Medications for Treating ADD / ADHD

Medications for ADD/ADHD

Although the causes of ADD/ADHD are not fully understood, most specialists believe that chemical imbalances in the brain play a major role. Medications work by correcting this imbalance. Author and ADD specialist Dr. Gabor Maté offers the following explanation of how medication works for people with ADD/ADHD:

• Even though people with ADD/ADHD are often hyperactive, their brain waves are slower at times when they would be expected to be faster (such as when reading or attempting demanding tasks).
• Like a policeman directing traffic at a busy intersection, the brain's prefrontal cortex sorts out and organizes sensations coming from the body and the environment, inhibiting those that are not useful in a given situation. When the prefrontal cortex does its job, there is order
• In people with ADD/ADHD, the prefrontal cortex is like a policeman asleep on the job. Sensory information floods in without being filtered or prioritized. The result is an unfocused, scattered mind. Traffic is gridlocked.
• ADD/ADHD medications wake the policeman up, allowing the prefrontal cortex to do its job and direct traffic more efficiently.

But while medications for ADD/ADHD can help improve concentration and behavior, they should never be the exclusive treatment pursued. Medication works best when combined with other types of treatments, such as counseling, behavior therapy, classroom accommodations, and relaxation techniques.

Safety concerns

Hyperactive children are regularly put on Ritalin and similar drugs that appear to work miracles on the disruptive and impulsive behaviors that are characteristic of ADD/ADHD. Many scattered adults also find new focus and drive when taking stimulant drugs. But despite the benefits, concerns about the safety of these medications remain.

Long-term effects of ADD/ADHD medication

Ritalin was introduced in the 1950s as a treatment for narcolepsy (a condition in which a person suddenly falls asleep), and began being used for ADD/ADHD in the 1960s. But 40 years later, Ritalin and other stimulants still have yet to be studied for their long-term safety and effectiveness.
According to the Canadian Medical Association the average drug trial for Ritalin is just 3.3 weeks. In contrast, people with ADD/ADHD may take the medication for years—even decades. Yet the impact of such long-term use is unknown. For children and young adults, whose brains are still developing, long-term use may cause permanent neurological changes. Some studies also suggest that stimulants can stunt kids’ growth. Finally, there may be an increased risk of addiction and abuse with prolonged stimulant use.

FDA Warning

In February 2007, the U.S. Food and Drug Administration ordered drug manufacturers to add warning labels to all ADHD stimulant medications. The warning label highlights the following safety concerns:

• Heart-related problems – ADD/ADHD medications can cause sudden death in children with heart problems. They can also cause strokes, heart attacks, and sudden death in adults with a history of heart disease. ADD/ADHD stimulant drugs should not be used by people with heart defects, high blood pressure, heart rhythm irregularities, or other heart problems. Additionally, anyone taking stimulant medication should have their blood pressure and heart rate checked regularly.
• Psychiatric problems – Even in people with no history of psychiatric problems, stimulants for ADD/ADHD can trigger or exacerbate hostility, aggressive behavior, manic or depressive episodes, paranoia, and psychotic symptoms such as hallucinations. People with a personal or family history of suicide, depression, or bipolar disorder are at a particularly high risk, and should be carefully monitored.

Because of the physical and mental health risks, the FDA recommends that all children and adults considering ADD/ADHD drug treatment consult with a doctor first. A doctor can take a full and detailed medical history and develop a treatment regimen that takes any health problems into account.

Stimulant medications for ADD/ADHD

Stimulants are the most common type of medication prescribed for ADD/ADHD. Stimulants also have the longest track record for treating ADHD and the most research to back up their effectiveness. Although some stimulants have been approved for children as young as age 3, most are recommended for ages 6 and older.

Stimulant medications used for ADD/ADHD include:

• methylphenidate (Ritalin, Concerta, Metadate, Daytrana)
• amphetamines (Adderall)
• dexmethylphenidate (Focalin)
• dextroamphetamine (Dexedrine)

As their name indicates, stimulants work by stimulating the central nervous system. In particular the ADD stimulant drugs increase dopamine levels in the brain, either by releasing the neurotransmitter directly or blocking its reuptake. Although counterintuitive, stimulants actually have a calming effect on people with ADD/ADHD. They help curb hyperactivity, increase attention and focus, and reduce impulsive behaviors.

Stimulants for ADD/ADHD come in both short and long-acting formulations. Short-acting stimulants peak after several hours, and must be taken 2-3 times a day. Long-acting stimulants last 8-12 hours, and are usually taken just once a day. The table below lists some of the common short and long-acting medications prescribed for ADD/ADHD. Note that these are average ranges for the peak effect and duration of action of each medication. Since people metabolize medication at different rates, you or your child’s response may fall at any place on the spectrum, or even slightly off of it.

