| 1.
General
As with all chronic illnesses, the
management of ADHD includes multiple modes of treatment, and the family
should be involved in all treatment decisions. According to the American
Academy of Pediatrics’ Clinical Practice Guidelines1
specific target outcomes should be established, and
children should be closely monitored to assess the achievement of
such outcomes over time. Examples include improvement in school grades
and reduction of impulsive and inattentive behaviors. Physicians and
parents may use school report cards, and behavior reinforcement charts
to track such behaviors.
Interval of clinic visits:
Children who are not receiving medication should be seen at least
twice per year, particularly during critical transitions (i.e. just
prior to the beginning of the school year, at the beginning of the
second semester of the school year, beginning of middle school, high
school or college). The monitoring schedule for children receiving
medication depends upon the stage of pharmacotherapy. It may range
from weekly during the titration stage to every three or four months
during the maintenance phase.
2. Medications
According to the American
Academy of Pediatrics' Clinical Practice Guidelines1
on the treatment of ADHD published in 2001 stimulant medications are
recommended as first line treatment of ADHD, due to sufficient evidence
to support their safety and efficacy. There are two main classes of
stimulants;
- amphetamines (dextroamphetamine such as Dexedrine®, or mixed amphetamine salts such as Adderall)
- methylphenidates (Ritalin®, Methylin™, Concerta™, Focalin™, Metadate®)
The stimulants are available in short, intermediate or long-acting preparations. The response rate to stimulants is approximately 70 percent. There is also one major non-stimulant drug (Strattera) that is used for patients in whom stimulants are not desirable or tolerated.
Side effects
Common:
Stimulants affect the dopaminergic and noradrenergic
systems, causing the release of catecholamines from storage sites
at the central nervous system (CNS) synapses. Common side effects
therefore include; anorexia or appetite disturbance (80 percent),
sleep disturbances (3 to 85 percent) and weight loss (10 to 15 percent).
Less common side effects include increased heart rate (3 to 10 beats/min),
and blood pressure (systolic increases of 3.3-8 mmHg, diastolic increases
of 1.5-14 mmHg), headache, irritability, and stomach pain. Deceleration
of linear growth may occur, but adult height has not been shown to
be affected. There remains a concern however that if children remain
on stimulants throughout adolescence, their epiphyses might close
when they are at a lower height than if they were not on stimulants.2
Manipulation
of the dose or duration may be helpful when children develop these
adverse effects.
Serious:
Despite a series of reports to the FDA of sudden
unexplained deaths in children taking stimulants, the rate of such
deaths remains smaller than in the background population of children
who are not taking stimulants.3 However,
given the sympathomimetic effect of stimulants, the FDA has recommended
that stimulants "generally not be used in children or adolescents
with known serious structural cardiac abnormalities,
cardiomyopathy, serious heart rhythm abnormalities, or other serious
cardiac problems that may place them at increased vulnerability to
the sympathomimetic effects of a stimulant drug." A careful history
and physical exam should therefore be performed to assess for such
risk factors. For children without a known cardiac problem the
AAP
statement may be used as the current standard to guide decisions
on whether screening EKGs should be performed. Unlike the AHA statement
which recommended screening EKGs in all children starting stimulants,
the AAP is instead recommending a careful cardiac history that should
be the same for all children with consideration of further evaluation
on the basis of that history. The AAP explicitly states that an EKG
is not necessary where there is no clinical indication for one after
a history and physical exam. In situations where a pediatrician and
family/patient determine that an EKG is necessary the following is
the procedure: At MSCH/Columbia patients may walk in to the heart
station. Each patient needs to have a Requisition with the Diagnosis
ICD-9 code, attending Dr's signature and reason for study indicated.
For ICD9, use Routine Pre-Procedure V72.81 for the
initial EKG and any subsequent studies should be coded Drug Effect
on the Heart 972.9.
How to prescribe - Initiate medications on a weekend or at a time when parents can monitor their child for behavioral change and side effects.
- See Table 2 on page 905 of the AACAP
Practice Parameters for ADHD4 for
medication dosing and other prescribing information.
- Stimulants are schedule II drugs. An Official New York State Prescription with DEA# and barcode is required.
- When initiating medication for the first time,
patients should return to clinic for each titration upwards. This
might be within a few days to 1-2 weeks time.
Link
to Harriet McGurk's ADHD Primer for Medications.
3. Psychotherapy:
Behavioral interventions are valuable
as primary treatment or as an adjunct in the management of ADHD, based
on the nature of coexisting conditions, specific target outcomes,
and family circumstances. Psychoeducation, parent training in the
management of a child with ADHD, and child behavior shaping are some
examples. A referral to a psychologist for such behavioral interventions
may be useful. See referral list.
Other
ADHD is considered to be a disability under the Individuals with Disabilities
Education Act (IDEA [PL-101-476]). Under this act, children with ADHD
may qualify for special education or related services. Alternatively,
they may qualify for appropriate accommodations within the regular
classroom setting under Section 504 of the Rehabilitation Act of 1973.
In addition, the Americans with Disabilities Act may provide individuals
with ADHD reasonable accommodations in secular private schools and
post-secondary education.
References:
1. American
Academy of Pediatrics. Clinical Practice Guideline: Treatment of the
School-Aged Child with Attention Deficit/Hyperactivity Disorder. Pediatrics,
October 2001:108: 4:1033-1044
2. Charach
A et al. Stimulant treatment over 5 years: effect on growth. J
Am Acad Child Adolesc Psychiatry, 2006 Apr;45(4):415-21
3. Wilens
TE, Prince JB, Spencer TJ, Biederman J. Stimulants and sudden death:
what is a physician to do? Pediatrics, 2006 Sep;118(3):1215-9
4. American
Academy of Child & Adolescent Psychiatry Practice Parameters for
the Assessment and Treatment of Children, Adolescents & Adults
with ADHD. Journal of the American Academy of Child & Adolescent
Psychiatry. 2007 July;46:7
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