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注意(力)缺陷多动障碍的治疗

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维基百科,自由的百科全书

注意力不足过动症的治疗是指在注意力不足过动症(ADHD)治疗上,以医学实证为基础,已确认有一定程度治疗效果的治疗方式。注意力不足过动症的治疗包括心理治疗行为治疗及药物,也有可能是用心理治疗配合药物进行治疗。治疗对病症会有长期的改善,但是无法完全根除病症的影响[1]

美国儿科学会针对病患的年龄不同,有建议不同的治疗方式。若是四岁至五岁的儿童,学会会建议有实证基础,且由家长或/和老师监督的行为治疗,只有在有中度到重度,持续性的功能紊乱时,才加上哌甲酯的药物治疗。若是六岁至十一岁的儿童,会建议使用药物以及行为治疗;而“中枢神经刺激剂”的药效会比“非中枢神经刺激剂”的药效要明显一些,虽然“中枢神经刺激剂”和“非中枢神经刺激剂”都能让孩子核心症状减少的程度在统计学上达到明显意义[2]。若是十二岁至十八岁的患者,强烈建议使用药物治疗,但用药仍需取得患者的同意;药物治疗之馀也建议能搭配行为治疗[2][3]。有其他研究指出若能合并药物治疗及行为治疗、认知行为治疗等心理治疗,将可带来更乐观的预后[3]

针对注意力不足过动症的药物治疗,有许多中枢神经刺激剂及非中枢神经刺激剂的药物。最常用的中枢神经刺激剂有哌甲酯(利他能、专思达)、阿得拉尔(Adderall, Mydayis)、右旋安非他命(Dexedrine)及甲磺酸赖氨酸安非他命(Vyvanse)。专门用来治疗ADHD的非中枢神经刺激剂有阿托莫西汀(Strattera)、胍法辛(Intuniv)及可乐定(Kapvay)。其他仿单外标示使用英语off-labell的药物有安非他酮(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[4][5][6]。若有罹患相关的疾病,会使得诊断及找到正确治疗方式的过程更困难及费时,因此建议同步评估是否有罹患注意力不足过动症的相关疾病,若有,也需同步进行治疗[7]

在注意力不足过动症的非药物治疗上,有许多心理治疗行为改变英语behavior modification的方式,其中包括心理治疗以及工作记忆训练英语working memory training。透过父母管理训练教室经营英语classroom management调整家庭及学校的互动方式,也可以提升儿童的行为表现[8]。专门的ADHD教练也可以提供改善日常行为的方式及策略,例如时间管理或是组织化建议。自我控制的课程似乎帮助不大。

非药物治疗

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心理学家及精神医学医师有许多不同的心理治疗方式,视病患及病患的症状而定。常见的治疗方式包括心理治疗认知行为治疗支持团体英语support groups、亲职谘商训练、冥想及社交技巧训练英语social skills training

家长及教室

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改善家中及学校的环境有助于提升ADHD儿童的行为[8]。ADHD患者的父母有可能也有类似的症状,因此无法帮助其子女处理ADHD的问题[9]。增加父母对其子女行为的了解,并且教导策略来强化子女的机能及沟通能力,并且对于一些不希望出现的行为加以制止,可以改善子女ADHD的情形[8]。这些不同的父母教育介入方式统称为父母管理训练,其技巧包括操作制约:持续的对符合目标以及好的行为给予鼓助(正增强)),对于没有符合目标或是不好的行为给予处罚(例如取消一些权利,或是time-out)[8]。教室管理类似对家长的管理训练:教育者学习有关ADHD的特质,并且学习在教室中改善ADHD者行为的技巧。策略包括渐进结构化的教室活动、每日回馈、以及通证经济[8]。为了让有ADHD的儿童可以从通证经济中获益,所有的人都要有一致的标准,因为相同的行为而得到奖励。另外,建立教室常规有助于确保有ADHD的学生可以一整天保持专注。

认知训练

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2013年由奥斯陆大学的二位研究者所发表的论文指出:工作记忆训练有助于短期的提升,但是有关持续性的提升证据仍不足,也无法扩展到语言能力、数学技巧、专注力或是文字解码能力的提升[10]。2014年由一群南安普敦大学研究者发表的论文,研究14个已发表的随机对照试验(RCT)的元分析,其结论是:“若要将认知训练作为针对核心ADHD症状的第一线治疗方式,还需要更多良好的双盲研究证据的支持。”[11]

