ADHD Treatment: Medication in Neurodevelopmental Disorders and Challenging Behaviours

Drugs form an integral part of treatment of Neurodevelopmental and Neuropsychiatric disorders. Their role in management does not necessarily mean curing the problem but they can alter the course of the disorder and improve the quality of life for the child and the family. However, the use of medications in developmental and behaviour problems has been fraught with difficulties. Misconceptions, excessive guilt and fear trouble the families of these children, professionals and teachers.

First of all I would like to refer to drugs as medicines as the word drugs is often associated in the lay public’s mind with recreational drugs. Unfortunately, drugs have got a bad name in the lay press. Unilateral and uninformed opinions abound especially on the Internet. Medicines have since time immemorial been used to ease the dis ease in the human condition. Initially they were obtained from herbs and plants and now also from chemicals. Medicines have been used for a long time in disorders like Epilepsy. However, their role in Neurodevelopmental medicine is more recent as our understanding of the disorders has improved. We now know the role of neurochemicals in the development of certain disorders like autism, attention deficit disorders and even depression and anxiety. We also understand better neuroimmune mechanisms in development of certain disorders like autism, Tourette syndrome and PANDAs. We also understand the effect of anxiety and depression on many challenging behaviours. With these newer understanding in mind we can see how medicines can help the child with developmental and behaviour problems.

The use of medication should be preceded by some important factors:

1. The diagnosis of the developmental disorder or challenging behaviour should be accurate. For example, Hyperactivity is often used loosely as a diagnosis. This is incorrect as hyperactivity is a symptom seen in several developmental disorders like ADHD, autism and Juvenile Bipolar Disorder to name a few.
2. The diagnosis should be complete. This means the diagnosis should not only include the specific condition but also the profile of the child’s emotional, intellectual/developmental and environmental status. Many of these factors affect the behaviour and outcome of the disorders and should be evaluated in detail.
3. Adequate parental and teacher training and understanding of what the medicine can and cannot do, what side effects should be looked for and the need for long term follow up.
4. It must be clearly understood by both the treating physician, the parents and teachers that psychotropic medication forms only a part of the total management of the child. Behaviour, communication and language and special education are some of the other important aspects that must be simultaneously addressed.

Some of the common medicines used in various conditions include psychostimulants – the best known being Ritalin or methylphenidate. Hundreds of studies on Methylphenidate over the last 50 to 60 years have shown that it reduces disruptive behaviour like restlessness, hyperactivity, irritability, lack of ability to follow instructions, aggression, lack of compliance and many others. It also improves on task behaviour, concentration, academic efficiency and performance. Unfortunately, it needs to be given every 3 to 5 hourly and that means a dose during school hours. Nonetheless, once a day methylphenidate like Concerta will be soon coming into the UAE.

Antidepressants, Anticonvulsants, Mood stabilisers and Antipsychotics are other frequently used medications. The first group is often used not only for disruptive behaviours but also for the shy, withdrawn and depressed child. Anticonvulsants and Antipsychotics act as mood stabilisers and are often used in Bipolar disorders. Autism also seems to respond very well to antipsychotics. Controlled studies have shown that Resperidone decreases ritualistic behaviours, psychomotor agitation and enhances social interaction.

Appropriate use of pharmacotherapy in conjunction with a comprehensive individualised psychosocial intervention treatment programme can enhance the child’s ability to benefit from educational and behavioural modification interventions.  A calmer child is more able to sit in class and follow instructions. They thus have a better chance of enrolling in normal mainstream schools or even benefiting from other interventions.

Causes of pharmacotherapy failure to help the child:

Case Reports: 

Reshma a 9-year-old girl was referred to the clinic for an evaluation before placing the child in a special school. Diagnosis indicated the child was very depressed, had Inattentive ADD and learning difficulties. With appropriate medication she was able to continue in a normal mainstream school but more importantly, she became more talkative and social and had more friends after a 6-month follow up.

Rodney a 5-year-old boy who appeared to be bright was very disruptive. He had severe aggressive behaviours when he would hit shout and break things. No amount of punishment changed his behaviour. He had been expelled from several schools. Ritalin had been tried but just made his behaviour worse. Evaluation showed a child with above average intelligence, at risk for dyslexia and Juvenile Bipolar Disorder. After appropriate medication and therapy he is now doing well in a mainstream school.

Harjit an 8-year-old child with moderate intellectual deficiency was very wilful, difficult and aggressive. He went to a special school but was on the verge of being expelled. Efforts at behaviour therapy and language therapy had been unsuccessful as he was a stubborn child. He was often physically punished because parents were unable to deal with him. He was not achieving his potential. With appropriate medications, Harjit calmed down, his language improved and he was on his way to achieve literacy