ADHD and treatment with stimulant medication
What is ADHD?
ADHD is a neurobehavioural condition characterised by the symptoms of inattention,
hyperactivity and impulsivity. While these symptoms are normal characteristics
experienced by all people at one time or another, among individuals who are
diagnosed with ADHD, there is an overabundance of these characteristics. Their
levels of overactivity, inattention and/or impulsivity are severe and persistent
and interfere with their learning, relationships and work.
While many children
and adolescents with ADHD improve as they grow up, many will continue to experience
symptoms as an adult. In adulthood the symptoms
are typically displayed somewhat differently to the way they are displayed
in childhood. A child who squirms, fidgets and is constantly ‘on
the go’ may become an adult who is less obviously physically overactive
but experiences intense feelings of restlessness. He or she may have
troubling relaxing and may overwork. An impulsive child who blurts out
answers in class, who constantly interrupts others and talks excessively may
become an adult who displays impatience when in queues or whilst driving, and
who may be impulsive with spending or quitting jobs. Inattentive children
who have difficulty listening and forget their homework may become adults who
often complain of losing things, such as keys and wallets, and are often late
for appointments.
Among children affected by ADHD, about one half will predominantly
have inattention problems, a quarter will mainly have hyperactive and impulsive
symptoms, while the remainder will have a mixture of these symptoms.
It is common
for children with ADHD to have co-occurring psychiatric conditions, the most
common of which are disruptive behaviour disorders (‘oppositional
defiant disorder’ or ODD – which involves a pattern of arguing
with multiple adults, losing one’s temper, refusing to follow rules,
blaming others, deliberately annoying others, and being angry, resentful, spiteful,
and vindictive; and ‘conduct disorder’ or CD – which is associated
with efforts to break rules without getting caught, and may include being aggressive
to people or animals, destroying property, lying or stealing, running away,
and skipping school), and mood disorders (depression, mania/bipolar disorder
and anxiety).
[back to top]
How is ADHD diagnosed?
For a diagnosis of ADHD to be made, a thorough assessment must be conducted by an experienced clinician, usually a paediatrician or psychiatrist, but sometimes a psychologist. The assessment process will differ according to whether the person being assessed is a child or an adult, but the key components include:
- a comprehensive interview with the person/adult caregivers (usually the parents in the case of young persons);
- review of the person's current concerns, including the frequency and duration of the symptoms and any associated behaviours;
- review of the person's history, especially childhood history;
- a developmental assessment to determine the child's developmental progress; this may lead to further assessment of vision, hearing and language ability;
- school-related assessments, including reports of behaviour, learning and attendance at school and information on how the school is managing the behaviour; for adults, historical records may need to be considered;
- completion of behaviour rating
scales by people
familiar with the person (such as parents, partners, other family members,
teachers and employers) that provide measures of the person's symptoms. Commonly
used scales include;
- assessment for other psychological conditions, such as anxiety, depression, conduct disorder, or learning disability;
- review of the person's family history, and assessment of current family functioning, including family relationships, parental management styles, and parental stress or conflict;
- a medical evaluation, to determine whether a medical condition (or possibly child abuse) contributes to the person's difficulties.
[back to top]
What should I expect when I'm diagnosed with ADHD? When ADHD is diagnosed, you can expect the doctor to provide you with:
- information about the disorder, including how the symptoms influence behaviour and the causes of the disorder, and
- information on the treatment options available and the benefits and disadvantages of each treatment option.
- The doctor may also provide you with a clinical report outlining the nature of your disorder, any assessments conducted or planned, and details of any treatments to be instituted.
[back to top]
What is multimodal treatment?
For most individuals diagnosed with ADHD, no single treatment is the answer. The
most beneficial treatment typically involves a combination of two or more of
the following: medication, behavioural therapy, psychotherapy, emotional counselling,
social skills training, family counselling and support, parent skills training,
educational management, time management training, and developmental therapies
such as language therapy. This combined therapeutic approach is known
as multimodal treatment.
The particular combination of therapies recommended
will depend on an individual’s
circumstances and needs. The multimodal approach to the treatment of
ADHD commonly involves numerous agencies and professionals.
[back to top]
The doctor has recommended stimulant treatment - what should I do?
The decision to go ahead with a particular treatment should only be made after a person has been fully informed about the proposed treatment. If stimulant treatment has been recommended, you can expect the doctor to explain:
- why stimulant treatment is being recommended,
- how and when the medication should be taken,
- what changes might be experienced when taking the medication,
- possible side effects from taking the medication,
- how progress will be measured and monitored,
- how frequently the treatment will be reviewed.
