Sunday, March 1, 2015

Increased Risks Associated with ADHD Diagnosis

Benedict Carey raised some interesting issues in a New York Times article titled A.D.H.D. Diagnosis Linked to Increased Risk of Dying Young.  The acronym ADHD refers to Attention Deficit Hyperactivity Disorder.  He reported on a study conducted in Denmark where medical records were studied for all children born there between 1981 and 2011.

“The team found that of 32,061 who had been given a diagnosis of A.D.H.D., 107 had died before age 33. That was roughly twice the rate of premature death among those without the disorder, after factors like age, psychiatric history and employment were taken into account.”

This rate is about 3 out of 1000.  Automobile and other types of accidents were described as the most common causes of death.  It was also noted that many of those who died had behavioral problems such as “drug abuse or antisocial behavior” that would have made them more accident prone.  Curiously, the study also concluded that the risk of early death was higher for those diagnosed with ADHD at age 18 or greater.

A psychiatrist was quoted concluding that it is ADHD that is dangerous and the study results led him to claim that it is now more important than ever to seek out children suffering from ADHD and begin treating them.  However, that is inconsistent with what the study said.  Carey had it correct in his title: the Danish data suggest that it is the diagnosis of ADHD that is dangerous.  Any further conclusion is speculation.

Another study was performed by the Danes looking at other results that follow from an ADHD diagnosis.  This work was performed in the same timeframe and was reported in The Copenhagen Post by Lawrence Shanahan under the title Danish ADHD study makes grim reading for trigger-happy diagnosis countries like the US

“Children who take ADHD medication have twice the risk of developing heart problems, according to a study at the National Centre for Register-based Research at Aarhus University, reports Science Nordic.”

“The study, which took data from 714,000 children born between 1990 and 1999, showed that the risk of developing heart problems rose from around 0.5 percent to nearly one percent among children who took ADHD medication.”

Why should this be of special concern to the people of the United States?

“While only two percent of Danish children are prescribed ADHD medication, the rate is over three times as high in the States.”

“Nearly nine percent of American children aged 4-17 are diagnosed with ADHD, of which 69 percent are then medicated, according to the American National Resource Center on ADHD.”

“That amounts to a total of 3.5 million children taking medication that doubles the risk of developing heart problems.”

Please take note of the following when considering the conclusion that an ADHD diagnosis at age 18 or greater is particularly risky.

“ADHD medications such as Ritalin and Adderall are also becoming increasingly popular among university students and young adults who use the drugs for binge-studying purposes.”

This second report suggests that it is, in fact, the diagnosis and subsequent treatment that might be producing high risk among young adults.  In particular, it points to the medications used in treating the condition as a potential contributor to the increased risk.

Should we be more concerned about the frequency with which these drugs are prescribed to young children?  Alan Schwarz has produced a troubling article in the New York Times: Risky Rise of the Good-Grade Pill.  Schwarz investigates the growing practice of teenagers who feel threatened by academic expectations to turn to amphetamines and methylphenidates as study aids.  He provides this background on common ADHD medications which are classified by the Drug Enforcement Agency (DEA) as Class II drugs.

“The D.E.A. lists prescription stimulants like Adderall and Vyvanse (amphetamines) and Ritalin and Focalin (methylphenidates) as Class 2 controlled substances — the same as cocaine and morphine — because they rank among the most addictive substances that have a medical use. (By comparison, the long-abused anti-anxiety drug Valium is in the lower Class 4.) So they carry high legal risks, too, as few teenagers appreciate that merely giving a friend an Adderall or Vyvanse pill is the same as selling it and can be prosecuted as a felony.”

The physical response to these drugs is similar to that of cocaine, but providing it in pill form makes it less addictive because the chemicals reach the brain slowly (and after passing through the liver) producing a minimal high.  Cocaine users prefer to snort, smoke, or inject the drug in order to give the brain a quick and strong jolt.

Schwartz focuses on use in older children as a study aid.  A diagnosis of ADHD is trivial to acquire.  Anyone who has prescription authority can conclude that an individual would be helped by drugs.  There is no training required.  Many students acquire the drug by feigning ADHD symptoms to obtain a prescription.  They can then use the pills for their own purposes or sell the unneeded to others.  Not surprisingly, many of the students taking the drug in an uncontrolled environment develop a dependency, or move on to other, more dangerous drugs.

For young children, even in a controlled environment, it would not be surprising to discover that a few might develop a dependency after years of consumption.  One of the difficulties with drugs such as cocaine and versions of amphetamines (methamphetamine is also in this class) is that growth and familiarity will require greater doses to obtain the same effect.  Even the best-intentioned administration of the drugs can go awry. 

A list of issues associated with the common ADHD drugs can be found at this site provided by the National Institutes of Health (NIH).   Plenty of warnings are provided about risks involved in taking the drugs, particularly if any cardiovascular irregularity exists in the patient or there is a family history of cardiovascular problems.  A long list of “serious” potential side effects is also provided.  Recall that the first study discussed referred to drug abuse and antisocial behaviors as risk factors for early death.  Here are a few serious observed side effects (in addition to addiction) provided by the NIH that fall in the antisocial behavior category:

“motor tics or verbal tics

believing things that are not true

feeling unusually suspicious of others

hallucinating (seeing things or hearing voices that do not exist)

mania (frenzied or abnormally excited mood)

aggressive or hostile behavior”

Isn’t it interesting that some behaviors that might lead to a diagnosis of ADHD can also be caused by the drugs used to control ADHD. 

The drugs do provide behavior modification in most cases pleasing parents and teachers, but dosage must be increased over time.  The drugs also cause withdrawal symptoms if usage stops too rapidly, convincing parents that the drugs were beneficial and should be resumed.  This must be a terribly dangerous situation for untrained physicians who are merely trying to help distressed parents.  The tendency is to prescribe ever larger dosages until “beneficial” behavior modification occurs.  If side effects appear, then there are other pills to control these side effects.  For modern psychiatry to work there must be a pill for each side effect.  The drug companies have been quite happy to provide them.

But there is an even more serious issue with ADHD medications than side effects.  There is data that suggest they have no long-term effect at all on behavior.  L. Alan Sroufe has raised this issue in a New York Times article Ritalin Gone Wrong.

“Attention-deficit drugs increase concentration in the short term, which is why they work so well for college students cramming for exams. But when given to children over long periods of time, they neither improve school achievement nor reduce behavior problems. The drugs can also have serious side effects, including stunting growth.”

“Sadly, few physicians and parents seem to be aware of what we have been learning about the lack of effectiveness of these drugs.”

Sroufe provides data to support the contention that they are ultimately ineffective.

“To date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things we would most want to improve. Until recently, most studies of these drugs had not been properly randomized, and some of them had other methodological flaws.”

“But in 2009, findings were published from a well-controlled study that had been going on for more than a decade, and the results were very clear. The study randomly assigned almost 600 children with attention problems to four treatment conditions. Some received medication alone, some cognitive-behavior therapy alone, some medication plus therapy, and some were in a community-care control group that received no systematic treatment. At first this study suggested that medication, or medication plus therapy, produced the best results. However, after three years, these effects had faded, and by eight years there was no evidence that medication produced any academic or behavioral benefits.”

 This discussion began with data asserting that diagnosis of ADHD leads to a higher probability of early death.  Psychiatrists will argue that this proves that one must be even more vigilant in rooting out behavioral problems in children (and adults) and treating them—predominantly with medications.  One can also draw the opposite conclusion and demand that teachers, physicians and psychiatrists be extremely careful in prescribing dangerous medications.  The data clearly support this later stance.

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