Answering Questions About ADHD Medications

John Horton:

Hey there, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Medications for ADHD are widely used and very effective, but they also raise a lot of questions. What do these drugs actually do? Why are there so many options? And how do doctors decide which one may be the best fit?

To get answers, we're joined today by Dr. Carrie Cuffman, a specialist in pediatric developmental behavior. She's one of the many experts at Cleveland Clinic who join us weekly to break down important health topics in a way that's easy to understand. So with that, let's take a look at some of the most common ADHD medications and how they may fit into an overall care plan.

Welcome back to the podcast, Dr. Cuffman. Thanks for joining us again.

Dr. Carrie Cuffman:

Of course. My pleasure.

John Horton:

All right. So you're with us today to talk about ADHD medications, which millions and millions of people take to improve focus and reduce hyperactivity. But despite these meds being so common, it seems like there's still a lot of questions that surround them. So given that, let's kind of jump in here and talk about them and what they do and all of that. So can you give us a simple overview of how ADHD medications work and what they do in the brain?

Dr. Carrie Cuffman:

Yeah, of course. So there are a few different types of medications we use for ADHD, but the most common ones are the stimulant medications.

So the stimulant medications basically work by increasing the amount of certain chemicals that are called norepinephrine and dopamine, the amount of those chemicals that are in your brain, and specifically in the prefrontal cortex of your brain, which is where you're making your decisions and what controls your attention and focus and that sort of thing.

So basically, by increasing these chemicals, what we think happens is that you're better able to pay attention, better able to focus and control your body when there's more of these chemicals around.

John Horton:

OK. So that would be a case when, like you said, you're having trouble focusing, your mind's wandering off, you're zoning out, symptoms that you often see with ADHD. The stimulant side of the medication would address that?

Dr. Carrie Cuffman:

Yes, exactly. Yeah. So the stimulant works on those, what we call the core symptoms of ADHD. So inattention, lack of focus, being easily distractible, but also those hyperactive and impulsive symptoms as well — being on the go, a lot of movement or fidgetiness — it can help with all of those symptoms.

John Horton:

Well then, if we have a stimulant medication, I'm guessing that there is also a non-stimulant side.

Dr. Carrie Cuffman:

There are.

John Horton:

So what do those do?

Dr. Carrie Cuffman:

Yeah, so there are a couple different types of those, too, but they work basically in a similar way. So the two classes of non-stimulant medications are the SNRIs, so it's like norepinephrine reuptake inhibitors. So they increase the norepinephrine in your brain by stopping it from being recycled back into the cells, basically. And then, there's also alpha agonists, which are another non-stimulant medication, and they also increase the amount of norepinephrine that is floating around in your brain.

John Horton:

So it seems like these medications are just, they're trying to find the right balance of these chemicals in your brain so that way you can lock in and just function the way most people typically do.

Dr. Carrie Cuffman:

Yeah, that's exactly what they're doing. They're just getting you up to an attention level that lets you focus and do what you need to do. Exactly.

John Horton:

Sounds like they're either bringing you up or bringing you down so that you're in that sweet spot in the middle.

Dr. Carrie Cuffman:

Yes, exactly.

John Horton:

All right. So there are numerous ADHD medications that are on the market, but we're going to focus on a few of them that I guess people hear about a lot and often have questions on. And the two big ones I know are Ritalin® and Adderall®. I think we've all kind of heard of them. What's the difference between those two medications?

Dr. Carrie Cuffman:

Yeah, good question. So Ritalin and Adderall are one each of the two main classes of stimulants. So Ritalin is what's called a methylphenidate, and Adderall is what's called an amphetamine. So these two main classes of stimulants. Basically, all the stimulants are either related to one or the other, but Ritalin and Adderall are the very basic ones in those classes. They're kind of the no-frills medications. They're short-acting medications, so they last. Ritalin is like a three to four hour, Adderall is like a four to six hour maybe. But they're the basic medications, probably the initial medications that were created in each of these classes of stimulants that we have.

John Horton:

So it sounds like those two medications kind of attack ADHD from two different sides?

