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注意力不足過動症的治療：修订间差异

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藥物治療合併規律的運動能放大中樞神經刺激劑作用於執行功能上的效果。<ref name="ADHD exercise 2016 SystRev" />運動帶來的效果被認為是因為運動增加了腦中[[神經突觸]]間多巴胺和正腎上腺素的濃度。<ref name="ADHD exercise 2016 SystRev" />
藥物治療合併規律的運動能放大中樞神經刺激劑作用於執行功能上的效果。<ref name="ADHD exercise 2016 SystRev" />運動帶來的效果被認為是因為運動增加了腦中[[神經突觸]]間多巴胺和正腎上腺素的濃度。<ref name="ADHD exercise 2016 SystRev" />
=== 飲食 ===
[[健康]]及均衡的飲食（[[食物]]、[[飲用水]]及[[飲料]]）有助於病情的改善。[[維生素]]（例如：[[維他命B|維他命B群]]、[[維他命C]]等）對於改善病情的功效，有待更多的實驗證明。即便如此，成人注意力不足過動患者適度補充[[水溶性]]的維生素是合理的。<ref name="efficacy of vitamins on ADHD treatment">
{{cite web
|url = http://www.bbc.com/news/health-25946116
|title = Vitamins ‘effective in treating ADHD symptoms’
|website = BBC News
|author = Helen Briggs
|date = 2014-01-30
|access-date = 2017-04-13
|quote = After eight weeks of treatment those on supplements reported greater improvements in both their inattention and hyperactivity/impulsivity compared with those taking the placebo. "Our study provides preliminary evidence of the effectiveness for micronutrients in the treatment of ADHD symptoms in adults," said Prof Julia Rucklidge, who led the study.
|deadurl = no
|archiveurl = https://web.archive.org/web/20170414000342/http://www.bbc.com/news/health-25946116
|archivedate = 2017-04-14
}}</ref>{{noteTag|name=|1=攝取過多的維他命可能產生健康問題。<ref name="MedlinePlus 2017">{{cite web | title=Vitamins: MedlinePlus | website=MedlinePlus | date=2017-10-06 | url=https://medlineplus.gov/vitamins.html | access-date=2017-11-02 | deadurl=no | archiveurl=https://web.archive.org/web/20171107030642/https://medlineplus.gov/vitamins.html | archivedate=2017-11-07 }}</ref>例如：長期且高劑量的攝取[[維他命B6]]、[[維他命B12]]可能導致[[肺癌]]<ref name="The James - OSUCCC 2017">{{cite web | title=Long-Term, High-Dose Vitamin B6/B12 Use Associated With Increased Lung Cancer Risk Among Men | website=The James - OSUCCC | date=2017-08-22 | url=https://cancer.osu.edu/news-and-media/news/long-term-high-dose-vitamin-b6-b12-use-associated-with-increased-lung-cancer-risk-among-men | access-date=2017-11-02 | deadurl=no | archiveurl=https://web.archive.org/web/20170908174337/https://cancer.osu.edu/news-and-media/news/long-term-high-dose-vitamin-b6-b12-use-associated-with-increased-lung-cancer-risk-among-men | archivedate=2017-09-08 }}</ref><ref name="Brasky White Chen pp. 3440–3448">{{cite journal | last=Brasky | first=Theodore M. | last2=White | first2=Emily | last3=Chen | first3=Chi-Ling | title=Long-Term, Supplemental, One-Carbon Metabolism–Related Vitamin B Use in Relation to Lung Cancer Risk in the Vitamins and Lifestyle (VITAL) Cohort | journal=Journal of Clinical Oncology | publisher=American Society of Clinical Oncology (ASCO) | volume=35 | issue=30 | date=2017-10-20 | issn=0732-183X | doi=10.1200/jco.2017.72.7735 | pages=3440–3448}}</ref>}}

飲食的調整可能對少部份的ADHD兒童有幫助<ref name="pmid22176942">{{cite journal |vauthors=Nigg JT, Lewis K, Edinger T, Falk M | title = Meta-analysis of attention-deficit/hyperactivity disorder or attention-deficit/hyperactivity disorder symptoms, restriction diet, and synthetic food color additives | journal = J Am Acad Child Adolesc Psychiatry | volume = 51 | issue = 1 | pages = 86–97 | year = January 2012 | pmid = 22176942 | doi = 10.1016/j.jaac.2011.10.015 }}</ref>，一份2013年的[[統合分析]]針對有ADHD症狀，而且有補充[[游離脂肪酸]]或是減少食用有人工色素食品的兒童的相關研究發現，只有不到<big><big><big><big>⅓</big></big></big></big>的兒童在症狀上有改善<ref name=Sonu2013/>，這方面的助益有可能只是對有食物敏感的兒童有幫助，也有可能是這些兒童同時也在接受ADHD的治療<ref name=Sonu2013/>，這些已發表的文獻也發現目前已有的證據無法支持減少食用特定食物來治療ADHD的療法<ref name=Sonu2013/>。2014年發表的文獻也發現[[排除饮食]]在治療ADHD上的成效有限<ref name=NiggHolton2014>{{cite journal|vauthors=Nigg JT, Holton K|title=Restriction and elimination diets in ADHD treatment|journal=Child Adolesc Psychiatr Clin N Am|volume=23|issue=4|pages=937–53|date=2014-10|pmid=25220094|pmc=4322780|doi=10.1016/j.chc.2014.05.010|type=Review|quote=an elimination diet produces a small aggregate effect but may have greater benefit among some children. Very few studies enable proper evaluation of the likelihood of response in children with ADHD who are not already preselected based on prior diet response.}}</ref>，另一個2016年發表的文獻不鼓勵用[[无麸质饮食]]作為主要治療ADHD的方式<ref name="pmid26825336" />。

