The problem with stimulants is not that they don’t work or that they have side effects, but that they don’t work consistently.
I’ve spoken to dozens of adults with ADHD who went off childhood stimulant medications as soon as they could hassle their parents into quitting the stuff. “I was on Ritalin as a kid, but the ups and downs drove me crazy. I can’t go on those again.” The graph on the left shows the rapid shifts in blood levels that a child on Ritalin (methylphenidate) endures every day.
When the choices are limited to a) medication ups and downs with side effects or b) consistent under-performance without them, it’s hard to blame a child for hating side effects. Children have yet to learn how cruel the adult world is to under-performers.
Extended-release stimulants such as Concerta, Adderall XR, Metadate CD, Ritalin LA, Focalin XR and Quillivant XR represent a major improvement. To be clear, though, they were designed to eliminate repeat doses of medications, not to reduce the ups and downs. Fortunately, they often smooth things out a little too.
Vyvanse and Daytrana have very smooth concentration curves with no rapid shifts during the day. They probably represent the state-of-the-art in consistent, all-day effectiveness for stimulants and can be a godsend for people sensitive to stimulant level fluctuations.
Getting Going Then Stopping. Every Day.
The problem with even the smoothest stimulant is the need to get it into a person’s system in the morning, then out in the evening to allow sleep. In general, the smoother and longer-lasting a stimulant is, the longer it takes to start working in the morning. Vyvanse takes 3 hours to reach its best effect. It’s departure at the end of the day tends to be subtle.
Adderall pills are much quicker with full effect in 90 minutes, but their offset is often so rapid that people sometimes refer to it as a “crash”. The term is a colorful bit of hyperbole that refers to a notable loss of mental energy and efficiency. It is not remotely like a “meth crash” which has been described as “a deteriorated state, starved, dehydrated and utterly exhausted physically, mentally and emotionally.”
The main point here is that stimulants have a significant fluctuation “up” every morning, a large one “down” every evening and sometimes have smaller ups and downs in between. Personally, I like roller coasters once a year, but not every day.
The Nonstimulant Alternative
Nonstimulants don’t have the ups and downs in their effectiveness that stimulants do. People who use nonstimulant treatments for ADHD don’t have to order their to-do list around peaks and valleys in their executive function. However, nonstimulants tend to take a month or two to reach their full effect which makes them unpopular at that critical moment when you have to decide what medicine to try.
Pretend that your child with ADHD has six weeks to pull up some failing grades, and her teacher is begging you to do something that will decrease disruption in the classroom. Pretend further that you are frazzled from an expensive hour in your physician’s office trying to discuss ADHD treatments while your child was climbing into cupboards and dumping out boxes of tongue depressors. “So do you want to try the medication that will work in a month or two, or the one that will work by 8 am tomorrow?”
Now pretend that it’s six months later, the crisis is past and it’s a regular day at your house. Do you want your child on the medication that wears off every evening around suppertime or the one that works all the time?