ADHD: Stimulants, Alternative Treatments, and Criminality

Attention Deficit Disorders more than most I feel are diseases of civilization, particularly our hypermodern civilization. Certainly they are inherited, and many folks will show up at my office after a child has been diagnosed with ADHD, telling me, "you know what, I've always had trouble focusing as well." I've even seen old grade school report cards from the seventies, with neat teacher's script: "doesn't pay attention" "moves around too much" "too talkative" and "doesn't live up to potential." Of course there is controversy over the diagnosis, which is clinical, like every psychiatric diagnosis, and I have no doubt that a variety of different genetic and environmental influences on the frontal lobes are all swept together into a wastebasket diagnosis for the purposes of billing…on the other hand, sometimes I think the most good I do with the medicines at my disposal as a practicing psychiatrist is the judicious use of stimulant.

Now more than ever, in our world of 25 different passwords and constant stimulation and distraction, anyone who has a bit of ADHD potential may find himself quite debilitated. As a child where the only job you can have is school, if school is a problem (and school seems increasingly driven by perfect conduct and test scores), life becomes difficult. With classic hyperactive ADHD, if the child isn't the personable class clown, he may find himself ostracized by classmates who don't appreciate his distraction and hyperactive behavior. Many adults will have gone from job to job, rarely successful, and will often have a long track record of broken relationships and disappointments. Back in hunter-gatherer times, ADHD tendencies may have been an advantage, and one aspect of ADHD is to be able to "hyperfocus" during a crisis or on activities in which one has an emotional interest.

5% of the children in the western world meet criteria for ADHD (though in the US, the most recent CDC statistics show an increase in diagnoses from 7% to 9%.)

A recent study (from the New England Journal of Medicine, meaning it is a hot ticket)  made big headlines: Medication for Attention Deficit Hyperactivity Disorder and Criminality (hat tip to Dallas and every major news outlet). This study is one of those "wow socialized medicine with the very large registries makes for interesting data-gathering" sort of studies.

So, the researchers gathered data from 25,656 patients diagnosed with ADHD in Sweden between 2006 and 2009. They checked out the pharmacologic treatment and criminal convictions to compare the rates of convictions while receiving medicine or not receiving medicine. In short, criminal convictions decreased 32% in men and 41% in women if they were taking medication for ADHD compared to times while not taking medication. ADHD has previously been associated with criminality (1)(2), so it makes sense to investigate the circumstances more closely.

But the primary pharmacologic treatment of ADHD is controversial: stimulants. Ritalin and adderall in many, many different formulations. Stimulants are, in fact, much less potent versions of methamphetamines. They act on dopamine receptors (though, as always, it's complicated). What happens to a child's brain and body on stimulants over years and years? What happens if he or she has untreated ADHD and is not on stimulants? Those questions are important, but we don't really have the answers. Of course behavioral modification and accommodation at school also are big parts of appropriate therapy for ADHD.

Numerous studies have shown the short-term efficacy of stimulants in folks diagnosed with ADHD. Long-term it starts to get more murky, and most people discontinue medicines at one point or another (while many grow out of the "hyperactive" part, the inattentive piece often persists for a lifetime). By 36 months of treatment, many of the positive effects seen at 14 months are diminished (3). Questions have been raised as to the risks of stimulants with respect to tolerance, dependence, growth retardation, insomnia, psychosis, abdominal pain, decreased appetite, overprescription, and addiction (though a meta-analysis of studies of stimulants started in childhood show decreased risk of substance abuse later on compared to individuals with ADHD not treated with stimulants). 

In the large Swedish criminality study, the ADHD cases (16,087 men and 9569 women) were each matched with 10 controls according to year of birth, sex, and geographic location at time of diagnosis. Those who were defined as "in treatment" with stimulant medication included those who received at least 2 prescriptions within a 6 month period. 6 month intervals without prescriptions was defined as not receiving medication treatment. The outcome measure was any convicted crime (convictions in Sweden are supposedly independent of mental health diagnoses though a diagnoses may influence sentences). Date of the crime was used for the most part, but if none were recorded, the date of conviction was used. Confounding diagnoses (oppositional defiant disorder, antisocial personality, and substance use disorders) were also accounted for as well as whether or not a conviction would have interrupted medication treatment. In order to address the very obvious confounder that patients who decide to take medications are also perhaps at a point where they are making major changes with their lives, they also adjusted for non-medication treatments and the use of SSRI medication. Criminality was still highly associated with periods of time while not on stimulant medication. There was no long term association between use of stimulants for ADHD in 2006 and criminality in 2009. 

All in all, this is an observational study with the typical limitations, but the results are consistent with previous smaller studies. While there are many influences on ADHD behavior including diet in children, all treatment modalities are worth consideration.

That said, there is an interesting new article in Psychiatric Times by Dr. James Lake reviewing the alternative medicine treatments for ADHD. Up to 50% of families with a child diagnosed with ADHD will try an alternative therapy (typically diet or some sort of vitamin supplement), but supposedly only 10% admit the use of these complimentary treatments to the pediatrician.  

Studies of omega 3 fatty acids have been mixed. The most promising one used high doses (>16 g) of EPA and DHA. French maritime pine bark (Pinus pinaster) extract was effective in a couple of very small studies. Brahmi 50mg twice a day also fared better than placebo in a randomized controlled trial of 36 children. Zinc (up to 150mg daily) has helped in a few trials, and also as an augmentation strategy for stimulants. Iron was also shown to be helpful in children with low ferritin (but who weren't iron deficient by other measures). Carnitine has had mixed results. None of these herbal treatments have nearly as much evidence as the stimulant treatments, and the long term effects for all treatments are unknown. 

"Green play" is also a studied remedy for ADHD. Children who spend more time out of doors playing tend to have fewer symptoms of hyperactivity and inattentiveness (4). This study has some serious limitations, though it is difficult to imagine how more playing outdoors wouldn't be helpful for hyperactive children in particular. 

All told, in this modern world, ADHD can be a huge impairment, though it does have some advantages. I'm all in favor of green play and behavior and dietary modification first, but sometimes further medical interventions are necessary. 

Next up will be OCD!