Play Attention, the neuro-feedback system for treating ADHD run a blog on ADHD related issues. Their latest post has a long look comparing neuro-feedback with mediation as an ADHD treatment. Obviously there is a certain amount of bias in the article but it does a good job looking at the relative merits of the research done into these two forms of treatments.
In Sweden, they have been doing research on the impact of white noise (static) on the performance of children ADHD. Unexpectedly they found that it improved the performance of those with ADHD but reduced the performance of the control group of non-ADHD kids. The author goes on to speculate that dopamine levels underly this behaviour. A summary of the research can be found on Medical News Today or you can read the researcher’s thesis on the subject: Noise Improves Cognitive Performance in Children with Dysfunctional Dopaminergic Neurotransmission [ PDF ]
Diet and food additives have been suspected as a cause of ADHD since the 1970s and the Dr Feingold diet. After its period in the sun, the idea that certain types of food or chemicals in the food causing ADHD was discarded by mainstream science because the research failed to show any consistent results. This did not stop many thousands of parents changing their children’s diets, often with remarkable success stories.
Now, the UK Food Standard Agency has released the results of complex and top-rate research it has been doing into food colorings. Rather than looking for an individual cause, it looked at mixtures of chemicals commonly found in drinks aimed at children. They tested two mixtures on 260 children split into two age groups, three years old and eight years old. The children including a range of ADHD symptoms from none to extreme so that the study could assess whether the chemicals increase existing symptoms or cause ADHD in those with no symptoms. The study lasted six weeks and during which the children were assessed by the parents, teachers and most importantly, a trained independent observer. The trial was a double blind study so that none of the children, parents, teachers or observers knew whether the child was receiving mixture A, mixture B or a placebo. A second stage of the study used a subset of the children and observed them under tightly controlled laboratory conditions.
The results were complex. Three year olds responded with a significantly increased level of hyperactivity to mixture A whereas the eight year old responded more to mixture B. Also not all children responded the same way and the levels of response where not connected to the child’s existing levels of hyperactive behaviour.
Part of the research was to see if genetic make-up played a role in how children reacted to the drinks. They found that children with genes relating to impair histamine clearance (histamine N-methyltransferase, HNMT Thr105le and/or HNMT T939C). Children with these genes did show a significantly greater reaction to the both mixtures.
One area the research did not clarify is how long the effects last. At various points during the study, children were on a placebo to give the body a chance to remove any residual chemicals. This seemed to be enough but as the children had only been taking the chemical mixtures for a week or two, its is not clear how long they would stay in the body if the child regularly consumed them over several months.
The study has not produced a clear culprit for ADHD and the study authors admit that the results they have seen could be down to chance. However this study and previous work does indicate diet can have an effect, and sometimes a very strong effect, on some children. Should parents avoid these chemicals? I think my advice from the last time Myomancy looked at diet and ADHD still holds true:
The best advice currently available is for children to eat a balanced diet with lots of fruit and vegetables. This will certainly help prevent weight problems and improve the child’s overall physical and neurological development. If the diet helps treat ADD / ADHD then that’s a bonus.
FSA’s Press Release
Comments on the study from the FSA’s Chief Scientist
Chronic and acute effects of artificial colourings and preservatives on children’s behaviour: Study design and results.
Detailed review by the FSA’s Committe on Toxicity of Chemicals in Food, Consumer Products and the Enviroment. [ PDF ].
The chemicals and colorings used in the study
Mix A replicated the food colours and preservatives used in a previous study and consisted of:
* Sunset yellow (E110)
* Tartrazine (E102)
* Carmoisine (E122)
* Ponceau 4R (E124)
* Sodium benzoate (E211)
Mix B consisted of:
* Sunset yellow (E110)
* Quinoline yellow (E104)
* Carmoisine (E122)
* Allura red (E129)
* Sodium benzoate (E211)
Sodium benzoate was included in both mixes, but the effects observed were not consistent. The Agency therefore considers that, if real, the observed increases in hyperactive behaviour were more likely to be linked to one or more of the specific colours tested.
