Treatment of ADHD
Basic Principles of Treatment
Section titled “Basic Principles of Treatment”Treatment for ADHD in adulthood consists of several components:
- Medication
- Education about the condition (psychoeducation)
- Psychotherapeutic measures
When Is Treatment Necessary?
Section titled “When Is Treatment Necessary?”An ADHD diagnosis does not automatically necessitate treatment.
Treatment is recommended when, after a thorough examination:
- Clearly ADHD-caused symptoms of clinical significance exist
- Pronounced impairments in at least one area of life are present
- Or less pronounced impairments in multiple areas of life
Multimodal Treatment Concept
Section titled “Multimodal Treatment Concept”A multimodal treatment concept is generally recommended:
- Medication
- Psychotherapeutic treatment
- Psychoeducational measures (especially for parents of children)
Research Findings
Section titled “Research Findings”Studies by the National Institute of Mental Health demonstrate:
- Medications are significantly more effective than behavioral interventions alone
- After discontinuing medication, some of the effect is lost
- With behavioral therapy, this loss is smaller
- Nevertheless, due to the greater initial effect, more effectiveness is retained
- Regular (monthly) medical check-ups are superior to exclusively medicinal treatment with infrequent check-ups
Medication
Section titled “Medication”Stimulants
Section titled “Stimulants”The most important medications for ADHD:
| Active Ingredient | Brand Name | Half-Life | Daily Dosage | Doses per Day |
|---|---|---|---|---|
| Methylphenidate | Ritalin (10mg) | 2.5 hrs | 10-40 mg | 1-3 |
| D-L-Amphetamine | Amphetamine solution | 5-8 hrs | 5-20 mg | 1-3 |
| Fenetylline | Captagon (50mg) | 5-8 hrs | 12.5-100 mg | 1-2 |
Mode of Action
Section titled “Mode of Action”Methylphenidate and amphetamine increase available extracellular dopamine in the striatum and cortical brain areas:
- Methylphenidate: Blocks dopamine transporters
- Amphetamine: Promotes dopamine release from nerve endings
Risk of Dependence
Section titled “Risk of Dependence”Driving
Section titled “Driving”According to available studies, the administration of extended-release methylphenidate is safe for driving and promotes concentration in ADHD sufferers, reducing errors due to inattention.
Side Effects and Risks
Section titled “Side Effects and Risks”- Psychoses can be triggered (especially with family history)
- High blood pressure
- Cardiovascular disease
- Slightly reduced growth in children
Psychotherapy
Section titled “Psychotherapy”Behavioral Therapy
Section titled “Behavioral Therapy”A meaningful complement to medication, as improved self-organization is an essential therapy goal in ADHD.
If Medication Is Rejected
Section titled “If Medication Is Rejected”If a patient refuses medication:
- First pursue psychotherapeutic measures
- Due to the severe self-esteem issues, this can be beneficial
- If symptoms do not satisfactorily improve (which is likely):
- Offer trial medication
Consequences of Non-Treatment
Section titled “Consequences of Non-Treatment”Treatment of Comorbidities
Section titled “Treatment of Comorbidities”Comorbid disorders of great relevance in adult ADHD should be considered in treatment planning:
- Depression
- Anxiety disorders
- Substance abuse
- Personality disorders
Situation in Germany
Section titled “Situation in Germany”Challenges
Section titled “Challenges”- Methylphenidate falls under the Controlled Substances Act
- In the USA, treatment for both children and adults is considerably simpler
- Fears about these medications are also lower there
For Adults
Section titled “For Adults”Treatment with stimulants in children was first described in 1937, with initial reports on this therapy in adults dating 10 years later - with good and rapid improvement under long-term therapy.
Ineffective Treatments
Section titled “Ineffective Treatments”Further Unproven Methods
Section titled “Further Unproven Methods”- The effectiveness of non-directive or depth psychology therapy as sole treatment for the core hyperkinetic symptoms is not proven
- The effectiveness of motor therapy, physiotherapy, psychomotor therapy and occupational therapy as sole treatment is not proven
- The effectiveness of relaxation techniques (including autogenic training) is not sufficiently proven
Heritability of ADHD
Section titled “Heritability of ADHD”Family Studies
Section titled “Family Studies”- In families of affected individuals, 17-41% are affected
- In control families: 0-8%
- ADHD in fathers of affected individuals: 15-44%
- ADHD in mothers of affected individuals: 4-38%
Twin Studies
Section titled “Twin Studies”- Identical twins: Concordance 51-79%
- Fraternal twins: Concordance 33%
- Heritability is estimated at 64-88%
- With concurrent dyslexia: heritability up to 98%
Adoption Studies
Section titled “Adoption Studies”The risk depends on whether the biological parents were affected by the disorder - not the adoptive parents.
Mode of Inheritance
Section titled “Mode of Inheritance”This is a multifactorially determined condition for which no single gene is responsible. Some studies suggest an incompletely penetrant autosomal dominant mode of inheritance.
Structural Brain Findings
Section titled “Structural Brain Findings”Structural brain studies showed:
- Slight reduction in total brain substance
- Reduced volume in the right frontal lobe and the caudate nucleus
- Changes in the dorsal prefrontal cortex bilaterally
- Reduced gray matter in the anterior temporal cortex
These areas are part of an association cortex that serves attention, behavioral control and impulse control.
In ADHD, there is abnormal processing of perceptions in the brain’s attention networks with a specific dysfunction in striatal circuits.