Académique Documents
Professionnel Documents
Culture Documents
management
Attention decit hyperactivity disorder management modication for ADHD are eective.[7]
are the treatment options available to people with As of 2006 there was a shortage of data regarding ADHD
attention-decit/hyperactivity disorder (ADHD).
drugs potential adverse eects,[8] with very few studies
There are several eective and evidence-based options assessing the safety or ecacy of treatments beyond four
to treat people with ADHD. The American Academy months,[9] and no randomized controlled trials assessing
of Pediatrics recommends dierent treatment paradigms for periods of usage longer than two years.[10][11]
depending on the age of the person being treated. For
those aged 45, the Academy recommends evidencebased parent- and/or teacher-administered behavior ther- 1 Psychosocial
apy, with the addition of methylphenidate only if there
is continuing moderate-to-severe functional disturbances.
There are a variety of psychotherapeutic approaches
For those aged 611, the use of medication in combiemployed by psychologists and psychiatrists; the one
nation with behavior therapy is recommended, with the
used depends on the patient and the patients sympevidence for stimulant medications being stronger than
toms. The approaches include psychotherapy, cognitivethat for other classes. For those aged 1218, medication
behavior therapy, support groups, parent training, medishould be prescribed with the consent of the treated adotation, and social skills training.
lescent, preferably in combination with behavioral therapy. The evidence for the utility of behavioral interventions in this aged group was rated only C quality, 1.1 Parent education and classroom manhowever.[1]
agement
2 MEDICATIONS
1.3
Timers
Timers have been found to be eective for allowing people with ADHD to concentrate more eectively on the
task at hand.[15] When a target is set, one method is to
only turn the timer on whilst working on the given task.
A physical stopwatch or an online timer may be used.
2
2.1
Medications
Stimulants
Stimulants are the most commonly prescribed medications for ADHD. The most common stimulant
medications are methylphenidate (Ritalin, Metadate,
Concerta),
dexmethylphenidate (Focalin),
dextroamphetamine
(Dexedrine),
amphetamine
(Adderall),[16] methamphetamine (Desoxyn)[17] and
lisdexamfetamine (Vyvanse).[18] According to several
studies, use of stimulants (e.g. methylphenidate) can
lead to development of drug tolerance to therapeutic
doses; tolerance also occurs among high dose abusers
of methylphenidate.[19] Controlled-release pharmaceuticals may allow once or twice daily administration of
medication in the morning. This is especially helpful
for children who do not like taking their medication in
the middle of the school day. Several controlled-release
methods are used.
Stimulants used to treat ADHD raise the extracellular concentrations of the neurotransmitters dopamine
and norepinephrine, which increases cellular communication between neurons that utilize these compounds.
The therapeutic benets are due to noradrenergic effects at the locus coeruleus and the prefrontal cortex
and dopaminergic eects at the ventral tegmental area,
nucleus accumbens, and prefrontal cortex.[20][21]
Stimulant medications are considered safe when used under medical supervision.[6] Nonetheless, there are concerns that the long term safety of these drugs has not
been adequately documented.[8][9][11][22] and social and
ethical issues regarding their use and dispensation. The
U.S. FDA has added black-box warnings to some ADHD
medications, warning that abuse can lead to psychotic
episodes, psychological dependence, and that severe
2.1.1 Amphetamine
Further information: Amphetamine Medical and
Amphetamine Pharmaceutical products
2.2
Non-stimulants
Amphetamine is a chiral compound which is composed of two isomers: levoamphetamine and dextroamphetamine. Levoamphetamine and dextroamphetamine
have the same chemical formula but are mirror images
of each other, the same way that a persons hands are
the same but are mirror images of each other. This
mirror dierence is enough to cause the two compounds to be metabolized dierently. Three dierent amphetamine-based pharmaceuticals are currently
used in ADHD treatment: Adderall, dextroamphetamine,
and lisdexamfetamine.[34] Lisfexamfetamine is an inactive prodrug of dextroamphetamine (i.e., lisdexamfetamine itself doesn't do anything in the body, but it
metabolizes into dextroamphetamine).[34] Adderall is a
proprietary mixture of (75%) dextroamphetamine and
(25%) levoamphetamine salts, which results in very
mild dierences between their eects.[34] Adderall begins to work before dextroamphetamine because of
levoamphetamine.[35] Levoamphetamine also provides
Adderall with a longer clinical eect than dextroamphetamine. Some children with ADHD and comorbid
disorders respond well to levoamphetamine.[26]
Methylphenidate
2.2 Non-stimulants
2.1.2
Dextromethamphetamine
The body metabolizes dextromethamphetamine into dextroamphetamine (in addition to less active metabolites).
