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often spend the most time with children in a structured environment ... Most of what we know about ADHD/psychostimulants is based on local community ... – PowerPoint PPT presentation

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Title: ADHD

ADHD Stimulants
Background Significance
  • So what? What is the significance of ADHD and
  • ADHD is the most commonly diagnosed behavioral
    disorder in children, making up more than 50 of
    all child psychiatric diagnoses
  • 75-85 of children diagnosed with ADHD are
    prescribed psychostimulant drugs (e.g.,
    Ritalin, Adderall, Dexedrine, Concerta)
  • the U.S. population consumes 90 of the worlds
    production of psychostimulants
  • school-age children in the U.S. consume 4 times
    more psychiatric medication than children in the
    rest of the world combined

Background Significance
  • So what? What is the significance of ADHD and
    psychostimulants? contd . . .
  • an estimated 3-5 of school-age children have the
    disorder (NIH Consensus Statement, 1998) other
    estimates 4-12 (Vanderbilt, MUSC)
  • (1.5-to-6 million kids, 1-to-3 students in
    every classroom in the U.S.)
  • ADHD prevalence estimates from actual community
    studies range from as low as 1.7 (Calif. Bay
    Area) to as high as 20 (military bases near
    Virginia Beach)
  • rates of psychostimulant use vary as much as
    3-fold between states and 10-fold within them
    (Rappley et al., 1995 Wennberg Wennberg, 2000
    Zito et al., 1997)
  • At the peak age for psychostimulant use, 11,
    almost 1 in every 10 boys in the U.S. uses these
    drugs (Cox et al., Journal of Pediatrics,
    February 2003).
  • big approximately 1.2 billion spent in 2001
    on ADHD related drugs
  • (new potential growth markets pre-schoolers
    and adults)

History of ADHD Stimulants Moral Deficiency
  • "Passionate, deviant, spiteful, and lacking
    inhibitory volition."
  • That's how one pediatrician, GEORGE FREDERICK
    STILL, described children with symptoms of
    attention deficit hyperactivity disorder (ADHD).
    The year was 1902, and Still puzzled over his
    young patients in The Lancet.
  • What was their disorder, exactly--and what caused
  • Alfred Tredgold 1922 and mental defectives

History of ADHD Stimulants Tredgold (1922)
History Influenza 1918 Bradley Home 1930s
  • encephalitis lethargica

History Rise of Special Education NIMH
  • NIMH begins pediatric psychopharmacology research
    in 1958
  • Ritalin first approved for use in 1961
  • Conners Eisenberg, 1963, 1st article advocating
  • different era for child research
  • MBD minimal brain dysfunction in DSM-II (1968)
  • 1970 Washington Post Omaha Pupils Given
    Behavior Drugs
  • 1975 Schrag Divokys The Myth of the
    Hyperactive Child and Other
  • Means of Child Control
  • 1980 DSM-III Attention Deficit Disorder ADD

DSM-IV Diagnostic Criteria for ADHDDiagnostic
and Statistical Manual of Mental Disorders, 4th
edition (American Psychiatric Association)
  • Either (1) or (2)
  • (1). 6 (or more) of the following 9 symptoms of
    inattention have persisted for at least 6 months
    to a degree that is maladaptive and inconsistent
    with developmental level
  • Inattention (a) often fails to give close
    attention to details or makes careless mistakes
    in schoolwork,
  • work, or other activities (b) often has
    difficulty sustaining attention in tasks or play
    activities (c) often does not seem to listen
    when spoken to directly (d) often does not
    follow through on instructions and fails to
    finish schoolwork, chores, or
  • duties in the workplace (not due to
    oppositional behavior or failure to understand
    instructions) (e) often has difficulty
    organizing tasks and activities (f) often
    avoids, dislikes, or is reluctant to engage in
    tasks that require sustained mental effort
  • (such as schoolwork or homework). (g)
    often loses things necessary for tasks or
    activities (e.g. toys, school assignments,
  • books, or tools) (h) is often easily
    distracted by extraneous stimuli (i) is often
    forgetful in daily activities

