Stimulant Medications (Ritalin, Concerta, Dexedrine, Adderall)
Stimulants have long been considered the “first line” medication, or “drug of choice”, for ADD. They have a long history of use (greater than 60 years) and many, many studies showing they work. It is important to note that all of these studies focus on short-term effects – reduction in hyperactivity, increase in attentiveness, less impulsivity, less distractibility, improved grades in school, improved behavior. There have never been long-term outcome studies done comparing things like High School graduation rates, college attendance, career success, poverty levels, or ultimate life happiness as they mature in ADD children treated with medications vs. those who have not been. Nonetheless, it is the belief of most professionals that the proven short-term benefits are worthwhile and probably do translate into an improved long-term prognosis.
The most commonly prescribed stimulant in America is Ritalin (Methylphenidate). Others include Dexedrine, Adderall, and Cylert (Pemoline). All are in the amphetamine family and are related to “speed”. It seems paradoxical that “speed” should help a “hyperactive” child. However, the common “image” of what speed does is based on very high doses taken by drug abusing adults. These medications behave differently in low doses and in children.
At a very low dose, stimulants improve attention (in all age groups). As an example of how that works, think about caffeine. Caffeine acts in a very similar way to the amphetamine-like stimulants, but is much weaker. Most everyone is more alert and attentive after a morning cup of coffee! Conversely, many adults who drink large quantities of coffee (and may consider themselves “caffeine addicts”) probably actually have some degree of ADD which they are “self-treating” without knowing it. Indeed, sometimes drinking caffeinated beverages can be an alternative to medications in a child who is resistant to taking them.
At somewhat higher (medium) doses, stimulants mainly suppress the appetite. Indeed, for many years in the middle part of this century, they were most commonly used as diet pills. Their use for this purpose has fallen out of favor, but they were effective. This accounts for stimulants most common side effect when treating ADD – decreased appetite and resultant poor growth. This side-effect is seen in 20-30% of children taking stimulants, but it is dose-related and it can usually be fixed by adjustments to either the dose, the timing of the medication, or changes in the particular stimulants being used.
Human’s respond differently to high doses of stimulants, depending on whether they are before or after puberty. Adults become “wired”, “manic”, nervous, and jittery. Children do just the opposite – they become lethargic, sleepy and act “drugged”. This response can also be seen as a side-effect to stimulants during ADD treatment but should be rare, since the doses necessary to create this effect are really beyond those which should be used for ADD in most children. However, some individuals are highly sensitive to the medication, and may experience this effect even at what would be a moderate dose for another child.
Other possible side effects from stimulant medications include headaches, increased blood pressure, and difficulty sleeping. The headaches are often transient – resolving once the child has been on the medication for more than a few weeks. They too, often respond to changes in the dose or in the particular stimulant being used. Blood pressure elevations need to be monitored for and, along with monitoring weight gain, are the reason that most children on stimulants should be seen by their prescribing physician on a regular basis. Sleep difficulties are the least common of these side effects, they only happen in 2-5% of patients who are prescribed stimulants. At least as many children with ADD actually have improved sleep once they have started taking stimulants as bedtime difficulties can be a common theme in such children. Once again, adjustments to the medication usually are adequate to solve these problems when they occur.
Much has been written and said about the association between stimulants and tics. Tics are involuntary movements or vocalizations which, in their severest form, are sometimes referred to as “Tourette’s Syndrome”. It used to be thought that stimulant medication could sometimes cause or trigger Tourette’sSyndrome. Careful studies have now proven that this is not the case. What is true, however, is that children with ADD (medicated or not) have a higher risk of having tics to begin with! While stimulants will not trigger tics in a child not so predisposed, stimulants do bring on or worsen tics in a child who is. Just because a child has a history of tics, or a family history of Tourette’s Syndrome, is no longer considered an “absolute contraindication” to using stimulant medications. The potential benefit to the child in improved attention needs to be weighed against the severity and possible psychosocial impact of worsened tics. Sometimes, this situation can be managed to a combination of stimulants for attention and other medications to control tics. At other times, the tics are deemed mild enough to be tolerable, while the inattention is a more significant problem needing to be treated. Finally, sometimes the presence of tics can be a good reason for moving on to another class of medication for the ADD which may not have this side effect.
Perhaps the most important, and yet the least discussed, side effect or risk of stimulant medications is it’s impact on personality and mood. When a child with ADD also has emotional difficulties (depression, anger, aggressive tendencies, anxiety), stimulant medications may worsen these things. Even in a child who does not have such significant emotional difficulties, stimulant medications can transform the previously “happy-go-lucky” ADD child into a more serious, even morose personality. When we see such changes in a child, this can be another reason for considering a switch to another class of medications. When we know in advance that a child suffers from emotional difficulties, sometimes we choose not to start with stimulants as a first line because of this worry.
Stimulants have the same effects on all human beings, regardless of whether they have ADD. Even someone without ADD will attend somewhat better on a stimulant as opposed to off. The difference between the response of a child with ADD and that of another child is simply that treating him with a stimulant is like “hitting the nail right on the head”. If your ability to pay attention is not the thing “getting in your way”, taking a medication to improve it a bit does not make a huge difference in your performance. On the other hand, a slight improvement in attentional ability when this is the main obstacle you face can make a huge difference. It is like the difference between widening an hour glass at it’s neck vs. widening it an inch above. In the first case, the sand flows faster, while in the second case, it does not. Attention is the “neck” of the ADD child’s functional hourglass, while that is not the case for other children.
