In the past 1 1/2 years, there has been a lot of news about the safety of medications for ADHD/ADD. While this has led to many people being very concerned about using medication for ADHD, I hope that it is also reassuring - i.e. the fact that active ongoing monitoring of medication is going on should reassure people taking the medication.

The FDA, Health Canada, and other monitoring agencies in different countries have kept active watch on medications for ADHD.

Last week, the FDA announced new concerns and warnings for ADHD medications - including Dexedrine and Ritalin. I am preparing a summary of this issue - and it will be posted shortly.

With this post, I wanted to provide some background about the issues, taken from two previous reports I have done:

1) Adderall XR: its removal and reinstatement in Canada
2) The FDA concerns and suggestion of a black box warning in February 2006.

Adderall XR - The Canadian Story:

On February 9, 2005, Health Canada (the Canadian version of the FDA), suspended Adderall XR from the Canadian market due to safety concerns. There were concerns that Adderall may have been associated with an increased risk of sudden/cardiac death, and stroke in children and adults taking the medication. View the original statement by Health Canada here.

The FDA in the United States reviewed the Health Canada concerns about Adderall, and decided that there was not a need to change the labeling or availability of Adderall XR based on their review of the data. View their original statement here.

Health Canada established a ‘New Drug Committee’ (NDC) to review the data on safety and adverse events on Adderall XR. The committee included three members - a specialist in childhood behavioral disorders (doctor who is an expert in ADHD), a pediatric cardiologist (heart specialist for kids), and a pharmaco-epidemiologist (expert in research on medicines).

The New Drug Committee reviewed Adderall XR, the safety concerns, and found that there was no increased risk for Adderall compared to other ADHD Medications. So, Adderall was reinstated in Canada on August 26, 2005. The NDC did include the following quote at the end of their report:

That ALL stimulant drugs prescribed in the management of ADHD should be used with caution in patients who:
(a) are involved in strenuous exercise or activities
(b) use other stimulants or,
(c) have a family history of sudden/cardiac death.

You can see the full report of the New Drug Committee here.

Many patients were affected by Adderall XR being taken off the market in Canada. If you or someone you love were affected when Adderall XR was taken off the market, please post a comment and describe the impact on you or your loved one.

2) The FDA concerns about ADHD medications and the suggestion of a ‘Black Box’ Warning in February 2006

On February 9th, 2006, an advisory committee of the FDA met to review safety in ADHD medication. This subcommittee shocked the ADHD world by coming out with the recommendation of a Black Box warning for ADHD Medications - which is a the strongest warning possible by the FDA.

On that day, I prepared a detailed, audio ’special report’ to summarize the issues. You can hear or download this report here:
FDA concerns about ADHD Medication

This article is just the start of a series of articles which will help to review the evolving issues about safety of ADHD medications.I want to keep you up to date and informed!

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Hi - it’s Dr. Kenny Handelman here with the next edition of your ADHD Audio Newsletter (This is a transcription, please visit The ADHD Doctor to subscribe to the actual newsletter).

Last week we talked about the diagnostic criteria of ADHD coming from the question, “How do you know if you have ADHD?”

This week we’re going to pick up and talk about the assessment of ADHD because I think that this question requires more than one week.

To get the diagnosis you have to see a professional who is experienced in assessing and diagnosing Attention Deficit Hyperactivity Disorder.

First and foremost I want everyone to know there is no test for ADHD.

Brain Scans:

There is no blood test, there is no X-ray, no CT scan, no MRI, no PET scan, SPECT scan or anything.

Let’s go through brain imaging scans for ADHD. There have been research studies that have shown with brain imaging studies like MRI or PET scanning that there are brain differences in ADHD individuals. Now these are important research findings because we know that ADHD is a brain disorder, and these studies confirm that. Even though there are brain differences, having any one individual go for a brain scan would not necessarily show the findings. The reason is that when research studies are done, they show a population effect. In other words if you take 100 children or individuals with ADHD and compare them to 100 age matched controls you would see differences but any one individual may not show that difference. The way I view it is - it is not worth the exposure to radiation for the test unless you want to be part of a research trial.

