The Delta Kappa Gamma Bulletin 19

ADHD Treatment and Medication:What Do You Need to Knowas an Educator?

LciVonne Kirkpairick

M o w Attention Deficit Hyperactivity Disorder (ADHD) can best be treated is a matter ofintense debate. Typically, current treatments involve medication, behavioral therapy or both.Edueators need to be aware of the pros and cons of stimulant medication. They also shouldrealize that the abuse and misuse of ADHD tnedications are real. The author shares knowl-edge teachers need in order to be more informed about ADHD and to work more effectivelywith ADHD children and families.

Louring your teaching career, you may havefelt challenged and uncertain in workingwith a child who was not paying attention,couldn't seem to sit still, and was not learn-ing in the classroom setting. Perhaps youplaced a phone call OT a series of phone callsto parents voicing your concern. You mayhave had face-to-face conferences with themas well. Did the conversations result in par-ents asking a doctor about using stimulantmedication to help Iheir child in focusingand being more attentive? Were ihe terms

LaVonne Kirkpatrick, Ed.D.. has been president otboth Iota and Gamma lola Chapters. Arkansas, andrno.sl recently has completed a six-year term on iheKappa Slate Kducalioii Foundation Board of Trustees.She is an assistant professor in ihe Department uT Cur-riculum and Instruction at the tlniversity ol Arkansas.Fayetteville,

"ADD" or "ADHD" used?Attention Deficit Disorder (ADD) or

Attention Deficit Hyperactivity Disorder(ADHD)? Whieh is the right name? Whilethe condition has been known for over 100years, il has not always been called thesame thing.

As a result of studies conducted in the1970s and 1980s, researchers began torecognize the existence of different typesof attention deficit. Even though differenttypes have major differences, they are morealike than different. Consequently, doctorsbegan to see that different types are all partofthe same major condition.

The American Psychiatric Associationpublishes official guidelines for naming anddiagnosing mental disorders. This book,called Diagnostic and Statistical Manual of

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Mental Disorders {DSM), is updated regu-larly as more scientific knowledge is learned.In 1994. when DSM-IV was published, thename ADD (attention deficit disorder) was"officially" changed to ADHD because ofthe advance.s in research.'

ADHD is the most common behavioraldisorder in children. Professionals whodiagnose ADHD use the criteria of the DSM.The DSM-IV-TR, which is the most recentversion, classifies the disorder into the fol-lowing three subtypes:• Predominantly inattentive• Predominantly hyperactive/impulsive• Combined-

Some doctors and mental bealth profes-sionals, however, still continue to use thelerm ADD. If this is a .student's diagnosis.most likely he or she has the inattentive typeof ADHD. Such an individual is easily dis-iracted and jusi can't .seem to pay attention.Additionally, this child may be forgetful anddisorganized, as well as often appearing lobe daydreaming. This is definitely not theindividual described as "bouncing off tbewalls" or being "incapable of sitting still."

ADHD is the term currently being usedin diagnosing all subtypes of this disorder.Therefore, whether a student is primarilyinattentive, primarily hyperactive/impulsiveor a combination of the two. for simplifi-cation the term ADHD will be used whenreferring to this disorder throughout thisarticle.

Prevalence and ConsequencesADHD is far from a benign disorder.

According to the International ConsensusStatement on ADHD of January 20{)2. stud-ies suggest that those who have this disorderare far more likely than the general popula-tion to drop out of school (32-40 percent),to graduate rarely from college (5-10 per-cent), to have few or no friends (50-70 per-cent), to under perform at work (70-80 per-cent), to engage in antisocial activities (40-50 percent), and to use tobacco or illegal

Fall 2005

drugs more than the normal population. Inaddition, children growing up wiih ADHDare more likely to become pregnant as ateenager (40 percent), experience sexuallytransmitted diseases (16 percent), to speedexcessively and be involved in multiple caraccidents (20-30 percent), and to experiencedepression (20-30 percent) and personalitydisorders (18-25 percent) as adults.^

Approximately 3-5 percent of tbe school-aged population in the United States isthought to have ADHD, although someexperts would place the percentage at aneven higher rate. Being diagnosed as havingADHD increases the likelihood of havingseveral other problems as well. Individualswith ADHD are at risk for such conditionsas oppositional defiant disorder, conductdisorder. learning disabilities, anxiety anddepression. This phenomenon of coexistingconditions is referred to as comorbidity."*

Children with ADHD have been identifiedin every country in which ADHD has beenstudied. While it bas long been thought tbatADHD is mt>re common in boys than girls,recent research indicates that the actualnumbers may be almost equal.'' Boys withADHD are typically more aggressive thangirls. Therefore, girls are often older thanboys by tbe time they are diagnosed, andthey are less likely to be referred for treat-ment.^

TreatmentDe.spite these serious consequences, stud-

ies point out that less than half of thosewith tbe disorder are receiving treatment.As a teacher of ADHD children, you needto become more informed on this topic. Nodoubt you are well aware of how challeng-ing your job can be; you definitely want toobtain the very best possible information fortbe children in your classroom and their par-ents or caregivers.

