Stimulant medications are the primary medications used to treat Attention Deficit Hyperactivity Disorder (ADHD). These medications can be very helpful for children and youth who struggle with hyperactivity, impulsivity, and inattention so that they can more successfully function in the home and school environments. At times, these medications can lead to problematic side effects such as decreased appetite, stomach pain, sleep problems, and moodiness, that can make it challenging to continue the medication. There are ways to help patients deal with these side effects so that they can continue to take a medication that is beneficial for them. Of course, if these strategies do not work, you should consider changing to a different class of stimulant medication or to a non-stimulant medication.
Decreased appetite:
If your patient’s appetite decreases because of stimulant medicine, advise the parent to give the morning dose after breakfast so that their child will eat better in the morning. Also advise them to serve a large dinner in the evening when the medication is beginning to wear off. Have them keep healthy, high-calorie, protein snacks on hand for whenever a child asks for food, even if it is before bedtime. Some children do better with two doses (morning and right after lunch) of an immediate-release preparation rather than a long-acting preparation to allow for some food intake at lunch time before the afternoon dose. Discuss with parents that it is more important to monitor the child’s weight rather than his day-to-day appetite. Advise them to let you know if the child’s poor appetite lasts for a long period of time, and consider reducing the dose or stopping the medication on weekends or summer breaks to allow appetite to return to normal.
Stomach pain or upset:
Advise parents not to give the medication on an empty stomach. Taking the medication with or immediately after food can be helpful for this side effect.
Sleep problems:
Parents should set up a regular bedtime routine that includes calming activities, such as bathing or reading. Make sure that a long-acting stimulant is only given in the mornings, typically no later than 10am, and an afternoon dose of a short-acting stimulant should not be given later than 3pm, sooner if there is sleep disturbance. If the sleep disturbance persists, consider switching from a long-acting to a shorter-acting form or reducing the dose or stopping an afternoon dose. If the child is struggling with hyperactivity at bedtime and having a hard time settling down to sleep because of his ADHD, a non-stimulant medication for ADHD, such as an alpha-agonist) can sometimes be helpful as an adjunctive measure.
Rebounding effects:
When an ADHD medication wears off in the afternoon or evening, some children have more ADHD symptoms or irritability and moodiness. This is more common with the stimulant medications than the non-stimulant medications. To prevent this “rebounding” consider using a long-acting formulation or prescribing a small dose of short-acting stimulant later in the day. Rebound effects sometimes are a sign that the overall dose of medication is too high. In these cases, it is also important to assess for co-occurring mental health concerns like anxiety and mood issues.
Mood Changes:
Make sure the parents are keeping an eye out for changes in the child’s mood and anxiety. Stimulant medications can negatively affect mood symptoms and anxiety in some children. This often improves as the child adjusts to the medication. If that does not occur, consider using a non-stimulant medication as an adjunctive or as a substitute to address the ADHD symptoms.
It is our hope that this article on addressing the common side effects for stimulant medications is helpful to address problems that may arise in the primary care office. Feel free to reach out to us at the Native American SmartCare Provider Line to discuss specific cases that you might be stuck on.
AUTHOR: Charmi Patel Rao MD, DFAACAP
Co-Medical Director, Vista Hill Foundation
Health Science Clinical Professor, UCSD Department of Psychiatry
President, San Diego Academy of Child and Adolescent Psychiatry