ADHD Medication: Options for Drug Treatment

It's natural for children to not always give their full attention to a task, family member or peer in the moment, or for them to be impulsive sometimes. Depending on a child's age and stage of development, this may just be par for the course.

But for kids with attention deficit hyperactivity disorder, a high level of inattention, impulsivity or hyperactivity can be not only developmentally inappropriate but severe and disruptive. For children, adolescents and adults with ADHD, left untreated, it can get in the way of normal daily function and seriously undermine quality of life. Research shows children with ADHD frequently struggle academically and in other ways, such as with relationships and even difficulty participating in extracurricular activities, and adults with the disorder are similarly more likely to struggle at home and professionally and face a higher rate of unemployment.

In individuals of all ages, experts stress, the first step before deciding on a treatment course of any kind for ADHD is ensuring proper diagnosis. For parents, that means seeing a trusted child's doctor to spend time discerning whether things like a child's lack of focus, constant squirming or fidgeting, impatience or other concerns truly are symptoms of ADHD and not just within a typical range of what's expected for the child, or a sign of another issue altogether.

That starts with a really thorough assessment of symptoms to make sure that this is in fact ADHD, says Dr. Jeffrey Strawn, director of the Anxiety Disorders Research Program and associate professor of psychiatry and pediatrics at the University of Cincinnati. That should include evaluating for other causes for inattention or academic difficulties, for example, like a learning disorder or even an anxiety disorder or depression -- "all of which may have concentration or difficulty focusing as a symptom," Strawn points out.

For the youngest children diagnosed with ADHD, nondrug treatment is usually recommended to start. For preschool-aged children who are 4 to 5 years of age, "the primary care clinician should prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment," according to practice guidelines from the American Academy of Pediatrics.

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"For some children with ADHD, if behavioral interventions are not sufficient or if there are significant concerns -- maybe safety concerns or (they're) not able to learn because of such significant ADHD symptoms, the medication could be considered," Dr. Elizabeth Harstad, a developmental behavioral pediatrician at Boston Children's Hospital. However, she emphasizes that medication is not a first line treatment for preschool-aged children.

Generally speaking, behavioral interventions for ADHD include what's called individual training -- for the person, child or adult with ADHD -- and parent management training or parent behavioral training for caretakers of kids with ADHD, notes Dr. Heather Joseph, a postdoctoral scholar and practicing psychiatrist in the Youth and Family Research Program at the University of Pittsburgh.

Behavioral therapy can involve helping an individual with ADHD size up their strengths and weaknesses, and then trying to hone in the skills they may need to overcome the challenges they face. "So, for example, for an adolescent child who's in school and failing to turn in homework because they've forgotten to bring home books or organize assignments, it could be as simple as working with them on organizational skills," Joseph explains. Additionally, another behavioral intervention may tap into specific skills and provide integral strategy that parents need to manage children with ADHD, including practicing positive reinforcement and providing structure and time for kids to transition from one task to the next.

For school-aged kids, adolescents and adults, medications are generally recommended, often in combination with behavioral support, to treat ADHD. Drug treatment can help reduce symptoms and improve aspects like focus and attention.

ADHD medications fall into two primary groups: stimulants and nonstimulants. "Usually we start with a trial on a stimulant medication, because for most children they're more likely to effectively reduce the ADHD symptoms," Harstad says.

Stimulant medications fall into two classes: methylphenidate, like Ritalin, and amphetamine preparations, like Adderall. Clinicians emphasize that different medications work better for different patients -- kids and adults. As a result, often some trial and error, whether in terms of the changing the dosing, medication or both is necessary to ultimately find a drug treatment that's most suitable to the patient.

"It's always a decision that's made together with the child's health care provider about which medication to start first, and certain factors such as what form it comes in, if a child can swallow a pill or not, how long we want the medication to last," Harstad says.

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That also means choosing between different short-acting and long-acting medications -- and some drugs with an effect duration in the middle, lasting around six to eight hours. So where some short-acting stimulants like Ritalin or Focalin may last for three to four hours, or four to six hours, as with Adderall, long-acting simulants can last two to three times as long; that includes drugs like Concerta and Adderall XR (eight to 12 hours), Vyvanse (10 to 12 hours) or Mydayis (12 hours), which is for patients 13 and older, can last two to three times as long.

While stimulants are typically a first choice, there's also cause for caution given their potential for abuse, which is most pronounced in long-acting ADHD medications, like recently approved Adhansia XR extended-release capsules that have an effect lasting 16 hours. Given that, and that the medications don't work for everyone and stimulant side effects, clinicians sometimes recommend nonstimulants such as atomextine (Strattera) or clonidine (Kapvay).

"Stimulant medications are the gold standard treatment. But there are a lot of reasons why you may not use a stimulant," Joseph says. Some of the common side effects include decreased appetite, which could lead to weight loss. "So if you have a child who's struggling to gain weight as is, you might not choose that medication," Joseph notes.

"They also contribute to difficulty falling asleep if they've been taken too late in the day," she adds, where ADHD is already associated with insomnia. "So if you have a child who's already struggling to fall asleep or to wind down at night, stimulants could worsen that problem."

Nonstimulant medications by contrast typically don't result in trouble with appetite, trouble with weight gain and are generally well-tolerated, Harstad says. There's also less potential for misuse or abuse of the drugs.

Stimulant medications may also potentially increase serious cardiovascular risk, such as for stroke, heart attack or cardiac arrest in people who already have pre -existing heart disease or other cardiac problems; although debate continues about the cardiovascular safety of the medications. "Anyone who has a family history of a cardiac disease would require additional testing before starting a stimulant," Joseph says. "But in most cases they're safe for use."

There's also some research that finds a small risk for so-called new-onset psychosis, such as having hallucinations or first developing schizophrenia, after starting stimulants.

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Taking it all in, experts say, it's important to discuss the potential benefits and harms of any medication prescribed for ADHD. In addition, while ADHD medications like stimulants can treat symptoms -- inattention, fidgeting, restlessness -- you still have to learn the skills necessary to do well in any setting, Joseph says -- whether that's at home, work or school.

"For students, "they need to know how to study for test. They need to know how to organize their homework. They need to know those basic things. So if they have never learned that, the medications don't improve that," Joseph says. So being realistic about what medications can -- and can't do -- and exploring a comprehensive approach to address ADHD is key. "That's why," Joseph says, "treating behaviorally and with medication is particularly important."

Michael O. Schroeder has been a health editor at U.S. News since 2015. He writes health stories on a wide range of topics from mental health to medication side effects, and he manages the blog For Parents.

Michael has reported on health and wellness since 2005, and he's also covered everything from business news to governmental affairs for various newspapers. His stories have also been published in HuffPost, MSN, Yahoo!, WTOP, The Washington Post and The Indianapolis Star. He's also an active member of the Association of Health Care Journalists.

Michael has a bachelor's degree in English from Wabash College and a master's degree in journalism from Indiana University.

You can follow him on Twitter or email him at mschroeder@usnews.com.