Medicine for ADHD for children and adolescents

ADHD is one of the most frequent psychiatric neurodevelopmental disorders. Children and adolescents with ADHD can be significantly challenged in their everyday lives.

Fortunately, there is today extensive knowledge about ADHD and about how to help children and adolescents with ADHD, both educationally and medically, so that they can have a good life despite the challenges they face.

ADHD is an abbreviation from the American Diagnostic System for Attention Deficit Hyperactivity Disorder.

*ADD: In children and adolescents with attention difficulties without hyperactivity and impulsivity, we call the diagnosis ADD, which stands for Attention Deficit Disorder.

The medical treatment for ADD and ADHD is the same. In the following, we use ADHD for readability. 

The most frequent ADHD symptoms can be divided into three main areas:

• Attention deficit
• Hyperactivity and
• Impulsiveness

ADHD symptoms may manifest themselves differently from child to child. While, for example, some children primarily have attention difficulties, others may be very hyperactive or impulsive.

ADHD symptoms may also change over time. For example, hyperactivity is often seen to decrease with age.

Below, you can see a list of typical symptoms.

Inattentiveness

• Problems concentrating
• Forgetfulness
• Being easily distracted
• Confused
• Fluctuating energy levels
• Feeling indisposed

Impulsiveness

• On the go
• Impatient
• Interrupts others
• Quick
• Superficial
• Thrill-seeking

Hyperactivity

• Restless
• Fidgeting
• Hectic
• Fiddling with things
• Having difficulty sitting still for long periods

To help your child with ADHD, it is important that action is taken in relation to the child himself/herself, the family, school/daycare centre and/or other parties around the child.

ADHD treatment is divided into three areas:

• Psychoeducation (knowledge of ADHD)
• Pedagogical measures
• Medication

Psychoeducation

It is important that the child, parents, teachers/educators and any other relevant network know what ADHD is, how it manifests itself and what support can help the child in his or her everyday life.

The better you understand the child’s challenges, the better you can understand why the child reacts the way he or she does. This can help you understand that when the child says no, it may not be because he or she does not want to, but because he or she needs more help with something. Or when he or she gets angry, it may not be because he or she is being contrary, but because he or she is under strain. This enables you to help the child and to avoid that the child is scolded, which will, in turn, increase his or her self-confidence.

Pedagogical measures

It is important for the child that a framework is created both at home and at school that takes his or her challenges into consideration.

Overall, a child with ADHD needs a clear structure and predictability, and that there is focus on ensuring that the child is not exposed to sensory overload. There may, for example, be a need for clearer explanations, clearer plans for how to do things, small breaks, and more help to remember things along the way.

The pedagogical measures are very important to prevent the child from being overburdened.

Medication

Not all ADHD patients need medication. Some will be treated with psychoeducation and pedagogical measures. However, in children with moderate to severe ADHD, there may be a need to include medication in the treatment.

However, it is important that pedagogical measures are first tried and that the pedagogical measures continue after treatment with medication is commenced.

Medication is thus part of an overall treatment and should not stand alone.

Help and treatment for ADHD are provided both at home and at school and leisure facilities, while treatment with medication is commenced in child and adolescent psychiatry.

Psychoeducation

After a psychiatric examination, the child and his or her parents are often offered a short course of psychoeducation. There are also courses held through the Danish ADHD Association, and the municipalities have various offers.

Pedagogical measures

School/the Pedagogical Psychological Counselling (PPR) service and the social services are important for implementation of the measures needed in collaboration with the family.

Medication

Treatment with ADHD medication is commenced during consultation at a child and adolescent psychiatric department or with a psychiatrist in private practice who specialises in children and adolescents. In many patients, medication follow-up passes to their own doctor at some point.

Treatment with ADHD medication has been known for at least 50 years, and we have acquired much more knowledge in this field in the past decades. Many studies have been conducted on the use of ADHD medication in children and adolescents, and there is consequently wide knowledge about the effect and side effects of ADHD medication. Several drugs have also been introduced on the market over the years, which provides more options in adjusting the treatment to the individual child.

Overall, we can say that ADHD medication – combined with pedagogical measures – provide a highly effective treatment. It is also a treatment for which no serious long-term side effects have been ascertained.

As more side effects and often poorer efficacy are seen in the youngest children, the Danish Health Authority generally does not recommend ADHD medication for preschoolers (0-6 years).

Which medication works best differs greatly from child to child as do the side effects seen and consequently which drug is best suited for the individual child. Therefore, it may take some time to find the medication that is best suited for the individual child.

There is a difference between:

• Which medication works best for the individual child.
• How well the child tolerates the medication (side effects).
• How quickly the medication is metabolised in the body, and thus how quickly the effect is achieved.
• How large doses are needed.
• For how much of the day the child needs to be under the effect of medication. 

Before start-up

When a child receives an ADHD diagnosis, it is considered:

• whether the pedagogical measures have been sufficiently tested.
• whether the child’s symptoms are so severe that medication is needed.
• whether the child receives adequate support at school and at home.

If the use of medication is considered, the parents and the child are invited to a start-up interview where they are given information about the medication.

Before your child can begin treatment with medication, he or she must be examined by a doctor, who will, for example, ask questions about the child’s health, check blood pressure and heart rate and measure height and weight. Sometimes an electrocardiogram (ECG) will be done before start-up. This only takes a very short time and it does not hurt.

Start-up

The nurse or the doctor will provide information about the medication that your child will receive, how it works and the side effects to which you should pay attention. A dose escalation plan is provided, and an agreement on follow-up is entered into.

