Treating Attention Deficit Hyperactivity Disorder

As per NICE NG87, our team closely monitors children and young people who are on treatment in our follow up clinics and we use a safe approach to ensure that medication is effective to enable best possible outcomes.

There are five types of medication licensed for the treatment of ADHD:

• methylphenidate
• dexamfetamine
• lisdexamfetamine
• atomoxetine
• guanfacine

N.B. New drugs are regularly in development and therefore ADHD treatment is not limited to the named drugs above. In the UK, all of these medications are licensed for use in children/young people and teenagers. Atomoxetine is also licensed for use in adults who had symptoms of ADHD as children/young people.

These medications are not a permanent cure for ADHD, but they can help someone with the condition concentrate better, be less impulsive, feel calmer, and learn and practice new skills.

Some medications need to be taken every day, but some can be taken just on school days. Treatment breaks are occasionally recommended, to assess whether the medication is still needed.

If your child/young person is prescribed one of these medications, you will probably be given small doses at first, which may then be gradually increased. Your child/young person will need to see the ADHD team for regular check-ups, to ensure the treatment is working effectively and to check for signs of any side effects or problems. Your specialist will discuss how long you should take your treatment but, in many cases, treatment is continued for as long as it is helping.

At clinic appointments your child/young person's height, weight, blood pressure and heart rate will be checked, questions will be asked and care is planned together to ensure the treatment is effective and there are no noted side effects. We will also liaise with your child/young person's school and other servcies if required. 

A clinic appointment will usually last up to approximately 20 minutes and will take place between six weeks and six months, dependent on stability of treatment.

Attendance of the child/young person at the clinic is compulsary in order to continue with treatment. 

As a parent you may have been told about medication. Parents need to know what the possible benefits and side effects are to using treatment. 

Research studies have demonstrated clearly that stimulant medication can produce short-term benefits for many children/young people with ADHD. Many parents have commented on the dramatic improvements which can occur. As children/young people calm down they are able to mix better with others, and they can respond more effectively to teachers and parents.

It may seem strange to prescribe a drug described as a ‘stimulant’ to a child/young person who is overactive. You may wonder why your child/young person is not being offered a sedative or calming drug.

The answer is that these drugs work by stimulating those parts of the brain which control behaviour and regulate activity.

The drugs therefore seem to help many children/young people to concentrate and regain control over their actions.

Children/young people may become less aggressive as well as less hyperactive, and their performance at school may improve significantly.

Are there any problems associated with medication (drug treatment)?

One of the main concerns about using stimulant medication is that these drugs may be used too readily to deal with behaviour problems which are not due to ADHD at all. It is therefore important to understand what the drugs can achieve and what their limitations are. They should only be prescribed to children/young people who are carefully assessed and who have received a professional diagnosis. Medication does not cure ADHD - but it can provide a ‘window of opportunity’ in which we can help children/young people learn to manage their own behaviour.

Methylphenidate for ADHD (sometimes known as methylphenidate hydrochloride)

Immediate Release Brands: Medikinet®, Ritalin®
Modified-release brands: Equasym XL®, Medikinet XL®, Xenidate XL®, Xaggitin XL®, Concerta XL®.

Why is it important for my child/young person to take this medicine?

This medicine will help to reduce the symptoms of hyperactivity and impulsive behaviour. It will also help to increase attention and concentration span. Methylphenidate is used as part of a comprehensive treatment programme for ADHD.

What is methylphenidate available as?

• Tablets: 5 mg, 10 mg, 20 mg; these contain small amounts of lactose. Ritalin® contains gelatine.
• Modified-release tablets: (Xenidate XL®/Xaggitin XL®/Concerta XL®): 18 mg, 27mg 36mg, 54 mg; these may contain lactose, except Xenidate XL®.
• Modified-release capsules: (Medikinet XL® and Equasym XL®): 5mg (Medikinet XL®), 10mg, 20 mg, 30 mg, 40 mg; these contain gelatine and a small amount of sugar.

