| | | Vice chairman of psychiatry at New York University, Koplewicz believes thatADHD is a legitimate brain disorder. He wrote It's Nobody's Fault: New Hopeand Help for Difficult Children and Their Parents. He is director for the New York University Child Study Center. | | ||
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. . . The good news is that the medications are remarkably safe. The reasonthat they're so safe is that you take them and they have a very shorthalf-life, meaning that you metabolize them very quickly and they're out ofyour system in several hours. Because of that, you have to know that they onlywork when you take them, so that this is a treatment, not a cure. When it doeswork--and it works in about 80 percent of the cases--you see children who, allof a sudden, are able to use their intelligence, able to use their wit, theircharm, so that they can focus on the blackboard. They can listen to theteacher. They can pick up social cues. . . .
A lot of parents have a hard time giving kids medication. How would youallay their fears and make them feel a bit more at ease?
I can understand completely why most parents wouldn't want their childrentaking medicine. . . . But if you have a disorder, if you have a realillness, and if the illness is Attention Deficit Hyperactivity Disorder, theonly treatment that we know is effective is medication. ...
The potential side effects of taking this medicine are usually very short term.They decrease your appetite and they decrease your ability to fall asleep. Thegood news is that frequently those two very common side effects disappear withtime, and sometimes when lowering the dose, they will be able to get rid ofthose effects.
There are some less frequent symptoms that are very bothersome. Kids willbecome more zombie-like; they seem to lose their spark. They don't seem to beas fresh and as with it. In those cases . . . even though the child's ableto pay attention, you've lost the essence of who that child is. The good newsis that all these side effects are short term and are reversible. If you stopthe medicine, the side effect goes away.
The thing is that I think most parents worry about are the myths about thesemedicines. They think, "If my child takes this medicine, I'm teaching my childhow to take drugs." The truth is that kids who have ADHD who don't get treatedare much more likely to abuse illicit drugs, bad drugs, than kids who take themedication. Because when you're taking the medication, you're less impulsive;you're more attentive; you're more on-target. And you're also learning,hopefully, from your parents and your doctor that you have a more sensitivebrain, and that you should really avoid these bad drugs like marijuana andcocaine and even alcohol, because they may have a stronger reaction in you thanit would in an average person. ...
We hear about children abusing Ritalin or selling their Ritalin, and it alwaysbaffles me, since it's a lousy drug of abuse. It doesn't make you high; itdoesn't give you the euphoric feeling. Kids supposedly chop it up and snortit. I think the only thing it's going to do is make your nose bleed. It'sgoing to make you super-focused, but it doesn't sound like a great recreationaldrug. So I question the necessity of keeping Ritalin on a Schedule II.
| | | Professor of psychiatry and neurology at the University of MassachusettsMedical Center in Worcester. Author of numerous books on ADHD, includingADHD and the Nature of Self-Control and Attention-DeficitHyperactivity Disorder: A Handbook for Diagnosis and Treatment. | | ||
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Stimulants seem to work by increasing activity within certain brain regions.By increasing or stimulating these brain regions, they result in greater powersof inhibition. The individual is able to stop and is able to engage theirprocesses before they act. . . .
Now, as far as what they're doing at the level of chemistry and proteins, we'renot quite sure yet. We do have some indications that the stimulants areachieving an increase in the amount of dopamine that is within the synapsesbetween brain cells--those critical gaps between the brain cells where theneurotransmitters are supposed to do their job. Evidence indicates that drugslike Ritalin slow up how much of that chemical is being reabsorbed into thenerve cell, so that more is left in the synapse. Other medications, likeDexedrine, may just increase the production of dopamine within these nervecells.
However they do it, the stimulants all have in common that more dopamine seemsto be available within these critical brain regions to allow them to be moreactive, and to do the job of inhibiting behavior that they're supposed todo.
Why are these drugs compared to cocaine?
