Treatment



__Treatment__

Since the DSM IV defined the criteria for ADHD in 1989, finding the most effective treatment both in minimization of symptoms and minimal overall harm to the clients lifestyle and wellbeing is not an easy task. From 1990 to 1999 over nine hundred thousand cases were diagnosed as ADHD, with a significant rise comes the question on how to treat these increasing number of cases (Diller, 1998, p.2). Treatments that have had proven success include: pharmacotherapy, parent training/counselling, parental and classroom applications of contingency management, and cognitive behavioural therapy (Gordon, 2002, p. 402). The three main areas of focus in terms of intervention include:

**1) ** **Child and parent intervention (ex. Changing consequences of behaviour)** Interventions and parent specific information. Child interventions include: self monitoring and regulations of deficits in a child’s impulsivity, poor organizational skills and difficulty adhering to authority. The goal is to build a child’s self awareness of their behaviour and less reliant on the contingency management of adults. Research has shown in these areas are not as successful as children need constant reinforcement.

For parent interventions included education of ADHD and the best approaches in specific setting, as well as, creating a token reinforcement at home. These forms of intervention have been shown to be successful for many of the behavioural components of ADHD; however, a parent’s motivation to adhere to this system affects the ability to maintain this consistency within the home (Gordon, 2002, p. 403-405).

 ** This form of intervention is mostly seen within the classroom. Teachers, staff and peers follow a contingency management program that focus on task related modifications to increase the productivity of the child. For example, peer tutoring, the immediate corrections of an incorrect answer and a reinforcement system. The reinforcement system is the most influential and effective when trying to minimize the symptoms of ADHD. A good system of reinforcement should have the following: a good rate of reinforcement, variability of rewards (social praise, tangibles and activities), and appropriate punishment which can be rationalized to the child. While this intervention is effective, it is only temporary while in the classroom, consistency needs to be maintained in order for the effectiveness of this intervention to last (Gordon, 2002, p. 405-407).
 * 2) Environment/Changing consequences of behaviour (ex. Antecedent based intervention, consequence based intervention or both)


 * 3) ****Medication and Health**

While there are many different approaches to treating ADHD, the most common has been the use of medication. Fred A. Baughman and Craig Hovey noted that 97% of children diagnosed with ADHD are prescribed drugs as treatment (Baughman & Hovey, 2006, p. 212). Medication such as Methylphenidate (MPH or Ritalin), Dextroamphetamine (Dexdrine) and Pemoline (Cylet) are the most widely forms of used to treat the many symptoms of ADHD. These three medications are also known as phsycostimulants, they help to counteract the symptoms of ADHD. These pscyhostimulants help to increase attention span, decrease impulsivity, diminish task related activities, decrease disruptive behaviours and increase compliance. Research has shown that these medications affect the inhibitory process within the CNS in various domains in order to minimize many of the hyperactive nature of many children with ADHD (Gordon, 2002, p. 407-408). Ritalin (MPH) is the most commonly recognized treatment of ADHD. Since the classification of ADHD in the DSM-IV, the use of Ritalin increased by 700% (Diller, 1998, p. 2). While doctors try not to use medication as initial treatment for ADHD, it is the most effective and results are immediate. It treats the symptoms directly, within thirty minutes of oral ingestion, but only for a minimal amount of time, the half life of MPH is two and a half hours. Since the effects of Ritalin only last up to three hours, means that on average a person with ADHD will administer Ritalin up to three times per day (Gordon, 2002, p. 408). With medication being this demanding in the treatment of ADHD, it is hard for the physician to monitor the daily intake of Ritalin and get a full sense of a client’s dependency on such a drug as Ritalin (Diller, 1998, p.16). Therefore, monitoring a child on medical treatment is very important issue if chosen as the best approach of treatment.

