Attention disorder: overcoming the deficit

FDA Consumer, July-August, 1997 by Dixie Farley

I really see a difference in my grades. Without it, I don't think about things. I can't pay attention."

--Christy Rade, 16, Des Moines, Iowa, commenting in the Aug. 26, 1996, Des Moines Register on her treatment for attention-deficit/hyperactivity disorder (ADHD) with Ritalin, the brand name for the stimulant medicine methylphenidate.

"Teens Learn Dangers of Pitalin Use; 19-Year-Old Man Dies After Snorting Stimulant at Party "

--a headline in the April 24, 1995, Poanoke Times & World News, Roanoke, Va.

If, like Christy Rade, you're taking stimulant medicine for ADHD, you are not alone. In mid-1995, about 1.5 million school-age youngsters did so, reported Daniel Safer, M.D., and colleagues in Pediatrics, December 1996.

But, as the Virginia headline points out, abuse of this medicine can be deadly.

In ADHD, brain areas ruling attention and inhibition don't work very well. Most children with ADHD are inattentive, impulsive and hyperactive. In teen-agers, the hyperactivity often quiets to a restlessness. For some, paying attention is their biggest problem. Others are mainly impulsive and hyperactive.

The Food and Drug Administration has approved several stimulant medicines for treating ADHD: methylphenidate (Ritalin and generics), dextroamphetamine (Dexedrine and generics), methamphetamine (Desoxyn), and an amphetamine-dextroamphetamine combination (Adderall). FDA recently restricted another approved stimulant, pemoline (Cylert), to secondary use, as it can cause liver failure.

The drugs stimulate the central nervous system, but no one knows exactly how they work in treating ADHD.

"Stimulants have been used to treat ADHD for over three decades," says Nicholas Reuter, FDA associate director for international and domestic drug control affairs. "And the amount used has increased steadily during that period. Methylphenidate is the most widely used."

Not everyone with ADHD requires or responds to stimulant treatment.

Risk of Abuse

Because stimulant medicines have a high potential for abuse, the U.S. Drug Enforcement Administration has placed stringent controls on their manufacture, distribution and prescription. For example, DEA requires special licenses for these activities, and prescription refills aren't allowed. States may impose further regulation, like limiting the number of dosage units per prescription.

DEA has repeatedly urged greater caution in use of these drugs, especially in light of their abuse among adolescents and young adults.

Ritalin's manufacturer, Ciba-Geigy Corp., began a campaign in March 1996 to reduce abuse. In nationwide mailings to doctors and pharmacists, the firm called attention to the risk of abuse and cautioned doctors to be especially careful in diagnosing ADHD. Enclosed were behavior rating scales for doctors to use and handouts for patients, parents and school nurses.

Taken properly, Ritalin in and of itself is not addictive, says Wendy Sharp, M.S.W., a social worker and researcher at the National Institute of Mental Health's child psychiatry branch. So people with ADHD do not get addicted to their stimulant medicine at treatment dosages, she says. "There have been unfortunate cases reported in the press, however, of teenagers who have taken Ritalin from other kids and snorted it, like cocaine."

According to Reuter, "Although methylphenidate production and availability have increased dramatically since 1990, national drug abuse surveys indicate that abuse level and associated public health consequences remain below that of other stimulant medicines such as cocaine, amphetamine and methamphetamine."

Patricia Quinn, M.D., a developmental pediatrician in Washington, D.C., and author of many books on ADHD, adds, "There's actually less substance abuse in people diagnosed with attention deficit disorder who take medication and do well than in the general population. Adolescents I've worked with are trying to straighten out what's going on."

Diagnosing Difficulties

About 30 percent of young people with ADHD aren't diagnosed until middle school or later, says Quinn. These students are very bright, she says. "The more intelligent you are, the better you cope--until stressors in the environment outpace your ability to cope. Maybe your disorder becomes a problem in high school when you have only lecture classes, or in college when you have to do everything for yourself and go to class, too."

By the time someone with undiagnosed ADHD gets to middle school or high school, the main complaint is classroom underachievement rather than hyperactivity or distractibility, Quinn says. Some people shorten the name to ADD when it affects older people. "But you shouldn't assume that everyone who is underachieving has ADHD."

And, not everyone with attention difficulty has ADHD.

For example, when Linda Smith (not her real name) was 16, she had extreme difficulty concentrating. ADHD was suspected. Thorough examination, however, revealed the culprits were anxiety, depression and a sleep disorder, which are improving under a treatment plan that includes medicines and counseling.