Attention Deficit Hyperactivity Disorder Girls Complications

We have known for a long time that Attention Deficit Hyperactivity Disorder (ADHD) in boys has been associated with increased risk of several psychiatric problems in young adulthood but a recent study published in the American Journal of Psychiatry shows for the first time thst the same applies to girls with ADHD.

The study was a very good one in that it that it was a prospective longitudinal study that used a full follow-up assessment after an average of 11 years after enrollment in the study. There were 96 girls with ADHD who were compared to 91 girls without ADHD. 92% of the girls with ADHD had received medication treatment sometime in the intervening 11 years with 42% receiving treatment in the year preceeding the follow-up.

The researchers found that girls with ADHD had almost a seven times higher risk for developing depression or antisocial disorders, and over twice the risk of developing substance abuse problems, anxiety disorders or eating disorders. There are probably many reasons why this is the case such as general impulsivity and risk taking behavior. The rates of depression were high. Whether this represents genetic factors or the chronic demoralization that comes from problems in school,problems with peers, and problems within the families or some combination of factors.

It is discouraging to see that girls with ADHD have as many psychiatric problems in young adulthood as do boys. Hopefully some information will become available to see if early treatment can prevent these complications but for now we don't know.

Thought for the day

"From my first cry to my final breath God holds my destiny".

The Newsboys

American Academy Addiction Psychiatry 2009 part 2

I want to continue to update you on some of the studies recently presented at the annual meeting of Addiction Psychiatry held earlier this month. As I said before I did not attend the conference. I received my information from medical sites on the web. There was an interesting presentation The study was conducted by a professor of psychiatry at the University of Colorado School of medicine funded by National Institute on Drug Abuse and involved Concerta ( a slow release version of methylphenidate) which is used to treat attention deficit hyperactivity disorder.

The findings from 303 adolescents ranged in age from 13-18 from 11 community based treatment programs who had both ADHD and substance abuse showed that Concerta after a 16 weeks was no more effective in the treatment group than the placebo group. The drugs that were used were marijuana (91%) alcohol (56%) hallucinogens (12%) cocaine 10%) and smaller numbers for opioid and amphetamine abuse. One confounding factor which needs to be investigated further is that both the treatment and placebo groups received cognitive behavioral therapy. Both groups showed improvement but there is always improvement in placebo groups so we don't know whether the cognitive behavioral therapy had any effect or not. The study was not designed to address that question. But it is clear that Concerta is generally of no value in treating adolescents with ADHD who are abusing alcohol and drugs. It will be interesting to see if similar studies will show the same lack of effectiveness. I don't think any of the pharmaceutical companies will funding or helping fund such research.


Thought for the day


If you are abusing alcohol and drugs you might as well quit taking your medication as it won't work unless you quit.

INTUNIV Attention Defict Hyperactivity Disorder

Shire pharmaceuticals has announced the release of a new medication for Attention Deficit Hyperactivity Disorder (ADHD). They have received FDA approval to market and sell INTUIV which is a long acting form of the medication guanfacine. Guanfacine is a medication that is used to treat high blood pressure but has long been used as a third or fourth line treatment for ADHD when stimulants, Strattera, or imipramine were unsuccessful or could not be tolerated or safely used. It has a chemical cousin, clonidine, which also has been used. Now guanfacine has been approved as a first line treatment.

Guanfacine has been approved for the use in children and adolescents ages 6 - 17. It is thought to work by affecting norepinephrine receptors in the prefrontal cortex, an area thought to be implicated in ADHD. Gunfacine is not a controlled substance, is not a stimulant, and has no abuse potential. Like many medications it has it's potential drawbacks as well. Common side effects are sedation, headaches, fatigue, upper abdominal pain and small changes in heart rate and blood pressure. In some patients it can cause a potentially dangerous drop in blood pressure and heart rate leading to fainting episodes. It should not be mixed with any othrt medication that can lower the blood pressure or heart rate.

