ADHD

What can be done for ADHD?

Introduction

ADHD turns out to be the most studied disorder in child psychiatry. There are two major types of interventions, medical and non-medical.

Medical Interventions

There is no doubt that medical interventions for ADHD are effective. Not only that, medications are more effective than any other intervention. Furthermore, adding all sorts of non-medical interventions to carefully prescribed medications doesn't work any better than medications alone. Medications are also effective if there is comorbid Oppositional Defiant Disorder, Conduct Disorder, or anxiety disorders. 

On the other hand, medications have some real drawbacks. First of all, they can cause side effects. Given how serious ADHD usually is by the time I see it and how safe these medications are, this usually isn't a real reason not to use medications. That is, since the risk of serious side effects is very low and the risk of the disorder causing severe problems for the child is quite high, the balance favors using medications.

The main reason not to use medications has nothing to do with the medications themselves. It has to do with how much parents hate the idea of giving their children psychiatric drugs. 

Non Medical Interventions

ADHD has been around a lot longer than medications have been. There are a host of interventions that are useful in ADHD that do not involve medications. The usual approach is to use a number of these together. These interventions are not as potent, but in combination they sometimes can be helpful enough to make ADHD go from moderately disabling to mildly disabling. For mild ADHD, this is the place to start. Often times they are combined with medications, although the most recent work would suggest that the non-medical treatments don’t add too much to medical treatment. 

Medications

What exactly do the drugs for ADHD do?

These drugs alter the way signals are transmitted in the brain. They work on substances in the brain which help transmit messages. They work at different levels of the brain to alter the core symptoms of ADHD. The different drugs work on different parts of the transmission system. That is why sometimes one drug will work and not another, as they are working on different parts of the transmission system.

Why would anyone want to give drugs that affect the brain to children?

The main reason would be if the non-medical interventions are not working or in more severe cases of ADHD. No one would suggest trying medical treatments before the non-medical interventions are used in very mild ADHD. It is similar to diabetes in that way. If you have diabetes which is not severe, your doctor will first suggest you try diet control. If that doesn't work, only then will the doctor consider medical treatment. However, if your diabetes was severe, you would start on a diet and medication right away. In other words, if ADHD is severe, sometimes we use medical and non-medical treatments together from the start.

If the drug works, how will my child be different?

In cases where the drugs work very well, the three core symptoms of ADHD (inability to pay attention to things they aren't interested in, hyperactivity, and impulsiveness) are brought down to a level which is close to the average for their age group. As a result, people are usually more successful socially, academically, and there are less family problems. Usually a person's self esteem improves. When these drugs work right, the change can be quite amazing. When children take these drugs, in 75 % of the cases they are indistinguishable from normal children and nothing else is really necessary, that is, very few of these other interventions will be needed.

What if it doesn't work?

Sometimes a medication won't work because the dose is too high or too low. Some people will not respond to one medication for the treatment of this problem but they will respond to another. If the drug doesn't work, of course, it is discontinued, and then you and I decide what do next. Try something else? Abandon medical treatment? Both are sometimes reasonable options.

These drugs can do a lot of bad things. Is this true?

Yes, it is. Like all medical treatments, there are side effects and sometimes people can have pretty bad side effects. There are two types of side effects. One type is the kind that disappear when you stop the drug. The other kind can last long after the drug is discontinued.

What exactly are the side effects?

It depends on the drug. Some drugs can interfere with sleep and appetite. Others can make you depressed or angry. Some can affect the heart. Others can make you wet yourself or actually make the hyperactivity worse. Others can make people have movements they didn't have before. Or, they can make you like a zombie.

Are they that dangerous??

Yes, when used improperly they can be quite dangerous. However, when used carefully they can be very safe.

How can that be?

Each drug has certain problems that need to be watched for. The current medical literature suggests three basic principles when using psychiatric drugs in children. 1) Start low, 2) Go slow, and 3) Monitor carefully

What do you mean by Start Low?