鐵、鎂及碘等礦物質的攝取也可以改善ADHD的症狀<ref name="pmid22928358">{{cite journal |vauthors=Konikowska K, Regulska-Ilow B, Rózańska D |title=The influence of components of diet on the symptoms of ADHD in children |journal=Rocz Panstw Zakl Hig|volume=63 |issue=2 |pages=127–134 |year=2012 |pmid=22928358 }}</ref>，有一些證據指出身體組織內的[[鋅]]成份過低和其ADHD症狀有關<ref name="pmid16190793">{{cite journal |vauthors=Arnold LE, DiSilvestro RA|title=Zinc in attention-deficit/hyperactivity disorder|journal=Journal of child and adolescent psychopharmacology|volume=15|issue=4|pages=619–27|year=2005|pmid=16190793|doi=10.1089/cap.2005.15.619}}</ref>，不過一般不建議用補充鋅礦物質的方式來治療ADHD，只有在有{{tsl|en|zinc deficiency|鋅缺乏}}的地區（幾乎只會在[[開發中國家]]）才建議補充鋅礦物質<ref name=pmid25220092>{{cite journal|last1=Bloch|first1=MH|last2=Mulqueen|first2=J|title=Nutritional supplements for the treatment of ADHD.|journal=Child and adolescent psychiatric clinics of North America|date=2014-10|volume=23|issue=4|pages=883–97|pmid=25220092|doi=10.1016/j.chc.2014.05.002}}</ref>。不過若鋅礦物質和[[苯丙胺]]類藥物同時使用的話，會減低苯丙胺藥物的最小[[有效劑量]]，也就是可以服用較少的藥物而達到相同的效果<ref name="Zinc binding sites + ADHD review">{{cite journal | vauthors = Krause J | title = SPECT and PET of the dopamine transporter in attention-deficit/hyperactivity disorder | journal = Expert Rev. Neurother. | volume = 8 | issue = 4 | pages = 611–625 | date = 2008-04 | pmid = 18416663 | doi = 10.1586/14737175.8.4.611 | quote = Zinc binds at&nbsp;... extracellular sites of the DAT [103], serving as a DAT inhibitor. In this context, controlled double-blind studies in children are of interest, which showed positive effects of zinc [supplementation] on symptoms of ADHD [105,106]. It should be stated that at this time [supplementation] with zinc is not integrated in any ADHD treatment algorithm.}}</ref>。另有證據指出[[ω-3脂肪酸|Omega3-脂肪酸]]能提供對於病情些許的改善<ref name="Richardson Burton Sewell Spreckelsen p=e43909">{{cite journal | last=Richardson | first=Alexandra J. | last2=Burton | first2=Jennifer R. | last3=Sewell | first3=Richard P. | last4=Spreckelsen | first4=Thees F. | last5=Montgomery | first5=Paul | editor-last=Scott | editor-first=James G. | title=Docosahexaenoic Acid for Reading, Cognition and Behavior in Children Aged 7–9 Years: A Randomized, Controlled Trial (The DOLAB Study) | journal=PLoS ONE | publisher=Public Library of Science (PLoS) | volume=7 | issue=9 | date=2012-09-06 | issn=1932-6203 | doi=10.1371/journal.pone.0043909 | page=e43909}}</ref>，不過也有證據指出其功效非常有限<ref name="birmingham.ac.uk 2018">{{cite web | title=Omega Fish oils don't improve school children's reading skills or memory, study finds | website=birmingham.ac.uk | date=2018-03-02 | url=https://www.birmingham.ac.uk/news/latest/2018/03/fish-oils-dont-improve-childrens-reading-memory-skills.aspx | access-date=2018-03-14}}</ref><ref name="Montgomery Spreckelsen Burton Burton p=e0192909">{{cite journal | last=Montgomery | first=Paul | last2=Spreckelsen | first2=Thees F. | last3=Burton | first3=Alice | last4=Burton | first4=Jennifer R. | last5=Richardson | first5=Alexandra J. | editor-last=van Wouwe | editor-first=Jacobus P. | title=Docosahexaenoic acid for reading, working memory and behavior in UK children aged 7-9: A randomized controlled trial for replication (the DOLAB II study) | journal=PLOS ONE | publisher=Public Library of Science (PLoS) | volume=13 | issue=2 | date=2018-02-20 | issn=1932-6203 | doi=10.1371/journal.pone.0192909 | page=e0192909}}</ref>，因此不建議用Omega3-脂肪酸來取代醫學治療<ref name="tscap_20170503_2"/><ref name="pmid21961774">{{cite journal |vauthors=Bloch MH, Qawasmi A |title=Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-analysis |journal=J Am Acad Child Adolesc Psychiatry |volume=50 |issue=10|pages=991–1000 |date=2011-10 |pmid=21961774 |pmc=3625948|doi=10.1016/j.jaac.2011.06.008 |url=}}</ref>
<ref name="pmid27555775">{{cite journal | vauthors = Königs A, Kiliaan AJ | title = Critical appraisal of omega-3 fatty acids in attention-deficit/hyperactivity disorder treatment | journal = Neuropsychiatr. Dis. Treat. | volume = 12 | issue = | pages = 1869–1882 | year = July 2016 | pmid = 27555775 | pmc = 4968854 | doi = 10.2147/NDT.S68652 | url = }}</ref>。

