What medications are used to treat ADHD?

Attention deficit/hyperactivity disorder (ADHD) occurs in both children and adults. ADHD is commonly treated with stimulants, such as:

• Methylphenidate (Ritalin, Metadate, Concerta, Daytrana)
• Amphetamine (Adderall)
• Dextroamphetamine (Dexedrine, Dextrostat).

In 2002, the FDA approved the nonstimulant medication atomoxetine (Strattera) for use as a treatment for ADHD. In February 2007, the FDA approved the use of the stimulant lisdexamfetamine dimesylate (Vyvanse) for the treatment of ADHD in children ages 6 to 12 years.

What are the side effects?

Most side effects are minor and disappear when dosage levels are lowered. The most common side effects include:

• Decreased appetite. Children seem to be less hungry during the middle of the day, but they are often hungry by dinnertime as the medication wears off.
• Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose. The doctor might also suggest that parents give the medication to their child earlier in the day, or stop the afternoon or evening dose. To help ease sleeping problems, a doctor may add a prescription for a low dose of an antidepressant or a medication called clonidine.
• Stomachaches and headaches.
• Less common side effects. A few children develop sudden, repetitive movements or sounds called tics. These tics may or may not be noticeable. Changing the medication dosage may make tics go away. Some children also may appear to have a personality change, such as appearing "flat" or without emotion. Talk with your child's doctor if you see any of these side effects.

How are ADHD medications taken?

Stimulant medications can be short-acting or long-acting, and can be taken in different forms such as a pill, patch, or powder. Long-acting, sustained and extended release forms allow children to take the medication just once a day before school. Parents and doctors should decide together which medication is best for the child and whether the child needs medication only for school hours or for evenings and weekends too.

ADHD medications help many children and adults who are hyperactive and impulsive. They help people focus, work, and learn. Stimulant medication also may improve physical coordination. However, different people respond differently to medications, so children taking ADHD medications should be watched closely.

Are ADHD medications safe?

Stimulant medications are safe when given under a doctor's supervision. Some children taking them may feel slightly different or "funny."

Some parents worry that stimulant medications may lead to drug abuse or dependence, but there is little evidence of this. Research shows that teens with ADHD who took stimulant medications were less likely to abuse drugs than those who did not take stimulant medications.14

FDA warning on possible rare side effects

In 2007, the FDA required that all makers of ADHD medications develop Patient Medication Guides. The guides must alert patients to possible heart and psychiatric problems related to ADHD medicine. The FDA required the Patient Medication Guides because a review of data found that ADHD patients with heart conditions had a slightly higher risk of strokes, heart attacks, and sudden death when taking the medications. The review also found a slightly higher risk (about 1 in 1,000) for medication-related psychiatric problems, such as hearing voices, having hallucinations, becoming suspicious for no reason, or becoming manic. This happened to patients who had no history of psychiatric problems.

The FDA recommends that any treatment plan for ADHD include an initial health and family history examination. This exam should look for existing heart and psychiatric problems.

The non-stimulant ADHD medication called atomoxetine (Strattera) carries another warning. Studies show that children and teenagers with ADHD who take atomoxetine are more likely to have suicidal thoughts than children and teenagers with ADHD who do not take atomoxetine. If your child is taking atomoxetine, watch his or her behavior carefully. A child may develop serious symptoms suddenly, so it is important to pay attention to your child's behavior every day. Ask other people who spend a lot of time with your child, such as brothers, sisters, and teachers, to tell you if they notice changes in your child's behavior. Call a doctor right away if your child shows any of the following symptoms:

• Acting more subdued or withdrawn than usual
• Feeling helpless, hopeless, or worthless
• New or worsening depression
• Thinking or talking about hurting himself or herself
• Extreme worry
• Agitation
• Panic attacks
• Trouble sleeping
• Irritability
• Aggressive or violent behavior
• Acting without thinking
• Extreme increase in activity or talking
• Frenzied, abnormal excitement
• Any sudden or unusual changes in behavior.

While taking atomoxetine, your child should see a doctor often, especially at the beginning of treatment. Be sure that your child keeps all appointments with his or her doctor.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 08-3929
Revised 2008

I am writing to give you an update regarding your student, who has a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) / Attention Deficit Disorder (ADD).

Accommodations are essential for this student to function in the academic program. Specific accommodations will need to be devised for this student in collaboration with the youth and family.

There are many ways that schools can help a child with ADHD succeed in the classroom. Meetings between parents and school staff, such as teachers, guidance counselors, or nurses, will allow for collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom. Examples of some accommodations, modifications, and school strategies include the following options.

