Every family wants to determine what treatment
will be most effective for their child. This question needs to be answered by
each family in consultation with their health care professional. To help
families make this important decision, the National Institute of Mental Health (NIMH)
has funded many studies of treatments for ADHD and has conducted the most
intensive study ever undertaken for evaluating the treatment of this disorder.
This study is known as the Multimodal Treatment Study of Children with Attention
Deficit Hyperactivity Disorder (MTA).12 The NIMH is now conducting a clinical
trial for younger children ages 3 to 5.5 years (Treatment of ADHD in
Preschool-Age Children).
The Multimodal Treatment Study of Children with Attention Deficit Hyperactivity
Disorder.
The MTA study included 579 (95-98 at each of 6 treatment sites) elementary
school boys and girls with ADHD, who were randomly assigned to one of four
treatment programs: (1) medication management alone; (2) behavioral treatment
alone; (3) a combination of both; or (4) routine community care. In each of the
study sites, three groups were treated for the first 14 months in a specified
protocol and the fourth group was referred for community treatment of the
parents' choosing. All of the children were reassessed regularly throughout the
study period. An essential part of the program was the cooperation of the
schools, including principals and teachers. Both teachers and parents rated the
children on hyperactivity, impulsivity, and inattention, and symptoms of anxiety
and depression, as well as social skills.
The children in two groups (medication management alone and the combination
treatment) were seen monthly for one-half hour at each medication visit. During
the treatment visits, the prescribing physician spoke with the parent, met with
the child, and sought to determine any concerns that the family might have
regarding the medication or the child's ADHD-related difficulties. The
physicians, in addition, sought input from the teachers on a monthly basis. The
physicians in the medication-only group did not provide behavioral therapy but
did advise the parents when necessary concerning any problems the child might
have.
In the behavior treatment-only group, families met up to 35 times with a
behavior therapist, mostly in group sessions. These therapists also made
repeated visits to schools to consult with children's teachers and to supervise
a special aide assigned to each child in the group. In addition, children
attended a special 8-week summer treatment program where they worked on
academic, social, and sports skills, and where intensive behavioral therapy was
delivered to assist children in improving their behavior.
Children in the combined therapy group received both treatments, that is, all
the same assistance that the medication-only received, as well as all of the
behavior therapy treatments.
In routine community care, the children saw the community-treatment doctor of
their parents' choice one to two times per year for short periods of time. Also,
the community-treatment doctor did not have any interaction with the teachers.
The results of the study indicated that long-term combination treatments and the
medication-management alone were superior to intensive behavioral treatment and
routine community treatment. And in some areas—anxiety, academic performance,
oppositionality, parent-child relations, and social skills—the combined
treatment was usually superior. Another advantage of combined treatment was that
children could be successfully treated with lower doses of medicine, compared
with the medication-only group.
Treatment of Attention Deficit Hyperactivity Disorder in Preschool-Age Children
(PATS).
Because many children in the preschool years are diagnosed with ADHD and are
given medication, it is important to know the safety and efficacy of such
treatment. The NIMH is sponsoring an ongoing multi-site study, "Preschool ADHD
Treatment Study" (PATS). It is the first major effort to examine the safety and
efficacy of a stimulant, methylphenidate, for ADHD in this age group. The PATS
study uses a randomized, placebo-controlled, double-blind design. Children ages
3 to 5 who have severe and persistent symptoms of ADHD that impair their
functioning are eligible for this study. To avoid using medications at such an
early age, all children who enter the study are first treated with behavioral
therapy. Only children who do not show sufficient improvement with behavior
therapy are considered for the medication part of the study. The study is being
conducted at New York State Psychiatric Institute, Duke University, Johns
Hopkins University, New York University, the University of California at Los
Angeles, and the University of California at Irvine. Enrollment in the study
will total 165 children.
Which Treatment Should My Child Have?
For children with ADHD, no single treatment is the answer for every child. A
child may sometimes have undesirable side effects to a medication that would
make that particular treatment unacceptable. And if a child with ADHD also has
anxiety or depression, a treatment combining medication and behavioral therapy
might be best. Each child's needs and personal history must be carefully
considered.
Medications.
For decades, medications have been used to treat the symptoms of ADHD.
The medications that seem to be the most effective are a class of drugs known as
stimulants. Following is a list of the stimulants, their trade (or brand) names,
and their generic names. "Approved age" means that the drug has been tested and
found safe and effective in children of that age.
Trade Name Generic Name Approved Age
Adderall amphetamine 3 and older
Concerta methylphenidate
(long acting) 6 and older
Cylert* pemoline 6 and older
Dexedrine dextroamphetamine 3 and older
Dextrostat dextroamphetamine 3 and older
Focalin dexmethylphenidate 6 and older
Metadate ER methylphenidate
(extended release) 6 and older
Metadate CD methylphenidate
(extended release) 6 and older
Ritalin methylphenidate 6 and older
Ritalin SR methylphenidate
(extended release) 6 and older
Ritalin LA methylphenidate
(long acting) 6 and older
*Because of its potential for serious side effects affecting the liver, Cylert
should not ordinarily be considered as first-line drug therapy for ADHD.
