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| {{ADHD}} | | {{ADHD}} |
| ==Overview== | | ==Overview== |
| The mainstay of therapy for ADHD is the administration of such [[stimulants]] as [[Ritalin]] and [[Adderall]]. While there is no cure for ADHD, currently available treatments can help reduce symptoms and improve functioning. Other treatment options include [[psychotherapy]], education and training, or a combination of therapies.<ref name="#1">National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."</ref>
| | Treatment options include [[psychotherapy]], education and training, or a combination of therapies.<ref name="#1">National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."</ref> |
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| ==Medical Therapy==
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| Several different types of medications may be prescribed to mitigate the symptoms associated with ADHD.
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| *[[Stimulants]], such as [[Methylphenidate]] (Ritalin) and amphetamine salts (dextroamphetamine and amphetamine; [[Adderall]]), are used to increase the patient’s supply of the brain chemicals [[dopamine]] and [[norepinephrine]], which play essential roles in thinking and [[attention]].<ref name="#1">National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."</ref> Ritalin is safe and effective in preschool-aged children suffering from ADHD so long as they are closely monitored while taking the drug.<ref name="pmid23452683">{{cite journal| author=Riddle MA, Yershova K, Lazzaretto D, Paykina N, Yenokyan G, Greenhill L et al.| title=The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-year follow-up. | journal=J Am Acad Child Adolesc Psychiatry | year= 2013 | volume= 52 | issue= 3 | pages= 264-278.e2 | pmid=23452683 | doi=10.1016/j.jaac.2012.12.007 | pmc=3660093 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23452683 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23696095 Review in: Evid Based Ment Health. 2013 Aug;16(3):63] </ref>
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| * [[Lisdexamfetamine]] is a prodrug of dextroamphetamine. It may be dosed once a day and is less likely to be abused.
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| *[[Atomoxetine]] (Strattera) is a selective norepinepherine reuptake inhibitor (SNRI) approved for the management of ADHD. It is effective in adult ADHD and is often favored due to lack of abuse potential<ref name="pmid19445548">{{cite journal |vauthors=Garnock-Jones KP, Keating GM |title=Atomoxetine: a review of its use in attention-deficit hyperactivity disorder in children and adolescents |journal=Paediatr Drugs |volume=11 |issue=3 |pages=203–26 |year=2009 |pmid=19445548 |doi=10.2165/00148581-200911030-00005 |url=}}</ref>. Atomoxetine carries a black box warning as there is an increase risk of suicidal ideation in adolescents<ref>{{Cite web|url=www.ncbi.nlm.nih.gov/pmc/articles/PMC3896970/|title=ADHD Medication Use Following FDA Risk Warnings|last=Barry|first=Colleen|date=01/21/2014|website=NIH|archive-url=|archive-date=|dead-url=|access-date=06/12/2018}}</ref>. While it is non-inferior to [[methylphenidate]] in children, its adverse effects in children and adolescents render it a less favorable treatment option.<ref name="pmid12547466">{{cite journal |vauthors=Michelson D, Adler L, Spencer T, Reimherr FW, West SA, Allen AJ, Kelsey D, Wernicke J, Dietrich A, Milton D |title=Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies |journal=Biol. Psychiatry |volume=53 |issue=2 |pages=112–20 |year=2003 |pmid=12547466 |doi= |url=}}</ref>
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| *Non-stimulants such as extended release Guanfacine and Clonidine (both alpha-2 adrenergic agonists) are also used to treat ADHD<ref>{{Cite web|url=www.pediatrics.aappublications.org/content/136/2/351|title=Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety|last=Southammakosane|first=Cathy|date=August 2015|website=AAP|archive-url=|archive-date=|dead-url=|access-date=06/12/18}}</ref>.
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| *Other drugs, including [[anti-depressants]], may also be prescribed in cases of ADHD depending on the patient’s co-morbidities.<ref name="#1">National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."</ref>
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| ===Education and training===
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| *Educating the patient and his or her family members can prove useful in combating the negative effects of ADHD. For the parents or guardians of young patients, parenting skills training can help teach them the skills they need to encourage and reward positive behaviors in their children. Such training helps parents learn how to use a system of rewards and consequences to change a child’s behavior. In this intervention, parents are taught to give immediate and positive feedback for behaviors they want to encourage, and ignore or redirect behaviors that they want to discourage.
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| *Parents may also find it helpful to learn stress management techniques, which could increase their ability to productively deal with their [[frustration]] and enable them to interact with their child in a calm manner.
