In recent times, there has been a lot of controversy and discussion in the media regarding the behavioral disorder Attention Deficit Hyperactivity Disorder (ADHD). Especially in the past ten years, considerable attention has been brought to methods of diagnoses and medication. Between a high number of misdiagnosis and drug abuse among teens with such medications as Ritalin and Adderall, it’s understandable that people have begun to question the necessity of medicating a behavioral disorder as subtle (for lack of a better word) as ADHD. Is ADHD just a personality quirk in children and teens? Or is it in fact a serious disorder that must be recognized, and therefore medicated?
Subtle or not, studies have shown that ADHD is a serious disorder that can cause difficulties through adulthood. ADHD is best described as a clinical syndrome manifested by inattention, impulsivity, and hyperactivity [1]. Due to the range of difficulties those with ADHD can have, there have been three types of ADHD labeled to date. When a person has difficulty focusing or staying on task for long or at all, it is referred to as inattentive type. Hyperactive-impulsive type is when the person is especially active for their age and may act or speak without thinking. The last type is combined type, which is quite simply a combination of inattentiveness, hyperactivity, and impulsivity [2].
In order to be labeled as having ADHD, one must exhibit several symptoms for a period of six or more months. It is also important to keep in mind the person’s age and intelligence. Those with inattentive type ADHD must exhibit at least six of the applicable symptoms for at least a half-year. The major symptoms include failing to pay attention to detail or to make careless mistakes, seeming not to listen to what is said to him or her, disorganization, failing to follow instructions, difficulty completing tasks, being easily distracted, always losing necessary things (i.e. writing utensils, books, papers, assignments), avoidance of tasks requiring an exceptional amount of attention, and easily forgetful.
Hyperactivity difficulties can be identified by displaying 3 of 4 major symptoms for six months or more. These 4 major symptoms include excessively running or climbing, being unnecessarily noisy in activities or an inability to remain quiet, excessive fidgeting or squirming, or leaving their seat when expected to stay seated. To be labeled with impulsivity difficulties, one of three symptoms must be shown for at least six months, including blurting out answers before questions are completed, failing to wait in line, constant interruptions, or talking excessively regardless of the social suitability [3].
All of these behaviors and difficulties can be traced back to problems with one’s attention span. This system of diagnoses is to properly identify which type of ADHD one may have and what the best treatment available may be. One must also keep in mind that these symptoms must be shown in more than one setting, which makes it necessary for any parent of a suspected ADHD child to have close communication with faculty and teachers at the child’s school.
Many times children will go undiagnosed because parents are unaware that their children’s ‘eccentricities’ are anything out of the ordinary. They may also develop practices around the home that may mask the actual problem. This is no fault of the parents, and there is decidedly no evidence that ADHD is caused by bad parenting among other things. One major problem is that there is not a truly reliable source of information that parents can turn to if need be. One in three parents reported that they did not know where to get information once their child was diagnosed. A majority of parents did not know how to get treatment for their children, 91% blaming it on confusing media reports and 94% saying there was no reliable source of information available to them [4].
There is a lot of controversy surrounding the issue of medicating ADHD. Most of the medications used are stimulants, and since ADHD is most prevalent in children and teens, there is a concern over affected persons selling the drugs. Those on the medication are at a risk, especially in their teen years. At a stage that is already awkward enough, their disorder can put them in a bad social position, one that they think might be improved by selling drugs. Teens in this situation are by no means a majority, but it is enough that it has captured media attention.
The media attention brought ADHD to the public eye, and what were mild quirks in a child’s behavior suddenly became a symptom of ADHD. This resulted in a high number of misdiagnoses, one that is impossible to cite specifically. Some people may have been put on medication that really did not need it, while others who did are not being given treatment. This sort of attention causes many to dismiss ADHD as something that does not really require attention, but the truth is that it is a serious condition.
Lack of reliable information is truly inexcusable when looking at the disorder. Those who are medicated at an earlier age are less likely to abuse substances later in life [6], possibly due to an increased awareness about the effects of substance abuse, the risk of severe problems from mixing medications with other drugs, and treatment that gave those people a better outlook and feel less of a desire to ‘escape.’
There needs to be a widely known source of reliable information on ADHD. There are too many people who have the disorder and go untreated because of confusion or general lack of knowledge. There are several medications available that have proved to be effective in treating ADHD and parents need to be informed of how to treat their children’s condition.
