e.Treatment of ADHD

The desire to take medicine is perhaps the greatest feature, which distinguishes man from animals. William Osler

The treatment of ADHD, specifically with medications, like many other  psychiatric disordes has been heavily stigmatized, ignored and challenged. As a result, some experts avoid asserting treatment with psychostimulants as the mainstay and effective way of treatment. So it is common to hear that that ADHD treatment involves combination of medications, cognitive and behavior therapy, complementary and alternative medicine , lifestyle and diet changes, school-based interventions, social skills training, parent management training, neurofeedback, nature exposure, counseling and other psychotherapies.

But other than, cognitive enhancement and attention training therapies to some degree, the mainstay of treatment of ADHD remains to be psychostimulants, e.g. Methylphenidate and Amphetamine that basically increase the level of dopamine in the brain.  Other newer medications, exerting their effects primarily through other neurotransmitters, e.g. Atomxetine and Guanfacine yet remain to show their efficacy in comparison to the older rivals, the psychostimulants.  Here we need to emphasize that stimulants are not per se dopaminergic agents and only increase the level of brain dopamine, but through acting on dopamine primarily, they have impact on other neurotransmitters of cognition, e.g. Acetylcholine, serotonin and norepinephrine as well. Moreover methylphenidate and amphetamine do not just increase the dopamine and to lesser degree other neurotransmitters at the synaptic level in the brain, but also block the reuptake of dopamine to be more available for the synapses and also by acting on the dopamine transporters.

In short and in response to many hesitations, questions and doubts about the treatment with psychostimulants in ADHD, we need to emphasize the effectiveness of these medication in improving not only the cognition (attention, concentration, memory and academic performance), but controlling the hyperactivity, restlessness, impatience, impulsivity and disinhibiting behaviours, e.g. risk taking behaviours, substance abuse, conduct and anti-social behaviours and consequently preventing many post-morbidities.  In fact, psychostimulants in the the treatment of ADHD are the most effective medications among all psychiatric disorders.

But there are many nuances in the treatment of ADHD with stimulants that even many experts and physicians may not be aware! The most important concept in the treatment of ADHD with stimulants is related to the developmental aspect of the disease and the brain in growth through stages of life.  Dopamine that could be considered a brain fertilizer, vital for the development and growth of the brain, reaches its peak  by adolescence, then starts a downward trend as it is with the general growth and developmental process of the brain that finally stops  in mid-20’s.  Therefore, the dose graph of stimulants have an upward trend in childhood then down in adolescence until reaches its bottom or lack of efficacy in adulhood by mid-20’s.  This is in contrast with many other psychiatric or even medical disorders that the dose of medications increase by age, while in ADHD decrease by age!

Read more about these interesting concepts in the book “ADHD:Revisited” available at Amazon, Kindle books. 

Dr.Mostafa Showraki, MD, FRCPC Lecturer, University of Toronto,Head, Community Psychiatrists Association of Toronto (CPAT),Author: “ADHD:Revisited” Book “adhdrevisited.com”/”medicinerevisited.com”   

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