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Medical Treatment

Robert Wolff, MD and Martin L. Kutscher, MD.

New FDA Information about Strattera and harmful behaviors

New FDA Information about Adderall

New FDA Information about Antidepressants

New FDA Information about liver issues and Strattera

Ritalin and Related Stimulant Medications

What are stimulant medications?

Ritalin (methylphenidate), Concerta (a long lasting capsule form of methylphenidate), Dexedrine (dextroamphetamine), Adderall (a mixture of amphetamines) and Cylert (pemoline) are sometimes called "stimulants". When prescribed for people who have ADHD, they stimulate the frontal parts of the brain which are not inhibiting ("filtering out") distractions as well as they should. The medications work similarly to caffeine. They are not tranquilizers or sedatives. The children appear "calmer" because they are more focused, not because they are sedated. Many children require medication in order to give them the basic tools needed to work on behavioral modifications.


How can these medicines help?

They can improve attention span, decrease distractibility, increase ability to finish tasks, improve ability to follow directions, decrease hyperactivity, and improve ability to think before acting (decrease impulsivity).

Legibility of handwriting and completion of school work and homework can improve. Aggression and stubbornness may decrease in youngsters with ADHD.

Stimulant medication is not the only answer for ADHD! The medicine often works best when used together with special help in school and behavior modification procedures at home and school. Some youngsters and families also benefit from individual, family, or group psychotherapy. If stimulant medications do not help, or cause side effects that are a problem, you can discuss other medications with the doctor.


Should the medicine be taken for homework and weekends.?

The quick answer is: take the medicaton whenever it would lead to the next few hours being a more positive experience for the child. Certainly, this would usually include school hours. However, homework time usually benefits from medication as well, even though many parents try to "tough it out" at home without the medication. Unfortunately, this "martyr" approach--while lovingly intended--is often a mistake for both the child and the parents. It leads to lengthy and excessive yelling sessions during homework, and wears away at family enjoyment of their time together. Isn’t your child’s relationship with you and the rest of her family as important as her school grades? Use of the longer lasting preparations may help eliminate the need for a third dose after school.


How long does the medicine last?

Ritalin and Dexedrine last 3 - 4 hours. Sustained-release Ritalin (SR), Dexedrine Spansules, and Cylert may last at least 6 - 8 hours. Concerta should last 10 hours.


How will the doctor monitor this medicine?

From time to time, the physician (or nurse) will check height, weight, pulse, and blood pressure. When Cylert is used, blood is taken to check on the liver function and blood count -- usually before starting the medicine, and occasionally afterward. The doctor will ask for regular reports from your child’s teacher(s) to check on learning and behavior.


What side effects can this medicine have?

Any medication may have side effects, including allergy to the medication. Because each patient is different, your doctor will work with you to get the most positive effects and the fewest negative effects from the medication. The list below may not include rare or unusual side effects. It is important to note that except for a fraction of the children who experience mild appetite or sleep problems, the vast majority of people have no significant side effects from Ritalin.

Lack of appetite (Handle by encouraging a good breakfast, and afternoon and evening snacks; give medicine after meals, rather than before. Problem usually resolves.)

Trouble falling asleep, which usually improves over several weeks.



Irritability, crankiness, crying, or emotional sensitivity.

Rapid pulse or increased blood pressure.

Rarely, as the medicine wears off, hyperactivity or bad moods get worse than before the medicine was started. This is called "rebound". The doctor can make dosage adjustments to help this problem.

A few children may not grow quite as fast as usual. Current research suggests that the culprit is ADHD itself, not the medications used to treat it.

Occasionally, nervous habits (like picking at skin) or stuttering may appear.

Muscle tics or twitches, jerking movements. It is not clear that these tics can ever be permanantly induced.

There have been concerns regarding possible heart issues for certain populations. Ask your doctor.

Rarely, may cause behavioral changes such as induction of bipolar, mania, or psychosis.

Please talk to the doctor if you suspect the medicine is causing a problem.


What could happen if this medicine is stopped suddenly?

There are no medical problems in doing this. A few youths may experience irritability, trouble sleeping, or increased hyperactivity for a day or two, if they have been on daily medication for a long time, especially at above average doses. Occasionally, it is better to stop the medication gradually, over a week or so.


How long will this medicine be needed?

There is no way to know how long a person will need to take the medicine. The parent, the doctor, and the school will work together to find out what is right for each young person. Sometimes the medicine is needed for only a few years, but some people may need help from medicine even as adults.


What else should I know about this medicine?

Many people have incorrect information about this medicine. If you hear anything that worries you, please check with the doctor.

This medicine does not cause illegal drug use or addiction.

This medicine does not stop working at puberty.

Some young people take the medicine three or four times a day, every day. Others only need to take it twice a day or once a day on school days. Your doctor and you will work out what is best.

If a dose is missed, just pick up with the regular dose at the next scheduled time. Do not double up the next dose.

It is important not to chew Ritalin Sustained Release tablets or Dexedrine Spansules, because this releases too much medicine all at once.

If the medicine seems to stop working, it may be because it is not being given regularly (especially at school), because your child has gained weight and needs a higher dose, or because something at school or at home, or in the neighborhood, is upsetting your child. Please discuss your concerns with the doctor.


