[Prescribing ritalin in combined modality management of hyperactivity with attention deficit]

Attention Deficit Hyperactivity Disorder (ADHD) is a relatively frequent affection that can generate severe problems (school, social, professional) if no take in charge is done. Treatment of ADHD is generally multifactorial; it can associate medical treatment, comportemental and analytical psychotherapies, reeducation of associated disorders (orthophony, psychomotor reeducation) and educative approach. Methylphenidate, considered as therapeutic reference, is a central nervous system stimulant. It produces a stimulation of vigilance and superior mental activities, a diminution of fatigue sensation and sleep need, an anorexigen power and sympathomimetic effect. Its mechanism of action is abundantly studied and is not completely known. Principal hypothesis are: increase of chemical mediators biodisponsibility and change in cerebral blood flow delivery. In France, it is agreed since 1995 for treatment of ADHD in over 6 years-old child. Ritaline 10 mg is registered on the narcotic list and an initial hospital prescription is needed, reserved to specialists and/or to neurologic, psychiatric and pediatric services. Mid-1995, 2.8% (namely 1.5 millions) of 5 to 18 years-old american children have taken this drug. Methylphenidate is effective on each three principal symptoms of ADHD: it decreases the level of activity, it improves apprentice capacity, just as school performances and it eases social interactions. The therapeutic schedule at short and middle term is reassuring, with substantial profits on school, familiar and social plans, but unknowns subsist and opinions diverge about long term efficacity. Methylphenidate is not the only one used in ADHD treatment. Other products, like dextroamphetamine and pemoline have been used in the USA and are for those who can't tolerate methylphenidate or badly respond to it. Those other drugs are not commercialized in France. The limits of stimulating drugs (fear to favour toxicomania, undesirable effects that need to stop treatment or non-responsive hyperactive children), just as positives experiences with antidepressants (especially on enuresis) led to use tricyclic antidepressants as second-line agents in ADHD treatment. Their efficiency is less and their well known side-effects are sometimes constraining. Antidepressants that inhibit serotonin recapture, MAOI and bupropion, central antihypertensive, such as clonidine and guanfacine have been tried in ADHD treatment as third-line agents. They should be useful on non-responsive or patients who can't tolerate stimulants or tricyclic antidepressants. Analytical and comportemental psychotherapies are used in addition to medicamental treatment. Reeducation of troubles such as dyslexia, language delay, corporal scheme troubles or fine coordination trouble is obtained by orthophony and psychomotricity. It's very important to instaurate an educative strategy in order to contend inattention and hyperactivity. Regular conservations with parents and child are necessary. The whole american literature shows better efficiency of multimodal treatment of ADHD in child, as opposed to single stimulant treatment.