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  1. 1. Medical Treatments 1 Running Head: MEDICAL TREATMENTS FOR ADHD CHILDREN Medical Treatments for ADHD Children Misty Sommers-Tackett Kent State University
  2. 2. Medical Treatments 2 Abstract There is a question, within numerous settings, of whether or not medicating children with Attention Deficit Hyperactivity Disorder (ADHD) is appropriate, or necessary. Stigmas surrounding this disorder have made their way into the minds of the public, and there are a lot of debates surrounding the treatment styles of physicians and psychologists. Most of the experts agree that there is little success in using just medical treatment alone. Although studies have shown that medical treatment and behavioral treatment for ADHD works best in conjunction with each other, this article will discuss the medications used in treating ADHD children, as well as the benefits or drawbacks of medication. The variety of medications available now gives parents better options when deciding to use medication. However, the topic of medication for children with ADHD is a very sensitive one, and the appropriateness of medication is still under a great deal of debate. The goal of this article is to discuss all views of this topic without bias, while providing detailed information for those who want to learn more about the available medications for Attention Deficit Hyperactivity Disorder.
  3. 3. Medical Treatments 3 Medical Treatments for ADHD children Attention Deficit Hyperactivity Disorder (ADHD) is a behavioral disorder that affects children and adults. The mechanics of this disorder include problems with inattention, over- activity (hyperactivity), and impulsivity. The recent increases in production of methylphenidate, (more commonly known as Ritalin) and increased diagnosis of ADHD in preschool children (Safer, 2000) have increased the awareness of the disorder. More and more parents and teachers are learning about treatment possibilities for the disorder. The symptoms of ADHD are described solely on behaviors and there is no, or little, mention in diagnostic manuals regarding any biological symptoms. Though there may be some proof of a neurological basis, there have still been some stigmas developing which surround the medical treatment of ADHD. The topic of medicating any child is a very delicate one, but even more sensitive in nature is the topic of medicating children diagnosed with ADHD. Though the diagnosis of ADHD, and ADD, have been around for over a decade, there is still much debate in the public eye over the justification of such a diagnosis. These issues are the reason for this paper. Knowledge of ADHD, and knowledge of the possible treatment methods, is the key to understanding. With understanding, parents will be more able to make better decisions about their child, and will be able to detect when a physician or psychiatrist might be missing key symptoms or signs that would change their course of action. The nature of ADHD and the possible treatment methods will be discussed in this paper. First, a basic description of the disorder should be covered, to help in understanding the need for treatment. The second issue to discuss will be the research that has been done regarding the neurological factors for the disorder. Next we will cover the possible treatments available for children with ADHD, and the implications of the treatments for the parents and teachers. Finally,
  4. 4. Medical Treatments 4 the issues surrounding the benefits and drawbacks will be covered, and facts will be presented to help the reader become more enlightened on the topic of medications for ADHD. Attention Deficit Hyperactivity Disorder (ADHD): Description of the Disorder Support of ADHD being a true disorder lies in the fact that there are significant differences in cognitive, neurological, genetic, behavioral and social factors from normal childhood levels. Wakefield (as cited in Mash and Barkley, 2003) has argued that to be considered a disorder it must first show substantial harm to the individual or those around them, and second it must show dysfunction in survival value. Those who are diagnosed with ADHD have deficits in behavioral inhibition as well as inattention, which interfere with self-regulation. They also experience harm to their development (Mash and Barkley, 2003).. They are clumsy and uncoordinated with fine motor skills and balance. They also have learning impairment within academic settings. ADHD affects the social relationships of those diagnosed, as they are characterized as being more excessive, disorganized, impulsive, emotional and aggressive (Mash and Barkley, 2003). This includes parent-child interactions, which can be problematic, and can affect the teacher-student relationship as well (Mash and Barkley, 2003). Difficulties with trying to help ADHD children with academics or social interactions are a direct result of the symptoms of ADHD. According to the Diagnostic and Statistical Manual of Mental Disorders (4th Edition, Text Revision), it may be difficult to distinguish symptoms of ADHD from behaviors that are appropriate for young children (DSM-IV, 2000). ADHD is diagnosed in 3 different subtypes: Predominantly Inattentive, Predominantly Hyperactive-Impulsive, and Combined type. In order to make a diagnosis of ADHD, a child must display 6 or more symptoms of inattention or impulsivity/hyperactivity that have persisted for at least 6 months, across more than one setting