Using the Myomancy blogroll and a few other tools I trawl the internet for references to dyslexia, ADHD and everything related. Generally I find nothing of interest but its like beach combing. Amongst all the flotsam and jetsam, something useful occasionally turns up. On a recent search I came across a reference on a blog that I would not normally link to from Myomancy but because they touched on an important issue I will. Its People Having Sex, a Not Safe For Work adult blog, that was looking at Drugs & Sex. One of the drugs they mentioned was Ritalin.
Methylphenidate (Ritalin) is widely used both legally and illegally. It apparently causes increased or decreased sexual desire dependent on the dosage. At higher doses, it may aggravate premature ejaculation and impotence and cause anxiety
On ADHD fourms (such as ADD Forums) you often find people taking ADHD medication and talking about sexual dysfunction (such as this thread). It seems to be quite a common problem but because most studies are done on children, it isn’t well documented. See Concerta Side Effects, Ritalin Side Effects and Adderall Side Effects for more information on ADHD medication side effects.
The only work I can find on the issues is The Management of Medication-Induced Sexual Dysfunction [ PDF ] which in turn references Methylphenidate and SSRI-Induced sexual side effects. Unfortunately that study is not available online.
The effects that ADHD medication like Ritalin and Adderall have on sex drive and sexual performance is real and is highly disturbing for those it effects. It is an area where more research it definitely needed.
In a ground breaking study for the National Institute of Mental Health, researchers have found no difference between the effectiveness of ADHD medication when compared to behavioral therapy or combined drug and behavioral therapy. In earlier stages of the study, ADHD medication had a clear advantage but over time the advantages of medication were lost.
The study started with around six hundred children who were randomly split between four groups: Medication, Behavioral Therapy, Medication & Behavioral Therapy, or no treatment. For the next 14 months the children followed the treatment plan supplied by the researchers. Then, for the next two years parents were able to chose how to treat their children.
“It’s quite clear that each of these treatments is better than no treatment at all,” said lead study author Peter Jensen, director of Columbia University’s Center for the Advancement of Children’s Mental Health.
Its not clear why medication started so strongly as the best treatment but faded over time. Its possibly due to an age-related decline in ADHD symptoms, changes in medication management intensity, starting or stopping medications altogether, or a number of other factors.
The Guardian newspaper had a big splash on yesterday’s front page “New fears over additives in children’s food“. It claimed that colorings and preservatives effected children’s behaviour, possibly causing hyperactivity. Is there any science behind this latest “food is dangerous” story or is it just the latest in a long line of spacing filling, bad reporting of bad science?
ADHD and Diet
The first proponent that additives are dangerous and cause ADHD was Dr Feingold in the in the 1970’s. Backed by research he claimed that diet and adhd were linked and that if you cut out all colorings, hyperactivity went away. Later research found that the Feingold diet only helped 2% of children. However diet does seem play some part as it effects weight (see ADHD and Obesity) and diet can effect sleep patterns (see ADHD and Sleep Disorders). The current wisdom is that food additives are not dangerous but a bad diet full of fast food, sweets, fat and sugar, is dangerous and can amplify existing behavioral problems.
New Research on Additives and ADHD
The new research is a follow up to research from 2000 but only published in 2004. Researchers from the Isle of Wight in the UK looked at 277 three year old children who had been assessed for hyperactivity and atopy. The children’s diet was then changed so that for one week the children went without additives, then in random order, a week with added colorings, a week with added preservatives (sodium benzoate) and a week with a placebo. The children were assessed both by a research in a clinical setting and by their parents at home. Neither the researcher or the parents knew which order the children were receiving the additives, colorings or placebo.
When the results were analysed there were no detectable difference in the children’s behaviour when assessed by the researcher in the clinical setting. However the parent’s assessment found a significant reduction in hyperactivity in the week without additives and preservative plus an increase in hyperactivity in the week with the added preservatives.
The fact that this difference in behaviour was only notice by the parent’s is a warning sign that something might be problematic with the research. It might be that the criteria or the method of assessment being used was somehow biased or that it wasn’t sensitive enough to pick up behavioral changes in the clinical setting. It may be that parents are better judges of their own children’s behaviour or it could be that there was not difference and this is just a statistical anomaly. Without further research there was no way of telling.