This means that you do not start any of these drugs at the usual dose, or the maximum dose. When you have pneumonia, it can be a real emergency. You want to give people plenty of medicine right away, and if there is problems, then you reduce it. Unfortunately, many people use this same strategy in the medical treatment of ADHD. The problem is that big doses can cause big problems, and when the problems affect your mind and personality, this usually means trouble for the person taking the medicines.  That way, if the child is sensitive to the drug, it only causes little problems. Some children respond to drugs at very low doses, far below the usual recommendations.

What do you mean, Go slow?

ADHD is not an acute illness. Less than 10% of the people with this disorder need to be treated very quickly. Most people  with this problem have had it for years. As a result, there is no need to increase the dose quickly. By going slowly, it is a lot easier to manage any side effects because things don't happen suddenly. Also, it is easier to find the lowest effective dose.

What do you mean, Monitor?

For each of the medical treatments for ADHD, there are specific side effects that need to be checked regularly. Some common ones (see individual drugs below) are monitoring weight so that people are gaining weight, watch for tics, watch for depression, checking blood pressure and pulse, checking blood tests and EKGs, and making sure parents know what the side effects are of the different medications. In This way, if there is a problem, we can pick it up early and avoid the horror stories, some of which are true, about the medical treatment of this problem.

So what drugs do you use?

The medical treatment depends on a few things. Use the drug that is easiest to use, cheapest, and works best. It turns out that about half of the children with ADHD have other neuropsychiatric problems. It is the presence or absence of these other problems that can determine which drug to use. Do they have tics? If so, certain drugs work much better. Are there signs of anxiety and depression? This means certain things will work and other will not. The first choice of drugs for ADHD are the stimulants. The other drugs are all second choice and usually reserved for children who do not respond to the stimulant drugs.

Monitoring

Some drugs require minimal monitoring and some do not. Some drugs require blood tests, others require blood tests and EKGs. Others require heart rate and blood pressure to be monitored. What drug requires the least amount of monitoring? The stimulants (Ritalin and DexedrineTricyclics require blood tests and EKGs to figure out the right dose. Clonidines require blood pressure and pulse checks.

Number of dosages per day

Some of these drugs have to be administered three times a day or more. That means someone has to be very, very attentive to getting the drug in the child at school and usually after school, too. Almost no children  will reliably take their own medicine. Besides, some people really object to the stigma of having to go someplace at school and afterwards to get their medicines. The drugs that need to be given three times a day are short acting Ritalin and short acting Dexedrine (not Dexedrine Spansules). All the other drugs are once day or just morning and night.

Cost

Overall, these are very inexpensive drugs, usually costing less than $40.00 a month

In Summary

• Each of these drugs has some good points and some bad points. There is no perfect drug. After the description of each drug is a chart which summarizes all of this.
• You can not predict which drug will work in a child and which will not.
• You can not predict which drug will cause side effects in a child and which will not.

Stimulants

They are the most commonly used medications for ADHD and include Ritalin (methylphenidate), Dexedrine, and Dexedrine Spansules (dextroamphetamine). Others are available in the USA but not in Canada. Sometimes one drug in this group will work for a person but the others will not. They all have the same side effects, but some people will tolerate one drug in the group far better than another. It is currently impossible to know which drug will work or be well tolerated in a certain child. About 90% of children with ADHD or ADD will respond to one of the stimulants. Most of these will be able to tolerate at least one of the stimulants. There is more data to support the effectiveness of stimulants as a treatment in ADHD than in any other medical treatment in medicine! So how do you decide which drug to start with?

Special Populations

Preschool

In some circumstances, drugs are used in this group. Usually it is because the child's behavior is so disruptive that he or she can not attend a structured pre-school program. It is important to get children with severe ADHD into pre-school as it can be very helpful in building their social skills. Other times a child's behavior is so difficult, especially when combined with ODD, that people in the family are getting seriously hurt. Other times the child's behavior is causing a severe impact on parents, relationships or siblings. Overall, these medications are safe in this age group. However there do tend to be more side effects. In recent studies of preschoolers with ADHD and other common comorbid conditions, 45% had side effects. There was not so much of a problem with sleep and appetite, but rather mood changes, irritability, and withdrawal.  Overall, when used very carefully, these drugs can be very helpful in many, but not all, preschoolers with severe ADHD . The doses tend to need to be increased over time and are usually close to 1mg/kg. Over the span of two years, a recent study showed that 11% had to discontinue the medication due to side effects. Overall, about 75% of children in this age group respond to medications.

