Study Evaluates Two Medications For ADHD

University of Illinois at Chicago researchers are comparing two drugs commonly used to treat attention deficit hyperactivity disorder to determine if genetic factors predict which children will respond to either or both drugs.

Many different medications are used to treat ADHD, including stimulants and non-stimulants, says Dr. Mark Stein, principal investigator of the National Institute of Mental Health-funded study and director of the Hyperactivity, Attention, and Learning Problems Clinic at UIC.

“Unfortunately, clinicians are unable to predict in advance who will respond or not respond to a particular medication,” Stein said.

The study will be conducted in Chicago and New York. Stein and colleagues will enroll 160 children and adolescents between ages 7 and 17 in Chicago. Dr. Jeffrey Newcorn of Mt. Sinai School of Medicine heads the New York site.

Participants will undergo psychiatric evaluations, IQ and achievement tests, a blood test, an electrocardiogram and a physical exam. They will then receive several doses of atomoxetine (a non-stimulant medication), melthylphenidate (a stimulant medication), and a placebo, during a carefully monitored blinded dosing sequence to determine their optimal response to each medication.

During the 12 to 15-week study, researchers will assess the children’s ADHD symptoms, social functioning, problem-solving skills and sleep patterns to determine the efficacy and tolerability of each medication.

Previous research conducted by Stein and colleagues found that children with a variant form of a dopamine transporter gene — a variant known to be associated with ADHD — responded poorly to stimulant medication and had more side effects at lower doses. The new study will test whether patients with this genetic marker respond better to non-stimulant medication.

“At the end of the study we hope to be able to look at a child’s biological characteristics to statistically predict who is more likely to respond to a certain medication and to determine who is more likely not to respond or to have a particular side effect,” Stein said.

“The study provides an idealized standard of care in that the children will be carefully evaluated during their treatment with two different medications, with frequent monitoring that typically does not occur during the normal course of ADHD treatment,” said Stein.

At the end of the trial, participants will be referred back to their primary care provider or given a referral for ongoing treatment with information learned from the study.

Popular ADHD Drug Safe And Effective For Pre-schoolers?

A new study by researchers from the Johns Hopkins Children’s Center and five other medical centers concludes that carefully measured, low doses of methylphenidate (Ritalin) are safe and effective for attention-deficit and hyperactivity disorder (ADHD) in preschoolers. Investigators warn, however, that 3- to 5-year-olds appear more sensitive to the drug’s side effects, which include irritability, insomnia and weight loss, than are older children with ADHD and require closer monitoring.

Children who took the drug also experienced somewhat slower growth rates. On average, children on the drug grew half an inch per year less than expected and gained 2.9 pounds less than expected. Researchers recommend that pediatricians weigh the risks of slowed growth rates against the benefits of treatment. Children on long-term treatment with methylphenidate should be monitored carefully several times a year to assess growth changes over time.

Methylphenidate is the most widely prescribed drug for the treatment of ADHD in children but is not approved by the Food and Drug Administration (FDA) for use in children younger than 6.

Results of the federally funded research, the first large-scale, long-term study of the safety and value of the drug in younger children, appear in a special section of the November issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

“These results give us the missing links in the decision to prescribe a drug that’s been widely used off-label in preschool-age children,” says Mark Riddle, M.D., director of Child and Adolescent Psychiatry at the Children’s Center and a co-author on the study, which followed 303 children between 3 and 5 over 70 weeks. “We were able to confirm what many already suspected-that even lower doses in preschoolers can safely achieve the desired therapeutic effect and indeed that low doses are often optimal.”

Children in the study were started on a low-dose regimen of medication ranging from 3.75 mg total daily to 22.5 mg total daily. By comparison, the cumulative daily dose for older children ranges from 15 mg per day to 50 mg per day. The optimal dose needed to reduce symptoms ranged widely in preschool-age children, but on average, 14 mg daily was effective in reining in symptoms.

“One of the surprises was that in some cases, doses as low as even 3 to 4 mg a day were helpful to some preschoolers, which goes to show that lower doses need to be given a chance before higher doses are tried,” Riddle explains.

About 11 percent of those enrolled in the study experienced side effects severe enough to drop out. These included weight loss, anxiety, skin picking, mood disturbances and insomnia.