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| *[[Support groups]] can assist the parents and families of ADHD patients by connecting them with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.<ref name="#1">National Institute of Mental Health (NIH). (2016). "Attention Deficit Hyperactivity Disorder."</ref>
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| ==Monitoring response to treatment==
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| Methods of monitoring treatment for ADHD have been reviewed<ref name=""></ref>CHADD (2017). Which ADHD Rating Scales Should Primary Care Physicians Use? Available at https://chadd.org/adhd-weekly/which-adhd-rating-scales-should-primary-care-physicians-use/<ref name="pmid31150173">{{cite journal| author=Gaba P, Giordanengo M| title=Attention Deficit/Hyperactivity Disorder: Screening and Evaluation. | journal=Am Fam Physician | year= 2019 | volume= 99 | issue= 11 | pages= 712 | pmid=31150173 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31150173 }} </ref><ref name="pmid28184164">{{cite journal| author=Ramsay JR| title=Assessment and monitoring of treatment response in adult ADHD patients: current perspectives. | journal=Neuropsychiatr Dis Treat | year= 2017 | volume= 13 | issue= | pages= 221-232 | pmid=28184164 | doi=10.2147/NDT.S104706 | pmc=5291336 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28184164 }} </ref>.
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| The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) has higher diagnostic accuracy than the WHO Adult ADHD Self-Report Scale (ASRS)<ref name="pmid32285644">{{cite journal| author=Brevik EJ, Lundervold AJ, Haavik J, Posserud MB| title=Validity and accuracy of the Adult Attention-Deficit/Hyperactivity Disorder (ADHD) Self-Report Scale (ASRS) and the Wender Utah Rating Scale (WURS) symptom checklists in discriminating between adults with and without ADHD. | journal=Brain Behav | year= 2020 | volume= 10 | issue= 6 | pages= e01605 | pmid=32285644 | doi=10.1002/brb3.1605 | pmc=7303368 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32285644 }} </ref>.
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| ===Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS)===
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| One method is the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). The WRAADDS has been validated in a clinician administered format<ref name="pmid23647041">{{cite journal| author=Marchant BK, Reimherr FW, Robison D, Robison RJ, Wender PH| title=Psychometric properties of the Wender-Reimherr Adult Attention Deficit Disorder Scale. | journal=Psychol Assess | year= 2013 | volume= 25 | issue= 3 | pages= 942-50 | pmid=23647041 | doi=10.1037/a0032797 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23647041 }} </ref> and a self-administered format<ref name="pmid26554368">{{cite journal| author=Marchant BK, Reimherr FW, Wender PH, Gift TE| title=Psychometric properties of the Self-Report Wender-Reimherr Adult Attention Deficit Disorder Scale. | journal=Ann Clin Psychiatry | year= 2015 | volume= 27 | issue= 4 | pages= 267-77; quiz 278-82 | pmid=26554368 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26554368 }} </ref>. The self-administered version typically reports about 2 points higher than the clinician adminsitered version. The WRAADDS asks 30 questions in 7 domains, each with Cronbach alpha > 0.7:
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| # Attention Difficulties
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| # Hyperactivity/Restlessness
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| # Temper
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| # Affective Lability
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| # Emotional Over-Reactivity
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| # Disorganization
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| # Impulsivity
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| Benchmarks for the self-reported version (SR-WRAADDS) are<ref name="pmid26554368" />:
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| * Subjects ''without'' ADHD: 8.5 ± 4.6
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| * Subjects ''with'' ADHD: 23.4 ± 4.3
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| ** After treatment, score typically drops by 5 points or effect size (different / standard deviation) of 0.7
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| Definitions of treatment response or 'normalization' include<ref name="pmid28184164">{{cite journal| author=Ramsay JR| title=Assessment and monitoring of treatment response in adult ADHD patients: current perspectives. | journal=Neuropsychiatr Dis Treat | year= 2017 | volume= 13 | issue= | pages= 221-232 | pmid=28184164 | doi=10.2147/NDT.S104706 | pmc=5291336 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28184164 }} </ref>:
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| * "Follow-up scores falling within 1.0 standard deviation of the normal mean". For example, SR-WRAADD of less than 13.1
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| * "30% reduction in symptoms" or score
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| The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS)m has higher diagnostic accuracy than the WHO Adult ADHD Self-Report Scale (ASRS)<ref name="pmid32285644">{{cite journal| author=Brevik EJ, Lundervold AJ, Haavik J, Posserud MB| title=Validity and accuracy of the Adult Attention-Deficit/Hyperactivity Disorder (ADHD) Self-Report Scale (ASRS) and the Wender Utah Rating Scale (WURS) symptom checklists in discriminating between adults with and without ADHD. | journal=Brain Behav | year= 2020 | volume= 10 | issue= 6 | pages= e01605 | pmid=32285644 | doi=10.1002/brb3.1605 | pmc=7303368 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32285644 }} </ref>.