  5. 5. Medical Treatments 5 (ex.: home and school). However, the most important key here is that the symptoms must be determined to be maladaptive and inconsistent with other children in their developmental stage (DSM-IV, 2000). In other words, the severity of the symptoms, and whether or not the symptoms are actually hindering the child, is the key to distinguishing whether the child just has a problem, or a disorder. If this is simply the personality traits of a child, but does not affect scholastic, social, or developmental progress, then the diagnosis need not be made and the question of treatment is no longer pertinent. If the child indeed has a disorder that affects their day-to-day life across settings and is hindering their progress across multiple settings, then the next question is how to treat the symptoms of their disorder. Though there is a great debate regarding the cause of ADHD, or whether ADHD has a non-social basis or neurological basis, that debate is not the focus of this particular paper. However, to explain why medicinal treatments for ADHD have significant effects, it is important to note that there is information that supports the biological effects of this disorder. The Issue of Neurological or Biological Evidence Even while gathering research for this paper, one might notice that the information on the neurological basis for ADHD is still in need of much research. For now, it is important to look at the information currently available. The word neurological itself suggests a focus on brain activity. With the exception of extremely expensive measuring techniques, such as MRI’s and other brain scan techniques, brain activity is difficult to measure. So the next logical thing is to measure behaviors and to draw upon what we have learned over the years about the brain and its locality of thought processes. It has been shown that children with ADHD have more in common than just hyperactivity or problems paying attention. They also have associated developmental
  6. 6. Medical Treatments 6 impairments that seem to be characteristic of the disorder. The majority of these developmental impairments involve executive functions. That is, neuropsychological processes that help the child regulate themselves in order to alter their consequences (Mash and Barkley, 2003). A few examples of these impairments are color naming, story recall, verbal and nonverbal working memory, mental computation, verbal fluency, developing and applying self-monitoring strategies, adhering to restrictive instructions, and internalizing self-directed speech (self-talk) (Mash and Barkley, 2003). The one thing that all these executive functions have in common is that they all stem from the frontal lobe of the brain - to be more specific, the prefrontal cortex (Mash and Barkley, 2003). The impairments of these functions seem to be characteristic of ADHD, and yet they are all located in the same area of brain functioning. Although the frontal lobe is a large area of the brain, it still leads to believe that there is more than a coincidence that an ADHD child has impairments that occur in the same part of the brain. Even more convincing is the simple fact that these functions are not behaviors alone, they are cognitive functions that result in behaviors and changing the cognition itself will most likely change the outcome of the behavior. Even stronger support for a neurological, or even biological, explanation of this disorder is the observation that parents who have ADHD children are often diagnosed with ADHD themselves. Between 35 and 45 percent of parents of ADHD children are, or have been, diagnosed with ADHD themselves (Horacek, 1998). Once noted by J. Horacek, M.D., those with ADHD tend to not be able to stay in one place for very long and are naturally drawn to traveling and exploration in order to keep their attention and to avoid boredom (Horacek, 2003). Now consider the larger numbers of ADHD children who are diagnosed in the United States in comparison with those in other countries. Next, note the type of person that this country was
  7. 7. Medical Treatments 7 established from. The people who make up the United States are a large percentage of immigrants (with the exception of the Native American population). With a country made up of people whose ancestors are naturally drawn to exploration of new worlds and travel, then the next step in the logic is that we are naturally more prone to a disorder like ADHD because it is the nature of our ancestors who settled here so long ago (Horacek, 2003). This may seem to be a very long stretch of connections; however it is the one answer which appears to have the most logic to answer the question of why the United States has the highest population of ADHD children of all countries. If there is such a strong familial link for generations of ADHD type people, then it again leads to the base for a biological element of the disorder. The strongest evidence to support the effectiveness of medication on ADHD children, is the research that has been done on the dopamine D2 receptor gene, and the dopamine B- hydroxylase gene. The beginnings of research