Considering ADHD medication for your child? Here the 10 things every parent should know!

ADHD is a neurodevelopmental condition that affects the brain’s ability to manage attention, activity levels and impulse control.Thus, ADHD is characterised by inattention, lack of focus, hyperactivity and impulsivity, that are inconsistent with the child’s developmental level.

Every child with ADHD is unique – some may have difficulty focusing, while others have difficulty with regulating their activity levels or impulse control. Medications can help improve your child’s focus, reduce their hyperactivity and minimise their impulsivity. Medication can also help a child feel more successful and become better adjusted at home and at school.

In this article, I’ll be focusing on the medication management for ADHD. For more information on ADHD, please refer to my earlier articles discussing the diagnostic approach, the different conditions that coexist with ADHD, or the conditions that mimic ADHD.

The following are the 10 things to be aware of, before starting ADHD medication:

1. Set clear goals: Medications should only be considered in children in whom behavioural strategies, educational interventions and environmental measures, have failed to satisfactorily reduce or resolve ADHD difficulties. I list these non-medical measures in a child’s clinic report at the time of diagnosis. Nonetheless, consideration of ADHD medications should not be seen as a failure. On the contrary, we are fortunate to have very effective medications to address ADHD. These medications are evidence-based, and some of them have been tried and tested for over 70+ years. Very few medications can claim such a robust evidence base and have such a long history of use in clinical practice. But at the start, it is important to discuss and reflect on what the current situation is with your child, to gather a baseline of their functioning, and what you hope to achieve from starting ADHD treatment. Would you be looking for improvement in their attention span, social interaction and communication, better awareness of safety and danger, ability to complete homework, or an improvement in functioning at school? Making a note of the current situation will help to monitor and measure success.
2. Shared decision making: It is important to ‘involve your child’ in your discussions, before you arrange an appointment with your doctor to consider a trial of ADHD medication. Explaining your reasoning to them, in age-appropriate terms, helps them to understand and appreciate why they would benefit from the medication. Later, encouraging your child to share with you how the medication makes them feel, will help in gaining their cooperation with medication, and in adjusting the medication dose.I encourage parents to see their GP and to discuss their wish to explore the possibility of ADHD medication, if their child’s current needs have been unresponsive to nonmedical measures. Seeking the consent and cooperation of your GP upfront will be of invaluable help in obtaining repeat prescriptions.It is also my practise to always ask parents to discuss their concerns with their child’s school teacher and/or SENDCO (Special Educational Needs and Disability Coordinator). I always request parents to supply me with a copy of their child’s latest school report so that I get an idea of their child’s needs, challenges and the functional impact the ADHD difficulties are currently having on their learning and behaviour at school. Such a ‘team around the child’ approach is valuable for success with medications.
3. Arrange an appointment to discuss medications: I recommend parents to arrange a follow up appointment once they undertake the above steps. At the time of the appointment, I review the child’s current functioning, and any impact of the non-medical measures that have been tried. In each case, I undertake a brief physical examination that involves measuring the child’s height and weight and plotting these on a growth chart, listening to the child’s heart, and measuring the child’s baseline blood pressure, among other things.I also briefly discuss the types of ADHD medications and the side effects of each one. Essentially, ADHD medications fall under two categories:
   • ‘Stimulants’, such as, Methylphenidate and Lisdexamphetamine.
   • ‘Non stimulants’, such as, Atomoxetine, Guanfacine and Clonidine.

   Stimulant medications are fast acting and are highly effective. They are generally my first go-to medications, as also recommended by NICE. They work by increasing the levels of neurochemicals, such as dopamine and norepinephrine, in the prefrontal cortex of the brain – the seat of attention and impulse control.

   Non stimulant medications have a slower onset of action and are usually considered when there are unacceptable side effects with stimulants or when stimulants are not effective. Hence, they are my second line of medication. They act by inhibiting the breakdown of the neurotransmitter, norepinephrine, in the pre-frontal cortex. So, non-stimulant medications have a different side effect profile.

