Prescribing options to treat ADHD

New drug treatment for ADHD may help to control the condition, says Dr Anne Thompson

An estimated 5 per cent of children in the UK have attention-deficit hyperactivity disorder (ADHD), a neurodevelopmental disorder characterised by poor concentration, hyperactivity and impulsivity present since early childhood.

A child with one neurodevelopmental disorder is likely to have others, including autistic spectrum disorder, tics or learning difficulties.

An increased spectrum of medications is allowing specialists to find treatment regimens to match the needs of individual children, leading to sustained benefits for their concentration span, behaviour and self-esteem.

Drug treatment does not modify the underlying developmental deficit, which naturally improves with age in most children, but it can suppress the core symptoms of ADHD.

Following the publication of a NICE Technology Appraisal last year, drug treatment should only be initiated by an appropriately qualified healthcare professional with expertise in ADHD, and after a comprehensive assessment and diagnosis. Maximum benefit is gained by titrating and monitoring the treatment.

Recent guidelines suggest that medication should be the first-line treatment for children who have severe ADHD. This is a change in practice for UK child psychiatrists trained in earlier decades, who will have previously tried behavioural management first in all cases.

Milder forms of ADHD should be managed with parent training and behaviour modification techniques with, using medication only if these approaches do not produce adequate improvement.

First-line treatment
Until five years ago, the choice of first-line medication was limited to two immediate- release (IR) psychostimulants: IR methylphenidate and dexamfetamine. IR psychostimulants act within about

30 minutes of taking medication but last only three to four hours, so three-times daily treatment is usually necessary.

The side-effects of psychostimulants can be loss of appetite, initial weight loss, abdominal discomfort and headaches. Unpleasant dysphoria occurs in some younger children and may lead to treatment being abandoned.

Specialists monitor children regularly for signs of growth restriction or hypertension, but periodic blood tests are no longer recommended.

I tell children that the tablets help to give them more thinking time, which will help them make good choices about their behaviour.

Recent developments
Methylphenidate and dexamfetamine were previously supplied in one strength of tablet, and were difficult to break in half. However, 5mg and 20mg tablets of IR methylphenidate are now available and these are much more convenient.

Another recent development is the modified-release methylphenidate preparations that are taken once a day.

There are many obstacles to good compliance with any medication, particularly if it has to be taken during school lunchtimes. Adolescents with ADHD typically have poor organisation and are prone to forgetting to take medication. Many families prefer once-daily treatment regimes.

Modified-release preparations are also the treatment of choice when there is a risk of medication being sold on, as they cannot be easily crushed.

The Concerta XL preparation is active for 12 hours and is a potential choice for young people in secondary school as it avoids lunchtime administration and covers the early evening homework period.

The alternative modified-release preparation, Equasym, XL, is active for eight hours and releases a greater bolus of IR drug to assist settling at the start of the school day.

Not all children experience adequate control of ADHD symptoms from modified-release medication. If the drug is effective but wears off too soon, specialists may prescribe a second dose of IR methylphenidate to be taken in the afternoon. Some children do not get good control of ADHD symptoms at any time of day and may switch back to IR medication.

Atomoxetine is a noradrenaline reuptake inhibitor, not a stimulant. Potential benefits of choosing this drug include 24-hour symptom control and improved sleep. Side-effects are similar to those of psychostimulants. It takes at least a month to see the full benefit from this drug. Adequate dosage calculated according to body weight is said to be important for maximum efficacy.

NICE suggests that continued prescribing and monitoring of drug therapy for ADHD may be carried out by GPs under shared-care arrangements. Guidance on management of controlled drugs (www.dh.gov.uk/controlleddrug) suggests only 30 days supply of psychostimulants should be prescribed at a time.

Some children seem sensitive to changes in the brand of psychostimulant medication and have poorer symptom control on one preparation compared with another. It is therefore best to prescribe the same preparation that was initiated by the specialist.

 Dr Thompson is a consultant child and adolescent psychiatrist at the Lincolnshire Partnership NHS Trust, Lincoln

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