What is ADHD?

ADHD is a common behavioural disorder in children and young people. ^{1, 2} ADHD can be a lifelong condition and many children who have it continue to have the symptoms in adolescence and adulthood. ² Severe ADHD is sometimes known as ‘hyperkinetic disorder’.

The symptoms of ADHD include being: ^1,2

• inattentive – unable to concentrate for very long or to finish a task, disorganised, easily distracted and forgetful, and unable to listen when people are talking
• hyperactive – fidgety and unable to sit still, restless (children may be running or climbing much of the time), talking constantly, being noisy, and having difficulty doing quiet activities
• impulsive – speaking without thinking about the consequences, interrupting other people, and being unable to wait or take turns

Other symptoms can include clumsiness, inability to sleep, temper tantrums and mood swings, and finding it hard to socialise and make friends.

A person with ADHD has symptoms most of the time that can seriously affect their everyday life.

Treatment

There is no cure for ADHD, but treatment can reduce the symptoms and make the condition much less of a problem in day-to-day life. ^1,2 ADHD can be treated using medications or therapy, but it is widely agreed that a combination of both forms of treatment is the best way to improve the condition. ²

There are also other ways to treat ADHD that some people may find helpful, such as taking supplements and cutting down on certain foods. The treatment a child should be offered depends on how old they are, and their symptoms. ¹ A specialist should give the child most of their treatment and care when they are first diagnosed with ADHD, but after this, the GP may provide some care.

1. Medication

There is some controversy about using drugs to treat ADHD. Some experts have said that it gives both the children and their families a breathing space from the troubled behaviour, and helps parents to maintain a more loving relationship with their child. Others believe that children are being prescribed these drugs unnecessarily and fear that using them may mask emotional or other causes behind the behaviour, especially in very young children. ³ The long-term effects on the child’s brain are not yet known. ³

Medications for ADHD produce a short-lived improvement after each dose, but they are not a permanent cure. They create a short period when someone who has ADHD can concentrate better, be less impulsive, feel calmer, and learn and practice new skills. ^{2, 3}

There are three types of medication for ADHD: ^{1, 2}

• methylphenidate,
• dexamfetamine, and
• atomoxetine.

In the UK, all three of these medications are licensed for use by children and adolescents. Adults who were diagnosed with ADHD as children are licensed to use atomoxetine. However, there are no medications currently licensed for treating newly diagnosed adults, or for use specifically in adults.

Medications for ADHD are controlled drugs, which means their availability and use is more closely controlled than other prescription medicines. Children will need to return to their GP for regular check-ups to ensure that the treatment is still working effectively. If the child has shown an improvement and the condition appears stable, the GP may recommend a break from treatment, for example, over a weekend, or during school holidays.

• Methylphenidate

Methylphenidate, which comes in brands called Ritalin, Equasym and Concerta XL, is the most commonly used medication for ADHD in the UK. ^{1,2, 5}

- Ritilin tablets contain a 10mg dose.

- Concerta XL tablets contain either 18mg or 38 mg in a modified release formulation.

- Equasym tablets contain doses of 5, 10 and 20mg.

- Equasym XL capsules contain doses of 10, 20 and 30 mg in a modified release formation.

These medications are known as psychostimulants, or central nervous system (CNS) stimulants. It is not completely clear how they work, but it is thought that they stimulate a part of the brain that changes mental and behavioural reactions. ^{2, 4} They increase the activity of chemicals called dopamine and noradrenaline in areas of the brain that play a part in controlling attention and behaviour. ⁵

In the brain there are naturally occurring chemicals that help to carry messages between the nerve cells, these chemicals are sometimes called ‘neurotransmitters’. ⁶ Usually, these neurotransmitters work together, but in some illnesses the balance between them is upset, and one or more chemical becomes overactive or underactive. In ADHD, two neurotransmitters – dopamine and noradrenaline – are not as effective or active as usual. These neurotransmitters are important in the areas of the brain that control attention and concentration. Methylphenidate increases the amount of dopamine in the brain, helping to improve concentration.

Methylphenidate can be prescribed to children and young people with ADHD, who are over the age of six. ^{1, 2, 5} Although methylphenidate is not licensed for use in adults, it is thought to work in much the same way, and may be taken under proper supervision from a GP and specialist.

Methylphenidate cannot be taken by women who are pregnant, or breast feeding, and it should not be taken if the parent or child, has glaucoma, a tic, or Tourette’s syndrome.

Methylphenidate can be taken as either immediate release tablets, which are small doses taken 2-3 times daily, or as modified release tablets, which are taken once a day, usually in the morning, and gradually release the dose throughout the day. ²

- Ritalin and Equasym are immediate release tablets.

