off their growth trajectory, you would observe them and be able to take appropriate steps.
Dr. Max Wiznitzer: One of the other potential adverse effects that have been reported over the years with stimulant medications is the presence of tics. This is based on anecdotal reports from early on, yet the more recent research has shown that there really is no significantly increased risk of tic activity, either the occurrence or onset of tics, because, after all, the children who have chronic tic disorders, ADHD may become manifested in the preschool or early school-age years and the tics on average start up somewhere between seven to nine years of age after the ADHD is already symptomatic.
One of the things that we know is that the tics can actually improve if the stress and strain associated with school or with socialization or with life in general, lessens because the ADHD is being adequately treated. One of the times that the tic activity may be truly increased is if the medication aggravates an underlying anxiety disorder and that triggers tic activity itself.
Dr. Russell Schachar: Yeah, I agree with you completely. Most families where you have a joint presentation of tics and ADHD, which as you pointed out is extremely common, that comorbidity, it would tell you that it's the ADHD symptoms that are most imperative. In other words, children who are having trouble sitting still, paying attention to achieving at school, can't socialize very well because of these behaviors, are impulsive and et cetera. In other words, the ADHD component of their presentation, that's the most impairing aspect. If we treat the ADHD symptoms, there is a risk for increase of tics. Many times they will just say, "Well, that's fine. We can manage the tics." They're socially unacceptable, but they're not impairing the child in every other aspect of their life. Having said that, you're completely correct that just as often, tics will get better with stimulant treatment as they will get worse, if not more frequently.
Dr. Max Wiznitzer: Some people have heard anecdotal reports of death or adverse events such as cardiovascular or cardiac problems, but the research work has shown that these basically it's just anecdotal. There's doesn't seem to be an increased signal in both pediatric and adult studies of this event occurring. On the other hand, areas where people do raise other areas of concern about issues of abuse and diversion. Can you comment on that?
Dr. Russell Schachar: On that on abuse and diversion? Let me first comment on the coincidence of sudden cardiac death. It is just a statistical nightmare to try and find an association between a common phenomenon, a really rare phenomenon, like sudden cardiac death. You're absolutely correct. Looking in depth at the available literature does not make it look like there's a particular relationship between the two.
Dr. Max Wiznitzer: That implies that we have a normal heart in these individuals. Obviously, if a child or adult has preexisting heart problems, we always have to, we, at my medical center clear it with their cardiologists before we start any treatment for ADHD just to make sure that we may not have the potential for some adverse event that would occur that we have not foreseen.
Dr. Russell Schachar: Absolutely. I mean, I work in a pediatric hospital as well. I see children with cardiac abnormalities. That's one of the issues that comes to my clinic. For the most part, and almost in total, no cardiologist has ever told me not to use stimulant medication. I will tell you, anecdotally, I presented at a cardiac conference a number of years ago, and there met a child with a heart transplant who was treated with stimulant medication. I felt anxious shaking his hand, but his cardiologists and psychiatrists had felt that it was quite appropriate. When I discussed it with him and he said that it was a lifesaver. He was much more able to function in school and socially with the stimulant medication, regardless of the fact that he had had a heart transplant.
Dr. Max Wiznitzer: What about abuse and diversion?
Dr. Russell Schachar: I think one mustn't be naive about the potential of abuse and diversion. When it comes to abuse, it depends a little bit about what you mean by abuse. There are individuals, especially older teens and young adults, maybe even older individuals, adults, will use the medication in a way that is not prescribed by you and may not even be approved by you if you knew about it. Sometimes you do find out about these things. These would be individuals who will take repeated high doses of stimulant medication to get through exams or blitzes of studying at school or use them in a workplace situations where they might otherwise not.
Then there are people who use these medications to enhance the effects of other street drugs, nonprescription drugs, but for the most part, nonprescription drugs are somewhat easier to get your hands on than stimulants. The risk for substance abuse is more manifesting, let's say, early onset of cocaine use in individuals than it is in the use of diverted stimulant medication.
Dr. Max Wiznitzer: Does treatment of ADHD change the risk for abuse?
Dr. Russell Schachar: There is some evidence that that's true, that the risk of abuse is reduced by adequate treatment of ADHD. That involves the use of stimulant medication. There you have a paradoxical effect. You're not increasing the risk of substance abuse with stimulant medication. If anything, you're decreasing it.
Dr. Max Wiznitzer: One of the areas that people are always concerned about is using the medications, as we would say, off label, which means outside of what was originally recommended in the packages or with the medication. We know that there's research work that's been done in the preschool years that shows the effectiveness of medication for ADHD. Predominantly it's been methylphenidate products that have been used, although the effects, the effect size, how powerful the effect is may not be as great and there's a greater risk for adverse effects in relationship to the childhood and the adolescent years. What's been your experience in that regard?
Dr. Russell Schachar: My experience is that a stimulant medication can play a role in the severely affected preschool child. We want to proceed with caution in coming to the point where you use stimulant medications for the very young. In fact, the use of stimulant medication for anybody should be done only after careful consideration of the diagnosis, comorbidity and all other options for intervention. Having said that, there is a place for them in the preschool child, and the general medical old adage of start low and go slow, which works just fine in that context.
Dr. Max Wiznitzer: When I first started in medicine, I was taught that ADHD, basically what, the way when you were 16 years old and therefore, you didn't need to be on medication after that time. Over the years, we obviously know that that is not true. When we're looking at the older adolescent, the college student, the adult who requires intervention and treatment, what medications do people typically go towards as their choices?
