ADHD affects between five and seven percent (estimates vary) of children and adolescence in the United States. Medicine has been used to treat children with ADHD for nearly seven decades. The research on medical treatments for ADHD is abundant, and it clearly shows the efficacy of ADHD medications. In most cases, medication will be the most effective treatment the child with ADHD will receive. This course will discuss the common types of medications used to treat ADHD—stimulants and non-stimulants, how they work to improve ADHD symptoms, the safety and efficacy of these medications, adverse effects, and recommendations for their use. Information about commonly used medications to treat children with ADHD who have co-morbid disorders (anxiety, mood disorders, etc.) will also be presented because co-morbidity is quite common. This information is meant to serve only as an introduction to medication management. While this course provides basic information about medications that are useful in treating ADHD, a physician should be consulted before making any decisions about the use of such medications. The author of this online course is Harvey C. Parker, Ph.D.

Learning Objectives
Upon completion of this course participants will be able to:

• Describe the comparative efficacy of medical versus psychosocial treatments for ADHD.



• Discuss the effects of stimulant and non-stimulant treatments for ADHD in children and adolescents.



• Discuss adverse effects of medications given for treatment of ADHD.



• Describe new medications for the treatment of ADHD.

Introduction to ADHD
ADHD is a fairly common psychiatric disorder that is diagnosed and treated in children of all ages and in adults. ADHD receives a great deal of attention in the media because of the controversy surrounding treatment, particularly the practice of giving stimulants to children. Teachers are usually quite familiar with children who have ADHD and know from first-hand experience the types of challenges these children face in the classroom. The primary characteristics found in children with ADHD, namely, inattention, impulsivity, and hyperactivity, are exhibited by all children to some degree. What distinguishes children with ADHD from others is that these characteristics are prevalent to a far greater degree and in a wider range of situations and circumstances than would be true of children without this disorder.

Prevalence of ADHD within the United States school-aged population has generally been estimated to be between five percent and seven percent. In September 2005, The Center for Disease Control released the results of a national survey that documents that 4.4 million, or 7.8 percent, of four to seventeen year old children have a parent-reported history of ADHD. Differences between boys and girls have been found, with boys being anywhere from four to nine times more likely than girls to have ADHD.

ADHD symptoms can have a serious impact on the social, emotional, and academic performance of children. Paying attention in class, following rules, being able to exert self-control and think about consequences before acting, interacting appropriately in games and sports, and developing meaningful relationships with others can be a challenge for some students with ADHD.

Over the past fifty years, children with symptoms of ADHD were popular subjects for study. The name given to the disorder changed through the years to keep up with the growing body of knowledge learned from this extensive research. Previous names for this condition included: minimal brain dysfunction, hyperkinetic reaction of childhood, attention deficit disorder (with hyperactivity; without hyperactivity; and residual type), and, most recently, attention-deficit/hyperactivity disorder.

Types of ADHD
Currently, the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition-TR (DSM-IV-TR), published by the American Psychiatric Association, specifies criteria that need to be met to be diagnosed as having ADHD.

There are three subtypes of the disorder: combined type; predominantly hyperactive-impulsive type; and predominantly inattentive type.

• Predominantly Inattentive Type for someone with serious inattention problems, but not much problem with hyperactive or impulsive symptoms.
  
• Combined Type for someone with serious inattention problems and serious problems with hyperactivity and impulsivity.
  
• Predominantly hyperactive-Impulsive Type for someone with serious problems with hyperactivity and impulsivity, but not much problem with inattention.

To be diagnosed with either type of ADHD, symptoms must have been present before age seven, impairment from these symptoms must be present in two or more settings (i.e., at school, work, and at home), and symptoms must not be the result of another medical or psychiatric disorder. There is a category called ADHD Not Otherwise Specified for those with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet the criteria for ADHD.

Co-Morbid Disorders
Unfortunately, children who have ADHD also have a greater likelihood of having other problems, the most notable being problems with learning, behavior, and social or emotional development.

ADHD and Learning Disorders
In terms of learning, children with ADHD have a greater likelihood than other children of having a learning disability. Children with learning disabilities commonly show their greatest weaknesses in the basic psychological processes involved in understanding or in using spoken or written language. For learning disabled students, such weaknesses may result in reading, writing, spelling, or arithmetic skill deficits. There has been considerable confusion, and some controversy, regarding the relationship between learning disabilities and ADHD. Some have said that these two conditions are one in the same, with ADHD merely being a form of learning disability. Others argue that they are separate and distinct disorders, but with a fairly high degree of co-existence. In the past, it was generally accepted that the incidence of learning problems and underachievement within the population of children with ADHD was quite high, with estimates ranging as high as ninety-two percent. In practical application this greatly overestimates the number of children with ADHD that would qualify for help in school with a co-existing learning disability diagnosis. Most state departments of education have specific criteria that need to be met in order for a student to be classified as learning disabled. Often, this criteria includes heavy emphasis on academic functioning and requires the student to manifest a discrepancy between potential (often measured by IQ) and achievement (often measured by an individually administered achievement test). Studies found that when such an ability/achievement discrepancy formula was used to classify students as learning disabled, a much smaller percentage of elementary-aged children with ADHD would be classified as learning disabled. When appropriate diagnostic criteria for a learning disability and ADHD are applied, the prevalence of a co-morbid learning disability is probably in the range of ten to twenty-five percent in children with ADHD. However, since there is a significant overlap between ADHD and learning disabilities, school personnel identifying students with ADHD should also be alert for signs of co-existing learning disabilities.

ADHD and Behavior and Emotional Disorders
Children with ADHD have other behavioral and emotional disorders at a much higher rate than non-ADHD children. Between forty and sixty percent of children with ADHD will show signs of oppositional defiant disorder (ODD) and half of those children, in turn, will develop a conduct disorder (CD). The child with ODD is characterized by a pattern of negative, defiant behavior and irritable mood and is often described as difficult, although without the more serious aggressive components of behavior typically found in children with conduct disorder. The CD child or adolescent exhibits behavior which more dramatically transgresses social and legal norms. CD behavior is more profoundly aggressive and frequently can manifest itself in stealing, running away, lying, fire-setting, school truancy, destruction of property, or physical cruelty.

Parents of children with ADHD with ODD complain about the strong-willed, stubborn, and argumentative aspects of their child's behavior as much or more than they do about the inattentive, impulsive, and hyperactive components. It is also quite common for teachers to find the ADHD/ODD child's defiance more disagreeable than his short attention span and hyperactivity. A large part of the treatment planning for the ADHD/ODD child invariably addresses the oppositional aspects of the disorder. Indeed, such treatment planning is extremely important, for if oppositional defiant disorder develops into conduct disorder, the prognosis for a good outcome is much less favorable. It is estimated that such children are four times more likely to be retained in school and eight times more likely to drop out of high school before graduation. They have a greater likelihood of developing adult anti-social personality, substance abuse disorder, and other psychiatric and social problems.