===認知行為治療===
===認知行為治療===
著重在「常在成人患者身上觀察到的[[執行功能]]缺失」的認知行為治療，主要協助患者治療以下問題<ref>Safren SA, Sprich S, Perlman C, Otto M. Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program (TherapistvWorkbook), Oxford University Press, New York 2005.</ref><ref>Solanto MV. Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction, The Guilford Press, New York 2011.</ref>：
著重在「常在成人患者身上觀察到的[[執行功能]]缺失」的認知行為治療，主要協助患者治療以下問題<ref>Safren SA, Sprich S, Perlman C, Otto M. Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program (TherapistvWorkbook), Oxford University Press, New York 2005.</ref><ref>Solanto MV. Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction, The Guilford Press, New York 2011.</ref>：

2018年7月6日 (五) 13:34的版本

维基百科中的醫學内容仅供参考，並不能視作專業意見。如需獲取醫療幫助或意見，请咨询专业人士。詳見醫學聲明。

注意力不足過動症的治療是指在注意力不足過動症（ADHD）治療上，以醫學實證為基礎，已確認有一定程度治療效果的治療方式。美國兒科學會針對病患的年齡不同，有建議不同的治療方式。若是四歲至五歲的兒童，學會會建議有實證基礎，且由家長或／和老師監督的行為治療，只有在有中度到重度，持續性的功能紊亂時，才加上哌甲酯的藥物治療。若是六歲至十一歲的兒童，會建議使用藥物以及行為治療，而根據實證，興奮劑有比其他藥物要明顯的效果。若是十二歲至十八歲的患者，藥物治療需取得患者的同意，最好配合行為治療。不過此年齡層行為治療的效果只有C級而已[1]。

有許多的兴奋剂及非兴奋剂用在ADHD的治療上。最常見的兴奋剂有哌甲酯（利他能、專思達）、混合安非他命鹽類（阿得拉尔、Mydayis）、右旋安非他命（Dexedrine）及甲磺酸赖氨酸安非他命（Vyvanse）。特別用來治療ADHD的非兴奋剂藥物有阿托莫西汀（Strattera）、胍法辛（Intuniv）及可乐定（Kapvay）。其他仿單標示外使用的藥物有安非他酮（Wellbutrin）、三环类抗抑郁药、5-羟色胺和去甲肾上腺素再摄取抑制剂或是单胺氧化酶抑制剂[2][3][4]。而共病的存在也會讓正確的診斷及治療更加複雜、費時，以及花費金錢。因此會建議同時評估並治療可能的共病病症[5]。

有許多治療ADHD的心理治療及行為改正（英语：behavior modification）方式，包括心理治療以及工作記憶訓練（英语：working memory training）。若其家庭及學校也配合使用父母管理訓練及教室管理（英语：classroom management）的作法，對ADHD兒童的行為是有幫助的[6]。也有專門的ADHD教練提供一些像是时间管理及組織等生活機能上的服務，並且提供策略。已證實自我控制的訓練課程在這領域效果不大。

到2006年為止，有關ADHD藥物潛在不良反應的資料仍有不足[7]，很少研究有探討在治療超過四個月之後，治療的安全性以及效果[8]，也沒有針對治療超過二年的案例所進行的随机对照试验[9][10]。

非藥物治療

充足的睡眠

充足的睡眠能提升學習力與專注力，也能讓身體得到足夠的休養。正常的生長激素分泌有賴規律及足夠的睡眠[11][12]。研究指出，台灣孩子的睡眠時數相較其他國家，少了大約一個半小時[13][14][15]。足夠的睡眠能讓有ADHD的孩子更專注、更能自我控制 [16]。相形之下，睡眠不足連帶使得身體與精神狀況不佳，情緒較容易低落，形成惡性循環。[17][18][19] 注意力不足過動症往往直接導致患者「難以入睡」、「即便入睡，也難以持續多久」，這與注意力不足過動症所導致的「內在和外在的不安寧」[註 1]有關。[20][21]

治療ADHD或許能改善患者因ADHD之「內在和外在的不安寧」等症狀所引起的睡眠問題[22][23][24]；同理，改善睡眠品質或許能改善ADHD的症狀。[24] [25][20] 研究指出，「規律」的睡眠有助於提升睡眠品質，良好的睡眠品質會有較好的精神且能改善注意力不足過動症的症狀[20][26] [27]。

更多信息：睡眠與學習能力的關係（英语：sleep and learning）

運動

参见：體能鍛煉 § 與大腦神經元（腦功能）的關聯

適度且規律的運動，特別是有氧運動有助於改善許多中樞神經系統疾患的症狀，也證實為注意力不足過動症的有效附加療法（英语：add-on treatment）[a][28][29][30][31][32][33][34]。

長期規律的運動合併正規治療，將有更樂觀的預後（治療效果）-較好的行為以及運動協調性、大腦執行功能的提升（包含大腦認知領域中的：注意力、衝動克制力、和計畫組織的能力）、更快速的資訊處理速度、和更棒的記憶力。 [28][29][30][31][33][34]

統計由父母及教師填答的《孩子行為和社交情緒評量表》，結果顯示長期規律的有氧運動帶給孩子的效果是：身體所有功能的提升、ADHD的症狀減緩、焦慮和憂鬱的程度下降、身體症狀減少、較佳的課業及課堂中的表現、社交技巧進步。[31]

