Study finds divorce increases Ritalin use in children

Posted by Peter on August 14th, 2007 | Comments off

ADHD does not seem to be a condition like pregnancy where one is either pregnant or one is not. Rather it is a matter of degree. Some children and adults range from mildly inattentive to profoundly inattentive. The degree seems to be directly affected by a variety of environmental factors including divorce, parenting skills, etc. More frequently than not, drugs are prescribed to allay the symptoms. Obviously, they do not affect core issues that affect the child like divorce, marital discord, or learning disabilities.

Study finds divorce increases Ritalin use in children
HELEN BRANSWELL
Canadian Press
June 4, 2007 at 8:46 PM EDT
TORONTO — Children whose parents divorce are nearly twice as likely to be prescribed Ritalin in the aftermath of the split, a Canadian study reports.
But the author, a sociologist from the University of Alberta, cautioned against concluding that children of divorce are over-prescribed the drug, which is used to treat Attention Deficit and Hyperactivity Disorder, or ADHD.
Lisa Strohschein said the data she used can only identify the phenomenon and cannot reveal why Ritalin use rates are double when children of divorced parents are compared to children whose parents stay married.
“I’ve got the what, but not the why,” Ms. Strohschein said from Edmonton.
Ms. Strohschein suggests there may be a variety of answers. Some kids may need the drug to cope with the stress of the split, some kids may have ADHD and some kids may be getting a drug they don’t really need.
“The problem is I can’t be clear about it,” she said.
“I mean, I would love to be able to say ‘Yes, it’s divorce. That’s the problem,’ But it’s not necessarily so. It could just be our perceptions about divorce — and that’s the thing that makes me really cautious here.”
“(But) I don’t want to come out on the other side, either and say ‘Ritalin is bad’ because I think it clearly does help some kids.”
The psychiatrist-in-chief of the Hospital for Sick Children in Toronto said the study should serve as a reminder to doctors to move cautiously when prescribing Ritalin or other methylphenidate-based drugs to children in these circumstances.
“What we need is a deeper understanding of this issue, at the level of the primary care practitioners,” said Dr. Abel Ickowicz.
“Because . . . if we are going too quick to prescribe medication, like Ritalin, like methylphenidate, we may not only be masking the normal process of adaptation to divorce, but we may be contributing to the degree of distress the children of divorce are experiencing.”
The study, published in the Canadian Medical Association Journal, used data gathered by Statistics Canada through its National Longitudinal Survey of Children and Youth. The survey, which was first conducted in 1994, is completed every two years; Ms. Strohschein used data collected between 1994 and 2000.
Previous researchers had identified the fact that children who live in a household with only one parent or with a parent-step-parent combination were more likely to be on Ritalin than children growing up in households with both parents.
But it wasn’t clear whether the increased use was among all children in a single-parent household — in other words, children whose parents had divorced, children who had lost a parent to death and children born to a single mother — or whether some subset of these children was more heavily prescribed the drug.
Ms. Strohschein compared prescription rates among 4,151 children whose parents hadn’t divorced and 633 children who had. She found that 3.3 per cent of children in the two-parent families were prescribed Ritalin; among the children whose parents had divorced, that figure rose to 6.1 per cent.
The study notes a number of potential explanations for the doubling of the usage rate.
One possibility is that the stress of the divorce aggravated a child’s existing behavioural problems to the point where Ritalin would actually be helpful, she hypothesized.
It is known that ADHD can run in families. In addition to passing on the condition to their children, parents with ADHD-type behaviour might be more likely to divorce — a theory that points towards appropriate use of the drug.
Another possibility is that in divorce, the natural emotions children experience — anxiety, sadness, anger — may manifest themselves in behaviour that is mislabeled as ADHD-like, or that parents and doctors may be anticipating problematic behaviour because of the stress of divorce. The study suggested this type of rationale would reflect inappropriate use.
Dr. Anton Miller, a developmental pediatrician and child health researcher at the University of British Columbia’s Centre for Community Child Health Research, said it’s possible no single answer applies across the board for these children.
“None of them is an outlandish kind of suggestion. They probably all have some validity,” he said.
“It’s certainly possible in some instances that ADHD might have been prematurely diagnosed…. But I would caution anybody (against) saying ‘Well that’s why all these children are getting medication.’ “
“But there is a possibility that in a proportion of the cases we need to try and figure out how much that does happen in the real world and try and advocate … for children to have thorough and really in-depth assessments for these kinds of behaviour and emotional problems.”
Ms. Strohschein agreed: “I think the take-home message is just to be careful not to make that broad assumption that kids must necessarily be doing poorly when their parents divorce. Some kids will do better, some kids will do worse.”