药物治疗

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中枢神经刺激剂

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中枢神经刺激剂是最常用来治疗ADHD的药物。至少在用药后的14个月内,改善部分ADHD的症状[12][13]用来治疗ADHD的中枢神经刺激剂有哌甲酯(利他能,专思达)、右旋哌甲酯英语Dexmethylphenidate(Focalin)、混合苯丙胺盐类(Adderall)[14]右旋安非他命(Dexedrine)、甲磺酸赖氨酸安非他命(Vyvanse)[15],偶尔也会使用甲基苯丙胺(Desoxyn)[16]缓释制剂英语time release technology可以让患者只要每天早上服药一次即可,这对一些不希望在学校时还要服药的儿童格外有帮助。有许多不同的药物缓释方式。

治疗ADHD的中枢神经刺激剂会提升细胞外的神经递质多巴胺去甲肾上腺素)的浓度,可以增加神经元之间的沟通。其治疗效果是因为去甲肾上腺素蓝斑核前额叶皮质作用,而多巴胺能英语dopaminergic的作用是在腹侧被盖区伏隔核前额叶皮质[17][18]

中枢神经刺激剂若在医师处方下,依处方用量使用,一般来说是安全的[8],不过对于药物长期的影响及安全性,还没有具体的数据佐证[19][20][21][22],另一方面的疑虑是有关其使用以及药物分配上的社会问题及伦理问题,美国的FDA已针对一些ADHD药物加注黑框警语英语black-box warning,若是滥用这些药物,在停药时会出现精神病,心理依赖以及严重的抑郁症[23]

在治疗ADHD的药物中,中枢神经刺激剂的效果最好[24]。美国FDA已核可七种不同的ADHD中枢神经刺激剂药物,四种是以苯乙胺为基础的处方,有二种是以哌甲酯为基础的处方,以及盐酸右旋苯丙胺。美国FDA核可治疗ADHD的非管制类非中枢神经刺激剂只有阿托莫西汀胍法辛可乐定

根据短期的临床试验,已证实ADHD的疗效,不过这些试验有排外条款,目前有关ADHD药物的知识是基于临床实务上典型病患中的一小部份子群所得的[25],目前还无法证实对学业表现是否有帮助,而且也缺乏长期疗效以及副作用严重性的试验资料。不过中枢神经刺激剂可以减少ADHD儿童意外受伤的风险[26][27]

注意力不足过动症的中枢神经刺激剂药物一般会分在同一类内,但其影响脑部的方式有所不同[28]。有些研究致力于找到儿童对特定药物反应的相似性[28],不论儿童是否有ADHD,其对中枢神经刺激剂药物的行为反应是类似的[29]

中枢神经刺激剂药物用在成人注意力不足过动症上,也是有效的疗法[30][31][32],不过药效反应速度会比儿童要慢[33]。 有些医师会建议第一次用药时用抗忧郁药物代替中枢神经刺激剂[34],不过其治疗效应值比中枢神经刺激剂要低很多[35]

