Medication interventions for ADHD youth: a primer for school and mental health counselors.

This primer on the medical aspects of treating ADHD youth will help counselors feel better informed about the types of medications available, the possible side effects, and the advantages and disadvantages for use. In addition, we discuss the long- and short-term consequences for using interventions requiring medication alone, psychosocial interventions alone, or a combined, multimodal approach. Mental health and school counselors can partner to provide information to nurses, parents, physicians, and youth to design developmental interventions for our ADHD youth.

**********

Mental health counseling and school counseling roles are expanding to include not only working with ADHD youth, but also working with specific aspects of involvement related to their medication trials (James & Nims, 1996). For this reason, counselors need to know about medications and their side effects and about situations when drugs are either the sole intervention or when they are used in conjunction with psychosocial interventions. School counselors in particular may actually be expected to administer medications to youth, and they may do so in the belief that medication enables ADHD youth to better manage their classroom behavior. In many schools today, school counselors consider it their job to know about medications and their possible side effects. In fact, parents believe school counselors are competent in this role when counselors demonstrate knowledge in this area. If youth are to comply with their medication schedule, there often must be a person in the school who can administer and monitor its effect in youth as they proceed through their school day. When mental health and school counselors partner with school nurses, teachers, and parents to help youth manage their ADHD through the use of medication and psychosocial interventions, then youngsters often improve their academic performance.

School counselors are looking to team with other counseling professionals, including mental health counselors and marriage and family counselors to deliver more powerful intervention and prevention efforts in their schools. In fact, school comprehensive guidance programs encourage a team approach for delivering their services to all students, often involving at least a limited partnership with school staff, community counselors, and community members in order to effectively serve every child's academic, career, and personal/social needs. Consistent with this, school counselors may be expected to work with mental health counselors, family physicians, or with school nursing personnel to monitor the safe use of drugs for ADHD youth. This critical aspect of both intervention and prevention is necessary if our youth are to safely and effectively comply with their medical treatment protocol. With teachers suggesting to parents that youth could benefit from medication, it seems that schools are intimately involved with parents and children in determining whether or not medication is warranted. School counselors are often in the center of the communication hub related to treatment, care, and follow up of youth's progress and management of ADHD symptoms. Families decide whether or not to medicate a child based on perceived or actual severity of ADHD symptoms and their relation to problems at home, school, or with peers (Dulcan, Dunne, et al., 1997). For this reason, school personnel are intricately connected to the data gathering process associated with determining whether or not ADHD symptoms exist, symptom severity, and potential prevention or intervention efforts. Often, medication is the result of this complex process of detecting, treating, and monitoring ADHD symptoms.

The purpose of this article is to discuss the long- and short-term consequences of deciding to use interventions requiring medication alone, psychosocial interventions alone, or a combined, multimodal approach. Our hope is that mental health and school counselors can see how their roles as facilitators of communication between and among parties can ultimately improve the care of ADHD youth as they move from home, to school, to community. Even more, we hope that counselors can know their own views on this topic and be able to communicate their reasons for agreeing or disagreeing with the use of medication to help ADHD youth manage their academic and personal spheres of development. We do not advocate use or nonuse of medication. We simply advocate becoming informed so that mental health counselors can partner with school counselors as they take their rightful place as communication facilitators for parents, youth, teachers, and physicians who try to help ADHD youth live fuller lives.

Both mental health and school counselors are involved at some point in the process of gathering data, assisting with diagnosis or assessment, and determining a treatment plan for ADHD youth. When decisions are made to medicate, proper medical protocol requires careful comparison of a child's pre- and postbaseline performance in both the academic and behavioral domain. Several persons must monitor the effects of medication for impulsive ADHD youth who can neither be expected nor be allowed to self-manage their medication schedules. Several persons must also track specific potential negative effects in youth related to the use of medication such as low self-esteem, social isolation, dosage, and reliance on drugs. Monitoring is vital because research is contradictory regarding both the safety and effectiveness of medications. In fact, some of these drugs are even prescribed without FDA approval (James & Nims, 1996). Because ADHD children are seen for only parts of each day and by various people who interact in separate spheres of the child's worlds, someone must be designated as the "point person" who will communicate between and among these people so that continuity of care is accomplished. The mental health or school counselor may or may not be the point person, but they can see that someone serves in this capacity for these children.

