Q: I have long suspected that too many children were unnecessarily medicated with Ritalin and other ADHD drugs as a quick fix for minor behavior problems. Now my son has been diagnosed with ADHD. I’m very conflicted about medicating him. What guidance can you offer to help me do what’s best for my child?
Answer from Eugene Borkan, M.D., child/adolescent psychiatry, Providence Portland Medical Center: I share your concern about the unnecessary use of ADHD drugs for children who don’t have the disorder. However, for many children who do have ADHD (attention deficit hyperactivity disorder), these medicines can make a very positive difference. To make sure that ADHD medication is a good choice for your son, you should consider it only after a comprehensive evaluation, and only as part of a comprehensive treatment program.
I’m glad that you are weighing this decision carefully and thoughtfully. The following guidelines and information should help you and your family reach a decision that benefits your son, eases your conflicted feelings, and feels right for all of you.
First, make sure your child has a comprehensive evaluation.
A diagnosis of ADHD can’t be confirmed in a 10-minute exam. To be thorough, a clinician should observe the child’s behavior in multiple settings, and/or collect observations about the child’s behavior from multiple sources. In addition, the evaluation should include a complete physical, a thorough health history, selective laboratory evaluation, a full family history and a clinical interview of the youngster by a trained professional. (Read more about evaluating a child for ADHD.)
Taking the time for a comprehensive evaluation is the first step in making sure that a child is not put on medications unnecessarily.
Be aware that medication is not the only treatment option.
If a thorough evaluation confirms a diagnosis of ADHD, then medication may be an appropriate option to consider. However, it is not the only option; it should be considered only as one part of a comprehensive treatment plan that may include several other strategies. These other strategies may include any of the following:
Teaching you how to be an advocate for your child in the classroom and in other settings where he may be struggling
Advising your son’s classroom teachers about how they can support his learning
Providing your son with behavioral therapy and education to help him understand himself better and learn how to improve his judgment and decision making
Getting family counseling to help all members of the family learn how to cope with the challenges of living with a child who has ADHD
Engaging the child in extracurricular activities that offer positive social interaction and a healthy outlet for physical energy
Attending parent support groups to learn about strategies that have been valuable for other families of children with ADHD
Weigh the advantages and disadvantages of medication carefully.
The most commonly used drugs for treating ADHD are stimulant medications. These work by enhancing the function of dopamine – a neurotransmitter in the brain – thereby improving concentration, working memory and executive functions. (Executive functions are the brain’s managers – they control, organize and integrate all of the brain’s cognitive functions so we can perform tasks that require multiple parts of the brain.) Most of these drugs have been in use for decades, have been subjected to multiple studies, and have been proven to be quite safe.
The two most common families of ADHD stimulant drugs are those that contain methylphenidate (Ritalin is the most familiar), and those that contain dextroamphetamine(Adderall is an example). While chemically different, they have virtually identical pharmacologic function.
Several specific choices are available within each of these families, so if one type doesn’t appear to be working or causes unpleasant side effects, you can try a different one. Different formulations also give you a choice between short-acting (effective for two to four hours) or long-acting (effective for up to eight hours) pills.
Benefits of these medications may include:
Improved concentration
Diminished hyperactivity
Reduced impulsivity
Improved academic achievement
Potential side effects may include:
Sedation
Sleep difficulties
A jittery feeling
Nervous tics
Reduction in appetite
A child simply not feeling like himself
If the stimulants are unsuccessful, there are a number of other, secondary choices available. These include Strattera, Clonidine and Wellbutrin. Your physician can tell you more about the specific advantages and disadvantages of the medications you are considering.
If you decide to try medication, work closely with your physician and meet frequently to evaluate outcomes.
Medicating a child should always be done on a trial basis; if there are no visible benefits, or if the child experiences unpleasant side effects, then the drug or dosage should be changed or discontinued.
One convenient feature of stimulant ADHD medications is that they act more rapidly than many other psychotropic medications. That means you will be able to tell within days – as opposed to weeks – whether or not a drug is offering a benefit. If a drug causes side effects, you should be able to detect at least some of those within a few days, as well.
Besides watching for the previously mentioned benefits and side effects, you may want to ask your child how he feels: Do you feel like yourself? Does it feel like the medicine has changed who you are? Does it make you feel different in a good way or in a bad way?
Some families find that with stimulant medication, it is not necessary for a child to take the medication on weekends or during vacations. This depends on the symptoms being targeted and on the treatment strategy that your family and your physician have agreed upon.
As your son grows and changes, his medication plan should evolve, as well. Think of each prescription refill as an opportunity to continue the dialog with the prescribing physician and with your son as you reevaluate the appropriateness and effectiveness of the medication and dosage.
With or without medication, your support is essential.
Medication can never be a substitute for parental involvement. My best advice is to maintain an ongoing dialog with your son, with his teachers and with his physician; to keep asking questions; and to take the time to understand your youngster and to learn how to be a good advocate for him.