药物名 药物(主成分/有效成分)学名 作用时间 生效时间 备注
利他能(Ritalin) 哌甲酯[注 1] 短:3.5小时左右 约服用后30分钟
  • 在药物动力学上,食物可能增加立即释放型哌甲酯的口服吸收率,因此建议使用者于餐前30-45分钟用药。[36][37]
  • 安保美喜锭为利他能的副厂药品。 副厂名:安保美喜公司英语Apotex
  • 研究发现,胎儿在子宫接触到哌甲酯,相对控制组来说,较高的风险在出生后带有先天性心脏病,而苯乙胺则无此风险[38]
  • 质子泵抑制剂共服可能会增加哌甲酯的口服吸收率[39]
Adderall 右旋苯丙胺左旋苯丙胺
  • 短效型:4-5小时[40]
  • 长效型:10-12小时[40]
  • 短效型:30-60分钟[40]
  • 长效型:60-90分钟或更短[40]
Desoxyn 甲基苯丙胺 N/A N/A
Tyvense 甲磺酸赖氨酸安非他命 12小时 2 小时
Dexedrine 右旋安非他命
  • 立即释放型:3-7小时
  • 长效型:12小时
  • 立即释放型:0.5-1.5小时
  • 长效型:1.5-2小时
利他(长)能LA
(Ritalin LA/利长能)
哌甲酯 中:8小时左右 约服用后30分钟
  • 药物之半衰期介于利他能与专思达之间[43]
  • 研究发现,胎儿在子宫接触到哌甲酯,相对控制组来说,较高的风险在出生后带有先天性心脏病,而苯乙胺则无此风险[38]
  • 质子泵抑制剂共服可能会造成Ritalin LA无法达到缓慢释放的效果,并且可能会增加哌甲酯的口服吸收率[39]
专思达/专注达 哌甲酯 长:12小时左右 约服用后30分钟
  • 台湾译作专思达。
  • 中华民国中央健康保险署已经核定医师可将此药物作为十八岁以下患者的第一线处方[44][45]
  • 中国大陆翻译为专注达。
  • 研究发现,胎儿在子宫接触到哌甲酯,相对控制组来说,较高的风险在出生后带有先天性心脏病,而苯乙胺则无此风险[38]
  • 质子泵抑制剂共服可能会增加哌甲酯的口服吸收率[39]

苯丙胺

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苯丙胺是手性化合物,由两种同分异构的化合物组成:左旋苯丙胺(Levoamphetamine)及右旋苯丙胺(dextroamphetamine)。两种化合物互为对方的镜象(对映异构),就像人的右手和左手互为镜象一样。分子因为对映异构产生在空间排列上的差异,使得其药理学上的特质有些不同:左旋苯丙胺的代谢半衰期较长,但右旋苯丙胺是比较有效的中枢神经刺激剂。在抑制ADHD本身的症状(例如过动及不专注)很有效,不过也可能会有严重的副作用,例如头痛、焦虑、恶心及失眠[46]

目前在ADHD的治疗上,有五种不同的以苯丙胺为基础的药物:外消旋苯丙胺右旋苯丙胺甲磺酸赖氨酸安非他命,另外有二种混合的镜像异构物药物(阿得拉尔及Dyanavel XR)[47][48][49]。甲磺酸赖氨酸安非他命本身没有作用,但在人体内会代谢为右旋苯丙胺,属于前体药物[47]。阿得拉尔是有专利混合药物,其中包括75%右旋苯丙胺盐及25%左旋苯丙胺盐,其效果有些细微的不同[47]。Dyanavel XR是类似的混合物[48]。阿得拉尔因为有左旋苯丙胺,其药效会比右旋苯丙胺要快[50]。左旋苯丙胺也让阿得拉尔的临床效果比右旋苯丙胺要长。有些同时患有ADHD及其他共病的儿童对左旋苯丙胺的反应很好[28]

甲基苯丙胺
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人体会将甲基苯丙胺代谢为苯丙胺以及其他较没有药物活性的代谢产物。最后约有四分之一的甲基苯丙胺会变成苯丙胺[51]。若只比较右旋苯丙胺及右旋甲基苯丙胺(dextromethamphetamine),后者是较强的中枢神经刺激剂[52]

哌甲酯

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哌甲酯(methylphenidate)简称MPH,类似苯丙胺一样有手性的化合物,是由二种对映异构物组成:右旋哌甲酯英语dexmethylphenidate(也称为d-MPH)及以左旋哌甲酯(l-methylphenidate,也称为l-MPH)。不过这两种同分异构物的药效差异较大,l-MPH的药效明显的比d-MPH要弱,原因是因为这二个同分异构物之间的差异所造成[53][54]

有两种以哌甲酯为基础的药物,一种是由两种对映异构物等比例混合产生的外消旋混合物,是利他能(Ritalin)及专思达(Concerta),另一种是只含右旋哌甲酯的对映异构物,称为右旋哌甲酯英语dexmethylphenidate(Focalin)。

非中枢神经刺激剂

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阿托莫西汀[55]胍法辛可乐定等非中枢神经刺激剂常用来治疗注意力不足过动症。

