ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
Attention-Deficit Hyperactivity Disorder (ADHD) is a behavioural disorder that affects millions of children worldwide, sometimes even progressing into adulthood. It is sometimes hard to differentiate between normal and abnormal child behaviour as the symptoms vary for different children. The only similarity between affected children is that they are excessive, pervasive and persistent [1]. These behaviours are portrayed everywhere they go, be it at home, in school, or in the public. Besides, none of the children with this disorder are able to focus or pay attention to any task that does not reward them immediately and are easily distracted. They also have poor social cognition and do not adapt well in the society as their impulsiveness lead to difficulties in following rules and instructions.
The main cause of this behavioural disorder is yet to be confirmed but they are a number of competing theories about it. First of the theories are that ADHD may have a genetic basis. Russell Barkley, PhD has done extensive research on ADHD reported that 40 % of children with ADHD have a parent with ADHD [3]. According to the researchers, there is strong evidence for associating ADHD with the D4 dopamine receptor gene (DRD4) whereas the evidence for dopamine transporter gene (DAT1) is only suggestive. The symptoms may also arise from a combination of various genes, many of which affect dopamine transporters. Next, ADHD may be due to neurotransmitters imbalance in the brain. Three neurotransmitters that have received the most attention to be the cause include serotonin, dopamine and norepinephrine. Moreover, it is also said that environmental and diet factors also can be related to this disorder.
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A POSSIBLE SOLUTION:
The most common treatment of ADHD is with medication; stimulant, non-stimulant or antidepressants.
Stimulant Medication
This is one of the most widely used and effective treatment methods available for ADHD. Stimulants elevate the arousal level of the central nervous system, by affecting the amount or efficiency of neurotransmitters such as dopamine and norepinephrine that are available for cellular communication in the brain. These neurotransmitters are spread throughout the brain and play a critical role in a variety of functions, including arousal, attention, concentration, motor planning and motor control, to name a few.[2] Generally, stimulants effectively decrease inattention, distractibility, over activity and impulsivity in three quarters of individuals with ADHD. The table below shows a few of the frequently prescribed stimulants for ADHD patients.
Generic Name
Trade Name
Methylphenidate
Ritalin
SR methylphenidate
SR Ritalin
Dextroamphetamine
Dexedrine
Pemoline
Cylert
Adderall
Adderall
Table 1 Types of Stimulant Medications
Source: Attention Deficit/Hyperactivity Disorder, 2001, Greenhaven Press, Wiliam Dudley
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http://upload.wikimedia.org/wikipedia/en/thumb/5/5f/Ritalin.jpg/220px-Ritalin.jpg
http://bits.wikimedia.org/skins-1.5/common/images/magnify-clip.png
Figure 1 Ritalin (methylphenidate)
Source: http://en.wikipedia.org/wiki/Methylphenidate
Downloaded on 23 July 2010
The most popular and most researched stimulant is Methylphenidate or widely known as Ritalin. Ritalin functions as to increase the brain's ability to inhibit itself as the levels of dopamine and norepinephrine are boosted. The dosage of Ritalin is different for each patient and can vary quite significantly with some children responding to quite low doses while others require higher dosage. The dose, thus, should be titrated to an optimal level for each individual so that therapeutic benefit and minimal side-effects can be attained. This can range from anywhere between 5 mg twice daily to 60 mg four times a day. [4]
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Table 2 Number of symptoms before and after treatment for 10 patients.
Source:http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2004000300005
Downloaded on 19 September 2010
The table above shows a study carried out on 10 children with different degree of ADHD symptoms. Each of them was given a fix dosage of Ritalin daily for 113.7 days. The result from this study is in agreement with the effectiveness of stimulant drugs in decreasing aggression and increasing attention span. The findings depict that 90% of the patients had a decline in their ADHD symptoms.
