Will drugs cure ADHD, or are we overdosing?
by Eve Becker
Who isn’t familiar with attention deficit/hyperactivity disorder (ADD or ADHD)? Diagnoses increase each year. TV commercials pitch medications that can curb the symptoms. Celebrities such as Olympic gold medal winner Michael Phelps and Deal or No Deal host Howie Mandel have gone public with their condition.
ADD and ADHD are not solely childhood disorders. But with the Centers for Disease Control and Prevention (CDC) reporting almost 10 percent of children aged 4–17 having ADHD, the concern falls to the youth.
Kids with ADHD are routinely driven to distraction. They may act more impulsively and have difficulty paying attention, regulating their behavior and interacting appropriately with other children, all of which can raise difficulties in school.
Medication, most often stimulants, can help them focus. More than 66 percent of children with ADHD are treated with medication, the CDC says. Some of these medications—Ritalin, Adderall, Concerta—are very familiar names; the stuff TV drug commercials are made of.
But with ADHD rates rising, many people are asking: Are we overdiagnosing it, and are we overdosing our kids?
“It’s a disorder that surprisingly keeps increasing in prevalence,” says Dr. Mark Stein, professor in psychiatry and pediatrics at the University of Illinois at Chicago and director of the Hyperactivity, Attention and Learning Problems (HALP) Clinic. “We have learned a lot about the disorder and its treatment, but surprisingly, we have not found ways to prevent it or lower the incidence.
“ADHD is overdiagnosed in families where there is a premium on academic achievement, awareness of the disorder and access to health and mental health care,” he says. “However, it’s often underdiagnosed in stressed families and schools that do not have access to care and awareness of ADHD or that have negative perceptions of the ADHD treatment.
“Overdiagnosis gets a lot of media attention. But underdiagnosis and undertreatment affect more people and are probably bigger societal problems, given the impact of untreated ADHD,” Stein says.
In addition to stimulant medication, ADHD is typically treated by behavioral therapy. “For some people, medication by itself is enough. For others, behavioral therapy by itself is enough,” Stein says. “But the combination is often the best treatment, as it addresses a wider range of problems and results in more rapid improvement.”
About 80 percent of children and teens with ADHD have other problems that also require treatment, such as oppositional defiant disorder, learning disabilities, anxiety and depression.
These days, doctors are better at observing the symptoms and diagnosing ADHD, just like they’re better at diagnosing obesity and high cholesterol, says Dr. Charles Burda, a board-certified child, adolescent and adult psychiatrist in Hinsdale and Oakbrook. “We start to see things because we’re looking for them.”
In ADHD, various brain circuits linking the prefrontal cortex to other areas of the brain are less active or efficient. ADHD medications can help the brain work more efficiently, decreasing hyperactivity and improving executive functions like attention, problem solving, working memory, verbal reasoning, etc. It is important to achieve the proper dose for each individual, so the medication needs to be carefully titrated to find a dose that helps symptoms but doesn’t cause significant side effects.
Common medication side effects are loss of appetite, difficulty falling asleep and an increase in blood pressure and heart rate. The American Heart Association recommends that children receive an electrocardiogram (ECG) before starting stimulants.
Burda sees ideal results from kids on ADHD meds. “They start to sustain their attention better, and they procrastinate less and act more appropriately in the classroom,” he says.
Yet many parents balk at giving their child medications, especially stimulants like Ritalin that are related to cocaine. But Burda says that not using ADHD medication is like telling a diabetic to watch his diet without taking insulin. “It’s like saying, I have a disorder, but let’s not treat it. If a child had diabetes or asthma, we would treat it.”
Medications can be effective in helping kids increase their focus on less interesting tasks and reduce impulsivity. Short-acting ADHD drugs are in and out of the body in three to four hours, so by the time school ends, any trace of the effects on the child are gone—a benefit for parents hesitant about meds. Newer, longer-acting medications can last 12 hours or more when a child needs to be productive longer, like at soccer practice or doing homework.
Other medications, such as nonstimulants, antidepressants and medications containing guanfacine (for high blood pressure), provide alternatives when stimulants haven’t worked or caused too many side effects.
“Although more than 200 studies have stated that ADHD medication has little to no long-term impact, some parents are still concerned that the medication might affect growth or that their child might end up addicted to stimulants later in life,” says Arthur Lewis, ADHD coach and chapter coordinator of Lincolnshire Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD).
“Parents don’t have confidence in the protocol,” Lewis says. “They don’t have confidence in our science. It’s hard to give a child something the rest of the world thinks of as a stimulant. Does this mean he’ll be more likely to experiment with drugs when he gets to his teenage years? Although the scientific studies conclude that proper use does not increase the risk of substance abuse, the tribal lore is, don’t do this to your kid.”
Yet, when Lewis’ son was diagnosed with ADHD in the fifth grade, his family faced that very decision. “We got to the point where our child was having difficulty in school—a piece of that was academic, and a piece of that was social,” he says. “Like many parents, we as a family had to go through that discussion” about ADHD medication.
“Within three days [of taking a stimulant medication] we saw a positive change. It didn’t make it better by itself at school, but all of a sudden there was less disruption in how he was able to receive and process stimuli. We’re a family that has seen a marked positive impact,” Lewis says.
“We know that [medication] by itself isn’t going to change him,” he adds, citing the necessity of support in school, community and home environments to help children with ADHD manage their social skills and executive function deficits. Behavioral therapy focuses on teaching self-management skills and encourages parents and teachers to provide more consistent and clear directions and utilize positive reinforcement to increase on-task behaviors.
Medication is not a magic bullet. When the drugs wear off, children still have to make it through the rest of the day in an appropriate manner. Or they have to make it through the weekends, holidays and summer vacations, when some kids do not take medications.
“Nobody says that medication is the answer,” Lewis says. “Medication and behavioral support do better than [either one] alone. Medication may be a piece of the treatment for some. It’s a myth that medication [by itself] is the answer.”
But the right dosage is helpful.[email_link]
Published in Chicago Health Winter 2012