Management

There is considerable cultural variation with respect to the management of the childhood-onset symptoms of inattention, hyperactivity, and impulsivity. In the United States, central stimulants are considered first-line treatment. It has been estimated that between 2.5 per cent and 3 per cent of American children and adolescents aged between the ages of 5 and 18 years received methylphenidate treatment in mid-1995, (12.) meaning that about 1.5 million children and adolescents were taking this drug for attention-deficit hyperactivity in the United States alone. In many European countries central stimulants are seen as second- or even third-line treatment options. In Sweden, in 1996, about 0.02 per cent of the 5- to 18-year-olds received such treatment. (13)

Attention-deficit hyperactivity

Stimulants should never be the only treatment in children and adolescents with attention-deficit hyperactivity, nor should they ever be prescribed without a thorough examination of the individual child and an assessment of the specific circumstances under which he or she is living. Psychoeducational measures, remedial education, parental counselling, and behaviour modification should always be considered, and are often sufficiently effective (in various combinations). However, in children 5 years of age or older meeting the full criteria for attention-deficit hyperactivity, there might be a case for including a stimulant in the treatment regimen if other interventions have failed to produce the desired positive effects, or if the condition is so severe as to warrant consideration for the removal of the child from his or her normal environment (to a residential setting or a foster-home).

The initial medical work-up should include height (usually stunted by less than 1 cm in the longer-term perspective) and weight (usually reduced by 1 to 2 kg during active treatment), pulse, heart auscultation, and blood pressure (cardiovascular effects are generally mild), as well as a screen for pretreatment levels of potential side-effects. It is recommended that these procedures be repeated twice to four times a year after the dosage has been titrated to an appropriate level. Monthly contacts with a parent are reasonable for monitoring progress and side-effects, but these can often be limited to telephone consultations. Children receiving pemoline should have liver function tests at least twice yearly, given the reports that this drug can adversely affect liver functions.

Treatment can be started with either methylphenidate or dextroamphetamine, usually at a dosage of 5 mg twice daily (e.g. at 7.30 a.m. and 11.30 a.m. to obtain maximum beneficial effects during the school day) and then increasing by 2.5 to 5 mg per week up to a total daily dose of 25 to 50 mg, depending on age and on desired and unwanted effects. Some children experience behavioural rebound effects in the afternoon, and may need a smaller third dose in the afternoon. The addition of a third dose may either lead to increased problems of insomnia or may help to offset the rebound phenomena, so much so that the child can 'calm down' in the evening and go off to sleep without major problems. If one stimulant is ineffective, the other two may be tried in succession, and either one may prove to be useful.

It is generally accepted that, if effective, stimulant treatment may be continued for one school year at a time, with possible discontinuation being considered at the end of each spring term. Some children need the medication during holidays, but others can manage without stimulant treatment in between the school terms. The evidence is that medication may be safely continued for several years, up to adolescence (and even beyond). The research data do not suggest the development of addiction or tolerance, and ultimate height is minimally affected, if at all. Even though there is no indication that cardiovascular long-term effects are of importance, continued monitoring of cardiac function and blood pressure should be performed at regular intervals during the years of continued treatment. (See also Chapter 9.2.3.)

Other indications for central stimulant treatment

It appears that central stimulants are effective for the treatment of inattention, impulsivity, and hyperactivity, whether or not these symptoms exist within the context of an 'attention-deficit hyperactivity diagnosis'. Thus, some children who present with a primary problem of conduct disorder, Tourette's syndrome, or autism spectrum disorder, and who also have major symptoms from the attention-deficit hyperactivity complex, may well benefit from stimulant medication. Management guidelines should be similar to those outlined above for attention-deficit hyperactivity, but the comorbid problems related to conduct, tics, or social interaction need attention in their own right and should not be automatically expected to be improved by the stimulant treatment.

Healthy Sleep

Healthy Sleep

A Guide to Natural Sleep Remedies. Many of us experience the occasional night of sleeplessness without any consequences. It is when the occasional night here and there becomes a pattern of several nights in arow that you are faced with a sleeping problem. Repeated loss of sleep affects all areas of your life The physical, the mental, and theemotional. Sleep deprivation can affect your overall daily performance and may even havean effecton your personality.

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