(ADHD Teacher Inservice Program)
M.C.Edwards, Ph.D., E.D.Schultz, MD.
Project Directors Arkansas Children's Hospital Research Institute
There are four classes
of medication that have been used to treat Attention Deficit Hyperactivity
Disorder (ADHD): the stimulants, antidepressants, adrenergics, and
* Methylphenidate (Ritalin)
* Dextroamphetamine (Dexedrine)
* Pemoline (Cylert)
* Imipramine (Tofranil)
* Desipramine (Petrofrane)
* Fluoxetine (Prozac)
* Buspirone (BuSpar)
* Thioridazine (Mellaril)
* Haloperidol (Haldol)
* Chlorpromazine (Thorazine)
* Clonidine (Catapres)
* Gaunfacine (Tenex)
Each drug has it's own effects and side effects. The three stimulant medications are the most commonly prescribed, the most extensively researches, and have the most evidence for their effectiveness. Although these stimulants have similar effects and side effects, methylphenidate is the most frequently used medication.
The Effectiveness of Stimulant Medications for ADHD
Research studies indicate that the majority of children treated with stimulant medications (about 70%) will show a mild to moderate improvement on global and parent ratings of behavior (Wilens & Biederman, 1992)
Positive Effects of Stimulant Medications
The positive short-term effects of stimulant medications have been well documented in the scientific literature. They have been shown to temporarily improve inattention, impulsivity, and hyperactivity. In addition, improvement have been shown in problem areas associated with ADHD, such as academic productivity, behavior, aggression, and social interaction (Swanson et al.,, 1993). These specific effects should be udes as target management goals.
Negative Side Effects of Methylphenidate (Ritalin)
Common Side Effects. A loss or decease in appetite is the most frequent reported side effect of the stimulant medications (Barkley, McMurray, Edelbrock & Robbins, 1990). For this reason, medication should be given with or after meals. Most children will initially experience a transient loss of appetite, especially around the noon meal. Mild weight loss can be expected, which is typically noted during the initial one to two months of medication treatment. Progressive weight loss should be considered abnormal and a medical evaluation should be obtained (Reeve & Garfinkle). Monitoring of the stimulant dosage is necessary to minimize this side effect. Sleep difficulty or insomnia is another side effect commonly experienced by children on stimulants. If a sleep problem persists, alterations and fine tuning of the medication schedule need to be considered. As an example, changing the timing of the late afternoon dose can usually minimize the sleep problem; however, these changes need to be weighed against the appetite suppression around the evening meal. If insomnia worsens over time or interferes with the child's daily function, the physician should be notified. Other common side effects include: various aches and pains, (i.e., headaches, stomach aches, leg pains), whining, moodiness, irritability and crying for no apparent reason. Most of these side effects abate after a few weeks. In general, the child who experiences these common side effects should be send to school, unless fever, vomiting or diarrhea occur.
About 1/3 of children with ADHD treated with stimulants may experience behavioral rebound or increased hyperactivity several hours after taking the medication (Johnston, Pelham, Hoza & Sturges, 1988). This unwanted side effect, typically seen when the last dose was at noon, can be offset by an additional low dose of medication prior to the onset of the rebound (e.g. 3-4 pm). When administering an afternoon dosage, the risks of insomnia and appetite suppression need to be considered.
Serious Side Effects
Stimulant Stimulant medication has been shown to unmask a tic in 9% of children started on stimulant medication (Lipkin, Goldstein & Adesman, 1994). Tics are involuntary, non-purposeful, repetitive muscle movements or vocalizations, such as eye-blinking, facial grimacing, sniffing, snorting, throat clearing, coughing, and compulsive utterances. The tics usually abate with the discontinuation of the medication; however, for a small minority of children, the tic will remain permanent (about 1% of children started on stimulants). If tics occur, the prescribing physician should be notified and the medication discontinued.
Although rare, hallucinations can also occur as a side effect of stimulant medication. Once the drug is excreted, there is no increased risk for continued hallucinations. Other rare side effects include slowed growth and increases in heart rate and blood pressure. In order to monitor these side effects, physicians are encouraged to check height, wirght and blood pressure three to four times per year. If problems are noted, the stimulant medication can be reduced, discontinued or an alternative medication tried.
