Tips to Reduce the Side Effects of ADHD Medications

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For many children, ADHD medications curb restlessness, impulsivity, and inattention well enough for them to flourish at home, school, and on the playground. But the drugs can also prompt common side effects, such as low appetite, stomach pain, or sleep problems. In rare and serious cases, they can cause heart problems, such as chest pain, liver problems, or suicidal thoughts.

“We do deal with both wonderful treatment response, but at the same time, medication-related side effects,” says Murat Pakyurek, an associate clinical professor at the University of California-Davis Medical Center department of psychiatry and the UC Davis M.I.N.D. Institute’s ADHD program. “The majority of the medication-related side effects are mild and temporary in nature. But there are a few side effects that are more severe and that need to be addressed immediately,” he says.

If your child takes ADHD medications, follow these tips to reduce common side effects. Be on the alert, too, for rare side effects.

Tips for Coping With ADHD Drug Side Effects

  • Decreased appetite: If your child’s appetite wanes after taking ADHD medicine, give the dose after breakfast so that he or she will eat better in the morning. Serve a large dinner in the evening, when the drug is beginning to wear off. Keep plenty of healthy snacks on hand; a balanced diet with nutritious, higher-calorie foods and drinks will help to offset any weight loss from the ADHD drug. If your child’s poor appetite lasts for a long period, ask the doctor about reducing the dose or stopping the drug on weekends or summer breaks to allow appetite to return to normal.
  • Stomach pain or upset: Don’t give your child medicine on an empty stomach. “For any GI discomfort, taking the medication with or immediately after food will make a very big difference,” Pakyurek says.
  • Sleep problems: Set up a regular bedtime routine that includes relaxing activities, such as bathing or reading. If a stimulant type of ADHD medication prevents your child from sleeping well, ask the doctor about taking the drug earlier in the day or switching from a long-acting to a shorter-acting form . Ask, too, about reducing the dose or stopping the drug in the afternoon to help your child sleep at bedtime.
  • Daytime drowsiness: If the ADHD drug atomoxetine (Strattera) is making your child sleepy during the day, ask about giving the drug at bedtime instead of in the morning. You can also check with the doctor about lowering the dose or dividing the dose and giving it twice a day.
  • Rebounding effects: When ADHD drugs wear off in the afternoon or evening, some children have more ADHD symptoms or irritability. To prevent this “rebounding,” ask your child’s doctor about using a longer-lasting medication or taking a small dose of fast-acting stimulant later in the day.
  • Mood changes: Keep an eye out for changes in your child’s mood. If you see changes, such as lessened emotional expression or suicidal thinking, alert your child’s doctor right away.
  • Heart problems: Since there have been rare reports of serious heart problems in patients taking ADHD drugs, tell your child’s doctor about any heart problems in the family. “If there’s any history of significant heart problems, the physician may closely monitor, particularly if they’re using stimulants. Or they may even decide to get an EKG to make sure that the child does not have any cardiac problem,” Pakyurek says.

Regular exams: While your child is on ADHD drugs, he or she will need regular visits with the doctor who prescribes the drugs, in part to watch for side effects. The doctor will monitor vital signs, such as blood pressure and pulse, as well as height and weight. If there’s a change in your child’s growth trajectory, treatment may need adjusting so that your child can catch up, says Ben Vitiello, a psychiatrist and chief of the Child and Adolescent Treatment and Preventive Intervention Research Branch at the National Institute of Mental Health. Ask the doctor, too, if your child needs tests, such as an EKG or periodic blood tests to check liver enzymes.

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Types of ADHD Drugs and Their Related Side Effects

Doctors now have many ADHD drugs that they can prescribe. When your child begins a new drug, talk with the doctor about dosage. “The principle should be, ‘Start low and go slow,’ especially with children,” Pakyurek says.

“Starting with a very small dose and adjusting the dosage slowly, rather than starting with a high dose and increasing in significant amounts” will cut the risk of side effects, he says.

But side effects can still happen, even with careful dosing. While mild ones often go away on their own, Pakyurek tells parents to call their child’s doctor promptly if they notice symptoms. “If any side effect is lasting more than a day or so, or if it’s getting worse, it’s very important to get in touch with the physician immediately,” he says.

What side effects might your child encounter? It depends on the particular type of medication. There are two main groups of ADHD drugs: stimulants and nonstimulants.

