Towards better care of ADHD: 
How Does Recent Research Inform Diagnosis and Treatment?

Probably the most common add-on is adding short acting stimulant to augment the duration of effect of long acting stimulant. Beyond that, the alpha-2 agonists work very well together with stimulants and are very good for behavioral control. Plus they have a very long duration of effect. Also, in selected cases, atomoxetine or viloxazine and even buprprion could be considered as add-on medications.

Bottom line is that there is not an absolute contraindication, and there might be rare circumstances where one might consider it, but its best to use the same medication and not mix. The only circumstance that I would consider mixing is for someone on a long-acting amphetamine formulation who needs short acting later, you could consider MPH over AMP because of its shorter half-lef (in someone who is sensitive to sleep problems with stimulants).

The atomoxetine have not been systematically evaluated in patients with patients with epilepsy. During the clinical trials, only 0.1%(1/748) adults with ADHD repoted epilepsy. See Wernicke et al., Dev Med Child Neurol 2007 Jul;49(7):498-502.

Organizational skill training is very helpful for children and adults with ADHD regardless of whether they are on medication, and would be very helpful in the circumstance you mentioned here. As far as deciding whether medication works, its most important to identify target symptoms - the two or three behaviors that the patient wants to make better. Target behaviors usually lie at the interface of symptoms and functional status.

If you look at the International Consensus statement on ADHD published by the World Federation under Steve Faraone's leadership, you will see that both stimulants and atomoxetine have positive data in relation to treatment of emotion regulation. Effect sizes are better for stimulants on average. One problem, though, is that stimulants have a relatively short duration of action and problems with emotion regulation often occur at any time of day. In this regard, alpha-2 agonists could be helpful. But there is limited study of their effects on irritability or other symptoms outside the core symptoms of ADHD.

There is not sufficient evidences showed that ADHD is a risk factor for Covid sequelae. But amount of publications showed patients with ADHD is more vulnerable for Covid and Other mental disorder during pandemic. Furthermore, attention deficit is one of the most common symptoms of long-term effects of Covid.

For insomnia - giving the drug earlier, shifting to a shorter acting formulation, adding on an effective ADHD medication that supports sleep. For appetite, give after breakfast, alter when one eats, allow liberal snacking. If all else fails, cyproheptadine - an antihistamine drug often used for weight gain - can be given and usually leads to increased appetite and supports weight gain.

I would advise to consider impairment in function, difficulty with peer interactions and self-esteem (in childen), job and relationship failure in older people, and availability or ability to participate in psychosocial treatment as considerations in whether to use medication.

The studies of Fran Levin and colleagues that essentially use amphetamine in higher dose as a replacemtn therapy are well designed and should be given seriuos consideration. 

A case report (Naguy A, et al. CNS Spectr. 2021) showed the effect of solriamfetol for a 15-year-old male diagnosed with ADHD. The boy accepted methylphenidate and atomoxetine administration but showed poor outcomes. After 4 weeks titration with maximum solriamfetol dose of 150 mg qd, parents’ observations in tandem with school reports were very reassuring.

No specific recommendations here about who to contact about getting medications for compassionate use. But consider bupropion as an alternative to stimulants that may be more widely available

Viloxazine is a norepinephrine reuptake inhibitor that has post-snaptic effects at a variety of serotonin receptors. The serotonergic effects are of uncertain meaning - they may contribute to response but this has not been demonstrated. Viloxazine has a longer half-life than atomoxetine does in extensive CYP2D6 metabolizers (93-95% of the population). There are no comparator studies of the two drugs.

There are no studies that, to my mind, conclusively show that treatment with stimulants or any other medication has positive long-term effects on the brain after the treatment is discontinued. This would be a very difficult and costly experiment to do. Separating out positive effects from medication vs development would be very difficult. For the issue of breaks in treatment and potential tolerance, the short answer is that this can be helpful for selected peoplle but isn't needed for the large majority of people. Again, this is an area where considering individual needs and tailoring treatment to that is essential.

Insufficient evidence.

The benefits of cogntive training and neuro-feedback for ADHD-related cognitive deficits remain uncertain - meta-analyses show benefits of WM training on WM - evidence for the benefits of neuro-feedback in this regard remain uncertain. 

A meta-analysis (Van der Oord S et al., Clin Psychol Rev. 2008) evaluated both methylphenidate and psychosocial treatments. However, this meta-analysis did not distingush blinded from non-blinded outcomes - so I would be cautious about interpreting the effects of psycho-social treatments.

Previous one-year follow-up study (Boyer BE et al. Eur Child Adolesc Psychiatry. 2016) showed the treatment effect of CBT for ADHD children and initial improvements remained stable or continued to improve from posttest to 1-year follow-up. 25.9 % of adolescents showed normalized functioning.

A good head-to-head study is warrented.

Yes - without a doubt. ADHD impacts on functioning in schools with long term cosequences. Reasonable adjustments should be encouraged.

This is an important area for future research. 

I agree with the sentiment of the question. A more wholistic approach is needed that take into acccount the psychological impact of ADHD the self concept and broader aspects of the internal life of people with ADHD. Having ADHD can have a crippling effect on children relationships including the very earlist ones with parents.

Psychosocial interventions with children with ADHD can have a positive effect on some executive functions like  visuospatial memory and planning.

I think psychosocial intervention are best used for associated problems rather than core symptoms - so I would base decisions on what are the associated problems.

In general its seems unlikely that trauma is a cause of ADHD but rather than ADHD leads to a higher incidence of trauma - there are exceptions say in realtion to severe negelct/deprivation. However, I agree that that trauma represents a potentially important clinical context. Parental attachment problems and environmental mediating factors were significantly associated with childhood ADHD. Adults with ADHD had a much higher incidence of insecure attachment styles than reported in the general population. 

This area need so much more research - it’s a top priority.

I think the claim that early medication cures ADHD is highly speculative and dubious and should be taken off wikipedia. There has been no relevant long term prevention RCT to test this hypothesis in humans. 

Both psychotherapy and medication have pros and cons. In the process of adjusting the clinical treatment plan, it is necessary to weigh the risks of drug treatment and non-drug treatment and try to avoid the harm caused by delayed treatment. Different treatment methods are used according to different ages of children with ADHD.

Good question - it may be that genetically based developmental brain deficits are less responsive to remidation than acquired lesions. 

Very useful to imporve parenting and reduce the negative context in which people with ADHD grow up which can impact their development very significantly. 

I think we need better trials with blinded outcomes. 

We did some work looking at cognitve bias' in ADHD suggesting altered motivational responses to threat - this I sprobably a secondary effect - but it would be good to try to see if they can modified to reduce long term negative risk for anxiety etc. 

You may be thinking about the results of the meta-analysis published by Sonuga-Barke et al in 2013, which showed that whereas the effect size for all studies of parent management training on ADHD symptoms was significant with good effect sizes of .40-.64, the results for the subset of studies in which the raters were "probably blinded" was non-significant.  It is important to keep in mind here, however, that it is difficult to create a control condition for PMT when the parents (or teachers) are necessarily the ones delivering the treatment as well as rating the outcomes.  The largest and best studies of PMT, including the MTA, have not accomplished that.  There may be some consolation in the follow-up meta-analysis by Daley...Sonuga-Barke (2014) on the same data, that found significant effects for other outcomes, as follows, and these remained significant even when limited to studies that were "probably blinded."  
•Parenting quality : SMD = 0.68***
•Negative Parenting: SMD=0.57 ***
•Conduct Problems (SMD=0.26)***