ADD & ADHD Medications ( Stimulants )

Stimulants

The first group is called the stimulants. They are the most commonly used medications for ADHD. Sometimes one drug in this group will work for a person but the others will not. They all have the same side effects, but some people will tolerate one drug in the group far better than another. It is currently impossible to know which drug will work or be well tolerated in a certain child. About 90% of children with ADHD or ADD will respond to one of the three stimulants. Most of these will be able to tolerate at least one of the stimulants. There is more data to support the effectiveness of stimulants as a treatment in ADHD than in any other medical treatment in medicine! So how do you decide which drug to start with?

Special Populations

Preschool
In some circumstances, drugs are used in this group. Usually it is because the child's behavior is so disruptive that he or she can not attend a structured pre school program. It is important to get children with severe ADHD into pre school as it can be very helpful in building their social skills. Other times a child's behavior is so difficult, especially when combined with ODD, that people in the family are getting seriously hurt. Other times the child's behavior is causing a severe impact on parents, relationships or siblings. Overall, these medications are safe in this age group. However there do tend to be more side effects. In a recent studies of preschoolers with ADHD and other common comorbid conditions, 45% had side effects. There was not so much of a problem with sleep and appetite, but rather mood changes, irritability, and withdrawal. (20) Overall, when used very carefully, these drugs can be very helpful in many, but not all, preschoolers with severe ADHD (7)

Teenagers
These drugs are very effective in this group. The biggest problem is with medications requiring multiple dosages a day. Usually a drug like Ritalin would have to be given three times a day. This is very hard to remember, even if you do not have ADHD. As a result, the first line choice are drugs which can be given once or at most twice a day. Obviously, if drug abuse is a problem, stimulants are not used.

Questions about abusing stimulants
The stimulant medications are closely related to certain drugs of abuse. For example, if you crush Ritalin (methylphenidate) and smoke it, you can get high. Large doses of dexedrine by mouth can be addictive. Some people try to combine these drugs with other street drugs to get high. As a result, these stimulant medications do have some street value.

Will my child get addicted to Ritalin or Dexedrine?
No. the only situation that can lead to addiction is when a confirmed drug abuser is allowed unlimited access to these drugs.

If my child uses Ritalin or Dexedrine now, will he be more likely to use street drugs and alcohol later?
No, in fact there is some evidence to suggest the reverse. That is, teenagers with ADHD who are treated with stimulants are less likely to end up abusing drugs than teenagers with ADHD who do not take stimulants. That is, it seems like stimulants might actually protect children from drug abuse. (24)

My son has ADHD but also abuses drugs if he can get a hold of them. Are stimulants safe?
Maybe, the usual approach is to make sure people are clean with urine drug screens and then make sure that they do not have access to the supply of medication.

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How do you give these drugs?

I start with a dose that is quite low and watch the child for a few days.

One of three things will happen:

Absolutely nothing. Then we increase the dosage.
Amazingly better and minimal side effects. We thank God and leave things alone.
A little improvement and no side effects. Then we increase the dosage.
Lots of side effects. Then we stop the drug and consider something else.
Some side effects and some benefit. Then we try to figure out whether the benefit is worth the side effects.

After each dose increase I check things out and we see what happens. I am after a dosage that will control the symptoms at not cause a lot of side effects.

Once a drug is working, there is no guarantee that the dosage is going to stay the same. In fact, over 70% of children have to have their dosages adjusted over the span of a year. Of those dose adjustments, 60% were increases in dosage, 30% were decreases in dosage and a few (7%) were changes to different medication.(30)

Side Effects of Stimulants and their management
Remember, all the stimulants have the same side effects. Some people will have no side effects on one stimulant, and many on another. You can not predict who will have what side effect on which stimulant.

Sleep
Many children with ADHD have insomnia. Sometimes the stimulants actually improve sleep. Sometimes they don't. A child may be able to go to sleep, but awaken a few hours later ready to go. More commonly, the child just can't fall asleep. This is very serious business for a number of reasons. First, the child will become sleep deprived leading to irritability, poor concentration, and fatigue. Second, since most parents do not go to sleep before their children do, the parents are sleep deprived with the same problems as the child. This is a very bad combination!

