Ritalin, Adderall, and Other Stimulant Medications for ADHD

As awareness of adult attention deficit hyperactivity disorder (ADHD) has grown, the use of ADHD medication in adults has skyrocketed. Between 2002 and 2005 the number of prescriptions received by adults for the most common ADHD drugs rose by 90%, according to data published in 2006 in The New England Journal of Medicine. Adults now account for about a third of all patients taking ADHD medications.

The most widely used ADHD drugs are stimulants, such as methylphenidate (the active ingredient in Ritalin) and mixed amphetamine salts (Adderall). Many ADHD drugs—Ritalin, most notably—have not been approved by the FDA for use in adults, although physicians do prescribe them to patients off-label.

When it comes to prescribing stimulants, however, doctors shouldn’t simply treat ADHD adults as extra-large children. More so than kids, adult patients are often taking medications for other conditions (such as depression or anxiety disorders) that could interact with ADHD meds. Many adults also struggle with heart-related problems such as high blood pressure, which stimulants may exacerbate. Other side effects, including loss of appetite and insomnia, may occur in patients of all ages—although they often subside in the first few weeks of treatment.

Still, medication is widely accepted as the most effective treatment for ADHD. It can drastically improve the quality of life for people who otherwise have trouble succeeding at work, maintaining relationships, and accomplishing their goals. Stimulants can start working in a matter of days, faster than the only approved nonstimulant ADHD medication, Strattera.

The following information from our A-Z Health Library describes stimulant medications used to treat ADHD. Not all of these drugs have been approved for adults.

How It Works?

Stimulants affect how the brain controls impulses and regulates behavior and attention. They do this by influencing the availability of certain chemicals, called neurotransmitters, in the brain.
Why It Is Used

Stimulants are considered for people with moderate to severe attention deficit hyperactivity disorder (ADHD) who have difficulty in at least two different settings, such as school and home.1 Stimulant medicines with amphetamine, such as Adderall, that are used for the treatment of ADHD are approved by the U.S. Food and Drug Administration (FDA) for children age 3 and older. Stimulant medicines with methylphenidate, such as Ritalin, are approved for children age 6 and older. A doctor may prescribe Ritalin for a child under age 6 based on the child's specific needs.
Methylphenidate (such as Ritalin or Concerta) is often the preferred choice for treating ADHD because it has fewer side effects than other medicines and generally works well to control behavior.
Dextroamphetamine or the combination dextroamphetamine and amphetamine (Adderall) is usually the second choice when the person does not improve with methylphenidate. But either may be the preferred medicine for older children. The long-acting form of dextroamphetamine controls behavior for a longer period of time, so fewer doses are required during the day.
The dextroamphetamine and amphetamine combination medicine (Adderall) is used when other stimulants have not improved symptoms or when the combination of medicines may be more beneficial.

Stimulants may be used in people with ADHD who also have mood disorders, such as depression. The priority of which condition is treated first usually depends on which is thought to be the main disorder.

Stimulants may be used in adults when antidepressants fail to control ADHD symptoms. If antidepressants alone are not controlling symptoms, stimulants may be added.

How Well It Works?

Stimulants may be the most effective treatment for the symptoms of ADHD: inattention, impulsivity, and hyperactivity. These medicines can suddenly and dramatically improve behavior. But some people need to try different types and dosages of stimulants to find the one that works best for them. If treatment with a stimulant is successful, it usually helps control symptoms over time without increasing the dosage.

In about 70% of people with ADHD, stimulant medicines improve their symptoms.1 In children, 75% to 80% improve after starting a stimulant medicine.

Children often become calmer, more organized, and less stubborn. Examples of behaviors that improve include:

• Less interrupting, fidgeting, and finger tapping at school; increased on-task behavior.
  
• Better relationships at home with parents and siblings; better focus and on-task behavior; better compliance with parent requests and authority.
  
• Improved social relationships; increased attention during sports and other activities.

Although stimulants may also improve social adjustment or academic performance for some children, they have not been shown to maintain this benefit over the long-term.

A recent study found that children with ADHD whose symptoms were predominantly related to inattention showed significant improvement when they took lower doses (36 mg or lower) of long-acting methylphenidate (Concerta) and had less benefit from higher doses. In children with ADHD who had symptoms of both hyperactivity and inattention, most showed increased improvement in symptoms when they took higher doses (36 mg to 54 mg). But higher doses resulted in increased insomnia and decreased appetite in both groups of children.3

Side Effects

The most common side effects (affecting about 50% of people) of stimulants are usually related to the dose and go away after the first 2 to 3 weeks on the medicine. Persistent side effects can usually be relieved by changing the dosage level, changing when the medicine is given, or trying a different type of stimulant. The most common side effects include:

• Decreased appetite. About 80% of people have decreased appetite. The appetite is usually least during the daytime, increasing in the evening. If the medicine is given after meals and snacks are added, especially in the evening, it may help improve the child's appetite and prevent weight loss.
  
