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New Treatment Options for Children with ADHD

Wednesday, June 18, 2003

            Neurologists have shown that many children with attention deficit hyperactivity disorder (ADHD) who have long been denied the medication most commonly used by doctors, methylphenidate (MPH, also known as Ritalin), can be treated effectively with it. The study in the February 26 issue of Neurology, published by the American Academy of Neurology, also puts forth the idea that a combination of medicines works best for many children with ADHD.

            “This is an effective medicine that doctors have been told for decades not to use in children with tics, such as children with Tourette’s syndrome,” says lead author Roger Kurlan, M.D., a neurologist at the University of Rochester Medical Center. “There’s even a warning in the Physician’s Desk Reference, and for 40 years physicians have avoided treating children with ADHD and tics with Ritalin because of a fear that the tics would worsen. But the warning was based on slim evidence and had never really been checked out thoroughly.”

            The study was conducted by the Tourette’s Syndrome Study Group, a collection of physicians and nurses from 15 institutions who focus on developing and testing new treatments for the disorder. About one-third of children diagnosed with ADHD also have a tic disorder like Tourette’s.

            Since about half of children with tics also have ADHD, doctors like Kurlan who specialize in treating children with Tourette’s long encountered difficulty treating many of their patients. Many specialists had found MPH effective at treating children with tics and ADHD, despite the conventional thinking. So the Tourette’s study group proposed to settle the question in a study which the National Institute of Neurological Disorders and Stroke agreed to fund.

            Doctors at 12 hospitals and medical centers around North America studied 136 children ages 7-14 who had both ADHD and tics. Children received either MPH, clonidine, both, or neither; doctors, nurses, parents, teachers and children did not know which children received which treatment until the study was completed. Children were examined by nurses and doctors, and their behavior was monitored and reported by parents and teachers for 16 weeks.

            Kurlan says doctors had assumed MPH shouldn’t be used in children with Tourette’s because it was thought that the medicine, a stimulant, would worsen tics. But the study found otherwise: Not only did youngsters treated with MPH experience no more tics than their counterparts not on MPH, dispelling that long-held notion, but the medicine actually eased their tics. The same was true for children in the other two groups that received medication.

            “This longstanding practice has left a large number of children in a difficult situation,” Kurlan says. “Though they have ADHD, their doctors have been told not to give these children the best available treatment. It’s been frustrating for doctors, and there are many parents out there who have felt cheated out of an effective treatment for their children with ADHD.”

            The study marks the first time that MPH has been tested in children with tics; it’s also the first time that the effectiveness of ADHD and clonidine have been tested head to head in any children with ADHD.

            The findings may spur changes in treatment for all children with ADHD, not just those with tics, the investigators say. The group also compared the effects of the combination of MPH and clonidine to MPH alone and clonidine alone. Doctors found that the combination was more effective than either medication alone. The drugs seem to complement each other, with MPH more effective helping children concentrate and clonidine helping counter patients’ impulsivity and hyperactivity.

            “This makes possible the whole idea of individualizing medication treatment,” Kurlan says. “It makes sense for a doctor to think of the individual patient and which symptom is most bothersome to that patient. If hyperactivity is dominant, the doctor might prescribe clonidine; if the child is have trouble focusing, methylphenidate makes sense.”

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