Medication in attention deficit hyperactivity disorder and adhd with Autistic Spectrum Disorder (ASD)

Medication in attention deficit hyperactivity disorder and adhd with Autistic Spectrum Disorder (ASD)

Available online at www.sciencedirect.com Procedia Social and Behavioral Sciences 5 (2010) 655–497 655–659 WCPCG-2010 Medication in attention defic...

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Available online at www.sciencedirect.com

Procedia Social and Behavioral Sciences 5 (2010) 655–497 655–659

WCPCG-2010

Medication in attention deficit hyperactivity disorder and adhd with Autistic Spectrum Disorder (ASD) Bohane L.,Young. M., Rowlandson.P. a

Oak House Multi-Agency Centre, Halberry Lane, Newport, Isle of Wight, PO30 2ER Received January 14, 2010; revised February 3, 2010; accepted March 12, 2010

Abstract We have developed an inter-agency referral and assessment process for children with behaviour problems. ADHD is diagnosed using the DSM IV criteria (DSM IV, 1994). During the period 1st June 2001 to 1st May 2008 303 children and young people with ADHD were entered on to the database. We set out to compare two time lines: 1st May 2007 and 1st May 2008. On 1st May 2007, 37.6% of patients were on LAMPH and 42.5% were on ATX. One year later 53.5% were on LAMPH and 17.5% were on ATX. Methylphenidate continues to be the drug of choice in the management of ADHD. © 2010 Elsevier Ltd. All rights reserved. Keywords: Attention Deficit Hyperactivity Disorder (ADHD), long acting methylphenidate (LAMPH), atomoxetine (ATX).

1. Introduction Over the past 70 years, doctors have used medication to help manage the core symptoms of ADHD. The mainstay of treatment until 10 years ago was stimulant medication such as methylphenidate (MPH). Non-stimulant medication has recently become more popular in the form of Atomoxetine (ATX) The National Institute for Clinical Excellence Guidelines (NICE, 2008) were published in 2008. We set out to look at the situation in our clinic. We have the impression that the overriding factor in determining which medication the child or young person uses is parent and patient choice, rather then severity of symptoms. 2. Methods The service for children with ADHD and Autistic Spectrum Disorder (ASD) on the Isle of Wight is described elsewhere (Rowlandson & Smith, 2009) Each child seen in ADHD clinic was added to a database. We now have 303 patients on the ADHD database, with varying degree’s of severity of symptoms. See tables 1 and 2.

1877-0428 © 2010 Published by Elsevier Ltd. doi:10.1016/j.sbspro.2010.07. doi:10.1016/j.sbspro.2010.07.160

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Bohane L. et al. / Procedia Social and Behavioral Sciences 5 (2010) 655–659 Table 1. Patient information

ADHD diagnosis

Males (n=258)

Females (n=45)

TOTAL

69

15

84

Under 11 Over 11

Subtotal ADHD+ASD diagnosis

Under 11 Over 11

98

13

111

167

28

195

33

7

68

58

10

40

Subtotal

91

17

108

TOTAL

258

45

303

Table 2. Severity of symptoms Males (n=258) Mild Symptoms*

49

13

62

Over 11

49

11

60

98

24

122

Under 11

36

7

43

Over 11

56

2

58

92

9

101

Subtotal Severe Symptoms*

TOTAL

Under 11

Subtotal Moderate Symptoms*

Females (n=45)

Under 11

20

2

22

Over 11

48

10

58

Subtotal

68

12

80

TOTAL

258

45

303

*Severity characterised by: Mild - ADHD symptoms do not lead to exclusion from school, or cause disruption to family life. Moderate - Suffering impairment at school, and/or short term exclusion, family life difficult but not unbearable. Severe - Facing permanent exclusion from school, and/or parents requesting respite care from social services.

When choosing medication, our starting point is the NICE guidelines. In moderate and severe cases, medication is recommended. In conjunction with drug treatment, we provide behavioural support and dietary advice. Outcomes are discussed in clinic in terms of attendance at school, academic performance, and we use the Dundee “difficult times of day” rating scale (Coghill, 2006) 3. Results It can be seen in figure 1 that a higher percentage of children were on medication in 2008 compared with 2007. The more striking difference was that the use of ATX had fallen from 53.5% to 17.5% in 2008 and the use of LAMPH had risen from 37.6 % to 53.5%. This was due to the fact that parents of children on ATX reported: no apparent effect at all (1/3) headaches or gastro-intestinal side effects (1/3), or emotional upset, excessively weepy and/or aggressive (1/3).

