Guest Bloggers:

In order to expand the variety of blogs available for my viewers, I plan to ask colleagues I respect to post their thoughts about topics that I think will be of interest to my readers.

For my first guest blog, I am delighted to introduce my son, Josh Rosenthal, M.D., who is an adult and child psychiatrist in Columbia, Maryland.

He writes about a common concern among parents of children with attention deficit hyperactivity disorder (ADHD) — to medicate or not to medicate?

————————

Your ADHD Child: What Can You Expect From Medications

Joshua Z. Rosenthal, M.D.*

Stacy, a charming and precocious 8-year-old, paced around my office and fiddled with the pens on my desk as her mother rattled off the list of what she hoped medications could do for her daughter.

“I just want her to be able to stay on task and finish her work, be better organized in the morning so that it doesn’t take forever for us to get out of the house, be able to sit still at the dinner table, listen when I’m trying to talk to her so that I don’t have to repeat things over and over before she registers what I’m saying.” Without missing a beat, the little girl—who up until that point appeared to be in her own world—chimed in, “Isn’t that a lot to ask from one pill?” I could see both points of view.

As a parent, you may not be surprised to hear that attention deficit disorder with hyperactivity, better known as ADHD, has 18 different characteristic symptoms. You probably know what most of them are but in case you want the whole list, they are shown in Table I below.

So much has been written, both pro and con, about the value of medications to bring these symptoms in check. How does a parent make sense of it all? This is how I see it as a child psychiatrist who treats many children with ADHD. For most of these children, it is difficult to get the best results without medications. The good news is that medications usually help and such side-effects as may occur are generally quite tolerable. The not such good news is that medications won’t solve all your child’s problems.

It’s easy to see how you might be skeptical that a pill could really bring many of your child’s problems under control – and your child might feel the same way. But the condition is so frustrating for both parents and children that mostly people are willing to give medications a try.

Although we don’t fully understand the causes of ADHD, some research suggests that people with the disorder may not have enough of two key neurotransmitters – dopamine and norepinephrine – firing in the prefrontal cortex (PFC), that part of the brain just behind the forehead. The PFC can be considered the CEO of the brain, which helps the brain focus on priorities and organize what needs to be done. When it is not working properly, the brain may seem like a disorganized committee in need of a chairman. Most of the medications we use to treat ADHD boost concentrations of the two key neurotransmitters in question. That brings the CEO on line and helps organize the committee to get tasks done.

To decide on the best course of treatment, I assess the child’s specific needs, keeping in mind what side-effects may be of greatest concern (see Table II below). I consider, for example:

* Age – if the child is young and has an early bedtime, I avoid medications that wear off too late and cause insomnia.

* Size – if the child is a picky eater and small for her age, I shy away from drugs that are likely to cause appetite suppression.

* The child’s homework schedule: Does it require a great deal of concentration in the evening or is daytime the most critical time for study?

All this, of course, requires close collaboration between parent, child and doctor. Once we have thought through the issues – goals, concerns, special considerations – we are ready to choose an appropriate medication.

Medications for ADHD are typically divided into stimulants and non-stimulants. Since stimulants are still the primary treatment, this discussion will focus on that class of drugs. Usually I start with a long-acting medication, such as Concerta, Vyvanse, or Adderall XR (See Table II below for list of medications—stimulants), in the morning before school, in the hope that it will last through the school day. Then, depending on what the evening schedule is like, I often recommend a second short-acting medication, such as Ritalin, Focalin, and Adderall (not XR) to help the child focus on evening activities, such as homework, or music lessons.

I tend to avoid using long-acting medications in the morning if the child is falling behind on the growth chart, preferring a shorter-acting medication, which will hopefully wear off in time for the child to have a good appetite at lunchtime. After lunch would be a good time for the child to get a second dose of medication from the nurse’s office to help with focus and concentration through the afternoon.

It is important to customize medication treatment according to each child’s needs and circumstances, with parent, child and doctor working together as a team.

One challenge with medication is getting children to take it in the first place. Swallowing pills is the number one reason that they object to medication. One way around this is that most drugs come in capsule form, which can be opened and poured into an easy-to-swallow food, like yogurt or pudding (Concerta is an exception in this regard).

If swallowing is an absolute impediment, I recommend a skin patch version of Ritalin, called Daytrana, that works just as well as the long-acting capsules. The challenge is remembering to take it off after 9 hours of use so that it doesn’t last too long and keep your child up at night.

Many children shy away from the idea of taking medications because they regard it as a stigma, which somehow brands them as being abnormal. To counter this, I tell them that I know many successful people, including doctors, lawyers, and engineers, who have gone far in life despite having the diagnosis of ADHD, because they were helped by their medication.

