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The pros and cons of treating ADHD with drugs

Published: July 2010

Medication helps many children with attention deficit hyperactivity disorder (ADHD), but it's not a cure-all, as our survey of 934 parents revealed. We found that most of the families turned to medication—84 percent at some point. And more than half of the children in our survey had tried two or more medications in the past three years.

The children who were prescribed medication tended to be older and their symptoms more severe before treatment than those who had never tried medication. The average age of the children who had tried medication was 13, while the average age of those who had never tried medication was 10.

A closer look at ADHD drugs

The drugs usually prescribed to treat ADHD are generally effective and safe. Most children and teenagers (60 percent to 80 percent) who take them become less hyperactive and impulsive, are better able to focus, and are less disruptive at home and school. But there is no good evidence showing that these benefits last longer than about two years, and the long-term consequences of taking stimulants for years on end have not been fully evaluated in studies.

Fortunately, many children with ADHD—even when they are not treated—improve as they reach the teenage years and early 20s. But the disorder can persist into adolescence and adulthood about 30 percent to 70 percent of the time.

All of the ADHD stimulant medicines have been linked to rare cases of heart attack, stroke, and sudden death, so children should first be evaluated for underlying heart problems.

The severity of symptoms and abnormal behavior patterns in children and teenagers with ADHD varies widely. Diagnosis, too, can be quite subjective, varying from doctor to doctor. Because diagnosis of the condition can be difficult, and a variety of medical and psychiatric disorders can cause symptoms that mimic ADHD, many children and teenagers taking medication might not have ADHD or have only mild symptoms that do not require it. Be sure to get a diagnosis from a physician or mental-health professional with expertise in ADHD and a second opinion if you have doubts. Even if your child meets the criteria for ADHD, he or she might not need a drug. A pediatrician can refer you to a mental-health specialist (some specialize in ADHD), who should begin by ruling out other possible reasons for the behavior.

The most effective strategy for treating ADHD consists of more than one approach. There is some evidence that the combination of behavioral therapy with medication can work better than drugs alone for some children. But behavior therapy alone does not work for all children, especially those who have severe symptoms.

As with most disorders for which multiple medications are available, there are no definitive comparison studies to show which ones work best in specific circumstances, according to Michael L. Goldstein, M.D., a child neurologist with Western Neurological Associates in Salt Lake City, and a former vice president of the American Academy of Neurology.

Two classes of medication are available for treating ADHD:

  • Stimulant medications, such as dextroamphetamine-based drugs (Adderall, Vyvanese) and methylphenidate-based drugs (Concerta, Daytrana, Ritalin). They are also available as generics.
  • Nonstimulant medication, such as the antidepressant bupropion (Wellbutrin and generic) or atomoxetine (Strattera), which is not available as a generic.

Those medicines don't cure ADHD but they can keep symptoms under control, which may improve a person's daily functioning. Each raises different safety issues, however, which your doctor should discuss with you. Dosing convenience (taking one pill a day instead of two or more; oral solutions for those who have difficulty swallowing tablets; or the use of a patch) and how long the medicine is active are critical elements of ADHD treatment. You should be skeptical if a doctor or therapist diagnoses ADHD at the first visit and immediately prescribes a drug and should seek a second opinion.

The stimulants are controlled substances, while Straterra is not. Fewer restrictions apply to prescriptions for Straterra, and some parents think that makes it safer. If families are worried about using a controlled substance for children, Straterra might be more acceptable, Goldstein says, although many professionals think it might be less effective.

Medication was helpful

In our survey, parents of children who tried medication reported positive changes within a few days of starting amphetamines or methylphenidates. Second-line medications (Strattera) took longer to work, but most parents noticed positive changes within a few weeks. About 10 percent of the parents whose children tried amphetamines and methylphenidates said they didn't notice any positive changes.

According to the parents we surveyed, children on medication had slightly better outcomes than those who weren't. And while medication was cited as the strategy most helpful in managing ADHD (see ADHD treatments that work), parents were not very satisfied with it overall. In fact, only 52 percent of the parents agreed strongly that if they had to do it over again, they would have their kids take medication, and 44 percent wished there was another way to help their child. (See Parent satisfaction with medication below.)

Medication helped more in some areas than others. Parents in our survey said medication helped equally—and most of all—with academic performance (very helpful for 35 percent) and behavior at school (very helpful for 35 percent). It also helped well with behavior at home (very helpful for 26 percent), and fairly well with social relationships (very helpful for 19 percent) and self-esteem (very helpful for 18 percent).

Furthermore, the degree of helpfulness with academic performance, behavior at school, and behavior at home most likely accounted for how helpful the parents rated medication as a specific strategy. Medication seems to lessen some ADHD symptoms, but behavioral strategies can help manage the condition for the long-term.