阿托莫西汀
阿托莫西汀的疗效会比中枢神经刺激剂要弱一些,偶尔会有肝脏受损的副作用,但非常少见[56]:5,美国FDA用黑框警语英语black box warning警告此药物有和自杀意图有关的罕见副作用[57]。对照研究指出,此药物会让心率变快、体重变轻、没有食欲以及因治疗产生的恶心症状[58]
胍法辛
FDA已核准用延长释放型式的胍法辛来治疗ADHD,作为替代中枢神经刺激剂的药物。其正面效果可能是因为此药物可以强化前额叶皮层,强化有关调节专注力以及行为的能力[59]
可乐定
美国也已经核可α2A肾上腺素能受体激动剂。可乐定一开始是设计来治疗高血压的药物。在傍晚及(或)下午低剂量的使用,并且配合中枢神经刺激剂一起使用,可以帮助睡眠,有时可乐定可以缓解冲动和对立行为,也可能会减少抽动综合症的症状[60],对于共病的抽动综合症可能效果更好。

其他药物

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因为一些原因,有些治疗ADHD的药物是用在FDA核可适应症英语Indication (medicine)以外的仿单外标示使用英语Off-label use[61]。美国FDA要求两次的临床实验,以确认此潜在药物在治疗ADHD的效果及安全性。以下的药物尚未通过二次的临床实验,因此FDA尚未核可这二种药物来治疗ADHD,而其合理的用量及和其他药物的交互作用也还不明确。

安非他酮
安非他酮(Bupropion)会分类为非典型的抗忧郁药,是最常用来治疗ADHD的仿单外药物[来源请求]。安非他酮会抑制神经元突触中去甲肾上腺素的再摄取,也会较小程度的抑制多巴胺[62],对于血清素的再摄取没什么影响[63]。安非他酮不是管制类药物,其处方药物常会设计为分时释放的药物,以避免副作用的风险
莫达非尼
莫达非尼(Modafinil)是觉醒促进剂英语wakefulness-promoting agent,主要效果是选择性的、效果较弱的、非典型的多巴胺再吸收抑制剂英语dopamine reuptake inhibitor。有在儿童ADHD的患者中进行过双盲随机对照试验,验证过其疗效及耐受性[64][65],不过有些严重副作用(如皮肤不良反应)的风险,因此不建议将莫达非尼用在儿童病患身上[66]:7。在美国市场,此药物一开始在市场上是以Sparlon的名称向FDA申请核可,不过因为在临床试验中有出现过史蒂芬斯-强森症候群,FDA对此有疑虑,因此没有核可此药物的使用[67]

其他可能会以仿单外治疗形式,用来治疗注意力不足过动症的药物,有包括一些抗抑郁药,例如三环类抗抑郁药 (TCA)、5-羟色胺和去甲肾上腺素再摄取抑制剂(SSRI)或单胺氧化酶抑制剂(MAOI)[5][6][4]

对于中枢神经刺激剂的疑虑

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有些家长及研究者对于药物的副作用以及长期使用的影响有些疑虑[61]

接受治疗人数的增加

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近年来,注意力不足过动症的门诊治疗比率稳定不变。之前,美国注意力不足过动症的门诊治疗比率从1987年每一百名儿童中0.9名,上升到1997年的每一百名儿童中3.4名[68]美国疾病控制与预防中心2011年至2012年的调查指出年龄4岁至17岁的儿童中,有17%曾经由医疗人员给出有一定程度ADHD的诊断(男孩中占15%,女孩中占7%),比2007年增加16%,比上个世纪增加41%[69]。CDC也指出上述的抽样中,美国儿童ADHD的盛行率比美国精神医学学会DSM-5提到的要高5%(2011年的调查,有8.8%的儿童确诊有ADHD)[69][70]。不过在2011年时,只有6.1%的儿童有服用ADHD的药物,因此推测患有ADHD的儿童中,可能有17.5%没有接受治疗[69]

学龄前的用药

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ADHD儿童的家长一般是在儿童较小时就发现其ADHD的症状,有关儿童使用中枢神经刺激剂长期影响的纵向研究还不多[71]。FDA没有核可对六岁以下的儿童用药物治疗[72],目前的趋势在较小的儿童身上就诊断出ADHD。有关五岁以下儿童的药物处方从2000年至2003年增加了50%[73][74]。有关此议题的研究也指出中枢神经刺激剂可以让帮助“有严重ADHD症状”的幼童,但其剂量会比年龄较大儿童的剂量要少。研究也指出,较小年龄的儿童对副作用较为敏感,需要密切监控[72]。有证据显示认真的评估以及个人化的行为介入显著的改善其社交技巧及学业表现[2][75][不可靠的医学来源?],而药物只对其症状有帮助。“使用药物治疗的比例增加的一个主要原因,是许多医师认知到心理治疗的方式费用很高,而且很难持续。”[76]

