ADHD Medications and Treatments

Strattera Approved for Maintenance Treatment of ADHD in Children and Adolescents

2008-06-11T15:15:00.001-04:00

The FDA has approved Strattera for maintenance treatment of ADHD in children and adolescents. This is important as ADHD is often a chronic problem, with symptoms often persisting into adulthood that require long-term treatment.

An 18-month relapse prevention study of approximately 600 children and adolescents aged 6 to 15 years old was conducted. Of those who responded to initial, acute treatment with Strattera (approximately 69%), only 2.5% relapsed with continued treatment. The most common side effects in this study were headache and the common cold.

In summary, "Strattera is effective for up to a year in patients who respond well to initial treatment," according to the global medical director of Eli Lilly and Company.

Related Topics:

Vyvanse Approved for Adult ADHD

2008-06-11T14:15:00.001-04:00

Vyvanse has been FDA approved for the treatment of ADHD in children aged 6 to 12 since July of 2007. Shire announced on April 23, 2008 that it had received approval from the FDA for the treatment of ADHD in adults. Shire also markets Adderall XR, which also has FDA approval for treatment of adult ADHD.

A four week study of 414 adults aged 18 to 55 years old with ADHD found significant improvement in ADHD symptoms after one week. Doses studied were 30 mg, 50 mg, and 70 mg. The Clinical Global Impressions-Improvement scale, used to rate severity of illness and improvement, found that 57 to 61 percent of subjects improved across all doses. The most common side effects were decreased appetite, difficulty falling asleep, and dry mouth, according to Shire.

Related Topics:

Should Your ADHD Child See a Cardiologist Before Taking Medications?

2008-04-28T17:24:00.001-04:00

The American Heart Association recently recommended an ECG (electrocardiogram, sometimes mistakenly called an EKG) before a child is started on a stimulant medication for ADHD. Approximately two years ago, the FDA recommended a black box warning for patients taking AD/HD medications regarding the potential for cardiovascular events in patients with serious, pre-existing structural cardiac abnormalities.

Should parents of children with AD/HD be alarmed by these recommendations? The answer is no. Medications for AD/HD are considered safe when used in appropriate doses used to treat AD/HD in children, adolescents, and adults without serious cardiovascular disease. The incidence of serious cardiovascular events in children taking medications for AD/HD is very low, and is similar to the incidence of cardiovascular events in children not taking medications.

The above recommendations were not made to limit the use of AD/HD medications, but to help identify children with pre-existing heart disease who may be at risk when taking such medications.

Your child's doctor should take a "Heart History" prior to prescribing AD/HD medications, and your child should be seen regularly (approximately every three months) to monitor their blood pressure and heart rate. A heart history should include:

A family history of a sudden, unexplained death at an early age; a heart attack in relatives younger than 35; a history of cardiac arrhythmias; and a family history of any cardiac "syndrome."

A history in the child of fainting or dizziness (particularly with exercise); a history of any chest discomfort, chest pain, or shortness of breath with exercise; a change in exercise tolerance; a history of palpitations, increased heart rate, extra beats or skipped beats, high blood pressure, or a significant heart murmur.

A history of prescribed medications, over-the-counter medications, and "natural" supplements taken by the child

Your child's doctor should do a physical examination looking for an abnormal heart murmur and other cardiovascular abnormalities, features of Marfan's syndrome (an inherited connective tissue disorder), and measurement of blood pressure and heart rate.

The American Heart Association is also recommending that an ECG be done prior to starting a medication for AD/HD, and if abnormal, a referral to a pediatric cardiologist. Not all doctors will order an ECG if the heart history and physical examination are normal, without evidence of heart disease, because the potential incidence of cardiac toxicity from AD/HD medications is so low. Even the American Heart Association admits that there have been no large studies proving that AD/HD medications have caused sudden cardiac events.

In summary, although recent recommendations are not cause for alarm, taking a heart history, doing a physical examination, and monitoring children, adolescents, and adults on medications used to treat AD/HD should be standard practice. No mother and child should walk into a doctor's office with a rating scale completed by the child's teacher, and walk out 15 minutes later with a prescription. An evaluation for AD/HD should be comprehensive, and should include a comprehensive history of possible medical problems, emotional problems, and problems commonly co-existing with AD/HD. A comprehensive evaluation should lead to a comprehensive treatment plan, with a specific treatment for each problem identified.

Related Topics:

Technorati Tags: ADHD, heart screening, FDA, stimulant medications, healthy children

Iron Supplements for ADHD

2008-04-07T14:25:00.003-04:00

Iron supplements are sometimes recommended as a treatment for ADHD. Studies have found that children with ADHD are more likely to have low levels of iron than children without ADHD, and iron deficiency seems to correlate with the severity of ADHD symptoms.

Iron is needed by the body to make the neurotransmitters involved with ADHD, including dopamine, norepinephrine, and serotonin. There is not enough scientific evidence to recommend iron supplements to all children with ADHD. However, there are a few early studies, which have not been confirmed by additional research, suggesting improvement in ADHD symptoms, as well as learning problems, in children low in iron.

The recommended dose of iron sulfate is 5 mg/kg/day. High doses of iron are toxic, and rarely lethal, so caution is needed about giving the appropriate dose and keeping iron supplements in a safe place to prevent accidental poisoning by younger children.

Related Topics:

Technorati Tags: ADHD, ADD, iron supplements

Home DNA Testing for ADHD

2008-03-31T13:58:00.003-04:00

Many companies are now offering self-administered genetic tests over the internet for various conditions, including ADHD and Bipolar Disorder. However, many of these tests might be misleading to the public because they offer predictions that are not scientifically proven and may provide information that is not meaningful.

Genetic testing looks at genes (DNA instructions inherited from relatives), chromosomes (contain DNA), or biochemical tests that test for enzyme levels. Genetic testing might help diagnose a disease or condition if someone already has symptoms, show whether someone is a carrier for certain genetic conditions, determine whether an unborn child will have a genetic condition, screen infants for missing proteins that can cause a disease, determine whether someone has a genetic predisposition to a disease before symptoms become apparent, and guide the selection of a particular medication or dose of medication for a particular person.

Testing is useful for rare types of cancers that run in families, for conditions such as Sickle Cell Anemia and Cystic Fibrosis, and for women who might be at risk for having a child with a chromosomal abnormality. However, I wouldn't send a sample of your saliva or cheek swab for psychiatric or behavioral conditions, along with a check for hundreds of dollars, just yet.

