Treatment of attention deficit hyperactivity disorder in children

Treatment of attention deficit hyperactivity disorder in children

Author
Kevin R Krull, PhD
Section Editor
Marilyn Augustyn, MD
Deputy Editor
Mary M Torchia, MD

Disclosures

INTRODUCTION — Attention deficit hyperactivity disorder (ADHD) is a condition that causes trouble paying attention, hyperactivity, and impulsive behavior. It is often first recognized in early childhood. ADHD can affect a child’s thinking, performance in school, behavior, feelings, and relationships with others. In 20 to 50 percent of cases, ADHD continues into adulthood.

Treatments for ADHD include medicines, behavior training, counseling, and changes at school. These treatments can be used alone or in combination. The best treatment or combination of treatments depends on your child’s situation. A doctor or nurse can guide you and your child as treatment begins.

The treatment of attention deficit hyperactivity disorder in children and adolescents will be reviewed here. A topic that discusses the symptoms and diagnosis of ADHD is available separately. (See “Patient information: Symptoms and diagnosis of attention deficit hyperactivity disorder in children”.)

More detailed information about ADHD in children is available by subscription. (See “Attention deficit hyperactivity disorder in children and adolescents: Clinical features and evaluation” and “Attention deficit hyperactivity disorder in children and adolescents: Pharmacotherapy” and “Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents”.)

DOES MY CHILD NEED ADHD TREATMENT? — Some parents wonder if treatment for ADHD is necessary. Most experts agree that unrecognized and untreated ADHD can have serious consequences, including school failure and drop out, depression, poor behavior, failed relationships, poor performance in the workplace, and drug or alcohol abuse. Treatment can help a child to:

Have better relationships with parents, teachers, siblings, or peers (eg, play without fighting at recess)
Perform better in school (eg, finish school work)
Follow rules (eg, not talk back to the teacher)
What treatment is best? — The most effective treatment for most children with ADHD is a stimulant medicine. Behavioral treatments and counseling are sometimes added if needed.

Parents who prefer that their child avoid medicine should work closely with the child’s doctor or nurse. While it is reasonable to consider using behavioral treatments alone, this may not work as well as medicine alone [1].

The American Academy of Child and Adolescent Psychiatry, in partnership with the American Psychiatric Association, has developed a medicine guide for parents. This is available online at www.parentsmedguide.org/pmg_adhd.html.

ADHD STIMULANT MEDICINES — Stimulant medicines are the first-line ADHD treatment for children. However, there are criteria that must be met before medicine is considered. In addition, parents (and the child, when appropriate) should understand the need for close monitoring during treatment.

Despite their name, stimulants do not cause a child with ADHD to become more stimulated, but instead improve communication between several areas of the brain. This helps to improve attention and concentration. However, medicines do not cure ADHD or teach the child to behave, work well with others, perform well in school, or be motivated.

Two medicines, methylphenidate and amphetamines, are the most commonly used stimulants for the treatment of ADHD.

Methylphenidate — Methylphenidate (Ritalin®, Methylin®, Concerta®, Focalin®, Metadate®, and others) is available as a tablet, capsule, and liquid.
One formula, called immediate release, is usually started with one dose per day, and then increased to twice daily.
Another formula, called sustained release, is usually taken once per day.
A methylphenidate patch (Daytrana®) is also available; the child wears the patch on the skin for up to nine hours per day.
Amphetamines — Amphetamines are also available in immediate and sustained release formulas (Dexedrine®, Dextrostat, Adderall®).
Lisdexamfetamine (Vyvanse®) is an amphetamine that is taken once per day. It is a slow release formula that was developed to discourage drug abuse because it does not cause a “high” feeling.

How well do stimulants work? — If the stimulant dose is correct, it will begin to work within 30 to 40 minutes. If the dose is not correct (for example, if the dose is too small, which is common when starting treatment), most experts recommend waiting one week before increasing the dose. Your doctor or nurse will tell you when or if you should increase your child’s stimulant dose.

