Testimony by

House Democratic Policy Committee’s Public Hearing on the Use of Ritalin

Presented December 14, 1999 and Revised 2005

Issues

• Definitions of ADHD
• Associated conditions
• Treatment issues

 

• ADHD issues in adults

 

Is this a marketing scheme to sell Ritalin?

• No, the use and effectiveness of Ritalin is well established.
• Ritalin is referenced in 1157 studies in medical journals from 1960 to 1999 and the evidence overwhelmingly supports the therapeutic benefits.
• About 100 years ago Dr. Still, a pediatrician, defined the disorder.

 

• Original symptoms included hyperactivity, learning problems, inattention and conduct problems.

 

Is ADD/ADHD just new name for old-fashioned hyperactivity?

• The name is not as important as the key concept of inattention.
• Many names are associated with this problem of inattention.
• Minimal Brain Dysfunction (MBD) was an early name.
• Others include Hyperactive Child Syndrome
• Attention Deficit Disorder (ADD) was introduced in 1980

 

• Attention Deficit Hyperactivity Disorder (ADHD) since 1994

 

Does everyone have ADD?

• No, a longstanding dysfunctional pattern is necessary.
• Symptoms or features must be distinguished from a life long pattern before 7 years old.
• Exuberance is different from symptoms way beyond average and causing dysfunction in life.
• Using standard rating scales such as Conners or others is necessary for assessment.

 

• Rule out other disorders that can cause similar symptoms

 

What are the criteria?

Inattention

 

• Careless mistakes
• Not listen

 

• Fail to complete tasks

 

Impulsivity

• Frequently interrupts

 

• Shouts out answers

 

Hyperactivity

 

• Fidgeting
• Out of seat

 

• Excessive talking

 

Is the disorder mostly in boys?

• Yes, boys are often inattentive and hyperactive. Girls do have the disorder but are usually not hyperactive or a conduct problem.
• Girls are mistakenly called lazy, slow or spacey.

 

• Women and girls are often misdiagnosed as anxious or depressed.

 

Will they outgrow it?

 

• Yes and no
• 70% persist from childhood to adolescence in some form.
• 30-40% of grownup ADHD children do well.
• 30-50% have persistent symptoms as adults.
• 10-20% have significant impairment and disability.

 

• 80-90% do not need medication as adults.

 

Do they just need to try harder?

• Worst advice is to try harder as symptoms increase.
• Best strategy to try “different” and find new ways to do things.
• Brain imaging shows areas are inhibited by increased effort.

 

• Brain imaging demonstrates abnormal anatomy and physiology in ADHD as in other disorders, such as the medical abnormalities in diabetes or asthma.

 

Is this disorder overdiagnosed?

• It is underdiagnosed especially in girls.
• 5-12% of all school-aged children have the disorder.
• Less than 1 in 8 (about 12%) are treated with stimulant medication.

 

• Adults get even less treatment, yet 2-5% or more have symptoms.

 

Caused by poor parenting or teachers?

• No, it is physically based.
• It is a genetic or developmental disorder.

 

• Parents will best not search for external cause, but they can find external solutions in dealing differently to find solutions to problems.

 

Do they often abuse stimulants like Ritalin?

• No, the problem is with they are not taking medication.
• ADHD boys treated with medication are 84% less likely to develop a substance abuse disorder than those not treated.
• Medication is safe, effective and has little abuse potential in prescribed doses.
• Adolescents should be monitored for abuse and a count kept of their medication.

 

 

What are the risks of ADHD?

• Social alienation
• Academic failure
• Antisocial behavior
• Legal problems

 

• Substance abuse

 

What are other causes of ADHD symptoms to consider?

• Learning disabilities
• Conduct disorder
• Anxiety disorders
• Mood disorders
• Environmental factors

 

• Stress

 

What other medical causes, such as diet or allergy, are possible?

• Not usually diet or allergy
• Sensory deficits
• Chronic illness
• Seizures
• Traumatic brain injury

 

• Fetal drug effects, especially alcohol

 

What about comorbidity (other associated disorders) in children?

• Anxiety and mood disorders
• Bipolar disorder
• Conduct and oppositional defiant disorders
• Tourette’s disorder

 

• Obsessive compulsive disorder (OCD)

 

What are adult symptoms?

• A history of clear childhood symptoms
• Disorganization
• Poor concentration
• Not finishing projects
• Procrastination
• Anticipatory anxiety

 

• Impulsive outbursts

 

What signs seen in adult work history?

• Careless mistakes
• Failing to complete projects
• Sense of restlessness

 

• Impairment in functioning

 

Comorbidity in Adults

• Depression
• Anxiety

 

• Substance abuse

 

What is Multimodal Treatment?

• Family therapy
• Behavioral program
• Educational and vocational
• Cognitive therapy

 

• Medication when indicated

 

What treatment do they receive?

• About one-fourth receive special services at school.
• Nearly one-third receive behavioral therapy or psychotherapy.
• Less than 1 in 8 receive stimulant medication.
• Fewer than half of children receive the services that their parents think they need.

 

• Many with diagnosed ADHD receive no treatment.

 

Treatment: Psychopharmacology (Stimulants)

• Methylphenidate (Ritalin) and longer acting (Concerta and Metadate)

• Dextroamphetamine (Dexedrine)
• Adderall and Adderall XR (combination medication)

 

• Focalin

 

Duration of Time that Ritalin is Effective

• About 3 to 4 hours for cognitive enhancement
• About 1.5 to 2 hours for behavioral control

 

• Long acting types can last through the school day

 

ADHD Response in Children

• 70% of children respond to the first medication.
• 70% of children respond to the second medication.

 

• Always try at least two medications sequentially.

 

Side Effects compared to cognitive and behavioral performance

• Side effects gradually increase with dose and become a problem with cognition and emotions if the beneficial dosage is exceeded.

 

What should improve with stimulants?

• Less overactivity
• Better attention span
• Less impulsivity and more self-control
• More compliance
• Less physical and verbal aggression
• Better social interactions with peers, teachers, and parents

 

• Improved academic productivity and accuracy

 

What may not improve with stimulants and require other therapies?

• Reading skills
• Social skills
• Learning
• Academic achievement

 

• Antisocial behavior or arrest rate

 

Secondary Medications

• Atomoxetine (Strattera)
• Bupropion (Wellbutrin)
• Clonidine (Catapres and Kapvay)
• Guanfacine (Tenex and Intuniv)

 

 

Other Medications – less often used

• Tricyclics antidepressants: nortriptyline, imipramine and others

 

• Pemoline (Cylert) – liver toxicity

 

Summary

• Ritalin and similar medicines are safe and effective when used appropriately as part of a comprehensive treatment plan including multimodal treatment.
• Attention Deficit Hyperactivity Disorder is a diagnosable disorder in medical practice and assessment requires information from parents and teachers.

 

• Proper evaluation includes assessing for other possible problems and associated conditions.

 

House Democratic Policy Committee’s Public Hearing on the Use of Ritalin is certified by the American Board of Psychiatry and Neurology in the specialties of Psychiatry and Child and Adolescent Psychiatry. He is a Fellow in the American Psychiatric Association and in the Academy of Child and Adolescent Psychiatry. He is an Assistant Professor in the Departments of Psychiatry and Pediatrics at the Penn State University College of Medicine. He serves on the Committee on Child and Adolescent Psychiatry of the Pennsylvania Psychiatric Society.

 

Considerable information on treatment can be found at ADHD mainpage.