副作用

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成长迟缓及体重减轻
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有些证据显示若儿童较长期的使用中枢神经刺激剂,在儿童成长方面有轻微的减缓,不过还没有找到其因果关系,而且持续长期使用似乎没有再看到类似的影响[77]。体重减轻一般和食欲减轻有关,食欲减轻是药物可能会引起的副作用,不过很少会有严重体重减轻的症状。食欲减轻只是一时性的,当中枢神经刺激剂的日常效果减退了之后,食欲就会恢复正常。恶心、头晕、头痛及其他症状都会影响食欲,也会让体重减轻[78]

心血管疾病
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有些研究者对于中枢神经刺激剂及阿托莫西汀的疑虑,会增加心率及血压,可能会引起严重的心血管问题[79][需要较佳来源]。近来FDA的极大规模研究指出,针对儿童、青年人及成人而言,找不到严重心血管疾病(心搏停止心肌梗死中风)和使用苯丙胺、哌甲酯及其他ADHD药物的相关性[80][81][82][83]

精神医学
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治疗ADHD的药物中,有许多会有生理及心理上的依赖性[84][页码请求],也可能会有睡眠方面的问题[85]

哌甲酯可能会恶化精神科患者思觉失调的症状,在极少数的案例中,和新出现的精神科症状有关联性[86]。若是患有ADHD和躁郁症的患者使用,需高度注意,因为有潜在诱发狂躁轻度狂躁的可能性[87],有非常罕见自杀意图英语suicidal ideation的案例,不过目前还没有相关性的证据[77]。还不清楚长期使用哌甲酯对于后来精神疾病是否有影响[88]

2009年FDA针对49个临床实验的回顾性研究指出,接受ADHD药物临床试验的儿童中,有1.5%有精神疾病或是狂躁的症状。也分析了售后报告,约半数是和不到11岁的儿童有关。其中约90%的案例之前没有精神疾病或是类似症状的病史。最常见的症状是有关蛇、蠕虫或是昆虫的幻觉[89]

长期使用

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有些物种长期使用哌甲酯或苯丙胺有可能会造成多巴胺系统发展异常,或是可能会让神经受损[90][91]不过人类接触后的发展及神经成长却都正常[92][93][94]核磁共振成像研究指出ADHD患者长期使用哌甲酯或苯丙胺治疗,可以减少其脑部结构及机能上的异常,也可以促进右尾状核的机能[92][93][94]

有关中枢神经刺激剂临床研究的评论,已经确定了ADHD患者长期使用苯丙胺的安全性及疗效[95][96]。两年的受控临床试验已确定了连续治疗的安全性及疗效[96][97]。有一个评论针对长达九个月,针对儿童使用苯丙胺的随机对照试验,指出其智商平均增加了4.5,且其注意力变好,而破坏行为及过动都有改善[97]

戒断及回弹

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中枢神经刺激剂的治疗效果可能会出现抗药性[98],当剂量减少时也可能会有回弹效应英语rebound effect[99]。回弹效应一般是在中枢神经刺激剂量太高,或是患者无法负荷中枢神经刺激剂时出现。剂量太高会出现的症状包括易怒、感受或是人格的受激或是钝化[100]

中枢神经刺激剂可能会有药物戒断或是rebound reactions英语rebound reactions的症状,若用几个星期或是几个月来渐渐减少药量,其症状可以减到最轻[101]。有一个有关刺激剂快速戒断的小型研究,认为戒断反应其实不是典型反应,只会在一些易感的人身上出现[102]

癌症

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有一个针对哌甲酯的小规模研究,让大家对于使用后是否会造成染色体畸变及癌症可能性有所疑虑,后来美国食品药品监督管理局(FDA)的审核中发现其中有重大的方法论问题,因此不能作为参考[103]。用改善过的方法论进行的后续研究找不到哌甲酯可能致癌的证据,该研究指出“有关长期使用哌甲酯,可能会提高致癌风险的说法,找不到相关证据可以支\持。”[104]

