CCPR: You noted that effects can be different for younger children. How is this addressed?
Ms. Vaughan: The younger the patient, the lower the starting dose we will use, and the slower we will go in titration because there is a difference in clearance from the body of, for example, a dose of methylphenidate. The Preschool ADHD Treatment Study (PATS) showed that there is a difference in how little ones metabolize medicine and how quickly it is out of their system. Clearance of a single dose of methylphenidate was slower in children in PATS than in children in the MTA study (Wigal et al, J Child Adolesc Psychopharmacology 2007;17:53-164). That data is on children between three and five (Greenhill et al, JAACAP 2006;45:1284- 1293). For them start low, go slow. The younger the child, the more likely we are to start with behavioral interventions, school interventions, and skills training before we go to medication. If the ADHD is significant enough that it needs to be treated, then we use the smallest doses, and the immediate release medicines, because the duration of action is shorter. We also consider whether the medicine comes in a liquid or something they can chew if swallowing a pill might be something that a three- or a four-year-old isn’t capable of.
CCPR: Is giving the child “medication vacations” an important part of the prescription process?
Ms. Vaughan: The answer to that question can go one of two ways. If you are looking at a child who may have some side effects—and specifically those involving appetite or affective flattening where they aren’t the cheerful, bubbly, sparkly kid that everybody loves—we may say when they don’t need the medication, we can hold it, or have the child take it on school days only and not on weekends or during the summer. Some children have symptoms that need treatment seven days per week. Your question emphasizes what we need to do as clinicians to make sure that the patient still needs the treatment. We need to be constantly evaluating: “What is the child like when the medicine is working, and then when it wears off? Is this still something that the child needs in order to function and be part of the family and his/her social circle and do well in school?”
CCPR: Does that typically involve education of family for younger children on how to collect that information and be good reporters?
Ms. Vaughan: Absolutely. Family, teachers, babysitters, grandparents—those additional reporters provide invaluable information to have in assessing how patients are doing. With regard to behavioral and school interventions, if the environment is structured enough and consistent, kids may not need medication.
CCPR: Are there still concerns about the cardiac risks of stimulants?
Ms. Vaughan: There were reports questioning whether the risk of sudden death in children who were taking Adderall or amphetamines for ADHD is higher than the risk for children in general (Gould et al, Am J Psychiatry 2009;166:992-1001). We know that stimulants can increase heart rate and blood pressure, and alpha adrenergics can affect heart rate and blood pressure as well as produce potential effects on the heart rhythm that we want to monitor closely (Perrin et al, Pediatrics 2008;122:451-453). If we have a child with a history of a congenital abnormality or cardiac issue—any kind of murmur, fainting, syncope—we refer them to their pediatrician or to pediatric cardiology for an assessment first. Also, if there is any history in the family of sudden cardiac death we might want to get an okay from a cardiologist before we treat them.
We need to be constantly evaluating: “Is this still something that the child needs in order to function and be part of the family and his/her social circle and do well in school?”
~ Brigette Vaughan, APRN, MSN
CCPR: Are there other risks related to medication that prescribers ought to be aware of?
Ms. Vaughan: I think we all need to be alert for signs of abuse or diversion with controlled substances. Unfortunately, we have to have a high degree of suspicion sometimes. Not being afraid to ask those questions is a good thing. The other thing is to make sure we know what we are treating. I recently coauthored a paper on treatment-refractory ADHD, and a lot of what we found calls for making sure we are treating what we think we are treating: is this truly ADHD or are these symptoms of another disorder? Once someone is on medicine we want to make sure that we don’t mistake a side effect for a symptom of something else, or that we don’t miss another disorder and say “Oh that is just ADHD.”
CCPR: For readers who want to keep up with medication effects, are there resources that you would recommend as particularly good sources of ongoing information?
Ms. Vaughan: I think the American Academy of Child and Adolescent Psychiatry website, parentsmedguide.org, is very up-to-date. It is reviewed by experts in the field and is written very objectively and thoroughly. It is also a good resource for parents and for teachers because it explains things in language that is easy to understand.
CCPR: Thanks very much for sharing your experience with ADHD medications.