ADHD

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ADHD Stimulants
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Background Significance

• So what? What is the significance of ADHD and
  psychostimulants?
• 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

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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)

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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
  it?
• Alfred Tredgold 1922 and mental defectives

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

• encephalitis lethargica

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History Rise of Special Education NIMH
1950s-1970s

• NIMH begins pediatric psychopharmacology research
  in 1958
• Ritalin first approved for use in 1961
• Conners Eisenberg, 1963, 1st article advocating
  Ritalin
• 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

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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,
  pencils,
• books, or tools) (h) is often easily
  distracted by extraneous stimuli (i) is often
  forgetful in daily activities

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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
  disorder

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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
  decision-makers
• - etiology unknown - concern
  about side-effects/stigma
• - time constraints - most
  concerned about the child

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The Diagnostic Triangle with the Child/Adolescent
in the Middle
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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
  settings
• 3. Allegation Ritalin is really kiddie
  cocaine and parents who give their kids these
  kinds of drugs are simply doping up their problem
  children.
• 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
  country.
• number of ADHD diagnoses and
  psychostimulants Rxs increased dramatically in
  the 1990s

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Diagnostic and Prescribing Trends

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

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Diagnostic and Prescribing Trends American
Exceptionalism
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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

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New State Policies Regarding Psychostimulants
School Staff

• Connecticut, Minnesota, Wisconsin, New York, New
  Jersey, Utah, Arizona, Virginia
• VIRGINIA CHAPTER 314
• 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
  Virginia
• 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.

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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,
  Adderall.
• 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

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Current Controversies II

• American College of Neuropsychopharmacologys
  Annual Meeting (2004)
• McLean Hospital and Harvard Medical School
  researchers
• 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
  adults.
• Overall, the animals showed more evidence of
  dysfunctional brain reward systems and
  depressive-like behaviors in adulthood.

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Public Policy Implications Questions

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

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Main Limitation of Existing Studies
Generalizability

• 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.

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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
  psychostimulants.

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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?

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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
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Characteristics of Children With ADHD Odds
ratios adjust for all other predictor variables
in the table
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NHIS Dataset Conditional Probability of a Child
Being Diagnosed with ADHD
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Methylphenidate and Amphetamine Distribution,
2000 (DEA data)(average 4,150 grams/100,000
individuals)
0 to 1,600 Low
(4.6)
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
(4.9)
8,350 to 11,000 Extremely High (1.8)
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Childhood
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