历史

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第一个将中枢神经刺激剂用来治疗儿童专心及过动问题的记载出现在1937年[105]美国罗德岛普罗维登斯的医师查尔斯·布拉德利英语Charles Bradley (doctor)记载了一群有行为问题的儿童在接受中枢神经刺激剂苯丙胺的治疗后,症状有改善[105][106]。中枢神经刺激剂哌甲酯(利他能)在1944年问世,在1954年时已可以贩售,目前仍为最常用来治疗ADHD的药物之一[105]。此药物最早是用来治疗发作性嗜睡病、慢性疲劳、忧郁症,以及减缓其他药物的副作用[105],1960年代起就开始用哌甲酯来治疗ADHD。

美国FDA在1975年核可用匹莫林英语pemoline(塞洛德)来治疗ADHD,在症状控制上的效果很好,不过之后的二十七年内,有14例肝脏衰竭的案例,因此药商将此药物从市场上撤回。药品内新的给药系统在1999年发明,使药品成为可以渐渐释放的长效型药物,避免一天要多次服药,或是需要在学校中服药的情形。这个新的系统包括药锭外面包覆著不同时效的物质,让药品可以在8至12小时的时间内慢慢溶解释放(Metadate CD, Adderall XR, Focalin XR),也有渗透泵英语OROS可以在食用后八至十二小时从药品中挤出液态的哌甲酯(专思达)[来源请求]

2003年FDA核可将阿托莫西汀(择思达)用来治疗ADHD,是FDA头一次核可用不是中枢神经刺激剂的药物来专门治疗ADHD[107]。2007年甲磺酸赖氨酸安非他命(Vyvanse)成为第一个获得FDA核可治疗ADHD的前体药物[108][109]普度药厂英语Purdue Pharma的一个子公司在2019年3月获得FDA核可,用Adhansia XR英语Adhansia XR(一种哌甲酯药物)来治疗ADHD[110]

成本-疗效比较

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若考虑注意力不足过动症治疗的疗效,效果最好的是结合药物治疗以及行为治疗的方法,其次是只用药物治疗,再者是行为治疗[24]。若同时考虑成本及疗效,首先会考虑纯药物的治疗、其次是行为治疗,再者是结合药物治疗以及行为治疗的方法[24]。以个人而言,最有效以及疗效-成本比(cost-effective)最好的是用中枢神经刺激剂的药物治疗,长效性药物的疗效-成本比会比短效性的药物要好[111]。若有出现共病(二个疾病同时出现,例如重度抑郁症及ADHD)会使诊断及治疗的成本更高。

其他治疗方式

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有时会用咖啡因来治疗ADHD

大部份的ADHD替代治疗方式还没有足够的证据以佐证其疗效,目前也还不建议使用[112][113]。就算考虑其中最好的实验结果,其效果也只是类似安慰剂的效果[113]

神经回馈

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神经回馈英语Neurofeedback(NF)是一种针对患有儿童、青少年或是成人的治疗方式[114]。此疗法会用电极来测量人脑所释放的电能。当有beta波出现时会发出警告,此理论认为罹患ADHD的人可以透过训练来降低ADHD的症状[来源请求]

目前还没看到神经回馈疗法有造成严重的不良反应[115],有关神经回馈的研究,目前还没有高品质的成果[115]。目前有些有关神经回馈成效的资讯,不过说服力还不足:[115][116]。在大部份的双盲实验中,看不出神经回馈的效果,因此正面效果也有可能是类似心理作用的安慰剂效应[117]

饮食

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健康及营养均衡的饮食(食物饮用水饮料)是保持身心健康的基础,从而减少疾病(例如:慢性病)的生成。[118][119][120]

截至2019年7月,没有任何科学证据显示、或甜食(包括:糖分含量远高于一般菜肴的食物)会影响人类的行为或导致ADHD[121] [122]<[123]

