Ritalin's Side Effects: Real, or Imaginary-Real?
Much has been written about the attention deficit disorders ADD and ADHD, and there is no need to repeat it here. Let us just say that these conditions are generally discovered in certain children anywhere from toddler age to the early elementary school years.
Children with this condition typically have difficulty controlling their behavior and/or paying attention for long periods. Some also suffer from motor skill problems and faulty hand-eye coordination. Other issues involve short-term memory problems, reading and writing problems, difficulty remembering lists of tasks, and the like. These can negatively affect the child's behavior and social integration, leading to negative self-image, loss of self-confidence, and a negative cycle of problematic issues.
Despite the above, when given proper treatment, and with the help of their parents and teachers, these children can generally be helped to actualize their potential and live successful lives.
Medically, ADD and ADHD are neuro-cognitive and neuro-psychological conditions, i.e., disturbances rooted in central nervous system dysfunction. It is important to emphasize that learning disorders have nothing to do with intelligence, and can appear even in gifted children. In fact, it is especially important to recognize the combination of giftedness, learning disorders, and attention problems precisely because of the great frustrations it brings on; the child sits in class and senses that he should be able to understand, yet fails time after time.
We must change our thinking about these children. Instead of saying about them, "If they would just try, they would succeed," we must say, "If they would only succeed, they would try."
We must be cautious not to fall into the trap of deciding on our own who has this condition and who does not. There are many difficulties that are superficially similar to ADHD, such as sensory issues, hearing and vision problems, medicinal side effects, giftedness, sleep disturbances, slow speech processing, emotional problems, bipolar disturbance, ODD, and more. As such, ADHD can only be properly diagnosed by a professional, who will recommend the proper treatment for the child's specific problem.
One of the most widely-discussed, and perhaps most widely misunderstood, treatments is methylphenidate, often sold under the trade name Ritalin. Taken as part of a comprehensive treatment program, Ritalin can bring about positive results, both long-term and short-term. It does involve undesirable side effects, but only for some of those who take it – and even then, there are ways of dealing effectively with them.
Let us enter the realm of brain activity for a few moments and watch how it is affected by Ritalin and similar drugs. When the brain functions normally, neurons communicate effectively with each other, transmitting messages via nerve agents known as neurotransmitters. These agents are secreted from the edge of a neuron (nerve cell), through the space between cells known as a synapse, and are then absorbed by receptors in the neuron at the other end of the synapse. Not all of the neurotransmitters reach the receptor cell; those that do not are reabsorbed, via transformers, in the sending cell, where they are kept for later reuse.
Dopamine and norepinephrine, also known as noradrenaline, are neurotransmitters that play an important function in brain activity responsible for attention and concentration, organizing and performing tasks, regulating emotions, and the like. In ADHD children, the transformers in the sending cell, responsible for the reabsorption of dopamine and noradrenaline, do so in a disorderly way. They absorb them too quickly from the synapse, before enough of them have been absorbed into the target cell. As a result, the availability of dopamine and norepinephrine where they are needed, decreases.
One of the most common ways to raise dopamine levels is via stimulants that prevent dopamine and norepinephrine from being reabsorbed too quickly in the sending cell. Using these stimulants increases the availability of neurotransmitters in the synapse, enables efficient communication between the neurons, and leads to improved attention, concentration and controlled behavior.
Ritalin, of course, is one of the most common stimulants of this type. As explained, it can lead to improved behavioral and learning skills. However, the professional literature tells of not a few undesirable side effects that accompany the taking of Ritalin, and these must be related to.
Of course, everyone responds differently to Ritalin. There are some who will be stricken with all possible side effects, some who will suffer from none at all, and some who will respond somewhere in between. The only way to know for sure how a given child will respond is to try it and experiment.
The side effects of these medicines are either passing, persistent, or long-term. In the first category we find headaches, stomach aches, apathy, nervousness and drowsiness; these symptoms generally pass as the patient becomes accustomed to the medicine. If not, the prescribing doctor should be consulted.
Persistent side effects can include loss of appetite, difficulties sleeping, and the appearance or exacerbation of tics. Loss of appetite can be dealt with very simply: The child must be given a proper breakfast and supper when his appetite is not affected, together with light snacks throughout the day. Parents often complain that the child does not eat, but when asked if he eats a healthy breakfast, they say, "There's no time" or other such excuses. It is critical to ensure that the child eats a healthy breakfast – and not only cereal and milk. In general, a child can be expected to be alert only if he eats properly throughout the day, including all food groups and necessary vitamins and minerals.