Dr. Carrie Cuffman:

So I mean, yes and no. There's a lot of similarities in the way they work. They do the same things in the brain that we mentioned before, but different people do respond differently to them. So one may work for one kid, while another works better for a different kid. So they do similar things, but the way the specific medication, how it interacts with an individual's brain can be very different.

John Horton:

When you compare Ritalin and Adderall, are there differences that patients tend to notice in real life? Things like how quickly the medications kick in, how the person feels, how long they last and any side effects?

Dr. Carrie Cuffman:

Yeah, good question. So across the board, it's very individualized how kids react to these. There are a few things we tend to see that are common across many different patients. So Ritalin, for example, maybe tends to kick in a little bit quicker and maybe more on the order of 20 to 30 minutes. Whereas Adderall maybe takes a little bit longer to start working on the upper side of 30 minutes. And then Ritalin, as I mentioned, doesn't work quite as long as Adderall does. So Ritalin maybe works three or four hours; Adderall works maybe four to six hours depending on the patient.

But then, the side effect part of it is really just variable by person. So any individual can have any of the side effects, which I'm going to mention, but often, they may have more of them to Adderall and less of them to Ritalin, for example, or vice versa. So the side effects, the “side effect profile,” we call it, so the possible side effects are the same, but an individual can experience very different side effects between the two of them.

So really, common side effects with the stimulants, almost everybody has a decreased appetite during the time the medication is working, and that is the same between Ritalin and Adderall. Sometimes, these medications can mess with your sleep, especially falling asleep, especially some of the longer-acting versions we'll talk about later. They can also cause some mood changes, irritability in some kids, and they can also cause some just differences in personality.

I think all parents come in worried about the zombie effect, these medications, that blunted affect. And if that's happening, these side effects, a lot of them, we can work to choose a different medication to help with the side effects so they're not so troublesome. So if those things are happening to a big degree, they're causing a lot of problems; it's probably not the right medication for the kid, or we just need to tweak some things.

John Horton:

So are there situations where Ritalin is prescribed instead of Adderall or vice versa, or is it a case where you start with one, see how it works, and then adjust from there?

Dr. Carrie Cuffman:

Yeah. So in most patients, people start with one, see how it works, and adjust from there. The caveats for me for this is if a family member of my patient has been on a medication that's worked really well, I typically start there because there is kind of a genetic role in our metabolism-

John Horton:

…it makes sense.

Dr. Carrie Cuffman:

...and response to this. So if a parent's done well on Adderall, I start the kid on Adderall. But by and large, every provider has a place they like to start, maybe a medication that they feel like they've had good luck with having people do well on, and that's where we start. And then, we try different things based on how the child does on them.

John Horton:

It sounds like, they pretty much do, like you said, the same thing. So it's just a matter of everyone's head's working a little bit different. So you're trying to find that right key, and even though they look really close, there's maybe only one that's going to turn the lock.

Dr. Carrie Cuffman:

Exactly. Yep, yeah.

John Horton:

All right. Now, you had mentioned that there are also longer-acting medications, which I'm guessing would be really good if you're a kid in school or things like that, and you need a few more hours out of it. And those are, these names, is it Concerta® and Vyvanse®?

Dr. Carrie Cuffman:

Vyvanse, yeah.

John Horton:

Vyvanse? All right. Like I said, I'm so glad you get to say the names more often than me because I keep stumbling over them. But when you compare those two, Concerta and Vyvanse, how do they work? Is it a similar thing where they're close to each other, or do they have big differences?

Dr. Carrie Cuffman:

Yeah, good question. So Concerta is the methylphenidate, so it's a long-acting Ritalin basically, and Vyvanse is an amphetamine, so the longer-acting version of Adderall.

Concerta and Vyvanse are each special in their own ways in how they work. Biochemically in the brain, still that same thing. We're still increasing the levels of dopamine and norepinephrine, but each of them have some little quirks that do make them a little bit different than some of the other medications, and sometimes a little bit smoother. So both of them are very long-acting, which is nice. So Concerta is probably, we're getting 11 or 12 hours maybe.

John Horton:

Oh, wow. It's a whole day.