Management
If it is mild, sometimes attending to sleep hygiene or good sleep habits will do the trick. Things like an earlier bed time, certain foods, no TV or computer, quite activities in the evening and no naps sometimes will do the trick. More often they do not. What to do depends on how well the child is doing on the drug at that particular dose. If the child isn't that much better anyway, I discontinue the stimulant and try another stimulant or another drug for ADHD. If the child is markedly better, often I will add one of two drugs, Clonidine or Trazadone. Both of these drugs have been safely used in young children. They are not addictive. They are not related to sleeping pills. They do not, when used properly, make a child dull the next day. The key thing is to do something. Sleep deprivation will undo every intervention you have made.

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Medical Treatments for stimulant induced insomnia in ADHD

Clonidine (Catapress, Dixarit)
This drug was originally developed for treating blood pressure in children and it is very safe. It turns out to be useful for a lot of things. Indications for Clonidine are; tics, severe ADHD, severe aggression, sleep disturbances in ADHD, detoxifying Heroin addicts, menopausal flushing, and sometimes autism. The good thing about this is that it never aggravates tics, works well when autism is present, and works in very aggressive kids who never sleep. It is safe for pre-schoolers and comes in a pill called dixarit which is sweet tasting and looks exactly like smarties. As a result, kids will easily take it. It also comes in a larger size. It is a good choice when tics are present, in autism, preschoolers, and very aggressive kids with ADHD and severe insomnia.

And the bad side of Clonidine?
About one out of every 10 to 20 people who take this will get depressed. It comes on within about 3-4 days and after the drug is stopped, it can take 3-4 days to clear. However, if you are not watching for this, you might think the child is depressed for another reason, and never stop the drug, thus leaving the child depressed. With careful monitoring, that never happens. You have to check a person's blood pressure when you are starting this. It will make some children sedated, but usually by cutting back the dose you can avoid this.

Trazadone (desyrel)
This drug was developed in the 1980s to treat depression. It works for that, but the reason it is used in children has nothing to do with depression. It turns out to be a very safe drug for helping children sleep. It has virtually no side effects. It is not addictive at all. The problem? In less than one in 1000 men, this drug can lead to prolonged erections (priapism) which can be so severe that it requires surgery. It has never been reported in male children, however, I have read some unofficial reports of one or two cases in the USA. It has been used for years in Autism in children. If a child has a history of depression and has stimulant induced insomnia, I would use this, even if they were a male.

Appetite
The stimulants can reduce a person's appetite. After all, these are the same family of drugs used for weight loss. Often a child will not be quite as hungry on one of these drugs. Other children are finally able to sit down long enough to eat something and actually gain weight. Problematic weight gain is very rare, but weight loss is. I weigh children regularly who are taking these drugs. If there is substantial weight loss in an already thin child, we try something else. Some children will eat no breakfast lunch or afternoon meal but not lose weight because they spend their evenings eating. Usually, children have other complaints then like stomach ache. Unless nothing else has worked, it is time to change treatments if that has occurred. Sometimes with a little encouragement a child will be able to eat enough at mealtimes to not loose weight. If this has been tried and a child is still losing weight, it doesn't matter how well they are doing. It is time to stop that particular drug.

Rebound
The short acting drugs often can cause this (regular dexedrine, regular ritalin). What this means is that as the drug is wearing off the child does not return to their usual severity of ADHD, but to a much worse state. They will stay this way for 1-3 hours before returning to their old selves. The usual story is a child who is taking Ritalin at breakfast and at lunch with great result. The drug wears off right after school and they are a monster until evening. If this is severe, something has got to be done, no matter how well they might be doing in school. It is better to be consistently hyper than Dr. Jeckyl at school and Mr. Hyde at home. When this happens, the first thing to do is re-evaluate the treatment. The first solution is to stop Ritalin and use a drug which does not have rebound like cylert, Dexedrine Spansules or a tricyclic. Sometimes, you can get around this by giving a small dose of the short acting drug (usually ritalin) in the afternoon.

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Unwanted psychiatric signs and symptoms

Perhaps 30-50% of children will have this on stimulants to one degree or another. These signs and symptoms are all reversible when you stop the drug. Everyone involved in the medical care of children with ADHD needs to be watchful for these. It is important to remember that even if this happens with one stimulant, it does not necessarily mean it is going to happen with a different stimulant.

