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ADHD Treatment

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The AACAP has offered several recommendations for treatment of ADHD (Pliszka, 2007):

  • The treatment plan for the ADHD patient should be comprehensive and “well-thought-out”:
    • This requires providers to recognize ADHD as a chronic disorder which presents different developmental challenges over time. Thus, exploration of the many treatments (including medical and behavioral) and combinations of treatments that are available (for ADHD children, teens, and adults as well as for parents and partners of ADHD clients), as well as ongoing review and adjustment of the treatment plan over time, is required.
    • Treatment should be based on the newest literature on both effective and ineffective treatment for different age-groups of clients. For example, medication and behavioral treatment have been shown to be effective; however, cognitive-behavioral therapy, diet changes, social skills training, and neurofeedback have not been shown to be effective. While research has shown that medication is effective for school-age children and for teenagers and adults, results have shown less responsiveness and more undesired side-effects for pre-school children (Biederman et al., 2004).
    • Treatment should include psychoeducation about ADHD for the patient and parents/partners. IN the case of child and teen clients, treatment should address how the impact of ADHD will change over time, and recognize that families must be active participants in treatment. Sometimes families may begin with a preference for one type of treatment over another. At other times, a family may explore more than one treatment option, weighing the various benefits, costs, and side-effects of these options, before deciding on a treatment for their specific child or teen.
  • Medication trials should begin with medications which are approved by the FDA for treatment of ADHD, and should be monitored closely over time in order to determine the best dose for each individual. Only after medications and behavioral therapy have failed should alternative medications (those not approved by the FDA for treatment of ADHD) be tested.
  • If the client responds well to medication alone, showing good functioning in school/work, family, and social settings (in other words, the client does not show any serious comorbid disorder), then treatment with medications alone is acceptable as long as the symptoms continue.
  • However, if problems are seen in these areas (in other words, the client shows either a serious comorbid disorder or a significant change in life circumstances), then adjunctive treatment is advised.
  • Children and adolescents taking medications should have their height and weight checked regularly. The research on the effects of stimulants on growth have been confusing:
    • Overall, research has failed to show consistently that medicated children with ADHD are significantly shorter or weigh significantly less than their peers without ADHD by adulthood. This means that children with ADHD who are treated with medication appear to grow up and be of average height and weight.
    • Some children treated with stimulant medication have been shown to lag behind their peers in growth by small amounts during the first two years of treatment, especially with higher doses of stimulant medication. However, these deficits seemed to disappear during puberty. In other words, short-term deficits in height or weight may be noticed in some children, but these deficits seem to disappear over time.
    • In some of the studies showing no delays in growth, children had “drug holidays”; for example, they did not take medications over the summer when school was out of session. Thus, some argue that it is possible that the children did experience a decline in growth while taking the medication, but the children recovered during drug holidays.
    • Of note, two large studies showed that medicated children with ADHD lagged slightly behind their peers in terms of how much they grew or gained weight each year. However, the children with ADHD in these studies tended to be slightly taller and heavier than their peers without ADHD at the outset of the study, and so the differences in height and weight gain over the years made no difference because they still fell in the average range for height and weight by adulthood.
    • For ADHD children who are below average height and weight when they begin medication, any small short-term deficits in height or weight may be concerning to families.

Treatment with Medication

Ritalin (methylphenidate) was developed in 1954 by Leandro Panizzon, a Swiss chemist (read more about the history of ADHD). He created it for his wife Marguerite (Rita) who had low blood pressure; the drug helped her prepare for tennis competitions. In the 1940’s, certain doses of stimulant drugs were shown to impair attention and focus for some people, but paradoxically were shown to improve attention and focus for other people. Today, for people with ADHD, stimulants like Ritalin appear to increase vigilance, verbal learning, and memory in a general way; however, they appear to improve functioning in these areas by increasing the length of time the person can spend attending to information without distractions.

As for risks and side-effects, there have been many debates about prescription of stimulants, and people often argue based on feelings more than facts:

  • Some dismiss concerns about methylphenidate, noting that caffeine is also in the same class of drugs, and 90% of the US population (including children and teens) consume caffeine daily. Thus, they argue, if you are not worried about caffeine use, you have no reason to worry about Ritalin. However, caffeine and Ritalin work by completely different mechanisms. Caffeine blocks A1 and A2 adenosine receptors in the brain; these receptors limit the release of dopamine, so blocking these receptors means the limiting is blocked, and so increases the amount of dopamine released into the brain. Ritalin, as discussed below, works by slowing carrier molecules that remove dopamine from the synapses; slowing the carrier molecules does not change the amount of dopamine released, but rather increases the length of time that the dopamine has to stimulate neurons. As a result, we cannot dismiss concerns about Ritalin for the same reasons we dismiss concerns about caffeine use. Note that I am not saying there are no reasons to be concerned about caffeine use; rather, I am saying the reasons some people give for dismissing concerns about the use of caffeine do not apply to the use of Ritalin.
  • Some worry that methylphenidate is in the same class of drugs as amphetamines, and so since stimulants are addictive Ritalin must be too. However, methylphenidate is only one tenth the strength of “street” or illegal amphetamines. Thus, Ritalin is not as strong as amphetamines. Further, most forms of Ritalin are packaged to release Ritalin over several hours. Thus, Ritalin is not released all at once into the body’s (and brain’s) system as are amphetamines. As a result, we cannot say that Ritalin is addictive for the same reasons that stimulants are addictive. Note that I am not saying that there is no reason to be concerned about taking Ritalin; rather, I am saying that the reasons some people give for worrying about the addictive power of stimulants in general do not apply to the use of Ritalin (or caffeine).
  • Further, some argue that people raise concerns about caffeine and stimulant use based on their effect on non-ADHD people. It’s not clear whether caffeine and stimulants affect people with ADHD in the same way they affect people without ADHD, so these arguments are even more uncertain.

