666 CHAPTER 14
Treating Disorders of Disruptive Behavior
and Attention
Treatments for disorders of disruptive behavior and attention are usually compre-
hensive, targeting more than one type of factor and possibly all three factors. And
children with ADHD may be legally entitled to special services and accommoda-
tions in school. Specifi c treatments for ADHD focus on both attentional symptoms
and, when present, hyperactivity/impulsivity symptoms.Targeting Neurological Factors: Medication
Although there are no medications specifi cally intended for oppositional defi ant dis-
order or conduct disorder, medication for ADHD often helps children with comor-
bid oppositional defi ant disorder or conduct disorder. One type of medication for
ADHD targets dopamine, which—as noted earlier—plays a key role in the func-
tioning of the frontal lobe (Solanto, 2002). Many of these medications are stimu-
lants, which may sound counterintuitive because people with ADHD don’t seem
to need more stimulation. However, these stimulants increase attention and reduce
general activity level and impulsive behavior. The medications appear to disrupt
the reuptake of dopamine, leaving more dopamine in the synapse and thus correct-
ing at least some of the imbalance in this neurotransmitter that has been observed
in the brains of people with ADHD (Volkow et al., 2005). In addition, this disor-
der may arise in part because the person is understimulated, and hence seeks addi-
tional stimulation; by providing stimulation internally, the medications reduce the
need to seek it externally. Consistent with this view, researchers have found that
people with ADHD perform memory and verbal tasks better when auditory white
noise is present in the background (which presumably stimulates them) than when
such noise is not present; in contrast, the presence of white noise impairs perfor-
mance for control participants (Söderlund, Sikström, & Smart, 2007).
Stimulant medications for ADHD may contain methylphenidate (Ritalin,
Concerta, and Focalin) or an amphetamine (such as Adderall), and are available
in shorter-lasting formulas (requiring two or three daily doses) and in a timed-
release formula (requiring only one dose per day). Methyphenidate is also avail-
able as a daily skin patch. For some people, side effects of these medications can
include headache, insomnia, and decreased appetite, and the medications may be
associated with increased risk of heart problems. About 65–75% of people with
ADHD who receive stimulants improve (compared to 4–30% of controls who
receive placebos), and the side effects are not severe for most people (Pliszka,
2007; Pliszka et al., 2006). In fact, stimulants have been shown to improve the
functioning of various brain areas that are impaired in this disorder (Bush et al.,
2008; Clarke et al., 2007; Epstein et al., 2007). The Federal Drug Administration
has approved these medications for children 6 years old and over; for children
under 6, the medications appear to be less effective than they are for older chil-
dren, and side effects, such as slowed growth and weight loss, are worse (Wigal
et al., 2006).
Another medication for ADHD is atomoxetine (Strattera); it is a noradrenaline
reuptake inhibitor, not a stimulant. Atomoxetine has effects and side effects similar
to those of the stimulant medications (Kratochvil et al., 2002) and currently is the
medication of choice for people with both ADHD and substance abuse.
Medications for ADHD reduce impulsive behaviors, which seems to de-
crease related aggressive behaviors (Frick & Morris, 2004). This effect can have
wide-ranging consequences. In particular, as noted earlier, for some children,
the symptoms of ADHD give rise to feedback loops involving interactions with
their families or with peers that cause the disruptive behaviors to escalate. Suc-
cessful treatment with medication disrupts these feedback loops, reducing the
frequency and intensity of disruptive behaviors, which in turn leads family mem-
bers or peers not to become as irritated and angry, which thereby reduces theirP SN