Evidence-Based Treatments for ADHD

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course during Spring 2014. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on evidence-based treatments for those disorders and the other focused on a particular myth or misunderstanding about mental illness.

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Evidence-Based Treatments for ADHD by Hunter Holder

Attention Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that affects both children and adults. Persons who suffer from ADHD are more likely to act impulsively, have problems with sustained attention, and/or are hyperactive, which can be defined as restless shifting or excess movement. There were three subtypes of ADHD in the DSM-IV (hyperactive-impulsive type, inattentive type, and combined type) although this has changed with the DSM-5. About 90% of school-aged children have traditionally been diagnosed with the combined subtype. However, newer studies are showing that symptoms present much differently in adults, with over 90% having primarily inattentive symptoms. ADHD is one of the most prevalent mental disorders in children, affecting 3-7% of the population. Many of these children have academic problems such as high rates of expulsion, poor grades, and lower rates of graduation as well as problems with family and peer relationships. Economically, ADHD is estimated to cost around $40 billion each year.

Treatments for ADHD are primarily psychotherapy and pharmacological, much like many other mental illnesses. There are several factors outside of the condition that clinicians must consider when treating ADHD. These include safety of treatment, comorbid mental and physical conditions, and potential substance abuse problems. ADHD is primarily treated with stimulants, which were serendipitously discovered to treat symptoms of ADHD in 1937. Behavioral therapy involving parents and teachers is also effective, but far more so when combined with pharmacological treatment.

In 1999, the National Institute of Mental Health published the largest clinical trial of treatment strategies for ADHD known as the Multimodal Treatment Study of ADHD or MTA Study (find a summary of the study here). The study spanned over 14 months and compared four treatment groups: medication only, behavioral therapy only, medication and behavioral therapy (combined), and community care, which acted as a control (in this group, parents were given a list of mental health institutions and were able to chose the method of treatment they preferred). In all four observed groups, symptoms of ADHD were reduced. The combined group and the medication only group showed significantly more improvement than the behavioral therapy and community care groups. The combined group showed more improvements for some symptoms such as aggressive and internalizing symptoms than any other group. However, there was not a significant difference of overall improvement between the combined group and the medication only group. This suggests that medication alone is the most adequate treatment and adding behavioral therapy can help, but isn’t always necessary.

It is very important to note that the methods used in this study to determine the dosages of medication each child should take were extremely thorough and detailed. Unfortunately in the real world, these thorough evaluations are very rare or nonexistent. The same case is made for the behavioral therapy in the study. The treatment used was very state-of-the-art and used the “gold standard” of behavioral therapy that is highly unlikely to be found in the typical real world setting. Therefore, the effects of these treatments in this study are probably greater than what would be seen in the real world. With this in mind, recent research has been conducted using more typical real-world conditions and found that behavioral treatment was as effective as medication and, when paired with medication, had far greater improvements than the MTA study above previously suggested.

Since the study was conducted before Adderall was available for use, the primary prescription medication used was methylphenidate (some other prescriptions were used in cases where participants had adverse reactions to methylphenidate). Methylphenidate (more commonly known as Ritalin – see the chemical structure to the left) is a central nervous system stimulant that is among the most common pharmacological treatments along with dexamphetamine (otherwise known as Adderall). While there are some risk factors and side effects associated with each of these medications, specifically cardiovascular risks, studies show that the risks and side effects are minimal and when compared to each other, methylphenidate appears to present fewer side effects. However, each type of medication is associated with potential abuse and, in some cases of overdose, death. For example, without these harmful side effects in mind and especially in college students, Adderall is widely abused because it increases sustained concentration.

In a study comparing these two most common medications used to treat ADHD, researchers found that while both drugs produced dramatic improvements in the negative symptoms of ADHD, Adderall appeared to be the superior choice. The study’s findings suggest that the reason for this is because Adderall tends to last longer. In the study, children were given either Adderall or Ritalin twice a day. In the Ritalin condition, the effects of the medication were smaller and wore off around midday before it was time for a second does while the effects of Adderall lasted throughout the day.

Non-pharmacological treatments for ADHD are far less common, but can also be useful and effective. These treatments are important because studies show that as children who suffer from ADHD grow into adolescence, they seem to stop taking their prescribed medications. The reason for this is perhaps the stigmatization that comes with ADHD and the increased importance of peer relationships at this age as well as an increase in responsibility to take the medication independent of parental instruction. Other reasons that psychological intervention may be preferable include the short-term only benefits of medication, possible intolerance to medication, or, obviously, non-responsiveness to medication.

The primary types of psychological interventions used to treat ADHD are cognitive behavioral therapy (CBT) and social skills training. In adults, treatment primarily focuses on CBT. In children, treatment focuses on both of theses interventions as well as family therapy, academic interventions, and classroom behavior management (see a review of these treatments here). In all of these interventions, the primary goal is to improve daily functioning of the individual in all affected aspects of life by improving behavior as well as family and peer relationships. While psychological intervention may not be as effective in treating ADHD as pharmacological approaches, all of these therapies still improve the symptoms ADHD.

CBT, as the name suggests, focuses on the cognitive and behavioral aspects of the disorder. Behaviorally, it is common for good behaviors to be rewarded and negative behaviors to be punished. Rewards can range from tangible items to social praise and are used more often than punishments or consequences. Cognitively, therapy typically focuses on self-instructional training in which individuals are taught techniques like self-evaluation and self-reinforcement. Ideally, clients will use these techniques to improve their behavior to be more acceptable.

Social skills training is primarily used in children and adolescents. Typically, and especially in children and adolescents, those who suffer from ADHD have poor social skills which causes significant difficulties in creating and maintaining peer and family relationships. Social skills training simply involves teaching patients the smaller, less noticeable aspects of social interactions such as appropriate eye contact, smiling, and body language, which help facilitate constructive social relationships.

ADHD will continue to be a disabling condition for children and adults, but research in the past 70 years has discovered many very effective methods of treatment. If recognized and diagnosed, it is highly likely that individuals will be able to have fairly typical lives with minimal symptomatic effects. Overall, it is important to note that even though some approaches to the treatment of ADHD are more effective than others, both psychological and pharmacological interventions seem to show significant improvements in daily functioning and behavior.