Treating ADHD

Treating ADHD usually involves a combined approach, including medication, psychological therapies, educational support and behavioral management.

Get in touch with a medical professional if the following applies:

• You notice that your child is exhibiting some of the symptoms of attention-deficit hyperactivity disorder (ADHD) described in this article.
• Your child's teacher tells you that he or she is negatively influenced by concentration problems and is difficult or disruptive at school. Note that other emotional and behavioral issues may stem from the person’s inability to cope.

A full evaluation may determine whether ADHD is the issue, or part of the problem. Treating attention-deficit hyperactivity disorder (ADHD) requires medical, psychological and educational intervention, as well as behavioral management. It therefore requires a team approach. 

In addition, parents need to be educated on how to cope with and assist a child with ADHD. Parental support is a crucial component in any successful ADHD treatment program. Positive reinforcement, in which desired behavior is rewarded, is the most appropriate and effective form of behavioral management. It’s important that reinforcement is consistently applied.

Many children with ADHD can be taught in a regular classroom with minor adjustments to the environment, but some children require additional assistance using special educational services, especially if they have complex learning difficulties.

Treatment for adults with ADHD involves medical intervention and psychotherapy. Psychotherapy is important because adults with ADHD need to be helped to understand that their educational, vocational and/or personal difficulties are not the result of an irremediable personality flaw.

People with ADHD often present with emotional difficulties and problems due to the negative impact of ADHD on their lives. Psychotherapy and coaching helps with understanding the condition, taking control of the symptoms of ADHD, and making better choices.

Medication: For most children and adults with ADHD, medication is an integral part of treatment. Medication isn’t used to control behavior; instead, it’s used to improve the symptoms of ADHD.

This leads to success in controlling the core symptoms of the disorder and, especially in younger children, learning from positive feedback and experiences.

Between 70% and 80% of children with ADHD respond positively to these medications. Attention span, impulsivity and on-task behavior improve, especially in structured environments.

Some children also demonstrate improvements in frustration, intolerance and non-compliance levels. Even their handwriting may improve, as medication can improve fine-motor control and visual-motor co-ordination in about 30% of children with ADHD. Relationships with parents, peers and teachers may also improve.

Medication can also be effective in adults who have ADHD. The reaction to these medications can be similar to that experienced by children with ADHD – a decrease in impulsivity and an increase in attention. Many ADHD adults treated with a stimulant medication report that they’re able to bring more control and organization to their lives.

Medical management of ADHD involves medication that has an influence on the neurotransmitters involved. These medicines include:

• Stimulants: methylphenidate 
• Non-stimulants: (a) atomoxetine; (b) tricyclic antidepressants
• Other

1. Methylphenidate: Methylphenidate (MPH) acts on dopamine levels in certain areas of the brain, especially those involved with executive function in the prefrontal areas. There is inhibition of the reuptake of this neurotransmitter, and thus an increase in the levels of dopamine in the synapse, with better transference of information. This improves the core symptoms of ADHD.

MPH acts immediately when taken (within 20 minutes), and the effect disappears when serum levels drop. Different preparations and release forms lead to a choice of medications with a difference in the period of efficacy:

• Ritalin IR 10mg: 4 hours (a generic is available) 
• Ritalin LA 10mg / 20mg / 30mg / 40mg: 8 hours
• Concerta 18mg / 27mg / 36mg / 54mg: 12 hours (this dose is sometimes increased to 72mg or 90mg in adults). There is a clone and a generic available.

There is a wide variation in response to the dosage of medication, so the appropriate dose needs to be carefully determined for each individual. This is achieved through a medication trail, which begins with a low dose that is gradually increased until clinical benefits are achieved, while trying to avoid unwanted side effects.

Effects of stimulant medications have been well researched for the past 50-60 years, making them among the most studied and effective medications in pharmacological history.

Side effects of stimulant medication: Most immediate side effects related to these medications are mild and tend to diminish over time. The most common side effects are headaches and abdominal pain. Reduction in appetite when medication is active may affect eating patterns (especially around mid-day). Problems may develop with sleep onset.

If side effects continue after 2-3 weeks, an adjustment in dosage or a change in the release form may improve side effects.

Some children experience a negative mood or an increase in activity (rebound) when the effect of the medication is beginning to wear off. This problem can usually be remedied by using a sustained-release form of medication. This allows the medication to be released at a steady rate, so that the level of medication in the bloodstream doesn’t rise and fall to the same extent as it does with the ordinary form of medication.

There is a small subgroup in which a consistent negative mood and, at times, an increase in anxiety levels may lead to the use of alternative medication for ADHD.

The use of stimulant medication can, initially, cause a slight decrease in the height and weight of some children, but research suggests that the ultimate height and weight aren’t affected.

Concerns regarding the possible cardiac effects of MPH have led to an extensive review. At present there are no increased clinical concerns. In people with cardiac problems, the use of stimulants is not advocated without cardiac consultation.

In individuals with tic disorders, the use of a stimulant may improve tics (this is the case in about a third of patients), worsen tics (also the case in about a third of patients), or make no difference.