Having another option for ADHD, particularly one that is not abusable is welcome. It is good to have another first line treatment. It does bring up the point I have made before about the need for caution in using any of the ADHD medications as they all have some effects on the cardiovascular system. It is my belief that all patients who are going to take these medications should have a prescreening electrocardiogram to help rule out any underlying heart disease. Not everyone agree with me about this. The American Heart Association does but the pediatric and pediactric psychiatry organizations have not yet adopted this viewpoint. I hope they will.

Thought for the day

All medical treatments have risks as well as benefits.

Attention Deficit Hyperactivity Disorder Update

I recently completed a series on Attention Deficit Hyperactivity Disorder (ADHD) where I mentioned the possibility of increased risk of sudden cardiac death in those children taking Ritalin or other stimulant medication. This was based on anecdotal reports. A study just published in the American Journal of Psychiatry demonstrates fairly conclusively that there is some small risk. This has been difficult to study as sudden death in children is a very rare event. Because of this and the methodological limitations of the study the FDA has urged caution in interpreting the results.

The FDA released a statement that says "Given the limitation of this study's methodology, the FDA is unable to conclude that these data affect the overall risk and benefit profile of stimulant medication used to treat ADHD in children. FDA believes that this study should not serve as a basis for parents to stop a child's stimulant medication".

It does serve as a reminder though that all medical treatments carry some risk. It also confirms my idea that the American Heart Association is correct by recommending routine electrocardiogram screening in addition to taking a careful history prior to stating someone on stimulant medication for ADHD. The American Academy of Pediatrics has disagreed with this recommendation but perhaps may change their viewpoint in light of this study.

Thought for the day

All medical treatments carry some risk.

Attention Deficit Disorder part 6

This is the second to the last in a series on Attention Deficit Hyperactivity Disorder (ADHD). Today I would like to talk about the unique medication atomoxatine or Strattera. Next we will review some behavioral and psychosocial treatments.

Strattera is the only non stimulant medication that is FDA approved for the treatment of ADHD. It is a selective norepinephrine reuptake inhibitor that works by making available more of the neurotransmitter norepinephrine which is responsible for alertness and attention focusing. It is very similar to some antidepressant medications and unlike stimulants has no abuse potential. This makes it an ideal medication to use in those patients who have substance abuse problems as well as ADHD.

Unlike the stimulants Strattera does not carry a "black box warning" about abuse potential. Instead, like antidepressants it carries a black box warning of increased risk of suicidal ideation in children or adolescents which is the same for all
antidepressants. The black box indicates though that no suicides have been reported and recommends close monitoring. Like all medication it carries some risks and I will discuss these below.

Like the stimulants two of the major risks are cardiovascular and psychiatric. Strattera does increase the blood pressure to a small degree and should be used with caution in those who have hypertension, cerebral vasular disease or underlying cardiac disease. There have been reports of sudden death in those taking Strattera who have underlying cardiac disease and like the stimulants I strongly recommend a baseline electrocardiogram as well as a careful medical history. Unlike the stimulants it has no net effect on growth taken long term. The psychiatric risks of Strattera are the same as for the stimulants and include emergence of new manic or psychotic symptoms as well as increase in aggression or hostility. So the main difference between Strattera and the stimulants is the lack of abuse potential.

After reading of the possible risks of both the stimulants and Strattera you may be wondering why anyone would even take these medications? There are three factors to take into consideration. The first is that these risks are relatively small. The second is to realize that all medications of any type carry some possible serious risks. The third is that ADHD is very often severely disabling and affects psychological development, school and occupational functioning, and impairs interpersonal relationships to a great extent. I am bringing the problems with these medications to attention to emphasize that the use of ADHD medications should not be taken lightly, involve a thorough assessment and require close monitoring which is not the normal standard practice among many pediatricians, primary care physicians,and psychiatrists at this time. This leads to charges of overuse and inappropriate use which threaten the availability of these medications for those who very much need them.

Again I welcome any comments or questions.

Thought for the day

The same as yesterday. All medical treatments involve possible risks as well as benefits.

Attention Deficit Hyperactivity Disorder part 5

Yesterday I discussed the medications that are used to treat Attention Deficit Hyperactivity Disorder (ADHD). Today I want to talk a bit about the potential side effects and risks of the medications. I will take the stimulants first as the possible problems are basically the same for all of them and secondly to review Strattera.

