Guisou Zarbalian, MS
The use of stimulant medications to treat attention deficit/ hyperactivity disorder (ADHD) steadily increased in the United States from 1991 to 1999,1 and the most recent statistics estimate that about 10% of all preadolescent boys in the U.S. are prescribed stimulant medication for the treatment of ADHD.2 Common complications of ADHD medication include weight loss and insomnia, and Dr. Stephen Borowitz of the University of Virginia estimated that a third of the children he sees are taking at least two prescription medications, usually a drug for ADHD and an antihistamine to prevent those side effects.3 However, ADHD is no longer just a childhood condition. Treatment of ADHD in adults is also on the rise, with a reported 90% increase in adult use of these drugs over the past three years. Current figures for the number of U.S. adults who are prescribed ADHD medication are at 1.5 million. 4
Most studies have shown that stimulant medication is effective for 70-80% of children with ADHD. 5 However, the skyrocketing use of these drugs is worrisome, given the cardiovascular risks that have recently come to light. Researchers at the Centers for Disease Control and Prevention (CDC) surveyed 64 hospitals from August 1, 2003 to December 31, 2005. 6 During that time, the hospitals reported a total of 188 emergency room visits because of adverse drug reactions from any of five stimulant medications that are commonly prescribed for the treatment of ADHD. See the table below for the drugs that were involved in the study.
|Generic Names||Trade Names|
|methylphenidate,dexmethylphenidate||Ritalin, Concerta, Focalin, Metadate, Attenade|
|dextroamphetamine, amphetamine with dextroamphetamine, methamphetamine||Dexedrine, Adderall, Adderall XR|
Most visits were cases of accidental overdoses (61%), meaning patients took their medications more often than directed by their doctors or the drug label. Thirty-six percent had taken a drug that was not prescribed to them. As for the cardiovascular effects, 14% of the patients who visited the emergency room had cardiovascular symptoms, such as chest pain, stroke, fainting, increased heart rate, high blood pressure, or difficulty breathing.
Using these data collected from the 64 hospitals, the researchers estimated that on a national level, 3075 people visited emergency rooms for adverse drug reactions related to ADHD drugs (in the time frame studied). About 431 of these would have had cardiac-related adverse events, using the percentage they reported from the 64 hospitals.
Why some doctors are concerned, and what the FDA decided to do about it
What worries some doctors even more than the results of the CDC study is that it underestimates the frequency of adverse drug reactions from ADHD stimulant medications. Also, patients may experience some of these adverse reactions even when taking their medications correctly. Increased heart rate and blood pressure are common effects of ADHD stimulants, and for most people, these effects are not dangerous. But the researchers found that these effects could cause more serious problems in children and adults with known heart disease or heart conditions, meaning they are at higher risk of having a serious cardiovascular event. Although children have been the focus of this research, adults who are 50 or older and who have a diagnosed heart condition are at higher risk than children. This is because over a long period of time, raising blood pressure and heart rate in adults over 50 is known to increase the rates of illness and death.7
The senior author of this article, Dr. Steven Nissen, is a cardiologist at the Cleveland Clinic. In February of 2006, prior to the article’s publication, Dr. Nissen served as a consultant to the Drug Safety and Risk Management Advisory Committee of the FDA, and recommended that a black-box warning (the strongest warning that the FDA places on drug labels) describing the cardiovascular risks of the drugs be placed on their labels. His recommendation was based on a study by the FDA that reported 25 people who were on ADHD medication from 1999 to 2003 died suddenly, and another 43 people on the medication had serious but not fatal cardiovascular events, such as stroke, cardiac arrest and heart palpitations.8 The FDA analysis states that it is impossible to prove that the deaths and cardiovascular events were caused by the drugs, but Dr. Nissen thought the numbers from the report were enough reason to place a black-box warning on the medications.
The FDA, however, decided against it, choosing instead to add a new “highlights” section at the beginning of the label. This section is half a page and discusses all of the key information, according to Dr. Robert M. Nelson, chairman of the FDA’s Pediatrics Committee, but does not use strong warning language as would be found in a black-box warning.9
The Impact of Diet on Behavior
Currently, standard therapies for treatment of ADHD include stimulants, behavioral therapy, and diet changes. Sugar may seem like the obvious culprit, but this is not the case for all children.
