Medication

The following section is adapted from ADHD and Behavior Disorders in Children by Richard Milich and Walter Roberts.

The most common method of treating ADHD is prescribing stimulant medications such as Adderall™. These medications treat many of the core symptoms of ADHD—treated children will show improved impulse control, time-on-task, compliance with adults, and decreased hyperactivity and disruptive behavior. However, stimulant medication has adverse side effects such as growth and appetite suppression, increased blood pressure, insomnia, and mood changes. Although these side effects can be unpleasant for children, they can often be avoided with careful monitoring and dosage adjustments. This section illuminates the controversy around prescription stimulants, combining medication and behavioral supports, and controlling access to prescription medication.

Differing Opinions

Opinions differ on whether stimulants should be used to treat children with ADHD. Proponents argue that stimulants are relatively safe and effective, and that untreated ADHD poses a much greater risk to children. Critics argue that because many stimulant medications are similar to illicit drugs, such as cocaine and methamphetamine, long-term use may cause cardiovascular problems or predispose children to abuse illicit drugs. However, longitudinal studies have shown that people taking these medications are less likely to experience cardiovascular problems or abuse drugs. On the other hand, it is not entirely clear how long-term stimulant treatment can affect the brain, particularly in adults who have been medicated for ADHD since childhood.

Finally, critics of psychostimulant medication have proposed that stimulants be increasingly used to manage energetic but otherwise healthy children. The percentage of children indeed prescribed stimulant medication has increased since the 1980s. This increase in use is not unique to stimulant medication, however. Prescription rates have similarly increased for most types of psychiatric medication. As caregivers and teachers become more aware of ADHD, one would expect that more children with ADHD will be identified and treated with stimulant medication. Further, the percentage of children in the United States being treated with stimulant medication is lower than the estimated prevalence of children with ADHD in the general population.

Medication with Behavioral Support

Recently, a large-scale study, the Multimodal Treatment Study (MTA) of Children with ADHD, compared the pharmacological and behavioral treatment of ADHD. This study compared the outcomes of children with ADHD in four treatment conditions: standard community care, intensive behavioral treatment, stimulant medication management, and the combination of intensive behavioral treatment and stimulant medication. Regarding core symptom relief, stimulant medication was found to be the most effective treatment, and combined treatment was no more effective than stimulant medication alone. Behavioral stimulant medication has negative side effects; children receiving combined treatment were less disruptive at school than those receiving stimulant medication alone. Other studies have found that children who receive behavioral treatment require lower doses of stimulant medication to achieve the desired outcomes. This is important because children are better able to tolerate lower doses of stimulant medication. Further, parents report being more satisfied with treatment when behavioral management is included in the program. In sum, stimulant medication and behavioral treatment each have advantages and disadvantages that complement each other. The best outcomes likely occur when both forms of treatment are used to improve children’s behavior.

Abuse of Prescription Drugs

It is no secret that many of the drugs used to treat ADHD are popular drugs of abuse among high school and college students, and this problem seems to be getting worse. The rate of illicit stimulant use has steadily risen over the past several decades. It is probably not a coincidence that prescription rates for stimulant medication have increased during the same period. Students who abuse stimulants often report doing so because they act as an academic performance enhancer by boosting alertness and concentration. Although they may enhance performance in the short term, nonmedical use of these drugs can lead to dependence and other adverse health consequences, especially when taken in ways other than prescribed (e.g., crushed and snorted). Stimulants can be particularly dangerous when taken without a physician’s supervision because this may lead to adverse drug interactions or side effects. Because this increase in prescription stimulant abuse represents a threat to public health, an important goal for policymakers will be to reduce the availability of prescription stimulants to those who would use them for nonmedical reasons.

One of the first steps for addressing prescription stimulant abuse involves understanding how illicit users access medication. Probably the most common method of obtaining stimulants is through drug diversion. Most college students who abuse stimulants report obtaining them from peers with valid prescriptions. Another way that would-be abusers may gain access to medication is by malingering (i.e., faking) symptoms of ADHD. These individuals will knowingly exaggerate their symptoms to a physician to obtain a prescription. Other sources of illicit prescription drugs have been identified (e.g., pharmacy websites), but more research is needed to understand how much these sources contribute to the problem. As we understand how people gain access to illicit medication, policymakers and researchers can make efforts to curtail the rate of stimulant misuse. For example, because drug diversion is a significant source of illicit stimulants, policymakers have enacted prescription monitoring programs to keep track of patients’ prescription-seeking behavior.

In some cases, patients must pass drug screens before receiving their prescriptions. To address malingering, researchers are working to develop psychological tests that can identify individuals who are faking symptoms. Finally, pharmacologists are working to develop stimulant medications that do not carry the same risk of abuse as the currently available drugs (e.g., lisdexamfetamine).

Although these measures will reduce illicit users’ access to stimulant medication, it is important to consider how such policies affect access among people needing these medications to treat their ADHD symptoms. Prescription-tracking programs may reduce physicians’ willingness to prescribe stimulants out of fear of being investigated by law enforcement. Patients with ADHD and comorbid substance abuse problems may be denied access to stimulant medication because they are considered at high risk for drug diversion. Similarly, lengthy psychological evaluations to assess for malingering and mandated drug screenings may be prohibitively expensive for less affluent individuals with ADHD. These measures to reduce illicit drug use are necessary from a public health perspective. Still, as we move forward and enact policies to reduce stimulant abuse, it will be equally important to consider the impact of such legislation on patients’ access to treatment.