Teenagers

These drugs are very effective in this group. The biggest problem is with medications requiring multiple dosages a day. Usually a drug like Ritalin would have to be given three times a day. This is very hard to remember, even if you do not have ADHD. As a result, the first line choice are drugs which can be given once or at most twice a day. Obviously, if drug abuse is a problem, stimulants are not used.

• Questions about abusing stimulants

The stimulant medications are closely related to certain drugs of abuse. For example, if you crush Ritalin (methylphenidate) and smoke it, you can get high. Large doses of dexedrine by mouth can be addictive. Some people try to combine these drugs with other street drugs to get high. As a result, these stimulant medications do have some street value.

Will my child get addicted to Ritalin or Dexedrine?

No. the only situation that can lead to addiction is when a confirmed drug abuser is allowed unlimited access to these drugs.

If my child uses Ritalin or Dexedrine now, will he be more likely to use street drugs and alcohol later?

No. In fact there is some evidence to suggest the reverse. That is, teenagers with ADHD who are treated with stimulants are less likely to end up abusing drugs than teenagers with ADHD who do not take stimulants. That is, it seems like stimulants might actually protect children from drug abuse. 

My son has ADHD but also abuses drugs if he can get a hold of them. Are stimulants safe?

Maybe. The usual approach is to make sure people are clean with urine drug screens and then make sure that they do not have access to the supply of medication.

 Specific Stimulants

Ritalin (methylphenidate)

This is certainly the most frequently used drug for ADHD. It is a cousin of speed and cocaine. Unless you are a confirmed drug addict, you will no get high on this drug unless you crush it up and try to smoke it. When taken as a pill, it will not make you high, so it is not addictive. It requires no special monitoring. It comes in 5, 10, and 20 mg sizes. They are easy to crush can be given in anything sticky for children who can not swallow pills. It is usually given at breakfast, lunch, and after school. The usual dose is 1mg/kg, or half your weight in pounds. For example, a 60 lb. child would take roughly up to 30 mg a day total.

What about slow release Ritalin?

The good thing about slow release Ritalin is you can give it once a day and it works for about 8 hours, but not 12. The bad thing is it comes in 20mg pills and you can not cut them in half, so it is very hard to "start low". Another bad thing is that often it does not work as well as regular Ritalin. It is worth a try in a person who has a good response to regular Ritalin but who does not want to take the drug at school.

Dexedrine and Dexedrine Spansules

This is the oldest drug used for ADHD. The tablets last about 6 hours at the most. The Spansules last about 12 hours. The Spansules are tiny pills in a capsule like a cold capsule. I rarely use the regular tablets because they are so short acting. However, they are some children who will respond to short acting Dexedrine and nothing else. In fact they might respond to Short acting Dexedrine but not the Dexedrine Spansules! The drug is twice as potent as Ritalin, so you are usually taking about a quarter of your weight in pounds. The Spansules come in 10 and 15 mg sizes. The tablets come in 5 mg size. That means that if you weigh less than about 40 lb., The 10 mg spansule will probably be too much.

So exactly how do you give these drugs?

Start with a dose that is quite low and watch the child for a few days.

One of three things will happen:

1. Absolutely nothing. Then we increase the dosage
2. Amazingly better and minimal side effects. We thank God and leave things alone.
3. A little improvement and no side effects. Then we increase the dosage.
4. Lots of side effects. Then we stop the drug and consider something else.
5. Some side effects and some benefit. Then we try to figure out whether the benefit is worth the side effects.

Once a drug is working, there is no guarantee that the dosage is going to stay the same. In fact, over 70% of children have to have their dosages adjusted over the span of a year. Of those dose adjustments, 60% were increases in dosage, 30% were decreases in dosage and a few (7%) were changes to different medication

Side Effects of Stimulants and their management

Remember, all the stimulants have the same side effects. Some people will have no side effects on one stimulant, and many on another. You can not predict who will have what side effect on which stimulant.