for these genes came from comorbid disorders that showed evidence for a common allele on these genes (Horacek, 1998). For example, when looking at the comparison of genes for alcoholics to a control/norm group, it was shown that the dopamine D2 receptor gene occurred in 69 percent of alcoholics, compared to 20 percent of controls (Horacek, 1998). In a general sample of the population, this same allele was found in 25 percent of the general population, and 15 percent of those known not to be alcoholics. The frequency of this allele was increased when looking at patients with ADHD – 46 percent (Horacek, 1998). This percent is also increased when looking at disorders that are comorbid with ADHD, suggesting that these comorbid disorders are actually different disorders along a spectrum that occurs in conjunction with this particular allele mutation (Horacek, 1998). Though there is other evidence to suggest that ADHD is more than simply a behavior problem that teachers do not want to deal with, the important thing to consider is the severity of
  8. 8. Medical Treatments 8 the disorder, the nature of the symptoms, and the specific subtype of ADHD. Though medication can show significant differences in behaviors of ADHD children, there is still much research to be done that looks into the long term effects of stimulants and other prescribed medications on ADHD children. Because the disorder itself is relatively new to the scientific world, longitudinal studies are not as abundant as they should be. One drawback to the research that is being presented in this paper, is that there is no detail on whether the children participating in the study were tested before ever taking any medication. According to Peter Breggin, M.D. (Breggin, 2002), this is the reason why a great deal of research is invalid. Although there is significant evidence for the correlation of differences in brain size, corpus callosum size, or even differences in brain functioning, the cause of these problems is yet to be found. To be completely unbiased in presenting information, it must be noted that information gathered from research must take into consideration whether or not the children in the studies were participating before a medication or stimulant was ever prescribed and used. As this paper will discuss, there are significant side-effects to stimulant drugs, and many of these have shown damage to a normal population who were undiagnosed with ADHD. Some of the symptoms of stimulant medication include irritability, agitation, confusion (Breggin, 2002). Also, in 1997 a study published confirmation of a stimulant-induced depression in children who were treated for ADHD (Breggin, 2002). This is just a bit of the information that Breggin discusses, which prompts the concern of whether or not the medication, or the disorder, is the cause of these symptoms. Considering the fact that a child would not be diagnosed with ADHD without any symptoms, it is difficult to believe that medication alone would cause these reactions. But it does lead to the concern that medication might not be right for every child, and should be considered with great care.
  9. 9. Medical Treatments 9 Description of Medical Treatments Types of Medication There are 2 main types of medications used for children who are diagnosed with ADHD. The first, and most widely used, type of medication is a stimulant drug. The second type of medication for ADHD is a hydrochloride. This medication is used more commonly for ADHD children who also suffer from anxiety or depression. It decreases impulsivity, however it does not have the stimulant effects that can interfere with sleep during the night. This drug is used more commonly for ADHD children who have sleep disorders. This drug is sometimes used as a nighttime alternative to a second dose of stimulant medication in the evenings. Stimulant drugs are most commonly used for ADHD children. They tend to be the most prescribed. Various forms of stimulants are now available: methylphenidate (or Ritalin), amphetamines such as dextroamphetamine (or Dexedrine) and Adderall (amphetamine salts), and Pemoline (central nervous system stimulant) (www.rxlist.com). Pemoline is not recommended as a first-line of therapy. Methylphenidate is the most commonly known medication, but it also has spurred a great deal of controversy. Although stimulants normally increase activity and restlessness, and even anxiety in a normal individual, stimulants have been shown to act like a calming agent in ADHD children. It reduces restlessness, impulsiveness, and helps children to focus their attention. Adderall is newer to the medical world than Ritalin It has been shown to have longer lasting effects than Ritalin does, is at least as effective, and can be given in a single dose a day (Pelham, 1999). In this case, this would prevent the necessity of a mid-day dose, which can sometimes be inconvenient, as well as embarrassing for a child who has to be pulled out of class to take their ‘medication’. There is also the comfort of making sure
