Many studies have documented the efficacy of stimulants in reducing the core symptoms of ADHD. In many cases, stimulant medication also improves the child’s ability to follow rules and decreases emotional overreactivity, thereby leading to improved relationships with peers and parents. The most powerful effects are found on measures of observable social and classroom behaviors and on core symptoms of attention, hyperactivity, and impulsivity. The effects on intelligence and achievement tests are more modest. Most studies of stimulants have been short-term, demonstrating efficacy over several days or weeks.
Despite the efficacy of stimulant medications in improving behaviors, many children who receive them do not demonstrate fully normal behavior (eg, only 38% of medically managed children in one study received scores in the normal range at 1-year follow-up). Although there is demonstrated efficacy of stimulants lasting at least to 14 months, the longer term effects of stimulants remain unclear, attributable in part to methodologic difficulties in other studies.
Stimulant medications currently available include short-, intermediate-, and long-acting methylphenidate, and short-, intermediate-, and long-acting dextroamphetamine. The McMaster report reviewed 22 studies and showed no differences comparing methylphenidate with dextroamphetamine or among different forms of these stimulants. Each stimulant improved core symptoms equally. Individual children, however, may respond to one of the stimulants but not to another. Recommended stimulants require no serologic, hematologic, or electrocardiogram monitoring.
Current evidence supports the use of only 2 other medications for ADHD, tricyclic antidepressants2 and bupropion. The use of nonstimulant medications falls outside this practice guideline, although clinicians should select tricyclic antidepressants after the failure of 2 or 3 stimulants and only if they are familiar with their use. Clonidine, one of the antihypertensive drugs occasionally used in the treatment of ADHD, also falls outside the scope of this guideline. Limited studies of clonidine indicate that it is better than placebo in the treatment of core symptoms (although with effect sizes lower than those for stimulants). Its use has been documented mainly in children with ADHD and coexisting conditions, especially sleep disturbances.
Detailed instructions for determining the dose and schedule of stimulant medications are beyond the scope of this guideline. However, a few basic principles guide the available clinical options.
Unlike most other medications, stimulant dosages usually are not weight dependent. Clinicians should begin with a low dose of medication and titrate upward because of the marked individual variability in the dose-response relationship. The first dose that a child’s symptoms respond to may not be the best dose to improve function. Clinicians should continue to use higher doses to achieve better responses. This strategy may require reducing the dose when a higher dose produces side effects or no further improvement. The best dose of medication for a given child is the one that leads to optimal effects with minimal side effects. The dosing schedules vary depending on target outcomes, although no consistent controlled studies compare different dosing schedules. For example, if there is a need for relief of symptoms only during school, a 5-day schedule may be sufficient. By contrast, a need for relief of symptoms at home and school suggests a 7-day schedule.
Stimulants are generally considered safe medications, with few contraindications to their use. Side effects occur early in treatment and tend to be mild and short-lived. The most common side effects are decreased appetite, stomachache or headache, delayed sleep onset, jitteriness, or social withdrawal. Most of these symptoms can be successfully managed through adjustments in the dosage or schedule of medication. Approximately 15% to 30% of children experience motor tics, most of which are transient, while on stimulant medications. In addition, approximately half of children with Tourette syndrome have ADHD. The effects of medication on tics are unpredictable.
|Generic Class (Brand Name)||Daily Dosage Schedule||Duration||Prescribing Schedule|
|Stimulants (First-Line Treatment)|
|Short-acting (Ritalin, Methylin)||Twice a day (BID) to 3 times a day (TID)||3-5 hr||5-20 mg BID to TID|
|Intermediate-acting (Ritalin SR, Metadate ER, Methylin ER)||Once a day (QD) to BID||3-8 hr||20-40 mg QD or 40 mg in the morning and 20 early afternoon|
|Long-acting (Concerta, Metadate CD, Ritalin LA*)||QD||8-12 hr||18-72 mg QD|
|Short-acting (Dexedrine, Dextrostat)||BID to TID||4-6 hr||5-15 mg BID or 5-10 mg TID|
|Intermediate-acting (Adderall, Dexedrine spansule)||QD to BID||6-8 hr||5-30 mg QD or 5-15 mg BID|
|Long-acting (Adderall-XR*)||QD||10-30 mg QD|
|Antidepressants (Second-Line Treatment)|
|Tricyclics (TCAs)||BID to TID||2-5 mg/kg/day†|
|(Wellbutrin)||QD to TID||50-100 mg TID|
|(Wellbutrin SR)||BID||100-150 mg BID|
* Not FDA approved at time of publication. † Prescribing and monitoring information in Physicians’ Desk Reference.
Source: Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder, Volume 108, Number 4; October 2001, pp 1033-1044; American Academy of Pediatrics.