Treatment of Attention Deficit Disorder
How is ADD Treated?
First-line treatment (the preferred/recommended initial approach) for ADD includes the use of what are called psychostimulants (AKA “stimulant”) medications. These are recommended as first-line by the American Academy of Child and Adolescent Psychiatry and are suggested as a first step, even before behavioral/therapeutic interventions. Psychostimulants work on dopamine systems in the prefrontal cortex (PFC) of the brain. This area is in charge of “executive functioning” – the mental processes that enable us to remain attentive, inhibit or modulate behavior, and establish/plan for/achieve goals. Patients taking psychostimulants are calmer, more alert, more focused, and better able to access and use important memories to guide behavior. Long-acting psychostimulants, which are designed to last for 6-12 hours, are usually taken once a day in the morning, as they impart energy and alertness and disrupt sleep if taken in the evening. There are also short-acting psychostimulants that impart shorter duration of effect (2-4 hours) and can be dosed 2-3 times per day. They may also be taken once daily after a single, long-acting dose has worn off to ensure coverage of ADD symptoms in the afternoon/evening.
Evidence shows that stimulant medications are superior to non-stimulants in the treatment of ADD. However, there are non-stimulant medications that can be helpful in treating ADD. These may be used when stimulants are not well tolerated, are contraindicated, or are inadequate to manage all symptoms. Alpha-agonists are a commonly prescribed class of medications. Although originally used as centrally acting antihypertensive agents, alpha-agonists have been found to strengthen regulation of attention and behavior. These medications can also reduce hyperactivity and impulsive aggression. Alpha-agonists are also commonly prescribed for those who struggle with ADD symptoms in the evening, when additional doses of psychostimulants cannot be used (because stimulants may disrupt sleep; more on this below). The sedating properties of alpha-agonists usually occur immediately, but improvements on hyperactivity and impulsive behavior may take 3 weeks to be appreciated. These medications have a half-life of 16-18 hours and may help users to be calmer throughout the day and/or night, depending on when they are taken.
Though dopaminergic systems are thought to be strongly implicated in executive functioning, norepinephrine is also thought to influence the behavioral and cognitive symptoms of ADD. Atomoxetine, or Strattera, selectively inhibits norepinephrine in the brain and has been FDA approved for treatment of ADD. Strattera can be especially helpful in treating those with ADD and co-occurring anxiety, tics, depression, or Tourette’s Syndrome. Strattera’s effects on ADHD last 24-hours and do not wax and wane over the course of a day. However, it can take at least 6 weeks for Strattera to impart therapeutic effect.
What Are the Treatment Side Effects?
Psychostimulants are a wonderful tool for many that can be taken in the short- and long-term. However, this class of medication is not for everyone. Like all medications, there are side effects, including appetite suppression and sleep disturbance. If taken late in the day, stimulants interfere with sleep, including falling asleep, staying asleep or even producing early morning wakeup.
It is quite common for those talking psychostimulants to experience appetite suppression. Many lack an appetite at midday/lunchtime and experience rebound hunger later in the day. There are many ways to manage appetite suppression so that it does not lead to untoward consequences. It can help to give children a “medication holiday” from psychostimulants during weekends, holiday breaks, and summer vacation, (when attentional demands are low), to allow for additional calorie consumption and accelerated rate of growth. Psychostimulants can also slow a child’s progress along their growth curve, though projections for height and weight are usually eventually attained; medication holidays are very helpful in this regard, as well.
Psychostimulants are contraindicated in those with structural abnormalities of the heart or arrhythmias. Additionally, they come with a Black Box Warning stating that stimulants “have a high potential for abuse…Particular attention should be paid to the possibility of subjects obtaining stimulants for non-therapeutic use or distribution to others, and the drugs should be prescribed or dispensed sparingly.” Long-acting stimulants are more difficult to abuse, as their sustained-release pharmacokinetic properties do not allow the user to achieve a high. Immediate-release formulations, however, are more easily diverted for non-therapeutic benefit. Use of psychostimulants as prescribed does not typically result in dependence. Nonetheless, parents should monitor their children’s use of psychostimulants closely. Sudden death has also been reported in association with CNS stimulant treatment in children and adolescents with structural cardiac abnormalities or serious heart problems.
With non-stimulant medications, side effects are milder and easier to tolerate. Abuse/dependence are not considerations and appetite and sleep disturbance do not typically occur with non-stimulants. Alpha-agonists may cause hypotension (low blood pressure), bradycardia (low heart rate), dry mouth, constipation, or headaches, which typically occur at the outset of treatment and improve with time.
Strattera is generally well tolerated but may cause some side effects initially, including nausea, vomiting, fatigue, and somnolence. If drowsiness occurs, it is usually recommended that Strattera be taken at bedtime. Strattera is not prescribed to those taking MAOIs or who have narrow-angle glaucoma. Additionally, Strattera is not recommended for those with severe cardiovascular disorders, as it may raise heart rate and blood pressure. Additionally, Strattera comes with an FDA Black Box Warning indicating that children/teens/young adults who take it may experience increased suicidal thoughts or actions.
Are There Behavioral or Lifestyle Changes That Can Treat ADD?
Though medication side effects can often be managed, psychotropic medication may not be a good fit for everyone. There are some alternatives that can be employed in such cases.
Studies have found that those who are consistently physically active – whether it be with team sports, individual workouts, or other physical exertion – tend to require lower doses of psychostimulants to manage their ADD symptoms. Expending excess energy, especially through cooperative team sports or other prosocial activities, can help to reduce hyperactivity, impulsivity, and restlessness while also helping young people with ADD to build their social skills and friendships.
Families may also wish to seek out the expertise and support of coaches who specialize in enhancing executive functioning skills. Local coaches and resources can be found with a simple online search. Schools are also able to provide accommodations for children with attentional and behavioral challenges. Students with ADD should be evaluated for an “Individual Education Plan” (IEP), which can provide students with accommodations like additional academic support, extended time on tests and quizzes, testing in separate/quiet environments, smaller classroom sizes, support of a paraprofessional, and/or group and individual counseling. Consulting with your child’s school about their learning needs can be a key step to empowering young people as students and helping them to feel capable and supported.
Additionally, because many young people with ADD do not sleep well, ensuring consistent and restful sleep can be key to reducing daytime symptoms. Having a consistent bedtime routine and bedtime, sleeping in a cool/quiet/dark room, and the use of white or brown noise can help to improve sleep initiation and quality. Additional coaching on sleep hygiene with a therapist or psychiatrist may be helpful.
Some also find it helpful to reduce or eliminate dietary ingredients that exacerbate symptoms. This may mean reducing or eliminating things like sugar and artificial food dyes. Integration of omega-3 fatty acids into the diet has been shown to modestly reduce ADD symptoms. Elimination of certain artificial dyes, like those found in many common American snacks, can also help to reduce hyperactivity symptoms. However, it should be noted that dietary changes are not usually sufficient in treating/resolving ADD symptoms.