Questions About ADD Medication

The following are commonly asked questions concerning the medical management of children with ADD, compiled by CHADD (Children and Adults with Attention Deficit Disorders) and the American Academy of Child and Adolescent Psychiatry.

What medications are prescribed for ADD children?
Medications can dramatically improve attention span and reduce hyperactive and impulsive behavior. Psychostimulants have been used to treat attentional deficits in children since the 1940s. Antidepressants, although used less frequently to treat ADD, have been shown to be quite effective for the management of this disorder in some children.

How do psychostimulants such as Dexedrine (dextroamphetamine), Ritalin (methylphenidate), and Cylert (pemoline) help?
Seventy to eighty percent of ADD children respond in a positive manner to psychostimulant medication. Exactly how these medicines work is not known. However, benefits for children can be quite significant and are most apparent when concentration is required. In classroom settings, on-task behavior and completion of assigned tasks is increased, socialization with peers and teacher is improved, and disruptive behaviors (talking out, demanding attention, getting out of seat, noncompliance with requests, breaking rules) are reduced.

The specific dose of medicine must be determined for each child. Generally, the higher the dose, the greater the effect and side effects. To ensure proper dosage, regular monitoring at different levels should be done. Since there are no clear guidelines as to how long a child should take medication, periodic trials off medication should be done to determine continued need. Behavioral rating scales, testing on continuous performance tasks, and the child's self-reports provide helpful but not infallible measures of progress.

Despite myths to the contrary, a positive response to stimulants is often found in adolescents with ADD; therefore, medication can be continued as the child reaches adolescence, if it is still needed.

What are common side effects of psychostimulant medications?
Reduction in appetite, loss of weight, and problems in falling asleep are the most common adverse effects. Children treated with stimulants may become irritable and more sensitive to criticism or rejection. Sadness and a tendency to cry are occasionally seen.

The unmasking or worsening of a tic disorder is an infrequent effect of stimulants. In some cases this involves Tourette's syndrome. Generally, except in Tourette's, the tics decrease or disappear with the discontinuation of the stimulant. Caution must be employed in medicating adolescents with stimulants if there are coexisting disorders, for example, depression, substance abuse, or conduct, tic, or mood disorders. In these cases, medication may not be appropriate. Likewise, caution should be employed when a family history of a tic disorder exists.

One side effect, decreased spontaneity, is felt to be dose-related and can be alleviated by reduction of dosage or switching to another stimulant. Similarly, slowing of height and weight gain of children on stimulants has been documented, with a return to normal for both occurring upon discontinuation of the medication. Other less common side effects have been described, but they may occur as frequently with a placebo as with active medication. Pemoline may cause impaired liver functioning in three percent of children, and this may not be completely reversed when this medication is discontinued.

Overmedication has been reported to cause impairment in cognitive functioning and alertness. Children may be attending to tasks, but their academic performance might suffer. Some children on higher doses of stimulants will experience what has been described as a rebound effect, consisting of changes in mood, irritability, and increases in the symptoms associated with their disorder. This occurs with varying degrees of severity during the late afternoon or evening, when the level of medicine in the blood falls. Thus, an additional low dose of medicine in the late afternoon, or a decrease of the noontime dose, might be required. When are tricyclic antidepressants such as Tofranil (imipramine), Norpramin (desipramine), and Elavil (amitriptyline) used to treat ADD children?
This group of medications is generally considered when contraindications to stimulants exist, when stimulants have not been effective or have resulted in unacceptable side effects, or when the antidepressant property is more critical to treatment than the decrease of inattentiveness. They are used much less frequently than the stimulants, seem to have a different mechanism of action, and may be somewhat less effective than the psychostimulants in treating ADD. Long-term use of the tricyclics has not been well studied. Children with ADD who are also experiencing anxiety or depression may do best with an initial trial of a tricyclic antidepressant, followed (if needed) with a stimulant for the more classic ADD symptoms.

What are the side effects of tricyclic antidepressant medications?
Side effects include constipation and dry mouth. Symptomatic treatment with stool softeners and sugar-free gum or candy are usually effective in alleviating the discomfort. Confusion, elevated blood pressure, possible precipitation of manic-like behavior, and inducement of seizures are uncommon side effects. The latter three occur in vulnerable children, who can generally be identified during the assessment phase.

