Treatments for ADHD: From Medication to Melatonin

Attention Deficit Hyperactivity Disorder, or ADHD, is the most commonly diagnosed mental health disorder in children. To date there is no cure for ADHD, however, there are many treatment options that can help with managing its symptoms and skills one can learn to mitigate its impact on academics, work and relationships.

Treatment for individuals diagnosed with ADHD includes a range of therapies from prescription medication to behavioral interventions. For years, the primary treatment recommendation for ADHD was stimulant medications, such as Ritalin or Adderall; however, recent research has revealed that the most effective treatment for ADHD is a combination of medications and behavioral therapy.

Medications

There is no doubt that medication is an important component in the treatment of ADHD, with both stimulant and non-stimulant medications available. ADHD is most commonly treated with central nervous system stimulants, such as Ritalin (methylphenidate) or Adderall (an amphetamine). These stimulants tend to act quickly, are generally well tolerated, and can help to improve concentration and focus. One study, called MTA, examined the short and long term effects of stimulant medication on 579 children diagnosed with ADHD per the DSM-IV. The study compared four treatment approaches, and while stimulants were extremely effective in the short term, researchers found that there was insufficient evidence to prove their long- term effectiveness. In addition to Ritalin and Adderall there are many other medications both short and long acting that can be tested for effectiveness and tolerability. The more serious and rarer side effects of stimulants include hallucinations, increased blood pressure and allergic reaction, the more common side effects are appetite suppression, anxiety and trouble falling asleep.

In the case that the above stimulant medications are ineffective, or have caused uncomfortable side effects, psychiatrists and pediatricians may consider non-stimulant medications, such as Atomoxetine (Strattera), Clonidine ER (Kapvay), or Guanfacine ER (Intuniv), which have been shown to help with attention and memory. The potential common side effects of non-stimulants are headaches, grogginess, nausea, and the rare more serious side effects are suicidal thoughts. It is important to discuss your options with an expert medical practitioner before making a decision about medications. Many factors will determine what might be right for any one person and a medical expert will help to ensure that you have all of the information to make an informed decision.

Behavioral Intervention

There are a number of components to behavioral intervention for ADHD. These include:

• Psychotherapy: learning to cope with ADHD symptoms and how those symptoms affect their school, work and relationships; exploring behavior patterns, and learning how to make positive choices that will allow for movement forward at home and at school or work.

• Behavior Therapy: helping the child/adult to become aware of their behavior and to learn ways to develop behavioral strategies and make appropriate changes; also encompasses time management training and organizational skills training (parent and child and/or teacher, adult patient)

• Social Skills Training: helping the child/adult to learn appropriate behaviors, such as sharing, asking for help, waiting their turn, etc. in order to work and play better with others (adult, parent, child and therapist)

• Support Groups: helping parents of children with ADHD to connect with others to build a support network and to share strategies for coping (parents and support group)

• Parenting Skills Training: helping parents to discover and develop the tools and techniques for understanding and managing their child’s behaviors (parents)

Current Practices

Research studies have shown that the most effective treatment for ADHD is a combination of both medication and behavioral therapy. Second to that is medication only, and last in terms of effectiveness, is behavioral intervention only. A review article published in 2014 which examined the previous 13 years of research on treatment of ADHD in adolescents drew the following conclusions:

• A range of pharmacological and behavior therapies produced positive effects

• Cognitive enhancement trainings were not effective treatments for ADHD in adolescence

• Behavior therapy produced the greatest effects on impairment

• Medication produced the greatest effects on symptoms

Another review article published in 2017 compared stimulant medication and behavioral therapies among adolescents with ADHD. Among their conclusions:

• Stimulants have higher short-term efficacy, and are relatively safe

• Behavioral interventions have better long-term benefits e.g. executive functioning and organizational skills

• Stimulants seem to address symptoms while CBT improves learning

The results seem to suggest that medications have the greatest immediate benefit and are best for treating symptoms, while behavioral interventions have the greater long term and overall benefit. Neither study came to definitive conclusions on the best practices for treating ADHD and researchers note that more long term, placebo controlled, randomized studies are needed to determine the best intervention.

As always, talk to your psychiatrist to determine which treatment approach is best for you. Factors such as physical, neural, and emotional maturity as well as the personalities of the individual, child and parent(s) or guardian(s) will help to determine the best course of action.

ADHD and Melatonin

Research has shown that 25-50% of children with ADHD suffer from sleep problems, the most common being chronic sleep onset insomnia. We know that sleep is incredibly important for our health, affecting everything from our heart to our skin to our ability to think. During puberty, the brain continues to develop and it is normal for teenagers to experience changes in their sleeping habits and patterns. Children with ADHD, however, who already experience sleep problems, will likely follow a different pattern of developmental sleep changes. It is not well understood yet how ADHD might impact long term sleep patterns, nor do we know how sleep dysregulation caused by ADHD might impact the developmental trajectory of ADHD itself. Sleep may be a factor in determining whether ADHD persists into adulthood and is therefore important to consider in any treatment plan.

Sleep agents such as melatonin have been shown to be significantly helpful for children with ADHD. Melatonin is available over the counter at just about every pharmacy and chemist in the U.S. and is a synthetic form of a hormone our brains naturally produce to help us fall asleep. Melatonin has been shown to decrease the time it takes for children with ADHD to fall asleep. To date, no significant safety concerns have been found with the use of melatonin; however, discontinuing its use will likely lead to a relapse of sleep-onset insomnia. The side effects of melatonin are usually quite minor, such as headaches, grogginess, and a more serious but rare side effect in kids is increased bedwetting (likely due to the deeper sleeping habits).

There are certain things to consider however, when giving a child melatonin for improved sleep. It is not a “magic pill” and should never be substituted for healthy sleep practices. For example, regular nighttime routines should still be followed in order to help your child wind down, including stopping the use of any electronic or blue-light device at least one hour before bedtime.

Melatonin should be avoided in the following circumstances:

• For physical sickness (i.e. ear infection or coughing etc.)

• If there is an underlying physical cause of insomnia, not related to ADHD (i.e. sleep apnea, restless legs)

• If the child is under 3 years old

Discuss the use of melatonin with your child’s doctor. Even though melatonin is likely to have low risk and high benefit to a child with ADHD suffering from insomnia, it should be used in combination with the above described medications and behavioral therapies.

We have learned a lot about ADHD and the ways in which it presents in children and how it can impact their quality of life in the last several decades. Thanks to increased understanding of how the brain works and studies like the ones mentioned above, we are equipped with effective tools that help to alleviate short and long term impact of the condition. If you have a child with ADHD and are interested in learning more about the range of treatment options available- integrative, pharmaceutical, and behavioral- check in with your healthcare provider to see what might work best for your child.