There is insufficient evidence to identify which child with ADHD will respond to psychosocial or drug treatments. All cases of ADHD should be initially treated with psychosocial interventions alone. This is usually sufficient for milder cases, while moderate to severe cases of ADHD need medication in conjunction with psychosocial interventions. Often psychiatric referral is indicated to optimise the complex mix of medication, targeted psychosocial and specific specialist services that are needed to maximise learning and development.3,4These services include speech therapy for speech and language disorders, educational remediation for learning disorders, and occupational therapy for developmental coordination disorder.
At present, there is insufficient evidence to support targeted dietary adjustments or free fatty acid supplementation (for example, fish oils).2,4
Psychosocial interventions
Appropriate psychosocial interventions include positive reinforcement of desired behaviours (including token systems), penalties for undesired behaviours, and contingency contracts for older children and adolescents. Learning techniques to self-manage stress and group social skills training have also proven helpful. In contrast, other psychosocial treatment approaches such as psychodynamic therapies are ineffective, aside from improving a given child's or parents' level of satisfaction that something is being done.2
Dexamphetamine and methylphenidate
The psycho stimulants dexamphetamine and methylphenidate remain the primary effective drug treatments for ADHD.2,4 They do not differ in effectiveness or adverse effects, although individual patients may appear to respond better to one than to the other.
These drugs decrease ADHD symptoms, improve cognitive deficits (for example, attention, memory and working memory), decrease academic and social impairments due to ADHD, improve quality of life for children and their families, and increase adherence and learning from psychosocial interventions. These effects were evident in short-term (4–6 weeks) and long-term (1–2 years) controlled trials.
Psycho stimulant medications are thought to work by increasing the functional activity of dopamine and noradrenaline through inhibiting their presynaptic uptake. These actions appear to facilitate compensatory brain neural networks that promote more situation-appropriate cognitions, emotions and behaviour in a child with ADHD.5The effects are dose-dependent for hyperactivity/impulsiveness, while, in a subgroup of children, attention and working memory improve at low doses but can become impaired at high doses.
The clinical effects of dexamphetamine and methylphenidate last for 3–4 hours on average, necessitating 2–3 times daily dosing. Modified-release formulations of methylphenidate are available in Australia with the primary advantage of once-daily dosing which aids adherence. The medication can be taken every day during the week with a break on weekends. This is an option that some families may prefer because of mild adverse effects (for example mild initial insomnia) or for ideological reasons (they want their child to use the least amount of medication possible).
Initiating and monitoring drug therapy
Paediatricians, psychiatrists and neurologists are approved prescribers of psycho stimulant medication in Australia and should initiate and optimise the dosage in children with ADHD. General practitioners can be approved (through their state drug regulatory authority) to provide maintenance doses when working with a paediatrician or child psychiatrist. They can monitor for specific beneficial and adverse effects of psycho stimulant medication and seek a second opinion if unsure of either.
Before starting psycho stimulant drug therapy, children with pre-existing heart disease, a strong family history of heart disease or current symptoms and signs suggesting heart disease, require ECG monitoring.6
To assess for therapeutic and adverse effects in the early phase of treatment, children should be carefully monitored by their parent(s) for the first five days with weekly consultations by phone or in person. Dosing is usually optimised after 1–2 weeks, and then weekly to monthly face-to-face monitoring is recommended. Each child should be thoroughly reassessed every six months and their requirement for psycho stimulant medication re-evaluated. This involves a comprehensive diagnostic reassessment (including risk and resilience factors) and re-targeting of medication or psychosocial treatments to minimise impairment and maximise adaptation. Withdrawal of psycho stimulant medication should be considered to evaluate whether ADHD symptoms re-emerge.
Stopping treatment
Psycho stimulant treatment should be ceased if there is no beneficial effect at home or at school, unacceptable adverse effects emerge in the short- or long-term, or the legal guardian of the child requests a trial of an alternative treatment.
If psycho stimulant medication is ceased, it should be withdrawn gradually decreasing by one tablet per day until finished for short-acting preparations, and by switching from a long-acting to an equivalent short-acting form and then decreasing gradually until finished. Children should be monitored carefully over the following 1–2 weeks for re-emerging ADHD symptoms.
Adult use
Occasionally, psycho stimulant medication will need to be continued into adult life. The abuse potential of such drugs has been repeatedly noted in the media. Interestingly, the pharmacodynamic and pharmacokinetic properties of psycho stimulant medication and methamphetamine (the illegal form of amphetamine) differ to the extent that psycho stimulant medication has a much lower potential for abuse.
Adverse effects
Key adverse effects are all dose-dependent and can be managed through subtle dose reduction. Appetite suppression and initial insomnia are the most common adverse effects, along with nervousness, dysphoria, nausea and headache early in treatment. Motor or vocal tics and growth retardation (of small effect) can occur. Rarer adverse effects are vomiting, rash, dizziness, weight loss and irritability.
Other medications
When psycho stimulant medication is ineffective, has adverse effects such as emotional disturbance or worsening of tics, or is not a treatment option that a patient will use, alternative options can be considered.2,4These involve additional types of medication or specific psychosocial interventions known to ameliorate ADHD symptoms when mastered and put into practice by children with ADHD and their families.
Atomoxetine
Atomoxetine is the current second-line treatment for ADHD. It is a potent reuptake inhibitor of noradrenaline at the presynaptic terminal and is of some benefit for children with ADHD in the short and long terms. It has a longer duration of action than psycho stimulant medication and can be helpful during the evening and sleep as well as during the day. Its adverse effects profile is similar to psycho stimulant medication. Initial insomnia, appetite suppression, irritability and nervousness are the most common adverse effects along with nausea and headache. There is a precaution in the product information that atomoxetine may increase the risk of suicidal ideation.
Imipramine
Imipramine, a tricyclic antidepressant, is a current third-line treatment for ADHD, although it is being virtually phased out of routine clinical practice. It is similar to atomoxetine although it has significant potential for cardiac adverse effects, mainly cardiac arrhythmias and/or conduction defects.
Clonidine
Clonidine, a central adrenergic agonist that reduces the presynaptic release of noradrenaline, is an alternative to imipramine. It can be used when other options are ineffective or contraindicated. Clonidine decreases the hyperactivity/impulsiveness symptoms more than inattention at low doses, while there is some evidence of improved attention at higher doses.
Neuroleptic drugs
Atypical antipsychotics (for example, risperidone) and the sedative antipsychotics (for example, pericyazine) have limited benefit on core ADHD symptoms and unreliably improve cognition. However, they can be of benefit when there is severe co-occurring aggression or irritability/affective instability. Specialist assessment is required before these medications are prescribed, given the potential for drug interactions and effects on the psychosocial treatments being applied.
Drug combinations
Every attempt should be made to use a single medication that maximises benefits and minimises adverse effects. However, combinations of medication are frequently required that target specific key symptoms associated with impairment, for example psycho stimulants and clonidine to aid initial insomnia. Specialist advice is always recommended when drug combinations are used.