Alexander Lerman MD is a child psychiatrist and long-time Kos member - I've decided to move from posting on topics I don't really know much about, to one - child psychiatry - that I have spent several decades trying to learn. This entry is cross-posted on my blog Child Psychiatry Forum.
Treatment for ADD and ADHD (two names for different variants of the same problem) is a growing industry in America: the number of prescriptions for amphetamine alone (the active ingredient in Adderall), rose 463% between 1998 and 2007, with the annual rate of 2.5 million prescriptions in 1998 rising to 14.2 million prescriptions in 2007.[1] And this data includes only amphetamine prescriptions, not methylphenidate (the active ingredient in Ritalin and many other preparations).
There are many aspects of the explosion in stimulant prescriptions in the US, and arguments that may be made at the risks and costs of our present medical practice.
In this post, I’d like to begin with two words: "amphetamine" and "methylphenidate".
These cumbersome words refer to the two stimulant compounds used in the vast majority of medications for ADHD and related disorders[2]. That’s right – there are just two molecules that are packaged, tweaked, branded, and released under a dozen different product names – as I’ll get into below.
When I began my career, there just a few stimulant drugs on the market. Now the choices have exploded – as has the cost, since all these new preparations are patented, copyrighted, and promoted with expensive marketing campaigns. To be fair, some of these new preparations are very good – principally because they are more convenient, and allow more fine-tuning for children and adults who suffer from side effects from a given drug.
But it’s important to remember that fundamentally, all these medications represent the same two drugs that have been on the market since the 1960’s at the latest.
Here are some of the basic features of stimulant drugs:
Methlyphenidate vs. Amphetamine
Methylphenidate-based drugs include Ritalin, Ritalin LA, Ritalin SR, Metadate, Concerta, Focalin, Daytrana. Methylphenidate is generally felt to have less narcotic "speedy" potency than amphetamine, but this is often an academic distinction.
Amphetamine-based drugs: Adderall, Adderall XR, Vyvanse, Dexedrine, Dexedrine Spansules. Amphetamine is generally felt to have more abuse potential.
Generally, I start with methylphenidate, and switch to amphetamine if a person is having difficulty with side effects or is not getting an effective response.
"Immediate Release" vs. "Extended Release"
" Immediate Release" is a drug-marketing term which simply means that the drug is given in a regular form, with an expected duration of action of 3-5 hours for methylphenidate, and 4-6 hours for amphetamine. There’s nothing particularly "immediate" about it. Straightforward drug preparations offer tighter control over how much medication is given at a specific time (e.g. a higher dose when you need it), and higher peak levels.
"Extended Release" preparations release the drugs into the body via a variety of different methods, offering once-a-day dosing, and smoother transitions onto and off medication. Every sales representative will tell you how ingenious the XR system he or she is promoting – and yes, some of them are very clever, and very useful at times. But - all extended release preparations are inherently less predictable and reliable than regular preparations, because the release mechanism doesn’t always work the way it’s supposed to. Extended release systems also are also very effective at driving up the cost of the drug.
Which drugs do I prescribe?
I try to match the drug to the person. Regular, generic methylphenidate is cheap, simple, and easy to control. Despite the problems with extended release drugs, I tend to use them a lot. Concerta is the drug I most prescribe – I believe it’s a better-designed "delivery system" and has the least side effects. I use Metadate and Ritalin LA for a shorter-duration extended release. I use Ritalin SR for people who are not covered by insurance and need a lower-cost drug. Vyvanse, in my experience, has greater-than-average risks of causing mood disturbances (publicly-available drug company data does not coincide with my experience).
When to Prescribe Stimulant Drugs to Children
A Brief History of Stimulant use by Children
Amphetamine was first administered to patients in the 1930’s, and prescribed to children for "minimal brain dysfunction" (what we would now consider extreme hyperactivity) in the 1950’s. The practice became widely accepted in the 1970’s, and stimulants have been prescribed to an ever-widening spectrum of children subsequently, including to many children with less obvious "inattentive type" concentration problems (i.e. no signs of hyperactivity), and children with less-severe attention problems.
Some of this broadening pattern of use represents increased awareness by physicians of who can be helped by these drugs – adult ADD is a real phenomenon. But another part of the picture is an intense campaign to market stimulants to the general population, and campaign by the pharmaceutical industry to re-define the concept of ADHD to broaden the market for the drugs.
Do these drugs actually work – and if so, what’s the problem?
There is no question that modest doses of stimulants improve short-term memory and the ability to sustain attention on tedious tasks – in almost everyone. Nor is there any question that these drugs tend to diminish behavior and conduct problems in some children. There is also no disputing the fact that these drugs are relatively safe, and have played a beneficial role in the lives of millions of children.
The questions, and in some cases controversy, revolve around which kids to give them to and when. The diagnostic categories we have for kids can be pretty vague, particularly when is applying them to better-adjusted children. It’s easy to make mistakes: there are many children with attention problems – for example, anxiety issues – for which stimulants are not the treatment of choice.
To make matters worse, prescribing practices are the subject of intense pharmaceutical marketing campaigns, and other non-medical pressures which in the view of many experts distort treatment decisions. This can lead to children receiving diagnoses and pills they don’t need at best; and being exposed to adverse effects, and small unnecessary serious risks at worst.
