OSH
| ATTENTION DEFICIT DISORDER |
ADD Attention deficit disorder
Despite persistent skepticism, the most common childhood psychiatric
disorder is increasingly understood to be a brain malfunction. Different
forms of the disorder may have different biological roots. New versions of
older drugs are being introduced, and new drugs are being considered. Old
and new concerns about the risks of drugs are raised, and there is now
some evidence for alternative treatments. National, regional, and racial
disparities in diagnosis and treatment persist and raise difficult questions.
Discoveries in neuroscience are reinforcing a growing consensus that
attention-deficit/hyperactivity disorder (ADHD), as it is officially known, is not
just a set of behavior problems but a biologically based disorder of brain
function. The symptoms of impulsiveness, inattentiveness, and hyperactivity
arise, this research suggests, because misfiring of the brain’s executive
function — its management system — make it difficult to stay still,
concentrate, and exercise forethought and self-control.
ADHD is known to have a strong genetic component — one of the highest
among psychiatric disorders — and several genetic markers are known.
Similar symptoms have also been found in children with autism and fetal
alcohol syndrome and even those exposed to nicotine in the womb. In two
studies, ADHD-like symptoms appeared in 15 of 29 children who had
strokes, and in 16% of children admitted to trauma centers after a head
injury.
Executive function involves so many brain pathways that its specific
locations are not easy to tease out. But there’s evidence that in children
with ADHD, the disturbance occurs in a circuit that runs between the frontal
cortex, a seat of judgment and planning, and the basal ganglia, which
control habitual actions and convey reward signals. In one study, brain
scans of 10 children with ADHD indicated that they did not engage this
network normally but used other parts of the brain when performing certain
experimental tasks.
Some experts regard the problem as inefficient reception of signals for
delayed rewards. That causes impulsiveness, which in turn causes parents
and teachers with high expectations to criticize and punish the child. After a
while, the child stops trying to undertake projects that require long-range
planning and never learns the necessary skills. So the motivation problem
becomes a problem of executive function.
Stimulants
According to the National Survey on Children’s Health, about 8% of children
and adolescents ages 4–17 (a total of 4.4 million) have a diagnosis of
ADHD, and about 50% of them are taking stimulant medications. The most
important recent development in the drug treatment of ADHD is increased
use of new formulations of these stimulants. As of late 2005, there are
nearly two dozen versions of methylphenidate and dextroamphetamine,
under the old brand names Ritalin and Dexedrine and the more recent
ones Concerta, Metadate, Focalin, Methylin, Adderall, and DextroStat.
Added labels like LA (long-acting) and XR or ER (extended-release) refer to
gradual or staged rather than immediate release of the drug into the
bloodstream.
The long-acting and extended-release forms, which last 8–12 instead of 4–
6 hours, have conquered the market because both children and parents
prefer them. Users avoid the ups and downs produced by shorter-acting
versions. Children taking the long-acting forms don’t suffer the
inconvenience of taking the drug three or four times a day or the
embarrassment of taking it in school. Studies show that they are less likely
to quit than those taking short-acting forms. The most widely used brand in
late 2005 is Concerta, a type of extended-release methylphenidate with
effects that last 12 hours.
Stimulant risks
Meanwhile, spurred partly by reports of suicidal thinking and heart
problems in children taking antidepressants, concern has grown about the
risks of stimulants. In 2005, Canada temporarily suspended marketing of
Adderall XR (a long-acting version of dextroamphetamine) after reports of
sudden cardiac death in child and adult patients taking the drug. But the
FDA has not concluded that stimulants raise the risk of cardiovascular
problems for people without a heart condition.
Some animal experiments raise questions about long-term stimulant effects.
Rats given daily injections of methylphenidate at ages equivalent to human
childhood and adolescence became more sensitive to stress and less
responsive to natural rewards like sugar water as adults. Interpreting these
findings is not simple, because rats don’t absorb drugs exactly as humans
do, and injection directly into the abdominal cavity does not have the same
effect as swallowing a pill. Studies on monkeys might clarify some of these
issues.