Another important issue to mention with medication as treatment is multi-substance use. ADHD has multiple symptoms and medication will affect children differently (as discussed later in this page) and as a result many children take more than one medication on a daily basis. One statistic has shown that 49% of children with ADHD are using two or more drugs to treat their symptoms (Baughman & Hovery, 2006, p. 212). There is increased fear among doctors, researchers and parents that the increase dependence of medication as a form of treatment is creating a “zombie effect” in children and that children are learning at a young age that every problem they may have can be cured with a pill (Breggin, 2001, pg. 84-85).

Dr. Lawrence Diller, a pediatrician who has for many years diagnosed children with ADHD published a book called //Running on Ritalin// in which he noticed the drastic increase in the use of Ritalin to treat the symptoms of ADHD. He described how this reflects how society explains and deals with the problems many children and adults are having today opposed to say a hundred years ago. He stated:

**“What if Tom Sawyer and Huckleberry Fin were to walk into my office tomorrow? Tom’s indifference and Huck’s “oppositional” behaviour would surely be a cause for concern. Would I prescribe Ritalin to them too?”** (Diller, 1998, p. 10)

One potential solution in recent years is the use of Adderall. According to the FDA, Adderall is a pshycostimulant drug that combines amphetamines and dextroamphetamine that is similar to Ritalin but has a longer half life from 9-13 hours ("Adderall", 2006). This would mean taking fewer drugs on a daily basis.


 * Side Effects of Medication**

Every drug is not without its side effects on the body, for many of the medications used for ADHD the long term effects are still unknown. The following chart below illustrates eight clinic research studies that have focused on the side effects of Ritalin and Dexdrine on the body.

Drowsiness Uninterested in Others Nightmares Tics/Nervous Movements || 13 significantly worse Irritable Hand wringing/ arm waving/feet tapping || Tics and Nervous Movements Symptoms worsened with increased dosage || Sadness and behavioural deterioration Irritability, withdrawal, lethargy Violent Behaviour Increased likeliness of emotional and psychosocial effects || 1 case of tics 32% of abdominal pain 56% had poor appetite || 58% developed abnormal movements 51% developed obsessive compulsive reactions || 42% “over-aroused” || 3 stopped due to worsening tics || 
 * Table 1: Harmful Reactions to Ritalin and Dexedrine (Amphetamine) in Children Diagnosed with “ADHD”: Summarized from Eight Controlled Clinical Trials (Breggin, 2001, p. 34-35) **
 * **Authors ** || **Group Size ** || **Drugs ** || **<span style="font-family: Georgia,serif; font-size: 90%;">Duration ** || **<span style="font-family: Georgia,serif; font-size: 90%;">Salient Adverse Drug Reactions ** ||
 * <span style="font-family: Georgia,serif; font-size: 90%;">Firestone et. Al || <span style="font-family: Georgia,serif; font-size: 90%;">N = 41, ages 4-6 || <span style="font-family: Georgia,serif; font-size: 90%;">Ritalin || <span style="font-family: Georgia,serif; font-size: 90%;">7-10 days || <span style="font-family: Georgia,serif; font-size: 90%;">Sadness/Unhappiness
 * <span style="font-family: Georgia,serif; font-size: 90%;">Mayes et. Al || <span style="font-family: Georgia,serif; font-size: 90%;">N= 69, ages 2-13 || <span style="font-family: Georgia,serif; font-size: 90%;">Ritalin || <span style="font-family: Georgia,serif; font-size: 90%;">Around 8 days || <span style="font-family: Georgia,serif; font-size: 90%;">6 discontinued because of adverse effects
 * <span style="font-family: Georgia,serif; font-size: 90%;">Barkley et. Al (1990) || <span style="font-family: Georgia,serif; font-size: 90%;">N=83, ages 5-13 || <span style="font-family: Georgia,serif; font-size: 90%;">Ritalin || <span style="font-family: Georgia,serif; font-size: 90%;">14-20 days || <span style="font-family: Georgia,serif; font-size: 90%;">Decreased Appetite, Insomnia, Stomach Aches, Headaches
 * <span style="font-family: Georgia,serif; font-size: 90%;">Schachar et. Al (1997) || <span style="font-family: Georgia,serif; font-size: 90%;">N= 46, ages 6-12 || <span style="font-family: Georgia,serif; font-size: 90%;">Ritalin || <span style="font-family: Georgia,serif; font-size: 90%;">4 months || <span style="font-family: Georgia,serif; font-size: 90%;">10% drop out due to effects
 * <span style="font-family: Georgia,serif; font-size: 90%;">Gillberg et. Al (1997) || <span style="font-family: Georgia,serif; font-size: 90%;">N=62, ages 6-11 || <span style="font-family: Georgia,serif; font-size: 90%;">Dexedrine || <span style="font-family: Georgia,serif; font-size: 90%;">4-15 months || <span style="font-family: Georgia,serif; font-size: 90%;">3 cases of hallucinations
 * <span style="font-family: Georgia,serif; font-size: 90%;">Borcherding et. Al (1990) || <span style="font-family: Georgia,serif; font-size: 90%;">N=46, ages 6-12 || <span style="font-family: Georgia,serif; font-size: 90%;">Ritalin & Dexedrine || <span style="font-family: Georgia,serif; font-size: 90%;">3 weeks || <span style="font-family: Georgia,serif; font-size: 90%;">Focused on Obsessive-Compulsive reactions
 * <span style="font-family: Georgia,serif; font-size: 90%;">Solanto and Wender (1989) || <span style="font-family: Georgia,serif; font-size: 90%;">N=19, ages 6-10 || <span style="font-family: Georgia,serif; font-size: 90%;">Ritalin || <span style="font-family: Georgia,serif; font-size: 90%;">3 separate days || <span style="font-family: Georgia,serif; font-size: 90%;">Focused on cognitive dysfunction
 * <span style="font-family: Georgia,serif; font-size: 90%;">Castellanos et. Al (1997) || <span style="font-family: Georgia,serif; font-size: 90%;">N= 20, ages 6-13 (all had Tourette’s) || <span style="font-family: Georgia,serif; font-size: 90%;">Ritalin & Dexedrine || <span style="font-family: Georgia,serif; font-size: 90%;">3 weeks || <span style="font-family: Georgia,serif; font-size: 90%;">25% developed obsessive drug reactions