藥物治療合併規律的運動能放大中樞神經刺激劑作用於執行功能上的效果。[31]運動帶來的效果被認為是因為運動增加了腦中神經突觸間多巴胺和正腎上腺素的濃度。[31]

飲食

健康及均衡的飲食（食物、飲用水及飲料）有助於病情的改善。維生素（例如：維他命B群、維他命C等）對於改善病情的功效，有待更多的實驗證明。即便如此，成人注意力不足過動患者適度補充水溶性的維生素是合理的。[35][註 2]

飲食的調整可能對少部份的ADHD兒童有幫助[39]，一份2013年的統合分析針對有ADHD症狀，而且有補充游離脂肪酸或是減少食用有人工色素食品的兒童的相關研究發現，只有不到⅓的兒童在症狀上有改善[40]，這方面的助益有可能只是對有食物敏感的兒童有幫助，也有可能是這些兒童同時也在接受ADHD的治療[40]，這些已發表的文獻也發現目前已有的證據無法支持減少食用特定食物來治療ADHD的療法[40]。2014年發表的文獻也發現排除饮食在治療ADHD上的成效有限[41]，另一個2016年發表的文獻不鼓勵用无麸质饮食作為主要治療ADHD的方式[42]。

鐵、鎂及碘等礦物質的攝取也可以改善ADHD的症狀[43]，有一些證據指出身體組織內的鋅成份過低和其ADHD症狀有關[44]，不過一般不建議用補充鋅礦物質的方式來治療ADHD，只有在有鋅缺乏的地區（幾乎只會在開發中國家）才建議補充鋅礦物質[45]。不過若鋅礦物質和苯丙胺類藥物同時使用的話，會減低苯丙胺藥物的最小有效劑量，也就是可以服用較少的藥物而達到相同的效果[46]。另有證據指出Omega3-脂肪酸能提供對於病情些許的改善[47]，不過也有證據指出其功效非常有限[48][49]，因此不建議用Omega3-脂肪酸來取代醫學治療[50][51] [52]。

認知行為治療

著重在「常在成人患者身上觀察到的執行功能缺失」的認知行為治療，主要協助患者治療以下問題[53][54]：

  • 難以持續掌握任務和活動、難以對任務或活動抱持恆心。
  • 拖延。
  • 有分辨事情緩急輕重的困難。
  • 缺乏管理能力。
  • 做短期和長期計畫的能力不及格。[55]

家中的行為治療

参见：父母管理訓練
*治療師會定期與家庭成員會晤以觀察進度並提供持續的支持（左對話框）。
  • 在會晤中，家長現場實習從治療師那學來的技巧（右對話框）。
  • 即便療程結束，家庭成員仍能持續感受到行為的改善以及壓力的減輕（下方橫幅）。[56]
家長能在行為治療中學到的三種核心能力
家長能在行為治療中學到三種核心能力：正向溝通、正向激勵/強化（英语：Reinforcement#Positive_reinforcement）、結構與一致的紀律/規範/規則[56]

在行为治疗期间，治療師會定期與家庭成員會晤以觀察進度並提供持續的支持。在會晤中，家長現場實習從治療師那學來的技巧，即便療程結束，家庭成員仍能持續感受到行為的改善以及壓力的減輕。[56]家長能在父母教育訓練中學到三種核心能力：正向溝通、正向激勵/強化（英语：Reinforcement#Positive_reinforcement）、結構與一致的紀律/規範/規則[56]。

  • 用「愛」來溝通
  • 傾聽與陪伴[57]

正念療法

2018年4月出爐的最新文獻顯示，「認知行為治療+藥物治療+正念療法」的策略比「認知行為治療+藥物治療」帶給患者更大的進步，因此有成為未來正式治療策略的潛力。[58] 然而單獨就「認知行為治療」和「正念療法」相比，未服藥且單獨接受「認知行為治療」或「正念療法」的ADHD患者經過訓練後，並未發現「認知行為治療」和「正念療法」的療效有何差異。[59] 有鑑於前述不一致的實驗結果，正念療法尚需更多研究來證明其有效性。

藥物治療

中樞神經刺激劑

参见：苯丙胺 § 醫療

治療注意力不足過動症的第一线药物为中樞神經兴奋剂（又名為中樞神經刺激劑），其中包括：

藥物名 藥物（主成分/有效成分）學名 作用時間 生效時間 備註
利他能（Ritalin） 哌甲酯[b] 短：3.5小時左右 約服用後30分鐘
Adderall 右旋苯丙胺和左旋苯丙胺 N/A N/A
Desoxyn 甲基苯丙胺 N/A N/A
  • 為安非他命产品
利他(長)能LA（Ritalin LA/利長能） 哌甲酯 中：8小時左右 約服用後30分鐘
  • 藥物之半衰期介於利他能與專思達之間。有10MG、20MG、30MG、40MG及60MG等劑型。
專思達/專注達 哌甲酯 長：12小時左右 約服用後30分鐘
  • 台灣譯作專思達，有18MG、27MG、36MG、54MG等數種劑量。
  • 中華民國中央健康保險署已經核定醫師可將此藥物作為十八歲以下患者的第一線處方。[60][61]
  • 中國大陸翻譯為專注達。

[28] [62] [63] [64] [65]