Children with ADHD also have higher rates of emotional disturbance. They are at risk for low self-esteem, anxiety, depression, and socialization problems. Due to lack of success in school, within the family, or in social relationships, children with ADHD can become extremely demoralized leading to apathy, irritability, and withdrawal. Although the development of such problems can easily occur in hyperactive as well as non-hyperactive, inattentive children, they are more likely to occur within the non-hyperactive subgroup both because of their tendency to internalize rather than externalize stress and their seemingly more passive, sensitive nature.

Treatment of their emotional distress obviously requires considerable understanding on the part of parents and teachers in order to provide them with the support necessary to foster a more positive attitude towards them self and others.

It is important to note that although ADHD can lead to greater anxiety and depression, so too can anxiety and depression lead to diminished motivation and interfere with cognitive processes involved in the regulation of attention, concentration, and mood. Children and adolescents suffering from anxiety or depression may show behavioral signs that closely resemble ADHD symptoms. Sometimes this is a sudden, temporary reaction to an environmental situation involving family, school, or peer problems. In other cases, the emotional disorder is more chronic and pervasive, the origin of which may lie in the family or biological history of the individual. It is certainly not difficult to understand how children with problems on their mind would have difficulty paying attention in school and may become restless and impatient. Therefore, the symptoms alone cannot tell us the entire story. Understanding the whole child including family, home environment, social relationships, and previous background is essential before intervention is attempted.

ADHD: A Neurological Disorder
Scientific journals and textbooks contain numerous articles and studies that assume that ADHD is largely, or entirely, due to abnormal brain functioning. ADHD is frequently referred to as a neurological disorder, however, it would be wise to keep in mind that there are other (non-neurological) factors that can affect the expression of ADHD behavior. These can include environmental and social influences.

Certain areas of the brain control our ability to pay attention, plan, organize, inhibit impulses and movement, and remember. These functions are vital to effective self-management and problem solving. As I described in the last chapter, they are often referred to as “executive functions.” The frontal regions of the brain are presumed to control these executive functions. The frontal regions are highly interconnected with the limbic (motivational) system, the reticular activating (arousal) system, the posterior association cortex (perceptual/cognitive processes and knowledge base), and the motor (action) regions. In people with ADHD, development of executive functions lags behind and often never fully develops to the extent found in those who do not have ADHD.

Head injuries sustained as a result of automobile accidents, falls, or other head trauma can result in impairments in executive functioning. When such injuries affect the frontal region of the brain, the result can be disturbances in attention, hyperactivity, and self-control. Animal studies have also helped us identify the frontal region of the brain as being involved in ADHD-like symptoms. Chimpanzees, for example, were trained to perform certain psychological tests. Scientists then disabled the frontal region of their brains through surgery or other means and repeated the tests and observed their behavior. When the frontal region of the brain was altered, the chimpanzees showed behavior patterns that were quite similar to children with ADHD. They became more hyperactive, impulsive, and less able to pay attention for long periods of time. They could not inhibit their behavior and had social problems with other animals. When other areas of the brain were altered, these patterns of ADHD-like behavior did not appear. However, less than ten percent of children with ADHD can be shown to have suffered brain injuries. This has led scientists to conjecture that something else may be affecting the development of this part of the brain.

Many scientists have implicated neurotransmitters (chemicals in the brain that enable nerve cells to transmit information to other nerve cells) as a cause of ADHD. The brain is a complex information network made up of billions of nerve cells called neurons which transmit information to each other in much the same way as signals are transmitted electronically in a telecommunications network. However, messages within the brain are transferred by electrical conduction within a nerve cell and by chemical conduction between nerve cells. Once a message is carried along the axon (cell body) of a sending nerve cell, it has to cross a small space called a synapse to reach a receiving cell. At the tip of the axon are tiny sacs that contain neurotransmitter chemicals which are automatically released by the sending nerve cell. These neurotransmitter chemicals excite the receiving nerve cell, causing that cell to fire and thus once again propel the message along the axon to receptors in the next nerve cell. Once the message is received the neurotransmitter chemical is deactivated or taken up from the synapse and stored in sacs so as not to cause repeated firing of the receiving cell. Dopamine, norepinephrine, and serotonin are examples of neurotransmitter chemicals that play an important part in brain activity. They make up the dopaminergic, noradrenergic, and serotonergic chemical systems. These systems regulate our senses, thinking, perception, mood, attention, and behavior. The malfunction of any of these neurotransmitter systems can have a wide ranging impact on how a child behaves and learns.

Support for the idea that brain chemistry is responsible for ADHD comes from a number of sources. Certain drugs (stimulants and non-stimulants such as atomoxetine), known to affect neurotransmitters such as those listed above, can temporarily improve the ability of children with ADHD to regulate behavior and attention. These drugs increase the amount of these neurotransmitters in the brain. At least two genes that regulate dopamine have been identified as being associated with ADHD. One of these genes is involved in removing dopamine from the synapse between neurons and the other affects the sensitivity of neurons to the dopamine itself.

Studies using electroencephalography (EEG) while children with ADHD were sitting at rest and also while they were performing certain mental tasks, have found that there was lower brain activity in the frontal region. Other studies found that there was less blood flow in the frontal region, particularly in the caudate nucleus, an important structure in the pathway between the most frontal portion of the brain and the structures in the middle of the brain known as the limbic system. These areas are important in inhibiting behavior and sustaining attention. Dr. Alan Zametkin, using positron emission tomography (PET), found that adults with ADHD had less brain activity, particularly in the frontal lobe. This study was repeated with twenty adolescents with ADHD, and Zametkin again found reduced activity in the frontal region, more on the left side than the right. Other studies have found that when children were given drugs that lower brain activity, such as phenobarbital and dilantin, problems with inattention and hyperactivity increase.

In the past ten to fifteen years, magnetic resonance imaging (MRI) studies have found differences in the brain structure of people with ADHD. Dr. George Hynd and his colleagues at the University of Georgia (1991) found that the caudate nucleus of children with ADHD was somewhat larger on the right side than on the left. They also found, in other studies, that the corpus callosum, a large band of nerve fibers that connects the right and left sides of the brain, was somewhat smaller in children with ADHD than in children without ADHD. Additional studies done by Xavier Castellanos and Jay Giedd (1997) and Pauline Filipek (1997), and their colleagues, found further evidence of smaller brain regions (structures in the basal ganglia and certain regions on the right side of the cerebellum) in children with ADHD.



A great deal is known about treating childhood ADHD and the research literature on adult treatment is growing. There have been numerous studies to investigate the efficacy and safety of a number of different treatments. Three treatments have been proven to be the most effective for ADHD: behavior modification, medication, and the combination of the two. These treatments have been demonstrated to have short-term effects. No treatment has been shown to influence outcomes in children and adolescents with ADHD over the long term.

