Stimulant Rebound: How Common Is It and What Does It Mean?

Department of Psychiatry and Behavioral Science, State University of New York at Stony Brook, Stony Brook, New York 11794-8790, USA.
Journal of Child and Adolescent Psychopharmacology (Impact Factor: 2.93). 02/2003; 13(2):137-42. DOI: 10.1089/104454603322163853
Source: PubMed

ABSTRACT To examine rates and implications of stimulant-induced rebound - the behavioral deterioration that may occur as stimulant medications wear off.
This study compares nurse observations on evening shifts compared to day shifts in 149 psychiatrically hospitalized children treated with short-acting stimulants, usually methylphenidate, comparing nonmedication and stimulant-treated states.
Behavioral deterioration (rebound), was observed in 30% of children on at least one dose of stimulants but was serious enough to discontinue treatment in only 8.7%. Children experiencing rebound did not differ clinically from those who did not.
Rebound exists, occurs significantly in less than 10% of psychiatrically hospitalized children with attention deficit hyperactivity disorder, and does not appear to have specific diagnostic significance.

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    • "While there is evidence that stimulants are associated with disrupted or disturbed sleep in patients with ADHD (Ironside et al. 2010; Nutt et al. 2007; Spruyt and Gozal 2011; Stein 1999), clinical experience also indicates that stimulants produce paradoxical effects (Bradley 1937), whereby alleviation of symptoms can calm patients and promote sleep (Jerome 2001; Kinsbourne 1973; Kooij et al. 2001; Kratochvil et al. 2005). Furthermore , because of the potential for symptom rebound as blood drug concentrations wane (Carlson and Kelly 2003), an additional dose of a short-acting stimulant, or the use of a formulation with an increased duration of action, may prevent sleep disturbances resulting from worsening of hyperactivity or behavioral difficulties at bedtime (Cortese et al. 2013a, b; Lecendreux et al. 2000). In clinical trials using objective sleep measures, immediate-release methylphenidate has been reported to increase sleep onset latency and/or to decrease total sleep time in patients with ADHD (Boonstra et al. 2007; Galland et al. 2010; Greenhill et al. 1983; Sangal et al. 2006), with sleep quality either unaffected (Galland et al. 2010) or improved (Boonstra et al. 2007; Sobanski et al. 2008). "
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    ABSTRACT: Attention-deficit/hyperactivity disorder (ADHD) is commonly associated with disordered or disturbed sleep. The relationships of ADHD with sleep problems, psychiatric comorbidities and medications are complex and multidirectional. Evidence from published studies comparing sleep in individuals with ADHD with typically developing controls is most concordant for associations of ADHD with: hypopnea/apnea and peripheral limb movements in sleep or nocturnal motricity in polysomnographic studies; increased sleep onset latency and shorter sleep time in actigraphic studies; and bedtime resistance, difficulty with morning awakenings, sleep onset difficulties, sleep-disordered breathing, night awakenings and daytime sleepiness in subjective studies. ADHD is also frequently coincident with sleep disorders (obstructive sleep apnea, peripheral limb movement disorder, restless legs syndrome and circadian-rhythm sleep disorders). Psychostimulant medications are associated with disrupted or disturbed sleep, but also 'paradoxically' calm some patients with ADHD for sleep by alleviating their symptoms. Long-acting formulations may have insufficient duration of action, leading to symptom rebound at bedtime. Current guidelines recommend assessment of sleep disturbance during evaluation of ADHD, and before initiation of pharmacotherapy, with healthy sleep practices the first-line option for addressing sleep problems. This review aims to provide a comprehensive overview of the relationships between ADHD and sleep, and presents a conceptual model of the modes of interaction: ADHD may cause sleep problems as an intrinsic feature of the disorder; sleep problems may cause or mimic ADHD; ADHD and sleep problems may interact, with reciprocal causation and possible involvement of comorbidity; and ADHD and sleep problems may share a common underlying neurological etiology.
    ADHD Attention Deficit and Hyperactivity Disorders 08/2014; 7(1). DOI:10.1007/s12402-014-0151-0
