Treatment options for ADHD

The aim of treatment is to manage the symptoms of ADHD and improve psychological, social, educational and occupational functioning.¹ In this respect, treatment should encompass pharmacological and behavioural approaches.

Due to the chronic nature of ADHD, a management programme should be put in place that takes into account the need for treatment and monitoring over time.² A guide to managing ADHD may involve setting out desired improvements following discussions with the patient, the treating clinician and, if appropriate, parents, carers and school teachers. It may also be appropriate to set goals for treatment.²

Treatment – including psychological interventions, education, medication and diet – should be individualised for the patient according to their treatment plan.³

The basis of any treatment for ADHD is likely to be education, including learning about ADHD; from an awareness of the symptoms and its aetiology, to its clinical course, prognosis and treatment.³ Education on how to cope with the emotional as well as the physical impact of the disease can be beneficial to parents and patients (whether children, adolescents or adults). Some patients have expressed a sense of relief at finally receiving a diagnosis that explained their behaviour, and the need then to accept ADHD as a chronic condition that is part of their and their family’s lives.⁴

Multimodal treatment

Following a differential diagnosis, it is recommended that treatment for ADHD involves the integration of different approaches (see Guidelines for ADHD). Optimal treatment for ADHD is multimodal, involving psychosocial intervention to promote prosocial behaviour and medication-based therapy to address ‘biological’ symptoms (eg inattention).⁵

Psychological and behavioural therapy encompass a range of techniques, including psychoeducational input, behavioural therapy, cognitive behavioural therapy and parent management training;³ all aim to encourage the development of coping strategies for managing the behavioural disturbance of ADHD. Psychological interventions are effective as an adjunct to usual care medication.⁶

Medication-based treatment includes stimulants, such as methylphenidate and dexamfetamine, and mixed amphetamine salts or nonstimulants, such as atomoxetine.⁷ The availability of long-acting formulations of some stimulants eliminates the burden of medication administration during the school day, improves adherence with therapy and decreases the opportunity for abuse.⁷ Medication can be complemented by psychological and behavioural therapy, with the possibility of needing a significantly lower dose of medication.¹

Current thinking in ADHD
A greater recognition of ADHD in adults has led to a call for effective treatments beyond pharmacotherapy in these patients. A study of short-term individual cognitive behavioural therapy and cognitive training found that cognitive behavioural therapy was associated with a significant improvement in attention and memory scores compared with control patients who received no such therapy, while cognitive training resulted in a marked improvement in trained tasks. Most patients who took part in the study were already receiving medication. This was the first study to examine the effects of cognitive training in adults with ADHD; cognitive training in adults had been hypothesised to be less beneficial than in children because of the reduced plasticity of the adult brain. Short-term cognitive behavioural therapy was deemed to be more effective than cognitive training. The authors believed that "the participants who were most motivated to learn new adaptive skills benefited most from the cognitive behavioural therapy."⁸

References

1. American Academy of Paediatrics 2011. Subcommittee on attention-deficit/hyperactivity disorder, steering committee on quality improvement and management. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics 2011 Oct 16. [Epub ahead of print]
2. Remschmidt H. Global consensus on ADHD/HKD. Eur Child Adolesc Psychiatry 2005; 14: 127-137.
3. Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder – first upgrade. Eur Child Adolesc Psychiatry 2004; 13 (Suppl 1): I7-30.
4. National Institute for Health and Clinical Excellence (NICE). Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults, 2008. Accessed 8 August 2011.
5. Kutcher S, Aman M, Brooks SJ, et al. International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions. Eur Neuropsychopharmacol 2004; 14: 11-28.
6. MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Multi-modal Treatment Study of Children with ADHD. Arch Gen Psychiatry 1999; 56: 1073-1086.
7. Rader R, McCauley L, Callen EC. Current strategies in the diagnosis and treatment of childhood attention-deficit/hyperactivity disorder. Am Fam Physician 2009; 79: 657-665.
8. Virta M, Salakari A, Antila M, et al. Short cognitive behavioral therapy and cognitive training for adults with ADHD – a randomized controlled pilot study. Neuropsychiatr Dis Treat 2010; 6: 443-453.