New drugs among advances in ADHD treatment
June 08, 2004
Fort Worth Star Telegram
ADHD: The Great Misdiagnosis
Dr. Julian Haber
Three years ago, when Dr. Julian Haber published his book ADHD: The Great Misdiagnosis, he noted the long lines of children stretching down the hallways outside many school nurses' offices, waiting to take Ritalin.
Three doses of the short-acting stimulant were needed to carry a child through a full day, and the first dose usually wore off before lunch.
Now, most of the lines are gone -- not because attention-deficit hyperactivity disorder is being diagnosed -- and misdiagnosed -- in fewer children, but because new long-acting, time-released psycho-stimulants have been developed, and Strattera, the first nonstimulant approved for treatment of ADHD, is formulated for once or twice-a-day dosing, as well. It was introduced in 2002.
Since the advent of longer-acting ADHD drugs, the lines have decreased, but the number of children on medication continues to increase, says Haber, a developmental behavioral pediatrician at the Fort Worth Child Study Center.
"The new long-acting drugs are a major advance in treatment because they will take a kid through a school day. They are better because they are smoother. They give you fewer ups and downs," Haber says. "With short-acting drugs, you sometimes would get a kid almost in withdrawal before they got another dose, especially if they forgot and missed one. The longer-acting drugs avoid that sort of thing. You just get better compliance with once-a-day dosing."
The revised edition of his book came out in November and was sold out by March. Now in its second printing, it includes major additions on all the new drugs, how to negotiate the legal matrix and get the appropriate help for your child and educational services for young adults with ADHD. There is a sample letter for requesting special-education services and a list of colleges and universities that offer programs for college students with ADHD.
"As many as 15 percent of our children and adolescents are receiving medical treatment for ADHD," Haber says. "Many of them have ADHD and do much better on medication, but ADHD is massively overdiagnosed."
Learning disabilities, oppositional/defiant personality disorders, depression, sleeping disorders, hearing problems and other conditions are often misdiagnosed as ADHD.
"Children act out in ways that mimic ADHD, and some of them have ADHD along with a co-existing condition that may or may not respond to drug treatment," Haber says. "You can put a child on medication to correct a learning problem, and two or three years later, the child is still not learning. You have to treat learning disorders with special learning methods, not meds. Some schools are too quick to diagnose ADHD so they don't have to offer educational services, just meds."
Anti-depressants, the second group of medications often used to treat ADHD, particularly if it is accompanied by anxiety, mood disturbance or depression, should be used with caution and doses adjusted so that each child is getting the best possible response from the least possible amount, but there is no reason not to use anti-depressants appropriately, Haber says.
After a British study indicated there may be more suicides in children on anti-depressants, the U.S. Food and Drug Administration issued an advisory in March urging physicians, their patients and families and caregivers to use caution and closely monitor children on anti-depressants.
"When the FDA reviewed the medical literature, they found no significant studies that showed higher rates of suicide, but because of significant anecdotal evidence presented at hearings -- and it was significant -- the FDA issued a public health advisory and said it is important for physicians to use appropriate cautions, tell parents what can happen and what to watch out for, and follow the children very, very closely," Haber says.
"This is a high-risk group, so it is inappropriate to put these kids on drugs and not follow their progress. If they are severely depressed, they may not have the energy to hurt themselves, then you get them on drugs and they feel a little better, but they are still at risk and they have more energy and more ability to act on suicidal tendencies," he says.
Any real increase in risk of suicide, as well as the risk of drug or alcohol abuse or anti-social behavior, is more likely to be a function of untreated ADHD and associated conduct disorders than a side effect of one of the medications used to treat them, Haber says.
Self-esteem, coping skills, ability to concentrate and emotional stability are all enhanced with appropriate medical treatment -- but first you've got to get the diagnosis right, Haber says.
For more information, visit the American Academy of Pediatrics Web site at www.aap.org, Children and Adults with Attention Deficit Hyperactivity Disorder at www.chadd.org, or the Attention Deficit Disorder Association at www.add.org.