The NIMH Collaborative Multisite Multimodal Treatment of Children with ADHD (MTA)
There have been many treatment studies of children with ADHD, however, by far, the most comprehensive one was the MTA study. Initial results of this study were published in 1999.

Treatment Groups
In this study, 579 children ages seven to nine years, nine months with ADHD, combined type were randomly assigned to one of four treatment groups.

One group, intended to serve as a control or contrast group for the other interventions, was the community care (CC) group. Subjects in this group were given the same evaluations as the treatment groups, but were not given the specific treatment procedures. They were referred to their communities and given a list of community mental health resources. About two-thirds of these subjects received some type of psychiatric medication during the study period.

A second group, the medication alone group (MED), received medication to treat ADHD symptoms. The titration process was quite a bit more detailed and rigorous in evaluating each group member’s response to the medication and adjusting their doses than is typical in clinical practice. Children in this group were initially tested in a double-blind protocol for a twenty-eight-day period on methylphenidate and five drug conditions (placebo, 5, 10, 15, and 20 mg), randomly ordered across subjects. Medication doses were administered at breakfast and lunch with a half dose in the afternoon. Investigators reviewed graphs of the subject’s response to these different doses and selected an optimal dose for each child, which then became their initial maintenance dose in the study. If the child did not have a satisfactory response to methylphenidate, they were tested on one of several other medications in the following order: dextroamphetamine, pemoline, imipramine, and, if needed, an alternative medication approved by a panel. All the children in the medication alone group were seen monthly for monitoring dosage/medication adjustments.

A third group received psychosocial treatments (BEH). The types of behavioral treatments they were given were based on those previously found to be effective with children who have ADHD. This included group parent training classes in child management (twenty-seven sessions) along with individual parent training classes (eight sessions); child-focused counseling, including an intensive all day summer treatment program based on William Pelham’s approach; and school-based intervention. The school-based interventions were comprised of ten to sixteen bi-weekly teacher training and consultation sessions, twelve weeks of a classroom aide for the fall semester of school, and a daily school report card linked to home consequences throughout the academic year. During the eight week summer training program, the treatment group was given training in social skills, group problem solving, and sports skills. Point systems, time out, social reinforcement, and modeling were also used. These behavioral treatments were gradually reduced in intensity and frequency over the fourteen months of the treatment that all groups received.

The fourth treatment group (COMB) received a combination of the BEH and MED treatment procedures.

Outcome Measures
MTA study investigators used the following outcome measures to determine treatment efficacy:

• ADHD symptoms
  
• oppositional and aggressive behavior
  
• social skills
  
• anxiety and depression symptoms
  
• parent-child relations
  
• academic achievement
  

Findings
Initial findings from the MTA study were published in 1999 in the Archives of General Psychiatry, however, many papers have been written since then analyzing the data gathered from this study. Much of this analysis is beyond the scope of this course. The primary conclusion of the study was that medication management was superior to behavioral treatment and that the combined (medication plus behavioral treatment) was slightly better than medication alone. The group that received both medication and behavior treatment received a modest advantage over the medication alone group in terms of improvement of non-ADHD symptoms. In addition, parents expressed greater satisfaction with the combination treatment than with the medication treatment alone.


The MTA study was a landmark study in that it provided strong evidence as to the efficacy of certain ADHD treatments (medication in combination with behavioral strategies) and it underscored the importance of frequent and careful monitoring by healthcare providers to ensure that treatment goals were reached.

American Academy of Pediatrics Guidelines for Treatment of ADHD
In 2001, the American Academy of Pediatrics (AAP) published clinical practice guidelines for the treatment of school-aged children with ADHD. The AAP recommended the following:

• primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition
  
• appropriate target outcomes designed in collaboration with the clinician, parents, child, and school personnel should guide management
  
• stimulant medication and/or behavior therapy as appropriate should be used in the treatment
  
• if a child has not met the targeted outcomes, clinicians should evaluate the original diagnosis, use all appropriate treatments, and consider co-existing conditions
  
• periodic, systematic follow-up for the child should be done with monitoring directed to target outcomes and adverse effects. Information for monitoring should be gathered from parents, teachers, and the child

Behavioral Treatments
Behavioral treatments have been used for more than three decades to treat children who exhibit disruptive or aggressive behavior. An early paper published in 1967 by Daniel O’Leary and Wesley Becker described the successful use of a classroom token reinforcement system to manage disruptive classroom behavior. The system involved reviewing a list of classroom rules twice each day, praising appropriate behavior and ignoring disruptive behavior, as well as feedback to the children about how well they did academically and socially. In addition, the children received reinforcers in the form of prizes such as special pencils, rulers, and candy. The combination of these factors led to a significant decrease in disruptive behavior by the students.

Behavioral treatments have been successfully applied to children with ADHD to manage disruptive behavior, inattention, social skills building, improve academic performance, etc. William Pelham, an expert in behavioral treatments for children with ADHD, describes five categories of behavioral treatment:

• cognitive-behavioral interventions
  
• clinical behavior therapy/parent training programs
  
• direct contingency management
  
• intensive, packaged behavioral treatments
  
• combined behavioral and pharmacological treatments

Each of these behavioral treatments will be briefly described below.

Cognitive-Behavioral Interventions (CBI)
The goal of this form of behavioral treatment is to teach self-control through verbal self-instructions, problem-solving strategies, cognitive modeling, self-monitoring, self-evaluation, self-reinforcement, and other strategies. Typically, a therapist meets with a client once or twice a week in an attempt to teach the client through modeling, role playing and practicing cognitive strategies, the person can use to control his or her inattention and impulsive behavior. As a simple example, a child may be taught to say “stop” to himself when he is about to call out in class. Children with ADHD seem to lack these internal cues and so it was thought that teaching them such cues would be helpful. While CBI was popular in the 1980’s and early 1990’s for treatment of ADHD, its popularity has waned in the absence of strong research to support its efficacy.

Clinical Behavior Therapy (CBT)/Parent Training Programs
The goal of this form of behavioral treatment is typically to train parents, teachers, or other caregivers to implement contingency management programs with children. Parents generally attend parent training programs where they are given assigned readings and instruction in standard behavioral techniques. Therapists using CBT often work with teachers in a consultation model to teach behavioral strategies for application in the classroom. The use of a daily report card system wherein the child receives tokens or points for certain target behaviors in the classroom is a popular example of an effective CBT program for children with ADHD.

Psychologists have been at the forefront in developing programs to train parents in the use of behavioral strategies to manage noncompliance. Traditional parent training programs have common features in that they teach parents skills related to attending, rewarding, ignoring, instructing, and using time-out. The programs make use of home practice assignments and exercises and use direct instruction and modeling as primary teaching methods. One of the best known of these traditional parent training programs is Russell Barkley’s Defiant Children, which is suitable for children up to the age of twelve. In addition to the skills noted above, Barkley has incorporated a number of additional components to teach parents, including information specific to ADHD, a token reinforcement system, and a daily report card system for school problems.

