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Each discussion about individual stimulant medications is based on anecdotal evidence I have seen in my clinic. I will be talking in generalities. Some of the medications that I don’t like to see kids start with in general, end up working beautifully for some kids. It is not my decision. It is a child’s doctor’s decision. I always respect and honor the doctor’s decision. I do notice a difference in how a doctor prescribes medication based on their own personal experiences. If they have children who have taken stimulant medication, it changes their perspective.
Common Stimulant Medications for the Treatment of ADHD and ADD
The main difference between the medications is how long there effects last. There are short acting medications that have been around since the 1950’s. The effects of the short acting medications are about 3.5 to 4 hours. The short acting medications are not used as often anymore because they have to be given more than one time a day. I won’t discuss them unless I get questions about them. The effects of the long acting medications range from 6 to 12 hours. Everyone metabolizes stimulant medication differently, so what works great for one person can not work at all for another.
As seen in the table below, there are two main categories of stimulant medications: Methylphenidate and Amphetamine Derivatives. When people hear the word amphetamine, they hear drugs. Any pharmaceutical can be misused. If a proper diagnosis has been made, stimulant medication is like glasses for the brain. It helps it to focus. We can’t get glasses inside the brain, so we have to do it chemically. I find that teens and young adults who have a clear understanding of attention deficits and stimulant medication are less likely to use drugs. When teens and young adults use drugs, they are often self medicating. Often, they are self medicating for untreated attention problems!
The teenagers and young adults that I see in my clinic, who take stimulant medication, often have a love/hate relationship with stimulant medication. They love that it helps them pay attention, but they hate the way it makes them feel. They don’t like feeling not hungry. Sometimes, they don’t want to feel like paying attention, like on a Friday night, and the medication hasn’t worn off yet. Sometimes it makes them feel jittery or “weird.” It doesn’t mean the diagnosis is incorrect, it often means they are just very sensitive to ANY medication. One common perception is that medication makes kids into “zombies.” If medication makes any kid in my clinic look like a zombie, I don’t want them on it. As a precautionary measure, some of our physicians have started to drug test teens that are starting on stimulant medication for the first time. If the teen tests positive they decline to write the prescription.
Methylphenidate Derivatives Amphetamine Derivatives
Ritalin® LA Adderall XR®
Medidate® CD Vyvanse®
I think Ritalin® has a bad rap. It was the first medication used to treat attention problems. It has been around since the 1950’s as a short (3.5-4 hour) acting medication and the LA stands for long acting. In the 1990s, there was an substantial increase in the diagnosis and treatment of attention problems with Ritalin®. It was on the cover of national magazines and described in a way that made people fear it. Ironically, it has the same chemical make up as the medications we have come to accept.
I really like Ritalin® LA. It tends to have fewer side effects and if side effects are present, they are more easily overcome once the body gets used to it than some of the other medications. Ritalin® LA is a good choice for younger children who don’t have homework later in the day. Ritalin® LA is a 6-8 hour medication, but many people will metabolize it for longer periods of time. It is not uncommon for high school kids to take it in the morning and still be able to do their homework in the evening. For some, it is too short acting and they struggle getting their homework finished so a longer acting medication is better.
Medidate® and Methaline® are both under registered trademark, but are essentially the same thing as Ritalin® LA. It gets confusing because they are sometimes treated as generics for Ritalin® LA. Ritalin® LA is also not as readily available as it used to be, mostly because when it got a bad rap, doctors started prescribing the newer medications. Ritalin® LA is considered “old school” which I think is a shame because it is the best option for some kids.
For some kids, Focalin XR® works great. It is marketed to last 8-10 hours. Often, I get reports that it is more of a 6-8 hour medication. Many of the kids in my clinic have more side effects with Focalin XR® than with the other medications. The easiest way to explain it, is that it seems like when the medication is wearing off, it is not as smooth of a transition as the other medications seem to be. The result of a bumpy transition is more of what we used to call “rebound.” Rebound is showing the same, or more, symptoms that the child is taking the medicine for in the first place. Sometimes, I get reports of high emotionality and sensitivity for the hour that this medication is coming out of the child’s system.
Concerta® has a different delivery system than the other medications. It is a pill and how it releases into the body has been explained to me as a “plunger system.” I don’t really know how it works, but I know that it seems to taper off nicely so that there aren’t as many side effects of coming off of the medicine. This difference in how Concerta® gets into the body also makes it one of the only stimulant medications that can not be opened and sprinkled onto food or dissolved in water. It must be swallowed whole and is about the size of common over-the-counter pain medicines.
Concerta® is marketed as an 8-10 hour medication and reports from kids in my office confirm that time frame. I often have kids report that it lasts longer than 8-10 hours, which is probably why I also have many kids who report more significant appetite suppression and sleep onset problems than kids taking other medications. The other problem I have learned to watch out for with Concerta® comes after longterm use. After a year or more of continued use, I have had reports of it making kids feel depressed or irritable. Again, these reports are anecdotal and not scientifically proven.
