Q. My 16-year-old son has been taking stimulant medications since he was 6 for severe ADHD. Recently, his doctor switched from short-acting Adderall to sustained release, at a dose of 60 mg. At this point, my son developed a sudden, significant increase in blood pressure. What non-stimulant medications are available that will treat distractibility and which will not increase his blood pressure?

A. The best-tested and probably most effective medications for attention-deficit hyperactivity disorder (ADHD) are the stimulants, including methylphenidate (Ritalin and others) and amphetamine compounds. Adderall is basically a mixture of amphetamine salts, and has recently been released in a new, longer-acting formulation (Adderal-XR). I am not familiar with an Adderall "Sustained Release" other than this new XR-formulation.

The usual upper dose for Adderall-XR is 30 mg/day-so, 60 mg/day would be quite a large dose. That doesn't mean that your son's doctor is wrong. Since patients differ as to how much medication they absorb, some individuals may need these higher doses in order to achieve therapeutic blood levels. Nevertheless, I would advise checking with the doctor to make sure that you have the correct understanding of the medication type and the dose--and also, whether any blood levels of the medication have been obtained. In theory, a dosage reduction might reduce your son's elevated blood pressure, but I have no idea whether a reduced dose would be effective for him.

Regarding non-stimulant medications: there are certainly alternative medications to consider (if methylphenidate is not a good option), but none has been approved by the U.S. Food & Drug Administration (FDA) for the treatment of ADHD. Moreover, research and experience to date suggest that these non-stimulant alternatives may not be as effective as Ritalin or Adderall, with respect to core features of ADHD, such as distractability.

For example, guanfacine (Tenex) or clonidine have been used for ADHD children who tend to be irritable and/or aggressive, but these agents are not terribly helpful for inattention/distractability. They do, however, tend to reduce blood pressure. Antidepressants, including bupropion [Wellbutrin], venlafaxine [Effexor], and older tricyclic agents, have all been used with moderate benefit in ADHD; each, of course, has its associated risks and side effects, and may not be appropriate or helpful for every patient.

However, it might be possible to treat your son with, for example, a reduced stimulant dose in combination with one of these other agents, which generally do not elevate blood pressure very much (though this can happen with bupropion, venlafaxine, and occasionally, the tricyclics). Recently, another non-stimulant called modafinil [Provigil] has been used with mixed degrees of success in ADHD, and could be an option to consider; but it, too, is not FDA-approved as yet for ADHD.

If you and your son's doctor are not able to work out an effective and safe regimen for your son, I would suggest that you request a second opinion consultation with an expert in the treatment of ADHD. Also, keep in mind that various structured learning systems and behavioral modification are important components of ADHD treatment.

Other Resources:

• More Questions on ADHD

April 2002

Disclaimer Back to Ask the Expert