ADHD meds don’t help students without ADHD

The Pediatric Insider

© 2018 Roy Benaroch, MD

College students work hard, and many are looking for ways to improve their studying and learn more effectively. Getting more sleep and more exercise would probably help, but up to a third are trying ADHD medications to see if pills can give them that extra boost. A small, recent study shows that they’re not getting the effect they’re looking for.

We’re not talking, here, about teens who have ADHD. There’s robust evidence that medical and non-medical therapy helps people with ADHD stay focused, and medication can help them succeed. But what about the far-larger number of college students who don’t have ADHD. Can they benefit from the same medications?

Researchers at two universities in Rhode Island – a tiny state, but they’ve got 12 colleges overall – picked 13 healthy student volunteers to take tests of their cognitive ability, memory, and other academic measures. They took these tests in a random order on 2 different days. But on one day, they also took the commonly-used ADHD medication Adderall at a nice hefty dose of 30 mg. On the other day, they received placebo. The researchers were then able to compare the differences in their performance.

Some things did change. On Adderall, blood pressure and pulse were higher, as were self-reported positive emotions and energy. However, there were very small effects on actual cognitive or thinking ability, with some small positive and some small negative effects. Working memory – the ability to recall information – was much worse with the medication. Overall, Adderall did not help these college students study better or learn more.

This was a small study, with only 13 subjects. But the results are striking. On college campuses, medications like Adderall are being used both as study aids and as a way to stay up longer and party harder. But they’re not without risks, including depression, psychosis, weight loss, and addiction. These are serious medications, and while they can have a role in helping some people, they ought to be only used when necessary, under medical supervision.  They’re not for everyone, and especially not for most college students looking for a way to improve their grades.

What your kids do affects how their brains grow

The Pediatric Insider

© 2015 Roy Benaroch, MD

A short study to review today—from Pediatrics, November 2014, “Cortical thickness maturation and duration of music training: Health-promoting activities shape brain development.” Researchers looked at MRIs scans of healthy children that were being obtained as part of a larger study of normal brain development, correlating the development of several brain areas with musical training. They found that as kids age, the ones taking music lessons had more rapid growth and maturation of brain centers involving not only motor planning and coordination, but also emotional self-control and impulse regulation.

When you exercise a muscle, it grows bigger and stronger. The same thing, essentially, happens in the brain—but it’s more complicated, because different parts of the brain do different things. What this study confirms is that at least with music, the areas of the brain exercised with musical training become “stronger”—or, at least, larger and thicker, which in brain-terms means more effective. The authors speculate that conditions like ADHD, where those same areas of brain seem relatively under-functioning, might be helped by learning to play a musical instrument.

Think about the bigger picture, too. Whatever your kids are doing, that’s the area of the brain they’re exercising. If they’re reading, they’ll become better readers; if they’re playing tennis, they’ll get better at seeing and hitting a little fuzzy yellow ball. If video games are their main hobby, they’ll get better at making fast decisions and moving their hands quickly. Katy Perry fans will get good at dancing like sharks. You get the idea. At the same time, kids who don’t practice the self-control needed to learn a musical instrument might be missing out on at least one way to help their brains mature.

Get practicing!

What tests are available for ADHD?

The Pediatric Insider

© 2014 Roy Benaroch, MD

I wrote last week about getting started with an evaluation for a child who’s not doing well in school. Don’t rush to just do ADHD testing—there are many reasons for attention problems, and it’s best to not just zero in on ADHD at the start.

Still, there’s a time when confirmation and testing for an ADHD diagnosis is appropriate. What kinds of tests are available?

A clinical history is, well, talking with someone who gets to know your child through an informal interview. This can be done by a physician, psychologist, therapist, counselor, or social worker. Though a clinical interview might not be considered a “test”, I think it’s still the single best way to both rule in and rule out an ADHD diagnosis. Especially when done by someone who’s known your child for years, like a pediatrician you’ve been working with.

There are also standardized forms that are a way of making sure the exact same questions are asked in the same way, so the answers can be compared to answers given by thousands of other children in clinical trials. These are the “forms” often suggested by schools, with names like the “Vanderbilt” or “Conners” forms. Usually more than one person fills them out, including both parents and a few teachers. Some of these forms only ask questions relevant to an ADHD or ADD diagnosis; others ask some questions to screen for anxiety or depression or other problems. Because they’re standardized and frequently used, many centers seem to rely on these forms to establish a diagnosis. I’m not sure that’s always wise, but I do agree that forms like these can help confirm or refute the impression from an interview and other sources. They’re certainly not the only way, or even the most important way, to establish a diagnosis.

