Psychiatric Manifestations of Attention Deficit Hyperactivity Disorder Treatment & Management

  • Author: Stephen Soreff, MD; Chief Editor: Eduardo Dunayevich, MD   more...
 
Updated: Jan 5, 2012
 

Medical Care

Recent data suggest that carefully crafted stimulant therapy is more effective than behavioral therapy or regular community care (medication management by primary care provider). This finding has been born out for the treatment of adults with ADHD as well. Stimulants represent the best first-line therapeutic option.[20] For related areas of functioning, such as social skills and academic performance, medications combined with behavioral treatments may be indicated. Pharmacotherapy includes the following:

  • Stimulants (methylphenidate, dextroamphetamine)
    • These are first-line therapy and probably the most effective treatment.
    • All stimulants have similar efficacy but differ by dosing, duration of action, and adverse effect profiles in individual patients. Care should be made to start at the lowest dose and titrate up for clinical efficacy or to intolerance.
    • Targeted symptoms include impulsivity, distractibility, poor task adherence, hyperactivity, and lack of attention.
    • Some stimulants come in sustained-release preparations, which may decrease the number of total daily doses. Otherwise, dosing should be spaced every 4-6 hours.
    • Care should be taken to not dose too close to bedtime because stimulants may cause significant insomnia.
    • Other common adverse effects include appetite suppression and weight loss, headaches, and mood effects (depression, irritability).
    • Stimulants may exacerbate tics in children with underlying tic disorders.
    • Whether growth might be affected while a child is taking stimulants remains unclear. Drug holidays (during summer or on weekends) may or may not be recommended to allow periods of normal growth. The decision is based on the child's growth rate chart and behavior and cognition off medication.
    • There has been a long concern that the use of stimulate therapy leads to substance abuse. Recent studies have demonstrated that stimulant therapy does not increase the risk of future substance use or abuse.[21] Furthermore, 112 people with ADHD were observed for a period of 10 years. At the time of the follow-up assessment, 82 (73%) had been treated previously with stimulants and 25 (22%) were undergoing stimulant treatment. No statistically significant associations were noticed between stimulant treatment and alcohol, drug, or nicotine use disorders. The findings revealed no evidence that stimulant treatment increases or decreases the risk for subsequent substance use disorders in children and adolescents with ADHD when they reach young adulthood.[22]
    • Stimulant medications do enhance mental executive functions for those with ADHD.[23]
  • Atomoxetine (Strattera) has become a second-line and, in some cases, first-line treatment in children and adults with ADHD because of its efficacy and classification as a nonstimulant. However, studies have reported that the overall effect of atomoxetine has not been as extensive as that reported of stimulants.
  • Recent data suggest that bupropion or venlafaxine may be effective. Dosages are similar to those used to treat depression.
  • Tricyclic antidepressants (imipramine, desipramine, nortriptyline) have been found effective in numerous studies in children with ADHD; however, because of potential adverse effects, they are rarely used for this purpose. If these agents are used, obtain a baseline ECG because these agents can affect cardiac conduction. A few reports have described sudden death in boys taking desipramine, but the exact cause of death was unclear and may have been unrelated to desipramine use.
  • Clonidine and guanfacine have been used with mixed reports of efficacy. Sudden deaths have been reported in children taking clonidine with methylphenidate at bedtime. Again, the etiology of these deaths is unclear, and this remains a controversial topic. In September 2010, the FDA approved clonidine extended-release (Kapvay) for ADHD as adjunctive therapy to stimulants or as monotherapy.
  • Modafinil (Provigil) has recent placebo-controlled data supporting its efficacy in children with ADHD. This medication may currently be used as a third- or fourth-line treatment.
  • Magnesium pemoline (Cylert) had been used in the 1990s, but concerns of rare, potentially fatal hepatotoxicity have made it a rarely used medication.
  • Blader et al evaluated the ability of divalproex to reduce aggressive behavior in children with ADHD and a disruptive disorder. Children with persistent aggressive behavior that was underresponsive to psychostimulant therapy were randomly assigned to receive divalproex or placebo in addition to stimulant therapy for 8 weeks. A higher proportion of improved behavior was observed in the divalproex group (8 of 14 [57%]) compared with placebo (2 of 13 [15%]). A larger trial is needed to further study the use of divalproex to ameliorate aggressive behavior in patients with ADHD.[24]
  • Behavioral psychotherapy often is effective when used in combination with an effective medication regimen.
    • Working with parents and schools to ensure environments conducive to focus and attention is necessary.
    • Behavioral therapy or modification programs can help diminish uncertain expectations and increase organization.
    • For adults with ADHD, working to establish ways of decreasing distractions and improving organizational skills may be helpful.

