Prescribing Of Hyperactivity Drugs Is Out Of Control

Rise in ADHA?THE figures are mind-boggling. Nearly 4 million Americans, most of them children and young adults, are being prescribed amphetamine-like stimulants to treat attention deficit hyperactivity disorder (ADHD). Up to a million more may be taking the drugs illegally.

Now, amid reports of rare but serious side effects, leading researchers and doctors are calling for a review of the way ADHD is dealt with. Many prescriptions are being written by family doctors with little expertise in diagnosing ADHD, raising doubts about how many people on these stimulants really need them. Just as worrying, large numbers of children who do have ADHD are going undiagnosed.

Both trends could lead to problems with drug dependency, argue specialists in addiction. "There has to be a re-evaluation and reassessment of the extent to which there is proper prescription," says Nora Volkow, director of the National Institute on Drug Abuse in Bethesda, Maryland.

Last week, the debate intensified, following two meetings of advisers to the US Food and Drug Administration (FDA). First, the agency's Pediatric Advisory Committee suggested that parents and doctors should be warned about the risk of ADHD drugs triggering hallucinations. This followed a review of evidence of the drugs' psychiatric side effects, including disturbing hallucinations often involving worms, snakes or insects, experienced by up to 5 per cent of children taking the drugs. In February, a separate FDA panel recommended that they should carry the most prominent type of safety warning, following 25 reports of sudden deaths from heart problems (New Scientist, 18 February, p 7).

Another FDA committee last week voted to delay an application for a drug previously used to treat sleep disorders to be marketed for ADHD. The drug, modafinil, has less potential for abuse and addiction, but the FDA's Psychopharmacologic Drugs Advisory Committee wants to see more evidence proving its safety before backing the application (see "Alternative treatments for ADHD").

Stimulants such as methylphenidate, marketed by Novartis as Ritalin, have been used to treat ADHD for decades. As well as increasing arousal and heart rate, the drugs allow people who have difficulty concentrating to focus on tasks more effectively. Their use has exploded in recent years, especially in the US, where prescription rates are several times higher than across most of the developed world - in part because US doctors tend to use a broader definition of the condition.

Psychiatrists stress that side effects are rare, and say that the drugs have helped millions of people who would otherwise have had huge problems focusing at school and work. "These are some of the most effective treatments that we have in psychiatry," says Chris Kratochvil of the University of Nebraska Medical Center in Omaha.

To diagnose ADHD reliably, a psychiatrist would ideally observe a child for several hours, checking their behaviour against a list of symptoms relating to activity and ability to concentrate. But in many cases, family doctors are prescribing the drugs after just a few minutes of consultation, based largely on evidence of boisterousness.

Doctors are under growing pressure from children and their parents to prescribe the drugs, as many believe that stimulants will help them get better school grades. "I have a colleague whose son was mobbed by friends wanting prescriptions," says Scott Kollins, a child psychologist at Duke University in Durham, North Carolina.

“Doctors are under growing pressure to prescribe the drugs, as many believe they will help deliver better school grades”This demand is also fuelling an illegal trade. Findings published last month indicate that in 2002 more than 750,000 Americans aged 12 and over were taking the stimulants without medical supervision (Drug and Alcohol Dependence, DOI: 10.1016/j.drugalcdep.2005.12.011). Some may have been using the drugs for a traditional "high", or to keep going during all-night parties. But Larry Kroutil of RTI International in Research Triangle Park, North Carolina, who led the study, suspects that much of the illegal use is by children and young adults taking the drugs as study aids. In some cases, they are being bought by parents from illicit websites that do not ask for evidence of a prescription. "We need to look more at how people are getting these drugs, and why," Kroutil says.

Members of the FDA's Drug Safety and Risk Management Advisory Committee, which recommended the prominent safety warning on heart risks, say that they were motivated in part by concerns that many people who do not have ADHD are taking the stimulants. "It has been clear that the drugs are overused," says Peter Gross of Hackensack University Medical Center in New Jersey, who chairs the committee.