利他能[65]、利長能[62]、專思達[64]、安保美喜錠[66] ，所含之有效成分皆為哌甲酯，各自在藥效動力學上具有相同屬性；在藥物代謝動力學上的作用則有些微差異。[67][68][69]醫師可依患者的需求，視各種藥品之藥物動力學的特性，調整處方藥物，實現個人化醫療[70]。 常見的專思達，其12歲以下的使用者每日最大劑量上限為54毫克；13到17歲的使用者之每日最大劑量上限為72毫克[71][72]。若患者早上服用的中長效劑型藥物之藥效在傍晚開始消退，患者可視需要再服用短效劑型藥物，彌補隨著長效型藥物藥效退去後產生的空窗期。[13]

雖中樞神經刺激劑藥效約於服用後半小時左右開始，並不表示症狀會在服用後半小時就消失，如同其他疾病的治療一樣，病情的改善需要一定（段）時間的持續治療（時間長度因人而異）。藥物（包含：中樞神經刺激劑、非中樞神經刺激劑、......）會在這些患者的背後推他們一把，助他們一臂之力[73]。然而，即便如此，患者本身仍需認真努力地改變自己。藥物是注意力不足過動症整體治療的其中一環。[28][29][74]

根據世界反運動禁藥組織，中樞神經刺激劑在未事先申請醫療許可及非醫療所需的情況下服用都將被視同違規行為。[75]

部分用來治療注意力不足過動症的藥品（例如：中樞神經刺激劑）在美国食品藥物管理局划分为二级管制藥品（Schedule II，即指有滥用可能性的药品），在台灣則列為第三級管制藥品。[76][77][78][79]

中樞神經刺激劑如同多數藥物一樣，在正確使用下，造成內臟器官受損的機率非常低，但UpToDate仍強烈 建議用藥者應定期追蹤自己的體重、心跳與血壓等[80][81]，研究顯示中樞神經刺激劑造成的心血管作用與其攝取劑量多寡有關[81][82]（中樞神經刺激劑的副作用可能有：食慾降低、心跳與血壓上升等；而輕度、中度的心悸及高血壓可能不會被人覺察到，然而長期血壓超越正常範圍可能會導致許多健康問題；食慾降低可能不自覺地引起低血糖，導致心悸等副作用[83][84]）。[85][86][87][88][89][90][91][92][93][94]UpToDate指出，患者第一次用藥前必須先進行全面的心血管功能檢查，以確保患者沒有先天性心臟病或存有任何心血管問題。[95]有研究指出ADHD用藥可能會引起血管硬化，然而尚需更多研究確認，並且也要再確認此現象是否有到臨床上界定需要治療的程度[96][97]。

中樞神經刺激劑藥物可能的副作用包含口乾、失眠、急躁/急性子/靜不下來、煩躁、食慾降低、體重下降、頭痛、抖動、抽动综合症等[98][註 3][99] [100][101]；而在不超量使用中樞神經刺激劑藥物的情況下，其引發幻覺、偏執、心血管問題等嚴重副作用的機率極低，大約千分之一到萬分之一，而且發生的機率和沒有服用藥物的人沒有差異。[102][103][104][102][103][105] 因此期刊整理過去 185個研究（達一萬兩千多人），得到的研究結論是：注意力不足過動症的治療藥物並未增加嚴重副作用風險的機會。相對而言，常被忽略的是未經治療的注意力不足過動症所衍生出的嚴重風險[106]（約高達50%）。[註 4][108]不過考科藍協作組織於2015年發表的系統性文獻回顧指出，使用中樞神經刺激劑後，像失眠、食慾不振等較不嚴重的副作用常出現在服用者身上，並衍生出長期預後的不確定因素[109]。

所有用來治療注意力不足過動症的藥物只要依照醫師指示用藥，都是相當安全的。[76][77] [110] 而藥物成分為哌甲酯的中樞神經刺激劑，例如：利他能與專思達，可能導致：心悸、頭痛、胃痛、喪失食慾、失眠、因相對專注而變得冷淡（面無表情）等副作用，因此6歲以下的兒童不適宜將藥物當成第一線療法服用。（副作用產生與否因人而異） [111]

隨著時間推進與各方的努力，中樞神經刺激劑的相關副作用[註 5][註 6]已可藉由包括但不限於劑量調整、服藥時間、飯前飯後服用、服藥頻率等服藥模式之改變以及改變藥物組合等方式獲得相當程度的減少。[76] [112] [113] [114] [115]

UpToDate指出，使用者於中斷使用中樞神經刺激劑後恢復使用之，可能需要重新從較低的劑量開始逐步增加至理想劑量。[116][117]

  關於更多中樞神經刺激劑和其藥物，請見中樞神經刺激劑、哌甲酯、和安非他命尤其安非他命#醫療乙節。
右旋安非他命
禮來公司思銳60毫克膠囊（Lilly Strattera 60mg Capsule）
思銳（Strattera）外盒

第一線中樞神經刺激劑

專思達（Concerta）仿單（說明書）上的建議劑量
患者年紀 建議起始劑量 劑量範圍
6-12歲 18 毫克/每天 （mg/Kg） 18 - 54 毫克/每天 （mg/Kg）
13-17歲 18 毫克/每天 18 - 72 毫克/每天 每天每公斤不可超過2毫克。[註 7]
18-65歲 18 或 36 毫克/每天 18 - 72 毫克/每天

