Treatments and Medications for Attention Deficit Disorder

Topics:

• Stimulant Drugs
  • Overview
    • Mode of Drug Interactions
    • Contraindications
    • Drug Interactions
    • Side Effects
  • Specific Psychostimulant Medications
    Ritalin^®, Dexedrine^®, Desoxyn^®, Adderall^®, Cylert^®
• Other Medications
  • Antidepressants
    Desiprimine, Anafranil^®, Elavil^®, Tofranil^®, Wellbutrin^®, Prozac^®, Zoloft^®,Paxil^®
  • Neuroleptics
    Haldol®, Mellaril^®
  • Mood Stabilizers
    Lithium, Eskalith^®
  • Alpha-Andrenergics
    Clonidine, Guanfacine
• Alternatives To Medication
  • Psychological Treatment Methods
  • Diet
  • Supplements

Medications

Attention Deficit Hyperactivity Disorder - ADHD is often treated with stimulant medications such as Ritalin^®, Dexedrine^® and Cylert^®. A recent study states that an estimated 3 million children with Attention Deficit Disorder - ADD are taking Ritalin^® which is double the number in 1990. You will find information on how these medications are used as well as their side-effects. You will also find information on other medications used to improve behavior, mood and learning in children and teens.

Parents of children with Attention Deficit Disorder - ADD need to have full information. Alternatives to medication will be covered as well. A protocol for prescribing these medications is provided for physicians. The information is based on the latest research and guidelines related to the use of medications in the treatment of Attention Deficit Disorder.

Stimulant Drugs

Overview

The history of stimulant drug use dates back to the discovery by Bradley in 1937 of the therapeutic effects of Benzedrine® on behaviorally-disturbed children. In 1948, Dexedrine® was introduced, with the advantage of having equal efficacy at half the dose. Ritalin® was released in 1954 with the hope that it would have fewer side effects and less abuse potential. Although initially used as antidepressants and diet pills, stimulant drugs are not used for these purposes today.

In 1957, Laufer described the "hyperkinetic impulse disorder," which he believed was caused by a maturational lag in the development of the central nervous system. He asserted that stimulant drugs were the treatment of choice for this disorder and postulated that they acted by stimulating the midbrain, placing it in a more synchronous balance with the outer cerebral cortex. This was an oversimplification but the exact mechanism of action of these drugs is still unknown.

The most frequently used of the stimulant drugs is Ritalin^® followed by Dexedrine^®, Desoxyn^®, Adderall^®, and Cylert^®. Dexedrine^®, Desoxyn^®, and adderall^® are amphetamine preparations. Ritalin® and Cylert^® are non-amphetamines. Cylert^® works differently than the other drugs, taking 2-4 weeks before therapeutic effects are noted. Also, due to its potential for causing serious liver function problems, Cylert® should not be used as the first drug of choice to treat ADD. It should be used only after the trial of several other stimulants. SEE FDA WARNING. Also, recent studies and clinical experience is beginning to favor the use of Adderall® over Ritalin® in treating children and adolescents with ADHD. For more discussion of this issue, we refer you to a recent article in the Doctor's Guide to Medical & Other News.

Mode of Drug Action

It is postulated that the stimulant drugs act by affecting the catecholamine neurotransmitters (especially dopamine) in the brain. Some believe that ADD develops from a dopamine deficiency which is corrected by stimulant drug treatment. Recent research indicates that there is a group of individuals (up to 10% of the population) that have a lowered number of dopamine receptor sites. These individuals may exhibit ADD symptoms and are also prone to drug and alcohol addiction. At one time it was felt that the stimulant drugs created a paradoxical (opposite and unexpected) reaction (calming and sedation) in ADD youngsters and that this response was diagnostic. This is no longer believed to be the case as the response to stimulant drugs is neither paradoxical nor specific. Children with conduct disorder and no evidence of ADD may also respond to these drugs. Likewise, studies with normal and enuretic (bedwetting) children have shown that many experience a calming effect rather than the expected stimulation.