Where I find genetic testing sometimes useful is in determining the appropriate dose of Strattera, a medication used to treat ADHD. Genes determine how rapidly a person's liver enzymes break down Strattera. People who metabolize Strattera slowly will have higher than expected blood levels of a particular dose of Strattera, along with increased side effects, and people who rapidly metabolize Strattera have lower than expected blood levels corresponding to a poor response. I might have to use very small doses of Strattera for someone who is a slow metabolizer to achieve the appropriate response without significant side effects, and large doses for someone who is a rapid metabolizer to achieve therapeutic blood levels.

ADHD is highly heritable. If one parent or a sibling has ADHD, additional children have about a 30 percent chance of inheriting it, which increases to 50 percent if both parents have ADHD. However, I don't find genetic testing useful for ADHD as it only determines the probability of developing ADHD, not whether someone has ADHD. What you would do for a child at risk of developing ADHD would be good for every child: providing structure, a nutritious and balanced diet low in sugar and high in omega-3 fatty acids, plenty of exercise, and teaching them how to plan and organize their time for schoolwork and activities.

A child with a 30 percent chance of developing ADHD has a 70 percent chance of not developing it. Will genetic testing increase a parent's worry and change the way they interact with their child? Will everyone involved be so alert for signs and symptoms of ADHD that the child is at increased risk for getting a diagnosis when they don't have ADHD? ADHD most likely results from multiple genetic factors and the child's interactions with the environment. There is no genetic test that will diagnose ADHD, and the information provided by available tests tends to make little difference. Many internet sites are misleading, promising diets or nutritional additives that will avoid the use of medications. Someone should always check with their physician or genetic specialist prior to ordering self-administered genetic tests.

Related Topics:

Technorati Tags: ADHD, bipolar, DNA, genetic test, home DNA test

Image: istockphoto.com

ADHD and Other Disorders

2007-12-17T20:19:00.000-05:00

ADHD commonly co-occurs with other disorders, such as depression, bipolar disorder, anxiety, learning disabilities, tics, and substance abuse.

These disorders tend to run in families, tend to be inherited or have a genetic component, whether occurring separately or together. While it’s suspected that there might be a genetic link between ADHD and other comorbid disorders, it’s not yet scientifically proven.

Because of familial transmission and co-occurrence of ADHD and the above disorders, evaluation of ADHD should always include a detailed family history. Over 50% of children, adolescents, and adults with ADHD have a co-occurring disorder which also needs to be treated if treatment is to be successful.

Evaluation and treatment of ADHD should always be comprehensive. Simple rating scales and medication alone are not adequate for most people with ADHD.

Related Topics:

Technorati Tags: ADHD, anxiety, depression, bipolar disorder, learning disabilities, mental health

ADHD Medication Prescription Process Streamlined

2007-12-17T13:24:00.000-05:00

The Drug Enforcement Administration (FDA) is now allowing doctors to write up to three one-month prescriptions for ADHD medications during one office visit. Previously, doctors were allowed to write only one prescription per visit. The prescriptions still have to be filled on different dates, but this will streamline the process of obtaining prescriptions.

Technorati Tags: FDA, DEA, ADHD prescriptions

Boys and Girls Respond Differently to Ritalin

2007-12-13T08:19:00.000-05:00

Previous studies have not found a difference in response to methylphenidate (Ritalin, Concerta, Metadate CD) based on sex. However, a new study of 136 boys and 48 girls aged 6 to 12 did find different responses. Girls are more likely to have inattentive type of ADHD, compared to boys, and are more likely to have co-existing anxiety.

The children were randomized to receive Concerta (a 12-hour preparation), Metadate CD (an 8-hour preparation), or placebo. Girls responded significantly better to both Metadate CD and Concerta than the boys 1 ½ hours after dosing, but their response declined more rapidly than the boys from 6 to 12 hours after dosing. By 12 hours after dosing, boys had a much better response to both drugs.

Because of the steeper decline in response to medications toward the end of the day, girls being treated for ADHD might need special attention at the end of the day, e.g. more structure, supervision, or additional medication.

Related Topics:

Technorati Tags: ADHD, ADD, medications, health and wellness

Divorce and ADHD Medications

2007-10-03T15:22:00.000-04:00

Over the years, I've answered many posts from concerned parents (or stepparents) regarding their child being started on an ADHD medication by the divorced spouse. Frequently, it's the stepmother who complains that the child has been started on a medication by the mother, often implying that the mother is lacking in parenting skills (that of course the stepmother possesses) and is therefore inappropriately using medication to control normal child behavior. Since the child behaves perfectly well when visiting the stepmother and father, and since they don't have any problems with him, the mother must not be a fit parent.

Now there is a study that indicates that divorce might be a predictor of the use of ADHD medications. Lisa Strohschein from the University of Alberta analyzed the data from a longitudinal study (1994 - 2000) of 4,784 children, and of these children, 633 from 521 intact households experienced divorce while in the study. She found that methylphenidate (Ritalin) use was significantly higher among children (especially boys) whose parents divorced.

So why might the use of ADD medications increase after divorce? Strohschein feels that the stress of the divorce might increase a child's problem behaviors. Since ADHD is largely genetic (inherited), the parent's ADHD symptoms might have been a causal factor for the divorce. An increase in behavior problems related to the stress of the divorce might mean that the child is seen by a mental health worker, increasing the chances of also being diagnosed with ADHD.

I believe that it's very difficult being the single parent of a child with symptoms of ADHD, especially a single mother trying to parent a hyperactive, impulsive, and sometimes oppositional boy. It's far easier when two parents are working together on behavioral management, giving each other needed support.

Single mothers often have to work all day, then try to manage the hundreds of daily living tasks as well as the children, often with little support from others, and sometimes negative criticism from the other biological parent. Asking and seeking help from others, which might mean that the child is diagnosed with ADHD, seems to be a reasonable thing to do.

ADHD, Food Coloring and Additives

2007-09-11T13:03:00.000-04:00

A recent British study found that certain artificial colorings and preservatives commonly found in sweets and beverages can increase hyperactivity in children with and without ADHD.