In short, mental health and school counselors must know the most recent information regarding drug interventions with ADHD youth so that they can stay alert to signs that may suggest improved or diminished functioning in these children. This article is designed as an update on the use of medical interventions for ADHD and, as such, the information is technical yet necessary. To assist mental health counselors as consultants to school counselors and to provide them with accessible information for consultation purposes when working with parents or other school or medical personnel, we offer the following information on this vital topic, beginning with a description of how stimulants, tricyclic antidepressants, and nontricyclic depressants are used for treating ADHD symptoms.

STIMULANTS

Ritalin, Dexedrine, and Cylert

The use of stimulants in children is on the rise. Currently, more than 1.29 million children take some form of speed for ADHD, three of the most common of which are Ritalin (Methylphenidate), Dexedrine (dextroamphetamine), and Cylert (pemoline). In one well-designed study, 75% of children and 57% of adolescents responded positively to Ritalin (O'Toole, Abramowitz, Morris, & Dulcan, 1997; Smith, Pelham, Gnagy, & Yudell, 1998). We do not know why medication use is 13% more effective in children than in adolescents because so few studies compare medical treatments of children with adolescents.

Psycho-stimulants are effective in improving quality of thought and desired behaviors, although behavior varies depending upon the child and the setting. So an ADHD child who improves in one area of functioning may not improve in another (Dulcan, Dunne, et al., 1997; Spencer et al., 1996). Our assessment of a stimulant's effectiveness is considered in relation to how severe are the side effects (Dulcan, Dunne, et al., 1997). Stimulants work by producing complex neuro-chemical changes at both the micro and macro levels, and involve systems as small as the individual neuron and as large as systems of interactions in several different neurotransmitter action sites. Stimulants produce chemical changes that can last from 3 to 6 hours and can produce an on-off effect after each dosage that results in two or three jumps in functioning each day (Popper, 1997).

Currently, we have more questions than answers in terms of medical interventions with ADHD youth. For example, How can we tell which stimulant is right for treating ADHD? How does age interact over time with stimulant medication? Further, How do we assess the potential benefits of stimulant use when contrasted with their potential risks? We offer no simple formula for finding the right drug for a specific child or adolescent (Dulcan, Dunne, et al., 1997), but we offer the latest information about different drugs and their potential serious side effects, so that parents, teachers, mental health and school counselors can evaluate their own cost-benefit analysis of whether or not medication will be a part of their children's lives. Even the FDA can only offer general guidelines, none of which are fail-safe, although they do provide minimum ages for approved stimulants.

Guidelines for use of Ritalin, Dexedrine, Cylert, and Adderall are included here for counselors to consider. Keep in mind that each medication has benefits and serious risks. Ritalin is the best studied, most used, and possibly most effective drug in reducing motor activity. Dexedrine, however, is longer lasting than Ritalin and therefore requires fewer administrations and so is less expensive, except for the fact that its use is often not reimbursed in third party formularies. Also, in general, Cylert is effective in treating ADHD and may be preferred over Dexedrine because it can be taken once a day, lasts from 4 to 10 hours, and has the least substance abuse potential of most stimulants. Although it is unusual a child to abuse the use of Ritalin or Dexedrine, family members or friends may potentially use the child's drugs (Riggs, Thompson, Mikulich, Whitmore, & Crowley, 1996). Although effective, we do not recommend Cylert as a first choice stimulant because it can cause liver failure and death (Findling & Dogin, 1998). For yet another example, Adderall is an FDA-approved stimulant that was marketed for ADHD treatment in 1994, and that was formerly used as both an anti-obesity and minimal brain dysfunction drug in the 1960s under the name of Obetrol (Swanson et al., 1998). Although Adderall's combination of four different salts produce a dosage effect lasting 4 to 10 hours (similar to pemoline), the positive and negative effects of this drug require further testing (Popper, 1997).