Psychological Testing and Neuropsycholgical Testing

Psychological testing, or a psychoeducational assessment can be very helpful to look at learning strengths and weaknesses and intelligence. However, it does not diagnose ADHD. It may diagnose a learning disability or developmental delay.

There are some neuropsychological tests that look at aspects of neuropsychological functioning that may be impacted by ADHD, however they do not diagnose ADHD either. A full battery of these tests with a clinical interview may be helpful however there is a high false negative rate; at least 30% if not 50%. Now what is a false negative rate? This means that the result comes out false when it shouldn’t. In other words somebody has ADHD, they go through this testing and this testing shows that they don’t have ADHD. Now if you need a diagnosis of ADHD and you pay a lot of money to get a neuropsychological assessment and it says that there isn’t ADHD, when it is later diagnosed, that may be quite frustrating to you.

Neuropsychological testing may give you very important information which helps to understand what’s going on with the thinking and cognitive processes for the individual but it will not diagnose ADHD.

If there are no tests, how is ADHD actually diagnosed?

Well, we do it the old fashioned way. We ask questions.

ADHD is a clinical diagnosis, meaning it is made based on the clinical assessment (i.e. interview) and all of the information gathered. We do a thorough clinical interview and review all of the symptoms. It’s important to get reports from multiple sources. You’ll remember from last week that we wanted to have symptoms in multiple settings (at least two) - home and school in a child or teen, work in a teen/adult.

How do we get information from the other settings? It may be with an interview in person, a telephone interview, or at the most basic for a busy clinician is checklists from the school and parents for a child, or a spouse/partner for an adult. School report cards can be very helpful - and I generally ask all parents to bring in copies of old report cards, to see if there is a longstanding history. This is also helpful when assessing adults with ADHD. When reviewing report cards, I am looking mainly for comments, not necessarily marks. Report cards in kids with ADHD often say things like: ‘needs to put more effort into completing tasks next term’, or ‘needs to follow through next term’, or ‘although Michael has great social skills, he needs to talk less during class time’, etc. Observation of the individual in their natural environment is very helpful. It is often hard for a doctor to go to school or workplace to observe the behaviour as it is occurring, however this can be very useful information. Sometimes if a behavioural consultant is involved, he/she can do the observation.

The Mental Status Examination:

The mental status examination is an important part of the psychiatric assessment. It is the equivalent of the physical examination in other areas of medicine. The mental status examination is where the psychiatrist (or other clinician) reviews the mental state of the individual insofar as their behaviour, their eye contact, the way they speak, any motor movements noted (i.e. tics), their mood, how they describe their mood, how they interact with the individual, whether there are any thoughts of self harm (i.e. suicidal thoughts) or thoughts or harm to others, whether the individual has good insight into what is going on, whether they appear to have good judgment etc. So, instead of putting a stethoscope to the chest, the psychiatrist (or the psychologist, social worker, etc.) uses the mental status examination to assess the mental functioning. This is another important part of the assessment for ADHD.

After gathering all of the information it’s a matter of reviewing whether the individual meets the criteria of the DSM-IV TR for ADHD.

Next, one assesses for impairment. This means that the symptoms actually interfere with the individual’s functioning and changes their academic, social, and emotional development.

Criticisms of the Diagnosis of ADHD:

Now before we conclude on the issue of diagnosis of ADHD, some people criticize the process and say that it’s not as real as for many other medical conditions. For example if somebody has pneumonia they get an X-ray and it shows the pneumonia. Somebody has a broken bone you get an X-ray and see it. However, for ADHD, you can’t order tests, and so you ‘just talk about it’.

Critics of ADHD suggest that if you’re just talking about it, it must not be a real disorder, and the diagnosis must be ‘wishy-washy’.

The truth is that ADHD is a real disorder, with excellent research to back it up.