What about ADD children who do not respond well to medication?
Some ADD children or adolescents will not respond satisfactorily to either the psychostimulant or tricyclic antidepressant medications. Nonresponders may have severe symptoms of ADD, may have other problems in addition to ADD, or may not be able to tolerate certain medications because of adverse side effects, as noted above. In such cases, consultation with a child and adolescent psychiatrist may be helpful.

How often should medications be dispensed at school to an ADD child?
Since the duration for effective action for Ritalin and Dexedrine, the most commonly used psychostimulants, is only about four hours, a second dose during school is often required. Taking a second dose of medication at noontime enables the ADD child to focus effectively and to maintain appropriate school behavior and academic productivity. However, the noontime dose can sometimes be eliminated for children whose afternoon academic schedule does not require high levels of attentiveness. Some psychostimulants, Ritalin-SR (sustained release form) and Cylert, work for longer periods of time (eight to ten hours), and may help avoid the need for a noontime dose. Antidepressant medications used to treat ADD are usually taken in the morning, in the afternoon hours after school, or in the evening.

In many cases, the physician may recommend that medication be continued at nonschool times such as weekday afternoons, weekends, or school vacations. During such nonschool times, lower doses of medication than those taken for school may be sufficient. It is important to remember that ADD is more than a school problem—it is a problem that often interferes with the learning of constructive social, peer, and sports activities.

How should medication be dispensed at school?
Because an ADD child may already feel different from others, care should be taken to provide discreet reminders to the child when it is time to take medication. It is important that school personnel treat the administration of medication in a sensitive manner, thereby safeguarding the privacy of the child or adolescent and avoiding any unnecessary embarrassment. Success in doing this will increase the student's compliance in taking medication.

The location for dispensing medication at school may vary, depending upon the school's resources. In those schools with a full-time nurse, the infirmary would be the first choice. In those schools in which a nurse is not always available, other properly trained school personnel may take the responsibility for supervising and dispensing medication. How should the effectiveness of medication and other treatments for the ADD child be monitored?
Important information needed to judge the effectiveness of medication usually comes from reports by the child's parents and teachers, and should include information about the child's behavior and attentiveness, academic performance, social and emotional adjustment, and any medication side effects.

Reporting from these sources may be informal through telephone, or more objective via the completion of scales designed for this purpose.

The commonly used teacher rating scales are:

• CGI-T: Conners' Global Index-Teacher
• ADD-H Comprehensive Teacher Rating Scale
• Child Behavior Checklist
• ADHD Rating Scale
• Child Attention Problems (CAP) Rating Scale
• School Situations Questionnaire

Academic performance should be monitored by comparing classroom grades before and after treatment.

It is important to monitor changes in peer relationships, family functioning, social skills, capacity to enjoy leisure time, and self-esteem.

The parents, school nurse, or other school personnel responsible for dispensing or overseeing the medication trial should have regular contact by phone with the prescribing physician. Physician office visits of sufficient frequency to monitor treatment are critical in the overall care of children with ADD.

What are the common myths associated with ADD medications?
Myth: Medication should be stopped when a child reaches teen years.

Fact: Research clearly shows that there is continued benefit to medication for those teens who meet the criteria for diagnosis of ADD.

Myth: Children build up a tolerance to medication.

Fact: Although the dose of medication may need adjustment from time to time, there is no evidence that children build up a tolerance to medication.

Myth: Positive response to medication is confirmation of a diagnosis of ADD.

Fact: The fact that a child's attention span improves or activity levels decrease while taking ADD medication does not substantiate the diagnosis of ADD. Even some normal children will show a marked improvement in attentiveness when they take ADD medications.

Myth: Medication stunts growth.

Fact: ADD medications may cause an initial and mild slowing of growth, but over time the growth suppression effect is minimal or nonexistent, in most cases.

Myth: Taking ADD medications as a child makes you more reliant on drugs as an adult.

Fact: There is no evidence of increased medication taking when medicated ADD children become adults, nor is there evidence that ADD children become addicted to their medications.

Myth: ADD children who take medication attribute their success only to medication.

Fact: When self-esteem is encouraged, a child taking medication attributes his success not only to the medication, but to himself as well.