Treating ADHD requires medical, psychological and educational intervention, as well as behavioural 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 treatment programme. Positive reinforcement, in which desired behaviour is rewarded, is the most appropriate and effective form of behavioural management. It is 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.
Patients 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 and making better choices.
For most children and adults with ADHD, medication is an integral part of treatment. Medication is not used to control behaviour; instead, it is 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 70-80 percent of children with ADHD respond positively to these medications. Attention span, impulsivity and on-task behaviour improve, especially in structured environments. Some children also demonstrate improvements in frustration, tolerance and compliance levels, even handwriting, as it can assist with fine-motor control and visual-motor co-ordination. 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 are able to bring more control and organisation to their lives.
Medical management of ADHD involves medication that has an influence on the neurotransmitters involved:
1. Stimulants: methylphenidate
2. Non-stimulants: (a) atomoxetine; (b) tricyclics
Methylphenidate (MPH) acts on dopamine levels in certain areas of the brain, especially those involved with executive function in the prefrontal areas. There is an inhibition of the reuptake of the neurotransmitter, and thus an increase in the levels of dopamine, causing an improvement in the core symptoms of the individual’s ADHD.
MPH acts immediately when taken, and the effect disappears when serum levels drop. Different preparations and release forms thus 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 20/ 30/ 40 mg 8 hours
• Concerta 18/ 27/ 36/ 54 mg 12 hours (this dose is sometimes increased to 72/ 90 mg in adults)
There is a wide variation in response to 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.
Effects of stimulant medications have been well researched for the past 50-60 years, making them among the most studied 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 initially headaches and abdominal pain. Reduction in appetite when medication is active especially affects midday eating patterns. Problems may develop with sleep onset. If side effects continue after two to three weeks, adjustment in dosage, or change in 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 does not 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 of anxiety levels may lead to the use of alternative medication.
The use of stimulant medications can, initially, cause a slight decrease in the height and weight of some children, but research suggests that the ultimate height and weight are not affected. Concerns regarding the possible cardiac effects of MPH have led to an extensive review. At present there are no increased clinical concerns. In patients with cardiac problems, the use of stimulants is not advocated.
In patients with tic disorders use of a stimulant may improve tics in a third, worsen tics in a third, or make no difference.
Research has shown that substance abuse is not linked to the use of stimulant medication, but to ADHD and poor control of symptoms.
2.1 Atomoxetine (Strattera)
Atomoxetine acts on the norepinephrine neurotransmitters in areas of the brain and thus leads to 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 1.2-1.8 mg per kg and incremental increases are suggested in the first two weeks. Atomoxetine 10/ 18/ 25/ 40/ 60/ 80 mg is available. A very small subgroup may be poor metabolisers and a lower dose may be used.
It is critical to establish the correct dose. Atomoxetine is often prescribed at too low a dose.
Side effects of atomoxetine
Abdominal pain, nausea and heartburn may be the most frequent problems, causing a need for discontinuation. Other complaints include headaches, dizziness, sleepiness or other sleep disturbances, appetite changes and consistent tiredness.
Concerns about hepatic effects have proven to be of little clinical concern, as has a possibility of increased suicidality.
Because of a possible lesser effect on tics, in may be the preferred option in patients with tic disorders.
Tricyclics were developed as an antidepressant, but because of its effect on the norepinephrine system, it is sometimes used in patients with ADHD. 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 per patient. It has a 24-hour action and thus is taken once daily. Tofranil is available as 10/ 25 mg tablets.
Tricyclics are used infrequently in ADHD, but may be indicated if contraindications to the other medications exist, if there are unacceptable side effects, or other medications prove to be ineffective.
The most common side effects of 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 behaviours.
Supplements: Many vitamins, especially 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.
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 patients to take control of the symptoms. A psychologist/life coach may be invaluable here. A full educational evaluation is needed if learning problems are present. Hearing and vision should also be evaluated.
What is the outcome of ADHD?
Although people with ADHD can be very successful in life, without identification and proper treatment, ADHD can have serious consequences, including failure at school, low self-esteem, depression, behavioural 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 can’t 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, particularly those who receive appropriate intervention and support.
People with ADHD can be:
• Intelligent, imaginative, creative and original
• Inquisitive, exploratory, and open to new experiences
• Active and energetic
• Enthusiastic, spontaneous, and keen to try out new things
• Entertaining and interesting to talk to and be with
With proper treatment in the form of cognitive/behavioural 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.
Risk factors for developing ADHD
Causes of ADHD
Reviewed by Dr A van der Walt, MMed (Paed) BSc Hon (Human Genetics) April 2015.