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It has been shown in numerous studies that stimulant medication provides significant benefit to between 70 and 80% of children with ADHD. The most commonly prescribed medication used to treat ADHD is Ritalin (the generic form is called methylphenidate), although other stimulant medications are also used including Adderall, Dexedrine and Cylert. Available evidence suggests that stimulants work by correcting a biochemical condition in the brain that interferes with attention and impulse control.
What benefits can stimulant adhd medication produce?
The beneficial effects of stimulant adhd medication treatment can be dramatic. Attention to class work can improve to the extent that the child is no longer distinguishable from classmates; activity level can decline to within normal limits and impulsivity can be substantially reduced. Even associated difficulties such as disruptive behavior and peer relationship problems sometimes show dramatic improvement. Interactions between parent and child and between the child and his or her siblings have also been shown to improve. Academically, many children show clear improvements in the quantity and quality of the work they complete. It remains to be seen, however, whether these short term changes result in long term gains in children's academic, behavioral, and social functioning.
How long does it take stimulant adhd medication to work?
The effects produced by stimulant medication occur quickly, and parents and teachers often observe an improvement in the child almost right away. The beneficial effects of stimulant medication vary in length depending on the child and the type of stimulant, (i.e. Adderall, Dexedrine, and Cylert last longer than Ritalin) but are generally gone within 3-8 hours. For this reason, children often require several doses during the day. "How extensively has the use of stimulant medication been studied?" The efficacy and safety of stimulant medication for treating ADHD have been documented in over 150 controlled studies involving children, adolescents, and adults. Despite the impressive empirical support for stimulant treatment, several cautions should noted. These include the following:
Most studies have been conducted with school age children and the available evidence with other age groups is more limited. Stimulants appear to be quite effective with adolescents but less helpful with most preschoolers. Available data indicates that many adults with ADHD will also benefit.
Over 80% of studies done prior to 1997 examined the efficacy of methylphenidate (the generic name for Ritalin) and few well controlled studies on other stimulant medications To date, however, there is little evidence of differential effectiveness for different stimulants.
Almost all studies are very brief - not more than a few weeks duration at most - and the magnitude of long term benefits resulting from stimulant medication treatment are not clearly documented.
Most studies have been restricted to Caucasian males and less is known about the efficacy and safety of stimulant medication with females and minorities. To date, however, there is no reason to expect substantially different results in these populations.
What kinds of side effects are associated with stimulant adhd medication?
As with any medication, stimulant adhd medication used in treating ADHD can produce adverse side effects in some children. These can include: sleep difficulties, stomach aches, headaches, appetite reduction, drowsiness, irritability, nervousness, and excessive staring among others. In rare cases, stimulant medication can lead to nervous tics, hallucinations, and bizarre behavior.
The list of possible side effects can be scary to parents considering the use of medication for their child, but it is important to emphasize that the vast majority of children with ADHD experience no adverse effects. Based on the findings from many carefully controlled studies, physicians have concluded that when properly employed stimulant medication is safe and the side effects are minimal. When side effects do occur they are frequently short lived and often disappear when the dosage is reduced. Despite these data, however, it is obviously important for parents to discuss their questions and concerns with their child's physician.
But I've heard all kinds of bad things about using Ritalin?
There are a number of myths concerning stimulant medication that discourage many parents from considering its use for their child. These myths are summarized in an excellent book titled Attention Deficit Disorder and Learning Disabilities: Realities, Myths, and Controversial Treatments by Barbara Ingersoll and Sam Goldstein (highly recommended) and include the following:
- * Children treated with stimulant medication will become addicted to it and are more likely to abuse other drugs.
- There is no data which indicates that addiction to stimulant medication is a problem or that children treated with stimulants are more likely to abuse other substances.
- * Stimulant medication stunts growth. The available literature indicates that ultimate height appears to be unaffected if treatment is discontinued in adolescence. However, there have been no studies of growth in children treated continually from childhood into young adulthood so caution here is warranted.
- * Stimulant medication works by turning children into "zombies". Some children do become sluggish and withdrawn when on medication, but these symptoms generally indicate that the dose is too high, or that a co-existing condition such as a mood problem has not been identified.
- Studies have shown an increase in prosocial behavior in ADHD children treated with stimulants, which would not be the case if it simply turned children into "zombies".
***Factors to consider in deciding on the use of medication***
* What other interventions have already been tried?