Because of their relative safety, the stimulant drugs remain the treatment of choice for many children diagnosed with ADD. The drugs are unquestionably successful in decreasing hyperactivity, lessening impulsivity and improving attention span in approximately 70% of those treated. As a result of improved interactions with family members, peers, and teachers, the drug-treated children feel better about themselves and self-esteem rises. At the present time, however, there is some controversy as to the degree of learning and memory improvement resulting from the treatment of ADD-children with stimulant drugs. Overall, the ideal approach is one in which the children are involved in psychological treatment methods along with medication. Focus, a psychoeducational program, is an excellent adjunct to medical treatment of ADD.

In considering the use of stimulant medications, the following passage related to the prescription of stimulants from the Physicians Desk Reference (PDR) should be considered:

The prescribing information provided by CIBA ( the manufacturers of Ritalin®) states "Ritalin® is indicated as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms: moderate-to severe distractibility, short attention span, hyperactivity, emotional lability, and impulsivity."

The same literature also states, "Drug treatment is not indicated for all children with this syndrome..... Appropriate educational placement is essential and psychosocial intervention is generally necessary. When remedial measures alone are insufficient, the decision to prescribe stimulant medication will depend upon the physician's assessment...."

Of those ADD-children treated with stimulant drugs, 66-75% will improve and 5-10% will get worse. It is always important to verify that the medication is actually being taken, as some children will refuse to do so as a means of rebellion or defiance. There is a marked variation in drug response among different children, and even within an individual child on different days. Some children will not respond unless they are placed on extremely high doses, or on 4-5 doses a day, probably as a result of accelerated metabolism (drug breakdown).

Tolerance to the stimulant drugs may develop requiring an increase in dosage after the child has maintained nicely on a particular dosage for a year or so. Also, older children and teens may benefit from lower doses than younger children. Children who respond to one of these stimulant drugs will probably respond as well to any of the others. There are cases, however, in which a child will respond favorably to one drug but not another. Also, there is no evidence that children treated for years with stimulant drugs will have a greater likelihood of abusing drugs or narcotics during their adolescent years.

Contraindications

Drug Interactions

The drugs may decrease the effects of some antihypertensive drugs. They should be used cautiously with pressor agents (adrenaline-like drugs). They may affect the liver metabolism of certain anticoagulants, anticonvulsants, and tricyclic antidepressants. Insulin requirements in diabetic patients may be altered when the drugs are co-mixed.

Side Effects

The most common side effects encountered with stimulant drugs are: loss of appetite, weight loss, sleeping problems, irritability, restlessness, stomachache, headache, rapid heart rate, elevated blood pressure, sudden deterioration of behavior and symptoms of depression with sadness, crying, and withdrawn behavior. Two of the most disconcerting side effects are the intensification of tics (muscle twitches of the face and other parts of the body) and suppression of growth. It is rare that stimulant drugs cause tics but they may activate an underlying (latent) tic condition. There is some concern that this could even lead to a severe tic condition called Tourette Syndrome.

The growth retardation problem has caused considerable controversy and concern since an article written in 1972 described suppression in growth of ADD-children who had undergone long-term stimulant drug treatment. Subsequent studies have varied markedly in their findings. One study of adolescents who took the drugs as children showed no growth suppression. Another study demonstrated growth suppression during the first year but none during the second year of drug treatment. Others have demonstrated a rebound during the second of drug treatment. Others have demonstrated a rebound growth spurt when the drug is withdrawn or even in those taking the medication. There is also some indication that taller children are more vulnerable to growth suppression effect than are those who are smaller.

As a result of the the growth retardation scare, many clinicians are suggesting that the drugs be given on school days and not on weekends, holidays, or vacations. Realistically, most parents are unable to comply with the deterioration in behavior that ensues when the medication is withdrawn. At the very least, the drugs would be withdrawn once-a-year to reestablish the need to continue the medication. A popular approach is to discontinue the stimulant drugs during the first 2 weeks of the fall semester. If the medication is still required, it will be apparent soon enough, and not too late to endanger the child's grades and reputation among schoolmates and teachers.

