• Babies
• Building a Family
• Children
• General Parenting
• Newborns
• Teenagers
• Toddlers
• Pregnancy

Frequently Asked Questions About Ritalin and Other Stimulants

Stimulants and ADHD

Frequently Asked Questions About Ritalin and Other Stimulants Numerous studies have shown that stimulants such as Ritalin and Dexedrine improve the symptoms of ADHD for the overwhelming majority of patients who take them. The improvements are seen regardless of whether the patient is preschool age, elementary school age, adolescent, or adult.

Stimulants improve attentiveness; reduce hyperactivity, restlessness, and distractibility; and improve the ability to follow directions and stay on task.

By controlling aggressiveness and impulsiveness, these medications also have a dramatic impact on social relationships, both within the family and among peers. One study found that ADHD boys who started taking Ritalin were more likely to be rated as "cooperative" and "fun to be with" than they had been previously. Ritalin also reduces the incidence of verbal and physical aggression. And researchers find that when children are treated, parents and siblings respond with more warmth, more contact, less criticism, and greater cooperativeness.

The results are similar in the classroom: About 75 percent of ADHD children who are treated with stimulants show marked improvement according to teachers' evaluations. And these findings are borne out by measurements of the children's physical level of activity. Some research studies have used electronic monitors to measure ADHD children's level of activity, and they find that activity drops significantly with medication, both during daytime hours and during sleep. In fact, these changes can be detected as early as thirty minutes after the very first dose.

What are the benefits of stimulants for ADHD?
Of all the drugs used to treat ADHD, stimulants are the most consistently effective. What's more, they work quickly--often you can see changes starting with the very first dose.

In addition, stimulants are short-acting. They don't build up in the system. That makes it easier to fine-tune doses to get the best control. And it's reassuring to know that they clear the body quickly.

Also, stimulants have a decades-long track record of safe use in the treatment of ADHD. In fact, we know from this experience that they're among the safest medications prescribed to children.

What are the drawbacks?
While most people do well on stimulants, a small minority of patients can't tolerate the side effects (see discussion of side effects below), even after dosages are adjusted.

Another drawback is that control tends to be uneven with short-acting stimulants, because they do clear the system so quickly. As we'll see, you can time dosages to prevent this roller-coaster effect, but it can be a lot of work to maintain this schedule.

How do stimulants work?
Each nerve cell has two ends--a head and a tail, if you will. At the head, the cell manufactures chemicals known as neurotransmitters. As their name implies, these chemicals transmit an impulse from one nerve to the next.

The nerve cell stores these neurotransmitters until a signal reaches it; then it releases them from the head of the cell. Some of the neurotransmitters attach themselves to receptors on the next nerve's tail. They fit into these receptors like a key into a lock, triggering a signal in the second nerve. This signal, in turn, travels to the head of the second cell, where the process happens again. This chain reaction of chemical and electrical signals transmits the impulse along the nerve pathway.

To fire the second nerve, the first nerve has to release enough neurotransmitters to bind with the receptor sites. Normally, it releases more than necessary. After the neurotransmitters have done their job, the original cell recaptures some of them, storing them to be used again. But some of the neurotransmitters are destroyed. Thus, if you fire the nerves repeatedly, the cells deplete their supply of neurotransmitters and the nerves can't transmit signals as effectively until they manufacture more.

We're not quite sure what happens in ADHD, but it appears to involve a deficit in the neurotransmitters. The most powerful evidence for this idea is the fact that stimulants--and Dexedrine in particular--are close chemical cousins of the neurotransmitters and fit into the receptor "locks" quite nicely. It may be that they make up for a chronic deficit in natural neurotransmitters. Or the problem might be on the receiving end, with receptors that aren't sensitive enough. Or the medications might prompt nerve cells to produce or release more neurotransmitters. We simply don't know, because we don't yet have tools that can look at these processes on a chemical level in the brain.

What this complex process really boils down to is this: ADHD throws this electrical-chemical messenger system out of whack, creating "static" in the transmission. It's sort of like getting a weak signal from your television antenna-the picture gets through, but it's fuzzy. The medication acts to make the signal stronger so that the static disappears.

Chances are, the reason we see so many mimickers--and so many conditions that occur along with ADHD--is that so many factors can disrupt this delicate neurotransmitter balance and put static on the system. Depression, for example, upsets the balance of neurotransmitters, as do anxiety and other mood disorders. On the other hand, learning disorders such as dyslexia are not caused by alterations in this communication system, and therefore do not respond to medication.