Some children with ADHD can have their symptoms effectively managed via other means including appropriate behavioral and educational interventions. If you are concerned about using medication with your child, make sure that non-medical interventions have been tried first. This is an important issue to discuss with your child's physician.
* How much difficulty are the child's adhd symptoms actually creating?
The degree of impairment in academic, social, and behavioral functioning caused by ADHD can vary substantially. If the impairment experienced by your child is on the modest side, medication may not even be necessary.
* What is the child's attitude towards taking medication?
It is very important to discuss the rational for using medication with the child. The child needs to know why it is being suggested and how it can be helpful. This is especially true for older children and adolescents, who may have concerns about being teased should their peers find out that they are taking medicine. If children have strong objections to taking medication, these should be discussed and understood. Should these objections persist, using medication may not be productive.
* Will objective information about the effects of medication be provided?
In my opinion, this is critical. Despite the well documented benefits of stimulant medication, as many as 20-30% of children do not experience significant benefits. In addition, many parents are surprised to learn that when children with ADHD receive only a placebo (i.e. medication that appears to be the real thing but is not), teachers frequently report significant improvement in the child's behavior. This means that some children may receive stimulant medication for a sustained period even though they derive no objective benefit from it, or fail to receive the most beneficial dose.
"So how do I know for sure that the medication I really helping my child?"
Fortunately, it is not hard to conduct a careful trial that provides more objective information about a child's response to medication. This is accomplished by having the child receive different medications doses as well as a placebo over a 3-4 week period. At the end of each week, the child's teacher completes ratings of the child's behavior and academic performance. Because neither the child nor the teacher know what the child was receiving each week during the trial, the teacher's ratings provide more objective information. By comparing the ratings made each week one can determine whether:
- * medication was clearly superior to placebo;
- * what dose produced the optimal response;
- * whether any adverse side effects were observed (sometimes children report what appear to be side effects when they are only getting a placebo);
- * what problems with behavior and academics may remain even if medication clearly helped, and which need to be targeted via other means.
This procedure provides more reliable and objective information that can be used to decide about the benefits of ongoing medication use. Unfortunately, many physicians do not gather objective feedback and rely on anecdotal reports to base medication decision on.
If you are considering adhd medication for your child, and would like to gather objective information about it's effectiveness, I will send you the program I have developed to conduct careful medication trials. This includes the forms and instructions needed to conduct the trial, which needs to be implemented in cooperation with your child's doctor. At the end of the trial, you mail me the completed forms and I will send a report of the results to your child's physician that will address the issues outlined above.
This program can also be used to re-evaluate the effectiveness of medication for a child already receiving it. It works best with elementary school children, but can also be used with middle school children if there are teachers who know your child well.
To receive the packet, send your name and address to:
ADHD Assessment Services
4711 Hope Valley Rd. - Suite 207
Durham, NC 27707
Please include a check for $5.00 to cover the cost of the materials and postage. I will prepare the report at NO CHARGE. This will be helpful to you in deciding about medication for your child and will help me introduce this service to physicians around the country.
Because the effects of stimulant medication generally wears off within 3-8 hours, two doses per day - one before school and one at mid-day - is quite common. Some children are able to get by with only a single administration per day, while some may require a third dose to help with after school activities and homework.
"Do children with ADHD need to take medication on weekends and over vacations?"
For children whose symptoms are relatively mild, medication during the school day may be all they require. Unfortunately, some children have more severe forms of the disorder and may require medication to be successful in settings outside of school. In part, this will also depend on the effectiveness of other treatments that have been implemented. It is very unfortunate that changes in the insurance industry often prevent children from getting access to psychosocial treatments that can be very helpful.
"For how long do children with ADHD need to take medication?"
The best answer to this question is that a child should take medication for only as long as it is helpful and necessary. For some children with ADHD, symptoms dissipate over time to the point where medication is no longer necessary. Many other children struggle with ADHD symptoms into adolescence and young adulthood, however, and may benefit from medication during many years of their development. Because the need for, and effectiveness of stimulant medication may change over time, most experts recommend that this issue be re-evaluated on an annual basis.
"What other kinds of medication are used to treat children with ADHD?"
Tricyclic Antidepressants are also used in treating individuals with ADHD and the effectiveness and safety of these compounds has also been studied fairly extensively. Medications in this class of compounds include Imipramine, Desipramine, Amitriptyline, Nortriptyline, and Clomipramine.