DSM-IV Diagnostic Criteria for ADHDDiagnostic
and Statistical Manual of Mental Disorders, 4th
edition (American Psychiatric Association)
  • (2). 6 (or more) of the following 9 symptoms of
    hyperactivity-impulsivity have persisted for at
    least 6 months to a degree that is maladaptive
    and inconsistent with developmental level
  • Hyperactivity (a) often fidgets with hands or
    feet or squirms in seat (b) often leaves seat in
    classroom or in other situations in which
    remaining seated is expected (c) often runs
    about or climbs excessively in situations in
    which it is inappropriate (in adolescents or
  • adults, may be limited to subjective
    feelings of restlessness) (d) often has
    difficulty playing or engaging in leisure
    activities quietly (e) is often "on the go" or
    often acts as if "driven by a motor" (f) often
    talks excessively
  • Impulsivity (g) often blurts out answers before
    questions have been completed (h) often has
    difficulty awaiting turn (i) often interrupts
    or intrudes on others (e.g. butts into
    conversations or games)
  • ADHDs inherent subjectivity lends itself to
    criticisms of being a convenient social construct
    (for medicalizing and medicating annoying
    behavior) and fuels the controversy over the

The Diagnostic Triangle with the Child/Adolescent
in the Middle
  • Teachers
  • - usually 1st to identify ADHD, along with other
    school personnel
  • - increasingly faced with external performance
    pressures (e.g., achievement/outcome-based tests)
  • - often spend the most time with children in a
    structured environment
  • Clinicians Parents - no indep.
    medical test - ultimate
  • - etiology unknown - concern
    about side-effects/stigma
  • - time constraints - most
    concerned about the child

The Diagnostic Triangle with the Child/Adolescent
in the Middle
Four Aspects to the Controversy Over ADHD/Ritalin
  • Allegation ADHD is not a real disorder and
    could be part of a larger feminist conspiracy to
    make little boys more like little girls.
  • etiology is unknown and no independent
    medical test for diagnosing ADHD
  • biology vs. environment debate
  • 2. Allegation ADHD is a conspiracy on the part
    of public schools to warehouse kids instead of
    effectively teaching and disciplining them.
  • initial identification of ADHD is often
    by teachers or other school personnel in academic
  • 3. Allegation Ritalin is really kiddie
    cocaine and parents who give their kids these
    kinds of drugs are simply doping up their problem
  • psychostimulants are powerful,
    potentially addictive drugs susceptible to
    personal abuse and illegal diversion
  • (classified as Schedule II drugs by
    the DEA, along with Oxycontin and morphine)
  • Allegation ADHD is over-diagnosed and
    psychostimulants are over-prescribed across the
  • number of ADHD diagnoses and
    psychostimulants Rxs increased dramatically in
    the 1990s

Diagnostic and Prescribing Trends
  • 400-500 increase in ADHD diagnoses since 1991
  • 1991 800,000 to 950,000 children diagnosed with
  • 2001 4 to 4.25 million children diagnosed with
  • 800-900 increase in psychostimulant use since
  • 1991 2 million psychostimulant prescriptions
  • 2001 21 million psychostimulant prescriptions

Diagnostic and Prescribing Trends American
Increased Public Awareness During Clinton Years
  • As many of you know, the Journal of
    the American Medical Association recently
    reported that the number of preschoolers, ages
    2-4 who are taking psychotropic drugs increased
    dramatically from 1991 to 1995 200,000-300,000
    or 1.5 of the total. We know that the increase
    for Ritalin alone was 150 percent, and the use of
    anti-depressants increased over 200 percent. Now
    I am no doctor, as is obvious, but I am a parent
    and I have been a longtime childrens advocate.
    And these findings concern me. I know they
    concern Dr. Hyman Director, NIMH, Secretary
    Donna Shalala and countless other experts.
  • The White House -- March 20, 2000

New State Policies Regarding Psychostimulants
School Staff
  • Connecticut, Minnesota, Wisconsin, New York, New
    Jersey, Utah, Arizona, Virginia
  • An Act to amend the Code of Virginia by adding a
    section numbered 22.1-274.3,
  • relating to certain medication recommendations by
    school personnel.
  • H 90
  • Approved April 1, 2002
  • Be it enacted by the General Assembly of
  • 1. That the Code of Virginia is amended by adding
    a section numbered 22.1-274.3 as follows
  • 22.1-274.3. Policies regarding medication
    recommendations by school personnel.
  • The Board of Education shall develop and
    implement policies prohibiting school personnel
    from recommending the use of psychotropic
    medications for any student. Such policies shall
    not prohibit school health staff, classroom
    teachers or other school professionals from
    recommending that a student be evaluated by an
    appropriate medical practitioner, or prohibit
    school personnel from consulting with such
    practitioner, with the written consent of the
    student's parent.
  • For the purposes of this section, "psychotropic
    medications" means those medications the
    prescribed intention of which is to alter mental
    activity or state, including, but not limited to,
    antipsychotic, antidepressant, and anxiolytic
    medication and behavior-altering medication.

