Category — ADHD: Medications

A study published in the June 14 edition of the Journal of Developmental and Behavioral Pediatrics has sparked controversy regarding ADHD medication and the brain’s power to regulate itself.

The study was funded by the National Institutes of Health and conducted by Dr. Adrian Sandler, a developmental-behavioral pediatrician and medical director of the Olson Huff Center for Child Development at Mission Children’s Hospital in Asheville, North Carolina.  The research was performed over the course of eight years using 99 patients from Western North Carolina.

Sandler found that children with ADHD can do just as well on half their medication when the medication is combined with a placebo. They performed as well even when parents and children had full knowledge they were taking a placebo.

[Placebo --  A substance containing no medication and prescribed or given to reinforce a patient's expectation to get well. The placebo in this research was akin to a harmless inert pill].

Previous studies have shown that common stimulant medication causes side-effects like tics, weight loss, stunted growth, and even heart complications in some instances. This often causes trepidation in parents afraid of the possible side-effects on their children.

Sandler compared fully medicated children, children on reduced medication, and children on reduced medication with a known placebo. The results were quite intriguing.  Both the fully medicated and reduced medication groups had increased side-effects while the reduced medication with placebo demonstrated decreased side-effects. Furthermore, the reduced medication group reported decreased control of their ADHD symptoms. However, the control of ADHD symptoms was no different in the reduced medication with placebo group than in the full dose group, i.e. the reduced medication with placebo performed as well as the fully medicated group with less side-effects as well.

“I’ve been getting a lot of calls and e-mails,” said Sandler,, who conducted the research with James Bodfish, a professor in the departments of psychiatry and pediatrics at UNC Chapel Hill School of Medicine, and study coordinator Corrine Glesne.

“Medications work,” Bodfish said in a statement. “The question is whether we always need to use them at the highest dose. Many parents are concerned about placing their child on medication. Some choose not to treat their child because of concerns about side effects.”

While the research doesn’t address it, the obvious question is, Why? Parents and children in this study knew they were taking a placebo. Why then did they perform as well as their peers without the side-effects — at essentially half the dose as their peers? While the placebo effect has been studied widely, the exact mechanisms are unknown. We do know that the mechanism is governed by the brain. This clearly tells us that having ADHD or not, our brain is still a powerful weapon in our arsenal.

We also cannot exclude the influence of the parents during this research. Did they expect their child to do better? The authors suggest that this was so. This dynamic cannot be overlooked in your family either.

The bottom line is that we likely have far more control over our behaviors and cognitive processes than we are given credit for. Modern medicine, as this research suggests, is just beginning to understand the brain’s role in shaping our lives. We’ve known this for years at Play Attention. Cognitive training. Memory training. Motor skills. Attention training. Behavioral shaping. It’s time to take control over our lives. We’ve all got the power to do it. It lies right behind our eyes.

If I told you that women who received only basic education were 130 % more likely to have a child on ADHD medication than women with university degrees, you’d see a link, wouldn’t you? 

Well, that’s what a  study published this month in Acta Paediatrica found.  That implies that nearly half of the serious cases of ADHD  in children are closely tied to social factors. The study reveals that factors like single parenting and poor maternal education were directly tied to ADHD medication use.

While we know that a genetic propensity likely exists, the human brain develops based on a complex interplay between nature and nurture; between genetic endowment (nature) and environment/social factors (nurture). Epigenetic theory tries to explain this relationship.

Curiously, few large-scale studies have tried to determine the impact of social and family influences on ADHD. Researchers at the Karolinska Institute in Stockholm, Sweden assessed data on 1.16 million school children and examined the health histories of nearly 8,000 Swedish-born kids, aged six to 19, who had taken ADHD medication.

"We tracked their record through other registers … to determine a number of other factors," said lead author Anders Hjern.

Here’s what the researchers found:

• Living in a single parent family increased the chances of being on ADHD medication by more than 50 percent.
• A family on welfare upped the odds of medication use by 135%.
• Boys were three times more likely to be on medication than girls.
• Social dynamics affected both sexes equally.

"Almost half of the cases could be explained by the socioeconomic factors included in our analysis, clearly demonstrating that these are potent predictors of ADHD-medication in Swedish school children," Hjern said.

It’s clear that this study found a link between socioeconomic factors and ADHD medication use/diagnosis. Other US studies have found that minority children and children of low socioeconomic status were more likely to receive ADHD medication.

Factors like low income and diminished quality time are more common in single-parent families. These typically lead to stressors like family conflict and a lack of social support, Hjern said.

