ADHD Treatment: Medications and Alternatives

Guisou Zarbalian, MS, and Hana Rahman, National Center for Health Research The use of stimulant medications to treat attention deficit/hyperactivity disorder (ADHD) steadily increased in the United States from 1990-2020 and the most recent statistics estimate that diagnoses of ADHD increased by 36% in adults and 18% in youth, while a diagnosis and drug prescription […]

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Guisou Zarbalian, MS, and Hana Rahman, National Center for Health Research

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The use of stimulant medications to treat attention deficit/hyperactivity disorder (ADHD) steadily increased in the United States from 1990-2020 and the most recent statistics estimate that diagnoses of ADHD increased by 36% in adults and 18% in youth, while a diagnosis and drug prescription increased by 29% in female youth and 10% in male youth.^[1]

ADHD treatments can be very effective but common complications include weight loss and insomnia. Dr. Stephen Borowitz of the University of Virginia estimated that a third of the children he sees are taking at least two prescription medications, usually a drug for ADHD and an antihistamine to prevent those side effects.^[2] Traditionally, ADHD was considered a childhood condition primarily involving males, but as noted above, there has been an increase of ADHD diagnoses among females and adults aged ≥20 years.^[1]

Most studies have shown that stimulant medication is effective for 70-80% of children with ADHD.[3] However, the skyrocketing use of these drugs is worrisome, due to growing concerns about the drugs being inappropriately prescribed as well as prescription drugs being diverted for other uses and misuse, as well as harmful side effects. Both stimulant and nonstimulant drugs are prescribed for individuals with ADHD to manage symptoms. Stimulant drugs work on the prefrontal cortex of the brain to improve attention and executive function. Despite their effectiveness, stimulant drugs can produce unwanted side effects such as suppressing appetite, increasing sleep disturbances, and fatigue, resulting in the use of nonstimulant drugs to counteract these symptoms. Nonstimulant drugs work by increasing levels of norepinephrine, the hormone responsible for regulating attention, learning, and reactions to stress.4

The following table lists the different types of stimulant and nonstimulant ADHD drugs on the market.5,6

Generic Names	Trade Names
Nonstimulant Drugs:
Atomoxetine, Clonidine ER, Guanfacine ER	Intuniv, Kapvay, Strattera
Stimulant Drugs:
dextroamphetamine, amphetamine with dextroamphetamine, methamphetamine, Methylphenidate	Dexedrine, Adderall, Adderall XR, Vyvanse, Desoxyn, Ritalin

 

Why Some Doctors Are Concerned, and What the FDA Decided to Do About It

Patients may experience adverse reactions even when taking their medications correctly. Increased heart rate and blood pressure are common effects of ADHD stimulants, and although these side effects are not dangerous for most people, they can cause serious problems, especially in children and adults with known heart disease or heart conditions. An analysis of 60 U.S. emergency departments between 2017-2019 found that among patients aged 5 to 14 years, 3 medications that can be used to treat attention-deficit/hyperactivity disorder (methylphenidate, clonidine, and guanfacine) were among the 10 drug products that most frequently resulted in Emergency Department visits.7 Additionally, several studies have found that the increase in prescriptions for stimulant medications has led to an increase in the prevalence of stimulant misuse.8

In 2006, Dr. Steven Nissen, a cardiologist at the Cleveland Clinic who served on an FDA Advisory Committee, recommended that the FDA require boxed Warnings, also called Black Box Warnings, on several ADHD medications. Boxed warnings are the highest safety-related warning that FDA requires for medications, and are intended to bring greater attention to the major risks of a drug,10 and enable patients and physicians to consider the risks when deciding on treatment options. However, it was only after reviewing studies published from January 2006 to May 2020 on misuse and abuse of prescription stimulants and associated adverse events, that the FDA decided in 2023 to include Boxed Warnings on all prescription stimulants.9

These warnings have made patients, family members, and physicians more interested in alternatives to these medications, including cognitive behavior therapy and diet.