The American Psychiatric Association argues that the picture is more complex. "Yes, there is overprescribing," says Jason Young, the association's communications manager. "But there is also underprescribing." Among poorer sections of the US population, and particularly in minority groups such as African Americans and Hispanics, ADHD is believed to be widely underdiagnosed.

Volkow is worried that underprescription of stimulants could lead to problems with drug abuse. Children with ADHD who are not given stimulant drugs are more likely to develop problems with drug abuse and dependency than those who are, perhaps because they have to turn to illegal stimulants on which they can become hooked to get relief from their symptoms. So improving diagnosis and treatment among people with poor access to mental health services is important, Volkow argues.

Meanwhile, the long-term effects of giving prescription stimulants to healthy people remain largely unknown. Kroutil's team asked illicit users whether the drugs were interfering with various aspects of their lives. On this basis, the researchers estimated that about 10 per cent were having problems with dependency.

Volkow fears that problems with dependency may be more widespread. There are also hints that taking stimulants may lead to abuse of other drugs. Some studies suggest that exposing juvenile animals to stimulants makes them less likely to self-administer drugs such as cocaine when they are offered the drugs as adults, but other studies indicate the opposite. What is needed, says Volkow, are long-term follow-up studies on people who do not have ADHD and who have taken stimulants such as methylphenidate. In the meantime, she wants medical associations to take a stronger lead in educating doctors about the proper diagnosis and treatment of ADHD.

William Carlezon of Harvard Medical School agrees. He has studied the drugs' effects in animals and believes that they do have some lasting effect on the brain, even if its exact nature is not yet known. "Stimulant drugs leave molecular signatures on the brain, and we have to be very careful," he says. "Diagnosis needs to be taken less lightly."

From issue 2545 of New Scientist magazine, 31 March 2006, page 8 Alternative treatments for ADHD Despite concerns about the possible side effects of stimulant drugs such as methylphenidate, the alternative treatment options are limited.

A non-stimulant called atomoxetine was approved in the US for ADHD in November 2002. Although it belongs to a different class of drugs from the more widely used stimulants, atomoxetine was implicated in some of the cases of hallucinations considered by the FDA's Pediatric Advisory Committee last week.

ADHD specialists had hoped that atomoxetine would be joined by modafinil later this year. This drug is currently used to treat excessive sleepiness, and seems to improve focus and alertness (New Scientist, 18 February, p 34). But an application to approve modafinil for treating ADHD suffered a setback on 23 March when the FDA's Psychopharmacologic Drugs Advisory Committee recommended that the drug's manufacturer, Cephalon, conduct a further study in 3000 children. Committee members were worried about a single case of a potentially fatal skin condition among the 933 patients in Cephalon's trials so far.

Though slightly less effective than methylphenidate in treating ADHD, both modafinil and atomoxetine are less likely to lead to addiction problems. That may make them particularly useful in treating patients whose social environment makes them vulnerable to drug abuse.

Kids DO need to be properly tested. I'm glad you did.

It does bother me to hear that kids are being given ritalin with no more information given than that the child is very active. The teacher was right, my son doesn't pay attention. But the reason he is playing around instead of doing the work is (likely) because the work is difficult for him and he is 7 years old and who wants to work that hard?

But if he hadn't had the tests we wouldn't have known.

Dianna, I don't have first hand information. I may have spoken out of turn on this. I read an article on the forum some time back that I thought made it fairly clear that in that instance school staff were involved in the process, not a physician or a nurse.

I'd rather have someone else make a definitive offering on this.

Do schools call in a psychologist to make an evaluation for every child that gets Ritalin? Is a school nurse involved in every diagnosis or disbursement to the children?

This seems a gray area to me, but it is possible my understanding is the true gray area based on faulty memory or some misunderstood or faulty information.

I have had some incredible dealings with junior high staff. I'd like to say that I could rule out some of my perceptions here based on those unrelated dealings, but I can't.

