It was 3:20 and the rain had turned from a light sprinkle to a downpour. Danny would be getting off the bus in a few minutes, so I grabbed an umbrella and picked up a small bag of potato chips and went out the door. As I reached the corner, the bus was pulling up. The door opened and the kids started streaming out. Danny was one of the last ones out. I smiled and waved, but he kept his head down and didn’t see me. When he realized how hard it was raining, he jumped down the last step, and started to take off in a run towards our house. As he turned, he bumped into another boy, but this didn’t stop him. He took off running without an apology.

“Hey, Danny, over here,” I yelled, “Danny.” He turned, saw me, and ran over to get under the umbrella.

“Kind of wet, huh?”

He grunted, “Yeah, guess so.”

“Well, I brought you some water and potato chips.  Here you go.” He took them from me, opened the bottle and began slurping.

“Well, what about a thank you?”

“Yeah, thanks,” he said without much enthusiasm.

We arrived at our garage door a few minutes later, and Danny ran in, without saying anything. He dropped his jacket and bookbag to the floor and ripped open the potato chips.

“So, how was your day?”

Silence.

“Danny?”

“What?”

“How was your day?”

“Fine.”

“Well, what did you learn today.”

“Nothing.”

“You must have learned something. I can’t imagine that Mrs. Miller would just let you sit there all day.”

“Mom, stop asking me these stupid questions” He threw the bag of potato chips on the floor, stomped out of the room and went up to his room, slamming the door behind him.

“I went upstairs, and quietly stood outside his door. I wasn’t sure whether I should open the door and confront him for being rude, or whether I should just let it pass.

Danny had started on Ritalin for his ADHD about a week ago. One in the morning and one at lunch.  Mrs. Miller said that the effect was dramatic. Danny was happy, engaged and learning in school. She said that he was focused in the classroom, always had the correct answer when called upon, and his grades now reflected the intelligence that had been hiding within. She said that he was like a different kid, more confident and at ease. And the other kids had noticed as well. They were beginning to seek him out on the playground.  As a result, he just seemed…happier.

Which was very curious, because at home, he seemed to be constantly irritable, arguing at the least little thing. Granted, he wasn’t running around like before, he wasn’t as active and impulsive, but he was so irritable. Chris had noticed, as well, as it seemed to get worse round 4:00 – 5:00, right about the time that Chris would get home from work. Last night, after Danny had gone to bed, Chris and I had had another argument about the medication.

“I don’t know, Liz, I don’t think this medication is working. And Danny just seems mad all the time. I asked him to take out the trash yesterday, and he yelled at me. He has never done that before. He said the trash wasn’t his, so he shouldn’t have to take it out. I think it’s time to stop this medication.”

I was still outside Danny’s door. I knew I couldn’t let his rudeness pass, so I turned the doorknob. It was locked.  “Danny, could you please open the door?”

Nothing.

“Danny, please….”

“Go away,” he yelled.

“Danny, did something bad happen at school today.”

“Go away.  Get out a’ here”

“Danny, please open the door.” I waited about 15 seconds, and then turned to go downstairs. I heard a click and the door slowly opened. Danny was standing there, looking at his wet shoes.

“Danny, what’s wrong?”

Again, he said nothing. He stood there for a while, then rushed towards me. He wrapped his arms around my legs and began sobbing. “Danny, what’s wrong. You know I love you and don’t like to see you so upset. What happened?  What’s wrong?”

Ritalin was the first brand name of methylphenidate approved by the FDA for the treatment of ADHD in 1954. It is highly effective for treating the symptoms of ADHD, but like any medication, it has side effects. Even though Danny has had a negative change of personality at home, his mood has improved at school. He is doing so much better retaining what he has learned. He is getting along with the other kids. But why is he so angry?

Everybody’s emotional state changes throughout the day. Things can be going well, but then you open the mail and find out that you owe a little more on your taxes. This makes you irritable because you were expecting a refund. Then your best friend calls and invites you to dinner and you feel better again. You start to make lunch and realize that you are out of mayonnaise. These minor events represent the little ups and downs that we experience throughout the day.

Emotional Lability is different. Emotional Lability is a term used to describe mood swings that are sudden, usually due to some small disappointment, often without an obvious cause, and usually with an exaggerated emotional response.