Follow-up

Follow-up is often agreed by email or telephone after 2-4 weeks, where the parents report side effects and/or onset of efficacy. In the event of any side effects, the dose escalation plan is adjusted.

The child is called in for a medication control visit after 2-3 months, where it is reviewed whether the medication is tolerated by the child and whether there is efficacy. The review also attaches importance to how your child is doing at school.

If the child tolerates the medication and there is good efficacy, the child will continue the treatment and will be called in for a medication control visit every six months. If the medication is not working, the treatment provider will either make adjustments or replace the drug.

When the treatment has been stable for a period of time, your child can often switch to further medication follow-up by his or her own doctor. Other children need to be followed in child and adolescent psychiatry for an extended period of time.

Sometimes, there are children who do not tolerate the medication or in whom none of the drugs have any efficacy, and where treatment with medication must be given up or possibly postponed until the child is a little older and can perhaps better tolerate the treatment.

Why are blood pressure and heart rate measured?

• ADHD medication may result in slightly higher blood pressure and heart rate. This is usually of no significance, but if it becomes too high or the child experiences symptoms, it may be necessary to stop the treatment, reduce the dose or change medication.

Why are height and weight measured?

• ADHD medication may cause reduced appetite, and it is therefore important that we follow up on whether your child is growing as he or she should be even if he or she is on medication.
• If your doctor finds that there is an effect on growth, the medication can be replaced or discontinued.

It is known that ADHD patients have reduced quantity and function of the neurotransmitters dopamine and noradrenaline in specific parts of the brain. This imbalance causes problems with concentration, impulse control and restlessness. In fact, ADHD medication increases the quantity or function of dopamine and noradrenaline in specific areas of the brain.

Non-24-hour medication

A joint feature of the drugs in this medication group is that they act approximately 20-60 minutes after the child takes the pill. The short-acting drugs act for 3-4 hours and the extended-release medication acts for 6-12 hours.

Some children only need to be covered by medication during school hours and do fine without medication during their leisure time or at home. Conversely, other children also need to be covered outside school hours.

At the same time, it is very different from child to child how quickly they metabolise the medicine. Therefore, the same medication may work for a longer period of time in some children, while other children do not have an equally long-lasting effect.

Therefore, some children need to take medication several times a day to be properly helped, while other children only need to take the medication once a day.

Non-24-hour medication

Short-acting (acts for 3-4 hours)

• Ritalin, Motiron, Medikinet
• Attentin

Extended-release medication

• Ritalin Uno, Medikinet CR, Equasym (acts for 6-8 hours)
• Concerta/Methylphenidate (acts for 8-10 hours)
• Elvanse (acts for 10-12 hours)

24-hour medication

• Strattera/Atomoxetin
• Intuniv/Guanfacin

Side effects

The various drugs have different side effects. Many of the drugs may result in less appetite and sometimes nausea.

Some children may experience a mood deterioration or aggression, while other children may experience a mood improvement and reduced aggression. Likewise, some medication may exacerbate anxiety, and other medication may reduce anxiety. Some children may have a negative impact on their sleep from the medication, while other children sleep better on medication. 

Children who have a tendency towards tics can sometimes experience that they develop more, and more pronounced, tics. Conversely, the tics may also become fewer when the child is put on medication.

Blood pressure and heart rate may increase slightly, but this is most often of no importance.

24-hour medication

The 24-hour drugs Strattera and Atomoxetine have less appetite-reducing effect. Intuniv is completely different from the other drugs: it lowers pulse and blood pressure slightly and often results in increased appetite.

The side effects often diminish when the child has become used to the treatment, but, other times, it may be necessary to change medication because of side effects.

Treatment is most often commenced with one of the non-24-hour drugs. These are the best known drugs, and some of them are also the lowest-priced drugs. The Danish Health Authority generally recommends starting with certain types of non-24-hour medication.

Sometimes Strattera/Atomoxetine can be chosen to start with. Atomoxetine is especially used to start with in children with pronounced anxiety and tics or in children who need to be covered by medication on a 24-hour basis.

An individual assessment must consequently be made on a case-by-case basis regarding which drug the treatment provider finds will be the best choice for the individual child.

Some of the drugs are pills. Others are openable capsules where the contents are sprinkled on food or liquid, and yet others are found in liquid form.

You may be eligible for reimbursement of medication expenses from the Danish Medicines Agency. The treating doctor applies for reimbursement either before start-up for expensive medication or after start-up for lower priced medication.

Some ADHD medication may be abused if taken in much higher doses than prescribed by the doctor. As the medication can be abused, the authorities check carefully how much is prescribed to the individual patient. It is important that you as parents store the medication safely until your child becomes old enough to manage this.

In certain cases, ADHD medication may affect the effect of alcohol. Adolescents who receive ADHD medication should therefore be extra careful about drinking alcohol.

Some parents are concerned that ADHD medication may create a later addiction to alcohol or narcotic drugs in their child. There are no indications that this is the case. In fact, many studies show that treatment with ADHD medication can help reduce the risk of the subsequent development of drug or alcohol abuse.

Many may need medication also into their adolescence and adulthood, while others may grow out of their need for medication.

It is discussed at the follow-up consultations whether medication is still needed.

If an adolescent wants to try whether he or she can do without medication or if the parents think that they would like to see how their child does without medication, it is recommended that this be discussed with the child’s treatment provider.

It will often be agreed to suspend the medication for 1-2 months and to assess together how things are going.

Many children and adolescents can benefit from ADHD medication. It is important that the treatment is combined with pedagogical measures and close follow-up to assess efficacy and side effects. It is also important to decide on an ongoing basis whether the treatment should be adjusted or whether the child may be able to cope without medication at some point.