Advice & Support

Roy Boorady, MD

Senior Director, Psychopharmacology Service
Child Mind Institute

While stimulant medications can be very effective for helping kids with ADHD, we do know some kids will experience adverse side effects. For each child we try to find the medication, and the release formula, that will give him the most benefit, with the least side effects.

The key problems that we see are decreased appetite, insomnia, headaches, stomachaches, irritability, and what we call rebound. These are things for parents to be on the lookout for when we start a child on medication. But we also want to establish that child's baseline. Some kids with ADHD are bad sleepers to begin with. Some kids with ADHD are bad eaters to begin with. Identifying existing problems helps us avoid blaming the medicine for problems that were already there, allowing us to make good decisions.

Sleep Problems

In terms of sleep issues, they were more common when we didn't have the long-release forms of medicine. When we had only the tablets, kids were taking them three times a day: once in the morning, once at school, from the school nurse, and then usually after school. It was that third dose, sometimes given a little too late, that tended to interfere with bedtime.

The other thing I've noticed is that a lot of kids with ADHD don't like to go to bed because they're too stimulated, by reading or doing something on the computer, to calm themselves down and go to sleep. When the medicine has worn off, at night, it may actually be the ADHD that's keeping them awake.

When there are sleep issues caused by the medication, they tend to get better over time, so it's worth giving kids four to six weeks to see if they adjust to what they're taking and get back to their baseline. If they're taking medications that last 12 or 14 hours, that may be the culprit, and we may want to try a medicine that's not quite as long-acting.

There are also some medicines we can try for sleep problems: Melatonin can be effective. Benadryl, which was commonly used when I was in training, also works, but it caused a hangover effect the next day, and kids did not feel as alert as they should.

Eating Problems

In terms of appetite, the problem is that some of these extended-release medicines peak about four hours after you take it, which tends to be lunchtime. A lot of kids are not going to feel hungry. For younger kids who are growing, it's really an issue. So, you want to encourage them to eat whenever they do feel hungry—a good breakfast before the medicine has kicked in, and at the end of the day when the medicine is wearing off. Some kids get a kind of rebound hunger, and they'll eat dinner and maybe even another meal after that, before bedtime.

When it's a real problem for a child, I suggest breaks on holidays or the weekends. Another alternative is to go back to the immediate-release tablets, because if you take one in the morning, it will wear off by lunch. Unfortunately, a lot of kids don't like to go to the school nurse to take their second pill, but it might be the only way to get around the whole appetite and eating issue.

If you do use the tablets, there's an issue of avoiding the cranky downtime in between the time one wears off and the other kicks in. The way to do the second pill properly is to have the child take it 15 to 20 minutes before the first pill has worn off, so they cross over. If you can manage that and still not affect his mealtime, it's great—you won't get that rebound behavior from a drop in the blood level.

In terms of stimulant medications slowing growth, there was a very good paper that came out in 2010 that looked at records of thousands of kids over three or four years.  In the first year, boys seemed to not grow a centimeter. By the second and third year, they all caught up, so by the end of the study, they did attain the growth that they should have attained. This effect did not show up in the girls. And within the study, there were kids who didn't have that decrease in velocity in the first year; they were the kids who took weekend breaks and summer vacations from the medication.

Rebound Effect

Some parents describe something they call the "rebound effect," that after the medication wears off the child seems to have worse symptoms than he would have without taking the medication at all. They can be very irritable and aggressive. Sometimes parents tell me, it's the witching hour: "Every day at 4:30, I know it's going to happen."

What's happening is that the medication is leaving the receptors in the brain too quickly. One way to try to avoid rebound, if it's a problem, is by adding a smaller dose a half hour before it usually happens, to ease off the medication more gradually. Sometimes, rebound can be a sign that we haven't got the right dose yet. It also may be an indication that these kids aren't good metabolizers of this particular medicine, and you may want to try something different.

Even if we switch from one form of Ritalin to another, it might be one that the child can metabolize easier, and they might not come off of it as dramatically. Lastly, with the kids who rebound we want to ask whether there might be something else going on, like underlying anxieties or mood issues that come into play when they come off their ADHD medicine. You don't want to miss other things that could be muddying up the equation.

Cardiac Risks

There was some concern back in 2005 and 2006, based on a study of pooled data, with Adderall in particular, about increasing the risk of what's called sudden death. Sudden cardiac death usually means below the age of 21—some studies show the age of 30—and these are cases like young athletes who die on the track or the football field or the basketball court.

But when they went back and looked at all the data, it turned out that being on the medication does not increase your risk of sudden death, all the way up to 64 years of age. It's not greater than that of the general population.

Nonetheless, before we start a child on medication, we take a careful cardiac history. I always ask for a history of sudden death in the family on either side, and for the child's personal cardiac history. Did the pediatrician say he had a murmur? Has he complained of chest pain? Has he fainted? At the baseline, you want to check blood pressure, and if there's any family history, or if there's any indication of cardiac symptoms, then that patient should have a cardiac workup before he starts stimulant medication. Those are still the current guidelines.

For more read Dr. Roy Boorady's answer to why teenagers go off of ADHD medication.

Published: February 7, 2012

Hot Topics: ADHD