“We want parents to know that trained professionals can make an accurate diagnosis and prescribe helpful and safe treatment in preschoolers with ADHD,” Riddle says. “But do expect your prescribing physician to monitor side effects closely and regularly and to tweak the dose if necessary.”

ADHD is characterized by a wide range of symptoms, including inability to concentrate, being easily distracted, fidgeting and restlessness, among others. Left untreated, ADHD can interfere with academic progress and social and emotional development. More than 4.4 million children in the United States have ADHD, according to estimates by the Centers for Disease Control and Prevention. About 2 percent of preschool-age children are believed to have ADHD.

Brain Imaging Designs ADHD Treatment With Lower Risk Of Abuse

An article by Thomas J. Spencer, M.D, on a new study in the March 2006 issue of The American Journal of Psychiatry (AJP), the official journal of the American Psychiatric Association (APA), shows how brain imaging is used to identify a form of methylphenidate, a stimulant drug used to treat patients with attention deficit/hyperactivity disorder (ADHD), that is less likely to be abused during treatment.

The study, “PET Study Examining Pharmacokinetics, Detection and Likeability, and Dopamine Transporter Receptor Occupancy of Short- and Long-Acting Oral Methylphenidate,” conducted by Dr. Spencer, Assistant Director of Massachusetts General Hospital Pediatric Psychopharmacology Unit, investigates a new once-a-day capsule developed to release methylphenidate more slowly. Instead of dissolving in the gastrointestinal tract, it absorbs body fluids and uses osmotic pressure to slowly push the medication out of the capsule.

Methylphenidate increases attentiveness for patients with ADHD and lowers their hyperactivity. However, methylphenidate, like other stimulants, can also be abused by patients. Methylphenidate acts by blocking a protein called the dopamine transporter, which transports the neurochemical dopamine out of brain synapses. Blockade of the dopamine transporter by methylphenidate augments dopamine activity in the frontal cortex and improves the children’s ability to pay attention. Rapid increase of dopamine activity in other brain areas is perceived as pleasurable and can lead to patient abuse of methylphenidate.

Twelve healthy adults were randomly assigned to receive single doses of immediate-release methylphenidate or osmotic-release methylphenidate. Using positron emission tomography (PET), Spencer conducted a clinical comparison of conventional tablets and the new osmotic capsules. The new capsules succeeded in producing an adequate effect on neurotransmission, with fewer reports of pleasurable effects associated with abusable behavior.

PET scanning, the most sophisticated brain imaging technique for measuring dopamine transporter blockade, showed that the 90-mg capsule with sustained osmotic release produced the same blockade in the brains of healthy adults as 40 mg of immediate-release methylphenidate, but these effects occurred more slowly with the osmotic-release capsule.

“The study represents the first use of PET imaging to detect directly what is happening in the brain during the treatment of ADHD and to use that information to improve treatment,” said Robert Freedman, M.D., AJP editor-in-chief.

Study participants were asked about their subjective reactions to the two different capsules; those taking controlled-release methylphenidate reported significantly less detection of an effect and less liking of the effect. Detecting and liking a drug’s effects signal future abuse potential. Therefore, the controlled-release preparation offers the benefit of once-a-day dosing for patients with ADHD with less likelihood of future abuse.

The main features of ADHD include hyperactivity, impulsiveness, and an inability to sustain attention or concentration. These symptoms occur at levels that cause significant distress and impairment and are far more severe than typically found in children of similar ages and developmental levels. ADHD is a neurobiological disorder that can persist from childhood through adolescence and continue into adulthood.

The “PET Study Examining Pharmacokinetics, Detection and Likeability, and Dopamine Transporter Receptor Occupancy of Short- and Long-Acting Oral Methylphenidate,” study is supported by the National Institute of Mental Health and McNeil Consumer & Specialty Pharmaceuticals.

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Reference:
(Am J Psychiatry. 2006; 163: 387-395).

Do Medications Help Young ADHD Drivers Ignore Real World Distractions?

When a song on the radio or the cell phone on the car seat next to a young driver beckon, she may not resist the temptation to turn up the dial or take a call while maneuvering in traffic. Such distractions could lead to a car crash, especially for young drivers with Attention Deficit/Hyperactivity Disorder (ADHD).

