ADHD & Stimulant Medication | Thriving with ADHD

 

Childhood ADHD & Stimulant Medication

 

The decision whether or not to medicate your child is a very personal one. When making such an important decision it is beneficial to have some insight into the current research and understanding around this treatment modality, so that you can be confident the decision you make is an informed one.

This post provides a general overview of stimulant medication for information purposes only and does not replace the need for specialist medical advice and collaboration. It also does not take into consideration your child’s individual age, diagnosis, symptom duration and severity, past medical history, treatment history, personal needs, risk of injury or social situation.

 

 

Stimulant medication is the most commonly prescribed class of medication used to treat the symptoms of Attention Deficit Hyperactivity Disorder (ADHD). Whilst stimulant medication does not cure ADHD as its effects are only temporary, studies have consistently shown it improves an individual with ADHD’s ability to function (Barkley, 2015; DeVito et al, 2008) as it:

  • successfully reduces ADHD symptoms including hyperactivity, impulsivity and distractibility
  • may improve short term memory, learning performance, emotional regulation, social skills and peer relations
  • can lead to an increase in self-esteem.

Stimulant medication has also been found to reduce the risk of secondary harms associated with unmanaged ADHD.

 

Why consider stimulant medication?

While children with mild ADHD symptoms may respond well to behaviour interventions, such as parenting from an ADHD perspective and class room strategies alone, research shows children with moderate to severe ADHD symptoms tend to experience little improvement when these interventions are implemented in isolation.

Without effective treatment a child’s ADHD symptoms can negatively influence their ability to meet expectations, achieve their goals, maintain relationships and negotiate life.

For example, poorly managed ADHD symptoms can negatively affect a child’s academic achievement as they impact directly on a child’s ability to:

  • sustain focus and concentration (especially if a task is boring or tedious)
  • absorb, process and recall information
  • prioritise, plan and problem solve
  • work out what piece of information they should pay attention to (as they struggle to filter the information they receive from their internal world and from the world around them for relevance)
  • stay on track and complete tasks to fruition, as well as transition away or disengage from tasks they are absorbed in
  • pause and inhibit their words and actions (which can contribute to impulsive decision making, careless errors, accidents and injuries, as well as social violations such as interrupting others or blurting out answers in class)
  • inhibit and regulate/modulate their emotions
  • deal with delay aversion due to their inability to cope with discomfort (which may contribute to them acting impulsively in order to terminate the delay i.e. pushing in; interrupting or badgering others; opting for immediate smaller rewards rather than delaying gratification in order to achieve long term goals)
  • perceive time and regulate their attention, behaviour and motivation relative to time
  • interact effectively with their peers.

Poorly managed ADHD symptoms also greatly affect a child with ADHD’s ability to self-reflect, as well as develop self-awareness and accurate self-perception; communicate effectively; think socially; interact with others, be accepted by others and form bonded relationships; participate fully in extracurricular activities; and, develop independence. Their symptoms can also negatively impact upon parent-child and child-sibling relationships and family function.

As a result, a child with ADHD’s self-esteem and quality of life can suffer, for when children with ADHD are:

  • unable to meet the expectations placed upon them and therefore experience failure over and over again (even when they are trying their hardest)
  • constantly on the receiving end of correction, redirection, criticism (and possibly social rejection and isolation)

they are more likely to feel frustrated, embarrassed, humiliated, demoralised and discouraged, as well as ashamed, inadequate, unworthy and regretful. They may also come to believe over time that they are fundamentally different, flawed or broken, and begin to anticipate or predict future failure (Barkley, 2015).

Poorly treated ADHD in childhood no doubt contributes to the reason why adults with ADHD are at high risk of developing anxiety and depression, alcohol and substance abuse issues, and eating disorders. They are also at higher risk of criminality, self-harm and suicide with the suicide risk of individuals with ADHD being approximately 1.8 times higher than the general population (Barbaresi et al., 2013).

 

How does stimulant medication work?

Stimulant medication works by increasing the amount of neurotransmitters (dopamine and noradrenaline) in the regions of the brain responsible for the mental processes involved in self-regulation. Neurotransmitters are like chemical messengers in that they carry information in the form of electrical impulses from the presynaptic nerve terminal of one neuron (or nerve cell), across the synapse (or gap between two neurons), to the receptor of the next neuron. If neurotransmitter levels are low within the nerve synapse electrical impulse transmission between neurons is interrupted, which compromises brain function.

Individuals with ADHD are thought to have low levels of dopamine and noradrenaline in the regions of the brain responsible for one’s executive functions. Executive functions are the mental process you rely on to regulate or control your thoughts, words, behaviour and emotions. As stimulant medication increases the availability of dopamine and noradrenaline within the nerve synapse it helps facilitate the transmission of electrical impulses between neurons which improves an individual with ADHD’s brain function and executive  control.

