Treatments and Medications
for Attention Deficit Disorder

Stimulant Drugs

Overview

The history of stimulant drug use dates back to the discovery by Bradley in 1937 of the therapeutic effects of Benzedrine® on behaviorally-disturbed children.  In 1948, Dexedrine® was introduced, with the advantage of having equal efficacy at half the dose.  Ritalin® was released in 1954 with the hope that it would have fewer side effects and less abuse potential.  Although initially used as antidepressants and diet pills, stimulant drugs are not used for these purposes today.

In 1957, Laufer described the "hyperkinetic impulse disorder," which he believed was caused by a maturational lag in the development of the central nervous system.  He asserted that stimulant drugs were the treatment of choice for this disorder and postulated that they acted by stimulating the midbrain, placing it in a more synchronous balance with the outer cerebral cortex.  This was an oversimplification but the exact mechanism of action of these drugs is still unknown.

The most frequently used of the stimulant drugs is Ritalin® followed by Dexedrine®, Desoxyn®, Adderall®, and Cylert®.  Dexedrine®, Desoxyn®, and adderall® are amphetamine preparations. Ritalin® and Cylert® are non-amphetamines.  Cylert® works differently than the other drugs, taking 2-4 weeks before therapeutic effects are noted.  Also, due to its potential for causing serious liver function problems, Cylert® should not be used as the first drug of choice to treat ADD.   It should be used only after the trial of several other stimulants.  SEE FDA WARNING.   Also, recent studies and clinical experience is beginning to favor the use of Adderall® over Ritalin® in treating children and adolescents with ADHD.  For more discussion of this issue, we refer you to a recent article in the Doctor's Guide to Medical & Other News.

Mode of Drug Action

It is postulated that the stimulant drugs act by affecting the catecholamine neurotransmitters (especially dopamine) in the brain.  Some believe that ADD develops from a dopamine deficiency which is corrected by stimulant drug treatment.  Recent research indicates that there is a group of individuals (up to 10% of the population) that have a lowered number of dopamine receptor sites.  These individuals may exhibit ADD symptoms and are also prone to drug and alcohol addiction.   At one time it was felt that the stimulant drugs created a paradoxical (opposite and unexpected) reaction (calming and sedation) in ADD youngsters and that this response was diagnostic.  This is no longer believed to be the case as the response to stimulant drugs is neither paradoxical nor specific.  Children with conduct disorder and no evidence of ADD may also respond to these drugs.  Likewise, studies with normal and enuretic (bedwetting) children have shown that many experience a calming effect rather than the expected stimulation.

Because of their relative safety, the stimulant drugs remain the treatment of choice for many children diagnosed with ADD.  The drugs are unquestionably successful in decreasing hyperactivity, lessening impulsivity and improving attention span in approximately 70% of those treated.  As a result of improved interactions with family members, peers, and teachers, the drug-treated children feel better about themselves and self-esteem rises.  At the present time,   however, there is some controversy as to the degree of learning and memory improvement resulting from the treatment of ADD-children with stimulant drugs.  Overall, the ideal approach is one in which the children are involved in psychological treatment methods along with medication.   Focus, a psychoeducational program, is an excellent adjunct to medical treatment of ADD.

In considering the use of stimulant medications, the following passage related to the prescription of stimulants from the Physicians Desk Reference (PDR) should be considered:

The prescribing information provided by CIBA ( the manufacturers of Ritalin®) states "Ritalin® is indicated as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms: moderate-to severe distractibility, short attention span, hyperactivity, emotional lability, and impulsivity."

The same literature also states, "Drug treatment is not indicated for all children with this syndrome..... Appropriate educational placement is essential and psychosocial intervention is generally necessary. When remedial measures alone are insufficient, the decision to prescribe stimulant medication will depend upon the physician’s assessment...."

Of those ADD-children treated with stimulant drugs, 66-75% will improve and 5-10% will get worse.  It is always important to verify that the medication is actually being taken, as some children will refuse to do so as a means of rebellion or defiance.  There is a marked variation in drug response among different children, and even within an individual child on different days.  Some children will not respond unless they are placed on extremely high doses, or on 4-5 doses a day, probably as a result of accelerated metabolism (drug breakdown).

Tolerance to the stimulant drugs may develop requiring an increase in dosage after the child has maintained nicely on a particular dosage for a year or so.  Also, older children and teens may benefit from lower doses than younger children.  Children who respond to one of these stimulant drugs will probably respond as well to any of the others.  There are cases, however, in which a child will respond favorably to one drug but not another.  Also, there is no evidence that children treated for years with stimulant drugs will have a greater likelihood of abusing drugs or narcotics during their adolescent years.

Contraindications

Drug Interactions

The drugs may decrease the effects of some antihypertensive drugs.  They should be used cautiously with pressor agents (adrenaline-like drugs).  They may affect the liver metabolism of certain anticoagulants, anticonvulsants, and tricyclic antidepressants.  Insulin requirements in diabetic patients may be altered when the drugs are co-mixed.

Side Effects

The most common side effects encountered with stimulant drugs are: loss of appetite, weight loss, sleeping problems, irritability, restlessness, stomachache, headache, rapid heart rate, elevated blood pressure, sudden deterioration of behavior and symptoms of depression with sadness, crying, and withdrawn behavior.  Two of the most disconcerting side effects are the intensification of tics (muscle twitches of the face and other parts of the body) and suppression of growth.   It is rare that stimulant drugs cause tics but they may activate an underlying (latent) tic condition.  There is some concern that this could even lead to a severe tic condition called Tourette Syndrome. 

The growth retardation problem has caused considerable controversy and concern since an article written in 1972 described suppression in growth of ADD-children who had undergone long-term stimulant drug treatment.  Subsequent studies have varied markedly in their findings.  One study of adolescents who took the drugs as children showed no growth suppression.   Another study demonstrated growth suppression during the first year but none during the second year of drug treatment.  Others have demonstrated a rebound during the second of drug treatment.  Others have demonstrated a rebound growth spurt when the drug is withdrawn or even in those taking the medication.  There is also some indication that taller children are more vulnerable to growth suppression effect than are those who are smaller. 

As a result of the the growth retardation scare, many clinicians are suggesting that the drugs be given on school days and not on weekends, holidays, or vacations.  Realistically, most parents are unable to comply with the deterioration in behavior that ensues when the medication is withdrawn.  At the very least, the drugs would be withdrawn once-a-year to reestablish the need to continue the medication.  A popular approach is to discontinue the stimulant drugs during the first 2 weeks of the fall semester.  If the medication is still required, it will be apparent soon enough, and not too late to endanger the child's grades and reputation among schoolmates and teachers.

Other rare side effects include irregular heartbeat, hair loss, decreased blood cell count, anemia, and rash.  Elevated liver function tests may be associated with Cylert®.  A rare hypersensitivity reaction consists of hives, fever and easy bruising.  Occasionally, ADD-children on stimulant drugs will experience a personality change characterized by dejection, lifelessness, tearfulness, and oversensititivy.  Conversely, some may develop a state of excitement, confusion, and withdrawal.

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