take with a snack or mealDepression and attention deficit–hyperactivity disorder (ADHD) are common diagnoses in children and adolescents, and medications are often used to treat these disorders. Within the medical community of physicians and other health care professionals, some controversy surrounds the use of the different antidepressant and stimulant medicines that may be prescribed as part of a treatment plan. These controversies often extend to concerns parents and adolescent patients have, raising questions like these:
• Do antidepressants increase a risk of suicide?
• Are stimulant medicines used to treat ADHD addicting?
• Will stimulant medicines increase the likelihood of a teenager using street drugs or other drugs?
It is not uncommon for parents and adolescents to harbor certain stereotypes or beliefs about antidepressants and stimulants that are not totally medically accurate, and the stigmas attached to these medications can affect your, and your child’s or teenager’s, desire to use the medicines that are prescribed. In this chapter I discuss how these medicines can be effectively used to treat depression and ADHD, and I address the issues surrounding these controversies and stigmas in the hope of helping you become more informed about these medicines.
When you ask someone to picture a person with depression, what probably comes to mind first is an adult, not a child or adolescent. Yet depression commonly occurs in the pediatric population, with up to 9 percent of teenagers fulfilling the criteria to be medically diagnosed with depression at any given time, and up to 25 percent of teens having a history of depression at some time during their adolescence.
Depression in adolescents can appear in numerous ways and can have a significant debilitating effect on the adolescent’s life and his or her family’s life as well. Symptoms seen in depressed adolescents include:
• depressed mood; irritability and crankiness
• decreased interest in or enjoyment of favored activities, such as sports, video games, or socializing with friends
• insomnia or sleeping more than normal, such as refusing to get out of bed in the morning
• reduced physical activity and movement
• increase in not getting along well with family or friends
• noticeable weight gain or loss
• fatigue and loss of energy
• low self-esteem
• feelings of guilt
• decreased ability to concentrate or make decisions
• worsening academic performance, including an increase in school absence
• recurrent suicidal ideation or behavior
Some of these behaviors may seem to be “normal” for teenagers, and they can be typical, to some extent. However, when a child or adolescent displays many of them, and when they significantly affect the child’s or adolescent’s life, a medical diagnosis of depression is more likely. If these behaviors occur, they are best evaluated by a physician who can determine if the child or adolescent does indeed have depression. If your teenager is diagnosed with depression, the “good” news is that it likely can be successfully treated with a combination of different approaches, including psychotherapy (counseling) and medicine therapy.
If your child or teenager is diagnosed with mild depression, active support by your pediatrician and close monitoring may be tried initially, as many studies have demonstrated that this approach can be effective. If active support and close monitoring by your pediatrician are not helpful, or if moderate or severe depression is diagnosed, psychotherapy, or counseling, will be recommended. Psychotherapy alone can effectively treat moderately severe depression. If additional treatment is needed, antidepressant medicines are given.
Psychotherapy for depression generally entails cognitive behavioral therapy (CBT) or interpersonal therapy (IPT). These therapies are given by trained mental health professionals, such as psychologists, therapists, or counselors. CBT relates to how the child’s or teenager’s thoughts influence behaviors and feelings, and it targets thoughts and behaviors to improve mood. IPT relates to how interpersonal relationships or problems can affect mood and depression, and how depression can adversely affect interpersonal relationships and problems. Both of these therapies can be effective, and they typically require at least 8 to 12 weeks of treatment for benefits to be noticed.
Antidepressant medicines play an important role in the treatment of depression. Guidelines on the treatment of depression have been published by such professional medical organizations as the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics. These guidelines state that antidepressants are best used for moderate or severe depression, and in combination with psychotherapy. Several large, well-done clinical studies have demonstrated that psychotherapy plus antidepressants is more effective than either psychotherapy or antidepressants used alone.