Let’s review the diagnostic process in all of medicine. Diagnosis in all areas of medicine boils down to one thing: pattern recognition.

The doctor is looking for a pattern of symptoms that fit together. When these symptoms fit together into a ‘diagnosis’, that is relevant because diagnoses help us to understand the current and future problems, which treatments may help, and what the prognosis may be.

Let’s talk about the diagnosis of pneumonia. Pneumonia isn’t just diagnosed with an X-ray. In fact pneumonia is diagnosed by thorough clinical interview and physical examination. This includes a history of how long the cough has been there, whether there was any fever, chills, sweats at night, etc. Was there colour to the sputum or the phlegm? Now the clinician listens to all this, assesses the patient, listens to their lungs, takes their temperature, their blood pressure etc., and then orders an X-ray. Now you would think this is very straightforward and there is tons of research on which antibiotics work for different pneumonias and how to treat it etc. etc.

Although the diagnosis of pneumonia seems very straight forward, I was amazed in my medical training when I stood in front of Chest X-rays with medical specialists trying to figure out if they truly confirmed the diagnosis. Sometimes the X-rays are very clear, and sometimes they just aren’t. In the end, the decision to treat with antibiotics was made in many cases based on the ‘old fashioned stuff’ - the history and physical examination.

Diagnosing a broken bone should be the most straightforward - you look at the X-rays. Is it broken or not broken? But what about some of the hairline fractures? It can get tricky. The point is that it ultimately comes down to history and physical examination and the clinician’s experience and understanding of the case.

To summarize, ADHD is a diagnosis which is made based on a clinical interview, and the other information gathered. There are no tests for it, however, with a well trained doctor, it is a very reliable diagnosis.

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Modafinil is a medication which is approved for treating sleep disorders in adults - such as narcolepsy. This medicine stimulates alertness, and was found to improve functioning of the frontal lobe of the brain, and it did so in a different way than the standard stimulants, i.e. methylphenidate (Concerta, Metadate, Ritalin) or amphetamines (Dexedrine, Adderall, Adderall XR).

Modafinil is also called: Provigil, Alertec, Vigicer and Modalert.

Early studies looking at use of this medication in children and teenagers with ADHD was promising. A full report on the early studies is here.

In March 2006, a serious side effect occured in a clinical trial. There were 933 children in a study of modafinil for ADHD, when one child developed a life threatening skin rash, called Stevens Johnsons Syndrome. The company believed that this side effect was not related to the medication, however the FDA refused to consider approval of modafinil for ADHD without extensive safety studies. It appears that the company involved, Cephalon, is abandoning research at this time. To read more on this issue, click here.

Even though modafinil is not officially approved for use in ADHD, it is still possible for a doctor to prescribe it for ADHD. This would be called ‘off label’ prescribing. If your child is on modafinil, or your doctor was suggesting it for treating ADHD, it is important to discuss this safety issue with your doctor.

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Sometimes children who require medication for ADHD are not able to swallow the pills. There are a few medicines available which can be sprinkled - such as Adderall XR, and Dexedrine Spansules. (This means that the capsule can be openned and the contents sprinkled into a spoonful of apple sauce or something like it - check with your pharmacist).

However, there was a big leap forward for kids who can’t swallow pills when the first transdermal (skin) medication patch was developed. It is called Daytrana, and has been available in the US since earlier this year. It is a patch which has the medication methylphenidate in it - which is the same medication as ritalin, concerta and metadate. I have called the patch the ‘ritalin patch’, because I imagine that most people call it that. I have to imagine because this medicine is not yet available in Canada (where I live and work), so I have no direct experience with it - yet.

When Daytrana was announced, I was so excited that I wrote a news release sharing the importance of this delivery system of medication. You can read that news release here: Daytrana.

I am writing this post today, because I got an exciting piece of news yesterday - Daytrana may be coming to Canada very soon. Now, this is not such a reliable piece of information that I can share a date - but I am hopeful that it will be before 2007. If I get more specific information, I will be sure to update you on this blog. If you would like to keep up to date with the contents of this blog, just enter your name and email address on the right of this screen, and you will receive email updates - or you could use an RSS reader.

