Psychostimulant medication (Concerta, Ritalin, Equasim, and Medikinet) Main medication in ADHD is Methylphenidate. This comes in four different forms: Ritalin (usually 10mg tablets), Equasym XL 10, 20, 30mg tablets, Concerta (slow release form in 18, 27 and 36mg tablets) and Medikinet XL (10, 20, 30, 40mg capsules). Another stimulant medication is Dexamphetamine or Dexedrine which comes in 5mg tablets. Concerta is a long-acting medication and lasts between 8 - 12 hours. Tablets should be swallowed whole after breakfast. Up to 72mg Concerta can be given. Equasym XL is a long acting medication which lasts around 8 hours. Capsules should be swallowed whole before breakfast. Up to 60mg Equasym XL could be given. Occasionally, capsules can be opened and medication given on a spoon with food. Medikinet XL is similar to Equasym XL - up to 60mg can be given. Ritalin is short-acting and last between 2 - 4 hours. Maximum dose of 60mg is usually prescribed. The tablets can be cut or crushed if desired. They should be given after meals if possible. Dexedrine can also be cut or crushed. Maximum dose is 30mg. SIDE EFFECTS Withdrawn, Teary, Upset When starting medication a few children may become withdrawn, teary, upset, irritable, unhappy or angry. This is short-lived and quickly reversible as the dose is reduced or the drug changed. This is the most common reason why stimulants do not suit some children, but usually if dose is lowered or the other preparation given, the problem ceases. It must be emphasized that this withdrawal and upset happens at the start of treatment or when the dose is increased. If these problems are not present at the start they will not appear later, on the same dosage. Any child who appears doped, dazed or unhappy on medication is being incorrectly treated and must be reviewed. Once the child is stabilized on the correct dose of the correct medication, side effects will be extremely unlikely. Addiction is not a problem - In the fifty years stimulant medications have been used, addiction has not been shown as a problem in correctly diagnosed children. Most addictions are to drugs that send one on a "trip", not to bring you into "full focus reality" Stimulants help the child focus on reality, and for this reason it is unlikely that an ADHD child would become addicted. Appetite Reduction - In theory appetite should be diminished with stimulant medication but if the dose is correctly tuned a major reduction is surprisingly rare. The medication should be given with meals to allow the food to arrive in the stomach before the drug takes effect. If the food intake is greatly reduced, stopping the afternoon dose, or even lowering the midday dose, generally allows for catch up nutrition with the evening meal. Tics - (Involuntary movements) are frequently associated with ADHD. Though not thought to be caused by stimulants, the occasionally appear or become worse, during treatment. On rare occasions these movements become quite major and are then called Tourette's syndrome. There is a lot of conflicting information in the literature regarding the relationship of stimulants or tics and Tourette's syndrome. Let's play it safe and if you have any concern, stop the medication and discuss the options. Sleep Problems - These are said to be more common in children on medication, but this is a rare complication. Many ADHD children find it difficult to settle at night, even when off medication. If medication makes this worsen the afternoon dose can be reduced or suspended. Occasionally the M.D. Dose also needs to be reduced. When sleep is a very major problem the drug Clonidine or Melatonin may be given at night. Rebound Behaviour - A few children rebound into a brief patch of much worse behaviour as the drug wears off. This is after 31/2 to 41/2 hours and can usually be avoided by adjusting the previous dose or giving a small top-up dose before wear off time. It is less likely with Concerta. Growth Retardation - In the past it was suggested this can be a side effect of high dose, long term medication. A large study done ten years ago showed that, after three years of medication treatment, the children were shorter compared to the ones who were not on medication. It is not clear if these children will catch up in their growth. The growth reduction may be prevented by using medication lasting eight hours and/or not using medication