Robin, Arthur L., ADHD in Adolescents: Diagnosis and Treatment Guilford 1999
Amen M.D, Daniel,Healing ADD: The Breakthrough Program That Allows You to See and Heal the Six Types of ADD
Feingold MD Ben F. (Feingold Diet) Why Your Child Is Hyperactive
Hallowell, Edward M., Ratey, John J. Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood through Adulthood Simon & Schuster, 1995
Kelly, Kate, You Mean I'm Not Lazy, Stupid or Crazy?!: A Self-Help Book for Adults with Attention Deficit Disorder S
Silver, Larry B Attention-Deficit/Hyperactivity Disorder: A Clinical Guide to Diagnosis and Treatment for Health and Mental Health Professionals American Psychiatric Press 1999
Silver, Larry B Dr. Larry Silver's Advice to Parents on ADHD, Crown
Turecki, Stanley The Difficult Child Bantam 2000 imon & Schuster 1995
CHADD Children and Adults with Attention-Deficit/Hyperactivity Disorder 8181 Professional Place, Suite 201Landover, MD 20785 Phone:301-306-7070
Food additives tied to kids’ hyperactivity
Drinks spiked with coloring and preservatives led to behavior changes
Updated: 8:28 p.m. ET Sept 5, 2007
Certain artificial food colorings and other additives can worsen hyperactive behaviors in children aged 3 to 9, British researchers reported on Wednesday.
Tests on more than 300 children showed significant differences in their behavior when they drank fruit drinks spiked with a mixture of food colorings and preservatives, Jim Stevenson and colleagues at the University of Southampton said.
“These findings show that adverse effects are not just seen in children with extreme hyperactivity (such as ADHD) but can also be seen in the general population and across the range of severities of hyperactivity,” the researchers wrote in their study, published in the Lancet medical journal.
Stevenson’s team, which has been studying the effects of food additives in children for years, made up two mixtures to test in one group of 3-year-olds and a second group of children aged 8 and 9.
They included sunset yellow coloring, also known as E110; carmoisine, or E122; tartrazine, or E102; ponceau 4R, or E124; the preservative sodium benzoate, or E211; and other colors.
One of the two mixtures contained ingredients commonly drunk by young British children in popular drinks, they said. They did not specify what foods might include the additives.
Both mixtures significantly affected the older children. The 3-year-olds were most affected by the mixture that closely resembled the average intake for children that age, Stevenson’s team reported.
“The implications of these results for the regulation of food additive use could be substantial,” the researchers concluded.
The issue of whether food additives can affect children’s behavior has been controversial for decades.
Benjamin Feingold, an allergist, has written books arguing that not only did artificial colors, flavors and preservatives affect children but so did natural salicylate compounds found in some fruits and vegetables.
Several studies have contradicted this notion.
Stevenson’s team made up several batches of fruit drinks and carefully watched the children after they drank them. Some did not contain the additives.
The children varied in their responses but in general reacted poorly to the cocktails, Stevenson’s team reported.
“We have found an adverse effect of food additives on the hyperactive behavior of 3-year-old and 8/9-year-old children,” they wrote.
Dr. Sue Baic, a registered dietitian at the University of Bristol, said in a statement: “This is a well designed and potentially very important study.”
“It supports what dietitians have known for a long time, that feeding children on diets largely consisting of heavily processed foods which may also be high in fat, salt or sugar is not optimal for health.”
“The paper shows some statistical associations. It is not a demonstration of cause and effect,” said Dr. Paul Illing, a registered toxicologist and safety consultant in Wirral, Britain.
Copyright 2007 Reuters Limited. All rights reserved. Republication or redistribution of Reuters content is expressly prohibited without the prior written consent of Reuters.
New Heart Alert for Some ADHD Drugs
WebMD Health News 2006. © 2006 WebMD Inc.
Aug. 22, 2006 -- Amphetamine-based drugs for ADHD, such as Adderall and Dexedrine, now come with a new, expanded 'black box' warning for an increased risk of sudden death in patients with heart problems.
A black box warning is the most serious warning added to a drug's label information.
Earlier this year, two FDA advisory panels recommended new warnings and information for all stimulant drugs used to treat attention deficit hyperactivity disorder (ADHD). But the panels didn't quite agree on the warnings.
In February, one panel recommended a black box warning. But, in March, a separate panel stopped short of recommending the black box warnings.
Since Adderall and Dexedrine are amphetamines, they already had a black box warning about amphetamine abuse.
That black box warning for the two drugs now includes the following sentence: "Misuse of amphetamines may cause sudden death and serious cardiovascular events." Notice of the warning for Dexedrine appeared on the FDA's site yesterday.
Ritalin and Concerta, two other drugs used to treat ADHD, aren't amphetamines. So they don't bear the black box warning about amphetamine use.
However, they are stimulants and do carry warnings about the risk of sudden death in people with heart problems. The FDA has not decided these drugs need to carry a black box warning.
Ritalin is made by Novartis. Concerta is made by McNeil Pediatrics. Adderall is made by Shire. Dexedrine is made by GlaxoSmithKline. All are WebMD sponsors.
ADHD Drug Warnings
Warning information for all stimulant ADHD drugs includes the following:
Sudden death has been associated with stimulants at usual doses in children and teens with structural heart abnormalities or other serious heart problems.
Children, teens, or adults who are being considered for treatment with stimulant medicines should have a careful checkup (including family history and a physical exam) to check for heart disease.
Patients who develop symptoms such as chest pain during exertion, unexplained fainting, or other possible heart symptoms should promptly get a heart evaluation.
Sudden death, stroke, and heart attack have been reported in adults taking stimulant drugs at usual doses for ADHD.
Adults are more likely than kids to have serious structural heart abnormalities, cardiomyopathy (a disease of the heart muscle), serious heart rhythm abnormalities, coronary artery disease, or other serious heart problems.
Adults with such heart abnormalities should also generally not be treated with stimulant drugs.
GlaxoSmithKline, maker of Dexedrine, said in a letter posted on the FDA web site that it added the warning based on recommendations from the FDA advisory committees.
WebMD contacted the makers of Ritalin, Concerta, and Adderall for their comments.
In a statement emailed to WebMD, McNeil Pediatrics spokeswoman Julie Keenan confirmed that McNeil Pediatrics has worked with the FDA to update the warnings section of the prescribing information for Concerta extended-release tablets.
The update was "based on recommendations regarding use of stimulant medications to treat ADHD from two FDA advisory committee meetings," Keenan says.
"We encourage parents whose children use Concerta to contact their physician if they have any questions," she adds.
The makers of Ritalin and Adderall didn't respond before deadline.
The ADHD drug Strattera isn't a stimulant, so it doesn't carry the same warnings. Strattera is made by Eli Lilly and Company, also a WebMD sponsor.
Women With ADHD Less Likely to Be Diagnosed and More Symptomatic Than Men
Paula Moyer, MA
Medscape Medical News 2005. © 2005 Medscape
May 25, 2005 (Atlanta) — Women with attention deficit/hyperactivity disorder (ADHD) have more severe symptoms and emotional impairment than male patients, although they respond at least as well to treatment, according to investigators who presented their findings here at the 2005 American Psychiatric Association Annual Meeting.
"Physicians need to keep ADHD in mind when women are being treated for anxiety or depression and have continued symptoms that do not fully coincide with those diagnoses," said presenting investigator Fred W. Reimherr, MD, in an interview. "These patients might be more emotionally labile and irritable than one would expect to see in anxiety and depression." Dr. Reimherr is an associate professor of psychiatry at the University of Utah in Salt Lake City.
The investigators combined the results from two identical, placebo-controlled, 11-week studies of atomoxetine (Strattera) in adult ADHD patients, consisting of 536 people at 31 sites, and analyzed them for sex differences. Among these subjects, 348 (65%) were men and 188 (35%) were women. All had confirmed cases of childhood ADHD, and all were self-referred.
This proportion was much higher than is typically found in pediatric ADHD trials, Dr. Reimherr said. The women's ADHD had a different presentation than it typically does in girls. While girls typically have inattentive ADHD subtype, in the women, 46 (24%) had inattentive subtype and 141 (75%) had the combined subtype, which was also the most common subtype in the men, of whom 64% had the combined subtype and 35% had the inattentive subtype. One woman (1%) and 12 men (3%) had the hyperactive/impulsive subtype.
The investigators used the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS), which is a measurement scale developed by the investigators. The other scale used for ADHD was the Conner's Adult ADHD Rating scale-Investigator Total ADHD Symptom Score (CAARS-INV). Other scales used included the Hamilton Anxiety (HAM-A) and Hamilton Depression (HAM-D) Scales.
Women had worse average WRAADDS and CAARS-INV total scores (P < .001). Their scores on all subscales were more severe than the men's scores, Dr. Reimherr said. The women had worse scores on the HAM-A (P < .003) and on the HAM-D (P < .02). They had more emotional symptoms on the WRAADDS emotional dimension, the lifetime Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Patient Version, psychiatric diagnoses, as well as on the emotional subscores of the HAM-A and the HAM-D. In response to treatment with the study drug atomoxetine, women had significantly more improvement on the WRAADDS emotional dimension than did the men (P = .01). The investigators saw no significant differences between men and women in the posttreatment CAARS-INV or Clinical Global Impression-Subject scores.
"This study was interesting because the inattention subtype of ADHD is more commonly seen in girls," said Harold Eist, MD, in an interview seeking outside comment. "The number of women who had the combined subtype was more common than is conventionally seen in a combined subtype." Dr. Eist is a child and adolescent psychiatrist in private practice in Washington, DC, as well as a clinical professor of psychiatry at George Washington University in Washington, DC, and a past president of the American Psychiatric Association.
"There could be a selection bias because inattentive subtype often goes undiagnosed, while the combined type is more conspicuous," Dr. Eist said. "However, this study may help more women get diagnosed. If physicians are aware of undiagnosed ADHD in women, they can identify it more frequently. If you are aware, you will see that it is more common than you realize."
The study was funded by Eli Lilly and Company, the maker of atomoxetine.
2005 American Psychiatric Association Annual Meeting: Abstract NR497. Presented May 24, 2005.
Reviewed by Gary D. Vogin, MD
Attention Disorder Takes 2 Years to Detect - Survey
FRANKFURT (Reuters) - A disorder beginning in childhood which is characterized by hyperactivity, impulsive behavior and attention problems often goes undetected for long periods, said a survey of parents in eight countries on Monday.
The survey of 760 families, due to be presented at a Berlin conference on Tuesday, said that while diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) takes a year on average in the United States, it can take three years in Italy.
The average time until diagnosis, measured from when a parent first visited a health professional to talk about a child's behavior to a diagnosis by a specialist, was two years.
"The earlier you treat patients, and the longer you treat them, makes a difference," said Russell Barkley, psychiatry professor at the Medical University of South Carolina, who helped design the survey.
ADHD is a common disorder in childhood and adolescence, affecting 3 to 7 percent of schoolchildren. Barkley said diagnosing ADHD early can prevent severe problems in adulthood.
In the United States adults with ADHD who had received inadequate or no treatment were three to five times more likely to be fired from their jobs, while 75 percent got divorced. Forty percent of untreated teenagers had unwanted pregnancies.
