ADHD: Medication plus parent training may help kids with aggression

Combining two medications with parent training appears to improve anger, irritability and violent tendencies in children whose attention-deficit/hyperactivity disorder (ADHD) is coupled with severe aggression, a new study suggests.

"Augmented" therapy that consists of stimulant and antipsychotic drugs, along with parent training in behavioural management techniques, was rated more effective by parents than "basic" therapy pairing only the stimulant and parent training, researchers found.

"An important finding of this study was that at the end of nine weeks, approximately half of all children receiving basic therapy were still rated by their parents as being impaired... with symptoms interfering with school or social functioning," said study author Kenneth Gadow, a professor of psychiatry at Stony Brook University in New York.

"In the augmented group receiving three interventions for aggression, about one-quarter still, at the end of nine weeks, were rated by their parents as being impaired, and that suggests, even with highly effective therapies, that many of these children still have unmet treatment needs" " he added.

The drugs used in the study, published in the September issue of the Journal of the American Academy of Child and Adolescent Psychiatry, included the widely prescribed ADHD stimulant Concerta (methylphenidate) and the antipsychotic Risperdal (risperidone).

Approximately 11 percent of American children aged 4 to 17 have been diagnosed with ADHD, which includes symptoms such as impulsivity, hyperactivity, and difficulty focusing and controlling behavior, according to the U.S. Centers for Disease Control and Prevention.

As many as half of children with ADHD also display significant, disruptive aggression, according to an editorial accompanying the new research.

"This is very common among kids with ADHD, but unfortunately it complicates the picture for treatment," said Erin Schoenfelder, a clinical psychologist at Seattle Children's Hospital and assistant professor of psychiatry and behavioural health at University of Washington.

"It really is staggeringly high."

In the new research, Gadow and his colleagues divided a group of nearly 170 children aged 6 to 12 with ADHD and aggression problems into two treatment groups, basic and augmented.

The basic group received Concerta and their parents underwent behavioral management training.

The augmented group received Concerta and parental training as well, but also took the antipsychotic Risperdal. Both groups were followed for nine weeks.

While both groups of children displayed marked reduction in symptoms, improvement ratings varied depending on whether parents or teachers were making the assessment.

Parents reported that children on augmented therapy were less likely to be impaired socially or academically by their anger and irritability than children on basic therapy.

On the other hand, teachers found few differences in these measures.

Instead, teachers of those on augmented therapy reported significant drops in ADHD symptoms, especially impulsiveness, compared with teachers of children on basic therapy.

Gadow and Schoenfelder agreed that the conflicting parent-teacher ratings demonstrate a familiar concept: that children's behaviours vary in different settings, whether or not they have ADHD.

"Just like adults, they adapt their behaviours to be more appropriate for the setting they're in," Gadow said.

"People do differ, however, in their ability to modify their behaviour from one setting to the next, and some children are much more variable [in this regard]."

Schoenfelder said long-term evidence is needed indicating that combining Concerta and Risperdal is safe in children, but "it appears from this study that the combination was well-tolerated and something practitioners could [adjust the dosage of] effectively."

"Folks trying this type of treatment should have close monitoring," she added. "This is a starting point. It's a combination doctors may try when they see this blend of aggressive and hyperactive behaviours. It certainly will require adjustment . . . but it's exciting to find something helpful for a significant proportion of the kids studied."

The study authors pointed out that their findings only apply to children with ADHD who exhibit severe irritability and peer aggression.

They noted that the study's findings are not an indication of the ADHD population as a whole.

More Information: "Risperidone Added to Parent Training and Stimulant Medication: Effects on Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, and Peer Aggression" http://www.jaacap.com/article/S0890-8567(14)00369-4/abstract

ADHD Medication Mis-use

In the past decade or so, psychostimulants like Adderall have exploded in popularity among people without a diagnosis or prescription.

Studies indicate that as many as one in three students on major college campuses have used ADHD medications illicitly, most commonly as a study aid.

The insatiable demand has led to shortages at pharmacies across the country. The law draws a bright line between the use of Adderall by people with ADHD and by those without.

For the former, it’s therapy. For the latter, it’s felony drug abuse, punishable by up to a month in jail.

