http://www.upi.com/ConsumerHealthDaily/view.php?StoryID=20060329-044441-6143r

Ped Med: ADHD treatments then and now
By LIDIA WASOWICZ
UPI Senior Science Writer

SAN FRANCISCO, March 29 (UPI) -- The current reliance on drugs as a
preferred treatment for childhood behavioral problems has its roots in an
accident waiting to happen more than half a century ago.

On that day in 1937, a young psychiatrist named Dr. Charles Bradley, just
five years out of his residency, noted a "spectacular change in behavior" in
14 of 30 children given Benzedrine for a week to ease headaches suffered
from a painful and now obsolete medical procedure.

The chance discovery was the first clinical observation of the effect of
stimulant medication on hyperactive children. It would alter the course of
pediatric behavioral treatment, which at the time centered on talk therapy.
The drug proved no analgesic for the children who, as part of their
evaluation, had the cerebrospinal fluid drained from their brain and
replaced with air for a clearer X-ray picture. However, in an unexpected
turn, for some of the youngsters, it became the "arithmetic pill" that
helped them settle into their schoolwork.

A quarter of a century would pass before anyone attempted to replicate the
observations made by Bradley at the nation's first neuropsychiatric hospital
for children, the Emma Pendleton Bradley Home -- now Bradley Hospital -- in
East Providence, R.I. It would be another 25 years before stimulants took
their place as a staple of treatments for attention-deficit/hyperactivity
disorder.

Today, from among a multitude of options -- from numerous medications to
behavior-changing strategies to educational approaches to combination
therapies -- they are what the doctor orders most often.

Speedily producing dramatic effects, stimulants like Ritalin, Adderall and
Concerta are the professionals' No. 1 choice for the estimated 2.5 million
ADHD-diagnosed children managed with medication.

Recommended as a front-line drug treatment by such medical powerhouses as
the American Academy of Pediatrics, psychostimulants nevertheless sport a
Jekyll and Hyde persona.

On the one hand, studies attest to their ability to sharpen concentration
and focus and dull impulsivity and rashness in 60 percent to 80 percent of
children diagnosed with ADHD.

On the other, evidence exists of the devastation wrought by misuse of the
potent narcotics, which the Drug Enforcement Agency classifies, along with
opium and cocaine, as dangerously addictive and highly prone to abuse
Schedule II controlled substances.

Even with appropriate application, the pharmaceuticals can raise the risks
for a cascade of costly consequences, from stunted growth in some children
who lose their appetite to psychosis in those whose existing mental illness
worsens with treatment.

Earlier this month a Food and Drug Administration advisory committee was
told of a small number of children suffering hallucinations of snakes,
worms, bugs and other creepy crawlies after taking the drugs.

A preliminary FDA report released last month tentatively linked stimulant
medications to deaths and cardiovascular and other serious problems in fewer
than one case per million prescriptions written.

No causative relationship has been established in either case, but two
panels of experts agreed parents, patients and physicians should be alerted
to the potential risks in a tiny fraction of those treated with the drugs --  
a risk the pharmaceutical companies say is about equal to that faced by the
general population.

Equally varied are youngsters' responses to the medicines, which doctors
often dole out on a trial-and-error basis, having to switch doses, then
drugs, before fixing upon the right formula.

Specialists stress no definitive pattern of serious injury has emerged in
the literature over the more than five decades compounds like Ritalin have
been in use. However, critics note most of the studies have lasted no more
than a few years so no one knows for sure just how helpful -- or harmful --  
they may turn out to be for the growing number of children who take them for
far longer.

"Stimulant trials (have) proven short-term efficacy and safety, (but) there
are very few long-term safety and efficacy trials," noted Dr. John Walkup,
deputy director of the Child and Adolescent Psychiatry Division at the Johns
Hopkins Children's Center in Baltimore.

Used alone, the pharmaceuticals do not appear to offer long-range benefits,
scientists say.

"They don't improve an ADHD child's outcome in adolescence and adulthood,"
said William Pelham Jr., distinguished professor of psychology and director
of the Center for Children and Families at the State University of New York
at Buffalo. He helped develop the medicines Concerta and Adderall and
conducted numerous trials involving other ADHD stimulant drugs, including
the initial testing of a new methylphenidate skin patch.

His studies, some funded by pharmaceutical companies, have shown behavior
therapy in combination with drugs is the most effective treatment and
lessens the risk of drug side effects.

"I remain concerned that the medications are used too frequently (nearly 5
percent of children in the United States are medicated with one of these
drugs), at doses that are unnecessarily high (three times higher than
needed), and for much too long a duration for most children (years rather
than months)," Pelham said.

Rather, he advocates that behavioral therapy be used as the first-line
treatment of ADHD.

"(Drugs) should be used as adjunctive treatments for children for whom
behavioral treatments are insufficient, they should be used at the lowest
possible dose, and they should be administered only as long as necessary,"
he advised.

Next: Coping with confounders.

(Editors' Note: This series on ADHD is based on a review of hundreds of
reports and a survey of more than 200 specialists.)