• Sleep

Many children with ADHD have insomnia. Sometimes the stimulants actually improve sleep. Sometimes they don't. A child may be able to go to sleep, but awaken a few hours later ready to go. More commonly, the child just can't fall asleep. This is very serious business for a number of reasons. First, the child will become sleep deprived leading to irritability, poor concentration, and fatigue. Second, since most parents do not go to sleep before their children do, the parents are sleep deprived with the same problems as the child. This is a very bad combination!

Management - If it is mild, sometimes attending to sleep hygiene or good sleep habits will do the trick. Things like an earlier bed time, certain foods, no TV or computer, quiet activities in the evening and no naps sometimes will do the trick. More often they do not. What to do depends on how well the child is doing on the drug at that particular dose. If the child isn't that much better anyway, I discontinue the stimulant and try another stimulant or another drug for ADHD. If the child is markedly better, often I will add one of two drugs, Clonidine or Trazadone. Both of these drugs have been safely used in young children. They are not addictive. They are not related to sleeping pills. They do not, when used properly, make a child dull the next day. The key thing is to do something. Sleep deprivation will undo every intervention you have made.

Medical Treatments for stimulant induced insomnia in ADHD

This drug was originally developed for treating blood pressure in children and it is very safe. It turns out to be useful for a lot of things. Indications for Clonidine are; tics, severe ADHD, severe aggression, sleep disturbances in ADHD, detoxifying Heroin addicts, menopausal flushing, and sometimes autism. The good thing about this is that it never aggravates tics, works well when autism is present, and works in very aggressive kids who never sleep. It is safe for pre-schoolers and comes in a pill called dixarit which is sweet tasting and looks exactly like smarties. As a result, kids will easily take it. It also comes in a larger size. It is a good choice when tics are present, in autism, preschoolers, and very aggressive kids with ADHD and severe insomnia.

And the bad side of Clonidine?

About one out of every 10 to 20 people who take this will get depressed. It comes on within about 3-4 days and after the drug is stopped, it can take 3-4 days to clear. However, if you are not watching for this, you might think the child is depressed for another reason, and never stop the drug, thus leaving the child depressed. With careful monitoring, that never happens. You have to check a person's blood pressure when you are starting this. It will make some children sedated, but usually by cutting back the dose you can avoid this. As it can affect the heart, I check an ECG before using it and after the child has been on it.

This drug was developed in the 1980s to treat depression. It works for that, but the reason it is used in children has nothing to do with depression. It turns out to be a very safe drug for helping children sleep. It has virtually no side effects. It is not addictive at all. The problem? In less than one in 1000 men, this drug can lead to prolonged erections (priapism) which can be so severe that it requires surgery. It has never been reported in male children, however, I have read some unofficial reports of one or two cases in the USA. It has been used for years in Autism in children. If a child has a history of depression and has stimulant induced insomnia, I use this.

• Appetite

The stimulants can reduce a person's appetite. After all, these are the same family of drugs used for weight loss. Often a child will not be quite as hungry on one of these drugs. Other children are finally able to sit down long enough to eat something and actually gain weight. Problematic weight gain is very rare, but weight loss is common. I weigh children regularly who are taking these drugs. If there is substantial weight loss in an already thin child, we try something else. Some children will eat no breakfast lunch or afternoon meal but not lose weight because they spend their evenings eating. Usually, children have other complaints then like stomach ache.Sometimes with a little encouragement a child will be able to eat enough at mealtimes to not loose weight. Sometimes things like Ensure, Boost and instant breakfast can help. If this has been tried and a child is still losing weight, it doesn't matter how well they are doing. It is time to stop that particular drug.

• Rebound

The short acting drugs often can cause this (regular dexedrine, regular ritalin). What this means is that as the drug is wearing off the child does not return to their usual severity of ADHD, but to a much worse state. They will stay this way for 1-3 hours before returning to their old selves. The usual story is a child who is taking Ritalin at breakfast and at lunch with great result. The drug wears off right after school and the child behaves like are a monster until evening. If this is severe, something has got to be done, no matter how well they might be doing in school. It is better to be consistently hyper than Dr. Jeckyl at school and Mr. Hyde at home. Sometimes, you can get around this by giving a small dose of the short acting drug (usually ritalin) in the afternoon.