When taken at therapeutic doses, stimulant medication does not produce the euphoric effects associated with drug abuse in individuals with ADHD.

 

Finding the right stimulant medication and dose for your child

Children with ADHD can present in many ways. For example, they can present with predominantly impulsive-hyperactive symptoms, predominantly inattentive symptoms or a combination of both. They can also present with mild, moderate or severe impairment.

The reason for this diversity is thought to be due to the unique genetic make-up of each child, for as many as 25-44 genes may be involved in causing ADHD (although not all risk genes need to be present to create ADHD) (Barkley, 2015). This variability is also thought to be one of the reasons why individuals with ADHD may respond differently to stimulant medication options.

Studies indicate that between 65% and 75% of children treated with a stimulant medication experience an improvement in symptoms, whilst between 25% to 30% do not respond favourably or tolerate the medication. However, if a second stimulant medication is trialled, it appears positive response rates increase to 80-90% (Barkley, 2015).

In addition to this, the most appropriate dose of stimulant medication for your child will need to be established by your child’s specialist. To do this your child’s specialist will slowly titrate (alter up or down) your child’s stimulant medication dose, as well as regularly monitor the effects of the dose, until the lowest possible dose of stimulant medication that produces satisfactory clinical improvement without intolerable side effects, is identified. This may take some time, however it is important as too small a dose of stimulant medication will have little effect on your child’s ADHD symptoms, however too large a dose may exacerbate their symptoms.

It is also beneficial if the effects of the stimulant medication last as late in the day as possible, without interrupting appetite or sleep, so that your child can successfully participate in extra circular activities including play dates and sports, as these activities will have a profound effect on their self-esteem, ability to engage with others and sense of achievement.

 

Side effects

According to Barkley (2015) stimulant medication produces few mild negative side effects. However, if a child does experience negative side effects, they either develop tolerance for these symptoms or their symptoms can be reduced to a tolerable level by lowering their medication dose. Occasionally, changing to another stimulant medication (or non-stimulant medication) may be required. (Please note: medication dosage should only be adjusted by your child’s specialist).

The most common side effects experienced by individuals who take stimulant medication include decreased appetite, weight loss, headache, stomach-ache, small increases in heart rate and blood pressure and insomnia (Barkley, 2015). Additionally, some children may also become irritable late in the afternoon as their medication wears off. This is less likely to occur with the use of slow release medication formulations.

There are times, however, when stimulant medication may cause more severe side effects which may preclude its use. For example, stimulant medication may exacerbate (Barkley, 2015):

  • motor and vocal tics in some children with ADHD who also have a personal or family history of tics or Tourette disorder (however, they may reduce tics in others) (Gadow, Sverd, Sprafkin, Nolan, & Ezor, 1995)
  • psychosis in individuals with a pre-existing psychotic disorder
  • narrow-angle glaucoma.

Additionally, according to Barkley (2015, pp. 673), the “risk of stimulant-induced adverse cardiovascular events is elevated in children with ADHD and a family history significant for early cardiac death, arrhythmia, cardiogenic syncope or a personal history of structural cardiac abnormalities, exercised induced syncope, chest pain and palpitations.” For this reason, Barkley (2015) recommends at risk children undergo consultation with a paediatric cardiologist prior to stimulant medication being recommended.

There may also be other co-existing condition specific side-effects associated with taking stimulant medication. Your child’s specialist will discuss these with you if they may possibly be an issue.

(In regard to insomnia, many children with ADHD struggle to go to sleep because their brain is so active, regardless of whether they take stimulant medication or not. If this is the case, please speak to your child’s specialist as some children require medication assistance in order to fall asleep).

 

Stimulation medication & growth trajectories

There is also some concern that long-term stimulant medication use may affect the growth trajectories of children with ADHD resulting in mild growth suppression. For example, a meta-analysis of 22 studies found that stimulant medication had a statistically significant effect on a child’s height and weight. However, some studies suggest that children with ADHD may display different growth trajectories to neurotypical children, and that it is the disorder itself, not stimulant treatment, that is responsible for these differences (Barkley, 2015).

 

Stimulant medication & the risk of illicit substance abuse

Concerns that stimulant medication may increase the risk of later substance abuse appear unfounded as these claims have been refuted by more than 14 studies (Barkley, Fischer, Smallish, & Fletcher, 2003). Instead, the data suggests stimulant medication may significantly reduce substance abuse risk in individuals with ADHD (Chang et al, 2014). For example, in there 2016 study, McCabe et al.(2016) concluded when stimulant medication treatment is started early (before age 9) and continued for more than 6 years, it may cut the rate of substance abuse in half. In fact they found, stimulant medication reduced the risk of substance abuse in youth with ADHD back to the same level of risk associated youth without ADHD. 

