Ms. Vaughan: The most common medications used in child psychiatry or by family practitioners and pediatricians for ADHD are the stimulants dextroamphetamine/amphetamine (Adderall) and methylphenidate (Ritalin). They have been around for many years, so we have a lot of data on them—how they work, the duration of action, and the tolerability. They are well-researched medications. Following those in popularity are nonstimulant medicines like atomoxetine (Strattera) or some of the alpha-2 adrenergic agonists that are newer to the market, guanfacine ER (Intuniv) or clonidine ER (Kapvay).
CCPR: What kinds of side effects and adverse reactions do we need to be mindful of in children and adolescents with these medications?
Ms. Vaughan: In children and adolescents, the most common side effect is loss of appetite. This is true for the stimulant medications and Strattera. There are some children for whom the medication seems to irritate their stomach and so they just don’t feel like eating. There are others that, because they are stimulants, suppress appetite even in the absence of stomach upset. We worry about children, especially little ones, if they are not eating; we worry about what kind of impact there is on growth in the short and long term. There are also effects on sleep patterns. The stimulants can cause insomnia, both initial and middle insomnia, whereas medicines like Strattera (atomoxetine HCI) or the alpha-2s can cause sedation during the day. Younger kids tend to display more mood-related side effects to medication, more irritability, tearfulness, and outbursts.
CCPR: Do extended release formulations of stimulants have any effect on side effects?
Ms. Vaughan: Yes they can. Obviously, the longer the duration of the effect of the medication the longer you may experience side effects of that medication in the system. For children who are on a long-acting stimulant, we tell parents to make sure they eat breakfast before they take it, because if they lose their appetites during the day they may not eat as well at lunchtime or even dinner, and then they are starving at 8 o’clock. The other thing to consider, if there is stomach pain, nausea, or side effects that are more specifically GI related, is a transdermal form of methylphenidate (Daytrana) that allows you to bypass the stomach altogether. The effects on sleep can be similar, too. The long-acting stimulants can be more likely to cause insomnia, so often we adjust the time the medicine is administered, or combine preparations to make sure that we address the ADHD symptoms when they need coverage, but minimize the side effects. Some children experience “rebound” emotional symptoms when their medication wears off. For some this is irritability and anger, and others tearfulness.
CCPR: Among youths who are taking these medications, how often are side effects an issue?
Ms. Vaughan: Some patients may have side effects. For many kids, they tend to go away with time. The response and the tolerability to these medicines seem very individualized.
CCPR: Are there particular things that might predispose a child to experience side effects or reactions?
Ms. Vaughan: If we have children who have feeding or eating issues or other developmental issues, such as food texture issues, along with attention problems, we may be more reluctant to give them medication that might lower their appetite. For someone who has a co-occurring tic disorder, we used to be reluctant to use a stimulant, but now we may try it and make a change only if the tic worsens (Tourette’s Syndrome Study Group, Neurology 2002;58(4):527-536). If there are concerns about a comorbid anxiety disorder or a mood disorder, I might suggest starting with something like Strattera first, rather than going with a stimulant because it may affect the comorbid symptoms. Finally, if there are issues with drug abuse, either in the child or possibly in the household, we might be more particular about the stimulant preparation that we select, perhaps using long-acting rather than the short-acting, or even consider a nonstimulant alternative.
CCPR: In your research, which medications do you see as most tolerable or least likely to present side effects?
Ms. Vaughan: There isn’t one that stands out as superior to the other. It varies from patient to patient, and is hard to predict.
CCPR: Are there things you look out for and advise patients to be careful with, for example caffeine or energy drinks?
Ms. Vaughan: Definitely, and that isn’t limited to teenagers anymore, but young adults and even middle school and elementary age kids. We worry about an additive effect. Anytime you are giving multiple stimulants we are concerned about the effects on behavior, as well as effects on insomnia or loss of appetite. A lot of parents will ask about cold medications that have pseudoephedrine in them or Benadryl because of a warning from their pharmacist about using these types of medicines with stimulants. We advise them to watch for either an intensifying of the usual effect or a paradoxical effect. It can go either way. In the case of cold medication or an asthma medication, when there is a physical need, we may say to hold the stimulant on a given day, if that is possible, because we don’t want them feeling physically miserable if we can avoid it.
