ADHD

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While there is currently no cure for ADHD, there are many treatment options that can help those with the disorder focus, modify their impulsive or hyperactive behavior so as to function more effectively, and improve self-esteem. The latest research indicates that the most successful remedy is often a "multimodal" plan that includes a combination of behavioral therapy and medication. It is important that the chosen treatments be tailored to a patient's needs.

In most cases, treatment will include:

  • Setting a number of realistic goals, such as improved academic performance, healthier relationships, or being able to complete homework on one's own—all of which can and should be studied and assessed
  • Behavioral therapy and medication
  • Regular monitoring of progress: As with other chronic conditions like diabetes, ADHD must be managed on an ongoing basis with the help of families, teachers, and other caregivers.
  • It is essential for parents to be educated about ADHD, to inform all those involved in their child's life about the condition, and to encourage constant, consistent communication among these interested parties.

    More information on:

    • Behavioral treatments
    • Medications
    • Psychological counseling
    • Alternative treatments
    • Treating adults with ADHD
    • Behavioral treatments

      Once a diagnosis of ADHD is made, treatment usually includes behavioral modification, with the main goal being to increase the frequency of appropriate actions and decrease the frequency and severity of inappropriate conduct. Generally speaking, this involves adjusting a child's environment to promote more successful social interactions—first and foremost by creating additional structure and encouraging routines. Indeed, children with ADHD perform and respond best in an ordered, predictable setting, both at home and school. They need clear, consistent, and simple rules that are easy to understand and follow. When they do follow these rules, they should be rewarded; consequences need to be established ahead of time and delivered immediately. A very important part of treatment—teaching the child to operate in his or her own environment and to find his or her own successful coping strategies—can begin in elementary school.

      This section provides more on:

      • Behavioral modification at home
      • Behavioral modification at school
      • Behavioral modification at home

        Parents can in a positive way help their children develop organizational skills and an ability to follow through on tasks, as well as discourage impulsive behavior, by communicating clear, consistent expectations and limits and setting up an effective discipline system that rewards when appropriate and imposes immediate consequences when necessary. One popular technique is to create charts using icons or words that outline a few specific tasks and the rewards or positive consequences for their successful completion; it is always important to note accomplishments along the way. In order to teach new behavior, it is important to "catch the child being good." Punishment alone only teaches a child what not to do, it never teaches what to do.

        Other methods parents can try:

        • Set a schedule. Children may more easily develop good habits if they follow the same routine every day, from morning wake-up to bedtime. The same time is set aside each day for homework and household chores, as well as playtime.
        • Organize belongings. To avoid the frustration of constantly losing track of necessities, keep toys, clothing, backpacks, textbooks, and school supplies in designated places.
        • Behavioral modification at school

          Children with ADHD often struggle in school, not because they can't handle the work but because they can't concentrate on their lessons and have trouble following instructions. They frequently miss important pieces of information and forget or lose assignments because of poor organizational abilities.

          When the condition is severe enough to significantly impact performance, a youngster with the disorder may qualify for educational accommodations provided under a federally mandated 504 plan, such as extended time on tests and note-taking support. Others might qualify for special education services under the category of Other Health Impaired, or OHI. The exact form of educational assistance or special services children receive will depend on the nature and severity of their condition.

          Even if the child does not qualify for accommodations, parents may find that cooperative teachers would rather work with them on ways to develop better focus and organizational skills than simply discipline a child for constantly seeming to fool around. A teacher might seat the child in the front row and tap her on the shoulder when she seems to daydream, for example, and might be willing to break complex sets of instructions or assignments into simpler, discrete steps.

          In addition, parents might want to hire a tutor with special expertise in ADHD to help a child master better study and organizational skills.

          Medications

          A number of drugs have been approved to treat ADHD. But it's important to note that none of these medications cure the condition—they enable the child or adult to better control his or her attention and behavior. To that end, the patient and his or her family must work closely with the physician to:

          • Arrive at an accurate diagnosis
          • Decide whether medication is indicated and choose the correct prescription, if so
          • Assess the effects and success of the drug, and monitor side effects
          • Acknowledge that combinations of medicines may be necessary, especially when the patient has more than one diagnosis or when the symptoms are severe
          • Adjust the dosage if necessary, especially over time
          • Discuss a change to a different medication if necessary
          • A drug is selected by determining:

