ADHD (ADD) Treatment by Mitchell L. Glaser, MD.
Treatments for ADHD (formerly ADD) include both medicine and behavioral/cognitive talk therapy. Medications, in my opinion, and supported by studies, is the most effective long term treatment for ADHD. This opinion is based on my experience practicing psychiatry for over 15 years. It is also supported by research not funded by pharmaceutical companies.
Cognitive therapy is a type of talk therapy in which the patient and the therapist review the patients thoughts, feelings, and experiences. Through this understanding of how one thinks, feels, behaves the patient can link it to his/hers life experiences. This then allows a change to occur in how the patient may feel or act in a given situation. This type of therapy is important if the patient is suffering emotionally or if the patient is so oppositional that he thinks he does not need to change his behavior. Also, ADHD causes many deficits in social skills and can lead to severe stress in the home. Cognitive and family therapy can be most helpful for these types of problems. Behavior therapy involves a behavior management plan that utilizes rewards and sometimes punishments for targeted behaviors. So for example, if your daughter doesn't do her homework, then you establish a reward if the homework gets done. Behavior management works very well but it requires extreme responsibility on the part of the adult. If the adult ever stops consistently administering the plan, then the child will revert back to their old behavior as if the plan was never even attempted. Behavior management for an adult with ADHD involves self directed behavior targets with step by step plan to get there. The therapist then helps the patient monitor their progress towards goal attainment.
Medications for ADHD fall into four main categories. First is the stimulants, second is the antidepressants, third is antisympethetics, fourth is a broad category of everything else.
The stimulants are the most widely prescribed medication class for ADHD. This is for good reason. They have been around for decades, the risks are pretty well known by now. They work great. Two types of medication make up this class that is prescribed for ADHD; methylphenidate and dextro-amphetamine or amphetamine mixed salts. Dextro-amphetamine (or amphetamine mixed salts) is not to be mistaken with its cousin, the far more potent and addicting meth-amphetamine. Methylphenidate and dextro-amphetamine (or amphetamine mixed salts) work almost identically. They also have the same side effect risks. The serious risks are extremely rare. Muscle twitches, called "tics" can result. This is a quick jerky movement usually involving the muscles of the face, mouth or throat. Typical examples are an extra eye blink, or a throat clearing noise, or tongue thrust. I have never seen a tic not go away after the medicine was stopped, but the tic, according to the literature, can be permanent. Sometimes it can take months for the tic to resolve. If a tic appears, immediately stop the stimulant medication. Another risk is loss of expected height attainment by 1 or 2 inches. Heart attack has lately been reported to be a rare problem with stimulants as well as high blood pressure. Obtaining an EKG and blood pressure monitoring can minimize this risk. Weight loss often occurs due to decreased appetite. Patients will often get hungry at night when the medicine has worn off. It is a good idea to save some dinner to eat near bed time if the patient is hungry then. Stimulant medications are unique to psychiatry because they work the days you take it, and don't effect you the days you don't. Stimulants require no build up time typical to most psych meds. Therefore, if you want to not take the medication on some days then that is OK to do. For example, some children may not take the medication on weekends or holidays when school is out. Business men may only take the med on work days or long trips with the family. Methylphenidate products include Concerta, Ritalin, Metadate, Focalin, Methyline, Daytrana. The products vary in how long each pill or capsule lasts in your body. Concerta can last 12 hours, Ritalin can last 3 hours. One Concerta pill lasts all day, whereas Ritalin is generally taken 3 times a day. Ritalin is generic and is a third of the price of Concerta. Dexro-amphetamine brands include Dexadrine (where the name dexatrim comes from), Dextrostat, Adderall, and Vyvanse. Stimulant medications clearly are the most effective treatment for ADHD. The difference between before and after treatment is a dramatic improvement. Potential pitfalls are present however, there is always the risk of side effects including unknown ones. If an inaccurate diagnosis is made, stimulants can aggravate the condition rather than help it. This can particularly occur with prodromal bipolar disorder and schizophrenia. Also, if the dose is too high, then the patient will stare off like a zombie, appear flat. Another risk of too high a dosage is hallucinations, such as feeling bugs crawling over their skin.