Some raise concerns about stimulant use because they believe that stimulants create many negative side-effects. These include:

  • increased risk for tics (Biederman et al., 2004 note this is a questionable conclusion)
  • increased risk for substance abuse (though as discussed later, this has not been shown in most long-term follow-up studies)
  • sleep disturbances (though Kirov, et al., 2012, note that many studies have shown that ADHD children have irregular sleep patterns even when they do not take stimulants)
  • decreased growth and height for children (Biederman et al., 2004 note this is questionable as explained earlier)
  • decreased appetite (which might lead to decreased height and weight)

Many claim that stimulants like Ritalin do not bring about improvements for people with ADHD. This is not true. Stimulant treatment is associated with many improvements in functioning, including better school-based productivity (Famularo and Fenton, 1987), better scores on academic tests (Biederman et al., 2004), and better self-esteem and social functioning. Of note, studies have shown that many ADHD children have comorbid learning disabilities. Thus, medication could not be expected to compensate for a learning disability (Bergman et al., 1991; Faraone et al., 1993) or magically teach a child all they have missed in school because of their learning disability. However, stimulant treatment combined with educational intervention may be helpful.

Stimulants come in many forms, with the difference being in the form of stimulant, the immediate vs delayed effect of the stimulant, and the biochemical method for delaying the release of the stimulant:

  • Ritalin (methylphenidate) is the most common stimulant used, and is fast acting. It comes in different forms (see below). Usually it is given in two doses, about four hours apart, which are immediately released into the system.
  • Concerta (1x a day) was the first “new” form of Ritalin, and is a time-released pill that releases some Ritalin immediately (22%) and releases the rest slowly (78%), meaning that the effects of the drug can last for up to 12 hours in children.
    • Biederman et al. (2004) report that a 2001 double-blind study of almost 300 children showed it was effective over the 28 days of the study in reducing ADHD symptoms, and while there was some appetite suppression, it did not cause sleep disruptions (Wolraich et al., 2001).
    • Biederman et al., 2004 report another study of over 400 children followed for one year, which found that Concerta use had no effects on weight, height, blood pressure, pulse, or development of tics (Palumbo, 2002; Spencer, 2002; Wilens, 2002).
  • Metadate CD (1x a day) is like Concerta, but releases 30% of the Ritalin immediately and 70% over time.
    • Biederman et al., 2004 report a double-blind study of over 300 children at 32 sites showed it was effective based on teacher ratings, and less than 10% showed any appetite suppression or sleep disturbance.
  • Ritalin LA (1x a day) and Adderoll XR (2x a day) are also time-released, with a mix of 50% of the Ritalin immediately released and 50% released over time.
    • Biederman et al., 2004 report a double-blind study of Ritalin LA with 137 children and showed it was effective based on parent and teacher reports, and only 3.1% showed any sleep or appetite disruptions (Biederman, 2002).
    • Biederman et al., 2004 report a double-blind study of Adderoll XR with almost 600 children at 47 sites and showed it was effective based on parent and teacher reports (Biederman, 2002). A one-year follow-up of over 400 children on Adderoll XR showed continued effectiveness, no signs of cardiac risk, and little sleep or appetite disruptions (Chandler, 2002).
  • Focalin is a refined form (D-threo-methylphenidate) of Ritalin, or a specially shaped Ritalin molecule. This shape seems to be most effective slowing the carrier molecules for a specific kind of dopamine receptor, one that is largely found in the basil ganglia. Biederman et al. (2004) report several studies showing that since the medicine is refined to only include this shape of the molecule, smaller doses of Focalin are just as effective as larger doses of other forms of Ritalin.
  • Stimulant medication has not been shown to be equally effective for all clients, however. Approximately 30% of ADHD patients do not respond to stimulant medication (Biederman et al., 2004). Some have argued there may be multiple causes of ADHD, and so the problem is not the failure of stimulant treatments but rather our failure to understand and accurately diagnose types of ADHD. Other medications have been used for those who do not respond to stimulants:

  • MAOIs have been showed to be effective in a few studies with adolescents and adults, but the side-effects of MAOIs are sufficiently worrisome that they are not often used.
  • Trycyclic Antidepressants are supported in many studies to be effective with those who do not respond to stimulants.
  • SSRIs have also been tested, but only in a few studies.