Side effects of stimulantsThe most common side effects are insomnia, decreased appe- tite, weight loss (probably as a result of appetite suppression), headache, increased heart rate, slight increases in blood pressure, and an increased tendency to cry. Less common side effects include heart palpitations, dizziness, and anxiety.

With the doses used for treatment of ADHD, these side effects tend to be mild if they occur at all. If they do occur, they often disappear after a few weeks as the body adjusts. And if they persist, they can usually be managed by reducing the dosage temporarily or changing the time at which the child takes the medication (e.g., giving the medication earlier in the day to prevent insomnia). If insomnia still occurs from time to time, Benadryl at bedtime can help promote sleep. (Though Benadryl is usually used for allergies, it has a sedative effect and is safe for children.) Upset stomach can usually be managed by giving the medication with milk or about an hour after meals.

There have been several case reports of mania or psychotic episodes; it appears that in at least some incidents the drug worsened an underlying psychotic condition. Although high doses of stimulants can trigger seizures in people with epilepsy, the doses used for ADHD are usually too low to have any such effect. In fact, children who have both epilepsy and ADHD are usually treated with stimulants and an anticonvulsant medication.

Why prescribe a stimulant for a child who's already hyperactive?
Shouldn't you give him something to calm him down instead?
The short answer is that we don't use these medications in the way most people think of stimulants. We don't prescribe them as "pep pills" or to overcome fatigue. In fact, the doses are so low that you're unlikely to see any "stimulant" effect at all.

In a sense, the confusion comes from the term hyperactivity. The problem with ADHD children isn't that they have too much energy; it's that their energy tends to be uncontrolled. In fact, all of the key symptoms of ADHD--the attentional problems, the impulsivity, and the hyperactivity--reflect difficulties in controlling mental and physical activity.

If you look at studies of brain chemistry, you can see this loss of control reflected on the most basic cellular level. In people with ADHD, the cells in the part of the brain that control these behaviors have trouble communicating with one another. Treatment stimulates this "controlling" or "filtering" portion of the brain, making it work more normally.

What are the odds that treatment with stimulants will be effective?
These drugs are effective in more than 90 percent of cases, but about 15 percent of patients experience side effects that preclude their use. Sometimes these side effects can be overcome by switching medications or adjusting dosages. The bottom line is that treatment is successful in about 90 percent of cases.

How long have these drugs been in use?
The use of stimulants to treat ADHD and related disorders can be traced back as far as 1937. When a physician studying children in a residential treatment program gave them Dexe- drine, he found that the children--contrary to expectations--showed lower activity levels, better behavior, and improved school performance. In the 1960s, more rigorous studies, again looking at students in a residential school, found that the use of these drugs resulted in fewer conduct problems and better behavior and school performance.

However, at the time the concept of ADHD as a distinct disorder had not yet evolved; at this point it was simply known that for some children with conduct and school performance problems, stimulants seemed to help.

Ritalin was first commercialized in the early 1960s as a memory aid for geriatric patients, and some years later re- searchers, noting its chemical similarity to the amphetamines used in the earlier studies, began exploring its use for children with behavior and academic difficulties.

Pros and cons of RitalinThough Ritalin is still the most widely prescribed treatment for ADHD in the United States, more and more physicians are coming to view Dexedrine and Adderall as the treatments of choice for ADHD.

As we've seen, Ritalin has been well studied, and its effectiveness well established. In addition, it takes effect quickly and clears the system quickly, which may make it easier to adapt the dosing schedule to your child's needs. (For example, if your child has a "slump" in the evening, a late-afternoon dose of Ritalin will help, while still clearing the child's system by bedtime. With a longer-acting medication, you don't have this flexibility.)

However, Ritalin's short duration of action makes it more difficult to manage the typical child's school day. One dose lasts about three hours, so if the child takes the dose with breakfast, then gets dressed, waits for the bus, rides the bus to school, and sits through homeroom, he or she may be halfway through the first dose before the school day really gets started. That means the late-morning classes will be difficult. And if your child's school is one that will not administer a lunchtime dose, the afternoon is likely to be even worse.

In some children, Ritalin also has a tendency to blunt emotions. "He seems sad," a parent may tell me, but if you ask the child, he doesn't say he feels sad. It's more a feeling of distance, of being a little bit removed from things. "He doesn't seem like himself," another parent told me, and I think that's a better description.

This effect doesn't happen in every child who takes Ritalin; in fact, it doesn't happen in most of them. But if you see these effects in your child, there's a simple solution: Ask your doctor to switch to another medication. Dexedrine doesn't seem to have this side effect, and it's more convenient to administer because it's longer-acting.