When should I give methylphenidate?

Modified-release tablets/capsules (Xenidate XL®/Xaggitin XL®/Concerta®, Equasym XL®, Medikinet XL®) are usually given once each day. This is usually in the morning. These gradually release the medicine over the day.

• Equasym XL® is best given after breakfast – The effect can last for approximately 8 hours
• Medikinet XL® is best given before breakfast – The effect can last for approximately 8 hours
• Xenidate XL®/Xaggitin XL®/Concerta XL® can be taken with or without breakfast – The effect can las for approximately 12 hours

Medikinet® and Ritalin® tablets are usually given two or three times each day. This should be in the morning, then around midday and, where necessary, late afternoon. Ideally, these times are about 4 hours apart.

Give the medicine at about the same time(s) each day so that this becomes part of your child/young person’s daily routine, which will help you to remember.

How much should I give?

Your doctor will work out the amount of methylphenidate (the dose) that is right for your child/young person. The dose will be shown on the medicine label. You will probably give your child/young person a low dose to start with, and then increase it gradually. Your doctor will explain what to do. It is important that you follow your doctor’s instructions about how much to give.

How should I give it?

Tablets should be swallowed with a glass of water, milk or juice. Your child/young person should not chew the tablet.

Medikinet® and Ritalin® tablets can be crushed and mixed with a small amount of soft food such as yogurt, honey or jam. Make sure your child/young person swallows it all straight away, without chewing.

You must not crush any of the XL (modified-release) tablets, as they will not work properly.

Capsules should be swallowed with a glass of water, milk or juice. Your child/young person should not chew the capsule. You can open the capsule and mix the contents with a small amount of soft food such as yogurt, honey or jam. Make sure your child/young person swallows it all straight away, without chewing.

When should the medicine start working?

The medicine will start to work within 30–60 minutes, depending on which type of tablet or capsule your child/young person has.

What if my child/young person is sick (vomits)?

• If your child/young person is sick less than 30 minutes after having a dose of methylphenidate, give them the same dose again.
• If your child/young person is sick more than 30 minutes after having a dose of methylphenidate, you do not need to give them another dose. Wait until the next normal dose.

If your child/young person is sick again, seek advice from your GP, pharmacist or hospital. They will decide what to do based on your child/young person’s condition and the specific medicine involved.

What if I forget to give it?

Do not give the missed dose. Give the next dose as usual. Never give a double dose of methylphenidate.

What if I give too much?

It may be dangerous to give too much methylphenidate.

Are there any possible side-effects?

Side-effects you must do something about

Your child/young person may become irritable, aggressive, tearful or depressed. These effects are temporary and completely reversible on stopping treatment. You should contact your specialist or doctor as soon as possible. If you are worried, do not give any more doses of methylphenidate until you have talked to your doctor.

If your child/young person can feel their heart beating much faster than normal (they may say it is racing), contact your doctor straight away.

• Your child/young person may have less of an appetite so they may not want to eat much. It may help to give each dose of methylphenidate with or after a meal.
• Your child/young person may lose some weight during the first few months of treatment although they will probably put the weight back on. If you notice your child/young person is losing a lot of weight contact your doctor.
• Your child/young person may feel dizzy or light-headed when they stand up, or may faint. Encourage them to stand up slowly, and to sit or lie down if they feel dizzy or light-headed. If this happens often, contact your doctor who may need to check your child/young person’s blood pressure.
• If your child/young person is prone to tics (sudden muscle twitches of the face or body), methylphenidate may make these worse.

Other side-effects you need to know about

• Your child/young person may get indigestion, stomach ache, feel sick (nausea) or be sick (vomit). Giving the medicine with some food or milk may help.
• Some children/young people may get a dry mouth. Eating citrus fruits (e.g. oranges) and taking sips of water may help. This effect usually settles down quite quickly
• Your child/young person may have a blocked nose more often whilst taking methylphenidate. Usually this does not need treatment and will get better on its own.
• Your child/young person may have problems sleeping. This can be helped by taking the last dose at least 6 hours before bedtime.
• They may get a mild headache or pain in their muscles or joints.