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The Last Normal Child and ADHD

Posted by Peter on August 13th, 2007 | Comments off

Dr. Lawrence H. Diller’s book, The Last Normal Child: Essays on the Intersection of Kids, Culture, and Psychiatric Drugs, is a fascinating and provocative work. As an experienced developmental/behavioral pediatrician, Diller examines the current trend to quickly diagnose attention deficit hyperactivity disorder (ADHD) and the perfunctory prescription of stimulant drugs even when there is scarce evidence regarding academic improvement, social improvement, or long-term efficacy.

Diller’s perspective is quite evenly balanced; he prescribes stimulant medication for ADHD when indicated, but only as part of thorough assessment and comprehensive management program.

It is clear that Diller believes that ADHD is being over diagnosed. He states that over the last 15 years brand name stimulant production has increased by an astounding 1700% and generic stimulants by more than 3000%!

The number of U.S. children taking psychotropic drugs has doubled over the last ten years. We currently have more than 4.5 million children under 18 taking psychotropic drugs – mostly stimulants. Perhaps even more alarming are the percentages of ADHD children being reported by the Centers for Disease Control (CDC): typically common rates between 5% to 7% are reported in children in Colorado and 5.5% in California. However, as many as 10.5% of children in Louisiana are diagnosed with ADHD as are 11% of children in Alabama.

Diller suggests that the rampant diagnosis and pharmacological treatment of ADHD might be related to the fact that, “The drug industry hijacked American psychiatry in the 1990s….Insurance companies structure doctors’ reimbursement so as to reward short visits, ones in which a prescription brings the session to a definite conclusion.”

Diller also suggests that the Individuals with Disability Education Act of 1990, actually accelerated pharmacological treatment as well as the ADHD diagnosis because its amendment in 1991 now included ADHD as a diagnosis that makes a child eligible for special services and accommodations in public schools. As parents quickly learned, an ADHD diagnosis could gain their child special services and testing accommodations.

The pharmaceutical industry parleyed this trend by targeting parents with direct ADHD drug advertising. Parents, having diagnosed their child via the effects of the advertising campaign, could now approach their family practitioner to request stimulant drugs as a remedy. Diller suggests that many parents welcomed a brain-focused diagnosis that relieved them of responsibility for problem behavior.

The book encompasses far more than I’ve described here and is well worth reading. It is an excellent, balanced perspective that provides insight into the staggering $3 billion juggernaut known as ADHD.

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Insurers Question Studies of ADHD Drugs

Posted by Peter on September 13th, 2005 | Comments off

WSJ Article Excerpts:

By ANNA WILDE MATHEWS
Staff Reporter of THE WALL STREET JOURNAL
August 24, 2005; Page A1
DOWNEY, Calif. – When Eli Lilly & Co. wanted to get the big California health-maintenance organization Kaiser Permanente to use its new antidepressant, it ran straight into Debbie Kubota.