Other rare side effects include irregular heartbeat, hair loss, decreased blood cell count, anemia, and rash. Elevated liver function tests may be associated with Cylert®. A rare hypersensitivity reaction consists of hives, fever and easy bruising. Occasionally, ADD-children on stimulant drugs will experience a personality change characterized by dejection, lifelessness, tearfulness, and oversensititivy. Conversely, some may develop a state of excitement, confusion, and withdrawal.

When children and adolescents with severe behavioral and emotional symptoms do not respond to stimulant medications, other types of medications may be prescribed. These include antidepressants such as Wellbutrin®, Desiprimine and Prozac®. Sometimes, medications originally designed to treat high blood pressure such as Clonodine may be used. In other cases, medications used to treat psychosis, schizophrenia or to manic-depressive illness may be prescribed. The current thinking is that (in most cases) if these medications provide control for the symptoms, they are actually treating another mental disorder rather than attention deficit disorder. Unfortunately, some physicians may initially prescribe a medication other than a stimulant because the other medications do not require "triplicate" prescriptions as they are not considered controlled substances by the FDA. While this may be convenient, the other medications have far more serious side effects than the stimulants and should not be considered unless there is reasonable clinical information to support their use over stimulants.

Antidepressants

There are two basic types of antidepressants, the tricyclic antidepressants (TCAs) and the newer ones known as selective serotonin reputake inhibitors (SSRIs). When children or adolescents appear to have symptoms of depression with or without ADD like symptoms, an antidepressant may be prescribed. In earlier years Tofranil® was used to treat bed wetting with or without behavioral or emotional symptoms. There have been five unexplained sudden deaths reported in relation to the use of Desiprimine in treating children. Though no specific causal relationship was established, clinical practice now favors Elavil® and Tofranil® as the first choices among the tricyclics in the treatment of children. In any case, another medication Anafranil® has been found to be useful in treating obsessive-compulsive disorder in adults as well as children an adolescents. According to the American Academy of Child & Adolescent Psychiatry, "TCAs should be used only for clear indications and with careful monitoring of therapeutic efficacy and of baseline and subsequent vital signs and EKG." Also, "patient history of cardiac disease or arrhythmia or a family history of sudden death, unexplained fainting, cardiomyopathy, or early cardiac disease may be a contraindication to TCA use." Finally there has been a lot of interest in the use of SSRIs, particularly Prozac® in treating ADD and/or depression or anxiety in children and adolescents. As yet, there have been no major research findings to support the use of SSRIs in treating ADD. Furthermore, the Physician's Desk Reference (PDR) states that "safety and effectiveness in pediatric patients has not been established."

Neuroleptics

Neuroleptics were developed to treat serious mental disorders such as psychosis and schizophrenia. They are indicated for use in children and adolescents with significant psychotic symptoms such as hallucinations or delusions. Two of these drugs, Haldol® and Mellaril®, have been used to treat ADD like symptoms (especially aggression and explosiveness) in children and adolescents. These medications appear to have some usefulness in controlling severe symptoms that are not helped by other medications. However the American Academy of Child & Adolescent Psychiatry cautions that "they should be used only in the most unusual circumstances because of lesser effectiveness relative to other drugs, excess sedation and potential cognitive dulling, and risk of tardive dyskinesia or neuroleptic malignant syndrome".

Mood Stabilizers

In the last few years, it has become more acceptable by American psychiatrists to consider the diagnosis of bipolar disorder (manic-depressive illness) for children and adolescents. This has been common practice in other countries including Great Britain. Again, it is presumed that if a child's behavior improves on this type of medication that the cause of the symptoms is bipolar illness not ADD. Lithium and other medications containing lithium are most often used to treat bipolar disorder in adults and children. Anticonvulsant medications such as Tegretol® or Depakote® also can be used to treat bipolar disorder when it does not respond to lithium.

