The Risks of Not Treating ADHD, The Basics of Medication, Alternative Treatments, and Secrets the Doctor Didn’t Tell You
Most parents of kids with ADHD are painfully aware of how complex ADHD treatment can be. If you’re new to ADHD, get ready for a bit of a wild ride. I have found over the 8+ years since my son’s diagnosis that there’s so much more to ADHD treatment than doctors tell us. In fact, there’s so much to know to get medication to work effectively than doctors tell us when they’re handing us a prescription. So, in this article, I’m outlining every. single. thing. I know about treating ADHD from both my research and writing, and from my own experience. This is a must-read, comprehensive guide for every parent raising a child with ADHD. Remember, I’m not a physician, so it’s very important to work on your child’s ADHD treatment under the guidance of an experienced clinician.
Let’s dive in…
Let’s start with the most misunderstood and widely debated aspect of treating ADHD: medication. ADHD experts will tell you that these risks are wildly blown out of proportion, which scares compassionate, loving parents like us. Yes, there are some risks with ADHD medication, as there are with just about any medication. Yes, the doctor should do a complete physical exam before prescribing ADHD medication, especially stimulants since they can be dangerous to children and adults with heart conditions. The doctor should also have your child visit regularly to monitor how your child is doing on the medication.
I want to be clear — stimulants are not the only medications used to treat ADHD that carry the risk of serious side effects. Some kids with ADHD (like my son) have serious reactions to medications like SSRI antidepressants used to treat depression, anxiety, and sometimes ADHD when traditional ADHD medications aren’t effective. Straterra, which is approved as an ADHD treatment, has a warning of suicidal ideation. There are risks, no doubt, but they outweigh the benefits in the majority of patients.
Now, there are also risks associated with untreated ADHD. Lots of them: Self-medicating with illegal drugs and alcohol. New or worsening anxiety. New or worsening depression. Teen pregnancy. Car accidents. Inability to hold down a job. Criminality (25-40% of the US inmate population has ADHD, most undiagnosed and/or untreated).
When considering treating your child’s ADHD with medication, you must weigh the risks on both sides of the equation — treating and not treating.
The American Academy of Pediatrics’ (AAP) Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents recommends ADHD medication coupled with behavior therapy as the most effective treatment for school-aged children with ADHD.
“For elementary school–aged children (6–11 years of age), the primary care clinician should prescribe US FDA–approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence-based parent and/or teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation). The evidence is particularly strong for stimulant medications and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order) (quality of evidence A/strong recommendation).
For adolescents (12–18 years of age), the primary care clinician should prescribe FDA–approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both.”
Now, I’m a huge supporter of medication for kids with ADHD, when it’s necessary, but I respect that it’s a personal decision every family has to make. Most children with ADHD, especially elementary age, need medication to be able to slow down and focus enough to learn coping and management strategies for life with ADHD.
ADHD medication is not a “cure” for ADHD, and it certainly isn’t magic. It creates improvement, but it does not eliminate ADHD or all ADHD struggles. And ADHD medication should be one tool in a toolbox full of treatment strategies.
Did you know there’s more than one type of stimulant for ADHD? All stimulants are not created equal, although their function is the same — to increase focus and decrease impulsivity in kids with ADHD.
There are two types/classes of stimulant:
- methylpehnidate (Ritalin, Concerta, Daytrana, Quillivant…)
- amphetamines (Vyvanse, Adderall, Evekeo…)
Now, I consider the dex derivatives kind of their own category, although they’re lumped in with methylphenidate or amphetamine, whichever the dex is paired with in that specific medication. For instance, Focalin is a dexmethylphenidate and Dexedrine is a dextroamphetamine. I pull the dex- meds out in their own category because they are different. For instance, my son cannot take amphetamines at all (causes aggression and extreme mood changes), but he did well on Dexedrine. He also does well on methylphenidates. However, he had a severe reaction to Focalin, a dexmethylphenidate, despite doing well on methylphenidates alone and dexedrine alone. This is indicative of just how complex ADHD medication can be.
