Volume CXXXIII, Number 10 November 16, 2001 f

ADHD and the drugs to help
JEFF BENSON, M.D.
STAFF WRITER

Dear Dr. Jeff: I've recently been diagnosed with ADHD, and am wrestling with whether I want to take the Adderall my doctor prescribed. There are lots of rumors around, and I'm trying to separate fact from fiction. S.H.

Dear S.H.: "Attention Deficit Hyperactivity Disorder" is a neuropsychiatric disorder, characterized by inattention, impulsivity, and hyperactivity. These behavioral deficits cause problems which are performance-based, rather than skill-based. Although students with ADHD are of at least average, if not above average intelligence, and certainly possess their fair share of talents and abilities, 25 to 35 percent fail to graduate high school. Young adults with ADHD also have a six-fold increased risk of developing substance abuse problems.

ADHD is a chronic, life-long disorder, usually appearing first in childhood. It may affect as many as 3 to 5 percent of Americans, and 1 to 3 percent of college students. ADHD can be difficult to diagnose, and many experts feel that it is both over-diagnosed (especially in highly active, slow-learning boys) and under-diagnosed (in inattentive but quiet girls). A high percentage of people with ADHD also have a learning disorder, and complete neuropsychological or educational-psychological evaluation should be undertaken for anyone diagnosed with ADHD.

Stimulant medications (e.g. Ritalin and Dexedrine) remain the primary therapy for ADHD. They modulate levels of the neurotransmitter dopamine, and in so doing, are thought to decrease neurologic "white noise" from competing centers of the brain, facilitating focus and concentration on central tasks. They are now available in a variety of short- and long-acting preparations. The newer products are being marketed directly to consumers, sometimes with confusing results.

Ritalin.

Standard methylphenidate ("Ritalin") lasts only 3 - 5 hours, and is usually taken in multiple daytime doses. An older sustained release formulation ("Ritalin-SR") lasts 6 - 8 hours, but has a slow onset of action. "Metadate CD", the newest formulation, has the same 8 hour duration, but contains both immediate- and extended-release components, peaking first at 1.5 hours, and then again at 4.5 hours. "Concerta" tablets contain both an immediate-release coating of medication, and an osmotic pump which gradually releases the remainder of the drug over a 12 hour period. Concerta tablet shells are not digested, and leave the GI tract as empty "ghost" shells.

Typical monthly costs of the four preparations range from $32 to $70, respectively.

Standard dextroamphetamine ("Dexedrine") is as effective as methylphenidate in treating ADHD, and has about a 5 hour duration. Extended-release "Dexedrine Spansules" last about 8 hours. "Adderall" contains a mixture of amphetamines, lasts only 4 -5 hours, and so is best taken in two daily doses. A sustained-release formulation ("Adderall XR") is on its way, and will surely be advertised in magazines and on TV. The amphetamine preparations all cost about $25 per month.

All of these medications are controlled substances. The shorter-acting stimulants are readily abused for recreational purposes, and are all known to be frequently traded among friends as "study aids". At the University of Wisconsin, one in five students reported misusing this medication. At Bowdoin, this may be equally common.

Headache, abdominal pain, appetite suppression, insomnia and nervous tics are all common side effects of stimulants. Taken orally, in prescribed doses, stimulants are safe and effective medications. Rarely, in people with predispositions to seizure disorders or cardiac problems, they can be dangerous, even fatal. This is especially true when they are snorted.

Many "natural" products are also promoted for ADHD, including essential fatty acids, phosphatidylserine, ginkgo, DMAE, and Ephedra. None have been scientifically proven to be effective. And remember: "natural" doesn't necessarily mean safe.

A balanced, healthful diet and regularly scheduled exercise, on the other hand, can be very helpful for someone with ADHD. Compensatory strategies for structuring studies and organizing activities are also effective. Bowdoin students can find assistance in developing these strategies at the Baldwin Center. Joann Canning, Director of Accomodations for Students with Disabilities, can help coordinate these efforts. Providers at the Counseling Center can help students deal with the feelings of inadequacy, stress and frustration that often come with ADHD. And last, but by no means least, the student support group FORWARD! welcomes all to attend their Wednesday evening meetings in Moulton Union.

L'Chaim!

Jeff Benson, M.D.