If you had it to do over again, would you still give ADHD drugs to your child? About half of parents (52 percent) felt strongly that they would, according to a July 2010 survey of the parents of almost a thousand kids by Consumer Reports Health. About half (44 percent) strongly wished that there was another way to help their child besides the medication.

More parents were highly satisfied with the medication (41 percent) than felt strongly that they were concerned by the side effects of the medication (32 percent).But clearly this is a balancing act between benefits and costs.

What other strategies did parents report helped a lot?

• Changing schools to one better suited to help with ADHD (45 percent)
• Giving one instruction at a time (39 percent)
• Using a tutor or learning specialist (37 percent)
• Providing structure and schedules (35 percent)
• And seven other strategies, from changing class seats to taking fish-oil pills (12 to 27 percent)

An important key to managing ADHD is to set specific, measurable goals at home and at school. Then, when you try an intervention you can monitor progress, evaluate the treatment, and readjust the plan.

If you are considering ADHD medications, read this important brief post about long-term success and permanent side effects.

To me, the role of medications is not to “solve” ADHD, but rather one possible way to provide a window of relief and focus for a year or two in which to pursue lifestyle changes that can make a long-term difference. These might include changes in nutrition, in physical activity, in sleep, in chemical exposures, in peer groups, in study strategies, in parenting strategies, and in school environments.

Almost 40 million prescriptions were written last year for ADHD drugs in the US alone. Parents deserve to know if these drugs won’t improve the long-term success of their children. They also deserve to know if most of the kids these drugs long term will have permanent side effects. Both of these appear to be true. While these ADHD drugs may provide immediate relief of ADHD symptoms, after two years or so the kids on average are not better off than those who didn’t get the drugs at all. And those who take the drugs for three years or more appear to end up almost an inch shorter than they would have otherwise. Their growth rate slows and does not appear to rebound. These results come from a large federal study called the Multimodal Treatment Study of Children with ADHD (MTA). The latest news from this long-term study, the 8-year snapshot, was just released in the Journal of the American Academy of Child & Adolescent Psychiatry. At the beginning of the study, the children were randomly assigned to get medication alone, behavior therapy and parent training alone, medication and therapy combined, or routine community care for 14 months. At the end of the first year, those who got medication with or without the behavior therapy and parent training were doing significantly better than the others. But by three years, these differences had largely evaporated whether or not the child continued to take the medications.

Now we know that eight years later the type of treatment received initially made no difference in their long-term outcome, whether looking at grades earned in school, arrests, other psychiatric problems, or other ADHD symptoms – as assessed by parents, teachers, or the kids themselves. The specific question of substance abuse is being analyzed separately, and results are not yet available.

Some of the kids remained on the medications continuously for 6 to 8 years. Those children fared no better than those who never received meds or who used them briefly when comparing on almost all measures of success, including school grades, homework completion, quiz and test performance, school office visits, disciplinary actions, conflicts with parents, and so on. They did score a couple points higher score on a math achievement test. They also ended up shorter. Of course, these are averages. Some individuals may benefit significantly more from the medications. Or less.

To me, this suggests that when ADHD medications are used their greatest benefit would not be to “solve” ADHD, but rather to provide a window of relief and focus for a year or two in which to pursue lifestyle changes that can make a long-term difference. These might include changes in nutrition, in physical activity, in sleep, in chemical exposures, in peer groups, in study strategies, in parenting strategies, and in school environments.

“MTA at 8 Years: Prospective Follow-up of Children Treated for Combined-Type ADHD in a Multisite Study.” MOLINA, BROOKE S.G. Ph.D.; HINSHAW, STEPHEN P. Ph.D.; SWANSON, JAMES M. Ph.D.; ARNOLD, L. EUGENE M.D., M.Ed.; VITIELLO, BENEDETTO M.D.; JENSEN, PETER S. M.D.; EPSTEIN, JEFFERY N. Ph.D.; HOZA, BETSY Ph.D.; HECHTMAN, LILY M.D.; ABIKOFF, HOWARD B. Ph.D.; ELLIOTT, GLEN R. Ph.D., M.D.; GREENHILL, LAURENCE L. M.D.; NEWCORN, JEFFREY H. M.D.; WELLS, KAREN C. Ph.D.; WIGAL, TIMOTHY Ph.D.; GIBBONS, ROBERT D. Ph.D.; HUR, KWAN Ph.D.; HOUCK, PATRICIA R. M.S.; the MTA Cooperative Group. Journal of the American Academy of Child & Adolescent Psychiatry. Published ahead of print, March 24, 2009. DOI: 10.1097/CHI.0b013e31819c23d0.  “Effects of Stimulant Medication on Growth Rates Across 3 Years in the MTA Follow-up.” SWANSON, JAMES M. Ph.D.; ELLIOTT, GLEN R. Ph.D., M.D.; GREENHILL, LAURENCE L. M.D.; WIGAL, TIMOTHY Ph.D.; ARNOLD, L. EUGENE M.D.; VITIELLO, BENEDETTO M.D.; HECHTMAN, LILY M.D.; EPSTEIN, JEFFERY N. Ph.D.; PELHAM, WILLIAM E. Ph.D.; ABIKOFF, HOWARD B. Ph.D.; NEWCORN, JEFFREY H. M.D.; MOLINA, BROOKE S.G. Ph.D.; HINSHAW, STEPHEN P. Ph.D.; WELLS, KAREN C. Ph.D.; HOZA, BETSY Ph.D.; JENSEN, PETER S. M.D.; GIBBONS, ROBERT D. Ph.D.; HUR, KWAN Ph.D.; STEHLI, ANNAMARIE M.P.H.; DAVIES, MARK M.S.; MARCH, JOHN S. M.D., M.P.H.; CONNERS, C. KEITH Ph.D.; CARON, MARK Ph.D.; VOLKOW, NORA D. M.D. Journal of the American Academy of Child & Adolescent Psychiatry, August 2007. 46(8):1003-10014.

