Behavioral Issues

Attention Deficit Disorder - Treatment

Background

CDC: Percet of Youth Aged 4-17 Years Currently Taking Medication for ADHD by State: National Survey of Children's Health

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2010 AAP Guidelines for Treatment of ADHD

The most recent guidelines published by the AAP have updated and expanded both the diagnosis and treatment for ADHD. For different age groups, there are different treatment approaches based on evidence that is a revision from older guidelines.

Recommendations for Preschool-Aged Children (4-5 years of age): evidence-based behavioral interventions should be prescribed as the first-line of treatment. This therapy may be administered by the parents or by a teacher or both. If this is not sufficient to treat the patient, and there continues to be significant impairment of function, one may also prescribe methylphenidate in addition to the behavioral interventions. In areas where resources for behavioral intervention is limited or unavailable, the physician must weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment of ADHD. Methylphenidate was found to be effective in a multisite study in preschool-aged children, however it was limited to children with moderate-to-severe dysfunction.

Recommendations for Elementary School-Aged children (6-11 years of age): FDA-approved medications should be prescribed and behavioral interventions should be prescribed as well. The preference is that both therapies are initiated. The strength of evidence for medications is strongest in stimulants (ie. methylphenidate). Evidence is available for the following medications, in decreasing order of strength: atomoxetine, extended-release guanfacine, and extended-release clonidine.

Recommendations for Adolescents (12-18 years of age): FDA-approved medications should be prescribed, and assent from the adolescent must be given. The physician may also prescribe behavioral therapy, preferably in adjunct with medication (although the evidence for behavioral therapy in this population is not as strong as it is in the other populations).

Behavioral Modification

  • Child must be given structure and clear direction/routines
  • Stress in the environment must be reduced
  • Limit target areas and give immediate positive and negative consequences
  • Social skill training

Educational Interventions

  • Tutoring
  • Resource rooms
  • OT and PT to help maximize abilities
  • Give visual and verbal instructions
  • Utilize classroom aides or learning specialists
  • Structure the environment

Emotional Interventions

  • Improve the child’s self esteem
  • Psychotherapy for depression, anxiety, conducts disorders, and other co morbidities
  • Family therapy if there is marital discord, impending divorces, and family dysfunction

Pharmacotherapy

  • Before initiating medication it is necessary to alleviate fears about medications. Often starting with a low dose and a daily schedule will allow families to observe the child and look for Reponses to the medication
  • An improvement in over activity, attention span, self control, aggression, social interaction, and academic productivity should be expected
  • Reading scores, social skills, academic achievement, and antisocial behavior should NOT be expected to improve
  • Response to medication does not confirm the diagnosis because normal individuals also respond to stimulants
  • Titration of the effects of the medications is the basis of treatment

Criteria for the Initiation of Pharmacotherapy

  • Full and complete assessment confirming diagnosis
  • Child is at least 6 years old
  • Parents are agreeable to the use of medication
  • School will cooperate with administration and management of medication
  • No previous reaction to the medication chosen
  • Child has normal heart rate and blood pressure
  • No history of seizures
  • No history of Tourette Syndrome
  • No history of a pervasive developmental disorder
  • No Substance abusers in household

Medications

Stimulants (First Line):

Agents: Methylphenidate (Methylphenidate, Ritalin, Methylin, Focalin); Dextroamphetamines (Dexedrine, Dextrostat); Amphetamine-Dextroamphetamine (Adderall)
Sustained Release Preparations: Methylphenidate (Methylphenidate-SR, Ritalin-SR, Ritalin-LA, Methylin ER, Metadate CD, Metadate ER, Concerta, Focalin XR, Methylphenidate patch Daytrana; Dextroamphetamine (Dexedrine spansule, Lisdexafetamine); Amphetamine-Dextroamphetamine (Adderall XR)
Side Effects: Insomnia, decreased appetite, transient elevations of heart rate and blood pressure, tics- reversible with removal of medication

  • Start with a low dose in the morning and adjust if the child needs more in the afternoon or after school to complete homework.
  • Can use sustained release to avoid a needed dose at school
  • Must decide if necessary to treat on weekends, vacations, and during the summer months when the child is not at school
  • The efficacy of stimulant therapy compared with placebo has been demonstrated in randomized trials, meta analysis, and systematic reviews which suggest that stimulant therapy is an effective treatment for ADHD
  • The Multimodal Treatment Study of Children with ADHD (MTA study) found that combined medication and behavioral treatment was no more effective in reducing core ADHD symptoms than medication alone

