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- 1. Attention-Deficit/Hyperactivity Disorder Dispelling Myths is Good Medicine Karen J. Kraus, M.D. UCSF Fresno Psychiatry Residency Program
- 7. “ There is no such thing as ADHD”
- 11. “ The medicines used to treat ADHD are dangerous and addictive”
- 12. Efficacy and dosing guidelines have not been established for children Use of these medications may actually exacerbate the underlying disorder Associated with high rates of significant side effects such as irritability, restlessness,lethargy, hallucinations, hypertension & severe muscle stiffness, even death In one study, more than 50% of mothers interviewed had administered this medication within the past month During an investigative hearing, one congressman made the comment, “The sad fact is, much of the billion dollar medication industry is based more on hype then health care.”
- 14. Stimulant medications, doses and pharmacological activity
- 16. Non-stimulant Medications in ADHD
- 24. Rates of psychotropic medication use by children in the United States
- 32. Advice to Parents, Kids and other Interested Observers
Notes de l'éditeur
- I want to begin by thanking Borders and UCSF-Fresno for the invitation to speak tonight. Talking publicly about psychiatric illness - about advances in the understanding and treatment of these disorders, or about the struggles of affected individuals and families in their search for well-being - can only make things better. My topic tonight is ADHD. It is the most common psychiatric disorder in children and adolescents, and the most extensively studied. It is also the most controversial. We know more about ADHD than we do about the great majority of pediatric illnesses but our scientific knowledge about effective diagnosis and treatment has been drowned out by very alarmist drum beat of misinformation presented to the public. My goal is of my lecture is to help you, the members of the audience, separate out what we know and what we don't know about this complex subject. Before I go further, I'd like to do an informal survey. How many folks in the audience have a child with ADHD, work with or teach a child with ADHD, or have the disorder themselves? You know, I kind of thought that might be the case. There are no disinterested observers when it comes to ADHD. Although my presentation is focused on common myths about ADHD, the latter half of the hour is for questions and discussion and will give us an opportunity to perhaps look at specific issues in greater detail.
- I'd like to call your attention to the hand-out, which contains the DSM-IV criteria for the diagnosis of ADHD. This diagnostic system is atheoretical; that is, it makes no assumption about the cause of any particular disorder. It is also empirical. Data from extensive field trials were subject to a kind of statisical analysis that filters out traits - observable, reportable sx that travel or cluster together, and that have predictive value. This will change. As our knowledge of the the anatomical and physiological underpinnings of the disorder advances, we are able to offer a much more sophisticated description of sx of ADHD, and it's diagnostic boundaries. We now understand ADHD to be an neurodevelopmental disorder of self-control and self regulation. The affected areas of the brain are responsible for subtle functions such as integration and modulation of behavior. For instance,, the symptoms of ADHD described in DSM-IV are the superficial manifestions of underlying dysfunction in one's ability to plan, to organize, to pay attention to and remember details and instructions ,to screen out irelevant information, to carry out a plan to completion and to avoid distractions. The ratio of m:f ranges from 3:1 - 9:1 in clinical settings and 2:1 in community samples. The m:f ratio ranges from 4:1 for ADHD-H to 2:1 for ADHD-I. In adolescents the ratio is 1:1. You will see, I routinely use the pronoun "he" in my discussion w/ good reason. Girls are thought to represent 10-25% of those w/ ADHD, but are much less frequently identified, is is related to the fact that girls are more likely to have the inattentive type.
