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Dr. Zabrin Inan, MD
Child, Adolescent and Adult Psychiatry
 Chicago

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Attention Deficit Disorder

ADHD: Diagnosis and Treatment

Today, our best estimate is that attention deficit/hyperactivity disorder (ADHD) affects 5% of school-age children, although some published studies indicate a rate as high as 12% in certain groups.  ADHD occurs three times more frequently in boys than in girls.  That difference, however, may be explained in part by the fact that boys with ADHD typically act out and so are more easily identified, while girls with ADHD tend to withdraw, particularly those with a with a kind of ADHD known as "inattentive type" ADHD.

Recent clinical experience and research are giving us important new insights into this disorder.  For example, children may not outgrow ADHD: up to half of all children with ADHD continue to have problems in adolescence and even into adulthood.  Also, about half of all people who have ADHD inherited it.  This disorder, indeed, can "run in the family." 


template7_nav.cmp"The proper dose of a stimulant medication is the effective dosing delivery benefit with negligible or manageable side effects.  Far too many children with ADHD are started on, but then withdrawn from otherwise effective medication treatment merely because a parent or grandparent becomes unrealistically over concerned about temporary stimulant-induced side effects and/or will not follow through in employing physician-prescribed countermeasures."
�Corydon G. Clark, MD
www.addclinic.net

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Significant work is underway to better understand what may be critical differences between the two most recognized types of ADHD�hyperactivity and impulsivity. Further, only recently has �inattentive type� ADHD been recognized by the medical community. There appear to be many differences in the behavioral functioning of these children compared with those who exhibit hyperactivity or impulsivity and, possibly, in the kinds of deficits they are likely to experience.  We are evaluating these children on a wide array of neuropsychological measures.

The Medications Controversy

Widespread negative media coverage of the use of stimulant medications to treat ADHD resulted from failure to understand that different medical specialists typically see substantially different parts of the ADHD population:

  • Neurologists tend to see children who have seizures, severe learning disabilities, and mental retardation;
  • Child and adolescent psychiatrists tend to treat ADHD patients who also have comorbidity, that is, additional problems like oppositional defiance disorder, conduct disorder and anxiety disorder;  and depression or mood disorders; 
  • Adult psychiatrists tend to treat ADHD patients with personality disorders and accompanying psychiatric illnesses;
  • Pediatricians and family care physicians typically treat children with ADHD who have less severe symptoms.

On the other hand, news media reports about how children absorb, metabolize and excrete drugs differently than adults are accurate.  Drugs have shorter half-lives in children and adolescents than in adults. Studies also show that pre-schoolers need higher doses than school-age children to achieve the same benefits, and school-age children need higher doses than adolescents. Some preliminary findings even suggest that adults may require the lowest doses.

Dosage also varies widely based on the patient�s medical history. For example, it is well known that people who have been exposed to alcohol or drugs while still in their mother�s womb require larger amounts of medication, including stimulants, for effective treatment.

How is ADHD diagnosed?

One of the myths surrounding the treatment of ADHD is rooted in the paradox that stimulants can have a calming effect.  It is a common misconception that if a stimulant calms a child, that child must have ADHD because, the thinking goes, if the child didn�t have the disorder, the medication would have no effect.  That conclusion is wrong.  Stimulants increase attention span in children who do not have ADHD as well as in children with ADHD.

The ADHD diagnosis requires a comprehensive assessment that includes a review of the child�s developmental, social, academic and family and medical history, and an analysis of all the child�s symptoms. It is not a diagnosis that can be made in one visit to a doctor.


template7_nav.cmp"Of all the ADHD medications, Ritalin is the most inconstantly absorbed.  Some adults and children absorb as much as 80-90% of the medication, whereas others only absorb 30-40%�."
�Lewis Mehl-Madrona, MD, PhD
healing-arts.org

An ADHD diagnosis must include a thorough examination of all the symptoms.  Children with learning disabilities or auditory or visual problems, for example, can present signs and symptoms that mimic ADHD.  

