Ritalin & ADHD Basics

I. Attention Deficit Hyperactivity Disorder (ADHD)

What is ADHD?

Attention Deficit Hyperactivity Disorder is a behavioral disorder marked by severe inattentiveness, impulsivity, and hyperactivity, which usually emerge in early childhood.  A great deal of controversy surrounds the disorder because there is no known biological marker for it and critics say the diagnostic criteria are very subjective.  While such symptoms have historically been observed and treated in children for many decades, the condition was only added to the Diagnostic and Statistic Manual of Mental Disorders in 1980.

How many children have ADHD?

It is estimated that between four and ten percent of all school age children currently suffer from Attention Deficit-Hyperactivity Disorder, commonly referred to as hyperactivity. (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 50 (3d ed. rev. 1987))

II. Psycho-stimulant Medications

What are psycho-stimulants?

Psycho-stimulants are a class of drugs that stimulate the central nervous system.  They include drugs such as: Adderall®, Adipex-P®, amphetamine, amphetamine / dextroamphetamine, Banobese, Benzadrine, benzphetamine, Biphetamine®, chlorphentermine, cocaine, Cylert, Delcobese, Desoxyn®, Dexedrine, dexmethylphenidate, dextroamphetamine, DextroStat, Didrex, diethylpropion, Fastin®, fenfluramine, Focalin™, Ionamin, mazindol, Mediatric, methamphetamine, Methylin™, methylphenidate, Obenix, Oby-Cap, Oby-Trim, paramethoxyamphetamine, pemoline, phendimetrazine, phenmetrazine, phentermine, PMA, Pondimin®,  Ritalin®, Tenuate, Tepanil, Zantryl.

What psycho-stimulants are used to treat ADHD?

Methylphenidate (sold under the brand name Ritalin®, among others) and amphetamine (sold under the brand name Adderall, among others) are two of the primary central nervous system stimulants used to treat Attention Deficit Hyperactivity Disorder. 

How are these drugs taken?

Ritalin, a brand of methylphenidate approved for use in patients aged six years and older, is taken orally. Tablets are available in 5, 10, and 20 mgs. A 20 mg extended-release tablet (Ritalin-SR), is also available.  In addition, methylphenidate is also the active ingredient of the new medication Concerta. Concerta uses osmotic pressure to provide even release of the medication over a 12-hour period.

III. ADHD Diagnosis

How is ADHD diagnosed?

Current physician guidelines recommend that diagnosis should begin with thorough input from a child’s parents. The goal is to establish, in detail, under what circumstances the presenting symptoms occur and to take a complete developmental, medical, and family history. Following these interviews, the clinician should ideally interview the child in order to elicit his or her input.

A thorough medical examination is then used to rule out neurological or sensory problems (poor hearing or eyesight, for example) as the cause of symptoms.  Intelligence and achievement tests are then given, and the clinician will also evaluate questionnaires filled out by both parents and teachers. These questionnaires ask the respondent to indicate the degree to which the child displays the patterns of behavior that are considered markers for ADHD. Further tests may be required to rule out possible problems that emerge during this lengthy examination.  (See, Dennis P. Cantwell, M.D., in a recent review of the last decade of research on ADHD for the August 1996 issue of the Journal of the American Academy of Child and Adolescent Psychiatry)

What are the Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder?

According to the American Psychiatric Association (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington , D.C.: American Psychiatric Association, 2000, pp. 92-93), a diagnosis of ADHD is appropriate if a patient exhibits the following diagnostic symptoms:

(A) Either (1) or (2):

(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level;

Inattention

• often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• often has difficulty sustaining attention in tasks or play activities
• often does not seem to listen when spoken to directly
• often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• often has difficulty organizing tasks and activities
• often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
• often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
• is often easily distracted by extraneous stimuli
• is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

• often fidgets with hands or feet or squirms in seat
• often leaves seat in classroom or in other situations in which remaining seated is expected
• often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
• often has difficulty playing or engaging in leisure activities quietly
• is often "on the go" or often acts as if "driven by a motor"
• often talks excessively

Impulsivity

• often blurts out answers before questions have been completed
• often has difficulty awaiting turn
• often interrupts or intrudes on others (e.g., butts into conversations or games)

(B) Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

(C) Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

(D) There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

(E) The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder).