• Unwanted psychiatric signs and symptoms

Perhaps 30-50% of children will have this on stimulants to one degree or another. These signs and symptoms are all reversible when you stop the drug. Everyone involved in the medical care of children with ADHD needs to be watchful for these. It is important to remember that even if this happens with one stimulant, it does not necessarily mean it is going to happen with a different stimulant.

Decreased activity - some children will become very, very still on these drugs, especially in the first few hours after they take them. Often they are perfectly behaved, but are taking in next to nothing. This is usually due to the dose being too high, but can happen in low doses in susceptible people.

Increased hyperactivity - some children will actually become more hyper, not less with these drugs.

Mood changes - Occasionally these drugs will make a person sad, angry, and very easily upset. Irritability is also possible. The child appears to cry at the drop of the hat. Even less commonly, a child will be giddy and actually seem high.

Language - Occasionally a child who has a problem with speaking or understanding will actually go backward on one of these drugs and speak even less than usual.

Movements and compulsions - occasionally these drugs will make people have what appears to be nervous tics as in Tourette's syndrome. At times these can be compulsive, such as new onset of nail biting, licking the hand, or having to touch certain things.

The possibility of the above things happening to a child who is already having psychiatric problems is often scary to contemplate as a parent. It is another reason to start low, monitor, and go slow. These are all reversible, and most children do not have these side effects which affect the mind.

• Other mild side effects

Besides these, there are sometimes some mild nuisance side effects of the stimulants. Occasionally mild head ache, abdominal pain, and other mild physical symptoms are reported by children taking these drugs. Often they go away with time and most research has found that this type of side effect is as common in children treat with placebo as with the actual stimulant drug.

• Long term side effects

The truth is, there aren't any. Although occasionally there is a report that these drugs will do something bad to a person if taken for years, it isn't true. If a child is tolerating the drug well, it isn't going to do something down the line. This is very clear from the literature. These drugs have been carefully studied for at least 30 years.

• Side effects and the school

The side effects of the stimulant medications are rarely seen at school. Studies have shown that while teachers are good at determining how effective a drug is, there are not accurate in determining side effects As a result, it is not uncommon for teachers to be more enthusiastic about medical treatment or suggesting that the dose of the medication be increased.

Example

Ryan is 6. He has quite severe ADHD and it impairs him everywhere. His parents don’t know of any other first graders who got suspended in October. Ryan has taken medications (Ritalin) in preschool when he was biting everyone and they helped. He lost a few pounds, was whiney, and didn’t go to sleep until about 9 pm, but he was able to get through preschool without getting thrown out. During the summer we tried dexedrine and the side effects were even worse. We were able to figure out that at 10 mg a day, the side effects were mild, and he was better. Not great, but not getting thrown out. Once the dose went above that, his behavior was super at school. Except the rebound was horrible, he didn't eat and he whined all evening. Since his teacher never saw the side effects, she felt they were being too cautious. Even after discussing it with me, they still think the parents are exaggerating the side effects.

 Non-Stimulant First Line Drugs

Bupropion (Welbutrin)

This drug has been available in the USA for about 10 years. It is used primarily as an antidepressant. However, it affects the same chemicals in the brain (dopamine and norepinephrine) that other drugs for ADHD effect. As a result, it has been tried in ADHD in children and adults. There are only a few studies of this drug in children. However, all of them have found it to be effective. In the one study which compared it to Ritalin, it was found to be almost, but not quite, as effective as Ritalin.  It has been used in children who have Conduct Disorder, Substance abuse problems and Attention Deficit Hyperactivity Disorder and it has been found to be helpful.  It comes in a slow release form, which means there is no need for a middle of the day dosage. The average dosage is about 3-4 mg/kg. The drug is available only as a slow release preparation in Canada. It comes in 100, and 150mg sizes. The pills can be safely cut in half, but they don’t last longer than 24 hours in the cut form. Usually it is given once or twice a day and it is not recommended that any dose be greater than 150mg.