Administration of Methylphenidate
Methylphenidate is orally administered in tables of varying strengths. The medication is quickly absorbed into the bloodstream, and typically has as effect within 30 minutes. The positive effects usually last only one to three hours. This short duration of action requires that the medication be given several times per day, if the effects are desired throughout the day (administered with or after breakfast and at noon to cover the fuill school day). A late dose may be needed to cover the evening hours and homework time for some children.
Considering the Use of Medications
Unfortunately, ADHD does not have a cure. Medications are used to temporarily manage the disruptive symptoms of ADHD. Given the long-standing controversy associated with using medications to alter children's behavior, as well as the potential for negative side effects, other effective non-medical interventions need to be considered, such as classroom interventions and parent training in child management (Abramowitz & O'Leary, 1991; Anastopoulos, DuPaul & Barkley, 1991). However, given the well documented short-term effectiveness of stimulant medications and their relative safety (Swanson et al, 1998), the use of medication should be considered as part of an overall treatment plan for children with at least moderate severety of ADHD. Since ADHD is not a life threatening disorder, children do not have to take medications. The decision to use medication rests solely with the parents, in consultation with their physician. Parents need to be provided with the information necessary to make an informed decision, weighing the risks and benefits.
When the decision is made to start methylphenidate with a child, five questions should be answered.
1. Will the child respond positively to medication?
2. What is the optimal dosage?
3. What is the optimal interval between doses?
4. How many doses each day will be needed?
Since research has been
unable to identify any predictors of medication response, there are no
means of answering these questions short of trying the medication.
Therefore, in order to determine the optimal medication prescription for
an individual child, it will be necessary to undergo a titration process.
There are three titration methods commonly used.
|One is a blinded, placebo-controlled
trial. In this method, those involved in evaluating the medication
response are "blind" or unaware of the medication strength or doses. Typically,
only the pharmacist is aware of the dosage schedule. A blind trial
helps to control some of the effects that are not specific to medication,
such as expectations or bias.
Another method is the open, multi-dose trial in which all participants are knowledgeable of the dosages and order of dosage. In this method, the dosages are systematically changed over a short period of time and the response on the management goals is evaluated. This method is less expensive and easier to implement within an office setting.
A third, and more common method, consists of starting methylphenidate as a minimim dosage and increasing or decreasing the dosage or schedule until the desired response occurs.
An appropriate titration protocol will allow for the evaluation of a sufficient range of doses in order to determine optimal medication response. Feedback from parents and teachers about the effects and side effects of specific doses and the length of treatment should be provided to the prescribing physician.
The long term management of a child with ADHD is a dynamic process requiring periodic readjustments and fine tuming of all interventions, including medication. Management strategies change over time depending on the child's developmental level, presence of coexisting conditions, medication side effects and educational demands. While on medication, parents should seek a medical follow-up for the child every three to four months with their primary care physician. Opportunities for medications retitration and medication free intervals (i.e., drug holidays) should be considered.
Additionally, a child should be tried off the medication at least once a year to determine the need for continued medication. In the absence of significant side effects, medication treatment can continue into adolescence and adulthood, if a positive response continues and there is continued need for the benefits (Pelham & Milich, 1991). Information from parents and teachers is used to determine the need for continuation, reduction or an increase in medication.
For children who do not respond positively to stimulant medication, who experience intolerable side effects, or who have other or additional symptoms that need to be targeted, other non-stimulant medication can be considered. For example, clonidine may be the medication of choice for a child with ADHD tics. Imipromine may be the choice for a child with anxiety and/or a sleep problem, or busipirone for a child with a mood disturbance.
Adjuncts or Alternatives to Medication
Despite the positive effects of medication for managing children with ADHD, other forms of interventions should be included in the overall treatment plan for children with ADHD. Studies on the long-term outcome of children with ADHD treated with stimulant medication have failed to demonstrate imporvements in conduct problems, academic achievement, social behavior, and peer status (Swanson et al, 1993). There is general agreement among those that study and treat children with ADHD that additional interventions over time are required (Hinshaw, 1991). Two of the most commonly employed non-medical interventions for ADHD are the application of behavior management techniques in the school setting and trainging parents in child management strategies.
