Long-Acting ADHD Medications Are Very Beneficial For Children And Adults
Question: We are concerned about our seven-year-old son. He is a very smart boy, but he has difficulty learning in school. He is always very active and very busy. When he plays, he would move from one activity to another, with a very short attention span. He gets bored easily and needs us to entertain him constantly. When he plays with his friends, he will only play according to his rules. Since kindergarten, all his teachers have noticed that he struggles to pay attention, and gets distracted very easily. He was not able to read like other children in grade one. As a result, he was placed in grade two this year instead of being promoted. Homework is a real nightmare for us because he doesn’t want to do it, and it drags on as he gets distracted by just about anything. We have seen two paediatricians, and both of them confirmed that he has ADHD. One doctor told us that he should take medicine every day, while the other said that he only needs it when he goes to school. We are really confused, and our friends scare us even more about medications. We have seen some television commercials about new medications for ADHD that can last the whole day. Can you help us to make the right decision for our son?
Let me begin by saying that I will try to clarify some of the myths and concerns about medications that can help children with Attention Deficit Hyperactivity Disorder (ADHD). As parents, you are the ones that will make the final decision, whether to use medicine or not, and which one to use, with guidance from your physician. Hopefully, the following will make it easier for you to draw your own conclusion.
From your description, it is very possible that your son does have ADHD. However, the diagnosis requires detail examination of many pieces of information, including his birth and development, as well as observation at home and in school in the last few years. I am sure both paediatricians have taken everything into account before making the diagnosis.
The challenge for many parents is to accept the diagnosis, and to make the decision about medicine. Many parents feel guilty about making that decision. Others worry about the long-term side effect of medications. Some are concerned that since these medications affect the brain’s function, they may somehow alter their children’s mind.
Let me clarify the myths about the two most common medications for ADHD: Ritalin and Dexedrine. Both of them have been used for several decades, although many parents never heard about them until the last few years. Most children with ADHD will respond to one of these medications, with improvement in symptoms like inattention, distractibility, hyperactivity, and impulsiveness. Both of them can have side effects, but they are generally mild. Most parents are concerned that since these medications can suppress appetite, their children will not grow properly. Extensive research has shown that the effect on appetite is temporary, and these children will grow normally. I have followed many children for ten or more years, and everyone has continued to grow and reached their potential weight and height.
As you mentioned, another controversy is whether medicine should be used on weekdays and during school hours only to improve school performance, or should they be used daily without interruption on weekends or holidays. The consensus among most paediatricians and psychiatrists is that medications should be used daily, and the dose should be adequate to control ADHD symptoms for most of the day, instead of during school hours only. The reason is that ADHD affects not only the child’s ability to concentrate and learn in school, it also affects children’s social development and interaction with their peers and adults. You have already noticed this in your son: he will only play on his terms. He may be able to do this now, but soon enough, his friends are going to realize that and will likely drift away.
Let me describe here briefly about a ‘landmark’ research project that confirms the importance of medicine in children with ADHD. This study was initiated by the National Institute of Health in 1992. It was called Multimodal Treatment of ADHD (MTA). The study recruited 579 children between 7 to 10 years of age who were attending grades 1 to 4. These children were randomly divided into four groups.
The first group of children were given medications, mostly three times a day: before school, at noon, and a smaller dose after school, to provide control for homework and after school activities. The same doses were given on weekends and holidays. Most of these children received short-acting Ritalin, a smaller proportion was given Dexedrine. The dose of medicine was adjusted carefully until ADHD symptoms were optimally controlled.
The second group received the same medications and monitored the same way. In addition, they were given intensive behavioural treatment felt to be useful and important for children with ADHD. The third group received identical behavioural treatment as the second group, but without medicine.
The last group was treated by their regular physicians in the community. About two-thirds of them received Ritalin or Dexedrine (that means one-third was not treated), but the dose of medicine was not monitored or adjusted closely as in groups 1 and 2. As a result, these children only had two visits a year with their doctor, averaging about 17 minutes per visit.
The results of this MTA study were astounding. After 14 months of treatment, children in the first and second groups had the best improvement, and both treatment plans were equally effective. Careful adjustment of Ritalin or Dexedrine was able to provide the same amount of success, whether these children received behavioural treatment or not. The important thing to emphasize is that medications were adjusted carefully to achieve the best control of ADHD symptoms, not just settling for some improvement.
It is also interesting to note that the third group of children who received intensive behavioural treatment without medication didn’t do well at all. There was some reduction in the symptoms of ADHD, but the overall improvement was much less than the first two groups.
The worst result was in the last group, children who only saw their doctors twice a year for brief visits. Those children who did receive medication did have some improvement, although the improvement was far less than the first group, most likely because the dose of medicine was not adjusted closely to obtain the optimal effect.
The study concluded that Ritalin and Dexedrine were both effective in controlling symptoms of ADHD. The best results were achieved when medications were adjusted carefully to provide control of ADHD symptoms for most of the day, not just during school hours.
As a result of this study, extensive research was conducted to improve the formulation of medicine that can provide more sustained effect than Ritalin or Dexedrine. As a result, two new medications were introduced in Canada in the last few months to help children with ADHD, these are called Concerta and Adderall XR.
Concerta is a new formulation of Ritalin. This medicine can start to work quickly because the pill is coated on the outside with 20% of fast-acting Ritalin. The remaining 80% of medicine is released gradually over the next ten hours, using a pump mechanism inside the pill. As a result, one dose in the morning can provide effective medicine for about 10-12 hours.
Adderall XR is made by combining several amphetamine salts that are related to Dexedrine. The medicine is embedded in tiny beads inside a capsule. There are fast- and slow-acting beads. The fast-acting beads start to work within half to one hour, while the slow-acting beads provide sustained effect that can last 10 to 12 hours, if the right dose is given. If the dose is too low, the medicine works less effectively and for a shorter period of time.
The importance of these new medications is that only one dose is needed in the morning for most children with ADHD. There is no need to take medicine in school, therefore reducing the chance of losing or selling medicine.
Another important benefit is that the medicine is released smoothly over time, preventing the ups and downs that is often present with short-acting medicine. Most children and parents who have used short-acting Ritalin or Dexedrine before find that Concerta and Adderall XR work much better. The main drawback is their cost: they are much more expensive, although virtually all private insurance policies do cover both medications.
I should mention here that medicine for ADHD will only improve symptoms caused by this condition. As noted in many research studies, a large proportion of children with ADHD also have additional problems that can be separately diagnosed, including anxiety, depression, mood disorders, oppositional defiant disorder, conduct disorder, and Tourette Syndrome. These problems will persist although ADHD symptoms can improve with ADHD medications. The important thing is to recognize that these conditions can co-exist with ADHD, and deal with them appropriately.
Finally, many parents ask me how long a child may need ADHD medication. If the parents are worried that their children may need medicine for a long time, and therefore reluctant to start medicine, I would say that it is like putting the cart before the horse. The important thing is to try and find out whether medicine can help, instead or worrying about how long a person requires treatment. It is true that many children will improve in their physical hyperactivity when they reach teenage years, but inattention and impulsiveness often continue into adulthood, and still require the help of medicine. My general rule is to continue medicine when the student is pursuing education, whether it is high school, college, or university. Many adults with ADHD, because of the challenge of their work, find that they need medicine to help them to focus. The decision is very much individualized, depending on the person. Ritalin and Dexedrine have been around for several decades, and they do not have long-term harmful effects.
I hope the information that I have provided here can help you and your doctor to make the best decision for your son so that he can achieve his full potential.