Chemicals in Food
The UK’s Food Standards Agency Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) looked at this research. They conclued:
Published data suggest exclusion of specific dietary components can affect some measures of behaviour in some children. The researchers suggest that this study provides evidence that food additives had statistically significant effects on some measures of behaviour, irrespective of whether the children were atopic, hyperactive or neither. We acknowledge that the study is consistent with published reports of behavioural changes occurring in some children following consumption of particular food additives. We also note that the authors suggest that this may apply to children who are not considered to be hyperactive. However, we consider that it is not possible to reach firm conclusions about the clinical significance of the observed effects.
New research was funded to clarify the findings further and it was this new study that the Guardian was reporting on.
Are Food Additives Dangerous?
As with all good food scare stories in the media, the actual results of the study have not been published so facts cannot be checked. After the last study it took 4 years for the results to be published so don’t hold your breath. However the COT assessed the results on the 20th March and according to a member of the committee, quoted in the Guardian, the new results were the same the previous study.
Until the research is published and can be properly peer-reviewed it is impossible to say how safe or dangerous these food additives are. Until we do know, minimising children’s exposure to these additives though a healthy, balanced diet involving lots of fresh vegetables and fruit is the best advice available.
The Additives in Question
- Tartrazine (E102)
- Ponceau 4R (E124)
- Sunset Yellow (E110)
- Carmoisine (E122)
- Quinoline yellow (E104)
- Allura Red AC (E129)
- Sodium Benzoate (E211)
Original Research: The effects of a double blind, placebo controlled, artificial food colourings and benzoate preservative challenge on hyperactivity in a general population sample of preschool children
COT agenda and papers: 20 March 2007
Vyvanse is the new ADHD medication from Shire PLC, the makers of Adderall XR. It marks a significant change in the range of medication available as it uses a different type of stimulant than other medications, it a has long duration and it is especially formulated to prevent substance abuse.
How Vyvanse Works
The active substance in Vyvanse is lisdexamfetamine and is chemically very close to Dexedrine Spansules, a stimulant occasionally prescribed for ADHD. The advantage of lisdexamfetamine over methylphenidate (used in Ritalin and Concerta) is that it has a long lasting effect. Taken in the in the morning, the peak effectiveness last one to four hours but had a notable effect on symptoms for 12 hours.
Traditional ADHD medications have been easy to abuse and this has led to dependency problems. Vyvanse is a prodrug, a substance that is inert until it is digested. This mimics how the body creates useful chemical and vitamins from our food. As Vyvanse only acts as a stimulant once it is broken down by the stomach you cannot get a high from grinding it up and snorting it. Swallowing higher than prescribed doses (150mg compared to the recommend max of 70mg) will still produce a high indistinguishable from that produced by a comparable dose of Ritalin.
Vyvanse: Four Times More Side Effects
Because Vyvanse is new it has only been used by those adults and children who took part in the drug’s trials. In total, less than 1000 people. With such a small sample (compared to the millions who will end up taking the drug) there is very little first hand knowledge of the drugs effects. With each of the other major drugs, Ritalin, Adderall etc, different people can have very different reactions to the drugs. Someone who is fine on one drug may have numerous side effects from a chemically very similar drug. The body and brain are very complex chemical systems and stimulants are a very crude tool.
Currently we only have the Vyvanse prescribing information to go on as a guide to its effects but one things is very noticeable. In trials 10% of users stopped taking the drug due to adverse effects (i.e. side effects). This is much higher than Adderall where only 2.4% of participants were effected. In the Adderall trials more people stopped using the placebo than the real drug but for Vyvanse only 1% of placebo users dropped out. The new drug has a side effect rate 10 times higher than the base line and four times high than Adderall.
Vyvanse And The $1.5 Billion Goal
Shire PLC are introducing this new drug as a replacement for Adderall XR whose patent is running out. They hope to capture 50% of the market share with the drug and as the market is worth $3 billion, a 50% share will generate a lot of money. Expect to see a lot of advertising aimed at parents, not doctors, when Vyvanse is launched in July. In theory Vyvanse is a lot cheaper to make than competing drugs as its chemical formula is its key rather than the complex release mechanisms used by others drugs. However I expect that Vyvanse will retail at about the same as the other ADHD medications at about $130 – $150 for a months dose.