Decreased activity - some children will become very, very still on these drugs, especially in the first few increased hyperactivity - some children will actually become more hyper, not less with these drugs.

Hours after they take them, often they are perfectly behaved, but are taking in next to nothing. This is usually due to the dose being too high, but can happen in low doses in susceptible people.

Mood changes - Occasionally these drugs will make a person sad, angry, and very easily upset. Irritability is also possible. The child appears to cry at the drop of the hat. Even less commonly, a child will be giddy and actually seem high.

Language - Occasionally a child who has a problem with speaking or understanding will actually go backward on one of these drugs and speak even less than usual.

Movements and compulsions - occasionally these drugs will make people have what appears to be nervous tics as in Tourette's syndrome. At times these can be compulsive, such as new onset of nail biting, licking the hand, or having to touch certain things.

The possibility of the above things happening to a child who is already having psychiatric problems is often scary to contemplate as a parent. It is another reason to start low, monitor, and go slow. These are all reversible, and most children do not have these side effects which affect the mind. Lastly, even in the worst cases, a child does not have all of these side effects.

Other mild side effects
Besides these, there are sometimes some mild nuisance side effects of the stimulants. Occasionally mild head ache, abdominal pain, and other mild physical symptoms are reported by children taking these drugs. Often they go away with time and most research has found that this type of side effect is as common in children treat with placebo as with the actual stimulant drug.

Long term side effects
The truth is, there aren't any. Although occasionally there is a report that these drugs will do something in bad to a person if taken for years, it isn't true. If a child is tolerating the drug well, it isn't going to do something down the line. This is very clear from the literature. These drugs have been carefully studied for at least 30 years. So, Cancer, heart disease, ending up short, being less smart, etc. are all not caused by stimulants.

Side effects and the school
The side effects of the stimulant medications are rarely seen at school. Studies have shown that while teachers are good at determining how effective a drug is, there are not accurate in determining side effects (29). As a result, it is not uncommon for teachers to be more enthusiastic about medical treatment or suggesting that the dose of the medication be increased.

Example

Ryan is 6. He has quite severe ADHD and it impairs him everywhere. His parents don’t know of any other first graders who got suspended in October. Ryan has taken medications (Ritalin) in preschool when he was biting everyone and they helped. He lost a few pounds, was whiney, and didn’t go to sleep until about 9 pm, but he was able to get through preschool without getting thrown out. During the summer we tried dexedrine and the side effects were even worse. We were able to figure out that at 10 mg a day, the side effects were mild, and he was better. Not great, but not getting thrown out. Once the dose went above that, his behavior was super at school. Except the rebound was horrible, he didn't eat and he whined all evening. Since his teacher never saw the side effects, she felt they were being too cautious. Even after discussing it with me, they still think the parents are exaggerating the side effects.

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Monitoring

Some drugs require minimal monitoring and some do not. Some drugs require blood tests, others require blood tests and EKGs, others require heart rate and blood pressure to be monitored. What drug requires the least amount of monitoring? Ritalin and Dexedrine. Cylert requires blood tests ever 6 months. Tricyclics require blood tests and EKGs to figure out the right dose. Effexor and Clonidine require blood pressure and pulse checks.

Dosages per day

Some of these drugs have to be administered three times a day or more. That means someone has to be very, very attentive to getting the drug in the child at school and usually after school, too. Almost no children that I see will reliably take their own medicine. Besides, some people really object to the stigma of having to go someplace at school and afterwards to get their medicines. The drugs which need to be given three times a day are Ritalin and Dexedrine (not Dexedrine Spansules). All the other drugs are once day or just morning and night.

Cost

If you do not have insurance, this is a major concern if you have bigger child. Since all these drugs are given on a weight basis, a big child can cost you a lot of money to treat with certain drugs. What is cheapest? Generic Ritalin and Clonidine. After that it is the tricyclics. The next cheapest is Ritalin.

In Summary

Each of these drugs has some good points and some bad points. There is no perfect drug. After the description of each drug is a chart which summarizes all of this.
You can not predict which drug will work in a child and which will not.
You can not predict which drug will cause side effects in a child and which will not.