Treatment of attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is a common disorder among children and adolescents with reported prevalence rates of between 3 and 10 %. Recent reports suggest that a multimodal treatment approach is preferable to address many symptoms of ADHD and its associated problems for the children, the family, and the school. Stimulant medications remain the mainstay of treatment and are highly effective in more than 75% of patients. Improvement in the core symptoms of inattention, impulsivity, and hyperactivity are most noticeable. Recently approved extended release preparation of methylphenidate will allow once a day dosing. Reports of effectiveness of some non-stimulant medications such as bupropion, especially for adolescents, appear promising. A number of behavioral and psychosocial interventions can be used effectively as part of multimodal approach to address many ADHD-related problems. This article provides an update on practical information on the treatment of children and adolescents with ADHD who do not have other associated psychiatric disorders.     

Update on attention-deficit/hyperactivity disorder

PURPOSE OF REVIEW: Attention-deficit/hyperactivity disorder (ADHD) is present in 3% to 10% of children in the United States. Children with ADHD can have academic impairments, social dysfunction, and poor self-esteem. There is also a higher risk of both cigarette smoking and substance abuse. Given this, the importance of treatment for ADHD needs to be underscored. This article will briefly review the diagnosis, etiology, and treatment of ADHD, with particular focus on nonstimulant medication and alternative treatment modalities. RECENT FINDINGS: Recent evidence suggests that the overall rate of medication treatment for ADHD has been increasing, with over 2 million children being treated with stimulants in 1997. With this increase, controversy has arisen over the possible association of stimulants with growth suppression. In addition, estimates indicate that as many as 30% of children with ADHD either do not respond to stimulant treatment or cannot tolerate the treatment secondary to side effects. This has lead to the consideration of treatment with both nonstimulant medications as well as alternative therapies, including diet, iron supplementation, herbal medications, and neurofeedback. Considering the various treatment options now available for ADHD, along with the complexity of the condition, clinical practice guidelines are emerging for the treatment of ADHD and will be discussed. SUMMARY: ADHD continues to be a serious health problem. Adequate treatment is needed to avoid academic impairments, social dysfunction, and poor self-esteem. This treatment includes consideration of stimulant medication, nonstimulant medication, as well as alternative therapies. The child with ADHD is likely better served with a mutimodal treatment plan, including medication, parent/school counseling, and behavioral therapy. Implementing an evidenced based algorithm for the treatment of ADHD may prove to be most effective.     

Treatment experiences of children and adolescents with attention-deficit/hyperactivity disorder

Aim: To gain insight into the treatment experiences of children and adolescents diagnosed with attention‐deficit/hyperactivity disorder (ADHD). Methods: Convenience sampling was used to recruit eligible parents and carers at paediatric clinics of the Children's, Youth and Women's Health Service to participate in an interview to discuss experiences, using a semi‐structured questionnaire. Results: Thirty‐five interviews were conducted. Twenty‐five subjects had trialled an average of 1.5 interventions prior to receiving an ADHD diagnosis, namely, dietary modifications (46%), behavioural therapy (24%), learning assistance (8%) and natural remedies (8%). Following an ADHD diagnosis, 25 subjects tried an average of 2.8 interventions, most commonly behavioural therapies (48%), expressive therapies (48%) and fish oil (36%). All subjects started psychostimulant medication after receiving an ADHD diagnosis. Despite 52% of parents expressing initial reluctance towards psychostimulants, 97% reported positive experiences with use in terms of schooling, social interaction and family life. Of those being treated with psychostimulants, 22 (73%) were concurrently using other treatments at the time of interview. Conclusions: Few patients use psychostimulant medication in isolation, with the majority of parents using multiple approaches to manage their child's behaviour. Parents tried a variety of therapies before commencing psychostimulant medication, often because of fears regarding psychostimulant safety. Parents were generally happy with the results gained; however adolescents interviewed were less convinced of the benefits of psychostimulants.     

Etiologic classification of attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder is a neurobiological syndrome with an estimated prevalence among children and adolescents of 5%. It is a highly heritable disorder, but acquired factors in etiology are sometimes uncovered that may be amenable to preventive measures or specific therapy. Early reports have described symptoms similar to attention-deficit/hyperactivity disorder that followed brain trauma or viral encephalitis, and recent MRI studies have demonstrated brain volumetric changes that may be involved in the pathophysiology of the syndrome. The American Psychiatric Association's Diagnostic Statistical Manual, introduced in 1968, emphasizes symptomatic criteria in diagnosis. Here, an overview of environmental factors in the etiology of attention-deficit/hyperactivity disorder is presented to encourage more emphasis and research on organic causal factors, preventive intervention, and specific therapies. An organic theory and the genetic and biochemical basis of attention-deficit/hyperactivity disorder are briefly reviewed, and an etiologic classification is suggested. Environmental factors are prenatal, perinatal, and postnatal in origin. Pregnancy- and birth-related risk factors include maternal smoking and alcohol ingestion, prematurity, hypoxic-ischemic encephalopathy, and thyroid deficiency. Childhood illnesses associated with attention-deficit/hyperactivity disorder include virus infections, meningitis, encephalitis, head injury, epilepsy, toxins, and drugs. More controversial factors discussed are diet-related sensitivities and iron deficiency. Early prenatal recognition, prevention, and treatment of environmental etiologies of attention-deficit/hyperactivity disorder may reduce physician reliance on symptomatic modification with medication, a frequent reason for parental concern.     