Cognitive therapy for adults with ADHD

Metacognitive therapy involves the principles and techniques of cognitive and behavioral therapies to enhance time management. In doing so, these have made adult patients with ADHD better able to counter the anxiety and depressive symptoms they experience in task performance. Metacognitive therapy has proven to be more effective than supportive interventions and represents a viable therapeutic approach.[25]

Psychosocial interventions

A number of psychosocial treatments are effective. These include behavioral parent training (BPT) and behavioral classroom management (BCM).[26] These are best used in conjunction with psychopharmacological approaches.

Emerging evidence shows that nonpharmacological treatments should be considered the first treatment for children with ADHD. For preschoolers, intervention is best with parental training. For school-aged children, interventions of group training for parents and classroom behavioral approaches might be enough. Severe cases benefit from medication and behavioral interventions.[27]

Next

Diet

For decades, speculation and folklore have suggested that foods containing preservatives or food coloring or foods high in simple sugars may exacerbate ADHD. Many controlled studies have examined this question. To date, no adequate data set has confirmed the speculation.

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Contributor Information and Disclosures
Author

Stephen Soreff, MD  President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA

Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Denis F Darko, MD  Executive Director, Clinical Research and Development, Global Neuroscience, AstraZeneca

Denis F Darko, MD is a member of the following medical societies: American College of Physicians and American Psychiatric Association

Disclosure: AstraZeneca Salary Management position

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

Eduardo Dunayevich, MD  Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories

Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

References

  1. Rosack J. PET Scans Reveal Action of Methylphenidate in Brain. Psychiatric News. Sept 21, 2001;36, 18.

  2. Kooistra L, van der Meere JJ, Edwards JD, Kaplan BJ, Crawford S, Goodyear BG. Preliminary fMRI findings on the effects of event rate in adults with ADHD. J Neural Transm. Feb 16 2010;[Medline].

  3. Cherkasova MV, Hechtman L. Neuroimaging in attention-deficit hyperactivity disorder: beyond the frontostriatal circuitry. Can J Psychiatry. Oct 2009;54(10):651-64. [Medline].

  4. Yang P, Wu MT, Dung SS, Ko CW. Short-TE proton magnetic resonance spectroscopy investigation in adolescents with attention-deficit hyperactivity disorder. Psychiatry Res. Feb 10 2010;[Medline].

  5. Sobel LJ, Bansal R, Maia TV, Sanchez J, Mazzone L, Durkin K, et al. Basal Ganglia surface morphology and the effects of stimulant medications in youth with attention deficit hyperactivity disorder. Am J Psychiatry. Aug 2010;167(8):977-86. [Medline].

  6. Shaw P, Gilliam M, Liverpool M, et al. Cortical development in typically developing children with symptoms of hyperactivity and impulsivity: support for a dimensional view of attention deficit hyperactivity disorder. Am J Psychiatry. Feb 2011;168(2):143-51. [Medline].

  7. Volkow ND, Wang GJ, Newcorn J, Telang F, Solanto MV, Fowler JS, et al. Depressed dopamine activity in caudate and preliminary evidence of limbic involvement in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. Aug 2007;64(8):932-40. [Medline].

  8. Morein-Zamir S, Hommersen P, Johnston C, Kingstone A. Novel Measures of Response Performance and Inhibition in Children with ADHD. J Abnorm Child Psychol. May 9 2008;[Medline].

  9. Goodman DW, Thase ME. Recognizing ADHD in adults with comorbid mood disorders: implications for identification and management. Postgrad Med. Sep 2009;121(5):20-30. [Medline].

  10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association; 2000. 78-85.

  11. Semiz UB, Basoglu C, Oner O, Munir KM, Ates A, Algul A, et al. Effects of diagnostic comorbidity and dimensional symptoms of attention-deficit-hyperactivity disorder in men with antisocial personality disorder. Aust N Z J Psychiatry. May 2008;42(5):405-13. [Medline].

  12. Upadhyaya HP, Carpenter MJ. Is attention deficit hyperactivity disorder (ADHD) symptom severity associated with tobacco use?. Am J Addict. May-Jun 2008;17(3):195-8. [Medline].

