Almost one in eleven chldren in the US has been diagnosed with ADHD, making it one of the most common childhood conditions. Behavior therapy is recommended for pre-school children. But for children age six to eleven, the American Academy of Pediatricians (AAP) bluntly states, "(T)he primary care provider should prescribe FDA-approved medications."
The evidence for this recommendation is "A," the strongest evidence. AAP further states that evidence for the use of stimulants such as methylphenidate is particularly strong. Evidence for the effectiveness of behavior therapy is only "B." Evidence for three types of medication is sufficient to justify their use, according to the AAP.
Ideally, medications would be tailored to the signs and symptoms of each child. Unfortunately, such tailoring is often just a guess by the clinician; research has not definitively tied any medication to one type of ADHD, and often children display different behaviors at different times. So medication selection becomes only a general approach.
Types of Prescription Medications for ADHD
Prescription Medications for ADHD fall in two categories: approved and not approved. Approved medications are those that have been shown to be of benefit. Approved medications are of three types.
- Stimulants. Methylphenidate (MPD, available as Ritalin®, Concerta®, Methylin®, others). MPD is available in several forms. Plain MPD lasts about three to five hours. Long acting forms are available, e.g., Ritalin LA lasts eight to 12 hours. There are special instructions on how to give these medications. Focalin® is the dex-methylphenidate (hypen added), the active form of methylphenidate, and the dose is half that of methylphenidate. A trained medical librarian could find no trial that compared Focalin to MPD to compare side effects, so it can’t be said that one has fewer side effects than the other. MPD is a derivative of amphetamine, and several amphetamine medications also have been FDA approved for ADHD (Dexedrine®, Adderal®, others). All medications in this class increase brain norepinephrine and dopamine. One mechanism that may explain how they work is they increase activity in the pre-frontal lobe, which enhances control of impulsivity. Because they increase dopamine, they may increase risk of addiction. Stimulants should not be used in children with certain heart problems.
- Non-stimulant: Atomoxetine (Strattera®). This medication also increases brain norepinephrine (noradrenalin). Just as when adrenalin is running high from excitement or fear, this may increase attentiveness. It may also cause adverse effects that mimic hyperactivity. A drug warning was issued October 31, 2011, warning of possibly dangerous increased blood pressure and pulse from Atomoxetine. It also has been associated with liver damage.
- Non-stimulant: Guanfacine (long-acting form) (Intuniv®) It stimulates alpha-2 receptors. It inhibits norepinephrine in the brain (note this is the opposite of the medications above). It may increase prefrontal inhibition of undesirable behavior and allow desirable behavior to persist.
The above are medications approved by the FDA to treat ADHD. That means evidence has been presented that they do provide benefit, and the risks are comparatively acceptable. Another drug mentioned by AAP as having "sufficient" evidence to justify its use is clonidine. In long time use in adults for high blood pressure, clonidine acts similarly to guanfacine—it stimulate alpha-2 receptors and inhibits norepinephrine in the brain. In the evening, it may help with sleep. Sudden stopping the medication may cause serious high blood pressure.
Other Drugs Not Approved by FDA for Use in ADHD
These drugs are not recommended by the AAP or approved for ADHD by the FDA. Users should know that their effectiveness not been established, and the risks may exceed any benefits.
- Drugs that increase brain norepinephrine: (1) bupropion (Welbutrin). This drug also increases dopamine. (2) Tricyclic Antidepressants (many brands): They have many potential adverse side effects.
- Drugs that increase brain serotonin: SSRIs (Prozac®, Zoloft®, others). Approved for children with obsessive compulsive disorder.
- Drugs that affect dopamine: antipsychotics (Risperdal®, Seroquel®, others). These drugs decrease dopamine effect in the brain. Note this is the opposite of stimulant drugs. Antipsychotics have been associated with brain atrophy (shrinkage).
Summary
As can be seen, these drugs either increase or decrease one or another of certain chemicals in the brain. They may have that effect on different t parts of the brain, producing different effects, and there are individual sensitivities to the different medications. All this adds up to the distressing need for parents, patients and clinicians to have patience in searching for the best treatment.
Guidelines from the AAP are for children with ADHD but not with comorbidities (additional psychiatric or neurologic problems). In those cases, other guidelines may be more appropriate.
Parents should check PubMed Health for detailed information about each medication, including how to take it, side-effects, and interactions.
Sources
American Academy of Pediatrics
Product Information from manufacturers (Package Inserts, or PIs)
James Cooper - I'm on the faculty of a health science department at a large university. Most of my articles derive from conferences or presentations ...
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