I reassure people that they can always stop the medications if they want to and encourage them to tell me if they are considering doing so. As a parent, you might think such a reassurance is a bad idea, but it emphasizes the importance of self-reliance and making good choices. And let’s face it; most children know they can stop anyway. By giving them permission, they are more likely to tell you if they do stop their medication, which allows for an open discussion of the subject, including benefits, side effects and general feelings about medication.

In addition to side effects, there can be other limitations to medication, as well. A child may experience improvement in some areas, such as symptoms of hyperactivity, but not in other areas, such as inattention. Sometimes, even with the best possible combination of long- and short-acting medication, it is hard to extend the effect long enough into the evening to address all problems without causing insomnia.

Then there is a problem that I refer to as successful pill, unsuccessful child. It is not uncommon for me to see parents come in with high hopes only to be disappointed when they don’t see the results. The child will report feeling more focused and the teachers will notice better participation, but their grades are still poor. Parents will say that they rarely see the child crack open a book. So what happened? Sometimes there could be another undiagnosed problem, such as depression or a learning disability. But often, the problem is that the medication worked but the child isn’t interested in trying. When I raise this issue with the child, a common response is, “well I’m passing.” Sometimes we forget that the pill and the child are two separate things. These experiences have taught me to routinely to tell parents that their child will get as much out of the treatment as they put into it—that the best piano teacher can only lead you as far as you are willing to work for results, and the same can be held true for the best pill.

In conclusion, let’s return to the question posed by Stacy at the top of the blog: “Isn’t that a lot to ask from a little pill?” I hope I have shown you that a little pill can go along way, but that people with ADHD need a lot of help from both parents and professionals if they are to fully realize their potential.

Table I: DSM-IV Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder

A. Symptoms of inattention: Six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

1. often fails to give close attention to details or makes careless

mistakes in schoolwork, work, or other activities;

2. often has difficulty sustaining attention in tasks or play activities;

3. often does not seem to listen when spoken to directly;

4. often does not follow through on instructions and fails to finish

schoolwork or chores (not due to oppositional behavior or failure to understand instructions);

5. often has difficulty organizing tasks or activities;

6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework);

7. often loses things necessary for tasks or activities (e.g. toys, school assignment);

8. is often easily distracted by extraneous stimuli;

9. is often forgetful in daily activities

B. Symptoms of hyperactivity-impulsivity: Six or more of the following symptoms of hyperactivityimpulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

1. often fidgets with hands or feet or squirms in seat;

2. often leaves seat in classroom or in other situations in which

remaining seated is expected;

3. often runs about or climbs excessively in situations in which it

is inappropriate;

4. often has difficulty playing or engaging in leisure activities

quietly;

5. is often “on the go” or often acts as if “driven by a motor”;

6. often talks excessively

7. often blurts out answers before questions have been completed;

8. often has difficulty awaiting turn;

9. often interrupts or intrudes on others (e.g., butts into conversations or games).

In addition to the above behavioral criteria, the student must (1) d isplay hyperactive-impulsive or

inattentive symptoms severe enough to cause impairment prior to the age of 7 years; (2) display

impairment from symptoms in two or more settings (e.g., school and home); (3) must demonstrate clinically significant impairment in social or academic functioning; and (4) not have another disorder that can account for the behavioral symptoms.

Source: American Psychiatric Association. (1994). Diagnostic and statistical manual of mental

disorders (4th ed.). Washington, DC: Author.

Table II: Stimulant Medications for ADHD

Class Drug Name Form Duration Amphetamine Stimulants Adderall Short-acting 4-6 hours Dexedrine Short-acting 4-6 hours Dextrostat Short-acting 4-6 hours Dexedrine

Spansule Long-acting 6-8 hours Adderall XR Long-acting 8-12 hours Vyvanse Long-acting (prodrug) 10-12 hours Methylphenidate Stimulants Focalin Short-acting 4-6 hours Methylin Short-acting 3-4 hours Ritalin Short-acting 3-4 hours Metadate ER Intermediate-acting 6-8 hours Methylin ER Intermediate-acting 6-8 hours Ritalin SR Intermediate-acting 4-8 hours Metadate CD Intermediate-acting 8-10 hours Ritalin LA Intermediate-acting 8-10 hours Concerta Long-acting 10-12 hours Focalin XR Long-acting 6-10 hours Daytrana patch Long-acting 10-12 hour Common Side Effects: loss of appetite, weight loss, insomnia, irritability, tics, increased anxiety, jitteriness, or paradoxically feeling slowed down (zombie-like). Longer acting medications might lead to more pronounced appetite suppression or insomnia.



* Joshua Z. Rosenthal, M.D. is a child and adult psychiatrist, practicing in Columbia, Maryland. He can be reached via his web site at http://joshrosenthalmd.com.