Attention decit hyperactivity disorder

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

The most common stimulant medications are

amphetamine mixed (Adderall) or dextroamphetamine
(Dexedrine), and methylphenidate (Ritalin).
Less
common are non-stimulants, also approved for the
treatment of ADHD, are Atomoxetine (Strattera),
guanfacine (Intuniv), and clonidine (Kapvay). Other
medications which may be prescribed o-label include
certain antidepressants such as tricyclic antidepressants,
SNRIs or MAOIs.[2][3][4] The presence of comorbid
(co-occurring) disorders make nding the right treatment
and diagnosis much more costly and time-consuming.
Having a comorbid disorder makes the treatment and
diagnosis of ADHD more complicated, so it is recommended to assess and treat any comorbid disorders
simultaneously.[5]

Improving the surrounding home and school environment

can improve the behavior of children with ADHD.[6] Parents of children with ADHD often show similar decits
themselves, and thus may not be able to suciently help
the child with his or her diculties.[12] Improving the
parents understanding of the childs behavior and teaching them strategies to improve functioning and communication and discourage unwanted behavior has measurable eect on the children with ADHD.[6] The dierent educational interventions for the parents are jointly
called Parent Management Training. Techniques include
operant conditioning: a consistent application of rewards
for meeting goals and good behavior (positive reinforcement) and punishments such as time-outs or revocation
of privileges for failing to meet goals or poor behavior.[6]
Classroom management is similar to parent management
training; educators learn about ADHD and techniques to
improve behavior applied to a classroom setting. Strategies utilized include increased structuring of classroom
activities, daily feedback, and token economy.[6]

A variety of psychotherapeutic and behavior modication

approaches to managing ADHD including psychotherapy
and working memory training may be used. Improving the surrounding home and school environment with
parent management training and classroom management
can improve the behavior of children with ADHD.[6] Specialized ADHD coaches provide services and strategies to
improve functioning, like time management or organiza1.2 Cognitive training
tional suggestions. Self-control training programs have
been shown to have limited eectiveness. Behaviorally
A 2013 paper published by two researchers from the
based self-control does better than cognitive self-control
University of Oslo concluded that working memory traintraining. A meta-analysis found that the use of behavior
ing provides short term improvements, but that there was
1

2 MEDICATIONS

limited evidence that these improvements were sustained

or that they were generalized to improved verbal ability, mathematical skills, attention, or word decoding.[13]
A 2014 paper published by a group of researchers from
the University of Southampton presented the result of
meta analysis study of 14 recently published randomized
controlled trials (RCTs). The authors concluded that
more evidence from well-blinded studies is required before cognitive training can be supported as a frontline
treatment of core ADHD symptoms.[14]

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.

depression may occur during withdrawal from abusive

use.[23]
Stimulants are the most eective medications available
for the treatment of ADHD.[24] Five dierent formulations of stimulants have been approved by the U.S. Food
and Drug Administration (FDA) for the treatment of
ADHD: three derived from amphetamine and two derived from methylphenidate. Atomoxetine, guanfacine
and clonidine are the only non-controlled, less-stimulant
FDA approved drugs for the treatment of ADHD.
Short-term clinical trials have shown medications to be
eective for treating ADHD, but the trials usually use exclusion criteria, meaning knowledge of medications for
ADHD is based on a small subset of the typical patients
seen in clinical practice.[25] They have not been found to
improve school performance and data is lacking on longterm eectiveness and the severity of side eects. This
class of medicines is generally regarded as one unit; however, they aect the brain dierently.[26] Some investigations are dedicated to nding the similarities of children
who respond to a specic medicine.[26] The behavioural
response to stimulants in children is similar regardless of
whether they have ADHD or not.[27]
Stimulant medication is an eective treatment[28] for
adult attention-decit hyperactivity disorder[29][30] although the response rate may be lower for adults than
children.[31] Some physicians may recommend antidepressant drugs as the rst line treatment instead of
stimulants[32] although antidepressants have lower treatment eect sizes than stimulant medication.[33]

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

Adderall 25 mg XR. Adderall XR is one of the medications used

to treat ADHD.