Another well-known and widely used program for children between two and twelve years of age is Tom Phelan’s 1-2-3 Magic. This program focuses on the use of time-out as a consequence for noncompliance and teaches parents the appropriate ways to administer time-out and correct misbehavior.

Ross Greene has developed a program for difficult children who display noncompliance accompanied by angry and explosive behavior. Greene calls his approach Collaborative Problem Solving (CPS), and he describes it in detail in his best-selling book, The Explosive Child.

In their book, Try and Make Me, Ray Levy and Bill O’Hanlon teach parents to use an approach they call “Practice Academy” to manage non-compliant behavior. This approach incorporates the behavioral strategy referred to as “overcorrection” in an effort to teach the non-compliant child appropriate behavior. The Practice Academy approach contains four simple steps for parents to apply to correct misbehavior.

Contingency Management (CM)
Contingency management is a behavioral treatment that involves a more intensive program of behavior modification. Typically this type of program is implemented in a specialized treatment facility or specialized classroom. The techniques used in such programs include token economies set up to encourage specific behavior through the use of rewards and consequences earned by the child, time out, response cost and precise teacher responses to behavior through attention, reprimands and gain or loss of privileges.

Intensive Behavioral Treatments
The focus of intensive behavioral treatments is to combine clinical behavior therapy and contingency management into an intensive program to improve self-control and socialization. Children who attend the Children’s Summer Treatment Program designed by William Pelham (1997), for example, attend an eight-week program for nine hours a day. Children have a “summer camp” experience and are placed in groups of twelve. Each group spends two hours daily in classrooms where behavioral interventions and other types of instruction are provided. The rest of the day consists of recreationally based group activities. The children’s progress is tracked and rewarded at home by parents who attend classes to learn how to apply behavior management at home.

Combined Pharmacological and Behavioral Interventions
This form of treatment focuses on the combined use of medication and behavioral treatment. This combination has been shown to be quite effective in treating children with ADHD and has several advantages over medication alone or behavioral treatment alone. With the addition of medication, the behavioral component of treatment may be able to be scaled down, thereby reducing the amount of time parents and teachers need to spend on shaping behavior. The dose of medication can be reduced for children using a combined approach. Parents knowledgeable about the use of behavioral treatments can apply such treatments during times when the child is not taking medication (i.e., in the evenings for those on stimulant medication).

Medication Treatments for ADHD
The rate of medication treatment for elementary school students has increased from 1.07 percent in 1971 to nearly six percent in 1987; for middle school students, it increased from .59 percent in 1975 to nearly three percent in 1998; and for high school students it increased from .22 percent in 1983 to .70 percent in 1993 (Jensen and Cooper, 2002). A brief description of medication treatments for ADHD follows.

Stimulant medications are the most often prescribed. They are the best studied medicines for ADHD. There are basically two classes of stimulants: methylphenidate and amphetamine products. With more than 200 controlled double-blind studies of stimulant use in children with ADHD, the findings are well documented that these medicines improve attention span, self-control, behavior, fine motor control, and social functioning. Stimulant preparations can be quick-acting (within thirty minutes) and short lasting (four to six hours) or longer lasting (eight to twelve hours). Preparations, such as Concerta, Adderall XR, Metadate CD, and Ritalin LA, promise once-a-day dosing lasting from eight to twelve hours depending on the brand used. Atomoxetine, brand name, Strattera, a non-stimulant, was approved in November, 2002 and became available in the United States in early 2003 for children and adults with ADHD. It is a selective norepinephrine reuptake inhibitor. While the stimulants primarily affect the dopaminergic system, atomoxetine has its primary effect on the noradrenergic system. It has been shown to improve core symptoms of ADHD, namely, inattention, impulsivity, and hyperactivity. It has some weak antidepressant properties as well and may help improve and regulate mood. While stimulants start working within a half hour to an hour after ingestion, atomoxetine has a more gradual onset and the maximal effect may not be seen for several weeks. Certain anti-hypertensive medications known as adrenergic agonists (Clonidine and Tenex) are used in combination with other medications to help very hyperactive and impulsive children.

Educational Interventions—Programs and Accommodations
Educators understand the importance of providing assistance to students with ADHD. Under existing federal laws (IDEA 2004, ADA, Rehabilitation Act of 1973 [Section 504]), public schools are required to provide special education and related services to students with ADHD who need such assistance (Davila et al., 1991). Schools must meet the needs of those with ADHD who require accommodations in regular education classes. Such accommodations may “even the playing field” for those disabled by ADHD who must compete with other students in school.

Section 504 of the Rehabilitation Act of 1973 guarantees that no person “shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” To qualify for Section 504 services, there must be evidence of the existence of an identified physical or mental impairment that substantially limits a major life activity. Having a diagnosis of ADHD alone is not enough to qualify for accommodations under Section 504 unless the person’s ADHD significantly impacts on learning or behavior. Under Section 504, the definition of a disability is much broader than it is under the Individuals with Disabilities in Education Act (IDEA). While all IDEA students are covered by Section 504, not all Section 504 students would qualify for protection under IDEA. Under IDEA, the qualifying student will receive an Individual Education Plan (IEP) tailored to the child’s unique needs. The child may receive special education and/or related services at public expense in accordance with the IEP. Later chapters will describe educational interventions for students with ADHD more thoroughly.

Unproven Treatments for ADHD
With the increased interest paid to ADHD in the past decade, there has also been an increase in claims made by vendors of products or services that purport to effectively treat symptoms of the disorder. Consumers need to know how to evaluate these claims so they can determine the efficacy of such treatments. ADHD experts (Ingersoll and Goldstein, 1993) warn consumers about controversial and unproven treatments. Typically they advise consumers to be wary of any company boasting "miracle" cures that work for everyone with ADHD, claims based on the results of just one study, or studies that lack a control group, claims that the product is a harmless, "natural" remedy with few or no adverse effects, and product ads that attack established, mainstream medical treatments. ADHD experts often list the following treatments as either unproven, disproven, or controversial: dietary interventions, nutritional supplements, sensory integration training, anti-motion sickness medication, optometric visual training, applied kinesiology, treatment for lead toxicity, thyroid dysfunction, and candidas yeast therapy. Claims as to the effectiveness of EEG biofeedback training or interactive metronome training for ADHD have not yet lived up to the rigor of scientific investigation to be regarded as effective treatments.



The stimulants are the drugs that are most commonly used to treat ADHD. This group of medications includes methylphenidate (Ritalin, Ritalin LA, Focalin, Focalin XR, Concerta, Metadate CD, and Methylin) and amphetamine (Dexedrine, Adderall, Adderall XR, and Vyvanse). The use of stimulants with children who have ADHD has been widely publicized, hotly debated, and often questioned. Are stimulants overprescribed? Do they cause long-term problems? Are they not just covering up the real, underlying psychological problems that children with ADHD have? Are physicians rushing to put children on medication without first doing an adequate assessment? Will stimulant use lead to substance abuse in the future? Why is the use of these medications so much higher in the United States than in other countries around the world?

