Non-Stimulant for ADHD -- Full-Length Doctor's Interview

In this full-length doctor's interview, Thomas Spencer, M.D., explains how a different kind of drug is offering hope to the 2 million children in the United States with ADHD.

Ivanhoe Broadcast News Transcript with
Thomas Spencer, M.D., Child Psychiatrist,
Massachusetts General Hospital, Boston, Massachusetts,
TOPIC: Non-Stimulant for ADHD

What do you consider the main thing people think they know about ADHD but don’t?

Dr. Spencer: Well, it depends on when you heard about it. But in general, the public is a little bit behind on the wealth of new findings. [ADD] used to be defined as a motoric overactivity -- hyperactivity, minimal brain dysfunction, these old terms. In about 1980, the term changed to attention deficit disorder. It’s not really a total deficit, but a control of attention, more of a cognitive disorder, a brain disorder with behavioral features at times. That was a huge shift from kids who were overactive for whatever reason to somebody who had trouble paying attention, focusing, completing tasks, and who may or may not be hyperactive. There are other medical findings. Some psychiatric disorders are primarily psychosocial, primarily in relationship to family and upbringing. ADHD turns out to be more medical than many of these other disorders. It's 70 percent genetic. That is, on average, 70 percent of its ideology, its cause, is genetic. That’s rare and it’s among the most genetic of disorders. A number of the brain studies that they’ve been able to do with the individuals with ADHD show remarkable findings. We’ve seen them with some of the other brain or psychiatric conditions, but they’re really quite striking and quite consistent in this disorder. I think the public is usually unaware of these things. It takes several years for it to kind of get out.

It’s almost gotten to the point where the terms ADD and ADHD have become interchangeable. Do you think that’s another area where people get confused?

Dr. Spencer: That’s a good question. The names have changed over time, and by and large, when people use either name, they mean the same thing. It is a problem that some individuals with ADHD are very active and hyperactive, and some are not hyperactive at all. They simply have attentional problems or school-related problems, and we now think it's differing forms of the same condition, so the titles have changed over time. Essentially, we mean the same area of conditions and both parts of it, the hyperactivity and the inattention, are related and can go together.

Are they usually treated the same way?

Dr. Spencer: It depends on the type of treatment that you’re talking about. Medical treatments tend to work similarly for both conditions, but psychosocial treatments or environmental treatments may be quite different. If a child is simply disorganized, has poor discipline, and can’t function well in school, but is quiet and not a behavioral problem, you’d be working on school remediation, organizational issues, learning issues, per se, or social issues, say if those were primarily. There are other kids who are so full of energy that they’re a bit disruptive and they need some behavioral feedback. That’s a different kind of psychosocial treatment for a similar condition.

Does a child's diet have anything to do with ADHD?

Dr. Spencer: Your question about diet was actually formally studied. Everybody had the impression that diet was closely related. If diet was to be a cause of the problem, then if you changed diet, then people would get better, and it hasn’t been shown to be true. Kids with ADHD tend to crave junk food and sugar. They eat poorly. If you eat a lot of sugar, you’re a little more hyper, but even if you exclude sugar and all these additives and eat a very bland, difficult-to-enforce diet, you don’t improve that much. That was actually tested. There were lots of double-blind controlled studies of that. The American Academy of Pediatrics wrote a position statement saying that there may be a few sensitive individuals, but by and large, diet isn’t a good treatment for ADHD, and it's not usually part of the cause.

Then what is going on?

Dr. Spencer: The worry is that people without ADHD, with some other problem, would be getting Ritalin and that that would be inappropriate, and what’s even worse is that their real problem wouldn’t be addressed. Let’s say they had a chaotic family home and lots of stress at home and they were just upset and someone diagnosed it as hyperactivity, didn’t do a very good evaluation, and put them on Ritalin and so they’re on Ritalin or another ADD medicine. The downsides of that are actually not huge. The bigger issue for me is that the real problem wouldn’t be addressed. They’re upset, they’re not able to think at school, no one is asking them about their home environment. That would be important.