Further testing along similar lines—using standardized questionnaires—can be done through a professional, who administers these tests and then compiles a report. This is often called “school testing” or “psychometric testing” or “neuropsych testing,” and it’s usually done by a psychologist. This kind of testing can be far more in-depth, and can include tests of intelligence, memory, and processing; these tests can also help establish if a learning disability is present. Good, thorough testing can teach parents a lot about their child’s strengths and weaknesses, and will go far beyond just answering if a child has or doesn’t have ADHD. But it can be expensive, and often health insurance does not cover this kind of testing.

There are some more high-tech tests available now, and this can be where we’ll get into some controversy. Many companies are selling computer-assisted testing apparatus. Some of these systems use video and motion sensors to evaluate how jiggly a child is, or how well they look at what they’re supposed to be looking at. Other systems claim to analyze brain waves. There’s very little independent research into these systems, though there’s a lot of anecdotes and testimonials and company-sponsored studies that say these systems are terrific. Not only do they objectively establish a diagnosis (so the claim goes), but medical providers can bill big bucks for the testing. I’ve had sales presentations for these things, and I’m not sure that this kind of testing helps patients quite as much as they say.

There are no blood tests or brain imaging studies that are routinely helpful in the evaluation for possible ADHD. However, if a careful history and physical exam suggest other possible diagnoses, sometimes these kinds of tests are needed not to establish the ADHD diagnosis, but to rule out other things.

It would be great if there were one quick and easy test for ADHD. Instead, we have to rely on the overall picture, starting with a thorough history and physical, including a detailed diagnostic interview. A whole lot of questions, and a whole lot of time to talk. To do it right may take multiple appointments, including time to get feedback from parents and teachers. It won’t be fast, and it won’t be cheap. But in the long run, it’s better to do it right.

Evaluating children for ADHD: Getting started

The Pediatric Insider

© 2014 Roy Benaroch, MD

We frequently get this call at the office, something like this: “Brian’s teacher says he isn’t paying attention in class. The school wants us to get forms from his doctor to fill out to see if he has ADHD. Do I get those forms from you?”

I honestly don’t know how most pediatricians handle these calls, but I’ll tell you what I think parents faced with this situation ought to do.

I think it’s a mistake to assume children who aren’t doing well in school or aren’t paying attention in class should immediately be tested for ADHD. I can’t think of a single other medical symptom that’s evaluated like that—to start with one symptom, and immediately do one specific test to diagnose one specific diagnosis, over the phone, with no additional information or a physical exam or any consideration that there could be more than one possible diagnosis.

In medicine, what we’re supposed to do is start with a complaint or a symptom, get more information from a history and physical exam, and then develop what’s called a “differential diagnosis.” That’s a list of possibilities. Could be X, could be Y, could be Z. Then, if necessary, we use tests to narrow down the list, and then talk about treatment options for the diagnosis that’s either the most likely, or the most dangerous, or both. Let me give you an example:

Someone comes to see me with a pain in their foot. I don’t immediately assume it’s a broken toe and do an x-ray—I first ask when and how it happened. Maybe it started to hurt after you stepped on a bee, maybe it began after you swam in the Amazon river, maybe it began after you got a new pair of shoes. I then examine the foot. Maybe there’s a splinter or a swollen joint. Or maybe a piranha bite. I don’t know until I’ve asked the questions and done my exam. Only after that part do I consider whether I need an x-ray, or a blood test, or an Acme Piranha Repair Kit.

Yet, when kids aren’t paying attention in class, I often get calls to just do the ADHD testing. What if Junior isn’t paying attention because he’s not getting enough sleep? Or he has a hearing problem? Or a learning disability, or depression, or substance abuse? What if he’s being bullied, or has a vision deficit, or hypothyroidism? What if he doesn’t understand English well? What if his allergy medicine is making him dopey?

If the only thing we do is test for ADHD, we won’t even consider the possibility that something else might be going on. That’s a shame, and a disservice to the child and family.

Don’t start with testing. Start with a broad medical evaluation: a visit to the doctor for a complete history and physical. Then we’ll decide what ought to be done next.

Methylphenidate revealed

The Pediatric Insider

© 2014 Roy Benaroch, MD

Warning: this isn’t really a general interest sort of post. It’s more for people who prescribe methylphenidate (commonly called Ritalin), and maybe parents whose kids take the stuff. It gets odd and picky and technical, but since I had to look at this stuff up to keep it straight in my mind, I figured someone else out there needed this kind of detail. Enjoy, or skip it!

