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May 30, 2013

ADHD: Which Medication is Best?

Written by Dr. Robert Lowenstein, M.D.

The American Academy of Pediatrics (AAP)

The AAP provides guidelines to pediatric specialists indicating that behavioral treatment should be tried first before prescribing medication and, when prescribing, methylphenidate (Ritalin/Concerta) should be used first. However, the Cohen Children’s Medical Center in New York surveyed 3000 physicians and found that the majority of physicians use medication as a front-line option and that many do not start with methylphenidate.


It may be surprising to you that the AAP recommends that, after behavioral treatment, it’s best to begin with Ritalin/Concerta. Does any medication, among parents, have a worse reputation than Ritalin? However, the fact is that it’s been researched thoroughly since the 1930's, began being used by 1938, and has consistently been found to be very safe. Concerta is simply a longer-acting Ritalin. Adderall and Concerta are the two of the most commonly prescribed ADHD medications.

Research suggests that both methylphenidate (Ritalin/Concerta) and d-amphetaimine (Adderall) are essentially equally potentially effective but have differences in how they work and their potential side effects. There have also been concerns about d-amphetamine (Adderall) contributing to sudden death in children with a heart defect and, in fact, for quite some time an EKG was recommended before prescribing Adderall. However, subsequent research has largely alleviated this concern.

In terms of what I prescribe first, rather than adhere to a fixed, rigid, and inflexible protocol, after completing a thorough evaluation and assessing the child’s unique history, symptoms, and needs, I prescribe what is in the best interest of the child.

Why not use behavioral first?

It’s my standard protocol to first ensure that behavioral interventions, including counseling and parent-training, are utilized first before prescribing medication. Some physicians may alter this approach due to lack of behavioral therapists in more rural areas, and their belief that the medication alone will be helpful. However, more often than not, a behavioral therapist is available and while medication is effective for 80% of children with ADHD, the behavioral interventions are vital and should be the foundation of the treatment process.

A quick review

Why don’t we take a moment to quickly review the more effective behavioral strategies for ADHD. For starters:

· Keep the environment organized
· Maintain a consistent routine
· Use picture schedules and visual cues
· Give direction clearly, succinctly, in short steps, and ask your child to repeat the direction
· Remove distractions
· Break-down chores, tasks, and homework into doable chunks
· Remain calm and reassuring
· Use brief punishments such as time-out, and explain the rules ahead of time
· Use sticker charts to promote your child’s motivation

I hope this helps to clarify questions about treatment options for ADHD. Feel free to contact me at with any questions, or to schedule an evaluation.

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