by Dr. David Rabiner, Ph.D.

It has been shown in numerous studies that stimulant medication provides significant benefit to between 70 and 80% of children with ADHD (Attention Deficit Hyperactivity Disorder). The most commonly prescribed medication used to treat ADHD is Ritalin (the generic form is called methylphenidate), although other stimulant medications are also used including Adderall, Dexedrine, and Cylert. Available evidence suggests that stimulants work by correcting a biochemical condition in the brain that interferes with attention and impulse control.

"What benefits can stimulant medications produce?"

The beneficial effects of stimulant medication treatment can be dramatic. Attention to class work can improve to the extent that the child is no longer distinguishable from classmates; activity level can decline to within normal limits and impulsivity can be substantially reduced. Even associated difficulties such as disruptive behavior and peer relationship problems sometimes show dramatic improvement. Interactions between parent and child and between the child and his or her siblings have also been shown to improve. Academically, many children show clear improvements in the quantity and quality of the work they complete. It remains to be seen, however, whether these short term changes result in long term gains in children’s academic, behavioral, and social functioning.

"How long does it take stimulant medications to work?"

The effects produced by stimulant medication occur quickly, and parents and teachers often observe an improvement in the child almost right away. The beneficial effects of stimulant medication vary in length depending on the child and the type of stimulant, (i.e. Adderall, Dexedrine, and Cylert last longer than Ritalin) but are generally gone within 3-8 hours. For this reason, children often require several doses during the day.

"How extensively has the use of stimulant medication been studied?"

The efficacy and safety of stimulant medication for treating ADHD (Attention Deficit Hyperactivity Disorder) have been documented in over 150 controlled studies involving children, adolescents, and adults. Despite the impressive empirical support for stimulant treatment, several cautions should noted. These include the following:

• Most studies have been conducted with school age children and the available evidence with other age groups is more limited. Stimulants appear to be quite effective with adolescents but less helpful with most preschoolers. Available data indicates that many adults with ADHD will also benefit.
• Over 80% of studies done prior to 1997 examined the efficacy of methylphenidate (the generic name for Ritalin) and few well-controlled studies on other stimulant medications To date, however, there is little evidence of differential effectiveness for different stimulants.
• Almost all studies are very brief - not more than a few weeks duration at most - and the magnitude of long term benefits resulting from stimulant medication treatment are not clearly documented.

Most studies have been restricted to Caucasian males and less is known about the efficacy and safety of stimulant medication with females and minorities. To date, however, there is no reason to expect substantially different results in these populations.

"What kinds of side-effects are associated with stimulant medication?"

As with any medication, stimulant medication used in treating ADHD children can produce adverse side-effects in some children. These can include: sleep difficulties, stomachaches, headaches, appetite reduction, drowsiness, irritability, nervousness, and excessive staring among others. In rare cases, stimulant medication can lead to nervous tics, hallucinations, and bizarre behavior.

The list of possible side-effects can be scary to parents considering the use of medication for their child, but it is important to emphasize that the vast majority of children with ADHD experience no adverse effects. Based on the findings from many carefully controlled studies, physicians have concluded that when properly employed stimulant medication is safe and the side effects are minimal. When side-effects do occur they are frequently short-lived and often disappear when the dosage is reduced. Despite these data, however, it is obviously important for parents to discuss their questions and concerns with their child’s physician.

"But I’ve heard all kinds of bad things about using Ritalin?"

There are a number of myths concerning stimulant medication that discourage many parents from considering its use for their child. These myths are summarized in an excellent book titled Attention Deficit Disorder and Learning Disabilities: Realities, Myths, and Controversial Treatments by Barbara Ingersoll and Sam Goldstein (highly recommended) and include the following:

• Children treated with stimulant medications will become addicted to it and are more likely to abuse other drugs.

  There is no data which indicates that addiction to stimulant medications is a problem or that children treated with stimulants are more likely to abuse other substances.

• Stimulant medication stunts growth.

  The available literature indicates that ultimate height appears to be unaffected if treatment is discontinued in adolescence. However, there have been no studies of growth in children treated continually from childhood into young adulthood so caution here is warranted.

• Stimulant medication works by turning children into "zombies".

  Some children do become sluggish and withdrawn when on medication, but these symptoms generally indicate that the dose is too high, or that a co-existing condition such as a mood problem has not been identified. Studies have shown an increase in prosocial behavior in ADHD children treated with stimulants, which would not be the case if it simply turned children into "zombies".

Factors to consider in deciding on the use of medication:

1. What other interventions have already been tried?

   Some children with ADHD can have their symptoms effectively managed via other means including appropriate behavioral and educational interventions. If you are concerned about using medication with your child, make sure that non-medical interventions have been tried first. This is an important issue to discuss with your child’s physician.

2. How much difficulty are the child’s symptoms actually creating?

   The degree of impairment in academic, social, and behavioral functioning caused by ADHD can vary substantially. If the impairment experienced by your child is on the modest side, medication may not even be necessary.

3. What is the child’s attitude towards taking medication?

   It is very important to discuss the rational for using medication with the child. The child needs to know why it is being suggested and how it can be helpful. This is especially true for older children and adolescents, who may have concerns about being teased should their peers find out that they are taking medicine. If children have strong objections to taking medication, these should be discussed and understood. Should these objections persist, using medication may not be productive.

4. Will objective information about the effects of medications be provided?

   In my opinion, this is critical. Despite the well-documented benefits of stimulant medication, as many as 20-30% of children do not experience significant benefits. In addition, many parents are surprised to learn that when children with ADHD receive only a placebo (i.e. medication that appears to be the real thing but is not), teachers frequently report significant improvement in the child’s behavior. This means that some children may receive stimulant medication for a sustained period even though they derive no objective benefit from it, or fail to receive the most beneficial dose.

"So, how do I know for sure that the medication is really helping my child?"

Fortunately, it is not hard to conduct a careful trial that provides more objective information about a child’s response to medication. This is accomplished by having the child receive different medications doses as well as a placebo over a 3-4 week period. At the end of each week, the child’s teacher completes ratings of the child’s behavior and academic performance. Because neither the child nor the teacher know what the child was receiving each week during the trial, the teacher’s ratings provide more objective information. By comparing the ratings made each week one can determine whether:

1. medication was clearly superior to placebo

2. what dose produced the optimal response

3. whether any adverse side-effects were observed (sometimes children report what appear to be side effects when they are only getting a placebo)

4. what problems with behavior and academics may remain even if medication clearly helped, and which need to be targeted via other means.

This procedure provides more reliable and objective information that can be used to decide about the benefits of ongoing medication use. Unfortunately, many physicians do not gather objective feedback and rely on anecdotal reports to base medication decision on.

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