I know that there are many readers of this blog who are not in Canada, so this post will serve to share some information with you about Daytrana. For those of you in Canada - this post will serve to update you on something new coming down the pipe - hopefully very soon!

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Parenting a child with ADHD can be a very challenging task. The ‘natural intuitive’ parenting that most people use often just doesn’t work. The parenting of a child with ADHD needs to be informed by behavioral principles and strategies. It can take a lot of self learning, groups or therapy to develop the skills necessary to effectively parent an ADHD child. Sometimes, it can feel overwhelming to figure out how to improve your child’s behavior.

There is one important place to start.

It is to ensure to do something together, and enjoy each other’s company.

This may sound so simple, that you may dismiss it as irrelevant.

But think about it…

If you are a parent of an ADHD child, you know how frustrating it can be to just get your child ready in the morning. You know how running a simple errand like picking up the dry cleaning can become a huge ordeal. You know that playing with other kids may lead to fights or frustrations.

If you are a parent of an ADHD teen, you may feel that after all of the frustrations that have occurred, you just can’t talk to one another any more without an argument.

You want to improve your child’s behavior, but you don’t even know where to start.

You can start by finding something that you can all enjoy (that is non-threatening), so you can just enjoy some time together. Not only can this be fun, but you begin to create some common ground.

Why does the title of this blog post include the title of the reality TV show “So you think you can dance”?

Well, my wife, 7 year old daughter and I all love watching this show together. If there is a scheduling conflict - we tape it and watch it together later. Although none of us are trained in dance, we provide our own critiques of each routine and then listen to what the judges have to say. We laugh at the judges’ antics, we disagree or criticize them, etc. I personally would like Benji to win next Wednesday night (he is just so entertaining), but my daughter either wants Travis or Heidi to win. The point - we have a great time, sharing an hour together watching a TV show.

Of course, ‘family time’ hopefully means a lot more than just watching one TV show together. However, if you find yourself struggling to find something to do with your ADHD child or teen without being totally frustrated with them, pick a show that you can both get into, and watch it together. If you can incorporate some other rituals that make it more fun (i.e. popcorn, pizza night, special treats), that can make it all the more special. This is crucial to establish some common ground, where you enjoy each other, so your interactions are not all about frustrations, battles and discipline.

So, if you are looking for a place to get started in improving your parenting of your child or teen with ADHD, start with 1 hour of TV together. Not only will it improve your relationship and provide some enjoyment together, but it will make it easier to communicate with one another. This will lead to improvements in behavior and it may even make it easier to enforce rules and rewards when you are working on more complicated parenting approaches.

Does it sound too simple to work?

There’s one way to find out. Do what Nike says: ‘just do it’!

Go ahead and try it out for 4 weeks, and then post your experience as a comment to this blog post. I would love to hear your feedback.

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Hi - it’s Dr. Kenny Handelman here with the next edition of your ADHD Audio Newsletter.
This is one of our members’ questions “How do you know if you have it”? This is an excellent question and a great place to begin.

Essentially to get the diagnosis of ADHD you really need to see a professional who has expertise in assessing and diagnosing ADHD. It may be helpful to listen to (or read) educational products like this or go to web sites or get other information but to really get the diagnosis you’re going to have to see a professional and have a thorough assessment.

But let’s help you to understand the diagnosis of ADHD and how it is done by the professional. We’ll start with the diagnostic criteria. In North America we use the DSM-IV TR. This is a publication by the American Psychiatric Association that stands for the Diagnostic and Statistic Manual Fourth Edition Text Revision. This is a manual which summarizes psychiatric research and knowledge, into the diagnostic criteria for all psychiatric conditions.

The DSM first editions came out many years ago and over time it’s gradually revised. In 1994 the DSM-IV came out and in 2004 they did a text revision which basically added more evidence based information to the diagnoses and the diagnostic criteria, though most criteria were not changed.