Unfortunately, from the patient’s point of view, psychotherapy is often a more difficult treatment to pursue since it requires at least 8 to 12 visits with a counselor or psychologist and may not be fully covered by medical insurance. Antidepressant medicines are easier to use, swallowing just one or more tablets daily, and because most are available generically, they are relatively inexpensive. One of the largest studies of adolescent depression treatment, including more than 400 adolescents ages 12 to 17 years who had moderate or severe depression, compared CBT alone to a combination of CBT and an antidepressant, and to placebo (no active treatment). Of the adolescents receiving combination therapy, 71 percent improved, while 43 percent of those receiving CBT alone improved, 61 percent of those receiving an antidepressant medicine alone improved, and 35 percent of those receiving placebo (no active treatment) improved. This study demonstrates that a combination of psychotherapy and antidepressant medicine is most likely to help an adolescent with depression.
If an antidepressant medicine is recommended for your child or adolescent, your pediatrician or psychiatrist can choose from several different classes of medicines. One class in particular, selective serotonin reuptake inhibitors (SSRIs), is recommended and most commonly used. Serotonin is a neurotransmitter, a chemical that relays messages between nerve cells, and is located throughout our bodies, in blood, the gastrointestinal tract, and in our brain. In the brain, serotonin helps to regulate and control our mood, sleep, and to some extent, our appetite. SSRI medicines increase the amount of serotonin that remains active in our brains, and it is likely by this action that SSRIs help to decrease depression. “Likely” is used here, as researchers and health care professionals are not fully confident that this is how the SSRIs function to treat depression. The chemistry of the brain is complex, and the action of SSRIs in the brain may not be as simple as this.
Other types of antidepressants include tricyclic antidepressants and several other categories of medicines. The tricyclic antidepressants, such as amitriptyline, are much older medicines. These medicines have many more adverse effects than the SSRIs and they can be dangerous if too much is taken. An overdose of these medicines can be used in attempting suicide, so they are often avoided in treating a severely depressed person. The SSRIs are a much safer class of medicines in this respect.
The SSRI class of antidepressant medicines is preferentially recommended by the professional medical organizations discussed above and include the following (generic name followed by trade name):
• fluoxetine (Prozac); ages 8 and older
• escitalopram (Lexapro); ages 12 and older
• citalopram (Celexa)
• paroxetine (Paxil)
• sertraline (Zoloft)
• fluvoxamine (Luvox)
• vilazodone (Viibryd)
As indicated, among the SSRI antidepressants, only fluoxetine and escitalopram are labeled for use by the FDA to treat depression in children and adolescents. (Pediatric use labeling means that these specific antidepressants have been formally studied by a pharmaceutical manufacturer and the FDA has approved their safe and effective use.) Any of the antidepressants listed above can be prescribed by a physician, although the antidepressants with more pediatric use experience are the safer choice.
Fluoxetine (Prozac) has the most evidence for the beneficial treatment of depression in children and adolescents as compared to the other SSRIs, and for this reason it is often described as the first medicine of choice when treating depression in children and adolescents. If fluoxetine (Prozac) or escitalopram (Lexapro) are tried and are not as effective as desired in a child or adolescent, a pediatrician can reasonably prescribe one of the other SSRIs listed above, even though they are not labeled by the FDA for this use. Some pediatric studies have been conducted with these other antidepressants, just not as many as with fluoxetine (Prozac) or escitalopram (Lexapro). Other classes of antidepressants are available and are commonly used to treat depression in adults, including a similar class of medicines, referred to as SNRIs (serotonin–norepinephrine reuptake inhibitors). Commonly used SNRIs include venlafaxine (Effexor) and duloxetine (Cymbalta). We do not have as much experience with clinical studies of these antidepressants in children and adolescents, and thus they are not recommended initially.
As with any medicine, fluoxetine (Prozac) and escitalopram (Lexapro) have adverse effects, although these adverse effects do not prevent most children or adolescents from continuing to take the medicine. Occasionally, however, one or more adverse effects can be a problem and will make it necessary to stop the antidepressant. Common adverse effects from SSRI antidepressants, and what you can do to prevent them from occurring, or lessening their impact, include:
• nausea or upset stomach
take with a snack or meal
• headache
use acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) as needed; if headaches do occur, they should slowly resolve over 1 to 3 weeks
• feelings of sedation or tiredness
take at bedtime
take in the morning
• increased sweating
use an antiperspirant, or talk with your doctor if troubling
• sexual side effects (decreased libido or impotence)
talk with your doctor about trying a different antidepressant
• behavioral activation, including agitation, restlessness, irritability, acting silly, or impulsivity
talk with your doctor about trying a different antidepressant
Some of these adverse effects, such as nausea or sedation, may slowly resolve over the first 1 to 3 weeks of treatment. If the adverse effect is too troubling, speak with your pediatrician. Pediatricians or psychiatrists will often start an antidepressant with a low dose for 1 or 2 weeks, and if no or few adverse effects occur, then increase the dose after those first weeks.