Children taking either stimulants or nonstimulants who started off with serious symptoms showed the most change, with a greater likelihood of improvement. (Kids whose symptoms started off mild also improved, but the difference wasn't as great.) Amphetamines and methylphenidates were equally associated with symptom changes in all areas (See more about ADHD symptoms.)

Most children in our survey who were taking medication for ADHD had tried methylphenidate (84 percent) or an amphetamine (51 percent) in the past three years. A smaller percentage (17 percent) had tried a nonstimulant medication. There were no differences in the type of medication children were prescribed either by age or length of time since they had been diagnosed. Most children taking these medications had been taking them for longer than two years (35 percent overall), while 22 percent had been taking them for one to two years.

Our survey found there were no major differences in effectiveness between amphetamines and methylphenidates. But there were more reports of "irritability and anger" and "high mood/energy (manic behavior)" among children who used amphetamines. Here's how the children fared with medication in these specific areas:

Percentage of children experiencing each side effect while taking each type of medication
Side effects Methylphenidates (such as Concerta, Ritalin) Amphetamines (such as Adderall, Vyvanse)
Decreased appetite 54% 57%
Sleep problems 35 37
Weight loss 32 32
Upset stomach/Stomach ache 26 24
Irritability/Anger 22 28
Headaches 19 20
Flat affect (loss of personality) 16 18
Fatigue 13 13
Jittery/Tremulous 9 11
Tics (repetitive movements or sounds) 8 9
Overly high mood/energy (Manic behavior) 8 13
Talking about harming himself/herself 7 9
Heart palpitations 5 7
Hallucinations 1 2
None of the Above 19 16
Editor's Note: Source: Consumer Reports National Research Center.

We asked parents to rate how helpful each medication was in the following areas: academic performance, behavior at school, behavior at home, self-esteem, and social relationships. Both amphetamines and methylphenidates were equally likely to be helpful in all areas with the exception of behavior at school, where amphetamines were rated as slightly more helpful.

Although we don't have enough cases of children taking "second line" medications (e.g. Straterra) to report specific findings, the data we have indicates that they were generally less likely to be "very helpful" than amphetamines or methylphenidates in the areas we asked about.

If a child is struggling in the areas of self-esteem and relationships, and medication is not helpful, it might be useful to have him or her see a clinical psychologist or other mental-health professional.

Whenever the result of taking a drug is less than desired, it might be time to consider changing medication, Goldstein suggests. Some children experience different effects from a different formulation of the same medication. "Many children with appetite, sleep, or irritability problems with a methylphenidate-based medication do very well with an amphetamine-based drug, or vice versa," he notes.

Who prescribes and monitors ADHD medication?

A vast majority of children in our survey received medication from a pediatrician (60 percent), followed by a child psychiatrist (18 percent) and a general psychiatrist (15 percent).

All of the drugs carry a warning about rare cases of sudden, unexplained death. It is recommended practice to test for life-threatening conditions, including heart-related issues, before prescribing these medications.

Overall, physicians did a decent job of screening before prescribing medication. Eighty-five percent of the children we surveyed received some sort of screening, and 76 percent were given a general medical exam. But only 52 percent had their blood pressure tested, 43 percent had blood tests done, and 22 percent were given an ECG/EKG exam for heart conditions. "Blood pressure should be measured, since medications that treat ADHD sometimes cause a slight increase in blood pressure," says Michael L. Goldstein, M.D. It should be checked before starting medication, and at least once while the child is taking medication.

And even though 85 percent of the children were screened before starting medication, 15 percent did not receive any type of screening. A parent should always request basic screening of their child before starting medication for ADHD.

We also asked parents about other things they wished their prescribing physician had done. While 43 percent didn't express any concerns with the physician prescribing ADHD medication for their child, 29 percent said they wished the physician would "welcome their input about their child more than he/she currently does." Twenty-six percent said they wished doctors would "provide information about any financial relationships he/she may have with companies that sell ADHD medications," and 25 percent said they wished doctors would "discuss the long-term safety of prescription medications for my child."

Tips for working with your child's doctor

Parents didn't rate doctors well for managing their child's medication. "Patients or families should call whenever they have questions about a medication," Goldstein urges. He offers these additional tips:


Always call the doctor with questions. Even if all is well, check in by phone two weeks after beginning medication and schedule a visit one month after for a follow-up.


After that, return visits will depend on the success of the treatment and side effects. In general, children doing well can be seen every six months.


Reassessment should consist of a physical examination and direct questioning of the child and family member(s). Teacher evaluations are also helpful.


A complete re-evaluation with the family and input from others (including teachers) should be considered every year, although waiting two to three years is common.


ADHD drug side effects

Side effects are a major area of concern for many parents considering medication for their child's ADHD. Indeed, side effects might add to the overall stress of managing a child's condition.

