The 2 major components of treatment for children with attention deficit hyperactivity disorder (ADHD) are behaviorally focused psychotherapy and medication.

Usually, the primary care provider refers the person with ADHD to a psychotherapist. The more common components of psychotherapy are as follows (not all components are necessary for every individual with ADHD):

• School or education interventions: These interventions are aimed at improving the child’s study skills and behavior in the classroom setting. The age of the child and the severity of the ADHD symptoms affect the extent to which the child benefits from working with education specialists. Teachers have an important function. Their periodic feedback on school performance through the use of standardized scales, narrative descriptions, and telephone follow-up is generally an indispensable component of ongoing care.

• Psychotherapy: ADHD coaching, a support group, or both can help teens feel more normal and provide well-focused peer feedback and coping skills. Counselors such as psychologists, child and adolescent psychiatrists, behavioral/developmental pediatricians, clinical social workers, and advanced practice nurses, can be invaluable to both the children and families. Behavior modification and family therapy are usually necessary for the best possible outcome.

Medications

The medications used to treat ADHD are psychoactive. This means they affect the chemistry, and thus the functioning, of the brain.

Psychostimulants are by far the most widely used medications in ADHD. They work very well in most individuals with the disorder and, when used appropriately, have a good track record of relieving symptoms without causing major adverse effects.

• These medications stimulate and increase activity of areas of the brain with neurotransmitter imbalances.

• The most common adverse effects are short term. They include loss of appetite, sleep disturbances, rebound (for example, agitation, anger, lethargy as the last dose starts to wear off), and mild anxiety.

• Most individuals who take psychostimulants for ADHD build up tolerance to adverse effects within a few weeks, but growth rate needs to be followed closely in children throughout most of the time of their treatment, since any decrease in gaining height or weight may have long-term effects.

• Individuals with certain coexistent psychiatric disorders (for example, psychosis, bipolar disorder, some disorders of anxiety or depression) are particularly vulnerable to adverse effects if they do not receive appropriate concurrent treatment for the coexistent condition.

The psychostimulants most often used in ADHD include the following. The exact mechanism of how these drugs relieve symptoms in ADHD is unknown, but these medicines are linked to increases in brain levels of the neurotransmitters dopamine and norepinephrine. Low levels of these neurotransmitters are linked to ADHD.

• Dextroamphetamine (Dexedrine, Dexedrine Spansules, Dextrostat)

• Methylphenidate (Ritalin, Concerta, Methylin, Metadate CD)

• Dexmethylphenidate (Focalin, Folacin XR)

• Dextroamphetamine and amphetamine mixture (Adderall)

• Pemoline (Cylert) – Rarely used now because of side effects in the liver (Cylert [Abbott Laboratories] is being discontinued in the US market because of declining sales. Pemoline is not considered as first-choice therapy for ADHD because of reports of severe acute liver failure. Since pemoline was introduced on the market in 1975, 15 cases of liver failure were reported as of December 1998. Twelve of these cases resulted in death or liver transplantation, usually within 4 weeks of onset. Pemoline has previously been removed from the market in the United Kingdom and Canada. As of this date, it is not known if generic pemoline products will remain on the market.)

Atomoxetine (Strattera) is a new nonstimulant used to treat ADHD. This medication has been used for only a few years and less is known about its long-term side effects. This drug has several benefits over stimulants and its popularity is growing rapidly.

• It is not a controlled substance and is not considered a drug of potential abuse by the US Food and Drug Administration (FDA).

• It is usually taken only once a day for full 24-hour effectiveness.

• It is much less likely than stimulants to disrupt eating or sleeping.

• For some children, atomoxetine is not enough to control their ADHD symptoms. Many other children do very well on this medicine alone.

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Reviewed: 01/2008