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Frequently Asked Questions About Ritalin and Other Stimulants

Though Ritalin is still the most widely prescribed treatment for ADHD in the United States, more and more physicians are coming to view Dexedrine and Adderall as the treatments of choice for ADHD.

As we've seen, Ritalin has been well studied, and its effectiveness well established. In addition, it takes effect quickly and clears the system quickly, which may make it easier to adapt the dosing schedule to your child's needs. (For example, if your child has a "slump" in the evening, a late-afternoon dose of Ritalin will help, while still clearing the child's system by bedtime. With a longer-acting medication, you don't have this flexibility.)

However, Ritalin's short duration of action makes it more difficult to manage the typical child's school day. One dose lasts about three hours, so if the child takes the dose with breakfast, then gets dressed, waits for the bus, rides the bus to school, and sits through homeroom, he or she may be halfway through the first dose before the school day really gets started. That means the late-morning classes will be difficult. And if your child's school is one that will not administer a lunchtime dose, the afternoon is likely to be even worse.

In some children, Ritalin also has a tendency to blunt emotions. "He seems sad," a parent may tell me, but if you ask the child, he doesn't say he feels sad. It's more a feeling of distance, of being a little bit removed from things. "He doesn't seem like himself," another parent told me, and I think that's a better description.

This effect doesn't happen in every child who takes Ritalin; in fact, it doesn't happen in most of them. But if you see these effects in your child, there's a simple solution: Ask your doctor to switch to another medication. Dexedrine doesn't seem to have this side effect, and it's more convenient to administer because it's longer-acting.

Dexedrine's chief drawback, frankly, is its reputation. On the street, of course, Dexedrine is known as "speed," and when abused it is addictive and dangerous.

However, years of research have demonstrated that Dexedrine, as it's used in the treatment of ADHD, is safe and nonaddictive. In people with ADHD, clinical doses of Dexedrine don't make you "high." They don't create drug dependence. And they don't create tolerance--that is, you don't need bigger and bigger doses to produce the same effects.

In fact, this is one of the ways we know that ADHD is a disorder of normal brain metabolism: Whereas normal people develop tolerance to stimulants, people with ADHD don't. It seems that while stimulants throw the brain chemistry out of balance in most people, they make it more normal in people with ADHD.

How well does the long-acting form of Ritalin work?
The long-acting form of Ritalin requires only one dose every six to eight hours. Its primary benefit is that the school doesn't have to administer a lunchtime dose. For that reason, we may use it if the child is in a school that refuses to give the lunchtime medication. But I find--as do many of my colleagues--that it doesn't offer the same degree of effectiveness as standard Ritalin.

My doctor suggested a new stimulant called Adderall. What is it?
Adderall is a new formulation of dextroamphetamine (like Dexedrine) and amphetamines. We're using it with many of our patients, because a single dose offers good, consistent control over a longer period of time--six to seven hours. It accomplishes this by combining four closely related types of stimulants, some of which work more quickly and some more slowly.

This formulation--combining slow- and fast-acting components--is different from the long-acting Ritalin, which uses a single drug but releases it gradually over time. We find that it works much better, and it's a good way to avoid both the midday dosage and the peaks and valleys that we see with short-acting stimulants.

My child's doctor says to take the pills before eating. But then my son isn't hungry. Why can't he take it after meals?
Food interferes with the ability of the body to absorb stimulants, so the medications often don't work as well if you take them after you've eaten. In addition, some foods interfere more than others, so you may see the drugs acting inconsistently, depending on the menu. For example, citrus juice interferes with Ritalin.

But the standard recommendation to take them before meals can cause problems for some patients. As you pointed out, they can suppress appetite. Also, if breakfast is early in your household, that can throw off the medication schedule for the entire day, because the medication may start wearing off in mid-morning.

There are some other options, though. For example, we often recommend taking the drug after meals. The only caution is not to take them too soon after; wait at least an hour.

Some people also feel nauseous if they take a stimulant on an empty stomach. In that case, you can take it with milk.

It's important to find the dosage strategy that has the least impact on appetite, because poor nutrition can make ADHD symptoms worse (not to mention the impact on growth). For example, researchers have found that children who get protein at breakfast (for example, from milk or yogurt) do better in school than those who don't. For children with ADHD, that difference can be critical.



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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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