The survey, funded by Eli Lilly, showed 63 percent of parents believed the child's primary care physician did not seem to know much about ADHD.
Barkley said even the two-year average diagnosis time shown by the survey was probably an underestimate because the study focused on successfully treated individuals.
Barkley said a much greater use of schoolteachers to spot the disease early was vital, as was greater awareness among doctors, carers, parents and policymakers.
Seasonal Allergies Affect ADHD
By Colette Bouchez HealthScoutNews Reporter
THURSDAY, March 13 (HealthScoutNews) -- Symptoms of attention-deficit hyperactivity disorder (ADHD) may worsen with a seasonal allergy.
That's the word from doctors at Long Island College Hospital in New York City, who presented their findings this week at the annual meeting of the American Academy of Allergy, Asthma and Immunology in Denver.
The study involved 20 children between the ages of 5 and 18, all of whom had been diagnosed with ADHD. But only two had been evaluated for allergy problems, even though all had a family history of allergies.
The researchers screened the children for allergic rhinitis, using not only a focused personal and family history, but also blood and other types of allergy testing for mold, cockroaches, dogs, cats, feathers, ragweed, trees and grass.
The results? Eight of the children (40 percent) were diagnosed with asthma or atopic dermatitis; three (23 percent) with allergic rhinitis, and nine (69 percent) had at least one positive allergy test. Fifteen of the 20 also had a history of at least two allergic symptoms.
Based on those findings, the researchers concluded that a high percentage of children with ADHD may also harbor allergies and some of the behavioral patterns observed in ADHD might come from sleep problems caused by allergy symptoms -- particularly nasal obstruction.
The authors suggest all children diagnosed with ADHD should also be tested for seasonal and environmental allergies and that treatment might improve their overall behavior and symptoms.
The study was just one highlight among some important new findings that were presented at the six-day conference, which ended Wednesday. Here are some more:
Study: Ritalin linked to stunted growth
Drug used for attention disorder in children
The Associated Press
Updated: 9:04 a.m. ET April 05, 2004
CHICAGO - New research bolsters evidence that stimulants like Ritalin used for attention deficit problems may stunt children’s growth, but it does not address whether the effect is permanent.
Children who took stimulants during the two-year study grew more than half an inch less and gained over eight pounds less than those who weren’t medicated.
The study involved 540 youngsters with attention deficit hyperactivity disorder, who were aged 7 to 9 at the outset of the study and were randomly assigned to receive common treatments including medication, behavior management and a combination of the two.
Girls generally reach their final height around age 16 and boys around age 18, so it’s too soon to tell if the growth delays continued or were permanent, the researchers said.
No significant height reduction
American Academy of Pediatrics’ guidelines that recommend treating ADHD with stimulants and behavior therapy say evidence collected by following youngsters into adulthood indicates the drugs don’t cause any significant height reduction.
Weight loss, however, is a known potential side effect from long-term stimulant use.
The study, led by University of California at Berkeley researcher Stephen Hinshaw, was funded by the National Institute of Mental Health and appears in the April issue of Pediatrics.
Initial results after 14 months of follow-up, published in 1999, showed that drugs alone or used with behavior therapy were the most effective treatment.
The 24-month follow-up found that drug treatment with or without behavior therapy remained superior, though the effect diminished somewhat over time. The researchers attributed this in part to patients stopping or starting medication.
ADHD, the most common neurobehavioral disorder in childhood, affects 4 percent to 12 percent of U.S. school-age children. Symptoms may include short attention span, impulsive behavior, and difficulty focusing and sitting still.
© 2004 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
Mild Hyperactivity May Stem from Sleep Problems
Mon Mar 3,10:29 AM ET Add Health - Reuters to My Yahoo!
By Merritt McKinney SOURCE: Pediatrics 2003;111:554-563.
NEW YORK (Reuters Health) - In some children, hyperactivity that seems like a mild form of attention-deficit/hyperactivity disorder (ADHD) may actually be caused by snoring and other sleeping problems, researchers report.
When a true diagnosis of ADHD can be ruled out in a hyperactive child, evaluating a child for a sleep disorder may uncover the true cause of the symptoms, the study's lead author told Reuters Health.
Pediatricians and parents should be aware that in a portion of these children, "hyperactive symptoms may be due to the presence of snoring and sleep apnea," said Dr. David Gozal.
"In this subset of 'hyperactive' children who have sleep apnea, treatment of the sleep apnea should lead to marked improvement if not complete disappearance of their hyperactivity symptoms," said Gozal, who is at the University of Louisville School of Medicine in Kentucky.
"To the parent, if you have a kid who is hyperactive and snores, think about the possibility that the two may be connected," Gozal said. A referral to a pediatric sleep specialist may be a good idea, he added.
People with sleep apnea stop breathing dozens of times each night, causing them to gasp for breath. The condition is conservatively estimated to affect from 2% to 4% of middle-aged Americans, and is particularly common among obese people.
Sleep apnea has been linked to daytime sleepiness, as well as an increased risk of high blood pressure and cardiovascular disease.
There is some evidence that a considerable proportion of children who have sleep apnea or who snore may display hyperactive behavior and inattentiveness during the day.
To further examine this association, Gozal's team surveyed more than 5,700 parents about their children's behavior and sleep. A group of 83 children ages 5 to 7 with some symptoms of ADHD as reported by their parents underwent sleep testing and were compared to a group of 34 children with no reported ADHD symptoms.
The study found that children whose parents judged them to be hyperactive but who did not have true ADHD were much more likely to have sleep apnea. The authors caution that the results need to be confirmed, but say the study "strongly suggests" that sleep apnea can cause hyperactive behavior.
How sleep apnea may cause hyperactive behavior is unknown, but the authors do suggest that the focus on this behavior may delay treatment for the underlying problem, sleep apnea.
In contrast, children with true ADHD were not more likely to have sleep apnea. However, they were more likely than other children to have disturbances in REM sleep--the dream stage of sleep. These differences could have a mild effect on children's behavior, according to the report.
THURSDAY, Feb. 27 (HealthScoutNews) --
Group classes that teach behavioral and social skills may benefit children with attention-deficit hyperactivity disorder (ADHD) and their parents, says an American study.
The classes would be a supplement to standard care that includes medication.
The findings appear in the February issue of the Journal of Developmental and Behavioral Pediatrics.
ADHD affects 3 percent to 5 percent of school-aged children in the United States. It's usually treated solely with stimulant medications, which help reduce core symptoms such as hyperactivity.
This study included 100 children, aged 5 to 12, who were recently diagnosed with ADHD and were all receiving stimulant medication treatment.
More than half of the children and their parents were assigned to an eight-week behavioral and social skills class. The remaining children and their parents did not take any classes.
The class presented common ADHD case histories and included exercises on listening, self-esteem and friendship- building.
After three and six months, the parents and teachers of the children taking the class were interviewed to assess the effectiveness of the class.
Parents of children in the class reported more consistent use of discipline practices with their children, who had significantly fewer ADHD symptoms than the children not enrolled in the classes.
CHILDREN WHO CAN'T PAY ATTENTION/ADHD
Parents are distressed when they receive a note from school saying that their child "won't listen to the teacher" or "causes trouble in class." One possible reason for this kind of behavior is Attention-Deficit Hyperactivity Disorder (ADHD).
Even though the child with ADHD often wants to be a good student, the impulsive behavior and difficulty paying attention in class frequently interferes and causes problems. Teachers, parents, and friends know that the child is "misbehaving" or "different" but they may not be able to tell exactly what is wrong.
Any child may show inattention, distractibility, impulsivity, or hyperactivity at times, but the child with ADHD shows these symptoms and behaviors more frequently and severely than other children of the same age or developmental level. ADHD occurs in 3-5% of school age children. ADHD must begin before the age of seven and it can continue into adulthood. ADHD runs in families with about 25% of biological parents also having this medical condition.
A child with ADHD often shows some of the following:
trouble paying attention
inattention to details and makes careless mistakes
loses school supplies, forgets to turn in homework
trouble finishing class work and homework
trouble following multiple adult commands
blurts out answers
fidgets or squirms
leaves seat and runs about or climbs excessively
seems "on the go"
talks too much and has difficulty playing quietly
interrupts or intrudes on others
A child presenting with ADHD symptoms must have a comprehensive evaluation. A child with ADHD may have other psychiatric disorders such as conduct disorder, anxiety disorder, depressive disorder, or manic-depressive disorder. Without proper treatment, the child may fall behind in schoolwork, and friendships may suffer. The child experiences more failure than success and is criticized by teachers and family who do not recognize a health problem.
Research clearly demonstrates that medication can be helpful. Stimulant medication such as methylphenidate, dextroamphetamine, and pemoline can improve attention, focus, goal directed behavior, and organizational skills. Other medications such as guanfacine, clonidine, and some antidepressants may also be helpful.
Other treatment approaches may include cognitive-behavioral therapy, social skills training, parent education, and modifications to the child's education program. Behavioral therapy can help a child control aggression, modulate social behavior, and be more productive. Cognitive therapy can help a child build self esteem, reduce negative thoughts, and improve problem solving skills. Parents can learn management skills such as issuing instructions one step at a time rather than issuing multiple requests at once. Education modifications can address ADHD symptoms along with any coexisting learning disabilities.
A child who is diagnosed with ADHD and treated appropriately can have a productive and successful life. If a child shows symptoms and behaviors like those of ADHD, parents may ask their pediatrician or family physician to refer them to a child and adolescent psychiatrist, who can diagnose and treat this medical condition.
For additional/related information see other Facts for Families: Learning Disabilities (#16), Conduct Disorders (#33), Manic-Depressive Illness in Teens (#38), Questions to Ask about Psychiatric Medications for Children and Adolescents (#51), Comprehensive Psychiatric Evaluation (#52).
Kids With ADHD Suffer More Injuries
5 minutes ago Add Health - HealthScoutNews to My Yahoo!
By Jennifer Thomas
MONDAY, Feb. 3 (HealthScoutNews) -- Here's news that anyone with a child with attention deficit hyperactivity disorder (ADHD) may already know all too well.
Kids with ADHD are more prone to injuries, including fractures, wounds, poisoning, concussions, and burns, new research finds. And some of these injuries have nothing to do with their behavior problems.
What makes the study unique is that it's the first, population-based comparison between kids with ADHD and their peers without the disorder, says Jamie Brehaut, lead author of the study and a postdoctoral fellow at the Ottawa Health Research Institute in Canada.
"The finding that kids who have attention deficit disorder or behavioral problems are at greater risk for injury is one that parents and caregivers of these children would not find surprising," Brehaut says. "But when we went to look through the scientific literature, the evidence for it was not that great. There were a lot of studies, but they were small or had some flaws."
The study appears in the February issue of Pediatrics.
Researchers analyzed the injury rates of all children in British Columbia under age 19 as of December 1996. Out of more than 1 million children, 16,086 children had been prescribed methylphenidate, also known as Ritalin (news - web sites).
A prescription for Ritalin was used as a marker to identify those children with a "childhood behavior disorder." Though not every child with a childhood behavior disorder necessarily had ADHD, the vast majority probably had been diagnosed with it, Brehaut says.
Brehaut and his colleagues found children with a childhood behavior disorder were 1.5 times more likely to suffer a fracture, open wound, poisoning, concussion, or burn.