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    • "Proportions of participants who showed clinically significant symptom response and rebound, based on CPRS-R:S ratings in the morning, afternoon, and evening , were tabulated based on the evaluable population (i.e., participants with both baseline and endpoint scores for one or more of the same assessment time points). Criteria used to define response and rebound were based on approaches previously used in clinical trials of medication treatment for ADHD (Carlson & Kelly, 2003; Stein et al., 2003; Swanson et al., 2001). For " response, " a total score of ≤12 on the ADHD Index subscale was chosen because this suggests most items are rated as " not at all true " or " just a little true/occasionally " and a score ≤1 for each ADHD Index subscale item ensures, on average, the absence of any isolated residual symptoms that are of a moderate or severe nature. "
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    ABSTRACT: Objective: To describe symptom rebound in children with ADHD treated with lisdexamfetamine dimesylate (LDX) or placebo. Method: During a 4-week, randomized, double-blind, placebo-controlled trial of LDX, parents/caregivers completed the Conners' Parent Rating Scale-Revised: Short Form symptom rating scale throughout the day. Response, rebound, and emotional lability (EL) were assessed post hoc based on predefined criteria. Results: Most participants given LDX (n = 207) were responders throughout the day (50.7%-55.6%) versus placebo (n = 72; 11.1%-22.2%). A total of seven (3.4%) LDX participants showed rebound in the afternoon and/or evening versus seven (9.7%) with placebo. In both groups, most incidences of rebound occurred in the evening. EL (mean) was higher in LDX rebounders and nonresponders (range = 4.2-9.0) versus LDX responders (range = 1.3-1.6) and versus placebo rebounders (range = 0.7-1.9). Conclusion: ADHD symptom rebound occurred in few participants (3.3%) given LDX (accompanied by clinically significant EL). Overall, more participants given LDX versus placebo responded throughout the day. (J. of Att. Dis. 2012; XX(X) 1-XX).
    Journal of Attention Disorders 02/2013; DOI:10.1177/1087054712474685 · 3.78 Impact Factor
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    • "Rebound effects may be defined as a worsening of ADHD symptoms (particularly those of hyperactivity/impulsivity) beyond that of baseline levels. Carlson and Kelly (2003) who reported staff observations comparing day and evening changes in emotional symptoms plus insomnia in hospitalized children taking short-acting stimulants, concluded that 30% had behavioral deterioration, but less than 10% had significant " rebound. " Rebound is commonly observed in clinical practice but poorly understood; no clear explanation has been offered to date regarding why rebound occurs in some children and not in others. "
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    ABSTRACT: ADHD is one of the most common neurobehavioral disorders of childhood, and FDA-approved medications offer an efficacious treatment option. However, case reports and anecdotal sources suggest that children can have emotional responses, both salutary and detrimental, to these agents. We have previously conducted a comprehensive literature review and found very few research studies systematically examining changes in emotional expression (EE) associated with ADHD medication use. In addition, no empirical data pertaining to the management of these responses could be found. Although few methodologically stringent data are available for changes in EE, such changes should be recognized and measured to determine appropriate responses by clinicians and to maximize treatment benefits and reduce side effects. In this companion report, we draw on available research evidence and clinical experience to explore typical clinical manifestations, differential diagnosis, scales for monitoring, and management approaches of EE observed with pharmacologic treatment of ADHD. In the future, controlled clinical trials of ADHD pharmacotherapy should employ standardized ratings of EE at baseline, during and after treatment. In addition, future research studies should examine various management approaches of these EE changes, to ensure maximal treatment benefits and minimal risks to patients with ADHD who are treated with medication.
    Journal of Attention Disorders 02/2011; 15(2):113-21. DOI:10.1177/1087054710381232 · 3.78 Impact Factor
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