Stimulant dosage. Using small doses to begin, and then titrating if necessary and depending upon the response to side effects, the correct dose is considered the one that uses the least dose yet obtains the maximum benefit with the least side effects (Dulcan, Dunne, et al., 1997). For example, with Ritalin, the dose lasts for 3 or 4 hours, and would start at 5 mg, with breakfast and lunch. Dexedrine is given at one-half to two-thirds the dosage of Ritalin and is also dispensed at breakfast and lunch. With Adderall, the dose lasts for 4 to 6 hours, is dispensed in the morning, and can be increased at a rate of 5 mg a week. In a final example, with Cylert, the dose lasts for 7 hours, and has a maximum daily dosage of 112.5 mg, beginning at 37.5 mg, with a possible increase of 18.75 mg a week. With stimulants other than Cylert, when higher doses are needed, the increase is at a rate of 5 mg to 10 mg per week (Findling & Dogin, 1998).

Positive effects. Often the first choice for treating ADHD, stimulant use is effective in producing short-term improvement in attention, in decreasing hyperactivity and impulsivity, in reversing side effects, in ease of adjusting dose, in effecting a speedy response, and in creating a positive responses with even a single dose (Dulcan, Dunne, et al., 1997). In comparison with other medications, only stimulants have shown consistent improvement in the attention components of symptoms associated with ADHD, and so they remain the drugs of choice to date (Popper, 1997).

Side effects. Side effects related to stimulant dose are a concern. However, when given enough time to work, when reduced, or when removed altogether, these side effects often disappear (Cantwell, 1996). Side effects can include decreased appetite or anorexia, insomnia, stomachaches, headaches, and irritability. In this article, we discuss side effects such as growth problems, tic development, drug abuse, increased blood pressure, and rebound effect.

Regarding negative side effects related to growth, studies are contradictory. For example, Findling & Dogin (1998) quote research from a 1972 report suggesting that methylphenidate decreases children's height, but recent research suggests that ADHD itself, not the medications used to treat it, may cause a partial reduction in growth lasting through adolescence (Schachar, Tannock, Cunningham, & Corkum, 1997). Other research suggests that a decreased appetite may indeed cause some weight loss for those taking methylphenidate

Regarding negative side effects related to tic development, research indicates an increase in tic development in 9% of those who already have tic disorders and who also use stimulants. When dosage is stopped, less than 1% of those using stimulants actually develop a chronic tic disorder (Findling & Dogin, 1998). Recent research suggests that stimulants may in fact be safe and effective in improving ADHD in children with tic disorders.

Regarding negative side effects related to drug abuse, stimulant use is well-documented for its misuse as a recreational drug, street drug, or diet control drug; thus, except for Cylert, substance abuse is a concern (Popper, 1997).

Regarding negative side effects related to blood pressure and pulse rate, stimulant use can cause increased blood pressure in black adolescents, and so caution and increased monitoring must be employed for these youth (Findling & Dogin, 1998).

Finally, regarding negative side effects related to rebound behavior, stimulant use can exacerbate excitability, activity, talkativeness, irritability, and insomnia if there is a sudden withdrawal of daily doses (Dulcan, Dunne, et al., 1997). Countering increased excitability is possible when we structure the child's activities, give a smaller dose in the afternoon, or use a longer lasting medication. One example of a stimulant with little rebound effect is Premoline, because it is given only once a day (Riggs et al., 1996).

Sustain-release stimulants. Some youth are embarrassed to take medication at school and so they do not comply with their medical protocol. When stimulants such as Ritalin and Dexedrine are used, additional doses are needed during the school day because they are shorter acting stimulants than those such as sustained-release methylphenidate and dextroamphetamine, which boast effects lasting up to 8 hours (Findling & Dogin, 1998). When longer acting stimulants are used, we are able to eliminate the need for in-school medications. Other options include the use of two doses of the standard Ritalin, which is more effective and more reliable than Ritalin-SR because Ritalin-SR is only available in 20 mg tablets and does not allow smaller doses. For some, two doses of the standard Ritalin is more effective and reliable than Ritalin-SR, but for others, it may take 2 hours before the medication takes effect (Dulcan, Dunne, et al., 1997). Another consideration is that both Ritalin-SR and Dexedrine Spansule derive the sustained gradual release from special coated tablets (Findling & Dogin, 1998), which, if chewed, could lose the time-release action and could cause adverse effects. An advantage of Dexedrine Spansule over Ritalin-SR is a greater range of doses, with 5, 10, and 15 mg tablets.