For children with inattentive symptoms:

• Assign the child a seat that limits distractions. Sitting at the front of the class may be helpful.
• Reduce distracting sounds. Noisy classroom chairs can be quieted with tennis balls or padding at the end of the legs. Headphones may help a child’s concentration.
• Clarify the expectations for classroom behaviors. If children understand, ahead of time, what is expected of them and what the consequences are if expectations are not met, they will have a better chance at succeeding.
• Clearly draw attention to instructions that are given (for example, “Peter, this is a direction”). A child with ADHD often misses basic social cues.
• Ask the child to repeat instructions before carrying them out. Repetition reinforces the directions in the child’s mind and makes evident whether the child understood the instructions.
• Provide information in small chunks that will allow the child to follow each step
• Provide frequent check-in points during a lesson. Children with ADHD will respond well to supervision and encouragement that help keep them on track.
• Develop simple, discreet visual cues to help a child return to on-task behaviors. Children respond well to helpful reminders that do not embarrass them.
• Adjust to the child’s learning style. Untimed tests may be needed. For other tasks, a timer may help a child track the time needed to complete an assignment.
• Develop motivating strategies to complete assignments. By pairing easier tasks that a child prefers with more difficult tasks, a child will have more enthusiasm for all tasks.
• Help the child remember and retain important class materials. Write a list of needed class materials and develop a means for getting the list home (for example, tape it to a book or help the child place it in a backpack). Having a complete set of classroom materials at home and at school reduces time lost tracking down items such as pencils, erasers, paper, and textbooks. Taping important items such as pencils to the desk may reduce lost items.
• Help the child keep track of assignments by emailing assignments home

For the child with hyperactive or impulsive symptoms:

• Identify appropriate times/places when the child can move (for example, ask the child to bring the attendance sheet to the office). Children with ADHD may need to move more frequently than other children.
• Provide an alternative, less distracting source of activity, such as a squeezeball or fabric to rub.
• Develop cues to help students stop talking out of turn. Nonverbal cues can be powerful and effective for all students. Identify when the child will be able to talk again. For students who blurt out answers, encourage them to write down answers before raising their hands to give answers.
• Before an activity, clarify expectations. Identifying the expected volume level and activity level before unstructured activities will help reinforce desired behaviors.
• Design interventions that interrupt the behaviors. For a child with trouble standing in line, assign the child to a specific place to stand in line, or a specific student to stand beside. For a child with difficulty with taking turns, develop a routine for waiting, such as counting to 5, and then raising a hand.

For all children with ADHD:

• Provide assistance with peer interactions. An adult’s help may be very beneficial for both the child and his or her peers.
• Encourage small group interactions to develop increased areas of competency. Children with ADHD may put forth better efforts in more contained groups.
• Encourage the child to help develop interventions. Enlisting the child in the task will lead to more successful strategies and will foster the child’s ability to problem-solve.
• Develop a behavior plan that is a true incentive to the student, as described above in Interventions at Home. Rewards may be given at school by a teacher or school counselor or at home by a parent. Teachers, school counselors, and parents can collaborate to use similar reward systems at school and home.
• Reward a child’s efforts. Every good effort deserves to be praised.

Special thanks to Dr. Bostic and the School Psychiatry Program and the MADI Resource Center for permission to use this content.

To whom it may concern:

I am writing this letter to let you know that this employee requires accommodations and modifications in the workplace.

Specific accommodations and modifications will need to be determined after speaking further with this employee.

Nonetheless, here are some specific areas and possible strategies:

Time Management

This employee may experience difficulty managing time, which can make it hard for this person to get tasks completed on time.

Possible strategies include

• When you have an assignment for this employee
• Give several small tasks instead (rather than just giving one big task)
• When the employee is working on a task that is expected to take a specific amount of time, consider giving the employee a timer with an alarm that goes off after a reasonable time, to help remind the employee to stay on task
• Provide a checklist of assignments
• Supply an electronic or handheld organizer, and train on how to use effectively
• Use wall calendar to emphasize due dates
• Develop a color-coded system (each color represents a task, or event, or level of importance)
• Allow co-worker or supervisor to add entries on the calendar, or to double-check entries added by the employee with AD/HD

Memory

This employee may have memory problems, which makes it hard to complete tasks, as well as troubles remembering job duties.

Possible strategies

• Provide written instructions
• Allow additional training time for new tasks
• Offer training refreshers
• Use flow-chart to indicate steps in a task
• Provide verbal or pictorial cues
• Use post-it notes as reminders of important dates or tasks

Concentration

• This employee may have troubles concentrating and focusing on ‘boring tasks’
• Possible strategies
• If possible, put this employee in a workspace that has less noise
• Consider a white noise machine, or background music
• To reduce visual distractions:
• Install space enclosures (cubicle walls)
• Reduce clutter in the employee’s work environment
• Redesign employee’s office space to minimize visual distractions
• Relocate employee’s office space away from visual distractions

Organization and Prioritization

• This employee may have difficulty getting or staying organized, or have difficulty prioritizing tasks at work.
• Possible strategies
  • Help the employee develop some sort of organization system
  • Develop color-code system for files, projects, or activities
  • Use weekly chart to identify daily work activities
  • Use the services of a professional organizer
  • Use a job coach to teach/reinforce organization skills
  • Assign a mentor to help employee
  • Allow supervisor to assign prioritization of tasks
  • Assign new project only when previous project is complete, when possible
  • Provide a “cheat sheet” of high-priority activities, projects, people, etc.