- Concerta XL is a modified release tablet. The GP and specialist may recommend Concerta XL if the child needs the treatment to last into the evening. It may also be convenient for children who may not be able to take multiple doses at school. However, the doses of methylphenidate in Concerta XL are larger, and may not be suitable for young children.

Methylphenidate can cause side-effects, which may include: ^{2, 4, 5, 6}

• a small increase in blood pressure and heart rate
• loss of appetite, which can lead to weight loss (if a child is prescribed methylphenidate, the GP will monitor their weight to ensure that they are growing properly)
• trouble sleeping
• dry mouth
• painful joints
• tics
• abdominal pain
• headaches
• stomach aches and
• moodswings

There are ways to ease these side-effects, for example, loss of appetite may be avoided by taking the medication with a meal or snack. Adolescents and adults should avoid drinking alcohol during treatment because this can make the side- effects worse.

The Drug Safety and Risk Committee of the Food and Drug Administration (FDA) in America recommended in February 2006 that ADHD stimulant treatments should carry a black box warning of the risk of sudden death, following a report listing 25 sudden deaths in both adults and children, between 1999 and 2003. Some of these were patients with known heart disease, and the cautions for these drugs do include heart disease.³

Clinical studies by the Assessment Group have found methylphenidate to be an effective treatment to reduce core symptoms of ADHD in children who continue to take the medication. ⁶

• Dexamfetamine

Dexamfetamine comes in a brand called Dexedrine, and works in the same way as methylphenidate. It comes in tablet form and each tablet contains 5mg. ⁵ It is also classed as a psychostimulant, or CNS stimulant, and may be particularly effective in controlling hyperactivity. Dexamfetamine can be used by children and young people over the age of three. Although it is not licensed for use in adults, it is thought to work in much the same way, and may be taken under proper supervision from GPs and specialists. ^{1, 2}

Dexamfetamine cannot be taken by women who are pregnant, or breast feeding, and it should not be used if the parents or child, has epilepsy or kidney problems. Dexamfetamine is usually taken as a daily tablet, and may have side-effects that are similar to those of methylphenidate. Side effects include: ^{5, 6}

• sleeplessness
• irritability
• nervousnes
• night terrors
• shaking
• dizziness
• dry mouth
• sweating
• palpitations
• visual disturbances
• movement disorders, and
• tics.

Stimulants

Although stimulant drugs have been used to treat ADHD since 1937, one of the most popular drugs, Ritalin, was virtually unknown in Britain at the beginning of the 1990s, but between 2001-2002 prescription rates rose by 22%.3 Over a five-year period, the number of prescriptions for children rocketed by 102% to 254,000 items. ³

When the medication wears off, there can be a rebound effect, with the problem behaviour returning in an extreme form. In about 10% of children, the drug can make them tearful and withdrawn. Reducing the dose often helps. Doctors need to carefully calculate the right dose of the drug, and monitor the effect on each child. Some children take these stimulants for six months, others for much longer, depending on how helpful they prove. ³

The National Institute for Health and Clinical Excellence (NICE) states that these stimulants should not be used as the first, or only treatment. ³ Most doctors agree that they should only be used when absolutely necessary. The British National Formulary advises that the use of amphetamines (psychostimulants) should be discouraged, as they may cause dependence and psychotic states.

• Atomoxetine

Atomoxetine comes in a brand called Strattera, and it works differently to methylphenidate and dexamfetamine. ^{1, 2, 3} It is known as a selective noradrenaline uptake inhibitor, which means that it increases the amount of the chemical known as noradrenaline, which is found in the brain. This chemical passes messages between brain cells, so by increasing the amount, it is thought that atomoxetine aids concentration and helps to control impulses. It comes in capsule form and the smallest does is 10 mg, and the largest, 60mg.⁵

Atomoxetine can be used by children and young people who have ADHD, and are over the age of six. ^{1, 2, 4} It is also licensed to be used by adults who are continuing treatment following adolescence. However, it is not licensed to be used in adults who have been newly diagnosed with ADHD, but as it is thought to work in the same way, a GP may prescribe it to be taken under their supervision. Atomoxetine cannot be taken by women who are pregnant or breast feeding, and it should not be taken if the parents, or the child, have glaucoma.

Like methylphenidate and dexamfetamine, the use of atomoxetine must be closely monitored by a GP and specialist.