In some cases, physicians may also prescribe other anti-depressants to treat ADHD including fluoxetine (i.e. Prozac), and bupropion (i.e. Wellbutrin). Although there is some research evidence that these medications can be helpful in treating ADHD, few controlled studies on their efficacy have been conducted to date.
"Why would antidepressants be prescribed rather than stimulants?"
In most instances, stimulant medication (generally methylphenidate) will be the drug prescribed initially. If the initial stimulant prescribed does not help, it is quite possible that another stimulant will.
Antidepressants would generally be tried if:
- * stimulant medication was not effective - before giving up on stimulants,
- physicians may try several different types;
- * even though stimulant medication reduced ADHD symptoms, there were
- adverse side effects that prevent the child from taking it;
- * there is a clear indication of a co-occurring mood or anxiety disorder
- in addition to ADHD - there is some evidence that when these additional
- difficulties are present, stimulant medication may be less effective than
"What about using dietary changes to help with ADHD?"
The idea that ADHD symptoms reflected allergic reactions to food additives was popularized by Dr. Ben Feingold, a pediatrician and allergist. Dr. Feingold speculated that reactions to certain types of food additives accounted for many cases of ADHD and that dietary modifications would help many of these children.
Unfortunately, the data to support such a claim is lacking. There are probably a small group of children who respond negatively to certain food additives, however, and who will be helped by dietary changes. The odds that an ADHD child's symptoms can be successfully treated by dietary changes would appear to be quite small.
"What about the use of natural remedies to treat ADHD?"
Over the years, a number of natural remedies to treat ADHD have been proposed. To my knowledge, however, no controlled studies documenting the effectiveness of these remedies have been conducted. This is a real problem, because in many cases, the apparent benefits reported by individuals may represent nothing more than a placebo effect.
Does that mean that these treatments do not work? Not necessarily. It does mean, however, that compelling scientific evidence for their effectiveness has not yet been provided.
***SUMMARY AND CONCLUSIONS***
* Stimulant medication has been shown to provide significant benefits to the majority of children with ADHD. These benefits include reducing core ADHD symptoms, enhancing academic performance, reducing disruptive and aggressive behavior, and improving relationships with peers and family members.
* The improvements resulting from stimulant medication are based primarily on the results of short term studies and more data on the long term effectiveness of this form of treatment is required.
* Even though a child may benefit from stimulant medication, there will often be remaining academic and/or behavioral difficulties that need to be addressed by other forms of intervention.
* Most children do not experience any prolonged adverse side effects from taking stimulant medication when it is administered properly. It is very important, however, for parents to discuss their questions and concerns with their physician and pharmacist.
* Not all children benefit from stimulants, and it is important to use an objective procedure to determine medication effectiveness.
* A child's response to medication can change over time, as can the child's need for medication. Re-evaluating these issues on a periodic basis is important.
* Tricyclic antidepressants have also been shown to be helpful in treating ADHD symptoms, and may be helpful if stimulant medications are not successful, if stimulant medications produce unfavorable side effects, or if the child has concurrent symptoms of anxiety or depression. Newer antidepressants like Prozac and Wellbutrin may also be helpful, although less work documenting their effectiveness in treating ADHD has been conducted.
* Dietary changes and natural remedies currently lack scientific evidence of effectiveness in treating ADHD.
That's all for this month. I hope this information was useful to you in thinking about medication issues with your child. I want to thank Brandi again for giving me the opportunity to communicate with you all.
David Rabiner, PhD
A couple of issues that I'd like to address in up coming newsletters are Families where one parent does not agree with the diagnosis or treatment of an add/adhd child. Many of us have been there and even more parents are finding themselves in this situation every day. Whether both parents are in the home or not, when they disagree on the diagnosis and treatment of the child, what are the options? Please send your experiences, ideas, suggestions etc to me at BrandiV@ns.net.
The next issue I'd like to address concerns our ADDults and involves the possibilities of Career Coaching. Any ideas or suggestions in this area? If you are an Addult, what areas concerning employment do you feel are the most challenging and what help would you like to have as a career minded Addult? Please send your ideas and suggestions to me at BrandiV@ns.net
That's about it for this newsletter. For those of you who might have missed an issue, I now have all the back issues of our newsletter available for you to print right off of the website.
For those of you interested in reading the transcript from Dr. Dave's online conference with Concerned Counseling, you will find it at… http://www.concernedcounseling.com/ccijournal/conference/rabineradhd.htm
P.O.BOX 473 Browns Valley, Calif 95918 FAX: 530-743-4230