Garfield et al. (2012) used a national database of health records covering 4,300 physicians seeing patients from 2000 to 2010. They noted:

  • Physician visits for ADHD rose from 6.2 to 10.4 million from 2000 to 2010, meaning an increase of 66%. Most of this increase happened from 2000 to 2003. From 20003 to 2010, the number of visits per year remained about the same, and the number of first-time visits each year ranged from 12% to 14%.
  • Visits to pediatric psychiatrists for ADHD have increased from 24% in 2000 to 36% in 2010, while visits to pediatricians decreased from 54% to 47% during this same time. Combined, this likely reflects a shift in providers (people switched from seeing pediatricians to seeing psychiatrists), but is still an increase in the number of visits for ADHD.
  • Of note, some patients in the study were prescribed more than one medication. While they tried other medications over the 10 years of the study, prescription of any medication for ADHD decreased over this ten year period. Stimulants were prescribed in 98% of visits in 2001 and in 87% of visits in 2010.
  • A similar decrease was seen in prescription of atomoxetine (a non-stimulant treatment for ADHD, which seems to work on the neurotransmitter norepinephrine) which was prescribed in 15% of visits in 2003 (the year it was released) and 6% of visits in 2010. This decrease is likely the result of several FDA reports which raised concerns about the dangers of the drug.
  • Severity of the reported symptoms has remained fairly constant during this time. In 2000, 22%, 57%, and 10% of patients reported mild, moderate, and severe symptoms of ADHD respectively. In 2010, these percentages were 22%, 53%, and 9%. In other words, reports of the severity of ADHD symptoms is essentially unchanged.

References

Bergman, A., Winters, L., & Cornblatt, B. (1991). Methylphenidate: Effects on sustained attention. In L. Greenhill & B. Osman (Eds.), Ritalin: Theory and Patient Management, (pp. 223–231). New York: Mary Ann Liebert Inc.

Biederman, J., (2002). Methylphenidate extended release capsules: Once-daily therapy for ADHD. The Annual Meeting of the American Academy of Child and Adolescent Psychiatry. New York, NY: American Psychiatric Association.

Biederman, J., Spencer, T., & Wilens, T. (2008). Evidence-based pharmacotherapy for Attention-Deficit Hyperactivity Disorder. International Journal of Neuropsychopharmacology, 7, 77–97.

Chandler, M. C., (2002). Long-term safety and efficacy of Adderall Extended Release in children with ADHD. Annual Meeting of the American Psychiatric Association. Philadelphia, PA: APA.

Famularo, R., & Fenton, T., (1987). The effect of methylphenidate on school grades in children with attention deficit disorder without hyperactivity: a preliminary report. Journal of Clinical Psychiatry, 48(3), 112-114.

Faraone, S. V., Biederman, J., Krifcher, L. B., Spencer, T., Norman, D., Seidman, L., Kraus, I., Perrin, J., Chen, W., & Tsuang, M. T., (1993). Intellectual performance and school failure in children with attention deficit hyperactivity disorder and in their siblings. Journal of Abnormal Psychology 102, 616–623.

Garfield, C. F., Dorsey, E. R., Zhu, S., Huskamp, H. A., Conti, R., Dusetzina, S. B., Higashi, A., Perrin, J. M., Kornfield, R., & Alexander, G. C., (2012). Trends in Attention Deficit Hyperactivity Disorder ambulatory diagnosis and medical treatment in the United States, 2000-2010. Academic Pediatrics, 12(2), 110-116.

Kirov, R., Uebel, H., Albrecht, B., Banaschewski, T., Yordanova, J., & Rothenberger, A. (2012). Attention-deficit/hyperactivity disorder (ADHD) and adaptation night as determinants of sleep patterns in children. European Child and Adolescent Psychiatry, 21, 681–690.

Palumbo, D., (2002). Impact of ADHD treatment once-daily OROS formulation of MPH on tics. Annual Meeting of the American Psychiatric Association. Philadelphia, PA: APA

Pliszka, S., (2007). Practice parameter for the assessment and treatment of children and adolescents With Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7), 894–921. (see http://www.jaacap.com/article/S0890-8567%2809%2962182-1/fulltext)

Spencer, T., (2002). ADHD treatment with a once-daily formulation of MPH: Effect on growth. Annual Meeting of the American Psychiatric Association. Philadelphia, PA: APA.

Wilens, T., (2002). ADHD treatment with a once-daily formulation of methylphenidate: A two-year study. Annual Meeting of the American Psychiatric Association. Philadelphia, PA: APA

Wolraich, M., Greenhill, L. L., Pelham, W., Swanson, J., Wilens, T., Palumbo, D., Atkins, M., McBurnett, K., Bukstein, O., & August, G., (2001). Randomized controlled trial of OROS methylphenidate qd in children with Attention Deficit/Hyperactivity Disorder. Pediatrics, 108, 883–892.