Medications

Stimulants. Adderall, Ritalin, Concerta, Dexedrine, and Cylert are the available stimulant medications currently on the market. Cylert is less effective and associated with a potentially fatal liver dysfunction therefore it is rarely used. However, I do find that very few patients, about 1 in 1500, will respond to Cylert and no other stimulants. Currently a signed consent form is suggested in order to administer this medication.

Strattera. A newly introduced medication named STRATTERA (atomoxetine HCI) is available from January 2003. This is a new, non-stimulant, non-controlled substance medication from the Eli Lilly Company. Straterra works on a different neurotransmitter compared to the stimulants that increase dopamin activity. Straterra is a selective norepinephrine reuptake inhibitor, meaning it increases the norepinephrine activity. Straterra is available in 5mg, 10mg, 18mg, 25mg, 40mg, and 60mg capsules. The target dose is 1.2mg/kg in a single daily dose, but should be initiated at 0.5mg/kg to prevent side effects. In some patients (kids over 70kg body weight or adults), the dose was pushed up to a maximum of 100mg per day in a single daily dose or evenly distributed in a morning and late evening dose.

Side effects may include allergic reactions (rare), weight loss, mild growth retardation, hypertension and rapid heart rate, orthostatic hypotension (feeling dizzy when getting up from sitting due to a fall in blood pressure), urinary retention, dry mouth, abdominal pain, irritability, constipation, nausea, sleeping difficulties, erectile and ejaculatory disturbances. The experience with Straterra is limited to the use in about 2000 children and adolescents and 270 adults. It is too early to talk about any possible long-term side effects, but the FDA assures us that this is a safe medication. Further updates will follow.

Adderall. Adderall is my first line medication for AD/HD. It is safe, effective, long acting (6-10 hours) and easily dosed. Unlike Ritalin, which is slow acting and comes in 20mg sustained release (SR) tablets that cannot be broken into smaller pieces, Adderall comes in 5, 7.5, 10, 12.5, 15, 20, and 30 mg tablets, all scorable to halves and quarters that make dosing much easier, enabling one to customize the dose specifically to the child's needs. A newer form of Adderall is the Adderall XR or "extended release." This Adderall stays in the system for 12 hours, covering the homeworks needs and some of the evening difficulties. The Adderall XR comes in a capsule form at 5mg, 10mg, 15mg, 20mg, 25mg, or 30mg. Another advantage is that this medication comes in powder form that may be sprinkled on food, overcoming the need to swallow tablets or crush and ingest tablets that taste badly.

Treatment expectations. The treatment with stimulant medications is the backbone of treating AD/HD and the most important and effective measure of it. Parents have to be prepared for the fact that treatment may be prolonged. I like to compare treatment with stimulants and AD/HD in general, with placing glasses on eyes "which are out of focus." This approach and understanding helps the child deal with his condition on a more acceptable level, not as a mental or psychiatric disorder, but more as a physical disability. I tell them, "Your attention span is out of focus. Taking Adderall in the morning is doing for your attention span what my glasses do for my eyes." They are also told that "Without my glasses, despite having the ability to do well, I will not be able to read and I will most likely fail." The same applies to AD/HD and medication. The parents should understand that fluctuating grades, a common aspect of AD/HD, may be similarly explained. A child who needs glasses, without them may do poorly, but when a lot of pressure mounts on him he will give it a great effort, placing his face close to the books, trying very hard to satisfy his parents, eventually succeeding to get a good grade because he has the mental ability. This effort, however, will be very difficult to maintain and a relapse to the lower grades is expected. The same thing may happen to children with AD/HD, resulting in their parents blaming them for being lazy, "Because you can do it, you have done it before." This leads to increased frustration and more friction within the family.

Stimulants correct the underlying physiological abnormality causing AD/HD by increasing dopamine concentrations in the brain. The effect usually starts 1/2 hour after taking the medication. And with Adderall preparations, this lasts for an average of 8 or 12 hours. The effects must be clearly noticeable; a "questionable" response is unacceptable. Stimulants work in 70-80% of children with AD/HD. The effect of the stimulants may completely or partially correct the AD/HD. Once AD/HD is corrected, comorbid disorders may become more clearly noticeable. These include ODD (oppositional defiant disorder), anxiety disorder, OCD (obsessive compulsive disorder), and PDD (pervasive developmental disorder). These will be discussed in the next section.

Dosing and side effects. Dosing with the stimulant medication is not clearly formulated. This is more of an art than a science and requires sensitivity to improvements and side effects. Parents (rightfully) are most concerned with side effects. Even though side effects may exist, I like parents to regard AD/HD treatments with medications as a risk free proposition. "You like it, we will go ahead. You don't like it, we can always stop." I promise my patients' parents that I will not let their children have any side effects. This however places a great responsibility upon the parents to watch, observe, and be sensitive to any undesirable changes that only they can detect, such as minor "changes in personality, mild irritability, etc." Therefore, any changes with doses of medications should only be made over weekends and holidays, so that possible dose related side effects may be readily observed and corrected. About 80-90% of side effects are dos related and resolve as proper adjustments are made.

Dosing with Adderall starts low and is gradually increased, as directed by the physician, until the best effect is obtained. Certain increases may be made only on a weekly basis. And if side effects are observed, the dose should be decreased to the previous one that did not cause any side effects. This approach may enable the child to be without any undesirable effects.

Some side effects of the stimulant medication include, most commonly, a decrease in appetite. An allergic reaction (rash), which is an indication to stop the medication and never use it again, is rare. Side effects that are dose related (too much medicine) include increased irritability, tiredness, and "zoning out" (being too focused on one thing). These respond to lowering of the dose. In about 2% of children, nervous tics may develop, eye twitches, facial grimacing, neck movement, or frequent throat clearing. This may require stopping the treatment or decreasing the dose. Other unusual side effects may include abdominal pain, headaches, sleeping difficulties (if dosing late in the afternoon), and increased heart rate. No fatality was directly related to stimulant medications if dosed appropriately.