How ADHD can best be treated is a mat-ter of intense debate. Typically, current treat-ments involve medication, behavioral ther-

The Delta Kappa Gamma Bulletin 21

apy or both. Although these traditional treat-ments are extensively used and well known,the following overviews on medications andtherapy may be helpful.

MedicationsIf a fatnily is considering medication for

their ehild. he or she should lirst undergo athorough, comprehensive assessment to clar-ify the diagnosis and to identify any othermedical, psychological or learning problemsthat may be present. Next, a treatment planshould be developed in consultation withthe physician or other medical/mental healthprofessional. In this planning stage all par-ties (child, family and medical professional)should work as a team to consider the vari-ous options available for treatment.

Stimulant medications are the most com-monly prescribed drugs to relieve ADHDsymptoms. Most popular are Ritalin. Methy-lin. Adderall. Dexedrine, Cylert, and Con-certa. Antidepressants such Desipramine,Imipramine, and Wellbutrin may be pre-scribed for children who don t respond tostimulant medications or who have otherpsychiatric problems. A third group of drugssometimes prescribed for ADHD childrenare anti-hypertensive or blood pressure-low-ering drtigs such as Clonidine orTenex.^

At the beginning of the medication trial,careful monitoring is essential. If the firstmedication is not helpful or produces nega-tive side effects, the prescribing professionalwill need to adjust the dosage or timing orboth. If the response is not positive afteradjustments are made, another medicationmay need to be tried.

According to the new treatment guidelinesfor ADHD from the American Academy ofPediatries, children may respond favorablyto one slimulanl but not another. As a result.physicians should not switch to a non-stim-ulant medication for treating ADHD untilIhe child has been tested on at least two orthree different stimulants across a full rangeof doses without showing any significantly

positive response."With over 150 controlled double-blind

studies of stimulant use in children withADHD, the findings concerning medicationtreatments are well documented. However,as a knowledgeable educator, you need to beaware of both the pros and eons of giving achild stimulant medication.

Several positive aspects of using stimulantmedications are among the following:1. These medications are relatively easy to

use and they work quickly. Theicfore,the parents and child (and you) willknow in a short period of time whetherthey are going to help or not. Short-act-ing preparations generally are effectivefor about four hours. Longer-actingnewer preparations are more variable,with some lasting up to ten or twelvehours. Since there ean be wide individ-ual variation, however, the exact last-ing effect of the medieation only willbecome known once the medication istried.

2. Evidence indieates stimulant medica-tions imprt)ve both behavior and schoolperformance.

3. The medications are relatively inexpen-sive.

4. Stimulants have been used as a treatmentfor many years, so doctors have consid-erable experience in prescribing them.

5. Medication may provide immediaterelief for a child who is about to beexpelled from sehool or whose family isexperiencing a "melt-down" under thestrain ofthe situation."^

Current evidenee indicates that stimulantmedications are safe and well tolerated bymost children. Most side effects occur earlyin the treatment, appear short-lived and usu-ally can be managed successfully throughadjusting dosage or by changing medica-tions. Medieation often can help a multi-modal (combination) treatment program bemore effective. Although no adverse effectsof long-term use of stimulant medications

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currently arc known, there is a definite needlor long-tertn safety studies,'* '̂

Stimulant medications, however, are notwithout negative aspects. As a teacher, youneed to possess this informalion so you canjilay a valuable role in providing feedback toparents or your student's physician. Some ofthese concerns are as follows:1. About 20 to 30 percent of children with

ADHD do not respond to stimulantmedication.

