Autonomy is critical for teens with ADHD: make adolescents partners in terms of deciding whether, or when, they will take their medications.

ATLANTA -- Adolescents with attention-deficit hyperactivity disorder need to be listened to by their physicians and given a sense of being in control of their lives and their therapy, Dr. Howard Schubiner said at the annual meeting of the American Academy of Pediatrics.

This approach tends to improve compliance, increase motivation, and create an atmosphere for success for the adolescent, he said.

Teenagers must be made to feel that they are respected and that they are equal partners with their physicians in terms of deciding whether, or when, they will take ADHD medications, said Dr. Schubiner of Providence Hospital, Southfield, Mich.

"Teens want to be in control.... So I give them control, assuming that they are ready to make reasonable decisions for themselves. I ask them what their goals are, and they tend to respond well to this," he said.

"The reality is that I do not have access to any different medications than you do. What makes me effective with teens is my relationship with them," Dr. Schubiner told his audience.

ADHD can impair a teen's chances of success in life if it is not treated. It is true that adolescents can be difficult to reach, but if the physician makes an effort to "really listen to them, find out what they are good at and what they like to do, encourage them to pursue positive activities, and believe in them, they tend to do well," said Dr. Schubiner, who specializes in treating children, adolescents, and adults with ADHD.

A plethora of studies has demonstrated that taking stimulants improves distractibility, fidgeting, parent-child interactions, and problem-solving activities with a child's peers.

The studies also have shown that academic progress often is dramatically improved, and that spelling, math, and reading skills are enhanced when children who have ADHD take the appropriate medications, said Dr. Schubiner, who disclosed that he is a member of the speakers' bureaus for McNeil and Shire pharmaceutical companies.

Dr. Schubiner stressed the importance of rolling with a teen's resistance and never pushing medication use.

He gave some tips on ways to talk to patients, giving examples of how he talks to his teen ADHD patients to allay their fears (and the fears of their parents) about taking medication and--most importantly--to establish a good rapport with them and encourage them to be motivated:

* First, explain what ADHD is. "I explain that ADHD has no relation to intelligence, that it is a mild disability. Take myself, for example, I wear glasses. If I didn't have them, I wouldn't have been able to go to medical school and become a doctor. So my glasses have allowed me to use my potential," he said. He tells patients that "it is the same with you and medications for ADHD. You have potential, and you can realize your potential if you are successfully treated."

* Ask the patients what they are good at. "That is the most important question. I don't care if it's video games. I found out that one of my patients was interested in NASCAR racing, so I asked who was his favorite driver, what was that driver doing, and so on. The critical thing is to find something that you can connect with these kids on, to get them to show you their strengths," Dr. Schubiner said.

"I encourage them to recognize how they have been successful at learning new skills, such as video games, NASCAR, dance, art, or music, and show them that these same skills can help them in school or in any endeavor," he said.

* Reassure them they can stop taking their medication any time they want. "I treat a lot of people with medication because it works. I tell them, 'I don't care if you take the medication or not. It doesn't matter to me. But I care that you achieve your goals. I use medications because they usually help teenagers achieve their goals. But if you don't want to take medications, that's fine. We can discuss how you plan on achieving your goals without it. If you ever want to stop your medication, just let me know.'"

* Put the patients in control. "I tell them, 'If you choose to try medications for ADHD, I will work with you very closely to ensure that there is benefit and there are no side effects, because I would not want to give you any medications if you're not being helped or you are having any side effects.'"

Dr. Schubiner said that he has zero tolerance for side effects, and emphasizes to his patients that side effects simply mean that they are not on the right dose, or not on the right medication.

Common stimulant side effects include headache, insomnia, decreased appetite, dry mouth, and feeling sweaty, jittery, or spaced out. Rare side effects include tics, psychosis, seizures, glaucoma, arrhythmia, and sudden cardiac death.

"Sudden cardiac death is extremely rare, and most are due to an underlying cardiac abnormality. The rate of sudden cardiac death in children taking ADHD medication is 0.4 per 100,000 person-years. But the rate of sudden cardiac death in the general population of children is 1.5-8.3 per 100,000 person-years. So it's actually higher in the general pediatric population," Dr. Schubiner said.

Teens with a personal history of chest pain, shortness of breath, dizziness with exertion, syncope, hypertension, palpitations, or other potential cardiac problems should be evaluated further. In addition, physicians should inquire about a family history of sudden cardiac death, myocardial infarction prior to the age of 50 years, congenital heart disease, or rhythm problems.

BY FRAN LOWRY

Orlando Bureau