ADHD is a condition characterised by the symptoms of inattention, hyperactivity and impulsivity. While these symptoms are normal characteristics experienced by all people at one time or another, among individuals who are diagnosed with ADHD, there is an overabundance of these characteristics. Their levels of overactivity, inattention and/or impulsivity are severe and persistent and typically result in performance issues in social, educational or work settings.
While many children and adolescents with ADHD improve as they grow up, many will continue to experience symptoms as an adult. In adulthood the symptoms are typically displayed somewhat differently to the way they are displayed in childhood. A child who squirms, fidgets and is constantly 'on the go' may become an adult who is less obviously physically overactive but experiences intense feelings of restlessness. He or she may have troubling relaxing and may overwork. An impulsive child who blurts out answers in class, who constantly interrupts others and talks excessively may become an adult who displays impatience when in queues or whilst driving, and who may be impulsive with spending or quitting jobs. Inattentive children who have difficulty listening and forget their homework may become adults who often complain of losing things, such as keys and wallets, and are often late for appointments.
The main symptoms displayed by children with ADHD vary according to age, but generally about one half will predominantly have inattention problems, a quarter will mainly have hyperactive and impulsive symptoms, while the remainder will have a mixture of these symptoms.
It is common for children with ADHD to have co-occurring psychiatric conditions, the most common of which are disruptive behaviour disorders ('oppositional defiant disorder' or ODD - which involves a pattern of arguing with multiple adults, losing one's temper, refusing to follow rules, blaming others, deliberately annoying others, and being angry, resentful, spiteful, and vindictive; and 'conduct disorder' or CD - which is associated with efforts to break rules without getting caught, and may include being aggressive to people or animals, destroying property, lying or stealing, running away, and skipping school), and mood disorders (depression, mania/bipolar disorder and anxiety).
For a diagnosis of ADHD to be made, a thorough assessment must be conducted by an experienced clinician, usually a paediatrician or psychiatrist, but sometimes a psychologist. The assessment process will differ according to whether the person being assessed is a child or an adult, but the key components include:
When ADHD is diagnosed, you can expect the doctor to provide you with:
The doctor may also provide you with a clinical report outlining the nature of your disorder, any assessments conducted or planned, and details of any treatments to be instituted.
For most individuals diagnosed with ADHD, no single treatment is the answer. The most beneficial treatment typically involves a combination of two or more of the following: medication, behavioural therapy, psychotherapy, emotional counselling, social skills training, family counselling and support, parent skills training, educational strategies, time management training, and developmental therapies such as language therapy. This combined therapeutic approach is known as multimodal treatment.
The particular combination of therapies recommended will depend on an individual’s circumstances and needs. The multimodal approach to the treatment of ADHD commonly involves numerous agencies and professionals.
The decision to go ahead with a particular treatment should only be made after a person has been fully informed about the proposed treatment. If psychostimulant treatment has been recommended, you can expect the doctor to explain:
After starting treatment, the doctor will usually review it frequently. Once the optimal dose is achieved, the doctor should review treatment every six months, or sooner in some cases. Prescriptions for psychostimulant medication are valid for a maximum period of six months.
Psychostimulants are the most common medications used to treat ADHD. Studies show that they are the most effective medications for treating ADHD in children and adolescents. When psychostimulant treatment is conducted carefully, it can reduce ADHD symptoms in the majority of children with ADHD. It is commonly used for adults with ADHD, but fewer adults than children appear to gain benefit from stimulant treatment.
Psychostimulant medication is thought to work by altering the availability of particular brain chemicals or neurotransmitters (dopamine and noradrenaline) in regions of the brain involved with behaviour inhibition, impulse control, attention and working memory. The precise mode of action in not fully understood.
In NSW, only specialists who are authorised by the NSW Ministry of Health may prescribe psychostimulant medication. Generally, paediatricians and child psychiatrists may prescribe for persons under 18 years of age. For adults, psychiatrists are mainly authorised to prescribe psychostimulants.
In very limited circumstances, a general practitioner may be authorised to prescribe psychostimulant medication.
In Australia, the psychostimulant medications mainly used to treat ADHD are dexamfetamine, methylphenidate and lisdexamfetamine.
Methylphenidate is available as a short-acting preparation (e.g. Ritalin®) and as a long-acting or extended release preparation (e.g. Ritalin LA®, Concerta®).
Lisdexamfetamine is available as a controlled release preparation (e.g. Vyvanse®).
Some people get better results from dexamfetamine, while others get better results from methylphenidate or lisdexamfetamine. Currently it is not possible to predict which psychostimulant will be most effective for a particular person. In choosing the medication, the doctor has taken into account individual symptoms and circumstances. If one psychostimulant medication does not relieve the symptoms, the doctor may suggest trying the other.
Like many other conditions, there is no recognised cure for ADHD. Psychostimulant medication helps individuals to control their symptoms of ADHD, but only while they are taking the medication. Psychostimulants can help individuals to pay attention, and focus and stay on task. They may allow intellectual capabilities to function more appropriately but they cannot increase knowledge.
Side effects are quite common, but are usually minor and often disappear when the dose is adjusted. Higher doses usually produce more side effects. The most common side effects include decreased appetite, insomnia, increased anxiety, increased irritability, stomach ache, and headache. Weight loss and slowing of growth in height may occur in children on psychostimulant medication so growth rates should be monitored.