• Difficulty falling asleep.

Other side effects are also usually temporary or go away with dosage adjustment. These include:

• Stomachache.
• Headache.
• Slightly increased blood pressure (in black males).

Athough short-term studies have shown stimulant medicines to be safe, long-term effects have not been studied. In a recent 3-year study, children who took stimulant medicine grew almost 0.5 in. (1.3 cm) a year slower than those children not on medicine. The study followed 540 youngsters with attention deficit hyperactivity disorder (ADHD), who were ages 7 to 9 at the start of the study. But studies differ on whether delayed growth is shown in children who are taking medicine for ADHD. More studies are needed to determine whether growth is affected at other ages (younger than age 7, older than age 9) and whether children taking these medicines might catch up over a period of time.4 5 As with any medicine, parents should balance the benefits their child might receive from these medicines with any potential risks.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About?
All medicines approved for the treatment of ADHD come with an FDA warning about possible heart-related or mental problems. Before starting a medicine for ADHD, tell your doctor if your child or you have any heart problems, heart defects, or mental health problems.

Methylphenidate and dextroamphetamine usually take effect within 1 hour after the first dose. Talk to your doctor about the best time to take the medicine.

Treatment with stimulants may be continued as long as the symptoms are present, the medicine continues to work, and there are no significant side effects.

People with ADHD do not tend to abuse stimulant medicine and very rarely develop dependence (addiction) on the medicine. In addition, there is no evidence that people with ADHD who take stimulants are at greater risk for abusing other drugs. In fact, people who take stimulants for ADHD may be less likely to abuse drugs.

Some people buy or steal stimulant medicines. Parents need to be certain that their child takes his or her medicine and does not share it with or sell it to anyone else. If this is a concern, talk to your doctor about your child taking a medicine in a safer form.

Canadian health authorities stopped sales of Adderall XR in Canada, but after carefully reviewing the data, the drug was returned to the market. Health Canada withdrew the medicine from the market after learning that Adderall XR and Adderall (sold in the United States, not in Canada) have been linked to 20 sudden deaths and 12 strokes in children and adults in the U.S. After reviewing the Canadian decision and the medical reports, the U.S. Food and Drug Administration (FDA) has not recommended any immediate changes in the FDA labeling or approved use of this drug. The FDA recommends that you talk to your doctor if you have any questions or concerns about using this medicine.

When stimulants are used to treat ADHD, remember that:

• If a dose is missed, do not increase doses to catch up. If several doses are missed, begin taking the medicine again on the regular schedule.
  
• Methylphenidate often needs to be given every 3 hours to prevent the symptoms of ADHD from coming back.

Tips for giving methylphenidate or dextroamphetamine to children:

• It is best to start the medicine on the weekend so you can better see how the child reacts to the medicine.
• A low dose of methylphenidate is usually given at first. The dose is increased until the child's behavior is controlled. It is important to follow the prescribed dosage schedule and watch for changes in behavior.
• A typical schedule for giving the medicine is after breakfast and lunch and in the afternoon. Schedules may be changed to suit the needs of the child, his or her family, and school. It is better to give the medicine after meals rather than before so it doesn't interfere with the child's appetite and weight gain.

Most children who take stimulants for ADHD function best when medicines are used continuously. But some children may function well enough to take a break from medicines on weekends and holidays. Even for these children, it is usually helpful to continue the medicine on weekends if activities are planned that require concentration and attention, such as team sports, church activities, or educational programs.

Complete the new medication information form (PDF) (What is a PDF document?) to help you understand this medication.

References:
Citations:

1. American Academy of Child and Adolescent Psychiatry (2002). Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. Journal of the American Academy of Child and Adolescent Psychiatry, 41(2, Suppl): 26S–49S.
2. Hechtman L (2005). Attention-deficit/hyperactivity disorder section of Attention-deficit disorders. In BJ Sadock, VA Sadock, eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 8th ed., vol. 2, pp. 3183–3198. Philadelphia: Lippincott Williams and Wilkins.
3. Stein MA, et al. (2003). A dose-response study of OROS methylphenidate in children with attention-deficit/hyperactivity disorder. Pediatrics, 112(5): e404–e413.
4. MTA Cooperative Group (2004). National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: Changes in effectiveness and growth after the end of treatment. Pediatrics, 113(4): 762–769.
5. Jensen PS, et al. (2007). 3-year follow-up of the NIMH MTA Study. Journal of the American Academy of Child and Adolescent Psychiatry, 46(8): 989–1002.
6. Wilens TE, et al. (2003). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse: A meta-analytic review of the literature. Pediatrics, 111(1): 179–185.

U.S. Food and Drug Administration (2005). FDA Statement: Statement on Adderall. Available online:
Last Updated: April 17, 2008 See Full Credits Disclaimer