As the cost of drugs in the U.S. approaches $250 billion a year, pharmaceutical companies are running up against a growing breed of detective trained to see through marketing spin. Working for insurers, state Medicaid programs and nonprofit bodies, these detectives cast a wary eye on published studies in medical journals, once considered an unimpeachable source. They search for subtle aspects of clinical-trial design that might show the drugs are not all they’re cracked up to be.
“You could be duped,” says Siri Childs, who oversees pharmacy policy for the Washington state Medicaid program. “We know now that just because it’s published in a medical journal, that doesn’t assure its quality.”
The Cochrane Collaboration, a nonprofit that analyzes the quality of studies and collects the ones it considers good into broader analyses, has a volunteer corps of about 7,500 reviewers, mostly doctors and academics. That’s up from about 2,800 five years ago. Another player is the Drug Effectiveness Review Project, an effort by an Oregon nonprofit. It issues reports summarizing all the studies in a particular treatment area and often criticizes individual studies for failings such as inadequate controls and high dropout rates.
Some journals are trying themselves to help readers discover marketing messages slipped in amid the scientific data. Last year BMJ, a British journal, published a piece called “Users’ guide to detecting misleading claims in clinical research reports,” which came with a picture of a reader dumping salt on a medical journal. One piece of advice: Beware when the authors break out one subgroup of patients and claim benefits from the treatment that weren’t evident in the whole group.

Dr. Kubota, a 26-year Kaiser veteran who holds a doctor of pharmacy degree from the University of Southern California, is based in the industrial city of Downey, southeast of Los Angeles, across the street from an abandoned movie set. Kaiser tries hard to keep her and her colleagues away from the influence of the companies whose products they evaluate. Before meeting with Dr. Kubota, a representative of a drug company must fill out a form indicating who will be coming, what they plan to discuss and why the information can’t be relayed in written form. No gift pens, mugs or other trinkets are allowed. Dr. Kubota’s business card doesn’t show her direct phone number.
When Dr. Kubota started her current job in 1997, she says she “would just read the abstract,” the summary at the beginning of a study. “I guess I was naive,” she says. “You kind of assume everything is there for you in the abstract.” Today, she quickly homes in on details that aren’t mentioned in the abstract and generates a 6-inch stack of papers studded with Post-it notes for each drug.
When she reviewed Adderall, a stimulant now marketed by Shire Pharmaceuticals Group PLC to treat attention deficit hyperactivity disorder, she noted that one of the major trials included only people who had responded well to Ritalin, another ADHD drug. She thought the move likely improved the results. Dr. Kubota recommended leaving Adderall off Kaiser’s formulary. The physician committees partially overruled her, putting Adderall on the Northern and Southern California formularies but only for patients who failed to respond to another stimulant. Adderall later was added to the preferred list as a first-line treatment after a once-daily formulation went on the market.
A spokesman for Shire, Matt Cabrey, said that the designers of the trial, which was conducted when Adderall belonged to another company, felt that for ethical reasons they should give the drug to people with a “reasonable anticipated reaction.” James Swanson, the lead author of the article that described the trial’s results, said the trial was designed to show whether Adderall works faster than Ritalin.

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Can custom-made video games help children with attention deficit disorder?

Posted by Peter on September 8th, 2005 | Comments off

From the Berkeley Medical Journal:

y Attention!
Can custom-made video games help kids with attention deficit disorder?
By Gordon Kwan
For children with Attention Deficit Hyperactivity Disorder (ADHD), life can feel like a never-ending video game. They are wired–restless, impulsive, and easily distracted. Their minds are constantly bombarded with different elements of reality that compete for their attention.
So far, the most popular treatment for ADHD has been Ritalin, a rapid-acting stimulant for adults that has the opposite effect in children, calming the jitters associated with the disorder. According to the National Institute of Mental Health, about three percent of American school children take stimulants like Ritalin regularly. However current research suggests a surprising new strategy for treating this disorder: video games linked to brain-wave biofeedback that can help kids with ADHD train their minds to tune in and settle down.
It is difficult for a child with ADHD to learn how to self-regulate and know what it feels like to concentrate. Biofeedback teaches patients to control normally involuntary body functions such as heart rate by providing real-time monitoring of such responses. More than 15 years of studies show that with the aid of a computer display and an EEG sensor attached to the scalp, ADHD patients can learn to modulate brain waves associated with focusing. Increasing the strength of high-frequency beta waves and decreasing the strength of low-frequency theta waves, for example, creates a more attentive state of mind. With enough training, changes become automatic and lead to improvements in grades, sociability, and organizational skills.
Despite its proven success, the technique has not become a mainstream treatment for several good reasons. First, unlike drug therapy, which can have immediate results, a typical course of biofeedback treatment takes a series of about 40 one-hour sessions over a span of several months before benefits become apparent. Second, it is more expensive than drugs. Costs range from $3,000 to $4,000 for these treatments, so insurance companies tend to pick the less expensive option. Finally, biofeedback training requires the very kind of prolonged concentration that patients with ADHD struggle to attain.
Alan Pope, a behavioral scientist at NASA Langley Research Center in Hampton, Virginia, came up with a more engaging approach through work with NASA flight simulators. He was determining the degree of interaction with cockpit controls necessary to help pilots stay attentive during routine flights. In an experiment, he linked the level of automation in the cockpit to the pilots’ brain-wave signals, so that some controls switched from autopilot to manual when the pilot started to lose focus. He found that with practice the pilots could begin to adjust the controls to the level of automation that felt most comfortable by regulating their own brain waves.
Pope applied his findings to help ADHD patients stay focused by rewarding an attentive state of mind. He realized, however, that the simple displays that were already part of biofeedback treatment may not be enough to hold the interest of restless youngsters. He then chose several common video games and linked the biofeedback signal from the player’s brain waves to the handheld controller that guides the games’ actions. “In one auto-racing game, a car’s maximum speed increases if the player’s ratio of beta to theta waves improves. The same sort of feedback also controls the steering,” Pope says.
In the test, six Sony PlayStation games were used with 22 boys and girls between the ages of nine and thirteen who had ADHD. Half the group received traditional biofeedback training; the other half played the modified video games. After 40 one-hour sessions, both groups showed substantial improvements in everyday brain-wave patterns as well as in tests of measuring attention span, impulsiveness, and hyperactivity. Parents in both groups also reported that their children were doing better in school.
The difference between the two groups was motivation. “In the video-game group, there were fewer no-shows and no dropouts,” according to Pope. The parents were more satisfied with the results of the training, and the kids seemed to have more fun.
Since children are more motivated toward video-game biofeedback and may already be familiar with video games, they will not need one-on-one coaching to master the technique. As a result, the cost of the treatment should be reduced and maybe even permit “do-it-yourself” biofeedback. One North Carolina company markets their Play Attention system as a fun bike helmet and game-like video exercises that work on almost any computer. The helmet is lined with sensors that monitor the child’s brain waves, and the child actually controls the computer video exercises by mind alone. Parents should not expect regular video games to help their children. The wrong kinds of video games might actually hurt children with attention disorders.
Parents, however, may be hesitant to switch from traditional treatment programs. One parent whose child currently takes drugs to control ADHD says, “Our son is using drugs to control his attention problems and although we don’t like giving him the pills, he is no longer causing problems at school. We try to keep our son away from things that might make him hyperactive. Unless our doctor tells us to do this brain wave training in a hospital, we are not going to buy a machine to do our own treatment at home.”
Brain-wave biofeedback alone may not be a substitute for drug therapy. Professor Stephen Hinshaw, an expert in the field of child clinical psychology at UC Berkeley, gives a reserved opinion about biofeedback treatment. “Biofeedback is a promising potential alternative, but unfortunately the kinds of really well-controlled studies that might support its clinical benefits have yet to be performed.” The two treatments have complementary aspects that make them effective as adjuncts. A single dose of Ritalin, for example, acts quickly but only for a few hours, and most patients take it only on school days. Brain-wave regulation takes a long time to learn but has the potential for longer-lasting effects.
Researchers and clinicians are realizing that ADHD is not easily outgrown. Most doctors support an approach that combines good nutrition, sleep, exercise, and learning strategies as well as biofeedback and drug therapy. The possibilities for brain-wave biofeedback are very promising since its benefits could last a lifetime. Video game biofeedback therapy may provide a more tolerable and long-lasting form of treatment for children through a medium they are more likely to enjoy.

