ADD/ADHD Articles

Pharmacological Treatment of Attention Deficit Disorders

By Jay D. Tarnow, M.D.

Children with attentional problems may display a constellation of symptoms. These symptoms can be broken down into categories such as poor attention and concentration causing difficulty completing tasks, impulsiveness, aggression, and hyperactivity. Poor fine motor skills and difficulty with peer interactions are also frequently present.

Treatment of attentional problems typically begins with a thorough medical evaluation including vision and hearing screening. Behavioral interventions, such as managing the classroom or home to limit distractions, are also extremely important. However, when the diagnosis of Attention Deficit Disorder (ADD) has been made, behavior interventions alone rarely treat the symptoms sufficiently once the tasks in the classroom become truly challenging. To allow the child with attentional difficulties to succeed, medications are frequently prescribed.

In my practice, I have found that educating families about the possible medications to be used aids in identifying the best match for the patient. I feel it is extremely important that parents and patients work very closely to find the medication that produces the desired effect without causing adverse effects, called side effects. Through this article, I intend to provide general information, dispel common myths, and describe different options of medication therapy.

GENERAL MEDICATION INFORMATION

• Each person responds uniquely to medication.
• Stimulant medications are very safe. More studies have been done about children taking stimulant medications than any other medications including nonprescription drugs. Mediation should be prescribed in minimal, small doses. Prescribed correctly, they are not addictive. Individuals do not have a physical craving for medication. When medication is out of the blood stream, the individual goes back to exhibiting full-blown ADHD symptoms.
• The dosage for optimal learning in school may be different than the dosage needed for behavior improvement.
• Both hyperactive and nonhyperactive individuals with attentional problems can benefit from medications.
• Medication is effective for 54% of nonhyperactive children and 80 to 90% of hyperactive children.
• Nonhyperactive children are more apt to respond positively to lower dosages and negatively to higher dosages.
• Nonhyperactive and normal children have similar response to medication.
• Medications are prescribed for ADHD adults in the same small dosages given to children.
• When taking the appropriate dosage, medication should not affect personality.
• Medication does not cause psychosis but can precipitate a psychosis in susceptible individuals.
• Dosages should never be changed without discussion with the prescribing doctor.

Myths

Medication Does Not:
• Cure ADHD.
• Teach the ADHD individual how to cope and compensate for difficulties.
• Imply a "magic pill".
• Just treat hyperactivity. Medication also helps with impulsivity, attention difficulties, and aggression.
• Cause addiction. Long-term studies show that children who have taken stimulant medication are not more prone to substance abuse.
• Have a permanent effect on a child's growth, if carefully monitored.
• Sedate children so that their behavior improves.
• Lead to aggressive, dangerous behavior.
• Create personality changes.
• Cause seizures.
• Cause tics or Tourette's Syndrome.

Medication Does:
• Treat ADHD symptoms.
• Influence long-term progress and prognosis of ADHD children, when utilized in conjunction with treatment modalities specific for ADHD.
• Stimulate the attention center of the brain to function more normally.
• Affect impulsivity, attention and behavior positively. More specifically, stimulants can increase attention span, concentration and compliance; improve handwriting and fine motor skills; and allow improved peer relationships. Also, a decrease in impulsivity, aggressiveness, and hyperactivity can occur.

MEDICATIONS FREQUENTLY USED

Psychostimulants:
Psychostimulants stimulate the release of norepinephrine and dopamine from the nerve terminals in the attention center of the brain.

Medications:

Adderall
• A single product made up of 4 different amphetamine salts: Dextroamphetamine Sulfate, Dextroamphetamine Saccharate, Amphetamine Sulfate, and Amphetamine Aspartate.
• Usually taken once or twice a day.
• Can also be prescribed for young children.
• Effects may last 4 to 6 hours.
• Available in a generic form in tablets.

Adderall XR
• Capsules contain a mixture of different amphetamine salts.
• Usually taken once a day; lasts 12 hours.
• Dose is split into 2 separately timed releases which prevents a peak/valley effect.
• Capsule may be opened and given as "sprinkles" for young children.

Concerta
• Extended release formulation of methylphenidate which is designed to last 12 hours with just one dose.
• Helps maintain focus without in-school and after-school dosing.
• The medication is released gradually in a smooth pattern minimizing the peaks/valleys associated with short-acting medication.
• Capsule may not be opened or broken.

