Clare Intili

Prof. Charles Freeland

English Composition II

23 Mar 2021

Literature Review

While childhood ADHD is recognized internationally as a prominent psychiatric disorder,

ADHD in adults remains underdiagnosed and given less attention and treatment. It becomes

important to not just recognize the potential problems associated with adult ADHD, but the

proper ways in which it can be treated. What form of treatment works best in helping suppress

the symptoms of ADHD for adults? Is it non-stimulants, stimulants, behavioral management, or

something else?

The beginnings of ADHD start in 1798, where Sir Alexander Crichton writes about a

mental illness that has ‘the incapacity of attending with a necessary degree of constancy to any

one object’ (Lange). This instance is the first occurrence in documented history of ADHD being

mentioned, with the symptoms described matching those of modern editions of the DSM. As

time progresses, the definitions become more and more definitive - giving the disorder its name

and its trademark problems - an inability to focus, being inattentive, increased motor activity, etc.

This blueprint leads to The Goulstonian Lectures of Sir George Frederic Still, who discussed the

‘defect of moral control in children’ in 1902. Many scientists and authors consider this to be the

scientific starting point of how ADHD came to be. The thorough study conducted by Sir Still in

addition to the discovery of stimulants in 1929 by a Los Angeles chemist named Gordon Alles

helped to formulate not just the definition of the disease, but also how to treat it (Hicks). With

this psychiatric disorder still being fairly modern, few avenues have been ventured down to
determine the best course of treatment, but today the treatments are stimulants (amphetamine,

methylphenidate, etc.), nonstimulants (atomoxetine), and behavioral management.

The first course of treatment starts with the most well studied and best understood -

stimulants such as amphetamine and methylphenidate. Since its discovery in 1929, stimulants

have been used as a medication to elevate moods and help increase focus for important tasks

(Hicks). Originally marketed as a treatment for asthma, it was quickly found to be a more

suitable treatment in other areas and was thus put to use as a medication for inattentive children.

Due to its ability in improving focus and, according to the patent owner, invoke a ‘feeling of well

being’, it quickly became overprescribed and generally abused by the public. Public opinion

began to change, with the majority being against the usage of stimulants and in 1971 it became a

schedule II substance. It’s usage as a mood lifter for American troops and being the pick-me-up

behind late night study sessions for college students seemed to be no more. However, despite its

lingering social stigma, it still remains the most common form of ADHD treatment in the modern

era. Stimulants have proven that they are effective in managing ADHD symptoms in both adults

and children (Advokat et al). Medications like Adderall and Ritalin improve ADHD symptoms in

about 70% of adults and 70-80% of children. Their effects include, but aren’t limited to,

mitigating interruptive behavior, fidgeting, lack of focus, inattentiveness, and much more. The

cognitive performance of individuals who are prescribed stimulants are greatly enhanced with

consistent and controlled use. However, with all of the good that comes with stimulants, they

also produce a myriad of side effects. Large doses of stimulants can cause overstimulation. This

overstimulation often bleeds and causes anxiety, panic, seizures, headaches, aggression and

paranoia. Long-term use of strong stimulants can cause sleep disturbances and appetite
suppression. Appetite suppression can lead to eating disorders like anorexia nervosa if not

careful with dosages.

Not only do they help the patient keep focus and improve attentiveness, they also have

been shown to enhance long-term, short-term, and episodic memory. This has shown to impact

academia in children and impact financial issues, relationship problems, and employment

troubles in adults. The improvement of memory over time coincides with the enhanced cognitive

abilities. Additionally, this improvement on attentivity helps prevent accidental injuries and

motor vehicle accidents (Chang et al). Adults with ADHD are more likely to be involved in

motor vehicle accidents, contributing to a higher fatality rate. ADHD being partially responsible

for a person’s inability to direct attention towards the road, they are more likely to be the cause

of a car accident. The best way to prevent this from happening is by introducing stimulants into

someone’s treatment.

Stimulants promote the production of the neurotransmitters dopamine and norepinephrine

(UW-Madison). Dopamine is responsible for how humans experience pleasure, regulate body

movements, influences mood, and generates feelings of reward and motivation. Norepinephrine,

in tandem with adrenaline, increases heart rate and blood pressure to mobilize the brain for

action and improves energy and attentiveness. Together, these two neurotransmitters combine to

generate focus and productivity out of the patient. Due to the longevity of their existence,

stimulants have been thoroughly studied and experimented on. It’s discovery in 1929 means that

scientists have spent almost 100 years thoroughly picking apart the effects it has on the human

psyche and anatomy.

