NEWS
: The FDA has approved
Strattera (atomoxetine), a nonstimulant, and the first new drug in
three decades for treatment of symptoms of attention deficit
hyperactivity disorder, or ADHD.
Deciding which medicine to use to treat your
child with Attention Deficit Hyperactivity Disorder used to be
easy. The big choice was whether to use generic or brand name
Ritalin.
There are now a much larger choice among stimulants
that can be used to treat ADHD. Many of the newer medications have
the advantage that they only need to be given once a day and can
last for up to 12 hours. Although there has been a sustained
release version of Ritalin, called Ritalin SR, available in the
past, most people found that it worked inconsistently.
In addition to not having to take a lunch time dose, the
sustained release forms of these medications have the benefit that
the medication is often still working after school, as your child
is trying to do his homework.
Fortunately, according to the American Academy of
Pediatrics, 'at least 80% of children will respond to one of the
stimulants,' so if 1 or 2 medications don't work or have unwanted
side effects, then a third might be tried. But how do you decide
which medicine is best to try first? In general, there is no one
'best' medicine and the AAP states that 'each stimulant improved
core symptoms equally.'
It can help if you are aware of the different
medications that are available. Stimulants, are considered to be
first line treatments, and antidepressants, are second line
treatments and might be considered if 2 or 3 stimulant medications
don't work for your child.
Stimulants include different formulations of
methylphenidate and amphetamine available in short, intermediate
and long acting forms.
The decision on which medicine to start is a little easier to
make if your child can't swallow pills. While there are no liquid
preparations of any of the stimulants, the short acting ones, such
as Ritalin and Adderall can usually be crushed or chewed if
necessary. The sustained release pills must be swallowed whole
(except for Adderall XR).
In general, whichever medication is started, you
begin at a low dose and work your way up. Unlike most other
medications, stimulants are not 'weight dependent,' so a 6 year old
and 12 year old might be one the same dosage, or the younger child
might need a higher dosage. Because there are no standard dosages
based on a child's weight, stimulants are usually started at a low
dosage and gradually increased to find a child's best dose, which
'is the one that leads to optimal effects with minimal side
effects.'
Long Acting Stimulants
The
long acting stimulants generally have a duration
of 8-12 hours and can be used just once a day. They are especially
useful for children who are unable or unwilling to take a dose at
school.
Adderall XR
The latest medication to get approval to treat ADHD is Adderall
XR, and it is approved for use in children over the age of six
years, although regular Adderall can be used in younger children
from 3-5 years of age. Adderall XR is a sustained release form of
Adderall, a popular stimulant which contains dextroamphetamine and
amphetamine. It is available as a 10mg, 20mg and 30mg capsule, and
unlike many of the other sustained release products, the capsule
can be opened and sprinkled onto applesauce if your child can't
swallow a pill.
Update!
New forms
of Adderall XR include a 15mg and 25mg capsule for greater
flexibility in dosing for your child.
Concerta
Concerta is a sustained release form of methyphenidate
(Ritalin). It is available as a 18mg, 36mg and 54mg tablet and is
designed to work for 12 hours. Like Adderall XR, it is only
approved for children over the age of six years.
Metadate CD
This is also a long acting form of methylphenidate
(Ritalin).
Ritalin LA
This is is a new long acting form of methylphenidate (Ritalin).
It is available in 10 (New!), 20, 30, and
40mg capsules. Unlike the other long acting forms of
methylphenidate, like Adderall XR, the Ritalin LA capsules can be
opened and sprinkled on something if your child can't swallow them
whole.
Short/Intermediate Acting Stimulants
With all of these new medicines available to treat ADHD, is
there still a roll for the older short and intermediate acting
stimulants? Should you change your child to a newer medicine?
It is compelling to think about changing to a new long acting
medication because of the conveninence of once a day dosing and
their long lasting effects, but it is important to remember that
they shouldn't be any more effective than a short acting
medicine.
Short/Intermediate acting stimulants include:
-
Ritalin (Methylphenidate HCl)
-
Ritalin SR
-
Methylin Chewable Tablet and Oral
Solution
New!
-
Metadate ER
-
Methylin ER
- Focalin: an short acting stimulant with the active ingredient
dexmethylphenidate hydrocholoride, which is also found in
methylphenidate (Ritalin). It is available in an 2.5mg, 5mg, and
10mg tablets.
-
Dexedrine (Dextroamphetamine
sulfate)
-
Dextrostat
-
Adderall
-
Adderall (generic)
-
Dexedrine spansule
s
Short acting Ritalin, Adderall and Dexedrine do have the benefit
of being available in a generic form, which are usually less
expensive then all of the other stimulants.
