ADHD is a neurodevelopmental disorder which affects five to eight per cent of school-aged children, and approximately four per cent of adults. ADHD is often treated with medication. While there are decades of research behind the use of stimulant medications for ADHD, they still remain controversial.
A series of investigative articles in the Toronto Star this week bring forward concerns about serious side effects of ADHD medications, and sheds a dark light on Health Canada's system to monitor the safety of these medications.
This series of articles has become a lightening rod for concerns about ADHD and its treatment. This week, countless parents have called their doctor's offices, asking if it is safe for their child to continue on ADHD medication, or whether their child is at risk of side effects like: psychosis, suicide, or stroke. I suspect that many parents are just stopping their child's ADHD medication because of their fears.
While the Toronto Star's investigative reports bring to light serious concerns, in my opinion, they have sensationalized the risks of taking ADHD medication, and provide no balance into the hundreds of thousands of kids, teens and adults who have been helped by these medications.
To look at this situation in a balanced way, let's start with the logical first question: "Do people with ADHD need to take medication?"
To begin, we need to realize that ADHD is a real medication condition. The neurobiological research behind it is solid and growing year by year. The brain research, genetic research, and treatment research clearly show that this is a medical condition.
Research also shows that there are significant impairments and risks if ADHD is not treated. Long-term risks for untreated ADHD include: higher rates of depression, anxiety, substance dependence (i.e. drug and alcohol problems), academic underachievement, underemployment, more accidents and injuries, and more. These risks have been show to be lowered with effective ADHD treatment.
The best treatment for ADHD has been shown to be a "multi-modal" treatment. This refers to medication for ADHD, as well as non-medication approaches. The medication helps one to control hyperactivity, impulsivity and to focus better, and the therapies help one to learn skills to function better in day-to-day life.
While the general belief in the public is that doctors prescribe medicine for kids who just need a chance to get more physically active, the reality is that there is often severe impairment from untreated ADHD symptoms. Doctors who treat ADHD regularly see kids who are about to be expelled despite high IQ, kids with terrible self-esteem who develop suicidal thoughts, teens who self-medicate with drugs and alcohol, all related to their ADHD.
Contrary to popular belief, the vast majority of parents I see in my office are very hesitant to use ADHD medication, and ultimately make an informed choice after reviewing treatment options. They don't want to "drug" their children, they want to help them. And the reality is that the majority of the time, effective ADHD treatment literally changes children's lives dramatically for the better.
When thinking about using ADHD medications, it's important to consider the risk:benefit ratio. For most people with ADHD, the benefits of taking ADHD medication far outweigh the risks of taking these medications. There is approximately an 85 per cent chance of ADHD medications helping significantly, and about a 10-15 per cent chance of side effects.
Now for the critical question: "Are ADHD Medications Safe?"
To keep this in perspective, we have to remember that all medications have side effects. Whether it's an over-the-counter pain killer, an allergy medicine, or Ritalin for ADHD.
When I think about side effects for medications, I always like to think about common side effects, and rare but serious side effects. The common side effects for stimulant medications for ADHD often include: insomnia, decreased appetite, and headaches, among others.There are of course rare but serious side effects to ADHD medication. These are well researched and known, and in fact, there are often Health Canada warnings about these. They include:
Is everyone at risk of suicidal thoughts, heart complications or hallucinations if they take ADHD medication?
Theoretically, anyone could be at risk for any of these side effects, but there are known risk factors for them. If you work with your doctor, monitor the treatment effectively and let your doctor know about any concerns you have with the medication, your doctor will be able to help to minimize the risks of developing these side effects.
I always tell my patients: "I can't guarantee no side effects, but I can guarantee that if you have a side effect, I'll help you out."
What about risks of suicide?
I regularly have discussions with kids/teens and their parents about the fact that suicidal thoughts can be a side effect of one of the medications (Strattera). I discuss the side effect, and we discuss a "safety plan." If the child or teen isn't able to agree to a safety plan, then I don't prescribe that medication.
What about risks of cardiac issues?
Cardiac side effects to ADHD medication have been shown to be related to structural heart abnormalities, a history of arrhythmia (irregular heart beat), a family history of same, or other heart problems. With careful history taking, physical examination, and a visit with a cardiologist (if needed), these side effects are virtually not a concern. Several studies have shown that the rate of cardiovascular events in kids and teens on stimulant medication is at or below the rate of cardiac events in the general population i.e. the medication does not increase the risk.
What About Health Canada Safety Monitoring of ADHD Medication?
Health Canada tracks safety concerns with medications, and if you wonder if they actually do anything about this, I'll point you to the fact that Health Canada actually removed the medication Adderall XR from the Canadian market in 2005 because of safety concerns. Six months later, the medication was reinstated after a more thorough review of the data behind these concerns showed that it was safe to be used.
Doctors, nurses, pharmacists, and any member of the public can report a suspected medication concern to Health Canada (reference this link for more information). This reporting is voluntary, and not mandatory. The Toronto Star investigative articles express concern that these reports are not analyzed and not reported back to the front lines. It is in this context that I said the remark which was quoted in the Star: "It boils down to a simple thing: we need good safety monitoring for medication... That will help us be safer in prescribing medicines to people."
When these cases are reported to Health Canada, it does not mean that one can be certain that the medication caused the side effect reported. There are often complicating factors, and one can only suspect whether a medication was involved. For example, it is well established that over 75 per cent of kids with ADHD have at least one other diagnosis.
Specialists in ADHD often spend significant time and effort exploring for other co-existing disorders, such as anxiety disorders, depression, and behaviour disorders. If one has ADHD and Major Depression, and develops suicidal ideas, is that caused by the ADHD medication, or could it be cause by the depression itself? This can be even more challenging if the depression wasn't diagnosed in the first place...
Could our medication monitoring system be improved?
I believe that there certainly is room for improvement, and hopefully, that could help patient safety. It is my hope that the Toronto Star articles help to find ways to improve the monitoring system for medication.
What's The Bottom Line For You?
If you or a loved one are dealing with ADHD, medication can be a very helpful part of your treatment plan. With a spotlight shining on the risk of side effects with ADHD medication right now, here are five things to remember:
- ADHD medication is well researched to help ADHD, and the medicines have been used for decades. Side effects and drug interactions are known and researched.
- While there are common side effects, there are also rare but serious side effects. These are known, and there are also known risk factors which can be reviewed to help minimize your risks.
- Don't abruptly stop your child or teen's ADHD medication. Do call the doctor, or ask questions at your next appointment if you have any questions or concerns.
- Remember that we have to balance the risk: benefit ratio, and that the reason to take ADHD medication is the fact that there is significant impairment from ADHD without the medicine.
- Finally, remember to include multiple modalities in your ADHD treatment, including: medication, therapy, lifestyle (exercise, sleep), and even alternative treatments.
(Note: Although this entire article references ADHD (Attention Deficit Hyperactivity Disorder), all of the information applies to ADD (Attention Deficit Disorder) as well. The ADHD medications which are available in Canada are: Ritalin, Dexedrine, Concerta, Biphentin, Adderall XR, Vyvanse, Strattera).
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