The causes of those injuries included falls, motor vehicle accidents, being struck by an object, postoperative complications, adverse reaction to a prescribed drug, suffocation, and drowning.
"Kids with ADHD are generally more hyper, and in terms of sheer volume, the more active you are, the more prone you are to injury," says Dr. Andrew Adesman, director of development and behavioral pediatrics at Schneider Children's Hospital in New Hyde Park, N.Y.
"Part of ADHD is also poor impulse control, or not thinking about the consequences of your actions," Adesman says. That may be one reason risk-taking behavior might be increased in kids with ADHD.
But there could be other factors at work. Some evidence shows kids with ADHD tend to have poorer motor agility and are less coordinated, Adesman says.
While many of the injuries, such as fractures, can be easily attributed to hyperactivity or impulsiveness, others cannot, Brehaut says. For instance, researchers aren't sure why kids with ADHD are more likely to have postoperative complications.
One possibility is that kids with ADHD are less likely to follow doctor's orders for rest and self-care after surgery, says Adesman, a member of the board of directors of Children and Adults with Attention Deficit Disorder (CHADD).
One study found kids with ADHD may have a higher pain tolerance than other children, he says.
Another mystery is the adverse reactions to drugs. It's possible researchers are picking up on the already known side effects of Ritalin, Brehaut says, adding that Ritalin is generally a very safe drug.
"What it suggests to us that there may be greater cost to the health-care system associated with this particular group of kids that extended beyond the typical injuries you might expect," Brehaut says.
Indeed, one recent study found precisely that. It said that children with ADHD were more likely to need medical care than children without ADHD.
Researchers looked at the medical histories of more than 4,000 children for nine years. The median medical cost for children with ADHD was $4,306 compared to $1,944 for kids without ADHD.
Children's Stimulant Prescriptions Vary
Mon Feb 3, 7:32 AM ET Add Health - AP to My Yahoo!
By LINDSEY TANNER, AP Medical Writer
CHICAGO - Prescription rates for Ritalin (news - web sites) and similar attention deficit disorder drugs — both widely praised and widely maligned — vary dramatically across the nation, new research indicates.
While the prevalence of the disorder is not thought to vary greatly by region, a study being released Monday found that treatment rates ranged from 1.6 percent of children's prescriptions examined in Washington, D.C., to 6.5 percent of children's prescriptions in Louisiana. Significantly higher rates were found in the South and Midwest than in the West.
Overall, about 4 percent of prescriptions examined for children ages 5 to 14 in 1999 were for stimulants including Ritalin.
The study, appearing in February's issue of Pediatrics, was done by researchers at Express Scripts Inc., a Missouri-based pharmacy benefits management company. The researchers reviewed a nationally representative sample of company prescription claims for 178,800 children throughout 1999. The claims were for all types of medication.
Lead researcher Emily Cox and colleagues said that while they did not determine if higher prescription rates represented overuse or if lower rates represented underuse, "both may be occurring."
The variations should be examined "to reduce the risk to children from unnecessary drug therapy as well as the negative health and emotional consequences to children with untreated medical conditions," the researchers said.
Critics of excessive use of such drugs, including some doctors, have worried that the drugs sometimes are promoted by schools and others as a "quick fix" without other appropriate treatment.
Advertising of the drugs, physician practice styles, parents' and teachers' values and anti-Ritalin campaigns may have contributed to the varying drug use rates, the researchers said.
Methylphenidate, the drug more widely known by the brand name Ritalin, was the most common stimulant prescribed. Others were dexedrine and other amphetamines.
Stimulant use was found to be more prevalent among white children and those from higher-income families. Cox said the higher rates likely are representative of the nation's commercially insured population. The study did not look at Medicaid claims.
The American Academy of Pediatrics' guidelines for treating attention deficit hyperactivity disorder cite data suggesting the disorder affects 4 percent to 12 percent of school-age children, or as many as 3.8 million youngsters, most of them boys.
AAP guidelines, issued in 2001, recommend stimulants and behavioral therapy for treating ADHD and say that stimulants are generally safe and that side effects, such as decreased appetite and jitteriness, are usually short-lived.
"Research has clearly documented that this is a condition that exists across countries and across socio-economic groups," said Dr. David Fassler, a member of the American Academy of Child and Adolescent Psychiatry's governing council.
"In areas where only 1 to 2 percent of children are receiving a treatment which is known to be beneficial, we need to ask why," he said.
Biofeedback Aids Kids With ADHD
Fri Dec 20, 7:09 PM ET Add Health - HealthScoutNews to My Yahoo!
FRIDAY, Dec. 20 (HealthScoutNews) -- Children with attention-deficit hyperactivity disorder (ADHD) benefit from biofeedback therapy.
That's the claim of a study in the December issue of Applied Psychophysiology and Biofeedback.
The study found that a year of medication and counseling helped relieve ADHD symptoms in a group of children, but only the children who also received biofeedback therapy maintained that improvement after going off medication.
The study, by researchers at the FPI Attention Disorders Clinic, included 100 children aged 6 to 19 years old. They were followed through a year of ADHD treatment that included special parenting classes, treatment with the medicine Ritalin (news - web sites) and school consultation.
About half the children also received EEG biofeedback therapy. It uses an electroencephalograph to measure different kinds of brain waves (electrical activity) produced in certain brain areas.
Previous research indicates that reducing slow (low frequency) brainwaves and boosting the number of fast (high frequency) brainwaves can reduce some ADHD symptoms.
The children in this study who received EEG biofeedback therapy were rewarded for their attempts to change slower brainwaves to faster brain waves after they were shown how specific behaviors affected their brainwave patterns.
The study found that the year's worth of treatment with the drug Ritalin improved attention deficit and impulse control in most of the children. That improvement was independent of the parental counseling and biofeedback therapy.
When the children stopped taking the medicine, their ADHD symptoms returned. Not so for those children who had received biofeedback therapy. The study found that biofeedback therapy was the only one of the treatments that greatly reduced the level of slow brainwaves in the children.
Soy-Based Formulas May Be Linked to ADHD
Tue Oct 8, 2:07 PM ET By Holly VanScoy HealthScoutNews Reporter
TUESDAY, Oct. 8 (HealthScoutNews) -- California researchers have discovered a possible link between high levels of manganese, a mineral found in soy-based infant formulas, and the development of attention deficit hyperactivity disorder later in life.
Soy formulas can contain as much as 80 times the amount of manganese present in human breast milk. The popular formula Isomil, for instance, contains 25 micrograms of manganese in every five-ounce bottle.
The University of California-Irvine researchers found that supplementing the diet of rat pups with 250 micrograms to 500 micrograms of manganese per day -- the equivalent of 10 to 20 five-ounce bottles of Isomil -- resulted in developmental deficits and lowered dopamine levels in the same areas of the brain believed associated with attention deficits and hyperactivity.
"The problem with soy is that it is a bio-accumulator of metals. That means soybeans tend to soak up manganese from the earth," says Francis M. Crinella, a clinical professor of pediatrics at UC-Irvine and lead author of the study, published in the current issue of the journal NeuroToxicology.
Crinella also cites four studies dating as far back to 1977 in which testing done on the hair of children with various learning or behavior problems have shown elevated levels of manganese.
Although definitive evidence linking soy formula use in infancy with the development of attention deficit hyperactivity disorder (ADHD) has yet to surface, two new studies -- one involving humans and the other involving primates -- are currently in the works at UC-Irvine and the University of Califonia-Davis.
There are some experts, among them infant formula manufacturers, who disagree with the scientists' evidence so far, however.
"There is no known incidence of manganese deficiency or toxicity in infants," says Mary Beth Arensberg, director of public affairs for the Ross Products division of Abbott Laboratories, which makes Isomil. She points out that her company's product meets all U.S. Food and Drug Administration (news - web sites) guidelines for infant formula that presently require a minimum manganese level, but not a maximum.
"Humans normally eliminate excess manganese in the liver, so soy infant formula is typically a problem only when the infant has liver problems," she says.
However, the California scientists say their evidence seems to suggest otherwise.
According to the study, the gastrointestinal tracts of infants from birth to 12 months old are not sufficiently developed to absorb and excrete excess manganese. That's the development period during which Crinella and his colleagues hypothesize the damage to a rapidly developing infant brain may occur.
"In later childhood there is a very efficient manganese excretion system through bile," he explains. "Manganese ingestion doesn't seem to make any difference once an infant has reached one year of age." And, he notes, since adults typically have a fully developed mineral excretion system, the researchers do not believe mothers' breast milk is a likely source of high levels of manganese.
Bottle-fed infants also often show iron anemia, according to Crinella, which can amplify the affects of manganese toxicity. "The most impaired rats were those that were also anemic," he says. Isomil, it should be noted, is fortified with iron.
"This study lends support to previous studies that also found neurotoxic affects of manganese on the dopamanergic areas of the brain," says Aleksandra Chicz-DeMet, an associate adjunct professor of psychiatry at UC-Irvine, and a co-author of the article. "What our research adds to the knowledge of manganese's effects is that we have also looked at rat behavior and found that the rats with behavior disruptions had lower dopamine levels in their brains."
Dopamine levels can't be measured in the brains of humans, which explains why studies on the neurotransmitter had to begin with laboratory rats, but will next involve primates, Chicz-DeMet says. "If we see similar findings in primates, it will give our findings more support," she says.
The corresponding human study at UC-Irvine will follow premature infants, who for a variety of reasons often cannot be fed breast milk.
Ross Products also makes the popular cow's milk-based formula Similac, which has 10 micrograms of manganese per five-ounce bottle, less than the soy-based Isomil, but still significantly higher than levels found in breast milk.
"The levels of manganese in these products reflect natural levels of manganese," asserts Ross Products' Arensberg. "Manganese is a necessary mineral for skeletal growth and an essential trace mineral required by law to be in infant formulas. Although levels in cow's milk and soy milk are higher than levels in human milk, they are still within the ranges recommended by nutrition experts."
ADHD's Severity in Girls Overlooked
Wed Oct 2,11:50 PM ET
By Randy Dotinga
WEDNESDAY, Oct. 2 (HealthScoutNews) -- Many parents and pediatricians assume girls don't suffer as much from attention deficit/hyperactivity disorder as boys.
However, researchers in Northern California observed girls with the disorder at summer camps, and found they are much more impaired than their counterparts who don't have the condition.
The findings suggest the medical community doesn't appreciate the frequency and severity of ADHD in girls, says Stephen Hinshaw, a professor of psychology at the University of California at Berkeley and co-author of the new study.
"Boys and girls are similarly afflicted and impaired by the symptoms of the disorder," Hinshaw says. "Girls appear to be as affected as boys, if not more so in some instances."
ADHD affects an estimated 3 percent to 5 percent of American children, possibly as many as 2 million kids. Three boys are diagnosed with the disorder for every one girl.
However, several researchers have argued that many affected girls have been left behind, largely because they are less likely to be hyperactive and more likely to have trouble paying attention. "The hyperactivity tends to come to the attention of teachers and parents, and gets kids in trouble with their peers," while a lack of attention is less noticeable, says Nadine Kaslow, chief psychologist at Emory University School of Medicine.
