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Treatment of Attention-Deficit/ Hyperactivity Disorder (ADHD)

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

Treatments for ADHD include medications and psychotherapy. There is some controversy over how to decide when to use these different treatment options. When it comes to prescribing medications for ADHD, it is important to remember that these medications don't cure the condition; they help reduce and control the symptoms of ADHD, but these effects disappear once the medications are stopped. This means that many children with ADHD will continue to take these medications over a period of several years. It is thus understandible that concerns have been raised about whether it is safe and necessary to do this.

Guidelines for treating ADHD published by the National Institute for Health and Clinical Excellence (NICE), a scientific organization based in the UK, suggest that Behavioral Therapy (a form of psychotherapy), and not medications, should be the first-line treatment for most children and adolescents with ADHD [ref]. They suggest that medications should not be prescribed to pre-school aged children, and that when it comes to children and adolescents, medications should only be prescribed in cases where the condition is severe or where Behavioral Therapy has failed or otherwise not been a feasible option [ref]. In adults, medications can be used as a first-line treatment [ref].

The guidelines published by the American Academy of Child and Adolescent Psychiatrists (AACAP) differ considerably [ref]. These guidelines suggest that medications can be safely used as first-line treatment for ADHD in children and adolescents, and can even be used for pre-school children [ref]. These guidelines are in-line with studies showing that 80-90% of individuals with ADHD will experience a significant improvement in their condition if they try two kinds of stimulants consecutively (meaning that if the person does not respond to the first stimulant, that they then try another one) [ref]. These guidlines are also in-line with a very large study on children with ADHD Combined-Type, called the MTA Study, which showed that Methylphenidate (Ritalin) is considerably more effective than Behavioral Therapy, and that in general there is little benefit to be gained by adding Behavioral Therapy to Methylphenidate [ref].

Other guidelines, such as those published by the American Academy of Pediatrics [ref], take a middle stance, and promote the use of Behavioral Therapy as a first-line treatment for ADHD. These guidelines suggest that in pre-school aged children, medications should only be considered if Behavioral Therapy cannot be offered or has been tried and is not effective. For pre-adolescent children, Behavioral Therapy is viewed as a first-line treatment on par with medications, and that ideally a combination of medications and therapy should be used when possible.

Notwithstanding these controversies, here are the main treatment options for ADHD in children and adults:

Medications for ADHD

For both children and adults, medications are effective for controlling the symptoms of ADHD, that is, in improving attention and reducing hyperactivity and impulsivity.

The first-choice medication is Methylphenidate, based on the fact that it has the most research evidence to support its use [ref], and because it has been found to be relatively safe and effective even when a person has other concurrent mental health conditions, such as Substance Abuse or Dependence [ref], a Tic Disorder [ref], or stable Bipolar Disorder [ref].

If after a week or two at the maximum tolerated dose of Methylphenidate the ADHD symptoms are not adequately treated, then it should be stopped and an Amphetamine (including Vyvanse) can be tried instead. The Amphetamines work in a similar fashion to Methylphenidate, but they may carry a greater risk for worsening Tic Disorder when used at high doses [ref].

If after a week or two at the maximum tolerated dose of an Amphetamine the ADHD symptoms are not adequately treated, then it should be stopped, and replaced with one of the following options [ref, ref]:

Once an effective medication has been found, it should be continued for as long as needed to control the symptoms of ADHD. Trials of a few weeks off the medications can be done every few years, given that the symptoms of ADHD tend to diminish naturally with time; this is especially true regarding the Hyperactivity-Impulsivity symptoms in children and adolescents [ref].

Psychotherapy for ADHD

Besides medications, psychotherapy can also be considered. In children and adolescents, the form of psychotherapy that has been most researched is Behavioral Therapy, with many studies having shown that this form is treatment is effective to a moderate degree [ref]. When it comes to treating young children with ADHD, parents and/ or teachers are often included in the therapy so that they can then apply these principles at home and at school.

The MTA Study showed that using Behavioral Therapy alone, without any medications, is significantly less effective at treating the symptoms of ADHD than using medications alone [ref]. Therefore, the opinion of this site is that this would not be recommended [ref, ref], although, as stated above, many authorities promote Behavioral Therapy as a first-line option that is equivalent to medications.

Combining Behavioral Therapy with medications seems to give a slight advantage over using medications alone [ref]. This advantage is probably too small to justify recommending combined treatment for all children and adolescents with ADHD, but it should be considered for those individuals who also suffer from symptoms of other concurrent psychiatric conditions, such as Anxiety and possibly also Disruptive Behavior Disorders [ref, ref].

In adults, there is very little research to support the use of psychotherapy for treating ADHD, though there are some reports suggesting that CBT may be helpful [ref]. This should be considered on a case-by-case basis and would probably be more helpful in situations where there are clearly identifiable areas of difficulty that need to be addressed, such as specific interpersonal problems or work-related issues that may have resulted from the ADHD.

 

Further references: [ref, ref, ref, ref]

 

Associated Conditions (Comorbidity)

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