Treatment team
The treatment team involves behavioral and medical specialists. Concerning behavior, teachers play a very important role. Their daily observation of the child and the use of standard evaluation tests can help in the diagnosis and treatment of ADHD. More specialized consultants within the school system, such as psychometrists, may also be available. Outside of the school setting, psychologists, social workers, and family therapists can also be involved in treatment.
The use of medications involves physicians, nurses, and pharmacists.
Treatment
Behavior treatment can consist of the monitoring of school performance and the use of standard evaluation tests. For older children, adolescents, and adults, support groups can be valuable. As well, ADHD patients can learn behavioral techniques that are useful in self-monitoring their behavior and making the appropriate modifications (such as a time out). Behavior treatment is useful in combination with drug therapy or as a stand-alone treatment in those cases in which the use of medication is not tolerated or is not preferred.
Medical treatment can consist of the use of drugs such as Ritalin that are intended to modify over-exuberant behavior, or other drugs that have differing targets of activity. Psychostimulant medications like Ritalin, Cylert, and Dexedrine increase brain activity by increasing the brain concentration of chemicals such as dopamine, which are involved in the transmission of impulses or by stimulating the receptors to which the chemicals bind. Psychostimulant medications can sometimes disrupt sleep, depress appetite, cause stomachaches and headaches, and trigger feelings of anger and anxiousness, particularly in people afflicted with psychiatric illnesses such as bipolar disorder or depression. For many people, the side effects are mild and can become even milder with long-term use of the drugs.
Antidepressant medications such as imipramine act by slowing down the absorption of chemicals that function in the transmission of impulses. Central alpha agonists are particularly used in the treatment of hyperactivity. By restricting the presence of neurotransmitter chemicals in the gap between neurons, drugs such as clonidine and guanfacine restrict the flow of information from one neuron to the next. There have been four reported cases of sudden death in people taking clonidine in combination with the drug methylphenidate (Ritalin), and reports of nonfatal heart disturbances in people taking clonidine alone.
Finally, medications known as selective norepinephrine reuptake inhibitors restrict the production of norepinephrine between neurons, which inhibits the sudden and often hyperactive "fight or flight" response.
Recovery and rehabilitation
After a patient has been stabilized, typically using medication, follow-up visits to the physician are recommended every few months for the first year. Then, follow-ups every three or four months may be sufficient. The use of medications may continue for months or years.
Recovery and rehabilitation are not terms that apply to ADHD. Rather, a child with ADHD can be assisted to an optimum functionality. Assistance can take the form of special education in the case of those who prove too hyperactive to function in a normal classroom; the child may be seated in a quieter area of the class; or by using a system of rules and rewards for appropriate behavior. Children and adults can also learn strategies to maximize concentration (such as list making) and strategies to monitor and control their behavior.
Clinical trials
Beginning in 1996, the U.S. National Institute of Mental Health (NIMH) and the Department of Education began a clinical trial that included nearly 600 elementary school children ages seven to nine. The study, which compared the effects of medication alone, behavior management alone, or a combination of the two, found the combination to produce the most marked improvement in concentration and attention. Additionally, the involvement of teachers and other school personnel was more beneficial than if the child was examined only a few times a year by their family physician.
As of January 2004, a number of clinical studies were recruiting patients, including:
- Behavioral and functional neuroimaging study of inhibitory motor control. The basis of the inability to control behavior in ADHD was assessed using behavioral tests and the technique of magnetic resonance imaging (MRI).
- Brain imaging in children with ADHD. MRI was used to compare the connections between brain regions in children with and without ADHD.
- Brain imaging of childhood onset psychiatric disorders, endocrine disorders, and healthy children. MRI was used to investigate the structure and activity in the brains of healthy people and those with childhood onset psychiatric disorders, including ADHD.
- Genetic analysis of ADHD. Blood samples from a child with ADHD and his or her immediate family members were collected and analyzed to determine the genetic differences between ADHD and non-ADHD family members.
- Biological markers in ADHD. People with ADHD, their family members, and a control group of healthy people who had previously undergone magnetic resonance examination were assessed using psychiatric interviews, neuropsychological tests, and genetic analysis.
- Study of ADHD using transcranial magnetic stimulation. The technique, in which a magnetic signal is used to stimulate a region of the brain that controls several muscles, was used to investigate whether ADHD patients have a delayed maturation of areas of their nervous system responsible for such activity. Detectable differences could be useful in diagnosing ADHD.
- Clonidine in ADHD Children. The trial evaluated the benefits and side effects of two drugs (clonidine and methylphenidate) used individually or together to treat childhood ADHD.
- Nutrient intake in children with ADHD. The study determined if children with ADHD have a different eating pattern, such as intake of less food or a craving for carbohydrates, than children without ADHD. The information from the study would be used in probing the origins of ADHD and in devising treatment strategies.
- Preventing behavior problems in children with ADHD. The study was designed to gauge the effectiveness of a number of treatment combinations in preventing behavior that is characteristic of ADHD in children.
- Psychosocial treatment for ADHD Type I. The study focused on ADHD that is characterized by inattention. The aim of the study was to develop effective treatment strategies for Type I ADHD.
- Behavioral treatment, drug treatment, and combined treatment for ADHD. The effectiveness of the three treatment approaches was compared, and the interactions between different levels of the behavioral and drug treatments were examined.
- Attention deficit disorder and exposure to lead. The effect of past exposure to lead was studied in children with ADHD.
Prognosis
The outlook for a patient with ADHD can be excellent, if the treatment regimen is followed and other existing conditions and disabilities have been identified and are treated. Methylphenidate, the major psychostimulant used in the treatment of ADHD, has been prescribed since the 1960s. The experience gained over this time has established the drug as being one of the safest pharmaceuticals for children. Indeed, intervention can be beneficial. Researchers from the Massachusetts General Hospital reported in 1999 that drug treatment of children diagnosed with ADHD could dramatically reduce the future risk of substance abuse.
Special concerns
The diagnosis of ADHD continues to be controversial. While some children do benefit from the use of medicines, other children who behave differently than is the norm may be needlessly medicated. The inattention, hyperactivity, and impulsive behavior that are the hallmarks of ADHD can be produced by many other conditions. The death of a parent, the discomfort of a chronic ear infection, and living in a dysfunctional household are all situations that can cause a child to become hyperactive, uncooperative, and distracted.
Evidence since the 1960s has led to the consensus that the medications used to treat ADHD, particularly methylphenidate (Ritalin), pose no long-term hazards. However, research published in December 2003 documented that rats exposed to the drug tended to avoid rewarding stimuli and instead became more anxious. More research on the effects of long-term drug treatment in ADHD is scheduled.