In the UC-Berkeley study, researchers enrolled 228 girls aged 6 to 12 in day camps held from 1997 to 1999. Of the girls, 140 had ADHD and were specially recruited; the others, who weren't diagnosed with ADHD, were told the camps were for "enrichment."
The girls with ADHD went off their medications for the six-week day camp periods so researchers could observe their "natural" behavior.
The findings appear in the October issue of the Journal of Consulting and Clinical Psychology.
Researchers watched the girls closely, and found those with ADHD were often socially isolated and uninterested in following directions.
The girls with ADHD weren't as physically aggressive as boys with the disorder, but Hinshaw says they were more likely to engage in what is called "relational aggression" -- "getting back at someone by excluding them from an activity or social group, or spreading rumors rather than directly aggressing against them."
The girls scored as poorly as boys on tests of their abilities to set goals, alter strategies in response to changing situations, and make plans.
Kaslow praises the study, and says more attention to the ADHD problems of girls will help them later in life. "This really underscores the importance of teacher, parents and pediatricians paying attention when girls aren't doing as well as one thinks they should be," she says. "The longer these problems go untreated, the worse kids feel about themselves, the more social difficulties they have, and the harder life becomes for them."
Some adult women appear in her office with cases of ADHD that have been undiagnosed since childhood, Kaslow says. "They didn't know they had it, but they knew they struggled more to organize their work and their thinking. Sometimes teachers would say these kids weren't that smart, but it's not an intelligence issue. It's about an ability to organize it, and get it all together."
The good news is that ADHD drugs appear to work as well in girls as in boys, Hinshaw says. "ADHD is a serious, but treatable, problem in girls."
Are Sleep Problems Linked to Inattention and Hyperactivity?
Brown University Child and Adolescent Psychopharmacology Update 4(4):1, 6-7, 2002. © 2002 Manisses Communications Group, Inc
A new cross-sectional survey has found that children who snore, appear sleepy, or show other symptoms of sleep-disordered breathing are more likely to be rated by their parents as having problems with inattention and hyperactivity. Sleep-disordered breathing (SBD) is a condition characterized by repeated apneic and hypopneic episodes during sleep.
The study, conducted by Ronald D. Chervin, M.D., M.S., of the University of Michigan, Ann Arbor, and colleagues, examined the prevalence SDB in a sample of 866 children ages 2 to 13 years recruited from two general pediatrics clinics. Parental ratings scales and a validated Pediatric Sleep Questionnaire (PSQ) were used as the study's main outcome measures.The study revealed that 16 percent of subjects were habitual snorers (i.e., they snored during half of their sleep time) and that 13 percent of all subjects showed increased hyperactivity, as measured by the Connors' Rating Scale, Hyperactivity Index (HI). A ratings score of greater than 60 on the HI is considered to represent hyperactivity.
Chervin and colleagues found a significant association between habitual snoring and hyperactive behavior. Among all children, habitual snoring was found to be associated with an increase in the likelihood of hyperactivity from 12 percent (nonhabitual snorers) to 22 percent (habitual snorers). Snoring, sleepiness and SBD scores were significantly associated with a high score on the HI, as well as with the Inattention/Hyperactivity scale (IHS), on which a mean item response was determined high if greater than 1.25 on a four-point Likert scale.
When the sample was stratified by age and sex, Chervin and colleagues found a substantially strong association between snoring and behavior in male subjects who were younger than eight years old. In these younger male subjects, the likelihood of hyperactivity jumped from 9 percent (nonhabitual snorers) to 30 percent (habitual snorers). The investigators noted that the strong association between snoring and behavior in young males could not be replicated in subjects outside of this group and may represent a sex-based vulnerability to any impact that SDB may have on behavior.
According to Chervin, the bottom line is that the "association of sleepiness with daytime behavioral problems occurred in all ages and sexes tested, whereas the association of snoring with these problems derived primarily from boys eight-years old or younger."
Chervin concluded that the next step is to "better address the questions -- still unresolved -- of whether and to what extent sleep-disordered breathing may contribute to inattention and hyperactivity in children.
In their study, Chervin and colleagues discuss the importance of understanding how SDB can influence behavior, citing the high prevalence of attention-deficit/hyperactivity disorder among school-aged children today. They state that in some children, an unrecognized medical disorder such as SDB may lead to problem behavior.
In an interview with The Brown University Child and Adolescent Psychopharmacology Update, Judy Owens, M.D., said that SDB often results in arousals or partial brief awakenings during sleep, and which, if frequent, can lead to poor quality sleep and therefore daytime sleepiness.
Owens, an associate professor of Pediatrics at Brown University and director of the Pediatric Sleep Disorders Clinic at Hasbro Children's Hospital in Providence, R.I., further explained, "Daytime sleepiness in turn is associated with mood, cognitive and behavioral dysfunction. The dips in oxygen levels that also occur with SDB may also contribute to the neurocognitive impairment."
Specifically, Owens said that sleep deprivation can result in mood changes, inattention, delayed reaction time and impaired vigilance, decreased motivation, hyperactivity, aggressive behavior and impulsivity -- symptoms that may overlap with those commonly associated with ADHD. Thus children with sleep disorders may appear as if they have ADHD during the daytime.
Treatment of childhood sleeping problems is highly diagnostically driven, according to Owens. Often, SDB is treated surgically (adenotonsillectomy), or with weight management if obesity is a factor, she said. Other medical sleep disorders like Periodic Limb Movement Disorder (PLMD) may respond to pharmacologic treatment.
"There are many effective behavior treatment strategies available for more behaviorally based sleep disorders; pharmacology as an adjunct is only occasionally needed," Owens said.
Many mood and behavior problems in children may be partially caused by primary or co-morbid sleep disorders such as obstructive sleep apnea or PLMD, said Owens. "Clinicians should routinely screen for these sleep problems, and parents should be aware of their symptoms."
Owens said that in her clinic, they use an algorithm referred to as BEARS to screen for sleep problems in general. The acronym stands for bedtime problems ("B"), excessive daytime sleepiness ("E"), awakenings at night ("A"), regularity and duration of sleep ("R") and snoring ("S"). (See box on left.) Other specific screening questions include inquiries about breathing pauses, choking, gasping or snorting, restless sleep, sweating in sleep and mouth breathing during sleep.
Owens and colleagues also employ the Children's Sleep Habits Questionnaire (CSHQ) to help identify behaviorally and medically based sleep problems in school-aged children. The CSHQ is a parental-and self-report screening instrument that inquires about sleep patterns, behavior and daytime sleepiness (Owens 2000).
While the association between sleepiness and hyperactive behavior was found in both boys and girls throughout childhood and early adolescence, it is the association between snoring and behavior among younger children -- particularly among young boys -- that appeared especially strong. Chervin and colleagues state that the high frequency of pediatric SDB, the possibility that most children with the disorder may be undiagnosed, and evidence that SDB can affect behavior "all combine to suggest that occult SDB may have an important impact among children with inattentive and hyperactive behavior."
Chervin and colleagues conclude that if sleepiness and SDB do indeed influence daytime behavior, the results could constitute a major public health burden.
For more information on sleep and behavior, check out these web-based resources: www.sleepfoundation.org; www.kidzzzsleep.org
Chervin RD, Hedger Archbold K, Dillon JE, et al.: Inattention, hyperactivity and symptoms of sleep-disorder breathing. Pediatrics 2002; 109:449-456. Correspondence to: Dr. Chervin, Michael S. Aldrich Sleep Disorders Laboratory, 8D8702 University Hospital, Box 0117, 1500 E Medical Center Drive, Ann Arbor, MI 48109- 0117; e-mail: firstname.lastname@example.org.
Owens JA, Spirito A, McGuinn M: The Children's Sleep Habits Questionnaire (CSHQ): Psychometric properties of a survey instrument for school-aged children. Sleep 2000; 23(8):1043-1051.
Owens JA: Children's Sleep Habits Questionnaire. ©Judith A. Owens. M.D., M.P.H., 2000.
Sidebar: Tool Uses "Trigger Questions" to Assess Sleep History
The "BEARS" use a simple questionnaire to screen for the most common clinical sleep disorders in children and adolescents ages two to 18 years. Divided into five major sleep domains, the BEARS provides a set of developmentally appropriate "trigger" questions to be answered by both the parent and child. Following are some example trigger questions:
Bedtime problems: Does your child have any problems at bedtime?
Excessive daytime sleepiness: Does your child have difficulty waking in the morning, seem sleepy during the day, or take naps?
Awakenings during the night: Does your child seem to wake up a lot at night? Any sleepwalking or nightmares?
Regularity and duration of sleep: What time does your child go to bed and get up on school days? Weekends? Do you think he/she is getting enough sleep?
Sleep-disordered breathing: Does your child have loud or nightly snoring or any breathing difficulties at night?
© Owens JA: Taking a sleep history -- the BEARS approach.
Sidebar: Effects of Atomoxetine on Attention, Behavior and Sleep
The Department of Pediatrics and the Department of Child and Family Psychiatry at Rhode Island Hospital are currently conducting a study to evaluate the effects of the investigational non-stimulant atomoxetine on the sleep, learning, attention and behavior patterns of children. The study is actively recruiting children between the ages of six to 15 years who meet the criteria for ADHD, or who have symptoms suggestive of ADHD. Eligible participants will take the study drug for approximately seven weeks, then take methylphenidate (Ritalin) for another seven weeks. [For more on the investigational drug, atomoxetine, see The Brown University Child & Adolescent Psychopharmacology Update's special report, January 2002, page 1.]
The study offers a psychiatric and physical evaluation, all study medication, close monitoring of psychiatric and physical symptoms throughout the course of the study, and nominal compensation for each visit (to cover expenses related to time and travel). All study participants will also receive a handheld computer. For more information, contact the Leah Schaeffer at (401) 444-8815; or visit www.kidzzzsleep.org/adhd_and_sleep.htm.
What is a 504 plan?
Section 504 is a civil rights statute that prohibits schools from discriminating against children with disabilities and provide reasonable accommodations. Under some circumstances, these reasonable accommodations may include the provision of services.
Eligibility for Section 504 is based on the existence of an identified physical or mental condition that substantially limits a major life activity. As learning is considered a major life activity, children diagnosed with AD/HD are entitled to the protections of Section 504 if the disability substantially limits their ability to learn. Children who are not eligible for special education may still be guaranteed access to related services if they meet the Section 504 eligibility criteria
ADHD Symptom Checklist
Below is a checklist containing 18 items which describe characteristics frequently found in people with ADHD.
Items 1-9 describe characteristics of inattention.
Items 10-15 describe characteristics of hyperactivity.
Items 16-18 describe characteristics of impulsivity.
In the space before each statement put the number that best describes your child’s (your student’s) behavior
0 = never or rarely
1 = sometimes;
2 = often;
3 = very often
1. Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other actiivities.
2. Has difficulty sustaining attention in tasks or play activities.
3. Does not seem to listen when spoken to directly.
4. Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
5. Has difficulty organizing tasks and activities.
6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
7. Loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools).
8. Is easily distracted by extraneous stimuli.
9. Is often forgetful in daily activities.
10. Fidgets with hands or feet or squirms in seat.
11. Leaves seat in classroom or in other situations in which remaining seated is expected.
12. Runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
13. Has difficulty playing or engaging in leisure activities quietly.
14. Is “on the go” or often acts as if “driven by a motor.”
15. Talks excessively.
16. Blurts out answers before questions have been completed.
17. Has difficulty awaiting his or her turn.
18. Interrupts or intrudes on others (e.g., butts into conversations or games).
Count the number of items in each group
that you marked “2” or “3.”
group 1 = inattention (items items 1-9)
group 2 = hyperactivity-impulsivity( items 10-18)
If six or more items are marked “2” or “3” in each group this could indicate serious problems in the groups marked.
