Enhancing Quality in
School Mental Health

Attention Deficit Hyperactivity Disorder

Over the past 30 years there has been an increase in the number of medications that are used with youth. Many of these uses are rigorously studied scientifically, while many others are anecdotal and based on clinical experience with fewer research studies. For the purpose of our discussion, medications in both categories will be included if their use for a particular disorder is considered as the standard of care among Child and Adolescent Psychiatrists. Because of our limited space, only medication treatment for Attention Deficit Hyperactivity Disorder (ADHD) will be considered. Other disorders will be considered in later articles.
ADHD is the most common of all childhood psychiatric disorders. It has received a great deal of discussion in both the lay press as well as mental health literature because of its increasing prevalence over the past 30 years as well as the increase use of stimulants such as methylphenidate (Ritalin). The two hallmarks of ADHD are attention problems which result in poor focus on schoolwork, increased distractibility, and failure to follow through on tasks; and hyperactivity which is accompanied by increased motor activity, impulsivity, and difficulty awaiting turns, or blurting out answers.
Because there are many other conditions that mimic the symptoms of ADHD such as pediatric bipolar disorder, auditory processing problems, and childhood anxiety disorders, among others, it is incumbent upon the clinician to properly diagnose the youth before initiating mediations. This is done with screening instruments such as the Conner’s or SNAP-IV rating scales, a parental/guardian interview, and data from other settings such as school or other settings where the child spends a significant amount of time. Once the diagnosis is confirmed, there are a number of treatment options. The first line of treatment is behavior therapy and parenting skills training. For youth with relatively minor symptoms, this will likely be successful. For youth with more extensive difficulties, medications may be indicated.
The most commonly used medications are the stimulants. This category of medications include methylphenidate (Ritalin, Concerta), amphetamine (Adderall), dextoramphetamine (Dexedrine), among others. Stimulants are often effective at controlling both attention and hyperactive symptoms. Although many parents worry about youth becoming addicted to stimulants, there is significant evidence that when stimulants are appropriately used to treat ADHD, there is actually less likelihood of addiction later in life. Most side effects of the stimulant medications are minor and are usually related to the dosage of the medication being taken. Higher doses produce more side effects. The most common side effects are decreased appetite, insomnia, increased anxiety, and/or irritability. (see reverse)

Important Questions for Families

When developing a treatment plan for children and adolescents with depression, clinicians can discuss different issues related to psychiatric medications. The American Academy of Child and Adolescent Psychiatry states that “medication should only be used as one part of a comprehensive treatment plan” and should be monitored on an on-going basis by a physician.
Parents need to know about the benefits and potential side effects of a particular medication before their child begins taking it. Below is a list of questions that clinicians should know the answers to in order to help students and their parents gain a better understanding of psychiatric medications:
What is the name of the medication?
How has this medication helped other children and adolescents with similar conditions?
How long will it take before you see improvement?
What are the common side effects which can occur?
Is this medication addictive?
Who will monitor the student’s response to the medication?
How long will the student need to take the medication?
How much will the medication cost?
What activities/foods should the student avoid while taking the medication?
Does the school nurse need to be informed about this?

Medication Management

Some children report mild stomachaches or headaches. Appetite may be impaired in some youth, usually being low during the middle of the day and more normal by dinnertime. Adequate amounts of food that is nutritional should be available for the child, especially at peak appetite times.
Other medications used to treat ADHD include alpha-adrenergic blocking drugs such as clonidine (Catapress) or guanficine (Tenex). These medications are often beneficial for decreasing hyperactive and impulsive symptoms. The most recent medication that has been added to the armamentarium to treat youth with ADHD is Strattera. The major advantages of Strattera is that it is not a stimulant and it can be used to treat both attention and hyperactivity/impulsive symptoms. Other medications that may be beneficial in treating ADHD in youth with refractory ADHD are antidepressants and anticonvulsants such as Depakote.
Although the focus of this brief article is medication management of ADHD, ADHD is a disorder requiring multimodal interventions including psychotherapy, behavioral therapy, social skills training, support groups, and parenting skills training. Medication management is most successful when used in combination with these other treatment modalities.
Dr. Kenneth Rogers teaches in the Department of Psychiatry at the University of Maryland, School of Medicine.