ADHD Medications—A Look at Stimulant Side Effects

Hey Guys! 

I wanted to work toward finishing up this talk about ADHD so that you can have a better understanding of what I call both a disorder and a gift.  I’m calling it a disorder because that’s what the DSM V—our psychiatric guidebook--calls it.  I’m also calling it a disorder because ADHD can truly be debilitating for some people in the absence of treatment.  However, I am also calling it a gift because I do see it as a gift of sorts.  Yes, there are verifiable changes in the brain structure, networking, and chemistry of people with ADHD, but in my observation of patients with ADHD over time, I’ve seen patterns of extraordinary creativity, ingenuity, courage, and compassion that seems to run hand-in-hand with ADHD.  So, really—I like to think of ADHD as a manifestation of the variety and neurodiversity that we see within the human family.  It takes all kinds, right?   

I also wanted to take a moment to clarify this—in two or three of my previous talks on ADHD, I’ve mentioned that the front part of the brain—parts of the frontal lobes and specifically the right prefrontal cortex--has been found to be smaller in individuals with ADHD.  In the time since our last talk, I came across a larger and more recent study that showed the brains of study participants who had ADHD were smaller overall and that volumes of five specific regions of the brain were also smaller; however, the differences in brain sizes were much more obvious in children with ADHD and less obvious in adults with ADHD.  Again, this suggests that ADHD is a brain disorder characterized by delayed development in several brain regions.  ADHD is not an excuse for sloppiness or laziness but a true medical condition.  DO KEEP IN MIND THAT, BY ADULTHOOD, THE OBVIOUS STRUCTURAL DIFFERENCES LESSEN OVER TIME WITH BRAIN MATURITY. 

Now, let’s pick up with where we left off with potential side effects of stimulant medications.  First and foremost, before even considering whether a stimulant medication is a solid treatment option for a child with ADHD, it’s necessary to consider whether the child has a history of any symptoms that may indicate the presence of heart disease.  For example, if children have a history of a heart murmur, fainting spells, palpitations or the sensation of their heart racing, then there would be a need for further medical and cardiac evaluation to see if they could safely take a stimulant.  Also, if there is a family history of sudden death in children or relatively young adults, then further medical or cardiac evaluation might be needed to determine if a stimulant medication could be taken safely for treatment of ADHD symptoms. 

Now, it should be noted that stimulant medications are powerful and so the mantra we were taught in our training program is “start low and go slow” as far as the dosing of all behavioral medications and particularly these stimulant medications.  I have seen some serious side effects from stimulant medications.  I’ve had one young man experience a panic attack, but he had stopped taking his medication for an extended period of time. Then, on his own, he resumed taking the medication at the same dose.  The panic attack would have likely been avoided if he had come into clinic before resuming his medication so that we could start at a lower dose and work our way back up—which is actually what we ended up doing.  I’ve also seen a patient experience hallucinations while taking this medication, but we eventually realized that he had an underlying genetic condition that made him more likely to develop hallucinations, so we stopped the stimulant medication.        

Now, I want to shift to discussing some of the most common side effects I’ve seen with stimulant medications.  Decreased appetite is the most common side effect I’ve seen by far.  Sometimes, this gets better over the course of a few weeks, but sometimes it doesn’t.  This can be a significant problem because if children do not eat enough, their rate of growth will slow, so, in my opinion, this is not a side effect that should be overlooked or ignored.  There are ways to address this.  Some formulations of stimulant medications cause less appetite suppression than others.  In my observation of patients in clinic, the amphetamine category of stimulants suppresses appetite more than the methylphenidate category does.  If this is a side effect that your child is experiencing, you can talk to your provider to look at other formulation options.  It is highly encouraged that children taking stimulant medications eat robustly in the morning before the medication kicks in and in the afternoon or evening when the medication wears off.  There are also medications that can be prescribed alongside the stimulant that can help increase appetite if the appetite suppression is causing weight loss or slowing growth significantly.  I’ve also recommended to parents packing a lunch that their child would have a hard time resisting even if there is appetite suppression—for example, if your child loves cheeseburgers or pizza, consider packing it for lunch with a heating pack.  Otherwise, decreased appetite and skipping lunch can lead to blood sugar lows that can interfere with the ability to focus and can contribute to irritability.   

Headaches and stomachaches can also occur when taking stimulant medications.  Oftentimes, these will improve within a couple of weeks.  However, taking the stimulant with food can often prevent these side effects.  If headaches or stomachaches persist, then it may mean that the stimulant dose needs to be lowered or a different formulation should be considered. 

Another relatively common side effect of stimulant medications in children is what we mental health providers call “affective flattening” or “emotional blunting.”  Stimulant medication may cause a child to be less animated and emotional or seem to “lose their personality.”  A patient once told me that one of his previous stimulant medications prevented him from laughing.  We definitely don’t want that.  Laughter is good medicine.  If emotional blunting occurs, it is important to talk to the provider to consider lowering the dose or switching formulation.   

The last side effect that I’ll mention is the emergence of tic behavior like increased eye-blinking, throat clearing, and head shaking or twitching.  Again, if this were to occur, lowering the dose or switching formulations may resolve the tics.  Also, pairing the stimulant with a nonstimulant ADHD medication—like clonidine or guanfacine—may alleviate the tic while also treating ADHD symptoms.  Or the stimulant could be stopped altogether and a nonstimulant medication could be started in its place. 

And that brings me to a good stopping point for today’s talk.  We’ll plan to pick up with a discussion of nonstimulant medication options—like clonidine and guanfacine.  I hope that this content has been helpful to you today.  Remember to talk to your provider before implementing any suggestions I make in these talks.  This has been Dr. K with Mental Health | Plain Speak.  And remember, “Be kind.  For everyone you meet is fighting a hard battle.”