I have a gifted status, sixth grade, boy who I have seen in my clinic for three years. I diagnosed him with ADHD Combined Type (both Hyper-Impulsive and Inattentive Types) who also met the criteria for Obsessive Compulsive Disorder (OCD). Initially, he had a beautiful response to Concerta®. The OCD symptoms improved just by treating the ADHD. He is very tall and thin and now that he is just starting into adolescence, he had become irritable, argumentative, and his OCD symptoms started to come back. He needed his dosage adjusted, but he already could not gain weight. His pediatrician switched him to another medication, Quillivant®, and he is eating better and all of the negative symptoms, including the OCD symptoms, improved. A difficult call because the change happened very slowly and looked like typical pre-adolescent behavior.
Quillivant® is a relatively new option in the Methylphenidate category. The biggest difference between it and the other medications is that it is a liquid. The kids I see say it tastes like “fruit” or “bananas.” I have not had many complaints about the taste, except for the pickiest of my high sensory kids that don’t really eat anything! Because it is a liquid, it solves a lot of problems that are sometimes present with stimulant medication.
On rare occasions, I see kindergarten boys that are having such significant difficulty in the classroom that it would be cruel to not help them medically. With pills or capsules, only specific dosages are available, for example, 10mg or 20mg. Quillivant® allows the option of a dose in between. For the younger kids, the difference between too much and not enough is very small. One of our second grade boys had to be started on an extremely small dosage and gradually worked up. He had a lot of sensory integration deficits and attention deficits. After the dosage was slowly raised, he did great and became successful in the classroom for the first time.
In my clinic, I have also seen fewer of the common side effects with Quillivant®. If side effects are present to begin with, it seems to be easier for bodies to adjust and often completely overcome the side effects. I have also seen some kids who did not do well at all on Quillivant®. Remember, I am discussing generalities.
Daytrana® is a really great idea. It’s a patch that sticks to the skin and slowly releases medication into the bloodstream through the skin. Once it is removed, the medication begins to wear off and is no longer working 30-60 minutes later. It allows the wearer greater flexibility in how long the medication is working. If a child has dance or basketball in the evening, it can be left on longer. If s/he does not have homework and it’s a Friday afternoon, it can be removed sooner.
Theoretically, it should be one of the top prescribed medications. It’s not. It causes terrible skin irritation in many, not all, children who try it. Some parents worry their child will take the patch off on his/her own. I also don’t love that the packaging suggests parents flush the patch down the toilet after it is removed. I guess they suggest this method because if there is any active ingrediant left, someone else, like a toddler sibling, can’t get a hold of it. However, the problem with medication in our water supply is certainly not helped by flushing the patch. Others would argue a little stimulant medication in the water supply would help us all!
If you have teenagers, they have heard of Adderall®. I always acknowledge when I am evaluating a teen for attention problems that I know that you could go to any high school or college and find Adderall® pretty quickly. Sometimes it’s given away, sometimes it’s sold; a felony offense if caught. A surprisingly large number of these teens have tried their friend’s Adderall® and it helped so much that they got their parents to let them be evaluated. I do not recommend this. It automatically brings the teen’s judgement into question for a physician, let alone they have no idea how to dose it for their body and it is dangerous. On the other hand, if a teen confesses, I don’t get angry and send them away, either. The chances that if I don’t listen to them and do an evaluation that they will self-medicate without a prescription again, are too high. Many times these teens have been telling their parents for years that they can’t focus and their parents did not want to get them evaluated for any number of reasons.
Adderall XR® is a 6-8 hour medication. I used to think of it as an adult medication, primarily because so many adults with attention deficits take it. That’s not necessarily the case. It is often very comparable in results to Ritalin® LA. I prefer Ritalin® LA because teens and young adults don’t know what it is. Many times if one of the two of the medications does not work, the other one will. Longterm, up to a year and beyond, use of either one sometimes makes teenagers feel like they can’t talk in social situations. They feel awkward and sometimes describe it as feelings of depression. Switching to the other category usually solves the problem while still controlling attention deficit symptoms.
Up until the release of Quillivant®, Vyvanse® was the newest of the stimulant medications. The primary difference with Vyvanse® is that it lasts for 12 hours. Psychiatrists will sometimes say they could swear Vyvanse® also has antidepressant effects. I have seen it help depressive symptoms in some kids and create emotional sensitivity including depression in others. I have also see the same effect on other medications. I have seen some kids and teens have no side effects and others have the most severe and long lasting side effects on Vyvanse®. The only pattern I may have been able to see consistently is that it seems people who also have a lot of sensory issues (see my previous post Is it ADHD or OCD?) have the most trouble with Vyvanse®. My guess and opinion is that they metabolize Vyvanse® too well and, therefore, don’t eat or sleep for 20 hours of the day.