Dexedrine or Dextrostat (Dextroamphetamine)
• Dexedrine Spansule is given once per day.
• Dexedrine/Dextrostat tablets can be taken two or three times a day.

Focalin (dexmethylphenidate HCI)
• A refined formulation of Ritalin.
• Available in 2.5, 5, and 10mg tablets. The recommended dose will be half the dose of Ritalin.
• Taken twice daily.
• Short-acting benefit is that the side effects should wear off quickly.

Metadate
• 10 and 20mg extended-release methylphenidate capsule, which may be opened and used as "sprinkles".
• Offers an extended-release strength of methylphenidate and may eliminate the need for midday dosing.
• Effects last 8 hours which may be helpful because it covers the school day and may then wear off to improve appetite during after school hours.
• A generic tablet is available.

Ritalin (Methylphenidate)
• Usually taken twice a day; a third dose may also be prescribed to help the child participate in after-school activities, do homework, and interact with the family.
• Also available in sustained release form, Ritalin SR or Ritalin LA, which is taken once in the morning eliminating the need for a noon dose.

Signs of Overdosage:
• Irritability
• Increased hyperactivity
• Overly obsessive behavior or anxiety
• Social withdrawal
• "Zombie-like" appearance or sedation
• Increased blood pressure
• Decreased cognitive ability

Potential Side Effects:

None of these side effects are dangerous

Depression
Mood symptoms should be monitored closely after starting stimulant treatment.

Tics
There is an increased risk that children will develop these symptoms if there is a familial predisposition to Tourette's Syndrome. Children who have undetected Tourette's may develop tics and the full-blown symptoms of the disorder. Less than 5% have tics and the incidence of Tourette's is very rare. Symptoms of Tourette's are more pronounced under stress.

Appetite Suppression
This may be more of a problem if medication is given before meals. Appetite will usually return when the effects of the medication have worn off. Approximately 50-60% complain of appetite loss; 50-60% of difficulties falling asleep; and 20-40% of stomach cramps and headaches. There may be mild increases in heart rate and blood pressure. Mild weight loss may occur in the initial first or second month, but no overall effect on skeletal growth. Very rarely, children can experience a growth slow down. There are easy methods to deal with this such as adjusting medications to allow for time periods where appetite is not suppressed.

Behavioral Rebound
Increased excitability, talkativeness, impulsivity, or insomnia may appear 5 to 20 hours after the last dose treatment. Rebound resembles a return of the original symptoms after the medication wears off, except that the magnitude of symptoms actually increases above the baseline. Rebound has been clearly demonstrated in normal children and has been described, but less well documented, as a clinical problem.

Impaired Cognitive Performance
Mainly observed at high doses and probably represents the toxicity of mild over medication. Single doses of methylphenidate above 1mg/kg have been repeatedly found to impair cognitive functioning. In predisposed children, psychotic or psychotic-like symptoms which include hallucinations or delusions, mania, stereotyped or compulsive behavior, and self-biting may occur.

Neuropsychiatric Effects
Include tics or other abnormal movements, night terrors, and lip-licking or biting. Occasional adverse effects include dizziness, nausea, nightmares, constipation, lethargy, fatigue, anxiety, fearfulness, hypercusis (increased acuity of hearing), rash, hives, and a sensation of "ants crawling on skin. However, these effects are uncommon.

Relative contraindications:
Amphetamines should not be used in patients with known psychosis, a history of symptoms suggestive of a risk for psychosis, or a history of substance abuse in an adolescent patient, peers, or immediate family members without careful monitoring. Other contraindications include a child with a family history of tics or Tourette's Syndrome, cardiac cardiovascular or blood pressure abnormalities, or severe side effects in a previous stimulant trial.

Strattera (atomoxetine):
• Taken every day for 24 hour improvement in symptoms.
• A selective norepinephrine reuptake inhibitor.
• The first nonstimulant to be proven in studies to work well above placebo to improve symptoms of ADHD.
• Recently approved by the FDA in November 2002 and now available in pharmacies.
• Compared to stimulants, results in less decreased appetite and less incidence of insomnia.
• Does not cause or exacerbate tics.
• Does not require a special DEA controlled prescription thereby allowing easy access for refills.
• Not contraindicated for patients with history of Tourette's or substance abuse.
• May increase levels of Prozac and Paxil when used in conjunction with Strattera.
• Common side effects include stomach ache, sedation, increased pulse (average of 5-8 beats per minute).