- Out of habit, I use the term psychiatric disorder but the major diagnoses affecting children are also developmental disorders. ADHD is a great example. The same symptoms that are abnormal in ADHD, normally develop in children between the ages of 4 and 6. So, individuals with ADHD demonstrate both dysfunction AND a delay. Although recent studies support the validity of the DSM-IV diagnosis of ADHD in preschoolers through adolescence, the prominence of certain symptoms and most dramatically, the associated features vary. Younger children with ADHD typically appear more motorically driven. I refer to this phase as "atoms in space". As children age, the neurocognitive sx and the fall-out of their impulsivity become more prominent. Still, virtually everything we know about ADHD we know from the study of children between the ages of 6-12. On either side of this age group, diagnosis becomes more problematic because of the confounds of development and the co-occurence of other disorders. I'm focusing my discussion today on children and adolescents but it's important to note that in a sizeable number of kids - somewhere between 8-85%- experience significant, debilitating symptoms into adulthood. That's 3-5% of adults have ADHD. 8-85% is an impressive range, but I think it's a reflection of how little reliable data we have on adults and also, the limitations of our categorical diagnostic system. The first diagnostic schedules only appeared in the early 1980's and emphasized hyperactivity, which we now appreciate is much less prominent in older adolescents and adults. The actual rate of persistence is probably close to 66%. It's pretty clear that even when an affected child does not go on to meet the full DSM-IV criteria for ADHD as an adult, more often than not, they continue to experience a significant level of functional impairment. The first bullet also speaks to the central importance of pervasive, significant impairment to the dx. 25-50% of kids w/ ADHD will be retained @ least 1x. 37% won’t finish school. Only 5% will complete a college program. They are more likely to become pregnant as teenagers. They are 4x more likely to be in a car accident.
- Hyperactivity, impulsivity and inattention are the final common pathway of virtually all psychiatric disorders in childhood. The specific constellation of symptoms and the course of a child's difficulties distinguish one disorder from another. This brings up an important point. An accurate diagnostic assessment does more than determine the presence or absence of ADHD; it also assesses for the presence, absence or co-occurence of other psychiatric and developmental disorders. Approximately 2/3 of children with ADHD have an additional diagnosis; approximately 20% have 2 diagnoses. About 50% of children with ADHD have a disruptive behavioral disorder such as ODD or CD; 20-30% will have a learning disability; 34% will have an Anxiety D/O; 6% will have a depressive D/O. There's been a lot of press lately about the association of ADHD and juvenile BPD. Two groups reported that 19% of Kids w/ ADHD also have BPD, and that nearly 90% of kids w/ BPD meet criteria for ADHD @ some point in their clinical course. Kids w/ ADHD are 2x more likely to develop a substance abuse disorder as they get older, esp. if they also have CD or BPD. An accurate assessment also includes a physical examination to rule out medical disorders that can cause, or can mimic ADHD. Ultimately, ADHD may prove to be a group of disorders with different etiologies, risk factors and outcomes, rather than a single entity.
- Controversies about ADHD seems to fall into two broad categories. The first category, summarized in this slide, is comprised of concerns about the diagnosis itself. The second category, which we will come to shortly, relates to the medications used to treat ADHD, specifically the stimulants.
- One of our most deeply held cultural values is that a child’s behavior is a reflection of how they were raised. It is a belief so deep that it is nearly instinctual. Example: Imagine yourself on the cereal aisle of the grocery store. A child is having a massive screaming, crying, kicking tantrum as he clutches a box of chocolate cocoa puffs. Now, how many of you, in your heart of hearts, have witnessed such a seen and have thought, “What a brat. Why doesn’t she do something.” Even though I know better, and even though I’ve heard countless moms of ADHD children tell me about having to abandon a half-full grocery cart, the thought still occurs to me. So, if a child is unruly, willful, a social misfit or a school drop-out, the parent must be to blame, particularly the mother. Psychiatric disorders in children have been variously attributed to lazy and inconsistent parenting, mothers working outside the home and divorce. The same sort of moral judgements are ascribed to affected children as well.. The commonly heard phrase, “He could do it if he wanted to”, sort of sums it all up. Here’s what we know. Kids with ADHD are difficult to parent, but their symptoms are not the result of inadequate parenting, or of even divorce or working outside the home. Denying the existence of psychiatric disorders in children is a reflection of the enormous stigma attached to mental illness.
