Douglas Heck, Ph.D.; Duluth Psychological Clinic
Ann Hempel, PhD, ABPP; Pediatric Neuropsychologist, Minnesota Epilepsy Group
Armantina Espinosa, MD, Minneapolis Clinic of Neurology
In 2018 the International League Against Epilepsy published a review of the diagnosis and treatment of ADHD in those with epilepsy (https://pubmed.ncbi.nlm.nih.gov/30178479/).
ADHD is a condition in which an individual experiences persistent patterns of inattention and impulsivity/hyperactivity that interfere with daily functioning. An estimated 30-40% of those living with epilepsy experience ADHD in comparison with 12.5-15% of those in a population registry study. The prevalence of ADHD may be even higher in some forms of epilepsy, such as among children with absence epilepsy (30-60%). Treatment with ADHD medications typically do not adversely affect seizure control.
Even when ADHD is carefully diagnosed, parents are often concerned about trying a stimulant medication for their child with ADHD. In our work with parents and their children, a number of concerns are often raised, such as concern that stimulant medications might negatively interact with seizure medications, that their children are already “treated with so much medication,” and that the medication might be sedating. Some parents are concerned that stimulant medications for ADHD might increase the likelihood of an eventual substance use disorder (SUD). The data are clear, however, that although having ADHD itself increases one’s risk of an SUD, stimulant medication treatment for ADHD does not. In some studies treatment has been shown to reduce risk of an SUD (https://pubmed.ncbi.nlm.nih.gov/18307377).
The published data on parent focus groups and surveys indicate that there are a number of deterrents to parents’ willingness to have their child treated with a stimulant medication. These include the stigma surrounding ADHD and its treatment, disapproval from friends and family members regarding parents’ use of this treatment for their children, concern about their child being labeled if they need to take a dose of medication at school, and the belief that one needs to exhaust all other possible treatments before trying a medication. Some parents are concerned that their children will be “zombified” by the medication or experience a change in personality. It is important to note that each dose of a stimulant medication is effective in and of itself and does not require continuous use over days or weeks to control ADHD symptoms. Some children may experience more subdued facial expressions while each dose of medication is in effect, but once each dose wears off, they are back to their usual selves.
How Do Stimulant Medications Work?
It is often helpful for parents to understand how the medication works in the brain. In short, it increases certain neurotransmitters (which are the brain chemicals that allow brain cells to communicate) in certain brain regions where the neurotransmitter might not be prevalent enough or might be taken back up into nerve cells too soon in those with ADHD. A good explanation of how stimulant medications work for ADHD can be found in presentations by Russell Barkley, PhD, an internationally respected researcher in the field of ADHD (https://www.youtube.com/watch?v=j4kxqLw7WXc).
The reduced prevalence of neurotransmitters in those with ADHD can lead certain brain regions, particularly the frontal lobes and their subcortical connections, to be underactive. By optimizing brain function in these regions with stimulant treatment, children and adults with ADHD can be better able to sustain motivation and effort on academic and other routine tasks, control impulsive expressions of emotion, and use better self-restraint in their interactions with peers. For some children and adults there can be short-term side effects, such as appetite suppression while each dose is in effect and, for the first week or so of treatment, headache and stomachache, which often subside with continued use. Although parents are often concerned about negative side effects, there can also be positive effects of treatment, such as improvement in structural brain development in those with ADHD, suggesting that medications might promote brain development in those with ADHD that might not otherwise occur (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3801446/).
The medications for ADHD are not sedating if used in the proper dose. Rather, they enhance alertness (and hence their use for individuals with narcolepsy). For some individuals with epilepsy, a stimulant medication can help to offset reduced alertness associated with their anti-seizure medication regimen.
Making the Decision About Trying a Stimulant Medication
It is important to know that use of a stimulant medication for ADHD is reserved for those who have been carefully evaluated by a psychologist, neuropsychologist or physician. When a child or adult has mild but ordinary distractibility or impulsiveness, but otherwise functions quite well in all aspects of life, the individual is not considered an appropriate candidate for treatment, nor are those whose attention problems are caused by other factors. If an individual has not already received a thorough assessment for ADHD, your neurologist can refer you to a psychologist, neuropsychologist, psychiatrist or other mental health provider who is able to conduct a competent evaluation.
For many parents, making a decision about whether or not to try a stimulant medication for their child’s ADHD can seem monumental. It is often reassuring to know that deciding to try a medication does not mean making a long-term commitment to its use. The short-acting nature of ADHD medications allows parents, as well as adults with ADHD, to try the medication only briefly. If one experiences unacceptable side effects with a single dose, or finds that the medication is not of benefit, one can easily discontinue its use. It might also help to know that the medication can be used on an as-needed basis. For example, if treatment is needed only for school, it need not be taken on weekends when demands for attention and concentration are low.
It is important to note that managing ADHD medications is done in close collaboration with the treating physician, usually the primary care doctor. Working closely with the physician can optimize the medication’s effectiveness by making as-needed adjustments in timing and dosing of the medication. This can often be facilitated by open communication between parents and teachers about the medication’s effect on the child’s classroom behavior. Finding the best medication and dose can involve some trial and error; you should let your provider know if you or the teacher do not see benefits of the medication or if there are difficult to tolerate side effects.
Other Effective Treatments for ADHD
In addition to stimulant medication, a behavioral approach to managing ADHD symptoms is the best research-supported treatment. Behavioral approaches can include such things as use of incentives to enhance motivation in school, allowing breaks for movement to manage feelings of restlessness, and providing tools to enhance organization. Behavioral approaches are often used in conjunction with medication, as research has suggested that, for many with ADHD, a combination of medication and behavioral approaches works optimally. It can sometimes be a challenge to locate a qualified provider to help those with ADHD manage the symptoms through these behavioral methods. Ask your primary care provider, neurologist, or neuropsychologist for assistance in finding a mental health provider or ADHD coach who can meet your or your child’s needs.
Ineffective Treatments for ADHD
There are no known treatments that cure ADHD. For many, ADHD is a lifelong condition, usually of genetic origin, that requires ongoing management with behavioral strategies and often with medication. While nutritional deficiencies can interfere with optimal functioning in any individual, as yet there is no evidence that ADHD can be effectively treated with mineral or herbal supplements, nor is there evidence that EEG biofeedback, elimination of sugar, or brain training programs can effectively treat ADHD. There are lucrative industries, often promoted on social media, aimed at encouraging parents to believe that ADHD can be treated effectively with these non-medication forms of treatment. You are advised to seek out only information that has scientific merit, which can be found at www.chadd.org, or publications by authoritative researchers in the field of ADHD, such as Taking Charge of ADHD: The Complete Authoritative Guide for Parents- 4th Edition, Taking Charge of Adult ADHD- 2nd Edition, and Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment- 4th Edition, all of which authored by Russell Barkley, PhD.
Should you wish to discuss this information further, please know that you can contact EFMN and they will provide you with additional resources. Your primary care physician is also an excellent starting point as you begin to consider the treatment of ADHD.