Interview: Jason Law On ADHD Medication
Updated: Jun 24, 2020
There are a lot of misconceptions around ADHD medications.
Some parents worry that medication will turn their children into a zombie, or that their children will become addicted to their medication.
On the other hand, some parents think that there’s no way around medication, that it’s the only effective treatment for ADHD.
In truth, ADHD medications are safe and generally effective, but they’re also not the only way to treat ADHD.
To clear up the confusion, we’ve interviewed Jason Law of the Hallowell Todaro ADHD Center. Jason manages patient medications and also serves as the medical director for the center. Here he explains how ADHD medications work, why they’re so important, and how parents can make an informed decision about whether to start their children on medication.
What is your role at Hallowell Todaro?
I am the medical director. That means I supervise all of the medical staff – there are three total in Seattle, me and two other nurse practitioners. That’s a small fraction of the company – we have maybe 40 or 50 staff members, almost all are parenting coaches or therapists. And I also help with hiring and training medical staff in Palo Alto.
I’m also a nurse practitioner. As for interacting with patients, my role predominantly consists of prescribing and managing medications.
I’ve been specializing in ADHD for nine years now, ever since I became a nurse practitioner. Before that I was a nurse, and I worked in the inpatient psychiatric unit at Seattle Children’s Hospital. I joined Hallowell Todaro in 2014, right when they opened the Seattle clinic. So I’ve been in this field my entire career.
What medications are you usually prescribing these kids?
Mostly stimulants since we focus on ADHD. Of course there’s a lot of co-morbidities like anxiety and depression. We sometimes treat those things, we’ll sometimes manage medications for anxiety or depression, but we don’t consider ourselves experts in those fields.
Whether we treat other conditions or not depends on what we judge to be the primary condition. If it’s simple anxiety or depression we might treat it, but if it’s more severe or we get a feeling that it’s the primary issue, we’ll usually refer the patient to someone else, like a generalized psychiatrist or even their general pediatrician.
Note: He goes into more detail about this in his answer to the next question.
As for specific drugs, people are mostly familiar with Ritalin and Adderal, and those were the only options before the year 2000. Now there are other medications but they’re all essentially derivatives of Ritalin and Adderal.
The main problem with all of these is that they last around four hours, which isn’t really long enough. In practice it’s hard to re-dose as often, and as consistently, as you need to when a drug is that short-acting. The big advancement, more so than new drugs, really has been extended-release versions of the same drugs so you don’t need to take them every four hours, which doesn’t work very well in practice.
I pretty much always prescribe extended-release over short-acting because it’s so much easier to use. What I will sometimes do though is prescribe both for patients who find the extended-release pill wears off a bit too quickly, because taking two ER pills would be too much.
The classic example would be a student who goes to school, then has sports practice after school and homework after that, and finds the effects of the extended-release stimulant wearing off after the end of the school day. So I’d have them take an extended-release pill in the morning, and a normal-release pill after school. But most people are fine with just the ER pill.
How accurate do you think the diagnostic process for ADHD is?
I think the diagnosing process, in a lot of areas, has gotten a lot better over the years. There are questionnaires; you can ask people a series of questions and if they answer yes to a certain number of them, you can diagnose them with something. I don’t think that’s the best way to diagnose, but it works, and there’s no real gold standard method for diagnosing.
More to the point, practitioners have just gotten better at diagnosing, and way more thorough about doing it, over the years. So generally people are getting better evaluations when they’re being diagnosed now than they did a generation ago.
What I see more often is not necessarily that people are being misdiagnosed, but they have multiple issues and it’s not clear what is the primary issue.
So a common example would be someone coming in with ADHD, also anxiety or depression, some learning issues, and they’re really struggling but it’s not clear what their biggest issue is. So sometimes I’ll treat the ADHD, and then see that the other issues also improve, and that tells me that ADHD was their primary issue, that it was worsening or even causing the other issues.
Other times we’ll treat the ADHD, and maybe that’s effective at reducing impulsivity and hyperactivity, and helping them focus, but we see they’re still having a lot of struggles in those other areas. So then we say, maybe ADHD isn’t their biggest issue at this time and they need to address those other issues. And we might refer them to someone else at that point, if ADHD isn’t their main issue.
Why is it that stimulants have a calming effect on children with ADHD?
ADHD patients have too little norepinephrine and dopamine in the pre-frontal cortex, which is what controls attention and makes it harder to stay focused. But then when they get really interested in something they’ll have too much and get hyper-focused.
So stimulants raise the baseline levels of norepinephrine and dopamine in the pre-frontal cortex and make them more even, more consistent, throughout the day. And that creates more of a calm feeling because you don’t have the same amount of ups and downs anymore.
Stimulants are really good at treating ADHD; they’re not good at treating anything else, at least directly. If ADHD is the primary issue, they can indirectly help sometimes.
