|
OPPOSITION DEFIANT
DISORDER AND CONDUCT DISORDER |
42%-61% |
|
DEPRESSION |
15%-38% |
|
ANXIETY |
23%-30% |
|
TOURETTE’S/TIC
DISORDER WITH ADHD |
49%-100% |
|
OBSESSIVE-COMPLUSIVE
DISORDER WITH ADHD |
6%-33% |
As
the results of the five-year, multicenter, and multimodal treatment study of
ADHD (MTA)26
become available, it is becoming more and clearer that medications are the
treatment of choice. The initial reports indicate that medication alone
and medication plus intensive behavioral treatment were nearly identical and
that both were significantly superior to intensive behavioral treatment alone on
18 out of 19 outcome measures. The community treatment arm of the MTA also
showed that 1/3 of these children with clearly documented “screaming” ADHD
received no treatment whatsoever and that those who did get treatment of some
sort were almost always under-dosed on their medication. The MTA is just
the most recent evidence that ADHD remains grossly under-treated.
The results of the MTA do not mean
that adjunctive behavioral management is not helpful. Because ADHD often
inhibits development of social awareness and self-control at the critical times
it may be important to work on these issues through therapy. The MTA
clearly demonstrates that behavior management and “trying harder” do not treat
the major impairment domains of inattention, impulsivity and motor restlessness.
The MTA does show that ADHD is not
the result of bad parenting skills. These were good, involved parents who
received even more training and assistance. It just didn’t make any
difference. It also proved that ADHD is not the result of a defect in
character or laziness. Trying harder even with intensive support of
specialists in the field was ineffective.
In children referred to clinics
for learning or behavior problems, the number of ear infections correlated
significantly both with a diagnosis of ADHD and with the severity of the ADHD.27
Studies have not so far implicated diet, allergies or asthma as having any
connection to ADHD.
| C.
MEDICATIONS
Although there have been more
than 40 medications that have been shown to have some effect on ADHD there are
really only two first line medications for the disorder:
1.METHYLPHENIDATE (RITALIN, METHYLIN,
METADATE, CONCERTA)
2. AMPHETAMINE (ADDERALL, DEXEDRINE,
DEXTROSTAT)
There are now over 170 controlled
double blind studies showing the efficacy and safety of the psycho-stimulants
even with patients with comorbid eating disorders, chemical dependency and
bipolar disorder. All other medications should be reserved for the rare
person who cannot be managed with stimulant class medications.
|
 |
|
Percentage of 4-17 year
olds taking ADHD medication (according to CDC 2003) |
The psycho-stimulants are not
addicting although they are abusable. This is why they are Schedule II
drugs. It is rare for an ADHD person to abuse these medications.
Well regulated medication renders people with ADHD “normal” and over-dosing
produces an unpleasant “zombie effect.”
In spite of publicity to the
contrary, medications used for ADHD are not addictive. Some ways to
distinguish the difference are as follows:
|
Drugs of Abuse
|
Drugs for ADHD
|
- People take them to feel
good
- People
crave the drug
- Parents fight to get their kids
not to take them
|
- Feel nothing or
BAD if overdosed
- Commonly
forget to take their meds
- Parents fight to get their kids
to take them
|
What is probably more important
is the prospective longitudinal study by Biederman and his colleagues28
that shows that the stimulant class of ADHD medications actually protect against
the development of substance use disorders (SUD). Left untreated, persons
with ADHD have three times the incidence of Substance Use Disorder diagnosis
than does the population at large (47% vs. 15%). If the person with ADHD
is consistently treated with stimulant class medication the risk of developing
SUD is the same as the general population.
A recent review by Reeve and
Garfinkel29
demonstrates that “most researchers have shown no effect on expected weight or
height in long term follow-up studies. Initial growth suppression appears
to be corrected by rebound growth at a later date.” In addition, the same
studies have shown that drug holidays produced no detectable increases in height
and only mild effect upon weight gain. In contrast, the disruption to
children with ADHD and their families which these medication interruptions
caused is tremendous.30
The psycho-stimulants can be used
safely in spite of co-existing conditions. The only absolute
contraindication to the use of stimulant medication is glaucoma. Otherwise
minor accommodations can make stimulants the drugs of choice in virtually every
patient.
SEIZURES:
Amphetamine was once used as an anti-seizure medication. Stimulants only lower
the seizure threshold at very high doses.
TIC DISORDER/TOURETTE’S:
Recent research31
32has
found that properly adjusted stimulant medication usually does not worsen the
familial tic disorders and many patients with Tourette’s get better on stimulant
class medications.
PREGNANCY:
No problems have been reported with methylphenidate. Several cases of
biliary atresia and heart valve malformation have been reported with amphetamine33
but these were not in excess of the number expected in the general
population.
SECOND LINE MEDICATIONS:
- ANTIDEPRESSANTS
- MOOD STABILIZERS
- PSYCHOTROPIC MEDICATIONS
In summary, ADHD is a serious, neurobiological disorder which
has far reaching implications for those who have it. It affects every area
of that person’s life. There is no reason in this day and age for anyone
to suffer with this disorder for it is easily treatable with the safest and most
effective medications.
Previous Page • Home • First Page in this Series
Download
this 13 page document as a "printer friendly" pdf file.
26
MTA Cooperative Committee. A 14 Month Randomized Trial of Treatment
Strategies for Attention Deficit Hyperactivity Disorder. Arch Gen
Psychiatry. 56: 1073-1086, 1999.
27
Adesman AR, Altshuler LA, Lipkin PH, Walco GA (1990), Otitis media in
children with learning disabilities and in children with Attention Deficit
Disorder with hyperactivity. Pediatrics, 85: 442-446
28
Biederman J, Wilens T, Mick E, Spencer T, Faraone SV, Pharmacotherapy of
Attention Deficit Hyperactivity Disorder reduces rick for substance abuse
disorder. Pediatrics 104(2): 1999.
29
Reeve E, Garfinkel B, Neuroendocrine and Growth Regulation: The Role of
Sympathomimetic Medication, in Ritalin: Theory and Patient Management,
Greenhill LL and Osman BB, eds. Mary Ann Liebert, Inc.: 289-300, 1991.
30
Barkley R, et al., Driving-related risks and outcomes of ADHD in Adolescents
and Young Adults. Pediatrics 92(2) 212-218, August 1993.
31
Gadow KD, et al., Long-term methylphenidate therapy in children with
comorbid Attention Deficit Hyperactivity Disorder and chronic multiple tic
disorder. Arch Gen Psychiatry, 56(4): 330-336, 1999.
32
Law SF, Schachar RJ, Do typical clinical doses of methylphenidate cause tics
in children treated for Attention Deficit Hyperactivity Disorder? J Am Acad
Child and Adolescent Psychiatry. 38(8) 944-995, 1999.
33
Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 4th
Edition: Williams and Wilkens, Baltimore, MD; 28a-33a.
Dr. Victoria Martin, M.D. is a graduate of
the University of Texas Health Science Center at San Antonio. She
completed her residency at the VA Hospital in San Antonio, and her
fellowship at Timberlawn in Dallas. Dr. Martin is board certified in
Child, Adolescent and Adult Psychiatry by the American Board of Psychiatry
and Neurology. She has been in private practice in Dallas for over 20 years.
|