There is also a high degree of comorbidity with ADHD:

Children clinically treated for ADHD also can have oppositional defiance disorders (up to 40%), anxiety disorders (20-25%),  mood disorders (15-20%) and conduct disorders (15-20%).  Although ADHD is separate and distinct from learning disabilities, ADHD often will co-occur with learning disabilities (15-25%) and language disorders (30-35%). 

template7_nav.cmp"Ritalin lasts from 1-1/2 to 3 hours in most people, and the SR preparation is no bargain in that it only seems to last another hour or so.  Furthermore, the idea that people are getting slow release preparation is troubling as Paul Wender M.D. long ago studied the Slow Release form and found that this 20 mg pill only gave the equivalence of 7.5 mg of the quick release preparation."
  �John Ratey, MD
www.add.org 
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There is also a relationship between ADHD and disorders such as major depression.  Almost 33% of children between the ages of 6 and 12 who are diagnosed with chronic depression develop bipolar disorders within a few years. 

Because a child can have both ADHD and bipolar disorder, it is now recommended that bipolar disorder be ruled out or confirmed before diagnosing ADHD.  The reason is that conventional ADHD therapy, a stimulant, actually can worsen the bipolar disorder. Ideally, the physician will treat symptoms of the bipolar or mood disorder with a mood-stabilizing medication, and use a stimulant to treat ADHD.  Because ADHD is more common than bipolar disorder, considering or ruling out the latter may be overlooked without a thorough evaluation. 
(Click here for more information on Depression and Mood Disorders.)

When a child�s ADHD disorder is not identified and properly treated, the child runs an increased risk of dropping out of school, substance abuse, delinquency or other serious problems.  In November 2000, the Coalition for Juvenile Justice estimated in its annual report that 50-75% of teenagers in the juvenile justice system nationwide have a diagnosable mental disorder�and these numbers appear to be growing.

Click here to go to a Q&A on ADHD.

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CLINICAL LITERATURE

A review of highlights of the clinical literature of the last 10 years demonstrates the progress from former weight-based or �one size fits all� treatments to clear focus on the individual and optimum dosage.

  • March, 2003, Brown University Child and Adolescent Psychopharmacology Update �clinical consult� article on p. 3 cites a review of stimulants by Joseph Biederman, M.D., one of the most respected child psychiatrists in the U.S., and head of the psychopharmacology program at Massachusetts General Hospital in Boston. Dr.Biederman�s review cites Concerta doses as high as 144 mg (Concerta vs. Adderall XR, Today�s Therapeutic Trends 2002; 20(4):311-328) in efficacy and individual�s optimum dosage.
     
  • �Stimulant medications are not weight-dependent.  Patients should be monitored carefully on a regular basis because some medications may produce adverse effects.�
    �Stacey Fornarotto, MS, PA-C; Claire Babcock O�Connell, MPH, PA-C, �Managing ADHD and Comorbid ODD and CD,� Physician Assistant, 2002 July;26(7):20-31
     
  • �Dose-response data consistently indicate more robust responses at higher stimulant doses, hence, clinicians should titrate stimulants to an optimal dose based on efficacy versus the onset of side effects.� 
    �Timothy E. Wilens, MD, Clinical Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital, Associate Professor of Harvard Medical School. CNS New Special Edition, December 2001, pp. 75-79.
     
  • �With recent clinical trials, efficacy has not been greatly associated with the weight-based model, and more clinicians prefer to use an empiric dosing.� 
    �Mark D. Rapport, PhD, and Colin Denney, MA, �Titrating methylphenidate in children with attention-deficit/hyperactivity disorder: Is body mass predictive of clinical response?� Journal of American Academy of Child Adolescent Psychiatry, 1997; 36:523-530).
  • "Dosages (may) increase with change in the learning environment; change from name-brand Ritalin to generic form (generic form of Ritalin may vary in strength by 15%); even though dosage is not calculated by weight, the child may need a different dosage because his or her body is changing.�
    �Elliott, R., & Worthington, L. A. (1995). ADHD project facilitate: An in-service education program for educators and parents. Tuscaloosa: The University of Alabama
  • �Children, in some cases, need to receive higher doses of a drug than adults in order for them to feel its benefits, since children can absorb, metabolize and excrete a drug at different and less predictable rates than can adults.�
    �J.S. Werry and M.G. Aman, 1993, Practitioner's Guide to Psychoactive Drugs for Children and Adolescents

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