The new Methylin Chewable Tablet and Oral
Solution is a nice alternative for children with ADHD that can't
swallow pills.
Money Saving Tip: The prices of stimulants seem to be
based more on the number of pills in the prescription, rather then
on the total number of milligrams. So, instead of taking one 10mg
pill twice a day (60 pills), it is usually less expensive to get a
prescription for, and take, one-half of a 20mg pill twice a day (30
pills). Based on the average wholesale price for Adderall and
Ritalin, doing this could save you about 15-30% a month,
respectively. The savings based on the retail pharmacy price
usually seem to be even greater, often up to 50% a
prescription.
Side Effects
In general, side effects of stimulants can
include a decreased appetite, headaches, stomachaches, trouble
getting to sleep, jitteriness, and social withdrawal, and can
usually be managed by adjusting the dosage or when the medication
is given. Other side effects may occur in children on too high a
dosage or those that are overly sensitive to stimulants and might
cause them to be 'overfocused on the medication or appear dull or
overly restricted.' Some parents are resistant to using a stimulant
because they don't want their child to be a 'zombie,' but it is
important to remember that these are unwanted side effects and can
usually be treated by lowering the dosage of medication or changing
to a different medication.
Other Treatments
If 2 or 3 stimulants don't work for your child,
second line treatments might be tried, including tricyclic
antidepressants (Imipramine or Desipramine) or bupropion
(Wellbutrin). Clonidine is also sometimes used, especially for
children that have ADHD and a coexisting condition.
In addition to medications, the AAP policy
statement on the
Treatment of the School-Aged Child With ADHD
r
ecommends the use of behavior therapy, which
might include parent training and '8-12 weekly group sessions with
a trained therapist' to change the behavior at home and in the
classroom for children with ADHD. Other psychological
interventions, including play therapy, cognitive therapy or
cognitive-behavior therapy, have not been proven to work as well as
a treatment for ADHD.
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March 1st, 2008 at 1:23 pm
One of the worst thing about Ritalin is that it is so redily avaliable. I was floored when a friend of mine walked into a doctors office and convinced a doctor that he has focusing issuse and is try to get through the semester, implying ADD and the doctor wrote a percription for him without a formal DSM IV assessment by a psychologist.
Families need to be more vigilant about questions and not being affraid to get second opinions. This is a mistake me and my family made, which is why I mention this. We just assumed this “sepcialist” was looking out for my better interests and when I was perscribed 9 Ritalin a day, supposedly beause my body was developing a esistance to it …..I began thinking there was a problem.
I think this needs to be nipped in the butt by the professionals and stricter regulations on perscritions need to be in place, as well as assessment tools more easily accessable for those who do have ligitimate concerns about their state.
Its a pharmaceutical free for all out there and people are going to continue to get hurt.
March 6th, 2008 at 2:58 am
“I have experience with teens who realized that their dealer doesn’t want Concerta - so they come back to the doctor with a story about how they want short acting Ritalin. It is not necessarily for their ADHD - they may see it as an easy way to pay for their habits with marijuana or other street drugs.”
Hi Kenny-
I worry that your advice to parents might be a bit too narrow.
While addiction is certainly a concern with Ritalin and Adderall, parents should take an active interest in their kids’ lives, rather than just flippantly switching them to non-addictive meds. Frankly, that sounds like a lazy, simplistic solution to a complicated, nuanced situation. What about encouraging parents to listen to their kids, in addition to being suspicious of them?
I’ve taken short-acting Adderall for almost a decade, and never once sold my meds to drug-dealers. When the less-addictive Stratera hit the market, I was enthusiastic about it. But I found that it gave me horrendous stomach aches and did nothing whatsoever to treat my A.D.D. Thankfully, my parents trusted me, rather than requiring me to take an ineffective drug that gave me stomach pains.
March 6th, 2008 at 3:09 am
I was on prescribed Ritalin from 1994 to 2002; I was 61 when I started. Watching a TV special program convinced me that I had ADHD. This was one of those defining events in my life. I went for psychiatric counseling for 5 years and group for 2 years.
From the start, I was conscious of a desire not to become overly reliant on a drug and discussed with my psychiatrist the need to ween myself off of the drug later in life. When I did not take Ritalin for a few days or weeks, I seemed to really notice an improvement in memory and functioning (as did some of my friends) like a reduction in the frequency of not remembering what I came into the room to do and an ability to sit at the computer for longer periods of time.