If you are concerned about any of these sideeffects contact your doctor

Can other medicines be given at the same time as methylphenidate?

You can give your child/young person medicines that contain paracetamol or ibuprofen, unless your doctor has told you not to.

Check with your doctor or pharmacist before giving any other medicines to your child/young person. This includes herbal or complementary medicines.

Is there anything else I need to know about this medicine?

• Methylphenidate may affect the growth of some children/young people. Your doctor will monitor your child/young person’s growth.
• Your doctor will check your child/young person’s blood pressure regularly.

Additional information for patients:

• Methylphenidate products may rarely cause priapism – long-lasting and sometimes painful erections in males of any age. If not treated right away, priapism can lead to permanent damage to the penis.
• Seek immediate medical care if priapism or any erection lasting longer than four hours occurs with or without sexual stimulation.
• Do not stop taking your methylphenidate product without first discussing it with your doctor.

It is important that your child/young person always has the same brand of methylphenidate if they have been prescribed a modified-release tablet or capsule (Equasym XL®, Medikinet XL®, and Xenidate XL®/Xaggitin XL®/Concerta XL®) as there may be differences between brands. Keep a record of which medicines your child/young person has.

General advice about medicines

• Try to give medicines at about the same times each day, to help you remember.
• Only give this medicine to your child/young person. Never give it to anyone else, even if their condition appears to be the same, as this could do harm.
• If you are not sure a medicine is working, contact your doctor but continue to give the medicine as usual in the meantime. Do not give extra doses as you may do harm.
• It is important that you oversee your child/young person taking their medication.
• You are responsible for your child/young person’s health and ensuring that medication is taken. We recommend that daily reminders or alarms are used to help remember when to take medication.
• Follow the instructions and read the information labelled provided with the medication.

Where I should keep this medicine? 

• Keep the medicine in a cupboard, away from heat and direct sunlight.
• Make sure that children/young people cannot see or reach the medicine.
• Keep the medicine in the container it came in.

Who do I contact for more information?

Your child/young person’s doctor, pharmacist or specialist will be able to give you more information about methylphenidate and about other medicines used to treat ADHD.

Dexamfetamine can be used by children/young people over the age of 3-18 years. Although it is not licensed for use in adults, it may be taken under close supervision from your GP and ADHD specialist.

Dexamfetamine is usually taken as a tablet once or twice a day, although an oral solution is also available.

Common side effects of dexamfetamine include:

• decreased appetite
• mood swings
• agitation and aggression
• dizziness
• headaches
• diarrhoea
• nausea and vomiting

It can be used by children/young people with ADHD over the age of six if treatment with methylphenidate hasn't helped. You may continue to take it into adulthood if your doctor thinks you are benefitting from treatment.

What is Lisdexamfetamine available as?

Capsules: 10mg, 20mg, 30mg, 40mg, 50mg, 70mg.

How should I give it?

• Can be taken with and without food
• Can be swallowed whole
• Can be opened with the entire contents dissolved into water and drunk immediately

Lisdexamfetamine comes in capsule form, which you or your child/young person usually takes once a day in the morning. Its effects can last up to 13 hours.

Common side effects of lisdexamfetamine include:

• decreased appetite, which can lead to weight loss or poor weight gain
• aggression
• drowsiness
• dizziness
• headaches
• diarrhoea
• nausea and vomiting

Atomoxetine works differently to other ADHD medications.

It is known as a selective noradrenaline uptake inhibitor (SNRI), which means it increases the amount of a chemical in the brain called noradrenaline. This chemical passes messages between brain cells, and increasing the amount can aid concentration and help control impulses.

Atomoxetine can be used by children/young people over the age of six. It is also licensed for use in adults who are continuing treatment after taking the medication as a teenager. It is not licensed for use in adults newly diagnosed with ADHD, but your GP and specialist may prescribe it under their supervision.

