62 Chapter 5
reduce family stress and children’s negative behaviours. In the process,
they may improve the children’s long-term outcome by reducing the
likelihood of future substance abuse and antisocial personality disorder. It
is less clear how useful behavioural or cognitive-behavioural approaches
are when targeted on the core ADHD symptoms. It is possible to reward
children when they concentrate for progressively longer periods, just as
it is possible to teach them cognitive strategies to increase reflectiveness.
However, it is not clear how much real-life benefit this confers.
Medication
Stimulant medication is a well-tested treatment for ADHD that is under-
used in some places and over-used in others. Indeed, over-use and under-
use can occur side by side, with some children getting medication they
don’t need, while other children with severe ADHD are never tried on a
medication that might have brought considerable benefit. The most com-
monly used stimulant is methylphenidate, but dexamfetamine has very
similar properties. A good response to stimulant medication is predicted by
severe and pervasive ADHD symptoms, and by the absence of emotional
symptoms. Many parents have reservations about medication, and it is
true that medication can have side effects and is a symptomatic rather
than a curative treatment. It is also true that the short-term benefits of
medication may not translate into any long-term advantage. However,
much the same could be said of treating a child’s fever or headache with
paracetamol: the relief of symptoms can be important. Consequently, it
may be worth encouraging parents to consider a brief trial of medication if
their child seems likely to respond. After seeing the positive and negative
effects, the family can then join with professionals in deciding whether
medication should be continued when the trial period is over.
When medication does improve attention and activity level, there are
often parallel improvements in compliance, peer relationships, family
relationships and learning ability. Methylphenidate and dexamphetamine
are not addictive for children, do not make them ‘high’ and do not
cause sedation. Side effects are rarely troublesome. Headache, stomach-
ache, low mood and jitteriness often wear off spontaneously or respond
to reduction in dose. Appetite suppression or difficulty getting to sleep
can usually be overcome by adjusting the timing or dosage. Repetitive
activities or stereotypies can be provoked by over-medication but these
side effects usually disappear when the dose is reduced. Since stimulants
can exacerbate tics, they are not usually the first choice in children with
tics or a strong family history of tics. Stimulants can be administered for
months or years. Long-term use of stimulants is remarkably safe – the only
possible complication of long-term use is a very slight reduction in adult
height, and even this is controversial.
Atomoxetine is a more recent alternative to stimulants; it has a smaller
effect on average, but it may work when stimulants have failed, or when
stimulants have unacceptable side effects. Other drugs that are sometimes
used for hyperactivity include clonidine, buproprion and tricyclics such as