A quarter of dextromethamphetamine will ultimately become dextroamphetamine.[36] After comparing only the
common ground between dextroamphetamine and dextromethamphetamine, the latter is said to be the stronger
stimulant.[37] In theory and in practice a larger
dose of dextroamphetamine is needed to achieve dextromethamphetamines clinical potency. In fact, when
dextroamphetamine and methylphenidate are unhelpful,
some doctors may prescribe dextromethamphetamine.
Although more rarely prescribed, anecdotal reports suggest dextromethamphetamine is very helpful in cases
where the other two are ineective, or cause limiting side
eects.[38]
2.1.3
Methylphenidate-based medications
2.3
Other
Antipsychotic medication
The use of atypical antipsychotic medication as an olabel treatment has been rising.[59] Antipsychotics work
by blocking dopamine, whereas stimulants trigger its release. Atypical antipsychotics have been approved for
use in children and teenagers with schizophrenia spectrum disorders and autistic spectrum disorders by the
U.S. FDA.[60]
4.4
The CDC notes that community samples suggest the incidence of ADHD in American children is higher than
the ve percent stated by the American Psychiatric Association in DSM-5.[130] Using data from the 20112012
survey, CDC estimates that diagnoses rates in the U.S. are
15% for boys and 7% for girls.[131] Approximately twothirds of children with current diagnoses are prescribed
stimulants.[129] Likewise, there is concern about the rising
use of methylphenidate (Ritalin), mainly to treat ADHD
and similar disorders, in the UK.[132]
4.2
Medication in preschoolers
Parents of children with ADHD note that they usually display their symptoms at an early age. There have been few
longitudinal studies on the long-term eects psychostimulants have on children.[133] The use of stimulant medication has not been approved by the FDA for children
under the age of six.[134] A growing trend is the diagnosis of younger children with ADHD. Prescriptions for
children under the age of 5 rose nearly 50 percent from
2000 to 2003.[135][136] Research on this issue has indicated that stimulant medication can help younger children
with severe ADHD symptoms but typically at a lower
dose then older children. It was also found that children
at this age are more sensitive to side eects and should
be closely monitored.[134] Evidence suggests that careful
assessment and highly individualized behavioural interventions signicantly improve both social and academic
skills,[137][138] while medication only treats the symptoms
of the disorder. One of the primary reasons cited for
the growing use of psychotropic interventions was that
many physicians realize that psychological interventions
are costly and dicult to sustain.[139]
4.3
4.3.1
Side eects
Growth delay and weight loss
5
4.3.2 Cardiovascular side eects
There is concern that stimulants and Atomoxetine, which
increase the heart rate and blood pressure, might cause
serious cardiovascular problems.[143] The current US
FDA position on ADHD stimulants is that they are not
likely to induce serious adverse cardiovascular events,
unless there is already a pre-existing cardiovascular
condition.[123][124][125][126]
Children, young adults, and adults taking ADHD medications are no more likely to suer sudden cardiac death,
stroke, or heart attack than members of the general
population.[123][124][125][126]
4.3.3 Psychiatric side eects
Many of these drugs are associated with physical
and psychological dependence.[144] Sleep problems may
occur.[145]
Increased rates of psychosis and/or mania are associated
with many stimulants used to treat ADHD, including
Concerta, Ritalin LA, d-MPH, Atomoxetine, Adderall
XR, Modanil, MTS, and Metadate. A 2009 FDA review of 49 clinical trials found that one to two percent of
children taking stimulants for ADHD experienced hallucinations or other psychotic episodes. Nearly half of
these were under the age of eleven, and approximately
90% had no history of similar psychiatric events. Hallucinations involving snakes, worms or insects were the
most commonly reported.[146][147] Even this incidence
rate may be low, however, since the clinical trials often excluded children with previous, adverse reactions to
ADHD medication.[146]
On occasion, treatment-emergent psychosis can emerge
during long-term therapy with methylphenidate. Stimulants such as methylphenidate should be avoided in people
who have a vulnerability to schizophrenia or addiction,
but psychotic symptoms may emerge even in individuals
without these risk factors. Regular psychiatric monitoring of people who are taking methylphenidate for adverse
eects such as psychotic symptomatology (with regard to
the need for dose adjustment or discontinuation of medication) has been recommended.[148]
The long-term eects on mental health disorders in later
life of chronic use of methylphenidate is unknown.[149]
6 HISTORY
methylphenidate decreases abnormalities in brain structure and function found in subjects with ADHD, and improves function of the right caudate nucleus.[152][153][154]
5 Cost-eectiveness
Combined medical management and behavioral treatment is the most eective ADHD management strategy, followed by medication alone, and then behavioral
treatment.[24] In terms of cost-eectiveness, management
with medication has been shown to be the most costeective, followed by behavioral treatment, and combined treatment.[24] The individually most eective and
cost-ecient way is with stimulant medication. Additionally, long-acting medications for ADHD, in comparison to short-acting varieties, generally seem to be costeective.[172] Comorbid (relating to two diseases that
Stimulant withdrawal and rebound ef- occur together, e.g. depression and ADHD) disorders
makes nding the right treatment and diagnosis much
fects
more costly than when comorbid disorders are absent.