School staffs do not seem to realize they must be honest and above board with parents. And some of those people use some of the worst convoluted logic I've ever seen.

Sorry I could not answer your question with certainty.

Do schools call in a psychologist to make an evaluation for every child that gets Ritalin? Is a school nurse involved in every diagnosis or disbursement to the children?

School districts do, typically, employ a psychologist. If a child is having academic trouble, the school psychologist MAY do testing, observations, etc. A psychologist CANNOT prescribe medication to anyone.

I chose the option of having the psychological testing done by a private doctor (covered by my medical insurance). He was in contact with my pediatrician and could have recommended ritalin for my child. The pediatrician would then write the prescription if one were needed.

It is possible that school psychologists are telling parents that their kid has ADD. The parent MUST find a doctor to prescribe the med. That would be either a pediatrician or a psychiatrist. IMO, it is up to these doctors to be vigilant and not just take the word of the school psychologist.

I really like my son's teacher. I trust her judgement. But there was no way in hell that my son was going to be tested by the school psychologist. When dealing with an issue of such importance, I like the involved parties to be as un-influenced by each other as possible.

Is a school nurse involved in every diagnosis or disbursement to the children?

A school nurse would have nothing to do with diagnosis, but if the med is needed during school, it MUST be disbursed by the nurse (or possibly a designated person acting as nurse if one is not available full time). I've never heard of, say, a classroom teacher disbursing meds like this.

In order to take a prescribed medication at school, my son needed the medication in it's original container with the prescribing information on it (his name, the doctors name, dosage, etc). He also needed a separate letter from the doctor restating what the med was, what it is used for, and dosage information. The medication must be brought to the school by an adult.

Common sense goes a long way when developing a strategy for these situations. It sounds like you did everything right.

I didn't have to face the Ritalin problem. Medicating my child because they were hyperactive or some such would be about the last thing I would do.

This topic came up another time on the forum. At that time a gentleman related how he felt he had benefited from a Ritalin regimen. I couldn't argue with him and did have to accept on face value that Ritalin therapy might in fact be positive at times. I will admit that I wondered how the guy would have done, had he not gotten the Ritalin.

Thanks for relating your experince.

My experience was less, but similiar. My daughter couldn't sit still through church. I had to pull her out almost every Sunday. One day the pastor's husband came by and said that maybe my daughter "needed help,", i.e. counseling and drugs. I laughed and said," No, she's just like I was. I got through it and so will she." 7 years later, she all of her school classes are for the "gifted." She still has issues, but she knows that there is a line that if crossed, will bear consequences. Some kids just rebel a little more than the rest. But as long as the line is clear to all, then everything tends to work out well.

When my son was in 8th grade he was evaluated for ADD by a "Child Study Team". It consisted of the school psychologist, his teachers and the school doctor, a local pediatrician. There may have been others, I don't recall. He was tested for his skills in all areas of studies and had a 23 yr. old level in reading, but comprehension, attention, etc. was off. Before the study was completed, I had to take him to the private office of the school pediatrician. He evaluated him in like 5 minutes only going by the fact that he was being evaluated by the Child Study Team. It was just part of the process to get him on the ritalin, which the doctor said YES he needs it. The Child Study Team's final conclusion was that he wasn't ADD. My own conclusion was that something happened to him back in the 1st grade. He had a teacher that didn't like him. She belittled him, mocked him, and shamed him in front of the class which eventually made him a class clown type since all the other kids would laugh at him when the teacher would rip him to shreds, i.e. your fingernails are dirty (and yes, I bathed my child, ever hear of recess and there was dirt on the field where recess was); he drooled (he was 6 going on 7, teeth falling out and coming in); and she would look in his ear and ask him if he had a brain in there...the other kids really enjoyed this putdown of him. I think it contributed to him losing seriousness for school work. And thanks to my daughter, it was discovered that my son was color blind, more reason he didn't do well coloring by number back there in the first grade. His 2nd grade teacher thought he was stupid because, while LEARNING TO READ, he couldn't remember how to pronounce the same word a sentence or two later. He also overheard the 2nd grade and old 1st grade teacher talking about him, one saying to the other, "I'd like to squash him like a bug"...not exactly something that would make a kid too happy. 3rd & 4th grade went very well with great caring teachers, but by 8th the lack of interest kicked back in. I think he was much smarter than given credit for in those formative younger grades and it hurt his entire future education. He did graduate from high school, by the skin of his teeth perhaps, but he did it! (without any ritalin)