Some recent studies have shown that many children with ADHD may break down fatty acids differently from others. The omega-6 and omega-3 fatty acids are two types of fatty acids, and they are called “essential fats,” or “essential fatty acids” (EFA’s). The body cannot make them and they must be obtained from one’s diet. One study found that children with low omega-3 fatty acid concentrations display more behavior problems than children with normal levels. These same children also exhibited other signs of low fatty acid levels, including thirst, frequent urination, dandruff, and dry skin, all of which can be treated effectively with essential fatty acids.10, 11
Another study examined the fatty acid content of certain cells, taken from children with and without ADHD. The researchers found lower levels of certain omega-3 and omega-6 fatty acids in children with ADHD. Children who were given foods that contained the EFA’s they were missing displayed less hyperactivity and generally behaved better than before the study.12
Another link between diet and hyperactivity or misbehavior was reported at a Appleton, Wisconsin alternative high school. The school replaced their vending machine and bag lunch program with more nutritious options for breakfast and lunch and with water coolers throughout the school. Researchers reported a dramatic improvement in students’ behavior. Before the change in diet, students were described as uncontrollable; weapons were brought to class, disruptions were common, and a police officer was on duty at all times during school hours. Afterwards, faculty reported that students were able to focus longer, class disruptions dropped, and weapons were no longer seen on school grounds. In addition, for several years, the school conducted a one-day experiment, “junk food day,” during which the students ate junk food instead of the usual healthier foods. Staff and students agree that junk food day has a negative impact on students’ mood and physical symptoms, and school attendance drops the following day. For more information on the Appleton findings, see this case study report: http://www.greenearthinstitute.org/nutrition/Documents/ACACaseStudyFinalVersion.doc
The Wisconsin study is interesting, but is based on interviews at one school, and therefore is not conclusive. It not known what types or percentage of ADHD, if any, can be completely managed by eating more nutritious foods, or foods that contain EFA’s. However, these studies show a link between diet and behavior that deserve further study, since there are no risks to changing diet in these ways, and many possible benefits. For many parents, a change in diet is more difficult to control than medication, but is certainly worth a try.
Behavior Therapy as an Alternative Treatment
Behavioral therapies can also help with your or your child’s symptoms. For children, behavior therapy teaches parents how to set and enforce rules, use discipline effectively, help your child understand what he or she needs to do, and encourage good behavior. The children learn to follow directions, stay on task, achieve reasonable goals that are set for them, and find better ways to control their behavior. For adults, behavioral treatment can help them cut down on distractions, stay on task, reward themselves for small, achievable goals, and help them control their own behaviors. These strategies can be used in combination with medication or changes in diet. For more information, see this website by the American Academy of Pediatrics: http://www.aap.org/pubed/ZZZWWPFTXSC.htm?&sub_cat=18.
What This Means for You or Your Child
People on ADHD stimulants who have a diagnosed heart condition are at greater risk for experiencing a potentially deadly or debilitating cardiovascular event. However, even children who do not have a heart condition can be at risk, especially if they take more medication than they are supposed to, but even if they follow directions exactly. If you or your child currently take these drugs, talk to your doctor about any concerns you have, and consider whether the risks seem too great. You may also want to ask your doctor or nutritionist about changes that you can make in your or your child’s diet. And, psychologists and other health professionals can help design behavioral therapies to reduce your or your child’s symptoms.
1. “Use of Drugs to Treat ADHD and Depression in Youth Steadily Increased from 1995-1999.” US Department of Health and Human Services, Agency for Healthcare Research and Quality 2002 Press Release. March 28, 2002. http://www.ahrq.gov/news/press/pr2002/adhdpr.htm
2. Mosholder, AD. “Overview of ADHD and its pharmacotherapy.” 2006.www.fda.gov/ohrms/dockets/ac/06/slides/2006-4202S1_01_FDA-mosholder_files/frame.htm
3. Cordes, H. “Doping Kids.” Mother Jones. September/October 2003.http://www.motherjones.com/news/outfront/2003/09/ma_503_01.html
4. Young, D. “FDA ponders cardiovascular risks of ADHD drugs.” Am J Health-Sys Pharm. 2006 March; 63: 492 -494.
5. Barbaresi, WJ et al. “Long-term stimulant medication treatment of attention-deficit/hyperactivity disorder: results from a population-based study.” J Dev Behav Pediatr. 2006 Feb; 27(1): 1-10. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16511362&query_hl=1&itool=pubmed_docsum
6. Cohen, A. et al. “Stimulant Medications and Attention Deficit-Hyperactivity Disorder.” Correspondence, N Engl J Med. 2006 May; 354(21):2294-2295.
7. Nissen, S. “ADHD Drugs and Cardiovascular Risk.” Perspective, N Engl J Med. 2006 April; 354(14): 1445-1448.
8. “FDA Panel Suggests Adding Black Box Warning to ADHD Medications About Risk of Sudden Death, Heart Problems.” Medical News Today. February 16, 2006. www.medicalnewstoday.com/medicalnews.php?newsid=37631
9. Osterwiel, N. “FDA Pediatric Advisers Say Nay to ADHD Drug Black Box.” MedPage Today. March 23, 2006. http://www.medpagetoday.com/Psychiatry/AttentionDeficitDisorder/tb/2921
10. Stevens, L. J., et al. “Omega-3 fatty acids in boys with behavior, learning, and health problems.” Physiology and Behavior. 1996; 59: 915-920.
11. Colquhoun, I., and Bunday, S. “A lack of essential fatty acids as a possible cause of hyperactivity in children.” Medical Hypothesis. 1981; 7: 673-679.
12. Kane, P. “Metabolic assessment and nutritional biochemistry: clinical and research aspects.” Symposium conducted at the Great Lakes College of Clinical Medicine, XXXI International Congress, Asheville, NC. (cited in)Schnoll, et al. “Nutrition in the treatment of ADHD: a neglected but important aspect.” Appl Psych Bio. 2003 March; 28(1): 63-75.