CASA of Arizona

ADHD - pg. 6

Treatment of Attention-Deficit Hyperactivity Disorder



A wide variety of treatments have been used for ADHD including, but not limited to, various psychotropic medications, psychosocial treatment, dietary management, herbal and homeopathic treatments, biofeedback, meditation, and perceptual stimulation/training.

Clinical experience has shown that the most effective treatment for ADHD is a combination of medication (when necessary), counseling to learn coping skills and adaptive behaviors. Medication is often used to help normalize brain activity. The stimulant medications (Ritalin, Dexedrine, Adderall) are commonly used because they have been shown to be most effective for most people with ADHD, however, many other medications may also be used at the discretion of the physician. Behavior therapy and cognitive therapy is often helpful to modify certain behaviors and to deal with the emotional effects of ADHD. This type of therapy has been shown to help adults with ADHD manage problem behaviors and develop coping skills, such as improving organizational skills and improving productivity.

Pharmacological Treatments

Pharmacological treatment with psycho-stimulants is the most widely studied treatment for ADHD. Psycho-stimulants are highly effective for 75 to 90 percent of children with ADHD. At least four separate psycho-stimulant medications consistently reduce the core features of ADHD in literally hundreds of randomized controlled trials: methylphenidate, dextroamphetamine, pemoline, and a mixture of amphetamine salts.

These medications are metabolized, leave the body fairly quickly, and work for 1 to 4 hours. Administration is timed to meet the child's school schedule, to help the child pay attention and meet his or her academic demands, and to mitigate side effects. These medications have their greatest effects on symptoms of hyperactivity, impulsivity, and inattention and the associated features of defiance, aggression, and oppositionality. They also improve classroom performance and behavior and promote increased interaction with teachers, parents, and peers. Small effects were found on learning and school achievement. However, psycho-stimulants do not appear to achieve long-term changes in outcomes such as peer relationships, social or academic skills, or school achievement.

Children who do not respond to one stimulant may respond to another. Children should be reevaluated without the medication to see if stimulant treatment is still indicated. Many families choose to have their child take a "drug holiday" on weekends and vacations to reduce overall exposure, but the utility of this strategy has not been demonstrated.

Other important barriers include those perceived by patients, families, and clinicians. These include lack of information, concerns about risks of medications, loss of parental rights, fear of professionals, social stigma, negative pressures from families and friends against seeking treatment, and jeopardizing jobs and military service. For health care providers, the lack of specialists and difficulties obtaining insurance coverage as outlined above present significant obstacles to care.

Stimulants

Methylphenidate (Ritalin, Metadate) is the most commonly used drug for ADHD. Ritalin needs to be administered several times a day, making compliance difficult. Metadate, an extended release form, may help. Medication regimens are generally recommended for hours spent at school, with drug holidays during the evenings, weekends, and vacations. Some physicians argue, however, that too much emphasis is placed on improvement only during school hours. When taken in the morning, the medication usually wears off in the late afternoon; at this point, a rebound effect can occur and ADHD symptoms intensify. The family members, whose affection and on-going support is so important, become victims of the disruptions generated by rebound, and the quality of life can worsen for everyone. Some physicians recommend a "homework" dose given after school to prevent rebound. Under investigation is a purer form of methylphenidate, which may prove to be more effective in treating symptoms in children and have fewer side effects.

Some people have become concerned about Ritalin abuse and the risk of addiction. Although Ritalin is a stimulant with properties similar to amphetamines, at the oral doses given for ADHD, levels of Ritalin rise very slowly in the brain, preventing a so-called "high" and subsequent addiction to the drug. Dependence has not been reported in children who have taken this drug for long periods in appropriate dosages. Crushing the pills and inhaling them nasally, however, can provide a euphoric state. The primary danger for drug abuse appears to come from peers; in one study, 16% of ADHD children reported pressure from their fellow students to sell or give them their medication.

Adderall combines four kinds of amphetamine salts. It is inexpensive and only needs to be taken once a day. In two studies comparing Adderall given once daily with two daily doses of Ritalin, both drugs were beneficial and the effect on behavior was similar. In one of these studies, Adderall was superior to low-dose Ritalin in preventing evening wearing-off effects and the staff involved in monitoring the children recommended Adderall over Ritalin by three to one. Eventually, this drug may prove to be a good alternative to Ritalin, since dosing at school is not necessary. Studies are needed to determine long-term risks.

Pemoline (Cylert) is an effective stimulant in children and may also prove to be beneficial for adults with ADHD. It takes longer (sometimes weeks) to produce improvement than the other drugs; its advantage, however, is that it allows once-daily administration. Cylert increases the risk of liver damage, particularly when taken in combination with other medications or alcohol. Although the risk is small, physicians should test children if they exhibit any symptoms of liver toxicity, including tenderness of the abdomen, yellow skin or eyes, vomiting, weight loss, or malaise.

Dextroamphetamine (Dexedrine) is similar to Ritalin. Although it is commonly believed that it is both less effective and less safe than Ritalin, there is no evidence of this, and one study reported a slightly better response with dextroamphetamine. Side effects are similar. The arguments against dextroamphetamine mainly rest on widespread abuse of this drug in earlier decades. Some experts believe it may be a useful alternative for people who do not respond to Ritalin.

Side Effects - The most common side effects of any stimulant are nervousness and sleeplessness, although some parents have reported improved sleep patterns in their children after taking stimulants. Other side effects include irritability, withdrawal, depression, hallucinations, and lack of spontaneity. (Children with developmental disabilities may be more susceptible to these side effects.) Tics or jerky, disordered movements occur in about 9% of children, although some studies indicate they are not caused by standard doses of Ritalin. In any case, low doses are often effective in controlling impulsivity without causing tics, even in many (but not all) children who also have mild to moderate Tourette's syndrome. Lower doses (defined in one study as 0.28mg per kg of body weight) may not be as effective, however, at improving attention as higher doses (0.56mg/kg). Symptoms of overdose include confusion, breathing difficulties, sweating, vomiting, and muscle twitches; if they occur, parents should call the doctor immediately. Children may also lose weight and growth may be retarded during long-term treatment, although not permanently. Rebound activation (i.e., a sudden increase in attention deficit and hyperactivity) has been noted anecdotally after the child's last dose of medication wears off. Most of the side effects are mild, recede over time, and respond to dose changes. Children rarely experience cognitive impairment, which, if it does occur, can be resolved with reduction or cessation of the drug. A few cases of psychosis have been reported. Many people have taken Ritalin for years without experiencing adverse effects or loss of effectiveness. Of some concern were studies reporting liver cancers in mice given very high doses of Ritalin. There have been no reports of an increased risk in people.


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