After starting treatment, the doctor will usually review it frequently. Once the optimal dose is achieved, the doctor should review treatment every six months, or sooner in some cases. Prescriptions for stimulant medication are valid for a maximum period of six months. [back to top]
Why are stimulants used to treat ADHD? Stimulants are the most common medications used to treat ADHD. Studies show that they are the most effective medications for treating ADHD in children and adolescents. When stimulant treatment is conducted carefully, it can reduce ADHD symptoms in the majority of children with ADHD. It is commonly used for adults with ADHD, but fewer adults than children appear to gain benefit from stimulant treatment.
Stimulant medication appears to work by altering the availability of particular
brain chemicals or neurotransmitters (dopamine and norepinephrine) in regions
of the brain involved with behaviour inhibition, impulse control, attention
and working memory.
[back to top]
Who can prescribe stimulant medication?
In NSW, only specialists who are authorised by the NSW Department of Health may prescribe stimulant medication. Generally, paediatricians and child psychiatrists may prescribe for persons under 18 years of age. For adults, psychiatrists are mainly authorised to prescribe stimulants.
In very limited circumstances, a general practitioner may be authorised to
prescribe stimulant medication.
[back to top]
What stimulants are used to treat ADHD?
In Australia, two stimulant medications are used in the treatment of ADHD – dexamphetamine
and methylphenidate. Methylphenidate is available as a short-acting preparation
(eg. Ritalin®, Attenta®) and as a long-acting or extended release preparation
(eg. Ritalin LA®, Concerta®).
Slow release dexamphetamine preparations may be compounded by individual chemists,
but their effectiveness has not been evaluated by scientific studies.
Other stimulant medications are used to treat ADHD but are not available in
Australia (eg. Adderall®, Cylert®).
[back to top]
Why has the doctor suggested trying dexamphetamine instead of methylphenidate?
Some people get better results from dexamphetamine, while others get better
results from methylphenidate. Currently it is not possible to predict which
stimulant will be most effective for a particular person. In choosing the medication,
the doctor has taken into account individual symptoms and circumstances. If
one stimulant medication does not relieve the symptoms, the doctor may suggest
trying the other.
Up until recently, dexamphetamine was the less expensive of the short-acting stimulant medications due to its listing as a pharmaceutical benefit on the Commonwealth Government’s Pharmaceutical Benefits Scheme (PBS). In August 2005 short-acting methylphenidate (Ritalin®) was also included on the PBS as a treatment for ADHD (Attenta® was listed on the PBS in December 2005) and can now be obtained for around the same cost as dexamphetamine.
Long-acting (or extended-release) methylphenidate became available in Australia in 2003. Experience in its use by Australian specialists is relatively new. The extended-release preparation Concerta® was listed on the PBS in April 2007.
[back to top]
Will stimulant treatment cure ADHD?
Like many other conditions, there is no recognised cure for ADHD. Stimulant
medication helps individuals to control their symptoms of ADHD, but only while
they are taking the medication. Stimulants can help individuals to pay attention,
and focus and stay on task. They may allow intellectual capabilities to function
more appropriately but they cannot increase knowledge.
[back to top]
Does stimulant medication have any side effects?
Side effects are quite common, but are usually minor and often disappear when
the dose is adjusted. Higher doses usually produce more side effects. The most
common side effects include decreased appetite, insomnia, increased anxiety,
increased irritability, stomach ache, and headache. Weight
loss and slowing of growth in height may
occur in children on stimulant medication so growth rates should be monitored.
As
a dose of stimulant medication wears off, ADHD symptoms return and sometimes
these symptoms can be more intense than prior to taking the dose. This ‘rebound’ effect
and its impact may be lessened by modifying the dose and adjusting the time
at which a dose is taken.
Tics (spasmodic twitching of certain muscles, usually
of the face or neck) may be exacerbated by treatment, or may appear during
treatment in some cases.
Some people will discontinue taking stimulants because
of side effects.
[back to top]
Is stimulant medication suitable for everyone?
In certain cases stimulant treatment will not be suitable. Contraindications to the use of stimulants include glaucoma, symptomatic cardiovascular disease, hyperthyroidism, and hypertension. People with certain psychiatric conditions, including psychosis and schizophrenia, should not take stimulants.
Stimulants may cause a small increase in pulse and blood pressure. In children with normal hearts this is unlikely to cause any problems.
The treating doctor will determine whether stimulants are suitable for a person following a thorough assessment, including a review of the person's medical history. As part of this assessment the doctor will determine whether a person needs a heart evaluation before commencing stimulant medication.
[back to top]
How often does stimulant medication need to be taken?
The effects of stimulant medication remain for as long as the dose is acting. How much and how often a person needs to take medication will depend on a number of things, including the formulation of the drug and its duration of action, the effect on the person's symptoms and whether any unacceptable side effects occur. Short-acting stimulants usually wear off within 3 to 6 hours and therefore up to three doses a day may be needed to control symptoms. Persons who are prescribed long-acting or extended release stimulants may need only one dose a day.