What the heck is going on with methylphenidate (MPH)? Generic substitutions may not be what you expect. If you’re picky about the form and kinetics of what’s being prescribed, you have to pay attention.

Plain MPH is still easy. Tabs come as generic or “branded” as Ritalin or Methylin, in 5s, 10s (scored), and 20s (scored.)

When you get to the time release MPH, that’s when things get tricky. The oldest one used to be branded as Ritalin SR, and it’s still out there—20 mg of MPH in a wax-impregnated tablet, only at one dose (20 mg), with irregular breakdown and absorption. It falls apart when it wants to, and no two tabs are the same. A “generic”, of sorts, of Ritalin SR in a similar wax tablet came out as brand Metadate ER tabs (originally in 10s and 20s, now only in 20s.) You’ll see either marked as generic “methylphenidate ER tabs”—always in tablets, always 20 mg.

Metadate then extended their brand into capsules, marketing these as Metadate CD (available in 10, 20, 30, 40, 50, and 60 mg.) Rather than wadding up all of the MPH into one lump of wax, this line of capsules contains individual small beads of medicine, some of which are wax coated for delayed release. The Metadate CD line has 30% of the MPH uncoated (immediate release), and 70% coated for delayed release. Generics of these are called “methyphenidate ER capsules”—so beware, capsules and tabs are very different when you see methylphenidate ER. Caps = reliable sustained-release technology; tabs = blob of wax.

Ritalin LA brand is also a capsule of beads, though they use a 50:50 mix of immediate and delayed beads. If a patient on Metadate CD needs more of an AM “push”, switching to the same mg dose of Ritalin LA will provide more of an immediate action. Ritalin LA comes in 20, 30, and 40 mg capsules. Some pharmacies will substitute Ritalin LA, Metadate CD, and methylphenidate ER caps, even though they are NOT interchangeable because of the differing ratio of immediate to delayed beads in the caps. You want real 50:50 Ritalin LA? You’ve got to “Brand Necessary” the rx.

Concerta (or, at least, brand-name Concerta) uses a unique time-release delivery system for the MPH, called “OROS.” An undigestible shell surrounds a core of MPH, with a tiny sponge inside that slowly absorbs gut juice, expanding to push MPH out gradually through a tiny hole. Clever! And it really should provide even delivery. They also coat the outside of the shell with about 20% of the total MPH for an immediate effect (that’s less than Metadate CD’s 30% — Concerta is the time-release MPH that starts the slowest.) Concerta comes in weird doses: 18, 27, 36, and 54. There are now generics of Concerta, called methylphenidate ER (yes, the same name as other generic time-release methylphenidate), in the same weird milligram amounts. But only SOME of these generics use the OROS system. Others use some kind of wax matrix (that I suspect is as low-tech as old-school Ritalin SR.) The generic Concerta that doesn’t use OROS is still shaped like Concerta, making it difficult to spot, but the delivery is very different from real Concerta. If you want to ensure you’re getting the expected time-release technology, you have to either specify “Brand Necessary” Concerta, or write “only substitute generic with OROS delivery technology.”

Daytrana is still out there, plugging away. It’s a patch that delivers MPH very evenly over up to 9 hours (that’s what FDA says. It probably lasts longer, or could last longer if you leave it on.) Drug delivery starts about 1h after the patch is applied, and stops 2 hours after the patch is removed. It comes in 10, 15, 20, and 30 mg patches, all of which are pretty darn irritating to many patients.

Then, the newest stuff: Quillivant XR, a liquid time-release MPH that the manufacturer claims lasts 8-12 hours. The strength is 5 mg/mL, and it’s non-substitutable. There’s also a traditional, ordinary, generic MPH liquid at both 5mg/5mL and 10 mg/5mL.

For you single-isomer buffs, Focalin (dexmethylphenidate) comes in 2.5, 5, and 10s, and there’s a generic available (though according to Goodrx.com via Epocrates, the generic is actually a little more expensive.) Focalin XR, their bead-technology time-release form, comes in all multiples of 5 from 5 to 40 and has no generic form… yet*!

I think I’ve covered all of them, but welcome any comments, especially from pharmacists. The complexities of prescribing this one compound are just silly, and I’m sure this is leading to all kinds of misadventures. The FDA should step in and require more-transparent, easily understood labeling. Until they do, I’ll keep ya posted.