The diagnosis of ADHD increased 100 percent in just a decade. The percentage of kids who are overweight increased 100 percent between 1980 and 2002 (and increased 200 percent in teens). Is there a link between the two? Are kids diagnosed with ADHD more likely to be overweight? Or more likely to be underweight. It looks like the answer is yes to all three questions. A large study of more than 62,000 kids and adolescents appeared in the July 2008 Pediatrics. The children who had been diagnosed with ADHD, but were not being treated with medications, had about 1.5 times the odds of being overweight compared to their non-ADHD peers. This is consistent with other research linking ADHD and being overweight. These investigators propose that the increased weight may come from increased impulsivity and decreased self control of the kids with ADHD both leading to increased eating, coupled with more time spent watching television or playing computer or video games, leading to decreased physical activity.

In contrast, though, kids diagnosed with ADHD who are taking medications for their ADHD had about 1.6 times the odds of being underweight compared to their non-ADHD peers. Loss of appetite and weight loss are known side effects of some ADHD medications.

To me, the causes and effects of these patterns aren’t so clear cut, but it makes sense for people caring for kids with ADHD to be paying attention to their weight: they may be at greater risk of weight problems than their peers. And it makes sense to pay attention to the behavior of kids who are becoming overweight: they may be more likely to have ADHD than their peers.

Waring ME and Lapane KL. Overweight in Children and Adolescents in Relation to Attention-Deficit/Hyperactivity Disorder: Results from a National Sample. Pediatrics July 2008; 122:e1-e6.

The American Heart Association (AHA) has released April 2008 recommendations for monitoring the hearts of all children taking stimulant drugs, such as those used to treat ADHD. Parents may also want to learn about other options for managing ADHD.

We know that these medicines tend to increase the blood pressure of children by three or four points and the heart rate by one or two beats per minute. This has been considered safe for most kids, but potentially very serious for some with underlying heart problems. Since February 2007 the FDA has required that medications used to treat ADHD include a warning about their use in children with heart problems.

The AHA now recommends that physicians specifically check for these problems before starting ADHD medicines, in case they haven’t been diagnosed, and then take steps to recheck at every follow up while the child is still on the medicines. Pediatricians have already been doing many of these things, but not all of them. The biggest change is the recommendation that children have an electrocardiogram (ECG) before starting the medication, and again if the child develops cardiac symptoms, turns 12 years old, or has a change in family history while still on the medicines. A problem seen on the ECG does not mean skipping the medicine, but does mean that a cardiologist should be consulted about whether to start or continue.

Other recommendations include listening to the heart, checking the pulse and blood pressure, and asking a number of key questions (see below) before starting the medicines, again 30 to 90 days after starting, and again every 6 to 12 months for as long as the child is taking the medicines. Again, a problem here does not mean skipping the medicine, but does mean that a cardiologist should be consulted about whether to start or continue. With any medicine it is wise to weigh the risks and benefits of taking the medicine against the risks and benefits of not taking it.

These recommendations are reminders of the strength of ADHD medicines, and underscore the value of efforts to prevent ADHD and to learn about other ways to manage it where practical – including improving diet, exercise, and sleep.

Key questions to consider about the child should include:

• History of fainting or dizziness (particularly with exercise).
• Seizures.
• Rheumatic fever.
• Chest pain or shortness of breath with exercise.
• Unexplained, noticeable change in exercise tolerance.
• Palpitations, increased heart rate, or extra or skipped heart beats.
• History of high blood pressure.
• History of heart murmur (other than innocent or functional murmur) or history of other heart problems.
• History of viral illness with chest pains or palpitations.
• Current medications (prescribed and over the counter).
• Health supplements (non-prescribed).

The family history should include questions about any of the following in the family:

• Sudden or unexplained death in someone young.
• Sudden Cardiac Death or “heart attack” in family members under 35 years of age.
• Sudden death during exercise.
• Heart rhythm problems.
• Cardiomyopathy
• Significant ECG abnormalities
• Event requiring resuscitation in young members (under 35 years of age), including fainting requiring resuscitation.
• Anyone with Marfan syndrome.

