Is Medication for ADHD (Attention Deficit Hyperactivity Disorder) child necessary? (ADHD Part -I)

Do you know ADHD occurs in about 5% to 7% children? If a child behaves a little different from others, then teachers recommend them to be taken to the psychiatric counsellors. The counsellor might diagonise the disorder as ADHD (Attention Deficit Hyperactivity Disorder).

There are many concerns among parents: Whether we should take the child for a counselling section? If the counsellor says that the child has to take medicine, then do we really have to follow the advice? Is Medication for ADHD (Attention Deficit Hyperactivity Disorder) child necessary? Will there be any side-effects of the medication? Will the child be branded as mentally unfit, if he goes for the counselling sections?

I had a discussion with Dr. Varghese Punnoose, an MD in Psychiarty regarding ADHD (Attention Deficit Hyperactivity Disorder) and its medication. He discussed every aspect of the disorder from the symptoms to the medication and the misunderstandings. Dr. Punnoose is specilaised in Child Psychiatry.  He is currently  Professor and Head of Department at Government Medical College, Kottayam, Kerala. 

Read on to know more about Medication for children with ADHD………..

When do you prescribe medicine for children with ADHD?

In moderate to severe ADHD, we give the option of medication to the parents. Medications are not prescribed on the first day that the child comes to us. The medication is suggested only after two or three sitting. After a complete assessment, if the child needs medication, the parents have to take the decision. The child is a minor by legal terms and they cannot take a decision on their own. And we do not force our decision. We give a recommendation of medication as an evidence-based scientific option. Medications available in India are mainly two types – Methylphenidate, a stimulant group of medication and Atomoxetine.

What are the concerns parents have regarding the medications?

Many a times parents are apprehensive about the medicines that the doctor prescribes for hyperactivity. They are doubtful that the medicines are sedatives which will damage the child’s brain or make him dull and sleepy. Or the child may develop some addiction or dependence on medication.

[third] These are much-distorted facts which are being propagated partly from ignorance and partly from some vested interest.[/third]

These are much-distorted facts which are being propagated partly from ignorance and partly from some vested interest. These medicines are specifically developed by scientific authorities with evidence for their efficacy as well as safety. They are used all over the world. Methylphenidate is available in the last thirty/forty years. Atomoxetine is available for the past 10-15 years.

Is there any benefit of the medication?

They will not cure ADHD, but they will correct some of the symptoms of ADHD. 70% of the children will improve attention span. The child will be able to hold attention for a long time.  They can bring down hyperactivity not by sedating but by bringing down the extra overactivity. The brain gets a better control of motor activity.

[third] Most of the side effects are not serious, that is why these medicines are approved for paediatric treatment.[/third]

There is no sedation or tranquillizing. The brain gets more ability to control the impulses. So the attention span improves that translates to improvement in academic functions. Hyperactivity and impulsivity in reduced. That translates to improvement in behaviour. 60%-70% children get benefitted from medication.

Will the medications cause any side effects?

Of course, they produce side-effects. But no major side effects like brain damage or addiction. Most of the side effects are not serious, that is why they are approved for paediatric treatment.

Government is very strict about approving medicines for paediatric cases. These two molecules have passed all the tests, and they are time-tested.

Loss of sleep

The possible adverse effects that we come across are if we give methylphenidate as a night time dose. The medicine will interfere with sleep. Usually, they are given as daytime dose – one in the morning or one in the afternoon.

Loss of appetite

The second problem is that they may produce loss of appetite and weight loss. In some children, it may produce anorexia, loss of appetite. But again it is for a limited period. After a few weeks, they will get out of it.

Growth retardation

There were apprehensions that use of Methylphenidate could result in growth retardation. But long-term follow-up studies have not demonstrated any significant growth retardation in children on Methylphenidate. However, height monitoring is recommended.

What is the consequence if the medication is withdrawn?

If at all the parents are worried, then there is no problem in withdrawing the medicines or discontinuing the treatment. Very rarely some children may develop liver dysfunction or some other issues for which the children are carefully monitored. But practically we do not come across such issues.

How long to continue medication?