Alpha-Andrenergics

It is currently assumed that biochemically ADD is related to problems with the neurotransmitter, dopamine. Another neurotransmitter, norepinephrine, is a derivative of dopamine. Stimulants are thought to primarily effect dopamine. In some cases, norepinephrine may be involved. In these cases two medications originally developed to treat high blood pressure, Clonidine and Guanfacine have proven to be useful. These drugs have been found to be effective in treating ADD symptoms in children who were exposed to drugs as a fetus. These drugs have been effective in treating Tourette Syndrome and therefore are useful in treating ADD children who have or have a tendency for motor tics. Some psychiatrists use Clonidine in conjunction with a stimulant to treat ADD in children with motor tics. These drugs can have serious side effects and should be used only when clinically indicated.

Medications Commonly Prescribed To Improve Behavior, Mood and Learning

*All of these medications have some possible additional effects, both detrimental and beneficial. Different children are apt to respond or react differently to the same drug. There are some differences in effects, side effects, and duration's of action between the drugs within a single category. Some of these medications have not been fully tested in children. (Click on any of the drug names in the above table for MORE information on that specific medication.)

Although much excellent research on the use of these medications continues, surprisingly little is actually known about them. Their precise dosages, their long-range side effects, and use in various combinations require further investigation. For this reason we suggest a conservative approach to their use.

References

Levine, Melvin D Developmental Variation and Learning Disorders, Educator Publishing Services Inc., Cambridge and Toronto, 1993

Physicians' Desk Reference. 52nd ed. Montavle (NJ): Medical Economics Data Production Company, 1998

Practice Parameters for the Assessment and Treatment of Children, Adolescents and Adults With Attention Deficit/Hyperactivity Disorder Journal of American Academy of Child and Adolescent Psychiatry, 36:10 Supplement, October 1997

Taylor, M Evaluation and Management of Attention-Deficit Hyperactivity Disorder. American Family Physician 1997: 55 (3); 887-894

Diet

The subject of diet modification in the treatment of ADHD continues to be controversial. Many parents insist that eliminating certain foods from a child's diet leads to a significant reduction in ADD symptoms. As we have stated elsewhere, removing sugar from diet does appear to help some children particularly younger children. Also, the American Academy of Child and Adolescent Psychiatry believes that the removal of certain dyes and other substances may be beneficial to some children (again very young children). Our viewpoint is that removal of sugar and other substances thought to be harmful to children may help and this action will not cause any harm.

The most widely followed diet for the treatment of ADHD is the Feingold Diet. While it does have it's supporters, generally, the scientific and medical communities do not recommend this diet. There are certainly a large number of parents who feel this diet has been extremely beneficial to their children. We do not recommend the diet but we also would not discourage any parent from giving it a try. We have provided several links which provide useful information about the Feingold Diet. They provide both pro and con discussions of this approach to treating ADD.

The Feingold Association of The United States

Quack Watch

National Network for Child Care

University of Virginia: Information and Links About the Effects of Sugar and Diet on Children's Behavior

References

Practice Parameters for the Assessment and Treatment of Children, Adolescents and Adults With Attention Deficit/Hyperactivity Disorder Journal of American Academy of Child and Adolescent Psychiatry, 36:10 Supplement, October 1997

Taylor, M Evaluation and Management of Attention-Deficit Hyperactivity Disorder. American Family Physician 1997: 55 (3); 887-894

Supplements

There are a wide variety of "natural" remedies for ADHD being promoted on the world wide web and elsewhere. The official position of the American Academy of Child & Adolescent Psychiatry is: "Megavitamin therapy, the prescription of vitamins in quantities greatly in excess of the Recommended Daily Allowance guidelines, has been suggested as a treatment for hyperactivity and learning disabilities. Extreme claims have been made from uncontrolled studies. Not only is scientific evidence of effectiveness lacking, but there is a possibility of toxic effects....Herbal remedies also have no empirical support."

