Other Medications

When children and adolescents with severe behavioral and emotional symptoms do not respond to stimulant medications, other types of medications may be prescribed.  These include antidepressants such as Wellbutrin®, Desiprimine and Prozac®.  Sometimes, medications originally designed to treat high blood pressure such as Clonodine may be used.  In other cases, medications used to treat psychosis, schizophrenia or to manic-depressive illness may be prescribed.  The current thinking is that (in most cases) if these medications provide control for the symptoms, they are actually treating another mental disorder rather than attention deficit disorder.  Unfortunately, some physicians may initially prescribe a medication other than a stimulant because the other medications do not require "triplicate" prescriptions as they are not considered controlled substances by the FDA.  While this may be convenient, the other medications have far more serious side effects than the stimulants and should not be considered unless there is reasonable clinical information to support their use over stimulants.

Antidepressants

There are two basic types of antidepressants, the tricyclic antidepressants (TCAs) and the newer ones known as selective serotonin reputake inhibitors (SSRIs).  When children or adolescents appear to have symptoms of depression with or without ADD like symptoms, an antidepressant may be prescribed.  In earlier years Tofranil® was used to treat bed wetting with or without behavioral or emotional symptoms.  There have been five unexplained sudden deaths reported in relation to the use of Desiprimine in treating children.  Though no specific causal relationship was established, clinical practice now favors Elavil® and Tofranil® as the first choices among the tricyclics in the treatment of children.  In any case, another medication Anafranil® has been found to be useful in treating obsessive-compulsive disorder in adults as well as children an adolescents.  According to the American Academy of Child & Adolescent Psychiatry, "TCAs should be used only for clear indications and with careful monitoring of therapeutic efficacy and of baseline and subsequent vital signs and EKG."  Also, "patient history of cardiac disease or arrhythmia or a family history of sudden death, unexplained fainting, cardiomyopathy, or early cardiac disease may be a contraindication to TCA use."  Finally there has been a lot of interest in the use of SSRIs, particularly Prozac® in treating ADD and/or depression or anxiety in children and adolescents. As yet, there have been no major research findings to support the use of SSRIs in treating ADD.  Furthermore, the Physician's Desk Reference (PDR) states that "safety and effectiveness in pediatric patients has not been established."

Neuroleptics

Neuroleptics were developed to treat serious mental disorders such as psychosis and schizophrenia.  They are indicated for use in children and adolescents with significant psychotic symptoms such as hallucinations or delusions.  Two of these drugs, Haldol® and Mellaril®, have been used to treat ADD like symptoms (especially aggression and explosiveness) in children and adolescents.   These medications appear to have some usefulness in controlling severe symptoms that are not helped by other medications.  However the American Academy of Child & Adolescent Psychiatry cautions that "they should be used only in the most unusual circumstances because of lesser effectiveness relative to other drugs, excess sedation and potential cognitive dulling, and risk of tardive dyskinesia or neuroleptic malignant syndrome".

Mood Stabilizers

In the last few years, it has become more acceptable by American psychiatrists to consider the diagnosis of bipolar disorder (manic-depressive illness) for children and adolescents.  This has been common practice in other countries including Great Britain.  Again, it is presumed that if a child's behavior improves on this type of medication that the cause of the symptoms is bipolar illness not ADD.  Lithium and other medications containing lithium are most often used to treat bipolar disorder in adults and children.  Anticonvulsant medications such as Tegretol® or Depakote® also can be used to treat bipolar disorder when it does not respond to lithium.

Alpha-Andrenergics

It is currently assumed that biochemically ADD is related to problems with the neurotransmitter, dopamine.  Another neurotransmitter, norepinephrine, is a derivative of dopamine.  Stimulants are thought to primarily effect dopamine.  In some cases, norepinephrine may be involved.  In these cases two medications originally developed to treat high blood pressure, Clonidine and Guanfacine have proven to be useful.  These drugs have been found to be effective in treating ADD symptoms in children who were exposed to drugs as a fetus.  These drugs have been effective in treating Tourette Syndrome and therefore are useful in treating ADD children who have or have a tendency for motor tics.  Some psychiatrists use Clonidine in conjunction with a stimulant to treat ADD in children with motor tics.   These drugs can have serious side effects and should be used only when clinically indicated.

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