Whether or not there is a relationship between food colorings and additives has been controversial for many years. In 1975, Dr. Benjamin Feingold proposed that synthetic flavorings and colors in the diet might be a cause of hyperactivity, and proposed an elimination diet, the Feingold Diet. Dr. Feingold's opinions were not based upon research studies, but on his own clinical experience. In response, the federal government funded several large research studies. The results of these and other studies have consistently found that elimination diets are not generally effective for treating hyperactivity except in about 1% of children.

Occasionally a parent will feel that her child is more hyperactive after eating sweets, Kool-Aid, or certain cereals and foods, or after taking medications with red or yellow dyes. This might be a child who does respond to an elimination diet with reduced hyperactivity. However, most core symptoms of ADHD would remain (inattention, distractibility, problems with planning, organization, time management, and follow-through) and would still need treatment.

Related Topics:

Technorati Tags: adhd, additives, hyperactivity

ADHD Diagnosis: What Tests are Needed?

2007-06-21T19:04:00.000-04:00

An interesting question was posted on my message board last week about how to go about testing for and diagnosing ADHD.

Question:

Is it mandatory for everyone prescribed ADHD meds. to have blood tests, EEG's, EKG's and other medical tests? A cl on another board (not WebMd) stated that "a Pediatric Psychiatrist, or Neurologist should do all of that for an eval. ADHD cannot be diagnosed, there are no "tests " for it, until everything else has been ruled out. There are so many thing that can mimic ADHD, things like hearing problems, lead poisoning, pinworms, that these tests must be done( bloodowork HAS to be done before meds can be prescribed)."

My son has been on Concerta for three years, doing wonderfully (thank you for your help at the beginning) and is very healthy. He has never had these tests.

My Answer:

AD/HD is a diagnosis of exclusion, meaning that symptoms similar to AD/HD can be caused by many different problems, which need to be ruled out before making a diagnosis. However, these can be ruled out by doing a careful clinical evaluation.

Wikimedia Commons

Although some people spend thousands of dollars getting a total body MRI scan every year, this isn't necessary for AD/HD. If someone doesn't have symptoms of hypothyroidism, there is no need to do a thyroid test. If someone doesn't have a family history of heart disease and doesn't have symptoms suggesting heart problems, and ECG is not needed. If someone has never had symptoms suggesting a seizure (e.g. loss of consciousness), and EEG is not indicated.

Lead paint and lead in gasoline have not been readily available for years (although lead paint is sometimes found in toys made in China). Although lead intoxication can cause ADD-like symptoms, as well as learning disabilities, the incidence is so small that tests for lead levels are generally only done when there is a chance that someone has been exposed to materials containing lead (e.g. old, inner city buildings).

High blood sugars can cause problems with attention, but a test for diabetes isn't done unless there are symptoms of diabetes. Sleep apnea can cause similar symptoms, but sleep studies aren't done unless the child's tonsils are severely enlarged and the child snores loudly. I could go on and on, but tests aren't done when all evidence indicates a healthy child, adolescent or adult.

This is true of any other medical condition. If a young women complains to her doctor of feeling tired, a blood test should probably done to see if she's anemic from blood (iron) loss from her periods, but hundreds of other tests to rule out the hundreds of causes of tiredness shouldn't automatically be done unless there are symptoms suggesting another problem.

Related Topics:

Technorati Tags: ADHD, ADD, psychiatry, diagnose ADHD, lead exposure

Heart History and ADHD Medications

2007-03-24T23:30:00.000-04:00

Sudden cardiac death occurs in about 600 children per year in the United States. The most common cause is an inherited disorder called hypertrophic cardiomyopathy.

Medications used to treat ADHD should not be prescribed for children and adolescents with structural heart defects. A thorough health history should always be taken by the physician before prescribing any medication. Before prescribing medications for ADHD, make sure that your doctor or your child's doctor asks about a history of:

Chest discomfort.
Severe shortness of breath, especially with exercise.
Fainting spells or unexplained dizziness.
High blood pressure.
Unexplained deaths in family members below age 30, a family history of heart attacks prior to the age 50 in men or 60 in women, or a family history of congenital heart disorders.

If any of these possible risk factors are present, more extensive cardiac testing or a referral to a cardiologist would be justified.

Related Topics:

Technorati Tags: ADHD, ADD, ADHD medications, hypertrophic cardiomyopathy, sudden cardiac death, health-and-wellness

Scared From Treatment

2007-03-19T10:15:00.000-04:00

Although the intent of the FDA's Black Box Warnings is to educate doctors, patients, and parents about the potential side effects of medications, I'm concerned that when combined with sensationalized and distorted media reporting, they frequently create unnecessary fear and the decision to stop treatment or to not seek treatment at all.

Tragically, current evidence suggests that the black box warning regarding the use of antidepressants in children and adolescents is related to a dramatic increase in the number of suicides. Ever since SSRI antidepressants have been prescribed to treat depression in children and adolescents, the annual rate of youth suicide has steadily declined. A media frenzy started in 2003 when committee meetings were held at the FDA to discuss data suggesting that a very small number of youth experienced an increase in suicidal thoughts shortly after an antidepressant had been started. The result of this frenzy was a 20% decline in the number prescriptions written for antidepressants for children and adolescents in 2003, and a very disturbing increase in suicides by 18.2% from 2003 - 2004.

There is now a media frenzy over the black box warnings regarding medications for the treatment of ADHD and the potential for cardiac side effects in someone with structural cardiac abnormalities or heart disease, which has frightened many parents and care providers. Yet untreated ADHD is related to increased rates of academic failure, low self-esteem, alcohol and drug use in adolescents and adults, motor vehicle accidents, relationship problems and occupational problems. Some children with ADHD are "traumatized" and demoralized by frequent negative interactions with teachers and peers and live in fear and humiliation, and "give up" on learning.

While it's very important that accurate information regarding medications and their potential side effects is well known to doctors, patients, and parents, there shouldn't be the effect of scaring people without risk factors away from needed treatment. Black box warnings need to do far more than identify risk factors of medications, as often the risk of not providing treatment far outweighs the risk of providing it. They should also include, "Warning: untreated depression is a major cause of suicide. Warning: untreated ADHD is a major cause of..."