As a dose of psychostimulant medication wears off, ADHD symptoms return and sometimes these symptoms can be more intense than prior to taking the dose. This ‘rebound’ effect and its impact may be lessened by modifying the dose and adjusting the time at which a dose is taken.
Tics (spasmodic twitching of certain muscles, usually of the face or neck) may be exacerbated by treatment, or may appear during treatment in some cases.
Some people will discontinue taking psychostimulants because of side effects.
In certain cases psychostimulant treatment will not be suitable. Contraindications to the use of psychostimulants include glaucoma, symptomatic cardiovascular disease, hyperthyroidism, and hypertension. People with certain psychiatric conditions, including psychosis and schizophrenia, should not take psychostimulants.
Psychostimulants may cause a small increase in pulse and blood pressure. In children with normal hearts this is unlikely to cause any problems.
The treating doctor will determine whether psychostimulants are suitable for a person following a thorough assessment, including a review of the person's medical history. As part of this assessment the doctor will determine whether a person needs a heart evaluation before commencing psychostimulant medication.
The effects of psychostimulant medication remain for as long as the dose is acting. How much and how often a person needs to take medication will depend on a number of things, including the formulation of the drug and its duration of action, the effect on the person's symptoms and whether any unacceptable side effects occur. Short-acting psychostimulants usually wear off within 3 to 6 hours and therefore up to three doses a day may be needed to control symptoms. Persons who are prescribed long-acting or extended release psychostimulants may need only one dose a day.
To determine the optimal dose, the doctor will usually monitor the person's response to various doses over a period of time.
Psychostimulant medication is effective while it is being used. The length of time a person will undergo psychostimulant treatment will vary from one individual to another. For some, a short duration of treatment may only be necessary; they may outgrow their symptoms, or learn strategies and skills that negate the need for medication. For others, many years of treatment may be necessary.
Medication should only be taken for as long as it is helpful and necessary. To assess the continuing need for medication, a period without medication may be trialled. If symptoms return or worsen during this time, it is likely that medication is beneficial and worthwhile continuing.
Whether an individual needs to take psychostimulant medication every day or not will usually depend on the severity of his or her symptoms, but also on the effectiveness of other therapies being used. For example, a child who has few problems outside school may only need their medication on school days. For some individuals, medication may be needed every day.
If there is concern about a child’s growth that appears to be related to psychostimulant medication, a doctor may recommend medication-free periods. These medication-free periods, which typically occur on weekends and during school holidays, are commonly referred to as ‘drug holidays’.
Psychostimulant medications are classified as ‘drugs of addiction' under NSW law and have the potential to be abused. When taken as prescribed – orally and in a therapeutic dose – psychostimulants do not induce euphoria and are unlikely to lead to abuse.
Studies have shown that psychostimulant treatment for ADHD in children does not lead to an increased risk of substance abuse. Rather it appears that psychostimulant treatment may lower the risk of a child with ADHD developing substance use problems in later life. Children with ADHD who are at greatest risk from developing substance use problems are those who have co-occurring disruptive behaviour disorders, particularly conduct disorder.
All community pharmacies are able to fill a prescription for psychostimulant medication. By law, the pharmacist who supplies the psychostimulant prescribed is required to keep the prescription. Any repeats specified on the prescription must then be obtained from that pharmacy.
It is not okay to give anyone else your medication. The medication you have been prescribed is suitable for your condition and may not be suitable for another person even if you think they have the same problems. In some cases it may be harmful to them. In addition, it is unlawful to give (or ‘supply') psychostimulant medication, and unlawful for someone to have (or ‘possess') psychostimulant medication that has not been dispensed for them on a prescription. If someone is harmed by the medication you give them, you may be held responsible for that harm.
In the case of children, and in particular adolescents, who are prescribed psychostimulant medication, parents should monitor usage and ensure that their children are taking the dosage that is prescribed. If a parent is concerned that their child may be taking their medication inappropriately or providing it to others, they should talk to their child about the dangers involved and discuss the matter with the child’s doctor.
In Australia, atomoxetine (Strattera®) is the only non-stimulant medication approved by the Therapeutic Goods Administration (Commonwealth Department of Health) for the treatment of ADHD. Atomoxetine is quite a different compound to the psychostimulant drugs and the effects it produces on chemicals in the brain are different to those produced by psychostimulants. For some children with ADHD for whom psychostimulant medication is not suitable, treatment with atomoxetine may be considered.
Antidepressants have been studied as a treatment for ADHD and have generally been found to be less effective than psychostimulants. Their current place in the treatment of children and adolescents is under consideration.
Clonidine (Catapres®), an alpha-2 noradrenergic agonist, is sometimes prescribed by doctors. It is usually prescribed to reduce persisting aggression and hyperactivity in children with ADHD, or for children with ADHD who are experiencing sleep disturbances. Due to its cardiovascular side effects, a careful medical history of the patient should be taken and rapid changes to dosage should be avoided.
Disclaimer: The information provided here should not be used as a substitute for the medical care and advice of your doctor. There may be variations in treatment that your doctor may recommend based on individual facts and circumstances.