Pharmacological treatment of ADHD in children and adolescents
Attention deficit hyperactivity disorder (ADHD) is a condition that primarily causes problems paying attention, hyperactivity, and impulsive behavior.
ADHD can affect school performance, behavior, feelings, and relationships with others. It is a neurobiological disorder that begins in childhood and is usually diagnosed in the early years, although symptoms often persist into adulthood.
Does ADHD cause brain abnormalities?
Brain neuroimaging studies have shown that in children with ADHD there are problems in the regulatory circuits that connect two brain areas:
- The prefrontal cortex: responsible for executive functions such as planning actions, initiating them, noticing and correcting errors, avoiding distractions from irrelevant stimuli, being flexible if circumstances change, and being able to finish the action.
- And the basal ganglia: involved in impulse control by coordinating or filtering information coming from other brain regions and inhibiting automatic responses.
The circuits that connect to the anterior cingulate cortex would also be affected: responsible for affective management and the handling of emotions, the regulation of attention and the elimination of distractions.
Neurotransmitters are chemical messengers that allow neurons to communicate with each other throughout the nervous system via receptors. In this way, neuronal impulses are transmitted from one neuron to another and from one brain region to another.
ADHD, a common disorder in the child population
The prefrontal cortex and basal ganglia communicate through the neurotransmitters dopamine and noradrenaline .
The alteration of these neurotransmitters:
- It decreases attention span and the ability to initiate and continue activities.
- It impairs working memory.
- It impairs the ability to neutralize irrelevant stimuli and the ability to block inappropriate responses.
- It makes planning and organizing complex activities difficult.
- It increases physical activity and impulsivity.
How does medication help with ADHD?
Drug treatment can reduce ADHD symptoms in a large number of people by helping to make the flow of neurotransmitters more efficient between neurons in the different affected brain regions.
However, ADHD treatment is not limited to medication; it must involve a multidisciplinary and integrated approach at all levels, including the family, the school, and the individual being treated, and tailored to individual needs and preferences.
Combined or multimodal treatments are usually the most effective. They will help control many of the symptoms of ADHD and reduce its impact on daily life, but they are not a cure.
Treatment is usually prescribed by a specialist, such as a pediatrician or psychiatrist, and the effect of the treatment and the person's clinical progress should be monitored.
Pharmacological treatment options for ADHD
The main division we will make between this type of drugs will be between stimulant drugs and other types of drugs or non-stimulant drugs.
It will be necessary to keep in mind that some of the medications must be taken every day and others can only be taken on school days.
Combined treatments will help control many of the symptoms of ADHD and reduce its impact on daily life, but they are not curative.
Occasionally, treatment breaks are recommended to check the need for treatment or to reduce side effects.
The medication will be started gradually, beginning treatment with low doses and optimizing the dose according to clinical response and drug tolerance.
Stimulant drugs:
Stimulants are the first-line treatment for ADHD in school-aged children. Despite their name, stimulants don't make a child with ADHD more excited; instead, they improve communication between different areas of the brain. This helps improve attention, concentration, and self-control.
Methylphenidate, lisdexamfetamine, and dexamphetamine are the most commonly used stimulants for the treatment of ADHD.
- Methylphenidate: It is available in short-acting formulas (you can receive up to 3 doses per day) and long-acting formulas that are generally taken once a day.
- Lisdexamfetamine and dexamphetamine: in Spain it is only available in long-acting formulations.
Numerous studies have consistently demonstrated a short-term improvement in the behavioral, academic, and social functioning of children treated with these types of drugs.
Mindfulness to improve the symptoms of children and adolescents with ADHD
Regarding long-term effects, several meta-analyses confirm its positive effect on behavior and social functioning compared to placebo.
Stimulants appear to have a greater effect on ADHD-related symptoms when combined with multimodal treatment.
Most side effects will be mild or temporary. The most common side effects associated with this type of medication are loss of appetite, weight loss, and insomnia. In most cases, side effects lessen or disappear with a dose reduction or a change to a different stimulant. For loss of appetite or weight loss, certain alternatives can be considered, such as:
- Administer the medication after breakfast.
- Switch to a non-stimulant drug.
- Consume foods rich in protein and carbohydrates at breakfast, before taking your medication, or within 10-15 minutes after taking it. Also, have protein-rich or high-calorie snacks, eat dinner, and even consider a late-night snack.
These medications will only work on the day the child or adolescent takes them. They won't remain in the body for long, so their effects will wear off quickly once treatment is stopped. In the case of long-acting medications, it's important not to administer them too late in the day, as they can cause insomnia that night.
Non-stimulant drugs:
There are other psychotropic medications that are also used to treat ADHD, since not all children and adolescents respond significantly to stimulant medication and others experience side effects that warrant a change.
These alternative drugs consist of:
- Atomoxetine:
This drug works as a selective norepinephrine reuptake inhibitor (SNRI), which means it increases the amount of norepinephrine in the brain, helping to improve concentration and impulse control.
Atomoxetine is a stimulant-free alternative that can be used in people with a history of drug abuse or who have family members with a history of drug abuse. It is a medication that has been shown to be effective in reducing ADHD symptoms, making it a good alternative to stimulant drugs. However, continuous treatment is recommended; interruptions during school breaks are not advised.
The most common side effects usually include weight loss, decreased appetite, vomiting, nausea, stomach upset, and difficulty sleeping.
- Guanfacine and clonidine:
Both drugs belong to the antihypertensive family, specifically alpha-2-adrenergic agonists, but they have also been shown to have an effect on attention deficit in individuals with ADHD. They can also be used as an alternative to stimulant medications in cases where these are not feasible.
Because they also act as antihypertensives, one of their side effects will be a decrease in blood pressure. Other common and also temporary side effects include tiredness or fatigue, headache, abdominal pain, or dry mouth.
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