The drug itself, however, does not draw the same bright line and neither do a growing number of high-achieving, non-ADHD users who see it as the perfect cognitive-enhancement drug—a way to work more, sleep less, and get a better handle on their busy lives.

In today's competitive economy, some might label that cheating, akin to athletes taking anabolic steroids to gain an unfair edge.

Others might suspect that nonprescription Adderall users are only cheating themselves — that the drug won’t really help you if you don’t have ADHD, or that deleterious side effects will counteract any short-term advantages the drug may confer.

But Adderall is not the first prescription medication to find a black market among the tired and ambitious.

As Joshua Foer noted in a Slate story in 2005, Jack Kerouac wrote On the Road while dosed up on Benzedrine, a stimulant that was once prescribed as a nasal decongestant.

But the prevalence of ADHD, about one in 10 children in the United States meet the diagnostic criteria, according to a recent survey, and the popularity of Ritalin and Adderall for treatment mean that they are far more widely available than other types of brain drugs.

That’s especially so because inexperienced doctors have a hard time distinguishing a patient who has ADHD from one who’s faking the symptoms to get a fix.

Some people take the prevalence and subjectivity of the symptoms to mean that ADHD is not even a real disorder, that it’s simply an excuse for lazy parents to medicate their kids.

It’s true that the disorder lies on a spectrum, as opposed to something like juvenile diabetes that you either have or you don’t.

Scott Kollins

But as psychiatric disorders go, ADHD is in fact “quite discrete and very diagnosable,” says Scott Kollins, director of the ADHD program at Duke’s medical school.

“It’s just not easy to diagnose within 15 minutes,” the length of a standard primary-care doctor visit. In a health care system that isn’t set up to reward careful psychiatric evaluations, some doctors simply shrug and write out the prescription.

Others, wary of being played for fools, refuse prescriptions to patients who could really use them.

By law, Adderall is a controlled substance, in the same class as cocaine and methamphetamine but many of the college students who are taking it don’t see it that way, says Alan DeSantis, a sociologist at the University of Kentucky who studies the culture of ADHD drug use on campus.

He got interested in the topic a decade ago while conducting research for a book on fraternities and sororities. “I was asking students about drugs, and they kept saying something very interesting.

They kept saying, ‘I don’t do drugs, but I do Adderall.’ The difference, in the students’ minds, is that drugs are bad for you and make you unproductive.

They view Adderall more like a study aid, DeSantis says, and talk about it openly. In his surveys, up to 50 percent of University of Kentucky upperclassmen have reported using ADHD stimulants at one time or another, most often to cram for midterms or finals.

To some, those numbers are cause for alarm. “The evidence is pretty clear that these are potent stimulants,” says Craig Rush, a professor of behavioural science at Kentucky.

"They produce euphoria, and they have significant abuse potential.” Nora Volkow, director of the National Institute on Drug Abuse, told 60 Minutes in 2010 that she believes even casual use can lead to addiction. “It’s not worth the risk to be playing with a drug that has potentially very adverse affects.”

ADHD: Medication addresses the condition not Motivation

"I take ADHD medication, and it has helped me focus at work and at home but it hasn’t helped with my motivation. I still don’t want to clean up or get organised. Why don’t meds for attention deficit improve my motivation?" 

Lots of people ask this question but believe me, it sounds as if your medication is doing what it should do -- improving your focus and your attention to detail, making things easier to remember, and making you more aware of time.

However, medication doesn’t necessarily improve your motivation, especially for doing the tasks that you describe. But don't be alarmed. Self motivation can be learned.

Chores such as this will probably never be fun. However, if medication makes it easier for you to consider doing a task, and to stay focused while you are working, you may find that, over time, you will become motivated to do things.

It will become a matter of developing a more positive mindset to tackle challenges instead of avoiding them.

Of course you can sit around waiting for that to happen, which I don't recommend. Better if you can take some positive steps to get support to increase your motivation.

There are numerous self-help books, motivational coaches and psychologists who dedicate their lives to supporting people with motivation issues.

In most cases it's not the task itself, it's getting 'started.' It may help to ask someone to get you started and then you can carry on regardless.

