Treatment

As is the case with many other chronic diseases such as diabetes and asthma, the current goal for treatment of ADHD is not a cure but instead to manage the disorder or reduce the symptoms.7 The current philosophy advocates a multimodal approach using pharmacological and psychosocial treatments combined with supportive management/environmental manipulation and family support strategies.1,8 Peer group placement is an example of environmental manipulation. Parents play a major role in the treatment of a child's ADHD. Parental training can include help giving clear instruction to the child and appropriate use of positive and negative reinforcement. Since this disorder impacts the rest of the family, all family members need guidance in how to negotiate or solve problems associated with raising and managing a child with ADHD.1,8 Parents must enforce a specific daily drug regimen designed to increase the child's attention span, complete tasks and maintain interest. Adherence to such a course of therapy provides the child with the greatest chance of acceptance with themselves, friends and society.8 In addition, since genetics is an important factor in the disorder, be aware that the parent may be struggling with their own ADHD. Psychosocial treatments are beneficial in the management of ADHD symptoms.7 A widely used technique is behavior management training which includes contingency management, positive/negative reinforcement and time out.7 These strategies, which are most effective with preschool or grade school aged children, can be easily taught to parents and teachers in an individual or group setting.7 Since many children with ADHD have deficits in social skills, training is often employed, in a group setting, to encourage appropriate social interactions. As the child becomes old enough to engage in ‘talk therapy', individual or family therapy may be useful in targeting symptoms such as low self-esteem or demoralization.7 Academic accommodations are typically necessary and include preferential seating, untimed testing and incentives for remaining on task.7 While some religions and parents may be hesitant to ‘drug a child' pharmacological treatments are warranted to control symptoms. Stimulant drugs are most frequently used to treat ADHD.9 These medications inhibit dopamine and norepinephrine reuptake in the brain which results in increased attention and concentration and reduced hyperactivity and impulsivity. Methylphenidate (Ritalin) is most often prescribed to treat ADHD.10 This drug acts by normalizing cerebral blood flow and glucose metabolism. These actions serve to increase a child's mood; decrease motor activity, aggressive behavior and anxiety; and improve the ability to focus attention and concentration.10 Long term use of methylphenidate in pre-pubertal children may be associated with growth suppression expressed as weight loss and limited height growth.10 A ‘drug holiday' – interruption of treatment – is often suggested on weekends and summers to allow the child to ‘catch up' growth.10 Additional side effects may include insomnia, stomachaches and headaches.10 Methylphenidate is a short acting stimulant, usually lasting 3-4 hours. This may result in extreme irritability between doses.7 Concerta is an extended release form of methylphenidate, lasting up to 12 hours and does not produce this ‘rebound effect'.7 Other CNS stimulants such as dextroamphetamine (Dexedrine), amphetamine/dextroamphetamine (Adderall) and pemoline (Cylert) may be prescribed to ADHA patients.7 Pemoline was recently removed from the market due to concerns of liver damage. For those who respond poorly to stimulant medication, antidepressants such as Bupropion (Wellbutrin) have been prescribed. This class of medication may not address the impulsivity/aggressivity symptoms, so hypertensive agents which alter norepinephrine activity are used in conjunction with certain antidepressants.11 Atomoxetine (Strattera) selectively raises norepinephrine levels at the synaptic cleft and appears to improve all 3 core symptoms of ADHD – inattention, hyperactivity and impulsivity.11