Santosh P J, Taylor E
Department of Child & Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London, UK.
Eur Child Adolesc Psychiatry. 2000;9 Suppl 1:I27-43. doi: 10.1007/s007870070017.
Stimulants are a key element in the treatment of ADHD. Carefully designed trials of stimulants have found substantial improvement in ADHD core behaviours in 65-75 % of subjects with ADHD. Most standard stimulants are rapidly absorbed, with their behavioural effects appearing within 30 minutes, reaching a peak within one to three hours and disappearing within five hours. Doses at school are often necessary, in spite of the risk of peer ridicule and added adult supervision requirements. The mechanism by which stimulants act to reduce hyperactivity is not completely understood, but they improve impulsivity and activity levels. Several controlled evaluations made over periods of time greater than a year show a clear persistence of medication effects over time. A carefully crafted programme of treatment with methylphenidate is more effective in the reduction of hyperactivity symptoms than an intensive programme of behavioural and cognitive intervention. The combination of stimulants with psychosocial interventions in ADHD offers few advantages over medication alone. Unchallengeable guides to practice that would be appropriate everywhere are difficult to propose. It is imperative that clinicians prescribing stimulants should monitor the use of the drug properly, making sure that it is not being abused by the child's family, peers or those dispensing medication at school. Polypharmacy should only be embarked on by a specialist service and the combination of methylphenidate and clonidine should be used cautiously. Apart from ADHD, stimulants are useful in narcolepsy, resistant depression and partial syndromes of attention and hyperactivity. Major gaps in knowledge remain; pharmacokinetics, pharmacodynamics and pharmacogenetics of stimulant effects need further study. Details of stimulant administration regimes seem to have a major effect on the response achieved. Further research is needed, preferably in realistic practice settings, comparing different forms of combination with psychological interventions, investigating the effects in groups of children outside the core of schoolaged children with typical ADHD: preschool children, adults, those with partial syndromes (such as inattentiveness) and those with co-morbid disorders.
兴奋剂是治疗注意力缺陷多动障碍（ADHD）的关键要素。精心设计的兴奋剂试验发现，65%至75%的ADHD患者在ADHD核心行为方面有显著改善。大多数标准兴奋剂吸收迅速，其行为效应在30分钟内出现，1至3小时内达到峰值，5小时内消失。尽管存在被同龄人嘲笑的风险以及需要额外的成人监督，但在学校服药通常是必要的。兴奋剂减少多动行为的作用机制尚未完全明确，但它们能改善冲动性和活动水平。多项为期一年以上的对照评估表明，药物疗效会随时间持续显现。精心制定的哌甲酯治疗方案在减少多动症状方面比强化行为和认知干预方案更有效。在ADHD治疗中，将兴奋剂与心理社会干预相结合相比单独使用药物优势不大。很难提出适用于所有情况的无可争议的实践指南。开具兴奋剂的临床医生必须妥善监测药物使用情况，确保儿童的家人、同龄人或学校的药物分发人员不会滥用药物。联合用药应由专科服务机构进行，哌甲酯和可乐定的联合使用应谨慎。除ADHD外，兴奋剂还可用于发作性睡病、难治性抑郁症以及部分注意力不集中和多动综合征。知识方面仍存在重大差距；兴奋剂作用的药代动力学、药效学和药物遗传学需要进一步研究。兴奋剂给药方案的细节似乎对治疗效果有重大影响。需要进一步研究，最好是在实际临床环境中，比较不同形式的联合心理干预，调查典型ADHD学龄儿童核心群体之外的儿童群体（学龄前儿童、成年人、有部分综合征的儿童（如注意力不集中）以及患有共病的儿童）的治疗效果。
