Fig. 1 Pet scan No ADHD vs ADHD http://www.adhd.org.nz/neuro1.html

medications http://info.medoptimizer.com/blog/bid/81307/The-Best-Fit-to-Reduce-ADHD-Medication-Trial-and-Error

Attention deficit hyperactivity disorder

The Problem

Attention deficit hyperactivity disorder (ADHD) is a developmental chronic disorder. It is a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness. Common symptoms of ADHD include: a short attention span, restlessness, being easily distracted constant fidgeting [1].

ADHD is the most commonly studied and diagnosed psychiatric disorder in children, affecting about 3 to 5 % of children globally [2] and diagnosed in about 2 to 16 % of school aged children, with 30 to 50 % of those individuals diagnosed in childhood continuing to have symptoms into adulthood. The disorder is classified into three general subtypes: predominantly hyperactive-impulsive, predominantly inattentive, and combined [3]. Treatment for ADHD can be effective I will now explore several solutions to explain how symptoms of the disorder can be alleviated.

A Possible Solution

Stimulant Medications

Stimulant medications are widely accepted as the medication of choice for ADHD sufferers. [4] Stimulant medications can greatly improve the quality of someone’s life aiding them allowing them to sustain relationships, concentrate at work and function attentively throughout the day. These

drugs include methylphenidate -- Ritalin, Metadate, Concerta -- or amphetamines, including Dexedrine, Dextrostat, and Adderall. Stimulants affect how the brain controls impulses and regulates behaviour and attention. They do this by determining the availability of certain chemicals, called neurotransmitters, in the brain.

Ritalin for instance belongs to a class of mind-altering drugs known as psychotropic drugs, or amphetamines. Ritalin increases the extra-cellular dopamine levels in the brain causing the user to feel more aware of his or her environment and consequently, the task at hand. At the same time, Ritalin lessens other cells that function in the brain’s “background”, causing even more

attention to be placed upon necessary tasks. It achieves this by activating the part of the brain stem and the frontal lobe that either produces or uses dopamine for various functions [12]. One form of Ritalin releases immediately into the body and usually begins working within one hour of taking an effective dose. The effect of the medicine normally lasts for three to four hours, depending on a person's metabolism. The dose usually needs to be repeated a couple of times throughout the day for lasting coverage. The time-release form is taken once a day and can take up to two hours to

Fig. 3

Chemical structures of stimulant drugs used on ADHD sufferers

show therapeutic benefit. Once the body begins absorbing the medicine, control over ADD or narcolepsy symptoms can last up to 12 hours. Ritalin is a stimulant and therefore speeds up mental as well as physical processes. It does this by stimulating the underactive neurons in the brain so they work harder, which allows the person to focus and pay attention [13].

Stimulants are considered for people with moderate to severe attention deficit hyperactivity disorder (ADHD) who have difficulty in at least two different settings, such as school and home.

Methylphenidate (such as Ritalin or Concerta) is often the preferred choice for treating ADHD, because it has fewer side effects than other medicines and generally works well to control behaviour. Dextroamphetamine or the combination dextroamphetamine and amphetamine (Adderall) is usually the second choice when the person does not improve with methylphenidate. But either may be the preferred medicine for older children. The long-acting form of dextroamphetamine controls behavior for a longer period of time, so fewer doses are required during the day. The dextroamphetamine and amphetamine combination medicine (Adderall) is used when other stimulants have not improved symptoms or when the combination of medicines may be more helpful [10].

All stimulants work by increasing dopamine levels in the brain—dopamine is a brain chemical (or neurotransmitter) associated with pleasure, movement, and attention. The therapeutic effect of stimulants is achieved by slow and steady increases of dopamine, which are similar to the natural production of the chemical by the brain. The doses prescribed by physicians start low and increase gradually until a therapeutic effect is reached. The stimulant medications increase the release or block the reabsorption of dopamine and norepinephrine, two brain neurotransmitters. This increases the transmission between certain neurons. Each stimulant has these effects in slightly different ways. Thus each may have similar or different effects on the AD/HD symptoms of a given individual [11]. A recent study (using specially bred mice) reported in the Jan. 1999 issue of Science [17] suggests that methylphenidate elevates levels of serotonin, and that this may account for some of its calming effects as this extract explains:

“Tests pointed to the serotonin system. Although the researchers didn't measure brain serotonin levels, they found that giving the animals a serotonin mimic had effects similar to those of the psychostimulants. So did giving them an inhibitor of the serotonin transporter, the drug Prozac, or administering other treatments designed to raise brain serotonin levels, such as injecting the animals with compounds, such as 5-hydroxytryptophan or L-tryptophan, that are converted to the neurotransmitter in the brain. These results indicate, Caron says, that the psychostimulants calm the

hyperactive mice by raising serotonin concentrations to balance the animals' high brain dopamine levels.”

