Attention-deficit hyperactivity disorder medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2], Haleigh Williams, B.S.

Overview

The mainstay of therapy for ADHD is the administration of such stimulants as Ritalin and Adderall. While there is no cure for ADHD, currently available treatments can help reduce symptoms and improve functioning. Other treatment options include psychotherapy, education and training, or a combination of therapies.[1]

Medical Therapy

Main article: Attention-deficit hyperactivity disorder treatments

Several different types of medications may be prescribed to mitigate the symptoms associated with ADHD.

  • Stimulants, such as Methylphenidate (Ritalin) and amphetamine salts (dextroamphetamine and amphetamine; Adderall), are used to increase the patient’s supply of the brain chemicals dopamine and norepinephrine, which play essential roles in thinking and attention.[1] Ritalin is safe and effective in preschool-aged children suffering from ADHD so long as they are closely monitored while taking the drug.[2]
  • Lisdexamfetamine is a prodrug of dextroamphetamine. It may be dosed once a day and is less likely to be abused.
  • Atomoxetine (Strattera) is a selective norepinepherine reuptake inhibitor (SNRI) approved for the management of ADHD. It is effective in adult ADHD and is often favored due to lack of abuse potential[3]. Atomoxetine carries a black box warning as there is an increase risk of suicidal ideation in adolescents[4]. While it is non-inferior to methylphenidate in children, its adverse effects in children and adolescents render it a less favorable treatment option.[5]
  • Non-stimulants such as extended release Guanfacine and Clonidine (both alpha-2 adrenergic agonists) are also used to treat ADHD[6].
  • Other drugs, including anti-depressants, may also be prescribed in cases of ADHD depending on the patient’s co-morbidities.[1]

Education and training

  • Educating the patient and his or her family members can prove useful in combating the negative effects of ADHD. For the parents or guardians of young patients, parenting skills training can help teach them the skills they need to encourage and reward positive behaviors in their children. Such training helps parents learn how to use a system of rewards and consequences to change a child’s behavior. In this intervention, parents are taught to give immediate and positive feedback for behaviors they want to encourage, and ignore or redirect behaviors that they want to discourage.
  • Parents may also find it helpful to learn stress management techniques, which could increase their ability to productively deal with their frustration and enable them to interact with their child in a calm manner.
  • Support groups can assist the parents and families of ADHD patients by connecting them with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.[1]

Monitoring response to treatment

Methods of monitoring treatment for ADHD have been reviewedCHADD (2017). Which ADHD Rating Scales Should Primary Care Physicians Use? Available at https://chadd.org/adhd-weekly/which-adhd-rating-scales-should-primary-care-physicians-use/[7][8].

The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) has higher diagnostic accuracy than the WHO Adult ADHD Self-Report Scale (ASRS)[9].

Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS)

One method is the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). The WRAADDS has been validated in a clinician administered format[10] and a self-administered format[11]. The self-administered version typically reports about 2 points higher than the clinician adminsitered version. The WRAADDS asks 30 questions in 7 domains, each with Cronbach alpha > 0.7:

  1. Attention Difficulties
  2. Hyperactivity/Restlessness
  3. Temper
  4. Affective Lability
  5. Emotional Over-Reactivity
  6. Disorganization
  7. Impulsivity

Benchmarks for the self-reported version (SR-WRAADDS) are[11]:

  • Subjects without ADHD: 8.5 ± 4.6
  • Subjects with ADHD: 23.4 ± 4.3
    • After treatment, score typically drops by 5 points or effect size (different / standard deviation) of 0.7

Definitions of treatment response or 'normalization' include[8]:

  • "Follow-up scores falling within 1.0 standard deviation of the normal mean". For example, SR-WRAADD of less than 13.1
  • "30% reduction in symptoms" or score

The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS)m has higher diagnostic accuracy than the WHO Adult ADHD Self-Report Scale (ASRS)[9].

Conners Abbreviated Symptom Questionnaire (CAARS)

This scale includes the Conners Adult ADHD Rating Scales (CAARS). It has 66 items. It is available for download[12].

The CAARS has been used to measure response to treatment in randomized controlled trials.

Affective Lability Scale–Short Form (ALS)

The ALS has 18 items.[13]

Vanderbilt NICHQ

WHO Adult ADHD Self-Report Scale (ASRS)

The Adult ADHD Self-Report Scale (ASRS) is the World Health Organization's (WHO) rating scale for adult ADHD. It has 18 items. It also has a 6 item scale for screening. ASRS-v1.1 is available for download at the Attention Deficit Disorder Association[14]

The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS)m has higher diagnostic accuracy than the WHO Adult ADHD Self-Report Scale (ASRS)[9].