Emotional Lability is a fairly frequent effect of taking Ritalin, but it is not a direct side effect of the medication itself. Instead, this anger and irritability is a problem with how Ritalin is often prescribed, not a direct effect of the medication itself. It is included here because most parents and even most physicians believe that it is a side-effect.

The following explanation will take a few pages, but it is important to understand this aspect of the ADHD medications, because timing is the key to understanding just about everything with ADHD medications. This explanation will use Ritalin as an example, but it is relevant for any of the short acting, immediate release medications (Methylin, Focalin, Adderall, Dexedrine, DextroStat, and Evekeo).  

Ritalin takes effect quickly. You begin to see the benefits within 20-30 minutes after taking a dose. But Ritalin doesn’t last very long, usually wearing off about 4 hours after it is taken. As a result, most of the time Ritalin is prescribed twice or even three times a day.  Most parents give the medication around 7:00 in the morning. And because it wears off before lunch, the school nurse is asked to give the child another dose, just before lunch. Sometimes a third dose is prescribed when a child gets home from school so that she can get her homework done. 

This graph depicts what is happening. The horizontal axis represents the time of day and the verticals axis represents the blood levels of methylphenidate (the generic ingredient that is in Ritalin) at each hour of the day. The red line represents how much medication has been absorbed by the body and you can see the effects of each of these three doses. The first dose rises rapidly, reaches a peak about 2 hours after a dose and wears off quickly. The second dose, if given early enough, will be added to the amount already in the body from the first dose, so that the peak effect of the second dose is a little higher than from the first. And then a third dose is often given after school, so that your child can do homework before dinner, or see a tutor or go to baseball practice.

I have added  two horizontal lines to the graph. The lower horizontal line represents the amount of medication needed to have a positive effect on the ADHD symptoms. When the methylphenidate blood levels are below this amount, the medication has little beneficial effect. If the blood level rises above this horizontal line, the medication will be effective and do what it is supposed to do.

A blood level above the higher horizontal line represents the methylphenidate level that produces side effects. The range between the two horizontal lines is called the Therapeutic Range. Ideally, we would prefer to have all our medications stabilize between these two horizontal lines, so that we can realize the benefit of the medication without a side effect. 

Each person will metabolize a medication differently and the medication curve will vary greatly by person, by dose and by medication. However, it is easy to see that this situation is not ideal. This child is spending some time during the day when the medication is highly effective without side effects. But he is also spending periods of time throughout the day where side effects are prominent and other times when the medication is not effective at all.

Notice how often the red (medication) curve and the two horizontal (Therapeutic Range) lines cross. To delineate these times more clearly, let’s draw a blue, vertical line every time the red curve crosses a black line.

Something very significant is happening at each vertical line. At 7:00am, a child takes a dose of Ritalin and the body starts to absorb the medication into the bloodstream almost immediately. Just before 8:00am (1^st Blue Vertical), the amount of Ritalin that has reached the bloodstream is within the Therapeutic Index and the child is realizing the benefit of the medication. However, as more medication is absorbed, the methylphenidate level rises. By 8:45am, the methylphenidate blood level has risen above the side effect line and the child is beginning to exhibit side effects (2^nd Blue Vertical). One of the common side effects of a higher dose of Ritalin is suppression of mood. As the medication reduces impulsivity, that lack of impulsivity might be seen as a reduction in spontaneity. And as the blood level rises further, the child’s mood may become more somber and quiet, and he is less likely to contribute to the classroom discussion. By 10:00am (3^rd Blue Vertical) the methylphenidate blood level has dropped a little so that the amount of medication is again within the Therapeutic Range. Side effects diminish while the benefits continue. However, by 11:00am the blood level has dropped further, and the medication is producing no benefit at this lower level (4^th Blue Vertical). So a second dose might then be prescribed at 11:00am. Danny has to go to the nurse’s office to get his medication, and he doesn’t like taking it. Sometimes a teacher will remind him, sometimes the nurse will come to him, and sometimes Danny just forgets. Needless to say, Danny does not get his medication every day and when he does, he does not get it at the same time every day. But when he does get the second dose, what happens? Danny goes through the same emotional roller-coaster that he went through in the morning.

If a child is having trouble staying on task and focused on homework (and most of the time they will), a third dose of medication might be given when the child gets home to help with homework, and the roller-coaster ride repeats a third time.

What happens at each vertical blue line? Danny experiences a change in his Psychological Mental State. Mental state refers to a dominant mode of the brain reacting to its environment. There are many different mental states (love, fear, pleasure, pain, etc.) 

