Examining Drugs for ADHD, Particularly Strattera

In memory of 14 year old Matthew Smith; 11 year old Stephanie Hall; and 10 year old Shaina Dunkle and other children who have died from the use of psychotropic drugs for "ADHD".

The Eli Lilly company has been marketing a new drug for those who are labeled as ADHD known as Strattera. This drug is purported to be a non-stimulant medication, however the side effects are similar. Rather than effecting the dopamine system as do the stimulants such as methylphenidate and dextroamphetamine, it works upon the norepinephrine neurotransmitter. Strattera is considered a Norepinephrine reuptake inhibitor. Norepinephrine is the brain's adrenalin. Norephinephrine is involved in the increased rate and force of the heart muscle, constriction of heart muscles, pulmonary function (Hedaya, 1999).

If these functions are increased, it would be evident that Strattera could produce possible untoward effects on the cardiovascular system. It is interesting to note that in the safety information that Eli Lilly provides on its website, it refers to possible hazards to those who have heart disease or high blood pressure. Information provided by Eli Lilly accompanying prescriptions of this drug note the possibility of tachycardia, and increased blood pressure. Tourette's disorder, though the etiology is not fully known is being examined as difficulties arising in the metabolism of dopamine, serotonin, and norepinephrine. it is known that stimulant drugs can produce Tourette's like behavior in some children (Breggin, 1998).

If Strattera affects the norepinephrine system, then it would seem evident that the possibility of such Tourette's like behavior could also become manifest in some children using Strattera. Therefore, though Strattera is being marketed in the fashion of being a non-stimulant drug, its ill effects are quite similar to that manifested by the stimulant medications. Eli Lilly's website notes that growth suppression is a common side effect and needs to be monitored in children making use of this drug. Loss of appetitite and weight loss is also seen. The most common side effects as listed by Lilly are upset stomach, decreased appetite, nausea and vomiting, dizziness, tiredness, and mood swings. These are not unlike that associated with the stimulant medications.

Lilly states in its press release in regards to Strattera's introduction: "It's not known precisely how Strattera reduces ADHD symptoms. Scientists believe it works by blocking or slowing reabsorption of norepinephrine, a brain chemical considered important in regulating attention, impulsivity and activity levels. This keeps more norepinephrine at work in the tiny spaces between neurons in the brain." If we examine this statement carefully, we see it states 'it is not precisely known', therefore once again a drug is being prescribed whose effects are not fully known for a'disorder' whose psychopathology is not yet delineated. Clinical trials for Strattera have been limited and any information on long term effects has only been studied by Lilly itself. It is interesting to note that before Strattera was actually placed on the market and had just received FDA approval that the stocks for Eli Lilly rose 6% at the announcement (CBS Marketwatch, November 27, 2002). Lilly is aware that it will profit highly by being able to market a drug as a non-stimulant (though its ill effects are similar), that is not a Schedule II drug thus less subject to scrutiny and regulation. Hemant K. Shah, an independent analyst qouted in an AP Health News Report (August 15, 2002) states that Strattera's market potential is large at a time when Eli Lilly is seeking to offset recent setbacks. , "Parents who have refused stimulant dangers because of their knowledge of the hazards involved will now be coerced to utilize Strattera being led to believe it is somehow safer because it does not fall into the category of a stimulant/ Schedule II drug.

There is no test for ADHD and neurological testing shows these children to be perfectly normal. Dr. William Carey of Children's Hospital in Philadelphia states, "common assumptions about ADHD include that it is clearly distinguishable from normal behavior, constitutes a neurodevelopmental (brain) disability, is relatively uninfluenced by the environment (home, school)...all of these assumptions...must be challenged because of the lack of empirical support and the strength of contrary evidence...what is now described in the US as ADHD is a set of normal behavioral variations. This discrepancy leaves the validity (of ADHD) in doubt." The U.S. National Institutes of Health Consensus Development Conference on ADHD in 1998 reported, " we have do not have an independent, valid test for ADHD, and there are no data to indicate that ADHD is due to a brain malfunction...and finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains speculative." Further, Dr. Edward C. Hamlyn, a founding member of the Royal College of General Practitioners in 1998 stated, "ADHD is fraud intended to justify starting children on a life of drug addiction." The U.S. Surgeon General Report declares, "the exact etiology of ADHD is unknown." Lastly, Dr. Joe Kosterich, Federal Chair of the Australian Medical Association states, " "The diagnosis of ADD is entirely subjective.... There is no test. It is just down to interpretation.

Maybe a child blurts out in class or doesn't sit still. The lines between an ADD sufferer and a healthy exuberant kid can be very blurred." What we are experiencing are children in conflict. We cannot blame and denigrate the child and not respect his dignity. We cannot label and suppress behaviors. If a child is conflict, we must take responsibility to see why this child is in conflict and to use responsible and carefully planned interventions to aid this child in being successful. Some believe that they see enormous benefits from children on medication. I will give them this benefit, only if we see suppression of behavior, basically chemical restraint, and the creation of zombies as our idea of 'progress' or 'success'. But once again, we are taking normal children and drugging them to suppress their behaviors. In order to achieve such a 'result', just what is going on in this child's body? Stanley I. Greenspan, a clinical professor of psychiatry at George Washington University states that, " The growing use of medication on their own is a worrisome trend while more and more people on Prozac or Ritalin are becoming bolder and less distractible, at the same time, more and more people are altering their moods without understanding what is happening to them or how it relates to their core personalities."