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

eect.[39] Methylphenidate has high potential for abuse

and addiction due to its pharmacological similarity to
cocaine and amphetamines.[40]

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

There are two dierent medicines derived from

methylphenidate: Ritalin, which is half dextrothreomethylphenidate and half levothreomethylphenidate,
that is, a mixture of the chemical mirror images"
of methylphenidate, and Focalin, which is pure dextrothreomethylphenidate. Dextrothreomethylphenidate
has a higher pharmacological activity than its mirror
levo-form or enantiomer. Levothreomethylphenidate has
much weaker activity than the dextro isomer, and so for
instance if Daytrana (methylphenidate in transdermal
patch form) is used, then the levothreomethylphenidate
comprising half of the administered dose, accounts
for only around one thirteenth of the total clinical

Atomoxetine (Strattera),[41] guanfacine (Intuniv) and

clonidine (Kapvay) are less-stimulant drugs approved for
the treatment of ADHD. Other medications which may
be prescribed o-label include certain antidepressants
such as tricyclic antidepressants (TCAs), SNRIs, SSRIs
or MAOIs.[3][4][42]
Atomoxetine (Strattera) is less eective than stimulants for ADHD, is associated with rare cases of liver
damage,[43]:5 and carries a U.S. FDA black box warning
regarding suicidal ideation.[44] Controlled studies show
increases in heart rate, decreases of body weight, decreased appetite and treatment-emergent nausea.[45]
Intuniv is an extended release form of guanfacine. Intuniv has been approved by the FDA for the treatment of
attention-decit hyperactivity disorder (ADHD) in children as an alternative to stimulant medications. Its benecial actions are likely due to its ability to strengthen prefrontal cortical regulation of attention and behavior.[46]
Clonidine (Kapvay), an A adrenergic receptor agonist
has also been approved in the US. Clonidine was initially
developed as a treatment for high blood pressure. Low
doses in evenings and/or afternoons are sometimes used
in conjunction with stimulants to help with sleep and because clonidine sometimes helps moderate impulsive and
oppositional behavior and may reduce tics.[47] It may be
more useful for comorbid Tourette syndrome.
Certain antidepressants such as tricyclic antidepressants,
SNRIs or MAOIs are sometimes prescribed and appear eective in the treatment some of the symptoms
ADHD.[2][3][4] With concerns of side eects TCAs overall usefulness is not clear.[48]

2.3

Other

Some medications used to treat ADHD are prescribed

o-label,[49] outside the scope of their FDA-approved
indications for various reasons. The U.S. FDA requires
two clinical trials to prove a potential drugs safety and efcacy in treating ADHD. The drugs below have not been
through these tests, so the ecacy is unproven (however
these drugs have been licensed for other indications, so
have been proven to be safe in those populations), however proper dosage and usage instructions are not as well
characterized.
A 2012 systematic review found evidence for the
utility of amantadine inconclusive.[50]
Bupropion (Wellbutrin) is classied as an
antidepressant. It is the most common of olabel prescription for ADHD. It inhibits the
reuptake of norepinephrine, and to a lesser extent,
dopamine, in neuronal synapses,[51] and has little or
no eect on serotonergic re-uptake.[52] Bupropion
is not a controlled substance. It is commonly prescribed as a timed release formulation to decrease
the risk of side eects.
Milnacipran, an anti-depressant drug, is currently
being investigated for potential to alleviate the
symptoms of ADHD in adults.[53]
Modanil (Provigil/Alertec/Sparlon) Doubleblind randomized controlled trials have
demonstrated the ecacy and tolerability of
modanil,[54][55] however there are risks of serious
side eects such as skin reactions and modanil is
not recommended for use in children.[56]:7 In the
U.S., it is o-label pending decision by the FDA
on 22 August 2006. It was originally pending marketing on-label as Alertec but denied for a reported
incidence of Stevens-Johnson Syndrome.[57]

CONCERNS REGARDING STIMULANTS

Non-ADHD children do not respond dierently from

ADHD children when prescribed antipsychotic drugs,
which are also increasingly prescribed o-label for children with aggression or deant behavior.[61] Social pressure to control a childs dicult and disruptive behavior,
both at home and at school, may inadvertently change focus from what is in the best interest of the childs wellbeing; to how to render the child more compliant and easier
to manage.

3 Comparative ecacy, tolerability and regulatory status of

ADHD medications
4 Concerns regarding stimulants
Main article: Attention-decit hyperactivity disorder
controversies Concerns about medication
The National Institute of Mental Health states that, a
one-size-ts-all approach does not apply for all children
with ADHD.[119] Some parents and professionals have
raised questions about the side eects of drugs and their
long-term use.[120] A 2008 review stated that ADHD
studies have major methodological deciencies which
are compounded by their restriction to school-age children, relatively short follow-up, and few data on adverse
eects.[10]