The drugs are compared to cocaine because chemically, they are similar tococaine. That doesn't mean that they act like cocaine. For a drug to besimilar doesn't mean that it's identical or that it does the exact same thingsthat cocaine happens to do. Many critics of the stimulants have badly misledthe public into thinking that, because the drug is chemically similar, it isidentical. What makes a drug like cocaine addictive ishow quickly it enters and clears the brain. Cocaine, because it is inhaledthrough the sinus passages, is rapidly absorbed into the bloodstream and takenimmediately into the brain. There is a rapid change in consciousness. Andit's that rapid change in consciousness that humans perceive as addictive, asso seductive to them.
On the other hand, drugs like Ritalin and the other stimulants are takenorally. They're absorbed very gradually through the intestine. They enter thebloodstream in very slow, gradual amounts. Therefore, they're entering andleaving the brain in a very controlled and subdued fashion. As a result, theyare not addictive whatsoever when they are taken orally. All of the evidencepoints to these being non-addictive drugs when taken as prescribed.
Of course, if you were to crush a tablet of a stimulant medication and inhaleit, you might well become psychologically dependent, and possibly even addictedto inhaling this medication. But, of course, you can do that with airplaneglue and paint thinner and gasoline. But I don't see anybody requiring thesebeing prescribed monthly the way we control access to the stimulants. Any drugcan be abused if you administer it through a different route than the way it'sintended to be used. But, used as prescribed, the stimulants are notaddictive. ...
These meds are performance-enhancers. Are they also life-enhancing?
Well, many medications can be considered life-enhancing orperformance-enhancing medications. Prozac, for instance, when it first came onthe market, was criticized, because people were taking it to fine-tune some ofthe edges of their personality when they really didn't have major depression.And undoubtedly some people are taking stimulant medications, not because theyhave ADHD, but because they want to stay up and get more work done. ...
There are certainly people who can misuse the stimulants as performanceenhancers. But the fact is that the largest percentage of prescriptions forthe stimulant medication are being prescribed for the disorder, for a validcondition, and are being prescribed appropriately. There's always going to bea certain small percentage of the public who wants to try a medication to tweaktheir personality a little bit, to see if it makes them more competitive inthis competitive environment that we live in. I don't think you're going to beable to stop that. But that's no reason to keep people with a legitimatemental disorder from having access to treatments that are well established andthat are safe and effective for them.
| | | Castellanos is a pediatrician and child psychiatrist conducting neuroimagingand genetic studies of ADHD. He is the head of ADHD research at the NationalInstitute of Mental Health (NIMH). | | ||
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. . . A very respected researcher wrote an article that was entitled, "Howis Ritalin, or Methylphenidate, Like Cocaine?" The researcher wrote a paper inwhich she examined the similarities between methylphenidate, or Ritalin, andcocaine. They go to some of the same places in the brain; but there are alsosome major differences. Cocaine leaves the basal ganglia much more rapidly.She also studied the differences between injecting Ritalin and swallowingRitalin, and it makes a huge difference in the kind of response you get. So,Ritalin, when it's taken as a pill, has a very safe profile. When it'sinjected or when it's snorted, it becomes a very dangerous drug.
So I think that that's the truth in this. And it's not something to play with.There have been deaths from kids who thought it was fun to take Ritalinrecreationally. But when it's taken as prescribed, it's remarkably safe.There's always a risk. But there are fewer adverse events than from vitaminswith iron, which are quite toxic when children take too many of them, oraspirin, or Tylenol, or antibiotics. ...
How do the medications work on the brain?
We know the first step of how medicines like the stimulants work, but we don'tknow many other things. We know that they increase dopamine andnorepinephrine, which are important neurochemicals, in regions where thosechemicals are being released normally. We know that they enhance the amountthat's available to those neurons. But we don't know if that is important inall of the brain regions that have those chemicals, or if they're interactingin more complicated ways. We just flat-out don't know.
. . . Why use a stimulant, and why not a tranquilizer? People have a hardtime understanding that.
. . . The first person who found out that stimulants can be helpful forhyperactive children was Charles Bradley. And he guessed, or hypothesized,that they must be stimulating some of the centers that allow inhibition andself-control more than they stimulate other parts of the brain. That was in1937, and that's still a pretty good explanation of what we know. So wehaven't progressed as much as we'd like. We know that they do work in manykids. ...
