Stephen Sulkes

Treatment of ADHD in children with tics: A randomized controlled trial

BACKGROUND The treatment of children with attention deficit hyperactivity disorder (ADHD) and Tourette syndrome (TS) has been problematic because methylphenidate (MPH)--the most commonly used drug to treat ADHD--has been reported to worsen tics and because clonidine (CLON)--the most commonly prescribed alternative--has unproven efficacy. METHODS The authors conducted a multicenter, randomized, double-blind clinical trial in which 136 children with ADHD and a chronic tic disorder were randomly administered CLON alone, MPH alone, combined CLON + MPH, or placebo (2 x 2 factorial design). Each subject participated for 16 weeks (weeks 1-4 CLON/placebo dose titration, weeks 5-8 added MPH/placebo dose titration, weeks 9-16 maintenance therapy). RESULTS Thirty-seven children were administered MPH alone, 34 were administered CLON alone, 33 were administered CLON + MPH, and 32 were administered placebo. For our primary outcome measure of ADHD (Conners Abbreviated Symptom Questionnaire--Teacher), significant improvement occurred for subjects assigned to CLON (p < 0.002) and those assigned to MPH (p < 0.003). Compared with placebo, the greatest benefit occurred with combined CLON + MPH (p < 0.0001). CLON appeared to be most helpful for impulsivity and hyperactivity; MPH appeared to be most helpful for inattention. The proportion of individual subjects reporting a worsening of tics as an adverse effect was no higher in those treated with MPH (20%) than those being administered CLON alone (26%) or placebo (22%). Compared with placebo, measured tic severity lessened in all active treatment groups in the following order: CLON + MPH, CLON alone, MPH alone. Sedation was common with CLON treatment (28% reported moderate or severe sedation), but otherwise the drugs were tolerated well, including absence of any evident cardiac toxicity. CONCLUSIONS Methylphenidate and clonidine (particularly in combination) are effective for ADHD in children with comorbid tics. Prior recommendations to avoid methylphenidate in these children because of concerns of worsening tics are unsupported by this trial.

Clinical Settings for Health Care Delivery

The provision of quality medical care for premature infants and children born with congenital anomalies, along with the many social and educational services that have evolved over the last five decades to assure that all children have opportunities for success in life, coupled with the movement of individuals with intellectual and developmental disabilities (IDD) out of monolithic institutional settings, has led to a shift in the pattern of health care delivery to the community. Once served in segregated settings, now children and adults with IDD can receive community-based health care included within the generic health care delivery system. While the generic system allows for a variety of options, the challenges faced by individuals with IDD and their families relate to the complex nature of their health care needs coupled with the emotional, social and economic factors that play out in these situations. This brief chapter will outline the trajectory of health care needs across the lifespan and of the way in which the services are configured to meet the needs, by using the example of a single child. It should be noted that this format is designed to orient the reader to the following chapters that address, in more detail, the different aspects of health care needs and health care delivery systems available in the community.

Electronic Medical Records

Electronic medical records (EMRs) are changing the nature of practice in health care for people with intellectual and developmental disabilities (IDD). Many practitioners bemoan the barriers created, but used to their fullest advantage EMRs can improve care coordination, facilitate quality improvement, and improve service delivery. National standards for data sharing within and across EMR systems would further enhance the utility of such tools, but remain difficult to achieve.

The implementation of postgraduate training programs through state and local resources

A profile of implementation strategies for funding postgraduate training programs using local or state resources is described. The need for those implementation strategies as well as basic principles for successful implementation is documented. Two programs are briefly described--a University Affiliated Program (UAP) in western New York and a UAP in Missouri--as the basis for generating implementation strategies. Finally a discussion is provided reviewing the strengths and weaknesses of these strategies.