Do We Really Have to Go There? ADHD Meds and Children

Let’s be honest.  Most parents—at least the ones I know—simply don’t want their children to take medications to regulate emotions or behaviors.  To knock out an ear infection?  Sure, meds are okay.  To manage asthma or allergies?  Sure, meds are acceptable.  But to manage emotions or behaviors?  Screech.  No.  Something about that doesn’t sit well with a lot of people—it kind of sets their teeth on edge, and I get it.  Parents have all sorts of concerns and fears about the immediate and long-term effects of medications on their children.   

My name is Dr. K, and I’m a general as well as child and adolescent psychiatrist based in the Southeast.  I’ve been creating brief videos to provide education about mental health conditions, and today I am going to talk about the use of medication for the management of ADHD symptoms in children.  

Now one reason that parents may have concerns about using medications to manage emotions or behaviors is that emotional or behavioral disorders are not seen as biological problems.  Infections are biological in nature, so you treat them with medications.  Asthma and allergies are biological in nature, so you treat them with medications.  Right?  Well, over the few decades, there have been new discoveries about the biological roots of mental illness.  What research has shown is that changes in the structure, function, and communication between various parts of the brain—through chemical messengers, circuits, networks—can lay the groundwork for the development of mental illness.  Medications, therapy, and other interventions can affect the biological functioning of the brain to help a person better regulate emotions and behaviors.  Now with this in mind, I want to dive deeper into a discussion about medication use for the treatment of ADHD.  ADHD is one of the more common mental disorders that affect children and adolescents, and I often have parents I know on a personal level—outside of clinic—ask me casual advice about potentially using medications for the treatment of ADHD in their children. 

First, let’s start with the standing recommendations: 

The American Academy of Pediatrics recommends parent training for behavioral management of ADHD symptoms in children less than six years old. 

For children older than six years old, a combination of medication and behavioral therapy are recommended for treatment of ADHD.   

Prescription medications approved by the FDA for the treatment of ADHD can be broken down into two main categories: stimulants and non-stimulants. 

Today, I’m going to talk about stimulant medications. 

Stimulant medications are considered the first line treatment for ADHD for multiple reasons. 

Number one:  they have the most research behind them supporting them as a safe and effective treatment for ADHD, 

Number two:  for about 70%-80% of children with ADHD, this class of medication works. 

Number three:  these medications work fast.  Usually, within 30-60 minutes, the medication starts to take effect.  When the right dose of stimulant medications is found, you should notice an improvement in focus and a decrease in hyperactivity, impulsivity, and distractibility.   

Now, there are two categories of stimulant medications.  On this side, you have the methylphenidate category.  On this side, you have the amphetamine category.  And within each category there are over a dozen different formulations, so there are a lot of options out there.  

Both the methylphenidate category and amphetamine categories work to do pretty much the same thing--increase the availability of dopamine and norepinephrine in parts of the brain that are important for attention, concentration, planning, and impulse control.  Now, if you’ve watched the other ADHD videos I’ve posted, dopamine and norepinephrine are thought to be decreased in amount, availability, or capacity in ADHD.  Dopamine and norepinephrine serve as chemical messengers that work within different parts of our brains and different networks of our brains that help us dismiss distractions, control ourselves, work toward our goals, and figure out what’s the most important stuff we need to get done.   

Now these two categories of ADHD medications--methylphenidate and amphetamine—appear to be roughly equal in how effective they are, although there may be some evidence that amphetamine preparations may be slightly more effective. Still there aren’t enough studies to clearly say that amphetamine-based medications are better than methylphenidate-based medications. 

The benefit of having multiple different formulations is that you can pick the medication that best serves your child’s needs.  The majority of the formulations are oral, but there are ADHD medications delivered through patches applied to the skin.  This is particularly helpful for people who do not like to swallow pills.  Also, the medication stays active in the system for as long as the patch is properly applied to the skin, and once the patch is removed, the medication remains active for another two hours or so.  There are also liquid and chewable formulations for those who have a hard time swallowing pills.  For individuals with ADHD who really struggle with symptoms interfering functioning early in the morning, there is a stimulant formulation that can taken in the evening so that on awakening, it’s actively treating ADHD symptoms.  Also, formulations differ in the length of time that they are effective.  Some last 4-6 hours, some 8-10 hours, some 12-16 hours.  Formulations also differ in the amount of medication that is delivered at a given time of day.  Some longer acting formulations release 20-30% of the medication within an hour of a child taking it and then release the remainder about four hours or later.  This can be helpful for a child who has more academic demands later in the day.  Other formulations may release 50% of the medication within an hour of a child taking it and the other 50% four or so hours later.  This type of formulation can be helpful for a child who has more academic demands in the first part of the day. 

Stay tuned for the next part of the talk about ADHD medications.  I plan to discuss potential side effects and ways of potentially managing those side effects. 

I’m Dr. K, and this has been Mental Health | Plain Speak.  I hope this content has been helpful to you in some way.  And as always, remember to “Be kind, for everyone you meet is fighting a hard battle.”