            • How well it successfully reduces the symptoms of ADHD
            • Whether depression, anxiety, and severe impulsivity are present in addition to the symptoms of ADHD
            • Side effects, such as "rebound" (i.e., exaggerated expression) of ADHD symptoms as a stimulant wears off,upset stomach, sleep delay, loss of appetite, or the presence of motor or vocal tics
            • You and an older child or adolescent should discuss the choice of medicine with the doctor, reviewing the pros and cons of different options. Patients who do not respond to an ADHD medication can usually be prescribed a different drug. If no drugs are found to be beneficial, the doctor and the patient's family must investigate further. It's possible that the ADHD diagnosis may be wrong, or that the patient may have another condition that is interfering with drug therapy.

              This section contains more information on:

              • Stimulants
              • Nonstimulants
              • Other drugs
              • Stimulants

                The largest class of drugs for the treatment of ADHD is the stimulants, which work by arousing the parts of the brain that are responsible for organization and management. Specifically, they increase levels of attentional control by targeting the neurotransmitter dopamine. Neurotransmitters are chemicals in the brain that transmit nerve impulses.

                Stimulant medications are the most effective type of drug at helping patients focus, and 70 to 80 percent of patients with combined ADHD and inattentive ADHD are treated effectively with them, with the former having the most predictable response.

                The stimulant drugs include the following:

                • Methylphenidate (Ritalin, Methylin)
                • Methylphenidate, intermediate-acting (Metadate ER, Metadate CD, Methylin ER)
                • Methylphenidate, long-acting (Concerta, Ritalin LA, Ritalin SR)
                • Methylphenidate transdermal (patch) system (Daytrana)
                • Dextroamphetamine (Dexedrine, Dextrostat)
                • Dexmethylphenidate (Focalin)
                • Dexmethylphenidate extended release (Focalin XR)
                • Amphetamine (Adderall)
                • Amphetamine, extended release (Adderall XR)
                • Lisdexamfetamine dimesylate (Vyvanse)
                • Children who take a stimulant medication will usually see an effect on their symptoms—an improved ability to concentrate and less impulsivity—within an hour. The "immediate release" or short-acting versions of ADHD drugs typically have to be taken every three to four hours. Stimulants that are designated as "extended release," "controlled release," "intermediate-acting," or "long-acting" take longer to break down in the body, so a patient may take only one pill during the day to last six to 12 hours. Because each person's reaction to drugs is different, the dosage and scheduling of an ADHD medication must be adapted specifically for each patient.

                  As with all drugs, stimulants can have side effects, though they tend to happen early in treatment and are usually mild and short lived. They include:

                  • Insomnia
                  • Decreased appetite or weight loss
                  • Increased anxiety
                  • Irratitability
                  • Headaches
                  • Stomachache
                  • A small number of sudden deaths and nonfatal heart attacks and strokes in people taking stimulants have raised concerns about the drugs, and people with heart problems and high blood pressure are cautioned about taking them. Parents will benefit by working with a doctor who has known a child for some time before prescribing ADHD medicine, and has knowledge of any structural heart abnormalities (such as heart murmurs). Conscientious doctors also will want to observe whether a child has an adverse response to medicine after it is introduced. It should be noted that millions of people take stimulants safely and that the incidence of life-threatening adverse events is extremely small. Moreover, a causal relationship between the drugs and the adverse reactions has not been established.

                    A small percentage of children who take stimulants develop tics, which are involuntary movements of various muscles, usually in the face and hands.

                    Side effects can often be managed by changing dosages, adjusting the dosing schedule, or by switching to a long-acting version of the drug or a different medication altogether.

                    Some parents worry that children who take stimulant drugs may be at greater risk of becoming addicted to drugs in general. Although newspapers often run stories of, say, Ritalin diversion among college students, studies have shown that stimulants do not cause a greater risk of drug abuse as children get older. In fact, the opposite appears to be true: Compared with children who had been previously treated with medicine, children who do not take medication for their ADHD symptoms have been shown to have a greater risk of developing substance abuse problem later in life as they try to self-medicate.

                    Nonstimulants

                    Not all patients are able to choose stimulant medications for ADHD. They may have contraindications to these drugs; children with heart defects are steered away from stimulants, for example. Or they may have tried the medications and found them to be ineffective or experienced troublesome side effects.