As stated throughout this book, every medicine has a potential to cause unwanted adverse effects. It is always important to consider the medicine’s benefit-to-risk effects—that is, if the medicine is providing a noticeable benefit in treating the disorder, and the adverse effects are mild and manageable, it seems reasonable to continue the medicine. If the adverse effects are troubling, then the risk of taking the medicine can outweigh the benefit, and it then seems reasonable to try a different medicine.
Common problems that adolescents face when taking antidepressant medicines are listed below, with suggestions for prevention or improvement:
• stopping the antidepressant too soon
the SSRI antidepressants require at least 2 to 3 weeks, and often 4 to 6 weeks, to have a noticeable benefit
give the antidepressant 4 to 6 weeks before deciding it is not helping
positive changes in mood are often not noticeable for 3 to 4 weeks after starting an antidepressant
doses of the SSRI antidepressants are normally given once a day; it usually is not important what time of day the antidepressant is taken
if the antidepressant causes tiredness, then give it at bedtime, and if it causes your child to feel more awake or active, give it in the morning
whatever time of day that suits you and your child is a good time to take the antidepressant, and it is best to take it at about the same time each day
if your child misses one dose, the missed dose can be taken up to 12 hours later; for example, if a normal bedtime dose is missed, it can safely be given the next morning, and that same day’s bedtime dose can still be given
do not take 2 or more doses at the same time
• stopping the antidepressant because your child doesn’t believe it is helping, or your child believes it is no longer needed
as discussed above, as many as 4 to 6 weeks are often needed for an antidepressant medicine to help
family and friends may notice more than your child does that the antidepressant is helping, perhaps in subtle ways
it is possible that the antidepressant is not helping, but discuss this with your pediatrician before stopping the medicine; it is important to visit with your pediatrician for follow-up appointments so these concerns and questions can be discussed
• stopping the antidepressant because your child doesn’t like taking a medicine to feel “normal”
some people do not like to take medicines, especially medicines that may carry a stigma; understandably, some people do not want others to know they are taking medicine such as antidepressants
consider that medicines can help all of us at times for many medical conditions, such as an infection or a headache, and, because depression is a medical condition, medicines may help
it is certainly reasonable to keep private that your child is taking an antidepressant; if it is helping your child feel better, this is what is most important
• taking antidepressant medicine only “as needed”
some medicines can be taken as needed, whenever the medical condition needs treating, such as a headache or a stuffy nose from a cold
other medicines, including antidepressants, are best given on a regular daily basis, and are not effective when only taken as needed
although your child may feel that the antidepressant is not needed some days, it is best to take it daily for at least several weeks, and then after 4 to 6 weeks, discuss with your pediatrician whether the medicine is helping and still needed
POTENTIAL FOR INCREASED RISK OF SUICIDE
A controversial area surrounding the use of antidepressant medicines in children, adolescents, and young adults is the potential for an increased risk of suicide. Since 2004, all classes of antidepressants have a required “black box” warning, as mandated by the FDA. A black box warning is the highest level of warning or concern the FDA can require for a medicine. It does not necessarily mean that the medicine definitively produces the adverse effect, but because of the potential seriousness of the adverse effect, the warning is required. The following is the black box antidepressant warning about suicidal thinking and behavior:
Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. Short-term studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressants compared to placebo in adults beyond age 24; there was a reduction in the risk of suicidality with antidepressant use in patients aged 65 and older. In all patients of all ages who are started on antidepressant therapy, monitor closely for worsening of depression and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber.