While more research must be done, one has to ask, is medication the answer to social stressors like lack of time and money? Sounds too silly to ask, but it seems that our answer, ridiculously, is a resounding, YES!

We are the masters of our lives. We can make significant personal changes, but we must have the tools to do so. That’s why I began Play Attention (www.playattention.com) years ago.

Research tells us that during the summer, the average student loses one to three month’s math and reading gains made over the prior year. Academic losses are so common among students that educators have given the phenomena a name: Summer Brain Drain.

Summer Brain Drain may even be worse for ADHD students already having trouble at school.

Going to school daily provides schedules and routines. The summer break means those routines aren’t there. Expectations are lowered or relaxed. Even sleep schedules are often totally abandoned.

Unfortunately, exercise is often replaced with computer time, watching movies, or playing video games with friends. That’s a bad idea. While there’s nothing wrong with playing video games or watching movies, sedentary activity must always be balanced with exercise. This is especially important for an ADHD student. 

I’ve included some specific articles that approach this topic from varying perspectives. Enjoy and gain the benefits this summer!

Children with ADHD benefit from time outdoors enjoying nature

(http://www.news.uiuc.edu/NEWS/04/0827adhd.html)

News Bureau at the University of Illinois at Urbana-Champaign from May 15 through June 8. — Kids with attention deficit hyperactive disorder (ADHD) should spend some quality after-school hours and weekend time outdoors enjoying nature, say researchers at the University of Illinois at Urbana-Champaign.

The payoff for this “treatment” of children 5 to 18 years old, who participated in a nationwide study, was a significant reduction of symptoms. The study appears in the September issue of the American Journal of Public Health.

“The advantage for green outdoor activities was observed among children living in different regions of the United States and among children living in a range of settings, from rural to large city environments,” wrote co-authors Frances E. Kuo and Andrea Faber Taylor. “Overall, our findings indicate that exposure to ordinary natural settings in the course of common after-school and weekend activities may be widely effective in reducing attention deficit symptoms in children.”

ADHD is a neurological disorder that affects some 2 million school-aged children, as well as up to 2 to 4 percent of adults, in the United States. Those with ADHD often face serious consequences, such as problems in school and relationships, depression, substance abuse and on-the-job difficulties.

“These findings are exciting,” said Kuo, a professor in the departments of natural resources and environmental sciences and of psychology at Illinois.

“I think we’re on the track of something really important, something that could affect a lot of lives in a substantial way,” she said. “We’re on the trail of a potential treatment for a disorder that afflicts one of every 14 children – that’s one or two kids in every classroom.”

If clinical trials and additional research confirm the value of exposure to nature for ameliorating ADHD, daily doses of “green time” might supplement medications and behavioral approaches to ADHD, the authors suggest in their conclusion.

Kuo and Faber Taylor, a postdoctoral researcher who specializes in children’s environments and behavior, recruited the parents of 322 boys and 84 girls, all diagnosed with ADHD, through ads in major newspapers and the Web site of Children and Adults with Attention Deficit/Hyperactivity Disorder. Parents were interviewed by means of the Web and asked to report how their children performed after participating in a wide range of activities. Some activities were conducted inside, others in outdoor places without much greenery, such as parking lots and downtown areas, and others in relatively natural outdoor settings such as a tree-lined street, back yard or park.

The researchers found that symptoms were reduced most in green outdoor settings, even when the same activities were compared across different settings.

“In each of 56 different comparisons, green outdoor activities received more positive ratings than did activities taking place in other settings, and this difference was significant or marginally significant in 54 of the 56 analyses,” Kuo said. “The findings are very consistent.”

The two researchers have been pursuing the ADHD issue as an extension of a long line of previous research they’ve conducted on the nature-attention connection among the general population in mostly urban settings.

“The medications for ADHD that are currently available work for most kids, but not all,” Kuo said. “They often have serious side effects. Who wants to give their growing child a drug that kills their appetite day after day and, night after night, makes it hard for them to get a decent night’s rest? Not to mention the stigma and expense of medication.”

Simply using nature, Kuo said, “may offer a way to help manage ADHD symptoms that is readily available, doesn’t have any stigma associated with it, doesn’t cost anything, and doesn’t have any side effects – except maybe splinters!”

There are a number of exciting possible ways in which “nature treatments” could supplement current treatments, she said.

Spending time in ordinary “urban nature” – a tree-lined street, a green yard or neighborhood park – may offer additional relief from ADHD symptoms when medications aren’t quite enough. Some kids might be able to substitute a “green dose” for their afternoon medication, allowing them to get a good night’s sleep.