Stimulant concerns. Positive effects of stimulant use include short-term effectiveness, fewer irrelevant activities and disturbances, and more compliance and attention (Richters et al., 1995). However, two difficulties with stimulant use are that there is no long-term effectiveness and that parents often do not see the positive behaviors at home that are evident in school. Regarding the latter, one study attempted to determine behavioral, situational, and temporal effects of methylphenidate treatment in ADHD. For this study, both teachers and parents rated the behavior of their children. Teachers found that the treatment group's behavior improved more than the placebo group and saw no increase in side effects; however, parents saw no improvement in the behavior in either the treatment group or in the placebo group and saw an increase in side effects (Schachar et al., 1997). Perhaps the medication had worn off by the time the children got home or perhaps improved behavior at home was the result of improved self-esteem from having a successful school day. So, stimulants are only effective in the short term, and there is a difference in the way teachers and parents view the benefits of stimulant use, with teachers seeing more of an advantage for the use of stimulants than parents.

Tricyclic Antidepressants

Stimulants appear to be safe and effective and so are prescribed more than any other medication for treating ADHD (Findling & Dogin, 1998). However, side effects exist because these are short-acting medications that require multiple daily doses. Needing to take medication while in school can lead to both noncompliance and social embarrassment (Wilens, Biederman, Geist, Steingard, & Spencer, 1993). In addition, stimulants do not work for about 25% of all children, and multiple doses do not work for up to 15% of these children (Findling & Dogin, 1998; Popper, 1997). Therefore, we need safe, effective medication that can be used when stimulants fail. One alternative to the use of stimulants is the use of antidepressants, especially the tricyclic antidepressants (TCAs). School counselors need to know that TCAs are gaining popularity in mental health counseling settings today (Wilens et al., 1993), and so counselors need to think about what effects, both positive and negative, their use could have on youth, and about what needs may arise in the school setting as their use becomes more widespread.

Imipramine, amitriptyline, desipramine, and nortriptyline. TCAs do have a narrow margin of safety, but they may be an option for those who do not respond to stimulants, have severe depression, suffer side effects from stimulant use, or have tics or Tourette's disorder (Dulcan, Dunne, et al., 1997). Several tricyclic antidepressants are prescribed, but some of the common medications include the tertiary amines like imipramine (Tofranil) and amitriptyline (Elavil) and secondary amines like desipramine (Norpramine) and nortriptyline (Aventyl; James & Nims, 1996). Antidepressant medication increases the supply of the neurotransmitters norepinephrine and serotonin by blocking the reuptake of these neurotransmitters (Biederman, 1998).

Positive effects. Tricyclic antidepressants (TCAs) function similarly to longer acting stimulants (Popper, 1997) and appear to be therapeutic. Spencer et al. (1996) reviewed 29 studies to determine the effectiveness of TCAs for treating ADHD. Twenty-six studies looked at the effect of TCA in treating young school children, one in treating adolescents, and two in treating adults. Almost all (93%) showed moderate improvement for ADHD symptoms (Biederman, 1998). Based on these findings, TCAs may be considered a drug of second choice when people do not respond to stimulants (Wilens et al., 1993).

Some advantages of using TCAs over stimulants include a longer half-life (therefore fewer doses per day are needed), minimal abuse, and less co-morbid anxiety and depression with ADHD (Wilens et al., 1993). In addition, hyperactivity, impulsivity and rebound effects all decrease with TCA (Cantwell, 1996). Critics argue, however, that such positive effect on cognition and attention do not hold in repeated studies (Popper, 1997). The available literature suggests that TCAs are as effective as stimulants in managing behaviors connected with ADHD, but they may be less effective in improving cognition (Biederman, 1998).

TCAs and co-morbidity. Tic disorders can be simple motor tics or complex motor and vocal tics called Tourette's syndrome (TS). Ten percent of ADHD children may have a tic disorder while 50% of children with TS may also have ADHD. For children with both tics and ADHD, stimulants do not work well (Spencer, Biederman, Wilens, Steingard, & Geist, 1993). In such cases, tricyclic antidepressants such as nortriptyline appear to work better. For example, Massachusetts General Hospital investigated TCAs as an alternative treatment for children with ADHD and tic symptoms and reviewed cases where patients with tic disorders and ADHD were treated with desipramine and nortriptyline. TCAs were associated with improvement, even in patients who had previously failed to respond to desipramine. Recent research also suggests that nortriptyline may help co-morbid anxiety and major depressive disorder (MDD) with ADHD, which could lead to treating co-morbid disorders, associated with TS patients (Spencer, Biederman, Wilens, et al., 1993).

