Back to School—and Medicated for ADHD

For parents, medicating a child is always an uneasy trade-off for the condition itself. If you have a son or daughter headed back to school this fall with a diagnosis of attention-deficit/hyperactivity disorder, your child's first-day jitters surely pale in comparison to your own anxiety about the risks and effectiveness of available treatments.

Is the possibility of improving school performance worth subjecting a young student to the laundry list of potential side effects that accompanies each prescription for ADHD?

Balancing benefits and risks

The nearly unanimous consensus among health experts is yes, take the meds.

"Doctors want families to be informed but also to keep risks in perspective," says R. Scott Benson, M.D., a child and adolescent psychiatrist in practice in Pensacola, Fla., and member of the American Psychiatric Association. "We are all looking for children to be as successful in school as they have the ability to be. If they have serious problems with focus that interfere with learning, we have treatments that can help them."

A great deal has been written in the popular press about the risks associated with ADHD medications, prompting both concern and confusion. In particular, the "black box" warnings added to labels by the FDA in 2006 were met with a storm of publicity, followed by a flood of panic among parents. Missing, however, was an informed understanding of who should be concerned and a thoughtful weighing of risks and benefits.

Getting a handle on major concerns

According to experts, the most adverse side effects from ADHD medications are also among the most rare. The potential for heart-related problems and drug abuse are noted risks for  methylphenidates (Concerta, Metadate, Methylin, Ritalin) and amphetamines (Adderall, Desoxyn, Dexedrine), the two stimulants that dominate the ADHD category. Heart-related problems have been cited in a number of fatal cases and are behind the frightful "sudden death" warnings currently carried on labels—sometimes in a box, sometimes not. Labels warn against the possibility of drug dependence following prolonged periods of use and against distribution of the drug to others.

However, very few candidates for the drugs are actually at risk for these dangers, and attentive physicians do not have difficulty screening candidates. Thorough medical, personal and family histories are likely to reveal whether a patient has a pre-existing heart problem or a history of significant drug abuse—either one signalling a "no go" for ADHD meds.

"These medicines are cardioactive, meaning that they will engage the heart," explains Dr. Jess P. Shatkin, director of education and training at New York University's Child Study Center. "Someone who's had an arrhythmia of the heart or a valve problem, for example, would not be [a candidate] for a stimulant. But that's very rare in children. There's also a suspicion that the drugs may cause arrhythmia, although none of our data to date really supports that. There's a concern, but not good evidence."

Dr. Shatkin, who is author of the forthcoming book Treating Child and Adolescent Mental Illness, often fields parental concerns that children will turn into "little junkies" who need to stay on medication for life. However, evidence cited by the National Institute on Drug Abuse shows that children with ADHD who take medication are in fact less likely to have problems with substance abuse than kids with the condition who don't receive treatment.

"For the thousands of kids I've treated for ADHD, I've probably needed to stop treatment once," says Dr. Shatkin. "I don't own stock in the drug companies. But if a kid really has ADHD, it's important to treat them."

Because it's not a stimulant, atomoxetine (Strattera) is something of an exception among ADHD medications. Its leading warning is for suicidal ideation, which means there is a slightly increased risk—about 4 per 1,000, according to health authorities—of a patient voicing suicidal thoughts. Though the risk is low, it's recommended that the mental health of a child on atomoxetine be closely monitored.

As a representative of the FDA pointed out to MSN Health & Fitness during research for this article, patient guides and labels for FDA-approved ADHD meds were last updated in 2007 and are available to the public here.