I am a psychiatrist who has treated many children and adults with ADHD. The diagnosis requires that besides exhibiting the usual target symptoms of ADHD, the person must experience "significant impairment" in areas of functioning, such as academic, relational, social, vocational, etc.

The problem is not a simple "one size fits all" situation. In some communities ADHD is overly (mis)diagnosed, and in other communities it is underdiagnosed.

Stimulant medications can only be prescribed by a licensed M.D. The treatment results can be dramatically positive and life-changing for the child and their families.

There is a problem in some communities where the school can persuade a family practice physician, or even a psychiatrist, to prescribe medications without a careful evaluation.

I don't know if this brief discussion is helpful to you or others on this thread. I would be glad to answer any other questions you might have about ADHD.

he's a freshman in community college now and so far doing well.

He's my husband's brother's son, his mother and I have often compared our children. We each have a daughter and a son. Daughters are oldest and both were A+ students throughout all schools and college. Both sons had difficulty and both are color blind. Both father's drank more before, during, and after conception with the pregnancies of the sons...have any studies ever been done on the alcohol affect on a fetus due to a father having drank? Both mother's did not drink at all during pregnancy, me never before or after. Just something my daughter and I have wondered about for years.

Thanks.

I'm not aware of any studies of the effects of father's alcohol use prior to conception. Nor have I heard of any correlation between color blindness and ADHD. There is a genetic component in the risk of developing ADHD, but its not 100%. People with ADHD are often quite intelligent although they may have poor grades due to poor test-taking skills and/or missing assignments.

Glad to hear that your nephew is doing well.

Well it would be an interesting study I think, to see how many of the diagnosed ADD or ADHD kids have drinking parents, and specifically the fathers. All the attention is always on the mother not to drink, but I've always pictured little drunken sperm and what effects there might have been, and the father's were big drinkers not just once in a while. (mine is sober 10 yrs.-yeah!) My daughter even posed the question to a health teacher in school, to no avail of course, because no one thinks of it I guess.

Your last sentence is exactly how it was with my son. There should be a special way to teach these kids to capture the attention of their fast paced minds, because they aren't stupid at all. I don't believe in medicating them into robots just to get better grades. My nephew averaged C work with the drugs and was praised, where my son was ridiculed for only getting C's by their respective teachers and schools. Not all kids are geniuses, that's just the way it is, that's why there is the word average.

Thanks for all your responses!

You are more than welcome. I would like to see the studies on those drunken sperm too. Can't think of any wealthy sponsor who would be willing to fund the studies though.

I don't believe in medicating kids into robots either. And we are learning ways to improve how we educate ADHD kids. At this stage of the game, however, it usually requires alot of attention and advocacy by parents to make sure that these kids get a quality education.

Best wishes to you and yours.

ADHD is real, but not nearly as pervasive as the drug-pushers in the Pharm lobby would like us to believe.

A great number of those mis-diagnosed are actually highly intelligent kids who are simply bored to tears by the current ethic of our lowest-common-denominator 'no child left behind' public schools.

Others just don't take to the socialist brain-washing that goes on there. Others are just more suited to physical tasks (they are hard workers). I also partially credit the de-emphasis on physical education. Kids need excercise.

When drugs are being prescribed purely to facilitate a lack of creativity on the part of educators, the kids are being done no favors.

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