At least 80 percent of children with ADHD will respond to a stimulant. However, is not clear if stimulants have a long-term benefit for the child’s thinking, school performance, behavior, or feelings.

Side effects — Stimulant medicines have a 50-year history of being safe and working well when used properly, and few children have serious side effects. Stimulants are not addictive. Methylphenidate and amphetamines are equally likely to cause side effects. Some of the most common side effects include:

Decreased appetite (80 percent)
Trouble with sleep (3 to 85 percent)
Weight loss (10 to 15 percent)
Motor tics (sudden, involuntary movements) (15 to 30 percent)
Less common side effects include increased heart rate and blood pressure, headache, social withdrawal, nervousness, irritability, stomach pain, and moodiness.

Many of these side effects are mild and temporary. Decreases in appetite can be improved by taking medicines after meals, or eating within 30 to 40 minutes after taking the medicine.

Cardiovascular effects — Stimulants are not recommended for children with serious heart problems. There have been rare reports of serious side effects, including sudden unexpected death, in children taking stimulant medicines. However, it is not clear that the stimulant was the cause of death. Millions of children with ADHD have used stimulants and very few have had serious side effects.
Psychiatric effects — There have been a small number of reports of children who take stimulant medicines developing suicidal thinking, hallucinations, or aggressive behavior.
Call your child’s doctor or nurse if you notice irritability, anxiety, panic, difficulty sleeping, hostility, suicidal thinking or behavior, or other unusual changes in behavior. The child should also see a doctor or nurse on a regular basis while taking stimulant medicines.

Dosing — Stimulants are generally started at a low dose on the weekend so that parents can observe the child more closely. The dose and time the medicine is taken can be adjusted as needed (this is called “titrating” the dose).

The child may need to try more than one medicine or dose to find the one that works best and has the fewest side effects. Typically, only one stimulant is used at a time.

If the child needs to take medicine at school, he or she should have a separate bottle. A school nurse or faculty member should keep this medicine and give it to the child at the appropriate time. To avoid misuse and loss, the child should not keep the medicine in his or her school bag or desk.

Drug holidays — A “drug holiday” is a time when medicine is not taken on the weekend or during school vacations. If you or your child are interested in trying a drug holiday, talk to the child’s doctor or nurse.

Certain children can consider trying a drug holiday, including those who:

Only need ADHD treatment on school days
Are having trouble with weight loss because of an ADHD medicine
Stopping stimulants — The length of treatment with a stimulant medicine depends upon the child’s situation. For some children with ADHD, it is reasonable to consider a trial period without medicine. Talk to your child’s doctor or nurse about the risks and benefits of stopping treatment.

ATOMOXETINE (STRATTERA®) — Atomoxetine is a non-stimulant medicine used in the treatment of ADHD. It is more expensive than stimulant medicines. Atomoxetine is an alternative to stimulants that can be used in children with a history of drug abuse or who have family members with a history of drug abuse. It can also be used if a child has intolerable side effects with stimulants.

It is usually taken once or twice per day, and is available only in capsule form. Capsules should not be opened or chewed. Drug holidays are not recommended with atomoxetine.

Atomoxetine works as well as methylphenidate for treatment of ADHD.

Side effects — Side effects of atomoxetine can include weight loss, decreased appetite, vomiting, nausea, upset stomach, and trouble sleeping. Severe liver injury has been reported in children and adults treated with atomoxetine. Call your child’s doctor or nurse immediately if the child develops jaundice (yellowing of the skin or whites of the eyes), which is a sign of liver injury.

There is also a small increased risk of suicidal thinking with atomoxetine, similar to stimulant medicines. (See ‘Side effects’ above.)

Other medicines — There are other medicines available to treat ADHD if stimulants or atomoxetine do not work or have unacceptable side effects. A developmental behavioral pediatrician, child psychiatrist, or psychopharmacologist is usually consulted in these situations.

ADHD BEHAVIORAL TREATMENTS — Behavioral treatments for ADHD include changes in a child’s environment, which are designed to help the child change his or her behavior.