ADHD Rating Scale (for children and adolescents)

For children and adolescents, the ADHD Rating Scale[15] has been used in systematic reviews[16]. In a systematic review, "A clinically meaningful response is generally considered to be improvement of 25% or greater from baseline (a within-group reduction of approximately 10-15 absolute points or a mean difference of approximately 6-7 points between the treatment and placebo groups"[16].

References

  1. ↑ 1.0 1.1 1.2 1.3 National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."
  2. ↑ Riddle MA, Yershova K, Lazzaretto D, Paykina N, Yenokyan G, Greenhill L; et al. (2013). "The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-year follow-up". J Am Acad Child Adolesc Psychiatry. 52 (3): 264–278.e2. doi:10.1016/j.jaac.2012.12.007. PMC 3660093. PMID 23452683. Review in: Evid Based Ment Health. 2013 Aug;16(3):63
  3. ↑ Garnock-Jones KP, Keating GM (2009). "Atomoxetine: a review of its use in attention-deficit hyperactivity disorder in children and adolescents". Paediatr Drugs. 11 (3): 203–26. doi:10.2165/00148581-200911030-00005. PMID 19445548.
  4. ↑ Barry, Colleen (01/21/2014). [www.ncbi.nlm.nih.gov/pmc/articles/PMC3896970/ "ADHD Medication Use Following FDA Risk Warnings"] Check |url= value (help). NIH. Retrieved 06/12/2018. Check date values in: |access-date=, |date= (help)
  5. ↑ Michelson D, Adler L, Spencer T, Reimherr FW, West SA, Allen AJ, Kelsey D, Wernicke J, Dietrich A, Milton D (2003). "Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies". Biol. Psychiatry. 53 (2): 112–20. PMID 12547466.
  6. ↑ Southammakosane, Cathy (August 2015). [www.pediatrics.aappublications.org/content/136/2/351 "Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety"] Check |url= value (help). AAP. Retrieved 06/12/18. Check date values in: |access-date= (help)
  7. ↑ Gaba P, Giordanengo M (2019). "Attention Deficit/Hyperactivity Disorder: Screening and Evaluation". Am Fam Physician. 99 (11): 712. PMID 31150173.
  8. ↑ 8.0 8.1 Ramsay JR (2017). "Assessment and monitoring of treatment response in adult ADHD patients: current perspectives". Neuropsychiatr Dis Treat. 13: 221–232. doi:10.2147/NDT.S104706. PMC 5291336. PMID 28184164.
  9. ↑ 9.0 9.1 9.2 Brevik EJ, Lundervold AJ, Haavik J, Posserud MB (2020). "Validity and accuracy of the Adult Attention-Deficit/Hyperactivity Disorder (ADHD) Self-Report Scale (ASRS) and the Wender Utah Rating Scale (WURS) symptom checklists in discriminating between adults with and without ADHD". Brain Behav. 10 (6): e01605. doi:10.1002/brb3.1605. PMC 7303368 Check |pmc= value (help). PMID 32285644 Check |pmid= value (help).
  10. ↑ Marchant BK, Reimherr FW, Robison D, Robison RJ, Wender PH (2013). "Psychometric properties of the Wender-Reimherr Adult Attention Deficit Disorder Scale". Psychol Assess. 25 (3): 942–50. doi:10.1037/a0032797. PMID 23647041.
  11. ↑ 11.0 11.1 Marchant BK, Reimherr FW, Wender PH, Gift TE (2015). "Psychometric properties of the Self-Report Wender-Reimherr Adult Attention Deficit Disorder Scale". Ann Clin Psychiatry. 27 (4): 267–77, quiz 278-82. PMID 26554368.
  12. ↑ Australian Council for Educational Research. Available at
  13. ↑ Weibel S, Micoulaud-Franchi JA, Brandejsky L, Lopez R, Prada P, Nicastro R; et al. (2019). "Psychometric Properties and Factor Structure of the Short Form of the Affective Lability Scale in Adult Patients With ADHD". J Atten Disord. 23 (10): 1079–1089. doi:10.1177/1087054717690808. PMID 28152669.
  14. ↑ Attention Deficit Disorder Association. https://add.org/wp-content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf
  15. ↑ DuPaul GJ, Power TJ, Anastopoulos AD, Reid R. ADHD Rating Scale IV (for Children and Adolescents): Checklists, Norms, and Clinical Interpretation. New York, NY: Guilford Press; 1998
  16. ↑ 16.0 16.1 Chan E, Fogler JM, Hammerness PG (2016). "Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents: A Systematic Review". JAMA. 315 (18): 1997–2008. doi:10.1001/jama.2016.5453. PMID 27163988.


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