October 6, 2007. 6:10 p.m.
 Let Them Eat Ritalin.

 It seems strange that the diagnosis of Attention Deficits Hyperactivity Disorder (ADHD)  
has been increasing so dramatically over the past few years.  
Ten per cent of boys in America are prescribed some  
kind of stimulant for the treatment of ADHD or other mental conditions.  
The elimination of recess, lengthening of the school year, and insistence that  
children remain rigidly fixed in the chairs without making a  
peep flies in the face of the realities of normal childhood.  
That said, we have to do our best to help our children move ahead in the world as it exists.  
 
Ritalin (methylphenidate, Methylin) works by increasing the release of dopamine,  
which helps kids concentrate. Ritalin needs to be taken a couple of times or more a day.  
Ritalin suppresses growth in children, and other side effects include palpitations,  
nervousness, rapid heart rate, loss of appetite, increased blood pressure, headache,  
upset stomach, and mood changes. High doses can cause psychosis.  
Another stimulant medication used in the treatment of ADHD is the amphetamine Adderall  
(mixed amphetamine salts), which is a mixture of two forms of amphetamine,  
and is marketed as a medication that only has to be taken once a day.  
Amphetamines are also used as diet pills, and as a consequence Adderall often  
has serious appetite suppression effects and can suppress long term growth.  
Other side effects are palpitations, nervousness, rapid heart rate, and upset stomach.  
Adderall has also been linked to rare cases of sudden death. About 15 cases of  
sudden death have been reported to the FDA over the past 10 years.  
This prompted Canada to take it off of the market.  
Children with heart defects are particularly at risk. The other cases of  
sudden death occurred in children on multiple medications undergoing strenuous activities.  
The mechanism is probably the increase in catecholamines (chemical messengers in the  
body that send signals to the heart, increasing the heart rate and influencing  
electrical activity of the heart) caused by Adderall that affects the function of the heart, leading to cardiac arrest.  
All of the amphetamine like stimulants, including Ritalin and Adderall, have been  
linked to approximately a doubling of heart related deaths in children.  
This prompted the FDA recently to put a black box warning on these medications.  
Death from heart disease is rare in children, however, so a doubling of heart  
disease deaths should not necessarily preclude use of these medications completely.  
Atomoxetine (Strattera) blocks uptake of norepinephrine into the neuron,  
and is also used in the treatment of ADHD. Strattera has the advantage over  
Adderall and Ritalin that it is not a stimulant and is therefore not  
associated with cardiac side effects. Side effects include indigestion,  
fatigue, dizziness, decreased appetite, and mood swings. Like Adderall,  
Strattera can inhibit growth in children.  
Another medication worth noting is Pemoline (Cylert). It is associated  
with liver toxicity that has led to nine documented deaths in children.  
For this reason it was removed from the market in the UK in 1997  
but remains on the market in the US, although it is not commonly prescribed.  
It mechanism of action is unknown but is thought to act on dopaminergic systems.  
It should not be used as a first line treatment for ADHD. Since it has not been  
shown to be efficacious in patients not responsive to first line drugs its use is questionable.
 
Bottom line? These drugs should be used as last resort but do help with  
attention.

Doug Bremner, MD, is a physician
and researcher in Atlanta GA
and author of Before You Take That Pill:
Why the Drug Industry May be
Bad for Your Health

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