Side effects. Even with the advantages, TCAs have side effects such as low blood pressure, dry mouth, constipation, dry eyes, nasal congestion, dizziness, unsteadiness, and drowsiness (James & Nims, 1996). People taking TCAs must be monitored for cardiovascular problems, potential cardiac problems, accidental or intentional overdose, possible ineffectiveness over time, and risk of hypertension (Wilens et al., 1993; Dulcan, Dunne, et al., 1997). For these reasons, secondary amines (such as nortriptyline and desipramine) are preferred because of reduced side effects. However, overdosing is a serious problem with the tricyclic antidepressants, with desipramine having the highest risk (Popper, 1997). Specifically, death by desipramine overdose is high (1%) in both children and adults. So, parents must carefully observe their children when using tricyclic antidepressants, and they must take care to keep the medication in a safe place so that overdose is less likely.

TCAs deaths. Benefits of using tricyclic antidepressant may be outweighed by the sudden, unexplained death of seven children, ages 7 through 15, where six had used desipramine and one imipramine, and where none had previous cardiovascular problems (Varley & McClellan, 1997). If using TCAs, it is critical that cardiac functioning is carefully monitored, from baseline through follow-up electrocardiogram (ECG). In addition, it is essential that pulse, blood pressure, and drug blood levels are monitored. Although no causal relationship has connected these deaths to TCA use--but since all TCAs treat ADHD behavioral symptoms equally--the use of desipramine may be an unwise choice (Popper, 1997). Awareness of these deaths lead us to question whether it is ever right to recommend TCAs for use in ADHD treatment even if they are effective (Varley & McClellan, 1997). Informed consent should precede TCA use. Mental health counselors can work with school counselors to warn youth and their parents of TCA use and the side effects that could lead to death.

Mental health and school counselors can also help parents understand that the pharmacological properties of TCAs are not the same in children as in adults (Dulcan, Dunne, et al., 1997). Children have a smaller fat-to-muscle ratio and so are not protected from an excessive dosage because they have less fat in which to store the drug. Also, relative to body size, children have a larger liver that causes faster metabolism and more rapid absorption. Because of this, children will probably need a higher TCA dosage than adults.

So, with everything considered, it may be the case that too many risks are associated with using tricyclic antidepressants. Although mental health counselors, school counselors, parents, and doctors can help the ADHD child attain positive results through medication use, keep in mind that even small risks must be considered carefully. Although TCAs (except for desipramine) offer certain advantages over stimulants, stimulants still appear to be the first choice for treating ADHD.

Nontricyclic Antidepressants

Research on other medications for ADHD treatment is limited. Nevertheless, two nontricyclic antidepressants that show potential are bupropion and monoamine oxidase.

Bupropion. Bupropion can reduce ADHD symptoms in children (Findling & Dogin, 1998). In a study using bupropion, hyperactivity, impulsivity, and cognition improved (Popper, 1997). Barrickman et al. (1995) compared the effectiveness of bupropion to that of Ritalin in treating children with ADHD and found that both were effective, and Ritalin was better. Bupropion might be used as an alternative to Ritalin when children cannot take Ritalin because of stimulant allergies, drug reaction, no tolerance to stimulants, or no response to treatment. Side effects in adults that may generalize to children taking bupropion may include aggravating tics, skin rash, or seizure. Reducing dosage may reduce these side effects.

Monoamine oxidase. Preliminary studies on monoamine oxidase used by youth with ADHD revealed improvement in 90% of the 29 children who participated and no serious side effects (Biederman, 1998). Problems associated with this study included restrictive diet risks (most cheeses) and negative drug interaction between monoamine oxidase and cold medicines and amphetamines.

