By Elaine Cassel
It is estimated that as many as one-third of grade school children are being treated with Ritalin for attention deficit-hyperactivity disorder, an externalizing childhood behavior problem associated with cognitive deficits and maladaptive behaviors. Up until now, there has been only one type of medication available for attention deficit hyperactivity disorder—a class of stimulants known as amphetamines. The drugs are marketed under the names of Ritalin, Dexedrine, and Adderal. On November 26, 2002, the Food and Drug Administration approved a new drug that acts on one of the brain’s neurotransmitters.
Stimulants are drugs that increase behavioral and mental activity. Amphetamines do their work by increasing the release and decrease the removal of norepinephrine and dopamine at the neurons’ synapses, causing increased activity at these neurotransmitters’ receptors. Norepinephrine, also called noradrenaline, occurs in both the central and peripheral nervous systems. It, along with its close relative epinephrine (adrenaline), are the neurotransmitters associated with arousal for action, learning, wakefulness and sleep, and regulation of mood.
Amphetamines help treat the symptoms of ADHD because they increase alertness and response speed, especially in tasks requiring prolonged attention. They also improve memory for verbal material. The new drug, atomoxetine (marketed as Strattera), also works on the norepinephrine system. Strattera is a selective norepinephrine reuptake inhibitor. It is not clearly understood how it reduces the symptoms of ADHD. Researchers speculate that it works by blocking or slowing reabsorption of norepinephrine, thus keeping more of the neurotransmitter at work in the synapses.
Strattera, marketed by Eli Lilly, has been tested in six placebo-controlled studies involving children older than 6, adolescents, and adults. So far, 4000 patients have taken the drug, some for as long as two and one half years. Ritalin is currently approved by the FDA only for use in adults, but it has been prescribed for children (a permissible practice by physicians that is known as "off-label" use) for years. The first experimental clinical trials involving Ritalin and children have only just recently begun.
Stimulants are considered to be controlled substances under federal drug laws. This means that doctors must place time and quantity limits on prescriptions and monitor their effects on patients. Strattera is not a controlled substance; doctors could prescribe it for longer periods of time, without requiring close monitoring by physicians. They can also distribute samples to patients and their families.
Pediatricians are hopeful that the drug will be more advantageous for children whose symptoms can be stabilized on medication, because they will not need to be monitored more than a couple of times a year. Atomoxetine also is longer acting than some versions of the amphetamines currently prescribed. It need be taken only once a day, thus sparing a child from being pulled out of class and lined up with other children to take their mid-day dose of medication. The stigmatization that comes with being identified as in need of medication prompts some children to beg to be taken off the drug.
As beneficial as the new drug might be, research indicates that drugs alone are not sufficient treatment for ADHD. Drugs address the symptoms of inattention. But behavioral management techniques at home and at school are necessary to help the ADHD child develop good study and work habits and self-discipline.
Elaine Cassel, Marymount University and Lord Fairfax Community College