Attention Deficit Hyperactivity Disorder (ADHD) Treatment & Management

Updated: Mar 03, 2017
  • Author: Stephen Soreff, MD; Chief Editor: Glen L Xiong, MD  more...
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Treatment

Medical Care

The therapeutic approach to ADHD has been shifting. In some cases, environmental restructuring and behavioral therapy alone has been effective. Developments in behavioral parent training (BPT) and behavioral classroom management (BCM) have also proven useful. Furthermore, behavioral psychotherapy often is successful when used in conjunction with an effective medication regimen. The medications of choice are stimulants, and for adults with ADHD stimulants represent the best first-line therapeutic option. [23] 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)

Regarding medication for ADHD, stimulants are the 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. [24] 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. [25]

Stimulant medications do enhance mental executive functions for those with ADHD. [26]

Other medications

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. [27]

Behavioral psychotherapy

Behavioral psychotherapy often is effective when used in combination with an effective medication regimen. Behavioral therapy or modification programs can help diminish uncertain expectations and increase organization.

Working with parents and schools to ensure environments conducive to focus and attention is necessary.

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. [28]

Psychosocial interventions

A number of psychosocial treatments are effective. These include behavioral parent training (BPT) and behavioral classroom management (BCM). [29] 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. [30]

Nonpharmacological interventions

Concern about medications to treat ADHD has increased interest in alternative treatments. Researchers conducted a systematic review and meta-analysis of randomized controlled trials of dietary and psychological treatments for ADHD and found that free fatty acid supplementation produced small but significant reductions in symptoms. A larger effect was observed with artificial food color exclusion, but this was seen in individuals selected for food sensitivities. Further studies are needed to assess behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets. [31]

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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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Activity

In one study of the effect of physical activity on children's attention, researchers found that intense exercise has a beneficial effect on children with ADHD. It can improve their attention and may help their school performance. In the study, 28 volunteers (14 with ADHD and 14 without symptoms) engaged in intense physical activity promoted by a relay race, which required a 5-minute run without a rest interval. After 5 minutes of rest, the volunteers accessed a computer game to accomplish the tasks in the shortest time. The groups of volunteers with ADHD who performed exercise  showed improved performance for the tasks that require attention with a difference of 30.52% compared with the volunteers with ADHD who did not perform the exercise. [32]

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