It is recommended practice to watch for suicidal ideas or actions in all children and adolescents, whether they are taking antidepressant medicines or not. Unfortunately, suicidal thinking and behavior are relatively common in adolescence. The Centers for Disease Control and Prevention (CDC), the federal government’s primary health agency, reports that 17 percent of adolescents think about suicide in a given year. Fortunately, most of these adolescents do not successfully commit suicide, but about 2,000 adolescents die from suicide each year. In 2014, suicide was the second leading cause of death among adolescents 15 to 19 years of age, with 1,834 suicides occurring in this age group in 2014.
What prompted the FDA to issue this required black box warning for all antidepressant use in children and adolescents? In 2004, the FDA reviewed the results of 24 studies of several different antidepressants including, but not exclusively, SSRI antidepressants, used to treat depression, anxiety, and obsessive-compulsive disorder in children and adults. More than 4,400 children and adults were enrolled in these studies that compared antidepressants to placebos. Overall, the FDA found that more of the study subjects 24 years of age and younger receiving antidepressants spontaneously reported thoughts of suicide or attempted suicide as compared to those taking a placebo. Of the study subjects taking an antidepressant, 4 of 100, or 4 percent, spontaneously reported thinking about suicide or attempted suicide, as compared to 2 of 100, or 2 percent, of the study subjects taking a placebo. There were no completed suicides in these studies.
The black box warning the FDA required for all antidepressant medicines for children and adults 24 years of age and younger is controversial among many pediatric experts. It is important to view this black box warning in light of other information about suicidality (suicidal thinking and behavior) in children and adolescents. Other studies and surveys of adolescents have demonstrated that as many as 50 to 80 percent of adolescents are thinking about suicide when they are first diagnosed with depression, and up to 35 percent have made a previous suicide attempt.
The method of determining how many adolescents had suicidal thoughts is important to consider in weighing the FDA’s study review. Suicidal thoughts that were spontaneously reported by the study adolescents were evaluated. Many experts believe that using a structured rating scale form to ask adolescents directly about their suicidal thoughts is a more reliable method to assess for suicidal behavior than spontaneous reporting, as was done in the FDA’s initial study analysis. In fact, when the FDA re-analyzed those studies that used structured rating scale forms to evaluate suicidal thinking among adolescents taking an antidepressant, they found antidepressant medicine treatment did not increase suicidal behavior and thinking. This led some professional medical organizations, such as the American Academy of Child and Adolescent Psychiatry, to not fully agree with the FDA’s analysis and assessment about the potential for antidepressants to increase suicidal behavior in adolescents and young adults.
Another group of researchers re-analyzed these initial FDA studies, in addition to several other relevant studies, and found a very small, 0.7 percent, increased risk of suicidal behavior among adolescents taking an antidepressant. Other researchers, using different statistical analytic techniques, evaluated the FDA studies and concluded that antidepressants do not increase suicidal behavior in adolescents. Additional important information comes from several different studies that demonstrate that as antidepressant prescribing declines due to fear of increasing suicidal behavior, the rate of adolescent suicide increases. This finding suggests that antidepressant therapy is effective in treating depression, decreasing the likelihood that treated adolescents will attempt suicide. In other words, many experts feel that the risk of not prescribing an antidepressant to depressed adolescents is greater than the risk of increased suicidal behavior, as suggested by some of these studies.
Why do some of the studies suggest an increase in suicidal behavior from antidepressant medicine therapy while other studies point toward a reduced risk of suicidal behavior from antidepressant medicines? The answer has not been clearly determined, although some ideas have been described in published medical journals. Some experts believe that as an antidepressant begins to improve an adolescent’s depression, the adolescent may be more likely to talk to someone for the first time about past or present suicidal thoughts. Other experts have suggested that in a small number of depressed adolescents, as antidepressant medicine therapy begins to treat depression, small decreases in inhibitory thought and activity allow enough increased energy to cause underlying suicidal gestures to be noticed.