The American Heart Association feel that it is prudent to

carefully assess children for heart conditions before treating them with stimulant medications.[121][122] Recent extremely large-scale studies by the FDA indicate that, in
children, young adults, and adults, there is no association
between serious adverse cardiovascular events (sudden
death, myocardial infarction, and stroke) and the medical
use of amphetamine, methylphenidate, or other ADHD
Reboxetine (Edronax) is a selective stimulants.[123][124][125][126]
norepinephrine reuptake inhibitor which is mainly
used as an antidepressant. Studies outside the Several studies have found growth and weight suppression
U.S. have found it to be an eective treatment for for stimulants. Compared to the behavior modication
ADHD,[58] and it is prescribed o-label for this group at 8 years of the government-funded MTA study,
purpose in Israel and some European countries, the stimulant group had higher level of reported substance
[127]
however reboxetine has never been approved by the abuse.
U.S. FDA.

4.1 Increase in use

2.3.1

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]

Outpatient treatment rates have held steady in the U.S.

recently. Prior to this, outpatient treatment for ADHD in
the U.S. grew from 0.9 children per 100 in 1987 to 3.4 per
100 in 1997.[128] A survey conducted by the Centers for
Disease Control and Prevention in 20112012 found 6.4
million children between the ages of 4 and 17 have been
diagnosed with ADHD at some point, a 16% increase
since 2007 and a 41% increase over the last decade.[129]

4.4

Issues with long-term use of stimulant medication

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

The stunting of growth in children has been a concern.

Past studies suggested that long-term use of the drugs
could stunt childrens growth.[140] A considerable amount
of growth hormones (20-40%) are released during the 6090 minute period after falling asleep. This part of the
sleep cycle is suppressed by stimulants, causing a decit
of growth hormones in the body.[141] However, more recent studies suggest that children eventually do reach normal height and weight. According to Wilens (2004),
treated children with ADHD tend to grow at a slower rate
but catch up during adolescence and adulthood.[142] One
notion is that psychostimulant medication can decrease
appetite which may result in loss of weight and may be a
factor in stunted growth.

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]

4.4 Issues with long-term use of stimulant

medication
Long-term methylphenidate or amphetamine exposure in some species is known to produce abnormal
dopamine system development or nerve damage,[150][151]
but humans experience normal development and nerve
growth.[152][153][154] Magnetic resonance imaging studies
suggest that long-term treatment with amphetamine or

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.

Reviews of clinical stimulant research have established

the safety and eectiveness of long-term amphetamine
use for ADHD.[155][156] Controlled trials spanning two
years have demonstrated continuous treatment eectiveness and safety.[156][157] One review highlighted a 9
month randomized controlled trial of amphetamine in
children that found an average increase of 4.5 IQ points
and continued improvements in attention, disruptive behaviors, and hyperactivity.[157]

4.5

Tolerance to the therapeutic eects of stimulants can

occur,[158] with rebound of symptoms occurring when the
dose wears o.[159] Due to the risk of discontinuation
and rebound eects doses should be gradually decreased
rather than the medication being stopped abruptly.[160]
Rebound eects are often the result of the stimulant 6 History
dosage being too high or the individual not being able
to tolerate stimulant medication. Signs that the stimulant
dose is too high include irritability, feeling stimulated or The rst reported evidence of stimulant medication
blunting of aect and personality.[161]
used to treat children with concentration and hyperacStimulant withdrawal or rebound reactions can occur tivity problems came in 1937.[173] Charles Bradley in
and should be minimised in intensity, i.e. via a grad- Providence, Rhode Island reported that a group of chilual tapering o of medication over a period of weeks dren with behavioral problems improved after being
or months.[162][163][164] A very small study of abrupt treated with the stimulant Benzedrine.[173][174] In 1954,
withdrawal of stimulants did suggest that withdrawal re- the stimulant methylphenidate (Ritalin, which was rst
actions are not typical. Nonetheless withdrawal reac- produced in 1944) became available; it remains one of
tions may still occur in susceptible individuals.[165] The the most widely prescribed medications for ADHD.[173]
withdrawal or rebound symptoms of methylphenidate Initially the drug was used to treat narcolepsy, chronic
can include psychosis, irritability and depression and a fatigue, depression, and to counter the sedating eects
return of ADHD symptoms in an exaggerated form. of other medications.[173] The drug began to be used for
Methylphenidate may be worse for causing rebound ADHD in the 1960s and steadily rose in use.
and withdrawal eects due to its very short half In 1975, pemoline (Cylert) was approved by the U.S.
life. Amphetamine may cause less severe rebound FDA for use in the treatment of ADHD. While an eecor withdrawal eects due to its somewhat longer half tive agent for managing the symptoms, the development
life.[166][167][168] Up to a third of ADHD children expe- of liver failure in 14 cases over the next 27 years would
rience a rebound eect in ADHD symptoms when the result in the manufacturer withdrawing this medication
methylphenidate dose wears o.[169]
from the market. New delivery systems for medications

