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CHAPTER 37 • Mental Disorders of Childhood and Adolescence

BOX 37.7

Medication Profile: Methylphenidate DRUG CLASS: Central nervous system stimulant

medication improves concentration and the ability to sit still can help strengthen patient motivation. Often, parents are reluctant to initiate treatment with psychostimulants because of the fear that their use in childhood will increase the risk of using substances in adulthood. Studies show that children and adolescents who have taken simulants medications for ADHD are no more likely to develop later substance use than those who did not take stimulant medications (Molina et al., 2023). Teaching patients and families about the biologic basis of ADHD helps parents understand that these children are not “bad” kids but that they have issues with impulse con trol and attention. It may be helpful to review the pur poses of the medications and assure parents that evidence shows that medications help most affected children. Psychosocial Interventions Behavioral programs based on rewards for positive behavior, such as waiting turns and following directions, can foster new social skills. Behavioral parent training, behavioral classroom management, and behavioral peer interventions are well-established treatments. Specific cognitive-behavioral techniques are helpful in which the child learns to “stop, look, and listen” before doing. These approaches have been refined and several use ful recommendations are available (Dentz et al., 2024; PEAK EFFECT: 1 hour; half-life: 3 to 4 hours for the immediate- release preparations SELECT SIDE EFFECTS: Nervousness, insomnia, dizziness, headache, dyskinesias (including tics), toxic psychosis, anorexia, nausea, abdominal pain, increased pulse and blood pressure, palpitations, tolerance, psychological dependence. WARNING: The drug is discontinued periodically to assess the patient’s condition. Contraindications include marked anxi ety, tension and agitation, glaucoma, severe depression, and obsessive-compulsive symptoms. Use cautiously in patients with a personal or family history of tic disorders, seizure disor ders, hypertension, drug dependence, alcohol use disorder, or emotional instability. SPECIFIC PATIENT AND FAMILY EDUCATION • Do not chew or crush sustained-release tablets; they must be swallowed whole. • Take the drug exactly as prescribed; if insomnia is an issue, the time and dose may need adjustment. The drug is rarely taken after 5 pm. • Avoid alcohol and over-the-counter products, including decongestants, cold remedies, and cough syrups; these could accentuate side effects of the stimulant. • Keep appointments for follow-up, including evaluations for monitoring the child’s growth and use of parent and teacher ratings to monitor benefit. • Note that the prescriber may discontinue the drug periodi cally to confirm effectiveness of therapy.

ineffective, or in combination with a stimulant to increase effectiveness. The four Food and Drug Administration (FDA)-approved nonstimulants for ADHD are a norepi nephrine update inhibitor (atomoxetine), a norepineph rine reuptake inhibitor (viloxazine), and alpha-2 receptor agonists (guanfacine and clonidine) (CDC, 2024b; NIMH, 2024a; Peterson et al., 2024). Nonstimulants are less likely to be misused than stimulant medications due to a lack of immediacy of effect (a lower speed of action and feeling stimulated) and therefore are often used for those who are more likely to be substance dependent. These medications are generally well tolerated in chil dren and adults. Common side effects associated with atomoxetine and viloxazine include GI symptoms, somnolence, headaches, moodiness, and irritability. The more common adverse effects experienced by individuals taking the alpha-2 receptor agonists include fatigue, sedation, and somno lence (Peterson, 2024). Teaching Points Medication can help the child’s hyperactivity, impul siveness, and inattention; therefore, teaching the parent, child, and school personnel about the importance of the medication in ADHD and the potential side effects is a place to begin. Explaining to the child that the Adult Dosage: Must be individualized; range from 10 to 60 mg/day orally in divided doses bid (twice a day) to tid (three times a day), preferably 15 to 30 minutes before meals. If insomnia is an issue, drug should be administered before 6 pm. Child Dosage: The immediate-release formulation can be started at 5 mg twice or three times daily on a 4-hour sched ule with weekly increases depending on response. Starting doses of the long-acting preparations are equivalent to the total tid dose (e.g., 5 tid of short acting would translate into 18 mg of the long-acting preparation). Usually given on a tid schedule, with the last dose being roughly half that of the first and second doses. Daily dosage of more than 60 mg is not recommended. Discontinue after 1 month if no improve ment is seen. RECEPTOR AFFINITY: The mechanisms of pharmacologic effect are not completely clear. At low doses, it provides mild cortical stimulation similar to that of amphetamines. This stimulation results from methylphenidate’s ability to promote release and interfere with the reuptake of dopamine in the synaptic cleft. Main sites appear to be the brain stem arousal system and cortex to produce its stimulant effect. INDICATIONS: Treatment of narcolepsy, attention-deficit disorders, and hyperkinetic syndrome. ROUTES AND DOSAGE: Available in 5- to 10-mg imme diate-release tablets and 20-mg sustained-release tablets. Long-acting preparations in various dose strengths are also available.

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