Here’s a list of ADHD medications, by type, although it hasn’t been updated this year to include new medications, like Evekeo: ADHD MEDICATION CHART. (Evekeo is 50% amphetamine and 50% dexamphetamine — Adderall is 75%/25%.)
Most individuals with ADHD do well on one type or the other, but not both. That’s very important to know when you’re trialing stimulant medications. If your child has bad side effects on one medication, try something from the other class next — a different type of stimulant altogether.
There aren’t nearly as many non-stimulants on the market for ADHD as there are stimulants. That’s due to the fact that non-stimulants simply aren’t as effective as stimulants for most individuals with ADHD (see the quote from the AAP guidelines above). Some, Stratterra namely, carries with it a black box warning regarding suicidal thinking in pediatric patients. So there’s definitely risk involved with non-stimulants, as well.
The other non-stimulants approved and marketed to treat ADHD are Intuniv and Kapvay, both alpha 2 adrenergic agonists, and their short-acting versions were created to lower blood pressure, but were used off-label for ADHD for years. The science is weak on why this particular type of medication works for ADHD, but studies have proved some efficacy, nonetheless.
There are many other medications that are commonly prescribed for kids with ADHD. They are referred to as “off-label” because they aren’t FDA approved specifically for ADHD. These medications include amantadine, Wellbutrin, mood stabilizers, and tricyclic antidepressants. Typically, a physician will not prescribe these medications alone to treat ADHD unless the patient has tried stimulants or non-stimulants specifically for ADHD first, with little or no benefit.
Getting ADHD Medication Right
Giving your child ADHD medication is not like giving them Tylenol for a headache. There is no way to know what dosage is required for your child, other than to try it. The reason is that the most effective stimulant dosage is dependent on that individual’s unique mix of neurotransmitter levels, metabolism, and genetics. A 300-pound man could need only the lowest dose of stimulant, while a 50-pound first grader could need the maximum dose. The only ADHD medication dosed by size is the non-stimulant Intuniv.
The best standard of care for ADHD medication is to start on the lowest dose, and increase slowly, only as needed (also called titration). If your doctor tries to start on a higher dose, or gives you a schedule of dosage increases with the first prescription, they are not following the standard of care for ADHD. That could signal that it’s time to find a different doctor to manage your child’s ADHD treatment.
Doctors often don’t tell parents ADHD symptoms and behavior could get worse before they get better when starting medication. If the dose is too low, behavior could actually deteriorate, contrary to common sense. If the lowest dose increases negative behavior and ADHD symptoms, it’s wise to try a dosage increase before changing the medication altogether.
People often think that choosing to try medication for ADHD automatically means you have to accept nasty side effects. That simply isn’t true. Side effects for ADHD medications are greatly decreased with the right medication and dosage for that individual. And many side effects can be addressed when the medication is helping a great deal. If your child is like a “zombie” or moody and aggressive when they weren’t before, that means it’s the wrong medication and/or the wrong dosage. ADHD medication is not meant to dope a child into submission, or change their personality. If it does, it’s wrong.
There’s No Comparison
Every individual reacts differently to each medication. For instance, my son cannot take Vyvanse or Adderall without significant and intolerable side effects. However, I know a lot of children who do phenomenally well on these same medications. Since efficacy of medication depends on an individual’s neurotransmitter needs, metabolism, and genetics, results are very individual. Don’t worry about what works or didn’t work for your friend’s child, or even a family member; that doesn’t mean anything at all for your child.
As I mentioned above, the AAP recommends both medication and behavior therapy as the most effective treatment for kids with ADHD. That stems from a large, long-term study on the multimodal treatment of ADHD, funded by the National Institutes of Mental Health back in 1999. It is widely regarded as the study that defines and supports the ideal treatment for ADHD in children.
