by Georgina Lee, PharmD 2011 | firstname.lastname@example.org
Does your mind wander when you’re trying to study or read the newspaper? Do you tend to switch the subject often when you’re having a conversation? Do people call you “hyper” or “energetic” when you go out? If the answer is yes to any of those questions, we’d like to congratulate you on being just like the rest of us who exhibit normal behavioral tendencies (like constantly flipping between radio stations while driving). Then how exactly is one diagnosed with ADD or ADHD (Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder)? Currently, about 3-10% of children and 4% of adults worldwide have ADD/ADHD with a strong propensity for boys over girls (4 boys to every 1 girl). According to the DSM-IV criteria (Diagnostic and Statistical Manual of Mental Disorders), ADD/ADHD is considered a childhood and adolescent psychiatric disorder in which the person has either inattention or hyperactivity-impulsivity (or both) as defined by the following:
Inattention (≥ 6 of the following apply):
- Fails to pay close attention to details or makes careless errors in schoolwork, work or other activities
- Has trouble keeping attention on tasks or play
- Doesn’t appear to listen when being told something
- Neither follows through on instructions nor completes chores, schoolwork, or jobs (not due to oppositional behavior or failure to understand)
- Has trouble organizing activities and tasks
- Dislikes or avoids tasks that involve sustained mental effort (homework, schoolwork)
- Loses materials needed for activities (assignments, books, pencils, tools, toys)
- Easily distracted by extraneous stimuli
Hyperactivity/Impulsivity (≥ 6 of the following apply):
- Squirms in seats or fidgets
- Inappropriately leaves seat
- Inappropriately runs or climbs (in adolescents or adults, this may be only a subjective feeling of restlessness)
- Has trouble quietly playing or engaging in leisure activity
- Appears driven or “on the go”
- Answers questions before they have been asked
- Has trouble or awaiting a turn
Interrupts or intrudes on others
To classify as ADD/ADHD, the symptoms of inattention or impulsivity/hyperactivity must:
- Have persisted for ≥ 6 months
- Be more frequent and severe than is typical of the individual’s level of development
- Have onset prior to age 7
- Cause some impairment in 2 or more settings (ie. in social, academic, or occupational functioning)
Not be better accounted for by another mental disorder
So what causes ADD/ADHD? Poor parenting? Junk food?
According to older literature, attention disorders used to be called “minimal brain damage” or “minimal brain dysfunction” because we believed it was caused by head injuries or trauma. It turns out we were wrong. We now know that the vast majority of people who have ADD/ADHD have no history of head injury or brain damage (although, they probably have parents who tell them not to eat too much junk food). Some researchers have found that first-degree relatives of someone with ADD/ADHD have a four to eight-fold chance of developing the condition. Additionally, children with fetal alcohol syndrome (growth and developmental problems caused by maternal alcohol exposure), lead poisoning, maternal smoking and meningitis (swelling and inflammation of the membranes covering the brain and spinal cord) are at increased risk of developing ADD/ADHD. It’s important to look into background risks including a tumultuous home, school and occupational environment in which the person may experience these symptoms out of frustration and stress. Clinical studies are examining a genetic variation in the presynaptic dopaminergic transport protein, which transports dopamine (a chemical in the brain that is associated with reward-seeking behavior) known as DAT1. DAT1 has been linked to ADD/ADHD risk and to a positive response to drugs like methylphenidate (Ritalin, Concerta) and atomoxetine (Strattera). One of the most common explanations for ADD/ADHD symptoms involves deficits in the prefrontal cortex of the brain known as “response inhibition” which causes children to have difficulty controlling their behavior, resisting distractions, and displaying insufficient alertness alternating with overarousal (sounds like a typical Friday at work). The prefrontal cortex along with the basal ganglia and caudate nucleus are all also consistently reported to be smaller in people who have ADD/ADHD. This is significant because these areas are sensitive to chemicals like dopamine and norepinephrine, the key chemicals that we target with most pharmacological treatments.
So how do you help people with ADD/ADHD? Tie them down in a chair and force them to sit still?
As with most psychiatric disorders, treatment typically involves a combination of both behavioral and pharmacological interventions. As of March 2006, two million prescriptions were dispensed for ADD/ADHD monthly for children and adolescents in the US compared to one million dispensed to adults. We have to ask ourselves, “Why are these medications so popular?”