Current Controversies I
  • Wall Street Journal (November 8, 2004)
  • Pressed to Do Well On Admissions Tests, Students
    Take Drugs
  • Stimulants Prescribed for Attention Disorders
    Find New Unapproved Use
  • By NICHOLAS ZAMISKA, Staff Reporter
  • BETHESDA, Md. -- On the morning he was to take
    the SAT last March, a 17-year-old senior at
    Bethesda-Chevy Chase High School in suburban
    Washington went looking for a bottle of pills.
    His score on practice tests had been too low and,
    with his sights set on an Ivy League college, he
    needed a miracle. Or, friends suggested,
  • He grabbed a tiny blue pill from his little
    brother's prescription stash and swallowed it two
    hours before the test. Despite some jitters when
    he took the test that he attributes to the drug
    -- a stimulant prescribed for attention deficit
    hyperactivity disorder, or ADHD -- he scored 200
    points better than he had on a previous test. In
    an interview recently, he credited the drug with
    keeping him alert and confident "It just felt
    like I was on top of my game. I knew I was going
    to get the questions right.
  • UofR sample 15-35 use stimulants illicitly
    Bates College 35

Current Controversies II
  • American College of Neuropsychopharmacologys
    Annual Meeting (2004)
  • McLean Hospital and Harvard Medical School
  • William Carlezon and Nancy Anderson
  • Finding Long-term use of Ritalin and similar
    drugs can permanently alter a developing childs
    brain and may lead to increased likelihood of
    depression in children who do not have ADHD.
  • Dr. Carlezon and Dr. Andersen exposed normal rats
    to twice-daily doses of Ritalin during a period
    that is equivalent to approximately 4-12 years of
    age in humans.
  • Drs. Carlezon and Andersen found that the animals
    had a reduced ability to experience pleasure and
    reward. In addition, they found that the animals
    exposed to Ritalin during pre-adolescence were
    more prone to express despair-like behaviors in
    stressful situations (such as swim tests) as
  • Overall, the animals showed more evidence of
    dysfunctional brain reward systems and
    depressive-like behaviors in adulthood.

Public Policy Implications Questions
  • Over-diagnosis of ADHD (Are we pathologizing
  • Does the U.S. have a monopoly of wisdom on
    diagnosing and treating ADHD?
  • Over-use of psychostimulants (public health
  • waste of limited resources Society for
    Neuroscience findings, 2001
  • --------------------------------------------------
  • Under-diagnosis of ADHD (public health/education
  • Children with unmet mental health needs are
    more likely to suffer academically and
  • Under-use of psychostimulants (public
    health/education issues)
  • Studies show that untreated ADHD can lead to
    increased self-medication and drug addiction.

Main Limitation of Existing Studies
  • Most of what we know about ADHD/psychostimulants
    is based on local community studies of children
    with ADHD and psychostimulant use.
  • Thus, to date we have relied primarily on massive
    meta-analyses and the NIH funded Multimodal
    Treatment Study of ADHD (MTA) to cobble together
    a national profile of both ADHD and
    psychostimulant use.

On the Road to Model Building . . .
  • 1st place to start constructing a national
    profile of the ADHD population and determine if
    there are any independent socio-demographic
    predictors of the disorder.
  • A national profile is our first value added
    contribution to the knowledge base of ADHD and

A National Profile of Children With ADHD
  • Data Set National Health Interview Survey
    (NHIS), 1999
  • nationally representative, cross-sectional health
    survey conducted jointly by the
    National Center for Health Statistics (NCHS) and
    the Centers for Disease Control
    Prevention (CDC)
  • sample size 37,573 households 97,059 persons in
    38,171 families
  • child component 12,910 children less than 18
    years old
  • response rate, 90.8
  • survey question Has a doctor or a health
    professional ever told you that childs name
    has ADHD?

Characteristics of Children With ADHDAdjusted
Odds Ratios for Prevalence Estimates of ADHD from
the NHIS Odds ratios adjust for all other
predictor variables in the table
Characteristics of Children With ADHD Odds
ratios adjust for all other predictor variables
in the table
NHIS Dataset Conditional Probability of a Child
Being Diagnosed with ADHD
Methylphenidate and Amphetamine Distribution,
2000 (DEA data)(average 4,150 grams/100,000
0 to 1,600 Low
1,600 to 3,150 Below Average (25.5)
3,150 to 5,150 Average (43.5)
5,150 to 6,750 Above Average (19.6)
6,750 to 8,350 High
8,350 to 11,000 Extremely High (1.8)
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