Taking stimulant medications to treat symptoms of attention deficit and hyperactivity disorder (ADHD) modestly drives up a child's risk of suffering a sudden fatal heart attack, a new study shows. The Food and Drug Administration helped sponsor the latest effort to clarify the risks of ADHD medication. But the agency cautioned Monday that the study's findings were too weak to justify a change in its safety recommendations for physicians prescribing stimulant drugs to young patients.
"It's not a robust finding," said Dr. Robert Temple, director of the FDA's Office of Drug Evaluation. In a group of 564 children who died of sudden cardiac failure between 1985 and 1996, researchers found that 10 were thought to be taking stimulant medications at the time of their death. Among a matched group of youngsters who were killed in car accidents in the same period, only two were thought to be under treatment with stimulant medications.
Researchers assumed that for the children in car crashes, stimulant use was unlikely to be a contributing factor to death. So when they found a higher rate of stimulant use among children who died of sudden cardiac arrest, the difference suggested that the medications were a factor contributing to death by heart attack. They considered the difference "significant" -- meaning it was highly unlikely to have been a chance event. The study came out Monday online in the American Journal of Psychiatry.
The FDA already has urged physicians to consider a child's personal and family history of cardiovascular disease before prescribing stimulant medications for ADHD and to lean against prescribing stimulants for children with underlying heart disease. But such a condition is difficult to detect in most children. As a result, the American Heart Assn. has proposed that all kids being prescribed ADHD medications should first be screened for heart disease with echo- or electro-cardiogram. The FDA recommends such screening only in cases where a physician suspects heart disease may be present.
ADHD researcher Dr. Benedetto Vitiello of the National Institute of Mental Health acknowledged the study is unlikely to settle the debate over routine heart-disease screening for kids treated with stimulant medications. Instead, physicians and ADHD patients and their parents will probably have to wait for the results of two more studies due to be released next fall and winter. Those studies will look at rates of heart attack and stroke -- whether fatal or not -- in children and adults who take stimulant medication for ADHD and compare them to cardiovascular events in populations not on ADHD medication.
She writes: "In recent years Adderall and Ritalin, another stimulant, have been adopted as cognitive enhancers: drugs that high-functioning, overcommitted people take to become higher-functioning and more overcommitted."
She tells her story in some part through a recent Harvard graduate named Alex. He makes a compelling case for what can be accomplished with a little help.
Photo: Ritalin -- the little helper for people with attention deficit hyperactivity disorder and overworked, over-stressed students -- is going mainstream.
Doctors have known that some children and adolescents taking stimulant medications for attention deficit hyperactivity disorder experience psychiatric symptoms from the drugs, such as hallucinations, hearing voices, paranoia and mania. In 2007, the Food and Drug Administration ordered manufacturers of stimulant medications to add new warnings about psychiatric and cardiovascular side effects to package inserts. And patient medication guides are also required to explain the risks of ADHD drug treatments. At the time of the FDA order, experts estimated the risk of an adverse psychiatric event from medication use at about 1 in 1,000 children.
A report published today in the journal Pediatrics, however, estimates the incidence of psychotic symptoms at 1.48 per 100 person-years. (Person-years is defined as total years of treatment with a drug. For example, 100 people taking a drug one year is 100 person-years.) The statistic was based on data from 49 randomized, controlled trials of ADHD medications. In those same studies, no psychotic symptoms were reported in children who did not receive medication. Moreover, an analysis of spontaneous adverse-event reports to the FDA showed more than 800 reports of psychosis or mania. Psychotic symptoms were found with every ADHD drug tested.
Just under 8% of U.S. children, ages 4 to 17, have been diagnosed with ADHD, according to a survey conducted in 2003 by the Centers for Disease Control and Prevention. More than half of these children were taking a medication for the disorder. However, the research reported today shows that psychotic symptoms occurred even in children who were not considered at high risk for psychosis or mania, such as children who abuse drugs or have other mental illnesses. In more than 90% of the cases, the children had never experienced hallucinations or psychosis. In most cases, the hallucinations were visual and tactile and involved seeing or feeling bugs, worms or snakes. The symptoms typically disappeared after the children stopped taking ADHD medication.