All experts agree that when an antidepressant medicine is begun for a child, adolescent, or young adult, it is important to carefully monitor for changes in activities or behavior that may indicate an increased risk of suicide. These behaviors and changes include increased restlessness, irritability, or agitation. This watchfulness is most important in the first several weeks of starting an antidepressant. If your child or adolescent is prescribed an antidepressant, your pediatrician will discuss this need for watchfulness with you. It is also important to frequently communicate with your pediatrician during this time, and to attend scheduled follow-up appointments. When antidepressant medicines are effective, benefits noticed first commonly include improvements in sleep and appetite, with improvements in productive thinking and activity following next. Improvements in mood are often not noticeable until 3 to 6 weeks after the antidepressant is begun.
CONSIDERATIONS AT THE PHARMACY
All of the SSRI antidepressants listed above are available in generic form, with the exception of vilazodone (Viibryd). The SSRIs having the most experience of use in children and adolescents, fluoxetine (Prozac) and escitalopram (Lexapro), are available as generic tablets, capsules, and liquids. These generic SSRIs are inexpensive, with a one-month’s supply costing as little as $4 at some pharmacies. Most SSRI tablets are “scored,” which means each tablet has a line of demarcation in the middle of the tablet, so it can be easily broken into equal half tablets. This scoring helps when smaller doses are needed. Some insurance companies require that half-tablet pieces of higher-strength tablets be given, rather than whole tablets of the prescribed dose, and the scoring on the tablets helps if your insurance company has this requirement. The insurance companies save money by, for example, asking patients to get a 10 mg daily dose by taking one-half of a 20 mg tablet, rather than taking a 10 mg tablet.
St. John’s wort is a CAM product (complementary and alternative medicine) derived from the plant Hypericum perforatum. (See chapter 3 for additional information about CAM products.) St. John’s wort has been studied in adults with mild or moderate depression, and some studies have determined that it is an effective antidepressant. However, several larger studies have determined that it is not effective. No studies have been performed in children. None of the studies in adults found St. John’s wort to be more effective than SSRI antidepressant medicines. St. John’s wort is not recommended in pediatric published treatment guidelines.
As discussed in chapter 3, CAM products are loosely regulated for content and purity and may not contain the active ingredients in the amounts stated on the product bottle or package. Additional studies have shown that St. John’s wort can interact with many other medicines, resulting in increased adverse effects from or reduced effectiveness of these medicines. If you are interested in using nonmedicine therapy for your child’s depression, psychotherapy (counseling) is more likely to be effective and is safer than St. John’s wort. I recommend not using St. John’s wort to treat your child’s depression until more studies testing its effectiveness and safety in children are conducted and published in medical journals.
With 8 percent of children and youth diagnosed with attention deficit–hyperactivity disorder (ADHD), it is the most common neurobehavioral disorder of childhood. ADHD is considered to be a chronic condition; more than half of the people who have ADHD as children will continue to display symptoms into adulthood. Symptoms that define ADHD are described as three main types: inattention, hyperactivity, and impulsivity. ADHD is diagnosed by a pediatrician when these symptoms become noticeable to parents, teachers, and others, as the symptoms become disruptive to the child’s normal daily life, including social interactions and school academic performance. Pediatricians use information obtained from parent- and teacher-completed rating scales to diagnose ADHD in a child. The prevalence of ADHD has increased over the past 20 years, although it is not clear whether more children are developing ADHD or recently published, more-inclusive diagnostic criteria is a main reason. Some experts believe that ADHD is diagnosed too easily and frequently by pediatricians and other physicians.
ADHD has been well studied and we have good evidence from many published studies that treatment with medications is effective. Behavioral therapy can be additionally beneficial for some children, especially younger children. The goal of behavioral therapy is to modify a child’s physical and social environment to change behavior and manage common symptoms of ADHD. Behavior training techniques can be used by parents at home and teachers in the child’s classroom and school environment. These techniques are not as effective as medicine therapy, but the combination of behavior therapy and medicine therapy may allow the child to require less medicine for good control of ADHD symptoms.
Many clinical studies have evaluated various medicines for ADHD, with these studies providing good evidence that medication therapy successfully manages ADHD symptoms for most children. The most effective class of medicines is stimulants, which includes various formulations and chemical modifications of two stimulant medicines: methylphenidate and amphetamine. It seems paradoxical that stimulant medicines can help control a medical disorder that is characterized in part by increased activity. Although we do not fully understand how stimulant medications improve ADHD symptoms, it is believed that they increase the activity of dopamine in the brain. Dopamine is an important neurotransmitter, a chemical that relays messages between nerve cells in our brains and other parts of our bodies. A main function of dopamine is regulation of the reward-behavior systems of our brains, which control pleasure, learning, and appetite behaviors.
