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The What, When, And How Of Taking Ritalin by Lawrence Diller


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.
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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.

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 labor-intensive effort.)

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. ...



SIDE EFFECTS AND OTHER CONSIDERATIONS

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 drug.



editors note

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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