The BrownLetter on ADD

A free quarterly newsletter of information and opinion about ADD/ADHD

May, 2006

In This Issue:

Excessive Fears about Stimulant Medications for ADHD

Many parents and some physicians have been excessively worried about the safety of stimulant medications for ADHD after media reports in February that the FDA might put “black box” warnings about cardiac risks on all stimulants used to treat ADHD. Many have not yet heard that on March 22, 2006 the FDA Pediatric Advisory Committee declined to endorse such a warning for these ADHD medications because available scientific data do not warrant such an action.

Initial news articles frightened many readers by announcing that 25 people died suddenly after taking drugs to treat ADHD. This number was obtained from a government report for the FDA panel, but several additional bits of information are needed to understand what it means.

First, the time frame: 25 is the total number of sudden deaths reported for individuals on stimulants over a five year period from 1999 to 2003—an average of 5 per year for the entire U.S. Second, the denominator: even when 26 other serious, but not fatal adverse events such as heart attack or stroke were added to the total number of sudden deaths, the total amounted to one serious adverse event per one million ADHD drug prescriptions filled.

Any risk of a serious adverse event is frightening. But to understand the real significance, one must compare this risk to the risk of sudden death among persons not taking stimulant medications. Current data indicate that the rate of sudden death in the general population is about 5-6 per 100K children per year and about 1 per 1000 adults per year. When these rates are compared with rates of sudden death among individuals taking stimulants for ADHD there is no significant difference!

The FDA Pediatric Advisory Committee in March, 2006 found that taking approved stimulant medication for ADHD does not increase cardiovascular risks in healthy children. The risk of such medications in children who have structural heart defects is similar to the risk in child athletes.

Any patient, child or adult, should have a routine medical examination prior to starting treatment with stimulant medications. This allows the physician to determine whether there are any medical problems that would warrant additional cardiovascular evaluations prior to starting medication or that would require more monitoring than is usually needed.

What gets lost in many discussions about risks of medications for ADHD is the risk of not treating ADHD with appropriate medications. In any medical treatment, the critical question is always: What is the risk of not providing the appropriate treatment vs. the risk of providing treatment?

There is considerable evidence that an individual with untreated ADHD incurs seriously elevated lifetime risks of academic underachievement, employment problems, relationship problems, substance abuse, motor vehicle accidents, etc. Compared to those perils, the risk of treatment with appropriate stimulant medications is extremely small.

Coming Soon: Skin Patch to Administer Methylphenidate

The FDA has now approved a new skin patch to administer methylphenidate to children with ADHD. This methylphenidate transdermal system (MTS) should be available early this summer under the name Daytrana. The patch will be available in 10, 15, 20 and 30 mg sizes. It has been tested in children with ADHD between the ages of 6 and 16 years.

Using a novel technology, the patch releases through the skin the same methylphenidate currently dispensed in pill form to treat ADHD. When worn on the hip (below the waistline) for up to a max of 9 hours each day, it can provide medication coverage for about 12 hours. Reported side effects are very similar to those seen in the pill form of methylphenidate: headache, stomach upset, decreased appetite and some insomnia. Some children found that the patch irritated the skin (usually mildly) on which it was placed, even when location was alternated.

As with other forms of stimulant medications for ADHD, the amount of Daytrana that will work best for an individual does not depend upon age, weight or symptom severity. The optimal amount depends upon the sensitivity of a given individual’s body to this specific medication administered in this form.

When starting this medication, it is recommended that each patient start with the smallest size (10 mg) for the first week and then gradually increase at weekly intervals until an optimal effect has been obtained. The amount of patch-administered methylphenidate that will work best for a person may not be the same as the amount that works best when using pill form methylphenidate. Careful fine-tuning of dose and timing is needed for any stimulant used to treat ADHD.

Making an ADHD Diagnosis on Impairment vs. Symptom Counts

Often the diagnosis of ADHD is based heavily upon whether the patient has the specified number of symptoms on the DSM-IV list. A recent article contributed by a team of ADHD researchers highlighted the central importance of carefully assessing impairment when trying to determine whether a person has ADHD or not.

They reviewed 4 major studies of individuals with ADHD and found that looking at symptoms alone predicted less than 25% of the variance in impairment. They noted that, in their analysis, the strongest relationship between symptoms and impairment emerged in the association between inattention and school functioning. This contradicts the usual emphasis on impaired inhibition as a primary factor in ADHD.

The critical question for diagnosis, of course, is not how many symptoms of ADHD a person has, but how much the individual is impaired in daily functioning by those symptoms. The article noted: “…someone can display the full range of ADHD-type symptoms without necessarily displaying significant impairment. Conversely, one can also show few ADHD symptoms and still suffer significant maladjustment…(p. 472).”

This article is a helpful reminder for clinicians to carefully explore with each patient questions about how ADHD symptoms interfere with their schooling, work, social interactions, family life, etc., rather than just checking off whether or not 6 of 9 symptoms are present. (Gordon, M., Antshel, K., Faraone, S. et al. “Symptoms Versus Impairment: The Case for Respecting DSM-IV’s Criterion D” J. of Attention Disorders
9 (3): 465-475.)

New Paper on “Conflicting Views of Executive Functions in ADHD” now in PDF

In the last issue of the BrownLetter on ADD I mentioned a forthcoming article I had prepared to describe two conflicting views of how ADD/ADHD is related to “executive functions” (EF), the brain’s management system. That paper has been published and is now available in a PDF file on my website.

The article describes two different models of how EF is related to ADD. One model, used by many researchers, claims that EF functions are impaired only in those persons with ADHD who obtain very low scores on neuropsychological tests called “tests of EF.” If this definition is used, only about 30% of children or adults with ADHD are found to have significant EF impairments.