Stimulant use has increased five-fold over the past dozen years, and production of methylphenidate and amphetamine has greatly increased over a ten-year period. More than ninety percent of the methylphenidate produced in the United States is used domestically. The increase in use of stimulants has led to concerns about identification of ADHD in children, prescription for profit, and abuse of these medications. What explains this increase? Certainly more children are being diagnosed with ADHD than before. Prevalence estimates of the disorder were between three and five percent in the 1980’s and now have reached as high as seven to twelve percent in children. However, ADHD may still be under-diagnosed and under-treated. One survey in four different communities found that only about twelve percent of diagnosed ADHD children received adequate stimulant treatment (Jensen, et al., 1999). In contrast, another study in rural North Carolina found that many school-aged children on stimulants did not meet criteria for a diagnosis of ADHD (Angold, et al., 2000). Also pushing the rise in methylphenidate use is the fact that stimulants are being dosed at higher levels and more frequently than before as clinicians realize the benefits of having kids on medication after school, on weekends, and during holidays. More diagnosis of adult ADHD has contributed to the rise in use as well since it is estimated that about one to three percent of adults suffer from ADHD and more are being treated than ever before.

The media has expressed concern about this dramatic increase in medication use. Fringe religious groups have prepared media campaigns designed to mislead, alarm, and provide biased information about stimulant medication. As a result, controversy continues to abound in the use of these medications. The public is often confused by conflicting reports about safety and efficacy.

How do Stimulants Work?
Stimulant medications increase activity or arousal in areas of the brain that are responsible for inhibiting behavior and maintaining effort or attention. They work by influencing the action of certain brain neurotransmitters, primarily dopamine and norepinephrine, both of which occur naturally throughout the brain, but are found in higher concentrations in the frontal region. The stimulants increase the amount of these chemicals that are available in the brain. Their action enhances executive functioning. These effects are observed in both ADHD and non-ADHD children, so the fact that a child improves when taking such medication should not be used to confirm a diagnosis of ADHD.

Stimulant medications are rapidly absorbed in the body, often within the first thirty minutes after taking them. Short-acting forms of stimulants (Ritalin, Methylin, Metadate, Focalin, Adderall, Dextrostat, and Dexedrine) last three to four hours while mid- to long-acting stimulants (Ritalin LA, Focalin XR, Concerta, Methylin ER, Metadate CD, Adderall XR, and Vyvanse) last six to twelve hours. Thus, short-acting forms of the medication are often given two to three times per day. The longer-acting forms not only have the advantage of once-a-day dosing for many children, but they reduce the likelihood of multiple withdrawals from the medication per day due to wear off. They also reduce the inconvenience and stigma of in-school dosing. With long-acting medications, there is also greater likelihood of compliance and a lower risk of abuse.

Health care providers often consider the school hours as the most important time when children should be on medication, but children with ADHD can benefit from taking medication that will last after school as well. Consider problems settling down and paying attention to homework, difficulties participating in sports after school, problems related to social behavior, noncompliance at home, difficulty waiting in restaurants or on long car rides, etc. All of these areas of functioning are important and stimulant medication may benefit the child in each of them. The final decision of whether to administer stimulants continuously during the day and throughout the evenings, on weekends, and holidays should be made by the parent in consultation with the child’s physician as the risks versus benefits of medication are weighed.

There have been hundreds of studies on thousands of children with ADHD to support the fact that stimulants improve symptoms of ADHD. In general, seventy to ninety percent of children with ADHD will respond. That still leaves ten to thirty percent who may respond poorly or not at all, or who might have significant adverse side effects to the stimulants and cannot take them. One cannot assume that a child will benefit from stimulants. The only way to know is to try and see. Furthermore, while overall, methylphenidate and amphetamine compounds are similar, they do vary in terms of specific action in the brain. Different stimulants may affect the child’s ADHD symptoms to different degrees. If the child does not do well on Ritalin or Concerta, for example, he may respond very well to Dexedrine or Adderall XR.

Parents trying different medications for their child should be advised to be patient and keep a scientific mind about them. Systematically trying a medication at different doses and/or trying different medications to achieve the optimal response is recommended. Parents will need to work closely with their child’s physician to find the right medication and dosing and close communication with the child’s teacher(s) will be necessary to determine optimal response.

Documented Effects of Stimulants
The following is a list of documented effects of stimulant medicines on children with ADHD.

• reduced activity level to normal
  
• decreased excessive talking and disruption in classroom
  
• improved handwriting and neatness of written work
  
• improved fine motor control
  
• improved attention to tasks
  
• reduced distractibility
  
• improved short-term memory
  
• decreased impulsivity
  
• increased academic productivity (i.e., work produced)
  
• increased accuracy of academic work
  
• reduced off-task behavior in classroom
  
• decreased anger, better self-control
  
• improved participation in organized sports (i.e., baseball)
  
• reduced bossy behavior with peers
  
• reduced verbal and physical aggression with peers
  
• improved peer social status
  
• reduced non-compliant, defiant, and oppositional behavior
  
• improved parent-child interactions
  
• improved teacher-student interactions

Dosing of Stimulants
The dose of stimulant prescribed is not related to body weight, but to how rapidly it is metabolized. A 180-pound adult may derive substantial benefit from five mg of a short-acting stimulant given three times a day, while a seventy-five pound child may need three times as much. Usually the child’s physician will start with a low dose and gradually increase it until caregivers (parents and teachers) note optimal levels of improvement in behavior and attention.

Irritability or hyperfocused (spacey) behavior seen within thirty minutes or a couple of hours after taking the medication may suggest that the dose is too high for that child. On the other hand, if the dose is not sufficient, the physician may increase it every five days or so until the child is functioning at the optimal level, until adverse side-effects become a concern, or until the maximum recommended dose is reached. With each adjustment in dose, the physician should obtain information from a caregiver (parent and teacher) as to how the child is functioning.

For short-acting stimulants, the average length of action is about four hours. However, for some children the medication may last only two or three hours, and for others, it may last five or six hours. Thus, the dose interval must be established for each child.

Using feedback from parents and teachers, the physician may be able to determine when the medication is “wearing off” and when another dose should be given. Long-acting stimulants can take a child through the entire school-day, but an additional short-acting tablet may be needed to get through homework and after school activities, hopefully, without significantly affecting appetite and sleep.

Long-Term Effects of Stimulants
The long-term effects of stimulants have not been carefully studied, but in the MTA study, the behavioral and cognitive effects of stimulants were monitored over a twenty-four month period. This is a relatively short term considering people with ADHD take stimulants for years. Nevertheless, findings from the MTA study showed significant reduction in the core symptoms of ADHD and associated problems of aggression and oppositional behavior as measured by teacher and parent ratings. There is no evidence that children build up a significant tolerance to stimulants, even after taking them for years throughout childhood and adolescence.