Adderall and the other stimulants all carry a "black box warning". This refers to the FDA instruction to manufacturers requiring them to outline a particular drug risk, put in in a box with the warning highlighted as the first piece of prescribing information that any clinician will review. The stimulants all carry the warning of the possibility of misuse and drug dependence as well as the risk for serious cardiovascular complications if misused. Although it appears that almost any medication can occasionally cause almost any side effects the main risks are the cardiovascular events, psychiatric events, drug dependency, and growth retardation.

Stimulants can increase the heart rate, blood pressure, put more demands upon the heart, and in people with underlying structural cardiac defects or other serious heart problems there have been reports of sudden death. For this reason the American Heart Association has recommended that all patients being placed on stimulants be prescreened with a baseline electrocardiogram or EKG. Because this raises the cost of providing treatment this stance is somewhat controversial as the history, family history, and physical exam are likely to pick up any heart problems.The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry have not yet adopted this position but it is one that I very much agree with and I will not start a patient on stimulant medication without having a baseline EKG.

The second group of potential complications are psychiatric problems. Although these medications are used to treat a psychiatric disorder they can occasionally cause exacerbation of symptoms of patients with an underlying psychotic disorder, induce mania in patients with bipolar disorder, cause treatment emergent new onset of manic or psychotic symptoms, and aggressive behavior or hostility.

Careful followup studies have shown that persistent use of the medications seven days per week can result in growth suppression between the ages 5 to 10 or 13 of an average of 2 centimeters of height and 2.7 kilograms of weight with no growth rebound after cessation of the medication. Two centimeters average in itself is not a huge issue but this average means that some children have significantly more growth retardation therefore growth rates need to be monitored.

The issue of drug dependency is a difficult one. Most patients on stimulants for ADHD do not develop a drug dependency, need for higher and higher doses of the medication or misuse the medication but the possibility exists. The complicated thing however is that substance abuse is a risk of untreated AHDH so many with this disorder have co occurring substance abuse problems. In many cases the problems can be avoided by treating ADHD with Strattera instead of stimulants but what about the many patients who do benefit from or cannot tolerate Strattera? The decision of whether or not to use stimulants in patients with any kind of substance abuse disorder needs to be individualized but I will not use these medications in anyone with a history of stimulant, cocaine, or methamphetamine abuse. For others risk can be decreased by using one of the stimulant formulations that are slow release and compounded in a way unlikely to give the high that people are seeking. These are methylphenidate in the form of Concerta and amphetamine in the form of Vyvanse but both are expensive medications with no generic substitutions available.

I will talk about the problems of Strattera tomorrow. I welcome any questions or comments.

Thought for the day

All medical treatments involve both potential benefits as well as risks.

Attention Deficit Hyperactivity Disorder part 4

I want to talk a little bit about medication treatment for Attention Deficit Hyperactivity Disorder (ADHD). First of all, medications are effective at improving not only symptoms of the disorder but also can increase the level of functioning and complications of the associated features such as poor academic performance, decreased self esteem and demoralization, anger outbursts and mood problems as well as decreasing the likelihood of development of Oppositional Defiant Disorder and Conduct Disorder. Secondly as I mentioned before the psychosocial and behavioral interventions for this disorder are generally not very effective in the absence of medication treatment. Thirdly, any medication is not without it's hazards and difficulty and the medications used to treat ADHD are no different.

A number of medications have been tried and used for ADHD including antidepressants, anti hypertensives, and stimulants but there are two groups of medications that have current FDA approval for the treatment of this disorder. The first are the stimulants. These are amphetamines or amphetamine like drugs. Some commonly known ones are methlyphenidate (Ritalin), and the amphetamines Adderall and Dexedrine. Methlyphenidate now comes in various extended release forms for ease of use which include Concerta, Focalin, and the transdermal patch Daytrana. In addition to the amphetamines Dexedrine and Adderall there is a relatively new medication, Vyvanse, which when first metabolized becomes dextroamphetamine. All of these medications work by increasing the availability of the neurotransmitter dopamine. The second type of medication FDA approved for the treatment of ADHD has only one drug, atomoxatine (Strattera) which works by increasing the availability of the neurotransmitter norepinephrine. Both dopamine and norepinephrine are neurotransmitters that are necessary for many brain functions and include the functioning of the prefrontal cortex which is responsible for planning and foresight, monitoring and error correction, delayed gratification, impulse inhibition ,decision making, abstract thinking, attention shifting, information manipulation and social functioning all of which are impaired in ADHD.

