The Great Medication Debate: Understanding ADHD Meds and Multimodal Treatments

Posted on July 19, 2017 by Kate Barrett, One of Thousands of ADD ADHD Coaches on Noomii.

To medicate or not to medicate? This question will likely be asked during the development of an ADHD treatment plan. Regardless of which side of this debate you are on, it is important that you have all of the facts as you and your doctor develop the best treatment plan for you or your child.

To date, the most successful and widely studied types of medication for ADHD are methylphenidate-based (including Ritalin) and amphetamine-based (including Adderall) stimulants. Stimulants have been used to treat ADHD since 1937 (Benzedrine (racemic amphetamine)) . According to the National Resource Center for ADHD, there have been more than 200 scientific research studies on the use of medication for the treatment of ADHD.

It is interesting to note that in spite of the volume of studies conducted, two prevalent myths persist in today’s society regarding medication for ADHD.

MYTH #1: Medication is over-prescribed in the treatment of ADHD.

Many people assume an ADHD diagnosis is synonymous with a prescription for Ritalin. In reality, medication does not work for everyone who is diagnosed with ADHD, but everyone responds favorably to medication. In fact, up to 75% – 80% of patients respond positively to medication (AACAP 2002; AAP 2002). This is one of the many reasons that it is important to work closely with your medical professional when establishing a treatment plan for your child. The right medication can alleviate some symptoms and improve functioning.

FACT: Up to 11% of all children have a diagnosis of ADHD but only 6.1% (55.45% of children with an ADHD diagnosis) are actually treated with medication.

MYTH #2: The use of stimulant medication increases the risk for future substance abuse

This is a common misconception that is played over and over in the media. Numerous studies have shown that the medication most often used to treat ADHD does not increase the patient’s likelihood to abuse drugs . It actually normalizes the likelihood of substance abuse to be no more than that of a non-ADHD person, as long as the medication is taken orally and as prescribed.
It is the lack of any treatment of ADHD that raises a patient’s risk for substance abuse, which may include the use of stimulant medications. This is why treatment plans are so important for everyone diagnosed—the successful management of symptoms through education and intervention is key.

FACT: Treatment with stimulant medication does not increase the risk for later substance abuse.

You may be wondering exactly what these drugs do for the ADHD brain. It is well-known that ADHD is a neurobiological disorder. The major neurotransmitter systems involved in ADHD are dopamine and the norepinephrine, with serotonin also having a role. Dopamine is the neurotransmitter that carriers the impulse from one neuron to another. The more dopamine that is captured by the cells, the clearer the message to the brain. Stimulant medication increases the levels of dopamine in the brain, thus resulting in improved message receptors. Non-stimulant medications boost norepinephrine, which is the other neurotransmitter that aids in mobilizing the body and brain for action. This appears to improve impulse control, attention, and working memory in some patients.

With this in mind, it is also important to be very clear about what medication can actually do for someone with ADHD. Below are four common effects of successful medication use in ADHD :

1. Decreased hyperactivity levels—to help with symptoms such as fidgeting and to enable someone to sit for longer periods of time.
2. Increased focus for longer periods—which can impact listening and create the potential for improved work accuracy in some patients.
3. Decreased impulsivity—to help slow down reaction times and increase the likelihood of being able to think before acting.
4. Decreased reactivity—particularly in situations where explosive emotions may be a hinderance.

Just as important is an awareness of what medication cannot do for ADHD. Medication cannot:

1. Teach your child good behavior.
2. Teach a child to deal with their feelings.
3. Teach skills that they have yet to learn or master.
4. Provide motivation to complete or start tasks.
5. Provide a cure for ADHD.

Medication should be regarded as one of the many possible tools for treating ADHD. The most successful treatment data suggests that medication alone is not the answer, which is why many doctors suggest a multimodal treatment plan in which more than one intervention or therapy is combined with others to address each of the symptoms of ADHD as necessary.

In the first long-term landmark study on ADHD, the National Institute of Mental Health and the U.S. Department of Education published the results of a 36-month study that concluded that after 14 months of treatment “… long-term combination treatments, as well as careful medication management alone, are both significantly superior to intensive behavioral treatments… in reducing AD/HD symptoms.” (MTA, 1999) . This study, released in 1999 by the MTA Cooperative Group, has since been updated with data of its original participants in 2008 and has spawned several other studies on multimodal treatment as it relates to topics such the types and severity of ADHD symptoms, anxiety and ADHD, maternal symptoms, etc.

The forms of treatment that may be included in a multimodal treatment approach for ADHD are behavior therapy (also known as cognitive behavior therapy or CBT, talk therapy), parent and child ADHD education, specific behavior management techniques, school programming and intervention supports (including IEP/504Plans if needed), and medication.

In addition to these approaches, there are complimentary interventions that show promising data in the relief of the severity of ADHD symptoms. Some include balanced diets, multivitamins and omega-3 supplements, exercise, yoga/meditation, mindfulness practice, treatment of sleep disorders, and EEG neurofeedback such as CogMed.

Although many of these techniques have been anecdotally successful in some patients, there are other interventions that are considered controversial in the treatment of ADHD. It is important to keep in mind that anything that markets itself as a “cure” for ADHD should be approached with caution. As you explore treatment options, it is helpful to run through the following checklist recommended by CHADD.org:

 How safe is it?
 How is it promoted?
 Will it work for my child?
 Is it scientifically researched or is it only backed by case studies and/or testimonials?

Again, it is important to consult your health care provider before investing or ingesting any product.
Make sure you are well-informed, educated, and fully invested in doing the groundwork required to put your chosen treatment plan into action. Successful ADHD treatment plans take into account the whole person, not simply an end result.

Resources & References:
1. Strohl, Madeleine P. “Bradley’s Benzadrine Studies on Children with Behavioral Disorders” Yale J Biol Med. 2011 Mar; 84(1): 27–33.
2. National Resource Center on AD/HD, What We Know v3 “Managing Medication for Children and Adolescents with ADHD” (2011)
3. Visser S, Danielson M, Bitsko R, et al. Trends in the Parent-Report of Health Care Provider-Diagnosis and Medication Treatment for ADHD disorder: United States, 2003–2011. J Am Acad Child Adolesc Psychiatry. 2014,53(1):34–46.e2
4. help4adhd.org/Portals/0/AM/Images/TrainingAndEvents/R3-CHADD_PRESS_RELEASE_ON_SUBSTANCE_ABUSE%20(1).doc
5. NIDA and NIH, 2008. Wilens, 2003; R.A. Barkley, 2003
6. CHADD Parent-to-Parent Family Training for ADHD Program, Module 2: Assessment to Multimodal Treatment for AD/HD (Revised 2014), slide 2-24.
7. CHADD Parent-to-Parent Family Training for ADHD Program, Module 2: Assessment to Multimodal Treatment for AD/HD (Revised 2014), slide 2-25.
8. The MTA Cooperative Group. A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Arch Gen Psychiatry.1999;56(12):1073-1086. doi:10.1001/archpsyc.56.12.1073.
9. Complementary and Alternative Treatments: Neurofeedback in AD/HD, What We Know #6A – CHADD NRC