 

*edit: see the comments below– Focalin XR does have a generic, since Nov 2013.

Holding children back: Can it “prevent” ADHD?

The Pediatric Insider

© 2013 Roy Benaroch, MD

I’ve been skeptical of the trend of “holding back” children with late birthdays. These are kids, usually born in the summer, who are just a few months short of the next grade cut-off. Some parents wonder whether it would be wise to hold them back a few months, so they end up one of the oldest (rather than youngest) kids in their class. This might seem to confer an advantage in terms of maturity, academic ability, and physical size, strength and coordination. Since children usually continue tracking up yearly, without later switching grades, kids “held back” in kindergarten will end up perhaps bigger and stronger and faster when trying out for teams in high school. A good idea?

Recent research has shown some stark differences in children who end up as the youngest versus the oldest kids in a classroom, which gives support to the idea of re-considering firm birthday-based rules for choosing when to start kids in school.

One good study was performed by researchers collaborating in Boston and Iceland. They looked at a nationwide cohort of Icelandic children, about 12000 kids, specifically grouping them by both birthdate and grade in school. Some findings from the study:

• Mean test scores were lowest among the youngest children, especially in early grades. This gap lessened by middle school, but was still significant.
• Children in the youngest third of a class were about 50% more likely to be prescribed medication for ADHD than kids in the oldest third of the class.

Similar findings have been reported by other researchers—this seems to be a real effect. Lumping children together by age creates a disparity in abilities within a classroom, with the youngest children being put at a relative disadvantage. That seems to create a greater likelihood of medical diagnoses and treatment for attention deficit disorder. It’s not known if holding back these younger kids with ADHD would allow them to become better students without fulfilling an ADHD diagnosis.

I’m not certain what the best approach is, here. Some kind of division between grades is inevitable, and some kids in any group are going to be the youngest. Perhaps smaller classes with a smaller age-range of children would help; or, perhaps an individualized approach to determining which kids will do best to start sooner versus later would address this disparity. In the held-back year, children who weren’t ready for school could get extra help with their attention abilities and other skills that will help them advance. However, this could lead to other problems later on, when kids of greatly varying age (and therefore physical and sexual maturity) are mixed together.

I don’t have a solution, but it seems like this is a genuine problem. We’d better figure out a way to work this out that doesn’t depend on more medications for the youngest kids in a grade.

Exercise: A simple treatment for ADHD

The Pediatric Insider

© 2013 Roy Benaroch, MD

Many years ago, I worked as a counselor at the city camp in North Miami Beach, Florida. Camp “No Mi Be” was attended by what seemed to be a countless number of very active, very inquisitive, and pretty-much-unstoppable 10 year old boys.

We learned quickly that the best way to start the day was with running. Run, run, run. We’d make the kids run back and forth to the fence, or run around the building, or whatever we could come up with. We’d challenge them to race us—it turned out that 16 year old legs, even on a non-athletic type like me, were long enough to beat any 10 year old. And it turned out that 10 year old boys, having lost races to their counselor 4 weeks in a row, would be more than happy to try again the next day.

Good times.

On those unfortunate rainy days, we’d run ‘em anyway. But on really really rainy days with lightning and hail, the wimp camp director would make us keep our monsters indoors all day. Those days were called “nightmares.” We counselors would end up hiding under desks.

So: a 2012 study looked at 20 kids with ADHD and 20 matched controls to see how they did on tests of attention and cognitive functioning after a twenty minute period of exercise, versus after a twenty minute period of sitting around. Surprise—both groups performed better on arithmetic and reading after exercise. The ADHD kids also showed improvements in their ability to regulate their behavior, with improved self-control after exercise.

Not a huge study—but it confirms what experienced teachers and 16 year old camp counselors know. Kids need exercise to settle their minds and get to work.

The AAP has weighed in on this, too. Recess at school is crucial and necessary, and it should be part of every school curriculum. Recess should not be withheld as a punishment for misbehavior or poor grades.

Kids of all ages, whether they have ADHD or not, need time for active play. I don’t think anyone is saying that exercise can “cure” ADHD, but it does seem to be one simple, safe intervention that ought to be part of every child’s day. Though I’m not sure it would be fair to expect the teachers to run back and forth to the fence, too….

Are sweets at bedtime a bad idea?

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jack wrote, “What is the deal with not allowing kids to eat dessert before bed? That’s how I was brought up, and how my kids have been brought up. My fiancée doesn’t allow her kids to have sweets after about 7:30 because she fears it will interfere with their sleep. Any truth to that theory? Or is it an old wives tale like not swimming after eating?”