Why is the rate of ADHD diagnosis in the United States controversial?

Doctors do not always follow the recommended guidelines for diagnosing the disorder.  In a recent survey of pediatricians, published in the Archives of Pediatric and Adolescent Medicine, nearly 50 percent of doctors confess to spending an hour or less with a child before making a diagnosis and prescribing medication (usually Methylphenidate)

Current diagnostic criteria may be over-inclusive.  Dr. Mark Wolraich and his colleagues at the Vanderbilt University Child Development Center applied the criteria for ADHD from both DSM-III-R and DSM-IV to the same sample of 8,258 children and found that 7.3 percent of them have ADHD according to DSM-III-R, while more than half again as many, 11.4 percent, qualify using DSM-IV criteria.

IV            Treating ADHD

What causes ADHD?

Advocates of ADHD as a diagnosis and of stimulant drugs as a treatment for ADHD, have claimed that ADHD is associated with changes in the brain.  However, both the NIH Consensus Development Conference (1998) and the American Academy of Pediatrics (2000) report on ADHD state that no biological marker for ADHD has been found.

Proposed by James McCracken, professor of psychiatry at UCLA, and Steven Plisz and James Maas, professors of psychiatry at the University of Texas Health Science Center in San Antonio, the catecholamine hypothesis, posits that persons with ADHD have a catecholamine, or neurotransmitter, imbalance in the part of the brain that controls attention.  They believe that stimulant drugs such as Ritalin increase the amount of time that certain catecholamine molecules remain active in certain synapses.  (March 1996 issue of the Journal of the American Academy of Child and Adolescent Psychiatry.)

How does methylphenidate work?

Doctors are still uncertain exactly how methylphenidate works in the body. Recent research indicates that it affects the balance of Serotonin working with Dopamine in the brain. (Nora Volkow, et al., Therapeutic Doses of Oral Methylphenidate Significantly Increase Extra-cellular Dopamine in the Human Brain, The Journal of Neuroscience, 2001, 21:RC121:1-5.)

What side effects are associated with methylphenidate?

The most common side effects are loss of appetite and difficulty with sleeping.

Is psycho-stimulant therapy effective?

70% of ADHD-diagnosed children respond to psycho-stimulant drugs, most of them to methylphenidate.  Another 15% show improvement when given anti-depressant drugs known to affect catecholamine neurotransmitters. Some children do not respond to any of these drug therapies.  (Ken Livinston, “Ritalin: Miracle Drug or Cop-Out?” The Public Interest, No. 127 (Spring 1997), pp. 3-18 ©1997 by National Affairs Inc.)

Do I have to put my ADHD-diagnosed child on psycho-stimulants?

No. As a parent or legal guardian, you have the right to make medical decisions for your child, and your doctor, school personnel, and others must respect your decision.

How can I decide if psycho-stimulants are right for my child?

The first step is to get an accurate diagnosis by a health care professional. Discuss your questions about the disorder and all possible treatments with this professional and come to a decision that is in the best health interest of your child.

V. Drug Use Rates

The United States uses approximately 90% of the world's methylphenidate. (Peter R. Breggin M.D. Testimony September 29, 2000 Before the Subcommittee on Oversight and Investigations Committee on Education and the Workforce U.S. House of Representatives)

A recent report in the Journal of the American Medical Association by Zito et al. has demonstrated a three-fold increase in the prescription of stimulants to 2-4 year old toddlers.  (Zito, J.M., Safer, D .J., dosReis, S., Gardner, J.F., Boles, J., and Lynch, F. (2000).  Trends in the prescribing of psychotropic medications to preschoolers.  Journal of the American Medical Association , 283, 1025-1030.)

In 1999, 9.9 million methylphenidate prescriptions were written in the United States.  (Do It Now Foundation, Ritalin: Fast Facts, # 526, April, 2000.  On the web at http://www.doitnow.org/pages/526.html) 

8.5 tons of Methylphenidate are produced each year globally. (United Nations, INCB Report, 1999).