Even if we don't know the long-term consequences of using thesemedications?
We don't know long-term consequences of many things. And sometimes, thelong-term consequences of not doing something have to be weighed as well. Thebest way to learn the long-term consequences of a treatment . . . is to doan impossible study--to take 1,000 children and randomly decide who's going toget Ritalin and who's going to get placebo for the next 20 years, and not lettheir parents change their minds about what they're going to do. That's notgoing to be done. . . .
We also know, from the fact that millions of children have taken thesemedicines, that the risks are not dramatic or obvious, because those are thingsthat people notice. We can't be glib or certain that there are no long-termrisks. But there's no large mass of doubts amassing and suggesting that wehave a generation of children developing cancer or things of that type.
But it is an open question. And when the decision is made whether ornot to use medications in the child, the uncertainty about that needs to beacknowledged. For some people, that weighs more than the potential benefit;and for other people, the distress is more important. . . .
If you had a child with ADHD, would you give him medication?
With what I know, I'd be willing to have thatchild take medication, but I'd want to make sure that it was really necessary.And I would put it off as long as I could; I would not be comfortablemedicating a child who was two, three, four years of age, unless it was theonly option. . . .
| | | Author of Running on Ritalin, Diller received his medical degree fromColumbia University's College of Physicians and Surgeons. While he hasdiagnosed some children in his private practice with ADHD, Diller hascriticized the proliferation of the ADHD diagnosis and the rise of "cosmeticpsychopharmacology." | | ||
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. . . I think 60 years of experience with stimulants suggests it's prettysafe stuff. If we're choosing to medicate children who, if they had a smallerclassroom size, or one parent could be home, or issues like that, that becomesa moral ethical decision, rather than one of physical safety. I think we havea pretty good track record. Three to five years' worth of Ritalin use isprobably pretty safe. . . . We have no data on adolescents taking this drugfor any length of time. And we have anecdotal data that if you don't abuseamphetamines too much, as an adult, it's probably safe. But it's not any kindof systematic data. . . . I wish we could have a balanced discussion on this. . . . Itquickly tends toward exaggeration and hyperbole that Ritalin is the best thingsince sliced white bread, or Ritalin is the devil's drug. And it's neither. . . .
We interviewed a psychiatrist and he argued that the medications to treatADHD would not help most kids. It only helps a small percentage, maybe 5percent to 15 percent of them.
It's astonishing that this myth continues. During the 1970s, the NIMH firststudied adult volunteers and gave them Dexedrine. ... The researchers decidedto give it to their own children, and also to their colleague's children. Loand behold, their performance improved also. ... This is what happens. TheADHD children are now operating normally, and the normal children are operatingabove average. The question is, where is that line for the normal child versusthe ADHD child? ...
| | | A psychiatrist in Denver, Colorado, Dodson ascribes ADHD mostly to biologicalcauses. He is paid by Shire Richwood, the makers of Adderall, to educate otherphysicians about the drug's efficacy. | | ||
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You say multimodal, but the most effective treatment is the medication,correct?
Yes.
How do you know that?
The federal government, about six years ago . . . established theMultimodal Treatment Study of ADHD--the MTA--which was published inDecember,1999. That's the largest study ever undertaken of a mental healthdisorder in children. It's a huge study.
They took 579 elementary school-aged boys and girls who had the combined typeof ADHD. And they broke them into four different treatment arms. The firstgroup got just medication, and the medication was fine-tuned to the . . .child. The second group got intensive behavior management. By intensive, Imean two months of an immersion summer camp program--12 weeks of somebodycoming in every day into the school to work with the teachers; 26 weeks ofparent training, so the parents could use these techniques at home; 26 weeks ofthe kids getting individual and group treatment. In other words, a verymoney-, labor-, and time-intensive treatment. A third group got medicationplus behavior management. And a fourth group, armed with world class work-ups,got referred out into their communities to see what would happen.
