Module 7 – Recognised Approaches to ADHD

Recognised Approaches to ADHD

Estimated Time: 20 minutes

In this module, you will learn:

·       Key medications used for the treatment of ADHD

·       Potential side effects associated with ADHD medications

·      Effective therapies for the treatment of ADHD

·    What to do if you feel that the treatment is not helping

Recognised Approaches to ADHD – 5m07s

7.1 Key Medications Used for the Treatment of ADHD

In this module we look at an area of ADHD that is of the utmost importance – the treatment of it via medication and therapy.

As with any treatment, there is no guarantee of its success, although it has to be stressed that a considerable amount of research has gone into these treatments and therapies, and improvements in treatment are being made all the time.

Even though the thought of taking tablets may be off-putting, especially for children, there is no doubt that the medications available for the treatment of ADHD can make a significant difference.

You will discover that there are a number of different medications that can be used. The ones which are administered will be decided on by the relevant specialist.

There are some well-known medications and all those mentioned below were researched and studied in some detail before they were declared to be safe for this purpose. However, like all medications, there is the risk of side effects, and these may be a factor in determining which medications can be tolerated by each individual.

In the UK there are five types of medication licensed for the treatment of this disorder.

• Methylphenidate
• Lisdexamfetamine
• Dexamfetamine
• Atomoxetine
• Guanfacine

ADHD medications fall largely into two categories: stimulants and non-stimulants. Each one is seen as being quite effective, although it will have different degrees of success depending on the individual.

The most common medication used is the stimulant methylphenidate, which is widely known by the brand name Ritalin. Other brand names are Concerta, Delmosart, Equasym, and Medikinet.

Stimulant Medications

Methylphenidate, lisdexamfetamine and dexamfetamine are all stimulant medications. Their purpose is to increase brain activity in certain areas, in order to improve behaviour and attentiveness while reducing impulsivity. They are all similar, but as methylphenidate is the most widely used, we will use it as an example throughout this module.

Methylphenidate is known to increase the levels of dopamine in the brain.

This is important because of the role that dopamine is known to play in our ability to pay attention – and also, self-control. For people who have ADHD these are two key areas, as those with the condition often have poor self-control – meaning they act on impulse – and have the inability to concentrate, or pay attention to instructions. With methylphenidate, these areas of the brain are able to function better and, as a result, the individual is then able to deal with things more easily.

Methylphenidate comes in standard form and slow-release form. For the standard form the starting dose is a 5mg tablet taken two or three times a day for adults, or once a day for children. The dosage will be adjusted gradually until the correct level is determined.

The starting dose for the slow-release option is 18mg. It is taken once a day, in the morning. Like the standard form, the dosage can be increased if necessary, but it will still only be taken once a day.

As with any medication, you want to know how quickly it will have an effect, and how long it will last. In most cases, the patient will start to see an improvement within 20 minutes and with the standard form, its effects should last around four hours – which is why it must be taken three times a day. With the slow-release form, it takes longer than 20 minutes to get its way into the bloodstream, but one single tablet will be effective for upwards of 12 hours.

You should be aware that with any medication, there is likely to be a period of adjustment where dosage and even the optimum type of medication are determined. There may be side effects during this period – we will cover those later in the module.

Non-stimulant medications for ADHD

Although stimulant medications are usually the preferred mode of treatment, there are also non-stimulant medications available for the treatment of ADHD, and their use is becoming more widespread. They don’t have the same success rate as stimulant medications but are still very effective where the use of stimulants is unsuitable.

Non-stimulant medications may be prescribed in certain cases where the patient has not responded to stimulant medication or if the patient has experienced severe side effects. Common examples of non-stimulant medications in the UK include atomoxetine and guanfacine.

Atomoxetine is in a class of drugs known as selective noradrenaline reuptake inhibitors or SNRIs. They increase the amount of the neurotransmitter noradrenaline in the brain, and this is thought to help control impulses and increase attentiveness.

Guanfacine is part of the alpha agonists family of drugs. These medications are also used to treat high blood pressure, and they work by controlling nerve impulses. As a serendipitous side effect, they are thought to affect parts of the brain which control working memory, attentiveness and impulse control, and so are an effective treatment for ADHD.

FACT

For adults who are diagnosed with ADHD, drug treatment is the first type of treatment that is attempted, unless the individual prefers psychological treatment.

Source:AADD-UK.com

Whatever the kind of medication used, for the initial phase of treatment it usually takes about 5-7 days to decide if the treatment is working well. Signs of the treatment working include improved mood, sustained focus, better memory, improved sleep, reduced impulsivity and improved attention to detail. Conversely, severe side effects would indicate the medication is unsuitable.