4.6

Cancer

Concerns about chromosomal aberrations and possible

cancer later in life was raised by a small-scale study on the
use of methylphenidate, though a review by the Food and
Drug Administration (FDA) found signicant methodological problems with the study.[170] A follow-up study
performed with improved methodology found no evidence that methylphenidate might cause cancer, stating
the concern regarding a potential increase in the risk of
developing cancer later in life after long-term MPH treatment is not supported.[171]

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]

7.4 Dietary supplements

Ginkgo is a natural supplement used by some with ADHD.

Alternative medicine

See also: Alternative therapies for developmental and

learning disabilities

Dietary supplements and specialized diets are sometimes

used by people with ADHD with the intent to mitigate
some or all of the symptoms. However 2009 article in
the Harvard Mental Health Letter states, Although vitamin or mineral supplements [micronutrients] may help
children diagnosed with particular deciencies, there is
no evidence that they are helpful for all children with
ADHD. Furthermore, megadoses of vitamins, which can
be toxic, must be avoided.[187] In the United States, no
dietary supplement has been approved for the treatment
for ADHD by the FDA.[188]

Most alternative therapies do not have enough supporting

evidence to recommend them.[175][176] Moreover, when
only the best conducted studies are taken into account results tend to be similar to placebo.[176] Some proponents
of alternative medicine advocate that alternative therapies Some popular supplements used to manage ADHD symptoms:
may be tried before ADHD medications.[166]

7.1

Neurofeedback

Neurofeedback (NF) or EEG biofeedback is a treatment

strategy used for children, adolescents and adults with
ADHD.[177] The human brain emits electrical energy
which is measured with electrodes. Neurofeedback alerts
the patient when beta waves are present. This theory believes that those with ADHD can train themselves to decrease ADHD symptoms.
No serious adverse side eects from neurofeedback have
been reported.[178] Research into neurofeedback has been
mostly limited and of low quality.[178] While there is some
indication on the eectiveness of biofeedback it is not
conclusive: several studies have yielded positive results,
however the best designed ones have either shown reduced eects or non-existing ones.[178][179] In general no
eects have been found in the most blinded ADHD measures, which could be indicating that positive results are
due to the placebo eect.[180]

7.2

Media

Preliminary studies have supported the idea that playing video games is a form of neurofeedback, which

Zinc Although the role of zinc in ADHD has not

been elucidated, numerous controlled studies report cross-sectional evidence of lower zinc tissue
levels.[189]
Omega-3 fatty acids A 2012 Cochrane review
found little evidence that supplementation with
omega-3 or other polyunsaturated fatty acids provide any improvement in the symptoms of ADHD
in children or adolescents.[190] A 2011 meta analysis found a modest benet relative to stimulant
medications, but concluded that supplementation
should be considered based on its benign side eect
prole.[191]
In the 1980s vitamin B6 was promoted as a helpful
remedy for children with learning diculties including inattentiveness; however, a study of large doses
of vitamins with ADHD children showed that they
were ineective in changing behavior.[192]
Mild stimulants Caeine intake in moderate
amounts may have benets in ADHD due to caffeines positive eects on cognition. Anxiety is
the main side eect of caeine, especially at high
dosage.[193][194] Nicotine may improve the symptoms of ADHD in some people.[195]

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

Because ADHD comorbidities are diverse and the rate of

comorbidity is high, special care must dedicated to certain comorbidities. The FDA is not set up to address this
issue, and does not approve medications for comorbidities, nonetheless certain such topics have been extensively
researched.

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

The stimulants are the rst line of treatment for

ADHD, with proven ecacy, but they do fail in
up to 20% of cases, even in patients without tic
disorders.[207] Current prescribed stimulant medications
include: methylphenidate (brand names Ritalin, Metadate, Concerta), dextroamphetamine (Dexedrine), and
mixed amphetamine salts (Adderall). Other medications
can be used when stimulants are not an option. These
include the alpha-2 agonists (clonidine and guanfacine),
tricyclic antidepressants (desipramine and nortriptyline),
and newer antidepressants (bupropion and venlafaxine.
There have been case reports of tics worsening with
bupropion (brand name Wellbutrin). There is good
empirical evidence for short-term safety and ecacy
for the use of desipramine, bupropion and atomoxetine
(Strattera).[207]

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REFERENCES

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