What you need to know about ADHD Medications – their effects, costs, side effects and alternatives
What ADHD Medications are Available?
There are three main ADHD Medications: Ritalin (the original ADHD medication), Adderall and Concerta. Each has its own advantages. Ritalin is the oldest, the simplest chemical formulation, and the cheapest because it can be purchased as a generic medicine. Made up of methylphenidate, it is taken two or three times a day. Having been used since the 1960s as medication for ADHD its effectiveness is well documented.
Concerta like Ritalin uses methylphenidate as its active ingredient. Unlike Ritalin and other ADHD medications at the time, it was specially designed to provide a steady stream of medication through-out the day. Allowing parents to give their child one tablet in the morning before school and the medication will be effective all through the school day and into the evening. Concerta does this by placing the medication in a very cleverly design tablet which includes a laser drilled hole that allows the methylphenidate to slowly seep out.
Adderall is unlike the other ADHD medications because it uses a mix of different forms of stimulants. In theory this gives a smoother trip up to and down from the medication’s peak effectiveness. This avoids sudden peaks and troughs in the child’s attention span and energy levels. Adderall XR is a variant on standard Adderall designed to give a whole day’s supply in a single tablet, similar to the Concerta tablet.
With the introduction of Concerta and then Adderall XR, most users of ADHD medications switched to extended release formulas. To combat this loss of sales, Ritalin introduced two versions, Ritalin LA and Ritalin SR. For more information see Adderall XR and Slow Release ADHD Medications.
What Effect do ADHD Medications Have?
ADHD medications are stimulants and have a similar effect to caffeine, nicotine and street drugs such as cocaine and speed. They stimulate the activity of central nervous system which increases energy levels and helps maintain concentration. How exactly this helps with ADHD is unknown. On the patient information sheets of the ADHD medications you will find the drug companies explicitly saying they do not know how their drugs work.
Current ADHD medications treat the symptoms of ADHD and not the underlying causes. When testing the drugs, patients were measured by teachers and parents on various behaviour scales. Typically these reported increases in concentration, a reduction in hyperactivity and a general improvement in behavior. For a parent’s first hand account on the effects of medication see this video: Lil’ Renetto… talking about ADHD… and making videos….
Side-Effects of ADHD Medication
No medicine is free of side effect and ADHD medications are no different. As they are stimulants their effects are very similar to drinking too much coffee. The most the common side effect is insomnia with loss of appetite and stomach upsets being close seconds. About 20 – 30% of mediation users will have one or more side effects. These are very minor but can cause further problems and lead to the use of sleeping tablets or appetite enhancers to combat the effects of the ADHD medication.
Unfortunately there are more serious side effects. A lot less is known about these because the drug companies do not run long term trials prior to their ADHD medication getting approval from the FDA. The longest trial run by a drug company is four weeks. This is for a tablet that is routinely used for months and years at a time.
Others have researched the long term impact of ADHD medications and found some worrying effects. Up to 9% of users over a 27 month period developed facial tics. Children with who took the medications for more then 12 months were found to grow 2cm less than their non-drug using peers. There is also concern that the constant stimulation of the central nervous system will train or acclimatize it high levels of stimulation. This may impact in adulthood and result in great use of illegal drug such as cocaine and other high risk behavior.
The Cost of ADHD Medications
If your insurance or health care system doesn’t cover you for the price of your ADHD medications, treatment can get very expensive. For a month’s supply, the price of the drugs range from $26 for a generic versions of Ritalin up to $150 for Concerta and Adderal XR. The prices of the timed release versions of the drugs (Adderall XR, Ritalin LA or Ritalin-SR) are about twice the price of the normal versions. The reason for this is simple. The standard versions can be made by generic drug companies because the patents have run out. Where as the timed released version have several more years to run on the patent and so the drug companies can charge what they like for them.
When considering ADHD medication, its worth remembering this is a not a simple course of antibiotics. These a drugs that will be taken for months, if not years, because when you stop taking them the symptoms will return. Consequently the costs will added up, month after month, year after year.
If you are tempted by offers of cheap ADHD medication from online or foreign pharmacies then read this: Want No Prescription Adderall? – Read This Now!.