The other model, presented in slightly different versions by Dr. Russell Barkley and by me, claims that all persons with ADHD suffer from impairments of EF, that ADHD essentially is impairment of EF. Dr. Barkley sees this as true only for those whose ADHD includes significant hyperactivity/impulsivity symptoms; I argue that EF impairments are the essence of all subtypes of ADHD.

This argument hinges on how EF are defined. In Attention Deficit Disorder: The Unfocused Mind in Children and Adults, I’ve explained why I believe that the so-called neuropsychological “tests of EF” do not adequately measure EF impairments; my claim is that problems with EF are seen more clearly in how a person performs tasks of daily life that require self-management with attention and working memory. Click here to view a PDF of the full article on my website.

Treatment for Adults with Asperger’s Disorder

Gradually increasing numbers of clinicians are learning to recognize and provide appropriate treatment for children with Asperger’s Disorder and other syndromes on the higher functioning end of the autistic spectrum. Typically these children have average or above average IQ, but suffer from severe lack of empathy and have chronic difficulty in understanding reciprocal social relationships and getting along with peers. Often they also have problems in social communication and operate with an excessively narrow and rigid range of interests. The best book I know about this is Tony Attwood’s Asperger’s Disorder: A Guide for Parents and Professionals (Jessica Kingsley, 1998).

Despite increased interest in children with Asperger’s Disorder, in most areas there are few treatment resources for adolescents and adults with Asperger’s Disorder. Many clinicians trained to treat adults have had little experience in diagnosing and treating those with these impairments on the autistic spectrum.

Patricia Howlin in the UK has written an excellent overview of the wide range of outcomes and treatment needs for adolescents and adults on the autistic spectrum (Autism and Asperger Syndrome: Preparing for Adulthood. 2nd edition. Routledge, 2004). She summarizes recent outcome studies which show that while about 20% of individuals with Asperger’s and higher functioning autism have a good outcome in adulthood, about 50% have a poor outcome. At least 30% continue to live with their family or in residential treatment during adulthood while about 12% eventually acquire a home of their own.

Many of these individuals suffer from ADHD and other psychiatric problems in addition to Asperger’s. Such combinations of impairments can seriously interfere with functioning in college or university and with getting and holding a job, even for those with very high IQ. Affected individuals and families often have great difficulty in getting adequate treatment.

Dr. Anthony Rostain and Dr. Russell Ramsey at the University of Pennsylvania in Philadelphia have developed a pioneering program for assessment and treatment of adults with these “social learning disorders.” Their combination of careful assessment, education, medications and cognitive-behavioral psychotherapy provides a model that could be useful in many other clinical settings interested in providing these desperately needed services (See www.med.upenn.edu/add and their paper in Psychotherapy: Theory, Research, Practice and Training. 2005, 42: 483-493).

Updated Guidelines for Medications to Treat ADHD

Guidelines developed in 1998 for use of medications to treat ADHD in children have recently been updated and published in the June, 2006 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. The guidelines, known as the Texas Children’s Medication Algorithm Project, were developed and now revised by a panel of academic researchers and clinicians together with practicing clinicians, consumers and families.

These consensually developed guidelines for treating ADHD with or without comorbid disorders were updated in light of new research since 1998. The guidelines review approved options and, for some situations, suggest a sequence of steps for rational trials of appropriate medications.

Changes made in this update include the addition of Atomoxetine (Strattera) as an approved treatment for ADHD and the elimination of pemoline (Cylert) as an option.

For ADHD uncomplicated by another disorder, the guidelines recommend starting with a stimulant (methylphenidate or amphetamine) and then, if not successful, trying the other class of stimulant. If neither stimulant works well, a trial of atomoxetine (Strattera) is recommended.

For ADHD with anxiety, the guidelines recommend starting with atomoxetine to treat both disorders, but also offer the option of treating the ADHD with a stimulant and then adding an SSRI to treat the anxiety. The guidelines also offer specific suggestions for treatment of ADHD complicated by depression, tics or aggression.

Two Useful New Books

Scattered Minds: Hope and Help for Adults with Attention Deficit Hyperactivity Disorder by Lenard Adler with Mari Florence (Putnam, 2006).

This concise, easily understandable book describes ADHD as it appears in adults and offers practical information about how the disorder can be recognized and how it can be effectively treated. Dr. Adler, director of the Adult ADHD Program at New York University School of Medicine, offers a number of case examples to illustrate the variety of ways in which ADHD can impair more than 8 million adults in the U.S., some of whom do not recognize that they have ADHD and are not getting appropriate treatment. A useful book for adults who may have ADHD and would like to know more about it.

Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition by Russell A. Barkley (Guilford Press, 2006).

This third edition of Dr. Barkley’s encyclopedic handbook provides a rich resource of updated information about the history of ADHD, research on its nature and outcomes, assessment, and a variety of treatment interventions. This is an excellent, well-documented and well-indexed resource for researchers and clinicians seeking a solid background of information about ADHD. An accompanying workbook, sold separately, includes a wide variety of useful forms and rating scales that can be photocopied for clinical use.

News From My Office

Recent months have brought gratifying recognition for my book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults (Yale University Press, 2005).

  • ADDitude Magazine published a nicely formatted excerpt from the book’s first chapter. Click here for a PDF of the full article.
  • A review in The Lancet, a respected medical journal, commented: “Drawing on recent findings in neuroscience, this highly readable text about an often misunderstood disorder…argues persuasively for the legitimacy of ADHD. Irrespective of which side of the debate the reader champions, there’s little doubt that Brown makes a compelling case.”
  • The American Medical Writers Association has honored the book with a Will Solimene award for excellence in medical communication.

Click here to link to the Amazon.com site where you can look inside this book and can place a money-saving order.