There is one substance that has been shown in some scientific studies to be beneficial in treating ADHD, L Tyrosine. This is an amino acid (a protein) that the body uses to synthesize dopamine and norepinephrine, the two neurotransmitters believed to be involved in ADHD. These neurotransmitters are the targets of the medications used to treat ADHD. Some studies have shown that children with ADD may have lower levels of this amino acid. By increasing the intake of L Tyrosine through diet or supplements, it is possible to increase the amount of dopamine and norepinephrine available in the brain.

[The figure above shows the biochemical process in which the body synthesizes L Tyrosine into dopamine and norepinephrine.]

Biochemically, ADD/ADHD is likely caused by a deficiency in dopamine, a natural "feel-good" brain chemical called a neurotransmitter. Some of the dopamine that brain cells make, projects to and activates the frontal lobes. One of the most important functions of the brain's frontal lobes is the integration of thoughts, feelings, sensory information and updated feedback about current motor activity. The frontal lobes compile all this information and are instrumental in "choosing" the next task to attain goal completion. So it is little wonder that when dopamine activity is compromised, thus interfering with the frontal lobes, a person becomes unfocused and distractible.

How can we put natural dopamine back into our bodies? First, a brief lesson in basic chemistry. Dopamine is made from tyrosine, or phenylalanine, two of the essential amino acids which are the building blocks of all life. These are converted by our enzymes (made from the DNA in our genes) into the next natural brain chemical called L-DOPA. Folic acid, Vitamin B3 (niacin) and iron, (a mineral) are required for this enzyme to make L-DOPA from tyrosine. Next, another enzyme, (from our DNA), converts the L-DOPA into dopamine, as long as there is enough Vitamin B6 available. Dopamine converts to norepinephrine, as long as Vitamin C is available. And finally converts to epinephrine. Norepinephrine deficiency can cause depression and dopamine deficiency causes ADD/ADHD. Both can be treated with nutrients and amino acids, the raw materials the body uses to make these neurotransmitters, naturally.

The original dopamine deficiency may be caused by a combination of factors: exposure to environmental pollutants, nutritional deficiencies, food or airborne allergies, stress of a high paced lifestyle, gastrointestinal injury and genetic vulnerabilities. These all combine to cause changes in brain chemistry which underlie the behavioral problems listed above.

It could be just a dietary deficiency of the necessary nutrients mentioned above. It could be a "brain allergy", such as a food allergy causing the deficiency. Most of the time, if it's an allergy, it has something to do with casein (milk protein) or gluten (wheat protein). So it is wise to eliminate these offending foods from the diet. If the allergy is due to an airborne allergen, like pollen, then allergy shots may help.

If the allergy is due to Leaky Gut Syndrome, which allows proteins to leak into the bloodstream, causing an immune problem, that can also be tested for and treated properly. Intestinal damage can be caused by toxins in the environment and the free radical by-products created when the body rids itself of those toxins. The Nutrient Transfer® in NSR Focus helps heal the GI tract while delivering the necessary nutrients. Antioxidants also may help in this situation.

Supplementing the nutrients listed above may be enough to alleviate many ADD/ADHD symptoms. However, if the cause is due to a complicated combination of factors mentioned above, other companion treatments may be necessary.

References

Bornstein, R et al, Plazma Amino Acids in Attention Deficit Disorder Psychiatry Research 1990 33(3) 301-306

McConnell, H Catecholamine Metabolism in the Attention Deficit Disorder: Implications for the use of Amino Acid Precursor Therapy Medical Hypotheses 1985 17(4) 305-311

Nemzer, E et al, Amino Acid Supplementation as Therapy for Attention Deficit Disorder Journal of American Academy of Child and Adolescent Psychiatry, 1986 25(4) 509-513

Practice Parameters for the Assessment and Treatment of Children, Adolescents and Adults With Attention Deficit/Hyperactivity Disorder Journal of American Academy of Child and Adolescent Psychiatry, 36:10 Supplement, October 1997

Shaywitz, S & Shaywitz, B Biologic Influences in Attentional Deficit Disorders in Levine, M et al Developmental-Behavioral Pediatrics, W.B. Saunders Company, Philidelphia 1983

Alternatives to medication - psychological treatment methods

The Use of Focus with Children and Young Teens with Attention Deficit Disorder Is Backed by Clinical Research and Professional Practice

Professional Guidelines Recommend The Use of Proven Psychological Methods Along With or Without Medication In The Treatment of Attention Deficit Disorder:

The prescribing information provided by CIBA ( the manufacturers of Ritalin^®) states "Ritalin^® is indicated as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms: moderate-to severe distractibility, short attention span, hyperactivity, emotional lability, and impulsivity."

