John C. Raiss, MD.
Assistant Clinical Professor of Child and Adolescent Psychiatry, UCLA David Geffen School of Medicine, Los Angeles, CA.
Dr. Raiss has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
After a thorough assessment, you diagnose your 16-year-old patient Alex with ADHD and recommend a trial of stimulant medication. Alex wants to try the medication, but his mother feels he just needs tips and skills to improve his focus and doesn’t need to “take pills for the rest of his life.”
ADHD is one of the most treatable conditions in psychiatry if patients adhere to medication regimens. Stimulants are widely used in treatment and are usually safe when taken as prescribed; however, parents are often skeptical and concerned about psychotropic medications. In this article we’ll talk about parental resistance to stimulant medications and how to best work with parents when discussing treatment.
Risks of ineffective therapies or avoiding treatment Medication nonadherence or avoidance increases the morbidity of psychiatric ADHD conditions as patients are less likely to have their condition respond or remit. Common risks of untreated ADHD include (Biederman J et al, Psychiatric Services 2019;70(10):874–880):
Underachievement at school and work
Injuries, including traumatic brain injury
Results from questionnaires show that many parents believe that psychotropic medication can make children more likely to develop later drug addiction (Lazaratou H et al, Ann Gen Psychiatry 2007;6:32). The American Academy of Pediatrics recommends behavioral approaches (CBT) as the first treatment for ADHD for pre-school children, but not school -aged children , in line with the Multimodal Treatment Study of Children with Attention Deficit/Hyperactivity Disorder (MTA) which demonstrated that stimulant medications are more effective than behavioral treatments for core symptoms of ADHD in school-aged kids. Other reasons often cited by parents range from concern about weight related issues to stigma.
Parents may believe that supplements are natural and less harmful than stimulants, but with the possible exception of saffron, most supplements have little evidence of efficacy in ADHD. Long-chain polyunsaturated fatty acids and minerals have “at best marginal beneficial effects,” and zinc, iron, and magnesium lack convincing evidence (Lange KW et al, Curr Psychiatry Rep 2017;19(2):8). Micronutrients showed no effect either (Johnstone JM et al, JAACAP 2021; in press). Saffron is an exception and may be on par with methylphenidate (Baziar S et al, J Child Adolesc Psychopharmacol 2019;29(3):205–212, reviewed in CCPR November 2019).
At follow-up two weeks later, Alex reports that he is still unable to focus for even short periods of time. He is drinking products with excessive amounts of caffeine and pulling all-nighters to finish his work. You decide that you need to understand his mother’s concerns about stimulants more fully. She confides that she’s heard stories of kids misusing their medication. She also doesn’t want Alex to be labelled as “an ADHD kid.”
Talking with parents
Find out what each parent thinks about medication and what their hesitations or worries might be. A good way to initiate this conversation is to simply state, “Please help me understand your specific concerns.” Some parents are truly set against using medication, but most can engage in productive conversation. Once you know what their concerns are, you can take various approaches to encourage parents to partner with you in treating their child or teen. Some helpful tips for talking to medication-hesitant parents include:
Put medications in context. “Medications are part of an overall plan that includes exercise, structure, nutrition, and sleep.”
Share specifics. “Every medication has its good and bad points. Let’s go over them one by one in detail. And remember, we will learn very quickly whether the medication is helpful or not—most likely within a few weeks.”
Destigmatize treatment. “It might be unfair to your child if we don’t treat their symptoms. That might make their life unnecessarily difficult. Lots of kids have ADHD and are relieved to get treatment.”
Address family and cultural aspects. “Do you have family members with similar issues? How do people in your family and culture understand and manage ADHD symptoms?”
Discuss the benefits. “Most kids can focus better when they take these medications. They learn better and get their work done more easily, more like their friends and classmates. Kids often feel a lot better about their abilities, and they have more time for recreation and to enjoy life.”
Talk about the risks of not treating ADHD. “Kids who don’t get treatment struggle harder to get their work done. It takes them longer than their friends. They are often criticized for errors, failing to follow instructions, or not turning in assignments.”
Stress that treatment can have other benefits. “Treating ADHD can reduce the risk of accidents, substance use, depression, criminal activity, and teenage pregnancy” (Faraone SV et al, Neurosci Biobehav Rev 2021;128:789–818).
Acknowledge legitimate risks and their management. Be sure to directly address appetite, growth or weight loss issues, height, sleep, blood pressure, and pulse. “Stimulants can reduce appetite, so we will track growth. If your child is not eating enough, we can brainstorm some ideas together. We often use medication holidays during weekends and vacations, as well as other strategies to support growth and minimize the amount of medication you give to your child.”
Discuss sleep challenges. “If issues arise with sleep, we can adjust the timing of the medication to minimize these effects.”
Talk about drug interactions. “ADHD medications can be taken with most other prescriptions, including antidepressants and birth control pills. But we will need to talk about other meds your child is currently taking, including cold medications such as pseudoephedrine. And be sure to keep me updated about future prescribed or over-the-counter meds, as well as supplements.”
Discuss sexual side effects, even if parents and teens do not directly ask about them. “You may have heard that medications have sexual side effects. Stimulants can cause painful erections. This is rare, but you should seek rapid medical attention if that happens.”
Talk about addiction/diversion. “It is important for you to dispense the medication to your child and to keep careful control of it to prevent misuse, but stimulants actually can protect kids against substance misuse.”
Address possible barriers to prescriptions. “Many of these medications are covered by insurance, but some may need a prior authorization.” “These medications are more carefully controlled than most to avoid misuse—you may need to show identification when you pick it up.”
After talking about her concerns, Alex’s mother agrees to a careful one-month trial of stimulants. Alex has a rapid response to 10 mg of extended-release mixed amphetamine salts, and his focus improves. He has mild irritability in the afternoons, which improves with scheduled afternoon snacks. Over the course of the semester, Alex’s grades and confidence improve.
CCPR Verdict: The first three rules for helping parents understand the risks and benefits of ADHD medication are listen, listen, and listen. Address their concerns point by point and be sure they understand that medication can be life changing.