4. Discuss side effects: At each appointment, I discuss with parents which side effects are normal and which need immediate attention. Consequently, parents should know ‘what to look out for’ and ‘when to seek help’. The most common side effects to watch out for are reduced appetite, difficulty falling asleep, emotional regulation difficulties, headaches, stomach-aches, tics, irritability and increased anxiety.Some side effects such as headaches and stomach-aches are mild, temporary and tend to occur only in the first few weeks of starting medication, before resolving. However, certain serious side effects such as chest pain, racing heart rate, severe anxiety, and suicidal ideation are rare, but require immediate medical attention! Side effects are typically mild and transient, and serious side effects are fortunately rare. Nevertheless, they must be monitored.At the appointment, I also discuss what time the medication should be administered, what happens if the child forgets the dose, and whether to give medication during weekends and holidays.
5. ‘Start low and go slow’: This has been my mantra when it comes to ADHD medication, be it stimulant or non-stimulant. When it comes to medication there is no one size that fits all, as each child is unique.
   ‘I give written instructions to parents regarding the starting dose of the medication and the step-wise regime to increase the dosage gradually over a four-to-six-week period. Medications are titrated according to the child’s weight and the clinical profile. There is no way of knowing what dose will be optimal for a given child at the outset.
   Hence, this gradual titration of the medication dosage is advised so that we can find out what the optimal dosage was during the follow up appointment. This first follow-up appointment is generally between 6 to 8 weeks after the commencement of medication.
6. Be Aware: It is important for parents to know that the ‘stimulant’ medications for ADHD are ‘Controlled Drugs’. Hence there are many regulations that need to be complied with that make prescribing, dispensing, and monitoring of these medications slightly bureaucratic and challenging, at times. Most general practitioners (GP’s) these days request a separate ‘Shared Care Agreement’ (SCA) before they can agree to take on the responsibility for issuing repeat prescriptions. I’m always happy to send an SCA with my clinic letter once the child has been stable on a given dosage.
   Since the stimulant medications are controlled drugs, they have street value and so there is potential for misuse. Hence, parents would need to carry a copy of my clinic letter if travelling abroad. In addition, I recommend that parents store these medications in a locked cupboard.
   To further complicate the requirements for controlled drugs, there has been a national and international shortage of ADHD medications for a variety of reasons that are beyond the remit of this article. Thus, the brand of medication I prescribe may not be available, necessitating a change of brand or medication type. This is an unfortunate situation that is sadly out of my control.
7. Journaling: It can be very helpful to make a note, on your phone or in a small diary, of the side effects or any notable effects of the ADHD medication that your child experiences while taking it. This is especially important during the first few weeks after starting the medication. Make a note of any changes in appetite, sleep patterns, mood changes, or behaviour. Also, note the specific time you notice when the symptoms improve and the time when the medication seems to wear-off, i.e. when the symptoms worsen.
   Keeping a diary of symptoms will help you to share your concerns early with your doctor. It will also act as a reminder for you to discuss possible options for changes to the medication dose or the form of medication, i.e., short acting versus long acting. Having a regular dialogue with your child’s class teacher/SENDCO or keeping a home-school diary can be invaluable as teachers see your child in a context that a doctor or a parent cannot.
   Hence, a child’s teacher’s observations in the form of a School Report, is crucial at each follow up appointment. Such feedback from the school can help to make necessary adjustments to the dosage of the ADHD medication your child is on.
8. Don’t ignore the non-medical measures: Though ADHD medications are very effective and are a powerful tool in effecting the necessary changes in your child’s functioning, they work best when used with behavioural, educational and environmental interventions.These non-medical measures, some of which have been listed below, are covered in detail in my earlier articles and are also listed in my clinic report.
   Some of the strategies that could help your child to thrive at school, function better at home, and excel in out-of-school activities, are as follows:
   • Establishing clear routines around mornings, meal times, evenings can be of huge help, as they provide structure, offer predictability and help reduce anxiety. 
   • Use visual calendars and visual schedules to reinforce routines.
   • Use reward systems, such as, sticker charts or points to motivate them.
   • Give one instruction at a time.
   • Break tasks into small manageable chunks
   • Allow short breaks between tasks to help refocus their attention
   • Model desired behaviours, such as maintaining calm and problem-solving.
   • Offer access to a sensory or calming activity to help regulate their emotions.
   • Regular physical activity in their daily schedule helps reduce hyperactivity and improves their focus.
   • Establish good sleep hygiene and a good sleep routine 
   • Aim for a balanced diet. Seek expert opinions from a dietitian or paediatrician before embarking on an exclusion diet.
   • Maintain limits around screen-time and use screen time as reward.
   • Use demand avoidance strategies.
9. Regular reviews: In a vast majority of my patients the benefits of medication are clear for everyone to see. Nevertheless, side effects do occur and are common, but they can be managed. Occasionally, progress is slow and there can be setbacks. Hence regular reviews are essential for success in ameliorating ADHD symptoms and the impairment they cause in all aspects of day-to-day living. Therefore, a trial of ADHD medication is never a one-off event.
   As side effects are common, careful monitoring and follow up is required. As children grow and develop, their needs change. Hence, medication needs to be adjusted or even stopped where necessary.
   Regular review appointments help monitor your child’s inattention, hyperactivity and or impulsive behaviours. If there is a poor response to medication, then a number of things can be done, such as increasing the dosage of medication, trying a different medication, addressing any coexisting neurodevelopmental conditions, or involving the services of a psychologist or even a psychiatrist when required.
10. Focus on the long term: There is huge amount of literature that demonstrates that undiagnosed or untreated ADHD, can place a child at risk of adverse long term outcomes, and can result in lower educational attainment, lower income, relationship difficulties, employment issues, poor mental health, substance use, accidents, injuries, legal problems, and even early death.Fortunately, effective medical treatments are available that can prevent or minimise these adverse outcomes. ADHD medications have the potential to change the trajectory of your child’s attainment and help them fulfil their potential, and thus should not be shied from.In conclusion, as is evident from the above list, managing ADHD is a journey and not a sprint. Management involves looking after yourself, practising self-care, seeking support, staying patient, collaborating with your child’s school, and undergoing regular reviews with your doctor. Starting ADHD medication is not an irreversible decision. One can always stop medication if things don’t go to plan, which is rare. Moreover, as a parent you will never have regret due to trying ADHD medication for your child, where clinically indicated, as there is comfort in knowing that you have done all you could. The same cannot be said of not undertaking a trial of ADHD medication.
     
    Further resources:
    1. ADDISS (National Attention Deficit Disorder Information and Support Service). http://www.addiss.co.uk
    2. Addersorg. http://www.adders.org
    3. Hyperactive Children’s Support Group. http://www.hacsg.org.uk

     

    Key references:

    1. Gada S, Neurodisability and Community Child Health, 2^nd Edn, Oxford University Press 2022. ISBN 978-0-19-885191-2
    2. Barbaresi WJ et al. (2020). Society for Developmental and Behavioural Paediatrics clinical practice guideline for assessment and treatment of children and adolescent with complex ADHD. J Dev Behav Pediatr, 41 Suppl 2S, S35-S57.
    3. NICE (2018). Attention Deficit Hyperactivity Disorder: diagnosis and management. NICE guideline NG87. https://www.nice.org.uk/guidance/ng8