Other Medications for ADHD

In addition to the stimulant medications, there are several other medicines that may also be extremely useful. As anxiety and depression may be very frequent components of Attention Deficit Disorder, it is important to recognize that medicines with an anti-anxiety or anti-depressant effect may prove to be of significant help. The following medications are considered for such therapies:

Strattera (atomoxetine)

Strattera is a recently FDA approved medication for the treatment of ADHD. It selectively increases norepinephrine levels in multiple brain areas, and dopamine levels only in the frontal lobes. As such, it is more “selective” than the “stimulants.” Preliminary data suggest that it may not increase tics, insomnia, or anxiety in ADHD patients; and that it may have a role in improving family interactions over a 24-hour period.  While initial data look promising, more direct comparisons with the stimulants and more long term follow up will be needed to see if it is truly as effective as the stimulants. For more information on Strattera, see http://www.johnswank.com.  Recent warnings regarding possible liver damage and harmful behaviors can be found above.


Catapres (clonidine) and guanfacine (Tenex)

Catapress and Tenex are "alpha agonists" which have been been chiefly used in the treatment of hypertension in adults. They has been of some use in youngsters with attention deficit problems, particularly for the symptoms of impulsivity. They have been also used to some degree in the treatment of youngsters with tic disorders, such as in Tourette’s syndrome. These medications have a potential sedating effect and are probably best given at bedtime initially. Catapres is sometimes used in youngsters who have insomnia to allow them to go to sleep at night at a more reasonable hour. Headaches, dizziness and fatigue are occasional problems with the use of these medications, and need to be monitored carefully. Blood pressure needs to be periodically followed, but rarely becomes a significant problem. Sudden changes in the regimen can cause blood pressure swings, and should be avoided.


Tofranil (imipramine)

This "tricyclic antidepressent" is frequently used as an adjunct to the treatment of ADHD. It provides an anti-anxiety effect without sedation, as well as some improvement of inattention.

When given before bedtime, it may allow the youngster to fall asleep more readily.

In many children, when a stimulant medication is used, they become more focused on their sense of anxiety regarding school performance, social performance, etc. There are many occasions when starting him/her on treatment with Tofranil or a similar agent may be useful even before initiating a trial of stimulant medicine such as Ritalin.

Increasingly, Tofranil has been used for many years by pediatricians in the treatment of simple bed wetting. In this regard, it has a long safety record. All medicines, of course, have side effects, and Tofranil has its own special list. Perhaps the greatest concern is if the dosage exceeds more than 2 milligrams per kilogram, and here there is a small possibility of a potential adverse effect on the cardiac or heart conduction systems. An EKG may be monitored. More commonly, the higher dosages are not at all required in the treatment of mild anxiety. Additionally, there are very rare case reports of liver and bone marrow toxicity. If a youngster is maintained on medication for any length of time, routine blood work to check these functions is performed. Occasionally, constipation, dryness of mouth, blurry vision, fatigue and rapid heartbeat may occur.

Unlike stimulant medication, Tofranil does not work immediately, but often takes close to two weeks before there is any perceived benefit. The most likely benefit is an improved ability to tolerate frustration. The youngster may appear to be more outgoing and sociable as well.

Tofranil is itself a member of a medication group known as the tricyclics. In much higher dosages, these medications are used as anti-depressants. In low dosages Tofranil and similar agents have been used in the treatment of anxiety attacks. See FDA link above about possible relationship of antidepressants to thoughts of self-harm.


Elavil (amitriptyline)

Elavil is very similar in its chemical composition to the above-mentioned Tofranil. Elavil is also widely used in the treatment of migraine headaches. Elavil has a tendency to cause a much greater sedation than Tofranil, and is particularly useful in youngsters who have a significant sleep problem. It is given usually an hour before bedtime. Similar to Tofranil, it usually takes a few weeks to show benefits, which include lessened anxiety and a greater threshold for frustration. Its spectrum of side effects is very similar to that of Tofranil. When given in high dosages, it is used also as an anti-depressant medicine. See FDA link above about possible relationship of antidepressants to thoughts of self-harm.


Prozac (fluoxetine), Luvox, Zoloft, Celexa

The Selective Serotonin Re-uptake Inhibitors (SSRIs) such as Prozac are increasingly used in the treatment of depression, obsessive compulsive disorder and anxiety. It may have some beneficial effect in ADHD, but most evidence at present is anecdotal. Its increased use by physicians reflects its relative effectiveness as well as safety. Biochemically, it acts as a serotonin uptake blocker. It comes as both a tablet and a liquid.

During its initiation, it may paradoxically cause a slight increased degree of nervousness or disinhibition. It may also cause some decreased appetite or headache. It appears that Prozac can be safely given with stimulant medication, such as those mentioned above. The medication requires a long time to show effectiveness – anywhere from six to eight weeks. See FDA link above about possible relationship of antidepressants to thoughts of self-harm.


Wellbutrin (bupropion)

Wellbutrin is considered a "novel antidepressant." with dopamine agonist and noradrenergic effects. It clearly improves aggression and hyperactivitiy, as well as cognition and inattention. Although usually well tolerated, it may rarely precipitate tics or seizures.


Risperdal (risperidone)

Risperdal is an "atypical neuroleptic" that is quite effective in the treatment of tic disorders and explosive behaviors. Its role in the treatment of inattention is debated. Side effects include possible weight gain, sedation, and rarely a serious reaction called malignant hyperthermia. The risk of a permanent movement disorder (called tardive dyskinesia) related to its long term use is probably quite low. See FDA link above about possible relationship of antidepressants to thoughts of self-harm.

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Selected Web site

Internet Mental Health has an excellent pharmacy section.
For more information on Strattera, see http://www.johnswank.com.


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