Are Stimulants The Only Option For My Hyperactive Child?

Is it adderall or bust?

ADHD can be challenging to treat, as it can present so differently from child to child, has many different causes, and often presents with co-occurring medical and psychiatric conditions. For children specifically, ADHD often co-occurs with: ASD, learning, language, anxiety, and/or trauma. Medically, ADHD can also tie to Lyme, TBI, sleep apnea, epilepsy, CP etc. Per the research, pharmacotherapy for ADHD reduced symptom burden, improves quality of life, improves academic performance, social, functioning, and reduced rate of MVAs. The general idea is that these medications cross the blood-brain barrier and impact biochemical processes in the brain to improve control and efficiency, thus improving mood and everyday functioning. There has been significant increases in Adderall use during the pandemic and ever since, mostly adults and teens, to the point of some pharmacies running out of supply. The increase in prescriptions in recent years has largely been secondary to Telehealth care. Shockingly, over 75% of counties within the USA lack a mental health prescriber, leading to significantly increased wait times for the few providers in these areas, demonstrating the significant need for Telehealth options. Some more recent considerations: many teachers are expressing increased difficulty controlling children in the classroom leads to more teachers and more often suggesting to parents that children be placed on medication (recommendation should not be coming from a teacher directly), beginning in the parents bringing for evaluations, an increased number of children and teens have been prescribed medications since the pandemic as medication is sometimes easier and sometimes more cost effective as opposed to therapy or a formal evaluation.

Though stimulants (generally amphetamines and methylphenidate) can be very effective for some children and adolescents with difficulty regulating attention, they do sometimes present with temporary or longstanding side effects. Often, stimulants can result in emotional lability (e.g., moodiness, irritability), reduced appetite, difficulty initiating or maintaining sleep, weight loss, increased heart rate, increased blood pressure, and GI irritation. There are two other classes of medications (alpha-agonists and blood pressure regulators) which have been found to coincidentally demonstrate some improvements in attentional ability. Two main medications are Strattera and Intuniv. While not always as effective as stimulant medications, these medications tend to result is significantly less side effects and may be safer in younger children. As always, consult with your doctor and request educational and scientific materials prior to making any decisions about medicating your child. Additionally, many families are not comfortable with medicating their child and should never been judged or forced to do so. There are many behavioral and environmental supports that can be put in place to support and nurture a child with ADHD.

Stimulants have also been found to alter the blood flow to the brainstem and increase dopamine in the striatum, which is responsible for motor control, reward processing, attentional and behavioral regulation. So now that we understand a bit about arousal and attention as well as some parts of the brain involved, let's understand how and why stimulants became a first-line treatment for ADHD. The basic idea is that increasing dopamine and/or norepinephrine in the brain networks associated with arousal and behavioral/emotional regulation, can reduce ADHD symptoms. The two main groups of stimulants are amphetamines and methylphenidate, both of which can be short or long acting (fast-acting or extended release) and have been shown to be most effective in the short-term for core symptoms of ADHD. Amphetamines have been shown to have a generally large effect size, but have higher rates of side effects, while methylphenidate has generally been found to shown a moderate effect size and have slightly less adverse side effects. The most common amphetamines include Adderall, Vyvanse, and Adzenys and the most common forms of methylphenidate are Daytrana, Ritalin, Concerta, Focalin, Metadate, and Quillivant. Side effects for these medications can include: reduced appetite, irritability, reduced sleep and/or fatigue, headaches and nausea. Generally, there are minimal cardiovascular effects from stimulants; however, some studies have demonstrated potentially mild hypertension/arterial disease for long-term use. There may also be long-term adverse effects of growth/height/weight for children who have continuous stimulant use. Stimulants are effective for about 70% of patients; however, aside from the 30% it is not effective for, there are many who discontinue due to adverse effects, or are contraindicated for those who have anxiety, tics, sleep disorders, eating disorders and cannot take stimulants. Some stimulants can be addictive for some people, especially the short acting ones; however, this generally more so a concern for adults and stimulant generally do not produce euphoria in child who use them as prescribed.

As a result, pharmaceutical companies began exploring and repurposing other non-stimulant medications to treat ADHD symptoms. Per the research, non-stimulants are generally less effective than stimulants; however, they generally have less side effects. In recent years, there have been four main non-stimulants that were often prescribed for ADHD. The first is atomoxetine (Straterra), which reportedly has the most efficacy in terms of non-stimulants in the short-term for core symptoms of ADHD. Strattera is an SNRI, which increases NE only. Per the research, Strattera has reportedly demonstrated decent efficacy and safety and also may help comorbid tics and behaviors; however, it can have gastrointestinal symptoms or dizziness/fatigue as well as increased BP and heart rate, and is contraindicated in children with cardiovascular differences. The second is Viloxazine (Qelbree), which is considered a multimodal agent, as it increases both NE and 5HT, and also has generally good efficacy for inattention and hyperactivity, as well as few cardiovascular effects, and a low risk of abuse because lack of dopamine involvement; however, it is not always tolerated well (fatigue, headaches, reduced appetite/nausea). The last two, guanfacine (Kapvay) and clonidine (Intuniv) are both alpha-adrenergic agonists and are thought to act by modulating the activity of locus coeruleus neurons and prefrontal cortex by direct stimulation of post-synaptic alpha receptors. Research has demonstrated small to moderate effect sizes, with only 1-2 weeks for effects, as well as benefits for patients with sleep, tics, and/or rejection sensitivity; however, there may be some risk of low blood pressure or reduced heart rate.