Make a written list or plan of chores and tackle them one at a time. After you have completed one give yourself a small reward; a cup of coffee and a biscuit, will suffice.

Mundane chores, like cleaning up, are generally boring for everyone, but you will feel accomplished when you have made the effort. 

You will be able to appreciate the benefit of doing it and see yourself as capable of accomplishing it. This will lift your confidence.

The feel-good thoughts you get will increase your confidence and willingness to perform other mundane chores and tackle other issues you normally avoid but never be afraid to ask someone for help, even if it's only to get you started.

Medication may be only half the solution, a more positive mindset is the other half and you need them both.

Work on your motivation by seeking support from online articles, books, family, trained experts or medical psychologists. They are waiting and wanting to help and support you.

ADHD medication needs a addition of child-friendly message

More than half a million prescriptions for methylphenidate, a stimulant medicine to treat ADHD, sold under the brand names Ritalin, Concerta, and Equasym, are dispensed each year in England.

Up until now, however, the patient information leaflet included with every box has been written with only adults in mind.

Read the full Report here

Following an agreement with drug companies, the Medicines and Healthcare products Regulatory Agency (MHRA) decided that a youth-friendly section should be included in all brands of methylphenidate prescribed and dispensed in the UK.

The work was undertaken by researchers at the  University of Leeds in collaboration with the Leeds-based company Luto Research.

As reported in Pharmaceuticals Journal, the revised patient information leaflet now includes a section called “Information for children and young people” that provides clear and simple information about the consequences of possible side effects, using examples that may be relevant to children and teens.

For example, when advising users to avoid certain activities if they feel dizzy, it refers to horse riding, climbing trees, and riding a bike. The section also offers advice to youngsters who may be sexually active.

“Children and young people are the main consumers of these medicines,” says Theo Raymor, professor of of pharmacy at the University of Leeds.

“It is important that they have the opportunity to know why they have been given this drug treatment and how it can help them. The revised leaflet now gives them a chance to read about their medication in an easy and informative way.”

Words and phrases in the youth friendly section were tested by adults and teenagers, as well as children as young as 10 who read the leaflet with a parent. Feedback from this testing helped ensure that the messages on safety and side effects were clear to a wide range of ages.

“We gave particular thought to the layout of the text, as well as the content,” Raynor says. “Simple changes, such as making headings bolder, using bulleted lists, and dividing long sentences into shorter ones can make a real difference when writing for all people, including children.

“This is the first time that children and teens have had a chance to comment on the information that goes into medicine packs, and it has proven to be very successful.

“We are now hoping that this approach can be taken for other medicines that are used widely by children, perhaps medicines for asthma or epilepsy.”

The work was co-ordinated by the MHRA as part of its drive to help people of all ages understand the medicines they are taking.

“It’s vital that both children and adults understand the medication they are taking,” says MHRA Head of Patient Information Quality, Jan MacDonald.

“Children and young adults with ADHD will be better informed about their healthcare from the new style of patient information.”

More news from University of Leeds: www.leeds.ac.uk/news

Painkiller Addiction Increasingly Common In Newborns

When you picture a person going through painkiller withdrawals, a baby crying in his crib is usually not the first image that comes to mind. But the number of babies born with withdrawal symptoms has skyrocketed since 2000, according to a new study.

In 2000, approximately 4,300 babies were born with neonatal abstinence syndrome, a condition that occurs in some babies that were exposed to opiates such as heroin, Vicodin and oxycodone in the womb, according to the study. In 2009, the number jumped 300 percent to 13,000.

"That's about one baby per hour," Dr. Stephen Patrick, lead author of the study and postdoctoral researcher at the University of Michigan, told CNN. "We were surprised by it. That's a startling increase."

Opiates used by an expectant mother during pregnancy pass through the placenta and into the baby. The babies' bodies become dependent on the drugs but no longer have access to them once they are born, triggering withdrawal. Between 55 percent and 94 percent of babies exposed to the drugs before birth show signs of withdrawal once they are born, according to the American Academy of Pediatrics.

Signs of withdrawal unique to infants include a distinct, high-pitched cry and an aversion to light and sound. They may also show symptoms similar to adult withdrawal patients, such as insomnia, diarrhea and vomiting.