It's not clear just why some children experience psychotic reactions to the drugs or what causes the symptoms. However, doctors should explain to parents that any psychosis or mania that occurs during treatment could be from the drug itself, said the authors of the report. And, they add, their paper is fresh evidence regarding the limitations of short-term clinical trials. The clinical trials of stimulant drugs showed a much lower rate of psychotic symptoms, but it wasn't until the medications were widely prescribed in a broad range of people that psychotic adverse events became prominent.
As many as 2 million American children have attention deficit hyperactivity disorder, a condition that makes it hard for children to control their behavior or pay attention. That means that in a class of 25 or 30 kids, it's likely one of them will have the often disruptive condition. And parents know that getting a simple homework assignment done can take hours longer than it should.
Treatment can include behavioral management, medications such as Adderal or Ritalin, or some combination of both. But a new study in the Journal of Attention Disorders shows that parents might try a simple romp through nature as a way of gaining some peaceful, attentive time with their ADHD kids.
Researchers from the University of Illinois took children with the condition on 20-minute walks. On various days, they walked through urban downtowns, through residential neighborhoods, and through a grassy, tree-filled park. Each child took all three walks, and then was tested only against himself or herself on a standard neurocognitive test that measures attention. In the test, for which studying and preparation is useless, a series of numbers is given, and the child has to recite the series backwards.
The walk in the green space proved best for improving attention.
"What this particular study tells us is that the physical environment matters," said Frances Kuo, an author of the study. "We don't know what it is about the park, exactly –- the greenness or lack of buildings –- that seems to improve attention, but the study tells us that even though everything else was the same –- who the child was with, the levels of noise, the length of time, the time of day, whether the child was on medication -– if we kept everything else the same, we just changed the environment, we still saw a measurable difference in children's symptoms. And that's completely new. No one has done a study looking at a child in different environments, in a controlled comparison where everything else is the same."
The kids who were on medications skipped their doses of drugs on the days of the walks, and researchers found that a dose of nature was, at least for a while, as effective as a dose of medication.
It makes sense, in that sort of "well, it can't hurt" way. Parks are generally more peaceful and soothing in themselves than bustling downtowns or distracting residential areas. And it's easy enough to give it a try, what with a romp through nature being good for kids under any circumstances.
"I could imagine parents hearing about this research and immediately applying it -– just trying it out –- taking their child to the park either when their child's symptoms are exacerbated or as a regular routine. It's not that hard to incorporate, especially if they have a green backyard or if they can get to a neighborhood park," said Andrea Faber Taylor, lead author of the study. "Again, we can't say for sure that it would work for any given child –- but there's probably very little risk involved in encouraging your child to play outdoors and seeing if their symptoms improve."
Come to think of it, it might work for children and adults who don't have ADHD. Those of us who just have standard mental fatigue and a now-and-then inability to stay focused might benefit from a regular dose of calming nature. What could it hurt?
-- Susan Brink
Photo: A child plays on straw bales in Germany. Credit: Michael Probst / AP
On college campuses and in high school corridors, there's a lively market for Ritalin and other stimulant medication prescribed to those diagnosed with Attention Deficit and Hyperactivity Disorder, or ADHD. And studies have long shown that kids with ADHD are much more likely than kids without attention problems to experiment with drugs recreationally.
So, is it the stimulant medication or is it ADHD -- a disorder frequently accompanied by problems of impulse-control -- that makes a kid more likely to abuse illicit substances? Do attention problems make these kids more likely to engage in risk-taking behavior such as substance abuse? Or does the fact that they are likely to take a widely abused prescription drug make these kids more open to abusing other drugs?
It's a question that's long worried parents and sparked furious debate among those who research and treat ADHD, which is believed to affect 8% of all American school kids, as well as among skeptics of psychopharmacology: Does medicating a kid for ADHD make it more or less likely that he or she will abuse illegal substances? As the first generation of kids to be diagnosed and medicated in large numbers grows into adulthood, answers are becoming clearer.
A study published in the Archives of Pediatric and Adolescent Medicine takes the latest crack at the controversy, and finds that for girls with ADHD, being medicated for the condition makes substance abuse less likely. The study builds on recent findings -- by the same group of researchers at Massachusetts General Hospital -- suggesting that medicating boys who have the condition will help, at least, to delay their decision to try illegal substances.