Some of those that do know about the possibilities for treating ADHD do not treat it, because most medication used to treat ADHD are stimulants. This raises concerns for general health of the child as well as the life-long effects of medicating children with stimulants.
Dr. Russell Barkley and others looked to answer some questions about the life long affects of ADHD in a thirteen year study. The question they focused their attention to was whether or not treatment of ADHD with stimulants would contribute to drug use or abuse later in life. They used 147 clinic-referred hyperactive children for approximately 13 years until young adulthood (anywhere between 19 and 25 years of age). This entailed a series of interviews at a point in adolescent development (approximately age 15) and again in young adulthood. As a control, 81 non-hyperactive children were also selected for this study.
Since stimulant medication has been an effective and commonly used tool in treatment of Attention Deficit Hyperactivity Disorder, it makes sense to look into what sort of lasting effects the medication might have on the people who use it. After all, giving stimulant medication to children at such a young age (typically before the age of 10) will have some sort of impact, be it positive or negative, on their choices pertaining to drugs later in life.
Over the past two decades, stimulant medication has been used more and more in America. Studies have shown that anywhere from 1.3% to 7.3% of school aged children may be taking stimulant medication for behavior control. One city, Norfolk, Virginia, has an estimated 10% of school age children medicated with stimulants. This continuing and even growing trend of stimulant medication has been causing concern all across America that kids are being overmedicated.
Along with that concern, many questions have been raised. A lot of people are beginning to criticize this over prescribing especially the Church of Scientology’s Citizens Commission on Human Rights. Their argument is that by giving children stimulant medication, they are more likely to use or even abuse substances as adolescents and adults.
The concern that stimulant medication will lead to drug use is a valid argument for two reasons. The first reason is that methylphenidate (Ritalin, the most widely used stimulant medication for treating ADHD) is chemically similar to cocaine. As a result, it is possible that it may have the same potential for abuse and addiction. It has been noted that the two drugs do possess very different pharmacokinetic properties, as in Ritalin enters and acts on the brain more slowly than cocaine. This makes the addictive potential in Ritalin greatly reduced.
The second reason that people have begun to question the potential of use and abuse after stimulant medication is desensitization to later stimulant exposure. It has been shown in studies on mammals that repeated stimulant exposure leads to a greater craving and eventual self-administration of the drugs. The argument against this belief is that these studies do not accurately reflect the real world scenario. These results are taken from alternating between high dosages and drug-free periods dealing with a much higher dose of the drugs. The children that use these stimulants for treatment are receiving low doses on a consistent daily basis for long periods of time.
In actuality, there are very few cases where drug use or abuse could be related as a cause of stimulant medicated children. Only one of twelve studies addressing the issue posed the possibility that children with ADHD might have a predisposition to substance use or abuse. While the study did conclude that ADHD was associated with an increased frequency of drug use in adolescence, nothing in their study contended that there was a connection to stimulant medication.
In another study, there not only proved to be no connection between drug use and stimulant medication, but there was even a protective effect. A study conducted by Loney, Kramer, and Salisbury showed that medicated boys were less likely to become involved with tobacco, stimulants, inhalants, or opiates as well as a decreased likelihood to suffer from alcoholism in adulthood.
The case reviewed most worth noting showed that not only was there no evidence of medicated children were more likely to use or abuse drugs, but that those with ADHD who were not treated with medication as children were more likely to use or abuse drugs later in life. Most likely this can be attributed to overall quality of life. Unfortunately, this case did deal specifically with stimulant treatment, but psychopharmacological treatment overall (although a vast majority of the medication treatment involved stimulants). In addition, it only examined the children into adolescence and did not deal with the possibility of drug use later in adulthood.
One problem that plagued many of these studies was determining whether the participants had ADHD or a conduct disorder. Conduct disorder (or CD) is a complicated group of behavioral disorders that goes beyond what is typical of ADHD and is considered destructive. Some behaviors associated with CD include initiating fights, bullying, theft, destruction of property, habitual lying, and habitual truancy from school [5]. Since many people with CD also have ADHD, it is understandable that some results from these studies would be tainted by a group of people with CD in addition to ADHD. However understandable it may be, it does not give a clear answer to whether or not stimulant medication treatment is responsible for drug use/abuse later in life.