What are the arguments for giving stimulants to children?
When a child is suffering from certain kinds of neuro-cognitive problems (i.e. difficulties with attention, organization, memory, and impulse control), the benefits of medication treatment can be substantial, to at times dramatic.
For example a six year old whose is shunned on the playground due to her poor self-regulation one day, may be playing hopscotch with a group of girls the next. A 5th grader who can barely read off medication , may be able to write a book report without assistance on it. A hyperactive child whose hour-to-hour experience is of people yelling at him to STOP, may be able to go on a fishing trip with his grandfather.
For children who respond like this, there are benefits in self-esteem and social and emotional development that go far beyond the specific times when the drug is in use.
The children likely to benefit from stimulants the most tend to have clear-cut attention and impulse control problems, often dating from early childhood. Girls tend to have fewer behavioral problems, and present with "inattentive type" attention problems that also respond dramatically to treatment.
More generally, stimulants in modest doses can help brain development and self-repair – this has been demonstrated, for example, in people recovering from strokes and brain trauma. Many children captured in the "ADHD" diagnostic net have some manner of subtle disruption in brain development; and it is likely that stimulant medication can speed developmental recovery.
What are the arguments against giving stimulants to children?
The problems with stimulants can be grouped into a few broad categories:
a) the risks of side effects that are fairly common, and can usually be eliminated immediately by stopping the medication; b) the risks of side effects that are much rarer, but more serious; c) the risks of missing or ignoring other problems as a result of focusing on medication; d) I won't cover the serious risks associated with abuse of stimulants here - the doses involved in narcotic use of stimulants are much higher, and very different from the practices I'm describing.
Common side effects include:
• Appetite suppression, stomach aches
• Sleep problems
• Headaches
• Irritability and mood instability, especially when the medication is wearing off
• Feeling "wired" – less social, less emotional, less spontaneous
• Increased "stereotypic" habits (picking scabs, chewing on lips, biting fingernails)
• Exacerbation of motor tics
Rarer side effects include
• Chronic exhaustion and emotional impoverishment due to too-high doses.
• Growth suppression : some studies indicate that children maintained on high doses of stimulants are statistically likely to be about a inch shorter than unmedicated children (these studies are far from definitive, however)
• Onset of severe motor tics or emotional problems: after decades of study, there is a pretty strong consensus that such events represent the emergence of problems that would have occurred even if the child had not take medication.
• Cardiovascular risk: a very small number of children (probably less than 1 per 100,000) die of unexplained "sudden cardiac death" per year. There is controversy and uncertainty about whether stimulants can increase this risk – it is difficult to ascertain because these tragic events are so rare.
• Progression to drug abuse: this appears not to be a significant risk among kids who begin medication in elementary school years; whereas kids who receive prescriptions for the first time as high school and college kids are at increased risk to abuse the medication.
Risks of ignoring other problems include overlooking:
• Other emotional problems that can affect concentration and social adaptation
• Learning disorders
• Reaction to life stress, child abuse or family problems
• Deficiencies
What is the right way to go about a stimulant trial?
Good practice reduces risks, and improves outcome.
A good evaluation of a child prior to initiating medications involves getting a good sense of a child’s cognitive and emotional functioning, as well as social adjustment and medical screening. The child’s behavior in different environments, including the classroom, the playground, and home, should all be assessed. With different degrees depending on age, the child should participate in the treatment process, and understand the methods and the goals of the treatment intervention. Children should understand that medication is a tool, like "glasses for the brain" as one youngster told me; not a sign of illness or defectiveness.
If medication is started, the effect should be noted both at home and at school. Usually a child takes a test dose at home on a weekend when using the drug for the first time. I like to start medication at a very low dose, and gradually go up. Even if a drug seems to be at effective at a low dose, it’s a good idea to try somewhat higher doses, because some children exhibit a rising positive response at higher doses.
If side effects are present, a drug regime can be tweaked and altered in a variety of ways, eliminating or at least reducing problems for most children.
Even if everything is great, I like to see children three or four times a year. I have lost count of the number of problems that I have encountered and been able to address during routine follow up.
Lastly, most kids should have trials off medication to see if they still need it. As youngsters mature into teenagers, they should gain greater understanding of, and input into, their medication planning.
Do children from poorer and working middle-class families have problems getting access to quality psychiatric care?
You betcha! Many families are uninsured. Most parents who have insurance are in managed care programs that tend to curtail contact with clinicians to brief "med-check" visits that don't allow time to get to know the child and his or her family well, let alone talk to teachers.
Poorer children tend to get less therapy and more medication - but even middle class families tend not to have access to the resources - like therapists, parent counseling, educational specialists - that can make a huge difference in the lives of some children.
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[1] Belouin , S. Prescribing Trends for Opioids, Benzodiazepines, Amphetamines, and Barbiturates from 1998-2007 United States Public Health Service Report
[2] Atomoxetine (Strattera) improves alertness, but is a very different kind of drug. Guanfacine (Tenex, Intunive), clonidine (Catapres) are non-stimulant medications that aid in controlling hyperactivity, but don’t improve cognitive functioning.
Disclaimer: Dr. Lerman accepts no direct or indirect funding from the pharmaceutical or any other industry . Information in this posting is for educational purposes, and should not be considered a substitute for medical advice.