Since this drug is also an antidepressant, it is a first line choice if a child has both depression and ADHD. It is also a good choice if people have had problems with depression from stimulants. A recent study has shown that in children with depression and ADHD treated with Bupropion (Welbutrin) the drug worked quite well. Depression improved in 88% of the children and ADHD in 63% of the children. In 58% of the children, the drug helped both the ADHD and the depression. 

Side effects

Rashes are not uncommon, about one out of 6 children can get one which usually resolves over 3-4 days. Nausea and vomiting can occur. About 1/3 of children will lose a little weight. Less common side effects include irritability, sleep problems, and head aches.

There is only one serious concern. It can cause seizures. This is most frequent in over doses and when patients also have bulimia. In adults, 4 out of 1000 people will have a seizure using the short acting form of the drug. However, the long acting form used in Canada only causes seizures in 1 in 1000 people . This is about the same as most of the drugs used for depression. Seizures have occurred in children, but usually at higher doses. It is still unknown if the seizure rate in children is lower, higher, or the same as in adults. There are no other long term side effects or risks. On the other hand, it has not been around a long time. Over all, the early data suggests the side effects are slightly less than stimulants, but not a lot less.

Good points about Bupropion

Compared to the other non-stimulant drugs for ADHD, the monitoring necessary is minimal. No ECGs or blood tests are necessary. It can be helpful when depression is also present. It has been used a lot in the USA for ADHD without any major problems. If a child has failed to respond or tolerate the first line drugs it is the next choice. 

Bad points about Bupropion

There has been some, but not a lot of research on this drug. It seems quite safe in adults, and it probably is in children. However, there is a possibility that something will come up which is a problem with this drug in the future. More importantly, it is hard to use in little children. Since the smallest amount you can give is one half of a 100mg tablet, that means if the child weighs 20 Kg (45 lbs) or less, you are going to be starting the drug at the maximal dose. This is something I always try to avoid doing, so it is not a good choice in children under 50 lbs.

Second line Drugs

All of the medications below involve more risk. That is, in rare cases, people can have serious side effects. This means that there is additional monitoring required. Why do you use these drugs?

Because the drugs above have not worked.

Except in a few cases (comorbid severe tic disorders, some mood disorders, some substance abuse disorders) both the drugs above are tried first before considering the drugs below.

Because the risk of ADHD is far greater than the risk of the medication.

ADHD is not always a mild disorder. People with ADHD sometimes engage in very risky behaviors. These are risky to themselves and others. ADHD can totally demoralize a child and put them at significant risk for depression. The risks of things like substance abuse related accidents, motor vehicle accidents, demoralization, other psychiatric disorders and even suicide is not that small. If you look at a group of children with ADHD that go to see a pediatric psychiatrist and then see how they are doing four years later, 51% will have required tutuoring, 34% will have repeated a grade, 15% will be in special classes, and 16% will have been diagnosed with a learning disability. Compared to children without ADHD, they will be 10 times more likely to have manic-depressive disorder, 8 times more likely to have depression, and 4 times more likely to have major anxiety problems.  ADHD can be a very serious illness.

The risk of serious problems with the drugs below is on the order of 1 in 10,000 or less. To put that in perspective, your chance of being killed in a car accident on the way to my office is .7 in 10,000. Compared to the risks of ADHD, most people would say the risks of these medications are worth taking.

Your job is to learn about how these medications are monitored and what the risk is and then, with a pediatric psychiatrist, decide what to do.

Tricyclics

This is a group of medications (desipramine and nortryptiline) which were the first drugs used for depression in adults. One of them, imipramine or tofranil, has been used for years children who bedwet. They work in a slightly different part of the brain. The good thing is that they work very well in children who are also depressed or anxious. They do not wear off over the day. They can be given it at breakfast and bed time. They do not usually worsen tics. 

So why aren't they used more?

