To parents and professionals: Consider medication in addition to, but not instead of, other treatments, such as behavior and learning strategies.
HOW RITALIN WORKS
Every time you think or act, messages travel from one nerve to another telling the brain what to do. The messages are carried by neurotransmitters, chemicals secreted at the junction between brain cells to facilitate transmission of messages. Neurotransmitters include the chemicals norepinephrine, dopamine, and serotonin, names you may have run across in reading about other mental and physical disorders. Stimulant drugs are thought to increase, or stimulate, the secretion of neurotransmitters.
Here’s the theory that explains why stimulants help the child with A.D.D.: in children with A.D.D., the brain centers that influence attention (learning) and impulse control (behavior) are under aroused, and all the wiggling and counterproductive behavior these children engage in is actually an attempt to arouse these laid-back parts of the brain. By increasing the levels of neurotransmitters in the brain, stimulant medications arouse these learning and behavior control centers so that the child can pay appropriate attention and control inappropriate behavior. Stimulants work on centers of the brain whose function is to inhibit impulsive behavior. This explains the paradox of giving a stimulant to calm the child down. The drug acts like a disciplinarian reinforcing “yes, you may not do that” messages. Stimulant medications are often described as “putting brakes on the brain,” but in fact, what they really do is make the brain work better, so the child doesn’t have to daydream or bounce around in his seat to keep his brain waves working. Stimulants provide sort of a “zoom lens” that helps the child narrow his focus from general arousal to the task at hand.
ARE STIMULANTS SAFE?
Stimulants are generally regarded as safe drugs. They were first used for hyperactive children in the 1930′s, so they have been in use now for more than sixty years. Yet, like all medication, they are not a problem-free pill. I first began prescribing Ritalin for A.D.D. in 1972. Thirty years and hundreds of prescriptions later, I am impressed by how few undesirable side effects occur. When side effects do occur, they are minor and wear off quickly when the drug is stopped. Other physicians have different experiences, and some have observed complications severe enough that they have virtually stopped prescribing these medications. Prescribing and administering Ritalin is a decision parents, teachers, and health professionals must take seriously. The United States Drug Enforcement Administration (DEA) certainly does.
Because of the low incidence of side effects, it is tempting to regard using Ritalin as no big deal. It is even jokingly referred to as “Vitamin R,” a sort of “It can’t do any harm and it might help” classification. But the DEA lists Ritalin as a Schedule II drug, which means prescriptions for it are carefully regulated. Along with other drugs in this category, such as morphine and barbiturates, it is considered at high-risk for abuse. (The street drug culture would classify Ritalin as speed.) Doctors who prescribe it are required to obtain an expensive narcotic license, renew it every two years, and write the prescription (with annoying perfection) on special triplicate prescription pads provided by the DEA. The doctor retains a copy, the pharmacy retains a copy, and the DEA retains a copy. To further avoid “prescribing abuse” the doctor is limited by law to prescribing a one-month supply and the child must be reevaluated each month. A prescription for Ritalin cannot be called into the pharmacy over the phone; instead, the completed official prescription form must be mailed or handed directly to the patient. If the doctor forgets to cross a “t” or dot an “i” the pharmacist sends it back for fear that someone may have tampered with the prescription. The point is everyone involved with prescribing Ritalin takes it seriously, especially the doctor, the pharmacist, and the DEA, and so must everyone else.
It would be great if these medications worked selectively, that is, only on the brain functions concerned with attention or focusing ability (A.D.D.) or the areas that control movement and impulsiveness (A.D.H.D.), but they don’t. Ritalin and other stimulants have a wider action in the brain, which is clear from the four side effects that have been identified by placebo-controlled research: decreased appetite, insomnia, headaches, and stomachaches. Stimulants affect the whole brain, causing both desirable and undesirable neurological effects. Two to four percent of children cannot tolerate stimulant medication because of severe side effects. In addition to what is known, or at least theorized, about how stimulants work, there is a great deal that science does not know. Stimulant drugs change the neurochemistry of the brain, but the long- term effects are unknown. When the action of neurotransmitters is artificially stimulated for a long time, might the brain eventually slow down its own production of these chemicals? By giving a child stimulant medication, you are “fooling” the brain into thinking it makes more neurotransmitters than it really does. Might this interfere with the neurological system’s ability to regulate itself?
Normally, neurological systems work on a supply/demand or dose/response biological principle. During the thought process or physical activity the brain processes just enough neurotransmitters to make the right thought or perform the right activity. There is an internal self-regulating system. The problem with pills is they are not self-regulating.