Dr. Carrie Cuffman:

Yeah, a whole day. Exactly. Vyvanse is somewhere between 10 to 13, maybe even 14 hours in some kids. So we are getting through that school day, getting through homework, which is really, really nice.

The two of them, compared to their shorter-acting relatives, they're just smoother. So with the short-acting ones, the Ritalin and the Adderall we talked about, you take it and often, there's this switch flipping where all of a sudden you're paying attention, you're on.

John Horton:

A big surge, it sounds like that kicks in.

Dr. Carrie Cuffman:

Yeah, right. Exactly. And that could be not all kids like that feeling. It can be a little bit of a weird feeling. And the same thing when it wears off, the short-acting ones. So it can, again, be like a switch flips. And so sometimes we see some emotional dysregulation, kids getting upset when the medication wears off for those shorter-acting ones. That happens much less often with Concerta and Vyvanse because they're just smoother. They wear off more gently, so you don't have that big switch flipping when they're coming off. So those are some really, really nice things about the longer-acting medications in comparison to shorter-acting ones.

John Horton:

It sounds like with Ritalin and Adderall, you're getting peaks and valleys a little bit more in the course of the day.

Dr. Carrie Cuffman:

Yeah, exactly.

John Horton:

Would you take multiple doses of Ritalin and Adderall during the day? I mean, people are on it or is it just one?

Dr. Carrie Cuffman:

Right. So yes, if you're using the shorter-acting ones and you want to get through the whole day, we typically would dose it two or even three times a day. I, being a developmental pediatrician, some of my patients are younger who I'm prescribing these for, so sometimes maybe we only care about it working during a preschool day, which is only half the day. So in some of those kids, I do only dose it once a day, and that is a good fit for them because they have fewer side effects because it's not working as long, but it's also not working as long. So we see the downsides of that when we're at home, maybe after preschool.

So stimulants are medications that really, we work to individualize them as much as we can for the patient based on how long we need it to work and how they do want it in terms of side effects and how effective it is. But typically, yes, with the shorter-acting ones, you would be doing multiple doses a day. And I would say most providers are generally switching to the longer-acting ones for these older kids pretty much across the board.

John Horton:

Which makes sense because when you're a little older, your school day goes a little bit longer, like you said, you have homework later on, you need that effect to stay on for longer. And it sounds like that kind of plateau, where you just stay at that level, is really where you want to be.

Dr. Carrie Cuffman:

Exactly, yeah.

John Horton:

So are we talking about the same sort of side effects with taking the longer-acting ones?

Dr. Carrie Cuffman:

Yes. The side effects are very, very similar. I mentioned some things could be better with the longer-acting ones, like those emotional side effects. I don't see quite as much — we call it a rebound — when the medication is wearing off. I don't see as much of that with the longer-acting ones, although it still can happen.

Some of the things that are bigger problems when we have the longer-acting ones is the appetite suppression. So mostly, because our appetite is suppressed for more of the day, it's harder for kids to gain weight. And so in kids, it's obviously really important to gain weight, so we continue to grow. And so that can sometimes be a difficulty that we have, especially with the very long-acting ones like Concerta and Vyvanse, that the whole day we're really not wanting to eat very much. And so it can really be a process for kids and parents to figure out what they need to eat, how much they need to eat when we're suppressing their natural appetite. So that can be a little bit more of a difficulty.

And then, the other thing that can be more difficult with these longer-acting medications is sleep because they're lasting longer into the evening and they can bleed over into falling asleep and it can make that really difficult for some kids. So sometimes, we're looking to tweak what time we're taking it in the morning, can we move it earlier? Do we need to switch back to one of those mid-acting forms to help with that falling asleep difficulty that can be a problem with the longer-acting medications?

John Horton:

Do you see more anxiety and jitters, those sort of symptoms, with the longer-acting ones, too?

Dr. Carrie Cuffman:

Not necessarily. There's kind of a debate about, do these medications actually increase anxiety or not? And there's no great consensus, I would say. Clinically, I definitely have kids who this seems to maybe amp them up a little bit, kind of just if you drink too many espressos in the morning, same thing.

John Horton:

Been there, a few too many cups of coffee.