Stimulant Medications

Stimulants prescribed for children with ADHD include:

Many are short-acting drugs, while others are extended release, longer-acting versions.

For stimulants, reduced appetite, stomachaches, and sleep problems are common, but are typically mild and often go away after the early stages of treatment, experts say.

“It’s fairly common for children to have less appetite in the next few hours after taking the medication,” Vitiello says. Youngsters who take the drug in the morning may still have low appetite by lunchtime, but usually, they’ll make up for it by eating a larger dinner in the evening, he says.

In contrast, some children’s appetites become so severely suppressed that they need to decrease or stop the drug, according to Vitiello. If not, they’ll drop weight.

In some children, long-term use of stimulants can also slow height gains. “If the stimulant is taken every day for one or two years, there can be an effect on growth,” Vitiello says. On average, a child may be a quarter-inch shorter per year, according to him.

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Stimulants can also make some children more irritable or alter behavior in other ways. “Especially if the dose gets too high or if the child is very sensitive [to the drug], the mood becomes blunted. So it looks like the child is not expressing himself or his emotions in the usual way. It’s more constricted,” Vitiello says. “For some parents, it looks like he’s sad. Oftentimes, he’s not really sad, but his mood has changed in a way that becomes less prone to expressing emotions.” In such cases, the doctor usually needs to adjust the medication, he says.

During stimulant treatment, some children also develop tics, which can include excessive blinking, grimacing, or jerking of the head, Pakyurek says. It’s not clear whether the drugs cause the tics. Rather, he says, the tics may coexist with ADHD and stimulants make the tics more pronounced.

If your child develops tics, call the doctor right away, Pakyurek says. The dose may need to be reduced or stopped. Or, he says, “If [tics] are mild enough, you may just want to wait it out. ... They may improve and disappear, even though you did not change the medication that the child is being treated with.”

Nonstimulant Medications

In some children, stimulants aren’t effective or well-tolerated. Or if a child already has tics or anxiety, stimulants may worsen these problems. In such cases, nonstimulant drugs, such as atomoxetine, or other medications such as guanfacine and clonidine, may be good choices, Pakyurek says.

Here’s the rundown on nonstimulant drugs and possible side effects.

Atomoxetine for ADHD

Atomoxetine (Strattera) is an antidepressant-like drug that also has anti-anxiety effects, Pakyurek says. It can be taken once or twice a day.

Side effects include reduced appetite, stomach upset, nausea, and drowsiness, but these problems usually go away after the first month of treatment.

More serious problems can occur, although they are quite rare. “One potential problem that needs to be monitored closely with Stattera is potential for liver enzyme increase and liver injury,” Pakyurek says.” Children on atomoxetine will need blood tests to monitor liver enzymes, he says.

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Atomoxetine can also cause slight increases in pulse and blood pressure, Pakyurek says.

Strattera also carries a black box warning from the FDA for increased risk of suicidal thoughts in children and teens. “We have to warn parents about this potential side effect,” Pakyurek says, but he adds that this problem is rare among his patients.

However, if a child has depression along with ADHD, or “if there’s a concern that the medication may be contributing to increased suicidal thoughts, absolutely, the medication may have to be stopped,” he says.

Alpha-2 Adrenergic Agonists for ADHD

Two hypertension medications, guanfacine and clonidine, are also prescribed to treat ADHD. Both are called alpha-2 adrenergic agonists.

Intuniv, a long-acting form of guanfacine that lasts for 8 to 14 hours, is approved for children ages 6 to 17 with ADHD, Pakyurek says. Tenex is a short-acting form of guanfacine.

Clonidine is marketed under the name Kapvay.

Since alpha-2 adrenergic agonists also treat hypertension, they can cause blood pressure to drop too low in children. “The vital signs, just like with stimulants, have to be monitored closely in all these children,” Pakyurek says.

Nervousness, sedation, and tiredness are other possible side effects, he says.

WebMD Feature Reviewed by Louise Chang, MD on November 04, 2011

Sources

SOURCES:

American Academy of Child and Adolescent Psychiatry: “ADHD Parents Medication Guide.”

Murat Pakyurek, associate clinical professor, University of California, Davis, Medical Center Department of Psychiatry and the UC Davis M.I.N.D. Institute’s ADHD program.

Ben Vitiello, MD, psychiatrist, chief of the Child and Adolescent Treatment and Preventive Intervention Research Branch, National Institute of Mental Health.

News release, FDA.

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