2. Children's appetites may be ,suppressedby stimulants, thereby initially affectinggrowth and normal weight gain.

3. A few children complain of frequentstomach aches and/or headaehes whiletaking stimulant tiiedication.

4. Some children may be especially diffi-cult to manage later in the day or eve-ning when the medication has worn off,

5. Children on stimulants also may havetrouble falling asleep.

6. A very small percentage of children onstimulant medication develop latenttics. These involuntary movements mayinclude eye blinking, shrugging, and/orclearitig of the thioat. It is estitnated that7 percent of ehildren with ADHD havetics or Tourette's syndrome, a chronicdisorder that involves vocal and motortics, while 60 percent of childten withTourette's have ADHD. Although recentresearch indicates the development ofTouiette's in children with ADHD is tiotrelated to stimulant medication, a cau-tious approach to using stimulants isreeomniended if there is a family historyof Tourette"s or tics."

7. Some children experienee etnbarrass-ment if they have to get their medicationfrom the nurse during the school day.

TherapyChildten with ADHD often benefit greatly

from behavior therapy or counseling, wbiehmay be provided by a psychiatrist, psychol-ogist, social worker, licensed professional

counselor, marriage and family therapist orother mental-healthcare professional. Psy-chotherapy, behavior therapy, family ther-apy, social skills training, parenting skillsttaining and support groups are atnong avail-able treatment options.'-

Through psychotherapy, older childrenand adults with ADHD talk about variousissues that are bothering them and explorenegative behavioral patterns they have beenexhibiting. In tbis way. they learn moreeffective ways to deal with their symptoms.Some individuals with ADHD also mayhave coexisting conditions, such as depres-sion and anxiety disoider. In these cases ofcomorbidity, counseling therapies may helpboth the coexisting problem as well as theADHD.

Behavior therapy helps both teachersand parents learn sttategies for dealing withthe behavior of ADHD children. Some ofthese contingency management proceduresinclude token reward systems and titiieouts.Behavior modification utilizing contingencymanagement strategies has proven especiallybeneficial for individuals with ADHD.

Since children with ADHD are not theonly ones affected by this condition, fam-ily therapy may assist both parents and sib-lings to deal with the stress of living with anADHD child. Parents, often feeling hope-less and alone, are depressed and frustratedwith the challenge of raising a child withADHD. Additionally, siblings are signifi-cantly affected and should be edueated aboutADHD. It is important to assure youngerbrothers or sisters that ADHD is not a trans-mittable disease in order to prevent fear oravoidance of the ADHD brother or sister.Older siblings also may need assistance inunderstanding the symptoms of ADHD andhow to help their younger ADHD sibling.Being more knowledgeable will help themto deal with unpleasant situations and toavoid embarrassment, especially in front oftheir peers,'^

Social skills ttaining can help children

The Delta Kappa Gamma Bulletin

learn appropriate social behaviors. Mostchildren with ADHD have great difficultyin developing and maintaining peer relation-ships, ADHD symptoms such as inattentive-ness or impulsivity certainly ean cause thechild to have difficulty displaying the appro-priate behaviors. However, even more prob-lematic is that the child often does not learnappropriate behaviors or social cues thatguide all of us in our social relationships.Sometimes it is necessary to relearn whatis appropriate, as well as to pay attention tosocial cues. For many children with ADHD,the ability to read body language is a con-cept they do not comprehend.

Training in parenting skills can assist theparents in developing ways to understandand guide their child's behavior. For exam-ple, the American Academy of Pediatricsrecomtiiends the following three principles:• setting clear and specific rules• providing consistent eonsequences for

inappropriate behavior and positiverewards for appropriate behavior

• using these rewards and consequenceson a regular and long-term basis.'"*

Structure also is vital for an ADHD child.These ehildren, in partieular, need a stable,daily routine and elear organization in thehome as well as at school. Even a simpleroutine that creates a designated place foritems such as backpacks and toys will savethe child and the parent a great deal of frus-tration.

Support groups offer ADHD children andtheir parents and families a network of socialsupport, informatit>n and education. In addi-tion, support groups aid parents in feelingless alone, allowing thetn to share their mis-takes, frustrations and successes with othersin similar situations.

Children and Adults with Attention-Deti-cit/Hyperacti\ity Disorder (CHADD) is oneof the better-known organizations servingindividuals with ADHD. Loeal CHADDgroups offer various activities: supportgroups, community resource information.

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monthly meetings on topics of interest, out-reach programs and networking opportuni-ties with other adults, parents and profes-sionals interested in ADHD.'"'

Generally, best results occur when a teamapproach is used with parents/family, schoolpersonnel and therapists or physicians work-ing together. Also extremely important ismaking every effort to work with your stu-dent's parents and referring them to reliablesources of information to as.sist their effortswith their child.