7.2 Potential Side Effects Associated with These Medications

Many people are understandably concerned about the side effects of taking medication, especially as they are likely to be taking it for the rest of their life.

Generally speaking, there are few side effects associated with ADHD medications, and the vast majority of side effects are short-lived. Usually, the patient will notice that their body adapts as they get used to the medication. However, in the case of severe side effects, a different course of treatment should be considered.

Some people are also concerned that stimulant ADHD medication can be addictive, or can lead to drug abuse. This has been found to be untrue – when taken as prescribed, there is little risk of ADHD medication becoming addictive. Furthermore, the use of ADHD medications to control the disorder reduces the risk of substance and/or alcohol abuse.

The main side effects of stimulant and non-stimulant medications used for the treatment of ADHD are similar, and include the following:

• Irritability, anxiety, aggression
• Loss of appetite, and associated weight loss
• Stomach pain
• Diarrhoea, nausea and vomiting
• Dry mouth
• Headaches
• Insomnia
• Drowsiness
• Slightly increased blood pressure and heart rate
• Dizziness
• Fatigue

Anyone embarking on a course of ADHD medication should ask their doctor about the potential side effects of their particular treatment. Most medications also come with an information booklet which will detail specific side effects.

These side effects may be troublesome, but at the same time, the benefits of taking the medication will outweigh the negatives.

Finally, it is widely accepted that taking medication is essential if the ADHD is going to be brought under control. Indeed, extensive research has shown that the taking of medication, mixed with behavioural therapy, has been shown to be the most effective treatment for the condition.

7.3 Effective Therapies for the Treatment of ADHD

Taking medication for ADHD is just one option, as there are other accepted types of help that are available and are known to complement the positive effects of medication.

In particular, we are looking at behavioural therapies which have been shown to be effective at helping an individual to regain some sense of control, when previously this would have been difficult or impossible.

The success rate when it comes to therapy is something that does fluctuate quite considerably, but this should not deter you. However, it is important to find somebody who is a specialist in dealing with ADHD, as that will increase the chances of successful treatment.

Cognitive Behavioural Therapy

There are a variety of therapies for ADHD, such as Cognitive Behavioural Therapy (CBT), social skills training, behaviour therapy and coaching. Our first focus in this section is CBT, which is widely accepted as being the gold standard for ADHD treatment.

CBT is used for a number of different conditions and it involves trying to reprogram the brain and how it works when presented with certain thoughts, emotions or external stimuli.

The difficulty for many is that through personal experiences and learned behaviour, we can often make the wrong decisions or interpret things differently – and this can then lead to incorrect thinking. In the case of somebody with ADHD, this can trigger a chain of thoughts and emotions that lead to anxiety, depression, impulsive actions or even just an increase in energy levels.

The aim here is for the therapy to stop those negative thoughts that can be very traumatic for anybody with ADHD and are often at the root of the negative behaviour that then follows. CBT focuses on thoughts – with the aim being that if you change the thought pattern at the outset, you will, in turn, stop the negative emotions that inevitably follow.

In addition, it is also accepted that CBT is a wonderful tool in helping people to become better organised and to structure not only their thoughts but their day in general. If people with ADHD can gain more order in their lives, it reduces anxiety levels. This is enormously beneficial, as anxiety is also accepted as being a major trigger for those people with the condition.

CBT will challenge the anger that most people feel and help them to understand where that anger and frustration derives from. Furthermore, it is known that it is also very effective at helping people to get on with others – and this is clearly important when it comes to treating ADHD because people can often struggle in building relationships with their peers.

It takes a good therapist and a good relationship with the patient for CBT to work. In other words, you should seek a CBT specialist with prior experience in ADHD, as this should increase the chances of better results.

Behaviour Therapy

While CBT is an excellent kind of therapy for someone with ADHD, parents and teachers can also benefit from the use of behaviour therapy.

Behaviour therapy seeks to control negative behaviour using a system of rewards. It can be used at home and at school and encourages good behaviour by rewarding even small amounts of progress.

The following are some of the methods used in behaviour therapy:

• The theory of rewarding behaviour: The first method involves the individual being rewarded for positive behaviour, as this system is known to be effective with a number of conditions – not just ADHD. If a child becomes aware of a positive experience just because they acted in a particular way, they will be more likely to modify their behaviour slightly.
• The theory of consequences: Just as rewards can help when there is good behaviour, the opposite is also true when the child is aware of the consequences of poor behaviour. This will not involve you shouting at them, or going over the top, but instead calmly enforcing an agreed consequence.