One of the new and seemingly promising drugs coming on the market is Centanafadine, which does not have a brand name yet, but is an NDSRI, meaning it targets serotonin, norepinephrine, and dopamine. Presently, it is being developed as a sustained release formula and is currently in phase 3 human clinical trials, across randomized double-blind, placebo-controlled trials. Per the research, centanafadine may work as quickly as 1-2 weeks, has small to moderate effect size, and shown to improve executive functioning skills, emotional regulation, and focus. It may have a quicker response rate than other non-stimulants, has a reduced abuse potential, no cardiovascular effects, and less adverse effects than stimulants, which may improve treatment adherence. A second up and coming drug, Dasotraline is also a triple reuptake inhibitor, which increases mainly DA and NE, as well as some 5HT. Dasotraline was shown to reduce impulsivity, inattentiveness and overall ADHD symptoms in children and adults, with reduced concern of abuse/tolerance,; however, for some, adverse effects were significant (insomnia, reduced appetite, mostly but also headache, racing heart, irritability/anxiety, dizziness) resulting in lack of compliance in about 1/3 of clients, in addition to some reporting of hallucinations/delusions in children because of the increase in dopamine.

Many of the newer research studies have been exploring what they are calling, the Druggable Genome. This an attempt to identify a selection of genes that are potential targets for pharmacological interventions (kind of the reverse of pharmacogenetics). Genome-wide association studies may uncover genes and pathways involved in the disease etiology to find avenues for future drug development and repurposing. The reason this is relevant, is because as of now, all active ADHD drugs belong to a small pharmacological niche, so they are very limited in genes/pathways they address. The druggable genome may be important given all of ADHDs comorbidities. For example, per the early research, there may be some indication to use drugs that treat autoimmune diseases that would help with ADHD. I should note that there have been contradictory opinions regarding “chemical imbalance” theory in the psychiatric field, some feel conflict of interest with pharmaceutical companies, some feel its complicated because multiple causes of ADHD, “no biological marker.” Some argue behavioral observation and questionnaires are just as or more effective to identify ADHD as continuous performance tests because of variable validity and reliability, so if no consistency and biomarkers then chemical imbalance theory doesn’t work.

Now for some general tips are considerations. It is strongly recommended by medical professionals that you monitor your child (or yourself) before, during, and after meds for physical, emotional, and functional changes, document everything and ask school to document also. It is important to report any co-occurring medical or psychiatric disorder as well as medications you are currently raking, even if you think minor or irrelevant, because of potential interactions or adverse health effects. Some clinicians prefer to do an EKG and/or EEG prior to prescribing to ensure safety/rule-out any medical conditions. Overall, stimulants are easier to trial than non-stimulants because they are in and out more quickly with quicker effect (think Tylenol or Advil). Many of these medications can be available in many forms, including: oral solution, wearable patches (can be beneficial for those with ARFID), chewable tablets, or pills/capsules. Some can be sprinkled on food and ingested in various ways but need to check with prescribing doctor to ensure efficacy and safety. Some meds need a booster/second dose, which may need to be given by a school nurse, if permitted, so that is also something to consider. Also keep in mind that there are many avenues to try prior to medication, including behavioral therapy, supplements (do your research), environmental adjustments (school and/or home), neurofeedback (for certain profiles), and ruling out other medical concerns. In the school environment, it can be helpful to: provide verbal and physical prompts (e.g., say child’s name in close proximity, repeat instructions), place the child closer to teacher and away from distracting peers, permit non-distracting (NO FIDGET SPINNERS) fidgeting (e.g., silent tapping, movable chair, Velcro, stress ball) at desk as long as fidgeting does not distract other students, allow breaks/opportunities for movement (e.g., hand out paper, walk around room, serve as teacher’s assistant), consider using a timer and resulting reward (i.e., preferred reinforcer) for ability to remain quiet and seated, and/or modify presentation of information (e.g., shorter instructions, cueing). Of note, some of these interventions will be appropriate for some students and not for others, so it is important to understand your child’s individual profile and have a team of professionals working together to support your child. You should always feel comfortable with your decision as parents and don’t let anyone pressure you into something you do not feel is right.