These are government-regulated controlled substances that have strict dispensing rules enforced by the pharmacy (these can only be prescribed on a government issued prescription pad by the physician). Methylphenidate (Ritalin, Concerta, Methylin), dextroamphetamine and mixed amphetamine salts (Adderall) are all considered first-line agents due to their high efficacy rates (70-96%) in the treatment of ADD/ADHD. Both methylphenidate and amphetamine block dopamine (DA) and norepinephrine (NE) reuptake (therefore increasing the amount of these chemicals in the brain) and amphetamines increase the release of DA and NE. Most of these drugs are available as immediate-release (IR) formulations that require you to take them 2-3 times daily or once-daily products (XR, CD, LA which all mean extended release). The main difference is the potential for insomnia and risk of growth suppression with once-daily formulations of stimulants. Some of the most common side effects associated with stimulants include weight loss, gastro-intestinal pain, insomnia, headache, rebound symptoms and irritability. Rare side effects may include dysphoria (lethargy), zombie-like state, tics or abnormal movements, hypertension (high blood pressure), pulse fluctuations and hallucinations. If any of these occur, see your doctor! The doctor will either reduce the dosage, change medications and/or reassess the diagnosis should any of the above symptoms appear. Although this class of drugs is highly effective, they are also easily abused. Starting to see why the government wants to keep a close eye on them?
This class of drugs is usually reserved for people who have an inadequate response to stimulants or cannot tolerant its side effects. Atomoxetine (Strattera), is a selective norepinephrine reuptake inhibitor (meaning that it only increases the amount of norepinephrine in the brain) and is the first non-stimulant approved by the FDA for the treatment of ADHD. Since it has no abuse potential, less growth suppression, and is not a controlled substance, many providers and patients prefer it over the stimulants. However, atomoxetine has a slower onset of action than stimulants (2-4 weeks versus 1 hour) and can be associated with nausea, increased blood pressure and insomnia (less severe than with stimulants). Another non-stimulant is bupropion (Wellbutrin), which is a weak dopamine and norepinephrine reuptake inhibitor that has less toxicity in overdose, less appetite suppression compared with stimulants and a lower risk of insomnia.
The third-line of agents after stimulants and non-stimulants that have been shown to be effective against ADD/ADHD are TCA’s (tri-cyclic antidepressants) including imipramine, desipramine, and nortriptyline. However, these are the most dangerous in overdose and pose the greatest risk for cardiovascular side effects as well as an increased risk of weight gain and sedation. Clonidine and guanfacine (central α2 agonists that increase blood flow to the prefrontal cortex of your brain) are typically prescribed as adjuncts to stimulants and non-stimulants in order to reduce disruptive behavior, control aggression and/or improve sleep. Increasing blood flow to the prefrontal cortex has been shown to enhance working memory and executive functioning in people who have ADD/ADHD. For those who also have a predisposition to aggression and explosive behavior, some providers will add on a mood-stabilizing agent such as lithium and anticonvulsants to manage their symptoms.
What about treatments that don’t involve medications? After all, no one really enjoys taking pills (except for those tasty gummy vitamins). Techniques including positive reinforcement (providing rewards for a completed assignment), time-outs (physical removal of the child in the play area), response cost (losing privileges to the computer for not doing homework) and token economy (cashing in gold stars for a prize) are effective ways parents and providers can help a child who has ADD/ADHD. Enrolling in support groups or special classes for parents may also help family members discover new strategies to help control ADD/ADHD without medication.
Does ADD/ADHD persist into adulthood?
Currently, there are no formal DSM-IV criteria for adults who might have ADD/ADHD. The rate of persistence, which is defined as being diagnosed as a child and continuing to meet full criteria as an adult, is roughly 33%. Luckily, adults continue to respond to the same medications and behavioral interventions as children do (grown-ups like gold stars and lollipops too).
Although there are a wide variety of treatments for ADD/ADHD, we have to remember that this is a multifactorial condition that warrants an extensive conversation with your provider before beginning any treatment options. Don’t jump to conclusions if your child likes to drape a towel across their back and run around the pool like superman for hours at a time (we would too if no one was looking).
- “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Arlington, VA.: American Psychiatric Association, 2007. Print.
- Jacobson, James L., and Alan Jacobson. “Attention Deficit Hyperactivity Disorder.” Psychiatric Secrets. 2nd ed. Philadelphia: Hanley & Belfus, 2001. Print.
- DiPiro, Joseph T. “Childhood Disorders.” Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill, 2008. 1029-035. Print.
- Schneider, Robert K., and James L. Levenson. “Adult ADD.” Psychiatry Essentials for Primary Care. Philadelphia: American College of Physicians, 2008. Print.