Alternatives to ADHD Medications
If you are not keen on everyday, giving your child a drug that can have serious short and long term side effects but doesn’t actually treat the problem then you need to consider the alternatives to ADHD medication. There are two problems with the alternatives to medication. Firstly, unlike the drug companies, the alternatives do not have hundreds of millions of dollars to spend marketing their products. Secondly, the alternatives take many months to have an effect. ADHD medication have an effect on the symptoms almost instantly. Tackling the underlying cause takes a lot longer.
Probably the best known and most widely available treatment is the Dore Programme of cerebellum exercises. These simple exercise are done everyday for a year or more and train up specific parts of the brain related to coordination, movement and self-control. It is an approach that has many critics but also many customers who have found them to work.
Another movement based approach is Interactive Metronome. This teaches the child a sense of rhythm, timing and control. There has been some very good research on how effective this can be as an alternative to ADHD medications.
A third movement based approach to ADHD is INPP’s primitive reflex training. Similar to Dore in some ways, this approach focuses on primitive reflexes that in normal children develop before they are 18 months. The INPP hypothesis is that in children with ADHD the reflexes are retained or not fully developed. Two books related to this are Stopping ADHD and Infinity Walk.
There are various herbal remedies that claim to be alternatives to ADHD medications. The science behind these is very weak but some people claim they work. See ADHD Natural Remedies Part 1, Part 2 and Part 3. Omega 3 fish oil supplements have also been promoted as an ADHD treatment. See ADHD and Omega Fish Oils for more information.
Are expensive slow release medications like Concerta or Adderall XR better than traditional and cheaper stimulants?
Adderall XR and the Patent Problem
One of the problems for manufacturers of ADHD Medication such as Ritalin and Adderall is that anyone can make them. The stimulants used in them where discover 50 or more years ago and any patents on them ran out long ago. Generic version of Ritalin are very cheap to make which is why you can buy a month’s supply for about $26.
So how do the manufacturers make lots of money from an ADHD medication that anyone make? Simple, formulate it in a new way and patent the new technology. This is what Shire Pharmaceuticals did with Adderall XR and Novartis did with Ritalin LA and Ritalin-SR. These time release tablets cost two or three times as much as their generic equivalent.
What’s Different about Adderall XR?
Compared to the standard Adderall, Adderal XR contains a different mixture of stimulants that are processed at different speeds by the body. This gives Adderall XR, in theory, a longer lasting effect with a smoother trip to and from its peak effect. In addition Adderall XR contains is medication in two beads. These dissolve in the stomach at different rates, one almost immediately and the other after four hours. This allows the drug to have an effect for up to 12 hours.
With Ritalin, Novartis took a different track to Shire and Adderal XR. In addition to the standard Ritalin tablets they introduced Ritalin-SR (slow release) and Ritalin LA (long acting). The SR version is a just a normal Ritalin tablet that disolves more slowly in the stomach where as Ritalin LA is a capulet containing tiny beads of medication. These beads dissolve at different rates giving a more even release of the drug. With the Ritalin LA capulet you can sprinkle the contents on food if the child cannot swallow the pill. This may be an advantage over Adderall XR or Concerta which cannot be broken before being swallowed.
Both the Ritalin-SR and Ritalin LA have the same active ingredient, methylphenidate, as regular Ritalin tablets. The prescribed dose of the Ritalin-SR/LA should be equivalent to the total daily dose of standard Ritalin. The effect of the long acting and slow release is about eight hours compared to the 12 hours claimed for Adderall XR and Concerta.
Is Adderall XR Better Than Standard Adderall?
Standard Adderall tablets are known as instant release tablets as they are designed to take effect as quickly as possible. Whilst this is useful in situations when a quick impact is needed it does mean that additional doses will be required after a few hours. The big advantage of the slow release medication such as Adderall XR and Concerta is that they last up to twelve hours. This allows a child to be medicated before the start of the school day and for the medication to still be effective by the time child returns home at the end of the day. This avoids giving the child or the school nurse additional tablets to take at lunch time, reducing the risk of the child missing or abusing their medication.
The other main selling point of Adderall XR and the other tablets is its smoother trip to and from its peak effectiveness. Stimulants that quickly achieve full effectiveness and then quickly drop off have a higher risk of abuse and addiction. Cocaine is a classic example of the quick high and quick fall. The different formulations of the drugs, compared to instant release tablets, mean that Adderall XR is harder to misuse as they are less suitable to crushing and snorting or smoking.