Alpha 2 Agonist

Clonidine. The alpha 2-agonist clonidine is used to treat ADHD in children in spite of weak scientific evidence for its use, and in spite of a paucity of studies dealing with its effects (Popper, 1997). Although Clonidine can eliminate insomnia caused by ADHD, and although behavioral response has demonstrated benefits, inattention and cognition results were less decisive (Biederman, 1998). Before recommending Clonidine (methylphenidate), a doctor must conduct a complete cardiovascular history, including cardiac examination, pulse and blood pressure check, and blood count because of reports of unexpected sudden death. In addition, side effects include sedation, rebound (Popper, 1997), and cardiovascular effects (Dulcan, Dunne, et al., 1997). To reduce side effects, clonidine needs to be administered in gradual, frequent doses (Findling & Dogin, 1998).

Clonidine patch. Clonidine lasts from 3 to 6 hours and requires three to four doses a day (Broderick-Cantwell, 1999). An alternative is the clonidine patch, which is replaced every 5 days. Advantages to the use of the patch include less frequent dosages, eliminating the rebound effect, allowing even drug distribution, reducing side effects, and increasing compliance. Disadvantages include skin irritation and the fact that sweating can cause the patch to fall off (Popper, 1997).

Medication Summary

Popper (1997) concludes his summary of medication use by suggesting that stimulants are the drug of choice for ADHD treatment because they improve cognition. In contrast, although TCAs treat hyperactivity and impulsivity, they do not improve cognition. Avoid Desipramine altogether because other TCAs are safer. Bupropion may be comparable to stimulants, but tics and skin rash limit its usefulness. TCAs and bupropion may be preferred over stimulants for those who abuse drugs or who live with someone abusing drugs. Bupropion and stimulants would be more likely to aggravate tics in people with co-morbid ADHD and Tourette's disorder than would TCAs. For those with ADHD and seizure disorders, stimulants may be better than TCAs or bupropion.

Popper (1997) suggests that it would make sense for future medications to last longer than 6 hours to help eliminate midday dosing, to reduce daily on-off effects, and to reduce rebound. We must focus on medications that improve attention and cognition as well as motivation and organization, if we are to assist children with ADHD.

COMBINATION/MULTIMODAL TREATMENTS

Reasons for Multiple Treatments

No single medical or psychosocial intervention can treat ADHD (Erk, 1995). No single intervention will provide long-term benefit to ADHD children who have different levels of co-morbidity, family backgrounds, and functional deficits (Richters et al., 1995). So, combining drugs with multimodal psychosocial interventions is of great interest (Richters, 1995). As yet, little is known about the effects of combining medications for treating ADHD symptoms and so guidelines are limited (Spencer et al., 1996; Biederman, 1998).

Although adequate trials have not been completed, medications are beginning to be combined to treat resistant ADHD (Popper, 1997). Historically, stimulants and antipsychotics were combined, and two studies have combined a neuroleptic and a stimulant with better results than either used alone (Spencer et al., 1996). Findings suggest that combining the neuroleptics haloperidol or orpimozide with stimulants may help those who have tics or Tourette's syndrome (Cantwell, 1996). Also, Spencer et al. (1996) measured the separate and combined effects of Ritalin and desipramine. Results suggest that Ritalin alone improved alertness, both alone helped short-term memory and visual problem solving, and together they improved learning (Spencer et al., 1996). One study using Ritalin and desipramine for ADHD and a mood disorder yielded no side effects and a better outcome than when used alone. Another study using Ritalin and desipramine reported more side effects than when either was used alone, but with effects that were no more serious than when desipramine was used alone (Dulcan, Dunne, et al., 1997). Antidepressants and stimulants have been combined for ADHD and co-morbid depression, and lithium has been used with an anti-ADHD drug to control ADHD co-morbid with bipolar disorder (Spencer et al., 1996).

Imipramine and Ritalin were used safely in some situations but in others confusion, aggression, and agitation resulted (Dulcan, Dunne, et al., 1997). To improve behavior and attention, Clonidine and Ritalin are often used in combination (Popper, 1997). Note, however, that three sudden deaths occurred with this same combination and that an alternative is to switch Dexedrine with Ritalin and guanfacine (another alpha 2 agonist) with clonidine (Dulcan, Dunne, et al., 1997). When dealing with drug combinations, the major risk is cardiovascular failure, but this risk is lowered when doses are gradually titrated and closely monitored (Popper, 1997).