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Ritalin and Cancer

Posted by Peter on July 19th, 2005 | No Comments

The FDA has taken an interest in the University of Texas’ preliminary research regarding Ritalin and cancer. While the research is alarming, it is far too premature to be conclusive.

From HealthCentral.com:

Researchers Urge Caution on Ritalin-Cancer Link Finding Despite FDA concerns, Texas scientists say their study was only preliminary.
By Amanda Gardner HealthDay Reporter
FRIDAY, July 1 (HealthDay News) – As the U.S. Food and Drug Administration moved to examine a potential link between Ritalin and cancer, the scientists who first unearthed the connection stressed Friday that the finding was preliminary and should not be cause for panic.
The concerns about the drug, a stimulant that has been used to treat attention-deficit hyperactivity disorder (ADHD) for decades, surfaced during a FDA pediatrics advisory committee meeting Thursday. The findings, by researchers from the M.D. Anderson Cancer Center at the University of Texas, showed damage to the chromosomes of 12 children who had taken Ritalin for three months.
The advisory committee had been called to discuss yet another health issue surrounding the class of ADHD medications known as methylphenidates, to which Ritalin belongs: Some psychiatric side effects have been reported among children using Concerta, Ritalin and other versions of these drugs.
But the Texas scientists said their Ritalin study was far too small to prompt the parents of ADHD patients to abandon the drug.
“We’re not telling people to all go off their medication because you don’t know what this means,” said Melissa L. Bondy, co-author of the study, which first appeared in the Feb. 16 online issue Cancer Letters. “You can’t base changing practice on 12 patients. Look how many millions of kids are on this. Do you want to tell all the mothers and fathers to take their kids off of the drugs?”
Bondy said she and her colleagues have submitted a grant proposal to the National Institutes of Health for a larger study looking at more patients and more ADHD drugs.
“We definitely need a larger study,” said lead researcher Dr. Randa A. El-Zein. If approved, the study would not even be funded until March 2006.
The government interest is there, however.
Scientists from the FDA, the NIH and the Environmental Protection Agency traveled to Texas on May 23 to examine the study methods used by the researchers. “They thought, ‘Yes, we do have a public concern,’ and that a larger study should be performed,” El-Zein said.
“We’re hoping that they’ll see this as a major public health issue, and as something that needs to be done,” Bondy added.
Meanwhile, the question of labeling changes because of possible psychiatric effects of Ritalin and other methylphenidates have been put on hold after the advisory committee told FDA officials that it was hesitant to recommend such changes.
According to an FDA release, committee members suggested waiting until more safety data have been collected on two other types of drugs used to treat ADHD – methamphetamines such as Adderall and the non-stimulant Strattera, something that won’t happen before early 2006.
The FDA should “delay the labeling change until they have a good sense of class effect,” Acting Committee Chairman Robert Nelson, of The Children’s Hospital of Philadelphia, told FDA officials according to the release.
“We heard there is no terrible signal,” Office of Pediatric Therapeutics Director Dianne Murphy added.
The FDA had been considering labeling changes to all methylphenidates with regard to psychiatric events and potential cardiovascular side effects. A review had found 36 psychiatric events for Concerta, compared to 16 for Ritalin and other methylphenidates. These side effects included hallucinations and suicide ideation. Concerta had 20 cardiovascular event reports, while the other methylphenidates had four such reports.
Despite the committee’s advice, Murphy said the agency still may change labeling about psychiatric side effects to “try to make it clearer what the situation is with regard to certain adverse events.”
The FDA’s decision to take a closer look at the psychiatric side effects of medications for ADHD did not surprise some experts.
“These types of issues theoretically were possible with the medication because of the way it works. It’s not surprising that they’ve had some reports that relate to psychiatric side effects… ” said Dr. Lenard Adler, director of the Adult ADHD Program at New York University Medical Center.
The drugs have been around for 40 years, Adler added, and have a “wide margin of safety.”
“Any medicine that has therapeutic effect can have some side effects,” Adler continued. “This is appropriate scrutiny by the FDA, but the benefits are also very clear and clearly outweigh the risks.”
Another expert believes labeling changes may not be the answer.
“Labeling is an oversimplification of the problem,” said Dr. Eugenio M. Rothe, director of the child and adolescent psychiatry clinic at Jackson Memorial Hospital and an associate professor of psychiatry at the University of Miami School of Medicine. “It scares people, and it doesn’t address the other problems that are affecting the outcome. The problem is much more complex than that, and has to do primarily with the stigma associated with mental health conditions.”
This is just the latest chapter in the ongoing debate over the safety of ADHD medications.
In February, Health Canada ordered Adderall XR off the market, after reports of sudden cardiac death in 20 patients. The FDA, however, elected at the time only to require the company to update Adderall’s label to warn that it should not be used in anyone with structural cardiac abnormalities.
Almost 2 million children in the United States have been diagnosed with ADHD, according to the National Institute of Mental Health.