There is no clear-cut answer because we cannot prescribe the medicines are not like a course of antibiotics for the infection. This is a system dysfunction which varies from child to child.

Initially, the children are monitored weekly, then monthly, then once in three months, once in six months. And if the attention span in improving and ADHD score is coming down and the child is able to manage without medication, then the child may not require medication.

[third] If you discontinue, the only thing is that some advantage that you would get from the medication.[/third]

In most of the cases, children are diagnosed with ADHD when they are in fourth standard, fifth standard or sixth standard. And they may continue medication up to ninth, tenth or eleventh also. That varies from person to person. There is no worsening.

Sometimes parents are apprehensive that if they stop the medication then thinks will become worse. Nothing like that happens. Only thing is that some advantage that you would get from the medication will not be there if you discontinue.

Why there are some apprehensions regarding the medications?

There are apprehensions about methylphenidate, the stimulant group of medications. Methylphenidate can be abused by adults that is why there is a lot of restriction on prescription. Only a qualified psychiatrist can prescribe this medication. Because of the restriction, parents are worried that this is a very dangerous component. The abuse potential in the paediatric case is nil. This has been used for the past three or four decades.

Atomoxetine does not have such restriction for the prescription. Deciding which medication to give for the child is a clinical decision. There are conditions where we prefer methylphenidate and there are conditions where we prefer atomoxetine.

Is it compulsory to take Medication for ADHD (Attention Deficit Hyperactivity Disorder) child?

We always tell the parents that medication is not the only thing; it is part of the whole package. The main emphasis is on educating the parents and teachers and encouraging the child. All are involved to improve the behaviour of the child. In moderate to severe cases medications are used so as to take away the biochemical block. If the medication is taken then the behavioural therapy becomes more effective. But if the parents are unwilling then they are not forced to take medications.

What about suicidal behaviour due to Medication?

Suicidal behaviour is not related to ADHD. Impulsive behaviour may lead on to impulsive self-injurious behaviour. However, there are no such reports in India. Whenever there is such reporting it will be put to stringent examination by authorities like The Food and Drug Administration (FDA), of the United States of America. And if at all there is the slightest suspicion of such kind of a problem they will immediately order to suspend/ban the product.

[third] If at all there is the slightest suspicion of such kind of a problem authorities like FDI will immediately order to suspend/ban the product.[/third]

The first common cause of death in adolescence is accidents, the second is suicide. For an adolescent to commit suicide there can be a large number of factors.  If the child was on a medication when he committed suicide then that has to put for scientific scrutiny. None of the studies so far have shown such results, if in case there were any issues stringent measures would be taken. So far no instructions have come. In India, approval is there only for atomoxetine and Methylphenidate.

How long will the medicine remain the system after the medication is withdrawn?

It will be there in the blood for maximum two days. It is not going to be permanently deposited in the system.

Should medication continue in adulthood?

Almost 60 percent of the symptoms may continue. Whether medication is to be continued in adulthood is a very controversial topic. In our centre, we do not generally encourage medication for the adult. We leave it as an option for children and adolescents.

Why controversies regarding ADHD?

Controversies happen because of overdiagnosis of ADHD. From certain reviews, I find that overdiagnosis is done in certain provinces in the United States. From there the movement has come that children are being medicated unnecessarily. The overdiagnosis issue is not an issue in India. Here the issue in underdiagnosis.

Why there are advocacies against medications for ADHD?

There should be some advocacy to protect the right of the citizen. Children need protection. Advocacy is good because there will be checks and balances. The opposite result happens when deserving children, who should get the advantage of medication, are denied medication because of the stir.

[plain] Dr. Varghese Punnoose specilaised in Child Psychiatry. He is an MBBS and MD in Psychiatry from Government Medical College. He is currently  Professor and Head of Department at Government Medical College, Kottayam, Kerala.

He authored a book ‘Manorogangal’, in malayalam, about Pshycatric disorders. There is one chapter on ADHD also. [/plain]

READ MORE…

What is the behavioural approach used in ADHD? (ADHD Part -IV)

What is the behavioural approach used in ADHD? (ADHD Part -IV)

What is the behavioural approach used in ADHD? (ADHD Part -IV)