The addiction question
Dextroamphetamine and methylphenidate can be addictive. In their mode of
action and effects, they are similar to cocaine and the latest illicit drug
scourge, methamphetamine. And stimulants are being used to enhance
performance — by college students to win grades, by professional athletes
to win games. But these users usually take the drugs orally, so they pass
into and out of the brain too slowly to produce the highs and lows of
addiction. The risk of addiction is even less when the drug is packaged for
gradual or staged absorption. One reason for the popularity of Concerta is
that it must be swallowed whole; it cannot be broken up into a powder and
snorted or injected.
One review suggests that ADHD drugs actually lower the risk of later
addiction. This research is not based on controlled studies, and correlation
should not be confused with cause. Animal experiments have given
conflicting results. There is no reliable evidence that taking ADHD
medications affects the rate of addiction in later life.
Other drugs
The search for alternative drugs will continue as long as 30% of children
with ADHD do not respond to stimulants or cannot tolerate their side
effects. In 2002, for the first time in many years, the FDA approved a new
treatment for ADHD. Atomoxetine (Strattera) is apparently not addictive and
is therefore uniquely approved for adults as well as children. The FDA has
issued a warning about possible liver failure after two cases were reported
(both recovered). The FDA is also requiring a warning about suicidal
thinking on prescription labels. This caution is based on limited evidence
from clinical trials.
Other potential drug treatments, all experimental, include the alpha-2
adrenergic agonists clonidine and guanfacine; modafinil (Provigil); and the
antidepressants venlafaxine (Effexor), bupropion (Wellbutrin), imipramine
(Tofranil), and desipramine (Norpramin). All these drugs, like atomoxetine
and stimulants, increase the activity of norepinephrine or dopamine or both
— neurotransmitters that act in the brain pathways thought to be affected
by ADHD.
In 2005, magnesium pemoline (Cylert), which was rarely used and already
carrying warnings about liver failure, lost its FDA approval and was
removed from the market. Also in 2005, a review of 146 studies conducted
at the Oregon Evidence-Based Practice Center concluded that little is
known about the comparative effectiveness or side effects of different
versions of methylphenidate, dextroamphetamine, and atomoxetine and
even less about the alternative drug treatments. Individual genetic
differences probably affect responses to the drugs, and they may differ in
their effects on specific symptoms of attention deficit disorder — a hint that
more precisely targeted drug treatments could be developed.
Other approaches
Children diagnosed with ADHD often receive little more than medications —
not even further guidance from a physician. The American Academy of
Pediatrics guidelines recommend that families stay in frequent contact with
a doctor until the dose is adjusted and every few months after that. But in
one survey, the average was one follow-up visit in six months.
It’s not just that nondrug treatments are more expensive and time-
consuming. The trouble is that behavior therapy and psychotherapy have
been disappointing in controlled trials. Still, many parents and professionals
remain skeptical about medications because of concern about their long-
term effects, and many children and adolescents do not want to take drugs.
So the interest in alternatives persists. And there is preliminary evidence
that psychosocial treatment may be helpful if it continues long enough.
Extending an earlier program to two years, researchers found that parent
training, school intervention, and a special summer day camp program
reduced and occasionally eliminated the need for stimulant drugs in five-
and six-year-old children with ADHD.
Is television bad and green good for ADHD?
The American Academy of Pediatrics says that children should watch no
more than one hour a day of slow-paced programming before age six. But
according to parents, the average is 3½ hours a day by age four, much of it
consisting of fast-paced cartoons. It’s been suggested that exposure to
hours of rapid image and scene changes makes non-virtual life seem
boring by comparison and may even slow or divert brain development. But
cause and effect are not clear. Preoccupied or neglectful parents might let
children watch too much television, and children who love television too
much may also be more susceptible, for genetic or social reasons, to
hyperactivity and distraction.
Not only less exposure to television but more exposure to nature might be
good for children with attention problems. Several studies have found that
impulse control and other ADHD symptoms improved when children had
more access to trees and grass. This evidence, like the evidence for
damaging effects of television, is limited, and its practical significance might
be doubted. Still, it can’t hurt any child to spend less time as a couch potato
and more time outdoors in parks and playgrounds, woods and fields.
