Attention Deficit Hyperactivity Disorder: Treatment

Pharmacologic Treatments

Stimulants. Methylphenidate (Ritalin) and dextroamphetamine (Adderall), are effective in 60-70% of children with ADHD. They increase catecholamine release from presynaptic neurons. Sustained-release preparations and longer acting medications, such as dexmethylphenidate (Focalin), minimize rebound symptoms and irritability, as well as minimize disruptions in the school day caused by twice-daily or three-times-daily dosing schedules. Side effects may include decreased appetite, insomnia, anxiety, irritability, or headache. Moreover, sympathomimetic agents raise blood pressure and heart rate, potentially contributing to risk of sudden cardiac death.²

Modafinil (Provigil) is not yet approved for treatment of ADHD, due to several case reports of an association with Stevens-Johnson syndrome (a potentially fatal rash) in children.

Nonstimulants. Several classes of nonstimulant medications may be effective, although controlled studies are limited. They are generally used in patients who do not respond to or cannot tolerate stimulants.

Atomoxetine (Strattera) is a selective norepinephrine reuptake inhibitor and is the only FDA-approved nonstimulant for ADHD. The FDA has recently warned that this medication may cause hepatotoxicity. It should be avoided in patients with liver disease. If used, it should be discontinued in patients who develop jaundice or laboratory evidence of hepatotoxicity.

Among antidepressant medications, tricyclic antidepressants (eg, imipramine, nortriptyline) and dopamine reuptake inhibitors (eg, bupropion) have both been used with some anecdotal success, but are not approved for use in children. Bupropion is used frequently in adults as a first-line treatment because it is not a stimulant per se. Moreover, many adult patients have comorbid depression. Bupropion is not habit forming and is less likely to be abused than stimulants. Selective serotonin reuptake inhibitors do not appear to have as much effect as other antidepressants.

Clonidine is an alpha-2 adrenergic agonist, which may be useful in easily frustrated, highly aroused, and aggressive patients, as well as in children and adolescents with tic disorders. Side effects may include dizziness, syncope, palpitations, diaphoresis, pedal edema, or urinary changes. In addition, several drugs may interact with clonidine, including alcohol, barbiturates, beta-blockers, digoxin, cold medicines, and others. At this time, clonidine is not approved by the FDA for use in ADHD.

Gaunfacine is an alpha-2 adrenergic agonist, which may be useful in inattentive, impulsive, easily frustrated, highly aroused, and aggressive patients, as well as in children and adolescents with tic disorders.

Anticholinesterase inhibitors, such as tacrine and donepezil, and nicotinic analogues are currently being investigated.

Nonpharmacologic Treatments

Behavioral interventions are useful for many patients, particularly children. These might include seating near the teacher, daily report card with home reinforcement, and extended time to complete tasks.

Replacing television viewing with exercise may be a promising preventive approach. A growing body of evidence indicates that small children who watch relatively little television have a significantly lower risk for developing ADHD, compared to other children.³ In contrast to watching TV and other sedentary activities, physical activity in children plays a critical role in their growth and development.⁴ A meta-analytic review of studies found significant reductions in disruptive behavior in children who exercised regularly, particularly those with ADHD.⁵ The improvements may be partially explained by findings of a dopamine-agonistic effect of exercise.⁶ Also, sports and other social activities help children learn social skills appropriately.

Biofeedback. Electroencephalographic (EEG) biofeedback training may be a promising investigational treatment. Research studies have demonstrated that some individuals who have ADHD have excess slow-wave activity and reduced fast-wave activity, compared with matched peers. Using video and auditory feedback, individuals can learn to reduce their slow-wave activity and/or increase their fast-wave activity.⁷ Case series report that approximately 75% of patients have a positive clinical response.⁸