For an expert's overview of ADHD medications, Orly Avitzur, M.D., medical adviser to Consumer Reports, interviewed Martin L. Kutscher, M.D., a child neurologist in Rye Brook, N.Y., who has more than 20 years of experience diagnosing and treating ADHD. He is also the author of "Organizing the Disorganized Child" (with Marcella Moran, HarperCollins, 2009) and "ADHD: Living without Brakes" (Jessica Kingsley Publishers, 2008).
How do you select which medication to start a child on?
Stimulant medications are generally considered the first line of medical treatment for a typical child with ADHD. Stimulants include amphetamine- and methylphenidate-based medications.
In general, the goal is to utilize a long-acting preparation in order to help the child through the entire school day and homework time. Children who do not respond well to stimulants, and those with co-occurring conditions such as tics or anxiety, are candidates for nonstimulant medications such as atomoxetine (Strattera) or guanfacine (Intuniv). A significant proportion of children will respond better to one medication or the other in terms of both efficacy and side effects.
How often do you see the patient in follow-up after starting a medication?
I personally see children a month or so after starting medication, with phone calls in between for any questions, adjustments, or problems. Once a child is stabilized, I usually see the child every few months. Simple questions and adjustments might be handled over the phone in between visits after that.
How often should children have their medications evaluated?
Medications are evaluated at each follow-up visit. We ask about side effects as well as effectiveness at school, homework time, morning and evening routines, and weekends. At each visit we seek clear evidence of effectiveness via feedback from parents and teachers (including comments in report cards).
Often, we keep the teachers "blinded" to the initial onset of medication use in order to get objective feedback. Once we get this objective observation of usefulness of the medication by the teachers, we let them know about the medication use so they can more effectively give feedback regarding the extent of usefulness and side effects of the medication at different times through the day.
What are the common side effects and how are they managed best?
Appetite suppression (particularly at lunch) can be handled by "frontloading" the child with a large breakfast and lots of (hopefully healthy) snacks in the afternoon and after dinner. Height and weight should be monitored by a medical professional. Stomach upset can be minimized by giving the medication on a full stomach.
Sleep onset problems are common to begin with in children with ADHD but can be exacerbated by stimulants. The occurrence of insomnia does not always correlate with the time of the last dose of medication. Sleep hygiene can be recommended, including no caffeinated drinks after dinner, a consistent bedtime routine, a calm activity before sleep, a snack, and clear expectations. Sometimes the doctor might suggest use of a medication such as melatonin, which works best if taken several hours before desire sleep time.
Irritability can occur during or after the time that the medication is working. If the irritability is occurring during the first hours of medication use, then consider a preparation with a smoother release profile, a lower dose, or another medication.
If your child is experiencing "rebound," which is a brief period of tearful, irrational nastiness as the medication level drops too rapidly in the late afternoon, then your doctor needs to provide a medical regimen that provides a smoother "tail" as the medication wears off. This can be done as above, or by adding a tiny dose of a short-acting preparation just before the rebound starts (typically some time in the afternoon). Be sure that the stimulants are not exacerbating an underlying mood disorder. I also warn the family to watch for any tics (sudden, repetitive movements).
When do you decide to change a medication?
We change medication:
- When the time frame that the child needs support with changes; for example, as the child gets more homework, we may need to switch to a longer-lasting preparation or add an afternoon dose of a short-acting preparation.
- When there are side effects that cannot be handled as above or with dose adjustments.
- When other medical or psychological conditions occur that might be better treated with a different type of medication.
If one class of drug fails, can another work?
Yes, and frequently so. This may lead to an unpleasant sensation of "experimenting" with your child, but it may be necessary.
What are the most common misconceptions about ADHD and drugs?
Short attention span. ADHD is much more than just a short attention span. If all a child needed were a tap on the shoulder every 5 minutes to return to task—and if the child said, "Thanks for the reminder! Can you please come back again soon?"—then we would not need all of these interventions.
Rather, ADHD is more powerfully conceived as a problem with the brain's executive functions. This includes the abilities to apply "brakes" to one's behavior, organizational skills, foresight, hindsight, and calmly talking to oneself. This explains the traditional view of ADHD as involving distractibility; failure to put the brakes on internal distractions results in impulsivity, and getting up to check out those distractions results in hyperactivity. However, it extends our understanding, and thus empathy, much further to include trouble with putting brakes on our reactions (leading to "overreactions") and trouble with time management.
Stimulants work "paradoxically". There is nothing paradoxical about how stimulants work in children or adults. At any age, stimulants work by waking up the person's own attention functions. Think of caffeine. We "quiet down" and get back to work after coffee break because we're now awake, not because we're too tired after drinking a cup of coffee to bother milling around the room and chatting. If we think of ADHD kids as bicycles without brakes, then think of stimulants as giving the child effective brake pads.
Stimulants cure everything. Stimulants typically do a great job at controlling attention, impulsivity, and hyperactivity, which have traditionally been thought of as forming the core symptoms of ADHD. However, medications often do not help enough in the other areas of executive function, such as organizational skills, foresight, and hindsight. That's where organizational interventions from the school and parents come in. Caring adults will likely need to provide a "safety net" of organizational support while the skills are being taught and internalized. Sometimes a tutor or coach needs to be brought in if the child does not tolerate a parent in this role.
What can parents do to help the doctor? Provide accurate feedback from the school and home as to the child's progress and problems, and stay positive and calm.