In 1980, when the shift was made from hyperactivity to attention deficit with and without hyperactivity, we recognized that about a third of people with this condition weren’t hyper at all. We didn’t think girls had it at all. My sense is that it was a true gender bias and girls weren’t assessed. Girls could fail without causing a problem in the classroom. They weren’t considered to need to be breadwinners at the time, so they were allowed to fail in this way. We now think that almost as many girls have the disorder as boys and by looking at whether they’re achieving their potential and not whether they’re causing a problem, we’re able to, I think, correctly identify people who need some help, whether it's medication or not. Adolescents often outgrow the hyperactive part, but an adolescent with ADHD is at huge risk for problematic behavior. They’re failing in school. They have social problems. They’re taking risks, and likewise, our guess is that about half of the children continue to have enough of the problems as adults to severely affect their lives. They’re not typically running around and hyper anymore, so girls, adolescents, and adults account for some of the increased diagnosis, but just inattentive kids in general.

What do stimulants like Ritalin and Adderall do to treat this syndrome?

Dr. Spencer: Interestingly enough, stimulant treatment has been used for 50 years to 60 years. It predates all antidepressants and antipsychotics and other psychotropics, so we have a huge database on the effectiveness and relative safety of these medications. We don’t know exactly, but they appear to help the circuit in the brain that controls attention and motoric behavior. Dopamine and neuroepinephrine appear to be the signaling system that’s involved in this circuit in the brain, and they change the amount of dopamine and neuroepinephrine. They increase the natural amount of signaling that occurs in people with this condition.

What’s the downside to using stimulants in children with ADD or ADHD?

Dr. Spencer: Actually, my biggest downside is if you’re inappropriately using the medication or if you’re missing something that the medications aren’t addressing, then the child still has a problem and you think the stimulants are going to cure all the problems. In appropriate use, meaning correct diagnosis, ruling out other problems that could co-exist, any given stimulant works in about 70 percent of the children that it’s tried in. Then you would try another stimulant or a different medication. In most of the children, it's super-well tolerated. When they come in and you ask them do you feel anything on the medicine, they say I don’t feel a thing. The really perceptive children say I’m more successful. I can do my work more easily, and that kind of thing. I notice that I have a better day more often. I’m not Superman. I don’t feel different than I do at other times. I’m just more consistent. I have a good day, day to day. I’m able to study. I get through my homework without spending all evening going back and forth. Some of the kids that don’t understand as well just say people don’t yell at me anymore. When I don’t take the medicine, everyone is screaming at them. I take the medicine, people are so nice. They’re saying good job and they’re not telling me where’s your other shoe and the bus is here and that kind of thing. I tend to follow things they would say.

What was the motivation to create a non-stimulant that treats the same condition? Were some children having a problem with the stimulant?

Dr. Spencer: In general, in every area of medicine, it’s wonderful to have options. All the new serotonergic antidepressants that have taken over the field, on average, don’t work any better than the old ones. They are better tolerated; they have better side effect profiles. There are some people the other medicines didn’t treat, so they’ve actually replaced equally efficacious medicines. In this case, having a medicine that’s really different than the stimulants is a wonderful new option for many reasons. Not everybody gets better on the stimulants, though it’s an impressive success rate with the stimulants. Maybe 30 percent don’t get better on any given stimulant, and some kids don’t get optimally better on any of the medicines. So having another choice to turn to and, our guess is in the end, a combination of meds would be right for some kids with resistant conditions.

Let’s just talk about Strattera (atomoxetine). It's not a stimulant, so what is it and how is it working differently?

Dr. Spencer: The word stimulant is a funny word. If you give high doses of stimulants to animals, man included, they’re overstimulating and you induce increased movements. At therapeutic doses, stimulants help calm attention. So, they’re given this kind of funny word. The word non-stimulant means it doesn’t work on that same system, the dopamine system primarily. It works primarily on a different system, in this case neuroepinephrine. So, it works in sort of a parallel tract in the brain to help with similar issues. It helps with inattention, distractibility, hyperactivity, and that increase in those functions allows kids to study more easily, to pay attention in class, to be less distractible, to be more socially appropriate, and so you get the same kinds of improvement. Probably the one thing about some of the non-stimulants that’s also different than the stimulants that’s important is that they tend to work 24 hours a day. The stimulants tend to work for a short time. They’re a new improvement, so the newer stimulants have been developed with very technical delivery devices to work for eight hours or 12 hours a day, but this new one, Strattera and some of the other ones that are not approved for use, work for about 24 hours a day. And as we understand, ADHD is affecting some children in adolescents and adults their entire day. That’s an important issue.