Social Skills

• Employees in a similar situation may have troubles with their social skills, i.e. problems such as communicating with others, or exhibiting appropriate social skills.
• Possible strategies:
  • Provide a job coach to help understand different social cues
  • Identify areas of improvement for employee in a fair and consistent manner
  • Make attendance at social activities optional
  • Use training videos to demonstrate appropriate behavior in workplace
  • Encourage employees to minimize personal conversation, or move personal conversation away from work areas
  • Provide sensitivity training (disability awareness) to all employees
  • Encourage all employees to model appropriate social skills
  • Adjust the supervisory method to better fit the employee’s needs
  • Allow the employee to work from home
  • Adjust method of communication to best suit the employee’s needs
  • Use role-play scenarios to demonstrate appropriate behavior in workplace

Hyperactivity/Impulsivity

• Individuals may have an extremely high level of activity, and may even have troubles sitting still
• Possible strategies
• Within the work environment, give the employee opportuntiies to stand and move, rather than insisting on simply sitting still
• Consider standing desks (desk where the employee can stand up rather than just sit), or sit-stand stations (workstation that can be lowered so an employee can sit down, or can be raised so that the employee can stand up).
• Give frequent movement breaks

Multi-tasking

• Individuals with AD/HD may experience difficulty performing many tasks at one time. This difficulty could occur regardless of the similarity of tasks or the frequency of performing the tasks.
• Possible strategies
  • Separate tasks so that each can be completed one at a time
  • Create a flow-chart of tasks that must be performed at the same time, carefully labeling or color-coding each task in sequential or preferential order
  • Provide individualized/specialized training to help employee learn techniques for multi-tasking (e.g., typing on computer while talking on phone)
  • Identify tasks that must be performed simultaneously and tasks that can be performed individually
  • Provide specific feedback to help employee target areas of improvement
  • Remove or reduce distractions from work area
  • Supply ergonomic equipment to facilitate multi-tasking
  • Clearly represent performance standards such as completion time or accuracy rates

Paperwork

• Individuals may experience difficulty completing paperwork efficiently and effectively. Because paperwork is usually boring, it means that while doing paperwork, the brain of the person with ADHD is not getting enough stimulation.
• Strategies include:
  • Doing paperwork during the employee’s “peak periods”, e.g. early morning, late afternoon, etc.

For more information, please feel free to contact:

• Centre for ADHD Advocacy (CADDAC.ca)
• Job Accommodation Network, a service of the Department of Labour (USA)
  http://askjan.org/media/adhd.html

Sincerely,

Your NAME 

Examples of Common Workplace Accommodations

Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:

• Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be from within the organization.

• Flexible scheduling to accommodate effects of medications, time for appointments, more frequent breaks, switch to temporary part-time hours without fear of losing job.

• Changes in supervision, for example how feedback and instruction are given, or having weekly supervision appointments to check in and prevent problems before they can happen.

• In training, allowing more time for tasks to be learned, or allowing for individualized, one-on-one training.

• Appropriate technology like a tape recorder to tape instructions, head phones to block out loud noise, etc.

• Modifying work space or changing location so it is quieter, fewer distractions; allowing an employee to work at home.

• Allowing an employee to exchange minor job tasks with others.

Rights and Responsibilities of the Employer & Employee

The Employer Should:

• Create and maintain an atmosphere where people feel comfortable asking for accommodation, including providing information about the organization’s policies and creating ways for requests to happen confidentially.

• Assume that the employee’s request for accommodation is made in good faith.

• In a timely manner, work with the employee (and a professional, if necessary), to explore all options for accommodation.

• Maintain records of the request and steps taken to deal with the request.

• Maintain and respect confidentiality issues.

• Pay the cost of the accommodations, including fees for any medical certificates required.

• Request only information that is directly related to developing an appropriate accommodation.

• Ensure that managers and supervisory staff will not tolerate any discrimination or harassment as a result of an illness or an accommodation.

The Employee Should

• Tell the employer you need an accommodation, due to a disability, and give them the information they need to understand what the limitations are and what accommodations would address them.

• If requested, provide supporting documentation or medical certificates.

• Meet all relevant job requirements and standards once the accommodation has been provided.

• Continue to work with the employer to ensure that the accommodation remains effective and to check in with how you are doing.

SOURCE

Adapted from “Employment” , in “From Rollercoaster to Recovery”.

ADDITIONAL INFORMATION

• The Alberta Human Rights Commission has additional information on responsibilities for employers around employees with addictions issues
  http://www.albertahumanrights.ab.ca/publications/bulletins_sheets_booklets/ sheets/protected_grounds/drug_and_alcohol_dependencies.asp