Treatment

A combination of a psychostimulant, most commonly methylphenidate (Ritalin), and cognitive-behavioral therapy is proving to be the best option for treatment of children with ADHD.

In 1999, a large study compared medication, behavior therapy, a combination of both, and standard community care. While all four groups improved, medication, when carefully monitored, was more effective than behavior therapy alone, and its effects were similar to combination therapy. The combined approach, however, allowed lower doses of medication and also improved academic performance and family relations. In addition, it was more helpful for children who also had mood disorders (such as depression or anxiety) or oppositional-defiant disorder.

A 2001 study further suggested that 80% of adolescents with ADHD who were treated with a combined approach showed an improvement in academic performance.

Developing a Treatment Approach. The following guidelines may be useful in determining a treatment approach for children with ADHD:

  • Behavioral techniques, possibly including dietary changes, should be tried first, if possible.
  • If the symptoms are severe or do not respond, then a trial using medication (usually psychostimulants), in conjunction with behavior modification therapy, is advisable.

Unfortunately, most children do not have access to behavioral therapies, either because of lack of time or available resources. A 2000 study reported that fewer than half of all doctor's visits involving a psychostimulant prescription included psychologic intervention. In addition, there was no follow-up at all after 21% of these visits. One study suggested that a simple 8-week program conducted in the primary care doctor's office may be of some help. Children in the study received either a combination of drugs with the program or drugs alone. They had no complicating problems, such as anxiety or conduct disorder. Children who received the combination approach showed improved functioning at home that persisted for at least 6 months, although teachers observed no differences in two groups.

Specific Patient Populations. Unfortunately, such guidelines do not address the following specific patient groups:

  • There are no authoritative treatment guidelines for treating adolescents and adults with ADHD. Increasingly, evidence suggests that psychostimulants are a reasonable choice for adults with a confirmed diagnosis of ADHD.
  • There are no definite guidelines for treating preschool children with severe ADHD. Some parents have reported very good long-term results with behavioral interventions at this age.
  • There are no reliable guidelines on how to treat the inattentive subtype of ADHD, which might be more common in girls.
  • Finally, there are no defined treatments for ADHD patients with accompanying conditions, including impaired working memory and deficits in language processing.
  • There are no defined treatments for children with ADHD and accompanying emotional problems, such as bipolar or anxiety disorders. (There is some evidence, for example, that children with ADHD plus anxiety disorders do worse on psychostimulants.)

Arguments For and Against Psychostimulants. Many parents are very disturbed by the idea of putting their children on intensive stimulant drug regimens, possibly for years, particularly given the uncertainties in diagnosis and the negative publicity surrounding the use of these drugs. Although the decision to use these drugs should not be made lightly, the negative social and emotional effects of the disorder itself for many children with ADHD are far more severe and long-lasting than the use of these drugs. For some parents and children, medication seems like a miracle and can provide desperate families with a quality of life for which they had almost given up hope.

Still, there are a number of questions, particularly for taking psychostimulants alone without additional behavioral therapy. Of great concern is the dramatic increase in prescriptions for psychostimulants among preschool children, not only in the US but also in some European countries. There is evidence the drugs may be over-prescribed, and parents should discuss the question of medications very carefully with their doctors. ADHD represents a growing market for pharmaceutical companies. Although psychostimulants and alternative drugs are proving to be helpful for many families, no one should underestimate the influence of the economic issues involved.

It should be noted that a major study reported that children with ADHD will benefit to some degree from any treatment, whether behavioral therapies, medication, or simple mental health intervention. Combinations of behavioral therapy and medications appear to be best, however. Stimulants are not a cure-all, and children should not grow up believing that taking a pill will solve life's problems without their having to make self-efforts.

Help for Families and Teachers

Research increasingly supports the view that interventions for the ADHD child must also include the parents if they are to be successful. Teachers and school officials should also be educated and involved in the process.