[118] 註解：

  1. 在專思達的藥物試驗過程中發現，13-17歲的青年試驗組中，專思達的最低有效劑量為： 每天每公斤1.4毫克 (1.4 mg/kg/day)。[118]
  2. 18歲以上的兩個成人試驗組中，發現每天18-72毫克的劑量皆可達到在統計學上具顯著意義的療效。（然而以每天36毫克以上進而達到統計學上具顯著意義的療效的臨床試驗者為大多數。）[119]

非中樞神經刺激劑

數種非中樞神經刺激劑，例如：阿托莫西汀、可樂定、安非他酮和胍法辛，可與中樞神經刺激劑一起使用，也可以作為中樞神經刺激劑的替代方案。[120][121][122]

禮來公司（Eli Lilly）的思銳（Strattera），有效成份為阿托莫西汀[123]，與中樞神經刺激劑同樣為治療ADHD的第一線藥物。思銳為非中樞神經刺激藥物（非興奮劑），且歸類於選擇性正腎上腺素再回收抑制劑。思銳有六種劑量型，分別為：18MG、25MG、40MG、60MG、80MG和100MG。[123] 「對於年齡小於18歲且體重小於70公斤」的使用者來說「總計每天服用劑量的上限為每公斤1.4 毫克（mg/day）」；對於「年齡大於或等於18歲或年齡小於18歲且體重大於70公斤」的使用者來說「總計每天服用劑量的上限為每天100毫克（mg/day）」。[124]

思銳的副作用相較於中樞神經刺激劑來得輕微許多。思銳主要的副作用有：疲倦、口乾（唾液分泌減少）等[123]。（副作用產生與否因人而異）[123]患者如果對中樞神經刺激劑沒有反應、反應不佳或過敏，可考慮使用阿托莫西汀。患者可向醫生詢問，共同制定一個漸進的劑量法。

思銳的藥效可以持續24小時[125]。思銳從第一天服用開始約需持續服用28至56天（4週到8週）才會完全生效。[126][127] 然而患者或患者周遭的人在這期間便可能逐漸感受到藥效 [128] [129][130][131]。服用者建議定期追蹤監測心律、血壓、肝功能（英语：liver function）[132]，患者第一次用藥前建議先進行全面的心血管功能檢查，以確保患者沒有先天性心臟病或存有任何心血管問題[132]。

縱然阿托莫西汀與中樞神經刺激劑同樣為治療ADHD的第一線藥物，然而其對特定症狀改善的程度可能與中樞神經刺激劑不同（兩類藥物各有其長處）。阿托莫西汀在改善「過動-衝動」的症狀上，略優於派甲酯；派甲酯則在改善「分心」的症狀上，略優於阿托莫西汀。[133][134] [135] [136] [137]

而阿托莫西汀與哌甲酯併服的處方尚未經美國食品藥物管理局核可，但醫師會視個案的情況（如共病、預後等）以開仿單標示外使用的方式處方之。[138][139][140][141]在臨床試驗中，並未發現兩者併服後產生加乘的心血管副作用。換言之，兩者併服之心血管作用，與單獨服用哌甲酯所產生的心血管作用相同。[142]

可樂定與胍法新（英语：guanfacine）皆為非中樞神經刺激劑、α2腎上腺素受體（英语：alpha-2 adrenergic receptor）刺激劑/促進劑/活化劑 的一員；與哌甲酯併用或單獨服用都有顯著療效，其中兩藥物併服：可樂定或胍法新與哌甲酯或安非他命合併使用的療效優於單獨服用任意一者。[註 8] [112] [143] [144] [145] [146] [147]

請注意：

  1. 美國食品藥物管理局已證明數起曾因為併服：可樂定、胍法新、哌甲酯或安非他命而致命的個案群與四种药物本身並無關聯。[148]
  2. 《美國兒童青少年精神醫學會期刊（英语：Journal of the American Academy of Child and Adolescent Psychiatry）》所刊登之論文，「可樂定或胍法新與哌甲酯或安非他命合併使用的療效優於單獨服用任意一者」的結論是立基於使用「長效可樂定或胍法新」作為臨床實驗過程中的試驗物。[112][143][145][146]
藥品學名 藥物類別（屬性） 作用時間 備註
阿托莫西汀 （思銳）[註 9] 選擇性正腎上腺素再回收抑制劑、非中樞神經刺激劑（非興奮劑） 5.2小時 [131][150][151][152]
-
可樂定 [註 10] alpha 2 腎上腺素受體刺激劑/促進劑/激動劑/激活劑/活化劑、非中樞神經刺激劑（非興奮劑） 2-4 小時 [154][155][156][157][158]
胍法新（英语：guanfacine） alpha 2 腎上腺素受體刺激劑/促進劑/激動劑/激活劑/活化劑、非中樞神經刺激劑（非興奮劑） 4-8 小時[154]
  • 已經可在中國大陸取得。[161]

選擇性血清素再回收抑制劑、選擇性血清素及正腎上腺素再回收抑制劑（SSNRI, Selective Serotonin and Norepinephrine Reuptake Inhibitor）等俗稱抗憂鬱劑的介入可能對於某些個案病情的改善亦有幫助。[162] [163][164]

安非他酮（國際非專利藥品名稱：Bupropion[註 11]）是菸鹼拮抗劑和較微弱的去甲腎上腺素-多巴胺再吸收抑制劑：一种主要作为抗抑郁药和戒烟药使用的药物、也可用作治療注意力不足過動症的第二線藥品與中樞神經刺激劑合併使用，或作為中樞神經刺激劑的替代方案。[120] [165] [166] [167] [168]

