Prather Pediatric and Allergy Center - Ask Doctor Brent

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Title: Numerous Medications Are Now Being Used to Treat ADHD

Category: Child Care


At the recent American Academy of Pediatrics convention in Washington, D.C., two nationally respected child psychiatrists reviewed the use of many medications by pediatricians to treat ADHD. The psychiatrists were Henrietta L. Leonard, M.D., who is a child psychiatrist at the National Institute of Health and Jerry M. Wiener, M.D. who is the chairman of the psychiatry department at the George Washington University School of Medicine in Washington, D.C. They reviewed hundreds of articles in the literature over the past few years studying numerous medications to treat ADHD. They also discussed the breakdown of attention deficit disorder into categories including the predominantly inattentive type, and the predominantly hyperactive, impulsive type. They discussed further aspects of ADHD including the distress these children go through socially and academically.

They feel that ADHD is primarily genetic and that the impaired inability to delay quick body movement responses is an impaired defect in the central part of the brain. Aggressive conduct disorder children are those who are frequently found to have poor outcome over the long run. They felt that many girls are not diagnosed or treated and that many nonaggressive boys are not properly diagnosed. The prevalence, typically is felt to be about 3 to 5% of all children, but may be as high as 10% in some urban settings. Males are more common by about a 2 to 1 ratio and in some studies 3 to 1. It is felt that at least 2/3 of all cases are inherited, probably through a single major gene. There may be other causes of ADHD including alcohol, lead poisoning, prematurity, cocaine or other drugs used by parents at the time of conception and during pregnancy by the mother. This group of children frequently have other neurologic problems and serious learning disabilities.

The treatments for attention deficit disorder includes using behavior modification. Wise therapy starts with a good educational evaluation and a plan to work with the child in a unique way to help them learn optimally. Changes in the environment may be needed for some of these children. Family therapy may be recommended. Individual therapy for complications of attention deficit may be needed. Finally these doctors recommend medications for "most" properly diagnosed children.

The most commonly used medication is Ritalin, which is a stimulant. The reason for using stimulants such as Ritalin is because they work, they are generally safe, and they are targeted to treat the specific deficit found in ADHD which is lack of attention, impulsivity, and hyperactivity. They reviewed concerns which many people have based on misinformation and myths about use of stimulants. One myth is that is that the child will become psychologically dependent. Another is that it will lead them to later addiction. Another is that they will become a drug zombie.

A fourth concern is that it will cause Tourette's syndrome. All of these have been proven to be myths and are untrue. In my experience children who take Ritalin will not even take it unless they are reminded to by their parents. I do believe Ritalin, like anything else, including caffeine, could be dangerous if used improperly.

About 70 to 80 percent of children with attention deficit disorder or ADHD will improve on stimulants. They will improve in the areas of hyperactivity, attention, distractibility, impulsivity, and memory. They will improve their academic performance and their interpersonal skills. All of these are certainly convincing reasons, in my opinion, to treat children who are suffering with attention deficit hyperactivity disorder. Many are on the road to a very discouraging life with a low self-esteem. I think in most cases it is best to treat these children during school hours primarily, although some kids will need doses to help them with homework and even on non-school days if their general behavior is very much out of control. This might be a special family reunion day or a special holiday or weekend. In general, however, I like to treat patients mainly during school hours and let them get off the medicine on weekends, holidays and summers. I think this is the view of most pediatricians, and for most patients this is workable.




Two prominent child psychiatrists (at the recent American Academy of Pediatrics convention) reviewed numerous medications used in treating ADHD or attention deficit hyperactive disorder. The medicines including Ritalin in the short acting form and in the sustained release form, dextroamphetamine or dexadrine in the short acting and in the long-acting spansule form, and pemoline or Cylert. The general recommendation was to use Ritalin, first line, in either the generic or brand name form, and to use the short acting brand and to dose it about every four hours. They recommended dosing it with meals to decrease one of the most common side effects which is a drop in appetite. Another common side effect is abdominal pain which is usually resolved by giving it on a full stomach. Other side effects include irritability, difficulty sleeping and behavioral rebound, or a slight increase in hyperactivity as the medicine is wearing off, and impaired thinking ability if the child if over-medicated. The recommended dose is .3mg per kilogram, per day, up to a maximum of a milligram per kilogram, per day. Children in the over-medicated dose range seem to move in slow motion and it is easy to tell that they are taking too much medicine and need to be dosed down. Other less common side effects or adverse effects of the use of stimulants include an increase in "tics" (particularly if they have an undiagnosed case of Tourette's syndrome), depression, effect of growth in height, fast heart rate, and increase in blood pressure. It is recommended not to mix stimulants with other medicines including sympathimometics such as Sudafed, amphetamine, or cocaine. The key to avoiding these potentially dangerous side effects is proper dosing and supervision by an experienced physician.

Other medications reviewed extensively by the child psychiatrists included the use of tricyclic antidepressants, including imipramine, dicypramine and clomypramine. Also discussed was the use of Prozac, Welbutrin, and Clonadine. All these drugs have certain advantages and disadvantages and must be used by a very experienced physician, preferably a child psychiatrist or neurologist. In our area we are well blessed with two pediatricians who have the expertise to use and monitor many of these medicines effectively because of their great interest in the field of attention deficit, hyperactivity disorder and the ongoing education which they have received in the field. These physicians are Dr. Tom Jones in Opelousas and Dr. Mike Melancon in Lafayette.

The take home message for me after attending this very detailed and extensive workshop is that we continue to learn things about attention deficit disorder annually and we should all try our best to keep up with the best options for each individual patient. We should make the proper referrals so that each child who is struggling with this frustrating condition can be helped. The good news is that most children with attention deficit disorder if treated properly and given a supportive environment grow up to be very happy, successful and productive citizens. Unfortunately, those who are not diagnosed or who are not treated for whatever reason tend to suffer with a poor self image, lots of frustration with learning and peer relations and probably have a less bright future.