Stimulants as a medication family are the gold standard (the number one treatment) for ADHD per organizations such as the Texas Children's Medication Algorithm Project, AACAP and AAP. This is because they work in 70-80% of people¹who take them helping to control symptoms of hyperactivity and inattention.
Typically all treatment should first begin with a methylphenidate (or amphetamine) in the long acting formulation.
Methylphenidate is recommended over amphetamine for children based on data that suggests it is safer and slightly more effective². It is the opposite for adults where amphetamines are recommended first. However there are going to be cases where a methylphenidate just isnt working for a child for whatever reason. In this case it is perfectly find to use an amphetamine instead. Indeed, in preschoolers, your child's healthcare provider may want to start with an amphetamine as these are FDA approved for ages as young as 3 years old, whereas methylphenidates are not (yet) because the research studies did not look at their use in younger kids.
Ok, got it, start with a methylphenidate in kids unless they are preschoolers, or there is a reason not to. But why is long acting formulation recommended first? Shouldn't we start with the one that is out of their system faster to see how they respond first?
So long acting stimulants are recommended over short acting stimulants when first starting out.
Here are the reasons³:
It is easier to take one pill in the morning to cover the whole day instead of taking multiple pills throughout the day. The shorter acting forms may need to be taken twice per day to provide coverage.
Long acting avoids crashes. It's a gentler ramp up and ramp down so people feel less irritability/worsening of their ADHD symptoms when the dose starts wearing off. The ramp down as a long stimulant wares off is more gradual, like rolling down a hill instead of falling off a cliff.
Ok, but could we start with shorter acting instead, especially if my child is smaller or younger, or if we are just nervous about starting with something that hangs around in their bodies for a longer period of time?
Yes, you absolutely could, and this is a conversation to have with your child’s healthcare provider to go over your concerns.
So short acting stimulants definitely have benefits. Here are situations where it would be beneficial to start with a short acting instead:
For children who only need it to work for a few hours, ie they go to school just for half the day.
For children who have lost their appetite with the longer acting stimulants.
For children who are having problems with sleep on the longer acting stimulants
For smaller children, or preschoolers if there is no longer acting formulation available in low enough doses
So we could start with a short acting then switch to a long acting and vice versa?
Yes. Your child’s healthcare provider should be able to figure out the new dosing needed by using a table called an equivalency and conversion guide or a medication calculator. This tells them how to convert the dosing your child is currently on to the equivalent dosing the formulation that you wish to switch to.
Are the side effects the same with long acting and short acting, or is long acting worse?
Regardless of whichever you choose, all stimulants will have the same side effects such as appetite suppression and insomnia, so timing of when you give stimulants is important.
For example, if a shorter acting is taken in the morning, the side effects will still be present but they will wear off by lunch time meaning that your child should be able to eat in the afternoon and their sleep should not be impacted. So it's not the case of the side effects not happening on a shorter acting formulation, they did happen but they didn't impact the day much. If your child were to take a short acting stimulant in the afternoon, it may impact dinner and prevent them from sleeping, so timing is important.
For the longer acting stimulants some people will have problems with eating dinner or sleep, and some won't. It's down to what their body does to the drug and what the drug does to their body which is going to be different for everyone.
Would genetic testing be able to tell us whether to use long or short acting?
Genetic testing like GeneSight can tell us which stimulants from the family of methylphenidates (eg Focalin, Ritalin, Concerta) your child’s body is going to, or not going to, have side effects with. It cannot test for the severity of side effects from amphetamines such as Adderall, Dexedrine or Vyvanse because they have not discovered which genetic marker in the body is responsible for side effects for amphetamines specifically.
Genetic testing also can not tell you whether short or long acting would be best. It will only give results for the drug family as a whole, so methylphenidates as a whole in which there are at least 4 short acting, 3 intermediate acting and at least 12 long acting formulations within that family.
So in short, GeneSight can test for side effects to methylphenidate as a whole, not between short acting and long acting forms. It cannot test for side effects to amphetamines.
You’ve now settled on either a long acting or a short acting stimulant. Which brand to choose?
This is definitely going to be an in-depth conversation to have with your child's healthcare provider regarding what you hope to get out of the stimulant.
Questions to consider include times of days that you would like the stimulant to be working, how long you would like for it to last throughout the day, whether you want to give it just once or multiple times per day.
To some extent your child's body is going to make the decision for you based on how well they are able to tolerate the short or long acting stimulant that their health care provider prescribes.
Stimulants exist in a wide range of forms such as tablets, chewable tablets, orally disintegrating tablets, capsules, liquid, or patches. So which you choose is going to based on what your child would be able to handle daily.
The way that different brands release the medication can also differ from medication to medication with some using single, double or triple ‘pulse’ systems to release the medication into your child’s body.
So what you choose is really going to be based on preference and the medication that makes the most sense for your unique child and their day-to-day activities.
Conclusion
The choice between long acting and short acting stimulants is unique to your child and should take into account the age and weight of your child, the length of time you would like the stimulant to last, the number of times per day you would want to give it, and any prior responses to other stimulants in the past.
Long acting methylphenidate is typically recommended first in children except in instances where the child only needs symptom control for a few hours, or has difficulty eating or sleeping on a long acting form.
Stimulants all have slightly different characteristics so it is definitely going to be an in depth conversation with your child’s healthcare provider regarding the pros and cons of each to find the best for your child.
Genetic testing cannot test for side effects against amphetamines, only methylphenidate.
This site is for general informational purposes only and does not constitute the giving of medical advice. The contents do not constitute the practice of medicine, nursing, or other professional health care services. No provider–patient relationship is formed. Please consult with your child's healthcare provider when considering supplementation for children.
³ Feder, J., Tien, E & Puzantian, T. (2023) Child Medication Fact Book for Psychiatric Practice. Second Ed. Carlat Publishing
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