第一線非中樞神經刺激劑

思銳（Strattera）仿單上的建議劑量[123]
體重 每天服用的起始劑量 總計每天服用的目標劑量 總計每天服用劑量的安全上限
年齡小於18歲且體重小於70公斤 0.5 毫克/每公斤（mg/Kg） 1.2 毫克/每公斤（mg/Kg） 1.4 毫克/每公斤（mg/Kg）
年齡大於或等於18歲或年齡小於18歲且體重大於70公斤 40 毫克/天（mg/day） 80 毫克/天（mg/day） 100 毫克/天（mg/day）
  • 備註：
  1. 建議劑量與種族無關。[123]
  2. 肝腎功能不全的患者的服用劑量應低於建議劑量[123]（詳見：阿托莫西汀#劑量）
  3. 總計每天服用劑量的上限 = 無論分幾次服用，一天之內最多可攝取的劑量。
  4. 每天的起始劑量應服用至少三天，使身體適應後，才可開始服用每天的目標劑量。[123]
  5. 若每天目標劑量效果不符預期，則可逐漸增加劑量至每天服用劑量的上限[124]

對於治療方式的不同論點

参见：注意力不足過動症 § 治療方式的爭議

中華民國（台灣）有社會學學者從新聞媒體資料庫－聯合知識庫蒐集2001年起有關注意力不足過動症的新聞報導，並從記者的報導中，利用內容分析方法分析出「兒童的過動問題一開始就以生物醫學模式來解釋，在處遇建議上則呈現從行為治療轉向藥物治療的明確趨勢」的結論[169][170]。

美國有社會學家認為注意力不足過動症（ADHD）的治療是一個把「不常見且不被廣泛接受的行為」（deviant behavior）醫療化的例子。抱持這種想法的社會學家認為ADHD的治療是把早期不屬於醫療範疇的學生在學表現的問題給醫療化（另有一說是指這是「特教醫療化」）。[171][172]在中華民國，也有兩位學者附和這樣的論點。[173]

在美國，絕大多數的醫療人員相信ADHD是一個真實存在的「症」（genuine disorder）[172]，至少在症狀較明顯的人身上是這樣沒錯。[174][175]美國醫療人員之間的爭議主要是圍繞在那些症狀輕微的病患的診斷及治療方式[174][175][172][176][177][174][175][172]。（美國的ADHD流行率高於世界平均，詳見：注意力不足過動症 § 流行病學）

英國官方機構－英國傑出國家健康照護機構（英语：National Institute for Health and Care Excellence）在2009年發表聲明，聲明中有提及目前存在的爭議，但表示：當前的治療策略與診斷方法都是基於大量學術文獻所形成的學術界共識而得。 [178]

中華民國一位中央研究院歷史語言研究所的學者分析指出，台灣關於「西藥」的文化信念或成見在注意力不足過動症的治療方式的爭議之中，扮演著一個催化劑的角色。[179]

該學者建議精神醫學界「必須更認真思考大眾科學與衛教等議題」、全面向的介紹一個疾病以避免見樹不見林，從而化解相關爭議[179]。
除此之外，他也呼籲：強調精神疾病是生物性疾病的精神醫學與關注心理病理與心理發展的心理學、關注家庭社會病理與社會支持的社會工作專業、以及以教育矯正為職能及宗旨的教育與特教專業，彼此之間應有更緊密的合作。
他還指出「即使相信過動症的生物性本質，在目前的臨床實作上，從其症狀表現、發現認定、診斷到評估治療成效的指標，都還是以實際情境中的行為為基礎；而各種非藥物治療模式的施行，也需要多方面配合及參與。因此，在評估過動症的各種流行病學數據與藥物療效，以及要引入某種治療模式時，必然需要考慮在地的家庭、教育、社會環境與文化。」[179]