Since there has been no clear, specific answer to the question of stimulant treatment and long-term effects, Dr. Barkley attempted to find that answer with this study. The original study group used 158 children diagnosed with hyperactivity and a control group of 81 children. These two groups were evaluated between 1979 and 1980 when they were all aged between 4 and 12 years old. A majority of these original groups were evaluated again from 1987 to 1988, 123 of the original 158 hyperactive children and 66 from the control. For these evaluations, all participants were between the ages of 12 and 20 years old.
The final evaluations took place from 1992 to 1996, at which time all participants were between the ages of 19 and 25. All original participants were able to be located and 93% (147 of 158) of the hyperactive group were evaluated, as well as 90 % (73 of 81) of the control group. All participants had to meet 3 requirements to account for possible variables.
All participants had to have an IQ higher than 80. None of the children could have gross sensory or motor abnormalities. And finally, all must be the biological offspring of their current mother or should have been adopted shortly after birth. The study group was mostly composed of white males, but was not limited to them. The gender composition was 91% male and 9% female. Racially, the group was 94% white, 5% black, and 1% Hispanic.
In order to be eligible for the hyperactive group, the children had to satisfy 6 requirements. These requirements included significantly high scores on both the Hyperactivity Index of the Revised Conners Parent Rating Scale and the Werry-Weiss-Peters Activity Rating Scale. On the Home Situations Questionnaire, they must indicate significant behavioral problems in at least 6 of the 14 problem situations listed.
They must have teacher and/or parent complaints pertaining to poor sustained attention, poor impulse control, and excessive activity level. These behavioral difficulties must be identified before they were 6 years old, and must have exhibited these problems for at least one year. Finally, they must have no indication of autism, psychosis, thought disorder, epilepsy, gross brain damage, or mental retardation. The researchers concluded that meeting these requirements would qualify all the participants as being Attention Deficit Hyperactive. The researchers would also take into consideration whether the participants displayed symptoms of CD.
At the adolescent stage, each participant underwent a day of follow-up evaluations. They took psychological tests and were interviewed about having used various illicit substances while the parents were interviewed about their behaviors, history of mental health, medication, education, social history, and any known drug activity.
At the young adult stage, the follow-up evaluations were far more rigorous, using self-reports of psychiatric disorders, history of mental health treatments, adaptive functioning in life activities, antisocial activities and drug use. Parents were interviewed via telephone about the participant’s current ADHD symptoms. Those conducting the evaluations were not blind to whether the participant was originally in the control or hyperactive group.
As far as medicated treatment is concerned, 98 of the 119 participants in the hyperactive group were treated with stimulants. Three major stimulants were used in their medical histories were methylphenidate (Ritalin), d-amphetamine (Adderall, Dexedrine), and pemoline (Cylert). Some of the individuals were on multiple medications. Of the hyperactive group medicated with stimulants, 80% were on methylphenidate, 3% on d-amphetamine, and 20% on pemoline. Of those on methylphenidate, 2% were also medicated with d-amphetamine, and 22% were medicated with pemoline. All 3% on d-amphetamine were also medicated with pemoline.
At the young adult follow-up evaluations, 32 participants of the hyperactive group (22% of 147) reported treatment with stimulants throughout high school. Of those 32 participants, all had received stimulant medication through childhood. Only 7 of the hyperactive group (5%) were still being treated at the time of the young adult follow-up evaluation.
At the adolescent follow-up evaluation, the interviews with the participants were used over the interviews with parents on the issue of drug use. This is because there was a much higher frequency reported amongst the participants, a difference in perspective that has been seen in other studies of drug use among adolescents with ADD. This can most likely be attributed to symptoms associated with CD (ie lying, a generally secretive personality, etc.)
Alternatively, for the young adult follow-up evaluations, in the matter of what current ADHD behaviors or traits were exhibited by the participant, the parents’ interviews proved more reliable than the participants. This could probably be attributed to lack of self-awareness, which is not a particularly notable or surprising find.
