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


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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Available from: Gabrielle A Carlson, Apr 21, 2014
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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).
    Full-text · Article · Feb 2013 · Journal of Attention Disorders
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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.
    Full-text · Article · Feb 2011 · Journal of Attention Disorders
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    • "Survival analysis in this study indicated that emotional lability was significantly related to early termination from the titration phase (Wigal et al., 2006). Other studies have also documented significant emotional rebound effects; in hospitalized children treated with stimulants, 30% showed that symptoms such as sadness, crying, and irritability were linked to the time when the last daily dose of short-acting stimulant medication wore off (Carlson & Kelly, 2003). "
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    ABSTRACT: To describe clinically relevant effects of lisdexamfetamine dimesylate (LDX) on emotional expression (EE) in children with ADHD. Children with ADHD participated in a 7-week, open-label, LDX dose-optimization study. Expression and Emotion Scale for Children (EESC) change scores were analyzed post hoc using two methods to determine proportion of participants with different categories of clinical response based on (a) clinically significant (movement >2 SD from baseline mean)/reliable change (not due to measurement error) and (b) standard error of measurement (SEM) as a measure of clinically meaningful change. With LDX, no participants showed clinically significant/reliable improvement; 0.7% showed clinically significant/reliable deterioration of EE by reliable change index and movement from baseline mean. One third of participants had improved EE by SEM criteria; 9.2% had categorical worsening. Using clinically meaningful change and clinically significant/reliable change categories derived from the EESC, most participants had no worsening of EE with LDX.
    Full-text · Article · Dec 2010 · Journal of Attention Disorders
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