Biology 202
1998 Second Web Reports
On Serendip

Focus

Katie Cecil

Everyone has problems concentrating once in a while, moments when the words on the page don't seem nearly as interesting as one's own thoughts. Most everyone has days when they feel an unexplained burst of exuberance or restlessness . Maybe it was a promotion or a messy break up, but the work just wouldn't get done and not for lack of trying. Now imagine everyday like this, every day filled with frenetic energy that cannot seem to be channeled into anything productive. Sure it might be fun for a while, but what about when you really need to get something done and it doesn't happen. You go to clean your room, and six hours later there are still piles of clothing on the floor. You can't recall what it is that you've been doing all afternoon. All you know is that nothing got done. You go to read a book, but the words dissolve into marks on the page, patterns which make no logical sense, providing only the background for another means of staring off into space. You go to visit a friend, but she quickly tires of the way you seem to constantly interrupt her. You were listening to what she said, but you just got ahead of her somehow and started talking over her. You find yourself depressed and isolated. This is the world of someone who suffers from Attention Deficit Hyperactivity Disorder. (1,2)

According to the Diagnostic and Statistical Manual of Mental disorders, published by the American Psychiatric Association as the main set of guidelines for diagnosing mental disorders in the USA, there are four main subtypes of ADHD: inattentive, hyperactive/impulsive, combined, and not otherwise specified. The symptomology of each include:

1. ADHD-Inattentive* :
a. Fails to give close attention to details or makes careless mistakes
b. Difficulty sustaining attention
c. Does not appear to listen
d. Struggles to follow through on instructions
e. Difficulty with organization
f. Avoids or dislikes requiring sustained mental effort
g. Often loses things necessary for tasks
h. Easily distracted
i. Forgetful in daily activities.
2. ADHD-hyperactive/impulsive* :
a. Fidgets with hands or feet or squirms in seat
b. Difficulty remaining seated
c. Runs about or climbs excessively (exhibits as restlessness in adults)
d. Difficulty engaging in activities quietly
e. Acts as if driven by a motor
f. Talks excessively
g. Blurts out answers before questions have been completed
h. Difficulty waiting in turn taking situations
i. Interrupts or intrudes upon others
3. ADHD-combined: a subject who meets the criteria for both ADHD-inattentive and ADHD-hyperactive/impulsive.

4. ADHD-not otherwise specified: a subject who meets some of the criteria for the above, but does not exhibit enough of the symptoms for a full diagnosis. (1)

Generally, the above symptoms are generally first noticed during early childhood. They are chronic, lasting in periods of at least six months at a time, and are often present before the age of seven. The behaviors described in the criteria above are often seen as inappropriate for the age of the child or adult and thus often result in the impairment of the child or adult's functioning in social situations such as school or on the job. This trouble can lead a level of success markedly under what, according to their level of intelligence, they should be able to achieve. It is estimated that between 1% to 3% of school-aged children currently suffer from the full ADHD syndrome, and another 5% to 10% suffer from a partial ADHD syndrome or one comorbid with another psychological problem such as depression. Boys are three times more likely than girls to exhibit behaviors suggestive of ADHD. Fortunately many children grow out of their symptoms, however between 30% and 50% of those diagnosed will still have symptoms into adulthood. (1,2)

Thus one comes to understand the seriousness of the disorder when one considers it's implications in regards to the impairment of the sufferer's social, academic, and career worlds. Nevertheless, there are means by which ADHD can be treated. For over a quarter of a century, behavior modification techniques have been employed to help the person gain control of his or her actions. Nevertheless, much of the literature evaluating these techniques has found them to be insufficient in controlling the more extreme symptoms. (1)

Thus we turn our attention to medication. While seen as rather controversial, the most predominate means of treatment is the administration of mild psychostimulants which include: Ritalin (methylphenidate), Dexedrine and DextoStat (dextroamphentamine or d-amphetamine), Adderall (d-amphetamine and amphetamine mixture), Desoxyn and Gradumet (methamphetamine), and Cylert (pemoline). (7) The thought of giving stimulants to calm hyperactivity and/or increase the attention span in children must at first seem somewhat contradictory. In order to make sense of this decision, one must look to the etiology of the disorder. Seeking to localize the areas of the brain effected by the disorder, scientists have, through the use of brain imaging, found portions of the frontal lobe and basal ganglia which show a 10% reduction in size and activity in the those suffering from ADHD. Furthermore, research centering around genetic mechanisms suggests that dopamine, as a result of its pathways which link the basal ganglia and frontal cortex, is the primary neurotransmitter involved in attention deficit. (1) In other words, it is actually an understimulization of the brain that appears to lead to a lack of attention and hyperactivity.