How Diet Affects ADHD

Sugar may seem like the obvious culprit, but this is not the case for all children. Several studies have shown that many children with ADHD may break down fatty acids differently from other children. The omega-6 and omega-3 fatty acids are two types of fatty acids, and they are called “essential fats,” or “essential fatty acids” (EFA’s). The body cannot make them and they must be obtained from one’s diet. One study found that children with low omega-3 fatty acid concentrations display more behavior problems than children with normal levels. These same children also exhibited other signs of low fatty acid levels, including thirst, frequent urination, dandruff, and dry skin, all of which can be treated effectively with essential fatty acids.[11] [12]

A study published in 2003 examined the fatty acid content of certain cells, taken from children with and without ADHD. The researchers found lower levels of certain omega-3 and omega-6 fatty acids in children with ADHD. Children who were given foods that contained the EFA’s they were missing displayed less hyperactivity and generally behaved better than before the study.[13] Another study that divided participants with ADHD aged 7-12 into placebo and treatment groups found that participants given omega-3 treatments had small decreases in symptom severity regarding inattention and hyperactivity experienced improvements in these symptoms when compared to the placebo group.14

It is not known what types or percentage of ADHD, if any, can be completely managed by eating more nutritious foods, or foods that contain EFA’s. However, these studies show a link between diet and behavior that deserve further study, since there are no risks to changing diet in these ways, and many possible benefits. For many parents, a change in diet is more difficult to control than medication, but is certainly worth a try.

Cognitive Behavioral Therapy

Cognitive-behavioral therapy (CBT) can be especially useful as a treatment for ADHD. CBT aims to change the thoughts and behaviors that reinforce the harmful effects of the disorder by teaching people techniques to control the core symptoms.15 This is accomplished through goal-oriented talk therapy. One review analyzed several different studies that compared the effects of CBT compared to other treatments or to no treatment for 700 adults with ADHD, between 18 and 65 years of age.This study concluded that when CBT was used with ADHD medication, participants experienced significant  improvements in ADHD symptoms.15 This study also found that CBT alone produced significant improvements compared to other forms of supportive therapy or no treatment at all.15 A different  study found strong evidence that CBT in combination with stimulants was more beneficial than stimulants or non-stimulants alone.15 This study suggested that with more trained providers and funding, this form of therapy in tandem with medication has the most statistically significant results compared to any other form of treatment, including medication alone.16 For children and adults alike, CBT can be used to teach coping skills and encourage desirable behavior, emotions and thought patterns.17 Children can learn to follow directions leading them to achieve reasonable goals that are set for them, and find better ways to control their behavior. For adults, behavioral treatment can help them cut down on distractions, stay on task, reward themselves for small, achievable goals, and help them control their own behaviors. These strategies can be used in combination with medication or changes in diet.  [By the way, cognitive behavioral therapy is also considered most effective for insomnia, depression, and many other common problems.] For more information, see this website by the American Academy of Pediatrics: https://healthychildren.org/English/health-issues/conditions/adhd/Pages/default.aspx

Physical Activity 

Individuals with ADHD have reduced levels of dopamine and norepinephrine in the brain. Physical activity has been proven to alleviate symptoms of ADHD by increasing the neurotransmission of these hormones.18 Aerobic exercise, treadmill training, sprint interval training, and taekwondo practice are all examples of practices, which have been studied as treatments for ADHD.18 A 2019 study of around 570 participants between the ages of 8-16 with ADHD also found physical activity significantly reduced anxiety and depression.19  In that study, participants were assigned to physical activity and non-physical activity groups. Researchers noted that participants assigned to physical activity had reductions in difficult focusing, social problems, and aggressive behaviors.19  Physical activity has been shown to improve academic performance, behavior problems, motor and emotional control, and problem-solving. These findings suggest that physical exercise can help reduce symptoms of ADHD resulting in less need for pharmacological drugs, thus preventing adverse drug events or even over-consumption.

What This Means for You or Your Child

People on ADHD stimulants who have a diagnosed heart condition are at greater risk for experiencing a potentially deadly or debilitating cardiovascular event. However, even children who do not have a heart condition can be at risk, especially if they take high dosages but even if they follow directions exactly. If you or your child currently take these drugs, talk to your doctor about any concerns you have, and consider whether to try alternatives that may be safer and equally effective, such as changes in diet, exercise, or trying cognitive behavioral therapy.

 

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

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