Multimodal Approach

Although combining medications is an effective method with ADHD youth, some research indicates that a combined psychosocial and medical intervention is superior (Cantwell, 1996). Other research suggests that although people believe that a multimodal treatment approach is superior to either medication or psychosocial interventions used alone, evidence for multimodal treatment is meager because of the cost of conducting trials, complexity of studies, length of time required for such trials, or the large number of participants needed (Dulcan, Dunne, et al., 1997). Nevertheless, one advantage of a multimodal approach is that coping skills learned with the psychosocial intervention would remain when the effects of the medication begin to wear off. In addition, ADHD youth who have better coping skills may require a lower dosage of medicine. Short-term studies indicate that medication alone, or psychosocial interventions alone, are not enough to allow youth to control behaviors enough to do well academically (Dulcan, Dunne, et al., 1997). Studies also indicate that behavior modification, when used alone, is less effective than when medication is used alone, and they also indicate that a multimodal approach is needed for ADHD youth with co-morbid disorders (Popper, 1997).

Dulcan, Dunne, et al. (1997) describe a multimodal treatment plan in which, 3 years after the initial study, participants who received medication along with psychosocial interventions improved their home and school behavior and their academic performance and decreased their delinquent behavior. Some successful multimodal programs include summer treatment programs; other successful multimodal programs use stimulants and enlist strong parent involvement so that the social skills component was reinforced and generalized to other settings (Frankel, Myatt, Cantwell, & Feinberg, 1997). One specific multimodal approach that includes parent involvement is the Irvine Paraprofessional Program. In this program, children with severe ADHD symptoms are placed in a regular school classroom for 12 weeks to learn behavioral modification, skill training, and pharmacological assessment (Kotkin, 1998). Taken together, these research results indicate that combining interventions works when treating co-morbidity, when youth do not respond to a single intervention, and when side effects need to be reduced (Biederman, 1998). Regardless of the intervention ultimately used, individual assessment is a necessity.

Combining medications and using multimodal interventions are complicated processes where little is known and more research is needed before combination approaches are fully understood (Richters et al, 1995). The central question is this: Under what circumstances (co-morbid conditions, age, gender, family background) do which treatment combinations (medication, behavior therapy, parent training, school-based intervention) have what impact (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, physical, peer relations, family relations) for how long (short- versus long- term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)?

CONCLUSION

Although most mental health and school counselors know about the use of Ritalin, and although most know that medicines are used to reduce the symptoms associated with ADHD, many counselors do not know enough about this topic to be able to determine for themselves whether they believe that medication only, psychosocial intervention only, or both medication and psychosocial intervention ought to be used in treating ADHD in children and adolescents. We hope this article helps to clarify some of the key aspects of this controversial topic. In fact, we remain skeptical regarding the use of medical intervention given the serious known and unknown side effects. Nevertheless, medications are commonly prescribed, and mental health counselors are increasingly forming partnerships with school counselors to help ADHD youth. Counselors must be continuously informed on this topic so that they can at least know their own opinions when a parent, teacher, principal, or child asks for help in managing ADHD symptoms.

REFERENCES

Barrickman, L. L., Perry, P. J., Allem, A. J., Kuperman, S., Arndt, S. V., Herrmann, K. J., & Schumacher, E. (1995). Bupropion versus methylphenidate in the treatment of attention-deficit hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatric, 34, 649-657.

Biederman, J. (1998). Attention-deficit/hyperactivity disorder: A life-span perspective. Journal of Clinical Psychiatry, 59 (Suppl. 7), 4-16.

Broderick-Cantwell, J. J. (1999). Case study: Accidental clonidine patch overdose in attention-deficit/hyperactivity disorder patients. Journal of American Academy of Child and Adolescent Psychiatry, 38, 95-98.

Cantwell, D. P. (1996). Attention deficit disorder: A review of the past 10 years. Journal of American Academy of Child and Adolescent Psychiatry, 35, 978-987.