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Ritalin: Do your research!

Posted by Peter on July 15th, 2005 | No Comments

Who ya’ going to call? When so much negative publicity surrounds stimulant medication and psychotropic drugs, who can you believe? Well, according to their press release, trust the Journal of Child and Adolescent Psychopharmacology because it “Is The Expert Source on ADHD and the Use of Ritalin in Children.”

Journals do provide scientific evidence and controlled studies. However, by their very nature journals are like the old stack of National Geographics found in your grandmother’s basement; typically old, musty, and out of date because of the lag in publication time. So, while they do have their place, it’s important to use the Internet as a place to get the latest data and research as well as warnings – including those posted by the FDA about stimulant medications.

Their press release:

Journal of Child and Adolescent Psychopharmacology Is The Expert Source on ADHD and the Use of Ritalin in Children
Recent and ongoing controversy in the media about the safety and efficacy of psychotropic drugs, especially Ritalin, highlights the need for credible scientific research. Journal of Child and Adolescent Psychopharmacology has been the peer-reviewed journal of record in the field of psychopharmacology since 1991. Noted child psychiatrist Harold S. Koplewicz, M.D., Director, Child Study Center, New York University School of Medicine, Editor-in-Chief of the Journal, contends that the best science in the field does not support the claim that Ritalin may do more harm than good.
The Journal is published by Mary Ann Liebert, Inc., publishers, and selected papers on the treatment of ADHD are available free online through the end of July at www.liebertpub.com/cap.
Journal of Child and Adolescent Psychopharmacology is a peer-reviewed journal published bimonthly in print and online. The Journal is dedicated to child and adolescent psychiatry and behavioral pediatrics, covering clinical and biological aspects of child and adolescent psychopharmacology and developmental neurobiology. A complete table of contents and free sample issue may be viewed online at www.liebertpub.com/cap.
Mary Ann Liebert, Inc., is a privately held, fully integrated media company known for establishing authoritative peer-reviewed journals in many promising areas of science and biomedical research, including CyberPsychology & Behavior. Its biotechnology trade magazine, Genetic Engineering News (GEN), was the first in its field and is today the industry’s most widely read publication worldwide. A complete list of the firm’s 60 journals, books, and newsletters is available at www.liebertpub.com.

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Study finds divorce increases Ritalin use in children