Education

1. Parents, patients, and families must understand that they must manage the case
2. Educational material including pamphlets and support groups must be given to the families.  CHADD 1800 223-4050
3. Explain to parents that ADHD is a brain disorder without a known cause.
4. School must be educated as well.
 

Behavior Modification
1. Child must be given structure and clear directions- e.g. routines
2. Stress in the environment must be reduced
3. Limit target areas and give immediate positive and negative consequences
4. Social skill training

Educational Interventions
1. Tutoring
2. Resource rooms
3. OT and PT to help maximize abilities
4. Give visual and verbal instructions
5. Utilize classroom aides or learning specialists
6. Structure the environment

Emotional Interventions
1. Improve the child's self esteem
2. Psychotherapy for depression, anxiety, conduct disorders, and other comorbidities
3. Family therapy if there is marital discord, impending divorces, and family dysfunction

Medication
1. Before initiating medication, it is necessary to alleviate fears about medications.  Often starting with a low dose and a daily schedule will allow the families to observe the child and look at the child's reactions to the medication.
2. Should expect improvement in over activity, attention span, self control, aggression, social interaction, and academic productivity.
3. Should not expect improvement in reading scores, social skills, academic achievement, and antisocial behavior
4. Focus on behavioral improvement.
5. May evaluate effects of the medications by giving rating scales to the teachers to serve as a baseline. (Connor's rating)
6. Response to medications does not confirm the diagnosis because many normal individuals will respond to stimulants.
7. The basis of treatment is titration of the effects of the medications.
8. Stimulants  Methylphenidate (Ritalin) Dextroamphetamine, and Pemoline (Cylert)
     a. Side effects include insomnia, decreased appetite, transient mild elevations of the heart rate and blood pressure, and tics.  Tics are reversible when the medication is terminated.
     b. Begin with a low dosage in the morning and may adjust if the child needs more in the afternoon or after school to complete homework.  May use sustained release preparations instead of dose at school.  Must decide whether to treat on weekends, vacations, and during the summer months when the child is out of school.
9. Tricyclic Antidepressants- Imipramine and Desimpramine
     a. Useful if there are comorbid conditions such as depression, anxiety, and tic disorders.
10. Antidepressants
11. Antihypertensives- Clonidine
12. Unproved Therapies
     a. Biofeedback
     b. Sensory integration training
     c. Optometric training and exercises
     d. Megavitamins
     e. Restrictive diets
     f. Chiropractic manipulations
13. Follow up
     a. It is necessary to evaluate therapy and possible side effects.  Children on stimulants should have their weight and heights followed periodically
     b. May need to change medication or alter the dosage.  Prescriptions often need to be hand carried and not phoned in to the pharmacy.  They are not refillable and a careful record of when the prescriptions are refilled is important to prevent abuse by the patients and their families.
     c. Has there been improvement?  Are other strategies necessary?
     d. How long to treat?  Trials off medication may be suggested.
     e. Encourage compliance and reinforce any improvement that may have taken place.

Physicians caring for children must be aware of the over diagnosis of ADHD and the great increase in the use of psychotropic drugs in preschoolers and young children.  Also, stimulant medications have been found to be a common recreational drug among teenagers and college students and addiction may occur.