Recently, non-stimulants have been explored as options into treating both adult and

adolescent ADHD. Strattera, or its generic name atomoxetine, was originally developed as a
treatment for depression (Ledbetter). After being discontinued in 1990 and re-presented as an

ADHD medication in 1996, it was appealing to the pharmaceutical world due to it not being a

stimulant. Doctors who had patients with ADHD but an accompanying substance abuse disorder

now had a more comfortable and safe option to treat their patients. The potential for abuse was

assessed to be minimal, as there were no reports of pleasurable effects from taking atomoxetine.

The probability of overdosing on the pharmaceutical is also substantially low due to the amount

of medication needed to be taken in order for a serious problem to occur. For ADHD patients

with accompanying Tourette's syndrome and epilepsy, non stimulants provided a safer and less

invasive form of treatment. Atomoxetine had shown in the clinical trials that the usage did not

exacerbate tics - in fact, there was a trend of improvement. Atomoxetine was also appealing in

the realm of manageable side effects (at the time) as stimulants tend to have a number of

unpleasant reactions - such as a lack of appetite, poor sleeping habits, among others. After its

approval to market to consumers from the FDA in 2002, it began to be prescribed in droves

across the nation, reaching its peak in 2004. As the prescription rates rose exponentially,

however, the downsides of using non stimulants began to emerge. While being safer for patients

with substance abuse disorder, Tourette’s syndrome, epilepsy, and others, it posed a challenge for

those patients with bipolar disorder and major depressive disorder in addition to ADHD. The

usage of atomoxetine increases the risk of suicidal ideation in both adolescents and adults with

ADHD. Due to its original development leaning towards treatment for depression and the drug’s

current usage as a medication for ADHD, it shares common side effects with antidepressants as

well as stimulants. The side effects for atomoxetine include but don’t exhaust suicidal ideation,

agitated behavior, weight loss, mood swings, and others. Non stimulants, unsurprisingly, take

much longer to have an effect on the human body than its counterparts do. Stimulants are
effective in as little as 45-60 minutes: the medication crosses the blood-brain barrier and

influences the production of the neurotransmitters dopamine and norepinephrine. While slight

improvement may be seen as non-stimulants are taken accordingly and deliberately, it takes 4-8

weeks before the maximum benefits of the drug can be seen. It’s status as a norepinephrine

reuptake inhibitor (and its chemical composition being very similar to an antidepressant) means

that the patient will experience many instances in which they question whether their medication

is actually working or not. Lastly, a double-blind, randomized, head to head trial determined that

stimulants, specifically lisdexamfetamine dimesylate (Vyvanse) was significantly more effective

than atomoxetine in treating children and adolescents with ADHD (Nagy et al). A questionnaire

involving areas such as school, like skills, self-concept, social activities and risky activities was

composed and given to children aged 6-17. All patients were given the same dose of each drug

and measured in their efficacy. The mean score in effectiveness for Vyvanse was 95% and the

mean score in effectiveness for Atomoxetine was 91% - while the difference was not massive, it

still showed a difference in how each medicine worked. Both helped alleviate ADHD symptoms,

but stimulants were remarkably better.

While having pharmacological treatment is certainly important in understanding and

treating ADHD, it’s crucial not to forget about how cognitive behavioral therapy could be

effective in mitigating the symptoms that ADHD imposes on its patients (Lopez et al).

Acknowledging the biological side of ADHD doesn’t mean that the psychological aspect of the

disorder can be ignored. It is just as important for the patient to make lifestyle changes and

introduce better and healthier thinking patterns as it is to remember to take their medication in

the morning. Cognitive behavioral therapy in tandem with pharmacotherapy has been proven to

be far more effective than the usage of pharmacotherapy alone. It was also more effective than
dialectical behavioral therapy, meta-cognitive therapy, and mindfulness-based cognitive therapy.

Previously, I noted the fact that patients with ADHD often have coexisting psychological

disorders such as depression, anxiety, bipolar disorder, etc. Cognitive behavioral therapy doesn’t

just reduce the symptoms of ADHD, but it also helps lower the impact of the other comorbidities

that a patient might have. Reductions in core symptoms of ADHD were consistent across the

different comparisons - there was no instance in which cognitive behavioral therapy was used

and the patient had an increase in symptoms. The implementation of cognitive behavioral

therapy is important to include since 20-50% of people with ADHD do not respond to drug

treatment. The likelihood of experiencing side effects is also high, whereas going through

cognitive behavioral therapy poses no risk and has no adverse side effects. The only reason why

people dropped out of the study conducted proving this matter is because they had other

competing time commitments. The downside to cognitive behavioral therapy is that it takes

much longer than any pharmaceutical made to treat ADHD to take effect. On average, cognitive

behavioral therapy programs for adults with ADHD take 8 to 12 sessions to be beneficial. The

action of deconstructing old habits to free up space for newer, healthier ones takes patience and

discipline - qualities that most adults tend to not have. The intentions and purpose behind

cognitive behavioral therapy for ADHD treatment are to provide new, healthy, compensatory

strategies and skills for deficient attention, executive functioning, impulse control and emotion

regulation. It is less of a biological fault, and a testament of the patient’s willingness to commit

behind the success of cognitive behavioral therapy.