- The proponents of this idea view ADHD as a malignant social construct. ADHD is viewed as a social metaphor for our frenetic, competitive, conveyor belt of world. Tx therefore isn't about ameliorating impairment; it's about performance enhancement. It's about ambitious parents cultivating any advantage at the expense of medicating their children. It's about teachers and parents who want kids drugged and docile. It's about everyone and their brother looking for an excuse or an easy way out. These concerns are both true and false. There is evidence that the diagnosis of ADHD and it treatments have been misapplied. Most of the evidence is anecdotal; a physician named Lawrence Diller wrote an entire book about his clinical experiences entitled, "Running on Ritalin". Alot of people point to the dramatic increase in office visits for ADHD and the accompanying prescription of stimulants following the inclusion of ADHD under the IDEA in 1991 as evidence of this social phenomena. Some people view the same "Ritalin Explosion" as indicative of rampant illicit use of stimulants. The reality is that many factors have contributed to increased prescribing of stimulants, which I will review in just a bit. There have been a few studies looking at regional prescribing practices
- That is, if ADHD really existed, there would be an objective physical finding. The subjective nature of the diagnostic process in and off itself suggests that the disorder is an artificial construct or made up. “ where were these people when I was growing up?” The pervasive sense that “we” in pediatrics and MH don’t really know what we are doing is fueled by reports of misdiagnosis, and particularly, overdiagnosis.
- More controversy. I’d like to present a brief overview of the medical treatments of ADHD before discussing these myths. Understanding what these medications are and how they work goes a long way in disabusing people of the notion that they are dangerous and addictive. It also provides a context for a discussion of the risk vs. the benefit of taking medication. Every medication - including any medication or herbal remedy you can purchase over the counter - presents a risk of side effects. The question is, what is the risk of not taking a medication, and do the negative effects outweigh the positive.
- Guesses? OTC cold preparations. The one referred to in the last snippet was Coricidin. Many parents believe these preparations will cure or shorten the course of illness. The most frequently cited reasons given for administering these medications is that the parents want to, and that their sick child is keeping them up. Tp reinforce my earlier points: no medication is is inherently safe, nor is any medication inherently evil.. These statistics are concerning, but let me reassure you that we know a whole lot more about stimulants than Robitussin.
- There are two major classes of stimulants - the methylphenidate type - of which Ritalin is the prototype- and the dextro-amphetamine type - of which dexedrine is the prototype. They are chemically related to cocaine and methamphetamine and have similar mechanisms of action, but they are not the same. Ex. of hands. MPH comes in 4 different versions, one of which, dextro-erythro form, exerts the greatest effect. These are not trivial differences. For instance, MPH acts like cocaine until it gets to the brain. However, it binds much more tightly and is cleared very slowly. Cocaine’s rapid reversal of binding sets up a reinforcement paradigm which results in escalating use. Both medications are rapidly absorbed in the gut “ Both the DA and NE neurotransmitter hypotheses suggest a central role for DA in the manifestation of hyperactivity as an important role for the central NE pathways of the locus coeruleus in the regulation of attention, arousal and vigilance.”
- Both Dex and MPH work on the presynaptic neuron to increase the amount of DA and NE neurotransmitters available to communicate with the next cell (the postsynaptic neuron). You can think of neurotransmitters as messengers between the cells; increases in the amount of these molecules amplifies their message, which in for purposes of ADHD is to activate neurons that have an inhibitory function. Both classes of medications have a very similar action. They block the reuptake of DA into the cell (which terminates its action) and they interfere w/ an enzyme that breaks down NE and DA in the cell. They can also act like the neurotransmitters themselves, activating the postsynpatic neuron. Inside the cell they have slightly different actions, which is thought to account for DEX greater potency and its somewhat more negative side effect profile. The clinical effects of these medications are mediated most directly by their action on the DA transporter receptor. It's important to realize that the positive clinical effect exerted is not entirely due to the medications' actions at the level of a single neuron. They appear to mediate action "down stream" of the neuron as well, which in turn exerts broader modulatory effects. These overarching effects involve other neurotransmitter systems as well, such as serotonin. Decreased 5 HT = increases in aggression, impulsivity & activity. Early DA depleting lesions cause sprouting of 5HT terminals