                    A newer, nonstimulant option is atomoxetine (Strattera), which works on the neurotransmitter norepinephrine. Patients may have to take Strattera for three to eight weeks before seeing demonstrable effects on symptoms. However, it's important to note that last year the Food and Drug Administration issued a warning about the increased risk of suicidal thinking in children and adolescents taking Strattera. Your doctor can address any questions or concerns.

                    Other medication options

                    Other medications that are prescribed for ADHD for use alone or with stimulants include the blood pressure drugs clonidine (Catapres) and guanfacine (Tenex). These medicines can "calm" patients down and help reduce hyperactivity and insomnia symptoms in children with ADHD. In addition, they may decrease the incidence of tics and help children better manage anger.

                    There are also several types of antidepressant drugs that are used to treat ADHD, including:

                    • Venlafaxine (Effexor)
                    • Bupropion (Wellbutrin)
                    • Nortriptylione (Pamelor)
                    • Imiprimine (Tofranil)
                    • Desipramine (Norpramin)
                    • Such drugs primarily affect the neurotransmitter serotonin with collateral effects on dopamine and norepinephrine but may take up to three weeks to take full effect. They are sometimes used as the initial treatment for those who also suffer from significant depression. However, this class of drugs is generally not as effective as stimulants or the newer nonstimulant treatments at improving attention span and concentration. Further, last year the FDA warned that antidepressants may increase the risk of suicidal thinking and behavior in children and adolescents with depression and other psychiatric disorders, so it's important to discuss any questions or concerns with your doctor.

                      Modafinil is a drug used to treat sleep conditions like narcolepsy and sleep apnea, and the FDA may or may not approve its use, (under the trade name Sparlon) for children and teens with ADHD.

                      Psychological counseling

                      Psychological counseling will not cure ADHD, but it can be extremely helpful in managing secondary symptoms like depression and anxiety and can be an important part of the treatment plan. Therapy can help parents learn to provide an appropriate, stress-free environment for homework completion, for example, and also help children and their families deal more effectively with the social and emotional aspects of ADHD. A big danger for children with the condition is that the feeling of constantly "screwing up" and of disappointing or angering mom and dad and their teachers fosters low self-esteem, anxiety, and depression. Parents' acceptance of the various symptoms as part of who the child is goes a long way in treating ADHD.

                      Alternative treatments

                      Alternative approaches that have been investigated to date do not show strong scientific evidence that they are effective in reducing ADHD symptoms. They include:

                      • Brain gym—This technique claims to develop the brain's neural pathways through movement, thus better enabling students of all ages to master skills required for learning, including concentration and listening.
                      • Megavitamins
                      • Meditation
                      • Biofeedback
                      • Restricted diet: Some doctors believe that ADHD can be treated by eliminating foods that may cause an allergic reaction in children such as wheat, dairy, citrus, eggs, and corn and introducing supplements such as gingko and fish oils.
                      • Antimotionsickness medication
                      • Omega-3 fatty acids
                      • Massage
                      • Before commiting to an alternative treatment, it's wise for caregivers to ask whether there's any scientific evidence that it's effective.

                        Treating adults with ADHD

                        As with children and adolescents, the most effective treatment is a multimodal plan that includes medication and behavior therapy. Adults with ADHD may be helped by stimulants, and if not, they are sometimes prescribed antidepressants. These drugs work by affecting the neurotransmitters serotonin and may have a milder effect on dopamine and norepinephrine, but they may take up to three weeks to take full effect. Behavior therapy largely involves “coaching” the adult to effectively manage and structure the physical environment so that he or she stays organized and completes tasks. It focuses on teaching people to change the environment rather than changing themselves.

                        Adults who take medications for ADHD have requirements that are different from children’s. For instance, adults may need different dosing regimens to provide optimal coverage for the workday. Another consideration is that an adult is more likely than a child to have other conditions and therefore may already be taking other medications. The physician has to take this into consideration when prescribing ADHD drugs that may interact with other medications.

                        Adult ADHD may also be treated with one or more of the following:

                        • Individual cognitive and behavioral therapy to enhance self-efficacy and self-esteem
                        • Relaxation training and stress management to reduce anxiety and stress
                        • Behavioral coaching to teach the person strategies for organizing home and work activities
                        • Job coaching or mentoring to support better working relationships and improve on-the-job performance
                        • Family education and therapy to improve dynamics in the home that may have suffered because of impulsive behavior or lack of follow-through
                        • Last reviewed on 08/18/2008

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