The American Psychiatric Association publishes that the purpose of the DSM-IV is to provide clear descriptions of the diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study and treat people with various mental disorders.

There are other diagnostic classification systems. The World Health Organization has developed the ICD, which is the International Classification of Diseases. The ICD is on version 10. They have different diagnoses, and the equivalent diagnosis for ADHD in the ICD is hyperkinetic disorder (HKD). HKD refers to a more limited view of ADHD symptoms than the DSM diagnosis.

Now let’s go through the diagnostic criteria for ADHD. There are two main categories for the diagnosis: Inattention and Hyperactivity/Impulsivity.

For the inattentive criteria: there are nine symptoms (criteria) for inattention. To meet the diagnosis an individual has to have six or more of these symptoms. The symptoms have to be present for at least six months to a degree that is maladaptive and inconsistent with their developmental level.

Here are the DSM-IV criteria are for Inattention:

1. fails to give close attention to details and makes careless mistakes in school, work or other activities
2. often has difficulties sustaining attention in tasks or play activities
3. often does not seem to listen when spoken to directly
4. often does not follow through on instructions and fails to finish school work, chores or other duties in the work place (and this is not due to oppositional behaviour or failure to understand instructions)
5. often has difficulty organizing tasks and activities
6. often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort like schoolwork or homework
7. often loses things necessary for tasks or activities like toys, school assignments, pencils, books or tools
8. is often easily distracted by extraneous stimuli
9. is often forgetful in daily activities

Now of course if you went into any grade two class and asked how many kids have any of these symptoms there would be a large number who had one symptom, a large number who had two, some who had three etc. but when your getting to six of nine it’s getting to the relevant range insofar as a disorder.

The next major group are nine criteria for hyperactivity impulsivity. Similarly, one needs to have six or more present for six months to a degree that is maladaptive and inconsistent with a developmental level.

Here are the DSM-IV criteria for Hyperactivity/Impulsivity:

1. often fidgets with hand or with feet or squirms in ones seat
2. often leaves seat in classroom or in other situations which remaining seated is expected i.e. church or family meals etc.
3. 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, so they may not be so overtly hyperactive.
4. often has difficulty playing or engaging in leisure activities quietly
5. is often on the go or acts as if driven by a motor
6. often talks excessively
7. often blurts out answers before questions have been completed
8. often has difficulty awaiting one’s turn
9. often interrupts or intrudes on others - like butting into conversations or games

So those are the core criteria for inattention and hyperactivity impulsivity. Now there are further criteria. The DSM further states that there have to be some symptoms that caused impairment before the age of seven years old. This is to help eliminate the concern that at the age of 27 because of other factors an individual finds they’re having trouble with concentration and that may be related to depression or anxiety or something else and not ADHD.

Other criteria include some impairment from the symptoms as present in two or more settings. It is important to see symptoms present in home and school, for example. Because if the symptoms are only present in one setting - then there is a problem with that one setting, and not necessarily a diagnosis of ADHD.

There must be clear evidence of clinically significant impairment in social, academic or occupational functioning. Now this is very important. Impairment makes this a disorder. If there is no impairment there is no disorder. If you have six of nine criteria and no impairment then you don’t have ADHD. In other words it is a problem, it is a disorder because it interferes and impairs with the functioning. The normal developmental tasks for the individual are not working properly.

The last criterion in the diagnosis of ADHD is that the symptoms do not occur during the course of another disorder such as schizophrenia, psychotic disorder, PDD or autism, mood disorder etc.

There are three possible diagnoses with ADHD. They include:

• ADHD Combined Type
• ADHD Predominantly Inattentive Type
• ADHD Predominantly Hyperactive Impulsive Type

ADHD Predominantly Inattentive Type: This diagnosis used to be called ‘ADD’, or attention deficit disorder (i.e. without hyperactivity). This term is no longer officially used, though you can find it in many settings. This diagnosis includes people who have trouble paying attention, but do not have hyperactivity, or impulsivity.