As a group, young ADHD drivers are two to four times more likely to have a car accident than non-ADHD drivers. Daniel Cox, Ph.D., professor of psychiatry and neurosciences at the University of Virginia Health System, has conducted research aimed at improving those odds. His team’s newest study will look at the effects of methylphenidate (MPH), a controlled-release stimulant, on young ADHD drivers facing real-life distractions.

“In controlled laboratory studies, there are no cell phones, no pressures to get home before curfew, no passengers encouraging the driver to ‘get air,’ no pets that slip from the driver’s lap down to the pedals and no hamburger dripping with mustard in the driver’s right hand,” said Cox. “This, however, is real world driving. We want to investigate the benefits of medication in the context of such real world distractions and demands.”

This research team’s past studies have compared long- acting MPH to extended-release amphetamine salts and found that MPH is more effective in helping young ADHD drivers pay attention and have fewer driving mishaps while on the road. A second study Cox’s team completed showed that ADHD young drivers fare better when driving cars with manual transmissions rather than automatic transmissions. In this latest study, funded by Shire Pharmaceuticals, Cox’s team hopes to determine the benefits of MPH during routine, daily driving.

In the study, driver performance will be measured using a device called DriveCam. This video system will be mounted inside the vehicle and will measure and record all audio visual signals. When there is a marked change in driving force, DriveCam will store the 10 seconds before the change and the 20 seconds following the change. The study will last six months. For three months of the study, participants will receive MPH administered through a patch.

“We think that the drivers will perform better on the MPH patch than without the medication, even in light of real world situations,” Cox said. “This information will help young ADHD drivers decide what approach may be best.”

Study Suggests Strattera(R) Improved ADHD Symptoms In Patients With Comorbid Alcohol Abuse

Data from a recent clinical study showed Strattera(R) (atomoxetine HCl) improved symptoms of Attention- Deficit/Hyperactivity Disorder (ADHD) in patients with comorbid alcohol abuse disorder, suggesting ADHD can be treated safely and effectively with Strattera in patients with both disorders. Results from the 12-week study were presented today at a major medical meeting of psychiatrists.

The study was designed to test the hypothesis that Strattera is superior to placebo in the treatment of ADHD symptoms and prevention of relapse of alcohol abuse in adult patients with both ADHD and comorbid alcohol abuse disorder who were recently abstinent.

“ADHD is present in at least one-quarter of adults with alcohol abuse or dependence. Treating ADHD in adults with co-occurring alcohol abuse can be challenging, and up until now, no data have been available to help us know how to treat these patients. Often the first course of action is to treat the alcohol problem first, then later the ADHD,” said study author Timothy E. Wilens, M.D., director of substance abuse services in the Pediatric Psychopharmacology Clinics at Massachusetts General Hospital and associate professor of psychiatry at Harvard Medical School in Boston. “While additional studies are needed, this study is encouraging because it is the first to show that ADHD can be treated safely and effectively with Strattera in patients with ADHD and very recent alcohol abuse.”

Results of the study of 147 adults who met full DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders) criteria for ADHD and comorbid alcohol abuse, showed that Strattera was superior to placebo in the reduction of ADHD symptoms as measured by the ADHD Investigator Symptom Rating Scale (AISRS). At study endpoint of 12 weeks the reduction of ADHD symptoms in subjects with comorbid alcohol abuse disorder was significantly improved for the Strattera group (-13.63) relative to the placebo group (-8.31). The study showed no significant difference in time to alcohol abuse relapse between the Strattera and placebo treatment groups. However, an exploratory post hoc analysis undertaken to examine drinking throughout the study suggested a positive trend in reducing cumulative heavy drinking days by 26 percent in the treated group compared to placebo, though more study is needed to determine the validity of this specific finding.