Atomoxetine comes in capsule form, which your child/young person usually takes once or twice a day.

What is Atomoxetine available as?

Capsules: 10mg, 18mg, 25mg, 40mg, 60mg, 80mg.

How should I give it?

Atomoxetine should be swallowed whole.

Common side effects of Atomoxetine include:

• a small increase in blood pressure and heart rate
• nausea and vomiting
• stomach aches
• trouble sleeping
• dizziness
• headaches
• irritability
• sexual dysfunction (erectile and ejaculation dysfunction)

Atomoxetine has also been linked to some more serious side effects that are important to look out for, including suicidal thoughts and liver damage.

If either you or your child/young person begins to feel depressed or suicidal while taking this medication, speak to your doctor.

Intuniv® is a non-stimulant medicine used to treat symptoms of ADHD in children/young person and adolescents aged 6 to 17 years. Intuniv® can help improve your child/young person’s attention and concentration and make them less impulsive and hyperactive. Intuniv® is a long-acting medication which has been developed to provide ADHD symptom control throughout the day – from when your child/young person gets up
in the morning, to when they go to bed in the evening.

What is it available as?

Tablets: 1mg, 2mg, 3mg, 4mg.

How should it be taken?

Your child/young person should swallow the tablet(s) whole with a drink of water or other liquid (but not grapefruit juice). Your child/young person can take the tablet(s) with or without food, but must not take it with fatty foods (e.g. a full English breakfast).

Do not let your child/young person break, crush or chew the tablet as this will affect how the tablet works. Tell your child/young person’s Doctor if your child/young person cannot swallow the table whole.

What are some of the side effects?

• Sleepiness
• Headache
• Tiredness
• Tummy pain

Do not let your child/young person stop treatment.

• Be sure your GP or specialist helps you understand the difference between ADHD and other problems your child/young person may have.
• Think about who else needs to know about your child/young person’s ADHD, such as their school or nursery.
• Find out the side effects of any medication your child/young person takes and please read the information leaflet provided with the medication for what you need to look out for.
• Only take the prescribed drug and dosage, any changes in treatment needs to be discussed with your Clinician first.
• Most of the treatments are controlled drugs, and therefore need to be stored safely and appropriately.
• Prescriptions last 28 days. If Community Paediatrics issue your prescription, then you need to request more than one week for a new prescription to be issued.
• We have a Shared Care Agreement for most treatments with your GP. So as long as you and your child/young person attend appointments, and your GP is happy with the outcome/plan from the consultation, they will provide repeat prescriptions for your child/young person.
• If the child/young person experiences any side effects, then please contact Community Paediatrics.
• Getting to know people at local support groups can stop you feeling isolated and unable to cope.
• If you feel that you or other members of your family have difficulty then please seek an assessment of your personal, social and mental health needs, and join self help and support groups if appropriate.
• For information on local support groups contact Attention Deficit Disorder Information and Support Service (ADDISS) or call 020 8952 2800.

NHS ADHD page

Tell the child/young person to put the tablet or capsule on the back of the tongue, take a sip of their favourite drink, then tilt back their head and swallow

The following information has been adapted from Iannelli V. Pill swallowing tips for kids with ADHD:

• Give the child/young person a spoonful of yoghurt, apple sauce or mousse along with the tablet or capsule so they can swallow it all together
• Get the child/young person to put the tablet or capsule in their mouth and then drink a glass of water through a straw – many children/young people will concentrate on the straw and not think about the tablet or capsule, so it goes down easily
• Get the child/young person to take a couple of swallows of milk (making the tongue and throat more slippery) before taking the tablet or capsule.
• Put the tablet or capsule onto the child/young person’s tongue then get them to fill their mouth with water (so that their cheeks puff out) and then ask them to swish it all around and swallow.
• Get the child/young person to chew a piece of bread or a biscuit and put the tablet or capsule in their mouth just before they would swallow the bolus
• Get the child/young person to practice swallowing smaller things first, before switching to a tablet