Vetter VL, Elia J, Erickson C, Berger S, Blum N, Uzark K, Webb CL. Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Stimulant Drugs. A Scientific Statement From the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation. 2008 DOI: 10.1161/CIRCULATIONAHA.107.189473

ADHD is one of the most common behavioral and learning problems in childhood. It can affect the school experience, families, and friendships. It’s often associated with other problems as well, including learning disabilities and mood problems. Wouldn’t it be great if there were nutritional ways to help?

The relationship between what kids eat and their behavior is complex, and something we are learning a lot about in the 21st century. One emerging link is that between ADHD and other neurodevelopmental disorders with deficiencies in omega 3 fats.

Researchers in Australia, aware that EPA, DHA and other beneficial fats affect the brain, and aware that many kids get too little in their typical diets, decided to see what would happen to kids with ADHD if they got supplements of healthy fats. The results are published in the lead article of the April 2007 Journal of Developmental and Behavioral Pediatrics.

To measure the possible benefit, some kids got capsules containing EPA, DHA and other beneficial fats, while their counterparts got placebo pills containing palm oil. Their behavior was followed for 15 weeks, using the Connors Rating Scales. Those who got the supplements showed improvement in the core ADHD symptoms of inattention, hyperactivity, and impulsivity compared to their matched peers.

After the 15 weeks were up, those in the placebo group were switched to the real supplements, and they then showed similar improvement. Those who received the real supplements from the beginning continued to show sustained improvement after the full 30 weeks.

This preliminary study suggests that some children with ADHD might experience reduced symptoms if they get the healthy fats they need.

Sinn, N., and Bryan, J. “The Effect of Supplementation with Polyunsaturated Fatty Acids and Micronutrients on Learning and Behavior Problems.” Journal of Developmental and Behavioral Pediatrics. April 2007, 28, pp. 82-9

- and the United States does not. Adderall XR is a popular drug for treating ADHD. The active ingredients are amphetamines and dextroamphetamines. When used for ADHD, this drug has been linked to 20 known sudden deaths and 12 known strokes; 1/6 of the strokes and more than 2/3 of the sudden deaths were in children. In response to this data, Health Canada has now taken the drug off the market (even though none of the identified deaths or strokes was in Canada).

Not stopping there, Canada has also required that the manufacturers of similar ADHD medicines supply worldwide safety data for review. The U.S. FDA considered the same cases of stroke and sudden death and concluded in February 2005 that no action is needed in the United States, where about 700,000 people take Adderall XR. While many children have taken this medicine without ill effect, the potential for dreadful side effects underlines the value of considering other methods of treating ADHD. Whenever a child is identified as possibly having ADHD, there are likely to be exasperated parents, teachers, and/or children. I prefer to start addressing the situation with careful diagnosis, to be sure we are not giving the wrong treatment to kids who are just extra active or who have behavior problems. And whatever the diagnosis, I prefer considering a number of options before deciding to use controlled substances as the main treatment.

Dr. Greene’s Answer:

The most common side effects of Ritalin overall are nervousness and insomnia. In children, trouble with appetite and stomachaches can be even more common. If the stomachaches continue, you will want to report them to your doctor.

If Ritalin is the cause you might want to consider adjusting the dose or changing medications–though sometimes it can be continued as-is. I’m glad you asked this question–many parents don’t know that stomachaches can be a common side effect of Ritalin.

Evidence continues to mount about a strong connection between chronic sleep deprivation and ADHD. A fascinating study published in the March 2002 issue of Pediatrics found that among the 866 children studied, those who snored were almost twice as likely as their peers to have ADHD. The common denominator seems to be obstructive sleep apnea.

Large tonsils and adenoids can partially block the airway at night, causing snoring, poor sleep quality, and perhaps ADHD.

For children with true obstructive sleep apnea and ADHD, taking out the tonsils and adenoids might result in both better sleep and better behavior, without the need for medications.

A new NIH-funded study published in the February 26, 2002 issue of Neurology, is the first to systematically look at what happens when children are treated with Ritalin, clonidine, a combination of the two, or neither one. For 4 months doctors, parents, teachers, and children did not know which the children were receiving. At the end they discovered that those who had received both drugs did the best.

The two seemed to work in concert, the Ritalin helping more with focus and attention, the clonidine helping more with impulsivity and hyperactivity. By using the two together, the combination dose could be tailored to each child, raising or lowering one or the other to adjust for symptoms or side effects.

Many children labeled with ADHD do not need medication. Others who would truly benefit from treatment do not get it. When treatment is needed, combination therapy makes sense to consider, using the lowest dose of each medicine that achieves the desired effect.

About half the children with tics (involuntary repetitive movements) also have significant ADHD. By and large, this group of children has not been treated with methylphenidate (Ritalin) because of concern that this would worsen the tics. Caught between a rock and a hard place!

A new study by the Tourette’s Syndrome Study Group, published in the February 26, 2002 issue of Neurology, is the first to systematically look at what happens when these children are treated.

Children were treated for 4 months with Ritalin, clonidine, a combination of the two, or neither one. Doctors, parents, teachers, and children did not know which they were receiving. Ritalin did not increase tics — in fact children in any of the 3 medicine groups tended to have their tics decrease.

Combination therapy proved better than either drug alone, an idea that may have important implications for other children with ADHD.

More about this tomorrow…