Related Topics:

Technorati Tags: ADHD, FDA, black box warning, ADHD medication, SSRI, suicide, health-and-wellness

FDA Approves New ADHD Drug Vyvanse

2007-03-01T00:52:00.001-05:00

The U.S. Food and Drug Administration approved Vyvanse (lisdexamfetamine dimesylate) for the treatment of ADHD. Vyvanse was designed to lower the potential for abuse. Stimulant medications are the first-line treatment for ADHD, but many clinicians are reluctant to prescribe stimulants because they are often misused in our society. However, children and adolescents with untreated ADHD are at an increased risk of developing a problem with substance use, and effective treatment of ADHD significantly decreases that risk.

The route of administration of a stimulant has a strong affect on abuse potential. Drugs that are rapidly absorbed and achieve higher blood levels can produce a euphoric effect. This effect is easier to obtain by crushing short acting tablets and snorting or injecting them. Longer acting tablets and capsules are not easily put into a form that can be snorted or injected, and thus have a less abuse potential.

Vyvanse is d-amphetamine (dextroamphetamine) that is linked or bound to a naturally occurring amino acid, l-lysine. This compound is inactive (is inert) until this bond is broken by enzymes (metabolized) in the GI tract (stomach and intestine), releasing the active drug, d-amphetamine.

Since there are no enzymes in the nasal passages that can break this bond, blood levels would be 96% lower if Vyvanse were snorted than if d-amphetamine were snorted, and 75% lower if it were injected. When given intravenously to adults with histories of stimulant abuse, Vyvanse produced less euphoric effects than d-amphetamine, and the effects were not significantly different than intravenous placebo.

Absorption of Vyvanse is delayed, compared to d-amphetamine, and without a quick onset, the intensity and "likability" (drug-seeking behavior) drops. When Vyvanse is taken orally, increasing doses produce increasing blood levels, but only up to a certain point (130 - 150 mg), beyond which higher doses will not produce higher blood levels, which might reduce abuse potential and toxicity from overdose.

Vynase is given once daily in the morning, and it is significantly effective until at least 6:00 PM. Its effectiveness, potential for side effects, and safety is comparable to Adderall XR. It does have the potential to reduce stimulant abuse or misuse, and may protect against toxicity from overdose.

Related Topics:

Technorati Tags: ADHD, ADD, FDA, health-and-wellness, Vyvanse, stimulant medications, d-amphetamine, Adderall XR, stimulent abuse

Risks of ADHD Drugs

2007-02-26T14:08:00.000-05:00

The U.S. Food and Drug Administration (FDA) directed all manufacturers of medications authorized by the FDA for the treatment of ADHD (including all stimulants and Strattera) to develop Patient Medication Guides. These guides are intended to be handouts that would be given to patients and parents informing them of possible cardiovascular risks, risks of psychiatric symptoms, and of precautions that could be taken.

Similar medication information handouts are already in use, or should be in use, by physicians and pharmacies as part of patient education and informed consent when medications are prescribed and dispensed. Updated handouts for all medications are readily available for purchase from a variety of reputable sources and should always be a part of patient education. I also think it is important to review the information in the handout with the patient or parent, as it gives them a chance to ask questions while in the doctor's office rather than trying to reach him/her by telephone sometime later. Medications should not be taken unless the patient understands why the medication was prescribed, the potential risks, side effects, benefits, and alternatives to taking the medication, and has had a chance to have their questions answered.

The draft for the Patient Medication Guides for each individual ADHD medication can be found on the FDA website.

The information contained within these handouts is not new. Although extremely rare, there have been reports of sudden death in patients taking ADHD medications who have underlying serious heart problems. Therefore a careful history and evaluation should be done before starting a medication. There have also been reports of stroke or heart attack in adults with risk factors for these events. There are rare psychiatric side effects (one in 1,000) reported (hearing voices, paranoia, mania), especially in individuals with a prior history of these events, or when a close relative has experienced similar problems.

The information contained within these handouts is not intended to alarm anyone, but to educate them, as should be done with any medication or "natural" product. ADHD affects approximately 3 – 7% of children and 4% of adults to a degree that it significantly interferes with functioning in many life activities, such as school, family and peer relationships, and occupational activities. The majority of these people are healthy, do not have a serious heart problem or defect or other serious medical problem, and could benefit from treatment.

Related Topics:

Technorati Tags: FDA, ADHD, ADD, medication warnings

Sleep Apnea or ADHD?

2007-01-08T08:00:00.000-05:00

Sleep apnea is a condition that normally effects middle-aged, overweight adults. As one ages, tissues in the back of the throat become more flaccid. When severe, the tissues collapse, shutting off the airway during sleep.

Generally, someone's spouse complains of loud snoring that keeps her awake, of frequent episodes lasting up to a minute of silence (not breathing), followed by a sudden "gasping" arousal, followed by noise from breathing or snoring. The person with sleep apnea arouses from deep sleep to lighter stages of sleep, and are not usually aware of waking up. This can happen over and over again throughout the night.

Although the person feels that he slept through the night, he awakens exhausted because of the lack of deep sleep. They also don't feel refreshed after taking a nap. Because of lack of adequate deep sleep, they have problems concentrating during the day, just as you would if you only slept for four hours.

Children can also have sleep apnea, only it's not from aging, flaccid tissues in the back of the throat but from very enlarged tonsils blocking the airway. As with adults, they will be tired during the day, have problems concentrating, and might have other symptoms related to lack of sleep, such as irritability.

Only your pediatrician or an ENT specialist can determine whether your child's tonsils are enlarged enough to possibly block the airway and cause sleep apnea. If the tonsils appear to be significantly enlarged, confirmation of sleep apnea should be determined by a sleep study before any consideration of removing the tonsils. Not every child with enlarged tonsils or with loud snoring has sleep apnea, which can only be diagnosed by a sleep study.

Related Topics:

Technorati Tags: ADD, ADHD, sleep apnea

Preschoolers with ADHD

2006-12-13T23:38:00.000-05:00

While it is usually difficult for parents to decide on a trial of medications for ADHD for their children, it is much more difficult to think about using medications for their preschoolers. Stimulant medications, such as methylphenidate (brand name Ritalin), have been studied extensively in children, but there have been few studies in younger children regarding their safety or effectiveness. The few studies that have been done have implied that preschoolers have a lower rate of response to stimulants, and possibly a higher rate of side effects. Methylphenidate is approved by the FDA for use in children six years-old and older, but its use in younger children has increased dramatically in the past five years.

