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C

758 PEDIATRICS Vol. 80 No. 5 November 1987

Committee

on Children With Disabilities

Committee

on Drugs

Medication

for Children

With an Attention

Deficit

Disorder

0

BACKGROUND

In 1975, the AAP Council’ on Child Health issued a statement on medication for hyperkinetic chil-dren. Since that time, the nomenclature for such disorders has changed, as has the knowledge and usage of the medications involved. In this statement the role of medications for hyperactive children is reviewed in light of current nosology.

In recent years, the term “attention deficit dis-order” has become established as a recognized di-agnostic category with three major subtypes: (1) attention deficit disorder with hyperactivity, (2) attention deficit disorder without hyperactivity, and (3) attention deficit disorder residual.2 In 1987, the American Psychiatric Association2 adopted the new, inclusive term, attention deficit hyperactivity disorder.

Some clinicians and authors imply that the edu-cational problems in these children are caused by their attention deficit.3 Although attention deficit disorder may infrequently occur in isolation, it is more commonly manifested as one of a series of symptoms associated with disorders of higher con-tical functioning that include disturbances in move-ment, cognition, communication, and social com-petence.

Many educators and physicians do not realize that a differential diagnosis exists for these behav-ions much as it does for any other complex of symptoms. To establish an accurate diagnosis, in-formation must be obtained on factors such as: (1) the child’s birth, developmental, family, medical, psychosocial, and scholastic history; (2) sensory screening (ie, vision and hearing), and (3) a

physi-This statement has been approved by the Council on Child and Adolescent Health.

The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Van-ations, taking into account individual circumstances, may be appropriate.

PEDIATRICS (ISSN 0031 4005). Copyright © 1987 by the American Academy of Pediatrics.

cal, neurologic, and neunomaturational examina-tion.

As was originally stated by the Council on Child Health,’

The use of drug therapy in the management of the hyperkinetic child does not differ appreciably from drug therapy in other treatable maladies. In both instances prescription drugs should be prescribed only by appro-priately licensed physicians. Although the screening of

patients may frequently be done by other disciplines, the

ultimate selection of patients to be treated remains the responsibility of the prescribing physician.”

INDICATIONS AND USE OF MEDICATION

Medication may be indicated when a child man-ifests signs of an attention deficit such as short attention span, easy distractibility, impulsive be-havion, restlessness, and overactivity that interferes with his on her ability to learn. Such symptoms may result, in academic failure, inability to fulfill intellectual potential, or socially maladaptive be-havior leading to impoverished interpersonal rela-tionships.

Drug therapy is considered by some to be a pan-acea or cure-all. Educators sometimes recommend that a child be medicated for attention deficit dis-order. Unfortunately, some children are treated with a stimulant drug for prolonged periods of time without an adequate diagnostic evaluation or fol-low-up. Evaluating the effects of therapy on a neg-ulan basis must be part of any treatment plan.

Medication for children with attention deficit disorder should never be used as an isolated treat-ment. Proper classroom placement, physical edu-cation programs, behavior modification, counseling, and provision of structure should be used before a trial of pharmacotherapy is attempted. This inte-grated approach should continue once the medica-tion has begun.4 Medication should never be used unless it is clearly indicated for a child with an attention problem that significantly affects school performance on that is associated with a significant behavior disorder.

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AMERICAN ACADEMY OF PEDIATRICS 759

RECOMMENDED DRUGS AND DOSAGE

LEVELS

The medications used most effectively and fre-quently in the treatment of attention deficit disor-C den are the stimulants methylphenidate

hydrochlo-ride, dextroamphetamine sulfate, and pemoline. These drugs result in significant improvement in

70%

to 80% of affected children.3’5’6 The necom-mended initial dose usually given twice daily for methylphenidate is 0.3 mg/kg with a gradual in-crease to 0.6 mg/kg. The maximum dose, if re-quired, is 0.8 mg/kg. Most investigators have dem-onstrated that doses of methylphenidate greater than 1.0 mg/kg may cause a decreased performance

in attention testing and memory.3 Attention com-ponents and behavioral changes should be closely monitored at home and at school. The use of a qualitative rating scale as a baseline for behavioral observations is advisable before starting treatment and should be continued thereafter on a regular

basis.3’7’8

Dextroamphetamine and methylphenidate are manufactured as short- and long-acting medica-tions. (The recommended dose of dextroampheta-mine is one half that of methylphenidate.) When using the short-acting form, it is often necessary to add additional doses at noon or later in the day. Recently, methylphenidate has also become avail-C able in a sustained release tablet. Results with these long-acting preparations have generally been dis-appointing. They offer no clear benefit over the short-acting preparations.3

Pemoline, when administered at a dose of 2.25 mg/kg/24 h, seems to be as effective as methyl-phenidate and dextroamphetamine. It is given once a day in the morning and takes up to 3 to 4 weeks to achieve a clinical effect.

OTHER POTENTIALLY USEFUL DRUGS

Tnicyclic antidepressants also ameliorate the symptoms of attention deficit in selected patients.9 The most commonly used drugs are imipramine and desipramine. These do not seem to work as consistently in young children as do the stimulants. However, tnicyclic antidepnessants may be helpful and more useful than continued administration of stimulants in olden children and young adults who have become withdrawn and depressed after expe-niencing years of school failure on poor social ad-justment.

