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==Overview==
==Overview==
First line treatments for attention-deficit hyperactivity disorder include the use of stimulant medications. Medications such as [[atomoxetine]] may be a better alternative for patients with co-morbid substance abuse disorder. Behavioral modification with the use of medications has shown to have the most success in treating ADHD.
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.<ref name="#1">National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."</ref>
 
Measurement-based care may help<ref name="pmid22193788">{{cite journal| author=Bickman L, Kelley SD, Breda C, de Andrade AR, Riemer M| title=Effects of routine feedback to clinicians on mental health outcomes of youths: results of a randomized trial. | journal=Psychiatr Serv | year= 2011 | volume= 62 | issue= 12 | pages= 1423-9 | pmid=22193788 | doi=10.1176/appi.ps.002052011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22193788  }} </ref><ref name="pmid37099379">{{cite journal| author=Lawrence-Sidebottom D, Huffman LG, Huberty J, Beatty C, Roots M, Roots K | display-authors=etal| title=Using Digital Measurement-Based Care to Address Symptoms of Inattention, Hyperactivity, and Opposition in Youth: Retrospective Analysis of Bend Health. | journal=JMIR Form Res | year= 2023 | volume= 7 | issue=  | pages= e46578 | pmid=37099379 | doi=10.2196/46578 | pmc=10173032 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=37099379  }} </ref>.
 
Practice guidelines are available<ref name="pmid30453134">{{cite journal| author=Kooij JJS, Bijlenga D, Salerno L, Jaeschke R, Bitter I, Balázs J | display-authors=etal| title=Updated European Consensus Statement on diagnosis and treatment of adult ADHD. | journal=Eur Psychiatry | year= 2019 | volume= 56 | issue=  | pages= 14-34 | pmid=30453134 | doi=10.1016/j.eurpsy.2018.11.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30453134  }} </ref><<ref name="pmid37878798">{{cite journal| author=Baughman DJ, Watson CM, Beich JW, Herboso MNJ, Cuttie LK, Marlyne AC| title=Recommendation for Long-term Management of Adult Attention-Deficit/Hyperactivity Disorder in Military Populations, Veterans, and Dependents: A Narrative Review. | journal=Mil Med | year= 2023 | volume=  | issue=  | pages=  | pmid=37878798 | doi=10.1093/milmed/usad403 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=37878798  }} </ref>
 
==Medical Therapy==
Several different types of medications may be prescribed to mitigate the symptoms associated with ADHD. Approximately 3% of adults are treated with persistent medication<ref name="pmid35476068">{{cite journal| author=Li L, Chang Z, Sun J, Jangmo A, Zhang L, Andersson LM | display-authors=etal| title=Association Between Pharmacological Treatment of Attention-Deficit/Hyperactivity Disorder and Long-term Unemployment Among Working-Age Individuals in Sweden. | journal=JAMA Netw Open | year= 2022 | volume= 5 | issue= 4 | pages= e226815 | pmid=35476068 | doi=10.1001/jamanetworkopen.2022.6815 | pmc=9047436 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35476068  }} </ref>.