For example:

If children act out in some way, you may want to remove their video games for a while and if this kind of action is repeated time and time again, then the child’s behaviour can be modified through the process of repetition.

• An important factor in the theory of consequence is to have clear boundaries and expectations for behaviour. A behaviour plan is a very useful resource using the ABC model of behaviour management. Implementing this means having a clear understanding of the types of behaviour being displayed and being consistent in delivery.

A is for Antecedent or the triggers that cause a particular behaviour.

B is the Behaviour that the child is displaying.

C is the Consequence given for a particular behaviour.

Listing the antecedents, behaviours and consequences and discussing these with the child is an excellent starting point. Additionally, the language you use when addressing these behaviours should also be included.

• Goal orientated and rewards: If we just stick with the reward point for a bit longer, then setting the child goals and rewarding them when they achieve them is another positive way of tackling a number of the issues associated with this condition. For example, setting them the goal of completing their homework, with the promise of some kind of treat at the end, may motivate them.
• With this approach, we are not talking about the individual making huge leaps forward for them to then be rewarded. Instead, a teacher who is aware that a child has ADHD may offer some kind of small reward, simply because the child has been able to wait their turn to answer for longer than they had previously been able to do. This may seem like a small step, but it can signify a huge leap forward for the child and any kind of progress should be seen as such, no matter how small it may be.

Finally, with therapy, it is also worth noting that some schools have special education therapies that will allow the child to continue to make some kind of progress and prevent their grades from sliding back too far.

This may involve children being removed from the classroom on a regular basis for individual or group intervention work, and it can certainly reshape their approach to schoolwork and even make a difference to the level of qualifications that they receive.

In some specialist education environments, work is being carried out to relieve the symptoms by adapting the classroom environment. This can include more hands-on activities or tasks that require more movement at certain points in the day. Some classrooms have raised computer workstations, which allow the child to stand rather than sit during longer lessons. Some good results have been demonstrated using this approach.

How long does it take for therapy to work?

This is the big question and there is no way of accurately answering it, as it differs from person to person. The patient has to be willing to work hard at the therapy to see the results and, at the same time, there has to be consistency on the part of people involved in helping the person with ADHD.

This is not an instant cure by any means and practice really does make perfect, as it is all too easy for an individual with ADHD to take one step forward and then two steps back. It is all about relearning certain types of behaviour and doing so in a way that benefits the individual. However, therapy has been found to produce good results and it should certainly be used.

7.4 What to Do When the Treatment is Not Helping

Finally, what do you do if you believe that there has been no change and that the treatment is just not working?

The first thing to do is to accept this, but acknowledge that it does not mean that the condition cannot be treated – just that there may be a few tweaks and slight changes required to really feel the benefit. It’s important to be proactive about communicating your concerns with your doctor and/or therapist so that they can make some changes to the treatment plan.

Ideally, you should have some notes on issues which have not been resolved by the treatment, or were initially but have recurred. Go to any medical appointments armed with the relevant information to share.

If you believe that the treatment is not working, it may be best to try to establish why you think this is. Which part is the patient having difficulty with? Is the therapy too involved for the person, or too intensive? Are the sessions too long for a child to concentrate for that length of time? Perhaps the medication is not administered using the correct dosage? Is the medication being administered correctly? As you can see, there are a number of things to take into consideration when it comes to the reasons why treatment is not working.

Working out problems in treatment is one essential reason for maintaining contact with the specialist, as well as any therapists involved in the treatment process. It is common for things to be adjusted slightly from time to time – and the patient does have to be closely monitored for this reason. It could easily be the case that the current dosage of medication is no longer sufficient, or that previous triggers do not work in the same way. Whatever is going on, it is clearly in the best interest of the person with ADHD to seek an amended treatment plan as quickly as possible.

This may sound a bit like doom and gloom, but that is certainly not the case. Treatment for ADHD that involves medication and therapy is known to completely change the lives of those individuals with the condition. Yes, it is hard work and there will be a number of struggles ahead, but there is light at the end of the tunnel.

SUMMARY

In this module, we looked at the treatment of ADHD and have provided you with some information regarding the different options available.

There are several options for medication and therapy available in the UK for the treatment of ADHD. The gold standard of current ADHD treatments is a combination of medication and CBT.

As we have stressed throughout the module, there is no guarantee that any particular treatment method will work, although there is no doubt that treatments have changed lives considerably.

In the next module, we will look at some holistic approaches to treating ADHD.

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