HD28 - The Effects of the Use of Methylphenidate
Executive Summary: Attention deficit disorder (now more commonly conceptualized as Attention Deficit Hyperactivity Disorder, or·ADHD) is a serious condition affecting many children, adolescents, and adults. The disorder is generally characterized to include age-inappropriate levels of motor activity, and inattention. The etiology of the condition is not well established. Concepts of exactly which clusters of behaviors and deficits comprise the disorder have evolved -- and continue to evolve -- over time. There is considerable inexactitude in how these behaviors and deficits are measured. The probability of an ADHD diagnosis differs depending upon whether a single clinician or an interdisciplinary team conducts the evaluation and makes the diagnosis. Due largely to this lack of diagnostic clarity, estimates of the extent of the disorder in school-aged and the general population vary. Reported estimates of prevalence range from one to twenty percent. A more defensible estimate of prevalence for school-aged children appears to fall within a range of three to five percent. Psychostimulant medications, especially methylphenidate (Ritalin), are effective in controlling behavioral and other symptomatic manifestations of the disorder but do not constitute a cure. The behavioral and other effects last only as long as the effects of the medication. Ritalin is a Schedule II drug. A Schedule II drug is one which is a most restrictively regulated substance for approved medical treatment. Moreover, Ritalin is classified as a Schedule II drug because of its potential for abuse and/or dependency. Manufacturers of methylphenidate caution against its prescription to children under six (due to a lack of research in younger age groups), recommend careful titration of dosage, medical monitoring for side-effects, drug holidays, and discontinuation when negative side-effects occur. Further, it is recommended by professionals that the drug should not be used as the only intervention for ADHD. Side-effects of Ritalin therapy are generally mild and controllable, but some serious and persisting effects have been reported to occur in rare cases. There is no evidence of widespread abuse or diversion of methylphenidate in the Commonwealth, but dramatic increases in distribution of the drug to retail outlets over the last decade, and isolated incidents of abuse or diversion create cause for some concern. The major abuses of the drug, however, appear to lie in its use without appropriate adjunctive measures, and in its prescription without benefit of an adequate, interdisciplinary, differential diagnosis of ADHD or careful monitoring of children using the medicine over time. A task force appointed by the Departments of Education, Health Professions, and Mental Health Mental Retardation and Substance Abuse Services has studied the use of methylphenidate in the treatment of ADHD in response to House Joint Resolution 146 of the 1990 Session of the Virginia General Assembly. The task force found no evidence that the public was in eminent danger from prevailing diagnostic practice or the effects of methylphenidate, but there is evidence of the need to improve the monitoring and use of methylphenidate. The development of defensible public policy will require better documentation of the extent of ADHD and therapeutic intervention. A number of "best practice" recommendations seem prudent, but no policy interventions should be undertaken that prevent ADHD children who require appropriate medication from receiving it. The task force has presented its recommendations in the form of "best practice" suggestions with additional suggestions on how the recommendations might be implemented. A summary of these recommendations and suggestions follow. TASK FORCE RECOMMENDATIONS To improve the accuracy and coordination of the diagnosis and treatment planning for Attention Deficit Hyperactivity Disorder: • Diagnosis, treatment, and planning for children diagnosed as ADHD should involve a multidisciplinary process including medical, psychological, and educational professionals. Diagnosis and prescription of treatment for children with ADHD should include involvement of parents or their surrogates. To improve educational services for children diagnosed as having ADHD: • The Department of Education should conduct a survey to determine the prevalence of ADHD among school children and the use of methylphenidate. • Communication between physicians and educators regarding the use of methylphenidate for school-aged children should be improved. • Appropriate treatment and instructional approaches (behavioral and cognitive therapy and other accommodations and adjustments) should be developed to provide alternatives or to complement drug therapy. • Medical personnel should be available in every school to administer medications and record information on observable signs and other appropriate information associated with medication used to treat ADHD. • School nurses should provide leadership in coordinating health and related services for ADHD students, including the administration of medications. To facilitate the most appropriate use of methylphenidate as the preferred psychostimulant medication for ADHD: • (*1) Medication should not be used as an isolated treatment. Proper classroom placement, behavior modification, and counseling, should be used before a trial of pharmacotherapy is attempted. • The effects of the drug therapy must be evaluated on a regular basis. • The use of medication should he consistent with manufacturers' recommendations or current research regarding use, initial titration of dosage, monitoring, maintenance dosage, length of use, and drug holidays. • The effects of methylphenidate treatment should be carefully evaluated by the prescribing physician at least every six months. Accurate records should be maintained as required for Schedule II substances. • The child's medication records may be shared with school officials for proper coordination of treatment. • Adjunctive treatment should always accompany drug therapy to include appropriate school accommodation or adaptation and parent education. Other interventions should be used as needed, including psychotherapy (for parents and/or child), behavior therapy, specialized education programs, and family support. To assess the current levels of use and misuse of methylphenidate: • The pharmaceutical drug diversion study conducted by the Department of Health Professions and the Department of State Police under the direction of the Virginia Crime Commission should include information on the use of methylphenidate. • The Department of Medical Assistance Services should reinstate methylphenidate in its quarterly analysis of prescription, dispensing and consumption patterns related to Medicaid providers and recipients and provide these analyses to appropriate enforcement and regulatory agencies including the Department of Health Professions and the Department of State Police. To ensure that parents and families are appropriately included in the identification and management of ADHD: • Parents and families of ADHD children should participate actively in the professional management of children. • Membership in organizations of ADHD parents and families is encouraged as a means for understanding the disorder, its treatment, and the vital role played by family and in the homes of ADHD children. To facilitate the widest understanding and acceptance of these recommendations: • Intensive in-service educational programs should be instituted on the needs and appropriate interventions for children with ADHD for physicians, other health care professionals, mental health professionals, school personnel, and parents. • The members of the General Assembly of Virginia are requested to consider a resolution requesting the distribution of these recommended best practices by the appropriate public and private agencies, including regulatory boards, State agencies, professional associations, parents' organizations, civic and community organizations, and others. ____________________________________ (*1) One task force member does not agree that other interventions should be attempted before beginning pharmacotherapy, rather they should be used in combination. |
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