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ADHD Basics
Treatment of ADHD
Every
family wants to determine what treatment will be most effective for
their child. This question needs to be answered by each family in
consultation with their health care professional.
Medications
According
to several systematic reviews, good evidence suggests that stimulant
medications such as Ritalin or amphetamines can reduce the symptoms of
ADHD in children. The evidence is so persuasive that the American
Academy of Pediatrics includes the use of stimulants as one of its top
clinical guideline recommendations for treating the disorder. This
strong recommendation coexists, however, alongside a number of other
options for treatment and questions about how ADHD therapies might be
tailored to specific patient groups.
The medications that seem
to be the most effective are a class of drugs known as stimulants.
Following is a list of the stimulants, their trade (or brand) names,
and their generic names. "Approved age" means that the drug has been
tested and found safe and effective in children of that age.
Trade Name
Generic Name
Approved Age
Adderall- amphetamine -3 and older
Concerta -methylphenidate-(long acting) 6 and older
Cylert* -pemoline- 6 and older
Dexedrine -dextroamphetamine -3 and older
Dextrostat -dextroamphetamine- 3 and older
Focalin -dexmethylphenidate -6 and older
Metadate -ER methylphenidate-(extended release) 6 and older
Metadate- CD methylphenidate -(extended release) 6 and older
Ritalin -methylphenidate- 6 and older
Ritalin -SR methylphenidate-(extended release) 6 and older
Ritalin- LA methylphenidate-(long acting) 6 and older
*Because
of its potential for serious side effects affecting the liver, Cylert
should not ordinarily be considered as first-line drug therapy for
ADHD.
The U.S. Food and Drug Adminstration (FDA) recently
approved a medication for ADHD that is not a stimulant. The medication,
Strattera®, or atomoxetine, works on the neurotransmitter
norepinephrine, whereas the stimulants primarily work on dopamine. Both
of theses neurotransmitters are believed to play a role in ADHD. More
studies will need to be done to contrast Strattera with the medications
already available, but the evidence to date indicates that over 70
percent of children with ADHD given Strattera manifest significant
improvement in their symptoms.
Some people get better results
from one medication, some from another. It is important to work with
the prescribing physician to find the right medication and the right
dosage. For many people, the stimulants dramatically reduce their
hyperactivity and impulsivity and improve their ability to focus, work,
and learn. The medications may also improve physical coordination, such
as that needed in handwriting and in sports.
The stimulant
drugs, when used with medical supervision, are usually considered quite
safe. Stimulants do not make the child feel "high," although some
children say they feel different or funny. Such changes are usually
very minor. Although some parents worry that their child may become
addicted to the medication, to date there is no convincing evidence
that stimulant medications, when used for treatment of ADHD, cause drug
abuse or dependence. A review of all long-term studies on stimulant
medication and substance abuse, conducted by researchers at
Massachusetts General Hospital and Harvard Medical School, found that
teenagers with ADHD who remained on their medication during the teen
years had a lower likelihood of substance use or abuse than did ADHD
adolescents who were not taking medications.
The stimulant drugs
come in long- and short-term forms. The newer sustained-release
stimulants can be taken before school and are long-lasting so that the
child does not need to go to the school nurse every day for a pill. The
doctor can discuss with the parents the child's needs and decide which
preparation to use and whether the child needs to take the medicine
during school hours only or in the evening and on weekends too.
If
the child does not show symptom improvement after taking a medication
for a week, the doctor may try adjusting the dosage. If there is still
no improvement, the child may be switched to another medication. About
one out of ten children is not helped by a stimulant medication. Other
types of medication may be used if stimulants don't work or if the ADHD
occurs with another disorder. Antidepressants and other medications can
help control accompanying depression or anxiety.
Sometimes the
doctor may prescribe for a young child a medication that has been
approved by the FDA for use in adults or older children. This use of
the medication is called "off label." Many of the newer medications
that are proving helpful for child mental disorders are prescribed off
label because only a few of them have been systematically studied for
safety and efficacy in children. Medications that have not undergone
such testing are dispensed with the statement that "safety and efficacy
have not been established in pediatric patients."
Side effects of the medications
Most
side effects of the stimulant medications are minor and are usually
related to the dosage of the medication being taken. Higher doses
produce more side effects. The most common side effects are decreased
appetite, insomnia, increased anxiety, and/or irritability. Some
children report mild stomach aches or headaches.
Appetite seems
to fluctuate, usually being low during the middle of the day and more
normal by suppertime. Adequate amounts of food that is nutritional
should be available for the child, especially at peak appetite times.
If
the child has difficulty falling asleep, several options may be tried –
a lower dosage of the stimulant, giving the stimulant earlier in the
day, discontinuing the afternoon or evening dosage, or giving an
adjunct medication such as a low-dosage antidepressant or clonidine. A
few children develop tics during treatment. These can often be lessened
by changing the medication dosage. A very few children cannot tolerate
any stimulant, no matter how low the dosage. In such cases, the child
is often given an antidepressant instead of the stimulant.
When
a child's schoolwork and behavior improve soon after starting
medication, the child, parents, and teachers tend to applaud the drug
for causing the sudden changes. Unfortunately, when people see such
immediate improvement, they often think medication is all that's
needed. But medications don't cure ADHD; they only control the symptoms
on the day they are taken. Although the medications help the child pay
better attention and complete school work, they can't increase
knowledge or improve academic skills. The medications help the child to
use those skills he or she already possesses.
Behavioral
therapy, emotional counseling, and practical support will help ADHD
children cope with everyday problems and feel better about themselves.
Facts to remember about medication for ADHD
Medications
for ADHD help many children focus and be more successful at school,
home, and play. Avoiding negative experiences now may actually help
prevent addictions and other emotional problems later.
About 80 percent of children who need medication for ADHD still need it as teenagers. Over 50 percent need medication as adults.
Medication for the child with both ADHD and bipolar disorder
Since
a child with bipolar disorder will probably be prescribed a mood
stabilizer such as lithium or Depakote®, the doctor will carefully
consider whether the child should take one of the medications usually
prescribed for ADHD. If a stimulant medication is prescribed, it may be
given in a lower dosage than usual.
Behavior therapy
Behavior
therapy is an alternative treatment pursued by the significant number
of patients who do not respond to stimulants or are reluctant to take
the drugs. Many patients also supplement their drug treatment with some
kind of behavior therapy. The evidence for behavior therapy’s
effectiveness is much weaker than the evidence for stimulant
medications, however, and almost all studies comparing behavior therapy
with stimulants alone indicate a much stronger effect from stimulants
than from behavior therapy. Behavior therapy is not without some
supporting data, although few high quality studies of the treatment
exist.
Research shows that behavior therapy can be particularly
good for certain subgroups within ADHD patients, for example, children
who have poor relationships with parents or lots of opposition and
aggression in the family. ADHD is a unique chronic disorder that might
also be treated in some cases with educational therapy, although very
little information exists on such treatment.
Which treatment should my child have?
For
children with ADHD, no single treatment is the answer for every child.
A child may sometimes have undesirable side effects to a medication
that would make that particular treatment unacceptable. And if a child
with ADHD also has anxiety or depression, a treatment combining
medication and behavioral therapy might be best. Each child's needs and
personal history must be carefully considered.
I Teach To Reach is a Non- Profit Organization
Dr.Anders Osborne Ph.D.
10700 Pendragon Pl.
Raleigh,NC .27614
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