Even though the party line among A.D.D. professionals is that stimulant medications are non-addictive, the attitudes about drugs we are giving our children may have long-term undesirable effects. Also, even though some stimulant medications are listed in the “controlled substances” category, in reality the control walks out the door when the parent leaves the pharmacy. “Control” simply means controlling the doctor and the pharmacy. There is no way you can control what the parent or child does with the drug.
7 SIDE EFFECTS OF STIMULANTS
1. Insomnia. Sleep in adequate quality and quantity is important for anyone’s well being. Double that for children who have A.D.D. Individuals with A.D.D. have a low arousal and alertness level when they are involved in boring, repetitive activities, which accounts for adolescents and adults reporting that they have a great deal of trouble staying awake during lectures. This problem is worse for individuals who did not sleep well the previous night. Difficulties with going to sleep and staying asleep can be minimized by giving the last dose of Ritalin no later than 1 p.m., which allows the peak effect to occur during the afternoon school hours yet wear off by bedtime.
2. Diminished appetite. Of course, this is a side effect of stimulants. After all, the stimulant Dexedrine was once used as a popular appetite suppressant. The good news is appetite suppression can be minimized by:
- Feeding the child before giving the pill. Give your child breakfast before the pill begins to take effect. Start your child off with a breakfast high in proteins, calories, and complex carbohydrates that will reach his stomach before the medication reaches his brain. Your doctor or the package insert may recommend giving Ritalin “on an empty stomach” or “a half hour before a meal” because the drug is better absorbed this way. However, if the drug reaches the brain before the food reaches the stomach, the child may neither start nor finish his breakfast. So, in a child in whom appetite suppression is a problem, forget the empty stomach rule. When Ritalin is taken before meals, the child may need to take a higher dose. Discuss this with your doctor. (See)
- Encourage nutrient-dense foods. These are foods that pack a lot of nutrition in a small volume. Examples of good nutrient- dense foods are: California avocado, yogurt (regular rather than nonfat), fish (salmon, tuna, cod), granola cereal, cottage cheese, kidney beans, cheese, eggs, nut- butter, whole-grain pasta, brown rice, tofu, and turkey.
- Encourage grazing. Children under the influence of appetite suppressants may be uninterested in big meals and big platefuls. Be more flexible about your child’s mealtimes. Allow him to eat when he is hungry. Small, frequent feedings or grazing on nutritious snacks all day long is actually more biologically correct for the human body anyway. Besides, grazing is friendly to the food-mood connection characteristic of some of these children, as it prevents blood sugar swings and the moody behavior that goes with them.
- Drink the meals. High protein shakes, yogurt shakes, smoothies, or whatever nutritious blend your child likes is a fun way to get a lot of nutrition into your child. 3. Growth delay. Is the worry about stimulants stunting growth warranted? (Weren’t you always told that coffee would “stunt your growth?”) It is generally accepted that in most children stimulants have only a small effect on growth in height and weight. However, children differ, and some children may be affected more than others. Your child’s physicians should keep a careful record of height and weight if stimulant medications have been prescribed. Most children who may temporarily have a slowdown in growth catch up when the medication is stopped, such as over the summer months. Nevertheless, parents worry. If stimulants diminish appetite, causing the child to get insufficient nutrition, naturally growth will suffer. There is also some evidence that stimulants directly affect growth by upsetting the balance of growth hormones. High doses given uninterrupted over several years are more likely to suppress growth than lower doses, especially if the child is not given drug holidays during school and summer vacations.
The truth is, the stimulant-growth connection is hard to study, and statistical studies are not applicable to individual children. What would the child’s height have been a year later had he not been taking medication? This is an unanswerable question. We are left to use our common sense. Any drug that has a possibility of affecting growth hormones has the risk of affecting growth, especially during critical childhood years. Parents can minimize this risk by ensuring their child has adequate nutrition, “drug holidays” as often as possible (such as being off medication during the summer months), and close dosage monitoring to arrive at a dose high enough to achieve the desired effects, but not high enough to get the undesired effects.
4. The roller-coaster effect. What happens when the effects of the drug wear off and the child’s “true self” reappears? (Or, is the medicated version the true self?) Parents sometimes report, “He’s like two different persons. In the morning I like him; in the evening I don’t.” The ups and downs of this roller coaster effect can be quite obvious. Sometimes a stimulant- medicated child can be managed by teachers, but becomes unmanageable at home when the afternoon dose wears off. Yet, giving a late afternoon or evening dose of medication to make the child easier to live with runs the risk of interfering with the child’s sleep. Children sometimes report they don’t like the different feelings of being on and off medication. It’s like they themselves realize they have a sort of double personality.
Teachers also dread the roller-coaster effect. They recognize how different the child acts and learns when the medication begins to wear off during the last hour of morning classes.
