Overall, it seems that melatonin is the most well-studied, effective, and safe
medication option for treating sleep disturbance in individuals with developmental
disabilities. Although promising evidence for ramelteon, trazodone, mirtazapine, and
clonidine exists, further research is needed in individuals with developmental
disabilities. Research evidence does not seem to support the wide use of
diphenhydramine for sleep disorders in children, and although zolpidem and
benzodiazepines may be of benefit for sleep in some, they should be used with
caution, and primarily in adults for zolpidem, and those with parasomnias for
effects. T.T.’s clinician asks for your opinion.
You note that the dose of melatonin last year may have been on the lower range
and you would recommend another trial of melatonin before considering a controlled
substance. The dose you would recommend is 5 mg taken approximately 1 hour to
T.T.’s bedtime. You note that this dose can be increased to 10 mg if an adequate
Summary of Target Symptoms and Pharmacologic Treatment
Target Symptom Treatment Medications/Classes to Consider
Hyperactivity Stimulants, atomoxetine, α2
Irritability/aggression Risperidone, aripiprazole
Repetitive behaviors Risperidone, aripiprazole, fluoxetine, clomipramine, fluvoxamine,
Self-injurious behavior Risperidone, clomipramine, naltrexone
Sleep Melatonin, ramelteon, clonidine, trazodone, mirtazapine, zolpidem,
SSRI, selective serotonin reuptake inhibitors.
A full list of references for this chapter can be found at
http://thepoint.lww.com/AT11e. Below are the key references and websites for this
chapter, with the corresponding reference number in this chapter found in parentheses
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Attention deficit hyperactivity disorder (ADHD) is a heterogeneous
psychiatric disorder that consists of multiple subtypes, including
inattention, hyperactivity/impulsivity, and a combination of these two
types. For diagnostic criteria to be met, there must be evidence that
these symptoms are present in multiple settings and that the individual
exhibited this psychopathology before the age of 12 years. These
symptoms cannot be because of other illnesses.
Behavioral therapy is an important component of any effective treatment
plan and typically includes educational interventions, creation of a
structured environment for the child, and introducing contingency
Stimulant medications are highly effective for the rapid relief of ADHD
symptoms and substantially improve a child’s prognosis. Individuals who
fail to respond adequately to one type of stimulant will often do well
with another, suggesting that subtle differences exist in the
pharmacologic mode of action. Although the duration of pharmacologic
action is relatively brief for stimulants, a variety of preparations have
been approved that can prolong the relief of ADHD symptoms and
There are a number of non-stimulant medications that have proven to be
effective for ADHD over the years, including atomoxetine a NE
reuptake inhibitor, and α-agonists. These medications may be viable
options for the management of treatment-resistant illness as well as in
patients with a history of substance abuse. They also possess a different
side effect profile than stimulants and have a delay until therapeutic
Many people are reluctant to consider stimulant medications for ADHD
treatment because of unfounded fears about drug tolerability and abuse.
As a result, there have been a wide variety of alternative treatments
considered for use, including changes in dietary habits, ingestion of
herbs and supplements, and other somatic interventions. At the present
time, the evidence supporting these options is sparse, although the rigor
of investigations has steadily improved in recent years, and there is hope
that some of these options may prove to be beneficial.
ADHD is commonly associated with several psychiatric and medical
comorbidities, and these concurrent conditions often influence treatment
plans. Tic disorders such as Tourette syndrome are frequently found in
children with ADHD, but research evidence suggests that stimulants
are not only safe but also effective in this particular population.
Some children with ADHD will continue to have symptoms of their
illness well into their adult years, usually of the inattention subtype.
There is a growing awareness that adults with ADHD have significant
social and occupational impairments. Fortunately, medications used to
treat ADHD in children appear to be equally effective in adults.
Stimulants are the most effective agents but have the unique side effect
risk of abuse and diversion. Monitoring for this is essential. If abuse or
diversion occurs then a reevaluation of the diagnosis is necessary as
well as a change to a medication with less risk of misuse.
Although the diagnosis and treatment of attention deficit and hyperactivity disorder
(ADHD) have been associated with considerable controversy, ADHD is a serious
psychiatric condition that has been well described in the medical literature for more
1 There are highly effective pharmacologic treatments that
ameliorate the core symptoms of the illness. These agents are generally safe and have
been shown to improve long-term prognosis.
By definition, ADHD symptoms manifest in childhood and will often persist into
adulthood in many cases. If left untreated, ADHD can produce significant
impairments in academic performance and social functioning; adults with ADHD are
often hindered in occupational settings as well.
3 Psychiatric comorbidities are
commonly encountered among individuals suffering from ADHD, including
developmental disorders, mood disorders, and substance abuse.
