Short-acting stimulants in ADHD
Methylphenidate
Methylphenidate (common brand name: Ritalin) is a medication commonly prescribed for children with attention deficit hyperactivity disorder (ADHD). It helps children with ADHD improve their focus, attention, and control their impulses, which can significantly enhance their daily functioning. Methylphenidate is the primary drug of choice for children with ADHD.
Screening before starting Ritalin
Safety is paramount when taking Ritalin. It’s vital to inform your doctor of any pre-existing conditions, especially if your child has any heart problems, high blood pressure, or mental health issues. It’s also important to let your doctor know about any sudden death in the family or seizure disorder. Additionally, avoid alcohol while on this medication, as it can lead to unwanted interactions. Discuss any other drugs or supplements you take with your healthcare provider to ensure no harmful interactions.
Pre-existing medical conditions
Co-existing conditions, such as tics and anxiety, are essential to be considered, as stimulants can sometimes worsen these conditions. However, children can also be anxious as they are unable to focus. Therefore, stimulant medication may improve symptoms of anxiety if the primary issue is ADHD. Sleep can also be affected if the effect of stimulants lasts longer into the evening. Hence, the last dose may not be given late in the evening.
Congenital heart diseases and heart rhythm abnormalities are essential considerations while starting Ritalin. While it’s generally safe in most non-complex heart conditions, your primary care physician might discuss it with a cardiologist before starting stimulants. This approach is also adopted if the patient has a pre-existing seizure condition, where an opinion from the neurologist might be sought.
Although Ritalin is highly effective in most cases, it can be less effective in the presence of underlying conditions such as Autism, intellectual disability, and a history of complex trauma, which can be due to several reasons. Your clinician will again closely monitor and adjust the dose accordingly.
Ritalin Dosing
When starting Ritalin, it is essential to follow a carefully structured approach. Treatment begins with a low dose of 5 mg in the morning and is generally trialled at home. That way, the response can be evident to the parents and caregivers.
Depending on the need, additional doses can be added if there is a positive difference from the initial small dose. This initial dosage allows your healthcare provider to gauge your body’s response to the medication. Obtaining regular reports from school to understand the duration of Ritalin’s effect helps determine additional doses.
Taking the medication in the morning and early afternoon is recommended to minimise any potential disruptions to sleep. As your treatment progresses, your doctor may suggest gradually increasing the dosage. This adjustment is usually made based on the response and any side effects the child may experience. Generally, dose changes are made every week or two until the desired effect is achieved. The key is communicating openly with your healthcare provider during this period, ensuring that any changes in your condition are closely monitored.
The dose of Ritalin is adjusted based on response. The dose effects can usually be seen for four hours or so. However, it also depends on the body’s metabolism of the medication. Some children’s bodies metabolise the medication fast and may need a more frequent dose, while others metabolise slowly. I have children who are just on 5 mg once, and the family reports a good response in their child. Some children may even respond to a quarter of a dose, although this dose is complex to administer. And in some cases, more than twice the daily dose may be required.
In some children, the rebound effect can be seen in the evening. They may be emotional and inattentive in the evening after the afternoon dose effect wears off. In these cases, a slight dose of Ritalin in the evening might be helpful. But this must be carefully balanced to ensure sleep is not affected.
Ritalin can be taken with or without food, and it’s important to swallow the tablets whole without chewing or crushing them. Consistency is crucial; taking Ritalin at the same time each day helps maintain its effectiveness. If you miss a dose, take it as soon as you remember, unless it’s almost time for your next scheduled dose. In that case, skip the missed dose—never double up.
Adverse Effects
While many people tolerate Ritalin well, some may experience side effects. Common side effects include a loss of appetite, weight loss, trouble sleeping, nervousness, and stomach discomfort. Contact your healthcare provider immediately if you encounter severe side effects or signs of an allergic reaction.
