Part VI of VII
What Treatments Are Available?
For decades, medications have been used to treat the
symptoms of ADHD. Three medications in the class of drugs known as stimulants seem to be
the most effective in both children and adults. These are methylphenidate (Ritalin),
dextroamphetamine (Dexedrine or Dextrostat), and pemoline (Cylert). For many people, these
medicines dramatically reduce their hyperactivity and improve their ability to focus,
work, and learn. The medications may also improve physical coordination, such as
handwriting and ability in sports. Recent research by NIMH suggests that these medicines
may also help children with an accompanying conduct disorder to control their impulsive,
Ritalin helped Henry focus on and complete tasks for the
first time. Dexedrine helped Mark to sit quietly, focus his attention, and participate in
class so he could learn. He also became less impulsive and aggressive. Along with these
changes in his behavior, Mark began to make and keep friends.
Unfortunately, when people see such immediate
improvement, they often think medication is all that's needed. But these medicines don't
cure the disorder, they only temporarily control the symptoms. Although the drugs help
people pay better attention and complete their work, they can't increase knowledge or
improve academic skills. The drugs alone can't help people feel better about themselves or
cope with problems. These require other kinds of treatment and support.
For lasting improvement, numerous clinicians recommend
that medications should be used along with treatments that aid in these other areas. There
are no quick cures. Many experts believe that the most significant, long-lasting gains
appear when medication is combined with behavioral therapy, emotional counseling, and
practical support. Some studies suggest that the combination of medicine and therapy may
be more effective than drugs alone. NIMH is conducting a large study to check this.
Use of Stimulant Drugs
Stimulant drugs, such as Ritalin, Cylert, and Dexedrine,
when used with medical supervision, are usually considered quite safe. Although they can
be addictive to teenagers and adults if misused, these medications are not addictive in
children. They seldom make children "high" or jittery. Nor do they sedate the
child. Rather, the stimulants help children control their hyperactivity, inattention, and
Different doctors use the medications in slightly
different ways. Cylert is available in one form, which naturally lasts 5 to 10 hours.
Ritalin and Dexedrine come in short-term tablets that last about 3 hours, as well as
longer-term preparations that last through the school day. The short-term dose is often
more practical for children who need medication only during the school day or for special
situations, like attending church or a prom, or studying for an important exam. The
sustained-release dosage frees the child from the inconvenience or embarrassment of going
to the office or school nurse every day for a pill. The doctor can help decide which
preparation to use, and whether a child needs to take the medicine during school hours
only or in the evenings and on weekends, too.
Nine out of 10 children improve on one of the three
stimulant drugs. So if one doesn't help, the others should be tried. Usually a medication
should be tried for a week to see if it helps. If necessary, however, the doctor will also
try adjusting the dosage before switching to a different drug.
Other types of medication may be used if stimulants
don't work or if the ADHD occurs with another disorder. Antidepressants and other
medications may be used to help control accompanying depression or anxiety. In some cases,
antihistamines may be tried. Clonidine, a drug normally used to treat hypertension, may be
helpful in people with both ADHD and Tourette's syndrome. Although stimulants tend to be
more effective, clonidine may be tried when stimulants don't work or can't be used.
Clonidine can be administered either by pill or by skin patch and has different side
effects than stimulants. The doctor works closely with each patient to find the most
Sometimes, a child's ADHD symptoms seem to worsen,
leading parents to wonder why. They can be assured that a drug that helps rarely stops
working. However, they should work with the doctor to check that the child is getting the
right dosage. Parents should also make sure that the child is actually getting the
prescribed daily dosage at home or at schoolit's easy to forget. They also need to
know that new or exaggerated behaviors may also crop up when a child is under stress. The
challenges that all children face, like changing schools or entering puberty, may be even
more stressful for a child with ADHD.
Some doctors recommend that children be taken off a
medication now and then to see if the child still needs it. They recommend temporarily
stopping the drug during school breaks and summer vacations, when focused attention and
calm behavior are usually not as crucial. These "drug holidays" work well if the
child can still participate at camp or other activities without medication.
Children on medications should have regular checkups.
Parents should also talk regularly with the child's teachers and doctor about how the
child is doing. This is especially important when a medication is first started,
re-started, or when the dosage is changed.
The Medication Debate
As useful as these drugs are, Ritalin and the other
stimulants have sparked a great deal of controversy. Most doctors feel the potential side
effects should be carefully weighed against the benefits before prescribing the drugs.
While on these medications, some children may lose weight, have less appetite, and
temporarily grow more slowly. Others may have problems falling asleep. Some doctors
believe that stimulants may also make the symptoms of Tourette's syndrome worse, although
recent research suggests this may not be true. Other doctors say if they carefully watch
the child's height, weight, and overall development, the benefits of medication far
outweigh the potential side effects. Side effects that do occur can often be handled by
reducing the dosage.