The same literature also states, "Drug treatment is not indicated for all children with this syndrome..... Appropriate educational placement is essential and psychosocial intervention is generally necessary. When remedial measures alone are insufficient, the decision to prescribe stimulant medication will depend upon the physician's assessment...."(1)-Physicians' Desk Reference 1998

Dr. William Barbaresi notes that "Comprehensive treatment, including both medication and nonmedical intervention, should be coordinated by the primary-care provider."(2)-Mayo Clinical Proceedings 1996

Similarly Dr. Michael Taylor concludes, "The most successful management of children with attention deficit disorder involves a coordinated team approach, with parents, school officials, mental health specialists and the physician using a combination of behavior management techniques at home and at school, educational placement and medication therapy."(3)-American Family Physician 1997

Research and Clinical Practice Has Shown Well Constructed Behavior Modification Programs To Be Very Useful In The Management of ADD/ADHD:

Behavior modification programs emphasizing positive reinforcement of appropriate behavior have been useful in reducing maladaptive behavior at home and at school. Research has shown that behavior modification can improve impulse control and adaptive behavior in children of various ages (4)-Perceptual Motor Skills 1995, and (5)-Abnormal Child Psychology 1992.

The use of positive reinforcement related to daily reports from school has been found to be useful in improving task completion and reducing disruptive behavior in the classroom (6)-Behavior Modification1995.

Some parents have been found to prefer behavioral to medical treatment (7)-Strategic Interventions for Hyperactive Children 1985.

Families are often able to succeed with their behavior modification efforts through the use of written materials only (8)-Journal of Pediatric Health Care 1993.

Teaching children with attention deficit disorder how to relax can be effective in reducing hyperactivity and disruptive behavior while increasing attention span and task completion:

Relaxation training conducted by parents in the home has been found not only to be effective in improving behavior and other symptoms but also improves over all relaxation when measured by biofeedback equipment (9, 10)-Journal of Behavior Therapy & Experimental Psychiatry 1985 & 1989.

A review of a number of studies related to relaxation training with children concluded, "Findings suggest that relaxation training is at least as effective as other treatment approaches for a variety of learning, behavioral, and physiological disorders . . ."
(11)-Journal of Abnormal Child Psychology 1985.

Cognitive Behavioral Therapy Can Help ADD Children Improve Problem Solving and Coping Skills:

Cognitive Behavioral Therapy (CBT) consists of teaching children to change their thought patterns from ones that lead to maladaptive behavior to ones that produce adaptive behavior and positive feelings. This technique can be used to help children to improve their self-esteem. It can also be used to help them improve coping skills, problem solving skills and social skills.

In one study CBT was found to be helpful in helping hyperactive boys develop anger control. The findings indicated that "Methylphenidate (Ritalin®) reduced the intensity of the hyperactive boys' behavior but did not significantly increase either global or specific measures of self-control. Cognitive-behavioral treatment, when compared to control training, was more successful in enhancing both general self-control and the use of specific coping strategies. "(12) Journal of Abnormal Child Psychology 1984.(It should be noted that CBT has not proven to be successful in all studies. The problem may be related to the fact that each study uses different strategies and measures of success).