Side Effects of Stimulants
Common side effects of the stimulants are: headaches, irritability, stomachaches, appetite loss, insomnia, and weight loss. About half of the children started on a stimulant will experience one or more of the common side effects noted above. Interestingly, this same percentage of ADHD children will complain about similar side effects when they take a placebo pill without any active medication. Stomachaches and headaches occur in about one-third of children taking a stimulant. Decreased appetite occurs often and usually results in the child eating little for lunch due to the morning dose of medication. If a second or third dose is taken mid-day or later, this could affect appetite at dinner as well. For most children, however, their appetite returns after school, and they make up for the missed lunchtime meal. Parents should consult their doctor if appetite suppression is chronic and weight loss is significant. Medication dose or timing may need to be modified. Give the stimulant medication with meals. Nutritional supplements can be added to the diet. Serving a hearty breakfast, late night snack, or high-calorie snacks, like ice cream may help.

Some of the infrequent side effects that can be caused by stimulant use include rebound effects, difficulty falling asleep, irritable mood, and tics. These side effects are well understood in children.

Rebound
Some parents report that at the end of the school day, their child becomes more hyperactive, excitable, talkative, and irritable. This phenomena is referred to as “rebound,” and it can affect many children with ADHD who take stimulant medication during the school day. When rebound occurs, it usually begins after the last dose of medication is wearing off. The doctor may recommend a smaller dose of medication be given or use of another medication to reduce the child’s excitability. Rebound may be less common when using long-acting stimulants such as Ritalin LA, Concerta, Adderall XR, Metadate CD, or Vyvanse.

Difficulty falling asleep
Children taking stimulants may have trouble falling asleep. They may be experiencing a drug rebound, which makes it difficult for them to quiet down and become restful. In some cases the doctor may recommend reducing or eliminating the mid-day dose of medication or may prescribe a small dose of stimulant medication before bedtime. You might try administering the medication earlier in the day so it is completely worn off by bedtime. If the child is taking a long-acting form of the medicine, try a short-acting form so that is completely worn off by bedtime. Other medications, such as Clonidine or Benadryl, may be prescribed to help the child fall asleep. Non-medical interventions parents can try are: establish sleep routines in the home; avoid excessive activity or stimulation before bedtime; set a fixed bedtime and adhere to it; and teach the child how to relax in bed while trying to fall asleep.

Irritability
Clinicians and researchers have noted that stimulant usage in ADHD children may worsen the child’s mood. The child may exhibit more frequent temper outbursts and may become more moody and more easily frustrated than usual. Moodiness could lead to oppositional behavior at home. Stimulants can also produce dysphoria (sadness) in some children. If irritability, sadness, moodiness, or agitation become evident during the first one to two hours after the medication is taken the doctor may lower the dose. If irritability, sadness, moodiness, or agitation worsen as the medication wears off, the doctor may change to an extended-release form of the stimulant, overlap stimulant dosing (usually by thirty minutes), combine long-and short-acting forms, or consider using an additional medication. If irritability persists, the child should be assessed for other psychiatric problems.

Tics and Tourette’s syndrome
Simple motor tics consist of small, abrupt muscle movements usually around the face and upper body. Common simple motor tics include eye blinking, neck jerking, shoulder shrugging, and facial grimacing. Common simple vocal tics include throat clearing, grunting, sniffing, and snorting. Stimulants should be used with caution in patients with motor or vocal tics or in patients with a family history of tics. A little more than half of the ADHD children who start treatment with a stimulant medication will develop a subtle, transient motor or vocal tic. The tic might begin immediately or months after the medication is started. It might disappear on its own while the child is taking stimulants or it might worsen. Some physicians prefer to discontinue, reduce, or change the stimulant medication if tics appear. A child who has either a motor or a vocal tic (but not both), which occurs many times a day, nearly every day, for a period of at least one year (without stopping for more than three months) may be diagnosed as having a chronic tic disorder. Tourette’s syndrome is a chronic tic disorder characterized by both multiple motor tics and one or more vocal tics. These tics are more severe than the simple motor tics described above. They involve the head and, frequently, other parts of the body such as the torso, arms, and legs. Vocal tics may include the production of sounds like clucking, grunting, yelping, barking, snorting, and coughing. Coprolalia, the utterance of obscenities, is rare and occurs in about ten percent of children with Tourette’s. Stimulants should be used cautiously with children who have chronic tic disorder or Tourette’s syndrome and ADHD as the medication may exacerbate the problem.

Cardiovascular effects and seizure threshold
There has been concern that stimulant medications may produce adverse cardiovascular effects in children, particularly with long term use. Stimulant drugs can increase heart rate and blood pressure, which can cause problems for children and adults with underlying heart disease. Two disorders prompt the most concern: valvular heart disease, in which one of the heart's four valves fails to open or close properly; and hypertrophic obstructive cardiomyopathy, in which the wall between the heart's chambers is abnormally thick. Between 1999 and 2004 the FDA received reports of 19 children who died suddenly from unrecognized heart problems while taking ADHD medications. Twenty-six other children suffered strokes, cardiac arrests, or heart palpitations. We don't know the number of children who may have undiagnosed heart problems, but preliminary research presented in 2007 found that about 2 percent of seemingly healthy school-age children had potentially serious undiagnosed heart problems that were detected only by an electrocardiogram. An ECG, which only takes a few minutes, looks for abnormalities in heart function by reading electrical impulses from the heart's muscles. When combined with a thorough physical exam it can detect abnormal heart rhythms and muscle weakness.

In April of 2008, the American Heart Association (AHA) recommended that children should have cardiovascular screening before taking stimulant medication for treatment of ADHD and that they should continue to have blood pressure check ups every one to three months, as well as routine health check ups every six to twelve months. This recommendation was meant to address mounting fears that stimulants can raise the risk for cardiac complications among those with underlying heart disease. A month or so later, the AHA clarified their recommendation and with the American Academy of Pediatrics (AAP) jointly recommended that:

• Because certain heart conditions in children may be difficult (even, in some cases, impossible) to detect, it is prudent to carefully assess children for heart conditions who need to receive treatment with drugs for ADHD.
  
• Obtaining a patient and family health history and doing a physical exam focused on cardiovascular disease risk factors (Class I recommendations in the statement) are recommended by the AAP and AHA for assessing patients before treatment with drugs for ADHD.
  
• Acquiring an ECG is a Class IIa recommendation. This means that it is reasonable for a physician to consider obtaining an ECG as part of the evaluation of children being considered for stimulant drug therapy, but this should be at the physician's judgment, and it is not mandatory to obtain one.
  
• Treatment of a patient with ADHD should not be withheld because an ECG is not done. The child's physician is the best person to make the assessment about whether there is a need for an ECG.
  