The study followed 114 girls between the ages of 6 and 18 -- 94 of them medicated for ADHD and 20 of them not -- for five years. Those medicated for the condition were about half as likely to smoke cigarettes, drink alcohol or take illicit drugs as those who had the condition but were not medicated, found MGH psychopharmacologist Dr. Timothy Wilens and colleagues. Wilens says it's unclear that the protective effect of ADHD medications would follow the girls into adulthood, when the majority of kids diagnosed early tend to abandon the medications. But as long as girls with ADHD were "successfully treated," they were less likely to try cigarettes, alcohol or drugs.
A study released this week on the work habits of people with attention deficit hyperactivity disorder stirred up considerable angst among people with ADHD and those who treat them, according to a sampling of mental health blogs. The study, published online in Occupational and Environmental Medicine, found that workers with ADHD do 22 days less work per year than people who do not have the disorder. The research, which surveyed more than 7,000 employed people ages 18 to 44, was conducted by a World Health Organization research consortium based at Harvard Medical School.
The paper found that 3.5% of workers have ADHD but noted that many adults with the condition don't know they have it. The lead author of the paper said that employers might want to implement targeted workplace screening to assess ADHD and offer treatment to some employees. That suggestion raises all kinds of uncomfortable issues, such as the potential for discrimination against workers with ADHD and the specter of some kind of forced treatment in order to keep one's job - not to mention health privacy issues.
Besides, says the psych blogger, Furious Seasons, who among us doesn't have good work days and bad? He writes:
"Isn't America already the most (or second most) productive country in the world? Don't Americans already work more hours per week than just about any people on Earth? We're already working our butts off, the price of everything is going up dramatically, our wages are largely stagnant. Why do we need to perform even more? Who is this kind of policy wonk talk really serving? Workers? Eli Lilly? Harvard? Boeing?"
Tami Dennis, who takes the word "skeptic" to previously uncharted territory, is the Times' Health and Science editor. She's adamant that pitches promoting awareness days, weeks or months are, by their nature, non-stories. And, because she's an adult, she refuses to use words like "veggies," "tummy" and "yummy."
Rosie Mestel, deputy Health and Science editor, studied genetics before abandoning flies, fungi and DNA for health/medical writing. Her hero is the biologist Ernst Haeckel, whose jellyfish paintings inspired snazzy chandeliers. Her favorite toast-spread is Marmite, a British delicacy made of yeast extract. Her least-favorite word is "millenniums."
Melissa Healy is a staff writer for the Health section reporting from Washington D.C. Healy's a veteran of The Times' National staff, having covered the Pentagon, Congress, poverty and social welfare, the environment, and the White House before shifting to Health in 2003. She writes frequently about mental health and human behavior, about federal health policy, prescription medication and ethics in medicine. More wonk than wellness freak, Healy chooses to believe in the health benefits of coffee and wine, and considers water a better work-out medium than beverage.
Karen Kaplan covers genetics, stem cells and cloning. She and colleague Thomas H. Maugh II comprise about 25% of the unofficial MIT-Alumni-in-Journalism Club, and she is proud to have taken more math (5) than English (0) courses in college. Her contributions to Booster Shots will, she hopes, appear more frequently than postings to her mommy blog.
Thomas H. Maugh II has been a science and medical writer at the Times for 23 years. Before that, he was on the staff of the journal Science for 13 years.
He has bachelor's degrees in English and chemistry from MIT and a doctorate in chemistry from UC Santa Barbara.
After a brief stint as a sports writer, Shari Roan turned to health journalism and has covered the topic for The Times for 18 years. She is the author of three books and the mother of two daughters, both teenagers who refer to her as a "health freak." She likes to jog, watch baseball and is very happy that dark chocolate contains some health benefit.
Jeannine Stein writes about fitness, sports medicine and obesity for the Health section. She’s a gym rat from way back and never met an elliptical trainer she didn’t like. Well, maybe one or two. She tempers exercise with a steady diet of reality television because she believes it’s all about balance.
Doctors have known that some children and adolescents taking stimulant medications for attention deficit hyperactivity disorder experience psychiatric symptoms from the drugs, such as hallucinations, hearing voices, paranoia and mania. In 2007, the Food and Drug Administration ordered manufacturers of stimulant medications to add new warnings about psychiatric and cardiovascular side effects to package inserts. And patient medication guides are also required to explain the risks of ADHD drug treatments. At the time of the FDA order, experts estimated the risk of an adverse psychiatric event from medication use at about 1 in 1,000 children.
it's likely one of them will have the often disruptive condition. And parents know that getting a simple homework assignment done can take hours longer than it should.