pediatrics
Attention Deficit Hyperactivity Disorder (ADD, ADHD)
Treatment of ADHD
Behavioral therapy Drug therapy, typically with stimulants such asmethylphenidateordextroamphetamine(in short- and long-acting preparations) Randomized, controlled studies show behavioral therapy alone is less effective than therapy with stimulant drugs alone for school-aged children, but behavioral or combination therapy is recommended for younger children. Although correction of the underlying neurophysiologic differences of patients with ADHD does not occur with drug therapy, drugs are effective in alleviating ADHD symptoms and they permit participation in activities previously inaccessible because of poor attention and impulsivity. Drugs often interrupt the cycle of inappropriate behavior, enhancing behavioral and academic interventions, motivation, and self-esteem. Treatment of ADHD in adults follows similar principles, but drug selection and dosing are determined on an individual basis, depending on other medical conditions. Stimulant preparations that includemethylphenidateoramphetaminesalts are most widely used. Response varies greatly, and dosage depends on the severity of the behavior and the child’s ability to tolerate the drug. Dosing is adjusted in frequency and amount until the optimal balance between response and adverse effects is achieved. Methylphenidateis usually started at 0.3 mg/kg orally once a day (immediate-release form) and increased in frequency weekly, usually to about 2 to 3 times per day or every 4 hours during waking hours; many clinicians try to use morning and midday dosing. If response is inadequate but the drug is tolerated, dose can be increased. Most children find an optimal balance between benefits and adverse effects at individual doses between 0.3 and 0.6 mg/kg. The dextro isomer ofmethylphenidateis the active moiety and is available for prescription at one half the dose. Dextroamphetamineis typically started (often in combination with racemicamphetamine) at 0.15 to 0.2 mg/kg orally once a day, which can then be increased to 2 or 3 times a day or every 4 hours during waking hours. Individual doses in the range of 0.15 to 0.4 mg/kg are usually effective. Dose titration should balance effectiveness against adverse effects; actual doses vary significantly among individuals, but, in general, higher doses increase the likelihood of unacceptable adverse effects. In general,dextroamphetaminedoses are about two thirds those ofmethylphenidatedoses. Formethylphenidateordextroamphetamine, once an optimal dosage is reached, an equivalent dosage of the same drug in a sustained-release form is often substituted to avoid the need for drug administration in school. Long-acting preparations include wax matrix slow-release tablets, biphasic capsules containing the equivalent of 2 doses, and osmotic release pills and transdermal patches that provide up to 12 hours of coverage. Both short-acting and long-acting liquid preparations are now available. Pure dextro preparations (eg, dextromethylphenidate) are often used to minimize adverse effects such as anxiety; doses are typically half those of mixed preparations. Prodrug preparations are also sometimes used because of their smoother release, longer duration of action, fewer adverse effects, and lower abuse potential. Learning is often enhanced by low doses, but improvement in behavior often requires higher doses. Dosing schedules of stimulant drugs can be adjusted to cover specific days and times (eg, during school hours, while doing homework). Drug holidays may be tried on weekends, on holidays, or during summer vacations. Placebo periods (for 5 to 10 school days to ensure reliability of observations) are recommended to determine whether the drugs are still needed. Common adverse effectsof stimulant drugs include Sleep disturbances (eg, insomnia) Headache Stomachache Appetite suppression Elevated heart rate and blood pressure Depression is a less common adverse effect and may often represent an inability to easily shift focus (overfocusing). This can manifest as a dulled demeanor (sometimes described by families as being zombie-like) rather than actual clinical Depressive Disorders in Children and Adolescents . In fact, stimulant drugs are sometimes used as adjunctive treatment for depression. A dulled demeanor can sometimes be addressed by cutting the stimulant drug dose or trying a different drug. Studies have shown growth in height slows over 2 years of stimulant drug use, and slowing apparently persists into adulthood with ongoing chronic stimulant drug use. Atomoxetine, a selectivenorepinephrinereuptake inhibitor, is also used. The drug is effective, but data are mixed regarding its efficacy compared with stimulant drugs. Some children have nausea, sedation, irritability, and temper tantrums; rarely, liver toxicity and suicidal ideation occur. A typical starting dose is 0.5 mg/kg orally once a day, titrated weekly to 1.2 to 1.4 mg/kg once a day. The long half-life allows once-a-day dosing but requires continuous use to be effective. The maximum recommended daily dosage is 100 mg. Selectivenorepinephrinereuptake inhibitor antidepressants such asbupropionandvenlafaxine, alpha-2 agonists such asclonidineandguanfacine, and other psychoactive drugs are sometimes used in cases of stimulant drug ineffectiveness or unacceptable adverse effects, but they are less effective and are not recommended as first-line drugs. Sometimes these drugs are used in combination with stimulants for synergistic effects; close monitoring for adverse effects is essential. Adverse drug interactions are a concern with ADHD treatment. Drugs that inhibit the metabolic enzyme CYP2D6, including certain selective serotonin reuptake inhibitors (SSRIs) that are sometimes used in patients with ADHD, can increase the effect of stimulant drugs. Review of potential drug interactions (typically using a computerized program) is an important part of pharmacologic management of ADHD patients. Counseling, including cognitive-behavioral therapy (eg, goal-setting, self-monitoring, modeling, role-playing), is often effective and helps children understand ADHD and how to cope with it. Structure and routines are essential. Classroom behavior is often improved by environmental control of noise and visual stimulation, appropriate task length, novelty, coaching, and teacher proximity. When difficulties persist at home, parents should be encouraged to seek additional professional assistance and training in behavioral management techniques. Adding incentives and token rewards reinforces behavioral management and is often effective. Children with ADHD in whom hyperactivity and poor impulse control predominate are often helped at home when structure, consistent parenting techniques, and well-defined limits are established. Elimination diets, megavitamin treatments, use of antioxidants or other compounds, and nutritional and biochemical interventions have had the least consistent effects. Biofeedback can be helpful in some cases but is not recommended for routine use because evidence of sustained benefit is lacking. 