Dexedrine's chief drawback, frankly, is its reputation. On the street, of course, Dexedrine is known as "speed," and when abused it is addictive and dangerous.

However, years of research have demonstrated that Dexedrine, as it's used in the treatment of ADHD, is safe and nonaddictive. In people with ADHD, clinical doses of Dexedrine don't make you "high." They don't create drug dependence. And they don't create tolerance--that is, you don't need bigger and bigger doses to produce the same effects.

In fact, this is one of the ways we know that ADHD is a disorder of normal brain metabolism: Whereas normal people develop tolerance to stimulants, people with ADHD don't. It seems that while stimulants throw the brain chemistry out of balance in most people, they make it more normal in people with ADHD.

How well does the long-acting form of Ritalin work?
The long-acting form of Ritalin requires only one dose every six to eight hours. Its primary benefit is that the school doesn't have to administer a lunchtime dose. For that reason, we may use it if the child is in a school that refuses to give the lunchtime medication. But I find--as do many of my colleagues--that it doesn't offer the same degree of effectiveness as standard Ritalin.

My doctor suggested a new stimulant called Adderall. What is it?
Adderall is a new formulation of dextroamphetamine (like Dexedrine) and amphetamines. We're using it with many of our patients, because a single dose offers good, consistent control over a longer period of time--six to seven hours. It accomplishes this by combining four closely related types of stimulants, some of which work more quickly and some more slowly.

This formulation--combining slow- and fast-acting components--is different from the long-acting Ritalin, which uses a single drug but releases it gradually over time. We find that it works much better, and it's a good way to avoid both the midday dosage and the peaks and valleys that we see with short-acting stimulants.

My child's doctor says to take the pills before eating. But then my son isn't hungry. Why can't he take it after meals?
Food interferes with the ability of the body to absorb stimulants, so the medications often don't work as well if you take them after you've eaten. In addition, some foods interfere more than others, so you may see the drugs acting inconsistently, depending on the menu. For example, citrus juice interferes with Ritalin.

But the standard recommendation to take them before meals can cause problems for some patients. As you pointed out, they can suppress appetite. Also, if breakfast is early in your household, that can throw off the medication schedule for the entire day, because the medication may start wearing off in mid-morning.

There are some other options, though. For example, we often recommend taking the drug after meals. The only caution is not to take them too soon after; wait at least an hour.

Some people also feel nauseous if they take a stimulant on an empty stomach. In that case, you can take it with milk.

It's important to find the dosage strategy that has the least impact on appetite, because poor nutrition can make ADHD symptoms worse (not to mention the impact on growth). For example, researchers have found that children who get protein at breakfast (for example, from milk or yogurt) do better in school than those who don't. For children with ADHD, that difference can be critical.

Ritalin dosageThere's no black-and-white answer. Again, the key is to work with your doctor to create a plan that works for you.

Some parents using short-acting stimulants find it beneficial to skip the last dose; it gives the child a chance to wind down and fall asleep more easily. Other parents find exactly the opposite effect: The loss of control turns every evening into a battle.

So the best guide is your own experience. However, I do think that most children--not all--do better when medication levels are relatively steady throughout the day. ADHD isn't a disorder that happens just during school hours, and the fluctuations can be very disorienting and demoralizing. You can think of medication kind of like the brakes on your car. It gives you control. Imagine driving a car where your brakes are unreliable--where they work for a little while, then don't, then start working again. In some ways, it's worse than having no brakes at all, because you never know what to expect.

In many cases, that's what happens with ADHD. The sense of control--the ability to know what to expect--is often a critical part of building self-esteem and confidence, and preventing anxiety. I am a strong advocate for consistent medication.

Do stimulants cause tics?
There have been concerns over the years that stimulants may promote tics--involuntary muscle twitches of the face and body--in some children with ADHD. But it's not that simple.

Tics can range from something as mild and virtually unnoticeable as a slight facial twitch (or even excessive blinking) to involuntary spasms of the entire head or limbs or both. In a related condition, Tourette's syndrome, tics may be accompanied by involuntary outbursts of obscene or offensive speech. That's the bad news. The good news is that the vast majority of tic disorders are well toward the milder side of this scale. Even in cases of Tourette's syndrome, severe symptoms such as verbal outbursts are quite uncommon. Further good news: Tics don't really cause any physical harm, though severe ones may cause social problems. And best of all, most tics can be controlled with medication.

