Brand-name Ritalin, manufactured by Novartis (formerly Ciba-Geigy), comes in
the form of 5 mg, 10 mg, and 20 mg tablets, as does its generic counterpart,
methylphenidate, produced by MD Pharmaceuticals. Despite claims from the ADD
underground (encountered often on the Internet) of the brand-name drug's
superiority, Ritalin and generic methylphenidate have been rated as
bioequivalent in their actions by the Food and Drug Administration. Unless a
family insists on Ritalin, I prescribe generic methylphenidate because it is
less costly. (An article in the Journal of the American Academy of Child and
Adolescent Psychiatry, the leading child psychiatry journal,
reported on two children who responded differently to the two different
preparations, but the psychiatrists could not account for the differences.) I
have trouble accepting that the two versions of the drug really are different.
If a child wasn't responding to methylphenidate, I would consider another
medication entirely--say, Dexedrine--rather than switching to Ritalin.
Excerpted from Running on Ritalin: A Physician Reflects on Children,
Society, and Performance in a Pill (Bantam, 1998). (pp. 253-6; 262-265)
Copyright Lawrence Diller. Reprinted with permission.
Ritalin is a little pill, yellow or white. Even children describe the 5 mg
tablet as small (it's about 6 mm across), and the larger-dose tablets are only
slightly bigger. It has a somewhat bitter taste. No flavored liquid
preparations of Ritalin, or any other stimulant for that matter, are available.
On one hand, this is surprising, since the drug is prescribed for children as
young as three; even Prozac now comes as a mint-flavored drinkable solution.
However, the manufacturers of stimulants are probably concerned that a liquid
form of the drug would be attractive to abusers, who might attempt to inject
themselves. (Crushing the tablet and making a solution of the drug is a more
In any case, ingesting such a small pill isn't usually a problem for kids. One
doctor's claim to fame was a method for teaching youngsters how to swallow
Ritalin tablets by practicing with edible cake toppings. Some families crush
the tablets and put them in yogurt or other soft foods; one mother put the
tablet inside a small marshmallow. Children as young as five learn to swallow
the tablet whole.
One of the chief attractions of Ritalin is the rapidity of its effects. Unlike
some of the older antidepressants, for example, which could take up to two or
three weeks to work, Ritalin begins working within twenty to thirty minutes
after the child swallows it. So results are often observed immediately--but
finding the ideal dosage amount and frequency may take from several days to a
few weeks. It's pretty much a process of trial and error, because studies so
far have failed to correlate body weight, dosage size, and blood levels of the
drug to a reliable clinical response. Researchers therefore recommend in most
cases simply starting children on the smallest dosage tablet. After monitoring
the desired and undesired side effects for several days (I use three days), the
dosage is increased by one 5 mg tablet.
Thus, when starting Ritalin, a typical dosing schedule would be to take one 5
mg tablet for the first three days, then take two together on days four through
six. Every fourth day a pill is added, up to a total of 20 mg per dose--unless
the patient experiences significant and persistent negative side effects, in
which case no higher dose is attempted. Curiously, this 5 mg to 20 mg range
applies to three-year-olds weighing only forty pounds as well as to full-grown
men weighing six times that amount. I hypothesize (partly in jest) that the
response to Ritalin has more to do with the number of brain cells one
possesses, which doesn't change that much as young children become adults.
The purpose of this trial-and-error process, or titration, is twofold: to find
the lowest dose at which the best response is achieved, and to minimize side
effects. For most children, one 5 mg tablet is not enough to produce any
observable change in behavior or performance. Incrementally increasing the dose
allows the family to determine the dosage that produces the optimal response.
If 10 mg of Ritalin works better than 5 mg and as well as 15 mg, then the child
should take only 10 mg. In certain cases, however, even 5 mg may make a child
jittery or bring on a headache (both rare at 5 mg but possible). If such
complaints persist for more than a day or two, no further Ritalin is offered.
As for the three-day time frame, this allows for surer determination of the
medication's effects. The causes of behavior are complex, and it's difficult to
attribute any one day's good or bad behavior to a drug. Three days of
consistent results make it more likely that the medication is responsible.
If a patient, child or adult, is not responding to 20 mg, it is unlikely that
raising the dosage will make a difference. One medical report cites the use of
higher dosages--double the generally recommended limit--with much higher
frequencies of side effects. Despite the undesired effects, this practitioner
claimed the method worked for him and his patients, though the journal later
received critical letters about publishing the report. Experts are nearly
unanimous in advising against single dosages of more than 20 mg.
The ideal frequency of dosing is also determined in the first several weeks.