  13. Reiersen AM, Todd RD. Co-occurrence of ADHD and autism spectrum disorders: phenomenology and treatment. Expert Rev Neurother. Apr 2008;8(4):657-69. [Medline].

  14. Halmoy A, Halleland H, Dramsdahl M, Bergsholm P, Fasmer OB, Haavik J. Bipolar symptoms in adult attention-deficit/hyperactivity disorder: a cross-sectional study of 510 clinically diagnosed patients and 417 population-based controls. J Clin Psychiatry. Jan 2010;71(1):48-57. [Medline].

  15. Arcos-Burgos M, Jain M, Acosta MT, Shively S, Stanescu H, Wallis D, et al. A common variant of the latrophilin 3 gene, LPHN3, confers susceptibility to ADHD and predicts effectiveness of stimulant medication. Mol Psychiatry. Feb 16 2010;[Medline].

  16. Kopecková M, Paclt I, Petrásek J, Pacltová D, Malíková M, Zagatová V. Some ADHD polymorphisms (in genes DAT1, DRD2, DRD3, DBH, 5-HTT) in case-control study of 100 subjects 6-10 age. Neuro Endocrinol Lett. Apr 2008;29(2):246-51. [Medline].

  17. Faraone SV, Mick E. Molecular Genetics of Attention Deficit Hyperactivity Disorder. Psychiatr Clin North Am. Mar 2010;33(1):159-180. [Medline].

  18. Bellgrove MA, O'Connell RG, Vance A. Genetics of cognitive deficits in ADHD: clues for novel treatment methods. Expert Rev Neurother. Apr 2008;8(4):553-61. [Medline].

  19. Martel MM, Nikolas M, Jernigan K, Friderici K, Nigg JT. Personality Mediation of Genetic Effects on Attention-Deficit/Hyperactivity Disorder. J Abnorm Child Psychol. Feb 10 2010;[Medline].

  20. Tcheremissine OV, Salazar JO. Pharmacotherapy of adult attention deficit/hyperactivity disorder: review of evidence-based practices and future directions. Expert Opin Pharmacother. May 2008;9(8):1299-310. [Medline].

  21. Volkow ND, Swanson JM. Does childhood treatment of ADHD with stimulant medication affect substance abuse in adulthood?. Am J Psychiatry. May 2008;165(5):553-5. [Medline].

  22. Mannuzza S, Klein RG, Truong NL, Moulton JL 3rd, Roizen ER, Howell KH, et al. Age of methylphenidate treatment initiation in children with ADHD and later substance abuse: prospective follow-up into adulthood. Am J Psychiatry. May 2008;165(5):604-9. [Medline].

  23. Semrud-Clikeman M, Pliszka S, Liotti M. Executive functioning in children with attention-deficit/hyperactivity disorder: Combined type with and without a stimulant medication history. Neuropsychology. May 2008;22(3):329-40. [Medline].

  24. [Best Evidence] Blader JC, Schooler NR, Jensen PS, Pliszka SR, Kafantaris V. Adjunctive divalproex versus placebo for children with ADHD and aggression refractory to stimulant monotherapy. Am J Psychiatry. Dec 2009;166(12):1392-401. [Medline].

  25. Solanto MV, Marks DJ, Wasserstein J, Mitchell K, Abikoff H, Alvir JM, et al. Efficacy of Meta-Cognitive Therapy for Adult ADHD. Am J Psychiatry. Aug 2010;167(8):958-968. [Medline].

  26. Pelham WE Jr, Fabiano GA. Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. J Clin Child Adolesc Psychol. Jan 2008;37(1):184-214. [Medline].

  27. Young S, Myanthi Amarasinghe J. Practitioner Review: Non-pharmacological treatments for ADHD: A lifespan approach. J Child Psychol Psychiatry. Nov 4 2009;[Medline].

  28. Adler LD, Nierenberg AA. Review of medication adherence in children and adults with ADHD. Postgrad Med. Jan 2010;122(1):184-91. [Medline].

  29. Hosenbocus S, Chahal R. A review of long-acting medications for ADHD in Canada. J Can Acad Child Adolesc Psychiatry. Nov 2009;18(4):331-9. [Medline].

  30. Buitelaar J, Medori R. Treating attention-deficit/hyperactivity disorder beyond symptom control alone in children and adolescents: a review of the potential benefits of long-acting stimulants. Eur Child Adolesc Psychiatry. Oct 13 2009;[Medline].