In a small minority of cases, stimulants may trigger tics. It's not clear whether they actually cause the tic, or simply bring a preexisting condition out into the open. There's evidence that tic disorders may mimic ADHD in their early stages; in these cases, the tic might have developed whether we'd treated the patient with stimulants or not. Even though it looks as if the medication caused the tics, in such cases they would have emerged regardless of whether the child had been medicated or not.

Nonetheless, we do see a link between stimulants and tics, and it does create a dilemma.

It requires a careful weighing of risks and benefits. If the child has shown evidence of tics in the past, or if there's a family history (tic disorders tend to run in families), we proceed very carefully. In such cases, we usually begin with ADHD treatments other than stimulants.

Catapres (clonidine) or Tenex (guanfacine) are often the first choice. They're relatively safe, and in many cases it can control both tic disorders and ADHD. (Other drugs, such as haloperidol or respiridol, are more effective than clonidine for tics and Tourette's syndrome, but they have a lot of side effects. So they're usually used only in more severe cases, and only if Catapres doesn't work.)

If Catapres, Tenex or other similar medications don't control the ADHD symptoms, we do look at using stimulants. But we do so carefully, weighing the risks and consequences of exacerbating a tic against the risks and consequences of not treating the ADHD.

It's not a straightforward choice. For example, while stimulants may make tics worse, they sometimes make them better. Here's why: Tics are usually stress related. For example, many parents say their child's tics get worse on Sunday nights--but if there's no school the next day, the tic magically moves to Monday night instead. So if ADHD is creating a stressful situation for the child, treatment may calm the tic by reducing school-related anxiety. (One helpful hint: A good night's sleep provides an enormous benefit for both ADHD and tics--and it's a risk-free therapy.)

I don't want to leave you with the impression that you shouldn't be concerned about the relationship of tics and stimulants. Rather, I'm suggesting that it isn't a black-and-white issue, and it must be managed carefully. One approach that often works well is to treat the ADHD with stimulants and manage any tics with Catapres.

The issue can get complicated, but the alternative--not treating the ADHD at all--will have much more severe consequences. It's a matter of balancing risks and benefits.

Isn't it true that stimulants stunt growth?
Stimulants do affect the rate at which children grow, but numerous studies suggest that these children end up at the same height.

Studies of children treated two years or more with Ritalin or Dexedrine show a "decrease in weight velocity" on standard age-adjusted growth rate charts. In plain English, they don't gain weight as quickly. The effects are more pronounced with Dexedrine, presumably because it's longer-acting. Although researchers haven't identified exactly why this effect occurs, the most likely explanation is the drugs' effects on appetite.

Understandably, parents are more concerned about height than weight. Fortunately, most of the research has found minimal, if any, long-term effects on height from ADHD therapy. One study of sixty-five children found that initially they grew more slowly, but caught up during adolescence. By age eighteen, these patients had reached their predicted heights, based on their parents' heights. Other studies have confirmed these findings, showing that stimulants had only a mild and temporary effect on weight and "only rarely interfered with height acquisition."* And they have no impact on growth after puberty.

However, keep in mind that these studies look at group statistics, not individuals. It's possible that the effects may be more pronounced in some children and less so in others. That's why it's important that your child's growth be monitored regularly by your pediatrician. Most monitor height and weight from infancy onward against standard charts. These charts measure percentiles--for example, a child who falls in the fiftieth percentile for height and weight will be taller and heavier than 50 percent of children his age. It's not so important how quickly your child grows--this changes all the time--but whether this percentile score remains relatively steady. A change of a few points isn't significant, but if your child's height or weight percentile begins to drop noticeably, it's a reason to look more closely at whether the medication is affecting growth. Studies show that a drop in the weight percentile usually happens before declines in the height percentile, so it can give you an early warning.

Also, research suggests that the effects on height and weight may be more pronounced on larger children. So if your child tends toward the upper end of the charts, he or she may be at greater risk.

On the other hand, a differential of a few pounds in weight or a fraction of an inch in height will be less of a concern in a child who's well above the average norms to begin with.

*L. L. Greenhill et al. "Medication treatment strategies in the MTA studies: relevance to clinicians and researchers." Journal of the American Academy of Child and Adolescent Psychiatry 1996; 35:1304-13. This article describes the role of psychostimulant medication in the treatment of attention deficit hyperactivity disorder. Included are the drugs' putative mechanisms of action, pharmacology, toxicology, indications for their use, short-term and long-term actions, adverse effects, specific dosing regimens, therapeutic monitoring techniques, alternative medications, and drug interactions.

Offsetting side effectsChildren tend to make up for slowed growth when treatment is discontinued temporarily (at least through adolescence). That's one reason why many pediatricians suggest a "drug holiday" during summer vacations. In the summertime or on weekends, the thinking goes, the child has fewer academic demands and can "burn off" excess energy with sports and other activities.