Behavioral Programming in the School
Parents can request a Section 504 or Referral conference from the school principal to have the school consider whether their child qualifies for classroom modifications or special education on the basis of the child's ADHD. If the child qualifies, the school can develope a plan to address the child's performance problems.
Parent Training in Child Management
Training parents to implement specific child management proceedures in the home setting has been one of the more commonly advocated non-medical interventions for children with ADHD. Parent training programs typically provide a systematic approach to teaching parents to implement positive behavior management techniques, considtent and appropriate discipline techniques, and clear and consice communication. There is a substantial body of research evaluating parent training interventions with oppositional children (Kazdin, 1995) and results of studies that have employed parent training are, for the most part, supportive of its use with children with ADHD (Anastopoulos, DuPaul & Barkley, 1991). To obtain such services, parents can contact their local mental health center or other area mental health clinics and inquire about whether they provide "behavioral parent training in child management."
The Role of the Teacher in Medication Management
The Teacher can play an
important role in stimulant management; however, teachers are often
unclear of their responsibilities. There are several practical activities
in medication management that teachers can be involved in directly.
Confidentiality should be maintained. The teacher should respect the child by keeping the fact that the child is receiving medication confidential. The teacher should not talk about the child's treatment with the other children or with other adults that do not need to know. In addition, because of this confidentiality issue, the prescribing physician will not be able to discuss the child's treatment with the teacher without the consent of the parents.
The teacher can assure that the medication is being administered appropriately at the school. This will involve having the medication stored securely, having a responsible adult manage the dispensing of the medication at the prescribed dosage and time, keeping a daily record of administration, and notifying parents when refills are needed.
Teachers maintain good communication with the parents. Information about the child response to medication should be provided directly to the parents. As previously mentioned, teachers will not be able to talk directly with the physician without written consent, rather they will need to communicate with the physician through the parents. Teachers should be proactive in providing information about medication effects and side effects to the parents, encouraging the parents to relay this information to the physician. This is important because, many times, the teacher is the only observer of these medication effects.
Teachers may be called upon to provide information on an individual
child's behavior and performane within the classroom. This information
can be both qualitive and descriptive, as well as standardized (i.e.,
behavioral rating scales). The teacher facilitates the
evaluation and treatment process by cooperatively providing this information.
Commonly Asked Questions
How widespread is the
use of medication for children with ADHD?
Recentliterature continues to report that from 2%-6% of all elementary school-aged children may be treated with stimulants and from 60%-80% of school-aged children with ADHD are treated with stimulants.
Why is a comprehensive
Optimal management of ADHD, including medical management, is dependent upon a comprehensive assessment and proper diagnosis. The clinician must have knowledge of other conditions which can resemble ADHD or coexist with ADHD (for example, medical, sensory, psychoeducational or psychiatric conditions). A careful and thorough assessment is necessary to determine the presence of any of these conditions which could be interfering with a child's progress and treatment directed at these conditions.
What are the risks of
not having a comprehensive evaluation?
The use, or anticipated use, of medication may postpone the process of a comprehensive evaluation or prevent an accurate diagnosis and use of more effective long-term interventions. Once medication is started and a positive response is noted, the problem may be considered solved and may reduce motivation to deal more comprehensively with the child, their symptoms, and underlying disorders. In addition, some conditions, which can produce aDHD-like symptoms, such as anxiety, Tourette's Syndrome and social withdrawal can be worsened by the use of stimulants.
Does the use of stimulant
medications lead to later substance abuse?
There is no evidence that stimulant therapy in childhood or adolescence leads to the development of later substance abuse. Unfortunately, children with ADHD and coexisting Conduct Disorder use illicit substances at a rate of 2-5 times of children without ADHD, or with ADHD alone. These risks appear to apply regardless of previous medication usage.
How long does a child
need to take medication for ADHD?
Treatment with psychostimulants can continue indefinitely as the effects continue into adolescence and adulthood. Contrary to previous standards, puberty is not a reason to stop or not consider treatment with medication. As many as 80% of adolescents and 65% of adults, who were diagnosed with ADHD as children, continue to show evidence of the disorder.
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