The stimulant medicines methylphenidate and amphetamine are classified as first-line therapy for treating ADHD and are considered very effective, with at least 75 percent of children demonstrating good control of ADHD from a stimulant medicine. Children and adolescents beginning treatment with a stimulant will often notice benefits quickly, within the first 1 or 2 days of treatment. Many different stimulant medication products and formulations are available, which allows pediatricians to choose from a wide variety of options (table 4.1). Stimulants are available as swallow tablets and capsules, capsules that can be opened and sprinkled onto food, chewable and dissolvable tablets, liquids, and a patch formulation that is applied to the skin, similar to a bandage.
An important characteristic of the stimulant medicine products that can be used to individualize therapy for young children, older children, and adolescents is duration of effect, or how long the product controls ADHD symptoms. The stimulant medicine products are categorized as short-acting, medium-acting, and long-acting, with durations of 3 to 5 hours, 5 to 8 hours, and 8 to 12 hours, respectively. The medium-acting and long-acting products are especially useful in treating children and adolescents who are in school, because a dose can be given in the morning at home, before school begins, providing benefit for the entire school day. Many adolescents will also take a short-acting stimulant as needed in the early evening to help with homework, studying for exams, or additional work on school assignments.
Table 4.1. Several stimulant drug products
Stimulant |
Product names |
methylphenidate |
• Ritalin • Methylin • Metadate • Concerta • Daytrana (patch) |
dexmethylphenidate |
• Focalin XR |
amphetamine |
• Adderall |
dextroamphetamine |
• Dexedrine • Dextrostat |
lisdexamfetamine |
• Vyvanse |
Unlike SSRI antidepressants (discussed in the previous section), stimulant medicines can be taken as needed, when you and your child believe it is warranted. Most children and adolescents will take their stimulant medicines daily Monday through Friday for school, and depending upon how much schoolwork is assigned for weekends, they may or may not take medicine over the weekend. While stimulant medicines may not be needed on weekends when no studying or other schoolwork is planned, continuing stimulant medicines on weekends has the benefit of improved focus for other important activities, such as driving safely. Many adolescents who work at part-time jobs on weekends and need to concentrate and be attentive at their job take their stimulant medicine as needed prior to going to work.
Several nonstimulant medicines are available to treat ADHD. Although they do not control ADHD as effectively as the stimulant medicines, they can be beneficial and they have a role for some children and adolescents. Nonstimulants can be helpful for children and adolescents who have a contraindication for use of a stimulant (a medical reason for not using), such as a severe tic disorder, or for children who have developed unmanageable adverse effects from a stimulant medicine. The nonstimulant medicines include atomoxetine (Strattera), clonidine (Kapvay), and guanfacine (Intuniv). Clonidine and guanfacine can also be helpful as an additional medication to be taken with a stimulant, especially in children or adolescents who have other medical disorders, such as anxiety or aggression. Because clonidine and guanfacine commonly cause tiredness, they are often given at bedtime, unlike stimulants, which are best given in the morning. Nonstimulants can also be helpful when treating children and adolescents with a history of substance abuse, or when substance abuse is present in close family members, because nonstimulants are not likely to be abused and diverted to others.
ADVERSE EFFECTS OF STIMULANT AND NONSTIMULANT MEDICINES
Stimulant medicines are safe medicines overall and are used by thousands of children and adolescents without problems. Most of the adverse effects from stimulants can be managed without difficulty. Common adverse effects, and methods to manage them, include:
• decreased appetite, weight loss, and abdominal pain
give stimulants after breakfast or a snack in the morning; if weight loss occurs, encourage eating bigger meals and more calories in the evening, when the stimulant has worn off
• decreased sleep
give long-acting stimulants in the morning, preferably no later than about 10:00
• headaches
use acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) as needed; a reduced dose of the stimulant medicine may help lessen the headaches (discuss any adjustments in dose with your pediatrician)
These adverse effects can also be decreased by giving a smaller stimulant dose or changing to a different stimulant product. As with starting any new medicine, it is helpful to frequently communicate with your pediatrician about new adverse effects. Your pediatrician will discuss with you options for managing them.