That’d be one of those handy “little white lies.” Medically speaking, there’s no particular reason not to have sweets before bed, or (gasp!) not to eat prior to swimming.

I suppose if Junior does have a big bowl of ice cream, he’d better be sure to brush his teeth at bedtime. And a full belly at bedtime might just increase the chance of a nightmare. But I don’t think it really matters what the bedtime snack is.

There is a persistent feeling among many parents (and grandparents) that sugary, junky food gets kids hyper. I think that’s because these kinds of foods are often eaten at birthdays and happy occasions, when kids do get worked up. But when it’s been studied, simple carb meals don’t seem to change behavior in children, at least not when the kids and the observers are blinded. One study even looked at a small number of children with attention-deficit disorder, and found that sugar didn’t worsen their behavior. Those authors suggested that the perception of worse behavior may be related to those kids’ difficulty in adjusting back to classroom behavior after a snack.

In any case, I’ve found that it’s just about impossible to dispel the sugar-misbehavior contention, and I suspect it will be just as hard to convince parents that desserts before bed are no worse than desserts with dinner. It’s never bothered me or my kids, but if you’ve found it’s better to not have sweets later, that’s fine with me. It will at least make your dentist happy too.

Snoring isn’t good for children

The Pediatric Insider

© 2012 Roy Benaroch, MD

In children, snoring may be more of a problem than we thought.

A September, 2012 prospective study of 249 preschool children looked at parent-reported rates of persistent, loud snoring. About 10% of the 2-3 year old children in this sample had persistent, loud snoring—and these kids were much more likely to have significant behavior problems including hyperactivity, inattention, and symptoms of depression. Higher rates of snoring were found in homes with smokers, households with lower socioeconomic status, and among children who weren’t breast-fed—but even after controlling for these factors, snoring itself seemed to be associated with these behavior problems.

Previous studies have already documented that snoring is associated with poor school performance in older children, as well as decreased attention in adults. We also know that in its more severe form, snoring is associated with sleep apnea, which can cause heart and lung problems in adults if untreated.

Parents can look out for these signs of possible sleep apnea in their children:

• Frequent snoring (> 2 – 3 times per week)
• Labored breathing during sleep
• Gasps/snorting during sleep
• Prolonged bedwetting
• Sleeping in a sitting position
• Sleeping with the neck hyperextended (in a “looking up” position)
• Headaches upon awakening
• Daytime sleepiness
• Attention-deficit disorder or learning problems

In addition, the physical examination of children with sleep apnea can include overweight or underweight, big tonsils, poor growth, and high blood pressure. However, even without any of these findings, this recent study suggests that persistent loud snoring alone may have important consequences.

If your child is a loud snorer, look for the symptoms above and talk with the pediatrician. To know for sure if there are problems with breathing during sleep, a sleep study may be needed. Alternatively, some pediatricians may prefer to refer to a specialist like an ENT (ear-nose-throat) doctor for further evaluation.

Treatment can include a trial of medications. Though none are specifically FDA approved to treat snoring or sleep apnea, there is good evidence that inhaled nasal steroids may help, and a very recent study showed that a common asthma/allergy medicine called montelukast may also be worth a try. If medicines don’t work, or if symptoms are quite significant, the most definitive treatment is surgical removal of the tonsils and/or adenoids.

Snoring isn’t just a problem for Wilma Flintstone. If your child has significant, loud, persistent snoring it might be causing some real problems. Go get it checked out.

Your child isn’t ADD

The Pediatric Insider

© 2012 Roy Benaroch, MD

Your child isn’t ADD. Nor is he ADHD. Let’s be clear: what we say is important. Your child may have ADD, but I assure you that your child isn’t ADD, and isn’t any other disorder either.

This may seem like a bit of a rant today, but I’ve realized that a lot of parents and doctors seem to be talking about ADD and ADHD (Attention Deficit Disorder) as if it defines a person. The phrase “My child is ADD” may not seem very offensive at first, but think about it for a minute. Would you say “My child is asthma” or “My child is belly ache” or “My child is depression”? Physicians seem to be doing it, too. If a doc told me “Your child is ADD”, I’d say “no he is not.”

Your child is a person, with strengths and weaknesses. He might not be very good at staying focused, and he might be fidgety and impulsive. He might need to work on getting a good nights sleep and improving his exercise habits. He might even have ADD. But is he ADD? No. Your child, I promise, is not a disorder.