In understanding the different types of treatment for ADHD, a patient can help determine

what the best course of conduct would be to treat their specific kind of ADHD. Biology varies

from person to person and no two disorders are alike - many factors, environmental, sociological,
physiological, psychological, have an impact on determining what form of remedy best suits that

person. Adults with ADHD have the freedom to choose what kind of therapy best suits them, in

comparison to being a child diagnosed with ADHD. Adolescents are often at the mercy of their

superiors (parents) and simply do as they are told. The consequences then make themselves

known in less than favorable ways, leaving their guardians to try and understand how to fix the

situation they manifested into existence. People with substance abuse disorders, tics, tremors,

epilepsy, and a predisposition to accruing an unhealthy relationship with food might stray from

stimulants due to their proclivity in exacerbating problems relating to those areas. Stimulants, as

effective and fast-acting as they are, also have a myriad of side effects which earned them a place

on the DEA schedule II drug list. That fact shouldn’t be taken lightly when trying to determine

the best course of action for treating ADHD. Juxtapositioning with all the negativities of

stimulants, non-stimulants also have their fair share of problems to consider. They are safer for

the general public to take, they take additional cons with their pros. They take much longer than

stimulants to have the maximum benefit potential, and are proven to be less effective than their

stimulant counterparts. Their chemical composition makes it more likely for users to experience

suicidal ideation and bouts of mania - which becomes problematic if the comorbidities a patient

has includes major depressive or bipolar disorder. A patient may want to skip the side effects

altogether and only treat their ADHD with cognitive behavioral therapy. The safest option by far,

this has no physiological effect and is the only form of treatment that doesn’t have potential

downsides. However, cognitive behavior therapy requires 8-12 sessions before effective and

requires a concrete routine - if a patient strays from the routine, the benefits are reduced

significantly and thus appears to have ‘all been for nothing’. The question of what the best

treatment for ADHD doesn’t have a simple answer, because people aren’t simple.
 WORKS CITED

Advokat, Claire, and Mindy Scheithauer. “Attention-deficit hyperactivity disorder (ADHD)

stimulant medications as cognitive enhancers.” Frontiers in neuroscience vol. 7 82. 29

May. 2013, doi:10.3389/fnins.2013.00082

Chang Z, Quinn PD, Hur K, et al. Association Between Medication Use for

Attention-Deficit/Hyperactivity Disorder and Risk of Motor Vehicle Crashes. JAMA

Psychiatry. 2017;74(6):597–603. doi:10.1001/jamapsychiatry.2017.0659

Hicks , Jesse. “Fast Times: The Life, Death, and Rebirth of Amphetamine.” Science History

Institute, Science History Institute, 19 Apr. 2019,

www.sciencehistory.org/distillations/fast-times-the-life-death-and-rebirth-of-amphetamin

e.

Lange, Klaus W et al. “The history of attention deficit hyperactivity disorder.” Attention deficit

and hyperactivity disorders vol. 2,4 (2010): 241-55. doi:10.1007/s12402-010-0045-8

Ledbetter, Marcialee. “Atomoxetine: a novel treatment for child and adult ADHD.”

Neuropsychiatric disease and treatment vol. 2,4 (2006): 455-66.

doi:10.2147/nedt.2006.2.4.455

Lopez, Pablo Luis et al. “Cognitive-behavioural interventions for attention deficit hyperactivity

disorder (ADHD) in adults.” The Cochrane database of systematic reviews vol. 3,3

CD010840. 23 Mar. 2018, doi:10.1002/14651858.CD010840.pub2

Nagy, Peter et al. “Functional outcomes from a head-to-head, randomized, double-blind trial of

lisdexamfetamine dimesylate and atomoxetine in children and adolescents with

attention-deficit/hyperactivity disorder and an inadequate response to methylphenidate.”

 European child & adolescent psychiatry vol. 25,2 (2016): 141-9.

doi:10.1007/s00787-015-0718-0

University of Wisconsin-Madison. "Study Reveals How ADHD Drugs Work In Brain."

ScienceDaily. ScienceDaily, 26 June 2006.

<www.sciencedaily.com/releases/2006/06/060626091749.htm>.