New CDC Report Looks at Attention-Deficit/Hyperactivity Disorder
According to a new report released today by the Centers for Disease Control and Prevention (CDC), approximately 1.6 million elementary school-aged children have been diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD), a condition also known as Attention Deficit Disorder (ADD). In a national survey, the parents of 7 percent of children 6-11 years of age reported ever being told by a doctor or health professional that their child had ADHD.
The report, "Prevalence of Attention Deficit Disorder and Learning Disability," based on 1997-98 data from CDC's National Health Interview Survey, shows that about one-half of children diagnosed with ADHD have also been identified as having a learning disability.
"This report serves as a snapshot of a condition that has important consequences for the development of school-age children," said David Fleming M.D., Acting CDC Director. "However, much more needs to be learned about ADHD and about the spectrum of impairments associated with ADHD."
The report details many of the characteristics of children with ADHD, learning disability, and children with both conditions. Among children with a diagnosis of only ADHD, boys were nearly three times as likely as girls to have this diagnosis. White non-Hispanic children were more than twice as likely as Hispanic and black non-Hispanic children to report a diagnosis of ADHD.
In addition, access to health care plays an important role in the diagnosis and treatment of ADHD. Children with health insurance coverage were more often reported to have a diagnosis of ADHD than children without health insurance coverage.
The study shows that children with ADHD use more health care services than children without this diagnosis. Children with ADHD were more likely to have contact with a mental health professional and to have frequent health care visits.
"There has been concern in some circles that ADHD has been over-diagnosed among those with regular access to health care," said Fleming. "And there is equal concern that the problem may be under-diagnosed among those who have limited or no access to care. It's clearly important to accurately identify children with ADHD and ensure that they have appropriate health care."
The report "Prevalence of Attention Deficit Disorder and Learning Disability" was prepared by CDC's National Center for Health Statistics and can be found at the CDC/NCHS web site at www.cdc.gov/nchs.
US Costs for Treating Attention Disorder High-Study
Fri May 17, 3:20 PM ET
NEW YORK (Reuters Health) - The costs of treating attention-deficit/hyperactivity disorder (ADHD) in US children is similar to the price tag for fighting childhood asthma--and far higher than national average healthcare costs for kids, researchers report.
They say their findings indicate that ADHD and asthma "deserve similar emphasis" as public health concerns.
Dr. Eugenia Chan of Children's Hospital Boston, in Massachusetts, led the study. The findings are published in the May issue of the Archives of Pediatrics and Adolescent Medicine.
Chan's team used data from a 1996 national survey to estimate the annual healthcare costs of children and teens with ADHD, those with asthma and those in the general population with neither condition.
They found that on average, the cost of healthcare for a child with ADHD was $479 higher than for kids in the general population. The findings were similar for children with asthma, whose healthcare costs were $437 higher than average.
The bulk of the cost for treating ADHD was in doctor visits, prescription drugs and out-of-pocket expenses, according to the report.
"The potential economic burden of ADHD is enormous," Chan and her colleagues write.
Based on the survey's estimate of the prevalence of childhood ADHD (3.5%), the researchers put the yearly healthcare cost of the disorder at $1 billion.
They call for more research into which specific therapies, when used in the "real world," work best over the long-term for children with ADHD.
SOURCE: Archives of Pediatrics and Adolescent Medicine 2002;156:504-511.
Methylphenidate Formulation Can Be Mixed With Food Without Altering Drug Levels
NEW YORK (Reuters Health) Apr 29 - Removing an extended-release formulation of methylphenidate from its capsule and sprinkling it on food does not alter the drug's bioavailability, according to a report in the April issue of the Journal of the American Academy of Child and Adolescent Psychiatry.
The pharmacokinetic parameters of extended-release formulations often depend on the enclosing capsule, the authors note. The current formulation, produced by Rochester, New York-based drug company Celltech Pharmaceuticals, Inc. under the trade name Metadate CD Extended-Release Capsules, however, uses a different technology. Basically, the beads within the capsule, rather than the capsule itself, give the formulation its extended-release properties.
In theory, therefore, the drug could be removed from the capsule without altering its effects. To test this, Dr. Roy D. Simmons, from Celltech, and colleagues compared the bioavailability of the drug when administered as an intact capsule and when sprinkled over food. The study involved 26 healthy subjects, 21 to 39 years of age.
The pharmacokinetics of Metadate CD did not differ in any way with the method of administration, the researchers report.
The findings indicate that "the capsule contents may be administered once daily to subjects who experience difficulty swallowing capsules, thereby alleviating concerns of medication compliance due to dysphagia, while maintaining the expected drug plasma levels," the authors state.
J Am Acad Child Adolesc Psychiatry 2002;41:443-449.
Hallowell and Ratey's Suggested Diagnostic Criteria for ADD in Adults:
A. You must have a chronic distrubance in at least 15 of the following areas:
A sense of underachievement, of not meeting one's goals (regardless of how much one has actually accomplished).
Difficulty getting organized.
Chronic procrastination or trouble getting started on tasks.
Many projects going simultaneously; trouble with follow through.
Tendency to say what comes to mind without necessarily considering the timing or appropriateness of the remark.
A frequent search for high stimulation (always looking for something engaging, novel)
An intolerance of boredom.
Easy distractibilty, trouble focusing attention, tendency to tune out or drift away in the middle of a page or conversation, often coupled with an ability to hyperfocus at times.
Often creative, intuitive, highly intelligent.
Trouble in going through established channels, following "proper" procedure.
Impatient; low tolerance for frustration.
Impulsivity, either verbally or in action, as in impulsive spending of money, changing plans, enacting new schemes or career plans, and the like.
Tendency to worry needlessly, endlessly; tendency to scan the horizon looking for something to worry about, alternating with inattention to or disregard for actual dangers.
Sense of insecurity.
Mood swings, mood liability, especially when disengaged from a person or project.
Restlessness (fidgeting, shifting in seat, pacing)
Tendency toward addictive behavior.
Chronic problems with self-esteem.
Inaccurate self-observation (not accurately gauging the impact they have on other people, usually thinking that they are less powerful/effective than other people)
Family history of ADD of Bipolar Disorder (B.K.A. "Manic-Depressive Disorder") or depression or substance abuse or other disorders of impulse control and mood.
B. A childhood history of ADD must be noted. This does not mean that the disorder must have been diagnosed but rather that the symptoms were present in childhood.
C.The situation is not explainable by any other medical or psychiatric condition.
ADHD: It's a Girl Thing, Too
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By Jennifer Thomas HealthScoutNews Reporter
SUNDAY, Feb. 16 (HealthScoutNews) -- When Kathleen Nadeau was a little girl, she spent so many hours studying that her mother wondered what was wrong.
Nadeau was bright. Yet, while other girls were enjoying parties and after-school activities, Nadeau avoided all social events throughout junior high and high school as she struggled to keep up her grades.
It wasn't until she was an adult that Nadeau, now a psychologist in private practice in Silver Spring, Md., realized she had attention deficit hyperactivity disorder (ADHD).
"Only by keeping this hyper-focus on what I was doing could I do well," Nadeau says. "I knew I couldn't balance all the distractions the way most people do."
ADHD is a condition marked by distractibility, difficulty setting priorities and following through, impulsivity, difficulty with social relationships and, in some people, hyperactivity.
For years, it was believed that only boys suffered from ADHD.
However, a growing body of research -- and a greater awareness on the part of parents and doctors -- is finding that ADHD is quite common among girls.
Though boys with ADHD still outnumber girls, the gulf is not nearly as large as previously believed, says Stephen Hinshaw, a professor of psychology at the University of California at Berkeley.
Some estimates put the ratio at five boys for every girl with ADHD or even 10 to one, but Hinshaw believes the number is closer to two to one.
"ADHD can and does exist in girls," he says. "But many girls are diagnosed as having anxiety or depression, or their diagnosis is missed altogether."
Part of the problem in diagnosing girls is that their ADHD symptoms are often more subtle, as in Nadeau's case.
Many boys with ADHD, though not all, are hyperactive. They are defiant and disruptive in classrooms, which brings them to the attention of teachers and parents quickly.
Some girls with ADHD show symptoms of hyperactivity and aggressiveness. However, many more girls have what's known as "inattentive type" ADHD, Hinshaw says.
They are bright but have to work very hard to keep up in school. They can't follow their teachers' or parents' directions. They are often dismissed as "scatterbrained" or "flighty."
"Boys are clearly more aggressive and disruptive than girls in a physical sense, so they are the ones that get referred," Hinshaw says. "The 'inattentive type' is a less visible type because you're not disrupting a class, you're not running round. You are in some ways suffering in silence, because you're not processing information, you're not focusing attention on parents' demands or teachers' directions."
And it doesn't mean girls aren't struggling to cope with the difficulties of life with ADHD.
Hinshaw and his colleagues enrolled 228 girls aged 6 to 12 in day camps held from 1997 to 1999. About 140 of the girls had ADHD. The others were not suspected of having ADHD and were told the camps were for "enrichment."
The girls with ADHD stopped talking medicine such as Ritalin (news - web sites) for the six-week duration of the camps so researchers could observe their behavior.
Some of the girls with ADHD were overactive. Many others had problems following directions and getting organized.
Most striking was the social problems the girls with ADHD had, Hinshaw says.
The overactive girls weren't liked because they were aggressive and disruptive. The inattentive girls, meanwhile, became socially isolated.
"They were very poor at reading social cues," Hinshaw says. "But they did it in a more passive, 'clueless' way."
Hinshaw's study was published in a recent issue of the Journal of Consulting and Clinical Psychology.
About 2 million U.S. children, or 3 percent to 5 percent, have ADHD. The condition can run in families -- about 80 percent of the underpinnings of the disorder are due to genetics, previous research has found.
Years ago, doctors believed children outgrew ADHD. It's now known that some do outgrow the hyperactivity, but the cognitive problems often last a lifetime.
When Nadeau was growing up, her brother had a classic case of "hyperactive-type" ADHD. He did poorly in school. He was defiant, disruptive and took physical risks.
"I was so utterly different no one suspected I could have it, too," she says.
Nadeau continued her obsessive work habits throughout college and graduate school. She earned a Ph.D. and began a psychology practice. While treating children with ADHD about three decades ago, it dawned on her she had many of the same difficulties.
"I realized I was making all sorts of accommodations in my life for ADHD," she says.
At about the same time, a pediatrician diagnosed ADHD in her youngest daughter, now grown and working as a real estate agent.
Both she and her daughter have found Ritalin-like medications help them stay organized and think clearly.
And Nadeau has found ways to cope. She keeps her office calm and quiet to minimize distractions. She has an office staff that takes care of organizing paperwork and paying bills.
"But I still struggle with these issues every day," she says.
Not every case of a hyperactive or unfocused child -- or adult -- is a missed case of ADHD.
