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Attention Deficit Disorder

Whether to treat a child suffering from Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) is not questioned. The method of treatment and its consequences need to be considered a factor before administering chemical treatments. Attention Deficit Disorder (ADD) is characterized by short attention spans, impulsiveness, and in the case of ADHD, hyperactivity. The research acknowledged in the following paper suggests that ADD and ADHD are genetic brain conditions that have been misunderstood for decades.

Our children are the future and society needs to reconsider damaging it. Proper diagnosis and treatment can create peace and normalcy in otherwise chaotic lives. However, there is a threat with the progress and development of chemical treatment. Is the chance worth taking when regarding childrens present and future lives? ADHD has become a main topic in local and national newspapers, magazines, and TV programs. The programs have featured stories on ADHD and on Ritalin. There are many forms of medication used in the treatment of ADHD.

The most noted drug, Ritalin, a stimulant medication that has been prescribed for decades, has been featured as one of the main debated drugs. There are proven benefits of this treatment. Peter Jaksa, a psychologist and president of the National Attention Deficit Disorder Association, contends that the genetic brain disorder is misunderstood and treatment is condemned without weighing these benefits. In another aspect, here are media reports which have proven factors validating peoples fears and apprehensions about ADHD and chemical medications. These fears instill apprehension and guilt in parents considering medicating their children.

Understandably, the focal point in a number of books written by self-proclaimed experts that cover the controversial issue of ADHD and Ritalin is fear. Argumentatively, some believe that ADHD is a myth pushed by the health professions, teachers and educators for a number of reasons. Profit, notoriety and recognition are just a few reasons why this disorder and treatment may be glamorized. Advocacy organizations such as CHADD (Children and Adults with Attention Deficit Disorders) and other national organizations are supported and influenced by the pharmaceutical companies. The question then arises, Who do we trust?

The experts who write about the myth of ADHD and exaggerate the dangers of medication? Preference seems to lean towards actual documented testing results. The study examining the effectiveness of psychostimulant medication in preschoolers enlightens society with the benefits and side effects for methylphenidate and mixed amphetamine salts (Adderall). Twenty-eight preschoolers (ages 4. 0-5. 9) are evaluated and the results indicate preschoolers behavioral ratings by parents and teachers improved as a result of stimulant medication. The side effects are not considered dangerous and are left highly unannounced.

The evidence proving the medication safe is still extremely non-existent. Other common behaviors that often accompany ADHD include aggression, noncompliance, and lack of social judgment (Biederman et al. , 1991); that may be associated with oppositional defiant disorder or a difficult temperament. Behavioral responses resulting from environmental stressors, inadequate parenting skills, and other diagnoses can mimic ADHD symptoms. Excessive levels of the symptoms associated with ADHD can impede successful socialization, optimal learning, and goodness-of-fit in parent-child and teacher-child interactions (Barkley et al. , 2002; Gadow et al. 2001). Though diagnosis of mental health disorders in early childhood is problematic, the need for effective treatment of young children is critical (Cohen et al. , 1981). Gadow et al. (2001) found that preschool children referred for clinical evaluation evidenced higher levels of symptom severity than a community sample, with children with ADHD symptoms more impaired than other children. Untreated ADHD symptoms in young children may predict later substance abuse, poor academic achievement, compromised parental relations, and underdeveloped coping strategies when ADHD symptoms are untreated in young children (Connor, 2002; DuPaul et al. 2001; Wilens et al. , 2002).

Because pharmacotherapy has demonstrated efficacy, considerable attention is needed regarding both the effectiveness and safety of psychotropic medication for preschoolers (Greenhill, 1998). Despite the importance of early treatment of ADHD symptoms, no gold standard is available for the diagnosis and treatment of preschoolers assumed to have ADHD. One recent study addressing diagnosis and treatment of preschoolers with ADHD symptoms indicated notable variability in procedures. Rappley et al. 1999) identified 223 children aged 3 years or younger diagnosed with ADHD in the Michigan Medicaid system between 1995 and 1996. Forty-four percent had problems that coexisted with ADHD (e. g. , language disorders, oppositional defiant disorder, anxiety disorders, conduct disorder, and learning disability), 41% had chronic health conditions (e. g. , asthma, diabetes), and 40% experienced other injuries (e. g. , accidents, burns, poisoning). Approximately 29% of these preschoolers had one comorbid condition, with less than 15% experiencing two or more comorbid conditions.