饮食的调整可能对少部份的ADHD儿童有帮助[124],一份2013年的统合分析针对有ADHD症状,而且有补充游离脂肪酸或是减少食用有人工色素食品的儿童的相关研究发现,只有不到三分之一的儿童在症状上有改善[125],这方面的助益有可能只是对有食物敏感的儿童有帮助,也有可能是这些儿童同时也在接受ADHD的治疗[125],这些已发表的文献也发现目前已有的证据无法支持减少食用特定食物来治疗ADHD的疗法[125]。2014年发表的文献也发现排除饮食在治疗ADHD上的成效有限[126],另一篇在2016年发表的文献指出,根据研究结果,“无麸质饮食在未来成为ADHD的标准疗法”之机率是微乎其微[127]

铁、镁及碘等矿物质的摄取可能可以改善ADHD的症状[128],有一些证据指出身体组织内的成份过低和其ADHD症状有关[129],不过一般不建议用补充锌矿物质的方式来治疗ADHD,只有在有锌缺乏的地区(几乎只会在开发中国家)才建议补充锌矿物质[130]。不过若锌矿物质和苯丙胺类药物同时使用的话,会减低苯丙胺药物的最小有效剂量,也就是可以服用较少的药物而达到相同的效果[131]。另有证据指出Omega3-脂肪酸能提供对于病情些许的改善[132][133],不过也有证据指出其功效非常有限[134][135],因此不建议用Omega3-脂肪酸来取代医学治疗[136] [137]

一些研究发现,人工食用色素防腐剂可能与少部分儿童出现类似ADHD的症状,或者是与ADHD的流行率增加有关。[138][139]但是这些研究的证据力薄弱而且可能只适用于有食物不耐症的孩子。[139][125][140] 针对这样的疑虑,英国和欧洲联盟已经发布相关食品管理措施。[141]

对于某些食物的食物过敏食物不耐症,可能会恶化少数孩子既有的ADHD症状。[126]

中医

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中华民国中医师公会全国联合会曾在2018年8月于台湾召开记者会指出,“长久以来,传统中医在改善(ADHD)这类慢性长期精神生理疾病症状方面,具有显著的疗效”[142]

中华民国中医师公会全国联合会另表示,2010 年发表于《Complementary Therapies in Medicine英语Complementary Therapies in Medicine[注 2](一个替代医学的期刊)的随机双盲对照试验中提到,在头部、背部膀胱经足部肾经足部肝经的进行针刺治疗,有改善注意力不足与过动的症状[143][需要可靠医学来源]

运动

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适度且规律的运动,特别是有氧运动有助于改善许多中枢神经系统疾患的症状,也证实为注意力不足过动症的有效附加疗法英语add-on treatment[注 3][144][145][146]

长期规律的运动合并正规治疗,将有更乐观的预后(治疗效果)-较好的行为以及运动协调性、大脑执行功能的提升(包含大脑认知领域中的:注意力、冲动克制力、和计画组织的能力)、更快速的资讯处理速度、和更棒的记忆力[147][144]

统计由父母及教师填答的《孩子行为和社交情绪评量表》,结果显示长期规律的有氧运动带给孩子的效果是:身体所有功能的提升、ADHD的症状减缓、焦虑和忧郁的程度下降、身体症状减少、较佳的课业及课堂中的表现、社交技巧进步。[144]

药物治疗合并规律的运动能放大中枢神经刺激剂作用于执行功能上的效果[144]。运动带来的效果被认为是因为运动增加了脑中神经突触间多巴胺和正肾上腺素的浓度[144]

音乐

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北美放射医学会英语Radiological_Society_of_North_America和有限的研究结果表示,音乐治疗似乎有可能改善ADHD孩子在课堂上的表现[148]、增加注意力不足过动症及自闭症亚斯伯格症(ASD)患者的脑部特定神经连结并使得预后更加乐观[149],然而音乐治疗的有效性尚需更多相关论文支持[150][151]

台湾精神科医师高淑芬则表示,根据床经验,让ADHD患者听音乐较能持续工作,也能增加效率,但高淑芬也说,若患者是听有歌词的歌曲或新歌可能就比较不适合,因为患者可能把注意力集中到音乐的歌词上,沉浸在音乐中。[152]:117-118

体外三叉神经微电流刺激系统

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体外三叉神经刺激系统(external Trigeminal Nerve Stimulation System,简称eTNS)是在体外利用电流刺激三叉神经的设备。[153]