ADHD Predominantly Hyperactive Impulsive Type: This diagnosis refers to individuals who are quite hyperactive, fidgety, restless, and impulsive. However, they do not have significant trouble paying attention. This subgroup is the least commonly seen of the diagnoses of ADHD, and researchers suggest that by adolescence or adult life, most people with this diagnosis end up with the combined type.

ADHD Combined Type: This diagnosis refers to those individuals who have significant inattention as well as hyperactivity and impulsivity.

What are some of the criticisms of the DSM-IV ADHD Diagnostic Criteria?

1) Field trials were done on children with ADHD to help to establish the criteria and the cut off levels. However, the field trials were predominantly done in boys aged six to 12 years old. This means that these diagnostic criteria are not great for diagnosing girls with ADHD, as well as adults with ADHD. Expert clinicians will have to adjust the criteria to suit girls and adults.

2) This is the only disorder in the DSM that has an onset age where you have to have symptoms before the age of seven. When reviewing this with experts in the field I’ve learned that the scientists are challenging this. Now if somebody shows up at the age of 30 and never had trouble with inattention previously they wouldn’t get the diagnosis of ADHD. There would have to be something else going on. The reason for this criterion is that ADHD is a developmental disorder - i.e. it starts in childhood. However, the age of 7 is somewhat arbitrary, and it may be changed in the future editions of the DSM to ‘pre-puberty’.

So we started off with a question: How do you know if you have ADHD?

In summary, it is a clinical assessment - which means that you meet a professional with expertise in the field and you answer questions. There are no lab tests, xrays or brain scans which can diagnose ADHD.

This article served to review the DSM criteria and I will cover more of the diagnostic issues in our next newsletter.

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Summer camp for kids can be a lot of fun, and can lead to great skill development, as well as social development.

However, for kids with ADHD, it can lead to frustration, behavioral problems, and social difficulties.

The development of camps specifically designed for kids with ADHD is a great resource for parents who want their kids to have fun, and also receive an appropriate environment for their ADHD.

I came across a news video from New York, which you can see if you click the picture below. While I do not have a directory of ADHD camps for everyone, I think this video could give a parent an understanding of this as a possibility, and the video demonstrates the major components of a camp program for ADHD kids.

Enjoy the video!

N.B. As you can see - credit goes to ‘ABC-7- Eyewitness News’ for this story. Thanks for a great one. (opens in Windows media player) (also, you need to watch a brief ad before it gets into the content)

Camp for Kids with ADHD check this out! (New York-WABC, August 8, 2006) _ It’s a place for kids with ADHD to just be themselves, have fun, and also take some valuable lessons home with them. You’ll need a version of Windows Media Player 7 or higher to view the video. If you need to download it, go to http://www.microsoft.com/windows/mediaplayer/en/default.asp. The video player is supported by Microsoft IE 5.0 and above.

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As one of the newest medicines out for ADHD, there is the shortest long term track record for Strattera, compared to the other medications.

One question which people often ask is: “How long the benefits of Strattera last for?”

Although Strattera is not addictive at all, people also ask: “Will the benefits wear off, or will tolerance develop (i.e. will the dose have to be increased over time)?”

A recent study was published which addressed this issue. It was published in the Journal of Pediatrics (a great and respected Journal), and one of the authors was the researcher from Harvard - Dr. Timothy Wilens.

This study was a ‘meta analysis’, which means that it pooled the data from 13 individual studies. This is a common technique to gather more data than any one study can gather.

This study followed teens taking strattera for over two years. What was found was that the strattera started working in the first three months of treatment, and the benefit carried on for the full two years of the study. The teens did not require dose increases to maintain the benefit of the medication.

Of the initial 601 teens (12-18 years old) who started on Strattera, 219 completed a full two years of treatment in the study. While this may not look like a high percentage, it is actually a great number, as following up in a study requires a big time commitment and adherence to a protocol, which can get taxing over two years.