Non-stimulant Medication
Although stimulants may be effective in curing the majority of ADHD patients, some individuals do not respond to it or experienced unendurable side effects. For individuals like this, the prescription of non-stimulant medication is given. [5] For now, the non-stimulant drugs available on the market are Atomoxetine and Guanfacine. [6]
Figure 2 Example of Atomoxetine pills
Source: http://en.wikipedia.org/wiki/Strattera
Downloaded 23 July 2010 (687)
Atomoxetine, or its brand name Strattera is the first non-stimulant medication approved for treating ADHD and has the ability to elevate the amount of norepinephrine, which is similar to the functions of stimulants. That is why this drug is categorised in the class of medication known as the selective norepinephrine reuptake inhibitors. It aids by increasing attention span and reducing hyperactivity. Similarly, the dosage of this medication depends on each individual, either once or twice daily. [7]
Figure 3 Example of Guanfacine tablets
Source: http://en.wikipedia.org/wiki/Guanfacine
Downloaded on 23 July 2010
Guanfacine or rather known as Tenex (and the extended version Intuniv )[8] was originally developed to be a type of antihypertensive but later discovered to be favourable for treating ADHD. It regulates the level of norepinephrine and decreases the sensitivity of the prefrontal cortex to distracting stimuli and thus reducing inattention.[9]
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Antidepressants
Antidepressants are effective in treating ADHD patients with mood disturbance such as depression or anxiety. On the whole, antidepressants largely affect levels of neurotransmitters serotonin and norepinephrine. Antidepressants are usually given twice daily, usually in the morning and in the evening. The table below shows the types of antidepressants available. [11]
Generic Name
Trade Name
Trycylics
Imipramine
Tofranil
Desipramine
Norpramin
Nortriptyline
Pamelor
Other
Bupropion
Wellbutrin
Table 3 Types of antidepressants for treating ADHD
Source: Attention Deficit/Hyperactivity Disorder, 2005, Greenhaven Press, Wiliam Dudley
Trycyclics antidepressants are the most frequently used antidepressants for curing ADHD. Tricyclic antidepressants seem to amplify the amount of norepinephrine (similar to stimulants) in the brain. However, it may take several days or even several weeks to see the benefits of the medication, but once it is achieved, benefits can endure throughout the day. This drug should be taken daily as the effect is only short term. [10]
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SOCIAL, ETHICAL & ECONOMIC IMPLICATION:
One social issue that I came across when conducting this research is that very few people with ADHD are receiving the proper medication. This is happening as there is still a doubt among the scientific community on the existence of ADHD. It is said that ADHD encountered the most scientific scrutiny if compared to any other psychiatric disorder. [12]
"They made a list of the most common symptoms of emotional discomfiture of children; those which bother teachers and parents most, and in a stroke that could not be more devoid of science or Hippocratic motive--termed them a 'disease.' Twenty five years of research, not deserving of the term 'research', has failed to validate ADD/ADHD as a disease. Tragically--the "epidemic" having grown from 500 thousand in 1985 to between 5 and 7 million today--this remains the state of the 'science' of ADHD."
(Attention Deficit Hyperactivity Disorder (ADHD)--Compiled by Dr. Fred Baughman) http://www.adhdfraud.org, downloaded 15 September 2010.
One of the opinions against ADHD was that it is a mere creation by the psychiatric and pharmaceutical world aiming for profit from the dangerous and addictive drugs prescribed to the patients. Thomas Szasz, a great supporter of this theory, has gone so far as to state that ADHD was "invented and not discovered."[13] This, I believe, is the reason why a lot of people with ADHD are ignorant of their condition and not receiving the correct treatment and medication.
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Figure 4 A pie chart showing the number of ADHD patients receiving treatment.
Source: http://www.medscape.com/viewarticle/500028_3
Downloaded on 19 September 2010
This pie chart illustrates the number of adult and children that are actually treated for ADHD. It shows that more than half of the people with ADHD are not getting the treatment they are supposed to have.
"Analyzing medical information about more than 3,000 8- to 15-year-olds, researchers found that of those who met the accepted criteria for ADHD, less than half had actually been formally diagnosed and only 32% were regularly given medications to treat the condition in the past year. In other words, many of the estimated 2.4 million kids with ADHD who need help aren't getting it."
( Most Kids With ADHD Aren't Getting the Treatment They Need-http://www.education.com/reference/article/Ref_Most_Kids_ADHD_Arent/)
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Another implication related to this topic is an ethical one. The prescription of stimulants, such as Ritalin for children with ADHD has always been a controversial issue. This is because the effects of stimulant medications almost mirror that of cocaine and amphetamines.
"Cocaine, which is one of the most reinforcing and addicting of the abused drugs, has pharmacological actions that are very similar to those of methylphenidate (Ritalin, Concerta), which is now the most commonly prescribed psychotropic medicine for children in the U.S."