Abuse and Misuse of ADHD MedicationsIn recent years, various headlines in the

media have caught the attention of the gen-eral public as well as parents, educators andhealtheare providers:• "School Officials Report Student Pre-

scription Drug Problems"• "Survey Finds I in 5 Teens Getting High

On Medications, Over-Counter Drugs"• "Students Abuse Adderall to Improve

Concentration"How widespread is the problem of illicit

stimulant medication use? Results from tworecent studies help provide answers to thatquestion. In one study, over 1500 studentsin grades six through eleven reported theiruse, misuse and diversion (trading, sellingor offering) of prescription stimulant medi-eation. An anonymous, web-based surveyallowed middle and high school students torespond in an honest, non-threatening way.'^

Illieit use of stimulant medication wasreported by approxitiiately 4.5 percent ofstudents surveyed, including students whohad not been prescribed medication, as wellas those who had prescriptions but also wereusing their medications inappropriately. Therate of illicit use was about 2.5 times greateramong males than temales.

Of tbe students who reported prescriptionstimulant use, 23,3 percent reported beingapproached to sell, give away or trade theirprescription drugs. Females (29.6 percent)were more likely than males (20.6 percent)

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to be approached. High school students(46.4 percent) were significantly more likelythan middle school students (13.1 percent)[o be approached for diverting their stimu-lant medications. '̂

The use of alcohol, tobacco and otherdrugs for students who properly used theirmedically prescribed stimulants was verysimilar to the behaviors of those studentswho did not use any stimulant medications.Findings in this study indicated that middleand high school students who properly usedpreseribed medication for ADHD were notat higher risk for other substance misuse.

In a second study, a representative sam-ple of nearly 11.000 randomly seleeted col-lege students completed a web-based surveyregarding the non-medical use of prescrip-tion stimulants atid other substance-usebehaviors."^ Past year rates of non-medical(illicit) use of prescription stimulants rangedfrom zero to 2.'i percent, depending on theindividual college. Illieit use was higheramong college students who were male.white, members of fraternities or sororitiesand earned lower grade-point averages. Userates were higher at colleges in the northeastregion of the United States and also at col-leges with more competitive admission stan-dards.

Similar to the middle and high school .stu-dents participating in the first study, thosecollege students illicitly using prescriptionstimulants were more likely to display olherrisky behaviors as well. Behaviors these stu-dents engaged in more frequently includedthe following: smoking; binge drinking;using marijuana. Ecstasy, and cocaine; driv-ing after binge drinking; and being Ihe pas-senger of a drunk driver. ''̂

Various implications appear for practiceand policy from these studies. Physicians,pharmacists and various school personnel,such as nurses, social workers, counselors,principals and classroom teachers, shouldbe edueated to pay partieular attention tothe use and misuse of preseription medica-

tions among school-age children and adoles-cents. School personnel, particularly at themiddle school and high school levels, canplay a helpful role in monitoring whetherstudents who are preseribed stimulant medi-cation are being approached to divert theirmedications. Monitoring, however, becomesincreasingly more difficult, if not impossi-ble, at the eollege level.

Additionally, school policies can be devel-oped that require school health professionalsto administer and monitor stimulant medi-cation. Currently, some schools still permitstudents to carry their own. Finally, it isstill important to realize that not all schoolshave written policies regarding prescriptiondrugs.

Perhaps the most important implicationof these results is that educators, as wellas parents and health professionals, needto be aware that the misuse and abuse ofADHD medications are real. Illieit stimulantusers from middle sehool age through eol-lege are more likely to be involved in otherrisky behaviors, such as binge drinking andcigarette smoking. Informed school person-nel should educate their students about theappropriate steps to lake if and when a peerasks for medication. With such (raining inpiace, ihese students will be better preparedto deal with sueh situations, should theyarise.

Parents ultimately will be the decisionmakers about Ihe best treatmeni option fortheir ADHD child. Their choice may or maynot include medication. As an educator, it isnot your place to prescribe medication foryour students. However, it is your place tobe informed.

References1. Nalional Rcsourcf Cenier on AD/HD, ""Frequenlly

A.skcd Questions." Retrieved Mareh 23. 20(15 fromhttp://www.help4adhJ.org.raqs.cfm

2. Dia^iioslic and Siiiii.siital Manual of Menial Dis-orders. Fourth Edition. Toxi Revision. Washington.D.C: American Psyehialrie Association. 2()(H),

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