5. Ritalin rebound. When medication blood levels come down, children’s behavior changes. Some children become even more hyperactive than their original symptoms once the medication wears off; others, instead of getting “high,” seem to experience a “down” effect at the end of the day or evening, and a few may become downright depressed.
The effects of stimulant medication will be most noticeable as it enters the body (usually one-half to one hour after giving the medication) and as the medication is leaving the body (usually around three-and-a-half to four-and-a- half hours after the preceding dose). If the rebound effect of the medication leaving the body produces behavior worse than what you started with, lower the initial dose, and A.D.D. a small second dose. If a child’s after-school, at-home behavior is unbearable, ask your doctor about giving the second dose later in the afternoon or adding a small third dose in the late afternoon if that doesn’t interfere with sleep.
6. Stomachaches and headaches. Next to insomnia and diminished appetite, headaches and stomachaches are the most common side effects found with stimulant medications. Headaches are usually transient and lessen or stop after a few weeks on the medication. Taking the medication with a snack may help avoid associated stomachaches. These annoying symptoms occur only in a small minority of patients and subside when medication is stopped or the dosage reduced. It’s safe for a child to take acetaminophen for headache relief while also taking stimulants.
7. Tics. An unusual (around one percent incidence) but annoying side effect of stimulants are tics: muscle twitches like blinking, facial twitches, head shaking, shoulder shrugging, and nose wrinkling. Some children exhibit vocal tics: coughs, grunts, or sniffles. Some may blurt out a stream of obscenities. These nuisances, besides being disruptive in school, are embarrassing to the child and the parents who had been looking forward to taking a break from explaining their child’s behavior. Tics usually subside when the medication is stopped or the dosage lowered.
Rarely, stimulant medications can unmask an underlying, severe tic disorder, called Tourette Syndrome. This is not really considered a side effect of the medication, since the disorder is genetic, although brought out by the medication. People with Tourette Syndrome have a combination of motor and vocal tics. At first a parent may notice only repetitive sniffing, throat clearing, coughing, followed by vocalizations, including guttural sounds, high-pitched noises and barking. This disorder is thought to be the result of hypersensitivity to the neurotransmitter dopamine in the basal ganglia area of the brain. One in three children with this syndrome is made worse by stimulants; one in three children show fewer tics when treated with stimulants. Stimulant medications do not cause Tourette’s. If a child develops the tics while on the medication, it’s important to stop the medication to diagnose whether or not the tics are a side effect of the medication or the result of underlying Tourette’s Syndrome, which usually will not go away when the stimulant medication is stopped.
Tics are most common between seven and ten years of age, and they may even occur years after the child has been found to have A.D.D. If there is a family history of tic disorders, be sure to inform your child’s doctor before medication is prescribed. The doctor is likely to prescribe stimulant medication more cautiously if there is a family history of tic disorders.
THE PROBLEMS WITH PILLS
Pills tell children that something is wrong with them and they need to take a pill to fix it. Children may feel that they do better because of the pill, not because of themselves. Their success is attributed to the pill rather than to their own efforts. Children who are constantly on medications may label themselves as “sick”. It’s hard to convince children that nothing is really wrong with them when they have to go to the doctor once a month to have their medicine evaluated, or when they are standing in line for their medicine at the school nurse’s office while their friends are on the playground. You have to be sure that children do not feel they are bad, dumb, or sick when they need medication. When a child does succeed, reinforce the fact that he did it, not the pill. The pill only helped. The pill by itself cannot do anything. Only the child can make the good grade or hit the ball.
THE A.D.D.-Q/S – (side effects)
1. Teacher and parent should both fill in this questionnaire, according to who is with the child. Some questions, such as those concerning sleep, only the parent will be able to answer.
2. Do this for 2 days before starting medication and each day during the drug trial. .Name:__________________________________ Age:________________
Medication: ____________ Dose: _______ Time Medication Given: ________________
Date: __________ Time chart was filled out: ________________
These are unwanted effects apparently related to taking the medication.
1. Decreased Appetite
2. Problem getting to sleep
3. Problem staying asleep
4. Anxious or fearful
6. Looks like a Zombie – (staring)
7. Decreased Spontaneity
8. Depressed (even crying)
11. Tics (e.g., twitches, jerks, blinks, squints)
12. Vocal Tics (e.g., throat clearing, sniffing, grunting,)
13. Skin rash
14. Embarrassed because taking medication
15. Psychosis (irrational thinking, hallucinations, extreme anxiety or inappropriateness)
Rebound effect as drug wears off: increased symptoms, hyperactivity and/or depression
From The A.D.D. Book by Dr. William Sears and Dr. Lynda Thompson