He also states, "given appropriate nurturing, many affected children may not require medication." University of South Florida Professor of Psychology, Diane McGuinness comments, "The first factor of being put on drugs is to attribute your bad behavior to factors beyond your control. Drugs become a substitute for learning self-discipline. This problem is compounded when children are taken off medication and problem behavior initially rebounds to fantastic proportions. Second, longitudinal studies have confirmed that children on drugs actually deteriorate in academic performance over time. And we must consider the sense of worthlessness most of these young people experience. (McGuinness, 1985). Paul Wender, M.D. lists criteria when beginning medication, he states that a child must first understand why he is receiving medication, yet as Greenspan states above, this isn't always happening. Wender states, "Most acknowledge problems in his own behavior that he himself does not like, so that -he will not feel that medicine is being given to him simply so that other people can tolerate him more." Now, Wender is one who began the first tests on the use of methylphenidate and is in support of its use in treatment.

I have had instances of being kicked, and even bitten by children going through behavioral difficulties, but at the same time, I found methods to help a child be able to deal with behaviors and to have progress while at the same time encouraging the child's own responsibility and sovereignty, and working on the creative strengths of the child. Greenspan comments, "working with the strengths of a child can create motivation." A child needs to be able to recognize and be motivated to change behaviors and work on strengths. Even Wender states that getting a child to 'label' behaviors is effective, that a child must recognize what is appropriate and what is not, and that parents should not encourage the idea that because the medication was wearing off or so forth that such excuses a level of knowledge and responsibility for certain behaviors. In my experiences, I would argue that a child often has complete knowledge of some of his or her behaviors and may develop a manipulative manner and 'test' the parent and find various triggers and weaknesses where he the parent will give in to his immediate desire. My concern lies too in that whereas some may feel medication to create some responsive in level of focus and so forth, it comes with a cost in side effects. Some may take the view that the potential for progress outweighs the potential side effects.

This is where I disagree, and feel it better to avoid that which would cause any side effects, that psychotherapy alone can manage the difficulties. These are some of the things that bring alarm to me. Wender states, "Most common side effects of the stimulant medications are appetite loss...difficulty in falling asleep." He suggests the use of a small dose of sedative 'major tranquilizer' an hour before bedtime to solve this in some cases. So, here a see a cycle of drugs needing to be used and that's worrisome. Wender states, "Research is being conducted to determine the -exact- effects of stimulant medication on growth." This tells me they are prescribing something, which they really do not know yet what the effects are on growth. He states as well that stimulant medication IS addictive in adults, but says, "The results suggest that there is no increased risk for drug abuse associated with treatment, although -more research is needed to rule this out conclusively.-" Here again, if it is addictive to adults, I ask, why not children too, and he says that research is yet conclusive. With effects on the cardiovascular system, Barkley states, "studies have -not- specifically addressed this important issue." So, they are prescribing something for which they are unsure of the effects on growth as well as the cardiovascular system.

Barkley states as well, "The side effect that should receive serious attention from clinicians is the possible increase in motor or vocal tics produced by stimulant medication." He continues- "It still seems prudent to screen children with ADHD adequately for a personal or family history of tics or Tourette's Syndrome." I recall having a session with a child with the mother first and being informed that he was being treated with Ritalin, I later had subsequent time with the father, and he had visible tics, this really alarmed me in reading about the issue of tics and Tourette's and I had to question not to the family but within myself if this was really the best option for the child faced with this risk. Barkley also states, "Isolated cases may arise in which parents note that a child is no longer 'spontaneous' or childlike in his or her behavior and appears -controlled- or -socially aloof-. This is concerning, and it appears that stimulants do have an affect in gaining control and conformity. Many of the stated results of the stimulant medication are too subjective, and Barkley states clearly that, "an improved ability to master increasingly difficult or higher-level academic material, such as that assessed in achievement tests, has -not- been demonstrated.

Here we have an example that it would not have been as a result of stimulant medication if we see academic progress. Barkley also says that 'low and moderate doses of methylphenidate do reduce the frequency of aggression and noncompliance in groups of children but have no appreciate effect on either direction on prosocial or nonsocial behaviors." So, I will acknowledge that stimulants can help with short-term behavioral inhibition, but what about long term? This is my main concern, with the side effects and without evidence of a long-term result and without knowledge of long-term results on growth and cardiovascular development, is this really the best option? Barkley states, " Few studies employing rigorous methodology have evaluated the long term efficacy of stimulant medication. Those that have examined the issue have generally found little advantage of medication over no medication when evaluated over extended periods (Pelham, 1985, Weiss & Hechtman, 1993) Children who had been on drugs but were off at the time of follow-up were not found to differ in any important respect from those who had never received pharmacotherapy."

Another concern is the effects in mood, I worked with one child who was already experiencing social withdrawal and was going through the trauma of losing a loved one. After receiving stimulant medication, this intensified. Wender states, "Instead of becoming high or excited, these drugs in general calm down ADHD children and sometimes they may even become somewhat sad." Barkley states, "some children may evidence various mild negative moods or emotions in reaction to stimulants...Some children describe feeling 'funny', 'different' or dizzy as a function of medication." What about self-esteem and confidence, Greenspan acknowledges that creativity can be affected, and Barkley states, " some concern has been raised that diminished self-esteem could be a emanative effect of methylphenidate as children may attribute the source of their success while on medication to external rather than internal factors."

Article By: Dan L. Edmunds, MA, EdD candidate