Strattera Can Benefit Children With ADHD
Question: I am an elementary school teacher. Our youngest son is nine years old. Since he started walking, I knew he was hyperactive. Our suspicion was confirmed recently when we saw a paediatrician. He was diagnosed with ADHD. The doctor suggested that we should consider putting him on medicine because he not only has difficulty paying attention, he disrupts the class and makes it difficult for others to learn. His teacher is my good friend and colleague. Although she is trying to be patient, I know our son is putting a lot of stress on her. I have worked with many children with ADHD over the years, and have seen how medications can help them. However, some of these children did have side effects. I heard that there is a new medicine for ADHD. Should I ask for that medicine for our son?
You are right. There is a new medicine available in Canada for treatment of ADHD in both children and adults. It is called Strattera (the generic name is Atomoxetine). Unfortunately, just like any medicine, there are benefits as well as side effects, and you need to know them all before making your decision.
Since you are an experienced teacher, you were able to recognize Attention Deficit Hyperactive Disorder (ADHD) better than most other parents. Your son’s behaviour is a challenge, not only to you and his teacher, but also to his classmates. Many children with ADHD have difficulty learning because they cannot focus their attention on academic subjects or things that they are not interested in, even though they can focus very well on videos or computer games. Unfortunately, these children also tend to do things that would disrupt the class and make it difficult for the teacher to teach, and for other students to learn.
Therefore, the impact of an ADHD child in a classroom goes far beyond that student. That is why it is so important to help children with ADHD; it can benefit other students also. The stress to his teacher is also substantial. A more attentive and less disruptive student is always more fun to teach.
Since you have accepted that your son needs medicine, let me clarify some of the myths for you. The traditional medications for ADHD are Ritalin and Dexedrine. Both of them have been used for many decades, therefore, their benefits and side effects are well established. They belong to the class of medicine called stimulants. The caffeine in coffee and tea is also a stimulant. Both of these medications, when given at the right dose, can help children with ADHD to focus, especially on academic work and things that they are not particularly interested in.
However, both Ritalin and Dexedrine have a number of side effects. These include losing appetite, headaches, change of mood, as well as difficulty falling asleep. Most of the time, the side effects tend to decrease or disappear over time, especially if the medicine is taken every day. Some children may lose a few pounds (or kilos) at the beginning, but in the long run, they continue to grow and will achieve their expected height and weight. However, if the dose is too high, some children can become more sluggish, and parents often believe the medicine change their child into a zombie.
Another side effect of Ritalin and Dexedrine is the ups and downs, when the medicine is working well and then wearing off. This is because both of them tend to work for a relative short time. Even the slow release (SR) formulation of Ritalin and Dexedrine capsule may not be able to help a student through most of the day.
In recent years, new long-acting formulations of Ritalin and Dexedrine have become available. Concerta, which is made of Ritalin, can work for 8 to 10 hours. As a result, children can pay good attention not only during school hours, but into the evening when they can successfully complete their homework with much less struggle.
The long-acting Dexedrine is called Adderall XR. It can work for the same length of time, without the mood changes as a result of the medicine wearing off too soon.
The new medicine Strattera is a different class of medicine. It is a non-stimulant because it works on a chemical in the brain called nor-epinephrine. It works in a different way to help children and adults to pay attention, and has somewhat different side effects. The most common one is irritation of the stomach, which can be reduced by taking the medicine with food. Some children also find that Strattera can make them tired. If that happens, it can be given once a day in the evening instead of in the morning. Some children can become more sensitive to criticism and can get angry easily.
When Strattera was in the research phase, children were asked whether they have thought about hurting themselves after taking the medicine. Several said that they had. The significance of this response is unclear. I have seen many children who became frustrated with their ADHD that they had talked about hurting themselves even before taking any medicine. Therefore, I warn parents about this observation; but with proper monitoring, I still recommend Strattera when it is the right medicine.
Which medicine should your son use? This is a question only you and your doctor should decide. However, I can give you a few suggestions here. No one can know for sure which medicine will work for which person. There is no test that can give any kind of prediction.
Ritalin has been shown to work for 50 to 70 percent of children, therefore, some regard it as a first line medicine for children with ADHD. Dexedrine works for about 30 to 40 percent, and there is some overlap so that some children can respond to both Ritalin and Dexedrine. That leaves only a small proportion of children who won’t respond to either one. Furthermore, even though Ritalin and Dexedrine may work, some children experience too much side effect on these medications.
This is where Strattera has its place in the treatment of ADHD. When neither Ritalin nor Dexedrine works, or when there is significant side effect, one can try Strattera to see whether it is a better medicine. In my experience in the past year, this is exactly where Strattera works the best.
I would suggest that you should not avoid Ritalin or Dexedrine just because they are stimulant medications. Neither of them are addictive when they are taken as prescribed. The newer formulations, Concerta and Adderall XR, are even harder to be abused. They can start working sometimes even with the first dose, although it is best to start on a low dose and gradually increase to minimize some of the side effects.
Strattera, on the contrary, is a more slow acting medicine. The full effect sometimes takes several weeks to months. Therefore, it takes much longer to adjust to the best effective dose.
The downside of all these newer and long-acting medications is their cost. All of them are expensive, although almost all private insurance plans pay for these medications. Our difficulty nowadays is with the government subsidized plans. Most provincial pharmacies do not have these new medications on the formulary, although some provinces will allow them through an exceptional drug program if it is shown that Ritalin or Dexedrine either don’t work, or have significant side effects.
I hope this information is helpful for you. You should ponder the pros and cons of each medicine, and make the final decision with your doctor. However, as always, use of medicine in children with ADHD is a trial. If one doesn’t work or have serious side effects, try a second, or even a third one. There is a good chance that one of them can help your son.
[Note to Readers: Please read other more recent columns on this topic, there are newer medications available since the publication of this column. The original reported side effect of Strattera on the liver turned out to be unfounded, and it has been removed from the column here. Generic Strattera has become available in recent years, but it is still fairly expensive.]