4.5
4.6
Cancer
were invented in 1999 that eliminated the need for multiple doses across the day or taking medication at school.
These new systems include pellets of medication coated
with various time-release substances to permit medications to dissolve hourly across an 812 hour period (Metadate CD, Adderall XR, Focalin XR) and an osmotic pump
that extrudes a liquid methylphenidate sludge across an
812 hour period after ingestion (Concerta).
In 2003, atomoxetine (Strattera) received the rst FDA
approval for a nonstimulant drug to be used specically for ADHD. In 2007, lisdexamfetamine (Vyvanse)
becomes the rst prodrug to receive FDA approval for
ADHD.
7.3
Nature
7
helps those with ADHD self-regulate and improve
learning.[181][182] On the other hand, ADHD may experience great diculty disengaging from the game,
which may in turn negate any benets gained from these
activities,[183] and time management skills may be negatively impacted as well.[184]
7.3 Nature
Children who spend time outdoors in natural settings, such as parks, seem to display fewer symptoms of ADHD, which has been dubbed Green
Therapy.[185][186]
Alternative medicine
7.1
Neurofeedback
7.2
Media
Preliminary studies have supported the idea that playing video games is a form of neurofeedback, which
7.5
REFERENCES
Diets
physicians may be reluctant to use them. Others are comfortable using them and even advocate for a stimulant trial
Main article: Diet and attention decit hyperactivity when ADHD co-occurs with tics, because the symptoms
disorder
of ADHD can be more impairing than tics.[203][206]
Perhaps the best known of the dietary alternatives is the
Feingold diet which involves removing salicylates, articial colors and avors, and certain synthetic preservatives
from childrens diets.[196] However, studies have shown
little if any eect of the Feingold diet on the behavior of
children with ADHD.[197]
Results of studies regarding the eect of eliminating articial food coloring from the diet of children with ADHD
have been very varied. It has been found that it might
be eective in some children but as the published studies
have been of low quality results can be more related to
research problems such as publication bias.[198] The UK
Food Standards Agency (FSA) has called for a ban on
the use of six articial food colorings[199] and the European Union (EU) has ruled that some food dyes must be
labeled with the relevant E number as well as this warning: may have an adverse eect on activity and attention
in children. [200] Nevertheless, existing evidence neither
refutes nor supports the association between ADHD and
food colouring.[201]
Comorbid disorders
8.1
Tic disorders
Patients with Tourette syndrome who are referred to specialty clinics have a high rate of comorbid ADHD. Patients who have ADHD along with tics or tic disorders
may also have problems with disruptive behaviors, overall functioning, and cognitive function, accounted for by
the comorbid ADHD.[202]
The treatment of ADHD in the presence of tic disorders
has long been a controversial topic. Past medical practice held that stimulants (such as Ritalin) could not be
used in the presence of tics, due to concern that their
use might worsen tics;[203] however, multiple lines of research have shown that stimulants can be cautiously used
in the presence of tic disorders.[204][165] Several studies
have shown that stimulants do not exacerbate tics any
more than placebo does, and suggest that stimulants may
even reduce tic severity.[205] Controversy remains, and
the PDR continues to carry a warning that stimulants
should not be used in the presence of tic disorders, so
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