這位學者的結論是注意力在當代社會扮演的腳色日益重要[179]，並預期精神科在未來的人類社會中，將有更為多元的職能。[179]。

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维基文库中的相关原始文献：身心障礙者權利公約
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  109. ^ Storebø, Ole Jakob; Ramstad, Erica; Krogh, Helle B.; Nilausen, Trine Danvad; Skoog, Maria; Holmskov, Mathilde; Rosendal, Susanne; Groth, Camilla; Magnusson, Frederik L; Moreira-Maia, Carlos R; Gillies, Donna; Buch Rasmussen, Kirsten; Gauci, Dorothy; Zwi, Morris; Kirubakaran, Richard; Forsbøl, Bente; Simonsen, Erik; Gluud, Christian, Storebø, Ole Jakob , 编, Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD), The Cochrane database of systematic reviews (systematic review) (Chichester, UK: John Wiley & Sons, Ltd), 2015-11-25, (11), PMID 26599576, doi:10.1002/14651858.cd009885.pub2, Within the short follow-up periods typical of the included trials, there is some evidence that methylphenidate is associated with increased risk of non-serious adverse events, such as sleep problems and decreased appetite, but no evidence that it increases risk of serious adverse events.Better designed trials are needed to assess the benefits of methylphenidate. Given the frequency of non-serious adverse events associated with methylphenidate, the particular difficulties for blinding of participants and outcome assessors point to the advantage of large, 'nocebo tablet' controlled trials. 
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  129. ^ Frequently Asked Questions. Official website for Strattera. Strattera-Eli Lilly. 2016-09 [2017-02]. （原始内容存档于2017-01-09）. Strattera works gradually, so improvements are seen over time. When your child starts treatment with Strattera, it's important to set some small goals. Remember to be patient—some people notice small changes within 2 weeks, and by 4 to 6 weeks at target dose you should see significant improvement in your child's symptoms. 
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  133. ^ Chi-Yung Shang, Yi-Lei Pan, Hsiang-Yuan Lin, Lin-Wan Huang & Susan Shur-Fen Gau. An Open-Label, Randomized Trial of Methylphenidate and Atomoxetine Treatment in Children with Attention-Deficit/Hyperactivity Disorder. Journal of child and adolescent psychopharmacology. 2015-09, 25 (7): 566–573. PMID 26222447. doi:10.1089/cap.2015.0035. At week 24, mean changes in ADHD-RS-IV Inattention scores were 13.58 points (Cohen's d, -3.08) for OROS-methylphenidate and 12.65 points (Cohen's d, -3.05) for atomoxetine; and mean changes in ADHD-RS-IV Hyperactivity-Impulsivity scores were 10.16 points (Cohen's d, -1.75) for OROS-methylphenidate and 10.68 points (Cohen's d, -1.87) for atomoxetine. 
  134. ^ 衛生福利部精神疾病衛教叢書 注意力不足過動症，第22頁「atomoxetine，用在病情 較為複雜、或是無法忍受MPH副作用的患者，然而一般發現其對於專注度的改善沒有MPH明顯」
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  137. ^ Matthew Siegel, MD.,Craig Erickson, MD., MS, Jean A. Frazier, MD., Toni Ferguson, Autism Society of America., Eric Goepfert, MD., Gagan Joshi, MD., Quentin Humberd, MD., Bryan H. King, MD., Amy Lutz, EASI Foundation: Ending Aggression and Self-Injury in the Developmentally Disabled., Louis Kraus, MD., Alice Mao, MD., Adelaide Robb, MD., Jeremy Veenstra-VanderWeele, MD, PhD., Paul Wang, MD, Autism SpeaksCarmen J. Head, MPH, CHES, Director, Research, Development, & WorkforceEve, Bender, Scientific Editor. Autism_Spectrum_Disorder_Parents_Medication_Guide (PDF). 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007: American Academy of Child and Adolescent Psychiatry. 2016: 13. （原始内容存档 (PDF)于2017-04-11） （英语）. Atomoxetine (Strattera) has also been researched in controlled studies for treatment of ADHD in children with autism, and showed some improvements,particularly for hyperactivity and impulsivity. 
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  139. ^ Medical Encyclopedia → Attention deficit hyperactivity disorder. MedlinePlus.gov. 2017-01-05 [2017-01]. （原始内容存档于2017-01-26）. Medicine combined with behavioral treatment often works best. Different ADHD medicines can be used alone or combined with each other. The doctor will decide which medicine is right, based on the person's symptoms and needs. 
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參見

主要的文章
可分為
藥物
中樞神經刺激劑
非中樞神經刺激劑
相關支持團體（英语：support group）
台灣
相關或過時的議題

註解

  1. ^ 即表示可附加在現有具備科學實證且能在統計學上達到顯著意義之有效改善症狀的醫學療法。
  2. ^ 又稱為「派醋甲酯」
  1. ^ 或稱心理與身體無法保持安寧。 無法專心睡覺。
  2. ^ 攝取過多的維他命可能產生健康問題。[36]例如：長期且高劑量的攝取維他命B6、維他命B12可能導致肺癌[37][38]
  3. ^ See Obsessive–compulsive_spectrum#Tic_disorders（英语：Obsessive–compulsive_spectrum#Tic_disorders）
  4. ^ Elsevier BV曾經出版一篇文獻指出，未經治療的ADHD可能在往後的人生中直接或間接衍生出以下共伴疾病（已忽略重複項目）：吸菸、性成癮（包含：從事高風險性愛（英语：Risky sexual behavior）、罹患性感染疾病）。間接：體適能不足、醫療費用及就醫次數增加。極間接：糖尿病、高血壓。[107]
  5. ^ 「常見副作用」的定義為：在臨床試驗中，實驗組中至少5%的人出現此症狀，且在實驗組中出現此反應的比例為安慰組的兩倍。
  6. ^ 「較少見的副作用」的定義為：在臨床試驗中，實驗組中至少2%的人出現此症狀，且在實驗組中出現此反應的比例多於安慰組。
  7. ^ 舉例：一個三十公斤的服藥者每天不可服用超過60毫克的專思達
  8. ^ 延伸閱讀：腎上腺素受體、α2腎上腺素受體
  9. ^ 膠囊必須整顆與開水或其他液體一起吞服。其他注意事項請詳閱藥品說明書。[149]
  10. ^ 請注意（仿單標註）：
    • 除非經醫師評估後允許，否則在服用Clonidine期間切勿攝取酒精及其他與clonidine藥效相似皆會增加睡意的物質、藥物。
    • 不要在服用Clonidine期間駕車、操作機械或從事具危險性的活動，除非服藥者已明白且熟悉Clonidine對自己帶來的各種影響。
    • 避免讓自己脫水及中暑。

      clonidine常見的副作用為：
    1. 較低的血壓及心跳速率
    2. 想睡覺。 [153]
  11. ^ 舊名：amfebutamone

外部連結

取自“https://zh.wikipedia.org/w/index.php?title=注意力不足過動症的治療&oldid=50282630”