Some people believe that stimulant medicines may have dangerous adverse effects on a child’s or adolescent’s heart and blood pressure. This concern has recently been evaluated by several committees of experts, and the available evidence indicates that for a child or adolescent with a healthy cardiovascular system, stimulant medicines do not pose an increased risk. It is expected that the prescribing pediatrician will routinely check your child’s blood pressure at each follow-up visit.
Stimulant medicines may also worsen a tic disorder (abnormal repetitive muscle movements or vocal sounds). Most children and adolescents who have a mild tic disorder can still be successfully treated with a stimulant medicine, as the tic disorder will not be noticeably worsened. If it is, atomoxetine (Strattera), a nonstimulant medicine, can be used instead of a stimulant, and is less likely to worsen tic disorders.
Some adolescents will notice that they are “less fun” or less spontaneous in their actions when taking stimulant medicines. This is likely due to the stimulant medicine’s controlling impulsivity and hyperactivity, hallmark symptoms of ADHD. While the adolescent’s friends may miss the comical behavior, the increased academic performance from the stimulant’s beneficial effect is welcomed.
Common adverse effects from the nonstimulant medicines differ from stimulants, mainly for their potential to cause tiredness or sedation, especially with clonidine (Kapvay) and guanfacine (Intuniv). Atomoxetine (Strattera) can decrease appetite and result in weight loss as well, although it is usually not as noticeable as with the stimulant medicines.
BLACK BOX WARNING
Atomoxetine (Strattera) has a black box warning on its prescribing information and labeling, for a potential increase in suicidal thinking and behavior in children and adolescents. As described above in the discussion of depression, suicidal thinking and behavior commonly occur in adolescents overall, even when no medicines are given. In studies of atomoxetine used to allow the FDA to make a decision about approving its use, suicidal thinking and behavior was found to occur slightly more often, 5 of 1,357 study subjects (0.04 percent), as compared to none of the 851 study subjects receiving a placebo. Because of this very small percentage, recommendations include discussing the potential for an increased risk of suicidal thinking and behavior and what symptoms to be watchful for when atomoxetine is begun in an adolescent.
POTENTIAL FOR ABUSE AND DIVERSION OF STIMULANT MEDICINES
All of the stimulant medicines used to treat ADHD are classified as C-II controlled substances, which limits the amount of medicine the pediatrician can typically prescribe at one time to a 30-day supply with no refills. The reason for this controlled drug classification relates to the significant abuse and diversion potential for the stimulant medicines. Understandably, some parents express concerns about giving a controlled drug with abuse potential to their child or adolescent.
Children and adolescents with ADHD have a higher risk of abusing alcohol and drugs because of underlying ADHD symptoms and traits of the disorder. There is some evidence from studies that this risk is reduced when ADHD is successfully treated with stimulant medicines. There is very little evidence that stimulant medicines are abused or misused by successfully treated adolescents. A greater concern relates to the diversion of stimulant medicines to people who do not have ADHD for abuse and misuse. This is a primary reason for the controlled status of stimulant medicines, to limit the amount of medicine that is potentially available to others for nonmedical and inappropriate use. Surveys of high school and university students indicate that it is relatively easy for students without ADHD to obtain stimulant medicines from friends and family members for use as aids to improve exam scores and study time.
Some parents may have concerns about their child becoming “addicted” to a long-term use of stimulants. This concern is unfounded, as the term addiction implies that the person has physical and psychological dependence on the medication, which does not occur with stimulants when given to children and adolescents who have ADHD. Stimulant medicines can be stopped at any time without adverse effects, and it is common to stop the drug on weekends and summers, when school is not in session. The stimulant medicines with a longer duration of effect, such as Vyvanse, Concerta and Focalin XR, are less prone to diversion and abuse, as compared to the pharmaceutical dosage forms with a short duration of effect, such as Ritalin. Due to their pharmaceutical dosage form, the longer-acting dosage forms are not as likely to result in quick, immediate effects when abused and taken by others for whom the medicine was not prescribed.