- Side effects are due to the action of DEX and MPH on noradrenergic receptors outside of the brain. DEX in particular stimulates the heart muscle, which increases BP. Of note, less than 30 case of stimulant-induced toxic psychosis have been reported in the entire literature. This is an extremely rare event and commonly signals a misdiagnsos. Other rare effects not listed here are alopecia and leukocytosis. Although practice standards do not require or suggest any monitoring of laboratory studies, an annual CBC is probably warranted. Finally, I’d like to touch on concerns re: growth retardation. Loss of appetite is extremely common, is usually associated with some weight loss and often abates w/in 6 weeks. After studying many children over a long period of time, it appears that the issue is slowed velocity of growth, not retardation. Endocrine effects have been postulated but not demonstrated. Ultimately, kids are tall as they should be. Side effects can go one of three way. They either go away on their own as the body gets used to the medication; they can be managed by making alterations in either the dose or the administration schedule; or they are sufficiently severe and unamenable as to warrant a trail of a different medication. Polypharmacy is another option. By taking combinations of medications in lower doses, one can minimze the side effects associated with any one medication, and in many cases actually improve response through a neurochemical synergism
- These medications have been around since 1937. They have a wide therapeutic/toxic ratio. The dose threshold in which individuals begin to experience severe side effects is 60 mg for MPH, and 40 mg for Dex. The lethal dose of MPH is 48.3 mg/kg IV, and 367 mg/kg by oral route. So a lethal oral dose in a 110 lb. (50 kg) individual would be 18,350mg or 183.5 grams. In one recent study documenting trends and toxicity associated w/ MPH reported to PCC found 11,149 exposures over a seven year period. I’ll get back to this when I review the issue of addiction, but for our present purpose, it’s interesting to note that in the particular population studied, kids ages10-19 who intentionally ingested MPH (#1,244), there was only one major event noted (arrthymia). 99% of affected children experienced only mild to moderate side effects such as increased heart rate, increased blood pressure, agitation and irritability. There is only one known death attributed to stimulants, 19 y/o boy who experienced cardiac arrest after intranasal use.
- I'd like to begin by providing some context for our discussion. First, experimental use of both licit and illicit is extremely common among adolescents in general, most of whom engage in occasional experimentation with drugs such as ETOH and THC w/o becoming addicted. Second, addiction is defined by 3 features: psychological dependence or craving, & the behavior involved in satisfying that craving; physiological dependence, characterized by w/d sx upon discontinuation of the drug; and tolerance, or the need to use increasing amounts of the drug to obtain the same high. Finally, prescription stimulants can be abused. When taken in large doses either by IV or inhalation, they can produce a high. 12 studies using animals have demonstrated a reinforcing effects of injected MPH. These results were not replicated in human subjects, although more subjective studies using self-reported use in non-ADHD, high risk populations suggest a potential for abuse of MPH. However, it is careless reasoning to suggest, as some people have, that the prescription of stimulants is fueling a generation of Ritalin heads.
- Here it is again. This slide documents the increased use of stimulant in children and adolescents over a decade. It suggests about a 2 fold increase in the rate of prescribing for most groups. There are some interesting trends to suggest much of the prescribing was directed toward previously overlooked and under-treated groups like girls and adolescents. In another study looking @ prescribing practices between 1990-1993, ADHD related visits to primary care practitioners increased from 1.6-4.2 million/year. 90% of these kids were txed with medication, 71% of which were given MPH. 10 million prescriptions for MPH were written in 1996 - a peak year. The dispersal leveled off @ 11 million in 2001. The next slide shows that these rates were higher, but comparable to increased use of other psychotropic medications in children as well.
- In the Harvard studies, guess what was the #1 choice for drug of abuse? THC. In the seminal 1996 study of 70 teenagers with ADHD, not one reported illicit use of a stimulant. There was a single incident of cocaine use The evidence of a protective effect of stimulant therapy for ADHD on the development of substance abuse disorders is among the strongest within the field of child psychology
- Following 1998, the rates of abuse declined, a finding that was echoed in other surveys.
- This data has several important implications. One, is that the greatest concern is not the misuse of Ritalin or other stimulants by children with ADHD. The concern is diversion. In one study, 16% of group of adolescents with ADHD reported that other students had asked them to trade, sell, or give them medication