To determine the optimal dose, the doctor will usually monitor the person's response to various doses over a period of time.
How long should stimulant treatment be continued?
Stimulant medication is effective while it is being used. The length of time a person will undergo stimulant treatment will vary from one individual to another. For some, a short duration of treatment may only be necessary; they may outgrow their symptoms, or learn strategies and skills that negate the need for medication. For others, many years of treatment may be necessary.
Medication should only be taken for as long as it is helpful and necessary. To assess the continuing need for medication, a period without medication may be trialled. If symptoms return or worsen during this time, it is likely that medication is beneficial and worthwhile continuing.
[back to top]
Do I need to take stimulant medication every day?
Whether an individual needs to take stimulant medication every day or not
will usually depend on the severity of his or her symptoms, but also on the
effectiveness of other therapies being used. For example, a child who
has few problems outside school may only need their medication on school days. For
some individuals, medication may be needed every day.
If there is concern about
a child’s growth that appears to be related
to stimulant medication, a doctor may recommend medication-free periods. These
medication-free periods, which typically occur on weekends and during school
holidays, are commonly referred to as ‘drug holidays’.
[back to top]
Will treatment with stimulants lead to drug abuse?
Stimulant medications are classified as ‘drugs of addiction' under NSW law and have the potential to be abused. When taken as prescribed – orally and in a therapeutic dose – stimulants do not induce euphoria and are unlikely to lead to abuse.
Studies have shown that stimulant treatment for ADHD in children does not
lead to an increased risk of substance abuse. Rather it appears that stimulant
treatment may lower the risk of a child with ADHD developing substance use
problems in later life.
Children with ADHD who are at greatest risk from developing substance use
problems are those who have co-occurring disruptive behaviour disorders, particularly
conduct disorder.
For individuals at risk of substance abuse, stimulant treatment will only be
considered following careful and comprehensive assessment. As part of the
treatment, the doctor will closely monitor what has been prescribed and may limit
the number of tablets prescribed. The doctor may also require the patient
to undergo urine testing and to keep in regular contact with the doctor.
[back to top]
Can any pharmacy fill a prescription for stimulant medication?
All community pharmacies are able to fill a prescription for stimulant medication. By law, the pharmacist who supplies the stimulant prescribed is required to keep the prescription. Any repeats specified on the prescription must then be obtained from that pharmacy.
[back to top]
Is it okay to give someone else my stimulant medication?
It is not okay to give anyone else your medication. The medication you have been prescribed is suitable for your condition and may not be suitable for another person even if you think they have the same problems. In some cases it may be harmful to them.
In addition, it is unlawful to give (or ‘supply') stimulant medication, and unlawful for someone to have (or ‘possess') stimulant medication that has not been dispensed for them on a prescription. If someone is harmed by the medication you give them, you may be held responsible for that harm.
In the case of children, and in particular adolescents, who are prescribed
stimulant medication, parents should monitor usage and ensure that their children
are taking the dosage that is prescribed. If a parent is concerned that
their child may be taking their medication inappropriately or providing it
to others, they should talk to their child about the dangers involved and discuss
the matter with the child’s doctor.
[back to top]
What other medications are used to treat ADHD?
In Australia, atomoxetine (Strattera®) is the only non-stimulant medication
approved by the Therapeutic Goods Administration (Commonwealth Department of
Health and Ageing) for the treatment of ADHD. Atomoxetine is quite a different
compound to the stimulant drugs and the effects it produces on chemicals in
the brain are different to those produced by stimulants. Its use in the treatment
of ADHD is relatively new and doctors are only beginning to gain experience
in its use.
For some children with ADHD for whom stimulant medication is not suitable, a subsidy for the cost of treatment with atomoxetine may be available. Atomoxetine was listed on the Commonwealth Government’s Pharmaceutical Benefits Scheme in July 2007.
Antidepressants have been studied as a treatment for ADHD and have generally been found to be less effective than stimulants. Their current place in the treatment of children and adolescents is under consideration.
Clonidine (Catapres®), an alpha-2 noradrenergic agonist, is sometimes
prescribed by doctors. It is usually prescribed to reduce persisting aggression
and hyperactivity in children with ADHD, or for children with ADHD who are
experiencing sleep disturbances. Due to its cardiovascular side effects, a
careful medical history of the patient should be taken and rapid changes to
dosage should be avoided.
Disclaimer: The information provided here should not be used as a substitute for the medical care and advice of your doctor. There may be variations in treatment that your doctor may recommend based on individual facts and circumstances.
[back to top] |