Sleep difficulties can usually be solved by making sure not to take methylphenidate within a few hours before bedtime. Another idea is to switch to one of the new drugs, and/or to combine melatonin with the drug being taken.
The appearance of tics is not always a result of taking Ritalin and similar drugs. In order to check whether the tics are related to the attention deficit issues or Ritalin, it is advised to stop taking the drug for several days; if the tics continue even then, they are probably not due to the medicines. It is important to remember that tics often come and go and have no medical significance; psychotherapy or alternative medicines can help.
Long-term side effects: The use of methylphenidate has been studied since way back in 1957, and as of now, no evidence of long-term adverse effects has been found. It should be noted that a new large-scale study, conducted by researchers at Vanderbilt University, proves that the concern is actually superfluous. The study found that Ritalin, Adderall, Concerta and similar drugs do not increase the risk of stroke, cardiac arrest, or heart attacks. It was conducted by the U.S. Food and Drug Administration (FDA) among a population of 1.2 million children and adolescents between the ages of 2 and 24. It included documentation of what dosage was taken of what drug and for how long, alongside statistics of who among the subjects developed cardiovascular diseases. As stated, no connection was found between the taking of these medicines and the patients' health, particularly in the cardiovascular system. This study is just one of a comprehensive series of studies designed to ensure the safety of using medicines to improve attention and concentration.
The Rebound Effect
Up to a third of ADHD children experience a "rebound effect" when methylphenidate is withdrawn. That is, the symptoms that were being treated return, or others appear, after the medicine is discontinued or reduced in dosage, sometimes in an even more severe manner. When Ritalin is discontinued, some patients experience a form of depression or general disquiet. To prevent this, long-term preparations are used; there is then no sharp decrease in the level of the substance in the blood, and the rebound decreases. In some cases, a combination of two drugs is used.
Thus, there are currently several types of drugs for the treatment of ADHD. Not giving one's child Ritalin simply because of the side effects actually represents a very primitive approach! Many "new and improved" medicines are available, each one better than the other. The rule is: The newer and more sophisticated the drug, the fewer side effects it will have.
It is true that here in Israel it is a bit harder to obtain these medicines; some of them are expensive, and some can be acquired only with a special form known as Tofes 29. But this should not stop us from seeking out the best treatment for our children.
People sometimes ask, "What is the best medicine for ADHD?" A psychiatrist once gave me a succinct answer to this question: "There is no such thing as the 'best pill' for ADHD – for if there was, all the other manufacturers would go bankrupt! Rather, each person has a medicine that is best for him."
There are three types of professionals who can prescribe medicines for attention disorders: Neurologists, psychiatrists and family doctors who have undergone training in the field. We must remember, however, that not every neurologist, psychiatrist, or family doctor is necessarily qualified to deal with ADD issues. Only professionals with specific knowledge and experience in these areas can help you and accompany your child until the most effective and appropriate medicine is found for him.
It goes without saying that every case is different. The case for Ritalin and similar medicines must be made based on a cost-benefit analysis, as is the case with any medical treatment. Most of the time, the improvements in a child's life that stem from taking these medicines greatly outweigh the minor difficulties that they sometimes bring about.
Now we will continue to another family of side effects; very common but less well-known: psychosomatic side effects
Another kind of side effects is those that the patient seems to feel physically, but are actually rooted in his imagination (psychosomatic). Our thoughts influence our emotions, and our emotions influence our reactions and bodily sensations. The way in which we think affects the emotions that we experience as well as our behavior. Research has shown that extreme thoughts are accompanied by physiological arousal and internal organ activity such as changes in blood pressure, skin moisture and more.
"Suggestion" is a psychological process by which it is possible to guide, from the subconscious level, the thoughts, feelings and even physical sensations of another person. Very often, ADHD patients experience side effects when taking medicines prescribed for their condition – yet the side effects are actually caused not by the medicines, but rather by the knowledge and awareness of the existence of these effects, and the expectation that they will in fact occur. Sometimes, too, one takes a certain medicine that causes certain side effects, and then, when he switches to another drug, the side effects continue – even though the two drugs are not similar! This is often a psychosomatic phenomenon, and is sometimes caused by negative associations with the drug.