Our survey found that parents of children taking amphetamines and methylphenidates reported a high frequency of side effects. Overall, 84 percent of the children who tried amphetamines and 81 percent who tried methylphenidates experienced side effects. And among those who reported no longer taking a specific medication, 35 percent said it was because of side effects.

Decreased appetite, sleep problems, weight loss, irritability, and upset stomach were the side effects most frequently reported by parents for both types of medication. Amphetamines and methylphenidates were equally likely to produce these side effects with the exception of irritability, which was more likely to be reported as a side effect by parents whose children tried amphetamines. Although elevated mood or excessive energy wasn't among the more frequently reported side effects, it was more commonly reported by parents whose children were taking amphetamines compared with methylphenidates. Talk with your doctor if irritability, anger, or manic behavior become an issue.

Side effects such as a loss of appetite are very common but usually not significant, and they tend to improve over time, Michael L. Goldstein, M.D. says. Other problems children have after taking medication might not be due to the drugs at all. Sleep problems might have occurred before starting medication, for example. And taking medication at the correct time is another factor in determining side effects. "Some children don't want to take medication," Goldstein says. "It must be determined if they are doing well on the medication but just don't want to bother taking it despite the positive effects, or whether they are really having increased anxiety or mood changes from the medication."

Parents of children who tried second-line medications, which are often prescribed because of concerns about the side effects associated with amphetamines and methylphenidates, also reported a high frequency of side effects, but they were somewhat less frequent than with the other medications.

Although many parents reported side effects, they can often be managed. For example, some children have problems later in the day and a long-acting formulation is best, but sometimes the effect might persist into the evening, suppressing appetite for dinner and delaying bedtime. "There is no substitute for carefully evaluating the effect of a medication after it has been used to determine if it should be increased, decreased, or switched to something else," Goldstein says.

Parents should also note that a child might begin to show withdrawal symptoms when a dose wears off, and might need tips for avoiding this. These management skills are something that can be developed with the doctor responsible for prescribing the medication.

For more help understanding ADHD and what you can do to help your child, including whether to medicate, see HealthPoint.net's ADHD guide and Decision Point tool.

Parent satisfaction with ADHD medication

Taking all this into consideration, how satisfied are parents with medications their children are taking for ADHD? Overall, only 41 percent were highly satsfied (16 percent were "completely satisfied" and 25 percent were "very satisfied"). About one-third (29 percent) were dissatisfied and the remainder were fairly satisfied (30 percent). There were no differences in overall satisfaction between those groups trying amphetamines or methylphenidates.

Most amphetamines and methylphenidates are available in standard doses and extended- or sustained-release forms. Standard release means that the medication will be in your child's system for a given period of time (usually about three hours), at which point another dose needs to be administered to maintain the effect. Extended- or sustained-release medications are usually given in the morning and slowly release the effective component of the medication throughout the day.

Parents were more likely to report that the extended-release formulations were "very helpful" with academic performance, behavior at school, behavior at home, and social relationships. With extended-release formulas, parents don't have to rely on their child's school to give the medication. If you're considering medication for your child with ADHD, ask your treatment provider about this option.

We asked parents how strongly they agreed with a number of statements about having their child take medication. While most agreed strongly that if they had to do it over again they would still have their child take medication (52 percent), 44 percent agreed strongly that they wished there was another way to help their child besides medication, and 32 percent agreed strongly that they worried about the side effects of medication.

Overall, the process of having a child take medication for ADHD is one of constantly weighing the costs and benefits. As described above, parents reported that side effects are common. And the two major classes of medication (amphetamines and methylphenidates) were not "very helpful" in many of the areas we asked about. (For example, they were only "very helpful" with behavior at home in 30 percent of the cases.) But when compared with other common strategies used to manage ADHD, having a child take medication was the most helpful one for parents in managing ADHD. So in many cases, medication might be something a parent could try to help his or her child with ADHD.

If your child is going to try medication, first establish a baseline of behavior and academic performance so that you'll be able to make sure it is indeed working—especially since our results found that for some children, they don't work very effectively at all. And once he or she starts medication, make sure that the person prescribing it is aware of the degree of improvement you notice, along with any side effects. This will allow the professional to make an informed decision, along with you and your child, about the appropriateness of the medication.

Having a child take medication is not a simple fix, and balancing its effectiveness with the side effects (and difficulty of managing these side effects) should be constantly monitored. (See more tips for being your child's treatment coordinator.)

Tips for monitoring medications

Keep a log of your child's progress and "down" times to make sure dosing is correct and side effects are manageable.


Help your family manage stress by being patient and understanding during new experiences and among unfamiliar people.


If side effects are overwhelming, talk with your doctor about switching medications or dosing.


Talk with your doctor about taking time off (a drug "holiday") from medication, such as during the summer or vacations.


Record everything to create a baseline for your child. Document not just test results and dates, but also practitioners, dosages, and frequencies.


   

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