==Mediacl Therapy==
The research on treatment is summarized within reviews by the [https://research-information.bris.ac.uk/en/projects/cochrane-developmental-psychosocial-learning-problems-group Cochrane Developmental, Psychosocial & Learning Problems Group].
{{main|Attention-deficit hyperactivity disorder treatments}}
'
Singularly, stimulant medication is the most efficient and cost effective method of treating ADHD. <ref>Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf</ref> <ref name = "Jensen">{{cite journal | author = Jensen, et al | title = Cost-Effectiveness of ADHD Treatments: Findings from the Multimodal Treatment Study of Children With ADHD | journal = American Journal of Psychiatry | volume = 162 | pages = 1628–1636 (Page:1633) | year = 2005 | pmid = 16135621 | doi = 10.1176/appi.ajp.162.9.1628}} [http://ajp.psychiatryonline.org/cgi/content/full/162/9/1628 Free full text]</ref> Over 200 controlled studies have shown that stimulant medication is an effective way to treat ADHD.<ref>Barkley, Russell A. [http://www.continuingedcourses.net/active/courses/course006.php?PHPSESSID=169b92182fe1584725 Treating Children and Adolescents with ADHD: An Overview of Empirically Based Treatments.] ContinuingEdCourses.Net.  Retrieved on 2007-08-13.</ref>  Methods of treatment usually involve some combination of medications, behavior modifications, life style changes, and counseling. Behavioral parent training, behavior therapy aimed at parents to help them understand ADHD has also shown short term benefits.<ref>Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf</ref> [[Omega-3 fatty acids]], [[zinc]] and [[magnesium]] may have benefits with regard to ADHD symptoms.<ref name="pmid16190793">{{cite journal |author=Arnold LE, DiSilvestro RA |title=Zinc in attention-deficit/hyperactivity disorder |journal=Journal of child and adolescent psychopharmacology |volume=15 |issue=4 |pages=619-27 |year=2005 |pmid=16190793 |doi=10.1089/cap.2005.15.619}}</ref><ref name="pmid16962757">{{cite journal |author=Antalis CJ, Stevens LJ, Campbell M, Pazdro R, Ericson K, Burgess JR |title=Omega-3 fatty acid status in attention-deficit/hyperactivity disorder |journal=Prostaglandins Leukot. Essent. Fatty Acids |volume=75 |issue=4-5 |pages=299-308 |year=2006 |pmid=16962757 |doi=10.1016/j.plefa.2006.07.004}}</ref>
*[[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]].<ref name="#1">National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."</ref> Ritalin is safe and effective in preschool-aged children suffering from ADHD so long as they are closely monitored while taking the drug.<ref name="pmid23452683">{{cite journal| author=Riddle MA, Yershova K, Lazzaretto D, Paykina N, Yenokyan G, Greenhill L et al.| title=The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-year follow-up. | journal=J Am Acad Child Adolesc Psychiatry | year= 2013 | volume= 52 | issue= 3 | pages= 264-278.e2 | pmid=23452683 | doi=10.1016/j.jaac.2012.12.007 | pmc=3660093 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23452683  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23696095 Review in: Evid Based Ment Health. 2013 Aug;16(3):63] </ref>
* [[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<ref name="pmid19445548">{{cite journal |vauthors=Garnock-Jones KP, Keating GM |title=Atomoxetine: a review of its use in attention-deficit hyperactivity disorder in children and adolescents |journal=Paediatr Drugs |volume=11 |issue=3 |pages=203–26 |year=2009 |pmid=19445548 |doi=10.2165/00148581-200911030-00005 |url=}}</ref>. Atomoxetine carries a black box warning as there is an increase risk of suicidal ideation in adolescents<ref>{{Cite web|url=www.ncbi.nlm.nih.gov/pmc/articles/PMC3896970/|title=ADHD Medication Use Following FDA Risk Warnings|last=Barry|first=Colleen|date=01/21/2014|website=NIH|archive-url=|archive-date=|dead-url=|access-date=06/12/2018}}</ref>. While it is non-inferior to [[methylphenidate]] in children, its adverse effects in children and adolescents render it a less favorable treatment option.<ref name="pmid12547466">{{cite journal |vauthors=Michelson D, Adler L, Spencer T, Reimherr FW, West SA, Allen AJ, Kelsey D, Wernicke J, Dietrich A, Milton D |title=Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies |journal=Biol. Psychiatry |volume=53 |issue=2 |pages=112–20 |year=2003 |pmid=12547466 |doi= |url=}}</ref>
*Non-stimulants such as extended release Guanfacine and Clonidine (both alpha-2 adrenergic agonists) are also used to treat ADHD<ref>{{Cite web|url=www.pediatrics.aappublications.org/content/136/2/351|title=Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety|last=Southammakosane|first=Cathy|date=August 2015|website=AAP|archive-url=|archive-date=|dead-url=|access-date=06/12/18}}</ref>. 
*Other drugs, including [[anti-depressants]], may also be prescribed in cases of ADHD depending on the patient’s co-morbidities.<ref name="#1">National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."</ref>


