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Abstract

            This paper will discuss Attention Deficit Hyperactivity Disorder and the controversies building around it.  Covered here is the description of the disorder according to symptoms and the common treatments used today.  Being a subject of debate and arguments, the suspected negative effects, aside from the positive effects, of the medications will also be talked about in this paper. Various points of views are used here to present the facts and details.

Issues Concerning Ethics in Treating Attention Deficit Hyperactive Disorder

            Attention Deficit Hyperactivity Disorder or ADHD is a behavioral syndrome affecting mostly school-age children.  It is estimated that about 5 percent to 8 percent of children in early school age are diagnosed with ADHD.  These children are hyperactive and they have difficulty paying attention and controlling their behavior.  Although it is normal for children to have these behaviors at times, especially when they are energized, those diagnosed with ADHD have the symptoms in an extended period of time.

            It is not easy to diagnose ADHD among children because of its symptoms typified by hyperactivity, impulsivity and inattentiveness. It is important, then, that children showing signs of ADHD must be thoroughly assessed.    The latest report of the Diagnostic and Statistical Manual of Mental Health Disorders or DSM-IV-TR provides the three patterns of behavior signifying ADHD.

Predominantly hyperactive-impulsive type
Fidgeting or squirming
Difficulty remaining seated
Excessive running or climbing
Difficulty playing quietly
Always seeming to be “on the go”
Excessive talking
Blurting out answers before hearing the full question
Difficulty waiting for a turn in line
Problems with interrupting or intruding

Predominantly inattentive type
Inability to pay attention to details or a tendency to make careless errors in schoolwork or other activities
Difficulty sustaining attention in tasks or play activities
Apparent listening problems
Difficulty following instructions
Problems with organization
Avoidance or dislike of tasks that require mental effort
Tendency to lose things like toys, notebooks or homework
Distractibility
Forgetfulness in daily activities
Combined type or combination of the other two types (www.kidshealth.org)
The Manual of Mental Health Disorders or DSM-IV-TR also provides diagnostic criteria for ADHD:

The patient should be having the symptoms of one the 3 subtypes of ADHD before the age of 7
The behaviors displayed by the child should be more serious in comparison with other children having the same age
The behaviors should be persistent for no less than six months
The behavior should take place in and has negative effect on more than one area of the patient’s life like home, school and peers (www.nimh.nih.gov)
There is no substantial evidence that ADHD is a result of poor parenting or social factors.  Professionals are looking into neurobiology and genetics in identifying the cause of ADHD.  According to researches, “25% of the close relatives in the families of ADHD children also have ADHD” (www.nimh.nih.gov).  This means that the disorder is likely to be acquired genetically.  There is also a connection given to the use of alcohol and cigarettes during pregnancy to later ADHD in the offspring.  They are also considering brain injuries as one of the causes of ADHD in children, although very small percentage of children diagnosed with ADHD suffered from these.  Too much television is also viewed as a culprit in attention problems among children.

            There is still no known cure for ADHD but the behavior of the children can be dealt with through behavioral therapy and/or medication.

            Behavioral therapy assists in altering behavior patterns through restructuring a child’s environment, establishing a scheme of reward and punishment for proper and improper actions and by providing comprehensible commands and instructions. Some of the behavioral approaches that may aid ADHD child are: creation of a routine, staying away from disturbances like television and computer games, assisting the child in systemizing things, limiting choices, using goals and incentives, helping a child learn a talent and disciplining effectively.

                        Although ADHD was clinically described in 1902 by George Still, its main cause or causes are still not specified until today.  The diagnosis of this disorder is still based on the presence of indicative behaviors – hyperactivity, impulsivity and inattention. This fact that the basis of this disorder is not yet clear makes the medications prescribed for ADHD patients dubious as well.  The number of theories on the origins and nature of this disorder manipulates how people understand and consider ADHD.  In the belief that the cause of this disorder is biological and has something to do with malfunctions in the brain processes, medications targeting the brain started to be a justified means in alleviating this syndrome.