The November 2006 issue of the Journal of the American Academy of Child and Adolescent Psychiatry published the results of the first long-term study on the effects of methylphenidate in 3 - 5 year-old children with ADHD, called the Preschool ADHD Treatment Study.

This study was sponsored by the National Institute of Mental Health and several major universities and was not funded by drug companies. The study began with 303 children diagnosed with ADHD (children with other serious emotional disorders were excluded). There were several different phases of the study, with 140 children entering a 10-month maintenance phase with adjustments in the dose of their medication depending on the severity of ADHD symptoms or side effects.

Up to 30% of parents reported side effects. While the most common side effects were sleep problems and decreased appetite, some children experienced irritability, emotional outbursts, anxiety, sadness, crying, social withdrawal, fatigue, abnormal movements, stomachache, increased talking, restlessness, and impulsivity. There were no significant cardiovascular side effects reported that required a change or discontinuation of medication. Side effects were more common with higher doses. While irritability, tearfulness and sadness, and tiredness seemed to improve with time, many of the other side effects did not. While there were significant improvements in ADHD symptoms in many of the preschoolers, the improvements did not seem as great as with older children.

The preschoolers who responded to medication seemed to respond to relatively low doses of methylphenidate, and experienced significant more side effects at higher doses. Preschoolers should probably be started on no more than 2.5 mg of methylphenidate twice a day, with the dose slowly increased over the first couple of weeks to 5 - 7.5 mg two to three times a day if indicated and if well tolerated. While the dose of stimulant medication varies widely from person to person, the average dose in this study was 14 mg/day. Children who initially responded to a low dose of medication sometimes required an increase in dose for continued effectiveness.

The available studies suggest that preschoolers might experience less of a response, and an increased frequency of side effects, than school-aged children to methylphenidate. Behavioral treatments and classes to improve parenting skills should be considered prior to the use of medications, as well as in conjunction with medications, for most children. However, low doses of stimulants can often be used safely and effectively in children with more severe symptoms of ADHD.

If medications are prescribed, children should be monitored closely because of the increased risk of side effects. Because stimulant medications carry a risk of appetite suppression, weight loss, and reduction in growth rate, children should be seen at least 3 - 4 times a year to measure growth rates, assess efficacy, and monitor other potential side effects of medications.

Related Topics:

Technorati Tags: ADHD, preschoolers, ritalin, ADD, stimulant medications

Natural Supplements and Vitamins and ADHD

2006-11-19T19:36:00.000-05:00

It's often difficult for parents to have the child they love diagnosed with ADHD. Our natural instinct is to protect them from problems. It's harder still to consider a trial of medication for ADHD, and many parents wonder whether natural supplements are an alternative to medications. Almost anything that is 'good for someone's brain' is good for ADHD, including adequate nutrition, sleep, exercise, and methods of reducing stress (relaxations techniques, yoga, meditation, prayer. Although natural products are helpful for many medical conditions, there is little scientific evidence supporting the use of any natural product for the treatment of ADHD.

I am not an expert in natural medicines. I know physicians who have also completed their degree in natural medicine who are far more knowledgeable than I am. However, I do read the scientific research from studies on the use of natural products for various psychiatric conditions, including ADHD, depression, bipolar disorder, and anxiety disorders.

I am frequently asked about the effectiveness of caffeine for ADHD. A small amount of research reports mild improvement in symptoms of ADHD in a minority of children. However, most children primarily experience side effects and achieve little benefit from doses high enough for an effect.

Antidepressants have been used as second-line medications for the treatment of ADHD (e.g. Wellbutrin, imipramine), as they increase neurotransmitters involved with ADHD. Likewise, 'natural' antidepressants have been tried. St. John's wort has not been found effective for ADHD. Although some studies have found SAMe effective for ADHD symptoms in some adults, there has been no evidence for its effectiveness in children, and additional research is needed before SAMe can be recommended for the treatment of ADHD.

Ginkgo is thought to increase blood flow to the brain and is used for dementia. There is little evidence for the effectiveness of ginkgo when used alone in the treatment of ADHD, although one study indicated that the combination of ginkgo and American ginseng might treat symptoms of ADHD in some children. However, additional research is needed.

Dimethylaminoethanol (DMAE) was a prescription drug for ADHD-like symptoms until the 1980s when it was withdrawn because of lack of proof of effectiveness and safety, and it is now available as a dietary supplement. As was true in the 1980s, there still isn't enough evidence about effectiveness or safety to recommend it.

Many children with ADHD have difficulties falling asleep, either because they are restless and can't settle into sleep, or secondary to their stimulant medication. Some studies of melatonin have found it to be effective for treatment of insomnia in children with ADHD. However, risks vs. benefits must be weighed as there is some worry that melatonin might have an effect on gonadal (sex organ) development in children.

Antioxidants are felt to prevent oxidative damage in the brain and nervous system. Antioxidants from pine bark extract (pycnogenol) and grape seed extract are often recommended for ADHD. Although a small number of parents and adults with ADHD report effectiveness, no current research studies have found them to be effective.

Essential fatty acids (EFAs) are called 'essential' because our body cannot make them, and they must be ingested in our diet. About 25% of children with ADHD seem to have lower serum levels of omega-3 and omega-6 fatty acids. It would seem logical that giving supplements of omega-3 or omega-6 fatty acids would be beneficial for ADHD. However, most studies have not found EFA supplements to be of benefit. A recent study did find that a combination of flaxseed oil and vitamin C improved restlessness, impulsivity, and behavior in a significant percentage of children studied, but additional research is needed.

There is no evidence that taking very large doses of vitamins or minerals is effective for treatment of ADHD. However, some children with ADHD have lower levels of zinc and magnesium. Low zinc levels might be related to a poor response to traditional treatment with stimulant medications, and one study suggested that the addition of zinc to traditional treatments might improve that response. There is little research on the supplemental use of magnesium. A recent study suggested that iron supplements might improve hyperactive symptoms in boys with ADHD, but more research is needed, and too much iron can be toxic. Vitamin B6 was reported to be of some benefit in older studies, but those studies need to be duplicated using current diagnostic criteria for ADHD.

Blue-green algae is often recommended for ADHD, although there is little research to support its effectiveness, and there is concern about its purity from product to product and the possibility of contamination with heavy metals or toxins.