Stimulant Medictions
Brand name	Generic Name	Frequency	Peak Effect	Duration
Adderall	amphetamine mixed salts	2-3 times a day	1-3 hrs	4-6 hrs
Adderall XR	amphetamine mixed salts	Once in a.m.	1-4 hrs	8-12 hrs
Concerta	methylphenidate HCL	Once in a.m.	8 hrs	8-12 hrs
Dexedrine	dextroamphetamine sulfate	2-3 times a day	1-3 hrs	4-6 hrs
Dexedrine Spansules	dextroamphetamine sulfate	Once in a.m.	1-4 hrs	6-9 hrs
Focalin	dexmethylphenidate HCL	2 times a day	1-4 hrs	2-5 hrs
Metadate	methylphenidate HCL	Once in a.m.	5 hrs	8 hrs
Methylin	methylphenidate HCL	3 times a day	1-3 hrs	2-4 hrs
Ritalin	methylphenidate HCL	3 times a day	1-3 hrs	2-4 hrs
Ritalin SR	methylphenidate HCL	1-2 times a day	3 hrs	5 hrs
Adapted from: Northern County Psychiatric Associates

Long-acting stimulants, identified by the terms “extended release” or “sustained release,” are a good option for forgetful children and adults who have difficulty remembering to take multiple doses of medication. However, you may prefer a short-acting stimulant if you want more control over you or your child’s dosage, with the option to take a little more or less as needed.

Side effects of stimulants

The side effects of stimulants most commonly include:

Nervousness Difficulty sleeping Loss of appetite Weight loss Headaches Upset stomach Nausea or dizziness

Racing heartbeat Restlessness, agitation Irritability, mood swings  Lack of spontaneity Social withdrawal Depression Tics

But while all ADD/ADHD medications have side effects, some people are able to tolerate the long-acting formulations better. Long-acting stimulants don’t cause as many “peaks and valleys,” since the medication builds more gradually in the bloodstream and then wears off slowly. As a result, side effects and the rebound effect—the return of symptoms as the drug wears off—are milder.

Non-stimulant medications for ADD/ADHD

Stimulants don’t work for everyone with ADD/ADHD. For some, stimulants do little to help symptoms. For others, they cause intolerable side effects such as insomnia and anxiety. And for people with heart conditions, stimulants can be life threatening. However, there are other options to consider.

Strattera

Strattera, also known by its generic name atomoxetine, is the newest medication approved for the treatment of ADD/ADHD. Unlike the stimulant medications, which affect dopamine levels, Strattera increases levels of norepinephrine.
Strattera is longer-acting than the stimulant drugs, with its effects lasting over 24 hours—making it a good option for those who have trouble getting going in the morning. Since it has some antidepressant properties, it’s also a top choice for those with co-existing anxiety or depression. Another plus is that it doesn’t exacerbate tics or Tourette’s Syndrome, as the stimulants often do. On the other hand, Strattera doesn’t appear to be as effective for symptoms of hyperactivity.

Common side effects of Strattera include:

Loss of appetite Drowsiness Headache Stomach upset Nausea, vomiting Dizziness

Dry mouth Mild diarrhea or constipation Problems sleeping Sexual side effects Difficulty urinating Agitation or irritability

Other ADD/ADHD medications

• High blood pressure medications for ADD/ADHD – Blood pressure medications known as Alpha-2 adrenergic agonists can be used to treat hyperactivity, impulsivity, and aggression. Options include clonidine (Catapres) and guanfacine (Tenex). They are especially beneficial in children with Tourette’s Syndrome, since they may suppress tics. However, they don’t help with symptoms of inattention.
• Antidepressants for ADD/ADHD - For people suffering from both ADHD and depression, antidepressants such as bupropion (Wellbutrin), reboxetine (Edronax), and venlafaxine (Effexor) are often prescribed. These atypical antidepressants target multiple neurotransmitters in the brain, and can help with symptoms of depression, inattention, and impulsivity.

Deciding if medication is right for you or your child

If the symptoms of ADD/ADHD are causing significant problems for you or your child, then medication may be a treatment option. But remember that the decision to take ADD/ADHD medication is a personal one. Make sure it’s the right choice for you, and don’t let anyone—be it your physician or your child’s school—pressure you into it if you’re not comfortable with it or ready to take that step.