The persistence of ADHD
Probably the most important recent change in the understanding of ADHD
is the growing recognition that people don’t always grow out of it. The
number of adults receiving drug treatment for ADHD more than doubled
from 2001 to 2005 alone. The symptoms may even interfere with daily life
more in adults than in children because adults have to exercise more self-
control and do more planning.
In 2003, adult ADHD was included in a national survey for the first time;
4.4% of adults age 18–44 received the diagnosis, about half the rate in
children. The only childhood risk factor for persistence into adulthood was
the severity of the symptoms. ADHD is much more common in boys than
girls, but adult women are now using ADHD drugs just as much as men the
same age. Some think the symptoms are recognized more often in boys
because their behavior is more troublesome, and less often in adult men
because they don’t seek help.
It’s been said that identifying ADHD in adults can be like finding a missing
jigsaw piece that solves the puzzle of behavior that looked like laziness, a
character flaw, or a learning disability. Medications, group social skills
training, individual psychotherapy, vocational counseling, and coaching
may be helpful for adults with ADHD. The first controlled study of cognitive
behavioral therapy for adult ADHD, published in 2005, found improvements
in anxiety, depression, and attention.
Cultural issues
The diagnosis and treatment for ADHD still depend on who you are and
where you live. In some countries the disorder is rarely diagnosed. The rate
of stimulant use, for example, is as much as 10 times higher in the United
States than in Great Britain. Within the U.S., there is a great deal of
regional variation, and blacks and Hispanics are less likely to receive the
diagnosis than whites. A 2005 study found that African American parents
regard the problem chiefly as misbehavior and do not like to seek help
outside the family. They may mistrust the medical system or fear the stigma
of a diagnosis.
National, racial, and regional variations in the diagnosis may raise
unsettling questions about whether ADHD is a legitimate psychiatric or brain
disorder, but most experts believe it occurs all over the world in a similar
pattern. One review confirms this by showing that the disorder looks the
same in every way in Brazil and the United States. There may be room for
cultural variation, though, as long as the diagnosis is made only if
symptoms occur in more than one setting and interfere seriously with
personal life, work, or school.
National Institute of Mental Health
Despite persistent skepticism, the most common childhood psychiatric
disorder is increasingly understood to be a brain malfunction. Different
forms of the disorder may have different biological roots. New versions of
older drugs are being introduced, and new drugs are being considered. Old
and new concerns about the risks of drugs are raised, and there is now
some evidence for alternative treatments. National, regional, and racial
disparities in diagnosis and treatment persist and raise difficult questions.
Discoveries in neuroscience are reinforcing a growing consensus that
attention-deficit/hyperactivity disorder (ADHD), as it is officially known, is not
just a set of behavior problems but a biologically based disorder of brain
function. The symptoms of impulsiveness, inattentiveness, and hyperactivity
arise, this research suggests, because misfiring of the brain’s executive
function — its management system — make it difficult to stay still,
concentrate, and exercise forethought and self-control.
ADHD is known to have a strong genetic component — one of the highest
among psychiatric disorders — and several genetic markers are known.
Similar symptoms have also been found in children with autism and fetal
alcohol syndrome and even those exposed to nicotine in the womb. In two
studies, ADHD-like symptoms appeared in 15 of 29 children who had
strokes, and in 16% of children admitted to trauma centers after a head
injury.
Executive function involves so many brain pathways that its specific
locations are not easy to tease out. But there’s evidence that in children
with ADHD, the disturbance occurs in a circuit that runs between the frontal
cortex, a seat of judgment and planning, and the basal ganglia, which
control habitual actions and convey reward signals. In one study, brain
scans of 10 children with ADHD indicated that they did not engage this
network normally but used other parts of the brain when performing certain
experimental tasks.
Some experts regard the problem as inefficient reception of signals for
delayed rewards. That causes impulsiveness, which in turn causes parents
and teachers with high expectations to criticize and punish the child. After a
while, the child stops trying to undertake projects that require long-range
planning and never learns the necessary skills. So the motivation problem
becomes a problem of executive function.