[[Comorbid]] disorders or substance abuse can make finding the proper diagnosis and the right overall treatment more costly and time-consuming. Psychosocial therapy is useful in treating some comorbid conditions.<ref>{{cite journal | author =Foster, et al | title = Treatment of ADHD: Is More Complex Treatment Cost-Effective for More Complex Cases? | journal =HSR: Health Services Research | volume = 42 | issue = 1 | pages = 165–182 (Page:177) | year = 2007 | pmid = 17355587}}</ref>
{| class="wikitable"
|+  Pharmacotherapy of adult ADHD
|-
!
! Standard mean difference (SMD)* for<br/>patient-reported symptoms
! Discontinuation ratio
|-
| Amphetamines (dexamphetamine, lisdexamfetamine, mixed amphetamine salts)<ref name="pmid30091808">{{cite journal| author=Castells X, Blanco-Silvente L, Cunill R| title=Amphetamines for attention deficit hyperactivity disorder (ADHD) in adults. | journal=Cochrane Database Syst Rev | year= 2018 | volume= 8 | issue=  | pages= CD007813 | pmid=30091808 | doi=10.1002/14651858.CD007813.pub3 | pmc=6513464 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30091808  }} </ref>
| -0.51 (95% CI -0.75 to -0.28)<br/> &bull; dexamphetamine: SMD -0.77, 95% CI -1.14 to -0.40; two studies, 35 participants<br/>&bull; lisdexamfetamine: SMD -0.33, 95% CI -0.65 to -0.01; three studies, 67 participants
| 2.69
|-
| Bupropion<ref name="pmid28965364">{{cite journal| author=Verbeeck W, Bekkering GE, Van den Noortgate W, Kramers C| title=Bupropion for attention deficit hyperactivity disorder (ADHD) in adults. | journal=Cochrane Database Syst Rev | year= 2017 | volume= 10 | issue=  | pages= CD009504 | pmid=28965364 | doi=10.1002/14651858.CD009504.pub2 | pmc=6485546 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28965364  }} </ref>
| -0.50 (95% CI -0.86 to -0.15)
| 1.20
|-
| Methylphenidate, immediate-release<ref name="pmid33460048">{{cite journal| author=Cândido RCF, Menezes de Padua CA, Golder S, Junqueira DR| title=Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults. | journal=Cochrane Database Syst Rev | year= 2021 | volume= 1 | issue= 1 | pages= CD013011 | pmid=33460048 | doi=10.1002/14651858.CD013011.pub2 | pmc=8092481 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33460048  }} </ref>
| -0.59, 95% CI -1.25 to 0.06; I<sup>2</sup> = 69%; 2 trials
|
|-
| Methylphenidate, extended-release<ref name="pmid35201607">{{cite journal| author=Boesen K, Paludan-Müller AS, Gøtzsche PC, Jørgensen KJ| title=Extended-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults. | journal=Cochrane Database Syst Rev | year= 2022 | volume= 2 | issue= 2 | pages= CD012857 | pmid=35201607 | doi=10.1002/14651858.CD012857.pub2 | pmc=8869321 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35201607  }} </ref>
| −0.37, 95% CI −0.43 to −0.30; I<sup>2</sup> = 0%; 16 trials
|
|-
| colspan="3" | * Interpretation of standard mean difference (SMD):<br/>0.2 represents a small effect<br/>0.5 a moderate effect<br/>0.8 a large effect
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}
[[Category:Psychiatry]]
[[Category:Pediatrics]]

Latest revision as of 20:39, 3 January 2024

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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]

Measurement-based care may help[2][3].

Practice guidelines are available[4]<[5]

Medical Therapy

Several different types of medications may be prescribed to mitigate the symptoms associated with ADHD. Approximately 3% of adults are treated with persistent medication[6].

The research on treatment is summarized within reviews by the Cochrane Developmental, Psychosocial & Learning Problems Group. '

  • 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.[7]
  • 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[8]. Atomoxetine carries a black box warning as there is an increase risk of suicidal ideation in adolescents[9]. While it is non-inferior to methylphenidate in children, its adverse effects in children and adolescents render it a less favorable treatment option.[10]
  • Non-stimulants such as extended release Guanfacine and Clonidine (both alpha-2 adrenergic agonists) are also used to treat ADHD[11].
  • Other drugs, including anti-depressants, may also be prescribed in cases of ADHD depending on the patient’s co-morbidities.[1]
Pharmacotherapy of adult ADHD
Standard mean difference (SMD)* for
patient-reported symptoms 		Discontinuation ratio
Amphetamines (dexamphetamine, lisdexamfetamine, mixed amphetamine salts)[12] -0.51 (95% CI -0.75 to -0.28)
• dexamphetamine: SMD -0.77, 95% CI -1.14 to -0.40; two studies, 35 participants
• lisdexamfetamine: SMD -0.33, 95% CI -0.65 to -0.01; three studies, 67 participants 		2.69
Bupropion[13] -0.50 (95% CI -0.86 to -0.15) 1.20
Methylphenidate, immediate-release[14] -0.59, 95% CI -1.25 to 0.06; I2 = 69%; 2 trials
Methylphenidate, extended-release[15] −0.37, 95% CI −0.43 to −0.30; I2 = 0%; 16 trials
* Interpretation of standard mean difference (SMD):
0.2 represents a small effect
0.5 a moderate effect
0.8 a large effect