At the adolescent follow-up evaluation, the interviews with the participants revolved around displaying a diversity of antisocial behaviors associated with CD. However, they deliberately avoided asking questions concerning behaviors such as property destruction, cruelty to animals, and cruelty to humans; these are behaviors that are listed as typical of CD in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 3rd Edition (DSM-III-R). A possible reasoning for this is that questions of this nature might alarm the participant and cause them to be dishonest for fear of retribution. The item pertaining to ‘starting fights’ must have happened on at least 5occasions to qualify, and the items involving stealing and running away from home must have occurred at least twice. With this interview, it was determined that 27% of the hyperactive group could be considered to have Conduct Disorder. The average number of CD behaviors in the adolescent group was 1.9.
At the young adult follow-up evaluation, it was realized among the researchers that the perception of the participants concerning themselves may be drastically different from others’ perceptions of the participants. The parents, usually the mother, were interviewed over the phone about the extent to which the participant showed current levels of different traits or behaviors associated with ADHD. The parents of 134 hyperactive participants and 71 control participants were reached and interviewed. From these interviews, the hyperactive group averaged 9.2 symptoms while the control group averaged 1.7 symptoms.
At the adult follow-up evaluation the participants were asked about drug use in their life. Unlike the adolescent follow-up evaluation, they were not concerned with tobacco use. The participants were interviewed about how often they drank alcohol, how many times they had gotten drunk in the past three months, and how many times they had used illicit drugs in the past 3 months.
Some subjects had taken so many drugs they could not estimate how often they did so, and these participants (which was 7% of the hyperactive group) were given a special code in the database. Of all the drugs brought up in the interview, marijuana was used the most by far. In fact, 22% of the hyperactive group used the drug in excess of 1000 times and were also given a special code.
The results of this study showed that at the adolescent stage, the treated and untreated groups did not differ significantly in likelihood of drug use or abuse. After finding these results, the researchers subdivided the hyperactive group based on how long participants were treated with stimulants, but once again found no significant difference.
The data taken from the young adult follow-up evaluation yielded similar results. There was no significant difference between treated and untreated participants except for cocaine use. In the treated group, 26% of the participants had used cocaine compared to the 5% in the untreated group. Reanalyzing these figures taking into consideration the participants who displayed CD, the resulting difference between participants with ADHD who received treatment (excluding participants with CD) and participants with ADHD who did not receive treatment was no longer significant.
TABLE 1. Frequency of Drug Use as a Function of Stimulant Treatment in Childhood [6]
(Table unable to be viewed, if you really want to see it, E-Mail me)
When comparing the likelihood of cocaine use in treated and untreated groups, they used several variables of treatment. First they compared the groups based on duration of treatment, which showed that there was no significant difference. Then they compared the groups using treatment itself as a variable (treated or untreated as opposed to duration of treatment). This yielded the same results.
When comparing the data for those who had received stimulant treatment for less than one year as opposed to those who were treated with stimulants for more than one year, the participants with the shorter duration of treatment were more likely to use cocaine. This suggests a protective effect against drug use or abuse.
Among other drugs, the data showed no variables for which there could be any significant difference in the likelihood of drug use or abuse. The only drugs that did show 2 contributing variables worth noting were hallucinogens. The severity of CD symptoms in participants greatly increased the risk for abuse. The other variable was that if stimulant treatment had been going on for longer than a year, the risk was greatly reduced, once again showing the potential protective effect.
When looking at the young adult follow-up evaluations, they compared the 32 hyperactive participants who received treatment in high school to the 115 hyperactive participants who did not receive treatment in high school. Once again, the only difference worth note was a higher use of cocaine in the treated group. But when comparing the data while taking into consideration the participants with CD, the difference was no longer significant.
In conclusion, the results of the study conducted by Dr. Barkley et al are consistent with the other 11 studies. There is no real correlation between childhood treatment with stimulants and later drug use or abuse in people with ADHD. Those treated with stimulants and do use drugs (especially cocaine) later in life are people who exhibited a notable number of CD symptoms.
Maybe increased awareness of such reports will silence some of the critics of these helpful medications. It would certainly help if the news reports showed children leading more well-adjusted lives instead of teens selling Ritalin in high schools. Even though the latter scenario happens less in the real world, we see it far more on TV. And with parents’ sensitivity to the media today, children with ADHD cannot afford these misconceptions to affect their lives. If these studies have shown anything, it’s that not treating ADHD until later on can be more devastating to the child than not treating it at all.