2019年4月,美国食品药物管理局(USFDA)批准用此设备治疗美国7-12岁之未使用药物治疗ADHD的患者,是美国首度核准的第一项ADHD医疗器材,仅限医师处方。eTNS可以做为ADHD的单独疗法,亦即不必搭配其他的ADHD药物或是非药物治疗[153]。其治疗方式是儿童在晚上睡觉的时候,在其照顾者的督导下,在没有其他电磁波及电流的干扰下,将eTNS贴在额头表皮,以利eTNS传送微弱的电流刺激孩子的前额叶[153]。ADHD孩子可能需使用eTNS连续四周才能出现疗效,之后才回诊接受医师的疗效评估[153]。eTNS的副作用为:疲倦、食欲增加、睡不好、磨牙(teeth clenching)、头痛、与倦怠。然而其程度都十分轻微。其他较少见的eTNS之副作用,没有任何项目被USFDA评定属于严重或危险等级的[153][154][155]

不过有些在医疗现场直接面对患者(临床)的儿童与青少年精神科医师(儿童心智科医师)持保留态度,认为该双盲随机对照试验中的参与者(样本数)仅62人,因此觉得须留待日后更多的文献证明eTNS的疗效[156]

正念疗法

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2018年4月文献显示,“认知行为治疗+药物治疗+正念疗法的策略比“认知行为治疗+药物治疗”带给患者更大的进步,因此有成为未来正式治疗策略的潜力。[157]。不过有其他研究然而单独就“认知行为治疗”和“正念疗法”相比,未服药且单独接受“认知行为治疗”或“正念疗法”的ADHD患者经过训练后,并未发现“认知行为治疗”和“正念疗法”的疗效有何差异[158]。 有鉴于前述不一致的实验结果,正念疗法尚需更多研究来证明其有效性 [159]

媒体

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有前期研究支持玩电动玩具可以产生神经反馈,有助于认知,可以帮助患有ADHD的人自我管理,并且有助学习[160][161]。不过另一方面,患有ADHD的人玩游戏会很难结束,这会抵消游戏原来可以带给他们的帮助[162],也会影响其时间管理的技巧[163]

大自然

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花许多时间在户外(例如公园)的儿童比较不会有ADHD的症状,有些人称之为“绿色治疗”(Green Therapy)[164]

参考文献

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  1. ^ Shaw M, Hodgkins P, Caci H, Young S, Kahle J, Woods AG, Arnold LE. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC Med. 2012-09-04, 10: 99. PMC 3520745可免费查阅. PMID 22947230. doi:10.1186/1741-7015-10-99. 
  2. ^ 2.0 2.1 2.2 Wolraich, M.; Brown, L.; Wolraich, RT.; Brown, G.; Brown, M.; Dupaul, HM.; Earls, TG.; Feldman, B.; et al. Steering Committee on Quality Improvement Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. November 2011, 128 (5): 1007–22. PMC 4500647可免费查阅. PMID 22003063. doi:10.1542/peds.2011-2654. 5b: For elementary school-aged children (6–11 years of age), ...
    Action statement 5c: For adolescents (12–18 years of age), ...
    Similar to the recommendations from the previous guideline, stimulant medications are highly effective for most children in reducing core symptoms of ADHD.44 One selective norepinephrine-reuptake inhibitor (atomoxetine45,46) and 2 selective α2-adrenergic agonists (extended-release guanfacine47,48 and extended-release clonidine49) have also demonstrated efficacy in reducing core symptoms. Because norepinephrine-reuptake inhibitors and α2-adrenergic agonists ... Compared with stimulant medications that have an effect size [effect size = (treatment mean — control mean)/control SD] of approximately 1.0,50 the effects of the nonstimulants are slightly weaker; atomoxetine has an effect size of approximately 0.7, and extended-release guanfacine and extended-release clonidine also have effect sizes of approximately 0.7.
     
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注解

[编辑]
  1. ^ 又称为“派醋甲酯”
  2. ^ 中华民国中医师公会全国联合会将《Complementary Therapies in Medicine》翻译为“医学补充疗法”
  3. ^ 即表示可附加在现有具备科学实证且能在统计学上达到显著意义之有效改善症状的医学疗法。

注释

[编辑]

参见

[编辑]

外部链接

[编辑]