References

  1. ↑ 1.0 1.1 1.2 National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."
  2. ↑ Bickman L, Kelley SD, Breda C, de Andrade AR, Riemer M (2011). "Effects of routine feedback to clinicians on mental health outcomes of youths: results of a randomized trial". Psychiatr Serv. 62 (12): 1423–9. doi:10.1176/appi.ps.002052011. PMID 22193788.
  3. ↑ Lawrence-Sidebottom D, Huffman LG, Huberty J, Beatty C, Roots M, Roots K; et al. (2023). "Using Digital Measurement-Based Care to Address Symptoms of Inattention, Hyperactivity, and Opposition in Youth: Retrospective Analysis of Bend Health". JMIR Form Res. 7: e46578. doi:10.2196/46578. PMC 10173032 Check |pmc= value (help). PMID 37099379 Check |pmid= value (help).
  4. ↑ Kooij JJS, Bijlenga D, Salerno L, Jaeschke R, Bitter I, Balázs J; et al. (2019). "Updated European Consensus Statement on diagnosis and treatment of adult ADHD". Eur Psychiatry. 56: 14–34. doi:10.1016/j.eurpsy.2018.11.001. PMID 30453134.
  5. ↑ Baughman DJ, Watson CM, Beich JW, Herboso MNJ, Cuttie LK, Marlyne AC (2023). "Recommendation for Long-term Management of Adult Attention-Deficit/Hyperactivity Disorder in Military Populations, Veterans, and Dependents: A Narrative Review". Mil Med. doi:10.1093/milmed/usad403. PMID 37878798 Check |pmid= value (help).
  6. ↑ Li L, Chang Z, Sun J, Jangmo A, Zhang L, Andersson LM; et al. (2022). "Association Between Pharmacological Treatment of Attention-Deficit/Hyperactivity Disorder and Long-term Unemployment Among Working-Age Individuals in Sweden". JAMA Netw Open. 5 (4): e226815. doi:10.1001/jamanetworkopen.2022.6815. PMC 9047436 Check |pmc= value (help). PMID 35476068 Check |pmid= value (help).
  7. ↑ 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
  8. ↑ 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.
  9. ↑ 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)
  10. ↑ 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.
  11. ↑ 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)
  12. ↑ Castells X, Blanco-Silvente L, Cunill R (2018). "Amphetamines for attention deficit hyperactivity disorder (ADHD) in adults". Cochrane Database Syst Rev. 8: CD007813. doi:10.1002/14651858.CD007813.pub3. PMC 6513464 Check |pmc= value (help). PMID 30091808.
  13. ↑ Verbeeck W, Bekkering GE, Van den Noortgate W, Kramers C (2017). "Bupropion for attention deficit hyperactivity disorder (ADHD) in adults". Cochrane Database Syst Rev. 10: CD009504. doi:10.1002/14651858.CD009504.pub2. PMC 6485546. PMID 28965364.
  14. ↑ Cândido RCF, Menezes de Padua CA, Golder S, Junqueira DR (2021). "Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults". Cochrane Database Syst Rev. 1 (1): CD013011. doi:10.1002/14651858.CD013011.pub2. PMC 8092481 Check |pmc= value (help). PMID 33460048 Check |pmid= value (help).
  15. ↑ Boesen K, Paludan-Müller AS, Gøtzsche PC, Jørgensen KJ (2022). "Extended-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults". Cochrane Database Syst Rev. 2 (2): CD012857. doi:10.1002/14651858.CD012857.pub2. PMC 8869321 Check |pmc= value (help). PMID 35201607 Check |pmid= value (help).


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