Finally, be vigilant for any unusual symptoms. Contact your healthcare provider immediately if you notice uncontrolled movements, significant changes in mood or behaviours, or symptoms such as chest pain or shortness of breath. In my clinical practice, Ritalin is well tolerated without many side effects.
One of the most common side effects in clinical practice is weight loss. In this case, my approach is to liaise with a dietitian to improve calorie intake. I also advise on medication-free days, such as on weekends and taking medication with food. Providing drug-free days during school holidays is also a good strategy to reduce side effects. If appetite suppression is an issue, this may be a good time for children to regain weight.
Some children with neurobehavioral conditions, such as Autism, may not tolerate the medication, and sometimes have undesirable side effects such as aggravated behaviours. Your clinician will explore the reasons for this, consider stopping medication, and advise you on alternatives.
Long-term Management
Once short-acting Ritalin is well tolerated and once a suitable dose for the child has been identified, a switch to long-acting stimulants could be considered. However, some families elect to be on short-acting Ritalin. The choice of medications, dosing and ongoing management are all determined by the child’s response to the medication and the family’s preference.
In some cases, non-stimulants may be added to stimulants based on the clinical picture. For example, Guanfacine may be added to Stimulants, especially if impulsivity is a key concern. Again, this is a carefully considered decision by your practitioner.
Ritalin can be an effective part of managing ADHD, but it requires careful monitoring and open communication with your healthcare provider. By following your doctor’s guidance and keeping track of your progress, you can make the most of this treatment and improve your overall quality of life.
Non-pharmacological Measures
Managing sleep issues is a priority in managing ADHD. Poor sleep can cause irritability and poor focus during daytime hours, which should be addressed simultaneously. Regular exercise and participation in outdoor activities can help children with ADHD channel their energy productively. This can also improve sleep quality, overall well-being, and self-esteem.
Coordination of care
In my practice, I advise parents to consult their general practitioner weekly to adjust the dose, and once the dose is stable, stretch these visits to three monthly. During the GP visits, a detailed history of the symptoms, growth assessment, and any side effects of the medication are explored.
Your primary care physician would also send a letter to the school detailing the condition, as the child may need additional supports and accommodations at school. Furthermore, children may have co-existing learning difficulties that require additional measures at school. The letter will also detail the Ritalin dosing, especially where additional doses must be administered during school hours.
The General Practitioner remains the primary care specialist for the child, and I, as a paediatrician, provide specialist advice. Hence, there is a collaborative care ensuring safe, accessible and effective care for children with ADHD. But some paediatricians may prefer to be the primary care provider for ADHD management for your child, and in some countries, this is the norm. Hence, it’s essential to understand your physician’s framework of practice.
Since there is potential for abuse of the medication use and side effects, the prescription of the medication is very regulated. Hence, your practitioner will be diligent in using prescription monitoring during ongoing management of ADHD. The caregivers should ensure the medication is out of reach for the children.
Acknowledgement: I thank Dr Aster Kuriakose, Paediatrician and Specialist in Developmental Paediatrics in Queensland, Australia, for reviewing the article and contributing immensely.
Disclaimer: Other clinical practitioners may vary their practices. The choice and dose adjustments can vary between practitioners based on their clinical judgement. This article is a general view based on current evidence. It’s crucial to adhere to your physician’s advice on treating ADHD.
Suggested resources
Mark Selikowitz, Fast Facts, ADHD, Oxford University Press, 2021. The book provides information on all aspects of ADHD, including practical strategies and nuances in treating it.
Christopher Green, Kit Chee. Understanding ADHD. Doubleday,2001. The book is based on extensive research and is elaborate.
Chung LM, Hariharan G, Varma S. Safety of stimulant medications for attention deficit hyperactivity disorder in paediatric congenital heart disease. J Paediatr Child Health. 2023 Mar;59(3):580-588. doi: 10.1111/jpc.16380. Epub 2023 Feb 15. PMID: 36789801.