Q. What are behavioral treatments?
A. There are various forms of behavioral interventions used for children with ADHD, including psychotherapy, cognitive-behavioral therapy, social skills training, support groups, and parent and educator skills training. An example of very intensive behavior therapy was used in the NIMH Multimodal Treatment Study of Children with ADHD (MTA), which involved the child’s teacher, the family, and participation in an all-day, 8-week summer camp. The consulting therapist worked with teachers to develop behavior management strategies that address behavioral problems interfering with classroom behavior and academic performance. A trained classroom aide worked with the child for 12 weeks in his or her classroom, to provide support and reinforcement for appropriate, on-task behavior. Parents met with the therapist alone and in small groups to learn approaches for handling problems at home and school. The summer day camp was aimed at improving social behavior, academic work, and sports skills.
Q. What medications are currently being used to treat ADHD?
A. Psychostimulant medications, including methylphenidate (Ritalin®) and amphetamines (Dexedrine®, Dextrostat®, and Adderall®), are by far the most widely researched and commonly prescribed treatments for ADHD. Numerous short-term studies have established the safety and efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD. NIMH research has indicated that the two most effective treatment modalities for elementary school children with ADHD are a closely monitored medication treatment and a treatment that combines medication with intensive behavioral interventions.
In the NIMH Multimodal Treatment Study for Children with ADHD (MTA), which included nearly 600 elementary school children across multiple sites, nine out of ten children improved substantially on one of these treatments. Additionally, antidepressant medications may also be used as a second line of treatments for children who show poor response to stimulants, who have unacceptable side effects, or who have comorbid conditions (such as tics, anxiety, or mood disorders). Tricyclic antidepressants have shown clinical efficacy in 60-70% of children with ADHD. While the medications were extremely beneficial to most children, MTA findings indicated that medications alone may not necessarily be the best strategy for many children. For example, children who had accompanying problems (e.g., anxiety, stressful home circumstances, social skills deficits, etc.), over and above the ADHD symptoms, appeared to obtain maximal benefit from the combined treatment.
Q. Are there standard doses for these medications?
A. Careful medication management is important in treating a child with ADHD. For methylphenidate (Ritalin®), the usual dosage range is 5 to 20 mg given two to three times a day. The dose for amphetamines (Dexedrine® and Dextrostat® and Adderall®) is one-half the methylphenidate dose. Dosage requirements do not always correlate with weight, age or severity of symptoms in an individual patient. Dosages may need to be increased during childhood with increased lean body weight and decreases may be necessary after puberty. Different doctors use these medications in slightly different ways.
Q. How long are children on these medications?
A. The expected duration of treatment has lengthened during this past decade as evidence has accumulated that benefits extend into adolescence and adulthood. However, many factors work against continued treatment during adolescence including the partial resolution of the most obvious symptoms, the short-lasting effects of medications that require multiple doses per day, and the need for regular physician written prescriptions. Additionally, parents often discontinue medication even when benefit has been demonstrated or because they see the child improve and don’t think the medication is necessary any longer.
Q. How often are stimulant prescriptions used?
A. Data from 1995 show that physicians treating children and adolescents wrote six million prescriptions for stimulant medications—methylphenidate (Ritalin®) and dextroamphetamine (Dexedrine®). Of all the drugs used to treat psychiatric disorders in children, stimulant medications are the most thoroughly studied.
Q. Isn’t stimulant use on the increase?
A. Stimulant use in the United States has increased substantially over the last 25 years. A recent study saw a 2.5-fold increase in methylphenidate between 1990 and 1995. This increase appears to be largely related to an increased duration of treatment, and more girls, adolescents, adults, and inattentive individuals (in addition to those individuals with both hyperactivity and inattentiveness/attention deficit) receiving treatment.
Q. Are there differences in stimulant use across racial and ethnic groups?
A. There are significant differences in access to mental health services between children of different racial groups; and, consequently, there are differences in medication use. In particular, African American children are much less likely than Caucasian children to receive psychotropic medications, including stimulants, for treatment of mental disorders.