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| ===Conners Abbreviated Symptom Questionnaire (CAARS)===
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| This scale includes the Conners Adult ADHD Rating Scales (CAARS). It has 66 items. It is available for download<ref>Australian Council for Educational Research. Available at </ref>.
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| The CAARS has been used to measure response to treatment in [[randomized controlled trial]]s<ref name="pmid26536057">{{cite journal| author=Philipsen A, Jans T, Graf E, Matthies S, Borel P, Colla M | display-authors=etal| title=Effects of Group Psychotherapy, Individual Counseling, Methylphenidate, and Placebo in the Treatment of Adult Attention-Deficit/Hyperactivity Disorder: A Randomized Clinical Trial. | journal=JAMA Psychiatry | year= 2015 | volume= 72 | issue= 12 | pages= 1199-210 | pmid=26536057 | doi=10.1001/jamapsychiatry.2015.2146 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26536057 }} </ref<ref name="pmid26536057">{{cite journal| author=Philipsen A, Jans T, Graf E, Matthies S, Borel P, Colla M | display-authors=etal| title=Effects of Group Psychotherapy, Individual Counseling, Methylphenidate, and Placebo in the Treatment of Adult Attention-Deficit/Hyperactivity Disorder: A Randomized Clinical Trial. | journal=JAMA Psychiatry | year= 2015 | volume= 72 | issue= 12 | pages= 1199-210 | pmid=26536057 | doi=10.1001/jamapsychiatry.2015.2146 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26536057 }} </ref>.
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| ===Affective Lability Scale–Short Form (ALS)===
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| The ALS has 18 items.<ref name="pmid28152669">{{cite journal| author=Weibel S, Micoulaud-Franchi JA, Brandejsky L, Lopez R, Prada P, Nicastro R | display-authors=etal| title=Psychometric Properties and Factor Structure of the Short Form of the Affective Lability Scale in Adult Patients With ADHD. | journal=J Atten Disord | year= 2019 | volume= 23 | issue= 10 | pages= 1079-1089 | pmid=28152669 | doi=10.1177/1087054717690808 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28152669 }} </ref>
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| ===Vanderbilt NICHQ===
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| ===WHO Adult ADHD Self-Report Scale (ASRS)===
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| The Adult ADHD Self-Report Scale (ASRS) is the World Health Organization's (WHO) rating scale for adult ADHD. It has 18 items. It also has a 6 item scale for screening. ASRS-v1.1 is available for download at the Attention Deficit Disorder Association<ref name="">Attention Deficit Disorder Association. https://add.org/wp-content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf</ref>
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| The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS)m has higher diagnostic accuracy than the WHO Adult ADHD Self-Report Scale (ASRS)<ref name="pmid32285644">{{cite journal| author=Brevik EJ, Lundervold AJ, Haavik J, Posserud MB| title=Validity and accuracy of the Adult Attention-Deficit/Hyperactivity Disorder (ADHD) Self-Report Scale (ASRS) and the Wender Utah Rating Scale (WURS) symptom checklists in discriminating between adults with and without ADHD. | journal=Brain Behav | year= 2020 | volume= 10 | issue= 6 | pages= e01605 | pmid=32285644 | doi=10.1002/brb3.1605 | pmc=7303368 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32285644 }} </ref>.
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| === ADHD Rating Scale (for children and adolescents) ===
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| For children and adolescents, the ADHD Rating Scale<ref>DuPaul GJ, Power TJ, Anastopoulos AD, Reid R. ADHD Rating Scale IV (for Children and Adolescents): Checklists, Norms, and Clinical Interpretation. New York, NY: Guilford Press; 1998</ref> has been used in [[systematic review]]s<ref name="pmid27163988">{{cite journal| author=Chan E, Fogler JM, Hammerness PG| title=Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents: A Systematic Review. | journal=JAMA | year= 2016 | volume= 315 | issue= 18 | pages= 1997-2008 | pmid=27163988 | doi=10.1001/jama.2016.5453 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27163988 }} </ref>. In a systematic review, "A clinically meaningful response is generally considered to be improvement of 25% or greater from baseline (a within-group reduction of approximately 10-15 absolute points or a mean difference of approximately 6-7 points between the treatment and placebo groups"<ref name="pmid27163988">{{cite journal| author=Chan E, Fogler JM, Hammerness PG| title=Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents: A Systematic Review. | journal=JAMA | year= 2016 | volume= 315 | issue= 18 | pages= 1997-2008 | pmid=27163988 | doi=10.1001/jama.2016.5453 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27163988 }} </ref>.
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| ==References== | | ==References== |