There’s a common saying in the ADHD professionals community: “Pills don’t teach skills.” Medication treats the inattention and impulsivity, but it cannot teach the lagging skills inherent with developmental disabilities, like ADHD and autism. That’s why behavior therapy is such a crucial component of ADHD treatment.
Be sure to work with a therapist that is experienced and skilled with pediatric ADHD. This therapist or psychologist will provide you with parenting strategies, as well as work with your child on lagging skills, intensity, self-awareness, self-regulation, social skills, and more.
Now, you can implement some behavior modification at home too, which I detailed in this article.
Without behavior therapy, you have a child who is more attentive and less impulsive through medication, but who still struggles with life with ADHD. We don’t want that.
I wish I had realized how important parent training is when my son was diagnosed with ADHD. Although, I’m not sure there was much of it to be had then — if there was, I feel certain I would have signed up in a heartbeat.
There’s a considerable amount of research that shows that ADHD parent training not only improves ADHD symptoms and behavior in the child, but it also reduces parent stress and increases parent self-confidence. Learning strategies to effectively manage ADHD is one of the key ingredients to successful and happy kids, and happy families.
“Subjects receiving ‘Parent Training’ displayed significant changes in several areas of psychosocial functioning… ‘Parent Training’ parents reported, for example, improvements in the overall severity of their child’s ADHD symptomatology. These reported changes in child behavior were accompanied by… reduced parenting stress and enhanced parenting self-esteem.” — Parent training for attention-deficit hyperactivity disorder: Its impact on parent functioning, Journal of Abnormal Psychology
Over the years I have come to learn just how paramount the right parenting approach is for families with kids with ADHD, which is why I offer online parent training courses. It’s life-changing! A structured and positive parenting approach works for kids with ADHD; traditional parenting methods do not. My family is living proof!
There’s no debating that a healthy lifestyle is beneficial to every single one of us. It’s even more helpful to those with ADHD. Think about it… the way we feed our bodies is the way we fuel our brains.
Basically, the best diet for those with ADHD is more whole foods, less processed foods, and eating low GI, which keeps the blood sugar steady. Avoid artificial food additives like colors, flavors, and preservatives as much as possible. Be sure your child gets as much protein as possible, and as few simple carbohydrates as possible.
For instance, a proper low GI breakfast would include whole grain toast (could have sugar-free jam spread), 1-2 eggs, and a serving of fruit. Snacks could be apples with peanut butter, carrots with hummus dip, plain greek yogurt with a little honey and fresh berries, etc.
Please don’t expect a healthy diet, or even a tailored diet like Feingold, to “cure” your child’s ADHD, or to even take the place of medication. Think of it as optimizing brain function, which helps ADHD. Again, this is one tool in your treatment toolbox.
As with nutrition, exercise has great benefits for the brain. John Ratey is an expert on exercise and ADHD, and talks a great deal about it in his book, Spark: The Revolutionary New Science of Exercise and the Brain. Exercise activates portions of the brain responsible for attention and executive function. Even better, studies have shown that exercise in a green setting and exercise before testing results in better academic performance. Just what kids with ADHD need!
Vitamins and Supplements
While there’s little scientific evidence that ADHD can be treated with vitamin and mineral supplementation, there are plenty of individuals who feel their ADHD symptoms are reduced with certain supplements. And, it is true that individuals with ADHD (and/or autism) are prone to some common deficiencies, like B-6 and antioxidants. Common supplements for individuals with ADHD are iron, zinc, B-6, and fish oil. Please note, however, that some of these substances can be toxic if you have too much (like iron), so you want to work closely with your child’s physician on supplementation.
In a Nutshell
As I have said many times, ADHD treatment is complex. It isn’t as simple as treating a headache with two Tylenol. Instead, it’s most effective when many different treatment aspects are paired together to make an overall treatment plan that reduces ADHD symptoms and improves skills and coping strategies for your child.