(A research report in the Archives of General Psychiatry, http://www.adhdhelp.org/stimulants.htm)
It is considered unethical by some as it has a potential to be abused as the children enter into adulthood. Addiction may occur as stimulants used to treat ADHD will produce the same kind of euphoria if taken in large doses.
BENEFIT & RISK:
Stimulants
Most people using stimulants to treat ADHD experienced a lot of improvements in their attention span. Besides, activity level and impulsivity tend to decline to within a normal limit. Related difficulties such as unruly behaviour and communication problems show a tremendous improvement in the patients taking this medication. For school children, they seemed to portray improvements academically too. [14]
On the other hand, there might be some risk when this medication is taken in the long term. There is always a potential for stimulants to cause addiction in the patient. As the effect stimulants only lasts for a short period of time, the patient will experience mood swings and insomnia after it wears off. In addition, different type of stimulants might cause different side effects on certain individuals. Here are some of the common side effects of stimulants:
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Emotional oversensitivity, crying easily
Headaches
Irritability
Loss of appetite (anorexia)
Poor appetite and weight loss [15]
Non-stimulant
The utmost benefit of using non-stimulant is that it cannot be abused as drugs. Thus, the prescription to refill this medication is easier as it is not a controlled substance. It benefits the patient in almost the same way as stimulants but to a lesser degree.
The negative effect of this medication is less dangerous if compared to that of stimulants. The common side effects are waning appetite, constipation, drowsiness, dizziness, moderate stomach upset, sleeplessness, vomiting, weariness, headache, and coughing. These effects are normally not considered cause for panic as they tend to decline as the body gets used to the medicine.
Antidepressant
Antidepressants too, have similar effects on the main symptoms of ADHD as stimulants and non-stimulants: attentiveness, impulsivity, and hyperactivity. One of the benefits of using antidepressants is that although it is less potent than stimulants, this medication can lasts over a longer period of time.
The largest danger of taking antidepressants is the increased risk of seizure. The rest of the side effects include weight loss, insomnia, dizziness, constipation, dry mouth, and stomach upset.
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ALTERNATIVE SOLUTIONS:
ADHD Behavioural Modification
One of the nonconventional methods used nowadays to treat ADHD in children is ADHD Behaviour Modification. It works by rewarding desired behaviour while removing privileges or adding punishment for bad behaviour. [16] Scores or points can also be given to the child based on their behaviour throughout the week. Parents will record all the behaviours in the week and review it together with the child at the end of every week, thus determining whether they should be punished or rewarded. In addition to that, children should also be praised immediately after an exemplary action as well as reprimanded after a negative behaviour. [17]
Dietary and Nutritional Treatment
One of the most popular dietary treatments that ADHD patients go on is the Feingold Diet. It basically supported that ADHD is caused and aggravated by intolerance to food addictives and salicylates (even natural salicylates). Dr. Feingold, the initiator of this diet, suggested that up to 50% of 1200 cases, hyperactive children are sensitive to these chemicals. (18)The diet mainly insists that patients should avoid all food containing synthetic colourings, flavourings, preservatives and artificial sweeteners. This method is highly opt by the patients as the number of studies conducted since 1980 found out that more around 70% of the patients responded positively to it. [19]
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The Feingold Diet
Avoid all foods that contain artificial colors and flavors.
Avoid all foods containing natural salicylates:
Almonds
Currants
Plums
Prunes
Apples
Raspberries
Grapes
Strawberries
Blackberries
Mint flavors
Tea
Cherries
Tomatoes
Cloves
Oranges
Cucumbers
Peaches
Wine
Figure 5 List of food to avoid in the Feingold Diet
Source: http://www.healing-arts.org/children/ADHD/nutritional.htm#
Downloaded on 17 September 2010
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EVALUATION OF REFERENCES:
The purpose of the website http://www.adhdnews.com/adhd-medication.htm is to provide information for family members to help ADHD patients. It has been around for more than a decade and therefore should be considered as reliable and helpful. The information on this website is written by experts as well as ADHD patients themselves and is well supported by other valid sources.
The article on stimulant medication for ADHD (http://en.wikipedia.org/wiki/Methylphenidate) is under the Wikipedia website and it is one of the most used website in the world. The information provided in this website is from a variety of reliable sources and is considered to be up to date as it is constantly updated by various individuals. On the other hand, the drawback of this website is that it is open to the public to contribute any information on any article. This makes some of the details less accurate and not reliable. Nevertheless, the information I had taken from here is accounted by other sources as well.
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