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- Data comparing the efficacy of behavioral or educational therapy versus pharmacologic management are limited. Prevailing opinion favors a multimodal approach in which nonpharmacologic therapies can be used to target comorbid conditions or behaviors that have not responded to medication.
- Educational interventions are recommended, particularly in the setting of learning disabilities. Children with AD/HD are entitled to reasonable educational accommodations under a 504 Plan or the Individuals with Disabilities Education Act.
- Behavioral interventions (e.g., goal setting and rewards systems) show short-term efficacy and are endorsed by most national organizations (e.g., American Academy of Pediatrics, American Medical Association). Time management and organizational skills appear useful (but have not been studied).
- Psychotherapy (cognitive behavioral, group, social skills, and parent training) may be beneficial, particularly when there is coexisting psychiatric disease.
- Many support/advocacy groups provide education and other resources (e.g., Children and Adolescents with AD/HD, National ADD Association, American Academy of Child and Adolescent Psychiatry).
ACUTE GENERAL Rx
- Most studies on treatment of AD/HD performed in children. Limited data on adults.
- Mainstay of treatment is drug therapy, particularly stimulants and atomoxetine. Second-line therapies include antidepressants and alpha-agonists.
- Release/block uptake of dopamine and norepinephrine.
- Include short- and long-acting methylphenidate (Ritalin, Concerta), dextroamphetamine/amphetamine combinations (Adderall).
- Do not cause euphoria or lead to addiction when taken as directed.
- Improve cognition, inattention, impulsiveness/hyperactivity, and driving skills. Limited effect on academic performance, learning, and emotional problems.
- Side effects are mild, reversible, and dose dependent. Include anorexia, weight loss, sleep disturbances, increased heart rate/blood pressure, nervousness/irritability, headache, onset or worsening of motor tics, reduction of growth velocity (but not adult height). Do not worsen seizures in patients on adequate anticonvulsant therapy. Rebound of symptoms can occur with withdrawal of medication.
- All equally effective; however, not all patients improve with stimulants. Patients who do not respond well to one stimulant may respond to another.
- Atomoxetine (Strattera):
- Selective norepinephrine reuptake inhibitor that is approved for use in patients >6 years old.
- Efficacy/safety of long-term use has not been studied. Reports of behavioral abnormalities and increased suicidality in children.
- Side effects: gastrointestinal upset, sleep disturbance, decreased appetite, dizziness, sexual side effects in men.
- Monitor liver function as there have been reports of severe liver injury in adults and children.
- Antidepressants (bupropion, imipramine, nortriptyline):
- May be useful in patients with coexisting psychiatric disorders.
- Studies comparing efficacy versus stimulants are inconclusive.
- Side effects: arrhythmias, anticholinergic effects, lowering of seizure threshold.
- Use of medications, particularly stimulants (which are monitored under the Controlled Substance Act), require frequent monitoring.
- While symptoms may change over time, for many patients, AD/HD represents a chronic condition that requires lifelong management.
- Patients are at higher risk for academic underachievement, lower SES, work and relationship difficulties, high-risk behavior, and psychiatric comorbidities.