Medication is one of the mainstays for the treatment of attention-deficit hyperactivity disorder (ADHD), a neurobehavioral disorder marked by difficulty paying attention and controlling urges and restlessness. There are several classes of medications, including stimulants and non-stimulants, that can be used to ease ADHD symptoms, and medication is often used in combination with behavioral and other types of therapy to fully address the whole spectrum of the disorder.
ADHD affects about 5.4 million children and about 10 million adults in the United States, according to federal data. Exactly what causes ADHD isn’t fully understood, but genes, being born too early, and brain injury may play a role. Some experts believed that moms who smoke, drink alcohol or are under extreme stress during their pregnancy may be more likely to have children with ADHD, but new research questions this, notes the national nonprofit advocacy and support group CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder).
Not all cases of ADHD are the same. In fact, three subtypes have been identified — described as "predominantly inattentive," "predominantly hyperactive/impulsive" and "combined." Medication is chosen based on symptoms as well as the person's overall health and age, according to the Mayo Clinic.
Stimulant medication for ADHD
It may seem counterintuitive to treat a disorder marked by hyperactivity with a stimulant, but targeting certain brain chemicals has been shown to sharpen focus. Stimulants actually have a calming effect on people with ADHD.
Stimulants for ADHD are either methylphenidate- or amphetamine-based. They work by increasing dopamine and norepinephrine, which are two brain chemicals that help with thinking and attention.
Brand names of amphetamine-based stimulants, the American Academy of Pediatrics (AAP) notes, include:
Brand names of methylphenidate-based stimulants include:
Some stimulant formulas are short-acting, meaning their effects last about four hours, whereas longer-acting preparations last for 10 to 12 hours. Both have their share of advantages and disadvantages. Longer-acting medications may cause fewer “ups and downs” throughout the day. Children who take longer-acting stimulants may not need to take medication during the school day, which is a benefit. With short-acting medications, however, you have more control over when you take the medication and how long its effects stay in your body. If the medication causes any side effects, like sleeplessness, this may tip the scale in favor of short-acting stimulants. When attached to a drug name, the terms XL and XR mean extended release.
Stimulants are available as pills, capsules, liquids and chewable tablets. There’s even a long-acting Daytrana patch that is worn on your hip, according to AAP.
All drugs have side effects, and stimulants are no exception. Stimulant side effects may include:
- Loss of appetite
- Sleeping problems
- Anxiety and irritability
Other things to consider when using stimulants
Amphetamine-based stimulants must carry black box warnings — the most serious warning that the U.S. Food and Drug Administration (FDA) can issue. It states that stimulants may cause sudden death and serious heart-related adverse events. This is likely due to the fact that stimulants raise heart rate and blood pressure. It is important to discuss any underlying risks for heart disease with your or your child's doctor before taking stimulants for ADHD.
Stimulants also carry the risk for abuse and addiction and are considered a “controlled substance.”
With so many stimulants available to treat ADHD, there is usually some trial and error involved in figuring out which stimulant works best and at what dosage. The trial usually begins with a low dose that is gradually increased until symptoms improve. Be patient. It may take some time to find the correct dosage, and even then it's not set in stone. The dosage may need to be adjusted over time if side effects occur or, say, if a child experiences a growth spurt.
Personal preference also plays a role in choice of stimulants. For example, some children can’t swallow a pill so a chewable, a liquid or a patch will be better options.
If one family of stimulants does not improve ADHD symptoms, the other may. Both types of stimulants do affect the same neurotransmitters, but there are nuances in how they work in the brain, according to AAP.
Non-stimulant medication for ADHD
Non-stimulant medications may be prescribed if stimulants cause too many side effects or are not effective enough at reining in ADHD symptoms. Sometimes, non-stimulants are taken with stimulants for an added benefit. As a general rule, non-stimulants don’t start working as quickly as stimulants.
Some examples of non-stimulant medications for ADHD include:
Atomoxetine is considered the most effective of the non-stimulant medications used to treat ADHD. It works around the clock by increasing levels of the brain chemical norepinephrine. It may take up to six weeks before Atomoxetine is fully effective, unlike stimulant medications that start to work right away.
Atomoxetine side effects may include:
- Decreased appetite
- Nausea or vomiting
Atomoxetine carries a warning that it may cause suicidal thoughts in the first few weeks of use. Though this is rare, it's a concern because ADHD tends to travel with depression. Individuals with ADHD who are depressed are at greater risk of suicide than their counterparts who are depressed but do not have ADHD, the AAP notes.
Guanfacine XR (Intuniv)
This medication, initially developed to treat high blood pressure, is part of a class of drugs known as centrally acting alpha-2-adrenergic receptor agonists. Taken once a day, guanfacine is believed to interact with brain receptors that control attention and impulsivity.
Guanfacine side effects may include:
The long-acting form of guanfacine is a pill, but it cannot be crushed, chewed or broken. It must be swallowed whole. Guanfacine benefits are typically realized in three to four weeks, on average, according to the Mayo Clinic.
Clonidine XR (Kapvay)
Clonidine is in the same class as guanfacine. Unlike guanfacine, which is taken once a day, clonidine is taken twice daily. It may take several weeks before you notice the benefits of this medication. Two other alpha agonists are available, but not approved by the FDA specifically for ADHD.
Clonidine side effects may include:
- Dry mouth
- Nausea and vomiting
Antidepressants for ADHD
Although not FDA approved for treatment of ADHD, antidepressants are prescribed to treat ADHD-related conditions such as anxiety or depression. Older tricyclic antidepressants as well as newer drugs that increase the levels of the mood chemicals norepinephrine and serotonin may be effective. The latter group includes bupropion (Wellbutrin SR, Wellbutrin XL and Effexor XR). Antidepressants work more slowly than stimulants and may take several weeks before they reach maximum efficacy. The FDA cautions that antidepressant medications can increase the risk of suicidal thinking and behavior in children and adolescents with depression.
Common side effects of antidepressants for ADHD may include:
- Nausea and vomiting
- Weight gain
Wellbutrin XR and Effexor XR generally do not cause as many side effects as the older tricyclic antidepressants.
The bottom line
The good news is that ADHD is highly treatable, and a combination of medication and therapy may help reduce symptoms and improve your quality of life. It’s important to work closely with your doctor or therapist to find the optimal medication and dose with the fewest side effects. This may involve keeping a log of side effects to share with your doctor at your next visit. Once your ADHD symptoms are improved, you will likely see your doctor every three to six months unless something changes.
Medication is not always necessary. In fact, for children with ADHD who are younger than 6, the AAP recommends parent training in behavior management as the first line of treatment before medications are considered.
- Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), ADHD Overview. https://chadd.org/about-adhd/overview/
- American Academy of Pediatrics, Drug Look Up. https://www.aap.org/en-us/professional-resources/Psychopharmacology/Pages/Drug-Lookup.aspx
- Mayo Clinic, “Attention-deficit/hyperactivity disorder (ADHD) in children.” https://www.mayoclinic.org/diseases-conditions/adhd/symptoms-causes/syc-20350889
- AAP,”ADHD.” https://www.healthychildren.org/English/health-issues/conditions/adhd/Pages/default.aspx
- US National Library of Medicine, Guanfacine. https://medlineplus.gov/druginfo/meds/a601059.html