Cognitive Rehabilitation Exercises (Brain Training) Can Improve Attention & Concentration As Well As Other Intellectual and Self-Control Functions:

Victims of strokes or head injury may have significant impairments in attention and concentration. Cognitive Rehabilitation exercises are often used to help these people to improve their ability to concentrate and pay attention. This approach has been applied to children with attention deficit disorder with some success. The repeated use of simple attentional training exercises can help children to train their brains to concentrate and pay attention for longer periods of time. (13)-Behavior Modification 1996

Focus is a multi-media psychoeducational program that combines all of the above methods in a package that can be easily and effectively implemented at home by parents:

The training manual provides a behavior modification program using the daily report card to improve performance at school.

A token economy program is provided to improve behavior at home and foster a positive parent/child relationship.

The manual also provides a series of Cognitive Rehabilitation exercises that are fun and easy to implement to improve attention and concentration while also helping to reduce hyperactivity and improve impulse control.

The manual along with audio tapes help not only teach how to improve the ability to relax but also how to apply this skill to home, school, social and sport activities.

A temperature biofeedback card is supplied as an additional aide for relaxation training.

Audio tapes provide Cognitive Behavioral Therapy to help improve motivation, self-control and self-esteem.

The program is organized in a way to provide materials appropriate for two different age levels (6-11 and 10-14).

The program also provides additional parent education material related to attention deficit disorder as well as a set of forms for recording progress.

next:

References

1. Physicians' Desk Reference. 52nd ed. Montavle (NJ): Medical Economics Data Production Company, 1998
2. Barbaresi, W Primary-care Approach to the Diagnosis and Management of Attention-Deficit Hyperactivity Disorder. Mayo Clin Proc 1996: 71; 463-471
3. Taylor, M Evaluation and Management of Attention-Deficit Hyperactivity Disorder. American Family Physician 1997: 55 (3); 887-894
4. Cociarella A, Wood R, Low KG Brief Behavioral Treatment for Attention-Deficit Hyperactivity Disorder. Percept Mot Skills 1995: 81 (1); 225-226
5. Carlson CL, Pelham WE Jr, Milich R, Dixon J Single and Combined Effects of Methylphenidate and Behavior Therapy on the Classroom Performance of Children with Attention-Deficit Hyperactivity Disorder. J Abnorm Child Psychol 1992: 20 (2); 213-232
6. Kelly ML, McCain AP Promoting Academic Performance in Inattentive Children: The Relative Efficacy of School-Home Notes With and Without Response Cost. Behavior Modif 1995: 19; 76-85
7. Thurston, LP Comparison of the Effects of Parent Training and of Ritalin in Treating Hyperactive Children In: Strategic Interventions for Hyperactive Children , Gittlemen M, ed New York: ME Sharpe, 1985 pp 178-185
8. Long N, Rickert VI, Aschraft EW Bibliotherapy as an Adjunct to Stimulant Medication in the Treatment of Attention-Deficit Hyperactivity Disorder. J Pediatric Health Care 1993: 7; 82-88
9. Donney VK, Poppen R Teaching Parents to Conduct Behavioral Relaxation Training With Their Hyperactive Children J Behav Ther Exp Psychiatry 1989: 20 (4); 319-325
10. Raymer R, Poppen R Behavioral Relaxation Training With Hyperactive Children J Behav Ther Exp Psychiatry 1985: 16 (4); 309-316
11. Richter NC The Efficacy of Relaxation Training With Children J Abnorm Child Psychol 1984: 12 (2); 319-344
12. Hinswaw SP, Henker B, Whalen CK Self-control in Hyperactive Boys in Anger-Inducing Situations: Effects of Cognitive-Behavioral Training and Methylphenidate. J Abnorm Child Psychol 1984: (12); 55-77
13. Rapport MD Methylphenidate and Attentional Training. Comparative Effects on Behavior and Neurocognitive Effects on Behavior and Neuorcognitive Performance in Twin Girls With Attention-Deficit/Hyperactivity Disorder Behav Modif 1996: 20 (4) 428-430
14. Myers, R Focus: A Comprehensive Psychoeducational Program For Children 6 to 14 Years of Age To Improve Attention, Concentration, Academic Achievement, Self- Control and Self-Esteem Villa Park (CA): Child Development Institute 1998

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