  31. Habel LA, Cooper WO, Sox CM, et al. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults. JAMA. Dec 28 2011;306(24):2673-83. [Medline].

  32. Chronis-Tuscano A, Molina BS, Pelham WE, Applegate B, Dahlke A, Overmyer M, et al. Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. Oct 2010;67(10):1044-51. [Medline].

  33. Baving L, Laucht M, Schmidt MH. Atypical frontal brain activation in ADHD: preschool and elementary school boys and girls. J Am Acad Child Adolesc Psychiatry. Nov 1999;38(11):1363-71. [Medline].

  34. Biederman J, Faraone S, Mick E. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity?. J Am Acad Child Adolesc Psychiatry. Aug 1996;35(8):997-1008. [Medline].

  35. Biederman J, Faraone S, Milberger S. A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders. Arch Gen Psychiatry. May 1996;53(5):437-46. [Medline].

  36. Biederman J, Faraone SV, Milberger S. Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder? Findings from a four-year follow-up study of children with ADHD. J Am Acad Child Adolesc Psychiatry. Sep 1996;35(9):1193-204. [Medline].

  37. Bush G, Frazier JA, Rauch SL. Anterior cingulate cortex dysfunction in attention- deficit/hyperactivity disorder revealed by fMRI and the Counting Stroop. Biol Psychiatry. Jun 15 1999;45(12):1542-52. [Medline].

  38. Casey BJ, Castellanos FX, Giedd JN. Implication of right frontostriatal circuitry in response inhibition and attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. - Sarfatti SE;36(3):374-83. [Medline].

  39. Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. Oct 1997;36(10 Suppl):85S-121S. [Medline].

  40. Faraone SV, Perlis RH, Doyle AE, et al. Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry. Jun 1 2005;57(11):1313-23. [Medline].

  41. Faraone SV, Sergeant J, Gillberg C, Biederman J. The worldwide prevalence of ADHD: is it an American condition?. World Psychiatry. Jun 2003;2(2):104-113. [Medline].

  42. Green WH. Child and Adolescent Clinical Psychopharmacology. Baltimore, Md: Williams & Wilkins; 1995:56-77.

  43. Greenhill LL. Diagnosing attention-deficit/hyperactivity disorder in children. J Clin Psychiatry. 1998;59 Suppl 7:31-41. [Medline].

  44. Hauser P, Zametkin AJ, Martinez P. Attention deficit-hyperactivity disorder in people with generalized resistance to thyroid hormone. N Engl J Med. Apr 8 1993;328(14):997-1001. [Medline].

  45. Jensen PS. Fact versus fancy concerning the multimodal treatment study for attention-deficit hyperactivity disorder. Can J Psychiatry. Dec 1999;44(10):975-80. [Medline].

  46. Kaplan HI, Sadock BJ, Grebb JA. Kaplan and Sadock's Synposis of Psychiatry. 7th ed. Baltimore, Md: Williams & Wilkins; 1994:1063-8.

  47. MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry. Dec 1999;56(12):1073-86. [Medline].

  48. Multimodal Treatment Study. Moderators and mediators of treatment response for children with attention-deficit/hyperactivity disorder: the Multimodal Treatment Study of children with Attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. Dec 1999;56(12):1088-96. [Medline].

  49. Rugino TA, Samsock TC. Modafinil in children with attention-deficit hyperactivity disorder. Pediatr Neurol. Aug 2003;29(2):136-42. [Medline].

  50. Rutter M, Taylor E, Hersov L. Child and Adolescent Psychiatry: Modern Approaches. 3rd ed. Oxford, UK: Blackwell Science; 1994:285-307.

  51. Shillington AM, Reed MB, Lange JE, Clapp JD, Henry S. College undergraduate Ritalin abusers in Southwestern California: Protective and Risk Factors. J Drug Iss. 2006;36:4:999-1014.

  52. Spencer T, Biederman J, Wilens T. Nonstimulant treatment of adult attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. Jun 2004;27(2):373-83. [Medline].

  53. Vaidya CJ, Austin G, Kirkorian G. Selective effects of methylphenidate in attention deficit hyperactivity disorder: a functional magnetic resonance study. Proc Natl Acad Sci U S A. Nov 24 1998;95(24):14494-9. [Medline].

  54. White BP, Becker-Blease KA, Grace-Bishop K. Stimulant medication use, misuse, and abuse in an undergraduate and graduate student sample. J Am Coll Health. Mar-Apr 2006;54(5):261-8. [Medline].

 
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