All of the above side-effects and considerations apply equally to all the stimulant medications. They are all the same in these regards. There are always individual differences in how people respond to medications, however, and a child who experiences a particular side effect on one of the stimulants may not experience the same one to the same degree on another. Therefore, some “trial and error” to find the best medication for a particular child is always appropriate. Likewise, sometimes, a particular stimulant may work better for a particular child than another one does. The main differences between the stimulants mostly relate to how long acting they are.
One final thing to bear in mind is that stimulants do have some minor abuse potential. Particularly teenagers may find the effects of stimulants (on attention, on appetite, or even the “high” of a large dose) pleasurable. There have been some reports of stimulants being sold illegally both on the black market and informally by ADD teenagers to other teens whom they have not been prescribed for. Parents and doctors do need to be alert to this possibility, particularly when treating a teen.
- Methylphenidate – (Ritalin, Metadate, Concerta, other brands) is by far the most commonly prescribed stimulant in the U.S. It comes in short-acting (3-5h), sustained release (6-9h), and ultra-sustained release (10-14h) forms. The short-acting form usually will take affect within 30-60 minutes of giving it, while the sustained release versions may take up to twice that long to start working. It comes in tablets and capsules, and some of the latter can be opened and sprinkled in food. Unfortunately, there is no liquid or chewable. The usual dosing range of Ritalin for ADD is a total daily dose of between 0.3 and 1.0mg per kg of body weight.
- Dexedrine – in general is somewhat stronger than Ritalin and sometimes works for children whom Ritalin has not been successful. It also comes in short and long-acting forms – the short-acting form is a tablet which comes in 5 and 10mg sizes and which usually wears off after 4-6 hours. The long-acting form is a 5, 10, or 15mg capsule (which can be opened and sprinkled in food – again there is no liquid available), which usually wears off in 6-10 hours. The typical dosing range of Dexedrine for ADD is a total daily dose of between 0.1 and 0.5mg per kg of body weight.
- Adderall – Although the brand-named was introduced in the 1990’s, the generic chemical Adderall is made of has actually been around for many years. It is simply amphetamine. The strength, onset, duration of action, and dosing range of it’s tablets are very similar to the long-acting Dexedrine capsules. It also comes in an ultra-long-acting “XR” version which lasts 10-14 hours, and is a capsule which can be sprinkled in food. It’s main advantage over Dexedrine (other than the fact that some children may have fewer side effects with it) is that it comes in many different sizes which allows for very fine adjustments in medication dose, something which is more difficult with the other medications.
- Cylert – Although it’s effects on the body and it’s biochemical mechanism of action are no different than the other 3 stimulants mentioned above, Cylert is in some ways the “most different” of the 4 alternatives. One important difference is it’s length of action. Cylert is “super-ultra-long acting” – effects last in the body for more than 24 hours. Therefore, when given on a daily schedule, it never wears off! This can be either a blessing or a curse. A blessing when a child’s ADD is so severe that one desires 24 hour treatment that never wears off. A curse when it comes to certain side-effects – for instance, if a child is experiencing appetite suppression from stimulant, with Cylert it is likely to effect all three meals, whereas with some of the other alternatives, there may be certain meals through the day when the stimulant is not in their body. Likewise, if the personality changes coincident with stimulant administration are considered to be unfortunate, the other medications allow for “breaks” after school or on weekends, or during school holidays, when parents can have their “old Johnny back”. Cylert does not allow for such breaks. One of the frequent complaints of the other three stimulants, however, are the “ups and downs” attendant with their administration. They work very well when “peaking” in the body, and then a child will “crash” or sometimes even have an increase in ADD symptomatology over baseline when the medication is wearing off. Cylert is a very good way to avoid these “ups and downs”. Cylert comes in a 37.5mg chewable tablet, as well as in regular tablets of 37.5 and 75mg strengths. The usual dosing range is between 1 and 3 mg per kg of body weight per day.
Cylert does have one risk not present with any of the other stimulants. Its chemical structure bears some resemblance to the other stimulants but also to the drug Dilantin, which is usually used to treat epilepsy. While Cylert has no anti-epilepsy affect, it does share one potential side effect with Dilantin, the potential for liver damage. Many children being treated with Cylert will have slightly elevated liver enzymes when measured on blood tests. In most cases, this is a benign, harmless, and reversible phenomenon which goes away when the medicine is stopped without causing permanent harm. Very rarely, however, (approximately 1 in every 10,000 cases), a child can suffer irreversible liver failure which can be fatal or sometimes necessitate a liver transplant. This latter risk has only become known in the last 5 years and has caused the manufacturer to change it’s product labeling to make sure that Cylert should be considered a “second line” drug, for use when other stimulants are not as effective or have caused undue side effects. This new knowledge has also caused many physician’s (including myself) to cut back quite a bit on our use of Cylert. Unfortunately, liver enzymes measured on blood test do not correlate with the occurrence of these rare cases of full-blown liver failure and so monitoring them is not helpful in preventing such occurrences. Despite this risk, there remain some children for whom Cylert is the best choice, and the risk may be deemed worthwhile.
One final difference between Cylert and the other stimulants is related to it’s long duration of action. Because of the “overlap” between the effects of today’s dose and yesterday’s dose, there is a “build-up” effect in the body with Cylert which results in it’s full impact not being seen until several weeks after it has been started. With the other stimulants, their full effects are seen immediately, (with the first dose).