Other stimulants like caffeine can help to some degree. In fact, caffeine is used as a placebo in most studies on ADHD medications. It’s just that caffeine is more systemic in its effects, inconsistent in dosing when you’re getting it from beverages, and shorter-acting, so it wears off too fast. It has been shown to be somewhat beneficial, just not consistently.
ADHD medications are more targeted, reliable, and longer-lasting, at least if you use the extended-release version.
How long does it usually take for the medications to be effective?
Stimulants are very quick-acting, patients see results within an hour of the first dose.
However, actual behavioral change can take a little longer. But I would generally say within a week or two, we should have a clear idea of how well it’s working and what the benefits are.
With new patients I’ll try three different dosages with them, for one week at a time each, starting with the lowest dose and working up, then in week four have them stick with whichever dosage was most effective.
For students, I’ll always have them start on a Saturday, so if there are unexpected side effects those will hit them over the weekend and they can stop taking the medicine before Monday.
What misconceptions do parents usually have about medication?
A lot of parents say, “I don’t want to turn my kid into a zombie,” or “I don’t want to change my kid.” Now that certainly can happen if the wrong medication is used or the dosage is too high, but that would last for one day before we realize it’s not working and fix it. It’s not what should happen when medication is working right.
The other misplaced concern relates to addiction. They think ADHD medications will get kids addicted and more prone to addiction in general, and then they’ll move on to cigarettes or alcohol or cocaine.
In fact, studies say it’s just the opposite – people who are properly medicated for ADHD are 3-4 times less likely to have drug problems because they have better impulse control and don’t feel the need to self-medicate.
Now, you can get addicted if you take way more than prescribed for a prolonged period of time. Of course any good doctor or nurse practitioner will watch for this and refuse to feed that addiction. But at the medically prescribed dosages, these drugs are not physically addictive.
In general do you think parents are too quick or too slow to take the medication route?
I’ve seen it go both ways. I do see a lot of parents who exhaust every other option, like therapy and dietary changes, before they try medication. I don’t know if I’d say they’re too slow to consider medication; they’ve done their due diligence.
Most don’t regret trying everything else before putting their child on drugs, but a few do say, “Man, this works so well I wish I’d done it earlier.” But it’s not bad to explore lifestyle changes before you turn to medication.
I don’t have a whole lot of parents who are like, “Yeah, we want medication right away.” I do see a few people who are maybe a little too quick to ask about medication, but usually when parents go straight for medication it’s because they’ve done their research or they themselves are on medication and it works for them.
But I don’t think I see a consistent pattern overall, of people being either too quick or too slow to consider medication.
How long do people have to stay on medication?
It’s really dependent on the person, and it depends on when they started, what other issues and diagnoses they have.
There’s also conflicting evidence on when our brains are fully developed. The most recent evidence I’ve seen is that now it looks like maybe it’s not until we’re 28 or 29.
I think it’s usually best to put children on medication as soon as ADHD is identified, so that they can build good habits and do better in school early on, so they’re not playing catch-up later.
If someone needs medication, then the earlier they start and the more consistently they take their medication, in my experience, the more likely they’ll be able to wean off the medications later.
I have seen many kids who start medications at a young age be able to successfully wean off of their medications in their mid-20s, after they've graduated from school and gotten into a good routine in their working careers. It is also not uncommon to see kids who start medications early be able to wean off in their teenage years, while others may continue taking them into their adulthood depending on how demanding their profession is.
When I have patients who have been doing very well with their medications for a while and have been very consistent in taking it, I will sometimes have them take a break from medication for a few days to a week so that they can reestablish their baseline and measure that the medication is continuing to provide benefit. I would not recommend doing this without speaking with your prescriber however.
When should parents consider asking a doctor about maybe getting their child a prescription?
I would have that discussion and at least educate themselves more as soon as their child is diagnosed, whether that means going on medication or not. Some parents put off getting their child evaluated out of a fear of medication.
The misconception is, if I talk to a doctor about medication they’re going to put my kid on medication. But of course they’re not going to do that if you don’t want them to. I think parents are doing themselves a disservice if they don’t at least have a discussion to educate themselves on medication, what that would look like, what the pros and cons are.
One last point is, we’re also still learning a lot about ADHD. It’s been around for a long, long time, but most of what we know about it we’ve found out only recently. So I would encourage parents to get their children evaluated, talk to experts, and get the latest up to date information. Learn what a diagnosis looks like, what would happen afterwards; it’s not always medication. And talking to an expert is how you keep up to date on the current state of ADHD research.
Jason Law received a Master of Science in nursing degree from Seattle University and a Bachelor of Science in nursing degree from Seton Hall University (NJ). He is board certificated as both a family nurse practitioner and a psychiatric nurse. He has worked in the field of psychiatry since 2007 and has devoted his practice to specializing in the diagnosis and treatment of ADHD since 2011.