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.

When children and adolescents with severe behavioral and emotional symptoms do not respond to stimulant medications, other types of medications may be prescribed. These include antidepressants such as Wellbutrin®, Desiprimine and Prozac®. Sometimes, medications originally designed to treat high blood pressure such as Clonodine may be used. In other cases, medications used to treat psychosis, schizophrenia or to manic-depressive illness may be prescribed. The current thinking is that (in most cases) if these medications provide control for the symptoms, they are actually treating another mental disorder rather than attention deficit disorder. Unfortunately, some physicians may initially prescribe a medication other than a stimulant because the other medications do not require "triplicate" prescriptions as they are not considered controlled substances by the FDA. While this may be convenient, the other medications have far more serious side effects than the stimulants and should not be considered unless there is reasonable clinical information to support their use over stimulants.