I have spent several days on the diagnosis of learning and behavioral problems and non-medical, dietary and supplemental treatments that can be used for these issues. Today I will focus on the types of prescription medications used primarily for ADHD as well as their side effects. Tomorrow will cover how to get started on a medication for ADHD.
Approved vs not approved medicines
Physicians sometimes use treatments that have not been approved for the purpose or an age group because they know from general experience that it works or they are at a loss from approved treatments failing and they need to try something else.
One example is using a shorter acting form of guanfacine (Tenex) that has not been approved to treat ADHD, but it has some advantages over the longer acting form (Intuniv) that is approved for ADHD. The short acting form can be broken, allowing slower titration of dose changes. The long acting form cannot be broken.
Another common example is the use of albuterol, a medicine that helps breathing with conditions that cause wheezing. It is not approved for use under 2 years of age, but it is commonly used for younger children with difficulty breathing — and it helps them breathe, which might keep them out of the hospital and off of supplemental oxygen.
I do not think that all non-approved medicines are good or bad. It is a very individual decision of what medicines to use. Discuss with your doctor if a treatment is approved or if they are using something that is not. Although this is relatively common among people who treat children because many drugs have not been tested in children and have been “grandfathered” into use through experiences that show benefit, be sure the provider is not picking something that has no basis or supporting evidence, especially if he or she profits from the treatment.
Be very wary of anyone who promises a cure – if one really existed everyone would use it.
Medications approved to treat ADHD
When a medication is needed to control symptoms of ADHD, the first line medications are the stimulants unless there are contraindications. Non-stimulant medications are not found to be as effective as stimulants in the majority of children, but they do have a place in the treatment plan for some children. They are sometimes used in addition to stimulants for optimal results.
For information on these medicines, see A Guide to ADHD Medications. It reviews how stimulants act on dopamine and norepinephrine and various time release patterns of different medicines.
I love the ADHD Medication Guide (different from the similarly named post above) because it lists the medicines approved to treat ADHD in a colorful chart that groups the medicines in an easy-to-read format.
Categories of Medicines used for ADHD:
- Methylphenidates (Aptensio©. Ritalin©, Focalin©, Concerta©, Daytrana©, Metadate©, Quillivant©)
- Amphetamines (Adderall©, Vyvanse©, dexedrine)
- Atomoxetine (Strattera©)
- Guanfacine (Intuniv©)
- Clonidine (Kapvay©)
- Others are used off-label (no FDA approval for the purpose of ADHD treatment): Tenex, Catapres patch, antidepressants, and antipsychotics
Parents usually worry about medication side effects. This is a very legitimate concern, but must be balanced with the risks of not treating. Overall the medicines listed above are very well tolerated.
If a child has side effects to one stimulant, they can usually do well on a different class (methylphenidate vs amphetamine). When neither type is tolerated, a trial of a non-stimulant is indicated. If this isn’t tolerated, reconsider the ADHD diagnosis.
I often hear concerns that parents don’t want their kids changing their personalities or becoming “zombies”. If the right medicine is used at the appropriate dose, this is usually not a problem.
Finding that right medicine and right dose might take some trial and error. Work with your prescriber to get to the right one for your child.
Most commonly observed side effects of stimulants:
Appetite is often low in the middle of the day and more normal by supper time if kids take a long acting stimulant.
Good nutrition is a priority. Encourage kids to eat the healthy “main course” first and leave the dessert out of the lunchbox. They should have healthy snacks (think of mini-meals) after school when they get hungry.
Short acting meds improve mid day appetite since they wear off around lunch time. The downside is the child needs to take a dose around lunch time at school.
Kids are often very hungry in the evenings when medicines wear off, so encourage healthy foods at that time.
I have seen some kids who have a really hard time off medicine sitting down to eat. These kids actually gain weight better on medicine because they can finish the meal.
Some kids can improve their appetite with an appetite stimulant. I often use cyproheptadine if weight drops too much in a child. It works best if it is not used every day. I will have kids skip their cyproheptadine at least a couple days each week.
Trouble sleeping is common with ADHD — with or without medicines.
If it is due to the stimulant medicine still being active, trouble sleeping may be relieved by taking it earlier in the day.
If the child’s brain is too active in the evenings because the medicine wears off, learning relaxation exercises can help. Check out the Winding Down section of Sleep Tips for more details.
Moodiness is especially common as the medication wears off in the afternoon or evening and in younger children.
It makes sense if you consider that all day they are able to focus and think before acting and speaking, but then suddenly their brain can’t focus and they act impulsively.
