The effects of methylphenidate in ten children with attention deficit complicated by seizure disorders are reported from the Departments of Pediatrics and Neurology, Children’s Hospital of Pittsburgh, PA. The seizure types were partial complex in five, generalized tonic-clonic in two, generalized atonic in two, and partial motor with secondary generalization in one. The seizures had been well controlled for at least three months preceding the study. Monotherapy consisted of carbamazepine in five, phenobarbital in two, valproic acid in two, and phenytoin sodium in one. Methylphenidate was administered 0.3 mg/kg/dose at 8 a.m. and 12 p.m. on school days only and the study design was a double blind medication-placebo crossover. There were significant improvements on the Conners’ Teacher Rating Scale and on the finger tapping task. No seizures or changes in the EEG occurred during the study period. It was concluded that methylphenidate may be a safe and effective treatment for certain children with seizures controlled with anticonvulsant medication and complicated by attention deficit disorder. [1]

COMMENT. The Physicians’ Desk Reference includes a contraindication to the use of Ritalin as follows: “there is some clinical evidence that Ritalin may lower the convulsive threshold in patients with prior history of seizures, with prior EEG abnormalities in the absence of seizures, and, very rarely, in absence of history of seizures and no prior EEG evidence of seizures. Safe concomitant use of anticonvulsants and Ritalin has not been established. In the presence of seizures, the drug should be discontinued.” Based on the present study of ten patients and in a retrospective study of 23 patients [2] there is some support for the use of Ritalin in the hyperactive patient with seizures controlled by anticonvulsant drugs. Phenobarbital is generally a poor choice as an anticonvulsant in children with attention deficit disorder and alternative medications are preferred. Pemoline (Cylert) is generally considered to have less tendency to lower seizure threshold than does methylphenidate. Some recommend that all patients considered for treatment with methylphenidate should first receive an electroencephalogram; those with a history of seizures and/or epileptiform discharges in the electroencephalogram should receive treatment with an anticonvulsant drug such as carbamazepine concomitantly with the CNS stimulant. In a study of the electroencephalogram in 100 consecutive children with attention deficit disorder and hyperactivity, 7% had Grade III dysrhythmias consisting of spike-and-wave, spike or sharp wave abnormalities indicative of seizure activity. (Millichap JG. The Hyperactive Child with Minimal Brain Dysfunction. Chicago, Yearbook Medical Publishers. 1975). The frequency of significant abnormalities in the EEG is sufficient to warrant testing before treatment with methylphenidate.