A Guide to Treatment for ADHD

The number of children diagnosed with attention deficit hyperactivity disorder (ADHD) and treated with drugs has increased dramatically over the past decade.[1] If you are a parent, you may be confused or overwhelmed by the number of different treatment options and the prospect of dealing with a chronic illness in a young child. Learn the steps needed for an accurate ADHD diagnosis and understand the variety of treatments available before working with your child’s doctor on a plan for treatment.

An accurate diagnosis

Broadly speaking, ADHD is a pattern of inattentive, hyperactive or impulsive behavior that interferes with a child’s ability to function and persists over time.[2] But every child who displays these behaviors should not necessarily be diagnosed with and treated for ADHD. Such a diagnosis should be made only by a physician, ideally one with ample experience working with children who have ADHD.

Before confirming your child’s diagnosis, the doctor should verify that:[3]

• The child’s ADHD symptoms cause significant difficulties in functioning in more than one major setting, such as at home and at school.
• The significant difficulties have lasted at least six months.
• The child’s ADHD symptoms started before age 12. If the symptoms appear for the first time as a ADHDteen or adult, they are likely due to a different problem, such as substance abuse or anxiety.
• The symptoms occur often, and to a degree that is not appropriate for the child’s age.

If you don’t feel confident in your family doctor’s diagnosis, seek a second opinion from another family doctor or pediatrician or from a specialist with ADHD experience (this could be a neurologist, child psychiatrist or clinical child psychologist).

Behavior therapy and skills training

Both drugs and nondrug therapies can be used to treat children and adolescents with ADHD.[4]

There are two major types of nondrug therapy for ADHD. The first is behavior therapy, which can be used in children of all ages and adolescents. It typically involves coaching parents, teachers or other caregivers in the skills they can use to direct the behavior of the child.[5] It emphasizes selective reinforcement of desired behavior and selective ignoring of problem behavior.[6] (See more on behavior therapy in "First-Choice Treatment for Young Children With ADHD Largely Underused.")

The second is direct skills training, which can be used in older children and adolescents. It involves training them to address common ADHD-related deficits, targeting areas such as organization (for example, use of a planner), time management and study skills.

Parents may ask the child’s school for additional supportive services, and the child could have a right to such services under the Individuals with Disabilities Education Act, Section 504 of the Rehabilitation Act or the Americans with Disabilities Act.[7]

Drug treatment for ADHD

Stimulant medications are the oldest and most effective drugs for treating ADHD symptoms.[8] However, stimulants also have many adverse effects, including appetite suppression, weight loss, headaches, sleep disturbance and reduced growth.[9] Rarer but serious side effects include hallucinations, other psychotic symptoms and possible increased risk of suicide.[10],[11]

Stimulants approved for ADHD include methylphenidate (APTENSIO, CONCERTA, DAYTRANA, METADATE, METHYLIN, QUILLICHEW, QUILLIVANT, RITALIN), dexmethylphenidate (FOCALIN), and various amphetamines such as dextroamphetamine (DEXEDRINE), amphetamine sulfate (EVEKEO), dextroamphetamine-amphetamine salts (ADDERALL XR) and lisdexamfetamine (VYVANSE).[12]

Public Citizen’s Health Research Group has previously advised against using dexmethylphenidate and lisdexamfetamine, as these are essentially copies of older generic drugs and are usually more expensive.[13],[14]

Stimulant ADHD drugs are controlled substances that have special restrictions when prescribed because they can be abused or lead to addiction.[15] To avoid misuse, stimulant drugs should not be prescribed where there is a risk that the drug may be abused or sold by the child or a family member with substance problems.[16]

Stimulant drugs increase blood pressure and heart rate, and can have dangerous and even fatal effects for children and adults who abuse these drugs, as well as those who use the drugs as prescribed but have underlying heart problems.[17] Because of this, the American Heart Association recommends that all children be screened for heart problems before starting treatment with a stimulant, along with receiving assessments for adverse cardiovascular effects at each doctor’s visit while they remain on these medications.[18]

In addition to stimulant drugs, the FDA has approved the antidepressant atomoxetine (STRATTERA) and two central nervous system drugs, extended-release clonidine (KAPVAY) and extended-release guanfacine (INTUNIV), for ADHD treatment.

Atomoxetine and extended-release clonidine and guanfacine are three non-stimulant, non-addictive options for children and adolescents who cannot take stimulants.[19] However, these drugs are less effective and less well-studied than stimulants, and they have their own side effects.[20] Atomoxetine causes drowsiness, digestive symptoms, decreased appetite and raised blood pressure.[21],[22] It also carries a black-box warning indicating that it increases suicidal thinking in children and adolescents.[23] Extendedrelease guanfacine and clonidine cause drowsiness and can lead to dangerously high blood pressure if the medication is stopped abruptly.[24],[25]

Alternative medicine

Many alternative-medicine options have been suggested for children with ADHD, but none are proven safe and effective for this condition. Some alternative-medicine options, such as omega-3 fatty acid supplements, have few side effects, but most of the available evidence from clinical trials indicates that these supplements are not effective for ADHD.[26] Other treatments can be dangerous, including megadoses of vitamins or chelation (using chemicals to remove metals and minerals from the blood).[27] We categorize these alternative treatments as Do Not Use, but if you decide to use any alternative therapy, make sure that you inform your child’s doctor and are aware of the known risks and the lack of benefits.