Motor disorders and attention-deficit/hyperactivity disorder

Motor and perceptual output problems were associated with hyperactivity before ADHD was described in North America. Many European pediatricians continue to consider these deficits along with inattention and hyperactivity to be part of one disorder. Motor deficits are an associated neurodevelopmental deficit in a substantial number of ADHD patients. In order for the patients' need to be addressed, pediatricians must be able to recognize motor coordination deficits and make appropriate recommendations to the patients' caregivers.     

Diagnosis of attention-deficit/hyperactivity disorder in the office

The evaluation of the child with ADHD can be a complex and time-consuming process. Because there are no specific diagnostic tests, the physician must rely on the old standard of history and observation. An approach to diagnosis has been outlined in this article, which views ADHD as one of many clinical expressions of a more generalized impairment of neurologic processing. This approach suggest that four separate areas should be investigated: family and medical history, behavior, cognition, and coordination, while searching for signs of impairment in each area. This can provide a framework for the private practitioner to effectively and efficiently evaluate a child for ADHD within a busy office practice.     

The diet factor in attention-deficit/hyperactivity disorder

This article is intended to provide a comprehensive overview of the role of dietary methods for treatment of children with attention-deficit/hyperactivity disorder (ADHD) when pharmacotherapy has proven unsatisfactory or unacceptable. Results of recent research and controlled studies, based on a PubMed search, are emphasized and compared with earlier reports. The recent increase of interest in this form of therapy for ADHD, and especially in the use of omega supplements, significance of iron deficiency, and the avoidance of the "Western pattern" diet, make the discussion timely. Diets to reduce symptoms associated with ADHD include sugar-restricted, additive/preservative-free, oligoantigenic/elimination, and fatty acid supplements. Omega-3 supplement is the latest dietary treatment with positive reports of efficacy, and interest in the additive-free diet of the 1970s is occasionally revived. A provocative report draws attention to the ADHD-associated "Western-style" diet, high in fat and refined sugars, and the ADHD-free "healthy" diet, containing fiber, folate, and omega-3 fatty acids. The literature on diets and ADHD, listed by PubMed, is reviewed with emphasis on recent controlled studies. Recommendations for the use of diets are based on current opinion of published reports and our practice experience. Indications for dietary therapy include medication failure, parental or patient preference, iron deficiency, and, when appropriate, change from an ADHD-linked Western diet to an ADHD-free healthy diet. Foods associated with ADHD to be avoided and those not linked with ADHD and preferred are listed. In practice, additive-free and oligoantigenic/elimination diets are time-consuming and disruptive to the household; they are indicated only in selected patients. Iron and zinc are supplemented in patients with known deficiencies; they may also enhance the effectiveness of stimulant therapy. In patients failing to respond or with parents opposed to medication, omega-3 supplements may warrant a trial. A greater attention to the education of parents and children in a healthy dietary pattern, omitting items shown to predispose to ADHD, is perhaps the most promising and practical complementary or alternative treatment of ADHD.     

注意缺陷多动障碍的非中枢兴奋治疗药物

中枢兴奋剂是目前临床治疗注意缺陷多动障(ADHD)的首选药物,临床有效率达80%左右,但仍有相当一部分患者对中枢兴奋剂治疗无效,或不能耐受其不良反应,开发应用非中枢兴奋剂药物成为近年来研究的热点.托莫西汀是唯一获美国FDA批准的非中枢兴奋药物,对儿童和成人患者的各种ADHD核心症状均有显著疗效,在国外已成为ADHD的一线治疗药物;抗抑郁药(丙米嗪、去甲丙米嗪、安非他酮、瑞波西汀、文拉法辛等)和α2肾上腺素能受体激动剂(可乐定和胍法辛)证明对ADHD治疗有效,但其短期和长期安全性和疗效仍有待进一步的对照研究;其他非中枢兴奋剂司来吉兰、莫达非尼等作为潜在治疗儿童ADHD安全有效的新药,正受到研究人员的关注.     

Pharmacologic treatment of attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is highly prevalent in children and adolescents. Highly effective pharmacological treatments are available that allow the child and the adolescent to function at his/her full potential. Various preparations of methylphenidate and amphetamines have been used for a long time in the treatment of ADHD. This article reviews these and some of the newer drugs used in the treatment of ADHD, including atomoxetine and bupropion.