ADHD Medication Side Effects That No One Should Tolerate
ADHD medications sometimes make things worse before they get better. Common side effects include sleeplessness, loss of appetite, and tics — problems that no child should have to tolerate. Learn what to expect and how to adjust your child’s ADD treatment plan for the best results.
The right ADHD medication can make life much easier for children and adults who have attention deficit hyperactivity disorder (ADHD or ADD). But ADHD medications can also make things worse and cause severe side effects, including headaches, sleep problems, and a blunted appetite.
Some people (including more than a few doctors) seem to assume that ADHD medication side effects are merely the price to pay for taking a prescription. I couldn’t disagree more. No one should have to put up with side effects of ADHD meds. Often, a simple adjustment in the way a medication is used is all it takes to remedy the problem.
In this article, I’ll explain the strategies that I’ve found particularly effective at controlling side effects in children — which, by the way, also work for adults with ADHD. Try the strategies with your own child, or yourself. Tell your doctor what you are doing — to see what additional help he or she can provide.
What Are the Side Effects of ADHD Stimulant Medications?
Methylphenidate (Ritalin), dextro-amphetamine (Dexedrine, Evekeo), and dextro-amphetamine/levo-amphetamine (Adderall, Adzenys) have similar side-effect profiles, and the strategies that curb side effects for one medication generally work for the other two, as well.
Loss of Appetite. Along with difficulty falling asleep at night (see below), loss of appetite is the most common side effect of stimulant meds. This problem often clears up on its own within a few weeks, so I usually recommend a wait-and-see approach. If the problem persists, don’t delay taking action — especially if the appetite loss is severe enough to trigger decrease in total body mass, or, in a growing child, failure to grow appropriately.
First, observe your child’s eating patterns. Breakfast often goes well because the first dose of the day hasn’t yet kicked in. Lunch is likely to be a lost cause, nutrition-wise. Ditto for dinner. Your child probably becomes very hungry around 8:00 p.m., when the evening dose wears off.
There may be little you can do to boost your child’s appetite in the middle of the day (when medication is at maximum effectiveness). So instead of worrying about what gets eaten at lunch, create nutritional “windows of opportunity” at other times of the day.
For example, get a good, healthful breakfast into your child before the first dose of the day kicks in. Hold off on the 4:00 p.m. dose until 5:00 or 6:00 p.m. (During this time, you’ll have to provide more structure and supervision — and don’t expect homework to be done.) Your child’s appetite may return in time for dinner. Then give the third dose.
Does your child eat lots of sweets? If so, getting him to cut back should boost his appetite for more nutritious fare.
Another way to make sure your child is getting adequate nutrition is to offer a food supplement drink instead of nutritionally empty snacks — or in place of a meal that is likely to go uneaten. These tasty beverages, such as Pediasure and Ensure, come in different flavors. They can be made into milk shakes or frozen to make pops.
If these approaches don’t work, ask your doctor about trying a different stimulant. For reasons that remain poorly understood, some children who experience a loss of appetite while taking one stimulant medication experience no such loss on another.
If switching stimulants doesn’t help, ask your doctor about moving on to a non-stimulant.
Sleeplessness. For some kids, difficulty falling asleep is truly a side effect of stimulant medication. But other kids are kept awake at night by a lack of medication. That is, once the last dose of the day wears off, these children return to “being” ADHD. They feel restless, hear every sound, and find it impossible to “turn off” their brain.
There’s no easy way to tell which of these scenarios explains your child’s sleep problem. To find out, you’ll have to do a little trial-and-error: Pick an evening when sleeplessness is unlikely to prove disastrous (that is, when your child can sleep late the following morning). Have your child take an additional dose of her usual stimulant around 8:00 p.m.
If your child goes right to sleep, it’s a safe bet that her sleeplessness has been caused by a lack of medication. You should be able to remedy this problem simply by continuing with the extra evening dose.
Sometimes even the stimulant medications are not strong enough to overcome the severe restlessness that sometimes comes with ADHD. The standard response when this happens is to directly lower the hyperarousal component of ADHD using medications called alpha agonists. The medications guanfacine and clonidine are FDA-approved to lower the hyper-active component of ADHD and can be very effective for both hyperarousal during the day and sleep problems at night. Talk with your clinician about whether a trial on an alpha agonist might be helpful.
What if the sleep problem persists? See what happens if you reduce the 4:00 p.m. dose or give it up entirely. Of course, this might cause your child’s ADHD symptoms to flare up in the evening. If so, ask the doctor about trying a non-stimulant medication.
Some people with ADHD have a paradoxical or reverse response to stimulant medications. Instead of being further revved up, the stimulant medications shut off the mental and physical restlessness caused by ADHD and allow normal sleep. Many ADHD clinicians suggest a trial after the optimal dose of medication by asking the patient to nap about 30 minutes later. People with ADHD who cannot normally nap during the day may find that stimulant medication turns off the chatter in their heads and allows them to fall asleep. For these patients, it is clear that the ADHD medication helps with ADHD-based sleep problems rather than making sleep more difficult. The person may still have difficulty with sleep but the cause is not the stimulant medication.
Stomachaches or Headaches. No one knows why stimulants cause these problems in some children and adults. But often it’s helpful if the patient eats something before taking the pill. If the problem persists, it may be necessary to try a non-stimulant medication.