Healthcare professionals should warn that some people (especially young adults) taking atomoxetine may feel more agitated or irritable than usual, and may experience unusual changes in behaviour, especially during the first few months of treatment, or after a change in dose. ¹ Some studies have shown that a small number of children and young people who take atomoxetine, are more likely to think about suicide. ^{1, 2} Also, in very rare cases, there is evidence that, Strattera can cause liver damage (the signs of this are stomach pain, nausea, dark urine or jaundice), so regular check-ups with the GP are necessary. Parents or carers should report these effects to their healthcare professional. ^1,2

Other side-effects include: ^{2, 5, 6}

• a small increase in blood pressure and heart rate
• nausea
• waking early in the morning
• dizziness
• bedwetting
• palpitations
• shaking
• stiffness
• inflammation of the prostate gland
• menstrual disturbances
• stomach aches
• painful urination, and
• rashes.

Atomoxetine comes in tablet form and is taken once or twice a day. The tablets are long-acting, so the child will not need to take them at school. It may be prescribed as an alternative to methylphenidate, or dexamfetamine, if you or your child has a tic or Tourette’s syndrome.

If a child needs to be prescribed a medication for ADHD, the GP and specialist will take several factors into account before recommending a treatment. These factors will include any other conditions, the side-effects of each treatment, and whether or not the dosage times interfere with school or work.

Which medication should be offered?

For children and young people, this will depend on a number of things, such as: ¹

• whether they have other conditions such as Tourette’s syndrome, tics or epilepsy
• the side-effects associated with each medication
• whether the child or young person will need to take the medication while they are at school
• the child’s preferences.

In children and young people, methylphenidate may be offered if they do not have any other serious mental health problems or if they also have conduct disorder. ¹ Methylphenidate or atomoxetine may be used if the person also has tics, Tourette’s syndrome or anxiety, or if they are misusing stimulants. If methylphenidate has been tried and does not help, atomoxetine may be offered.

Methylphenidate is usually the first treatment offered to adults with ADHD.

Side-effects of medication

Healthcare professionals should also check for side-effects regularly. These could include: ^{1, 2, 3, 4, 5}

If there are side-effects, the dose of medication may need to be reduced, stopped or changed.

For all people taking medication for ADHD, their weight will be measured 3 months and 6 months into the treatment, and every 6 months after that. In children and young people, their height will be measured every 6 months. A healthcare professional may suggest stopping the medication over the school holidays to allow the child’s growth to ‘catch up’. ¹

If any person on medication for ADHD loses weight, then healthcare professionals will advise that the drug is taken with or after food, rather than before meals. Additional meals or snacks in the early morning or late evening may help. The healthcare professional may seek dietary advice and suggest high-calorie foods of good nutritional value. If weight loss continues, a different drug may need to be considered. ¹

All people taking medication for ADHD will have their heart rate and blood pressure checked every 3 months, and before and after any change in dose. The electronic Medicines Compendium (eMC) contains information about UK licensed medicines and can be found at http://emc.medicines.org.uk/default.aspx.  This contains detailed information about the various medications and brands such as:

• method of administration
• special warnings and precautions
• undesirable effects
• pharmacological properties
• shelf life.

2. Therapy

As well as taking medication, several different therapies can be useful in treating ADHD in children, adolescents and adults. ^{1, 2, 3} Therapy is also effective in treating any additional problems, such as conduct or anxiety disorders that may appear alongside ADHD. The therapies outlined below can be carried out with the help of counsellors, psychiatrists, psychologists, or social workers.

• Psychotherapy

Child psychotherapists are trained in helping children to recognise and tackle their own distress. ^{2, 3} Some children with ADHD can become very demoralised, anxious or depressed and a psychotherapist can provide intensive and long-term help for them. Psychotherapy is known as a ‘talking’ therapy, which means that parents, or the child, will be encouraged to discuss their experience of ADHD and how it affects them. It can help children, adolescents and adults to make sense of being diagnosed with ADHD, and can help them cope with living with the condition.

• Behaviour therapy

Behaviour therapy provides support for carers of children with ADHD, and may involve teachers as well as parents. Behaviour therapy usually involves behaviour management, which uses a system of rewards and penalties to encourage the child to try and control their ADHD. ^{2, 3}

For example, if your child has ADHD, you can identify types of behaviour that you want to encourage, such as sitting at the table to eat. Your child is then given some sort of small reward for good behaviour, and a small penalty for poor behaviour. For teachers, behaviour management involves learning how to plan and structure activities, and to praise and encourage children for even very small amounts of progress. ^{2, 3}

Parents learn how to best handle bad behaviour, how to set boundaries, and how to discuss why certain behaviour is wrong.

3. Parenting skills training

If your child has ADHD, parenting skills training may help you learn specific ways of talking to your child, and playing and working with them, in order to improve their attention and behaviour. ²

4. Social skills training

Social skills training involves the child taking part in role-play situations, and aims to teach them how to behave in social situations by learning how their behaviour affects others. ^{2, 3} It helps them manage relationships better by reading the hidden signals of communication. It teaches them to understand what impact their behaviour has had on other people, so they can work on changing it.