ADHD is a potential risk factor for developing alcohol abuse problems.(1) In addition, alcohol abuse problems may be more common among people with ADHD than among those without ADHD. According to data from the National Comorbidity Survey Replication, nearly three times the number of individuals with ADHD (12 percent) have comorbid alcohol abuse or dependence disorder compared to the general population (4.4 percent).(2)

Strattera was generally well-tolerated in this study. Adverse events were similar to those noted in previous trials and discontinuations due to adverse events were not different between groups. The most common adverse events reported were nausea, dry mouth, decreased appetite, dizziness, fatigue, constipation and urinary hesitation. Discontinuation rates reported in this study from adverse events were 9.7 percent for the Strattera group compared to 2.7 percent for the placebo group.

Methods

In this randomized, placebo-controlled study, 72 patients received Strattera (25-100 mg daily) and 75 patients received placebo for approximately 12 weeks, at which time, their ADHD symptoms were measured using the AISRS. Study subjects were recently abstinent from alcohol at least four days before study randomization and included 125 men and 22 women, mean age approximately 34 years-old.

The study design allowed investigators to evaluate whether Strattera is superior to placebo in the treatment of ADHD symptoms and effective in preventing alcohol abuse relapse in adults with ADHD and comorbid alcohol abuse disorder. Time to relapse was defined as four standard alcoholic drinks for females or five standard alcoholic drinks for males within 24 hours, or at least three standard alcoholic drinks per day for at least one week. A standard alcoholic drink was defined in this study as 12 ounces of regular beer, 5 ounces of wine or 1.5 ounces of 80-proof distilled spirits. Cumulative heavy drinking days were measured post hoc with a stratified Andersen-Gill recurrent-event Cox model.

Does Stimulant Treatment For ADHD Increase Risk Of Drug Abuse?

Parents, doctors, and others have wondered whether common treatments for attention-deficit hyperactivity disorder (ADHD) inadvertently predispose adolescents to future drug abuse. The answer may depend on the age at which treatment is started and how long it lasts, say the authors of a new brain-imaging and behavioral study conducted in animals at the U.S. Department of Energy’s Brookhaven National Laboratory. The results appeared in the online issue of the journal Pharmacology, Biochemistry and Behavior.

“Our study shows that the brain’s reward pathways are definitely influenced by methylphenidate, one of the stimulant drugs commonly used to treat ADHD,” said Brookhaven researcher Panayotis (Peter) Thanos, lead author of the study. “But the brain chemistry changes we observed suggest that the developmental stage at which treatment begins and the duration of treatment are important variables that need further study.”

In the study, rats were given methylphenidate mixed with distilled water beginning one month after birth — early adolescence for rats. Animals received either 1 or 2 milligrams methylphenidate per kilogram of body weight, consistent with clinical doses given to children with ADHD. A control group of rats was handled under identical conditions but given plain water.

After two months of treatment, and again after eight months, the scientists performed positron emission tomography (PET) scans to measure the levels of dopamine D2 receptors, a type of brain receptor important for experiencing reward and pleasure that has been linked to pleasure and drug abuse. After the eight-month treatment, animals were also tested for their propensity to self-administer cocaine.

Rats given the 2mg/kg dose of methylphenidate were significantly less likely to press a lever to self-administer cocaine, and received fewer self-initiated infusions of the drug following eight months of treatment than the lower-dose group or the control rats.

The changes observed in brain chemistry were specific to the age and duration of methylphenidate treatment: Specifically, after two months of treatment, brain scans revealed that both groups of treated rats had lower levels of dopamine D2 receptors in their brains than did control animals.

In contrast, after eight months of treatment, the brain scans revealed elevated levels of dopamine D2 receptors in treated rats compared with controls, with the higher-dose treatment group showing the highest level of D2 receptors. In the control group, D2 receptor levels declined with age.

Research at Brookhaven and elsewhere has suggested that low levels of dopamine D2 receptors may increase the likelihood of drug abuse, while elevated levels of dopamine D2 receptors may attenuate the propensity to abuse drugs.

“This new study provides evidence that chronic methylphenidate treatment begun in adolescence affects the brain’s dopamine D2 receptor levels, and thus the brain’s reward circuitry, differently depending on the age and treatment duration,” Thanos said. The scientists’ observation of lower rates of cocaine self-administration in the animals treated for eight months with a 2kg/mg dose of methylphenidate supports this idea.