Tics. These sudden, involuntary muscular contractions typically involve the eyes, face, mouth, neck, or shoulders. If the muscles in the throat are involved, the tic might cause sniffing, humming, or coughing. In many cases, children start experiencing tics shortly after starting on a particular medication.
The medication that is the most potent trigger for tics is not an ADHD stimulant, but rather caffeine. If a tic develops, many clinicians do nothing for two weeks since the natural history of tics is to come and go on a 2-week cycle. During that two weeks caffeine is removed from the diet (coffee, tea, energy drinks, No-Doz, etc.). More than half of people will lose their tics. If dietary manipulation is not successful, a trial on clonidine that is FDA-approved for both ADHD and tics can often lower the tic to the point that it is no longer disruptive or embarrassing.
If tics continue, stop the medication and try another one. In most cases, the tics will go away within several weeks. If there is a family history of tic disorder, however, the tics may not go away. (That’s why doctors generally avoid giving stimulant meds to kids with a family history of tics.)
Emotional Problems. When the dosage is too high, stimulants can cause children or even adults to seem “spacey” or “zombie-like,” or to be uncharacteristically tearful or irritable (a condition known as emotional lability). In general, the best way to rein in these side effects is simply to lower the dosage.
If reducing the dosage causes your or your child’s ADHD symptoms to reemerge, ask your doctor about trying another stimulant; just because one stimulant causes emotional problems doesn’t mean that others will. If all stimulants cause problems, you’ll have to move on to a non-stimulant.
Rebound. Some children experience 30 to 60 minutes of hyperactivity, impulsivity, and nonstop talking a half hour or so after the last dose of the day wears off. You may be able to avoid this problem by reducing this last dose.
Another helpful strategy is to add another short-acting dose to the regimen at 4:00 or 8:00 p.m. If this additional evening dose fails to help — or if it causes sleep problems — it’s probably best to switch your child to a non-stimulant medication.
Anxiety/Depression. 25 studies of childhood comorbidity of ADHD and anxiety showed that anxiety improved when a stimulant to treat the ADHD was added. Stimulants are similarly added to augment treatment for depression in some cases. In some cases, however, stimulants may worsen Bipolar mania and that of a psychosis of unknown etiology in which case stimulant medication should be stopped.
What Are the Side Effects of ADHD Non-Stimulant Medications?
If stimulants cannot be used because their side effects prove uncontrollable, consider using one of the non-stimulant medications. Some patients experience side effects on both stimulants and non-stimulants. In this case, combining much smaller doses of a stimulant and a non-stimulant might be the solution.
Tricyclic Antidepressants. Along with bupropion (Wellbutrin), three tricyclics are used to treat ADHD: Imipramine (Tofranil), desipramine (Norpramine), and nortriptyline (Pamelor). However, the effect size for these medications is barely detectable and for this and the high side effect burden described below these medications are not optimum for ADHD treatment.
Fatigue is the most frequent side effect of these four drugs. Fortunately, this problem typically diminishes over the first several weeks. If not, ask your doctor about reducing the daily dosage, or dividing one large dose into three smaller doses — one to be taken in the morning, another at about 4:00 p.m., and the third at bedtime. If divided doses don’t help, your doctor may wish to prescribe another tricyclic.
Bupropion and the tricyclics can also cause constipation, dry mouth, or blurred vision. These “cholinergic” effects often respond to symptomatic treatment. That is, eating high-fiber foods or taking a fiber supplement might eliminate constipation, throat lozenges might help moisten a dry mouth, and so on.
If these approaches fail, try another medication. Unlike the stimulant medications, tricyclic medications must be tapered off slowly. Stopping abruptly can cause aches and other flu-like symptoms.
Very rarely, these medications cause the patient to wake up at 4:00 to 5:00 a.m. and be unable to go back to sleep. If reducing the evening dose or giving it a bit earlier fails to ease this “early morning wakefulness,” try another non-stimulant medication.
In some children, tricyclics can affect brain wave activity. If your child has a seizure disorder, a tricyclic might exacerbate the problem. Discuss this matter with your doctor before starting your child on a tricyclic.
Tricyclics have also been known to affect the electrical conduction pattern within the heart, triggering a rapid pulse. The Am Acad. of Pediatrics recommends that a child have an ECG before starting a Tricyclic Antidepressant and another ECG one month after achieving a steady blood level. If you are concerned, discuss this with your family doctor.
Alph agonists. The blood-pressure drugs clonidine (Catepres) and guanfacine (Tenex) help control impulsivity in certain people with ADHD. The alpha agonists compliment the stimulants and are usually added to a finely tuned stimulant rather tha used as a stand-alone medication. The alpha agonists lowering hyperarousal that is manifested both in physical behavior and in the mental hyperarousal that is experienced as having multiple simultaneous thought constantly. Finally, they can also be very effective for emotional over-reaction and vulnerability to rejection and criticism.
However, these alpha agonists can cause daytime sedation. If this occurs, reducing the dose or spreading it out over the day may solve the problem. If not, ask your doctor about trying another non-stimulant medication.
Atomoxetine (Strattera). It can cause stomachaches, decreased appetite, nausea, vomiting, dizziness, fatigue, and mood swings. These problems often go away over time. If not, try lowering the dosage or replacing a once-a-day dosing regimen with several smaller doses during the day.
If these steps fail, try a different non-stimulant medication.
Updated on October 4, 2019