ADHD and medicine

The process of deciding whether to medicate a child starts with making the correct diagnosis. Dr Erasmus explains, “You must make sure it’s ADHD. There are other medical and emotional conditions that can cause a child not to concentrate.”

Next, the doctor should look for co-morbid conditions like anxiety or depression, developmental delays and learning problems that often go along with ADHD. Dr Erasmus says, “Only once you have a firm diagnosis and have identified the problems affecting the child, will you look at a treatment protocol for that specific child.”

Dr Erasmus says that while not every ADHD child requires medication, modern medicines can transform the lives of ADHD kids and their families.

The decision to prescribe medication

The decision to prescribe medication is based on how the child’s symptoms negatively affect his functioning in daily life, his routines at home, his social life or his school work.

He adds, “In terms of treatment, these days we look more at quality of life outcomes, not just at treating core symptoms or correcting a problem. A good outcome means that the child is happy, there is no personality change, he or she socialises well, copes academically and is an integrated part of the family.”

Individualised treatment

Therapy must be individualised for the specific child. Dr Erasmus explains, “You would take into account the child’s problems, and the nature of his school day. A child who mainly struggles in school and with homework, but has no behaviour problems, would probably be prescribed Ritalin or Concerta. They work quickly and are out of the system swiftly. However, if the child needs 24-hour help, for instance, if home life and familial relations are suffering because of his behaviour problems, Strattera would be the choice.”

Most parents are understandably loathe to medicate young children. To do so is a difficult decision, often arrived at after years of trying other methods. The fact is, says Dr Erasmus, that for many children medication is very effective in controlling hyperactivity, inattentiveness and impulsivity.

Why many doctors suggest medicating for ADHD

Dr Erasmus quotes the National Institute of Mental Health Multimodal Treatment Study of ADHD, which compared children on stimulant therapy, behavioural therapy, both and neither. This study found that in the right child, a combination of medication and therapy gets the best long term results.

His experience in his practice bears this out. He says, “Around 25% of children will come right on their own. They will learn to cope, using their individual strengths. The problem is that we don’t know who that 25% will be. If we treat and support all the children diagnosed with ADHD, 75% of them eventually settle down, learn to cope and are able to function well. 25% will, however, need support even into adulthood.”

Problems with the wait-and-see approach

It’s tempting to take a “wait-and-see” attitude, hoping that with maturity, the child will learn to manage his own behaviour more effectively. The trouble with this approach is that in the years when the child is struggling, he may fall behind in school, develop social problems, or suffer from falling self-esteem.

In children with untreated ADD (inattentive type) 50 - 70% will develop depression or anxiety, due to the fact that they try their best but never succeed. Likewise, says Dr Erasmus, in the hyperactive group, 50 – 70% will develop behaviour problems because of their impulsivity.

Dr Erasmus says, “The sooner you help these kids, the better the chance that they will develop coping and behaviour modification skills, and that they will not get other co-morbid conditions. If you can help kids in Grade 0 and Grade 1, the outcome is generally good and by 10 or 12 years old they have settled down and no longer need treatment.”

These children may go back onto medication when they hit adolescence, or when they get into the pressurised years of Grade 11 or 12. They may struggle to cope with change, and find themselves needing medication when they enter high school, or go off to university. About 25% need support throughout school and into adulthood.

Medication as treatment, not solution:

Medication is seen as part of a treatment plan, not the solution to the problem. A psychologist might be enlisted to help with behaviour modification or emotional problems. Because 60 – 80% of ADHD kids will have other developmental delays, such as reading problems, coordination, visual or auditory processing problems, the child might need speech and auditory, remedial or occupational therapy.

Dr Erasmus adds, “Parent guidance is probably the most important part of general therapy. Parents need to learn to cope with the problem and support the child.”

What do the medicines do?

With ADHD, levels of the neurotransmitters dopamine or nor-adrenalin are too low in specific areas of the brain. Drugs for ADHD work by increasing the levels of these neurotransmitters. It therefore normalises focus, planning and impulse control so that normal development can take place and other interventions can be more effective.

There are two basic types of medication, stimulants and non-stimulants. The most widely prescribed are the stimulants, such as methylphenidate (Ritalin or Concerta).

It has long been common practice to stop giving a child Ritalin on weekends and during the holidays. However, Dr Erasmus says that the latest research indicates that this is not ideal. He explains, “Research shows that kids who use methylphenidate every day do better in the long term. If you keep the concentration at the right level, you help the brain to learn to function correctly and the child learns to cope.”

Stimulant treatment

Stimulant treatment for ADHD is available as short-acting Ritalin (effective for about four hours), intermediate-acting Ritalin LA (eight hours) or long-acting Concerta (10-12 hours). Side effects may include appetite suppression, stomach ache, headache and, occasionally, tics. Emotional instability may occur in younger children.

Non-stimulant treatment

Non-stimulant treatment – available in South Africa under the brand name Strattera - controls symptoms for a full 24 hours with one dose a day.

Unlike stimulants, non-stimulant treatment does not reach its full effect from the first dose. Four to six weeks of treatment are required for treatment to be fully effective. Side effects include nausea, vomitting, stomach ache and sleep disturbances.

Dr Erasmus says that neither stimulants nor non-stimulants change the brain and that they are safe to use, even for life.

Stimulants have been in use for almost 60 years worldwide. Long-lasting behaviour, emotional and other problems are not the result of medication but consequences of the condition. In fact, says Dr Erasmus, the appropriate use of medication decreases the incidence of behaviour problems, depression and even substance abuse in adolescents and adults.
 

Contact ADHASA (ADHD/Hyperactivity Support Group) on (011) 888 7655 for more information.