Attention Disorders

symptoms of ADHD, and significant improvement in cognition has not been noted.22

A recent study has shown that when using RPD in an inpatient setting, significant improvement was found for inattention, aggression, and overactivity.30

This study also found no negative impact

on attentional functions (i.e. slowing of cognitive speed) as RPD may have a sedative effect. Two studies have found that at low doses RPD can be effective in controlling aggression and disruptive behavior in children with ADHD.31,32

Further research concluded that RPD, when

administered in conjunction with a psychostimulant, resulted in significant improvement in aggression based on parent report.33 However, no significant improvements with regard to aggressive behavior were found when these same children were assessed by their teacher. Atypical antipsychotics may be of very little use in the treatment of typical ADHD symptomatology. Due to the risks associated with these medications, they are generally reserved nearly exclusively for those who do not respond to more conventional treatments, or in other cases where severe behavioral concerns warrant their use.34

Anticonvulsants

Although CBZ was originally developed for the treatment of seizure disorders, at least three double-blind studies have shown that CBZ is effective and safe in treating childhood ADHD.36–38

The anticonvulsant carbamazepine (CBZ) has received little attention. However, it does appear to be an effective alternative for children with ADHD.35

These three studies

used both cross-over designs and placebo-controlled parallel groups. More than 70% of patients treated with CBZ experienced significant improvement, while only 26% of those receiving placebo showed similar improvements. For the drug–placebo comparison there was an effect size of 1.01. Some authors have noted that the effect size of the benefit of CBZ is equivalent to that of stimulants.39

However, there are some reported

adverse side effects for CBZ. The most common side effect is drowsiness, although others reported include vertigo, tremor, headache, diplolia, unco- ordination, and slurred speech.35

included hematological changes and liver abnormalities,40 others should be cautioned before beginning treatment with CBZ.

Significant adverse side effects have so parents and

Oxcarbazepine (OXC) is an alteration of CBZ and is designed to have fewer side effects. OXC has demonstrated efficacy in treating acute mania associated with bipolar disorder.41 look at OXC’s efficacy in ADHD in adults.42

Recent research has begun to This open pilot study

concluded that a significant proportion of adults treated with OXC showed improvement based on ADHD symptom checklist scores. As OXC is used in the treatment of seizures for children, this medication may warrant further investigation for ADHD treatment in all age groups.

Further research would be necessary to include this medication as a possible treatment option for ADHD.

Antidepressants

Tricyclics

In the mid-1980s, tricyclic antidepressants (TCAs) started to be used as an alternative medication treatment for children with ADHD.44

60

Another anticonvulsant that has been researched with ADHD is extended- release valproate (EVA). In a study limited to three boys diagnosed with ADHD who presented with associated large somatosensory-evoked potentials, EVA did demonstrate improvement in hyperactivity and impulsivity.43

Investigations have found that many children who do not respond to stimulants can be effectively treated with TCAs.45

TCAs have also been

found to be useful in treating youths with comorbid disorders including mood disorders, anxiety disorders, oppositional disorders, and tic disorders.46

have been particularly well-researched.

Researchers reviewed 58 cases and discovered that 76% showed a moderate to marked improvement in ADHD symptoms when prescribed nortriptyline.46

Three TCAs—nortriptyline, imipramine, and desipramine—

However, 47% of the children were on concurrent medications such as stimulants, lithium, clonidine, neuroleptics, or anticonvulsants. In another investigation it was found that 69% of the participants in a nortriptyline group showed efficacy and tolerability up to 2mg/kg daily.47

Research

This study also concluded that the medication must be taken for about six weeks for significant improvement to develop. Stimulant medications have been shown to exacerbate tics in children suffering from chronic tic disorder and Tourette’s syndrome.44

has found that nortriptyline substantially reduced tics for a period of up to 19 months.44

Another commonly studied TCA in the treatment of youth with ADHD is imipramine. Research has supported moderate to substantial efficacy of imipramine in reducing ADHD symptoms.48,49

Research has evaluated

the impact of imipramine on the cognitive functioning and academic performance of children diagnosed with ADHD. Gains in these areas were not found,49

but problematic behaviors were reduced.48,49 However,

these investigators raised caution about the impact of certain dosage levels reducing performance on fine motor control tasks.

Desipramine is also a frequently used TCA with children who have ADHD. Many studies have supported its success and have revealed similar efficacy levels to those of imipramine.50–53

Furthermore, several

studies have supported the use of desipramine in combination with methylphenidate. An investigation has suggested that the combination of methylphenidate and desipramine was effective in reducing ADHD symptoms and that the two drugs interacted well in youths who were engaged in demanding cognitive tasks.50

Although the combination is

generally well-tolerated, other studies have shown that the combination may produce a slight increase in heart rate.51,53 This combination has been demonstrated to be particularly efficacious when treating children with ADHD who have comorbid disorders. Greater improvement in reducing hyperactivity, inattention, and oppositional behavior has been found with this combination compared with either medication by itself.53

TCAs offer several advantages compared with stimulants, including longer half-life and minimal risk for dependency.47

However, it is

important to note that these medications are not without side effects. For example, they can produce mild cardiac abnormalities in some children. Occasionally, this abnormality may become severe. Researchers reviewed two reported cases of sudden death in children treated with desipramine.54

They concluded that there is a lack of

understanding of whether or how tricyclics have contributed to sudden death in children. It may be related to blood pressure level and pulse rate. Increases in diastolic blood pressure and pulse rate have been documented.44,45,51

It has also been established that this is particularly

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