However, the observation of lower levels of D2 receptors after two months of treatment suggests that shorter lengths of treatment or the age at which treatment is evaluated could result in different effects. “Lower dopamine D2 receptor levels following short-term treatment could make the animals more vulnerable to drug self-administration during early adulthood,” Thanos said. “Unfortunately, we cannot compare cocaine self-administration following eight months of treatment with that obtained after two months of treatment in the same animals, since animals were not tested for cocaine self-administration at this earlier time,” Thanos said. “We wanted to avoid any confounding effect that might have resulted from cocaine exposure during this early developmental stage,” he explained.

Evaluating the effect of treatment duration is one avenue the researchers are exploring in follow-up studies “to help assess optimal duration of treatment regimes to minimize adverse effects on the propensity to abuse drugs,” Thanos said.

Thanos notes that the findings from this study cannot be directly extrapolated to treatment regimes used for ADHD. Also, these studies were done in healthy animals, not in rodent models of ADHD. All experiments were conducted in conformity with the National Academy of Sciences Guide for Care and Use of Laboratory Animals and Brookhaven National Laboratory Institutional Animal Care and Use Committee protocols.

Effective Strategies For Decreasing Aggressiveness And Improving Behavior

Non-medicinal interventions are highly effective in preventing the behavioral and academic problems associated with Attention Deficit Hyperactivity Disorder (ADHD), according to a five-year study led by researchers at Lehigh University’s College of Education.

The study, titled “Project Achieve” and funded by the National Institute of Mental Health (NIMH), was the largest of its kind focusing on children aged 3 to 5 who have shown significant symptoms of ADHD. It also involved researchers from Lehigh Valley Hospital in Allentown, Pa.

The researchers, led by George DuPaul, professor of school psychology at Lehigh; Lee Kern, professor of special education at Lehigh; and Dr. John Van Brakle, chair of the pediatrics department at Lehigh Valley Hospital, studied 135 preschool students with ADHD symptoms. They evaluated the effectiveness of early intervention techniques in helping children decrease defiant behavior and aggression, while improving academic and social skills.

The study’s results are reported in a special series on ADHD in the most recent issue of School Psychology Review. Published by the National Association of School Psychologists, the quarterly is the world’s second-largest peer-reviewed psychology journal.

“Early identification and intervention are essential, but there has been a lack of research on how to identify and intervene effectively with these children during their preschool years,” said Thomas Power, editor of the journal and program director with the Center for Management of ADHD at The Children’s Hospital of Philadelphia.

“The investigation by Kern, DuPaul and their colleagues is the most ambitious study ever conducted of non-pharmacological, psychosocial interventions for young children with ADHD.”

The results were significant. Using a variety of early intervention strategies, parents reported, on average, a 17-percent decrease in aggression and a 21-percent improvement in their children’s social skills. Teachers saw similarly strong results; in the classroom, there was a 28-percent improvement in both categories. Early literacy skills improved up to three times over their baseline status.

“Medication may address the symptoms of ADHD,” says DuPaul, “but it does not necessarily improve children’s academic and social skills. And because this is a lifelong disorder, without any cure, it’s important that we start understanding what tools and strategies are effective for children with ADHD at such an early age.

“There’s simply a lack of understanding about the type of non-medicinal services that are available to preschool children and their families. Our goal is to address behavioral and academic issues before they become more problematic in elementary school.”

Early intervention techniques include highly individualized programs that often rely on positive supports to reinforce behavior. For example, in consultation with parents and preschool teachers, Project Achieve researchers modified the environments in home and school (such as altering tasks and activities in the classroom to accommodate for ADHD students) in an effort to improve behavior. The highly interactive techniques were presented as alternatives to medicine.

ADHD is a lifelong mental disorder that may become apparent in a child’s formative preschool years. The disorder, which makes it difficult for children to control their behavior and pay attention, affects about 7 percent of the school-aged population. The disorder has become a public health concern, however, because 40 percent of children who show signs of ADHD are suspended from preschool, while approximately 16 percent are eventually expelled.

The researchers suggest that a multi-tiered approach to intervention, offering more traditional services to at-risk children and more intensive services to children in greatest need, may be the most practical and cost-effective strategy for helping preschoolers overcome behavioral and academic challenges.