During the 2-year period, 99 subjects (16.5 percent) stopped taking Strattera due to lack of effectiveness and 31 (5.2 percent) discontinued treatment due to side effects. The most common side effects were: nausea, stomach aches and head aches. Importantly, there were no changes in height or weight over the two year study. Remember, this study did include 12 year olds, so they are in the age of significant growth.

The bottom line: for a relatively new medicine, this is a good study to show that this medication works well over time, and does not lose its effectiveness without dose increases (in general). There were no surprises with side effects, and the reasons for stopping treatment.

To read a full report of the study, click here.

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I have recently started posting to this blog. I have really appreciated the great response to it, and I am watching the comments to find questions which may be worth answering on the blog. As my subscribers know, I have a database of thousands of questions on ADHD, and I will use these as well to draw for content. To become a subscriber, please go to: The ADHD Doctor.

Tim wrote a comment the other day with a question: “I’ve recently started taking Strattera (2 weeks ago). Would you please comment on its effectiveness, how long it may take (should I already be noticing a difference if it is right for me?), why its not prescribed for kids (or is it or when it might be acceptable to use it if it is effective), and what I should be looking for in regards to figuring out whether or not it’s working?”

Let’s answer this one.

Strattera is the first non-stimulant medication which has come out for ADHD. It is FDA (and Health Canada - for us Canadians ;-)) approved for the treatment of ADHD from the age of 6 years old and up. It is approved for Childhood ADHD, Adolescent ADHD as well as Adult ADHD. As a Psychiatrist who deals predominantly with children and teens, I occassionally like to smile at the idea of there being ‘Geriatric ADHD’. While I cannot comment on that at length, I am aware of adults who have started Strattera in their sixties with good effect.

Stratter’s other name is: Atomoxetine.

How does Strattera work?

Strattera selectively blocks the reuptake of norepinephrine (or noradrenaline) in the brain. This, in and of itself, can increase the ability to pay attention and improve hyperactivity. The interesting thing is that Strattera gradually has a downstream effect on the dopamine in the brain, specifically in the frontal lobe. Now, I am throwing around a lot of medical terms very quickly here. Allow me to explain:

The frontal lobe is the ‘command center’ of the brain. This is the area that new brain imaging studies show is most affected in individuals with ADHD. This command center allows people to use their ‘executive functions’, which are the thinking skills which allow for: sustained concentration, impulse control, delayed gratification, etc.

Norepinephrine and Dopamine are called ‘neurotransmitters’. These are little brain chemicals which jump from one nerve cell to the next in the brain to carry a message through the brain.

In individuals with ADHD, research shows that they have ‘underactivity’ of the dopamine and norepinephrine in the frontal lobes.

ADHD medication generally increases the activity of the brain chemicals dopamine and norepinephrine in the frontal lobe, and in so doing, they increase the attention, and decrease hyperactivity and impulsivity (i.e. they increase these ‘executive functions’.

So, coming back to Strattera.

Strattera brought some very unique features to ADHD treatment which were not there prior to its release.

The benefits of strattera include:

• 24 hour symptom control - although it takes the medication about 3-4 weeks to ‘kick in’, when it does, it works 24 hours per day, contrary to the stimulants which work up to 12 hours per day
• No abuse potential at all: because there is no increase of dopamine in the part of the brain called the nucleus accumbens, Strattera cannot be abused to provide any pleasure
• No increase in tics: because Strattera doesn’t increase dopamine in the part of the brain called the striatum, there is no increase in motor or vocal tics with its use. So, for people with ADHD and Tourette’s, this is likely the best ADHD medication
• Good for ADHD + Depression or ADHD + Anxiety: A recent study showed that Strattera helped depression and anxiety (when they were present in combination with ADHD) and the ADHD. This can often mean that someone could take one medication for their condition - i.e. Strattera, instead of needing to take two medications - i.e. one for ADHD and one for the anxiety or depression
• May help for nocturnal enuresis: Strattera causes some ‘urinary retention’. This means that for some children who wet themselves at night, this medicine may lead to more dry nights. This is not a main treatment use for strattera, but it can be a side benefit
• May not cause ‘personality changes’: Some of my teenage patients complain that their stimulant medicine helps their concentration, but may take away their personality, or spontaneity. Strattera is a good option for this, as it does not clinically appear to cause these results