Ritalin's effects last about three to four hours. School lasts about six hours,
and most children are awake for at least twelve. Yet many children do very well
all day on just one dose of Ritalin, taken before they leave home in the
morning. This cannot be explained solely by the drug's pharmacological action,
since it is no longer detectable in the bloodstream after four hours. It's
possible that the child who manages on a single daily dose of Ritalin has a
milder temperament problem. In such a case, the medication helps him succeed in
the morning, when the bulk of academic instruction takes place in elementary
school. Afternoons are typically taken up with less challenging activities like
projects, art, or physical education. Having had a good morning, the child
feels better about himself, is able to delay his impulses toward immediate
gratification, and can concentrate on the more enjoyable afternoon activities
without need of more medication. Then, having experienced a happy and
successful school day, he returns home in a sustained good mood, able to
cooperate relatively well in the more flexible home environment.
However, many children (and nearly all teenagers and adults) benefit from more
than one dose of Ritalin during the day. If deterioration in performance or
behavior is noted after lunch (at school or at home), a second dose of Ritalin
can be given around the lunch hour. The dosage amount is titrated, like the
morning dose, in three-day increments. This need for a noontime dose accounts
for the lines of children forming around the school secretary's office in many
American schools. With a written note from the doctor, school staff must
deliver medication to children. School nurses are the logical and
best-qualified personnel for the task, but with nationwide cutbacks in public
education, most elementary schools no longer have a nurse regularly on the
premises. Other school personnel--secretaries, teachers, even janitors--have
been delegated the job of doling out medication.
Most school districts have a policy that prohibits children from taking their
pills by themselves. Such rules are difficult to enforce and regularly ignored
by both families and school officials. In particular, most teenagers I know who
take a second dose of Ritalin at school do not bother going to the office. This
laissez-faire attitude toward self-dosing is strongly challenged by law
enforcement officials, who have found children giving or selling their Ritalin
to friends who subsequently abuse the drug--primarily by snorting it. Indeed,
in some areas Ritalin is said to be easier and cheaper to buy on the grounds of
middle schools than on the adjacent neighborhood streets.
A third dose of Ritalin can be given around four o'clock in the afternoon,
again if observations of behavior seem to warrant it; this is happening with
increasing frequency. Despite the findings of a recent study indicating that
most children can handle a third dose without problems, that third dose does
increase the possibility, for some children, of unacceptable side effects
during the dinner hour and at bedtime. I'm not aware of any children who
receive more than three doses of Ritalin a day. For adolescents and adults,
whose attention and performance requirements remain constant through most of
their waking hours, two or three daily doses are the norm.
From a strictly physical standpoint, it appears Ritalin can be taken safely
every day. On the other hand, one can cease taking it for a day, a month, or a
year, and it should work pretty much the same as the last time it was taken.
Some argue that Ritalin should be taken on a fixed dosage schedule, 7 days a
week, 365 days a year--the frequently used analogy is to insulin for the
diabetic. While I object to the Ritalin/insulin analogy on several grounds, one
need only note that even daily insulin dosages are adjusted according to how
much the patient eats and how active he is. It doesn't make sense to take a
drug every day if it isn't needed. For individuals more severely affected by
attention or behavioral problems, taking multiple daily doses of Ritalin seems
reasonable. But for many children, problems manifest only in the school
setting; they do quite well without medication on weekends, holidays, and
vacations. For such children at such times, Ritalin seems unnecessary. ...
Research studies have determined a few unwanted effects of Ritalin, both
immediate and long-term. Ritalin in low doses lowers the heart rate and raises
blood pressure. These changes have not been found to be significant, either in
the short or long term. Ritalin can be taken with or without food. Complaints
of abdominal distress are commonly associated with taking any medication in
pill form, and Ritalin is no exception. These complaints pass with continued
use, however, and are rarely a reason for discontinuing the drug.
Decreased appetite is common while Ritalin is working, but as soon as the
drug's effects have worn off (typically less than four hours), hunger returns,
often with greater intensity. Therefore, in a typical dosing pattern--two or
three doses a day, beginning right after breakfast--the medication likely will
decrease a child's desire for lunch, but as its effects wear off, his appetite
for an afternoon snack and larger-than-usual helpings at dinner may increase.
(Dinner may need to be a bit later than normal for children taking three doses
daily.) Many parents worry that Ritalin use will cause persistent weight loss
or failure to gain weight--important in growing children--but this has been
much studied and occurs only rarely. Similar concerns that Ritalin use in
childhood could decrease eventual adult height were raised in studies during
the 1970s. Attempts to replicate these findings were inconsistent, however, and
very recent analyses of long-term growth patterns reveal no such effects.
