A full assessment and education about attention deficit hyperactivity disorder (ADHD) is the beginning of treatment. ADHD causes suffering: psychological hurt, failure, and conflict with others. The understanding that difficulties with attention are at the heart of some of this suffering may lead to relief. The title of the popular book You Mean I'm Not Lazy, Stupid or Crazy?! expresses this feeling.
It is not easy to train, discipline, or educate children to control their symptoms of ADHD. Children and adults with ADHD are not always aware of the behaviors that annoy others. Even when insight is present, these symptoms are often involuntary and never processed consciously. Individuals with ADHD know what they should do, and they could do most of these activities. The problem arises with how they actually perform in daily life. Medication improves the symptoms and therefore has an immediate and powerful impact on the impairment that these symptoms produce.
The 2 stimulants most commonly used are methylphenidate (Ritalin® or Ritalin SR®) and dextroamphetamine (Dexedrine®). These stimulants vary in how often they need to be taken during the day, as well as in their side effects. Some individuals who do poorly on one medication may do better on another. More than 75% of patients will improve on one or another stimulant. These drugs are not addictive. The side effects include decreased appetite, stomachaches, insomnia, irritability (especially when the medication is wearing off), and tics. If overmedicated, some children are described as too quiet. There are more than 350 studies that demonstrate unequivocally that these medications are effective for ADHD-combined type in children. There are good studies that also demonstrate that the medication is just as effective for adults. We have less research to demonstrate that the medication is effective for preschoolers and ADHD-inattentive types. Although there is some support for using methylphenidate in preschoolers who have moderate-to-severe ADHD and have not improved with behavior therapy, it is important to talk to a health care provider about whether or not the benefits of using this medication will outweigh the risks. We also do not have follow-up data on how the medication
affects long-term outcome beyond 2 years.
It is possible to change the environment to be more ADHD-friendly so that the symptoms of ADHD cause less trouble. For children this might include placement in a specialized classroom, more supervision, increased consequences and rewards, making work more interesting, avoiding difficult situations (such as restaurants or birthday parties), and finding other activities that lead to success, such as skiing or computers. In adults this might mean finding an ADHD-friendly occupation, delegating organizationally challenging tasks and paperwork, and using reminders, sticky notes, cell phones, computers, or other aids. Educating oneself and one's family and friends to understand ADHD helps affirm that the difficult behaviors that go along with ADHD are neither willful, nor personal, nor spiteful.
Margaret Weiss, MD, PhD, in association with the MediResource Clinical Team