Methylphenidate, sold under the brand name Ritalin, is a mild central nervous system stimulant that is administered to children and adults who exhibit symptoms associated with attention deficit hyperactivity disorder (ADHD). ADHD is a common condition that affects almost 1 in 20 children in the U.S. and the disorder more commonly affects boys. Children with ADHD consistently evidence abnormal patterns of behavior over a period of time, characterized by restlessness, inability to sit still for long, inattentiveness, and impulsiveness. The causes of ADHD are not completely understood. However, the condition often runs in families, which suggests that genetics may be involved. As has been commonly believed, ADHD is not caused by poor parenting or abuse.
The symptoms of ADHD develop in early childhood, usually between the ages of 3 and 7, and may include:
Inability to finish tasks
Short attention span
Inability to concentrate in class
Difficulty following instructions
Tendency to talk excessively
Frequently interrupting others
Difficulty waiting or taking turns
Inability to play quietly alone
Physical impulsiveness
Emotional liability
Children with ADHD may have difficulty forming friendships. Self-esteem is often low because an affected child is frequently scolded and criticized.
Ritalin is used as part of an overall treatment program for children who exhibit ADHD symptoms. Diagnosis of this condition should be based on a complete history and evaluation of the child, not solely on the presence of one or more of the aforementioned symptoms. Also, drug treatment should not be indefinite and usually may be discontinued after puberty.
Ritalin is administered orally in tablet form, both regular and extended release. The drug is quickly and extensively absorbed into the bloodstream. Data indicates that most of the drug is excreted in the urine and feces within 48 to 96 hours. Dosage should be individualized according to the needs and responses of the patient; and also according to the patient’s age and body weight. Timing of drug administration should coincide with the time of greatest need. It is not recommended to administer a daily dose above 60 mg. Also, if improvement is not noted after appropriate dosages over a 1-month period, it is recommended that the drug be discontinued.
Treatment with Ritalin is not indicated for all children with this syndrome. Administration of stimulants is not proper treatment for a child who exhibits primary psychiatric disorders, including psychosis. The right educational placement and psychosocial intervention are necessary. When these measures are insufficient, the decision to prescribe Ritalin depends on the physician’s assessment of the child’s overall symptoms.
Ritalin should not be administered to children under the age of 6, since its safety and effectiveness for this age group has not been confirmed. Suppression of growth has been reported with the long-term use of stimulants in children. Although the cause for this has not been established, patients requiring long-term Ritalin therapy should be monitored. In addition, it is recommended to withhold the drug during school holidays and on weekends if the clinical situation permits.
Cautions
Ritalin should not be used for or should be given with caution to individuals with the following conditions:
Severe depression – do not use
Normal fatigue states – do not use
Hypertension – use caution
Seizures – discontinue use
Pregnancy – do not use
Breast feeding mothers – do not use
Emotional instability – use caution
Abuse
Clinical data indicates that treatment with Ritalin during childhood and/or adolescence does not appear to cause an increased predisposition for addiction. However, when Ritalin is chronically abused, it can lead to a high tolerance and psychological dependence with varying degrees of abnormal behavior. Psychotic episodes can occur, particularly with injection of the drug.
Withdrawal
During Ritalin withdrawal, careful supervision is required because severe depression and the effects of chronic overactivity can result. Long-term follow-up may be necessary because of the patient’s basic personality disorders.
Precautions
Periodic CBC, differential, and platelet counts are advised during prolonged therapy.
Long-term effects of Ritalin in children have not been well established.
Ritalin may affect performance; therefore, patients should be cautioned against engaging in hazardous activities such as operation of automobiles or dangerous machinery.
Due to possible adverse drug interaction, use cautiously with pressor agents and MAO inhibitors.
Possible Adverse Effects
Nervousness
Insomnia
Decreased appetite (usually temporary)
Dizziness
Drowsiness
Headache
Impairment of body movements
Convulsions
Muscle cramps
Psychotic episodes
Psychological dependence
Transient depressed mood
Visual disturbances
Nausea
Abdominal pain
Palpitations
Blood pressure and pulse changes
Tachycardia
Angina
Cardiac arrhythmias
Skin rashes
Anemia
Weight loss
Minor retardation of growth in children
Symptoms of Overdose
Vomiting
Agitation
Tremors
Muscle twitching
Convulsions (may be followed by coma)
Euphoria
Confusion
Hallucinations
Delirium
Sweating
Flushing
Headache
Palpitations
Cardiac arrhythmias
Hypertension
Mydriasis
Dryness of mucous membranes
In treating a case of Ritalin overdose, the patient must be protected against self-injury and against stimuli that would exacerbate the overstimulation already present. If safe, gastric contents may be evacuated by appropriate measures. For severe intoxication, a carefully formulated dosage of short-acting barbiturate may be administered prior to performing gastric lavage. Intensive care should be taken to maintain adequate circulation and respiration. Also, external cooling procedures may be required if the patient exhibits high fever.
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