Approximately 5-10 children have died suddenly while taking one of these drugs, desipramine. This turns out to be a rate of about 8 per million. Children die of unknown causes at a rate of 8 per million. To put this in perspective, the childhood suicide rate is about 8 per million. The risk of dying in an auto accident are about 70 per million. So, although there is a very slight risk, compared to the risks of the disorder, it is very small. In my practice, it would be ten times more likely that someone would die on the way to their appointment with me in a car crash than die of sudden death related to these drugs. There is still a debate as to whether this small increase in deaths is from the medication or something else. It is also unclear as to whether monitoring as below will pick out these super rare cases. It has only happened with desipramine. A much more real risk is over dose. If children or adults take too much of these drugs accidentally or on purpose, they can die. These drugs can cause rhythm problems in the heart, blood pressure problems, and fast pulse, plus constipation and dry mouth and occasionally sweating and dizziness. It is very hard to figure out the dose.

Are they safe?

Yes, they quite safe if they are used correctly. The American Heart Association studied this issue and published their recommendations in August of 1999 They suggest the following.

First I get an EKG. If it is normal, we start the drug at a very small test dose amount. For Desipramine, this is usually 1 mg/kg. The doses for Nortryptiline are half of this. Over the next few weeks I slowly increase the dose to 3-5 mg/kg for desipramine or 2-3 mg/kg for Nortryptilin . At this point we check a blood level and another EKG. It takes a week to get the result back. Based on the results of the blood test, I adjust the dose, and occasionally a person will need another EKG and blood test, but not usually. I check the blood pressure and pulse after a few weeks. The toxicity of these drugs is mostly related to the blood level and the EKG. By following these very conservative guidelines, the drug is very safe and often very effective.. BUT, it is a fair amount of hassle. Obviously if someone is dead set against having their blood drawn, they will never get this.

I heard of somebody who was taking two drugs at the same time. Why would you ever do that?

Attention Deficit Hyperactivity Disorder is sometimes so severe that one drug won't control it. It can be a life threatening disease as it makes accidents much more likely. There are certain cases where it is necessary to use two drugs to control Attention Deficit Hyperactivity Disorder. This requires even more monitoring and even a more careful approach.. What follows is a table of the medications.

 The bottom line is.....

Drugs can be very beneficial. There is no free lunch; they all have side effects. If used carefully they can be lifesavers, if not, a nightmare.

Drugs can be very beneficial. There is no free lunch; they all have side effects. If used carefully they can be lifesavers, if not, a nightmare.

Alternative medicine treatments

There are quite a number of substances, which are supposed to help ADHD, which are "natural". Usually these are combinations of vitamins, herbs, minerals, and other plant products. They are usually advertised as being very safe and effective.

For the most part, they are very safe. There are far less side effects with these agents. On the other hand, there is not the same kind of research data that is found with medical treatments.

At the moment, no alternative treatment meets all these criteria. However, there is one that is relatively close. That is supplements with Omega 3 Fatty Acids (Fish Oil) in them. This is based on the observation that children who are hyperactive have lower levels of these substances in their blood.These supplements have been used for other purposes in medicine so we have a fairly good idea about their safety. Recently a careful study of these fish oils was done. They compared high doses of fish oil to placebo in children with ADHD. Although there were much larger amounts of Omega 3 fatty acids in the children' blood, there was no evidence that the fish oil helped ADHD. This was for 9 year olds. This careful study suggests it is useless to give fish oil to older kids. It is still possible that it might work in younger children. My experience is that it does occasionally work in preschoolers.

So when are they reasonable to consider?

When ADHD is only mild. Overall, they do have a lot less side effects than stimulants, and if the problem is not severe or urgent, it is worth considering. In the population of children I see with ADHD, less than a tenth respond to herbal treatments.

There are a number of sources of Omega 3 Fatty acids. Here in Southwest Nova Scotia, the three most popular are Evening Primrose Oil, Herring oil capsules, and a combination of tuna fish oil and Evening Primrose oil. These are available at pharmacies and health food stores.

Previous Related Articles

Psychiatry and Psychopharmacology Psychiatric Medications Emotions influence memory, learning Depression and Mania Attention Deficit Disorder Adults with Attention Disorder Show Memory Flaws Anatomy of Brain

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