At the end of the study in 14 months, more than a year, the results werestriking. . . . The two groups that got medication did wonderfully. Theydid exceptionally well. Adding the behavior management component did notimprove the outcomes, unless you had an anxiety disorder, a co-existingcondition, or you came from a single-parent family; then it made a difference.But it didn't make a huge difference. It didn't make a detectable differencein the outcome for ADHD.
And down from was the intensive behavior management program. . . . It wasnowhere near as effective as medication was. The big disappointment was that,when they came back after the intensive behavior management program had ended,there was no evidence that it had ever occurred. The hope had been that thesetechniques would be internalized by the children and that eventually, this veryexpensive treatment could be attenuated and ultimately stopped. What theyfound was that as soon as the treatment stopped, so did the benefits.
Most people think we're talking science here. In fact, we know that thisdrug has an effect on children and adults who display certain syndromes, but wedon't know what it is. Does that disturb or concern you?
It doesn't concern me. I'm curious and I want to know why it works, becauseonce we know why it works, we can probably develop better medications andbetter treatments. We did find, totally by accident, that these medicationswork. The original reason that they were used back in 1937 was due to theiranti-seizure properties. They found that they had a much more dramatic effectupon behavior and attention and impulsivity. . . .
If you look at the history of medicine use in psychiatry, until Prozac camealong in 1988, every single medication in psychiatry was discovered byaccident. They were using the medication for some other purpose and they foundthat mental health symptoms improved when you used that medication. I don'thave to know how a medication benefits my patient. All I need to know is thatit does. I won't wait around until some good hard-edged scientist can tell methe how. . . .
. . . But what if the parents say, "I don't want to take away my child'spersonality, his spirit, his uniqueness?"
Properly adjusted medication does not change the child's personality any morethan eyeglasses will change their personality. Eyeglasses help you to focus.The medication helps you to focus. It is true that if a dose is too high, thechild will have side effects. They will, perhaps, get what they call the"zombie syndrome," in which they do become dull. But that can be removedalmost immediately by lowering the dose.
| | | Formerly the head of child psychiatry at the National Institute of MentalHealth, Jensen was the principal author of the landmark NIMH study NIMH, theMultimodal Treatment Study of Children with Attention Deficit HyperactivityDisorder (MTA). He is now the director of Columbia University's Center for theAdvancement of Children's Mental Health. | | ||
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I think the Schedule II classification appears to be warranted from the federalperspective, and this was reviewed recently. I know there are varying opinionsat various parts of the federal government about this, but we know that thesiphoning off for illegal purposes of these medications does happen. It's nota major phenomenon. Cocaine, for example, is the big substance of abuse interms of the speed kinds of agents, and illegally prepared speed agents aremuch more common.
. . . If you wanted statistics, it's about one out of every 5,000 Ritalintablets . . . ends up getting hijacked or diverted, officially according tothe Drug Enforcement Agency. So we know it does happen. . . . If it's notcarefully monitored or watched, it's possible that it could end up being soldon the street. So the restrictions are appropriate.
There's a lot of confusion out there as to whether thesemedications--Ritalin, methylphenidate, Adderall--are similar to cocaine. Canyou dispel that myth once and for all?
The various stimulant agents can all potentially be abused. It really has lessto do with the exact specifics of the chemical structure, and that's not whatyou should be focusing on. There are similarities across some of these agents.. . . But that's not a really good argument. There's single atomdifferences between some things that are therapeutic and some things that arepoisonous. . . . There's one tiny chemical structure different betweenethyl alcohol that we drink for recreational purposes, and other forms ofalcohol that make you blind--just a tiny little switch in the chemicalstructure. So that's not where the story's told.
The story's told on research data that shows, "Is this abused? How much is itabused?" Cocaine is clearly abused. Cocaine is a street drug. Cocaine isimported illegally into this country. . . . We know Ritalin can be abused.It's a tiny amount of what's going on right now with Ritalin nowadays, comparedto the medicinal use, but it's part of the story and it should be watchedcarefully. . . .
Has Ritalin abuse risen dramatically in recent years? There's no evidence fromthe DEA or from the National Institute for Drug Abuse when they've actuallydone their studies. There doesn't seem to be any major new trend. But they'vegot their eye on it. . . .
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