Children may have trouble falling asleep if Ritalin is taken too late in the
day; thus, it is common practice to give the last dose not later than 4:00
P.M.--both to prevent insomnia and to allow the appetite to return in time for
dinner at a reasonable hour. A certain number of children cannot take a
late-afternoon dose because of these side effects. However, many children and
most adults can tolerate an afternoon dose without problems.
"Rebound" is a term used to describe the worsening of symptomatic
behavior after a drug has worn off. Rebound from Ritalin is not uncommon; some
parents feel that their child becomes even more "hyper" in the late afternoon
or evening, as the drug wears off. In studies of the phenomenon using Ritalin
and Dexedrine, some but not all of the children showed some aspects of rebound,
but none were so severely affected that stopping their medication was
indicated. Dexedrine or longer-acting preparations of Ritalin are often
recommended in situations where rebound persists. Some physicians prescribe a
second drug such as clonidine to treat the rebound. I try to identify
behavioral ways of dealing with late-day problems.
Another possible effect of Ritalin, though scientifically equivocal and
relatively rare, is that the medication can unmask the existence of involuntary
tics or the more serious condition, Tourette's syndrome. (Unmasking means that
symptoms manifest sooner than they normally would.) This link was identified by
researchers in the 1980s, but today there is growing consensus that the link
between tics and Ritalin is inconsistent. It's now thought that the medication
can be used for children with Tourette's (or a family history of the disorder)
if the child's behavior warrants treatment and responds to Ritalin.
Higher doses of Ritalin (more than 20 mg) usually lead to children's
complaining of nervousness, palpitations (feeling one's heart beating), tremor
(shakiness), and/or headaches. Teenagers and adults may experience similar
discomfort but also report mild euphoria when Ritalin is taken orally in higher
doses. Such doses given to children generally do not result in euphoria, but
there are exceptions. A recent report noted that an eleven-year-old boy was
stealing his own medication from his grandmother because the tablets made him
feel "nice" and "very happy." And a twelve-year-old patient of mine was caught
by his father taking an extra 10 mg tablet of Ritalin before playing in a Pop
Warner football game. He said it made him feel "sharper," though his father
felt he was "acting strange." In a culture where professional athletes still
attempt to use performance-enhancing drugs despite stiff penalties, such
occurrences should not be surprising. However, most of the time, the younger
child on a higher-than-normal dose doesn't care for the experience and will say
something like, "I feel weird."
Experiencing euphoria is, of course, one of the features of a drug that makes
it a candidate for abuse. The most serious drugs of abuse are those that
readily cause users to develop tolerance (the need for a higher and higher dose
to obtain the same effect) or addiction (a physical and emotional craving for
the drug). In the typical dose range of 5 mg to 20 mg, up to perhaps 60 mg
total per day, Ritalin does not produce either tolerance or addiction. Ritalin
does not accumulate in the bloodstream or elsewhere in the body, and no
withdrawal symptoms occur when someone abruptly stops taking the drug, even
after years of use. However, with teenagers and adults who abuse Ritalin--by
taking high doses, sometimes via snorting or shooting the drug--the phenomena
of tolerance, addiction, and withdrawal can occur.
No serious diseases have been linked with Ritalin use. The only slim evidence
of such a possible link is a 1996 study by the FDA of rats given large daily
doses of Ritalin over their whole life, which resulted in an increased rate of
liver cancer in these animals. In releasing the study, however, the FDA assured
doctors and patients that it was highly unlikely that Ritalin was carcinogenic
in humans. Liver cancer is common in rats and uncommon in people. FDA checks
found no correlation between records of liver cancer victims and the use of
Ritalin, nor have there been reports of increased liver cancer in children or
adults who've taken Ritalin.
I mention this study only to highlight the possibility, however unlikely, that
despite sixty years of stimulant use with children demonstrating remarkable
physical safety, some as-yet-undiscovered negative effect of Ritalin still
could be found. Each parent must weigh the use of Ritalin for a child on the
evidence of clear short-term improvements in behavior and performance with the
absence of long-term negative or positive consequences directly attributable to
the drug. However, the long-term negative consequences of continuing failure
and declining self-worth are well known. The possibility that Ritalin can
assist in breaking that pattern must be weighed against any downside to the
Although this excerpt deals exclusively with Ritalin, Diller notes
later in the book that "Virtually everything that has been said about Ritalin
applies to Dexedrine. Structurally and pharmacologically the two are very
similar, and studies of groups of children have shown that the benefits and
disadvantages of Dexedrine to be the same as for Ritalin." Running on
Ritalin was published before Adderall became a third popular treatment for
ADHD. Diller subsequently told FRONTLINE that Adderall is "virtually identical"
to Dexedrine, and that its effects--both positive and adverse--were similar to
both Dexedrine and Ritalin.
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