Stimulants for attention deficit hyperactivity disorder

Examples

How It Works

Stimulants affect how the brain controls impulses and regulates behavior and attention. They do this by influencing the availability of certain chemicals, called neurotransmitters, in the brain.

Why It Is Used

Stimulants are considered for people with moderate to severe attention deficit hyperactivity disorder (ADHD) who have difficulty in at least two different settings, such as school and home.¹ Stimulant medications with amphetamine, such as Adderall, that are used for the treatment of ADHD are approved by the U.S. Food and Drug Administration (FDA) for children age 3 and older. Stimulant medications with methylphenidate, such as Ritalin, are approved for children age 6 and older. A doctor may prescribe Ritalin for a child under age 6 based on the child's specific needs.

• Methylphenidate (such as Ritalin or Concerta) is often the preferred choice for treating ADHD because it has fewer side effects than other medications and generally works well to control behavior.
• Dextroamphetamine or the combination dextroamphetamine and amphetamine (Adderall) is usually the second choice when the person does not improve with methylphenidate. However, either may be the preferred medication in older children. The long-acting form of dextroamphetamine controls behavior for a longer period of time, so fewer doses are required during the day.
• The dextroamphetamine and amphetamine combination medication (Adderall) is used when other stimulants have not improved symptoms or when the combination of medications may be more beneficial.

Stimulants may be used in people with ADHD who also have mood disorders, such as depression. The priority of which condition is treated first usually depends upon age. In children, symptoms are treated first with stimulants; in adults, the mood disorder is usually treated first with antidepressants or other medications.

Stimulants may be used in adults when antidepressants fail to control ADHD symptoms. If antidepressants alone are not controlling symptoms, stimulants may be added.

How Well It Works

Stimulants may be the most effective treatment for the symptoms of ADHD: inattention, impulsivity, and hyperactivity. These medications can suddenly and dramatically improve behavior. However, some people need to try different types and dosages of stimulants to find the one most effective for them. If treatment with a stimulant is successful, it usually helps control symptoms over time without increasing the dosage.¹

In about 70% of people with ADHD, stimulant medications improve their symptoms.¹ In children, 75% to 80% improve after starting a stimulant medication.²

Children often become calmer, more organized, and less stubborn. Examples of behaviors that improve include:¹

• Less interrupting, fidgeting, and finger tapping at school; increased on-task behavior.
• Better relationships at home between parents and siblings; better focus and on-task behavior; better compliance with parent requests and authority.
• Improved social relationships; increased attention during sports and other activities.

Although stimulants may also improve social adjustment or academic performance for some children, they have not been shown to maintain this benefit over the long-term.

A recent study found that children with ADHD whose symptoms were predominantly related to inattention showed significant improvement with lower doses (36 mg or lower) of long-acting methylphenidate (Concerta) and had less benefit from higher doses. In children with ADHD who had symptoms of both hyperactivity and inattention, most showed increased improvement in symptoms at higher doses (36 mg to 54 mg). However, higher doses resulted in increased insomnia and decreased appetite in both groups of children.³

Side Effects

The most common side effects (affecting about 50% of people) of stimulants are usually related to the dose and go away after the first 2 to 3 weeks on the medication. Persistent side effects can usually be relieved by changing the dosage level, changing when the medication is given, or trying a different type of stimulant. The most common side effects include:

• Decreased appetite. About 80% of people have decreased appetite. The appetite is usually least during the daytime, increasing in the evening. If the medication is given after meals and snacks are added, especially in the evening, it may help improve the child's appetite and prevent weight loss.
• Difficulty falling asleep.

Other side effects are also usually temporary or go away with dosage adjustment. These include:

• Stomachache.
• Headache.
• Slightly increased blood pressure (in black males).

Although short-term studies have shown stimulant medications to be safe, long-term effects have not been studied. In a recent 2-year study, children who took stimulant medication grew almost 0.5 in. (1.3 cm) per year slower than those children not on medication. The study followed 540 youngsters with attention deficit hyperactivity disorder (ADHD), who were ages 7 to 9 at the start of the study. However, studies differ on whether delayed growth is shown in children who are taking medication for ADHD. More studies are needed to determine whether growth is affected at other ages (younger than age 7, older than age 9) and whether children taking these medications might catch up over a period of time.⁴ As with any medication, parents should balance the benefits their child might receive from these medications with any potential risks.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Some experts warn that these stimulant medications used to treat ADHD may increase the risk of heart attacks and strokes, especially in adults. Be sure to tell your doctor if your child or anyone in your family has had heart problems, high blood pressure, dizziness, fainting, shortness of breath, or severe tiredness. Tell your doctor if anyone in your family has died suddenly. Most people who have a history of heart problems should not take stimulant medications. Talk to your doctor about the benefits and risks of these medications.

Methylphenidate and dextroamphetamine usually take effect within 1 hour after the first dose. Talk to your health professional about the best time to take the medication.

Treatment with stimulants may be continued as long as the symptoms are present, the medication continues to work, and there are no significant side effects.

People with ADHD do not tend to abuse stimulant medications and very rarely develop dependence (addiction) on the medication. In addition, there is no evidence that people with ADHD who take stimulants are at greater risk for abusing other drugs. In fact, people who take stimulants for ADHD may be less likely to abuse drugs.⁵

Some people buy or steal stimulant medications. Parents need to be certain that their child takes his or her medication and does not share it with or sell it to anyone else. If this is a concern, talk to your doctor about your child taking a medication in a safer form.

Canadian health authorities stopped sales of Adderall XR in Canada, but after carefully reviewing the data, the drug was returned to the market. Health Canada withdrew the medication from the market after learning that Adderall XR and Adderall (sold in the United States, not in Canada) have been linked to 20 sudden deaths and 12 strokes in children and adults in the U.S. After reviewing the Canadian decision and the medical reports, the U.S. Food and Drug Administration (FDA) has not recommended any immediate changes in the FDA labeling or approved use of this drug. The FDA recommends that you talk to your doctor if you have any questions or concerns about using this medication.⁶

When stimulants are used to treat ADHD, remember that:

• If a dose is missed, do not increase doses to catch up. If several doses are missed, begin taking the medication again on the regular schedule.
• Methylphenidate often needs to be given every 3 hours to prevent the symptoms of ADHD from coming back.

Tips for giving methylphenidate or dextroamphetamine to children:

• It is best to start the medication on the weekend so you can see how the child reacts to the medication.
• A low dose of methylphenidate is usually given at first. The dose is increased until the child's behavior is controlled. It is important to follow the prescribed dosage schedule and watch for changes in behavior.
• A typical schedule for giving the medication is after breakfast and lunch and in the afternoon. Schedules may be changed to suit the needs of the child, his or her family, and school. It is better to give the medication after meals rather than before so it doesn't interfere with the child's appetite and weight gain.
• Most children who take stimulants for ADHD function best when medications are used continuously. However, some children may function well enough to take a break from medications on weekends and holidays. Even for these children, it is usually helpful to continue the medication on weekends if activities are planned that require concentration and attention, such as team sports, church activities, or educational programs.

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