Dr. Carrie Cuffman:

Right, exactly. So you can get a little bit jittery, but I don't see huge differences between long and short-acting with that. I would say in my patients, the bigger concern there is just, is the dose too high? And you can get too high of a dose in either form of the medication. So that is the main reason why I see that jitteriness coming out as maybe where just the dose isn't quite right or the medication isn't just quite the right one for that kid.

John Horton:

So it sounds like with any of these medications, what you're looking at is maybe dialing in the dosage, and those are adjustments that can be made, or like you said, just switching from one to the other to see if it just fits a little better.

Dr. Carrie Cuffman:

Exactly. Right. And we're talking about a few options, but there are a lot of options. There's some medications that are still stimulants with just slightly different chemical structures that maybe work a little bit better. So there are a lot of stimulant options and a lot of different ones that you can try to see if we can find one that works the best with the least amount of side effects.

John Horton:

I'm glad you brought that up because, obviously, we're focusing on four of them here, which are some of the most common ones. But like you said, there are a lot more medications out there. And if they are prescribed and they're not working quite right, your doctor might move from Concerta to Vyvanse to something else, and maybe that's the right one.

Dr. Carrie Cuffman:

Exactly, yeah. So you do have to be patient and allow your doctor to work on some trial and error with these medications. But if you stick with it, you're much more likely to be able to find that best one.

John Horton:

So we've tackled what those medications do, how they work, how, really, it's a matter of figuring out what's right for each individual. Now, I want to hit a couple broader questions, which I know you said you get asked a lot when people come in. And I know one of the big ones is, once somebody starts taking an ADHD med, is this a forevermore sort of thing?

Dr. Carrie Cuffman:

Right. Yeah, so I do get asked this question like literally all the time. So the answer is, it depends on the kid. I see solely pediatrics, so all my patients are children. Some kids outgrow their ADHD. Their brain matures. As they go into adulthood, they really have pretty minimal ADHD symptoms.

John Horton:

So it just kind of catches up.

Dr. Carrie Cuffman:

Exactly, yeah.

John Horton:

And all of a sudden, the chemicals all start to balance out.

Dr. Carrie Cuffman:

Right, exactly. Yeah, your brain just matures and you don't have those symptoms that are impairing to you anymore. So for those kids and those eventual adults, they probably don't need a medication. And that doesn't usually happen until I would say true adulthood, like in our 20s sort of thing. I don't see that happening in our teens because our brain is still growing and maturing, we know well into our 20s, maybe into our 30s. So that would be the timeline for that. So that's a group of kids, maybe say, about a third.

Another group of kids will continue to have symptoms, but maybe they're not so difficult to manage as an adult. We have a lot more agency over our lives as adults. We don't have to sit in a classroom. Our jobs, we can move around, we can do things we're really interested in. It's easier for everybody to focus on things they're interested in.

So maybe we don't really need our medication anymore. We have some coping tools combined with just the fact that we're an adult and we choose to do things we like. We don't have to learn everything in school that we are interested in. So those people maybe still have the ADHD symptoms to some extent, but really don't need the medications to get through their daily life.

And then, the last group of folks really does continue to need medications, continues to have significant symptoms into adulthood that maybe are impacting their ability to work or do family life effectively, remember to pay their bills, all that sort of thing. And so those folks really do continue to benefit from ADHD medication. But when I have a kid in front of me, I don't know which group you're going to fall into. So it's kind of a wait-and-see about whether we continue to need these medications forever.

John Horton:

And do you find out which camp you're in by just trial and error? I mean, maybe you go off them for a little bit and see how you respond?

Dr. Carrie Cuffman:

Yeah, I think from the parents I see who did, that's usually what happened, is they were like, "Well, I just stopped taking my ADHD medication. I felt like I was getting along OK and everything seemed to be going well." So often, that is kind of what happens. Or maybe they didn't like a side effect, so they just stopped it and realized, "Oh, I think I'm doing OK now." So yeah, usually that's what happens is end up not taking them sometimes and realize that things are really going OK.

John Horton:

Now, I know you said another question that you get asked a lot, especially from parents, is if a child takes an ADHD medication, does that somehow increase their risk of substance abuse later in life?

