Child Psychology and Psychiatry

Middle childhood
Institute for Health and Clinical Excellence [15].
Although there are short-term therapeutic effects
of ADHD medication, there is uncertainty about
long-term benefits [16]. Once medication has
been started, the child’s physical health, includ-
ing weight and height, and ADHD symptoms
need to be monitored regularly and the dosage
titrated accordingly (Figure 25.1). The potential
advantages of using medication are an initial
rapid reduction in core symptoms; this could help
children and parents better utilize non-medication
strategies, and reduce immediate stress at home
and school, which could avoid an escalation of
problems leading to school exclusion and family
breakdown in the short term. Disadvantages
might include an over-reliance on medication
alone, side effects, or repeat prescribing over
years without consideration of whether there are
continued benefits and whether there is the need
for additional new non-medication interventions.
Stimulants
Methylphenidate and dexamfteamine are central
nervous system stimulants. The mode of action of
methylphenidate is not entirely clear, although it
appears to result in an increased dopamine concen-
tration in the synaptic cleft by partially blocking the
dopamine transporter (DAT). Methylphenidate is
rapidly absorbed, reaching maximum plasma levels
1– 4 hours after oral administration (see Figure 25.1
for the treatment regimen). Sustained-release for-
mulations with a therapeutic effect of 8–12 hours
are also available, making single daily dose admin-
istration possible. The main advantage is that the
child does not have to take medication at school,
reducing problems with storage of tablets and asso-
ciated stigma for these children. Dexamfetamine
also enhances dopaminergic neurotransmission in
the central nervous system. The elimination half-
life of dexamfetamine allows once- or twice-daily
oral administration. The recommended starting
dose for treatment of ADHD depends on the age
of the child (see Figure 25.1).
Frequent short-term side effects of stimulant
drugs include:
•
decreased appetite
•
sleep disturbance, such as insomnia
Confirmed ADHD Diagnosis
Stimulants
Non-stimulant
Methylphenidate
Start at 5 mg twice
or three times a day
Start at 2.5 mg daily
(3 to 5-year-olds)
or
5 –10 mg/day
(> 6 year old)
Start at
0.5 mg/kg/day
(Minimum 7 days)
Monitor regularly
Max. 60 mg/day
Monitor regularly
Max. 20 mg/day
Monitor regularly
Maintenance dose
1.2 –1.8 mg/kg/day
Titrate the dose by
increasing
5 – 10 mg/week
according to
response
Titrate the dose by
increasing
2.5 mg/week
according to
response
Titrate the dose and
evaluate after
4 – 6 weeks
According to
response
Consider long-acting
preparations
Dexamfetamine
Atomoxetine