“While parents of children with ADHD usually trace the characteristic behaviors back to the preschool years,” says Van Brakle, “pediatricians have long questioned whether such children can accurately be identified, given the overlap with normal behaviors in young children. And if so, whether any intervention that does not involve medicine can be of value. Project Achieve suggests that with careful assessment, such children can be accurately identified and that appropriate behavioral interventions are an important part of the treatment plan.”

School Psychology Review’s special ADHD issue features two ADHD articles co-authored by researchers at Lehigh’s College of Education. DuPaul also contributed the Forward for the issue, which is titled, “School-Based Interventions for Students With Attention Deficit Hyperactivity Disorder: Current Status and Future Directions.”

ADHD Treatment Showed Sustained Improvement In Most Children

Most children treated in a variety of ways for attention deficit hyperactivity disorder (ADHD) showed sustained improvement after three years in a major follow-up study funded by the National Institutes of Health’s (NIH) National Institute of Mental Health (NIMH). Yet increased risk for behavioral problems, including delinquency and substance use, remained higher than normal.

The study followed-up children who had participated in the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA).

Initial advantages of medication management alone or in combination with behavioral treatment over purely behavioral or routine community care waned in the years after 14 months of controlled treatment ended. However, Peter Jensen, M.D., Columbia University, and colleagues emphasized that “it would be incorrect to conclude from these results that treatment makes no difference or is not worth pursuing.”

Their report is among four on the outcome of the MTA study published in the August, 2007 Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP).

“We were struck by the remarkable improvement in symptoms and functioning across all treatment groups,” explained Jensen.

After three years, 45-71 percent of the youth in the original treatment groups were taking medication. However, continuing medication treatment was no longer associated with better outcomes by the third year.

“Our results suggest that medication can make a long-term difference for some children if it’s continued with optimal intensity, and not started or added too late in a child’s clinical course,” added Jensen.

For the followup study, a multi-site research team evaluated, at ages 10-13, 485 children from the original MTA study, the first major randomized trial comparing different treatments for ADHD, published in l999. That study found that intensive medication management alone or in combination with behavioral therapy produced better outcomes than just behavioral therapy or usual community care.

Ratings from families and teachers favored the combination treatment, which allowed for somewhat lower medication doses. Also, the careful management of medication by MTA physicians produced better outcomes than medication provided through usual community care sources.

After the 14 months of assigned treatments ended, families were free to choose from treatments available in their communities.

To understand why the initial advantage of medication wore off, the researchers examined medication use patterns that emerged after formal treatment in the study ended. They found that children who had been assigned to intensive behavioral treatment were more likely to begin taking medication, while those who had been taking medication were more likely to stop. For example, among children originally in the behavioral treatment group, the incidence of high medication use increased from 14 to 45 percent.

In a secondary analysis of the data that searched for possible explanations for the findings, in the same issue of the JAACAP, researchers led by James Swanson, Ph.D., University of California at Irvine, reported finding substantial individual variability in responses to medication. They identified three groups of children with different patterns of response. One group, about a third of the children, showed a gradual, moderate improvement; a second group, about half of the children, showed larger initial improvement, which was sustained through the third year; a third group, about 14 percent of the children, responded well initially, but then deteriorated as symptoms returned during the second and third years. Swanson and colleagues suggested “trial withdrawals” for some children to determine if they still need to take medications.

Another report by Swanson and colleagues in the same issue of the JAACAP confirmed an earlier finding from the MTA study that taking medication slowed growth. A group of 65 children with ADHD who had never taken medication grew somewhat larger — about three-fourths of an inch and 6 pounds more, on average — than a group of 88 peers who stayed on medication over the three years. Growth rates normalized for the children on medication by the third year, but they had not made up for the earlier slowing in growth.

In a fourth article, Brooke Molina, Ph.D., University of Pittsburgh, and colleagues reported that, despite treatment, the children with ADHD showed significantly higher-than-normal rates of delinquency (27.1 percent vs. 7.4 percent) and substance use (17.4 percent vs. 7.8 percent) after three years. Earlier evidence of lower substance use rates among children who had received intensive behavioral therapy had lessened by the third year. “These findings underscore the point that ADHD treatment for one year does not prevent serious problems from emerging later,” noted Molina.

