Treatment for attention deficit hyperactivity disorder (ADHD)

Treatment for Attention Deficit Hyperactivity Disorder (ADHD) psychcentral.com/disorders/adhd/treatment-for-attention-deficit-hyperactivity-disorder-adhd/ February 3, 2017

Treatment for attention deficit hyperactivity disorder (ADHD) has two important components — psychotherapy interventions (for both the child and the parents; or the adult with ADHD) and medications. There is a significant amount of research demonstrating that medication alone won’t help address all of a patient’s attention and hyperactivity issues. So while medication may help with some immediate relief from some of the symptoms, the person with attention deficit disorder still often needs to learn the skills needed to be successful while living with the disorder.

This treatment article is divided into two major sections — medication treatments for ADHD are covered in the rest of this article, while psychotherapy and other treatments for ADHD are covered in the next section.

In the past, ADHD treatment has typically focused on medications. The specific class of medication most commonly prescribed for ADHD is stimulants. These stimulant medications — like Ritalin (methylphenidate) or Adderall (an amphetamine) — are commonly prescribed, welltolerated, act quickly (usually soon after a person takes them), and in most people, have few side effects. These medications also have a robust research base supporting their effectiveness in treatment of attention deficit disorder.

Children vary a great deal in their response to medication treatments. Finding the combination with the highest efficacy and fewest side effects is a challenge in every case. A child’s prescribing physician (preferably, a child psychiatrist rather than a general practitioner or pediatrician) will aim to discover the medication and dose that’s best for your child. If one medication doesn’t appear to be working after a few weeks of treatment, a doctor will often try another medication. This is normal and most people will switch medications at least once to find the one that works best for them.

The side effects of stimulants may include reduced appetite, headache, a “jittery” feeling, irritability, sleep difficulties, gastrointestinal upset, increased blood pressure, depression or anxiety, and/or psychosis or paranoia. If you experience any of these symptoms, you should talk to your doctor.

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Many parents may be concerned about having stimulant medications prescribed to their child.

This is a typical concern amongst parents, but such medications are not addicting, nor do they produce a “high” in a person with ADHD who takes them. Researchers are still unclear as to why stimulant medications do not “over-stimulate” people who take them, but it is hypothesized that people with ADHD have a problem with certain neurotransmitters in their brain that the medication helps correct. We do not yet know exactly why some drugs help some people, but not others, nor the exact mechanism that makes stimulants effective. We do know that they work in most people who take them, effectively treating the symptoms of attention deficit disorder.

Medications Used to Treat ADHD Stimulant medications commonly prescribed for attention deficit disorder include methylphenidate (Ritalin, Concerta, Metadate, Methylin) and certain amphetamines (Dexedrine, Dextrostat, Adderall). Methylphenidate is a short-acting drug, and in older forms, had to be taken multiple times a day. Longer-acting versions of the drug are now available for once-daily use. Although taking stimulants for treatment may seem risky, there is significant research that demonstrates that when taken as directed by your psychiatrist or physician, they are safe and effective in the treatment of adult ADHD. Drug treatment for ADHD began decades ago. Some of the best results have been found with the stimulant drugs listed below. “Approved age” means that the drug has been tested and found safe and effective in children of that age.

Trade Name

Generic Name

Approved Age

Adderall Adderall XR

amphetamine (extended release)

3 and older

Adzenys XR-ODT

amphetamine extended release (bioequivalent to Adderall XR)

6 and older

Concerta

methylphenidate (long acting)

6 and older

Daytrana (patch)

methylphenidate

6 and older

Dexedrine Dextrostat

dextroamphetamine

3 and older

Focalin

dexmethylphenidate

6 and older

Metadate ER Metadate CD

methylphenidate (extended release)

6 and older

Ritalin Ritalin SR Ritalin LA

methylphenidate (extended release) (long acting)

6 and older

Strattera

atomextine

6 and older

* – Because of its potential for serious side effects affecting the liver, Cylert should not ordinarily be considered as first-line drug therapy for ADHD. # – Tenex is short-term preparation and Intuniv is the long-term preparation brand name 2/5

Tenex, Intuniv #

guanfacine hydrochloride

12 and older

Vyvanse

lisdexamfetamine

6 and older

* – Because of its potential for serious side effects affecting the liver, Cylert should not ordinarily be considered as first-line drug therapy for ADHD. # – Tenex is short-term preparation and Intuniv is the long-term preparation brand name

Stimulant drugs are often beneficial in curbing hyperactivity and impulsivity, and helping the individual to focus, work, and learn. Sometimes the drugs will also help with coordination problems which may hinder sports and handwriting.

Under medical supervision, these stimulant drugs are quite safe and do not make the child feel “high”, although they may feel slightly different. To date, there is not convincing evidence that children risk becoming addicted to these drugs, when used for ADHD. In fact, a study at Massachusetts General Hospital and Harvard Medical School found that substance abuse rates were lower among teenagers with ADHD who stayed on their medication than those who stopped.

