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Ask the expert

Can people with ADHD stop taking their medication at one point?

Yes, in certain cases. Others, however, need to take medication throughout their entire lives.

Why do some children and adults respond to certain medications, while others do not?

Approximately 80% of people who use stimulant medications, such as Ritalin, have positive results, many of them dramatically so. The remaining 20% have no response to the medications or experience side effects that render it impossible to continue use. If we better understand how the stimulant medications benefit 80% of people, we can learn more about what is causing the disorder and be able to better screen people before stimulant medications are prescribed. (In these cases, often a different type of medication will be successfully prescribed in the place of stimulant medication.) Research conducted at the Douglas Institute supports the theory that most people with ADHD respond best to a combination of clinical therapy (ex. counselling or group therapy) and medication. The team of Natalie Grizenko MD is now investigating which combinations of therapies and medications are most effective.

Are there long-term risks for an 18-year-old who takes Strattera everyday?

If the medication is well tolerated, then there are no risks per se. Strattera can cause some side effects, such as an increase in hepatic enzymes, but this is very rare. No long-term study has been carried out to determine if Strattera is devoid of risk, but I have not heard that taking Stattera over the long-term leads to adverse effects. This medicine is well tolerated, but you still need to be careful.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Why is Adderall not available in Canada and why is it so different from other drugs?

It is available, although it was withdrawn from the market about five years ago for a period of two years due to a warning about sudden death, which turned out to be somewhat unsubstantiated. Adderall is what is known as a “d-amphetamine” (amphetamines come in two forms: the “l” and “d” forms, Adderall being the “d” form). It is in the same class of medications as Ritalin and Dexadrine, which are psychostimulants. It is actually quite a potent medication for treating ADHD symptoms and compares very well, if not better, to Ritalin, for example.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

When can you determine that medications should be stopped because of side effects?

If you have major side effects, stop the medication. For example, if a child is not able to sleep because of Ritalin, I will stop the medication and prescribe something else, such as Strattera, which does not have as great an impact on sleep. There can be other extremely serious complications though, such as hallucinations, which can lead to psychotic disorders. Psychotic disorders are related to an increase of dopamine in certain parts of the brain. If you prescribe medications that increase dopamine, such as psychostimulants, there is a minor risk of hallucinations or even visions. Overall, I stop the medications, look for other solutions, or add backup medications or other therapies to compensate for the side effects.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Will interrupting Ritalin have an adverse effect on the child's psychological well-being?

Stopping medication can produce varying effects from child to child. Speak to your doctor before making a decision.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Why do doctors give stimulants to hyperactive people?

The term "stimulant" is probably misleading. They are called psychostimulants because, when given to rats and mice, the animals move around quite a lot. In humans, these medicines improve attention and concentration in a remarkable way and do not lead to hyperactivity. I think that there are very big differences between the animal model and the effects observed in humans. The term "psychostimulant" is not really appropriate in this case.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Do children with ADHD have to take medication all their lives?

Yes, they may need to if the attention deficit remains during adulthood and significantly impacts their functioning. We now have more and more adults who take medication for ADHD. In other cases, medication is no longer necessary after a number of years, specifically when these children get to high school, as they may not feel the need to take medication anymore.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

If you don’t know the genetic background of a child, is it more risky to administer medication given the potential for cardiac problems?

It is important to ask questions about the cardiac health of any child, as there is a possibility of what is called cardiac myopathy, meaning that the heart is bigger in size due to a muscle disease. If its pace increases, there is a risk of sudden stoppage. This is an extremely rare condition, but it’s important to be careful nonetheless. I always ask parents about a child's cardiac history, and if I have any doubts, I do an electrocardiogram. If I see abnormalities, then I will refer to a cardiologist and abstain most of the time from treating with psychostimulants, as there are other treatments.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Can taking medication (such as Ritalin or Concerta) lead to dependency?

The literature indicates that Ritalin and Concerta do not lead to dependency. Concerta has the same active ingredient as Ritalin, whose long-term effectiveness has been established.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

What is the treatment for ADD without hyperactivity? Is Ritalin necessary in this case?

Medication, social skills workshops, and psychoeducation are useful, but each case must be assessed individually.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

What are the long-term side effects of taking medication for an attention deficit?

This medication can slow growth (by a few centimetres). Apart from slowed growth, the literature has not arrived at a unanimous opinion in terms of the long-term side effects. Ritalin and Concerta have the same active ingredient (methylphenidate), but they have different durations of action.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Do you think that all children with ADHD need to be medicated?

These children often need to be medicated. Medication allows them to concentrate better and therefore get a better handle on everyday life.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

How can Ritalin be stopped? Are there withdrawal symptoms?

It depends on the medication. You should discuss this with your doctor.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Are there known methods, other than medication, that can help children deal with an attention deficit?

Yes, psychoeducation for families and a number of educational initiatives that increase children's social skills are important and sometimes necessary. However, the effectiveness of these actions often increases in combination with pharmacological treatment.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Are physicians prescribing Ritalin as a quick fix for children who don't have ADHD?

This is an often-asked question. Psychiatric disorders vary in terms of symptoms, but have one common criteria: dysfunction. If you have hallucinations and you are not dysfunctional, it doesn't matter. If you have a child and he has AD/HD, but is not dysfunctional, it doesn't matter.

However, if you have a child with AD/HD and his interaction with you is becoming a nightmare and his interactions at school are disastrous, we know that medication can help a lot. The problem is knowing where to set the limits. What is a functional child? What is a dysfunctional child? This is a matter of clinical judgement and has to be discussed between parents, the school and the child.

A child with behavioural problems, who is not acquiring what he needs to develop normally, has an increased possibility of experiencing addiction, drug abuse, lower school achievement, greater family and professional problems, more car accidents etc. When you treat a child very early in life, you're taking a preventative approach—using the same logic you would use in physical disorders.

- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

Why is there a controversy in the medical community about the use of psychostimulants in the treatment of ADHD?

Most medical articles acknowledge that current medications are effective in treating ADHD.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

What are the long-term effects of Concerta and Ritalin, and how are doses reduced?

Dosage is essential when it comes to psychostimulants. In children, we first prescribe a mild dose and then increase it until there is a significant effect and remission. Our goal is always to normalize behaviour or at least achieve a level of quasi-normality, but the limiting factors are side effects, which need to be managed. Full remission without side effects is possible, but generally we have to look for a balance between side effects and benefits. In certain cases these are lifelong treatments, but some people will no longer suffer from an attention deficit when they reach adulthood.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

My son's medication seems to make him depressed and numb. What is the long-term social impact of these symptoms?

Discuss your concerns with your doctor; clearly explain the objectives that you and your child wish to achieve through medication.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

At what age can you start medication?

Most of the time, medications are started in the first grade and up. Extremely rarely, probably 2 or 3 cases in over 500, the medication is started before school.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Is it good to stop the medication of a child with ADHD for 1-2 days to give his body a rest?

This is possible if the child's behaviour is not too difficult to manage on the weekend.
- Ridha Joober, MD, PhD and Natalie Grizenko, MD, 2008

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