“A green dose could be a lifesaver for the 10 percent of children whose symptoms don’t respond to medication, who are just stuck with the symptoms,” Kuo said. As Kuo and Faber Taylor wrote, a dose could be as simple as “a greener route for the walk to school, doing classwork or homework at a window with a relatively green view, or playing in a green yard or ball field at recess and after school.”

The National Urban and Community Forestry Advisory Council, U.S. Forest Service, and the U.S. Department of Agriculture’s Cooperative State Research, Education, and Extension Service supported the project.

Exercise Improves Learning and Memory
Chalk up another benefit for regular exercise. Investigators from the Howard Hughes Medical Institute (HHMI) have found that voluntary running boosts the growth of new nerve cells and improves learning and memory in adult mice.
"Until recently it was thought that the growth of new neurons, or neurogenesis, did not occur in the adult mammalian brain," said Terrence Sejnowski, an HHMI investigator at The Salk Institute for Biological Studies. "But we now have evidence for it, and it appears that exercise helps this happen."
USA Today (http://www.usatoday.com/news/health/2006-03-26-adhd-treatment_x.htm)

ADHD treatment is getting a workout

http://www.usatoday.com/news/health/2006-03-26-adhd-treatment_x.htm
Doctors haven’t done many definitive studies about exercise and ADHD, says David Goodman, an assistant professor of psychiatry at the Johns Hopkins University School of Medicine. But Goodman says it makes sense that working out would help people cope with the condition. Studies show that exercise increases levels of two key brain chemicals — dopamine and norepinephrine — that help people focus.

"Your cognitive function is probably better for one to three hours after exercise," Goodman says. "The difficulty is that by the next day, the effect has worn off."

If kids could exercise strenuously three to five times a day, they might not need medications at all, says John Ratey, an associate clinical professor of psychiatry at Harvard Medical School. Ratey is so intrigued by the question that he’s writing a book about how exercise can reduce symptoms of ADHD or at least help patients cope.

Team sports might help children with ADHD in several ways, says James Perrin, a professor of pediatrics at Boston’s MassGeneral Hospital for Children. Children with the condition benefit from following a regular schedule. Coaches who lead kids through structured exercises also might help build concentration and organizational skills.

A Nottingham University research team in the United Kingdom found that the brains of children with ADHD appear to respond to immediate rewards in the same way as they do to medication. Their research was published in the journal Biological Psychiatry.

“Our study suggests that both types of intervention [medicine and immediate reward/reinforcement] may have much in common in terms of their effect on the brain,” said Professor Chris Hollis, the lead investigator of  the study.

The research team used an EEG (electroencephalograph) to measure the brain activity of children as they played a computer game that provided extra points for less impulsive behavior.

The researchers devised a computer space game which rewarded the ADHD children when they caught aliens of specific colors  while avoiding aliens of designated colors. The game design actually tested the children’s ability to resist the impulse to grab the wrong colored aliens.

To test whether immediate reward/reinforcement made a difference, one iteration of the game rewarded the children fivefold for catching the right alien and penalized them fivefold for catching the wrong one.  All of this was done while activity in different parts of their brains was monitored with an EEG.

Hollis found that the immediate rewards helped the children perform better at the game. This was verified by the EEG which  revealed that both medication and immediate reward/reinforcement were "normalizing" brain activity in the same regions.

Many parents of ADHD children are aware that giving a reward to an ADHD child a week after their good behavior is insignificant to that child. ADHD children respond better to immediate reward, not delayed reward.

"Although medication and behavior therapy appear to be two very different approaches of treating ADHD, our study suggests that both types of intervention may have much in common in terms of their effect on the brain. Both help normalize similar components of brain function and improve performance,"  said Hollis.

"We know that children with ADHD respond disproportionately less well to delayed rewards – this could mean that in the ‘real world’ of the classroom or home, the neural effects of behavioral approaches using reinforcement and rewards may be less effective."

It’s obvious that providing immediate rewards/reinforcement 24 hours a day and 7 days a week would be impractical and impossible. But what does this research tell us? It tells us that if we are to train an ADHD student, feedback, reward, and reinforcement need to be immediate if we are to get their brain to rewire.

We at Play Attention have known this for many years. This is why we integrated immediate feedback/reinforcement for attention training, cognitive training, memory training, and behavioral shaping by using feedback technology. We patented this method years ago because of its inherent strength. While we knew this was the best way to achieve success, we feel research like this rather reinforces our approach. It’s about time the world caught up!