Doctors use methadone, a drug used by addicts looking to kick the habit, to wean the babies off of the drugs slowly. Making them go cold-turkey could lead to seizures and possibly death, according to the study.

Getting the babies over their addiction could take weeks or even months and often requires long-term hospitalization. The cost of treating drug-addicted babies increased from $190 million in 2000 to $720 million in 2009, according to the study, published in the Journal of the American Medical Association on Monday.

The increase in opiate-addicted babies is a product of growing numbers of adults who abuse painkillers.. More than two-thirds of patients prescribed painkillers abuse them by taking them too often or by taking them in conjunction with other painkillers not prescribed to them, according to research published by Quest Diagnostics.

In addition, two million people in 2010 admitted to abusing prescription painkillers for the first time -- almost 5,500 per day, according to the Centers for Disease Control and Prevention.

Tennessee had the highest rate of painkiller abuse between 2007 and 2008, according to the National Survey on Drug Use and Health. It also has one of the highest rates of opiate-addicted newborns. At East Tennessee Children's Hospital, almost 50 percent of the babies in the neonatal intensive care unit are experiencing withdrawals.

"In Knox County, we're drowning," Susan Kovac, attorney for the Department of Children's Services in Tennessee, told CNN. "We've seen the number of children in foster care increase by almost 50 percent over the last few years, and that's just the tip of the iceberg because we're trying to keep the children out of foster care. We've got lots and lots of relatives who are raising drug-exposed infants."

Florida also experienced a surge in the number of addicted babies, which increased from 354 in 2006 to 1,374 in 2010, according to the study.

The researchers call for individual states and the Federal government to take action to reduce the amount of painkillers prescribed and say educating the public about the dangers of using the drugs while pregnant may also help. Cutting the number of prescriptions of opiates could drastically reduce the number of babies born with NAS, according to the study.

"Newborns with NAS experience longer, often medically complex and costly initial hospitalizations," the researchers wrote in the study. "The increasing incidence of NAS and its related health care expenditures call for increased public health measures to reduce [in utero] exposure to opiates across the United States."

Medication is not a way for ADHD kids to cheat

We are students living with learning disabilities and attention deficit hyperactivity disorder. We disagree with the "Abuse of ADHD drugs creates uneven playing field" (Open Forum, March 16), which compared ADHD medication with performance-enhancing steroids in sports and asked: "Is ADHD (medication) use cheating as well?"

While the author rightly criticizes student use of any stimulant or ADHD drug by those who are not diagnosed with ADHD to enhance their performance, and points out that the drugs don't work unless one has ADHD, she suggests that drug use even by those diagnosed with ADHD somehow gives an unfair advantage.

Wrong.

Accommodations and allowing the use of medication are legally required for students with disabilities. Accommodations are like supplying ramps for wheelchairs, assistive listening devices for the hearing-impaired, glasses for those who need them, or software that reads text aloud for the blind and dyslexic.

Accommodations give students with learning disabilities and ADHD an equal opportunity to succeed in an educational environment that caters to a narrowly defined learning style. They level the playing field. They keep us in school.

Medication is no "enhancer" for us. As one of our students with ADHD put it, those who do not have ADHD "only see the drug as a drug, and nothing else.

They don't see the fight that rages on inside me, my constant struggle to focus, my inability to stay organized, and my tireless efforts to complete tasks others would view as easy." For those with ADHD, medication is a tool, not a solution.

Attending school as a student with learning disabilities or ADHD is hard enough. Fighting the stigma is even harder.

Many students, fearful of the stigma, don't seek help, don't want to be identified and are fearful of being different.

Without good support, without the right accommodations (sometimes including medication), without understanding how we learn or discovering our strengths, we fail, we drop out, and society loses out on valuable contributors.

We now know that a disproportionate number of our most successful CEOs and entrepreneurs have dyslexia or ADHD. They think outside the box; standardized education and high-stakes testing does not hinder their brilliance.

So, please: Learning disabilities, including ADHD, are real. It's really hard to be a student with learning disabilities and ADHD. It's harder yet when people talk about us, not with us.