Economic and Social implications

There are both social and economic implications attached to ADHD. A growing body of literature, primarily published in the United States, has demonstrated that ADHD places a substantial economic burden on patients, families, and third-party payers. Results of the medical cost studies consistently indicated that children with ADHD had higher annual medical costs than either matched controls (difference ranged from $503 to $1,343) or non-matched controls (difference ranged from $207 to $1,560) without ADHD. Two adult samples found similar results as adults with ADHD had significantly higher annual medical costs among adults with ADHD (ranging from $4,929 to $5,651) than among matched controls (ranging from $1,473 to $2,771). A limited number of studies have examined other economic implications of ADHD including costs to families; costs of criminality among individuals with ADHD; costs related to common psychiatric and medical comorbidities of ADHD; indirect costs associated with work loss among adults with ADHD; and costs of accidents among individuals with ADHD. Treatment cost-effectiveness studies have primarily focused on methylphenidate, which is a cost-effective treatment option with cost-effectiveness ratios ranging from $15,509 to $27,766 per quality-adjusted life year (QALY) gained. [5] When assessing economic implications it is not only important to observe the implications on patients but also on families, clinicians and third parties.

A study on the social and economic impacts of ADHD discovered that adults with ADHD had significant difficulties in the quality of their lives, Compared with those without ADHD. The ADHD patients surveyed had higher divorce rates; more substance abuse; lower levels of satisfaction with all aspects of their lives; and less of a positive self-image or optimistic point-of-view. This study involved 500 adults diagnosed with ADHD who were compared with 501 adults from the general population. Study participants were evenly split between men and women and were drawn from all over the country, including people from urban, suburban, and rural areas. In a 25-minute telephone interview, all study participants were asked questions about: School performance; Substance abuse; driving records; Problems in the workplace; marital problems and problems with other relationships and General outlook on life. [6]

Benefits and Risks

It has been shown in numerous studies that stimulant medication provides significant benefit to between 70 and 80% of children with ADHD. The beneficial effects of stimulant adhd medication treatment can be dramatic. Attention to class work can improve to the extent that the child is no longer distinguishable from classmates; activity level can decline to within normal limits and impulsivity can be substantially reduced. Even associated difficulties such as disruptive behaviour and peer relationship problems sometimes show dramatic improvement. Interactions between parent and child and between the child and his or her siblings have also been shown to improve. Academically, many children show clear improvements in the quantity and quality of the work they complete. It remains to be seen, however, whether these short term changes result in long term gains in children's academic, behavioural, and social functioning [7].

Fig. 4 Graph showing the Side effects of Stimulant drugs on ADHD sufferers

http://www.winmentalhealth.com/adhd_drugs.php

 

Despite the well documented benefits of stimulant medication, as many as 20-30% of children do not experience significant benefits [7]. There are many awful side effects that come with these ADHD medications such as shortness of breath, fainting, chest pain, and paranoia. All of these symptoms are quite serious and patients are encouraged to contact their doctor immediately if they experience them [8]. Beyond the potential side effects, there are a number of safety concerns associated with the stimulant medications for ADD/ADHD. Some researchers are concerned that the use of drugs such as Ritalin in children and teens might interfere with normal brain development. ADD/ADHD stimulant medications have been found to cause sudden death in children and adults with heart conditions. The American Heart Association recommends that all individuals, including children, have a cardiac evaluation prior to starting a stimulant. An electrocardiogram is recommended if the person has a history of heart problems. Stimulants for ADD/ADHD can trigger or exacerbate symptoms of hostility, aggression, anxiety, depression, and paranoia. People with a personal or family history of suicide, depression, or bipolar disorder are at a particularly high risk, and should be carefully monitored when taking stimulants. Stimulant abuse is a growing problem, particularly among teens and young adults. College students take them for a boost when cramming for exams or pulling all-nighters. Others abuse stimulant meds for their weight-loss properties [9].