I think Vyvanse® is a great medication for some people. I like Vyvanse® for teens with few sensory issues. The 12 hour time span easily allows for practices and homework. I do not like Vyvanse® for kids under 13-years-old. They just don’t need the 12 hour coverage and it tends to be more disruptive to sleep and appetite for the younger kids.
Vyvanse® was also just approved for the treatment of Binge Eating Disorder. I don’t love this use of Vyvanse®. My biggest concern is that it puts a “bandage” on the problem. What happens when the Vyvanse® is discontinued? My guess is that the problem will actually get worse. I have seen teens go off of stimulant medication for the summer gain upwards of 20 pounds only to lose all or more when they start taking the Vyvanse® again in during the school year. Wild swings in weight are never good and I ask teens either to work toward managing binge eating while they are off medication or sometimes ask physicians if they will switch medications to try and minimize appetite suppression so they will eat normally most of the day.
Stimulant Medication Doesn’t Work, Has My Child been Misdiagnosed?
If you have taken your child to a qualified, usually Ph.D. level, psychologist and they have done an evaluation that meets the standard of care discussed in my earlier ADHD post, it may be that your child just does not respond to stimulant medication as expected. It does not mean the diagnosis is incorrect. I have had specialists question my diagnosis of ADHD on more than one occasion for various reasons. For each of those kids, the diagnosis has eventually been accepted.
Sometimes it looks as though the person prescribing the medication has no idea what they are doing. Some people try two, even three, different medications before they find one that works with the fewest side effects. General physicians or pediatricians usually know the basics when it comes to medication for attention deficits and sometimes depression and anxiety. If they try common medication and can not find anything that works, the best option is to go to a psychiatrist. Psychiatrists are medical doctors but they have been specifically trained to treat behavioral health concerns. Some kids react exactly the opposite of what one would expect, some kids need a much larger dose than usual, and other kids need a much smaller dose than doctors would expect.
Will My Child Take Medication for Ever?
It’s important to note that doctors range in their opinions about whether or not stimulant medication should be taken everyday. Some feel that is essential, especially for teens to take it everyday. There is proof in the research that kids with ADHD have a higher number of fatal accidents in motor vehicles. Some feel it is fine to take only on school days. Health workers used to always suggest a “drug holiday,” or time off of stimulant medication. Some doctors still believe a “drug holiday” is necessary, others do not.
In my opinion, it is a parenting decision when to give your child medicine. I have been assured by pediatricians that it does not hurt anyone to go on and off stimulant medication. I have had some kids in my clinic that do better taking it everyday all year. Going on and off stimulant medication makes it hard for them to control their emotions. Something to watch out for, but the majority of kids can go on and off stimulant medication and not have an negative effects.
It’s always my goal as a psychologist and mom for kids not to take medication forever. I don’t take giving medication to kids lightly. I do believe that third to sixth grade is the “sweet spot” for trying medication. Kids usually tolerate the medicine a little better by third grade and academic demands increase. Kids can often catch up later if they are having problems with reading or math in first and second grade, but after second grade it becomes more difficult.
Sometimes kids don’t show signs that anything is significantly effecting their academics until they start changing from class to class. Usually, the changing starts around sixth grade. Keeping the balls in the air becomes much more difficult when changing classes because everything isn’t right in the desk beside them. Also, beyond sixth grade adolescence really kicks in. It can be difficult to tell if lack of motivation and not turning homework in to the teacher is because of attention problems or normal teen rebellion.
I have seen in my clinic that if children are able to see what it feels like to pay attention when they are bored, don’t want to do, or don’t understand something between the third and sixth grade, they are more likely to NOT take medication when they get older. It is when a Junior in high school comes in and thinks they have an attention problem that it is more likely they will need to take medication into adulthood. Often, the older kids have great, well educated, parents. The parents have served the role as medicine by making sure they are turning everything in, keeping their grades up, reminding them of tests, or in other words, making them pay attention. It is late in the game to develop those skills, but possible.
College is different in that the young adult has a choice to attend and what classes to take. Required classes and prerequisites may be hard to pay attention in and do the homework. In classes they choose, usually they are fine and may not need to take medication. It’s also important that they choose a career path that they at least enjoy and it helps if they are passionate about the career they choose. I was pretty sure early on that neither my children nor myself would be math professors. It would be disastrous for anyone to try and force us.
I often think of people with attention deficit temperament as the old “Type A” label for personalities. If we are passionate about something, we are hyper-focused and extremely driven to accomplish our goal. Some of the world’s greatest thinkers, artists, and entrepreneurs have this temperament! They will be fine with or without medication. Some adults take the medication on an as needed basis. For example, a psychologist I worked with took it only when he had to go to continuing education meetings. When he was in the office, seeing kids and families, doing what he loved, he was fine. I end the way I started in my last post about ADHD, stimulant medication is a tool not a cure.