5. Other methods of treatment

There are other ways of treating ADHD that many people with the condition find helpful in controlling it, such as cutting out certain foods and taking certain supplements. However, there is no medical evidence that these methods work. ²

If someone has ADHD and wants to try an alternative method of treatment, alongside medication and therapy, they could try cutting out certain foods.^1,2,3 Sugar and caffeine are often blamed for aggravating hyperactivity, and some people may have intolerances to wheat or dairy products, which may add to their symptoms. However, a GP should be consulted before changing a child’s diet.

Alternatively, a supplement, such as omega 3, ginkgo, or zinc may help the symptoms. A GP should always be consulted before taking a supplement.

Useful Contacts

• Mind www.mind.org.uk

Mind is the leading mental health organisation in England and Wales, providing a unique range of services through its local associations, to enable people with experience of mental distress to have a better quality of life.

For more information about any mental health issues, including details of your nearest local Mind association, contact the Mind website or MindinfoLine on 0845 766 0163.

• ADDISS www.addiss.co.uk

The national attention deficit hyperactivity disorder information and support service

10 Station Road, Mill Hill, London NW7 2JU
tel. 020 8906 9068, fax: 020 8959 0727
email: info@addiss.co.uk

• The Association of Child Psychotherapists www.acp.uk.net

For information on child psychotherapists working in your area:
120 West Heath Road, London NW3 7TU
tel. 020 8458 1609, fax: 020 8458 1482
email: inquiries@acp.uk.net

• British Association for Counselling and Psychotherapy (BACP) www.bacp.co.uk

For details of local practitioners:
BACP House, 35–37 Albert Street, Rugby CV21 2SG
tel. 0870 443 5252, fax: 0870 443 5161
minicom: 0870 443 5162
email: bacp@bacp.co.uk

• Hyperactive Children’s Support Group www.hacsg.org.uk

The HCSG offers access to local groups throughout the UK.
71 Whyke Lane, Chichester, West Sussex PO19 2LD
tel. 01243 551 313, fax: 01243 552019
email: hyperactive@hacsg.org.uk

• United Kingdom Psychiatric Pharmacy Group www.ukppg.org.uk

Helpline run by pharmacists
tel. 020 7919 2999

• YoungMinds www.youngminds.org.uk

A national charity committed to improving the mental health of all babies, children and young people.
48-50 St John Street, London EC1M 4DG
tel. 020 7336 8445, parents info service: 0800 018 2138
fax: 020 7336 8446

• Youth Access www.youthaccess.org.uk

Information on youth counselling:
1–2 Taylors Yard, 67 Alderbrook Road, London SW12 8AD
tel. 020 8772 9900, fax: 020 8772 9746
email: admin@youthaccess.org.uk

References

1. National Institute for Health and Clinical Excellence (NICE) (2008) Attention deficit hyperactivity disorder. [online]. NICE, Available from: http://www.nice.org.uk/nicemedia/ pdf/CG72UNG.pdf. [Accessed 11 August 2009].
2. NHS (2008) Attention deficit hyperactivity disorder. [online]. NHS. Available from: http:// www.nhs.uk/Conditions/Attention-deficit-hyperactivity-disorder/Pages/Symptoms.aspx. [Accessed 11 August 2009].
3. Mind (2006) Understanding attention deficit hyperactivity disorder. [online]. London: Mind.
4. Royal College of Psychiatrists (2006) Stimulant medication for ADHD and hyperkinetic disorder. [online]. Royal College of Psychiatrists. Available from: http://www.rcpsych. ac.uk/mentalhealthinfoforall/mentalhealthandgrowingup/6stimulantmedication.aspx. [Accessed 11 August 2009].
5. Mind (2006) Drugs for attention deficit hyperactivity disorder. [online]. Mind. Available from: http://www.mind.org.uk/help/medical_and_alternative_care/drugs_for_attention_ deficit_hyperactivity_disorder_adhd. [Accessed 10 September 2009].
6. National Institute for Health and Clinical Excellence (NICE) (2006) Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents: Review of Technology Appraisal 13. [online]. NICE. Available from: http://www.nice.org.uk/nicemedia/pdf/TA098guidance.pdf. [Accessed 11 August 2009].
7. NHS (2009) Methylphenidate [online] NHS. Available from: http://www.cpft.nhs.uk/ LinkClick.aspx?fileticket=NktK%2BSloNmc%3D&tabid=149&mid=516&language=en-US. [Accessed 9 September 2009].

This information is not meant to replace the advice of any physician or qualified health professional. The information provided by Cerebra is for information purposes only and is not a substitute for medical advice or treatment for any medical condition. You should promptly seek professional medical assistance if you have concerns regarding any health issue.