The treatment for this condition is not to switch medicines, but rather to treat and change the thoughts associated with them, until the sensation of the undesirable side effects disappears. Occasionally, the tools of dynamic psychological treatment can be utilized, and /or CBT (Cognitive Behavioral Therapy.)
Making a patient aware that his problems are suggestive or psychosomatic is like awakening a chronic sleepwalker in the middle of his nocturnal unconscious stroll. That is, it is liable to worsen the situation. The process must be done with great professionalism and gentleness.
It is the job of psychiatrists and psychologists to diagnose each specific situation and determine when side effects are actually caused by the pills, and when the side effects must be dealt with psychologically. Problems sometimes arise when family doctors prescribe Ritalin and the like, when in fact they are not properly trained to diagnose the side effects as above. We have seen cases in which patients suffer from psychosomatic side effects, yet the family doctor may not be equipped to identify the underlying problem. Sometimes medicines are switched periodically for no reason, and sometimes they are not switched when they should be.
Part of the complexity of the issue is the fact that it is the patient himself who, in the final analysis, must evaluate the extent of the side effects and the linkage with the medicine. This process can easily be influenced by external factors such as obsessive thoughts, pessimism and difficulty in analyzing the situation, making the objective situation hard to measure.
Parents often tell me, "The medicine decreases my son's appetite." I ask them how they know, and they say, "Since he started taking the drug, we've been asking him every day, 'How was your appetite today?'"
But think about it: How is sweet little Moishy supposed to respond when all of a sudden his mother starts asking him every day if he has an appetite? After a while he begins to understand what he thinks she wants from him, so he says, "Yeah, I didn't have such an appetite today…"
Older children often immediately connect the questions with the new medicine they have started taking. Every day they have to answer an entire questionnaire: "Did your head hurt? Did your stomach ache?" They begin to realize that that's what the medicine is supposed to do, and soon they begin to really "feel" their head and stomach hurting … psychosomatic pains at their best!
To really check for side effects, parents need not be overly proactive. They must listen to their children and see if they complain – on their own, not because they heard from others – of various side effects.
A Fascinating Case
A man named Shlomo, 28, was diagnosed two years ago as having ADHD, and his neurologist prescribed Ritalin LA, a long-acting methylphenidate preparation. It comes in the form of a delayed-action capsule; some of the Ritalin is released immediately upon swallowing, and the rest is released four hours later, such that each capsule works for eight hours. This is as opposed to regular Ritalin, which works for only four hours. A very uncommon side effect with Ritalin LA is an unpleasant sensation and nervousness when the second stage kicks in.
Shlomo was greatly helped by Ritalin LA, but he suffered from the above side effect, and his doctor prescribed Vyvanse, another central nervous system stimulant. However, Shlomo continued to complain that four hours after taking Vyvanse, he would still experience the same side effects as with Ritalin LA. He approached me and asked if I could help him with a medicine that would not cause this unpleasant side effect.
What's interesting is that Vyvanse works totally differently than Ritalin LA. The stimulants are not released in two stages, but are rather absorbed fully into the digestive system, where they are broken down gradually in the bloodstream. The active material is thus released gradually and continually throughout the day, without sudden changes.
In light of this information, it is clear that it was impossible for Shlomo to have physically experienced the side effects that he said he did after four hours – because Vyvanse does nothing differently after four hours than it does after two, three, five, or six hours!
I explained this to Shlomo, but I added that this does not mean that he was not feeling the side effects. Even if the pain and discomfort was not physically present, he still felt it, and it must be dealt with as if it were physically real! The discomfort in his case was caused not by the medicine, but rather by his expectation of the side effect, based on his previous experience with Ritalin LA.
I explained that he should not stop taking Vyvanse, but should rather make a change in the way he thought about Vyvanse. Using the CBT approach, I explained to him the influence that thoughts can have on one's emotions and body.
I advised him as follows: In order to send a message to his brain and change his subconscious approach to Vyvanse, he should spend the next three weeks writing a "letter to his brain" each night before going to sleep. The letter was to read more or less like this:
Until now I was taking Ritalin LA for my ADHD issues, but unfortunately, it caused me some unpleasant side effects. I therefore switched to Vyvanse, a new and expensive medicine, which works very differently and does not cause those side effects. Good night, brain!
After two weeks, Shomo called me and told me that the side effects had disappeared and that he felt great with the new medicine!
When dealing with children, this process takes a bit more time and is somewhat more complex. Telephone accompaniment while the child writes the letter to his brain is advised.