during school holidays. Though we are not greatly concerned about growth retardation, it is still best to measure growth and keep the doses as low as possible. Do you need holidays off medication? Some experts suggest holidays and weekends should be lived without medication. If behaviour is a significant problem never stop stimulants at home. There is little evidence that if properly monitored, long term medication will harm children, but it is certain that difficult child do immense damage to their family relationships and thus their own esteem and happiness. How long will they needed? Stimulants will continue to be prescribed for as long as they can be seen to bring benefits. This may be three months, three years or until school leaving. Every parent will forget to give the tablets from time to time. If this brings about a great deterioration, you know the medication is still needed. If you are ever in doubt, give alternate weeks on and off the medicine, without informing the school. Then watch for the difference. Are Stimulants Completely Safe? There is no such thing as a completely safe drug but as medicines go these are well researched and relatively free of problems. However, the American medication regulatory authority (FDA) has decided to warn parents that, in extremely rare situations, stimulants can be associated with severe heart problems and should not be used in children known to have heart abnormality. About 2 per 100,000 who are not on any medication will die suddenly at any time without apparent cause being identified before death. In comparison, 2 per 1,000,000 children on stimulants die without a cuase being identified before death. ECG will be done when treatment is started to elucidate if there are any heart problems, although normal ECG can't rule out every heart rhythm problems. In addition, if children have pre-existing or undiagnosed psychotic disorders such as schizophrenia or bipolar disorder, further psychotic episodes can be precipitated. Remember that untreated ADHD is not without serious side effects, both to the child and their families. If you have any worry about a possible problem - stop the medication immediately. These medicines can be stopped abruptly without any need for tail-off gradually. The main side-effect when starting or raising drug dosage is for the child to become slightly withdrawn, teary irritable or "different". If at any time there are side effects which worry you, stop medication at once. When stopped, it will take between 4 - 12 hours for these effects to pass. After a trial of both medications, if you are sure of the benefits of this treatment we will fine-tune the dosage to achieve the best effects from breakfast to homework time. It after this short trial no great benefit is apparent, we will either abandon drug therapy or will try another medication. You will be in no doubt when the time has come to stop medication. There will always be some missed tablets and when this is found to make little difference, it is time to stop. As the months go by you must continually ask yourself if the benefits are still being seen. You will tell us when medication should cease. You will tell us if you ever have any concerns about side effects. Side Effects Assessment Criteria Instructions: Please rate each behaviour from 0 to 10 (serious). Circle only one number beside each item. A zero means that you have not seen the behaviour in this child during the past week, and a ten means that you have noticed it and believe it to be either very serious or to occur very frequently. Behaviour Absent to Serious *Insomnia or trouble sleeping 0 1 2 3 4 5 6 7 8 9 10 *Nightmares 0 1 2 3 4 5 6 7 8 9 10 Stares a lot or daydreams 0 1 2 3 4 5 6 7 8 9 10 Talks less with others 0 1 2 3 4 5 6 7 8 9 10 Uninterested in others 0 1 2 3 4 5 6 7 8 9 10 Decreased appetite 0 1 2 3 4 5 6 7 8 9 10 Irritable 0 1 2 3 4 5 6 7 8 9 10 Stomachaches 0 1 2 3 4 5 6 7 8 9 10 Headaches 0 1 2 3 4 5 6 7 8 9 10 Drowsiness 0 1 2 3 4 5 6 7 8 9 10 Sad/unhappy 0 1 2 3 4 5 6 7 8 9 10 Prone to crying 0 1 2 3 4 5 6 7 8 9 10 Anxious 0 1 2 3 4 5 6 7 8 9 10 Bites fingernails 0 1 2 3 4 5 6 7 8 9 10 Euphoric/usually happy 0 1 2 3 4 5 6 7 8 9 10 Dizziness 0 1 2 3 4 5 6 7 8 9 10 Tics or nervous movements 0 1 2 3 4 5 6 7 8 9 10 * QUESTION TO BE COMPLETED BY PARENTS / GUARDIANS ONLY DR BOZHENA ZORITCH/DR MARIUS POTGIETER - BEHAVIOUR ASSESSMENT TEAM