Research has shown that substance abuse isn’t linked to the use of stimulant medication, but to ADHD and the poor control of symptoms. In fact, treatment with stimulants in children may decrease the prevalence of substance abuse in teenagers and adults by 200%.

2. Non-stimulants

2.1 Atomoxetine (Strattera): Atomoxetine acts on the norepinephrine neurotransmitters in certain areas of the brain, and thus leads to an improvement in the symptoms of ADHD. As there is little action on the dopamine system, it can be classified as a non-stimulant.

Atomoxetine has a clinical effect that lasts for 24 hours. Its effect takes 6-8 weeks to develop and medication needs to be taken consistently on a daily basis after a meal. Dosage is 1.2-1.8mg per kg, and incremental increases are suggested in the first two weeks. An alternative is to start with half the dose for a week and then to increase to the full dose.

Atomoxetine (10mg / 18mg / 25mg / 40mg / 60mg / 80mg) is available. A very small subgroup of people are poor metabolisers in whom a lower dose has to be used. It’s critical to establish the correct dose. Atomoxetine is often prescribed at too low a dose.

Note that there is now a generic available.

Side effects of atomoxetine: Abdominal pain, nausea and heartburn are the most frequent problems, causing a need for discontinuation. Other complaints include headaches, dizziness, day time sleepiness or consistent tiredness. It has no effect on night-time sleep.

Concerns about hepatic effects (i.e. problems relating to the liver) have proven to be of little clinical concern, as has a possibility of an increased risk for suicide.

Because of a possible lesser effect on tics, in may be the preferred option in people with tic disorders.

2.2. Tricyclic antidepressants: Tricyclic’s were developed as antidepressants and are not registered to be used to treat ADHD. But because of its effect on the norepinephrine system, it’s sometimes used for people with ADHD, especially when all other registered medications are ineffective or if the side-effect profile is unacceptable. It can also be used for anxiety symptoms and sleep disorders. Its effect on ADHD symptoms may not be as robust.

Individual dosages need to be determined. These drugs have a 24-hour action and are therefore taken once daily. Ethipramine is available as 10mg and 25mg tablets.

The most common side effects of the tricyclics include abdominal pain, constipation and headaches. Emotional effects have to be watched and sleepiness may occur. Overdose may have serious cardiac effects.

3. Other medications

Clonidine: This can be used in ADHD, but has a primary effect on impulsive and intrusive behaviors.  Clonidine is often used in Tourette’s disorder for tics, or violent behavior in ADHD, but has many side effects, including low blood pressure and dizziness.

Supplements: Many vitamins (especially vitamins B6 and B12), as well as omega-3 and omega-6 essential fatty acids, are sold as treatments for ADHD. Research has shown some benefit in a group of patients with ADHD for the omega oils.

Coexistent conditions may need treatment with specific medications, e.g. SSRIs for depression and/or anxiety. These may have to be used in combination with specific treatments for ADHD.

Other treatments: Specific coexistent problems need to be addressed with the appropriate therapy, e.g. occupational therapy for coordination and sensory modular problems, and remedial teaching for specific learning problems. 

Training in specific techniques and strategies may help children and adults to take control of the symptoms. A psychologist or life coach may be invaluable here. A full educational evaluation is needed if learning problems are present. Hearing and vision should also be evaluated.

Exercise has become a very important treatment modality, with a recommendation of 20 minutes of vigorous exercise three times per week. This helps to improve both concentration and impulsive behavior.

Taking certain practical steps at home can also make a difference. For example, parents can stick a checklist on the fridge for their child to check each morning before he or she leaves for school. A predictable routine is very important in managing children with ADHD.

What is the outcome of treatment?

Although people with ADHD can be very successful in life, without identification and proper management, ADHD can have serious consequences. This includes failure at school, low self-esteem, depression, behavioral problems and substance abuse. In other words, ADHD is a condition that can have a negative impact on a range of long-term life skills. 

The good news is that early identification and treatment increases the likelihood of a positive long-term outcome. 

Up to 65% of children with ADHD will continue to present symptoms in adulthood. However, this doesn’t mean these children cannot have fulfilling lives and careers: one study found that about 90% of people who presented with ADHD as children were either gainfully employed or full-time students by the age of 25.

Two thirds of people with an ADHD diagnosis in childhood also show no evidence of a mental disorder in adulthood.

It’s important to note that, despite their difficulties, people with ADHD possess positive personality characteristics. With the appropriate intervention and support, they can live healthy, successful lives.

People with ADHD can be:

• Intelligent, imaginative, creative and original, thinking out of the box.
• Inquisitive, exploratory and open to new experiences.
• Active and energetic.
• Enthusiastic, spontaneous, and keen to try out new things.
• Entertaining and interesting.

With proper treatment in the form of cognitive behavioral therapy, medication, occupational therapy, exercise, good nutrition and, possibly, alternative therapies, your child’s future looks bright. 

Parents should also take a close look at their parenting style, and explore the possibility that they themselves may have undiagnosed adult ADHD.

Sources:
Reviewed by Prof André Venter, Head: Clinical Department of Pediatrics and Child Health, Faculty of Health Sciences at the University of the Free State. MB ChB, MMed, PhD (Canada), DCH, FCP (Paed) SA. July 2018.