ADD/ADHD Articles

Quick Reference on Stimulant Medications and ADHD

Psychostimulants

By Jay D. Tarnow, M.D.

Psychostimulants stimulate the release of norepinephrine and dopamine from the nerve terminals in the attention center of the brain. Of the pharmacologic options available for ADHD, stimulants are the most studied, most commonly used, most effective, and are usually the first used agents for treatment.

Stimulants Improve Core Symptoms

• Inattention
• Impulsivity
• Hyperactivity

AND

• Impulsive aggression
• Social interactions
• Academic productivity accuracy

Advantages of Stimulants

• Specifically treat ADHD core symptoms of inattention, highly active, and impulsiveness
• Largest effect on ADHD of any drug class, especially for children
• Significant benefit in 90% of ADHD if two ore more tried in succession and titrated carefully
• Calms comorbid aggression and oppositional-defiant behavior
• Results of given dose seen immediately; relatively easy titration

Stimulant Side-effects (most common):

• Insomnia
• Loss of appetite
• Rebound of hyperactivity after medication wears off
• Irritability
• Stomachache
• Headache
• Over focusing, compulsive behaviors
• Weight loss

Signs of Over dosage:

• Increased hyperactivity
• Overly obsessive behavior or anxiety
• Social withdrawal
• "Zombie-like" appearance or sedation
• Increased blood pressure and pulse

Potential Side Effects (proven safer than most psychiatric medications)

(None of these side effects are dangerous for healthy children.)

Side effects are usually experienced when medication is started and decreases over time.

Tics

There is an increased risk that children will develop these symptoms if there is a familial predisposition to Tourette's Syndrome. Children who have undetected Tourette's may develop tics and the full-blown symptoms of the disorder. Less than 5% have tics and the incidence of Tourette's is very rare. Symptoms of Tourette's are more pronounced under stress.

Appetite Suppression

This may be more of a problem if medication is given before meals. Appetite will usually return when the effects of the medication have worn off. Approximately 50-60% complain of appetite loss; 50-60% of difficulties falling asleep; and 20-40% of stomach cramps and headaches when first starting the medication. There may be mild increases in heart rate and blood pressure. Mild weight loss may occur in the initial first or second month, but no overall effect on skeletal growth. Very rarely, children can experience a growth slow down if they continue to lose weight. There are easy methods to deal with this such as adjusting medications, allow time periods where appetite is not suppressed, and using protein drinks at bedtime.

Behavioral Rebound

Increased excitability, talkativeness, impulsivity, or insomnia may appear 5 to 20 hours after the last dose treatment. Rebound resembles a return of the original symptoms after the medication wears off, except that the magnitude of symptoms actually increases above the baseline. Rebound has been clearly demonstrated in normal children and has been described, but less well documented, as a clinical problem.

Impaired Cognitive Performance

Mainly observed at high doses and probably represents the toxicity of over medication. Single doses of methylphenidate above 1mg/kg have been repeatedly found to impair cognitive functioning. In predisposed children who may have Bipolar Disorder, psychotic or psychotic-like symptoms which include hallucinations or delusions, mania, stereotyped or compulsive behavior, and self-biting may occur.

Neuropsychiatric Effects

Include tics or other abnormal movements, night terrors, and lip-licking or biting. Occasional adverse effects include dizziness, nausea, nightmares, constipation, lethargy, fatigue, anxiety, fearfulness, hypercusis (increased acuity of hearing), rash, hives, and a sensation of "ants crawling on skin." However, these effects are uncommon.

Relative contraindications:

Amphetamines should not be used in patients with known psychosis, a history of symptoms suggestive of a risk for psychosis, or a history of substance abuse in an adolescent or adult patient, peers, or immediate family members without careful monitoring. Other contraindications include a child with a family history of tics or Tourette's Syndrome, cardiac abnormalities or high blood pressure abnormalities, seizure disorder, or severe side effects in a previous stimulant trial.