  10. 10. Medical Treatments 10 that medication is given at the proper time and dosage, and can be controlled from home if the parent does not have to rely on the school nurse to administer the medication. Benefits Stimulant medications have been shown to improve the behavior of children with ADHD during structured parent-child interactions in analog settings (Pelham & Gnagy, 1999). As a sole form of treatment, stimulant medication yielded much superior outcomes than did psychosocial treatment alone (Safer, 2000). Using stimulant medication has the benefit of calming an ADHD child so that they will be able to focus more on the task at hand without hyperactive side-effects. The possibility to teach a child proper behavioral techniques without medication would be extremely difficult, as attention is absolutely necessary for proper learning and retention. Drawbacks Despite the benefits that stimulant medications give to ADHD children, they cannot be used for all children. Only 70-80% of children with ADHD respond positively to a stimulant regimen (Pelham & Gnagy, 1999). Different children respond to each medication differently (Whalen & Henker, 1991). Because children respond differently to different medications, as well as different doses of the same medication, stimulants can have unpredictable effects between and within children (Waschbusch, Kipp & Pelham 1998). Stimulant medication alone cannot teach a child the proper behaviors to use to replace the problematic social behaviors that they currently have. It may take care of the immediate symptoms of ADHD, but does not give them knowledge to help them learn long-term behaviors that focus their own attention, or control hyperactivity- impulsivity, without the aid of medication. It is naïve to believe that medication alone could resolve all, or even most, of family conflicts that are a result of ADHD behaviors (Pelham & Gnagy, 1999). At the same time, medication may give parents and teachers the impression that
  11. 11. Medical Treatments 11 they can rely on medical treatment alone, without supporting the children with proper behavioral guidance (Pelham & Gnagy, 1999). Social Issues/Concerns of Medical Treatments Over medication Concerns of medicating children too long, or with too high of a medication have created bad feelings for medical treatments (www.ritalindeath.com). Although rare, severe repercussions of any form of medication are always a concern, and wherever medication can be avoided or lessened, it should be. As noted in the included handout, there are various side effects that can lead to severe detrimental effects on health. Ritalin has implications for cardiac problems over long term usage. Pemoline can cause liver problems in some people. Imipramine can cause cardiac death or accidental poisoning (http://www.rxlist.com/cgi/generic/imip_ad.htm). Amphetamines have a possibility of overdose (Breggin, 2002). One of the biggest concerns is the possible withdrawal symptoms that come from stopping a medication abruptly. Along with the concern for withdrawal, is the possibility of irreversible damage that has resulted in taking a stimulant medication too long. Antipsychotic drugs, which are sometimes prescribed in conjunction with other medications for ADHD, have been shown to contribute, or sometimes cause, permanent tics. This is a disorder called tardive dyskinesia and is irreversible with long- time exposure. There are numerous precautions that should always be made for any type of medication, and as a result, public feeling for medications, of any kind, are usually extremely sour. Higher rate of stimulant use over 5-6 year period The increase in children receiving medication between 1990 and 1996 (180% increase in methylphenidate shipments) gives rise to the general public (Safer 2000). Unfortunately,
  12. 12. Medical Treatments 12 production of Ritalin and/or shipment of the medication does not determine actual usage of the medication. However, one must take into consideration that the increased rate of treatment is not uniform. Those with the greatest increases in usage are girls with ADHD (whose symptoms were previously ignored) and teenagers with persisting ADHD (which was previously un-medicated) (Safer 2000). Discussion Now that this information has been presented, and the benefits and risks of medication have been discussed, the ultimate question is how to use this information in relation to children with ADHD. Of course the ultimate choice of when, where, how, and if you should medicate a child is left to the parent. This doesn’t mean that there aren’t implications for educators of ADHD children. Numerous factors play on the relationship of a child’s medication and his performance in school. Having an ADHD child in your classroom can not only impact how well you teach to that child, but can also affect how well you teach the other children, and how well they learn. ADHD is considered a disorder if their developmental, social and academic progress is interrupted or hindered by specific symptoms that hinder their progress. In order to be considered a disorder it must have a level of severity that calls for action. If these typical ADHD behaviors do not interfere with their success or progress, then there is no reason to diagnose them with a disorder. The fact that their behaviors are interfering with their progress is why they are prescribed with a medication. Once these interrupting behaviors are under control, they can then begin to learn how to focus their attention and energy on the tasks required for their assignments in, and out of, class.