When it involves ADHD, psychologist William Pelham is one of the most prolific researchers around. Pelham and his colleague Dr. Brain Wymbs published a longitudinally study (Journal of Consulting and Clinical Psychology. Vol 76(5), Oct 2008, 735-744.) that tracked 282 families with and 206 without ADHD children. They found that couples who have a child diagnosed as ADHD are almost twice as likely to divorce or become estranged compared to couples without an ADHD child. A simple dynamic is causal: ADHD children can be stressful for parents thus magnifying conflicts between spouses. ADHD children also have oppositional behaviors which increase stress at home.

“We have known for a long time that kids can be stressful for their parents. What we show is they can be really stressful and can lead to marital dissatisfaction and divorce,” said Pelham, who works at the State University of New York at Buffalo. “What it means is ADHD should not be treated without involving the parents in the treatment.”

The researchers found that parents with ADHD children tended to reach the point of divorce or separation faster than their peers.

Parents of ADHD children are distinctly aware that battles over homework, chores, discipline are key stressors that provide further conflict between spouses. It is understandable that 22.7 percent for parents of kids with ADHD were divorced by the time the children were 8 years old as opposed to only 12.6 percent of the parents of non-ADHD children.

“Parents of children with ADHD report less marital satisfaction, fight more often, and use fewer positive and more negative verbalizations during child-rearing discussions than do parents of children without ADHD especially if the child also has conduct or oppositional problems,” Pelham and Wymbs noted in their paper.

The researchers discovered that regardless of whether parents had manageable or difficult children, if parents had an ADHD child they were three times as likely to be negative toward each other as parents who did not. Stress was up and patience was thin.

Does medicine help? Medicines can alleviate ADHD symptoms, however the researchers found that most meds were given in the daytime to improve school performance and wore off by evening when the children were to do homework and chores.

The Brits have taken the polar opposite approach to children with ADHD. I find it highly logical and practical: except in extreme cases, they advise parents to learn new parenting strategies to change and cope with their ADHD child. This may well curb the incredible divorce rate among ADHD parents as well as greatly improve their child’s future.

Generics don’t produce income for the pharma giants. Giant pharma’s manipulation of pricing affects users – perhaps more now that the economy is a mess. It also affects health and health related decisions. Ethically, this is wrong.

Shire hikes Adderall price as rumors fly

Amid new speculation that Pfizer might snag Shire in a buyout deal, the specialty pharma is following through on its strategy to switch patients to its newest ADHD med Vyvanse as blockbuster Adderall XR nears the end of its patent. Shire is hiking the price of Adderall by 20 percent, a boost that confounded analysts expecting a smaller increase.

The idea, of course, is that by making Adderall more expensive, Shire will shine the spotlight on Vyvanse, whose price is rising by a mere 7 percent. Cost-conscious patients will then switch to the cheaper brand, or so the theory goes. Then, firmly entrenched as Vyvanse users, the patients won’t move to generic Adderall when it hits the market.

Analysts apparently expect the switching to stick; Citigroup upgraded Shire stock on the prospect. But with insurers increasingly vigilant about drug prices, generic Adderall might woo away more Vyvanse users than Shire wants to lose. We’ll have to wait and see how that plays out.

In the meantime, though, investors are bidding up Shire stock on fresh rumors that Pfizer is kicking tires there. The U.K. company surfaces as a rumored Pfizer target from time to time, however, so it’s tough to know whether Pfizer is actually looking, or whether the habitual talk simply got stirred up when Pfizer chief Jeff Kindler made his “open to big deals” statement earlier this week.

The American Academy of Pediatrics has issued a new policy contradicting the American Heart Association’s: stance that children prescribed stimulant medication Schedule II drugs should get a heart screening or EKG prior to taking the drugs. The American Heart Association (AHA) cited the fact that approximately 2.5 million children taking these drugs are at risk of elevated blood pressure and increased heart rate.

The FDA recently insisted that a warning be placed on the medication’s labels indicating risks for sudden deaths in patients with heart problems. Approximately 20-30 sudden deaths have been reported related to stimulant medication in the US and Canada.

The longest study on families and their use of medication, the Multi-modal Treatment of ADHD Children (MTA) study also indicated other side-effects including decreased height and weight.

The American Academy of Pediatricians (AAP) has taken the stance that children taking stimulant medication do not need and ECG or EKG (electrocardiogram) tests because the rate of death is very small in respect of the overall number of children taking the medication. The AAP contends that EKGs are expensive [around $100] and could delay access to effective ADHD treatments which “could have serious implications.” The AAP does advocate careful physical examination, and a review of family history of heart problems including sudden death. It does not, however, advocate routine EKGs.