Questions to ask your doctor:

• Is it really ADD/ADHD that is causing the symptoms?
• What is the diagnosis?
• What medication do you suggest?
• What are the side effects?
• What are the risks?
• Are there any foods or other medications I will need to avoid?
• How long will I have to take this medication?
• Is withdrawing from this mediation difficult?
• What non-drug treatments may help?

ADD/ADHD medication guidelines

To maximize the effectiveness of medication for ADD/ADHD and to minimize the side effects and risks, it’s important to take the drug as directed. Here are some additional guidelines for safe use:

• Educate yourself. Learn everything you can about the medication, including potential side effects.
• Be patient. It takes time to develop an effective medication regimen. Finding the right medication and dose is a trial-and-error process. It will take some experimenting, as well as open, honest communication with your doctor.
• Start small. It’s always best to start with a low dose and work up from there. The goal is to find the lowest dose possible that relieves you or your child’s symptoms.
• Monitor the drug’s effects. Pay close attention to your body, emotions, and actions. Keep track of any side effects you’re experiencing and monitor the medication’s effectiveness in reducing ADD/ADHD symptoms.
• Taper off slowly. If you don’t like the way the medication makes you feel and want to stop taking it, get specific instructions from your doctor. You should never quit cold turkey. To avoid withdrawal symptoms, these drugs need to be tapered off, not stopped suddenly.

Managing Side Effects in Kids

Side effects are common in kids who take stimulant medications. Here are six common side effects, along with the strategies that may help alleviate them.

Loss of appetite, weight loss

• Record your child's weight in your medication log every six months.
• Give stimulant medications at mealtimes. Offer high-calorie snacks, like ice cream, in-between meals.

Growth problems

• Record your child's height in your medication log every six months.
• Attempt weekend and vacation drug holidays.

Trouble falling asleep

• Administer the stimulant earlier in the day.
• Change to a short-acting form of the stimulant.

Dizziness

• Have your child's blood pressure checked.
• Increase your child's fluid intake.
• Switch to an extended-release medication.

Irritability, sadness, moodiness, or agitation 1-2 hours after administering the medication

• Lower the dosage.
• Have your child assessed for depression and other problems.

Sadness, irritability, or worsening of ADHD symptoms as the drug wears off

• Change to an extended-release form of the stimulant.
• Overlap stimulant dosing, usually by 30 minutes.

Source: ADDitude

Related links for ADD/ADHD medications

General information about ADD/ADHD medications

Attention-Deficit Hyperactivity Disorder: Medications – Covers common ADHD medications for children and adults, including side effects, long-term complications, and concerns for abuse. (University of Maryland Medical Center)

ADHD Treatment: Your Guide to Common ADD Drugs - Find answers to parents' top 10 questions about the ADD/ADHD medications. (ADDitude)

An Update On Medications Used In The Treatment Of Attention Deficit Disorder –  Article by John Ratey, M.D., assistant professor of psychiatry at Harvard Medical School, on ADD drugs. (Attention Deficit Disorder Association)

Stimulant Medication and ADHD – In-depth article on stimulants for ADD/ADHD, including side effects, treatment guidelines, and effectiveness. (Northern County Psychiatric Associates)

ADHD Medications – Article written for teens about ADHD medications and their safety. (Nemours Foundation)

Side Effects and Safety Concerns

ADHD Medications: Are They Safe? – Q&A covers the FDA’s black box warnings and other safety concerns regarding ADD/ADHD medications (Mayo Clinic)

FDA Asks Attention-Deficit Hyperactivity Disorder (ADHD) Drug Manufacturers to Develop Patient Medication Guides – Overview of the FDA’s requirement for ADHD drug labels, with links to each specific medication. (U.S. Food and Drug Administration)

Early Ritalin Exposure May Cause Long-Term Effects on the Brain – A new study suggests that the misdiagnosis of ADHD combined with prescription drug use in children may lead to a higher risk of developing depressive symptoms in adulthood. (McLean Hospital)

ADD/ADHD Medication Guidelines

ADD Drugs 101: Stimulant Strategies – Guidelines for taking ADD/ADHD stimulant medications safely and effectively. (ADDitude)

ADD Drugs: Say No to Side Effects – Guide to finding the right medication for you or you child and minimizing side effects. (ADDitude)

What If Einstein Had Taken Ritalin? – Examines the effects of Ritalin and other ADHD drugs on active kids and questions what effects these drugs might have had if some famous people had taken them. (Overmatter.com - reprint of Wall Street Journal article)

Melinda Smith, M.A., Robert Segal, M.A., Jaelline Jaffe, Ph.D., and Jeanne Segal, Ph.D., contributed to this article. Last modified on: 9/15/07.