Dulcan, M., Dunne, J. E., Ayres, W., Arnold, V., Benson, R. S., Bernet, W., Bukstein, O., Kinlan, J., Leonard, H., Licamele, W., McClellan, J., Sloan, L. E., & Miles, C. M. (1997). Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 36 (Suppl. October), 85S-121S.

Erk, R. R. (1995). A diagnosis of attention deficit disorder: What does it mean for school counselors and mental health counselors. The School Counselor, 42, 292-299.

Findling, R. L., & Dogin, J. W. (1998). Psychopharmacology of ADHD: Youth. Journal of Clinical Psychiatry, 59 (Suppl. 7). 42-49.

Frankel, F., Myatt, R., Cantwell, D., & Feinberg, D. (1997). Parent-assisted transfer of children's social skills training: Effects on children with and without attention-deficit hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 36, 1056-1064.

James, S. H., & Nims, D. R. (1996). A catalog of psychiatric medications used in the treatment of child and adolescent mental disorders. The School Counselor, 43, 299-307.

Kotkin, R. (1998). The Irvine Paraprofessional Program: Promising practice for serving youth with ADHD. Journal of Learning Disabilities, 31, 556-564.

O'Toole, K., Abramowitz, A., Morris, R., & Dulcan, M. (1997). Effects of methylphenidate on attention and nonverbal learning in children with attention-deficit hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 36, 531-538.

Popper, C. W. (1997). Antidepressants in the treatment of attention-deficit/hyperactivity disorder. Journal of Clinical Psychiatry, 58 (Suppl. 14), 14-29.

Richters, J. E., Arnold, L. E., Jensen, P. S., Abikoff, H., Conners, C. K., Greenhill, L. L., Hechtman, L., Hinshaw, S. P., Pelham, W. E., & Swanson, J. M. (1995). NIMH collaborative multimodal treatment study of children with ADHD: I. Background and rationale. Journal of American Academy of Child and Adolescent Psychiatry, 34, 987-1000.

Riggs, P. D., Thompson, L. L., Mikulich, S. K., Whitmore, E. A., & Crowley, T. J. (1996). An open trial of premoline in drug-dependent delinquents with attention-deficit hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 35, 1018-1024.

Schachar, R. J., Tannock, R., Cunningham, C., & Corkum, P. V. (1997). Behavioral, situational, and temporal effects of treatment of ADHD with methylphenidate. Journal of American Academy of Child and Adolescent Psychiatry, 36, 754-763.

Smith, B. H., Pelham, W. E., Gnagy, E., & Yudell, R. S. (1998). Equivalent effects of stimulant treatment for attention-deficit hyperactivity disorder during childhood and adolescence. Journal of American Academy of Child and Adolescent Psychiatry, 37, 314-321.

Spencer, T., Biederman, J. & Wilens, T., Harding, M., O'Donnell, D., & Griffin, S. (1996). Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. Journal of American Academy of Child and Adolescent Psychiatry, 35, 409-432.

Spencer, T., Biederman, J., Wilens, T., Steingard, R., & Geist, D. (1993). Nortriptyline treatment of children with attention-deficit hyperactivity disorder and tic disorder or Tourette's syndrome. Journal of American Academy of Child and Adolescent Psychiatry, 32, 205-210. Swanson, J. M., Wigal, S., Greenhill, L. L., Browne, R., Waslik, B., Lemer, M., Williams, L., Flynn,

D., Agler, D., Crowley, K., Fineberg, E., Baren, M., & Cantwell, D. P. (1998). Analog classroom assessment of adderall in children with ADHD. Journal of American Academy of Child and Adolescent Psychiatry, 37, 519-526.

Varley, C. K., & McClellan, J. (1997). Case study: Two additional sudden deaths with tricyclic antidepressants. Journal of American Academy of Child and Adolescent Psychiatric, 36, 390-394.

Wilens, T. E., Biederman, J., Geist, D. E., Steingard, R., & Spencer, T. (1993). Nortriptyline in the treatment of ADHD: A chart review of 58 cases. Journal of American Academy of Child and Adolescent Psychiatry, 32, 343-349.

Alex S. Hall, Ph.D., is an assistant professor, Division of Counseling Rehabilitation and Student Development, The University of Iowa, Iowa City. Email [e-mail] Arlinn G. Gushee, is a teacher at Urbandale Middle School, Urbandale, IA.