Initiating treatment with medication

Existing research supports what seems to be the typical approach to establishing drug therapy for children with AD-HKD. Initially, one of the two stimulants, methylphenidate or dextroamphetamine, is used. Initiating treatment with a regular-acting preparation rather than a long-acting preparation permits a more precise adjustment of the timing and dosing of the medication throughout the day. If one stimulant fails to produce the desired benefits or causes side-effects that are unacceptable, another is tried. Long-acting preparations of the psychostimulants are used when compliance is an issue or when the waxing and waning effect of shorter-acting preparations is undesirable.

Initiation of the treatment involves a slow increase of the dose to some target dose, often in the range of 0.5 to 0.7 mg/kg, given twice daily to begin with. However, a dose based on the milligram-per-kilogram calculation may result in doses that are too high for older or heavier children. Conversely, fixed doses (e.g. a target dose of 10 or 15 mg, twice daily) could result in doses that are too high for younger or lighter children. Some hybrid approach seems optimal; for example, targeting a dose of 0.7 mg/kg, but stopping at a maximum single dose set at 20 mg. The use of a third late-day dose of medication may be particularly useful for social and academic activities in the evening. To minimize insomnia and anorexia in the evening, typically, the third dose is half the dose administered during the day.

Various authorities^..!7) have recommended that a double-blind placebo-controlled trial is a necessary part of the process of initiating medication, even in a typical clinical practice. A systematic trial involves the double-blinded administration of various doses of medication and placebo in random order. Systematic trials are not particularly complicated and can be organized in a typical clinical practice.

On the other hand, the use of a systematic trial seems to have little advantage over the open trial described above. There is little evidence of a sustained placebo effect, and doses determined by a systematic trial tend to be similar to those determined by open titration. Consequently, the extra cost of a double-blind trial may not be justified. Many parents, however, are reassured by the rigour of a systematic trial,(205) which may, in itself, be ample justification for conducting the trial.

Education is an important part of treatment because it helps parents and the affected child develop an understanding of the nature of the disorder. This understanding may improve their decisions about treatment. Moreover, increased knowledge may result in more realistic expectations and better adherence to the treatment.

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