Many of the stimulant drugs come in short-term and long-term forms, and some are made as “sustained-release” — they are taken in the morning before school and are effective all day.

The most suitable preparation for each child will be discussed by the parents and physician.

Even after adjusting the type and dosage of medications, about ten percent of children will gain no benefit from stimulant drugs. In this case, other types of drug can be tried, such as antidepressants.

Occasionally a child may be prescribed a drug “off label”, meaning that its use in children, or for ADHD has not yet been approved by the FDA. This is common with newer drugs, many of which are given for ADHD. Later studies will produce better evidence on their safety and effectiveness.

Other newer drugs have also been approved for the treatment of attention deficit disorder.

These non-stimulant medications include Strattera (atomoxetine, a selective norepinephrine reuptake inhibitor) and Vyvanse (lisdexamfetamine dimesylate). These drugs typically offer similar benefits to stimulants, but act in a different way on the brain. Some people may find they better tolerate these drugs.

Another useful category of drugs for adults with ADHD are the antidepressants, either alongside or instead of stimulants. Antidepressants which target the brain chemicals dopamine and norepinephrine are the most effective. These include the older form of antidepressant known as the tricyclics, as well as new antidepressants, such as Venlafaxine (Effexor). The antidepressant Bupropion (Wellbutrin) has been found useful in trials of adult ADHD and may also help reduce nicotine cravings.

ADHD Drug Side Effects

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The majority of side effects are minor and do not result in stopping the medication. They may be alleviated by lowering the dosage, but you should always consult the prescribing physician before making any changes to you or your child’s medication.

For most medications prescribed for attention deficit disorder, the most commonly observed side effects are: Decreased appetite – often low in the middle of the day and more normal by suppertime.

Good nutrition is a priority Insomnia – may be relieved by taking the drug earlier in the day, or adding an antidepressant Increased anxiety and/or irritability Mild stomach aches or headaches Tics (more rare) These medications only control ADHD symptoms on the day they are taken, so it’s important to remember that the disorder is not actually cured. While drugs can enable the child to use their skills more easily, efforts are still needed to improve schoolwork or knowledge in other areas.

In addition to medication, behavioral therapy, emotional counseling, and practical support will also help a person with ADHD cope with the disadvantages of the disorder.

Helpful Hints About Medication: ADHD drugs can help a child focus and improve behavior in many settings They may help reduce or avoid emotional problems or addictions Four out of five children with ADHD will still need medication as teenagers, and over half as adults Children who also have bipolar disorder, and are taking drugs such as lithium or Depakote, may or may not be suitable for ADHD medication as well. If so, it may be given at a lower dose.

Research References One of the large-scale studies that examined medication treatment for ADHD is called the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (or MTA).

The MTA included 579 elementary school boys and girls with ADHD. Four treatment programs were compared: (1) medication management alone; (2) behavioral treatment alone; (3) a combination of both; or (4) routine community care.

Treatment was given for 14 months, during which the children were regularly assessed for ADHD symptoms by specialists and teachers.

The children on medication were seen by the prescribing physician once a month. Those given behavioral treatment met with a behavior therapist up to 35 times and attended a special 8-week summer camp. The routine community care group saw a community-treatment doctor, 4/5

selected by the parents, once or twice a year.

The best improvements were seen in the group given combined treatments and the group on medication alone. Of these, combined treatment led to the biggest improvements in anxiety, academic performance, oppositionality, parent-child relations, and social skills. In addition, some children in the combined group could be successfully treated on lower does of medication than those on medication alone.

Another NIMH-funded study investigated drug treatments for pre-schoolers with ADHD. The Treatment of Attention Deficit Hyperactivity Disorder in Preschool-Age Children (PATS) study included 165 children, aged 3 to 5.5 years. It examined the safety and efficacy of a stimulant drug called methylphenidate, which has been widely given to children under the age of 6, despite a lack of evidence on safety and efficacy.

The children appeared to benefit from low doses of methylphenidate, but 11 percent stopped using the drug because of side effects. The drug was effective at doses from 7.5 to 30 mg/day, with a mean optimal dose of 14.22 mg/day. (Average adult daily dosage is between 20 mg and 30 mg).

The researchers said that more children taking the drug showed a decrease of ADHD symptoms than did those on placebo. They suggest that preschoolers be started at low doses, and that further studies are needed to test higher doses.

Overall, 30 percent of parents reported adverse events in their children, including emotional outbursts, difficulty falling asleep, repetitive behaviors/thoughts, irritability, and decreased appetite. But these may have been due as much to lack of medication efficacy as to the action of the drug, said the researchers.

Nevertheless, due to fears over side effects, preschoolers with ADHD on methylphenidate treatment need to be carefully monitored, they concluded.

Continue reading about psychotherapy and other treatments for ADHD in the next section.

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