You and your adolescent can take several measures to decrease the risks of abuse and diversion with stimulant medicines. Perhaps most important is to keep the stimulant medicine container in a safe, nonvisible place at home. I tell university students when they are prescribed a stimulant medicine to keep it out of sight in their dorm room or apartment, to reduce the likelihood that it will be noticed and possibly taken by someone who is visiting. Parents can also carefully monitor the number of tablets or capsules remaining in the stimulant medicine bottle, matching it to the expected number according to the date of when the bottle was obtained at the pharmacy.
CONSIDERATIONS AT THE PHARMACY
There are many different stimulant medicine products pediatricians can choose from to prescribe for your child or adolescent who has ADHD. As discussed above, a main difference among these products is how long they provide a beneficial effect; the time range is large, from 3 to 12 hours. Your pediatrician will discuss with you how long your child’s stimulant typically lasts and how many times a day your child or adolescent should be given the medicine.
Most of the brand name stimulant medicines, such as Ritalin, are available as generic dosage forms, and these will be less expensive. Many of the stimulant products can be relatively expensive, however, costing up to several hundred dollars for a 30-day supply. Some of the generic products can be rather expensive as well, although less costly than the equivalent trade name product. The amount you will pay at the pharmacy also depends upon your health insurance coverage, if any, and what medicines your health insurance plan will pay for. Discuss your insurance coverage with your pediatrician when a stimulant is first prescribed or changed, and check with your health insurance provider to verify what stimulant products are covered and at what level.
An additional difference among the stimulant products is how they are taken: some products can be chewed, dissolved in the mouth, sprinkled over soft foods, or taken as a liquid, while other tablet or capsule products must be swallowed whole, and not chewed or crushed. One stimulant product, Concerta, is manufactured with a unique capsule that may pass through your child’s intestinal tract without dissolving, and may appear whole and relatively intact in your child’s stool. This is normal; the medicine has been absorbed by the body. Be sure to discuss all of these issues with your pharmacist and pediatrician.
The CAM product polyunsaturated fatty acids, also called omega-3 fatty acids, has been studied to treat ADHD in children. A recent published analysis of 10 studies including 699 children with ADHD treated with omega-3 fatty acids demonstrated that this supplement can have a small beneficial effect to improve ADHD symptoms. Omega-3 fatty acids have not been directly compared to stimulant or nonstimulant medicines. If you decide to try treating ADHD by giving an omega-3 fatty acid to your child, it is best to use a product with a “USP Verified” stamp or logo on the bottle or package label, indicating that the product is more likely to accurately contain what is stated on the label, without contaminants. See chapter 3 for more information about choosing a CAM supplement product.
If used, an omega-3 fatty acid supplement is probably best added to a stimulant or nonstimulant ADHD medicine. Talk with your pediatrician to let him or her know that you would like to add this supplement to your child’s other medication. Parents with concerns about treating ADHD with medication therapy may also consider use of an omega-3 fatty acid supplement product alone, without a stimulant or nonstimulant ADHD medication. Speak with your pediatrician before trying this, however.
• Depression is common in adolescents.
• Psychotherapy, or counseling, effectively treats mild depression.
• Selective serotonin reuptake inhibitor medicines (SSRIs) effectively treat moderate and severe depression.
• A combination of psychotherapy and SSRIs is more likely to effectively treat moderate to severe depression than either used alone.
• It often takes 4 to 6 weeks for SSRIs to become effective, and they are best used daily, and not occasionally taken “as needed.”
• Most adverse effects from use of SSRIs are manageable.
• An increased risk of suicide from use of SSRIs is possible, although this risk is small and largely outweighed by the benefit of medication therapy to treat depression.
• Stimulant medicines effectively treat ADHD symptoms.
• Nonstimulant medicines effectively treat ADHD symptoms, and are best reserved for children unlikely to benefit from a stimulant medicine, because they are not as effective as stimulant medicines.
• Use of stimulant medicines in children and adolescents does not result in “addiction,” although these medicines can be abused by others.