Like all medications the use of the stimulants and atomoxatine carry some risks as well as benefits and these must be carefully weighed in each individual situation. I will outline some of these tomorrow.

Thought for the day

" Sometimes and ending can be the beginning of something wonderful".

Winnie Haller

Attention Deficit Hyperactivity Disorder part 3

Before I talk about treatments for ADHD I want to talk a little bit about the causes of this disorder. Basically we do not know a lot. We do know that ADHD has a heritable component, that it does run in families. We know that those infants with low birth weight (which is a nonspecific marker for problems in fetal development) have a higher incidence of ADHD. However most children with low birth weights do not develop ADHD and most children with ADHD did not have low birth rates. One environmental cause is the use of alcohol in pregnancy. There may be but I do not know whether or not there is any association with use of tobacco. But overall we do not know enough about the causes of this disorder.

Well how about treatment? This is an area where there is controversy. There is no controversy within the medical field about the benefits of ADHD medications. Evidence demonstrates their effectiveness. But there is some controversy in our society as a whole about the whole idea of using medications that affect the brain in children and adolescents. One thing I think people need to keep in mind is that the brain is an organ of the human body. In fact it is our most complicated organ. We know that disease states can affect every other organ. It only stands to reason that there can be problems with the brain itself. Yet very few people would take the position that we should not treat other organs but for some reason people put the brain in a separate category as if there can be no disorder in this particular part of our body. There is no question that children with this disorder suffer greatly and that their families suffer as well. I think it is extremely arrogant for those who oppose medication treatment for ADHD to want to make these medications unavailable.

What about psychosocial interventions? Wouldn't there be effectiveness in this approach? It only makes sense that there would be behavioral interventions that make a difference. However numerous studies have shown the same thing. Behavioral and psychosocial interventions are very effective, but only in those who are on medication treatment. Psychosocial and behavioral interventions in the absence of medication treatment are no more effective than no intervention at all. This only make sense when one considers that ADHD is a brain disorder. This is no different than in other areas of medicine and in disorders of other body organs. Exercise and proper diet as well as the cessation of smoking are very helpful in the treatment of coronary artery disease but the vessels must be clear by medical interventions before these behavioral approaches will work. Behavioral interventions and lifestyle changes are very useful in treatment of diabetes but the blood glucose levels must be brought down to normal to have these interventions make a significant difference. So disorders of the brain like ADHD are no different in this respect from other body organ problems.

In my next post I will discuss specific treatments and we will review not only medications but also effective psychosocial and behavioral treatments.

Thought for the day

We need to be empathetic and not critical and judgmental with parents whose children have emotional or behavioral problems.

Attention Deficit Hyperactivity Disorder part 2

This is the second in a series on Attention Deficit Hyperactivity Disorder (ADHD). I said yesterday that I would describe the disorder and it's associated features. ADHD affects about
3% of the school age population. Some studies put the number at 6-7% but I believe that those figures include over diagnosis as the rates of the disorder before there were medications and while still called minimal brain dysfunction were about 3%. Males are affected at higher rates than females. ADHD symptoms change with maturation but the disorder does persist into adulthood. It is a very common co-occurring problem we see here at Cottonwood as one of the problems with ADHD is a much higher rate of substance abuse problems.

Attention Deficit Hyperactivity disorder begins in childhood. It represents a neurodevelopmental problem from birth and truly is a brain disorder. It cannot be diagnosed before age 5 as the symptoms overlap with normal childhood development. But in order to diagnose ADHD there must be symptoms present before age 7. ADHD is often not diagnosed until much later but the disorder begins early. Attentional and behavioral problems with onset after seven are very likely due to other causes. Two additional factors must be present for the diagnosis. The symptoms must occur in two or more settings such as home and school or at home and at work. There also must be significant social, academic, or occupational impairment as to adversely affect the ability to function as needed.

