ADHD, part 3

By Alan Koenigsberg, M.D.

For this last part in the Attention Deficit Hyperactivity Disorder (ADHD) series, I intend to take a deeper dive into the treatments.

First, in very small children, cognitive behavior therapy is often recommended. It helps the parents and child better understand how to manage symptoms, make family modifications and encourage the child to have greater confidence and self-esteem.

Untreated children often grow up feeling dumb and defective and develop low self-esteem. They are also more prone to drug addiction, as the stimulant street drugs do help them focus. However, given that they are street drugs, there is no oversight and they can be dangerous.

In older children and adults, medications are generally the first-line treatments. Once the person has begun to notice benefit and improvement, some form of psychotherapy is often very helpful.

Now, to directly address some concerns parents have. Yes, these medications can be addictive in about 10% of the population — which means that roughly 90% of people do not have that problem, and take the medications as prescribed and do just fine.

Secondly, yes, the medications can develop tolerance and people can experience withdrawals if they stop abruptly. This is true with many other medications as well.

I explain all this to my patients and advise them to take their medications daily, to work with me to ensure they don’t run out and to be extremely vigilant in not losing them.

In children, many notice a decrease in appetite and weight loss along with a slowing of growth. It’s important that the parents work closely with the child’s psychiatrist and pediatrician to closely monitor this and change treatments if it persists.

Ironically, this persistent weight loss does not typically take place in adults, much to the disappointment of many who hoped these medications would be an effective weight loss option.

It has been my experience that most every patient needs at least two doses of these medications daily. In spite of the extended-release options, they do not seem to last a full day and my adult patients need to work, drive and tend to their families in the evening. A second dose around lunchtime or early afternoon generally takes care of that and does not impede sleeping.

Some of these medications may temporarily or initially raise blood pressure somewhat, but that tends to even off in a week or so.

Some parents as well as some adults are concerned about addiction or tolerance and ask about weekend “drug holidays.” While it seems to make sense, it’s actually not a good idea and here’s why:

Older adolescents need to pay attention when they are driving. Stopping their medications on the weekends can be dangerous.

Adults need to drive, operate machinery and generally pay attention on the weekends.

Secondly, if people are taking full, therapeutic doses of these medications and then stop them abruptly every weekend, they can go through withdrawals every weekend, which, while not usually dangerous, are unpleasant.

Lastly, we start at low doses and gradually increase to avoid side effects of the higher doses. If the person stops every Saturday and restarts them every Monday, they get hit very hard every week.

I have recommended to all my patients to take their meds every day and they have done well.

Lastly, I also recommend asking the pharmacist to provide a duplicate (usually free) labeled bottle of their medications, so they can take a smaller amount for daily use or vacation and leave the bulk at home, so as not to run the risk of losing their meds.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas.

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