The U.S. Food and Drug Adminstration (FDA) recently approved a medication for
ADHD that is not a stimulant. The medication, Strattera®, or atomoxetine, works
on the neurotransmitter norepinephrine, whereas the stimulants primarily work on
dopamine. Both of theses neurotransmitters are believed to play a role in ADHD.
More studies will need to be done to contrast Strattera with the medications
already available, but the evidence to date indicates that over 70 percent of
children with ADHD given Strattera manifest significant improvement in their
symptoms.
Some people get better results from one medication, some from another. It is
important to work with the prescribing physician to find the right medication
and the right dosage. For many people, the stimulants dramatically reduce their
hyperactivity and impulsivity and improve their ability to focus, work, and
learn. The medications may also improve physical coordination, such as that
needed in handwriting and in sports.
The stimulant drugs, when used with medical supervision, are usually considered
quite safe. Stimulants do not make the child feel "high," although some children
say they feel different or funny. Such changes are usually very minor. Although
some parents worry that their child may become addicted to the medication, to
date there is no convincing evidence that stimulant medications, when used for
treatment of ADHD, cause drug abuse or dependence. A review of all long-term
studies on stimulant medication and substance abuse, conducted by researchers at
Massachusetts General Hospital and Harvard Medical School, found that teenagers
with ADHD who remained on their medication during the teen years had a lower
likelihood of substance use or abuse than did ADHD adolescents who were not
taking medications.13
The stimulant drugs come in long- and short-term forms. The newer
sustained-release stimulants can be taken before school and are long-lasting so
that the child does not need to go to the school nurse every day for a pill. The
doctor can discuss with the parents the child's needs and decide which
preparation to use and whether the child needs to take the medicine during
school hours only or in the evening and on weekends too.
If the child does not show symptom improvement after taking a medication for a
week, the doctor may try adjusting the dosage. If there is still no improvement,
the child may be switched to another medication. About one out of ten children
is not helped by a stimulant medication. Other types of medication may be used
if stimulants don't work or if the ADHD occurs with another disorder.
Antidepressants and other medications can help control accompanying depression
or anxiety.
Sometimes the doctor may prescribe for a young child a medication that has been
approved by the FDA for use in adults or older children. This use of the
medication is called "off label." Many of the newer medications that are proving
helpful for child mental disorders are prescribed off label because only a few
of them have been systematically studied for safety and efficacy in children.
Medications that have not undergone such testing are dispensed with the
statement that "safety and efficacy have not been established in pediatric
patients."
Side Effects of the Medications.
Most side effects of the stimulant medications are minor and are usually related
to the dosage of the medication being taken. Higher doses produce more side
effects. The most common side effects are decreased appetite, insomnia,
increased anxiety, and/or irritability. Some children report mild stomach aches
or headaches.
Appetite seems to fluctuate, usually being low during the middle of the day and
more normal by suppertime. Adequate amounts of food that is nutritional should
be available for the child, especially at peak appetite times.
If the child has difficulty falling asleep, several options may be tried—a lower
dosage of the stimulant, giving the stimulant earlier in the day, discontinuing
the afternoon or evening dosage, or giving an adjunct medication such as a
low-dosage antidepressant or clonidine. A few children develop tics during
treatment. These can often be lessened by changing the medication dosage. A very
few children cannot tolerate any stimulant, no matter how low the dosage. In
such cases, the child is often given an antidepressant instead of the stimulant.
When a child's schoolwork and behavior improve soon after starting medication,
the child, parents, and teachers tend to applaud the drug for causing the sudden
changes. Unfortunately, when people see such immediate improvement, they often
think medication is all that's needed. But medications don't cure ADHD; they
only control the symptoms on the day they are taken. Although the medications
help the child pay better attention and complete school work, they can't
increase knowledge or improve academic skills. The medications help the child to
use those skills he or she already possesses.
Behavioral therapy, emotional counseling, and practical support will help ADHD
children cope with everyday problems and feel better about themselves.
Facts to Remember About Medication for ADHD.
Medications for ADHD help many children focus and be more successful at school,
home, and play. Avoiding negative experiences now may actually help prevent
addictions and other emotional problems later.
About 80 percent of children who need medication for ADHD still need it as
teenagers. Over 50 percent need medication as adults.
Medication for the Child with Both ADHD and Bipolar Disorder.
Since a child with bipolar disorder will probably be prescribed a mood
stabilizer such as lithium or Depakote®, the doctor will carefully consider
whether the child should take one of the medications usually prescribed for
ADHD. If a stimulant medication is prescribed, it may be given in a lower dosage
than usual.
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