  13. 13. Medical Treatments 13 The important thing for a teacher to observe is whether or not the child appears to be affected too much by the medication, or whether the medication is not working throughout the day. Stimulant medication is extremely unpredictable, and with the possibility of unhealthy side- effects, the level of medication should be monitored accurately to establish the optimal level of performance for a child without taking away that child’s personality. As far as school psychologists are concerned, constant evaluations and communication between teacher, parent and child are essential to benefit the health of the child involved. This also includes making sure that behavioral examples and lessons are given in conjunction with medication. Medication alone will not teach the child to monitor their own behavior and to self- regulate their actions on a day-to-day basis. Good modeling techniques in and out of the classroom are essential if the medication is to be effective in treatment. The goal should not be to continue the medication forever, but only until the child has grown and learned to make better decisions and to monitor their own behavior in a manner that helps them, instead of hindering them. The key to proper medication and safety of the child is to make sure that if something does not seem right, to listen to the instincts of the child, parent, and teacher. The teacher and the parent spend the most time with the child, and their observations of the child’s behavior, as well as the feelings and behaviors of the child, should be the biggest factor when determining whether a medication is needed, or a change in medication is needed. Without good communication from all those involved with the child, as well as the child themself, physicians and parents cannot make well educated decisions about the child’s welfare.
  14. 14. Medical Treatments 14 References Amphetamine Mixed Salts Description (2003), http://www.rxlist.com/cgi/generic/amphet.htm, Visited on 9/26/03, maintained by RxList which was founded and is maintained by Neil Sandow, Pharm.D.. Appleton, W. S., (2000). Prozac and the new antidepressants: what you need to know prozac, Zoloft, paxil, luvox, wellbutrin, effexor, serzone, celexa, St. John’s Wort, Vestra and others, Revised Edition, New York:Plume. Aurorix / Manerix Description, http://www.inhousepharmacy.com/anti-depressants/ manerix.html, Visited on 10/01/03, maintained by Inhouse Pharmacy 800-544-0470. Biederman, J., Spencer, T. (2000) Non-stimulant treatments for ADHD [Electronic version]. European Child & Adolescent Psychiatry 9(5), I51 - I59. Breggin, P., (2002), The Ritalin Fact Book, What your doctor won’t tell you about ADHD and stimulant drugs, Cambridge,MA:Perseus Books Group. Death from Ritalin, The Truth Behind ADHD, http://www.ritalindeath.com, Visited on 10/01/03, maintained by Lawrence T. Smith. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (2000), Text Revision, American Psychiatric Association, Washington D.C., 85-93. Horacek, H. (1998). Brainstorms: Understanding and Treating the Emotional Storms of Attention Deficit Hyperactivity Disorder from Childhood through Adulthood, Northvale, NJ:Jason Aronson Inc. Horacek, H. (2003, November). Brainstorms: Understanding and Treating the Emotional Storms of Attention Deficit Hyperactivity Disorder from Childhood through Adulthood,
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  16. 16. Medical Treatments 16 Pemoline Description, (2003) http://www.rxlist.com/cgi/generic/pemoline.htm, Visited on 10/01/03, maintained by RxList which was founded and is maintained by Neil Sandow, Pharm.D.. Safer, Daniel J. (2000). Are Stimulants Overprescribed for Youths with ADHD? [Electronic version]. Annals of Clinical Psychiatry, 12:1, 55-62. Waschbusch, D. A., Kipp, H. L., and Pelham Jr, W. E., (1998). Generalization of behavioral and psychostimulant treatment of attention-deficit/hyperactivity disorder (ADHD): discussion and examples [Electronic version]. Behaviour Research and Therapy, 36(7-8), 675-694.