Prescribing of hyperactivity drugs is out of control

Prescribing of hyperactivity drugs is out of control 31 March 2006 NewScientist.com news service Peter Aldhous

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."

I can't believe some of your statements here about ADHD meds. I agree they are overused and children who shouldn't be on them are, but some kids actually do need them and have better lives because of it.

My 8 year old son has ADHD and is on Strattera which is a non stimulant, however it is for ADHD. My son get all the love and attention I can give him and than some. He also eats his vegeteables, fruits, and sweets he only eats now and than. Heck, he turns down birthday cake at his brothers party last month, that is how much he doesn't have a sweet tooth!

I have ADHD and in was untreated. If I could go back and do it all over again I would have medicated, but there were no drugs existing at that time. My son had inherited my learning disabilities and my ADHD. I know exactly how it feels and what is going on in my sons head, I have been there. It is a hard thing to see him suffer everyday and his poor self esteem be affected the way it has been. I ask myself what kind of mother would I be if I didn't help my son? I will do whatever it takes.

So before people here think it is all about just giving your child attention and you must not be giving them enough attention I say that is rediculous! It has nothing to do with that!! I am a stay at home mom by choice so that I can go almost everyday to my sons school and eat lunch with him and play on the playground with him. I also go on every field trip, an involved with every school function he is in, and never miss a beat!! Is this a child that is not getting enough attention from his mother and father? My husband when home spends all his time with our boys outside playing sports, cars, whatever he can!

ADHD is real and I'm sorry there are few here who just think children need to eat less sweets and get more attention at home to be cured. I've done both and continue to do both and my son still has suffered. I hope and pray no one has to go through seeing your child beg for help the way I have seen my son beg!

We are no Ozzie and Harriet, that's for sure, but my son has all you mention. We have what some have described as the picture perfect family life. My son has both parents in the home, get lots and lots of love them they get more. They are disciplined, we attend a great church, we are finacially sound, my husband and I get along so there's no tension there, my family eats together every morning and every night. We are balanced in that the kids are not overextended in sports and such. We discipline our kids accordingly. You get the picture?

Of my 4 kids, my youngest is the one who struggles with academics. It's not that he is incapable of doing the work, he just has a problem staying on track and finishing what he starts. He gets lost with long sets of insstructions. He tends to wander mentally when a task exceeds certain amounts of time. Because of his inability to stay on task he gets frustrated and acts out behavior wise.

I believe there was ADHD in the olden days. It wasn't nowhere near as "common" as it is now. Those kids then were the daydreamers or the slackers. Looking back, I believe my brother had ADHD, and it is possible I did too. I know kids are energetic and sometimes hyper and believe it is normal for them to be. The difference in then and now, of course, is kids aren't allowed to expend the energy they need to expend. I do allow my kids to "be kids". At what point do I say this is more than normal "little boy energy" and see there is a problem?

You are absolutely correct. It is very real. It's so easy to sit back and JUDGE other people while never experiencing it for yourself.

Living with a child with ADHD is painful, frustrating, physically and mentally taxing. You love them, you discipline them, you give them a good moral upbringing, provide educational support, pshcological support and attempt to find medication to correct the endocrine imbalance.

You have probably tried every method known to man I'm sure. It is not an issue of discipline. It is often an issue of a chemical imbalance in the brain.

God bless you and good luck with the post, your fixin to get flamed by all sorts of people who think they know whats best for YOUR child.

Ah, I have found a kindred spirit, lol. Two years ago I would have been one that told you your son needed a whop on the behind not medication. Now, I completely understand. I haven't medicated my son and still don't know if I will but I believe there are wonderful parents who wouldn't do anything to harm their child who see there is no other option for the time being.

Agree with Halls. Had a "sprinter" daughter (meaning, she could burn brilliantly through any short-term project, but anything long-term would crush her) who was not formally diagnosed with ADHD until she was 20. The doc didn't just pull out a scrip pad. She was extensively tested.

Then doc starts talking to me, about me and my family history. Good grief, I and two brothers struggled like crazy with this back in the 50s. There is a hereditary component, and it was established then and there. (Looking back on my father's side of the family, there was a brother of his who was "no damned good, wouldn't stick to anything," back in the 30s. Poor bastard.)

Just because something is overdiagnosed doesn't mean it's nonexistent.

><>Just because something is overdiagnosed doesn't mean it's nonexistent.<><

Exactly. I agree that it is overdiagnosed, but when you see your good-hearted child struggling for years and he comes home the first day he takes medication so excited because for the first time in his life, he was able to take notes. Somehow the information wasn't lost between his ears, his brain, and his hands. Our child, in particular, isn't a bad kid. He is a loving, mostly happy youth who has spent much of his young life grounded with no privileges because of perceived lack-of-effort on his part. The medication is not the sole answer, he still has to apply himself (which is challenging also!), but the immediate response to the medication drove it home to me that there IS a chemical imbalance that CAN cause SOME kids to have problems with concentration and retention. We don't WANT to medicate our child, but neither do we want him to be pushed aside as a kid who is just "destined to fail", like so many kids are. The medication DOES help him concentrate and retain information. Try not to judge until you've walked in our shoes.

You are so right that there are properly diagnosed and successfully treated ADD children and adults. One thing I may add it that all drugs, including psychiatric, should be managed by a specialist, in this case, a psychiatrist

IMHO, one of the reasons for these frightening statistics is the lack of a psychiatrist, instead a general practitioner, or anything but a psychiatry's has make the diagnosis and prescriptions. See a psychiatrist.

This would cut down greatly on the number of "diagnoses" and subsequent prescriptions. And the meds must be managed by the a psychiatrist as well. This is extremely important to avoid highly dangerous circumstances towards oneself, or others.

Let's not discount this illness's validity based on a majority of misdiagnosed cases.

best to you...

but the immediate response to the medication drove it home to me that there IS a chemical imbalance that CAN cause SOME kids to have problems with concentration and retention

Perpetual drugging DOES NOT CURE ANYTHING! Society today is just clueless. 99% of drugs treat the SYMPTOM but do not do anything to CURE the root problem. (And hello... the drug companies would really not want it any other way.)

I agree that some kids need Ritalin or other neuromodulating drugs in the same way that diabetics need insulin. However, it is almost always prescribed to kids without any other therapy tried and without proper consultation. I personally suspect videogames and TV to be the main reason for ADHD.

The images on TV are quick, and cartoons often even quicker. Scientific study and common sense says that this rewires the brain so the child and sometimes adult can adjust, but then finds that it can no longer concentrate on anything that isn't flashing by at warp 10.

Horrible but true.

><>Perpetual drugging DOES NOT CURE ANYTHING! <><

And I never said it did. In fact, you will actually READ my post, I said it wasn't the sole answer and we still work at getting him to apply himself. He is being assessed and enrolled in a learning center also, because he needs to learn skills to cope with his lack of concentration power.

I work in the medical industry, BTW, so you don't have to preach to me about most drugs treating the symptom and all the woes of the drug comanies. But if the root 'problem' is that my child is lacking chemicals in the brain that help regulate attention and activity (dopamine and norepinephrine),(just like he could be lacking an insulin-producting pancreas and thus be diabetic), then substituting a medication that would at least allow him to learn and retain basic skills for dealing with this throughout his life would be the logical thing to do.

I have full confidence that with medication and proper schooling/training, that our son will learn the skills needed be the successful young man he can be. You're not talking to a parent who is just tired of parenting and wants to drug her kid.

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