C ADVERSE EFFECTS

The two most common side effects of stimulant medications are transient wakefulness at night and

loss of appetite. Abnormal involuntary movements

and depression may also occur. There was fear that stimulant medications would lead to growth retardation’#{176}; however, growth suppression is only minimally related to stimulant dosage.” Results of a study indicated that no growth suppression oc-curred at doses of methylphenidate up to 0.8 mg/ kg during a prolonged period.’2 Other research has shown that methylphenidate does not cause an alteration in the

hypothalamic-pituitany-somato-medin axis.’3

Pemoline may cause a hypersensitivity reaction and abnormal liver function test results.

Stimulant drugs can exacerbate the symptoms of other disorders. Among these conditions are mul-tiple tic disorders (eg, Tounette syndrome),’4 psy-chiatnic disorders (eg, schizophrenia and

depnes-sion), and pervasive developmental disorders, in-cluding autism.

Drug holidays on weekends and summers have been suggested for some children. The premise is to maximize the effect of the medication when it is most needed while minimizing any possibility of interference with growth. Because the symptoms of attention deficit disorder may not disappear during vacations on weekends, one must prescribe on an individualized basis. Medication should be contin-ued when the child’s impulsiveness, activity, and other traits result in significant socially maladap-tive behaviors toward family and peers.

RECOMMENDATIONS

There are definite indications for drug therapy in the treatment of attention deficit disorder. Care-ful evaluation of patients is essential for drug treat-ment. Monitoring and follow-up both at school and at home are vital; pediatricians must work in con-cert with parents, principals, teachers, special edu-cators, and school nurses. In view of requests from other professionals and school personnel to pre-scribe medications for hyperkinetic children, pedia-tnicians should be cautious of becoming surrogate prescnibers of medications. It is important to ne-member that “the overall management of school failure may well be a multidisciplinary venture, but the ultimate responsibility for chemical behavior modification is the physician’s.”

COMMITTEE ON CHILDREN WITH DISABILITIES, 1986-1987

Herbert J. Cohen, MD, Chairman Robert F. Biehl, MD

Lucy S. Cram, MD Julian S. Haben, MD Alfred Healy, MD Avrum L. Katcher, MD

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Sonya G. Oppenheimer, MD James M. Pernin, MD

Liaison Representatives Thomas R. Behnens, PhD Ross Hays, MD

Andrea Knight

Section Liaison

Barry Russman, MD

Bram Bernstein, MD

COMMITTEE ON DRUGS, 1986-1987 Robert J. Roberts, MD, PhD

Ralph E. Kaufman, MD

Bernard L. Mirkin, MD Barry H. Rumack, MD Wayne Snodgrass, MD

Stephen P. Spielberg, MD, PhD

Liaison Representatives

Donald R. Bennett, MD, PhD Paul Kaufman, MD

Martha M. Freeman, MD Martin L. Pennoll, MD Sam A. Licata, MD

Mary Lund Mortensen, MD Sumner J. Yaffe, MD

Section Liaison

Cheston M. Berlin, MD

C

C

760 ATTENTION DEFICIT DISORDER

REFERENCES

1. American Academy of Pediatrics, Council on Child Health: Medication for hyperkinetic children. Pediatrics 1975; 55:560-562

2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 3. Washington, DC, Amen-ican Psychiatric Press, 1980

3. Shaywitz SE, Shaywitz BA: Neurochemical correlates of attention deficit disorder. Pediatr Clin North Am

1984;31:387-397

4. McDaniel KD: Pharmacologic treatment of psychiatric and neurodevelopmental disorders in children and adolescents (part 1). Clin Pediatr 1986;25:65-71

5. Barkley RA: A review of stimulant drug research with hy-peractive children. J Child Psychol Psychiatry

1977;18:137-165

6. Ottenbachen KJ, Cooper HM: Drug treatment of hyperac-tivity in children. Dev Med Child Neurol 1983;25:358-366 7. Conners CK: Rating scales for use in drug studies with

children. Psycho Pharmacol Bull 1973, pp 24-9

8. Ottinger DR, Halpin B, Miller M, et al: Evaluating drug effectiveness in an office setting for children with attention deficit disorders. Clin Pedwtr 1986;24:245-251

9. Garfinkel BD, Wender PH, Sloman L, et al: Tricyclic

anti-depressant and methylphenidate treatment ofattention def-icit disorder in children. J Am Aced Child Psychiatry

1983;22:343-348

10. Safer JD, Allen R, Barr E: Depression of growth in hypen-active children on stimulant drugs. N EngI J Med 1972;287:217-220

11. Roche AF, Lipman RS, Overall JE, et al: The effects of stimulant medication on the growth of hypenkinetic chil-dren. Pediatrics 1979;63:847-850

12. Kalachnik JE, Sprague RL, Sleaton EK, et a!: Effect of methylphenidate hydrochloride on stature of hyperactive children. Deu Med Child Neurol 1982;24:586-595

13. Schultz FR, Hayfond JT, Wolraich ML, et al: Methylphen-idate treatment of hyperactive children: Effects on the hy-pothalamic-pituitary-somatomedin axis. Pediatrics 1982; 70:987-992

14. Lowe TL, Cohen DJ, Detlor J, et al: Stimulant medications precipitate Tourette’s syndrome. JAMA 1982;247:1168-1169

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1987;80;758

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Medication for Children With an Attention Deficit Disorder

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1987;80;758

Pediatrics

Medication for Children With an Attention Deficit Disorder

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