Smart Kids With LD

By Timothy E. Wilens, M.D.

ADHD is the most common psychiatric (neurobehavioral) disorder that pediatricians, family physicians, neurologists, and psychiatrists treat in children. It affects from five percent to nine percent of school-age children: At least 70 percent will continue to have the disorder into adolescence. About half will still have the disorder as adults. With age, the hyperactivity and impulsivity tend to diminish; however, the attentional problems tend to persist.

Medication is considered one of the most important treatments for ADHD. One large study in children with ADHD and without other disorders demonstrated that, compared to intensive multimodal treatment medications and psychotherapy properly prescribed stimulants had the greatest positive effect after two years. Another study funded by the National Institute of Mental Health produced similar results, showing that medications were superior to behavioral treatments alone for the core symptoms of ADHD; and also found that behavioral treatment along with medication was the most effective to address some of the noncore symptoms (self-esteem, peer relationships, family functioning, and social skills).  The current FDA approved medications for children include the stimulants, atomoxetine (Strattera), and an extended-release guanfacine (Intuniv).

Medications Primer

Stimulant Medications
These are the best-studied class of drugs for ADHD, and in many cases are the medication of choice. They generally work immediately when the correct dose is achieved. Although it is not common for children to develop a tolerance to these drugs, children may need increasing doses as they grow. Practitioners have found that if one stimulant is unsuccessful, it is worth trying another.

Nonstimulant Medications
Noradrenergic agents
If your child cannot tolerate the stimulants or has prominent anxiety or tics, Strattera should be considered. Strattera may take  a few weeks to see its full benefit and is sometimes used with stimulants.

Antihypertensives
For children as young as 3 to 5, in aggressive or particularly overactive kids, and for ADHD in general, the blood pressure medications (antihypertensives) may be useful. These drugs may also help with the sleep problems that sometimes plague children with ADHD or that result from its treatment, such as using Concerta or Adderall.

Antidepressants
Second-line treatments include the antidepressants. Although you may see an effect immediately, antidepressants may take up to four weeks to reach full effectiveness. As with the stimulants, if one is not effective, your child’s doctor would be wise to try another. Because of the lethality of tricyclic antidepressant overdose, you must carefully store the medication so it is inaccessible to all children in your family.

Antidepressants (atypical)

Antidepressants (tricyclics)

Another second-line treatment includes the wake promoting agent, Provigil (modafinil).  While shown effective in trials, concerns about a serious skin rash have limited its use. Modafinil may be useful in poorly motivated youth and those with difficulties in the arousal of their attention.

Caution

Children who have ADHD and other psychiatric diagnoses such as anxiety disorder, bipolar disorder, and depression may have an adverse behavioral or emotional response to medication and must work closely with their physician to determine the appropriate medications and/or combinations.

	Meds & Your Child: Tips For Safe Use By learning everything you can about the disorder your child has, the accepted treatments, and specifically the medications used, you can be an active collaborator in your child’s treatment rather than a passive and helpless bystander. Keep a detailed record of your child’s treatment history including a separate page that lists medication trials. Using a medication log containing information on each medication tried: when, at what dose, and what happened—whether it worked as expected and whether it produced any side effects can be helpful. You might find yourself becoming a sort of “team coordinator” for your child’s health care providers. You should sign releases allowing communication between or among caregivers. Don’t be afraid to ask a prospective health care provider about his or her credentials or experience, and be wary of one who gets irritated by your questions.

This information is excerpted from Straight Talk About Psychiatric Medications for Kids by Timothy E. Wilens, MD (3^rd Edition), © 2009 by Timothy E. Wilens. For more information or to order a copy, please visit www.guilford.com/p/wilens. Dr. Wilens is an Associate Professor of Psychiatry at Harvard Medical School and specializes in pediatric and adult psychopharmacology at Massachusetts General Hospital. Reprinted with permission of Guilford Press.