 

Stimulant medication & the long term effect on brain development

The prefrontal cortex, which is part of the cerebral cortex, is the part of the brain responsible for one’s executive functions. Studies currently show that taking stimulant medications to treat ADHD does not adversely affect the development of the brain’s cerebral cortex (Barkley, 2015).

Instead there is exciting evidence emerging that indicates stimulant medication may have a protective effect on a child’s brain, as there are over 32 studies that show the brains of kids with ADHD who continuously take stimulant medications in the long term, develop in a manner that is more in line with their neurotypical peers. In other words, stimulant medication appears to promote brain development (Barkley, 2015a).

 

Medication beaks or holidays

There are pros and cons for giving children who require stimulant medication to manage their ADHD a break from medication over the weekend and during the school holidays, which your child’s specialist will discuss with you. For example, as stimulant medication effects a child appetite and therefore weight gain and possibly growth, giving a child with ADHD a medication break over the weekend or during a school holiday period may assist the child to put on weight. However, as the laying down of neural pathways for healthy habits can only occur with repetition, withholding stimulant medication may interrupt healthy habit formation. (Developing healthy habits greatly assists with the management of ADHD symptoms). Medication breaks may also reduce the likelihood of stimulant medication having a positive effect on a child’s brain development.

Importantly, if a child with ADHD is constantly requiring redirection or is in trouble for not being able to manage his or her behaviour when they are unmedicated, then withholding stimulant medication may also increase the risk of the child developing poor self-esteem and the associated issues discussed above.

 

Examples of Stimulation medications available in Australia

Methylphenidate: Ritalin and Concerta

Dexamphetamine: Dexamphetamine and Vyvance (Lisdexamfetamine)

 

The importance of multimodal treatment

Stimulant medication should not be relied on as the only form of ADHD treatment.

Taking a multimodal approach to ADHD treatment is important for the following reasons (Chronis et al., 2006; Pelham 1999; Pelham et al., 1998, cited in Barkley, 2015):

  • Stimulant medication does not provide 24 hours a day coverage.
  • Medication alone does not teach children and adolescents with ADHD the skills they need to function more competently. Whilst behaviour treatment alone is ineffective when children and adolescents are unable to focus in order to absorb information and learn from interventions or instructions.
  • Children and adolescents with ADHD experience problems across multiple domains and these problems may respond differently to treatments. For example, stimulant medication has been shown to reduce ADHD symptoms, whilst psychosocial interventions appear to have more impact on family relationships and academic functioning.
  • Normalisation is rare with any singular treatment but there is some indication that combined treatments increase the chance of normalisation.

 

References

Barbaresi, W., Colligan, R.C., Weaver, A.L., et al. (2013). Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: A prospective study. Peds, 131(4), 637-644. doi: 10.1542/peds.2012-2354.

Barkley, R.A. (2015). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th ed. New York: Guilford Publications.

Barkley, R. A. (2015a). https://www.youtube.com/watch?v=HYq571cycqg&feature=youtu.be

Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2003). Does the treatment of ADHD with stimulant medication contribute to illicit drug use and abuse in adulthood? Results from a 15-Year prospective study. Pediatrics, 111, 109-121

Chang, Z., Lichtenstein, P., Halldner, L., D’Onofrio, B., Serlachius, E., Fazel, S., Larsson, H. (2014). Stimulant ADHD medication and risk for substance abuse. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 55(8), 878–885. http://doi.org/10.1111/jcpp.12164

DiVito, E. E., Blackwell, A.D., Kent, L., Ersche, K.D., Clark, L., Salmond, C.H. (2008). The effects of methylphenidate on decision making in attention-deficit hyperactivity disorder. Biological Psychiatry, 64(7), 636-639.

Gadow, K. D., Sverd, J., Sprafkin, J., Nolan, E. E., & Ezor, S. N. (1995). Efficacy of methylphenidate for attention-deficit hyperactivity disorder in children with tic disorder. Archives of General Psychiatry, 52, 444-455.

McCabe, S.E., Dickinson, K., West, B.T., & Wilens, T.E. (2016). Age of Onset, Duration, and Type of Medication Therapy for Attention-Deficit/Hyperactivity Disorder and Substance Use During Adolescence: A Multi-Cohort National Study. Journal of American Academy of Child & Adolescent Psychiatry, 55(6), 479-486.

Paloyelis, Y., Asherson, P., & Kuntsi, J. (2009). Are ADHD Symptoms Associated with Delay Aversion or Choice Impulsivity? A General Population Study. Journal of the American Academy of Child and Adolescent Psychiatry, 48(8), 837–846. http://doi.org/10.1097/CHI.0b013e3181ab8c97

Shaw, P., Sharp, W., Morrison, M., Eckstrand, K., Greenstein, D., Clasen, L., Rapoport, J. L. (2009). Psychostimulant treatment and the developing cortex in Attention-Deficit/Hyperactivity Disorder. The American Journal of Psychiatry, 166(1), 58–63.