Although hyperactivity had been recognized as a troublesome childhood behavior
for many years, ADHD was not formally described in the Diagnostic and Statistical
Manual of Mental Disorders until the third edition was released in 1980. The
recently released DSM-5 describes three different subtypes of ADHD including
“Predominantly inattentive presentation,” “Predominantly hyperactive/impulsive
presentation,” and “Combined presentation.”
4 The DSM-5 also requires the diagnosis
by age 12, in contrast to DSM IV that required the onset of impairment before age 7.
Qualitatively the core symptoms of ADHD will differ according to gender, with boys
more likely to exhibit the hyperactive/impulsive subtype (vs. girls).
often change with time as hyperactive and impulsive behaviors recede during
adolescence, and inattention predominates among adolescents and adults with
Although the effectiveness of pharmacologic treatments for ADHD has been
widely replicated, many children and adolescents with ADHD will receive
suboptimal treatment for a variety of reasons, including parental reluctance to
It is important to note that ADHD poses a huge economic burden to
Western society. A meta-analysis by Doshi et al. reports overall national incremental
costs of $143 to $266 billion in the United States.
8 The economic impact related to
adults with the disorder from productivity and income loss is greatest, although there
are also significant costs associated with youth with the disorder from educational
and health expenses. Further, the study documents significant “spillover costs” for
family members of individuals with ADHD.
Stimulants such as methylphenidate and amphetamine have been the mainstay of
ADHD treatment in children for more than 30 years, and recent studies have
demonstrated acute and long-term benefits in adolescents as well as adults.
Unfortunately, stimulants have not been consistently shown to decrease delinquency
rates. They have also been implicated with rare but serious side effects, and they
carry an elevated risk of diversion and abuse.
11–13 Pharmacologic alternatives to
stimulants have been identified in recent years and have proven to be useful, albeit
often as second-line agents among individuals who have significant side effects and
those with medical or psychiatric comorbidities.
behavioral psychotherapy have also been emphasized in recent years, and most
experts now contend that the combination of pharmacotherapy with family-based
cognitive behavioral interventions will generate the best long-term prognosis for
individuals with this disorder.
Recent landmark studies have helped clarify important aspects of diagnosis and
treatment with regard to ADHD. The Multimodal Treatment of Attention Deficit
Hyperactivity Disorder Study (MTA) is considered a groundbreaking study of
ADHD treatments and outcomes. The main findings were released in 1999, but
additional findings have been subsequently released. MTA was a multisite study that
differed from earlier studies of ADHD in that the duration of the study was
significantly longer (up to 14 months) and that the study compared the use of both
medication and cognitive behavior therapy, both alone and in combination with
routine community-based treatment. The central findings of MTA included the
following: (1) Medication alone and in combination with CBT was more effective
than intensive behavioral treatment alone or routine community-based care, (2) youth
receiving combined treatment required lower doses of medication, and (3) youth with
associated mental health issues, in addition to ADHD, had better outcomes with
combined treatment than with medication alone.
The question of medication treatment for preschool children presenting with
ADHD symptoms is a controversial issue. The “Preschool ADHD Treatment Study”
(PATS) is considered a landmark study in this arena. The majority of the findings
were released in 2006. The central findings include (1) preschool children tend to
respond better and with fewer adverse effects with lower doses of medication and
(2) preschool children are more sensitive to the adverse effects of psychostimulants
and require closer monitoring. In particular, younger children tend to have more
emotional adverse effects such as irritability and a tendency toward crying.
ADHD is a chronic neurobehavioral disorder, with an overall estimated prevalence
of 6% to 12% in school-aged children worldwide.
18 The Centers for Disease Control
and Prevention analyzed data from the 2006 National Survey of Children’s Health
and reported that the incidence of ADHD diagnoses has risen annually by an average
In 2006, 7.4% of US children aged 4 to 17 years
were diagnosed with ADHD. The DSM-5 reports that “ADHD occurs in most
cultures in about 5% of children and about 2.5% of adults.” The diagnosis is more
common in males with a ratio of 2:1 in children and 1.6:1 in adults.
hypothesized, however, that this gender predominance may be exaggerated because
the more overt hyperactive subtype is more common in boys and the less overt
inattentive subtype is more common in girls. As ADHD transitions into adulthood, the
prevalence falls to 4.4% (standard error 0.6), with a higher risk found in previously
married men who are unemployed and non-Hispanic white.
Various abnormal genetic and neurochemical abnormalities are associated with
ADHD. Estimates of heritability of ADHD range in the area of 0.7, indicating that
ADHD is one of the most heritable conditions in psychiatry.
demonstrated that the relative risk of ADHD is 6 to 8 times higher among first-degree
relatives of persons with ADHD compared with the general ADHD population.
Several candidate genes associated with ADHD have been identified, such as the
dopamine receptor, dopamine-transporter receptor, and serotonin transporter
22,23 Despite a small causal effect, no single gene is responsible for the
symptoms seen with ADHD, but rather these symptoms are likely the result of
interactions among several genes, which influence multiple neurotransmitters,
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