• Medications that treat ADHD have not been shown to cause heart conditions nor have they been demonstrated to cause sudden cardiac death. However, some of these medications can increase or decrease heart rate and blood pressure. While these side effects are not usually considered dangerous, they should be monitored in children with heart conditions as the physician feels necessary.

Abuse and dependency
Health care providers should not be overly concerned that the use of a stimulant medication would lead to dependence, addiction, or drug abuse. However, misuse/abuse of stimulants can and does occur, and caregivers should be aware of this. There have been fairly frequent reports of elementary and secondary school children giving away or selling stimulants, reports of diversion of stimulants into the hands of family members and school officials, and attempts by people to secure stimulants through unlawful prescriptions. Parents should maintain possession of any stimulant medication at home and carefully monitor the supply. The school should do so as well for medication dispensed during the school day. Hopefully, use of long-acting stimulants given once a day will reduce this problem.



There is general consensus among experts treating children with ADHD that stimulants are relatively safe and very effective. For these reasons, they are generally considered the first-line medication to use. However, not all children will show an adequate response to stimulants. Some may develop adverse side effects, and others may benefit from a medication that has twenty-four hour effectiveness rather than the limited coverage that stimulants can provide. The fact that stimulants are controlled substances worries some parents who would like an alternative medication. In addition, non-stimulants may help children and adolescents with ADHD who also have co-morbid conditions such as mood disorders, severe hyperactivity, tics, or other emotional and behavioral problems. Below are descriptions of commonly used non-stimulants to treat ADHD and co-morbid conditions.

Atomoxetine
Atomoxetine (Strattera) has been marketed for the past few years as an FDA approved treatment for ADHD in children and in adults. It is a selective norepinephrine reuptake inhibitor (SNRI), and, as such, it blocks the reuptake of norepinephrine in certain regions of the brain. It is administered in the morning (or at night if the child becomes too sedated) and the dose is based on body weight. The starting dose is 0.5 mg/kg and the target daily dose might be 1.2 mg/kg. Strattera comes in capsules of 10, 18, 25, 40, and 60 mg strengths. It could take four to six weeks (or more) to reach maximal effect, however, the effects last twenty-four hours a day. It is sometimes used in combination with stimulants. In children, the side effects most likely to be seen with Strattera include stomach aches, sedation, nausea and vomiting, loss of appetite, and headaches.

Tricyclic Antidepressants
Tricyclic antidepressants (TCAs) are primarily used in children for ADHD and tic disorders. They are regarded as alternatives for children who have not succeeded with stimulants, for whom stimulants produced unacceptable side effects, or who suffer from other conditions (such as depression, anxiety, Tourette’s syndrome, tics), or aggressive behavior and irritability along with ADHD. Imipramine (Tofranil), desipramine (Norpramin), amytriptyline (Elavil), and nortriptyline (Pamelor or Vivactyl), doxepin, and clomipramine (Anafranil) are TCAs. TCAs have the advantage of longer duration of action (all day) as opposed to four to twelve hours common to stimulants. This avoids the troublesome and even embarrassing mid-day stimulant dose taken at school. Unfortunately, TCAs may not be as effective as the stimulants in improving attention and concentration or reducing hyperactive-impulsive symptoms of ADHD. TCAs also can produce adverse side effects, the most common of which are drowsiness, dry mouth, constipation, and abdominal discomfort. More concern, however, has been expressed at possible adverse cardiac side effects, accidental overdose, and build up in the body to potentially lethal levels. By drawing blood, levels of the TCA can be measured to determine whether these symptoms are a result of too much medication in the body or other factors related to the child’s illness.

Antihypertensives
Antihypertensive agents such as clonidine (Catapres) and guanfacine (Tenex) have been found to be useful in the treatment of ADHD children, especially those who are extremely hyperactive, excitable, impulsive, and defiant. They have less effectiveness in improving attention. These drugs are also frequently used in to treat Tourette’s disorder and other tic disorders and they help control aggression in children with autism and pervasive developmental disorder. Clonidine is also prescribed to help children who have difficulty falling asleep. It can be a great benefit to children with sleep onset difficulties whether the cause is ADHD overarousal, stimulant medication rebound, or unwillingness to fall asleep. Clonidine works on the adrenergic chemical system in the brain and affects the release of norepinephrine.

Clonidine is a relatively short-acting drug as it works for about four hours in children so multiple doses are needed. It comes in a tablet form or in a skin patch. The skin patch may be useful to improve compliance and provide more even absorption in the body. Sudden discontinuation of this medication can cause increased hyperactivity, headache, agitation, elevated blood pressure and pulse, and an increase in tics in patients with Tourette’s syndrome. Sleepiness, which is the most common side effect of clonidine, gradually decreases after a few weeks. Other side effects may include dry mouth, dizziness, nausea, irritability, and light sensitivity. The skin patch can cause a rash.

Clonidine may be combined with stimulants for children with severe hyperactivity and aggression, for children with tic disorders and ADHD, or sleep problems in children with ADHD.

Guanfacine is a long-acting noradrenergic agonist similar to clonidine in effect, but it has a longer duration of action and less side-effects. It is used with children who cannot tolerate the sedative effects of clonidine or with children for whom the effects of clonidine were too short.

Antidepressants
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used antidepressants for children. These include fluoxetine (Prozac), paroxetine (Paxil), citalopram (Celexa), sertraline (Zoloft), escitalopram (Lexapro), and fluvoxamine (Luvox). These drugs have not been well studied in the treatment of ADHD. SSRIs have, however, gained considerable recognition for treatment of depression, anxiety, and obsessive-compulsive disorders. They are considered the first line of medication treatment for these conditions. They have fewer sedative, cardiovascular, and weight-gain side effects than other antidepressants. The SSRIs are similar in their overall effect of making serotonin available in certain regions of the brain, but they vary somewhat from one another in their chemical make-up. Therefore, when one SSRI proves ineffective for a child, another may be more effective. Parents should be cautious however, about the use of antidepressants in general (including the SSRIs) in children. In October 2003 the FDA issued a health advisory warning doctors to exercise caution in prescribing the SSRIs for children and adolescents and to closely monitor those who take these medications. There are concerns that the SSRIs may increase suicidal ideation or suicide attempts in children and adolescents.

Bupropion (Wellbutrin) is a novel antidepressant drug that has been used successfully for a number of years to treat ADHD. It has not been well studied in this regard, but clinicians using this medication find that it has a place in treating ADHD, especially in children who do not tolerate stimulants or who may have co-existing problems with mood. Bupropion appears to possess both indirect dopamine and noradrenergic effects. It works rapidly, peaking in the blood after two hours and lasting up to fourteen hours. The usual dose range in children is from 37.5 to 300 mg per day in two or three divided doses. There is a sustained-release preparation (100, 150, and 200 mg) that can be given once or twice daily. An extended-release form (150 mg and 300 mg) can be given once in the morning. The major side-effects in children are irritability, decreased appetite, insomnia, and worsening of tics. Irritability can be reduced with decreased dosing. Bupropion may worsen tics and should not be used when a seizure disorder is suspected.

