Fall 2010

Attention Deficit Hyperactivity Disorder:
Beyond the Practice Parameters

Shelly Flynn, RN, MA, ARNP
Division of Pediatric Neurology, Behavior, and Development
University of Iowa Children’s Hospital

Much has been written about the medical management of ADHD. I’ve chosen to discuss management beyond the practice parameters established by the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry. This article will address what some of my toughest and easiest patients have taught me.

Before medical treatment begins, the provider should feel confident that an accurate diagnosis of ADHD has been made and determine whether any co-morbid diagnoses, precautions, or contraindications to treatment exist. Stimulant medications are the drug of choice for most children and will significantly improve a child’s impulsivity, hyperactivity, and inattention.

Stimulant medications available are either a methylphenidate or an amphetamine derivative. Both groups of medications are equally effective and have the same side effect profile. The stimulants can be grouped into short-acting (about 4 hours), intermediate-acting (6-8 hours) and long acting (10-12 hours). I use them all, as there is value in each. Determining which medication(s), at what dose, will work best in each child without causing significant side effects, is the art of this practice, the fun of this practice, and a distressing part of this practice.

The medications are contraindicated and/or to be used with caution in a few situations. The patient and family history, review of systems, and child’s physical exam usually provide the information needed to safely prescribe medications.

 

Contraindications are:	Conditions that warrant caution when using stimulants include:
Symptomatic heart disease Drug dependence Concurrent and very recent use of MAOIs Glaucoma Severe hypertension Hyperthyroidism	Marked anxiety Mood disorders Impairing tic disorders Epilepsy History of substance abuse Structural cardiac or cardiovascular conditions that may be compromised by increases in blood pressure or heart rate

An EKG should be obtained if the patient’s history, family history, or exam indicates increased risk of cardiovascular problems. Refer to cardiology for clearance to safely take a stimulant medication if needed. I have patients with renal disease, hypertension, epilepsy, Tourette syndrome, anxiety, depression, history of drug use, and cardiac disorders whose specialty physicians have cleared them for medical treatment of ADHD. In these cases the potential benefits of treatment outweighed the potential risks. Treatment of these populations necessitates more frequent clinic visits, monitoring of vital signs, and collaboration with specialists.

Before beginning medication, get a good history of the child’s baseline sleep habits, eating habits, mood, growth history, personality, and any problems with headaches, stomachaches, and motor or vocal tics. The medications can cause problems with any of these.

Dealing with the medication side effects can be the most challenging aspect of medical management. Appetite suppression and sleep disturbance, the most common side effects, can be profound. Baseline documentation allows the provider to clearly identify whether prescribed medications create new problems for the child. ADHD is chronic. Kids deserve to feel good and should not be chronically bothered by a medication they take daily. Switch medications if side effects interfere with the child’s quality of life.

The goal is to find the right medication(s) and dosage(s) that promote success by obtaining reasonable control of the child’s symptoms without causing significant side effects. References to specific medications are included in the ADHD Medication Charts. The charts are not all-inclusive, but do list primary medications on a single page. It does not include the tricyclic antidepressants, as I refer to child psychiatry for that treatment.

Always start medication with the lowest dose available, in a formulation that is easy for the child to take (sprinkles, chewable, patch, tablet, or powder mixed with juice), and of a duration for which you want the symptoms controlled. These issues are more important than whether you choose a methylphenidate or an amphetamine, as there is no way to predict which medication will work best in each child without causing significant side effects.

Next, assess the response to the medication and evaluate for side effects. Increase to the next available strength if symptoms are still significant, as long as there are not significant side effects. Each of the stimulant medications has an FDA recommended maximum dose. Some providers increase beyond those dosages with discretion. One might assume it is best to choose the longest acting (10- to12- hour long) medication for all kids. The very young (4 to 7 years), though, have many fewer side effects on the intermediate-acting medications (6- to 8-hours long) than the longer acting medications. Combination therapy is useful in obtaining control of symptoms with few to no side effects. A little of this and that is less likely to cause side effects than a lot of this and none of that.

In addition to stimulants, guanfacine (Intuniv), clonidine, Strattera, melatonin, and cyproheptadine can be helpful additional medications for better symptom control and treatment of side effects, or for baseline problems with sleep, tics, anger, and poor appetite.

It can be helpful for parents to fill out tools such as the Vanderbilt Assessment Scale or Conners Rating Scales. I ask parents to call our nurses with an update within one to three weeks after starting medication, sooner if there are worrisome side effects. I adjust medication over the telephone as needed and see the child again within one to three months, and then two to four times per year. Excellent secretarial and nursing staff members assist parents by phone with fine tuning medications in a timely manner.

Educational accommodations, behavioral interventions, and support from a multitude of health and community providers combine to create the best treatment plan for children with ADHD. In the best of situations, these children require a lot of energy; remember to support the parents. As a provider, watching and helping these kids achieve success is worth all the energy they require.

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