The Doctor is in—

Questions and answers about behavioral problems in children

aWinter 2003

The parents of many of my patients with attention-deficit hyperactivity disorder (ADHD) ask about alternatives to Ritalin. What should I tell them?

Dr. Mina Dulcan responds:

Stimulant medications: Proven safety and efficacy

First you might want to explain to parents that stimulant medications, such as methylphenidate (Ritalin) and amphetamine, are the most studied, most effective, and safest medications for pediatric psychiatric problems.¹ Properly titrated and monitored stimulant medication also manages core symptoms of ADHD better than other treatment modalities, according to the National Institute of Mental Health-funded landmark multi-site study.²

Side effects of stimulants are almost always minor, short-term, and easily reversible. There is no evidence that prescribed use of stimulant medications for ADHD increases the risk of drug abuse by patients. In fact, substance abuse is more common in children with untreated ADHD.

The newer long-acting methylphenidate formulations, such as Concerta, Metadate CD, and Adderall XR, can be used as alternatives to the short-acting Ritalin. These stimulants provide even more options for improving adherence to medication schedules, avoiding the need for a medication dose during the school day, and attaining smoother symptom control.

Second-line medication choices

For children with ADHD who do not respond positively to methylphenidate or amphetamine, or who have unacceptable levels of side effects, a few second-line medication choices are available—bupropion, tricyclic antidepressants, clonidine, and guanfacine. Effectiveness of these medications for treating ADHD is supported by some research. Several new medications are in the research and development pipeline.

Multimodal treatment

In addition to medication, treatment for ADHD includes educational, behavioral, and psychological interventions. Behavioral therapies at home and school can be useful in dealing with ADHD symptoms that persist despite medication and for additional problems that children with ADHD may have.

Before medication is started, evaluation for ADHD should include reports from teachers, as well as psychological testing of intelligence and academic achievement, to see if special help in school is needed for learning disabilities or borderline intellectual functioning. Proper class placement, tutoring when appropriate, and a therapeutic alliance with the child and family are essential for successful treatment.

“Alternative” treatments and scientific evidence

Since a variety of alternatives to medication have been touted for ADHD, parents need to know how to assess the diverse claims of effectiveness. Many alternative approaches often consume time and money, with unproven benefits. During consultation, you might wish to emphasize the need to insist on clinically significant positive results of blind, controlled clinical trials, published in a peer-reviewed scholarly journal. See Table 1 for a brief review of some controversial therapies in respect to scientific evidence.

TABLE 1
Scientific Support for Alternative ADHD Remedies?

Feingold Diet
The Feingold diet (i.e., eating additive-free foods) is mildly helpful for a small number of very young children with ADHD, according to a few well-controlled studies. However, it is less potent than medication, difficult for the family to follow, and as soon as children have any independence in what they eat, impossible to maintain.

Sugarless Diet
There is conclusive evidence that ingestion of sugar is not related to symptoms of ADHD.³

Herbal Treatments
Herbal treatments for ADHD have not been supported by research, and some can even be dangerous. For example, there have been case reports of liver failure associated with the chronic ingestion of kava.

Vitamin and Mineral Supplements
Currently there is no empirical evidence for effective ADHD symptom management with vitamin and mineral supplements. The American Psychiatric Association and the American Academy of Pediatrics do not support treatment of behavioral and learning problems with megavitamins.

EEG training or Biofeedback
Effectiveness of EEG training or biofeedback has not been substantially demonstrated thus far. Some research has reported positive results, but the studies lacked appropriate control groups and involved small numbers of patients with ambiguous diagnoses.

Other
No scientific support is available for controlling ADHD symptoms through hair analysis, metronome therapy, or optometric treatments.

Resources for assessing alternatives to medication

For more information, excellent resources are available for evaluating alternative treatments for ADHD. Larry Silver, MD, has written a concise assessment of a long list of controversial treatments.⁴ Also, a new journal, the Scientific Review of Mental Health Practice, published by the Council for Scientific Mental Health Practice, provides detailed scholarly evaluations of the empirical evidence for “controversial and unorthodox claims in clinical psychology, psychiatry, and social work.” The first issue contains an article on neurotherapy for ADHD.⁵

Families can make use of resources offered on the Web site of the Children and Adults with ADHD (CHADD) national organization.⁶ Barkley’s guide for parents⁷ also can be very helpful.

In conclusion, the best way to deal with ADHD is a careful evaluation, tailored dosing and monitoring of stimulant medication, supplementary behavioral interventions, and a good relationship with the child, family, and school. ADHD is a chronic but treatable disorder. By helping parents discern research-supported approaches to treatment, the pediatrician can make a lasting contribution to the well-being of the child and family.

REFERENCES

1. AACAP. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. Journal of the American Academy of Child and Adolescent Psychiatry 2002;41:26S-49S.

2. MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry 1999;56:1073-1086.

3. Milich R, et al. Sugar and hyperactivity: a critical review of empirical findings. Clinical Psychology Review 1986;6:493-513.

4. Silver LB. Controversial Therapies. In: Attention-Deficit/Hyperactivity Disorder: a Clinical Guide to Diagnosis and Treatment for Health and Mental Health Professionals. 2nd ed. Washington DC: American Psychiatric Press; 1999:205-221.

5. Kline JP, et al. A cacophony in the brainwaves: a critical appraisal of neurotherapy for attention deficit disorders. Scientific Review of Mental Health Practice 2002;1(1). Available at: http://www.scientificmentalhealth.org/SRMHP.html. Accessed November 29, 2002.

6. Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) Web site. Available at: http://chadd.org. Accessed November 29, 2002.

7. Barkley RA. Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. 2nd ed. New York, NY: Guilford Press; 2000.

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