I wish that I could recommend an effective, safe, side effect-free natural supplement for the treatment of ADHD. Not everyone responds to or tolerates treatment with traditional medications, and many parents and adults with ADHD would prefer a 'natural' alternative. Although additional scientific studies are needed, two ADHD experts have reviewed their recommendations for use of natural supplements. I would recommend reading, "Healing ADD" by Daniel Amen (or read information on his website: www.amenclinics.com), and/or "Delivered from Distraction" by Edward Hallowell, M.D. and John Ratey, M.D.

Related Links: Are Herbal Supplements OK for Kids?, Choosing the Right ADHD Medication for Your Child

Technorati Tags: adhd, herbal remedies, ADHD treatment

ADHD and Anxiety

2006-11-07T12:04:00.000-05:00

Children, adolescents, and adults with anxiety disorders often have an increase in anxiety or experience side effects to stimulants used to treat AD/HD. Anxiety is also a common reason for inattention and distractibility in the classroom, and can sometimes be mistaken for AD/HD. However, anxiety disorders (as well as depression, and learning problems) also tend to coexist with AD/HD.

Strattera is probably the medication of first choice for someone with anxiety, although it has its own side effect profile and doesn't work for everyone. Frequently, anxiety needs to be treated first, and when treatment is successful, a stimulant can often be successfully added.

If your child is fearful or seems to have anxiety problems, I'd suggest a comprehensive evaluation by a good child psychologist and perhaps a referral to a child psychiatrist for medications.

More information about anxiety in children can be found in, "Your Anxious Child," by Dacey and Fiore.

Related Topics: High Cost of Mental Illness in Children, Ritalin for Preschoolers?

Technorati Tags: ADHD, anxiety, side effects, Strattera

Provigil Dropped as ADHD Medication

2006-10-09T16:15:00.000-04:00

The company that makes Provigil, Cephalon Inc., has decided to not market the drug for AD/HD (it was to be marketed under the name Sparlon).

Provigil is authorized by the FDA for daytime sedation related to narcolepsy and to treat sedation from changing shifts at work, and has been found useful in potentiating the effects of antidepressants. Several studies found Sparlon effective for AD/HD in approximately 50% of children, adolescents, and adults.

Since Sparlon works on different neurotransmitters than traditional stimulants used to treat AD/HD, it is sometimes effective for people who don't respond to other stimulants. It is also not a controlled drug and refills are permitted.

Sparlon was awaiting approval from the FDA. Unfortunately, the FDA advisory panel recommended "non-approval" because of concerns over the possibility of a rare but serious rash, and recommended the drug company conduct a 3,000-patient clinical trial to rule out its occurrence. Cephalon decided to not proceed with additional studies.

This decision does not mean that a physician cannot prescribe Provigil for AD/HD, but it is an expensive drug that might not be covered by someone's insurance if not prescribed for approved conditions, such as narcolepsy.

Related Topics: Choosing the Right ADHD Medication for Your Child, The ADHD Child and ADHD Teen: Minimizing the Side Effects of ADHD Medications

Technorati Tags: provigil, adhd, ad/hd, stimulant medications

ADHD Awareness Day: Careers

2006-09-20T04:18:00.000-04:00

Although ADHD is largely associated with children in school, many adults struggle with ADHD and in particular, struggle in their chosen careers. Since today is ADHD Awareness Day, I thought posting a question and answer from my message board concerning the possibility of ADHD creating career problems would be appropriate. The original question comes from a young lawyer, who writes:

I'm 29 and an attorney. In law school, I began to notice that I was extremely forgetful. I would forget conversations I had with people, things I had to do and places I had to go. I had a lot of difficulty studying and memorizing a lot of my subjects and things got progressively worse as I continued with my studies. However, I found workarounds for many of my "issues" and made it through law school and successfully passed the bar in three states.....

I do not know who to talk to or what to do. I am consistently surrounded by a sensation I can only describe as a "fog". I cannot focus on anything at any time. I lose interest in everything quickly. Things that made me exceptionally happy in the past-- no longer have the same affect. ...

Do any of these symptoms sound like anything that can be rolled into ADHD/ADD? If not-- does it sound like anything else? Who should I consult regarding whatever it is that is wrong with me?

My answer:

I see many lawyers with AD/HD. There are enough lawyers struggling with AD/HD in my state for the state bar to form a support and referral system for lawyers struggling with AD/HD issues in their practice.

Many bright lawyers succeed in law school, but struggle once in practice with the same issues that affect others with AD/HD: inattention and distractibility, planning, organization, time management, and follow through.

They have problems keeping track of billable hours, and might have to stay late at work because it takes them longer to do their work than others. They are stressed from the pressure to perform to make money for the firm, and with increased pressure, AD/HD symptoms increase. They feel overwhelmed and incapable of keeping up.

AD/HD is a lifelong problem, although someone might not have significant problems until the work load increases, such as in law school. When someone has not had lifelong symptoms of AD/HD and starts having them when under a great deal of stress, "pseudo ADD" must be ruled out--meaning symptoms due to stress of daily life. People who are depressed and/or anxious also cannot focus, are forgetful, and cannot keep up with their work load.

I recommend that you see someone who specializes in the evaluation and treatment of AD/HD, as they would be able to sort out possible AD/HD from stress, anxiety, depression, or other factors.

If your general physician doesn't have a referral, you could call the psychiatry department of the nearest medical school for a referral, or check for names of therapists on the CHADD site. In the meantime you might want to read (or listen to the audio tape in your car) either, "Driven to Distraction," or, "Delivered from Distraction," by Hallowell and Ratey.

Related Topics: Suffering in Silence: Women with Adult ADHD, Workplace May Overwhelm Adults with ADHD

Technorati Tags: ADHD Awareness Day, ADHD, Adult ADHD, career

Bipolar Disorder: Challenges in the Workplace

2006-09-05T14:59:00.000-04:00

Work is a meaningful part of most of our lives. It not only provides income, but is part of our self-esteem and our self-image, and often provides social interactions and friendships. Work adds structure, routine, and life goals. Returning to work after a bipolar episode is often an extremely important part of recovery. Although most people with bipolar disorder can be successful in their career, and are willing and able to work, workplace challenges may arise because of the stigma of bipolar disorder, the response of employers and coworkers who don't understand, and difficulty balancing fluctuating moods with a stable work life.