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Bohane L. et al. / Procedia Social and Behavioral Sciences 5 (2010) 655–659 (Legend: in the following graphs percentage of children is on the vertical axis, medication on the horizontal axis. SAMPH: short acting methylphenidate; LAMPH long acting methylphenidate; ATX atomoxetine; RISP risperidone; MEL melatonin.)

Percentage of patients (%)

60

53.5

50 42.5

40

37.6 33

2007

30

23.1 18.8

20 11.9

10 0

32.7

17.5

22.7

2008 20.7

15.8

14.5

6.6

No med icat io n

SA M PH

LA M PH

ATX

RISP

LA M PH + RISP

M EL

Medication

Figure 1. Medications prescribed in 2007 and 2008 (many children were on a combination of the above medications)

There were a higher percentage of males than females on medication (see figure 2). The striking difference was that females seemed to respond better to ATX than males.

Percentage of children (%)

60

55.8

50 40

40

35.7

35.6 32.2

31.1

30

24.4 19.8

20 11.6

13.3

15.1

13.3

17.8 13.3

10 0 No medication

SA MPH

LA MPH

ATX

RISP

LA MPH + RISP

Medication

MEL MALE (n=258) FEMALE (n=45)

Graph 2. Prescribed medication differences in males and females, in 2008

With regard to severity, those patients presenting with more severe symptoms, are more likely to be prescribed LAMPH or a combination of LAMPH and RISP (see figure 3) Atomoxetine is prescribed more commonly in those with mild symptoms.

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Bohane L. et al. / Procedia Social and Behavioral Sciences 5 (2010) 655–659

P ercentage of Children (%)

70

63.8 57.5

60 50 49.5

50

45 39.6

40

35.6 36.3

33.7

30

24.8

23

20

13.9 13.9

11.3

Moderate (n=101) Severe (n=80)

15.8

13.8 9.8

10

27.9

Mild (n=122)

11.5 6.6

6.25

0 No medication

SA MPH

LA MPH

ATX

RISP

LA MPH + RISP

MEL

Medication Figure 3. Prescribed medication compared to severity of symptoms

The outcome data suggests that the severity of symptoms improved in approximately 70% of males and 62% of females on medication (figure 4). Symptoms were monitored in regular clinic attendance.

Percentage of children

80 70

6 8 .6 6 2 .2

60 50

Male

40

Female

30

2 4 .4 19

20 9 .7

10

8 .9 2 .7

4 .4

0 better

worse

no change

unknown

Behaviour change Figure 4. Behaviour change following medication

4. Discussion In a condition such as ADHD adherence to medication is clearly going to depend 100% on the child and their parents, not only understanding, but agreeing with the rationale for medication, the therapeutic expectations and the possible side effects.

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A very high proportion of parents will have heard of methylphenidate and will be aware of concerns expressed in the popular press. When offered an alternative (ATX) which claims to work throughout the 24 hours, has an excellent side effect profile, and which is taken only once a day, many parents would opt for that medication; even allowing for the fact that it may take up to 6 weeks to have an effect. However, in real life 59% of those children who had started on ATX were withdrawn from the medication, due to lack of efficacy or side effects. A greater number of males were prescribed risperidone than females. The main indication for starting risperidone in our clinic is anxiety and aggression; it is not used to treat the core symptoms of ADHD. Risperidone is therefore used more commonly in children with a co-morbid diagnosis of ADHD and ASD. Some of the side effects of methylphenidate are ameliorated by the addition of risperidone. The beneficial effects and side effects of these medications become apparent very rapidly. Fine-tuning of the medication is therefore easier A similar amount of Melatonin was prescribed for both genders. It was very effective in the majority of patients and we experienced almost no side effects. 5. Summary In real life the decision to start medication and which medication, is largely based on parent choice. In our clinic, methylphenidate is the mainstay of treatment. Atomoxetine is a very useful drug, but not in the majority of cases. References Coghill, D. (2006) Dundee Difficult Time of the Day Scale (D-DTODS). University of Dundee. DSM-IV (ed.) (1994) Diagnostic and statistical manual of mental health disorders. 4th edn. Washington, D.C.: American Psychiatric Association. National Institute for Health and Clinical Excellence (2008) Attention Deficit Hyperactivity Disorder: diagnosis and management of ADHD in children, young people and adults. clinical guideline 72. National Institute for Health and Clinical Excellence. www.nice.org.uk Rowlandson, P.H., Smith, C. (2009) An interagency service delivery model for autistic spectrum disorder and attention deficit hyperactivity disorder. Child: Care, Health and Development, volume 35, issue 5, 681-690