Behavioral treatments work to improve problems with:

Behavior and learning at school
Relationships with friends, parents, and siblings
Following through with adult requests
A professional training program is recommended for parents because it can be difficult to learn these techniques and use them effectively without support. Adults can help to shape the behavior of a child who has ADHD with the following techniques:

Follow a daily schedule
Keep distractions to a minimum
Provide specific and logical places for the child to keep schoolwork, toys, and clothes
Set small, reachable, and clear goals
Reward positive behavior (eg, a sticker chart with a bigger reward for a certain number of stickers)
Use charts and checklists to help the child stay “on task”
Suggest physical activity breaks during tasks that require attention
Limit choices
Find activities where the child can be successful (eg, hobbies, sports)
Use calm discipline (eg, time out, distraction, removing the child from the situation)
Additional tips for parents are available through the NICHQ toolkit (www.nichq.org/parents.html).

ADHD AND SCHOOL — Children who are diagnosed with ADHD may need changes in how they are taught, including extra help with school work during or after class. This extra help can be given in the classroom or in a “resource” room setting.

Other suggestions for teachers include:

Write homework assignments down (on paper or send by email).
Have the child sit near the front of the classroom.
Allow the child extra time to complete school work.
Give the child a private signal when he or she is “off-task”.
Use a daily report card to help parents to monitor their child’s symptoms and how well the current ADHD treatment plan is working.
More information for teachers of children with ADHD is available through the National Resource Center on ADHD (www.help4adhd.org/en/education).

ADHD is considered to be a disability under the Individuals with Disabilities Education Act (IDEA [PL-101-476]). Under this act, children with ADHD may qualify for special education or related services. Alternatively, the child may qualify for changes in the regular classroom setting under Section 504 of the Rehabilitation Act of 1973.

In addition, the Americans with Disabilities Act may provide individuals with ADHD reasonable accommodations in certain private schools and colleges (table 1). To learn more about a child’s educational rights, contact a local Parent Training and Information Center (available in every state in the United States; for a list of centers visit www.taalliance.org).

COMPLEMENTARY AND ALTERNATIVE TREATMENTS FOR ADHD — Complementary and alternative medicine (CAM) treatments are treatments or products that are not considered to be part of conventional medicine. CAM treatments advertised to improve ADHD include vision training, special diets (eg, avoiding sugar, allergy triggers, or particular food additives), megavitamins, herbal and mineral supplements, EEG biofeedback, and applied kinesiology.

These treatment are often used by parents of children with ADHD because of advertising that these treatments “are safer than traditional medicines,” “are natural,” or “can cure ADHD.

However, studies have not confirmed the benefits of these treatments, and the risks are not well understood. One significant risk is that the treatment will fail and cause a setback for the child if symptoms of ADHD continue. Another risk is that these treatments are expensive; CAM therapies are generally not covered by health insurance.

Any parent who is considering use of a CAM treatment should gather information about the safety, risks, and benefits of the treatment. You can find reliable information about alternative treatments from your child’s healthcare team (physician, nurse, dietitian) and government-sponsored Web sites (www.nccam.nih.gov).

If you are considering a complementary or alternative treatment for your child, ask the following questions:

Does it claim to cure ADHD and multiple other health problems? There is currently no known cure for ADHD, and no single treatment is likely to cure multiple health problems.
Does it claim to be harmless or natural? Natural does not necessarily mean safe.
Is it offered by only one individual or is it a secret that only certain people can share? Reputable treatments that work well should be available from any licensed healthcare professional.
Is it based on multiple studies that have been published? To confirm the safety and benefit of a treatment, multiple clinical studies should be published in mainstream medical journals (see www.pubmed.gov).
Is it expensive? Spending a large amount of money on a treatment that is not proven is risky.
Is the group or person promoting the CAM treatment an expert in ADHD treatment? Verify the education and licensing of any person who claims to be an expert. All states within the United States have a licensing board that can verify a person’s credentials.
LIVING WITH ADHD

Other family members — Because ADHD is usually an inherited condition, parents and siblings of a child with ADHD could also have ADHD. Talk to your doctor or nurse to see if you should be evaluated. (See “Patient information: Symptoms and diagnosis of attention deficit hyperactivity disorder in children”, section on ‘Diagnostic criteria’.)

