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Medical Author:

John Mersch, MD, FAAP

John Mersch, MD, FAAP

Dr. Mersch received his Bachelor of Arts degree from the University of California, San Diego, and prior to entering the University Of Southern California School Of Medicine, was a graduate student (attaining PhD candidate status) in Experimental Pathology at USC. He attended internship and residency at Children's Hospital Los Angeles.

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Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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The medications used to treat ADHD are psychoactive. This means they affect the chemistry, and thus the functioning, of the brain.

Psychostimulants are by far the most widely used medications in treating ADHD. When used appropriately, approximately 80% of individuals with ADHD show a very good to excellent response in reduction of symptoms. These medications stimulate and increase activity of areas of the brain with neurotransmitter imbalances.

The exact mechanism of how these drugs relieve symptoms in ADHD is unknown, but these medicines are linked to increases in brain levels of the neurotransmitters dopamine and norepinephrine. Low levels of these neurotransmitters are linked to ADHD.

• The most common adverse effects occur over the short term. They include loss of appetite, sleep disturbances, rebound (for example, agitation, anger, lethargy as the last dose starts to wear off), and mild anxiety. Most individuals who take psychostimulants for ADHD build up tolerance to adverse effects within a few weeks.
• Individuals with certain coexistent psychiatric disorders (for example, psychosis, bipolar disorder, some disorders of anxiety or depression) are particularly vulnerable to adverse effects if they do not receive appropriate concurrent treatment for the coexistent condition.

The psychostimulants most often used in ADHD include the following:

• Amphetamine (Vyvance, Adderall, Adderall XR)
• Methylphenidate (Ritalin, Concerta, Methylin, Metadate CD, Daytrana)

Atomoxetine (Strattera) is a non-stimulant used to treat ADHD. This medication has been used for several years, and less is known about its long-term side effects. This drug has several benefits over stimulants, but its use may also carry several negative aspects.

• It is not a controlled substance and is not considered a drug of potential abuse by the U.S. Food and Drug Administration (FDA). Since it is not a controlled substance, pharmacies may accept phone-requested medical refills.
• It is usually taken only once a day for full 24-hour effectiveness.
• It is much less likely than stimulants to disrupt eating or sleeping.
• For some children, atomoxetine is not enough to control their ADHD symptoms. Many other children do very well on this medicine alone.
• Specialists treating individuals with ADHD have found Strattera seems to best help improve the problems associated with a disruption in executive function skills. Inattention and hyperactivity symptoms are less responsive.
• When starting Strattera therapy, a gradually increasing dosage schedule is recommended. It may take up to three weeks before full therapeutic benefit is achieved. For this reason, patients may need to remain on previously prescribed stimulant medication during the "build up" phase. In addition, Strattera must be taken daily; short-term "medication holidays" (for example, school vacations and weekends) will limit Strattera's efficacy.
• Studies have indicated a higher than expected incidence of suicide ideation during early treatment. This occurred in patients with pure ADHD as well as in those patients with ADHD accompanied by other emotional disorders (for example, depression, anxiety, bipolar disorder).

Some medications originally developed to treat depression (antidepressants) also have important roles in treating some individuals with ADHD. Since these medicines have been used for many years to treat other mental-health conditions, their adverse effects are well understood.

• Imipramine (Tofranil): an antidepressant that increases levels of neurotransmitters norepinephrine and/or serotonin in the brain
• Bupropion (Wellbutrin): an antidepressant that increases levels of neurotransmitters in the brain, especially dopamine
• Desipramine (Norpramin): an antidepressant that increases levels of the neurotransmitter norepinephrine in the brain

Other medicines that were originally developed to treat high blood pressure (alpha agonists) may also be useful in the treatment of those having ADHD. Again, due to widespread and long-term use, their side effects are well known to doctors.

• Clonidine (Catapres): an alpha-2 agonist that stimulates certain receptors in the brain stem; the overall effect is to "turn down the volume" of hyperactive movement and speech
• Guanfacine (Tenex, Intuniv): Recently, the U.S. FDA has licensed the use of guanfacine as a non-stimulant medication effective in treating ADHD when used in conjunction with other stimulant medications. It is not felt to be nearly as effective when used as a sole agent. Both a short-term preparation (Tenex) and a long-term preparation (Intuniv) are available. Unfortunately, 18% of Intuniv users discontinued use of their medication due to side effects including drowsiness (35%), headache (25%), and fatigue (14%).

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