<span style="font-family: 'Georgia','serif';"><span style="font-family: Georgia,serif;">Adderall is not without its side effects as well, noted effects include: tics, hypertension, decreased intake of certain acidic foods, decreased appetite, and weight loss. Potential long term effects include psychosis, can act as a tetragon if pregnant, and increased risk of suicide or death ("Adderall." 2006). <span style="font-family: Georgia,serif;"><span style="font-family: Georgia,serif;"> While each of these interventions have both positive and negative aspects to them, some treatments might be more effective than others. Medication appears to be more immediate, but the long term effects are still left to the unknown. Behavioural therapies have more long term effects but take longer to see the results. One of the first major studies to test the effectiveness of ADHD treatment in children tested a group of children from 7 to 9 and divided them into four groups over a fourteen month period. Group 1 received behavioural treatment (35 behavioural sessions with 10 school consults, a 12 week class and summer treatment program). Group 2 received medication 7 times a week. Group 3 received a combination of behavioural therapy and medication and lastly Group 4 were put into a community control comparison group. Based on the preliminary data Group 3 has been shown to be the most favourable option. (Gordon, 2002, p. 402-403)
 * What is the Best Treatment Option for ADHD?**

In concluding this discussion on treatment with ADHD, it is important to recognize the ongoing debate concerning the use of medication and the main form of treatment for children with ADHD. The National Institutes of Health (NIH) conference in 1998 came to five main consensus points about ADHD, one of those points stated:

“Although both medicines [including stimulants and tricycles] and behavioural therapies re effective treatment in ADHD, the preponderance of evidence indicates that medicines are somewhat more effective. Combined behavioural and pharmacological treatment may offer some modest advantages over medicine alone. Furthermore, there is no conclusive evidence that careful therapeutic use of medicines is harmful, ad the committee refuted the notion that current levels of use of stimulants have had a substantial effect of drug abuse among high school students” (Gordon, 2002, p. 377)

Links for further information about Ritalin: [] []