Tricyclic Antidepressants:
Elavil (Amitriptyline)
• Prescribed for ADHD children who are also experiencing anxiety and/or enuresis.
• Elicits mild improvements in attention and activity level, and decreased impulsivity, irritability, aggressiveness, and temper outburst.
• May be given 1-3 times a day.
• May become less effective over time.
• May improve sleep onset.
  Norpramin (Desipramine)
  Tofranil (Imipramine)

Side effects are numerous, including cardiac side effects such as irregular heartbeat, dry mouth, sedation, and hypertension.

Other Medications:

These medications are considered "3rd line". They are often prescribed when the other more commonly used medications have proven ineffective or if special problems exist that are associated with ADHD.

Catapres (Clonidine) or Tenex (Guanfacine)
• May be prescribed for ADHD children who have difficulty with aggression, impulsivity, insomnia, and/or severe hyperactivity.
• May have a sedation effect.
• Is utilized with Tourette's Syndrome and ADHD children with tics.
• Usually taken up to 3-4 times a day.
• A 5-day patch is available for Clonidine.
• Targets hyperactivity and impulsivity more than attention.
• Common side effects include dry mouth, irregular heart rate, hypotension, headache and dizziness, stomach ache, and vomiting.
• Uncommon side effects include depression, nightmares, anxiety and rebound hypertension if patient suddenly stops taking the medication.

Effexor (Venlafaxine) Primarily used as an antidepressant.
• Targets both serotonin and norepinephrine. May be useful in decreasing ADHD symptoms, particularly in ADHD adults or adolescents who are also experiencing anxiety and/or depression.
• Dosing is once daily.
• Common side effects include nausea, somnolence, dry mouth, dizziness, constipation, nervousness, and increased sweating.
• Uncommon side effects include increased blood pressure (greater chance of occurrence at dosages above 200mg/day). Blood pressure will normalize with dose reduction.

Tegretol or Carbatrol (Carbamazepine)
• The most responsive symptoms include aggressive behaviors, low frustration tolerance, and impulsivity.
• Usually given 2-3 times a day.
• Common side effects include stomach aches, dizziness, sedation, blurred vision and low blood count. A complete blood count should be done periodically especially when patient has repeated or severe infections.

Risperdal (Risperidone)
• Prescribed for the management of manifestations of schizophrenia.
• Improves a full range of psychotic symptoms including positive symptoms, negative symptoms, uncontrolled hostility/excitement, and disorganized thought.
• Usually given 2-3 times a day.
• Has been shown to improve impulsive aggression in children and adolescents. May also improve sleep and symptoms associated with severe anxiety and depression.
• Common side effects include sedation, dizziness, constipation, nausea, indigestion, runny nose, rash, and rapid heartbeat.
• Uncommon side effects include restlessness, tremors, involuntary slow or jerky facial or body movements, and muscle stiffness.

Wellbutrin (Bupropion)
• Antidepressant unrelated to all the others.
• Central nervous system stimulant effects.
• More frequently prescribed for ADD adults.
• Contraindicated in patients with seizure disorder, bulimia, or anorexia nervosa.
• Usually given 1-2 times a day.
• Common side effects include agitation, dry mouth, insomnia, headache/migraine, nausea, vomiting, constipation, and tremor.
• Uncommon side effects include seizures (4/1000), swelling, chest pain, shortness of breath, liver damage, urinary symptoms, incoordination.

There are other medications and chemical, herbal products that have been tried or are being investigated for their use in the treatment of ADHD symptoms. A physician who is familiar with the treatment of ADHD in children, adolescents, and adults should be consulted before making medication decisions.

This article is provided by the Tarnow Center for Self-Managementsm^SM. The article is provided to give you the latest information and research about the medications that are being used to treat Attention Deficit Disorder. Debra C. Stokan, M.D., and Jay Tarnow, M.D. provides articles for the Medication Corner in each of the ADDA Newsletters. In order for us to address your needs, we would like to encourage you to "ask the professionals" your questions. Write the Tarnow Center for Self-Managementsm with your questions and we will see that they are answered in each edition of the newsletter. You may contact us at: Tarnow Center for Self-Managementsm: The Medication Corner, 1001 West Loop South #215, Houston, Texas 77027, or fax: (713) 621-7015, or call: (713) 621-9515, or visit www.tarnowcenter.com.