Strattera works for approximately 75% of people who take it. There are some data which suggest that if one takes it after having had treatment with a stimulant, that this may yield a slightly lower response rate. Why is this? It is my clinical impression that this does not relate to the fact that the stimulant has ‘changed the brain’, but rather the fact that as in many conditions in medicine, if something doesn’t respond completely to the first treatment used, it is much less likely to respond to the second treatment - i.e. it is ‘harder to treat’.

How can you tell if strattera is working?

Generally, one should notice an improvement in concentration, and a decrease in hyperactivity and impulsivity. The benefits should generally last for 24 hours -and be more ’steady’ than they are with the stimulant medicines. As mentioned above, it takes about 3-4 weeks for Strattera to start working, so one needs a little patience.

The long acting nature of strattera means that the benefits of the medication last into the evening - meaning that if a teen has homework or a project to be done, they can still have the benefits of the medication to help them late at night.
Also, there are a lot of data that people with ADHD have many more troubles driving - increased tickets, motor vehicle accidents, etc. So, if a teen (or adult) is going to drive home late at night after a party -it is better if their ADHD medication is still working in their system.

The last part of your question, Tim, was why this medicine isn’t prescribed for kids. The answer is (as I am sure that you have gathered by now) that it is used for kids too.

There are some safety issues with Strattera, and these will be addressed in an upcoming blog post.

Thanks for the great question Tim, and I encourage other readers of the blog to comment on this or any other post. Please remember, that I cannot comment on every question, or every post, but I will try.

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ADHD and ADD are conditions which have been shown to be quite responsive to medication, including stimulants (methylphenidate, ritalin, concerta, metadate CD, Adderall or Dexedrine) and non-stimulants (atomoxetine or Strattera).

Approximately 80% of individuals with ADHD or ADD respond well to medication.

When I see patients in my office, many people say that medication for ADHD is over prescribed, and they often are hesitant to consider medication for themselves or their children because of these concerns. A recent study was published in the American Academy of Child and Adolescent Psychiatry which addresses this issue.

This Washington University Study followed twins and one of the issues that they looked at was the treatment of ADHD. The finding on this point was that only 58% of boys and 45% of girls with a full diagnosis of ADHD received medication for their condition.

This finding completely contradicts the general rhetoric in the media which suggests that ADHD is overtreated with medication. The basic point is that only approximately HALF of kids with ADHD take medication for it.

So, if there are a significant number of people with ADHD not getting treatment, what about the opposite?

Are there people without a diagnosis of ADHD who are receiving medication? The answer to this question would certainly help to shed light on the question of whether there is too much medication for ADHD being prescribed - especially to those who don’t have the diagnosis.

This study did address this question as well.

It found that in children without a diagnosis of ADHD, 3.6% of boys and 2.6% of the girls received medication. When the researchers delved more deeply into these cases - they found that these individuals had mild ADHD, or ’sub-syndromal’ ADHD, meaning that they had significant symptoms, but not quite enough to make the diagnosis. The other interesting factor was that these individuals were generally twins with a sibling with full ADHD. They did also benefit from the medication for their ADHD symptoms.

Overall, my reading of this study is that ADHD is not ‘over medicated’. Of course, this is only one study, and one sample, and cannot be generalised to all areas and different countries.

The important point for anyone with ADHD or who has children with ADHD is to have a clear, open discussion with the treating Doctor, and discuss whether medication can play a role. If there is one take away message from this study - it is that you need to take any preconceived ideas out of your treatment decisions, and just review your situation carefully with your health care professional.

To read a full report on this study, click here: Washington University ADHD Study.

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