Each blue, vertical line represents a change in mental state. Most of the time, we establish a relatively constant mental state, and we stay in that state until something causes us to change.  These changes in mental state are very disruptive to a child. And notice that the end of the second cycle kicks in about the time he is getting home. Teachers may see benefit, but all the parent sees is a very irritable child. This is often referred to as Medication Rebound.

So what happens when Danny’s mother meets him at the bus stop in the afternoon? Danny has been in his irritable, somber mode for the last 45 minutes and his medication, now 4 hours out from when he took it, is becoming ineffective. And that is why the teachers are describing one child and the parents are seeing another.

So if a parent tells me, “Doc, I know my son has ADHD and I know that he needs medication, but I don’t want him on Ritalin because it causes mood swings,” I want to scream. Of course it causes mood swings. He is moving from one Psychological Mental State to another, every hour or so. That would cause mood swings in anyone.

But what if we could produce a medication that generates more stable blood levels? This new medication (purple curve) would start like Ritalin and take effect early, but the big difference would be that when this new medication reaches the Therapeutic Range, it would stay in that range throughout the day, without the ups and downs of the short acting medication. A more stable medication, lasting longer, without the ups and downs of short-acting Ritalin, and wearing off more gradually at the end of the day, would prevent the changes in psychological state that made Danny so irritable when he got off the bus.

Many of the “newer” medications are designed to do just that, with varying degrees of success. Each medication uses either methylphenidate or amphetamine, but each medication uses a different approach to achieve that goal.

So, if your child is emotionally labile on ADHD medication, consider the following:

• If emotional lability was present prior to starting medication, is it the same, worse, or better on medication? If the emotional lability occurs as often and with the same intensity as before medication, then medication would not have caused it
• If the emotional lability is happening more often on medication, or when it occurs, it is more intense, then stimulant medication is the likely culprit. A change in medication might help. Alternatively, the dose might need to be given earlier or later.
• If the emotional lability is occurring less often on medication, then the Emotional Lability may actually be part of the ADHD, and the improvement is an indication that the medication is working. No change is needed, but in this case an increase in dose might reduce emotional lability even further.
• Does the emotional lability occur only when medication is wearing off, as in the example above? Most of the immediate release medications last about 3½ to 4½ hours, and most of the extended release medications last 8 to 12 hours. How long is it lasting? And when is the emotional lability most evident? If it seems that the emotional lability is displayed when medication is wearing off, then you can try three things:

• If your child is on immediate release medications, switch to an extended release medication.
• If your child is already on an extended release medication and the emotional lability is occurring only when medication is wearing off, then add a low dose of the immediate release medication a half hour before it seems to wear off.
• Consider switching from an amphetamine medication to a methylphenidate medication or vice versa.
• If you have tried the above potential solutions without success, then your child may benefit from a second, non-stimulant medication (clonidine, guanfacine, atomoxetine, bupropion).

The secret to any time-related side effect is to understand that for each child and for each medication, there are four important time periods:

1. Before medication is first given in the morning.
2. The period of effectiveness, after the medication has taken effect in the morning and before it begins to wear off.
3. The hour when medication is wearing off.
4. The remainder of the day (after medication has completely worn off and is no longer effective).

Before you next see your doctor, make sure that you understand when the Emotional Lability (or any other side effect for that matter) is happening. You will be much closer to a solution if prepared with this information.

Written By: By Walt Karniski, MD

Walt Karniski, MD is a developmental pediatrician, trained at Boston Children’s Hospital. He was director of the Division of Developmental Pediatrics at the University of South Florida in Tampa, Florida, for fifteen years. He then opened a private practice and for twenty years, evaluated and treated children with ADHD, autism, anxiety, learning disabilities, and other developmental difficulties. During that time, he developed and operated three private schools for children with ADHD, anxiety, and learning disabilities. Over the forty years he has been practicing, he has evaluated and treated close to ten thousand children, conducted numerous studies of brain activity in children, and has been director of a child abuse program and a program for enhancing development in children born prematurely. Dr. Karniski approaches each child as a unique individual, with distinctive strengths and weaknesses, where the diagnosis does not matter as much as understanding the specific needs of that child. His new book is ADHD Medication: Does It Work and Is It Safe? (Roman & Littlefield, May 15, 2022).