Parents who feel they have the most control over their child's situation also experience the least psychological stress and depression. Parents who are responsive in a positive way also help reduce the chances for their child developing oppositional behaviors. But it can be very difficult, particularly for parents who have ADHD themselves. In fact, parents who have severe ADHD symptoms are less likely to respond to parent training programs unless they get help for themselves.

In addition to behavioral therapy for the child, family therapy may help ADHD children and their parents and siblings cope with the emotional conflicts that nearly always arise in the lifelong process of managing the condition. Separate psychological therapies for specific family members might be needed, particularly in light of the high incidence of psychiatric and other emotional problems in families with ADHD children.

Ritalin and Other Psychostimulants for ADHD: Pros and Cons

Arguments For Medications

Arguments Against Medications

Effect on ADHD Symptoms

The effectiveness of Ritalin in improving ADHD symptoms has been established by more than 160 controlled studies, the largest amount of evidence on any subject involved with childhood behavioral disorders. They are equally effective in boys and girls with ADHD.

Positive results in many studies are most evident in children with severe symptoms, particularly those who suffer from aggression. The benefits with less severe conditions tend not to be as pronounced.

Effect on Intelligence and Academic Achievement

Some studies suggest that medications raise intelligence test scores, even in children who have accompanying disorders, such as autism, pervasive developmental disorder, and mental retardation.

There is no definite proof that drugs improve academic achievement. Psychostimulants, for example, do not improve a child's ability to memorize facts by rote. In fact, in a major study there was no difference in academic achievement between children taking medications and those being given behavioral therapies. A 2001 study reported that only low doses improved academic functioning in adolescents. In some young people higher doses was associated with worse performance.

Effect on Social Functioning

A 2000 study reported that medications had some positive effect on self-esteem, which was greatest in highest doses. (Presumably, then, children with the most severe symptoms felt the greatest improvement in self-confidence.)

One of the few long-term studies on ADHD children reported that patients who were effectively treated and responded well were more likely to be living independently as adults, to be either married or to be engaged. They had higher IQs and were less likely to have substance abuse problems or have attempted suicide. (Patients who were closely monitored for treatments as children, however, may also have had more positive parenting, which could also account for the better outcome.)

A child may still have social problems after taking psychostimulants. Medication alone rarely helps aggressive children with ADHD. And a major study found no difference in oppositional behavior or relationships with peers between children taking psychostimulants and those being given behavioral therapies.

Side Effects

Most young people report mild side effects, most often loss of appetite.

Some children report distressing side effects that include a "zombie" like effect, tics, and moodiness. Weight loss may be a problem for some children. Even in young people who abuse Ritalin, however, less than 1% experience severe side effects (rapid heart rate, hypertension).

Effect on Bone Loss and Growth

The drugs do not cause bone loss, as some people have feared.

These drugs may affect growth, although most studies suggest the impact is not significant and that children catch up later on.

Effect on the Brain

There is some recent evidence to suggest that medication may enhance growth of brain white matter--which consists of insulated nerve fibers that make up the core of the cerebral hemispheres.

No major studies have been conducted on the long-term effects of stimulant use in preschool children. Studies on animals being given such drugs during equivalent developmental periods report negative effects on memory, on important neurotransmitters, and other adverse effects.

Risk for Addiction

Studies on both animals and humans suggest that Ritalin lacks the properties that create addiction, particularly in doses used for treating ADHD. Furthermore, a major 2003 analysis of six studies suggested that the use of stimulants may protect against drug abuse in ADHD young people.

An emerging and serious problem is the sale of stimulants to non-ADHD peers, who are in danger of over-use and severe side effects. It should be noted that crushing the pills and inhaling them nasally can also provide a euphoric state.

Choosing Candidates for Drug Treatment

When used correctly, questionnaires and other screening tests for ADHD symptoms are proving to be very accurate for determining the best candidates for drug treatments.

There are no objective tests for diagnosing ADHD, so it is unclear if the appropriate people are being treated or not treated.

Review Date: 12/7/2005
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.