Stimulants
According to the National Survey on Children’s Health, about 8% of children
and adolescents ages 4–17 (a total of 4.4 million) have a diagnosis of
ADHD, and about 50% of them are taking stimulant medications. The most
important recent development in the drug treatment of ADHD is increased
use of new formulations of these stimulants. As of late 2005, there are
nearly two dozen versions of methylphenidate and dextroamphetamine,
under the old brand names Ritalin and Dexedrine and the more recent
ones Concerta, Metadate, Focalin, Methylin, Adderall, and DextroStat.
Added labels like LA (long-acting) and XR or ER (extended-release) refer to
gradual or staged rather than immediate release of the drug into the
bloodstream.
The long-acting and extended-release forms, which last 8–12 instead of 4–
6 hours, have conquered the market because both children and parents
prefer them. Users avoid the ups and downs produced by shorter-acting
versions. Children taking the long-acting forms don’t suffer the
inconvenience of taking the drug three or four times a day or the
embarrassment of taking it in school. Studies show that they are less likely
to quit than those taking short-acting forms. The most widely used brand in
late 2005 is Concerta, a type of extended-release methylphenidate with
effects that last 12 hours.
Stimulant risks
Meanwhile, spurred partly by reports of suicidal thinking and heart
problems in children taking antidepressants, concern has grown about the
risks of stimulants. In 2005, Canada temporarily suspended marketing of
Adderall XR (a long-acting version of dextroamphetamine) after reports of
sudden cardiac death in child and adult patients taking the drug. But the
FDA has not concluded that stimulants raise the risk of cardiovascular
problems for people without a heart condition.
Some animal experiments raise questions about long-term stimulant effects.
Rats given daily injections of methylphenidate at ages equivalent to human
childhood and adolescence became more sensitive to stress and less
responsive to natural rewards like sugar water as adults. Interpreting these
findings is not simple, because rats don’t absorb drugs exactly as humans
do, and injection directly into the abdominal cavity does not have the same
effect as swallowing a pill. Studies on monkeys might clarify some of these
issues.
The addiction question
Dextroamphetamine and methylphenidate can be addictive. In their mode of
action and effects, they are similar to cocaine and the latest illicit drug
scourge, methamphetamine. And stimulants are being used to enhance
performance — by college students to win grades, by professional athletes
to win games. But these users usually take the drugs orally, so they pass
into and out of the brain too slowly to produce the highs and lows of
addiction. The risk of addiction is even less when the drug is packaged for
gradual or staged absorption. One reason for the popularity of Concerta is
that it must be swallowed whole; it cannot be broken up into a powder and
snorted or injected.
One review suggests that ADHD drugs actually lower the risk of later
addiction. This research is not based on controlled studies, and correlation
should not be confused with cause. Animal experiments have given
conflicting results. There is no reliable evidence that taking ADHD
medications affects the rate of addiction in later life.
Other drugs
The search for alternative drugs will continue as long as 30% of children
with ADHD do not respond to stimulants or cannot tolerate their side
effects. In 2002, for the first time in many years, the FDA approved a new
treatment for ADHD. Atomoxetine (Strattera) is apparently not addictive and
is therefore uniquely approved for adults as well as children. The FDA has
issued a warning about possible liver failure after two cases were reported
(both recovered). The FDA is also requiring a warning about suicidal
thinking on prescription labels. This caution is based on limited evidence
from clinical trials.
Other potential drug treatments, all experimental, include the alpha-2
adrenergic agonists clonidine and guanfacine; modafinil (Provigil); and the
antidepressants venlafaxine (Effexor), bupropion (Wellbutrin), imipramine
(Tofranil), and desipramine (Norpramin). All these drugs, like atomoxetine
and stimulants, increase the activity of norepinephrine or dopamine or both
— neurotransmitters that act in the brain pathways thought to be affected
by ADHD.
In 2005, magnesium pemoline (Cylert), which was rarely used and already
carrying warnings about liver failure, lost its FDA approval and was
removed from the market. Also in 2005, a review of 146 studies conducted
at the Oregon Evidence-Based Practice Center concluded that little is
known about the comparative effectiveness or side effects of different
versions of methylphenidate, dextroamphetamine, and atomoxetine and
even less about the alternative drug treatments. Individual genetic
differences probably affect responses to the drugs, and they may differ in
their effects on specific symptoms of attention deficit disorder — a hint that
more precisely targeted drug treatments could be developed.