But I'm concerned that these "holidays" may actually do more harm than good. If you assume that ADHD is a disorder that affects only classroom learning, then medication holidays make sense. But we know that isn't so. ADHD affects every aspect of a child's life.

Take summer camp, for example. If your child's ADHD is making it difficult for him to make and keep friends, to participate in sports like softball and soccer, to learn how to swim, or to listen to his or her counselor, it's not much of a holiday. If your child's weekends are spent fighting with siblings and parents or bouncing off the walls, I'm not sure you're doing him or her any favors by withholding medication.

If you look at ADHD as a chronic physical disorder that must be managed with medication, you can begin to see the flaw in the logic of these holidays. Nobody suggests that children with diabetes should take a "holiday" from their insulin.

On the other hand, I understand the concerns that parents feel about keeping a child on medication. And there may be some benefit to forgoing medication over the summer to let growth "catch up" to normal--though there's no good evidence one way or the other.

As I've said before, one must balance the risks against the benefits, and the analysis will be different in every individual case. If you have a child with mild ADHD symptoms--perhaps without the hyperactive component--and these symptoms are usually an issue only when it comes to schoolwork, then a medication holiday may make a lot of sense. If you have a child with severe attentional difficulties, a lot of aggression, and significant social problems, the scales may tip toward more consistent medication.

There are no hard-and-fast rules, no right or wrong answers. The most important thing is always to keep in mind that the treatment of ADHD ultimately is about self-esteem and success, not about specific symptoms and medication regimens.

Why did my pharmacist refuse to refill my prescription?
Stimulants, including both Ritalin and Dexedrine, are "controlled substances" subject to legal restrictions. Because these drugs have a potential for abuse, the federal government imposes certain restrictions on how they're prescribed and dispensed. One prohibits automatic refills--not because there's anything wrong per se with taking these drugs over long pe- riods of time, but to prevent people from getting refills just to sell or abuse, and to ensure that they're being used under the continuing supervision of a physician.

What effect does caffeine have on ADHD?
For most people, not much. Although caffeine is a mild stimu- lant, its effects simply aren't strong enough to affect ADHD.

Can stimulants be used if my child is also on other medications?
It depends on the medication.

Stimulants should never be used in combination with MAO inhibitor antidepressants. Combining these drugs can raise blood pressure to extremely dangerous, even fatal, levels.

Less severe drug interactions can occur with stimulants and asthma medications-specifically, medications such as theophylline that are taken by mouth. Because these medications are chemically related to stimulants, the combination can cause such side effects as palpitations, weakness, dizziness, and agitation. If your child has asthma, ask your doctor if it's possible to switch him or her to an inhalant medication to prevent these effects.

Stimulants such as Ritalin will also raise blood levels of certain other medications, such as anticonvulsants and antidepressants such as fluoxetine (Prozac), increasing their effects. If your child is taking these or other medications, ask your doctor or pharmacist about potential interactions and whether the dosages should be adjusted. Stimulants may interact with cold medications (e.g., Sudafed), making the effects of both stronger.

My daughter was doing great on stimulants for several months. But all of a sudden they just stopped working. Why?
There is a possibility that your child has a mimicking disorder. We find that when people have something that looks like ADHD but isn't, the medications sometimes work for a while and then peter out.

But from this description--in which the medications just stopped working all at once--I would suspect another factor: allergies. Allergy reactions release histamines, chemicals that interfere with the action of stimulants.

Although I've seen no studies on the interaction between allergies and ADHD, I can tell you that every spring, I get a number of phone calls from parents telling me that their child's medication is no longer working. After looking at possible factors--for example, a sudden growth spurt or a change in the classroom environment--we often find that the only thing that's changed is the weather. And when I ask the parents if the child's allergies are bad, they almost invariably say yes.

You and your doctor might consider this simple solution: You don't need to increase the stimulant dosage. Just use antihistamines to control the allergy. That usually restores the effectiveness of the ADHD medications during allergy season.

The teachers say my child is doing better, but I don't see any change at home. Why not?
The reason may be your child's medication schedule. For example, if your child is taking Ritalin in the morning and at noon, the effects have probably worn off by 3 or 4 p.m., about the time your child is coming home from school. This phenomenon is common enough in ADHD to have its own name--"behavioral rebound"--and sometimes the symptoms are even more pronounced than before treatment began. Ask your doctor to consider three-times-a-day dosing; a final dose after school will carry you through to bedtime.