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.

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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Second line Drugs
All of the medications below involve more risk. That is, in rare cases, people can have serious side effects. This means that there is additional monitoring required. Why do you use these drugs?


Because the drugs above have not worked.
Except in a few cases (comorbid severe tic disorders, some mood disorders, some substance abuse disorders) both the drugs above are tried first before considering the drugs below.

Because the risk of ADHD is far greater than the risk of the medication.
ADHD is not always a mild disorder. People with ADHD sometimes engage in very risky behaviors. These are risky to themselves and others. ADHD can totally demoralize a child and put them at significant risk for depression. The risks of things like substance abuse related accidents, motor vehicle accidents, demoralization, other psychiatric disorders and even suicide is not that small. If you look at a group of children with ADHD that go to see a pediatric psychiatrist and then see how they are doing four years later, 51% will have required tutuoring, 34% will have repeated a grade, 15% will be in special classes, and 16% will have been diagnosed with a learning disability. Compared to children without ADHD, they will be 10 times more likely to have manic-depressive disorder, 8 times more likely to have depression, and 4 times more likely to have major anxiety problems. (1) ADHD can be a very serious illness.

The risk of serious problems with the drugs below is on the order of 1 in 10,000 or less. To put that in perspective, your chance of being killed in a car accident on the way to my office is .7 in 10,000. Compared to the risks of ADHD, most people would say the risks of these medications are worth taking.

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Bupropion (Welbutrin)

This drug has been available in the USA for about 10 years. It is used primarily as an antidepressant. However, it affects the same chemicals in the brain (dopamine and norepinephrine) that other drugs for ADHD effect. As a result, it has been tried in ADHD in children and adults. There are only a few studies of this drug in children. However, all of them have found it to be effective. In the one study which compared it to Ritalin, it was found to be almost, but not quite, as effective as Ritalin. (3) It has been used in children who have Conduct Disorder, Substance abuse problems and Attention Deficit Hyperactivity Disorder and it has been found to be helpful. (15) It comes in a slow release form, which means there is no need for a middle of the day dosage. The average dosage is about 3mg/kg. However, sometime higher doses are used. The drug is available only as a slow release preparation in Canada. It comes in 50, 100, and 150mg sizes. Usually it is given once or twice a day and it is not recommended that any dose be greater than 150mg.

Side effects

Rashes are not uncommon, about one out of 6 children can get one which usually resolves over 3-4 days. Nausea and vomiting can occur. About 1/3 of children will lose a little weight.

Less common side effects include irritability, sleep problems, and head-aches. It can cause seizures. This is most frequent in over doses and when patients also have Bulimia. In adults, 4 out of 1000 people will have a seizure using the short acting form of the drug. However, the long acting form used in Canada only causes seizures in 1 in 1000 people (9). This is about the same as most of the drugs used for depression. Seizures have occurred in children, but usually at higher doses. It is still unknown if the seizure rate in children is lower, higher, or the same as in adults. There are no other long term side effects or risks. On the other hand, it has not been around a long time. Over all, the early data suggests the side effects are slightly less than stimulants, but not a lot less. (4)

Good points about Bupropion
Compared to the other non-stimulant drugs for ADHD, the monitoring necessary is minimal. No ECGs or blood tests are necessary. It can be helpful when depression is also present. It has been used a lot in the USA for ADHD without any major problems. If a child has failed to respond or tolerate the first line drugs and won't have his blood drawn, it is a great choice. (5)

Bad points about Bupropion
There has been some, but not a lot of research on this drug. It seems quite safe in adults, and it probably is in children. However, there is a possibility that something will come up which is a problem with this drug in the future.

Tricyclics
This is a group of medications (desipramine and nortryptiline) which were the first drugs used for depression in adults. One of them, imipramine or tofranil, has been used for years children who bedwet. They work in a slightly different part of the brain. The good thing is that they work very well in children who are also depressed or anxious. They do not wear off over the day. They can be given it at breakfast and bed time. They do not usually worsen tics. It is my first choice in kids with mild tics and ADHD.

So why aren't they used more?
Approximately 5-10 children have died suddenly while taking one of these drugs, desipramine. This turns out to be a rate of about 8 per million. Children die of unknown causes at a rate of 8 per million. To put this in perspective, the childhood suicide rate is about 8 per million. The risk of dying in an auto accident are about 70 per million. So, although there is a very slight risk, compared to the risks of the disorder, it is very small. In my practice, it would be ten times more likely that someone would die on the way to their appointment with me in a car crash than die of sudden death related to these drugs. There is still a debate as to whether this small increase in deaths is from the medication or something else. It is also unclear as to whether monitoring as below will pick out these super rare cases. It has only happened with desipramine. A much more real risk is over dose. If children or adults take too much of these drugs accidentally or on purpose, they can die. These drugs can cause rhythm problems in the heart, blood pressure problems, and fast pulse, plus constipation and dry mouth and occasionally sweating and dizziness. It is very hard to figure out the dose.

