BEHAVIOURAL GUIDELINES - Attention Deficit Hyperactivity Disorder (ADHD) In-Depth From A.D.A.M. Treatment - COURTESY OF THE NEW YORK TIMES

 

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Attention Deficit Hyperactivity Disorder (ADHD)

In-Depth From A.D.A.M. Treatment

A combination of a psychostimulant, most commonly methylphenidate (Ritalin), and cognitive-behavioral therapy is proving to be the best option for treatment of children with ADHD. Although medication can be helpful during the initial years of treatment, some research indicates that the benefits of medication eventually wear off. It appears that ADHD symptoms may improve naturally over time, regardless of the treatment approach.
Signs that ADHD may be easing include not having to adjust medication dosages during growth spurts, no deterioration when a drug dose is missed, or new abilities to concentrate during “drug holidays.” (School vacation times are a good period to test the effectiveness of temporarily stopping medication.) The American Academy of Child and Adolescent Psychiatry suggests that parents evaluate whether medication can safely be withdrawn when children with ADHD have been free of symptoms for at least 1 year. If a child’s condition worsens after medication withdrawal, the drug should be resumed.
Developing a Treatment Approach. The following guidelines may be useful in determining a treatment approach for children with ADHD:

• Behavioral techniques should be tried first.
• If the symptoms are severe or do not respond, a trial using medication (usually psychostimulants), in combination with behavior modification therapy, is recommended.

Determining a Medication Regimen . Doctors still have a difficult time predicting which medications will produce beneficial results, so treatment is individualized and performed on a trial and error basis, which requires close observation and cooperation between all participants. In developing an effective medication plan, the following steps may be helpful:

• Before any drug is administered, a child should be given a thorough examination for any medical problems to be sure there are no medical conditions that interfere with the medication. It is especially important that children be checked for heart problems prior to initiating stimulant medication. (See “Risks of Stimulants” in the Medications section of this report.)
• Both the doctor and the parents should be very clear about the specific behaviors they hope the medication will target.
• The goal is to use the lowest possible dosage that produces improved behavior.
• If an initial regimen doesn't work, changing the dosage, or changing to a different medication often brings improvement.
• Frequent follow-up visits should be scheduled to assess the response and to detect possible side effects.

Arguments For and Against Psychostimulants. Many parents are very disturbed by the idea of putting their children on intensive stimulant drug regimens, possibly for years. Although the decision to use these drugs should not be made lightly, the negative social and emotional effects of the disorder itself for many children with ADHD are far more severe and long-lasting than the use of these drugs. For some parents and children, medication seems like a miracle and can provide desperate families with a quality of life for which they had almost given up hope. Whether or not psychostimulants are used, children and families should understand that ongoing efforts around behavior control will be necessary.
Of great concern is the dramatic increase in prescriptions for psychostimulants among preschool children. Although low doses of methylphenidate (Ritalin) may help preschoolers (ages 3 - 5 years) with ADHD, the drug can cause considerable side effects in many children. Doctors must carefully consider the risks versus benefits when prescribing ADHD drugs to preschoolers. Children who do receive these drugs need to be carefully monitored by their doctors.
Treatment for Adult ADHD . As with children, adults with ADHD are treated with a combination of medication and psychotherapy. For medication, stimulant drugs or the non-stimulant drug atomoxetine (Strattera) are usually first-line treatments, with antidepressants a secondary option. Most stimulant drugs, as well as atomoxetine, are approved for adults with ADHD. Adults who have heart problems or heart condition risk factors should be aware of the cardiovascular risks associated with ADHD medication. There have been ADHD medication-associated incidents of sudden death in patients with underlying serious heart problems, and reports of stroke and heart attack in adults with cardiac risk factors.

Help for Families and Teachers

Interventions for the child with ADHD should also include the parents if they are to be successful. Teachers and school officials should also be educated and involved in the process.
Parents who feel they have the most control over their child's situation experience less psychological stress and depression. Parents who are responsive in a positive way can help reduce the chances for their child developing oppositional behaviors.
In addition to behavioral therapy for the child, family therapy may help children with ADHD and their parents and siblings cope with the emotional conflicts that can arise in the process of managing the condition. Separate psychological therapies for specific family members may also be helpful.

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Review Date: 2/27/2012
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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