"Diagnosing ADHD requires a careful psychological assessment to find out if it really is ADHD, and not some other problem or poor child rearing," Hinshaw says.
What should parents look for?
Girls who are very intelligent but have problems at school is a telltale sign, Nadeau says. So are frequent stomach aches or anxiety about school.
Girls with ADHD are also often dismissed as "social butterflies," she says. In women, hyperactivity is often manifested as talkativeness.
| When Children With Attention-Deficit/Hyperactivity Disorder Become Adults
H. Patrick Stern, MD, Asha Garg, MD, Thomas P. Stern, MD
South Med J 95(9):985-991, 2002. © 2002 Southern Medical Association
Historically, attention-deficit/hyperactivity disorder (ADHD) has been viewed as a disorder confined primarily to pediatric patients, with only a small percentage persisting into adulthood. Recently, it has been reported that up to 50% of children with ADHD will continue to have manifestations of this disorder as adults. The sex disparity seen in childhood is much less pronounced than in adults; while the male-to-female ratio of ADHD in childhood is as high as 10:1, the ratio may only be 2:1 in the adult population. Primary care physicians who care for adults must be prepared to assume care of patients previously diagnosed with ADHD as children and to make the diagnosis in adults in whom it has not previously been diagnosed.
Diagnosis and Treatment of ADHD in Children and Adolescents
There are not standard, uniform criteria for diagnosis and management of the child or adolescent with ADHD. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines 3 subtypes of attention-deficit/hyperactivity disorder: combined, predominant inattentive, and predominant hyperactive/impulsive, based upon the predominant symptom pattern over the previous 6 months. Symptoms must be present before age 7 years and there must be some documented impairment of social, academic, or occupational function. More pervasive developmental disorders, schizophrenia, and other psychotic disorders must be excluded. The Classification of Child and Adolescent Mental Diagnosis in Primary Care, Child and Adolescent (DSM-PC) defines ADHD more broadly as a developmental variation, problem, and disorder, with ADHD variation and problem being of lesser severity than the ADHD disorder, which uses DSM-IV criteria. The American Academy of Child and Adolescent Psychiatry,[6,7] the American Academy of Pediatrics,[8,9] and the National Institutes of Health have written practice guidelines for diagnosis and treatment of the child/adolescent with ADHD, and recommend evaluations which include: 1) parent/child interviews, 2) school assessments, 3) a comprehensive physical examination, 4) speech/language evaluations, and 5) occupational/recreational testings. These guidelines for the child with ADHD do not apply to young people with mental retardation, pervasive developmental disorders, moderate to severe sensory deficits, or those taking drug therapies that affect behavior.
Treatment recommendations include medication, particularly stimulants, as well as psychosocial and educational interventions.[6,7,9] Caution is necessary in the use of stimulant medications because they are controlled substances which may be abused by family and patients, particularly adolescents or their peers.[7,8,10] Psychosocial interventions include parent behavior-modification training, support groups, family psychotherapy, social skills training, individual therapy, and day treatment programs. Educational interventions include token economies, time-out procedures, response-cost programs, and homework notebooks. Combined modality treatment is generally recommended (ie, medication and psychosocial interventions). The efficacy of medications, mainly stimulants, in the treatment of ADHD symptoms for up to 14 months has been established. Similarly, the effect of psychosocial interventions on symptoms particularly related to ADHD comorbidity has been established for this time period. There have not been studies to demonstrate long-term efficacy of medication or behavioral interventions. Most research has been performed in structured, academic, clinical settings, but has not been demonstrated in clinical practice. Furthermore, the short-term and long-term improvement in ADHD symptoms, academic/occupational functioning, and social/mental health have not been shown to be sustained if medication and/or psychosocial educational interventions are stopped.[6,9,10]
Some authors recommend that medications be prescribed based upon likely family compliance with psychosocial/educational recommendations and that drug holidays or definite plans to discontinue medication be formulated.[11,12] Behavioral counseling is also recommended in family setting. The primary care physician should seek consultation if there are comorbid mental disorders, a developmental delay, if the child is very young, or if there is not the expected response to given interventions.
Diagnosis and Treatment of ADHD in Adults
The DSM-IV outlines the criteria necessary to make the diagnosis of ADHD in both children and adults. The diagnosis of adult ADHD is usually a difficult one to make, because it requires integration of a broad range of information in the absence of a definitive diagnostic tool. A large differential diagnosis and a high rate of comorbid conditions further complicate making this diagnosis. Attention-deficit/hyperactivity disorder in an adult can only be diagnosed by DSM-IV criteria if the individual had ADHD symptoms as a child. If no diagnosis of ADHD was made in childhood, a retrospective determination of ADHD symptoms is required to make the diagnosis in adulthood. By strict adherence to the requirements of the DSM-IV, symptoms would have had to be present before the age of 7 years, although this specific age-of-onset criterion has been questioned. In order to establish a retrospective diagnosis of ADHD, obtaining a thorough history is paramount. The history should include parental reports of ADHD symptoms in a variety of settings, objective accounts of school conduct and performance, and previous psychiatric therapies.[15,16]
The triad of inattention, impulsivity, and hyperactivity symptoms are usually not present in adults with ADHD. Inattention is the most prominent symptom, seen in over 90% of adults with this disorder, while hyperactivity is less often a problem and is possibly the reason adult ADHD initially went unrecognized. The effects of adult ADHD can be strikingly similar to those seen in children (eg, school failure, occupational failure, legal problems, difficulty with interpersonal relationships). Bresnahan et al compared electroenceophalogram (EEG) findings in children, adolescents, and adults diagnosed with ADHD, and found that the changing symptoms in these age groups correlated with subtle differences in their EEGs.
There are several self-reporting tools used to screen for adult ADHD. Examples of these scales include the Wender Utah Rating Scale and the Copeland Symptom Checklist for Adult Attention Deficit Disorders. Although use of self-reporting scales in adults has been shown to accurately describe ADHD symptomatology, the scales lack specificity. Additional measures are needed to assist in making the diagnosis of adult ADHD.[19,20] Rating scales may aid in monitoring the symptoms and course of the disease.
The differential diagnosis of ADHD must exclude comorbid psychiatric conditions, such as major depression and substance abuse. Medical conditions in the differential diagnosis include hyperthyroidism, hepatic disease, intoxications, and sleep-disordered breathing. A thorough medical evaluation, including a thyroid panel, serum lead level, and urine drug screen, are indicated to rule out these disorders. No specific neuropsychologic testing is recommended for the diagnosis of ADHD, but it may be useful when the diagnosis is uncertain. The testing should be individualized for each patient.
Personality traits have been associated with adults who have ADHD, particularly an increased incidence of mild histrionic traits. Adults with ADHD and comorbid disorders demonstrated avoidant and dependent personality styles. When oppositional defiant disorder occurs with ADHD, avoidant, narcissistic, antisocial, aggressive-sadistic, and negativistic traits are often found.
Adults with ADHD frequently have comorbid disorders, including substance abuse, depression, oppositional defiant disorder, and panic disorder. Whether incidence of substance abuse is increased in adults with ADHD is unclear. Biederman et al[23,24] have published several articles implicating ADHD as a risk factor, but Lynskey et al question this association without a concomitant diagnosis of a conduct disorder.
Treatment for adults includes medication and psychosocial interventions. Medication continues to be the mainstay of treatment in adults because of its demonstrated short-term benefits; however, medication has not been shown to improve the long-term outcome of ADHD. Stimulant medications, such as methylphenidate hydrochloride, amphetamine, and pemoline, have been the most popular. Weight-adjusted doses of methylphenidate hydrochloride had a 74% efficacy in adults, similar to what has been found in children. Treatment with desipramine hydrochloride, a tricyclic antidepressant, showed a similar efficacy of 68%, and may be a good alternative for adults who cannot tolerate or have a contraindication to stimulants.[28,29] Buproprion hydrochloride therapy showed good efficacy in adults with ADHD in a randomized, double-blind, placebo-controlled trial.
The role of psychosocial interventions in adults is less clearly defined. The main form of therapy used in adults with ADHD is cognitive behavioral therapy, which includes problem-solving strategies, self-monitoring, self-reinforcement, and skills training. The goal of these therapies is to improve self-control. Psychosocial interventions, like medication, have not been shown to improve the long-term outcome of ADHD.
Hechtman describes 3 outcomes of adult ADHD. Thirty percent of adults with this disorder function well and are not different from adults who do not have ADHD. The majority of adults with ADHD continue to have problems with concentration, impulsivity, and social interactions, resulting in educational, occupational, and social problems. The third group consists of a minority (10%-15%) of adult ADHD patients with frequent hyperactivity who have concomitant significant psychiatric or antisocial symptoms. Peer-controlled, prospective follow-up studies on ADHD in adolescents and adults confirmed the above findings.
Transition of Care of ADHD Patients from Pediatricians to Primary Physicians Who Care for Adults
There are 2 circumstances in which primary care physicians of adults may encounter a patient who presents with adult ADHD. The patient may have been previously diagnosed in his youth or never have been previously diagnosed but have the disorder. A primary care physician may also have cared for the pediatric patient and may continue care for that patient in adulthood.
Diagnosing ADHD is challenging because of the large differential diagnosis, the many possible comorbidities, and the lack of a definitive diagnostic test.[4-6,8,10] Since the majority of children who are diagnosed with ADHD show no evidence of any mental disorder in adulthood, those who continue to have the disorder are a select group. Some possible explanations are that an incorrect diagnosis of ADHD was made, a comorbid diagnosis was missed or has subsequently occurred, treatment has been ineffective (possibly because of poor compliance), and/or the patient has a more complicated form of ADHD with persistent morbidity.
The physician who assumes care of an adult with a previous diagnosis of ADHD should determine how the initial diagnosis was made. Careful review of the record is necessary to determine the presenting symptoms, the evaluators, physical examination findings, medication use, prior medical disorders, and family history. The background of the diagnostician(s) must also be determined. Results of diagnostic tests (particularly psychoeducational testing and speech and language testing) should be reviewed. Records should also be reviewed to determine what medications and psychosocial and educational interventions have been tried, and what impact the interventions had.
A comprehensive medical and psychosocial history, as well as a complete physical examination, should be performed. An attempt should be made to obtain a medical history from a spouse or significant other, parents, other close relatives, teachers, employers, and/or friends. The updated assessment will likely take 2 or 3 visits to complete. Based upon the expertise of the primary care physician and the complexity of the case, consultation with a behavioral subspecialist should be considered. The primary care physician who is maintaining care of an adult with ADHD should also review how the diagnosis was made and examine previous treatment effects. An updated history, including sources other than the patient, should be taken and physical examination should be done.
Medication and psychosocial interventions continue to be the treatment options in adult ADHD. Unfortunately, no intervention has been shown to improve the long-term outcome of ADHD.[7,9,10] Stimulant medications, particularly methylphenidate hydrochloride and amphetamine, the primary treatment for adult ADHD, are controlled substances. Other kinds of medications, such as desipramine hydrochloride and buproprion hydrochloride, have been found to provide effective treatment in adults.[28-30] Prescribing these medications eliminates the possibility of stimulant abuse. Referral of adults for psychosocial interventions not offered by the primary care physician should be made. Consultation with or referral to a behavioral specialist should occur if increasing doses of stimulant medications are required, if multiple psychoactive drugs are needed, or if social, academic, or occupational functioning does not improve with optimization of pharmacologic and psychosocial interventions.