Does Adderall XR Do What it Claims?
Simply put, yes. Adderall XR is just as effective in treating ADHD as standard Adderall tablets and it does remain effective for up to 12 hours. This appears to be true of other extended release medications. However this must be treated with caution. Most of the research has been done by the pharmaceutical companies themselves and was scored using subjective criteria. Whether your child should use Adderall XR compared to normal Adderall or one of the other time release medications is something you and your doctor need to discuss.
Analog Classroom Assessment of a Once-Daily Mixed Amphetamine Formulation, SLI381 (ADDERALL XR), in Children With ADHD.
Long-Term Tolerability and Effectiveness of Once-Daily Mixed Amphetamine Salts (Adderall XR) in Children With ADHD.
No Prescription Adderall! Buy Ritalin Online! Concerta Without Prescription! Websites and spam email are all trying to sell you cheaper, easy access to drugs. Are they safe? Are the legal? Are they cheaper?
No Prescription Adderall!
In the US, Adderall, Ritalin and Concerta are Schedule II controlled drugs. The sale of these ADHD medications is strictly regulated by the Drug Enforcement Agency. In short it is illegal to buy Ritalin, Concerta or Adderall without a prescription. It is also illegal to buy online without a prescription from foreign pharmacies as you are then importing illegal drugs.
The situation is the same in the UK where these medications are counted as Class B drugs. ADHD medication such as Adderall, Concerta and Ritalin are heavy duty stimulants and have a long history of illegal use and abuse. Governments tend to frown on easy access to such powerful drugs so whatever country you are in, offers such as ‘No Prescription Adderall’ are going to be illegal.
Buy Adderall Online!
If you have an Adderall prescription, can you legally buy online?
Maybe is the most honest answer. The regulation of drugs is carried out by large and slow moving government agencies. These bodies are not best suited for dealing with the fast moving world of the global internet and most of the relevant laws were drawn up before the internet was created. So it may be legal to buy Adderall online (with a prescription) depending where you are. However buying from a foreign country, whether you have a prescription or no prescription, Adderall, Ritalin and Concerta will be illegal. Police, customs and the post office get very upset when you import controlled drugs through the post.
In the US it is legal to buy medication online if you have a prescription and the pharmacy you are buying from is in the US and is properly licensed. When it comes to schedule II ADHD medication such as Adderall, the DEA say:
Is it Possible for my Internet Pharmacy to Fill Prescriptions for Schedule II Substances?
You may fill valid prescriptions for Schedule II substances if the patient or prescriber provides you with the signed original prescriptions prior to dispensing. Practically, it is unlikely that most patients will want to wait the time required for such a transaction.
The key words in this are ‘signed original prescriptions’. Faxing a copy of your prescription is not enouigh to buy Adderall online.
Cheap Adderall Online!
You have a prescription for Adderall and you want to buy from an online pharmacy in the US. Is it any cheaper than your local store? According to the Consumers Union, the price for a month’s supply of Adderall XR (10mg) is $144 and $130 for Concerta (18mg). Prices from September 2006.
Seaching Google for ‘Buy Adderall Online’ I quickly found Meds For Cost who are selling Adderall XR (10mg) for $109.88. It can be had for $105.80 from Trusted Online Pharmacy or for $52.80 if join their site as a member ($25 a month). After ten minutes more of searching I could not find any other sites actually claiming to sell Adderall or Concerta online.
No Prescription Adderall – A Myth
If you are looking to buy no prescription Adderall online then don’t bother. Any legitimate pharmacy in the US will require you to send an original prescription before they can supply the medication. Even if you have an Adderall prescription, this is simply too much work for the customer and the company to make it worth while.
If you are tempted to buy online from foreign companies then think twice. For starters, you will be breaking serious laws by attempting to import them into your country. Secondly, Adderall, Concerta and Ritalin are powerful and dangerous drugs. Do you really trust a company that will sell you strong medications such as Adderall with no prescription? If a company is willing to behave that irresponsibly, they are willing to do anything. Including sending you fake pills made with god-knows-what. Caveat emptor