Treatment for children 6 and under

For children under age 6, the mainstay of treatment is behavior therapy — not drugs. (See "First-Choice Treatment for Young Children With ADHD Largely Underused.")

Where behavior therapy fails, the American Academy of Pediatrics recommends methylphenidate, because this drug has been better-studied in preschool-aged children than other ADHD drugs.[28] However, evidence of this drug’s effectiveness for such young children remains limited, side effects are a concern and the drug is still not FDA-approved for this age group.[29],[30] Public Citizen’s Health Research Group therefore recommends against using this or any other drug for preschoolers at this time.

ADHD in adults

Many children diagnosed with ADHD continue to experience symptoms in adult life.[31] While there is far less information available about the effects of ADHD medication in adults, short-term clinical trials have shown that drug treatment can relieve symptoms in adults, with greater benefits from stimulants than from non-stimulants.[32] Studies of adults in real-world settings also provide evidence that adults who take medication for ADHD have better self-esteem and social function.[33]

What You Can Do

Make sure your child has been accurately diagnosed with ADHD before starting treatment. If you are certain your child has ADHD, work with his or her doctor to develop a treatment plan and follow through on that plan, including any medications you have agreed to give your child. If treatment is not successful, ask your child’s doctor to re-evaluate his or her diagnosis and treatment plan, or seek a second opinion from a specialist.[34]

References

[1] Visser SN, Danielson ML, Bitsko RH, et al. Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry. 2014;53(1):34-46.e2.

[2] Centers for Disease Control and Prevention. Attention-deficit/hyperactivity disorder (ADHD): Symptoms and diagnosis. www.cdc.gov/ncbddd/adhd/diagnosis.html. Accessed July 21. 2016.

[3] Ibid.

[4] Krull KR, Augustyn M, Torchia MM. Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. UpToDate. Updated May 26, 2016. Accessed July 21, 2016.

[5] Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.

[6] Chan E, Fogler JM, Hammerness PG. Treatment of attention-deficit/hyperactivity disorder in adolescents: A systematic review. JAMA. 2016;315(18):1997-2008.

[7] Ibid.

[8] Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.

[9] Ibid.

[10] Mosholder AD, Gelperin K, Hammad TA, et al. Hallucinations and other psychotic symptoms associated with the use of attention-deficit/hyperactivity disorder drugs in children. Pediatrics. 2009;123(2):611– 616.

[11] Health Canada. ADHD drugs may increase risk of suicidal thoughts and behaviours in some people; benefits still outweigh risks. March 30, 2015. http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2015/52759a-eng.php. Accessed July 21, 2016.

[12] Krull KR, Augustyn M, Torchia MM. Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents. UpToDate. Updated April 18, 2016. Accessed July 21, 2016.

[13] Drug profile: dexmethylphenidate. WorstPills.org. Updated November 30, 2015. /monographs/view/34. Accessed July 21, 2016.

[14] A review of ADHD drug lisdexamfetamine (VYVANSE). Worst Pills, Best Pills News. January 2010.

[15] Krull KR, Augustyn M, Torchia MM. Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents. UpToDate. Updated April 18, 2016. www.uptodate.com. Accessed July 21, 2016.

[16] Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.

[17] FDA issues stronger warnings for ADHD stimulants; warnings don’t go far enough. Worst Pills. Best Pills News. November 2006.

[18] Vetter VL. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder [corrected]: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation. 2008;117(18):2407-2423.

[19] Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.

[20] Ibid.

[21] Ibid.

[22] Wernicke JF, Faries D, Girod D, et al. Cardiovascular effects of atomoxetine in children, adolescents, and adults. Drug Safety. 2003;26(10):729-740.

[23] Eli Lilly and Co. Label: atomoxetine (STRATTERA). June 30, 2015. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=309de576-c318-404a-bc15-660c2b1876fb. Accessed July 21, 2016.

[24] Concordia Pharmaceuticals. Label: clonidine extended release (KAPVAY). January 1, 2015. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=aa7700e2-ae5d-44c4-a609-76de19c705a7. Accessed July 21, 2016.

[25] Shire. Label: guanfacine extended release (INTUNIV). July 13, 2016. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b972af81-3a37-40be-9fe1-3ddf59852528. Accessed July 21, 2016.

[26] Gillies D, Sinn JKh, Lad SS, et al. Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev. 2012;(7):CD007986.

[27] Krull KR, Augustyn M, Torchia MM. Attention deficit hyperactivity disorder in children and adolescents: overview of treatment and prognosis. UpToDate. Updated May 26, 2016. Accessed July 21, 2016.

[28] Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.

[29] Ibid.

[30] Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284 -1293.

[31] Krull KR, Augustyn M, Torchia MM. Attention deficit hyperactivity disorder in children and adolescents: overview of treatment and prognosis. UpToDate Web site. Updated May 26, 2016. www.uptodate.com. Accessed July 21, 2016.

[32] Faraone SV, Glatt SJ. A comparison of the efficacy of medications for adult attention-deficit/hyperactivity disorder using meta-analysis of effect sizes. J Clin Psychiatry. 2010 Jun;71(6):754-63.

[33] Shaw M, Hodgkins P, Caci H, et al. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC Med. 2012; 10:99.

[34] Krull KR, Augustyn M, Torchia MM. Attention deficit hyperactivity disorder in children and adolescents: overview of treatment and prognosis. UpToDate Web site. Updated May 26, 2016. www.uptodate.com. Accessed July 21, 2016