The types of prescriptions given to ADHD patients are stimulants, non-stimulants and antidepressants.   Stimulants are considered the most effective treatment for ADHD. These include:

Adderall (amphetamine)
Concerta (methylphenidate)
Cylert (pemoline)
Dexedrine (dextroamphetamine)
Dextostrat (dextroamphetamine)
Focalin (dexmethylphenidate)
Metadate ER (methylphenidate)
Metadate CD (methylphenidate)
Ritalin (methylphenidate)
Ritalin SR (methylphenidate)
Ritalin La (methylphenidate)
Most of these drugs are allowed only for children with age 6 and above because of their side effects.

            Non-stimulants are recently approved medication for ADHD.  These drugs are seemed to have lesser side effects compared to stimulants.  These drugs also have longer effect that can last up to 24 hours.  One of these is Strattera or atomoxetine. It acts on the neurotransmitter norepinephrine which is deemed to have a major role in the disorder.

            Originally to alleviate depression, antidepressants are also considered as an alternative treatment of ADHD.  There is a warning from the FDA, though, stating that “these drugs may lead to a rare increased risk of suicide in children and teens” (www.kidshealth.org).

            Because of the assurance given by the makers that these drugs are helpful in treating ADHD, there is a significant increase in children using antipsychotic medications which sparked a number of controversies and issues.  According to statistics, the recommendation of these drugs to children dramatically increased by 80% despite warnings of side effects.  One of the main issues raised in regards to this is the safety of these medications, especially to children.  Atypical antipsychotic drugs, which include medicines for ADHD, are identified to cause increase in weight and are also linked with “an increased risk of diabetes and other obesity-related conditions” (www.webmd.com).

            Stimulants are the most prescribed and used medication for ADHD.  Generally, these drugs can cause loss of appetite, insomnia, headaches, anxiety, stomachaches, social avoidance, increased blood pressure, increased heart rate, paranoia, irregular heartbeats and rhythms, nausea, loss of creativity and sedation.

            Because of these side effects, authorities ordered the manufacturers of these drugs to provide warning guides to patients of potential risks for cardiovascular and psychiatric complications.  This concern was prompted by the FDA report on 25 deaths after taking ADHD medications between 1999 and 2003.

            “The medications affected by the action include: Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Dexedrine, Focalin, Focalin XR, Metadate CD, Methylin, Ritalin, Ritalin SR, Ritalin LA and Strattera”( www.mentalhelp.net).

            One non-stimulant drug that is now required to include a black box warning is Strattera.  Black box warning signifies that the drug has adverse effect. As for Strattera, it is said to “increase thoughts of suicide or suicide attempts in children and teens” (http://pediatrics.about.com).

            Black box warnings are also required to all antidepressant drugs which are used in treating ADHD as well.  Patients taking antidepressant drugs with black box warnings should be monitored carefully especially about their suicidal thoughts and tendencies.

            Another major worry about ADHD medications, specifically stimulants, is its tendency to cause addiction or substance abuse. Stimulants are classified as Schedule II medications because they are considered by the authorities as highly addictive in line with cocaine, methamphentamine and the most intoxicating opiates and barbiturates. In researches conducted on stimulants imposed during childhood, it turned out that it can prompt a person to be drug abusive in his later life.  These drugs also have the potential to impair brain cells, cause permanent alterations in the brain chemistry and put the cardiovascular system at risk.

            Looking closely at how stimulants act on the brain will give us a clearer view on what these drugs instigate. These drugs heighten the intensity of dopamine and norepinephrine neurotransmitters. Norepinephrine is believed to be associated with attentiveness and arousal while dopamine is deemed to have a major function in the development of memory and “the onset of addictive behaviors” (psychcentral.com).

            When these stimulants are taken in high dosage, it might result to sizeable “spikes” in the levels of the neurotransmitter in the brain.  This, in turn, will damage attention and increase the threat of developing addiction.

            A number of ADHD medications are also being used illegally because of the ‘high’ effect that the drugs cause.  Some people crush 5-, 10- or 20-mg pills and snort them.  The substance is absorbed in the bloodstream at a fast rate which also quickens the increase rate of dopamine. One particular drug that is being used illicitly is Ritalin which has parallel consequence to that of cocaine or amphetamine.  Methylphenidate is also used intravenously by drug users.  “Tablets of Ritalin are dissolved in water for intravenous use.” Since this drug uses talc as filler, this method can result to pulmonary granulomas, a life-threatening health problem. This, in turn, might cause pulmonary hypertension and pulmonary fibrosis.  This is unlawfully sold on streets for $3 – 5$. If used illegally, the common side effects of Ritalin include:

Insomnia
Irritability
Nervousness
Loss of appetite
Palpitations
Psychotic episodes
Blurry vision
Skin rashes and itching
Toxic psychosis
Dry mouth
Drug dependence syndrome
Cardiac arrhythmia
Change in blood pressure
Scalp hair loss
Anemia
Anorexia (www.gdcada.org)
Like many abused substances, Ritalin and Adderall have acquired street names. Ritalin is also called “vernies, diet coke, kiddie cocaine, kiddie coke, vitamin R, R-ball, poor man’s cocaine, rids, ritz, skittles, R-pop, baby blow, coke junior, smarties and study buddies” (www.gdcada.org).

 Adderall, on the other hand is also called “Addy, smarts, team blue, brain food, red (of Orange) fix, little speedy and Altoids.

            With these drugs actively targeting specific parts of the brain, it is tantamount to say that medications such as these manipulate brain and its function.  Another controversy building around ADHD medications is the requirement to take this type of drugs before attending school.  The requirement includes children who are not diagnosed with ADHD.  One particular drug that is being a requisite is Ritalin which may promote sharp memory and focused attention.  Another purpose of having the children on medication at school is to prevent them from making disruptions and stay alert in class.

            In the internet, many websites feature ADHD and their recommendation on how to treat this disorder.  One particular controversial website is the Children and Adults with Attention Deficit Hyperactivity Disorder or the CHADD.  Although this site encourages multimodal method in treating ADHD, importance of taking medications is stressed. In a multimodal method treatment, a person’s psychological, medical, behavioral and educational environments are intervened through counseling, modifications in education and behavioral therapies and training.  Along with these approaches, the use of medications is said to be “an integral part of treatment.” On its view on the safety of stimulants such as Ritalin, the site responded positively citing a small number of slight short-term side effects.

            Another point that reduces the credibility of CHADD is its connection with pharmaceutical companies producing medications for ADHD. The producer of Ritalin, Novartis, has allotted a huge amount of money for CHADD since 1985. Although not explicitly manifested in the write-ups of the website, this financial bond with pharmaceutical companies influences the information provided to the people.

            There are other websites on ADHD, on the other hand, that are seemed to be against the conventional treatment using medications. These websites are considering the use of alternative methods such as meditation, nutritional supplements and exercise.  What these website oversee are the potential dangers of these approaches, specifically on nutritional supplements. These supplements are not that advisable because the Food and Drug Administration usually doesn’t review these products for safety and efficacy.

            The rise in ADHD cases is alarming considering that its victims are mostly children in the preschool age. What is more alarming is the lack of full knowledge on the root of this disorder.  Without this information, providing the cure for ADHD is also still impossible. People today have divided concepts on ADHD affecting the way children are given treatments.  Taking medications, specifically stimulants, is the most common method in alleviating the symptoms of this disorder which sparked controversies and debates.  Taking into consideration that the focal point in this problem are the young victims, it is better to concentrate on solving the root of this matter than to argue.

Reference

Greater Dallas Council on Alcohol & Drug Abuse. (2006, March 6). Ritalin. Retrieved January 26, 2008, from http://www.gdcada.org/statistics/ritalin.htm

Grinnell College. (2001, August 20). Pay Attention: The ADHD Controversy and the Media. Retrieved January 25, 2008, from http://web.grinnell.edu/courses/sst/f01/SST395-01/PerfectDrugs/MediaCrits/dolph.html

National Institute of Mental Health. (2008, January 24). Attention Deficit hyperactivity Disorder. Retrieved January 25, 2008, from http://www.nimh.nih.gov/health/publications/adhd/complete-publications.html

Nemours Foundation. (2005, March). What is ADHD? Retrieved January 25, 2008, from http://www.kidshealth.org/parent/emotions/behavior/adhd.html

Time Inc. (2007, January 18). How to Change a Personality. Retrieved January 26, 2008, from  http://www.time.com/time/magazine/article/0,9171,1580389-2,00.html

WebMD Inc. (2006, May 3). More Kids Get Antipsychotic Drugs. Retrieved January 25, 2008, from http://www.webmd.com/news/20060503/more-kids-antipsychotic-drugs

 

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