My psychiatrist and I discussed a possible side effect and that was that the drug kind of put a damper on creativity and I did not want that to happen on a regular continual basis. I wanted to be creative when I wanted and have more control over myself at times when self-control was really called for. About that time a friend showed me how to grind up the pills and snort them. He called Ritalin “the poor man’s coke”. I really did not see anything wrong with this. In fact, I thought it was great improvement from taking a prescribed dosage every morning and night. It gave me the control I wanted that allowed me to the “creative meeting interrupter” when I wanted and the more controlled observer when I wanted.
Soon, I learned that I could mix a little cocaine powder in with the Ritalin and even be more productive when I needed to be. I went on to a more than casual involvement with illegal drugs. I was attracted to this community more because I needed friends at that time in my life and it was not till I tried Crack Cocaine that I began to experience symptoms of addiction. I was able to stop the dependence on Crack but not until 3 or 4 possession arrests and finally a charge for “intent to distribute”. I made life very difficult for myself but at the same time I was forced to faced the shame demons from my childhood that gave me the feelings of low self-worth which lead to my experimentation with drugs and even worse full blown co-dependency problems.
I am now 73 and am trying to develop some source of income to replace all that I lost and, although the pressure to succeed are extreme, I am managing to avoid drugs — for one thing I can’t afford them but on another level, I feel if I cannot use them when I need them then I risk the chance of becoming to reliant on them, I know others will say: “but thats the essence of addiction (taking drugs when you feel you need them rather than having some doctor who doesn’t really know how I feel tell me to take two in the morning and two in the evening. Frankly, I would rather avoid the whole drug thing and find some other way to adjust to life with people who happen to be from another planet than me.
March 7th, 2008 at 3:17 am
I’d like to say that your assertion that Adderall XR is not abusable is absolutely not true. I know this because I used to abuse Adderall XR recreationally for a few years. All you have to do is crush the little orange time release balls into a fine powder and eat it and you can get very “high” (anything from 30 to 90 mg total, or 2-4 pills). However, we frowned upon snorting it, no matter what kind of Adderall it was.
March 24th, 2008 at 9:07 pm
Hi Dr. Kenny
I read an article in Israeli newspaper that in examination period in one of universities Ritalin is popular among students. Regular students, without ADHD, try to buy the med illegally, they say they take Ritalin and just learn like rockets, this make them hyper focused before exams. Ohhh. I am scared to give meds to my ADHD son, and they …
I do alternative treatment with my son - to stop ADHD, to cure him of this. These are crawling exercises. Welcome to my site - watch our videos, crawling.
Arieh
CrawlingClub.org
June 2nd, 2008 at 6:01 pm
Hi Arieh and Dr. Kenny and everybody,
So, uh, I didn’t do crawling exercises, but I have to tell you that Ritalin and Concerta do NOT help me to HYPERfocus. They help my behavior, my hyper-emotionality, and my distractability, but I do not “learn like a rocket,” or whatever the phrase is. If you have ADHD, this medication will not make you hyperfocused. It will make you average, normal, adaptable. And it will help you to make positive changes in your life. Crawling sounds fun, but I’d rather take a pill and get on with my life.
June 13th, 2008 at 1:37 am
Before I share my thoughts on this article, I’d like to offer a bit of praise for the author.
As both a healthcare professional (nurse practitioner, diabetes educator) and a mother of four children, three of whom have been diagnosed with ADD and/or Adult ADD, this is an issue that hits particularly close to home. Naturally, I tend to seek out information about ADD and related topics, and I breathed a sigh of relief tonight when I first made my discovery of your blog.
I have read about eight of your articles since I first came upon this blog a few hours ago. I must say, so far I have been very impressed with what I’ve read.
Now for my thoughts regarding the subject of abuse of ADD medications, I suspect that the reason many of these teens and young adults may seek to avert Concerta is actually far more benign that an intention to resell the drugs. One of my own children with ADD tried Concerta long before ever trying Ritalin or Adderall. The therapy lasted for over a month, and my child reported no significant improvement in the condition. That same child found noticeable results the very first time taking Adderrall. This child didn’t even want to go see the doctor, much less take the medication, and certainly hasn’t been selling it.
My hypothesis is that many of these kids may simply not find Concerta effective. These kids will likely pass this information along to their friends when questioned about ADD by a friend who thinks he/she may suffer from the condition.
Granted, this will not hold true in some cases, and there is undoubtedly abuse taking place in some circumstances. However, I don’t agree though with the notion that a specific request for an alternative to Concerta is a tell-tale sign of drug-dealing activity or recreational drug habits by either the patient seeking the medication or his/her friends.