Are they safe?
Yes, they quite safe if they are used correctly. The American Heart Association studied this issue and published their recommendations in August of 1999 (21). They suggest the following:

First I get an EKG. If it is normal, we start the drug at a very small test dose amount. For Desipramine, this is usually 1 mg/kg. The doses for Nortryptiline are half of this. Over the next few weeks I slowly increase the dose to 3-5 mg/kg for desipramine or 2-3 mg/kg for Nortryptilin . At this point we check a blood level and another EKG. It takes a week to get the result back. Based on the results of the blood test, I adjust the dose, and occasionally a person will need another EKG and blood test, but not usually. I check the blood pressure and pulse after a few weeks. The toxicity of these drugs is mostly related to the blood level and the EKG. By following these very conservative guidelines, the drug is very safe and often very effective.. BUT, it is a fair amount of hassle. Obviously if someone is dead set against having their blood drawn, they will never get this.

I heard of somebody who was taking two drugs at the same time. Why would you ever do that?
Attention Deficit Hyperactivity Disorder is sometimes so severe that one drug won't control it. It can be a life threatening disease as it makes accidents much more likely. There are certain cases where it is necessary to use two drugs to control Attention Deficit Hyperactivity Disorder. This requires even more monitoring and even a more careful approach.. What follows is a table of the medications.

Medication
Brand name
Usual Dosage
Problems
Advantages

Methylphenidate
Ritalin
Up to 1mg/kg two to three times a day
Need to give at school, remembering to give it
Minimal monitoring

Dexedrine
Dexedrine Spansules
1/2 mg /kg once a day
Possibly slight increase in side effects
Once a day, Minimal monitoring

Dexedrine
Dexedrine Tablets
1/2mg/kg 3-4 times a day
Frequent dosing
Can be helpful when you want to start dexedrine at a very low dose

Tricyclics
Norpramin, Aventyl
1-3 mg/kg
Blood tests, ECGs, Blood Pressure, pulse
Can be helpful if other things have failed

Buproprion
WelbutrinSR
3mg/kg once a day
No long term data
Well tolerated

Clonidine
Catapress, Dixarit
5mcg/kg
ECG, Blood pressure, pulse
Helpful if tics are present



The bottom line is.....

Drugs can be very beneficial. There is no free lunch; they all have side effects. If used carefully they can be lifesavers, if not, a nightmare.

Alternative medicine treatments

There are quite a number of substances, which are supposed to help ADHD, which are "natural". Usually these are combinations of vitamins, herbs, minerals, and other plant products. They are usually advertised as being very safe and effective.

For the most part, they are very safe. There are far less side effects with these agents. On the other hand, there is not the same kind of research data that is found with medical treatments.

For me to recommend a substance or drug for any disorder, it must meet some tests.

Someone other than the company which makes it must do research on it. I wouldn't believe the Ford dealer about his trucks, and I wouldn't believe the Ritalin sales person about his drug and I wouldn't believe the herbal company about their new herbal treatment for ADHD.
The results should be published in a referenced medical journal. This way I know that reviewers have checked it out first and that the research meets basic criteria for scientific research. "Vitamin Retailer" is not one of those journals.
A double blind placebo trial should be completed. By this I mean that the substance or a placebo is given to a group of children and no one knows until the end of the study who really got the new substance and who got the placebo. This is the most accurate type of study.
At the moment, no alternative treatment meets all these criteria. However, there is one that is relatively close. That is supplements with Omega 3 Fatty Acids in them. This is based on the observation that children who are hyperactive have lower levels of these substances in their blood.(17) These supplements have been used for other purposes in medicine so we have a fairly good idea about their safety. There are no good independent studies of their effectiveness, however. They take a few weeks at least to work.

Based on my experience, they seem to be mildly to moderately effective. They work better on younger than older children and work better on hyperactivity than inattentiveness. Again, this is just based on my observations, not any research.

So when are they reasonable to consider?
When ADHD is only mild. Overall, they do have a lot less side effects than stimulants, and if the problem is not severe or urgent, it is worth considering.
When preschoolers have ADHD which requires medical treatment. As mentioned in the preschool section, this age group has more side effects and a poorer response to medical treatments such as stimulants. As a result it is worth trying these agents.
When the ADHD is mild and a child has severe tics. These supplements do not worsen tics.
There are a number of sources of Omega 3 Fatty acids. Here in Southwest Nova Scotia, the three most popular are Evening Primrose Oil, Herring oil capsules, and a combination of tuna fish oil, thyme oil and Evening Primrose oil called Efalex. These are available at pharmacies and health food stores. Since each company has its own directions and sizes, the only advise I can give is to follow the instructions.