The first goal of someone with a mood disorder is to maintain health and mood stability and to prevent future episodes. Staying consistent with medications and a sleep schedule and managing stress are important, but having some type of work allows someone to focus on something besides their problems and can help maintain mood stability. However, finding the right balance between levels of job stress, the number of working hours, job satisfaction, and working within a supportive environment are equally important.

Most people struggle with whether or not to inform their employer or their co-workers of their diagnosis. The standard advice from others with bipolar disorder is often "Don't do it!" However, some employers and co-workers will be empathetic and understand, and others will not and might use it against you. There is no single solution that is best for everyone.

What are the disadvantages of disclosing your diagnosis? A prospective employer might not hire you without telling you why you weren't hired. You might feel that you are being dishonest if you don't disclose your diagnosis when applying for a job, but there is no law that requires you to do so, and it's illegal for an employer to ask about the presence of a disability during a job interview.

Under the Americans with Disabilities Act (ADA), it is unlawful to discriminate against someone with a disability if they can perform the essential functions of their job (have the education, know-how, and ability to do the job), with or without reasonable accommodation. Bipolar disorder qualifies as a disability as it is "a physical or mental impairment that substantially limits one or more of the major life activities of such individual."

Although the law is on your side, proving that your disability was the primary reason you were not hired for a job can be difficult. Not everyone with bipolar disorder needs job accommodations, such as a modified work schedule, and disclosure might not be necessary. You have no way of knowing how a potential employer will react to disclosure of a diagnosis of bipolar disorder. It is up to you to decide whether or not to disclose your diagnosis of bipolar disorder during a job interview.

Other disadvantages of disclosing your diagnosis include dealing with the potential stigma at work, being fired, being demoted, not receiving a promotion, and a possible negative reaction from coworkers. Although many public figures have talked openly about their struggles with bipolar disorder, including Patty Duke, Ben Stiller, Jim Carrey, Robin Williams, and Jane Pauley, the stigma is still there and most employers don't realize the similarity of bipolar disorder to other medical disorders.

Some people who discuss their disorder with employers and coworkers receive empathy, support, and understanding, while others find insensitivity and even outright rejection. Again, you will have to decide whether disclosing or not disclosing your disorder is best for you. In general you should consider disclosing when you feel you'll receive a supportive reaction, or when you fear losing your job if you don't receive the accommodations you need. If you feel that your symptoms are significantly interfering with your ability to work, and if you would benefit from accommodations such as a modified work schedule, the ability to take time off from work to attend medical appointments, or being granted extended leaves of absence for treatment of a manic or depressive episode, it's probably best to discuss your disorder with your employer. A list of the types of workplace accommodations considered reasonable for people with bipolar disorder can be found at the Job Accommodations Network.

If you do decide to disclose your disorder, you'll need to document your disability (a letter from your physician) and describe your needs for particular accommodations. You do not need to disclose your personal medical information to everyone. Your employer is only allowed to disclose your difficulties to supervisors who must know about the accommodations that you require to perform your job. I recommend that you request needed accommodations in writing, including suggestions for alternative accommodations, and request that a meeting be scheduled to discuss your request.

A fact sheet that can help describe bipolar disorder to others can be found here. I also recommend the book, "The Bipolar Disorder Survival Guide: What You and Your Family Need to Know," by David J. Miklowitz, Ph.D.

Related Topics: Workplace Wellness, WebMD Video: Finding the Gene That Causes Depression

Technorati Tags: bipolar, work, ADA

Daytrana

2006-08-29T11:57:00.000-04:00

Once-daily preparations of medications used to treat AD/HD have become the standard of care. Concerta (OROS methylphenidate) and Focalin XR (dexmethylphenidate) are effective for about 12 hours, and Adderall XR (extended-release mixed amphetamine salts) is effective for 10 - 12 hours.

People with AD/HD have symptoms all day long, but taking medications several times a day, especially at school or at work, is inconvenient, is frequently "forgotten," and can be stigmatizing. Some people taking multiple doses of shorter-acting preparations feel as if they are on an "emotional rollercoaster," with symptoms increasing and decreasing as each dose is wearing off and the next dose is starting to work.

AD/HD is a life problem, not a school or work problem, and longer-acting preparations help people to normalize their life. Daytrana, a transdermal methylphenidate preparation, allows for a more flexible duration of effect - the longer you keep the patch on, the longer the effect.

Fast facts about Daytrana:

Daytrana is a clear adhesive patch containing methylphenidate that is applied to intact skin. Each area of the patch contains the same amount of medication, and dose is adjusted by wearing different patch sizes and by varying the wear time. It is available in four doses: 10, 15, 20, and 30 mg.

The 10 mg patch releases 1.1 mg of methylphenidate per hour and contains 27.5 mg per patch; the 15 mg patch delivers 1.6 mg/hr and contains 41.3 mg; the 20 mg patch delivers 2.2 mg/hr and contains 55 mg; and the 30 mg patch delivers 3.3 mg/hr and contains 82.5 mg of methylphenidate.

Daytrana is applied to the hip for nine hours. The mean peak concentrations of methylphenidate is nearly two times higher with Daytrana than with other once-daily methylphenidate preparations, thus the effective dose of Daytrana is often lower than an effective dose of Concerta or somewhat equivalent to an effective dose of Focalin XR.

Peak concentrations were also higher with Daytrana with chronic administration compared to peak concentrations after a single dose, and were higher in 6 year olds than in 12 year olds.

Daytrana is generally effective about two hours after the patch is applied. It should always be applied to intact skin, as application to inflamed skin increases the rate and extent of absorption, with peak concentrations up to 3 times higher. Heat should not be applied to the patch after application, as it would also increase the rate and extent of absorption of medication. Daytrana should always be applied to the hip as different areas of the body have different absorption rates. The patch should be removed after about 9 hours, and the medication remains effective for about 3 hours after its removal.

Potential side effects to Daytrana are similar to other methylphenidate preparations and include nausea, abdominal cramping, headache, nasopharyngitis, decreased appetite and weight loss, affect lability (increased sensitivity, emotional instability), tearfulness, insomnia, increased tics, and nasal congestion.