It's natural for parents to be concerned about whether
taking a medicine is in their child's best interests. Parents need to be clear about the
benefits and potential risks of using these drugs. The child's pediatrician or
psychiatrist can provide advice and answer questions.
Another debate is whether Ritalin and other stimulant
drugs are prescribed unnecessarily for too many children. Remember that many things,
including anxiety, depression, allergies, seizures, or problems with the home or school
environment can make children seem overactive, impulsive, or inattentive. Critics argue
that many children who do not have a true attention disorder are medicated as a way to
control their disruptive behaviors.
Medication and Self-Esteem
When a child's schoolwork and behavior improve soon
after starting medication, the child, parents, and teachers tend to applaud the drug for
causing the sudden change. But these changes are actually the child's own strengths and
natural abilities coming out from behind a cloud. Giving credit to the medication can make
the child feel incompetent. The medication only makes these changes possible. The child
must supply the effort and ability. To help children feel good about themselves, parents
and teachers need to praise the child, not the drug.
It's also important to help children and teenagers feel
comfortable about a medication they must take every day. They may feel that because they
take medicine they are different from their classmates or that theres something
seriously wrong with them. CH.A.D.D. (which stands for Children and Adults with Attention
Deficit Disorders), a leading organization for people with attention disorders, suggests
several ways that parents and teachers can help children view the medication in a positive
- Compare the pills to eyeglasses, braces, and allergy
medications used by other children in their class. Explain that their medicine is simply a
tool to help them focus and pay attention.
- Point out that they're lucky their problem can be helped.
Encourage them to identify ways the medicine makes it easier to do things that are
important to them, like make friends, succeed at school, and play.
Myths About Stimulant Medication
Myth: Stimulants can lead to drug addiction later in
Fact: Stimulants help many children focus and be more
successful at school, home, and play. Avoiding negative experiences now may actually help
prevent addictions and other emotional problems later.
Myth: Responding well to a stimulant drug proves a
person has ADHD.
Fact: Stimulants allow many people to focus and pay
better attention, whether or not they have ADHD. The improvement is just more noticeable
in people with ADHD.
Myth: Medication should be stopped when the child
Fact: Not so! About 80 percent of those who needed
medication as children still need it as teenagers. Fifty percent need medication as
Treatments To Help People With ADHD and Their
Families Learn To Cope
Life can be hard for children with ADHD. They're the
ones who are so often in trouble at school, can't finish a game, and lose friends. They
may spend agonizing hours each night struggling to keep their mind on their homework, then
forget to bring it to school.
It's not easy coping with these frustrations day after
day. Some children release their frustration by acting contrary, starting fights, or
destroying property. Some turn the frustration into body ailments, like the child who gets
a stomachache each day before school. Others hold their needs and fears inside, so that no
one sees how badly they feel.
It's also difficult having a sister, brother, or
classmate who gets angry, grabs your toys, and loses your things. Children who live with
or share a classroom with a child who has ADHD get frustrated, too. They may feel
neglected as their parents or teachers try to cope with the hyperactive child. They may
resent their brother or sister never finishing chores, or being pushed around by a
classmate. They want to love their sibling and get along with their classmate, but
sometimes it's so hard!
It's especially hard being the parent of a child who is
full of uncontrolled activity, leaves messes, throws tantrums, and doesn't listen or
follow instructions. Parents often feel powerless and at a loss. The usual methods of
discipline, like reasoning and scolding, don't work with this child, because the child
doesn't really choose to act in these ways. It's just that their self-control comes and
goes. Out of sheer frustration, parents sometimes find themselves spanking, ridiculing, or
screaming at the child, even though they know it's not appropriate. Their response leaves
everyone more upset than before. Then they blame themselves for not being better parents.
Once children are diagnosed and receiving treatment, some of the emotional upset within
the family may fade.
Medication can help to control some of the behavior
problems that may have lead to family turmoil. But more often, there are other aspects of
the problem that medication can't touch. Even though ADHD primarily affects a person's
behavior, having the disorder has broad emotional repercussions. For some children, being
scolded is the only attention they ever get. They have few experiences that build their
sense of worth and competence. If they're hyperactive, they're often told they're bad and
punished for being disruptive. If they are too disorganized and unfocused to complete
tasks, others may call them lazy. If they impulsively grab toys, butt in, or shove
classmates, they may lose friends. And if they have a related conduct disorder, they may
get in trouble at school or with the law. Facing the daily frustrations that can come with
having ADHD can make people fear that they are strange, abnormal, or stupid.