Although ADHD is the mental health disorder in the DSM-IV that has been most extensively studied in children, it continues to generate a great deal of controversy associated with diagnosis and treatment.[10,34] This is true, in part, because the number of symptoms required by the diagnostic criteria for ADHD has never been empirically validated, generally being defined as "often", which makes judgment of the existence of symptoms subjective. Treatment with stimulant medication is controversial because it has long been known that clinical response is the same in normal children and children with the ADHD diagnosis. It is also known that the diagnosis and treatment of ADHD in clinical practice may not reflect what is done in optimal, research-type settings.
A recent commentary in a supplement to Developmental and Behavioral Pediatrics highlights the controversy surrounding the diagnosis and treatment of ADHD in early childhood. An increase of more than 700% in the production of methylphenidate hydrochloride and of more than 2,500% in amphetamine production occurred in the United States between 1991 and 2000. Although guidelines for diagnosis and treatment of ADHD are available, it has been found that the use of methylphenidate hydrochloride (Ritalin) in primary care and community medicine is inconsistently linked to the ADHD diagnosis. The use of methylphenidate hydrochloride, which has escalated in the last decade, varies widely in different communities throughout the United States. Government policy may have affected the diagnosis and treatment of ADHD; the Individuals With Disabilities Act in 1991 made ADHD a covered diagnosis for education disability services, which correlated with the increase in both ADHD diagnosis and stimulant use.
The National Institute of Mental Health multimodal treatment study for ADHD has been touted as the gold standard for research in mental health disorders of children. The detailed analysis of this study by Pelham raises questions about the design of this research and the validity of the authors' conclusion that medication alone is the preferred treatment for childhood ADHD. The multimodal treatment study had 4 treatment groups: 1) medication alone (38 mg/day of methylphenidate hydrochloride); 2) intensive behavioral treatment (including parent training, a summer treatment program, and a school intervention with a short-term classroom aide); 3) a combination of behavioral interventions with medication; and 4) a community control group that received a mean prescribed dose of 23 mg/day of methylphenidate hydrochloride. Nineteen outcome measures were assessed over a 14-month period. It is noteworthy that the intensive behavioral interventions were reduced 4 to 5 months before the end of this period, while medication doses remained at maximally tolerable levels throughout the study.
All 4 treatment groups showed striking improvement from the time of baseline measurements to completion of the study 14 months later. Behavioral treatment was as effective as medication alone on 16 of 19 outcome measures, and was generally equivalent to community treatments. The results of combined treatment did not differ appreciably from those of medication management, but were generally superior to those of behavioral treatment. Both medication management and combined treatment were generally superior to community treatments. Although other authors have concluded that medication alone is the preferred treatment for ADHD, Pelham concludes that combined treatment, which "normalized" a higher rate of children than either medication or behavioral intervention alone, is the preferred treatment. He also notes that behavioral improvement is sustained after interventions are withdrawn, whereas medication effects stop. The persistence of improved symptoms may be one of the reasons that parents prefer the inclusion of behavioral treatment in the care of their children, rather than the use of medication alone.
The fact that stimulants are controlled substances with known abuse potential results in middle and high school students being approached to sell or trade their ADHD medications. Although research has indicated that children with ADHD treated with stimulant medication are less likely to abuse drugs than those who were not medicated, these patients are nevertheless using a controlled substance with the potential for abuse. The primary use of a controlled substance to treat ADHD raises philosophic questions, especially in children who may require lifelong treatment, which may explain why this disorder continues to generate heated controversy.
The diagnosis and treatment of ADHD are very complex and controversial. Although there is consensus that this disorder exists, professionals continue to struggle to make an accurate diagnosis and prescribe treatments with established long-term efficacy. Thoughtful, comprehensive care, both diagnostically and therapeutically, needs to be provided for patients who present with ADHD symptoms. A thorough reassessment should be done when a patient previously diagnosed with ADHD transitions from pediatric to adult primary care. Physicians must vigilantly monitor the evolving research related to this complex disorder to ensure that they continue to provide the quality of care that children and adults with ADHD symptoms need.
The print version of this article was originally certified for CE credit. For accreditation details, contact the publisher (Southern Medical Association, 35 Lakeshore Dr, Birmingham, AL 35209, telephone: (205) 945-1840; fax (205) 945-1840).
Hill J, Schoener E: Age-dependent decline of attention deficit hyperactivity disorder. Am J Psychiatry 1996; 153:1143-1146
Faraone SV, Biederman J, Spencer T, et al: Attention-deficit/hyperactivity disorder in adults: an overview. Biol Psychiatry 2000; 48:9-20
Millstein RB, Wilens TE, Biederman J, et al: Presenting ADHD symptoms and subtypes in clinically referred adults. J Attent Disorders 1997; 2:159-166
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (DSM-IV). Washington, DC, American Psychiatric Association, 1994, pp 78-85
Wolraich M, Felice ME, Drotar D: The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Elk Grove Village, Ill, American Academy of Pediatrics, 1996, pp 93-102
Dulcan M: Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 1997; 36 (suppl 10):85S-121S
Greenhill LL, Pliszka S, Dulcan MK, et al: Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 2002; 41(suppl 2):26S-49S
American Academy of Pediatrics: Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2001; 105:1158-1170
American Academy of Pediatrics: Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001; 108:1033-1044
National Institutes of Health: Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD). NIH Consens Statement 1998; 16:1-37
Taylor MA: Attention-deficit hyperactivity disorder on the frontlines: management in the primary care office. Compr Ther 1998; 25:313-325
Gordon N: Attention deficit hyperactivity disorder: possible causes and treatment. Int J Clin Pract 1999; 53:524-528
Cipkala-Gaffin JA: Diagnosis and treatment of attention-deficit/hyperactivity disorder: Perspect Psychiatr Care 1998; 34:18-25
McGough JJ, McCracken JT: Assessment of attention deficit hyperactivity disorder: a review of recent literature: Curr Opin Pediatr 2000; 12:319-324
Searight HR, Burke JM, Rottnek F: Adult ADHD: evaluation and treatment in family medicine. Am Fam Physician 2000; 62:2077-2086,2091-2092
Trollor JN: Attention deficit hyperactivity disorder in adults: conceptual and clinical issues. Med J Aust 1999; 171:421-425
Bresnahan SM, Anderson JW, Barry RJ: Age-related changes in quantitative EEG in attention-deficit/hyperactivity disorder. Biol Psychiatry 1999; 46:1690-1697
Murphy P, Schachar R: Use of self-ratings in the assessment of symptoms of attention deficit hyperactivity disorder in adults. Am J Psychiatry 2000; 157:1156-1159
McCann BS, Scheele L, Ward N, et al: Discriminate validity of the Wender Utah Rating Scale for attention-deficit/hyperactivity disorder in adults. J Neuropsychiatry Clin Neurosci 2000; 12:240-245
Schweitzer JB, Cummins TK, Kant CA: Attention-deficit/hyperactivity disorder: advances in the pathophysiology and treatment of psychiatric disorders: implications for internal medicine. Med Clin North Am 2001; 85:757-777
Fargason RE, Ford CV: Attention deficit hyperactivity disorder in adults: diagnosis, treatment, and prognosis. South Med J 1994; 87:302-309
May B, Bos J: Personality characteristics of ADHD adults assessed with the Million Clinical Multiaxial Inventory-II: evidence of four distinct subtypes. J Pers Assess 2000; 75:237-248
Biederman J, Wilens TE, Mick E, et al: Does attention-deficit hyperactivity disorder impact the developmental course of drug and alcohol abuse and dependence? Biol Psychiatry 1998; 44:269-273
Biederman J, Wilens T, Mick E, et al: Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 1999; 104:E20
Lynskey MT, Hall W: Attention deficit hyperactivity disorder and substance use disorders: is there a causal link? Addiction 2001; 96:815-822
Pelham WE Jr, Wheeler T, Chronis A: Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. J Clin Child Psychol 1998; 27:190-205
Spencer T, Wilens T, Biederman J, et al: A double-blind, crossover comparison of methylphenidate and placebo in adults with childhood-onset attention-deficit hyperactivity disorder. Arch Gen Psychiatry 1995; 52:434-443
Wilens TE, Biederman J, Mick E, et al: A systematic assessment of tricyclic antidepressants in the treatment of adult attention-deficit hyperactivity disorder. J Nerv Ment Dis 1995; 183:48-50
Wilens TE, Biederman J, Prince J, et al: Six-week, double-blind, placebo-controlled study of desipramine for adult attention deficit hyperactivity disorder. Am J Psychiatry 1996; 153:1147-1153
Wilens TE, Spencer TJ, Biederman J, et al: A controlled trial of buproprion for attention deficit hyperactivity disorder in adults. Am J Psychiatry 2001; 158:282-288
Hechtman L: Attention-deficit/hyperactivity disorder: predictors of long-term outcome in children with attention-deficit/hyperactivity disorder. Pediatr Clin North Am 1999; 46:1039-1052
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Giedd JN: Bipolar disorder and attention-deficit/hyperactivity disorder in children and adolescents. J Clin Psychiatry 2000; 61(suppl 9):31-34
Carey WB: Problems in diagnosing attention and activity. Pediatrics 1999; 103:664-667
Rapoport JL, Buschbaum MS, Zahn TP, et al: Dextroamphetamine in normal boys. Science 1978; 199:560-563
Jensen PS: Current concepts and controversies in the diagnosis and treatment of attention deficit hyperactivity disorder. Curr Psychiatry Rep 2000; 2:102-109
Diller LH: Lessons from three-year-olds. Devel Behav Pediatr 2002; 23:S10-S11
Pelham WE Jr: The NIMH multimodal treatment study for attention-deficit hyperactivity disorder: just say yes to drugs alone? Can J Psychiatry 1999; 44:981-990
Moline S, Frankenberger W: Use of stimulant medication for treatment of attention-deficit/hyperactivity disorder: A survey of middle and high school students' attitudes. Psychol Schools 2001; 38:569-584
Sidebar: Key Points
Childhood attention-deficit/hyperactivity disorder persists in adults more often than was previously hypothesized, but with a lesser male predominance.
Reassessment of an adult previously diagnosed with childhood attention-deficit/hyperactivity disorder is recommended.
Primary diagnosis of attention-deficit/hyperactivity disorder in adulthood is complicated and usually requires consultation.
The diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adults continues to be problematic because of the lack of definitive diagnostic tests and difficulty in evaluating long-term clinical outcomes.
Clinical Trials Involving ADHD. Details and contact information for current studies can be obtained from the National Institute of Mental Health Web site (http://www.nimh.nih.gov) and from the National Institutes of Health clinical trials Web site (http://www.clinicaltrials.gov).
A Behavioral and Functional Neuroimaging Study of Inhibitory Motor Control: This is an outpatient 2-day evaluation study comparing behavior on a computer game between children (ages 7-10) with and without ADHD.
Methylphenidate Efficacy and Safety in ADHD Preschoolers: This is an outpatient treatment study of methylphenidate hydrochloride to examine its safety and efficacy in treating ADHD in preschool and school-age children (aged 3-5 years, 6-8 years).