Daytrana is a skin irritant and the majority of people will develop erythema (redness) at the patch site that causes little discomfort. On rare occasions, contact sensitization could develop, and edema, papules, vesicles and other intense skin reactions could occur in addition to erythema. If such a reaction occurs, the patch should be removed and the doctor should be contacted. Patients who develop allergic contact dermatitis to Daytrana might develop an allergic reaction to methylphenidate in general, and might not be able to subsequently take oral methylphenidate.

Applying the Patch Properly

Daytrana is usually started at the 10 mg dose, then the dose is increased weekly until there is an appropriate effect. The patch should be placed on a clean, dry area of the hip and the skin should not be oily, damaged, or irritated. The waistline should be avoided as the patch might be rubbed off by clothing. The alternate hip should be used the following day. The patch should be held firmly in place with the palm of the hand for about 30 seconds to make sure there is good contact. After application, bathing or swimming don't affect patch adherence. If a patch does fall off, a new patch can be placed at a different site, but the total daily time of use shouldn't exceed nine hours. If a shorter duration of effect is desired, or if insomnia occurs, the patch can be removed earlier than 9 hours. The patch can also be removed early if someone experiences initial side effects, which would lower the total daily dose received and might decrease side effects until tolerance to them can develop.

Methylphenidate and other stimulants should not be used by people with heart disease, glaucoma, tics, by someone with significant anxiety, tension, or agitation, by someone taking a monoamine oxidase inhibitor (MAOI), or by someone with a history of psychosis. Daytrana has not been studied in children below six years old.

Related Topics: New Heart Alert for Some ADHD Drugs, Back to School with ADHD

Technorati Tags: Daytrana, ADHD medications

AD/HD Medications During Pregnancy

2006-08-07T14:57:00.001-04:00

Since approximately 3 - 5% of the adult population struggles with symptoms related to AD/HD, including women who are planning on having children, there are frequent questions about use of medications during pregnancy.

Stimulant medications, including methylphenidate (Ritalin, Concerta, Metadate CD, and others), mixed amphetamine salts (Adderall, Adderall XR), and dextroamphetamine (Dexedrine) remain the first-line medication for treatment of AD/HD.

There have been no well-controlled studies of stimulant use during pregnancy (ethically, a study giving a stimulant medications to pregnant women would not be authorized by the FDA). Stimulants are classified as Category C by the FDA (Animal studies show adverse effects, but there are no controlled human studies).

Amphetamines (Adderall and Dexedrine) given to mice in doses much higher than the usual human dose have reported cardiac defects. Studies of women addicted to amphetamines have shown higher rates of low birth rate and pregnancy complications. Another study found that children of women exposed to Dexedrine had a higher incidence of heart defects at three-year follow-up. A study of 48 women exposed to methylphenidate during pregnancy found higher rates of premature birth, growth retardation, and symptoms of withdrawal in the infants.

Modafanil (Provigil) and atomoxetine (Strattera) are also category C drugs, with inadequate information available to assess risk. There is also not enough information about bupropion (Wellbutrin) to assess risk, and although it's a category B drug (preferred over category C drugs), there is some concern about its use during pregnancy and a potential for congenital heart defects.

All medications are excreted into breast milk, exposing them to the infant. Amphetamines are concentrated in breast milk which causes concern about typical side effects of stimulant medications as well as withdrawal symptoms. There is no information about methylphenidate during nursing. There is too little information available about atomoxetine and modafanil to recommend their use during breastfeeding.

More information is needed regarding medications used to treat AD/HD during pregnancy and while nursing. Although the risks versus the benefits of using medications during pregnancy and while nursing should be thoroughly discussed with someone's physician, there is currently no information to indicate that treatment of AD/HD with medication is a safe choice.

Alternatively, I recommend working with an ADD Coach/ Organizer (or experienced therapist) on skills for planning, organization, time management, and follow-through.

Dr. Richard Sogn

Related Topics: Pregnancy Antidepressants: Baby Risk, Dads Get PostPartum Depression, Too

Technorati Tags: AD/HD, pregnancy, stimulant medication

ADHD and Menopause

2006-07-26T11:21:00.000-04:00

Many women with AD/HD report an increase in AD/HD symptoms when they enter perimenopause and menopause. Medications that were once effective for AD/HD may not work as well. Estrogen influences neurotransmitter systems and the levels of neurotransmitters (dopamine, norepinephrine, and serotonin) involved with AD/HD as well as depression and anxiety.

Someone with AD/HD already has dysfunction of neurotransmitter systems in the brain, which are only magnified when estrogen levels begin to fall in the perimenopausal period causing further dysfunction. Many women complain of memory problems, mood changes (sad, irritable, worried), hot flashes, sleep problems, memory problems, and problems with mental clarity during the years prior to the onset of menopause, which add to symptoms related to AD/HD.

Some women report increased symptoms of AD/HD during any low estrogen state: with increased hormonal fluctuations when girls enter puberty, in the premenstrual period, the postpartum period, and with the onset of menopause, and may report a decrease in AD/HD symptoms during pregnancy and while nursing, when estrogen levels are high. To make matters worse, some women with AD/HD entering perimenopause have a teenage daughter with AD/HD entering puberty!

Comprehensive treatments are often indicated for women with AD/HD whose symptoms are increasing during the perimenopausal period and during menopause.

Sometimes an increase in stimulant medications is effective, but sometimes it is not as some studies have found the response of stimulants to be related to estrogen levels (a better response with higher estrogen levels). Sometimes, estrogen replacement is beneficial, especially in women who not only have a worsening of AD/HD symptoms, but a significant worsening of mood.

However, risks versus benefits must be considered with estrogen replacement. Since falling estrogen levels influences the neurotransmitter serotonin, SSRI antidepressants that increase serotonin are often helpful for depression and anxiety (which can increase inattention and distractibility).

In summary, treatment of increased symptoms of AD/HD during the menopausal period often consists of some combination of a stimulant medication, an SSRI antidepressant, and sometimes short-term estrogen replacement. There are many other things to do about symptoms related to menopause which can be found on WebMD and on www.healthewomen.com.

It's extremely important for women with AD/HD to find a physician who is not only knowledgeable about AD/HD, but is knowledgeable about AD/HD in women.

Dr. Richard Sogn

Related Topics: WebMD Video: Menopause Myths, WebMD Video: Is it ADHD or Vision Problems?

Technorati Tags: ADD, ADHD, AD/HD, menopause, perimenopause