Often, the cycle of frustration, blame, and anger has
gone on so long that it will take some time to undo. Both parents and their children may
need special help to develop techniques for managing the patterns of behavior. In such
cases, mental health professionals can counsel the child and the family, helping them to
develop new skills, attitudes, and ways of relating to each other. In individual
counseling, the therapist helps children or adults with ADHD learn to feel better about
themselves. They learn to recognize that having a disability does not reflect who they are
as a person. The therapist can also help people with ADHD identify and build on their
strengths, cope with daily problems, and control their attention and aggression. In group
counseling, people learn that they are not alone in their frustration and that others want
to help. Sometimes only the individual with ADHD needs counseling support. But in many
cases, because the problem affects the family as well as the person with ADHD, the entire
family may need help. The therapist assists the family in finding better ways to handle
the disruptive behaviors and promote change. If the child is young, most of the
therapist's work is with the parents, teaching them techniques for coping with and
improving their child's behavior.
Several intervention approaches are available and
different therapists tend to prefer one approach or another. Knowing something about the
various types of interventions makes it easier for families to choose a therapist that is
right for their needs.
Psychotherapy works to help people with ADHD to like and
accept themselves despite their disorder. In psychotherapy, patients talk with the
therapist about upsetting thoughts and feelings, explore self-defeating patterns of
behavior, and learn alternative ways to handle their emotions. As they talk, the therapist
tries to help them understand how they can change. However, people dealing with ADHD
usually want to gain control of their symptomatic behaviors more directly. If so, more
direct kinds of intervention are needed.
Cognitive-behavioral therapy helps people work on
immediate issues. Rather than helping people understand their feelings and actions, it
supports them directly in changing their behavior. The support might be practical
assistance, like helping Henry learn to think through tasks and organize his work. Or the
support might be to encourage new behaviors by giving praise or rewards each time the
person acts in the desired way. A cognitive-behavioral therapist might use such techniques
to help a belligerent child like Mark learn to control his fighting, or an impulsive
teenager like Lisa to think before she speaks.
Social skills training can also help children learn new
behaviors. In social skills training, the therapist discusses and models appropriate
behaviors like waiting for a turn, sharing toys, asking for help, or responding to
teasing, then gives children a chance to practice. For example, a child might learn to
"read" other people's facial expression and tone of voice, in order to respond
more appropriately. Social skills training helped Lisa learn to join in group activities,
make appropriate comments, and ask for help. A child like Mark might learn to see how his
behavior affects others and develop new ways to respond when angry or pushed.
Support groups connect people who have common concerns.
Many adults with ADHD and parents of children with ADHD find it useful to join a local or
national support group. Many groups deal with issues of children's disorders, and even
ADHD specifically. The national associations listed at the [end] of this [series] can
explain how to contact a local chapter. Members of support groups share frustrations and
successes, referrals to qualified specialists, and information about what works, as well
as their hopes for themselves and their children. There is strength in numbersand
sharing experiences with others who have similar problems helps people know that they
Parenting skills training, offered by therapists or in
special classes, gives parents tools and techniques for managing their child's behavior.
One such technique is the use of "time out" when the child becomes too unruly or
out of control. During time outs, the child is removed from the agitating situation and
sits alone quietly for a short time to calm down. Parents may also be taught to give the
child "quality time" each day, in which they share a pleasurable or relaxed
activity. During this time together, the parent looks for opportunities to notice and
point out what the child does well, and praise his or her strengths and abilities.
An effective way to modify a child's behavior is through
a system of rewards and penalties. The parents (or teacher) identify a few desirable
behaviors that they want to encourage in the childsuch as asking for a toy instead
of grabbing it, or completing a simple task. The child is told exactly what is expected in
order to earn the reward. The child receives the reward when he performs the desired
behavior and a mild penalty when he doesn't. A reward can be small, perhaps a token that
can be exchanged for special privileges, but it should be something the child wants and is
eager to earn. The penalty might be removal of a token or a brief "time out."
The goal, over time, is to help children learn to control their own behavior and to choose
the more desired behavior. The technique works well with all children, although children
with ADHD may need more frequent rewards.
In addition, parents may learn to structure situations
in ways that will allow their child to succeed. This may include allowing only one or two
playmates at a time, so that their child doesn't get overstimulated. Or if their child has
trouble completing tasks, they may learn to help the child divide a large task into small
steps, then praise the child as each step is completed.
Parents may also learn to use stress management methods,
such as meditation, relaxation techniques, and exercise to increase their own tolerance
for frustration, so that they can respond more calmly to their child's behavior.
Understandably, parents who are eager to help their
children want to explore every possible option. Many newly touted treatments sound
reasonable. Many even come with glowing reports. A few are pure quackery. Some are even
developed by reputable doctors or specialistsbut when tested scientifically, cannot
be proven to help.
Here are a few types of treatment that have not
been scientifically shown to be effective in treating the majority of children or adults
- restricted diets
- allergy treatments
- medicines to correct problems in the inner ear
- chiropractic adjustment and bone re-alignment
- treatment for yeast infection
- eye training
- special colored glasses
A few success stories can't substitute for scientific
evidence. Until sound, scientific testing shows a treatment to be effective, families risk
spending time, money, and hope on fads and false promises.
NIH Publication No. 94-3572