Dr. Carrie Cuffman:

Yes, and I do get this question a lot, too. So there is no evidence that taking an ADHD medication increases your risk of substance abuse.

So stimulants are controlled substances. They can be misused, diverted, abused. But if we are appropriately treating ADHD, that does not increase your risk of substance abuse. And some studies have actually shown that it decreases your risk of substance abuse because you're not trying to treat your ADHD with other things, and your ADHD is appropriately treated, so you're not making bad, impulsive decisions. So probably no increased risk of substance abuse, maybe a decrease to that risk of substance abuse when we're appropriately treating ADHD with these medications.

John Horton:

Yeah, that kind of makes sense. It's basically, you're taking a medication to deal with your problem, and it's very targeted, as opposed to maybe experimenting on your own and just trying something out to see if it helps.

Dr. Carrie Cuffman:

Absolutely. Yes, that's exactly right.

John Horton:

All right. And then, the last big question that you said you get is this one, and it's, do ADHD medications actually change your brain? Obviously, it's messing with the chemistry that's going on in there, but is it doing anything that's lasting?

Dr. Carrie Cuffman:

So yeah, that's a good question. So generally, no. In the moment, we're just changing those chemicals, like you said, and helping our symptoms that way. I dove into the literature about this actually and found a couple of studies that did say maybe they actually help the brain. So they made some of the brains of adults look more like people who didn't have ADHD. So if anything, that's the case, but that hasn't been huge studies and not really replicated a lot. But basically, we really don't think they're causing long-term changes in the brain that are super significant.

John Horton:

Those small studies you mentioned, though, it does make sense. You almost wonder if the medication sort of teaches your brain-

Dr. Carrie Cuffman:

…yeah, like trains your brain.

John Horton:

...where the chemical level should be, yeah.

Dr. Carrie Cuffman:

Yeah, maybe, or maybe lets you develop some of the skills that beef up those places in your brain, like you're practicing them. So more to come, I think, on that, but if anything, they're helping, not hurting.

John Horton:

Well, Dr. Cuffman, we've covered a lot of ground here today. And I guess, to wrap things up, since eventually, we have to say goodbye, what advice would you give to someone who has been diagnosed with ADHD and is wondering where medications might fit in their management plan?

Dr. Carrie Cuffman:

So that's a great question. So I would say really give the ADHD stimulant medications a chance. They are some of my favorite medications to prescribe because they really work well and they can really change a kid's and family's life when they're working well. Along those lines, though, you have to find the right ones. So being patient and giving lots of good feedback to your prescriber is really, really helpful and really helps us to get your child on the right medication.

John Horton:

It really sounds like it's a matter of accepting this notion that you just have a step in a process off in your head, and taking one of these medications can kind of complete that and let everything function the way it's really supposed to.

Dr. Carrie Cuffman:

Yeah, that's exactly right. Yeah, these medications really, really work well, to do exactly what you said, for kids with ADHD.

John Horton:

And then, it sounds like, it's just a matter of working with your healthcare provider and just, like you said, figuring out which one works, what dosage works, and finding the right combo to just get you to where you need to be so you can be the best you can be.

Dr. Carrie Cuffman:

Exactly. And that's what all of us want for our patients with ADHD, is just helping them to be the best they can be and make as much progress as they can in school and at home and, in general, life.

John Horton:

Well, Dr. Cuffman, all of these answers are the reason why we keep asking you to come back on the podcast. You always share so much, and we really appreciate how you present it and just help us understand how these can fit into, I guess, an ADHD management plan, and just make everything work a little better.

Dr. Carrie Cuffman:

Absolutely. My pleasure to be here.

John Horton:

All right. Well, we'll have you back. Thanks again.

Dr. Carrie Cuffman:

Thanks. Bye.

John Horton:

ADHD medications can be incredibly helpful, but they're not one size fits all. As we discussed today, the right option really depends on you, your symptoms and how a medication fits into your overall care plan. If you or your child is navigating ADHD, talk with a trusted healthcare provider about what treatment approach makes the most sense for you.

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