Venlafaxine (Effexor) is an antidepressant that, like SSRIs, enhances serotonin in certain areas of the brain by blocking its reuptake, but it also possesses some noradrenergic properties. For this reason, it is known as an SNRI (serotonin-norepinephrine reuptake inhibitor). It can improve symptoms of ADHD and is also helpful for depression in children. The usual dose range is 12.5 mg up to a total of 225 mg daily in twice-a-day split dosing. An extended-release (XR) tablet is available allowing once-a-day dosing. Side effects can include nausea, agitation, stomachaches, headaches, and, at higher doses, blood pressure elevation. As with other anti-depressants, there may be a greater risk of suicidally in children and therefore, careful observation of your child while starting this treatment and during the earlier phases of treatment is very important.

Buspirone, an anxiolitic medication, has been used in children and adolescents with anxiety disorders and researchers have reported significant improvement with it. It has not been well studied in the treatment of ADHD in children. Fenfluramine, benzodiazepines, or lithium are of benefit in other psychiatric disorders, but there is no support to their use in the treatment of ADHD.

Antipsychotics
The group of medications called antipsychotics are commonly used to treat disorders other than psychosis and have been found to be very helpful in children who have severe mood lability. They include haloperidol (Haldol), pimozide (Orap), thioridazine (Mellaril), chlorpromazine (Thorazine), and others. They are frequently prescribed to children with severe mood disorders when other medications have failed. Because they have serious side effects, they are reserved for children who show severe problems and who don’t respond to other medications. Common short-term, reversible side effects are drowsiness, increased appetite and weight gain, dizziness, dry mouth, congestion, and blurred vision. Some of the anti-psychotic drugs can produce side effects that affect various muscle groups (extrapyramidal effects) leading to muscle tightness and spasm, rolling eyes, and restlessness. Some of these severe side effects may be reduced by using the newer, atypical antipsychotics.

Atypical Antipsychotics
This class of medication includes ziprasidone (Geodon), aripiprazole (Abilify), risperidone (Risperdal), clozapine (Clozaril), olanzapine (Zyprexa), and quetiapine (Seroquel). They are increasingly being used as first-line drugs for children with severe mood disorders, disruptive disorders, self-injurious behavior, bipolar disorder, and psychosis. These drugs affect the dopamine system and have less severe side-effects than the traditional antipsychotics. Side effects of Risperdal, Zyprexa, and Seroquel appear similar to those of the traditional antipsychotics, but the rate of side effects and the risk of long-term tardive dyskinesia (irreversible motor writing/twitches/spasms) seem to be much lower. One of the most problematic long-term effects of some of the atypical antipsychotics (particularly Zyprexa and to a lesser extent, Risperdal), is weight gain and potential effects on metabolism. It is unclear whether Seroquel or Geodon have these problems. Abilify does not appear to cause increased weight, but may cause motor spasms that may result in a greater risk for tardive dyskinesia with prolonged use.



A multi-modal approach to treatment is the most efficacious for children and adolescence with ADHD. Three treatments have been proven to be the most effective: behavior modification, medication, and the combination of the two.

Medications are commonly used to treat people of all ages who have ADHD. We used to think ADHD medications were a treatment of last resort, only to be used after other treatments have been tried and failed, or in children and adolescents who are most severely affected. This is no longer the case. The use of medication is common, generally safe, and very effective for the treatment of ADHD. Results of many controlled studies indicated that medication alone can be very effective to reduce core symptoms of ADHD if dosing is carefully adjusted and monitored.

There are several classes of medications used in the treatment of ADHD. Stimulants are the most frequently used, and antidepressants and anti-hypertensives are less often prescribed. There have been many controlled studies of stimulants in the treatment of ADHD. These studies confirm their effectiveness in more than seventy percent of children with improvements noted in attention, activity level, impulsivity, work completion in school, and compliant behavior. New, long-acting stimulants, which can last for ten to twelve hours, will eliminate the need for mid-day dosing and may reduce rebound effects.

Antidepressants have been less well studied, but are useful in treating adolescents who do not respond well to the stimulants or who are suffering from depression or low self-esteem in addition to ADHD. The antihypertensive medications have also been less well studied than stimulants and are used to treat those with ADHD who may be very hyperactive, who are aggressive, or who have an accompanying tic disorder. New medications are being tested for treatment of ADHD with some promising results.

When medications are used in treatment, their effects should be monitored. Adjustments in dosage, time taken, or changes in medication type may be made by the physician if problems arise. Parents, teachers, and the adolescent taking the medication should each be responsible for communicating medication effects to health care providers who should have a monitoring system in place to measure outcomes. Medication will rarely be the only treatment a child, adolescent, or adult with ADHD receives.

References
American Academy of Pediatrics. (2001). Clinical practice guidelines: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics, 108 (4), 1033-1044.

Angold, A., Erkanli, A., Egger, H.L., & Costello, E.J. (2000). Stimulant treatment for children: A community perspective. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 975-984.

Filipek, P.A., Semrud-Clikeman, M., Steingard, R.J., Renshaw, P.F., Kennedy, D.N., & Biederman, J. (1997). Volumetric MRI analysis comparing subjects having attention-deficit hyperactivity disorder with normal controls. Neurology, 48, 589-601.

Hynd, G. W., Semrud-Clikeman, M., Lorys. A.R., Novey, E.S., Elopulos, D., & Lytinen, H. (1991). Corpus callosum morphology in attention deficit-hyperactivity disorder: Morphometric analysis of MRI. Journal of Learning Disabilities, 24, 141-146.

Ingersoll, B., & Goldstein, S. (1993). Attention deficit disorder and learning disabilities: Realities, myths, and controversial treatments. New York: Doubleday Publishing Group.

MTA Cooperative Group. (1999). A fourteen month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1073-1086.

O’Leary, K.D., & Becker, W.C. (1967). Behavior modification of an adjustment class: A token reinforcement program. Exceptional Children, 33, 637-642.

Pelham, W. E. (2002). Psychosocial Interventions for ADHD. In P.S. Jensen & J.R. Cooper (Ed.), Attention deficit hyperactivity disorder: State of the science • best practices (pp 12-1-12-24) New Jersey: Civic Research Institute, Inc.

Rabiner, D. (1999). ADHD monitoring system: a systematic guide to monitoring school progress for children with ADHD. Plantation, FL: Specialty Press.

Vetter, V.L., Elia, J., Erickson, C., Berger, S., Blum, N., Uzark, K., and Webb, C.L. (2008). Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Medications for Attention Deficit/Hyoperactivity Disorder: A Scientific Statement From the American Heart Association Council on Cardiovascular Disease in the Young. Circulation, 117; 2407-2423.

Wilens, T. (2004). Straight talk about psychiatric medications for kids. New York: Guilford Press.
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