CCPR: You noted that effects can be different for younger children. How is this addressed?
Ms. Vaughan: The younger the patient, the lower the starting dose we will use, and the slower we will go in titration because there is a difference in clearance from the body of, for example, a dose of methylphenidate. The Preschool ADHD Treatment Study (PATS) showed that there is a difference in how little ones metabolize medicine and how quickly it is out of their system. Clearance of a single dose of methylphenidate was slower in children in PATS than in children in the MTA study (Wigal et al, J Child Adolesc Psychopharmacology 2007;17:53-164). That data is on children between three and five (Greenhill et al, JAACAP 2006;45:1284- 1293). For them start low, go slow. The younger the child, the more likely we are to start with behavioral interventions, school interventions, and skills training before we go to medication. If the ADHD is significant enough that it needs to be treated, then we use the smallest doses, and the immediate release medicines, because the duration of action is shorter. We also consider whether the medicine comes in a liquid or something they can chew if swallowing a pill might be something that a three- or a four-year-old isn’t capable of.
CCPR: Is giving the child “medication vacations” an important part of the prescription process?
Ms. Vaughan: The answer to that question can go one of two ways. If you are looking at a child who may have some side effects—and specifically those involving appetite or affective flattening where they aren’t the cheerful, bubbly, sparkly kid that everybody loves—we may say when they don’t need the medication, we can hold it, or have the child take it on school days only and not on weekends or during the summer. Some children have symptoms that need treatment seven days per week. Your question emphasizes what we need to do as clinicians to make sure that the patient still needs the treatment. We need to be constantly evaluating: “What is the child like when the medicine is working, and then when it wears off? Is this still something that the child needs in order to function and be part of the family and his/her social circle and do well in school?”
CCPR: Does that typically involve education of family for younger children on how to collect that information and be good reporters?
Ms. Vaughan: Absolutely. Family, teachers, babysitters, grandparents—those additional reporters provide invaluable information to have in assessing how patients are doing. With regard to behavioral and school interventions, if the environment is structured enough and consistent, kids may not need medication.
CCPR: Are there still concerns about the cardiac risks of stimulants?
Ms. Vaughan: There were reports questioning whether the risk of sudden death in children who were taking Adderall or amphetamines for ADHD is higher than the risk for children in general (Gould et al, Am J Psychiatry 2009;166:992-1001). We know that stimulants can increase heart rate and blood pressure, and alpha adrenergics can affect heart rate and blood pressure as well as produce potential effects on the heart rhythm that we want to monitor closely (Perrin et al, Pediatrics 2008;122:451-453). If we have a child with a history of a congenital abnormality or cardiac issue—any kind of murmur, fainting, syncope—we refer them to their pediatrician or to pediatric cardiology for an assessment first. Also, if there is any history in the family of sudden cardiac death we might want to get an okay from a cardiologist before we treat them.
We need to be constantly evaluating: “Is this still something that the child needs in order to function and be part of the family and his/her social circle and do well in school?”
~ Brigette Vaughan, APRN, MSN
CCPR: Are there other risks related to medication that prescribers ought to be aware of?
Ms. Vaughan: I think we all need to be alert for signs of abuse or diversion with controlled substances. Unfortunately, we have to have a high degree of suspicion sometimes. Not being afraid to ask those questions is a good thing. The other thing is to make sure we know what we are treating. I recently coauthored a paper on treatment-refractory ADHD, and a lot of what we found calls for making sure we are treating what we think we are treating: is this truly ADHD or are these symptoms of another disorder? Once someone is on medicine we want to make sure that we don’t mistake a side effect for a symptom of something else, or that we don’t miss another disorder and say “Oh that is just ADHD.”
CCPR: For readers who want to keep up with medication effects, are there resources that you would recommend as particularly good sources of ongoing information?
Ms. Vaughan: I think the American Academy of Child and Adolescent Psychiatry website, parentsmedguide.org, is very up-to-date. It is reviewed by experts in the field and is written very objectively and thoroughly. It is also a good resource for parents and for teachers because it explains things in language that is easy to understand.
CCPR: Thanks very much for sharing your experience with ADHD medications.