Attention Deficit Hyperactivity disorder is characterized by inattentive symptoms, hyperactivity and impulsivity or both as well as a number of associated features that are not part of the diagnostic criteria. The associated features are often the more disabling aspects of this illness. It can be diagnosed as ADHD - inattentive type or ADHD hyperactive type, or more commonly ADHD - combined type.

The symptoms of inattentiveness include failing to give close attention to details or making careless mistakes in schoolwork work or other activities, difficulty sustaining attention in tasks or play, difficulty listening when directly spoken to, inability to follow through on instructions and failure to finish tasks, difficulty organizing work or play activities, avoidance of tasks that require sustained mental effort, tendency to lose things, be easily distracted by extraneous stimuli, and forgetful in daily activities.

The symptoms of hyperactivity and impulsivity include tendency to fidget or be restless, leaving seat or situation in which it is expected to stay, runs about or climbs excessively or in adults easy restlessness or boredom, difficulty with engaging in leisure activities, tendency to be often on the go or act as if driven by a motor, talking excessively, blurting out things, difficulty waiting or taking turns and a tendency to interrupt.

The associated features include low frustration tolerance, temper outbursts, bossiness, excessive expectation and insistence that needs be met, mood swings, depression, demoralization, peer rejection, poor self esteem, academic impairment and development of oppositional and defiant behavior. In addition there is an increased risk of developing a substance abuse problem.

So we can see that this disorder is all pervasive, is not restricted to attention alone, and clearly is not made up by the pharmaceutical companies. I will talk some about treatment tomorrow.

Thought for the day

" Those who don't follow the movements of their own soul will be unhappy".

Marcus Aurelius

Attention Deficit Hyperactivity Disorder

First of all I would like to thank those who have kindly inquired about my health following the bike accident. It was not my accident but unfortunatley happened to one of my colleauges here. It sounds like a harrowing experience and I am glad there were no serious injuries.

I have been asked by a reader to do another didactic series so I decided I would wade into the often controversial subject of Attention Deficit Hyperactivity Disorder (ADHD). It is controversial because it involves different ideas about the causes of behavioral problems as well as the use of psychotropic medication in children. This is further complicated by the reality that pharmaceutical companies make a lot of money from ADHD medications. I will say that I think this debate like many others is too polarized and often doesn't take into account that reality is often more complicated than our dogmatic assertions. In my opinion ADHD exists, and there is both under and overdiagnosis of the condition as well as both underutilization and over utilization of pyschotropic medication in children.

As I have discussed before most psychiatric diagnoses are phenomenologically based. That is they are based upon signs and symptoms. There are as yet no laboratory tests to confirm a diagnosis. This leads to the charge by some that psychiatric diagnoses are too subjective. However phenomenologic diagnoses have been helpful in the history of medicine and remain useful in some other conditions such as migraine and epilepsy. With this type of diagnosis the more severe the symptoms present the more likelihood that we are dealing with a common entity and the more mild the symptoms the more likely we are dealing with a behavior spectrum that ranges from moderate to normal behavior. This is further complicated in children in that the younger the child the more limited the repitiore of behavioral expression. An infant crying can mean many things and a six or seven year old child's behavioral problems can result from many causes all of which look very similar in this age grouop. As we grow to maturity we develop a wider range of ways in which to express internal distress. So in ADHD greater the severity of symptoms results in a greater likelihood that we are dealing with an actual entity and the milder the symptoms results in greater likelihood that we are seeing is behavior on a spectrum of problematic to normal varience.

Tomorrow I will define and describe Attention Deficit Hyperactivity Disorder. One thing is clear. This disorder is not one made up by the pharmaceutical companies. There are classic descriptions of this disorder dating back to the 19th century and early twentieth century long before there were any medication treatments available.

Thought for the day

"It is possible not only not to be angry with the insensitive and ungrateful but even to care for them".

Marcus Aurelius