ADHD: When to medicate?

Medication may be seen as a simple solution to the challenges of ADHD. But parents who’ve been there know there’s nothing easy about filling that prescription.

Boy bored in class
Photo: iStockphoto

No gluten, white sugar, food colouring or additives; more protein, naturopathic treatments and behaviour therapy.

Partners Shannon and Carol Fitzsimmons* instituted this laundry list of changes when they suspected their preschooler, Jonah*, had ADHD (he was officially diagnosed at age six). The Toronto moms were determined to keep his condition under control naturally.

“Our worst nightmare was that he’d have to go on medication,” Shannon says. Their biggest concerns were the side effects that can result from taking stimulants (the most common class of ADHD medications) including weight loss, stunted growth, reduced appetite, insomnia and a dulled personality.

By reducing his sugar intake and ensuring his diet was rich in protein (to stabilize his blood sugar and avoid crashes that lead to moodiness), Shannon and Carol noticed that Jonah’s hyperactivity and impulsiveness decreased. They worked on behaviour modification techniques – breathing strategies and helping Jonah replace negative thoughts with positive ones – that they learned from an ADHD support group at the Centre for Addiction and Mental Health (CAMH) in Toronto.

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Despite the progress made, midway through grade one, Jonah’s moms were being summoned to school weekly to discuss his behaviour and lack of focus. He was climbing on tables in class and pushing kids on the playground. The realization dawned on them that Jonah had no hope of success in his current state.

“We were at the end of our rope and felt we had tried everything else,” Shannon says. “Medicating was the hardest decision we’ve ever had to make.”

Heidi Bernhardt, president of the Centre for ADHD Awareness Canada in Markham, Ont., and a mother with three grown sons who suffer from ADHD, says struggles at school are often the tipping point for parents considering medication. As a child’s success in the classroom decreases, negative feedback increases, and stress peaks and self-esteem plummets. While the decision to medicate should not be taken lightly, Bernhardt stresses that parents also need to consider the potential effects of not medicating. “For a kid who has mild ADHD, behavioural training might work like a charm. For other kids who just can’t focus, you’re almost crippling them by not considering medication,” she says. “You have to look at your child. How is he struggling? To what extent is he suffering?”

Doron Almagor, a psychiatrist who heads the ADHD Clinic in Toronto, says that in most cases, medication should only be considered as part of a comprehensive treatment plan, when behavioural therapy and educational interventions aren’t effective on their own. It often takes time, though, to figure out the right medications and dosages.

Jonah started on Ritalin, a stimulant. At first, his improvement at school was dramatic – his focus improved and his outbursts decreased. But at night, he experienced a “coming down” effect as the medication wore off, which is common. Jonah got aggressive with his parents; ultimately they had to lock him in a safe room where he could ride out his tantrums without hurting anyone. “I sobbed the day I put the lock on the door,” says Shannon. “What parent wants to lock her child in a room and sit outside the door listening to him scream at you?”

They went back to the drawing board several times, experimenting with different dosages of Ritalin, which they hesitated to abandon since it had such a positive impact on Jonah’s days. “We thought, as long as he does well in school, we can handle the bad nights,” Shannon says. But when the nights became unbearable, they tried Strattera, a non-stimulant. It dampened Jonah’s outbursts, but also his ability to focus at school. At home, he struggled with anxiety; he chewed on his shirts and couldn’t sit still at meals.

Read more: Help! My kid isn’t paying attention in school >

Shannon and Carol integrated other strategies, such as weighted blankets that Jonah could put over him in bed or place on his lap to calm him so he could stay seated at the table. They created a gym in the basement – with a trampoline, swing and a mini trapeze – to help Jonah pour out his energy. None of that, though, was enough to help him find an equilibrium. They tried a combination of Ritalin and Strattera, hoping to find a solution that didn’t force them to choose between happiness at school versus home. There were still negative side effects and the question of whether they were doing the right thing was never far from their minds.

Then, Concerta was recommended. The long-active stimulant has been life changing for the family. “Jonah has more focus overall,” Shannon explains. “He’s still very active, so we continue to use the tools we did before, but it’s so much better – we’re not constantly holding our breath anymore. But there’s going to be a time when he outgrows the drugs. We know we’ll have to go through all of this again at some point.”

A version of this article appeared in our September 2013 issue with the headline, “The Toughest Decision,” p. 112.

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