The follow-up of the MTA sample will continue as the participating children go through adolescence and enter adulthood.

New ADHD Drug Strattera

A new drug for the treatment of attention deficit hyperactivity disorder (ADHD) will be listed from 1 July 2007 on the Pharmaceutical Benefits Scheme (PBS).

The drug, Strattera® (atomoxetine), will provide treatment for children between the ages of six and 18 years who cannot take stimulants.

ADHD is a behavioural and developmental disorder that affect young children. The main symptoms of ADHD – inattention, hyperactivity and impulsivity – contribute to adverse academic and social behaviour, which can have consequences that persist throughout adolescence and into adulthood.

Treatment for ADHD normally involves stimulant therapy, so the listing of Strattera® on the PBS will especially benefit those who are unable to take stimulants.

About 18,000 people will commence Strattera® in the first full financial year of listing.

The listing of Strattera® will add around $101.2 million to PBS and Repatriation Pharmaceutical Benefits Scheme expenditure between 2007-08 and 2010-11.

Is ADHD Properly Diagnosed And Treated In Adults?

An editorial written by Professor Philip Asherson, a leading psychiatrist in adult ADHD (Attention Deficit Hyperactivity Disorder), at the Institute of Psychiatry, King’s College London strongly recommends that general adult psychiatrists should diagnose ADHD in adults appropriately with stimulant drugs. It is published in the January issue of the British Journal of Psychiatry.

Although ADHD can be effectively treated with stimulant medication, and such treatment is widespread in the young, general adult psychiatry has not yet followed suit in identifying and treating substantial numbers of affected people.

ADHD is a common disorder affecting children and adults, and is a predictor of adult mental health problems. Symptoms include high levels of inattentiveness, impulsiveness and restless over activity, and are regarded as a source of disability in children and adolescents, as well as a risk to adult psychological adjustment.

Young people are entering adult life whilst still receiving medication for ADHD, and adult psychiatrists are needed to take over treatment when symptoms persist. Moreover, some adult patients with ADHD may be misdiagnosed and ineffectively treated for other disorders, such as depression and personality disorder.

Research suggests that between 15% and 65% of children diagnosed with ADHD still have symptoms of the disorder in adulthood. However, many children with ADHD go unrecognised, and may be diagnosed in adulthood for the first time.

A survey of schoolchildren with ADHD in the London Borough of Newham found that although levels of restless activity diminished between the ages of 7 and 17, the 17-year-olds showed a level of hyperactivity similar to that found in a group of normal 7-year-olds.

When the same people were followed up at the age of 26, they were found to have disabilities associated with high levels of psychiatric disorder, which were all the more significant because of increasing demands in adult life for self-organisation and the ability to plan ahead.

Adult behaviours linked to ADHD are associated with the childhood symptoms of motor hyperactivity, attention deficit, unfocused thinking, mood changes, disorganisation and impulsiveness.

They include – at the severe end of the spectrum – feelings of restlessness, difficulty in relaxing, feeling depressed when inactive, lack of concentration on detail, depression or excitability, poor time management, difficulties sustaining relationships and a tendency to make rapid and facile decisions without full analysis of the situation.

Psychiatrists diagnosing ADHD in adults need to be aware of the fact that people with this disorder often show decreased symptoms in a novel situation like a psychiatric evaluation. It is therefore important to base mental state evaluations on a typical week and a variety of normal situations.

Mood instability is very common in adult ADHD, and can lead to diagnoses of depression or personality disorder. Many adults with ADHD also have other problems, such as antisocial personality, alcohol and drug misuse, anxiety disorders and learning difficulties. ADHD in childhood may also lead to the development of antisocial behaviour.

Some symptoms of adult ADHD are similar to those of bipolar disorder, but ADHD tends to show a persisting trait of irritability and volatility, very different from the grandiose and euphoric symptoms of mania and the depression found in bipolar disorder.

Professor Philip Asherson comments: “Adults with untreated ADHD use more healthcare resources because of smoking-related disorders, increased rates of serious accidents, and alcohol and drug misuse. Further research is needed to quantify the contribution of ADHD to psychiatric disorders in adulthood.”

Professor Asherson’s editorial is published in the British Journal of Psychiatry, January 2007.