According to the Associated Press, policy co-author Dr. James Perrin, a Massachusetts General Hospital pediatrician said the academy’s policy makes clear that there’s no scientific evidence to support “this fairly dramatic practice change.”

This is a rather disconcerting stance for several reasons. The first reason is that there are no long-term data demonstrating the safety or risks of stimulant medication especially in conjunction with cardiovascular risk. Secondly, according to the AHA, children with heart abnormalities have a higher incidence of ADHD. Third, stimulant medications are known to decrease both height and weight in children.

It’s also perplexing that the APA advocated cholesterol drug treatment for children as young as 8 years old. Given this history, then it is not out of character for the APA to minimize heart risk.  

Decision Resources Pharmacor report reveals that the UK’s Shire may be the ADHD top earner by 2017.

Shire currently markets ADHD stimulant medication, Adderall. Adderall’s instant release formula is now available as a generic drug. The report states that Shire´s ADHD drugs will be dominate this market by 2017. The report attributes this, at least in part, to Shire’s launch of Vyvanse´s, a new ADHD drug which has been approved for both children and adults. Vyvanse may lower abuse potential compared with other psycho-stimulants on the market. The Pharmacor report predicts that Vyvanse will generate almost $ 1.2 billion dollars in sales in 2017.

Shire’s ability to take the lead, according to the report, will be because of Shire’s Vyvanse and its patch sold as Daytrana. Additionally, Shire is pursuing a non-stimulant medication called Intuniv that will compete with Lily’s Strattera and secure dominance in the burgeoning international ADHD market projected to be worth $4 billion.

To facilitate continued sales increases and increased market share, all major pharmaceutical companies are marketing heavily in countries that traditionally have not accepted ADHD as a neurobiological disorder or treated it with medication.

In the wake of the deaths of 20+ children taking ADHD stimulant medication, the American Heart Association (AHA) cautioned this week that children should be screened for heart problems with an electrocardiogram(EKG) before getting drugs like Ritalin to treat hyperactivity and attention-deficit disorder.

The National Institute of Mental Health estimates that between 5% and 7% of children have ADHD. They speculate that about 2.5 million American children and 1.5 million adults take medication for ADHD to control behavior and increase focus.

Stimulant drugs like Concerta, Adderall, Ritalin, etc. are classified as schedule II drugs –the same category as cocaine. They can increase blood pressure and heart rate which is problematic for children with heart conditions. It could result in vulnerability to sudden cardiac arrest — an erratic heartbeat that causes the heart to stop pumping blood through the body — and other heart problems.

After review of these implications by the FDA, the FDA mandated that these medications carry warnings of possible heart risks in those with heart defects or other heart problems.

The AHA is now recommending children receive a thorough exam, including a family history and an EKG, before children are put on the ADHD drugs to insure that they don’t have any undiagnosed heart issues.

“We don’t want to keep children who have this from being treated. We want to do it as safely as possible.” said Dr. Victoria Vetter, a pediatric cardiologist at the University of Pennsylvania School of Medicine and head of the committee making the recommendation.

American Heart Association

AHA recommendations: http://www.americanheart.org/presenter.jhtml?identifier=3055953
http://www.americanheart.org/presenter.jhtml?identifier=3055974

The American Heart Association’s (AHA) recent recommendation that children be screened for possible heart problems before taking ADHD stimulant medication has spurred great anxiety among parents and professionals. The recommendation was given as a response to a number of deaths due to heart failure associated with ADHD stimulant medication.

In response to the AHA’s recommendation, the Pediatric Cardiology Division at the University of Virginia Children’s Hospital will begin offering electrocardiograms (ECG or EKG) for ADHD children taking stimulant medications for the disorder.

According to Dr. George McDaniel, director of the Pediatric Electrophysiology Program at UVA Children’s Hospital, this exam is important because not all children show obvious signs of a heart condition or abnormality.

The AHA also recommends that ADHD children receive a thorough family history and an EKG by their healthcare providers to screen for problems before they may arise.

Experts at UVA Children’s Hospital say the recommendations are conservative but the information is worth knowing.

Families should be reassured that there is no real urgency for a patient who is not having any difficulties,” said Dr. Paul Matherne, director of the Division of Pediatric Cardiology at UVA Children’s Hospital. “According to the guidelines parents should not stop their child’s medication and can have this screening done by their medical care provider at their next appointment.”