Other approaches
Children diagnosed with ADHD often receive little more than medications —
not even further guidance from a physician. The American Academy of
Pediatrics guidelines recommend that families stay in frequent contact with
a doctor until the dose is adjusted and every few months after that. But in
one survey, the average was one follow-up visit in six months.
It’s not just that nondrug treatments are more expensive and time-
consuming. The trouble is that behavior therapy and psychotherapy have
been disappointing in controlled trials. Still, many parents and professionals
remain skeptical about medications because of concern about their long-
term effects, and many children and adolescents do not want to take drugs.
So the interest in alternatives persists. And there is preliminary evidence
that psychosocial treatment may be helpful if it continues long enough.
Extending an earlier program to two years, researchers found that parent
training, school intervention, and a special summer day camp program
reduced and occasionally eliminated the need for stimulant drugs in five-
and six-year-old children with ADHD.
Is television bad and green good for ADHD?
The American Academy of Pediatrics says that children should watch no
more than one hour a day of slow-paced programming before age six. But
according to parents, the average is 3½ hours a day by age four, much of it
consisting of fast-paced cartoons. It’s been suggested that exposure to
hours of rapid image and scene changes makes non-virtual life seem
boring by comparison and may even slow or divert brain development. But
cause and effect are not clear. Preoccupied or neglectful parents might let
children watch too much television, and children who love television too
much may also be more susceptible, for genetic or social reasons, to
hyperactivity and distraction.
Not only less exposure to television but more exposure to nature might be
good for children with attention problems. Several studies have found that
impulse control and other ADHD symptoms improved when children had
more access to trees and grass. This evidence, like the evidence for
damaging effects of television, is limited, and its practical significance might
be doubted. Still, it can’t hurt any child to spend less time as a couch potato
and more time outdoors in parks and playgrounds, woods and fields.
The persistence of ADHD
Probably the most important recent change in the understanding of ADHD
is the growing recognition that people don’t always grow out of it. The
number of adults receiving drug treatment for ADHD more than doubled
from 2001 to 2005 alone. The symptoms may even interfere with daily life
more in adults than in children because adults have to exercise more self-
control and do more planning.
In 2003, adult ADHD was included in a national survey for the first time;
4.4% of adults age 18–44 received the diagnosis, about half the rate in
children. The only childhood risk factor for persistence into adulthood was
the severity of the symptoms. ADHD is much more common in boys than
girls, but adult women are now using ADHD drugs just as much as men the
same age. Some think the symptoms are recognized more often in boys
because their behavior is more troublesome, and less often in adult men
because they don’t seek help.
It’s been said that identifying ADHD in adults can be like finding a missing
jigsaw piece that solves the puzzle of behavior that looked like laziness, a
character flaw, or a learning disability. Medications, group social skills
training, individual psychotherapy, vocational counseling, and coaching
may be helpful for adults with ADHD. The first controlled study of cognitive
behavioral therapy for adult ADHD, published in 2005, found improvements
in anxiety, depression, and attention.
Cultural issues
The diagnosis and treatment for ADHD still depend on who you are and
where you live. In some countries the disorder is rarely diagnosed. The rate
of stimulant use, for example, is as much as 10 times higher in the United
States than in Great Britain. Within the U.S., there is a great deal of
regional variation, and blacks and Hispanics are less likely to receive the
diagnosis than whites. A 2005 study found that African American parents
regard the problem chiefly as misbehavior and do not like to seek help
outside the family. They may mistrust the medical system or fear the stigma
of a diagnosis.
National, racial, and regional variations in the diagnosis may raise
unsettling questions about whether ADHD is a legitimate psychiatric or brain
disorder, but most experts believe it occurs all over the world in a similar
pattern. One review confirms this by showing that the disorder looks the
same in every way in Brazil and the United States. There may be room for
cultural variation, though, as long as the diagnosis is made only if
symptoms occur in more than one setting and interfere seriously with
personal life, work, or school.
National Institute of Mental Health
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