The next category is the antidepressants. The old tricyclic antidepressants such as desiprimine and elavil and imimpramine have been shown to help ADHD. However, they have significant side effects, so they are seldom used for ADHD today except in rare cases. Newer antidepressants with much less side effects have been shown to be effective for ADHD. These are Wellbutrin, Effexor, and Strattera. Strattera is technically not an antidepressant but its structure and neurochemical effects are similar to antidepressants. Strattera increases norepinephrine in the brain. Effexor can increase blood pressure and may cause a racing sensation. Wellbutrin has a risk of a non-permanent seizure. Strattera may have a risk of permanent liver failure, but this is not for certain at this time. The theories as to how these meds work is based on the following. Stimulants markedly increase the levels of dopamine in certain parts of the brain. It is thought that this increase in dopamine stimulates the part of the brain that thinks and manages ones attention. The antidepressants work slightly through dopamine but more through norepinephrine, another neurochemical. Antidepressants must be taken every day for them to work, and a build up period of 2-4 weeks is required to see results for each dosage adjustment. Antidepressants are much milder than the stimulants and have a lower risk of serious side effects although both have a risk of suicide. The antidepressant while safer, are less effective at treating ADHD than the stimulant medications.
The next category is the anti-sympathetic medications. This includes clonidine (trade name Catapres) and guanfacine (trade name Tenex). There are long acting versions of tenex and clonidine available by prescription. Intuniv is long acting quanfacine and Clonicel is long acting clonidine. They are both fda approved to treat ADHD and are less sedating then the immediate release forms for some reason. The sympathetic nervous system is the part of your brain and spinal chord that activates your body and mind to respond to a dangerous situation and a few other things. It is commonly referred to as "fight or flight". If an animal gets cornered, its sympethetic nervous system tells it to fight or run away fast. The sympethetic nervous system speeds up the heart and breathing rate, diverts blood to the muscles, takes blood away from the intestines and skin since it is needed elsewhere, it widens the pupils to maximize site. So, the theory goes, if you decrease this system, you can reduce hyperactivity and inattention. Clonidine, and guanfacine are old medications originally used to treat high blood pressure. They have a risk of a heart attack, low blood pressure, passing out, and feeling very tired. In my practice, I prescribe them infrequently to help with sleep. There are studies supporting small improvement in ADHD symptoms. However, I have found the immediate release forms to be too sedating and hardly effective if at all, for my patients. Since they do not worsen bipolar disorder, it may be a good choice for combined ADHD and bipolar disorder. Before starting clonidine or guanfacine, an EKG must be done first to check for any arhythmias or conduction delays of the heart rhythm.
Other medications can also help with ADHD. These include the second generation antipsychotics such as Abilify, Seroquel, Geodon, Zyprexa, and Risperdal. Information about their mechanism of action and side effects can be found in the "Bipolar Treatment" section of this web site. In my practice, Abilify has been the most helpful for ADHD symptoms. Usually, I will use this medication as an adjunctive or second medication to be given in addition to another medication listed above. (an exception is to never combine clonidine or quanfacine with Abilify or a heart attack could result). Once hyperactivity and inattention are controlled with a medication listed above, sometimes anger can remain a problem. In those cases, I will add Abilify, Seroquel, Risperdal, or Geodon. The combination of for example, Concerta plus Abilify will control the hyperactivity, inattention, and rage. There is currently small amounts of promising data supporting the use of medications that treat alzheimers disease for ADHD, such as sinemet or donepazil. Also the medication that treats daytime tiredness called modafinil. I have no experience in using these meds for ADHD to date. In conclusion, the medications to treat ADHD (ADD) are well researched and have been shown to be extremely effective. Often the improvement is dramatic. One must always weigh the risks and benefits before deciding to embark on medication treatment of any disease including ADHD. All medications have risks of very serious side effects. The decision should not be made lightly. -Mitchell L. Glaser, MD.