Driving — Adolescents with untreated ADHD are two to four times more likely to have motor vehicle accidents than those without ADHD. They also are more likely to have their driver’s license suspended or revoked [2].

As a result, parents of adolescents with ADHD should discuss the issues surrounding driving before the adolescent is licensed to drive. A longer period of supervision (eg, the adolescent drives with an adult) can help to ensure that the teen is able to use good judgment, can react quickly and carefully, and is safe to drive independently.

Discussing medicines — If you decide to use medicine to treat ADHD, you should discuss this decision with your child. This includes discussing:

The purpose and expected benefits of the medicine
The need for the child to follow the rules and make good choices with the help of the medicine
The possible need to try more than one medicine or dose
Diversion and misuse of stimulant medicines are common concerns of many parents.

Diversion is defined as giving, selling, or trading stimulants
Misuse is defined as using a stimulant in higher-than-prescribed doses or in combination with illegal drugs or alcohol
Ways to avoid these problems include using long-acting medicines, keeping track of prescription dates, and talking to the child about the possibility that friends or peers may ask to divert or misuse medicine.

Seek support — Parenting a child with ADHD can be emotionally and physically exhausting, and most parents need support to cope. Support can come from multiple resources, including family, friends, and support groups. There are a number of organizations that can provide information about parenting a child with ADHD. (See ‘Where to get more information’ below.)

ADHD in adulthood — For many children, the effect of ADHD on behavior, social skills, and school performance continues into adolescence and adulthood. A separate topic discusses ADHD in adults. (See “Adult attention deficit hyperactivity disorder”.)

For adolescents or adults who have difficulty with organization and time management, certified “coaches” are available to provide support and instruction. Additional information about ADHD coaches can be obtained through the Children and Adults with Attention-Deficit Hyperactivity Disorder (CHADD) Web site (www.help4adhd.org/en/living/coaching).
Counseling or self-help groups also can provide support to adults with ADHD. Counseling is usually recommended along with medicines and skills training programs. Adults with newly diagnosed ADHD sometimes have a long history of low self-esteem, school failure, frequent job changes, and relationship problems.
Counseling for married adults can focus on improving communication skills, resolving conflict and solving problems, and educating the patient’s spouse about ADHD.
WHERE TO GET MORE INFORMATION — Your child’s healthcare provider is the best source of information for questions and concerns related to your child’s medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Symptoms and diagnosis of attention deficit hyperactivity disorder in children

Professional Level Information:

Attention deficit hyperactivity disorder in children and adolescents: Clinical features and evaluation
Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis
Attention deficit hyperactivity disorder in children and adolescents: Pharmacotherapy
Cardiac evaluation of children receiving pharmacotherapy for attention deficit hyperactivity disorder
Overview of the treatment and prognosis of attention deficit hyperactivity disorder in children and adolescents
Specific learning disabilities in children: Clinical features
Specific learning disabilities in children: Evaluation
Adult attention deficit hyperactivity disorder

The following organizations also provide reliable health information.

National Library of Medicine
(www.nlm.nih.gov/medlineplus/attentiondeficithyperactivitydisorder.html)

National Institute of Mental Health
(www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/complete-index.shtml)

Children and Adults with Attention Deficit Hyperactivity Disorder
(www.chadd.org)

REFERENCES
Brown RT, Amler RW, Freeman WS, et al. Treatment of attention-deficit/hyperactivity disorder: overview of the evidence. Pediatrics 2005; 115:e749.
Cox DJ, Merkel RL, Moore M, et al. Relative benefits of stimulant therapy with OROS methylphenidate versus mixed amphetamine salts extended release in improving the driving performance of adolescent drivers with attention-deficit/hyperactivity disorder. Pediatrics 2006; 118:e704.
A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry 1999; 56:1073.
Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. American Academy of Pediatrics. Pediatrics 2000; 105:1158.
American Academy of Pediatrics. Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement.. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001; 108:1033.