Alternative Solutions

Medical Marijuana

The preponderance of studies show marijuana use is overwhelmingly prevalent with ADHD sufferers, either as a self-medicament or for recreation. While some apply preconceptions that marijuana exacerbates ADHD almost all California cannabinologists believe camnabis and cannabinoids have substantially improved the lives of ADHD sufferers, and with less negative side effects than common stimulant drug ADHD treatments. As we have come to understand more about the brain and the role of dopamine and the endocannabinoid system we are starting to unravel how cannabis, anandamide and dranabinol act to free up dopamine and decrease the overstimulation of the midbrain. cannabis also frees up dopamine but it has a very benign side effect profile. Noting cannabis’ vastly superior side effect profile DEA Administrative Law Judge, Francis L. Young, after a two-year hearing to reschedule cannabis in 1998 said:

"Nearly all medicines have toxic, potentially lethal effects. But marijuana is not such a substance. There is no record in the extensive medical literature describing a proven, documented cannabis-induced fatality. In strict medical terms marijuana is far safer than many foods we commonly consume ... Marijuana, in its natural form, is one of the safest therapeutically active substances known to man." [14]

Art Therapy

Art therapy is a great tool for those with ADHD, as it allows a person to express feelings, emotions, and energy through the hands and it releases energy. A study, done by Anne Dalebroux, Thalia R. Goldstein, and Ellen Winner, is titled; Short-term mood repair through art-making: Positive emotion is more effective than venting. They had participants watch a movie with a negatively poised mood, and after have them engage in art that included either creating a drawing reflecting their current mood (venting), creating a drawing reflecting something happy (positive), or scanning the sheet for symbols (neutral) [15]. With art therapy, unlike other forms of therapy, children are often more free to express their true feelings. They aren’t restrained by their vocabulary, or even their artistic abilities, as emotions have a way of making themselves known even in the most rudimentary, “childish” art. Children with ADHD characteristically find it difficult to “slow down” and concentrate on even basic activities, but art can engage the mind and emotions more effectively than other forms of therapy [16].

“All three groups had an increase in mood state, but while there was no difference between negative and neutral groups, the happy group was in a statistically significantly better mood than the other two groups. I think this is profound as it is something I have felt intuitively for years, but have yet to seen in an actual study. When we want to express our negative emotions, we can do so either in a negative way (through addictions, escape, or focusing on the pain), or we can take the tremendous energy we get from the pain and put it into something positive.”

(Art Therapy is Most Effective when Positive By KATHRYN GOETZKE)

Fig. 5

Number 7 in a list of 10 benefits of medical marijuana shows clearly the positive outcomes from use of the drug by ADHD sufferes

health-benefits-of-medical-marijuana-infog

Internet resources

1. NHS Choices http://www.nhs.uk/conditions/Attention-deficit-hyperactivity-disorder/Pages/Introduction.aspx 5.02.12

2. National institute of Mental Health http://web.archive.org/web/20071018052052/http://www.nimh.nih.gov/health/publications/adhd/complete-publication.shtml5.02.12

3. National Centre for Bio Technology http://www.ncbi.nlm.nih.gov/pubmed/19405409 5.02. 12

4. Health.com http://www.health.com/health/condition-article/0,,20252269,00.html 5.02. 12 5. Cost Effectiveness and Resource Allocation

http://www.resource-allocation.com/content/3/1/5 5.02. 12 6. Medscape http://www.medscape.com/viewarticle/502480_3 5.02. 12 7. ADHD News http://www.adhdnews.com/adhd-medication.htm 5.02.12 8. Hub Pages http://sonji.hubpages.com/hub/ADHD-Medications-Do-the-Benefits-Outweigh-

the-Risks 5.02.129. Help Guide http://helpguide.org/mental/adhd_medications.htm 5.02.12 10. Webmd http://www.webmd.com/add-adhd/stimulants-for-attention-deficit-hyperactivity-

disorder 5.02.1211. Stimulant Medication and ADHD http://www.baltimorepsych.com/stimulants.htm 5.02.1212. Ritalin Advisor http://www.ritalinadvisor.com/brain-effects 5.02.1213. E how http://www.ehow.com/how-does_4597399_ritalin-work_.html 5.02.1214. ADHD: Medicinal Marijuana Breakthrough http://420441.blogspot.com/ 5.02.1215. Psych Central http://blogs.psychcentral.com/adhd/2010/07/art-therapy-is-most-effective-

when-positive/ 5.02.1216. Children and Anxiety Disorderhttp://www.childrenandanxietydisorder.com/benefits-of-art-

therapy-for-children-with-adhd-and-anxiety-disorders/ 05.02.12

Bibliography

17. Science, Vol 283, Issue 5400, 306 , 15 January 1999. Date accessed: 7.02.12