Fifty-seven percent of the sample received psychotropic medication (22 different medications used), while only about one quarter received psychological services (27%). The authors contended that the scarcity of information on the diagnosis of ADHD in preschoolers and the limited information on efficacy and safety of psychotropic medications for this age group created great variability in the medication regimens. Given the limited number of clinical studies on the effects of stimulants on preschoolers (Conners, 1975; Musten et al. 1997), the potentially greater variability of response to stimulants, and the possibility of unanticipated behavioral and cognitive side effects, it may still be prudent for physicians to advise psychological consultation or parent education as first-line treatments for families with a preschooler diagnosed with ADHD. Nevertheless, recent studies describe increased stimulant prescribing for Canadian and American preschoolers due to ease and availability (Minde, 1998). Similarly, a review by Zito et al. (2000) revealed sizable increases in the use of medications with preschoolers (increases 1. 7-3. 1 fold) in state Medicaid programs.

The increased use of psychotropic interventions, however, may stem from pediatricians realization that psychological interventions are difficult to sustain and costly, whereas medical management is readily available and easier to administer (Halasz and Vance, 2002). Despite the notable increase in the use of stimulants in preschoolers, efficacy and risk research with young children has been sparse and plagued by sample size problems (Greenhill, 1998). Byrne et al. (1998) reported findings on eight preschoolers diagnosed with ADHD and eight matched control preschoolers without ADHD over a 5-month period.

After treatment, parents rated medicated preschoolers with ADHD as exhibiting decreased episodes of inattention, problem behaviors, and hyperactivity compared to their pretreatment scores on these measures. In addition, medicated preschoolers with ADHD exhibited more age-appropriate skills, and fewer errors of omission and commission on a visual-search cancellation test and the Auditory and Visual Continuous Performance Tests than they did before treatment. Finally, medicated ADHD preschoolers no longer differed from matched typical controls on any of the dependent variables.

In another recent study, Handen et al. (1999) performed a double-blind, placebo-controlled, crossover design study of methylphenidate (MPH) in 11 preschool children with developmental disabilities and ADHD. Doses of 0. 3 or 0. 6 mg/kg of MPH and a placebo were given to preschoolers, with teacher behavior checklists and clinical observations of activity level, attention, and compliance to adult requests used to evaluate drug response. Eight of the 11 preschool children responded to the medication (a minimum 40% decrease in behavioral symptoms between placebo and drug condition).

Unfortunately, five children exhibited dose-related adverse events such as irritability, increased crying, and severe social withdrawal. These researchers suggested that preschoolers respond to MPH at similar rates to those of school-age children but appear to be especially susceptible to adverse drug side effects. Finally, Firestone et al. (1998) performed a double-blind, placebo-controlled preschool study examining the side effects of MPH over a 1-week period. Thirty-two children participated and received placebo or 0. 3- and 0. 5-mg/kg doses of MPH twice daily.

Side effects were monitored using a parent rating scale (Barkley et al. , 1990; Barkley, 1981, as cited in Firestone et al. , 1998). No preschoolers withdrew because of adverse events. Side effects in preschoolers appeared higher than usually reported in school-age children, but severe side effects were reported in less than 10% of the sample. Interestingly, side effects were reported as frequently in the children taking placebo as in those taking MPH. It is possible that parents mistakenly attribute behavior problems to side effects of medication rather than viewing these behavior problems as typical ADHD behaviors.

For example, emotional lability expressed as tantrums may be misconstrued as a medication side effect, when in fact it is often associated with ADHD (Barkley, 1997). These recent trials are consistent with Connors (2002) review in which he argued that preschoolers benefit from stimulants and side effects appear minimal, but great care nevertheless should be used in treatment. The purpose of the present study is to contribute to the extant literature on the safety and efficacy of psychostimulant treatment for preschoolers with ADHD.

We examine the quality of behavioral response and delineate the side effect profile of 4- to 5-year-old preschoolers, naive to previous psychostimulant treatment. Our preschool sample was not unlike children who might present in a typical pediatric practice for treatment of symptoms of ADHD, with one exception: the parents of our preschoolers opted to enroll their child in a medication trial for management of ADHD symptoms. Our data also include two medications: mixed amphetamine salts (MAS; Adderall) delivered once a day and MPH delivered twice a day.

MPH bid and MAS qd have been shown to yield comparable effects in larger samples of school-age children (Faraone et al. , 2001; Manos et al. , 1999). Using receiver operating characteristic (ROC) analysis applied to clinical trials and described by Faraone et al. (2000), we display our data in a clinically meaningful waythat is, curves are examined for the sample comparing placebo to best dose condition. Area under the curve (AUC) is a clinically useful index that indicates whether a randomly selected medicated preschooler will outperform his or her own nonmedicated performance or that of a randomly selected preschooler receiving placebo.

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