Atomoxetine (Strattera):  a selective norepinephrine reuptake inhibitor

  • Approved for children older than 6 with ADHD
  • Not controlled under the United States Controlled Substances Act
  • 1st ADHD medication approved for use in adults
  • More expensive than stimulant medications
  • May be more appropriate to use in families with a history of substance abuse
  • An acceptable alternative to stimulants
  • No drug holidays
  • Most trials have found Atomoxetine to be equally or less effective than stimulants in the treatment of ADHD

Side Effects: weight loss, abdominal pain, decreased appetite, vomiting, nausea, dyspepsia, sleep disturbance

Also associated with the onset of motor tics, liver injury, and an increase in suicidal thinking

Other Medications:

Although other medications can reduce the symptoms of ADHD studies have not found them to be as effective as stimulants and Atomoxetine.

Antidepressants: TCAs (Imipramine, Desimipramine)- Inhibit reuptake of norepinephrine and serotonin. Useful with comorbid conditions such as depression, anxiety, and tic disorders; Buproprion- block reuptake of norepinephrine and dopamine and has more stimulant properties than TCAs with a risk of lowering seizure threshold.

Alpha-2 Agonists: (Clonidine, Guanfacine)- few studies have been reported showing mild improvement in symptoms of ADHD. Side effects: Headache, abdominal pain, sedation, hypotension, and bradycardia

Drugs Under Investigation: Modafinil, tacrine, donepizil, and nicotinic analogues

Unproved Therapies

  a. Biofeedback
     b. Sensory integration training
     c. Optometric training and exercises
     d. Megavitamins
     e. Restrictive diets
     f. Chiropractic manipulations

Follow-up

  • It is necessary to evaluate therapy and possible side effects. Children on stimulants should have their height and weight followed periodically
  • May need to change mediation or alter dosage. Prescriptions often need to be hand carried and not phone to the pharmacy. They are not refillable and a careful record of when the prescriptions are refilled is important to prevent abuse by patients and their families
  • Evaluate for any improvement and and necessary adjustments/strategies
  • Decide on a length of treatment including trails off of medication
  • Encourage compliance and reinforce any improvement that may have taken place

Physicians caring for children must be aware of the over diagnosis of ADHD and the great increase in the use of psychotropic drugs in preschoolers and younger children. Also, stimulant medications have been found to be a common recreational drug among teenagers and college students and addiction may occur.

References:

  1. Zumethin Alan, Ernst Monique.  Problems in the Management of Attention-Deficit Hyperactivity Disorder.  NEJM Vol 340 No. 1 Jan 7, 1999
  2. Miller Karen, Castellanos F Xavier.  Attention Deficit/Hyperactivity Disorder.  Pediatrics in Review Vol. 19 No 11. November 1999
  3. Zito Julie, Safer Daniel, et. al. Trends in the prescribing of Psychogenic Medications to Preschoolers.  JAMA Vol. 283 No. 8 pp 1025-1030. Feb. 23, 2000
  4. Wender, Esther Managing Stimulant Medication for Attention-deficit/Hyperactivity Disorder Pediatrics in Review June 2001
  5. AAP Treatment of ADHD Pediatrics 2001;108: 1033-44
  6. Arnold LE et al. Treating Attention-Deficit/Hyperactivity Disorder With a Stimulant Trandermal Patch:The Clinical Art. Pediatrics Nov 2007
  7. rown RT, Amier RW, Freeman WS et al. Treatment of attention-deficit/hyperactivity disorder: overview of the evidence. Pediatrics June 2005 111(6): e749-757. 
  8. Schonwald, A. Update: attention deficit/hyperactivity disorder in the primary care office. Curr Opin Pediatr 2005; 17:265.
  9. Barbaresi, WJ, Katusic SK, Colligan, RC, et al. Long term stimulant medication treatment of attention deficit/hyperactivity disorder: results from a population based study. J Dev Behav Pediatr 2006, 27:1.
  10. National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: changes in effectiveness and growth after the end of treatment. Pediatrics 2004, 113; 9:185.
  11. Faraone, SV Biederman, J, Morley CP, Spencer, TJ. Effect of stimulants on height and weight: a review of the literature. J Am Acad Adolesc Psychiatry 2008; 47,994.
  12. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. A 14 month randomize clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry Dec 1999; 56(12):1073.
  13. Leslie LK. et al. Cardiac Screening Prior to Stimulant Treatment of ADHD:  A Survey of  US-Based Pediatricians.  Pediatrics Feb 2012