Typically kids learn to adjust to the medicine wearing off as they mature.
Sometimes just giving kids 30 minutes to themselves and offering a healthy snack can help.
Cognitive behavioral therapy can help.
Anxiety does occur with ADHD and might be under-appreciated before the ADHD symptoms are treated.
Symptoms of anxiety are often missed. They can include avoidance, irritability, moodiness, somatic complaints (headache, stomach ache), and more. HeySigmund has a great list of subtle anxiety symptoms.
When kids can focus better, they might focus more on things that bother them, increasing anxiety and making it more apparent.
It is also possible that anxiety is misdiagnosed as ADHD, which is one reason for stimulant medication failure.
If you notice signs of anxiety, talk to your child’s doctor and/or therapist.
Mild stomach aches or headaches
Stomach aches and headaches are occasionally noted with stimulant medications. It is my experience that they are most common with a new medication or a change in dose.
Because these have many causes, it can be hard to determine if they are really from the medicine or another cause.
If they persist with the medicine, changing to another medication might help.
Tics are related to treated and untreated ADHD.
People with ADHD are more likely to have tics than the general population.
It was once thought that tics were caused by the stimulant medicines, but it is now thought that they happen independent of the medicine, and medicines might even help treat the tics.
Weight gain can be difficult for some kids on stimulant medications due to the appetite suppression on the medicine.
Studies have shown a decreased final adult height of about 1-2 cm (1/2 – 1 inch). For most people this small height difference is not significant compared to the benefits in self esteem, academics and behavior children gain on stimulants.
Rare side effects of stimulants
I have only seen two children who could not tolerate stimulants due to hallucinations, but it is very scary for the family when it happens.
Unless there is a significant family history of them, I don’t know a way to predict which child is at risk.
These are a contraindication for continuing that medication, but another type of stimulant or medication can be considered.
Cardiac (heart) problems are overall a rare complication of stimulants and often times are not a contraindication to continuing the stimulant medicine.
There is a small increase in blood pressure and heart rate, both of which should be monitored regularly while on treatment and if the treatment is stopped.
A cardiologist should be considered to further evaluate a patient prior to starting a stimulant if there is any of the following:
- Shortness of breath with exercise not due to a known non-cardiac cause, such as asthma
- Poor exercise tolerance compared to children of the same age and conditioning
- Excessively rapid heart rate, dizziness, or fainting with exercise
- Family history of sudden cardiac death or unexplained death (such as SIDS)
- Family or personal history of prolonged QT syndrome, heart arrythmias, cardiomyopathy, pulmonary hypertension, implantable defibrillator or pacemaker
side effects for the non-stimulants:
Atomoxetine can cause initial gastroesophageal complaints (abdominal pain, decreased appetite), especially if the dose is started too high or if it is increased too rapidly.
It can also cause tiredness and fatigue when it is first started or if the dose is increased too quickly.
It can increase the blood pressure and heart rate, both of which should be monitored regularly during treatment with atomoxetine.
There is an increased incidence in suicidal thoughts, though uncommon, so children should be monitored for mood issues on this medication.
A rare complication of atomoxetine is hepatitis (inflammation of the liver with yellow jaundice and abnormal liver function labs). The hepatitis resolves with stopping the atomoxetine.
Guanfacine and clonidine
Guanfacine and clonidine both cause fatigue and tiredness, especially when first starting the medication or with increases in dose.
Both of these medications can lower the blood pressure and heart rate, and these should be monitored closely while on guanfacine or clonidine, especially when first starting and increasing dose.
Handouts for medicines
I absolutely love the handouts that Dr. Nerissa Bauer has made for ADHD medications. Click on the image’s caption to go to her website’s page for that handout. The two stimulant classes are first, followed by the non-stimulants.
Amphetamines (Adderall, Adderall XR, Vyvanse, amphetamine mixed salts, Dexidrine, Zenzedi)
Methylphenidate (ritalin, Aptensio XR, Concerta, Metadate CD or ER, Focalin, Daytrana)
Clonidine (Catapres, Kapvay)
Guanfacine (Intuniv, tenex)
Tomorrow’s blog will be about how to choose a medicine to start and how to titrate it to find the best dose.
Looking for more?
Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!
CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!
Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.
The Autism Society has an extensive list of resources.
Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.
Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.
Tourette’s Syndrome and Tic Disorders
Tourette’s Syndrome Association is a great resource for people with tic disorders.
General Support Group List
For a list of many support groups in Kansas: Support Groups in Kansas .
Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.
Midwest ADHD Conference – April 2018
Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.