Brain Imaging of Childhood Onset Psychiatric Disorders, Endocrine Disorders and Healthy Controls: This is an outpatient evaluation study of identical twins, aged 6-16 years, where only one twin has the ADHD diagnosis. Magnetic resonance imaging (MRI), computerized tests, and psychoeducational batteries will be used to study the twins.
Genetic Aspects of Neurologic and Psychiatric Disorders: The purpose of this observational study is to explore the genetic causes of specific neurologic and psychiatric disorders, particularly mental retardation, childhood-onset schizophrenia, ADHD, atypical psychosis of childhood, and bipolar affective disorder. Molecular genetic techniques will be used to identify the areas of chromosomes containing genes responsible for the development of these disorders.
Anatomic MRI Brain Imaging of White Matter in Children: This observational study will use MRI to examine connections between brain regions in children with and without learning/behavioral problems. The study will focus on twin pairs from 6 to 21 years of age, either with or without ADHD.
Cortical Correlates of Subtle Motor Signs in Children with Attention-Deficit/Hyperactivity Disorder and Healthy Controls -- A Study Using Single and Paired Pulse Transcranial Magnetic Stimulation (TMS): This observational trial will use TMS to analyze the association of clinical abnormalities with any delay/abnormality in maturation of areas of the nervous system responsible for motor activity.
Biological Markers in Childhood Psychiatric Disorders: In this observational study, researchers will examine the anatomy of brain development to better understand the causes of ADHD. This study will further analyze a group of patients previously diagnosed with ADHD by giving them structured psychiatric interviews and neuropsychologic tests. They will have MRI of the brain repeated, as well as further clinical and genetic testing.
A Behavioral and Functional Neuroimaging Study of Inhibitory Motor Control: This observational study will examine the brain's control over a motor act, such as pushing a button. This will help to assess whether an inhibitory deficit exists in children with ADHD.
Multimodal Treatment Study of Children with ADHD: This continuation of the MTA Study will track the persistence of intervention-related effects; test hypotheses regarding predictors, mediators, and moderators of long-term outcome in children with ADHD, and study patterns of risk/protective factors. This follow-up extends the study to 36, 60, and 84 months post-treatment.
Nutrient Intake in Children with Attention Deficit Hyperactivity Disorder: This observational study will examine the nutrient intake of children with ADHD and study the occurrence of carbohydrate craving in these children.
Methylphenidate for Hyperactivity and Impulsiveness in Children and Adolescents with Pervasive Developmental Disorders: This interventional study will examine the efficacy and safety of methylphenidate hydrochloride for treating hyperactivity, impulsiveness, and distractibility in children/adolescents with pervasive developmental disorders (PDD).
Psychopharmacology of Adolescents with Alcohol-use Disorder and ADHD: This interventional study will compare the effectiveness of buproprion hydrochloride versus placebo in the treatment of adolescents with ADHD and alcohol-use disorder.
A Treatment Study of Youth with Comorbid Attention Deficit Hyperactivity Disorder (ADHD) and Anxiety Disorder: This interventional study will gather information on the efficacy and safety of pharmacotherapy for children and adolescents (aged 6-17 years) with both ADHD and anxiety disorders. Stimulant medication will be studied alone and in combination with a selective serotonin reuptake inhibitor.
Attention Deficit Disorder and Exposure to Lead: This observational study examines lead's possible contribution to ADHD by assessing the past lead exposure of children with and without ADHD. X-ray fluorescence spectroscopy will be used to assess bone lead levels.
Clonidine in ADHD: This interventional study will evaluate the benefits and side effects of clonidine hydrochloride and methylphenidate hydrochloride used alone and in combination in children with ADHD.
The National Institute of Mental Health has a link on its Web site for information for the public (http://www.nimh. nih.gov). This section has information on available books, informational materials, and fact sheets in English and Spanish.
The National Institute of Mental Health has a link on its Web site for information for practitioners (http://www.nimh.nih.gov).
Patient handouts on ADHD can be found in English and Spanish at http://www.familydoctor.org, a site sponsored by the American Academy of Family Physicians.
Attention Deficit Information Network (Ad-IN), 475 Hillside Ave, Needham, MA 02194. Telephone: (781) 455-9895. Web site: www.addinfonetwork.com
National Attention Deficit Disorder Association (ADDA), 1788 Second St, Suite 200, Highland Park, IL 60035. Telephone: (847) 432-ADDA (2332). Web site: http://www.add.org
Children and Adults with Attention Deficit Disorders (CHADD), 8181 Professional Pl, Suite 201, Landover, MD 20785. Telephone: (800) 233-4050, (301) 306-7070. Web site: http://www.chadd.org
Alfutis S: Inside Attention Deficit Disorder: A Collection of Thoughts and Feelings on ADD by an Adult Who has Been There. Toledo, Ohio, ADDult Support Network, 1991. Available from ADDult Support Network, 2620 Ivy Place, Toledo, OH 43613. $16.00
Barkley RA: Hyperactive Children: A Handbook for Diagnosis and Treatment. New York, Guilford Press, 1981
Barkley RA: Defiant Children: A Clinician's Manual for Assessment and Parent Training. New York, Guilford Press, 2nd Ed, 1997
Barkley RA: Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York, Guilford Press, 1998
Barkley RA, Murphy KR: Attention Deficit/Hyperactivity Disorder: A Clinical Workbook. New York, Guilford Press, 1998
Goldberg R: Sit Down and Pay Attention: Coping with ADD Throughout the Life Cycle. Washington, DC, PIA Press, 1991
Weiss L, Hechtman L: Hyperactive Children Grown Up: ADHD in Children, Adolescents and Adults. New York, Guilford Press, 1993
American Academy of Pediatrics: The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Elk Grove Village, Ill, American Academy of Pediatrics, 1996
Dulcan M: Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. J Am Acad Adolesc Psychiatry 1997; 36(suppl 10):85S-121S
Greenhill LL, Pliszka S, Dulcan MK, et al: Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 2001; 41(suppl 2):265-495
American Academy of Pediatrics: Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/ hyperactivity disorder. Pediatrics 2000; 105:1158-1170
American Academy of Pediatrics: Clinical practice guideline: treatment of the school-aged child with attention-deficit/ hyperactivity disorder. Pediatrics 2001; 108:1033-1044
Institute for Clinical Systems Improvement: Diagnosis and Management of Attention Deficit Hyperactivity Disorder in Primary Care, Bloomington, Minn, Institute for Clinical Systems Improvement, 2000. Available at http://www.icsi.org
National Institutes of Health Consensus Development Panel on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder: Diagnosis and treatment of attention deficit hyperactivity disorder. NIH Consens Statement 1998; 16:1-37. Available at: http://consensus.nih.gov
We thank Linda Adams, CPS, for her expert assistance in the preparation of this manuscript, and Michele Stanek, MHS, for providing her expert advice identifying references and resources.
Reprint requests to H. Patrick Stern, MD, Department of Pediatrics, East Tennessee State University, PO Box 70578, Johnson City, TN 37614-1708.
H. Patrick Stern, MD, Asha Garg, MD, Thomas P. Stern, MD, Department of Pediatrics, East Tennessee State University, Johnson City; Department of Family and Preventive Medicine, University of South Carolina -- Columbia; and Internal Medicine/Pediatrics, Charleston, SC
Severe Attention Disorder Linked with Drug Abuse
WASHINGTON (Reuters) - Children with attention deficit/hyperactivity disorder are more likely to smoke, drink and use illegal drugs, U.S. researchers reported on Sunday.
It could be because children with the disorder -- called ADHD -- have trouble paying attention, have problems at school and difficulty with relationships with friends and family. This, in turn, could make them susceptible to abusing drugs and alcohol, the researchers said.
It also shows it is important to diagnose and treat ADHD early, the researchers write in the August issue of the Journal of Abnormal Psychology.
Psychologists Brooke Molina of the University of Pittsburgh School of Medicine and William Pelham of the State University of New York at Buffalo compared 142 teen-agers aged 13 to 18 who had been diagnosed with ADHD to 100 children without ADHD.
They looked for antisocial behavior reported by the teachers and parents and questioned the children.
Children with ADHD had a higher risk of abusing alcohol and heavier drugs, and were more likely to smoke, at younger ages, than non-ADHD children, they found.
"Childhood ADHD symptoms, particularly the inattention dimension of ADHD, predicted later substance use to a greater degree than childhood antisocial behaviors," Molina said in a statement.
About 72 percent of the children still had ADHD as teens and they reported getting drunk more often and more cigarette smoking than adolescents without childhood ADHD.
"A child may begin having poor academic performance and peer difficulties and then gravitate toward nonconformist peer groups as an adolescent where substance abuse is accepted as a way of life," said Molina.
| "AAN: Adults With Restless Legs Syndrome More Likely To Have Attention Deficit Hyperactivity Disorder"
PHILADELPHIA, PA -- May 7, 2001 -- Adults who have restless legs syndrome (RLS) are more likely to also have attention deficit hyperactivity disorder (ADHD) than adults who don't have the sleep disorder, according to research presented during the American Academy of Neurology's 53rd Annual Meeting in Philadelphia, Pennsylvania, May 5-11, 2001. In restless legs syndrome, patients feel sensations of discomfort in their legs when they are sleeping or not active. Moving or stimulating the legs relieves the discomfort. RLS can cause interrupted sleep and fatigue or sleepiness during the day. ADHD is a genetic, biochemical disorder characterized by inattention, restlessness, distractibility and impulsivity. For the study, researchers at the New Jersey Neuroscience Institute at JFK Medical Center in Edison, New Jersey tested 56 adults with restless legs syndrome for ADHD symptoms and compared them to 77 people who did not have RLS. Thirty-nine percent of the patients met the criteria for "possible" ADHD, compared to 14 percent of controls. Of those, 21 percent of the patients met the criteria for "highly probable" ADHD, compared to 4 percent of controls. Twenty-one of the 33 patients and controls with possible ADHD underwent additional, objective psychological testing. Of those, 100 percent of the patients had a profile consistent with that of ADHD, as did 86 percent of the controls. RLS patients with ADHD also had greater anxiety symptoms than controls with ADHD. Those patients who had both restless legs and ADHD also had more severe RLS symptoms than the RLS patients without ADHD. Researchers have a few theories why the disorders appear to be linked. "The leg discomfort from RLS could cause people to be more hyperactive and distractible," said study author Mary L. Wagner, Pharm.D., of Rutgers University in Piscataway, New Jersey . "And being tired from having your sleep disrupted could cause people to be more inattentive. But it's not proven that having RLS leads to having ADHD. It could be that these disorders simply appear together frequently -- they may be genetically linked." Another theory is that both disorders may be caused by a lack of dopamine in the brain. Dopamine is responsible for transmitting signals within the brain. A lack of dopamine can leave patients unable to control their movements normally. Evidence for this theory is that both disorders respond well to drugs that promote dopamine action in the brain. "People with RLS should also be tested for ADHD, and vice versa," Dr. Wagner said. "That way these disorders can be diagnosed and treated more effectively." The risk of ADHD or RLS is greater in people with a family history of the disorder. "A patient with ADHD or his or her family may be more likely to also have RLS, but more study is needed on this," Dr. Wagner said. SOURCE: American Academy of Neurology