- The most important telltale sign that a child may benefit from medication is when the child no longer feels accepted by peers, at school, or even at home. Social and academic impairment are important markers to take into consideration. In fact the American Academy of Pediatrics requires the impairment to be observed in more than one domain (social, home, school, playground, etc.) before medication treatment for ADD/ADHD is warranted.  

- From a medication perspective, the latest advances are the first-ever transdermal patch, and a new oral medication. The transdermal patch goes by the brand name Daytrana. The patch is applied directly to the skin with frequent site rotation. It has proven to be very effective, assuming of course, that the child wears it continuously throughout the day. The newest oral medication goes by the brand name Vyvanse. This drug is essentially the same as Adderall XR, and “supposedly” has less abuse potential than Adderall XR. Adderall XR will soon be losing FDA patent protection.

- Advice for parents and caretakers: Don’t be too quick to conclude that a child should be treated for this disorder. Some parents, teachers and even treating clinicians are intolerant of unruly behavior and therefore are often too quick to assign this “diagnosis.” Parents should be sure that academic or social functioning is impaired and should also consider a variety of information sources to assist in diagnostic confirmation. Optimally, a child should be assessed in multiple settings (home, school, social). Extensive interviews should be conducted with the child and at least one parent. These interviews should thoroughly review the child’s medical history and family history of ADD/ADHD, and rating scales should be employed – particularly in instances where diagnostic uncertainty is an issue. Most importantly, if ADD/ADHD is suspected, the child should be assessed by a clinician experienced in treating pediatric disorders of childhood.

• - To demonstrate the clinical need for medication to be continued
• - To provide a temporary respite from side effects such as anxiety, insomnia, gastrointestinal disturbances and weight loss
• - To satisfy the notion of caregivers that medication should not be used if it can be avoided

Some studies have found that weekend holidays from methylphenidate psychostimulants reduced insomnia and appetite suppression without significantly increasing ADHD symptoms. These side effect improvements were reported by parents, and extended to the Monday following the weekend, as reported by teachers. However reports by physicians that treat ADHD indicate that patients can experience difficulty adjusting to re-dosing for one to three days after their drug holiday is completed. Drug holidays also mean that the child will likely suffer from the symptoms of ADHD at a time when he or she would want to be able to enjoy time with family and friends. These relationships run the risk of becoming strained because of the child’s symptoms, particularly if medication discontinuation extends beyond a weekend.

Clinically, I am not a fan of drug holidays. In my estimation, the risks of symptom reemergence far outweigh the relatively short term benefits associated with a decrease in side effects in a child that has been responding favorably to psychostimulant medication. It is important to note that symptom return is rapid for most following drug stoppage, albeit somewhat delayed in the patient using the longer acting stimulant preparations. There is also little disagreement in the clinical literature or among clinicians experienced in treating ADHD regarding long term weight and height issues. That is, although weight loss and growth suppression can be consequences of stimulant use, these consequences are typically not long term, in that as children age throughout the developmental cycle, they tend to “catch up” in both weight and height.

Gradual dosage reduction over time seems to be a more viable option than the “cold turkey” discontinuation approach – even if it’s just for a weekend. The bottom line: The discontinuation of stimulant medication in a child for whom the drug has been effective means a re-experiencing of the nightmarish symptoms that plagued both the child and family.

Irritability, frustration intolerance, aggression and inattentiveness are present in both disorders.

Did I miss anything? What are your experiences when it comes to differentiating Bipolar disorder and ADHD?