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Ritalin and Other Medications

If you mention ADHD medication, most people--doctors and consumers alike--think of Ritalin. In the United States, it's the overwhelming choice for treatment.

But it's not necessarily the best choice.

There are two key reasons for Ritalin's popularity. The first is tradition. Since its introduction in the 1960s, most early studies on the effects of stimulants on ADHD used Ritalin, in large part because it is short acting. Because it clears the system so quickly, it's an ideal drug to use in scientific studies: We can quickly see whether it works, and there are no lingering effects to throw off the study results.

Though these qualities make it easier to design and conduct a clean research study, they're often a disadvantage in the real world. In daily life, we want a medication to have lingering effects, so that it's easier to use and provides a consistent benefit rather than peaks and valleys.

But as treatment of ADHD became more widespread, it was only natural that doctors would prescribe the medications that had been studied the most extensively. There were mountains of scientific evidence showing that Ritalin was safe and effective. Though other stimulants such as Dexedrine (which was introduced in the 1930s) seemed to offer certain benefits over Ritalin, they were overshadowed by Ritalin's popularity and ease of use. So cautious physicians tended to prescribe the better-known treatment.

And as time went on, the process snowballed. The more doctors prescribed Ritalin for ADHD, the more experience they gained with it--making them even more likely to use it on new patients. And as more doctors started diagnosing and treating ADHD, it was only natural for them to look to Ritalin as well.

But as Ritalin became more widely used, its limitations have become more apparent, too. And that's now prompting a closer look at Dexedrine and other stimulants.

The second reason that Ritalin emerged as the more popular choice than Dexedrine is perception. Though both medications are stimulants and both are controlled substances, the public views Dexedrine as a far more dangerous drug. It's closely linked with drug abuse. And under its street name, speed, it's often implicated in illegal activities. (One reason: It's relatively easy to manufacture in small illegal labs.)

But in fact, Dexedrine and Ritalin are two of the safest medications administered to children--and both have the track record to prove it. In the very low doses used to treat ADHD, they don't create a risk of addiction or make children more predisposed to drug abuse problems later in life. (As a group, ADHD children are at greater risk of developing substance abuse problems, but this is because of the disorder, not the treatment. In fact, treatment actually reduces the likelihood that a child with ADHD will develop drug problems later on.)

None of this is to say that Ritalin isn't effective. It is. Ritalin may be the best choice for many people--but not for everyone. Most important, it isn't the only choice. That's good news for people for whom Ritalin doesn't work, and those who have trouble tolerating its side effects. Comparing Medication Options to see which medication works best for you and your family.

Dosage is another area in which tradition sometimes gets in the way of effective treatment. Following the "standard" dosage regimens for ADHD medications is kind of like forcing everyone to wear a size 8 1/2 shoe. Just because it's right for most people doesn't mean it's right for everybody.

By tailoring the dosage and timing, it's often possible to improve vastly the effectiveness of these medications. Some people need larger than usual doses, but many actually get better control with lower doses. And by adjusting when these doses are given, one can get the maximum benefit of these medications--often with lower doses and fewer side effects.

Armed with these expanded options--more medications and more ways to administer them--you and your doctor can create an individualized medication regimen that will offer better and safer control.

The key to an effective medication plan for ADHD is to tailor the medication, dosage, and schedule to meet individual needs.

What medications are used to treat ADHD?
There are three general types of medication used to treat ADHD:

  1. Stimulants. Stimulants are by far the most common treatment for ADHD--and usually the most effective.

    Ritalin, Dexedrine and Adderall are the widely used and safe stimulants for treating ADHD. Another stimulant, Cylert (pemoline), should not be used to treat ADHD. It had been used to treat some cases that didn't respond to other medications. But it carries a risk of liver damage, and with other effective medications available, these risks outweigh the drug's potential benefits. As a result, the manufacturer and the Food and Drug Administration recommend that Cylert not be used in cases of ADHD.

  2. Antidepressants. Parents often voice concerns about this second category of ADHD treatments. "Why would you give my child antidepressants if she's not depressed?" The answer lies in the brain's chemistry. These drugs affect the brain chemistry in ways that can help control the symptoms of ADHD.

    There are several categories, or classes, of antidepressants.

    The first are known as tricyclics. Older tricyclics, such as Tofranil and desipramine, are effective, but they have many side effects (see chart).

    A newer drug in this class, Wellbutrin, is emerging as a key treatment for ADHD when stimulants can't be used or don't work, as well as for cases of ADHD complicated by depression. It doesn't have the side effects of the older drugs and is therefore easier to tolerate. While experience with ADHD is still limited, it appears to have positive effects on attention as well as depression.

    Another class of antidepressants known as MAO inhibitors has similar effects on these neurotransmitters, and they're now being tested as potential treatments for ADHD. However, dietary restrictions and associated risks make them an unlikely candidate for treating ADHD.

    Yet another class, the selective serotonin-reuptake inhibitors (SSRIs) such as Prozac, Zoloft, and Paxil, are terrific for de- pression but don't work for ADHD. They are, however, used in combination with stimulants when ADHD and depression coexist--as they often do.

    A new drug, Effexor (venlafaxine), is a combined serotonin-and norepinephrine-reuptake inhibitor. It does hold promise for treating ADHD, especially when it occurs with depression.

  3. Alpha-2-adrenoreceptor agonists. This is another tongue twister, but you may recognize the medications themselves--Catapres (clonidine) and Tenex (guanfacine)--as widely used blood pressure medications. They're emerging as an alternative treatment for ADHD, especially atypical forms of ADHD that don't respond to stimulants. They're useful in cases where there's a lot of impulsivity.

    Indeed, sometimes we use these drugs in combination with stimulants. Combination treatment can sometimes provide better control because the drugs work in different ways. In addition, they can help promote sleep, so they can counter the tendency of the stimulants to interfere with falling asleep. They may, however, cause nightmares.

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From The Attention Deficit Answer Book: The Best Medications and Parenting Strategies for Your Child by Alan Wachtel, M.D. Copyright 1998. Used by arrangement with Penguin Group (USA) Inc.

If you'd like to buy this book, visit amazon.com or click on the book cover.


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