Dr. Robert Hilt, a psychiatrist at Seattle Children’s who was formerly a community pediatrician, addresses frequently asked questions about medications used to treat attention-deficit hyperactivity disorder (ADHD). For a more in-depth discussion about monitoring ADHD medications, antidepressants and antipsychotics, see his article “Monitoring Psychiatric Medications in Children” in Pediatric Annals.
Q. At what age is it appropriate to start prescribing medications for ADHD?
A. It’s best to avoid using medications in children under 5 years old except for children with very severe symptoms. In those cases, there is research suggesting that some medications are safe and effective in children as young as 3 years old for high-severity ADHD symptoms not responding to behavioral interventions.1
However, it is difficult to diagnose ADHD with certainty in children under age 5. One of the main challenges is that inattention and hyperactivity can be caused by non-ADHD problems like anxiety, parent conflict, developmental disabilities or just normal immaturity when it comes to young children.
Our algorithm for diagnosing ADHD (PDF) on the Partnership Access Line site summarizes some of these diagnostic considerations and includes two symptom checklists: the ADHD Rating Scale IV – preschool version and the Vanderbilt ADHD Rating Scale (for school-age kids). It should be emphasized that symptom rating scale results are not sufficient to make a diagnosis of ADHD.
Q. Are ADHD medications ever prescribed inappropriately?
A. ADHD medications are sometimes prescribed inappropriately for children who are hyperactive or inattentive for other reasons. ADHD is best thought of as a developmental impairment starting in early childhood that typically remains present throughout the school years.
Not all problematic hyperactivity or inattention is ADHD. When diagnosing ADHD, it’s important to look at the overall picture and ask if there are other likely reasons why the symptoms are present. For example, inattention and aggressive acting out may occur in response to a child being bullied in school or struggling with an unrecognized learning disability.
Relatively sudden onset of inattention and behavior problems is generally not due to ADHD. Inattention problems that appear in middle school or high school may be due to depression, anxiety or a substance use disorder.
Q. What first-line therapy would you recommend?
A. Stimulants (methylphenidate or dextroamphetamine) continue to be most effective. They work for more patients and are generally well tolerated.
Q. When would you recommend the combination of an alpha-2agonist with a stimulant?
A. This combination, which is now approved by the Food and Drug Administration (FDA), can result in better symptom control, but there is a greater risk of side effects with the use of two medications.
Unless there is a patient-specific reason to start with an alpha-2agonist (clonidine or guanfacine), it’s best to try a stimulant first and adjust the dose. If results are inadequate, switch to the other family of stimulant. If symptoms still aren’t controlled, try an alpha-2agonist on its own. If there are benefits but they are insufficient, that is when I try combining a stimulant with an alpha-2agonist.
With alpha-2agonists as a single medication or in combination, watch for daytime sedation and worsened irritability, orthostasis, or blood pressure suppression.
Q. How long should you wait before trying a new medication?
A. If using a stimulant that is well tolerated but is not completely effective, consider increasing the dose. You can increase the dose as early as two weeks after prescribing. Even though full stimulant effects appear on their first day of use, you need one to two weeks to observe the patient’s overall patterns with the medication.
With other medications that are not stimulants, you would need to wait at least a month to see if it is effective. If a very problematic side effect occurs, like severe irritability, stop the medication and wait for the side effect to resolve before trying something new.
Q. What monitoring is needed with stimulants and alpha-2agonists?
A. The long-term impact on growth is still being debated, but growth should be monitored since appetite suppression is a common side effect of stimulants. Sleep is often altered by these medications.
For both stimulants and alpha-2agonists, check pulse and blood pressure after initiation. The average changes are small (i.e., around 2 to 4 mm Hg for blood pressure), but occasionally, there is a more significant vital sign change from using these medications.
Q. What side effects should be discussed with patients and their families?
A. In addition to the common side effects of stimulants, including appetite suppression, insomnia, dysphoria and rebound irritability, it’s important to review certain rare but serious side effects, particularly if the child has a history of hallucinations, mania or a seizure disorder. Stimulants, particularly at higher dosages, can cause hallucinations, mania, or lowering of the seizure threshold.
The Physicians’ Desk Reference prescribing recommendations say to avoid using stimulants in children with tics, but that’s not the current view. Most patients who have tics and take a stimulant do not have any change. Some will experience an increase; some will experience a decrease. So it’s important to tell the family that tics could increase, but usually they won’t.2
Q. What follow-up is recommended after a medication is prescribed?
A. See the patient regularly every two to four weeks until symptom control is achieved. Patients who have been treated successfully with stimulants should still be seen at least once every six months.
- Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. JAACAP, 2006 Nov; 45(11):1284-93.
- Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.