What are the disadvantages of using stimulant medication, such as (Attention Deficit Hyperactivity Disorder) ADHD medication, for children with Attention Deficit Hyperactivity Disorder (ADHD)?

From the Guidelines

Stimulant medications for ADHD in children have several important disadvantages to consider, including decreased appetite, sleep problems, and growth suppression with long-term use, as well as potential cardiovascular effects and risk of misuse or diversion, as noted in the most recent study by Wolraich et al. 1.

Disadvantages of Stimulant Medication

The use of stimulant medications in children with ADHD can lead to several adverse effects, including:

• Decreased appetite and initial weight loss
• Sleep disturbances, such as difficulty falling asleep
• Growth suppression with long-term use, with diminished growth in the range of 1 to 2 cm from predicted adult height, as observed in the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study 1
• Cardiovascular effects, such as increased heart rate and blood pressure, which requires monitoring, especially in children with pre-existing heart conditions
• Mood changes, including irritability, flattened affect, or rebound irritability when medication wears off
• Risk of misuse or diversion, particularly in adolescents

Additional Considerations

It is essential to note that about 10-30% of children do not respond adequately to stimulants or cannot tolerate them due to side effects 1. The medications also require careful dosing and timing, with effects typically lasting 4-12 hours depending on the formulation, necessitating multiple daily doses for some children. Parents should be aware that stimulants treat symptoms but do not cure ADHD, and behavioral therapies are often needed alongside medication for optimal outcomes.

Monitoring and Precautions

Clinicians are encouraged to monitor vital signs, such as heart rate and blood pressure, in patients receiving stimulant treatment, especially in children with pre-existing heart conditions 1. A thorough medical history, including specific cardiac symptoms and family history, should be obtained before initiating therapy with stimulant medications.

Non-Stimulant Alternatives

Non-stimulant medications, such as atomoxetine, guanfacine, and clonidine, may be considered as alternative treatment options for ADHD in children, especially in cases where stimulants are not effective or tolerated 1. However, these medications also have their own set of potential adverse effects and require careful consideration and monitoring.

From the FDA Drug Label

Assessing Cardiovascular Status in Patients Being Treated with Stimulant Medications Children, adolescents, or adults who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden death or ventricular arrhythmia) and physical exam to assess for the presence of cardiac disease, and should receive further cardiac evaluation if findings suggest such disease Psychiatric Adverse Events Pre-Existing Psychosis Administration of stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with a pre-existing psychotic disorder Bipolar Illness Particular care should be taken in using stimulants to treat ADHD patients with comorbid bipolar disorder because of concern for possible induction of mixed/manic episode in such patients Prior to initiating treatment with a stimulant, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. Emergence of New Psychotic or Manic Symptoms Treatment emergent psychotic or manic symptoms, e. g., hallucinations, delusional thinking, or mania in children and adolescents without prior history of psychotic illness or mania can be caused by stimulants at usual doses. If such symptoms occur, consideration should be given to a possible causal role of the stimulant, and discontinuation of treatment may be appropriate In a pooled analysis of multiple short-term, placebo-controlled studies, such symptoms occurred in about 0. 1% (4 patients with events out of 3,482 exposed to methylphenidate or amphetamine for several weeks at usual doses) of stimulant-treated patients compared to 0 in placebo-treated patients Aggression Aggressive behavior or hostility is often observed in children and adolescents with ADHD, and has been reported in clinical trials and the postmarketing experience of some medications indicated for the treatment of ADHD Although there is no systematic evidence that stimulants cause aggressive behavior or hostility, patients beginning treatment for ADHD should be monitored for the appearance of, or worsening of, aggressive behavior or hostility Long-Term Suppression of Growth Careful follow-up of weight and height in children ages 7 to 10 years who were randomized to either methylphenidate or non-medication treatment groups over 14 months, as well as in naturalistic subgroups of newly methylphenidate-treated and non-medication treated children over 36 months (to the ages of 10 to 13 years), suggests that consistently medicated children (i.e., treatment for 7 days per week throughout the year) have a temporary slowing in growth rate (on average, a total of about 2 cm less growth in height and 2. 7 kg less growth in weight over 3 years), without evidence of growth rebound during this period of development. Published data are inadequate to determine whether chronic use of amphetamines may cause a similar suppression of growth, however, it is anticipated that they likely have this effect as well Therefore, growth should be monitored during treatment with stimulants, and patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted Seizures There is some clinical evidence that stimulants may lower the convulsive threshold in patients with prior history of seizure, in patients with prior EEG abnormalities in absence of seizures, and very rarely, in patients without a history of seizures and no prior EEG evidence of seizures. In the presence of seizures, the drug should be discontinued Visual Disturbance Difficulties with accommodation and blurring of vision have been reported with stimulant treatment.

The disadvantages to using stimulant medication for ADHD children include:

• Cardiovascular risks: Stimulants may increase the risk of cardiac disease, and patients should be carefully evaluated for cardiac disease before starting treatment 2.
• Psychiatric adverse events: Stimulants may exacerbate symptoms of pre-existing psychotic disorders, and may induce manic episodes in patients with comorbid bipolar disorder 2.
• Aggression: Patients beginning treatment for ADHD should be monitored for the appearance of, or worsening of, aggressive behavior or hostility 2.
• Long-term suppression of growth: Stimulants may cause a temporary slowing in growth rate, and patients should be monitored for growth during treatment 2.
• Seizures: Stimulants may lower the convulsive threshold in patients with prior history of seizure, and the drug should be discontinued in the presence of seizures 2.
• Visual disturbance: Difficulties with accommodation and blurring of vision have been reported with stimulant treatment 2.
• Abuse and addiction: Methylphenidate has a high potential for abuse and misuse, which can lead to the development of a substance use disorder, including addiction 3.
• Common adverse reactions: Tachycardia, palpitations, headache, insomnia, anxiety, hyperhidrosis, weight loss, decreased appetite, dry mouth, nausea, and abdominal pain 3.

From the Research

Disadvantages of Stimulant Medication for ADHD Children

• Stimulants are associated with adverse effects including headache, insomnia, anorexia, and weight loss 4
• There is increased awareness about serious cardiovascular and psychiatric adverse events with ADHD drugs, including concern for growth suppression in children 4
• Stimulants have a high potential for abuse and dependence, and should be handled safely to prevent misuse and abuse 4
• Methylphenidate and amphetamines may cause minor increases in blood pressure and heart rate, although the risk of sudden death remains extremely rare 5
• Atomoxetine may increase blood pressure and heart rate in the short term, and its effects on the corrected QT interval remain uncertain 5
• High doses of stimulants may be associated with increased efficacy, but also increased likelihood of discontinuation due to adverse events 6
• Common side effects of combined methylphenidate and atomoxetine pharmacotherapy include irritability, appetite reduction, palpitations, and headache 7
• Serious adverse effects of methylphenidate, atomoxetine, and amphetamine include psychotic disorders, psychiatric and reproductive disorders, and cardiovascular and neurological effects 8
• Specific safety signals for each medication include:
  • Methylphenidate: precocious puberty, disturbance in social behaviour, and trichotillomania 8
  • Atomoxetine: elevated liver enzymes, testicle and penile lesions, and liver damage 8
  • Amphetamine: coronary artery dissection, carotid artery dissection, and suicide-related adverse reactions 8