Thus, believed to excite the brain stem arousal system and cortex although their precise mode of action is not known (3), psychostimulants show a high rate of efficacy in the treatment of ADHD: Cylert at 50% of subjects responding; Ritalin, as well as Dexedrine, at 65-75%. Although some professionals, who worry about the side-effects of the other drugs, prefer cylert even though it only works about half the time, this paper will focus on Ritalin as it is clearly the most popular drug therapy on the market. ADHD-Inattentive children seem to have a greater amount of success with Ritalin, with a positive response rate at between 75% to 80%, in contrast to the ADHD-Hyperactive/Impulsive children, who respond in 60% to 65% of cases. (5,6) Ritalin is a fast acting and short lived drug, taking effect in 15 to 30 minutes, peaking between 1.5 and 2.5 hours, with effects lasting for about 3.5 to 4.5 hours. (5) Less effective, though longer lasting, Ritalin in the form of an extended-release tablet takes approximately 1.9 hours to take effect but peaks at about 4.7 hours. (3) The results of the administration of Ritalin can be quite dramatic. Given twice to three times daily, once before school, once during, and sometimes once directly after, Ritalin can provide a marked improvement in scholastic and social achievement virtually overnight. Indeed, subjects given the drug show everything from higher self-esteem to a significantly reduced likelihood of getting into a motor vehicle accident. (8)

Nevertheless, even with such a high success rate, the administration of Ritalin remains controversial. Its critics urge the general population to remember that it is still a stimulant, in the same family as amphetamine and cocaine. (7) They emphasis that it is addictive, even though the Journal of Neurochemistry reports findings by Kuczensi and Segal (1997) which argue that the magnitude of the effect on the dopamine pathways is significantly less in the use of Methylphenidate (Ritalin) than in a comparable dose of amphetamine, thus making it considerably less addictive. (12) Furthermore, studies report no significant increase in the likelihood that a child treated with Ritalin will abused drugs in the future. (1) Regardless, the use of Ritalin should be closely monitored.

Ritalin does have other side effects. Diminished appetite, insomnia, abdominal fullness, and weepiness or overemotionality have been reported, but one can generally regulate these difficulties by taking the tablets with food or adjusting one's dosage or schedule of consumption. (8) Of more serious concern may be that Ritalin can disrupt the cycles during which growth hormone is released by the pituitary gland and thereby may retard growth. (7) Nevertheless, even on the rare occasion when the child's growth is stunted as a result of taking the drug, the amount of reduction is minimal. (8) Furthermore, use of Ritalin may result in tics, thus the family and personal history of the subject should be considered before prescription can occur. (1,7,8) While there are draw backs to taking Ritalin, in many cases, the benefits far outweigh the possible costs.

Along with an increasing amount of persons being diagnosed with ADHD, prescription of Ritalin is on the rise. A reported three fold increase in its use occurred between 1990 and 1996, and the number of prescriptions given is still growing. (10,11) This increase has some doctors and researchers worried. Nevertheless, estimates show that only 2.8 percent of school aged children are legally taking the drug. (10) This number is right in line with the DSM-IV's estimation of the percentage of people in the general population who suffer from the disorder itself. Thus, to my mind, the drug is not yet being over prescribed. Nevertheless, as stated above, the number of people being diagnosed with ADHD is also rising, and as the DSM-IV gives only behavioral criteria, there is no definite means of diagnosis for a supposed case of ADHD. Thus the field will greatly benefit from further research to help determine the specific physical deviations from the norm in the brains of those who suffer from ADHD. Such research would help clarify diagnosis and aid in the search for new and safer treatments for the disorder. Furthermore, it would prove once and for all that ADHD is a very real problem to those skeptics who believe it may not really exist, who believe that ADHD is simply another excuse for misbehavior. (9,10,11,12)

In my opinion, ADHD is a very serious disorder which can effect the course and outcome of one's entire life. It is not necessarily all bad. By entertaining a greater range of stimuli, ADHD can make the person seem more creative and free thinking. Nevertheless, lacking the ability to properly focus one's attention, the sufferer will also find him or herself at a serious disadvantage on a very fundamental level, which can effect his or her social, scholastic, and emotional life. Thus drug and behavioral therapies are a god-send to many families. Ritalin, as well as Dexedrine and Cylert, etc., should be carefully considered, then carefully monitored if the decision is made to try them. Attention deficit is not an easy thing with which to live, but if found and treated, the person can lead an entirely normal and happy life.

References:

1. AN OVERVIEW OF ADHD from CHADD

2. (dead link)

3. Information on Methylphenidate -- from MentalHealth.com

4. Ritalin information from Pathfinder's alt.culture section

5. Stimulant Medication: Ritalin, Dexedrine, and Cylert -- from the Family Information Library

6. EFFECTS OF METHYLPHENIDATE -- from International Abstracts in Psychiatry - June 1996

7. Vital Information About Ritalin, Attention Deficit-Hyperactivity Disorder and the Politics Behind the ADHD/Ritalin Movement -- Summarized from Talking Back to Ritalin by Peter R. Breggin, M.D.

8. (dead link)

9. More Frequent Diagnosis of Attention Deficit-Hyperactivity Disorder -- from The New England Journal of Medicine

10. (dead link)

11. Take Care With Ritalin -- editorial from the Detroit News

12. Effects of Methylphenidate on Extracellular Dopamine, Serotonin, and Norepinephrine: Comparison with Amphetamine -- an abstract from the Journal of Neurochemistry

13. Articles in Education Week about Ritalin


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