Dr. Russell Schachar: A couple of questions in that question. The first about ADHD going away. You're right, it doesn't go away. One of the things we haven't commented on is the fact that the evidence so far is not entirely clear on how much of a change in life trajectory is achieved by treatment with stimulant medication through the school-age years. When that's raised in my office, I suggest even if your outcome is not substantially altered by the use of stimulant medication, and this goes for any other intervention, if it can offer you a reduction in impairment and suffering in the short run, it is more than worth it. I mean, most of medicine, I mean, the definition of medicine in a way is assuaging human suffering. When we cure diseases, that's a bonus, but along the way, we are helping people have a better life in the here and now, as well as in the future.
Now, the real question you asked me is what do people use in later life. I think that people use very much the same treatment algorithm in later life as we use in younger individuals. There is more use of immediate release medication to tailor and tinker with the time course of effects over the course of the day or over the course of the week. That's in part because older individuals can start to tell you more clearly when they need or want the effect, the beneficial effect of stimulant medication and when they don't. Children who say, the teens who say, "I prefer to play hockey on Thursday night without a stimulant medication, but Tuesday and Wednesday is a heavy homework night and the long-acting, the controlled-release medication that I take in the morning wears off by three or four in the afternoon," and so we talk about adding an immediate release dose of medication to that regime.
There are many permutations and combinations. As individuals get older and as families gain more experience in the treatment with stimulant medication, my practice is to do more education along these lines, because it's just not possible for them to run back to the office or even email for that matter to ask if they can make a minor dosage adjustment, a change in the timing of the dose, or a small increase in the dose of the medication. Within certain parameters, I actually encourage that, but then I do follow my patients regularly so I'm learning about what's going on, and if they've taken a wrong turn, I can correct it.
Dr. Max Wiznitzer: What is the value of pharmacogenomic testing for management of medication on ADHD?
Dr. Russell Schachar: Well, the vast majority of medication of ADHD is stimulant medication. There, we know that so far, there is nothing available that really tells us whether you're going to benefit from this drug or that drug or what dose you might benefit from. In part, pharmacogenomics is a fabulous idea for a variety of reasons. If you take the problem of treating depression with antidepressants, where an adequate course of treatment may take six weeks, and there are plenty of adverse effects, and the pain of continued depression as you cycle through all of the different potential antidepressants, if you knew you could predict or narrow the range of possible beneficial drugs using pharmacogenomic assessment, that would be a great help. With stimulant medication, you can actually cycle through pretty much all of the preparations in a matter of weeks if someone is not benefiting and needs urgent attention. The added benefits, if you look at it from a public health perspective, the added benefit for the added cost is becomes less.
Dr. Max Wiznitzer: In addition to the use of medication, many families pursue other options. They look at what we would call complementary and alternative treatments. They look at diet, food colors and additives, vitamin supplements, micronutrients, omega fatty acids, and whatever the flavor of the week is in that regard. What's been your experience in terms of the impact of any of these interventions in terms of the long-term management of ADHD?
Dr. Russell Schachar: Well, in terms of short-term management, there is evidence that some children respond badly to food additives, colorings in particular. I discuss this with the families. This is actually a perfect example of how a family should refer to information that's available through the NRC or CHADD, to find out more about what is truly known about these different approaches to managing ADHD.
In the long term, what I find is that the families are completely unable to sustain any one of these interventions. I mean, children swap lunches. They go to people's houses. They go to birthday parties. They eat whatever, and parents have an extremely difficult time controlling children's diets. In practice, it can be almost impoverishing for some families to try and manage ADHD with diet. If I have a family who is convinced that they are seeing beneficial effect, I encourage them to continue.
Dr. Max Wiznitzer: There is ongoing research that's now being done, looking at some of these complements in terms of treatments. I think we have to wait for the final word on some of them. When we do actually the well-designed scientific studies, the randomized placebo controlled studies, that would be much more informative than anecdotal reports, which can clearly be influenced by bias and by other factors that basically can color the interpretation of the response by any individual.
Dr. Russell Schachar: Placebo has a very strong effect, and it can be, in the spirit of doing whatever you can to help the child, you're not setting public policy. You're treating a single patient, the one who's sitting in front of you at that moment. If you suspect there's a strong placebo effect to some dietary intervention, and it's not having an adverse effect on the family or on the child, it's probably not wise to interfere with it by disabusing the family of its potential benefits.
Dr. Max Wiznitzer: I think we agree that the use of medication is part of the entire package of intervention, a package that would include the behavioral interventions, interventions in the school and the work setting, education of the family and the affected individual, in addition to the use of medication. That is something that we have to continue to stress that it's not just a single modality that will typically get us to one place, because not all the associated conditions with ADHD respond to some of these medications. We have to basically look at it as the entire package. That way, at least from my view, I think that the individuals have the best chance for success.
Dr. Russell Schachar: Absolutely. I think that for those in this audience who are going to find themselves in a general pediatric practice or in a family medicine practice, they should anticipate that their role is to monitor the course of development for a young child with ADHD; that their transitions will be difficult, that things will be better at times and worse at other times, that this is all part of the natural history of ADHD. They could do well to anticipate these kinds of nodal events and work with families in anticipation of them. That is an extremely valuable role in the general healthcare system, because there are really no alternatives, but to have the case coordination done in that way.
Dr. Max Wiznitzer: We have to remember also families should utilize outside resources, such as those provided by CHADD and the National Resource Center on ADHD, as well as resources that are provided by professional organizations. Well, thank you, Dr. Schachar. It's been a very informative discussion and I hope our listeners get out of it as much as we did. This is the conclusion of our podcast on medication management of ADHD with doctors Max Wiznitzer and Russell Schachar.
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