You talk about that Ritalin, for example, working on the dopamine. Many people who pay attention to any health stuff know that dopamine is the reward center. What is epinephrine?

Dr. Spencer: Let me back up an inch. Dopamine is one of the main neurotransmitters for the pleasure center, but it's not always activated, so when you give the stimulants, you’re not causing reward or euphoria at all. In therapeutic doses, kids don’t feel funny or high or anything like that. It’s a very important distinction. It does increase the ability to turn on one part of the brain, to turn off parts of the brain, you know, to turn off noises you shouldn’t be listening to, to allow interest and focus on a particular task, and actually to increase your memory, your ability to hold things in your mind and to compare them -- you read two books and you compare them; you read two books and you compare what did this author mean and what did that author mean -- the ability to when you’re thinking about one thing to also think about another thing, so informational processing. Neuroepinephrine does much of the same thing. It’s a very related compound, so part of this is it's just a different area and it gets it in an optional way but very similar and part of it is that drugs that work on neuroepinephrine tend to work 24 hours a day.

Plain and simple, what does now having Strattera available as a treatment mean for helping children with ADHD?

Dr. Spencer: Given that the stimulants have been available for 40 years and have this track record that we know about. There are some new twists, but this is the first really new kind of compound that’s been proven and really tested for this condition. So, it really is a big paradigm shift. It's not another drug that’s like ones we have. It’s really a new one. It’s new in several ways. It’s different, so that some kids who don’t respond to stimulants will respond to it. It lasts 24 hours a day. It has some different profiles. That means that some kids will do better on it than the stimulants. Kids who are mildly anxious might do better. Kids with tics might do better on it. That being said, some kids do better on the stimulants than this. It's not going to replace the stimulants, but it really is a very different option. I think it allows anybody working in this area and parents and kids with this problem to really think what’s best for them. So, it's an important enough new edition to really be included in the menu of things that could be helpful.

What is the message to parents who have a child with ADHD who is being treated with one of the stimulant drugs and it's not necessarily working? What do they need to know about Strattera?

Dr. Spencer: You put it well. If your child is on a medication or a treatment plan in general that’s not working, you need to go back to your treater and be very clear this is what’s working; this is what’s not working. These are side effects I’m having. We’re not telling people to go in and ask for it by name, a new medication. They’re not going to be able to really know whether it’s right for them. But, the clinician they’re working with now has an option they didn’t have two months ago and so it's good for parents to know that. Some parents have gone to their clinicians for two years and they haven’t been able to come up with the right combination of things. There are some new improvements. There are new stimulants, there’s this new drug Strattera, things that might be helpful -- the ability to have the medication work when the child wakes up in the morning before having there be a lag from taking the medicine. A drug that works late into the evening and doesn’t interfere with sleep may help with tics and anxiety -- those kinds of things. So you shouldn’t determine yourself whether it's useful, but if those are persistent problems, there’s a new treatment that might be helpful and it would be worth talking to the clinician about it.

Are there side effects with this that are different?

Dr. Spencer: It's generally fairly benign. That being said, side effects are a little determined by the individual. If you have a side effect, then you hate whatever you’re on. It has mild appetite suppression, a little less than the stimulants probably. It doesn’t have any insomnia. Some kids, but relatively a minority, had some GI upset that tended to go away as you went up with the medicine. Occasionally, children are mildly sedated on it. That usually goes away. If it doesn’t go away, you wouldn’t continue with that medication, but nothing dire. There appears to be no serious. They’re sort of nuisance or uncomfortable side effects, but nothing medically serious has been determined so far.

Anything else you want to add?

Dr. Spencer: Well, I think some of what’s new about ADHD in general, or some of the medical findings, but also the appreciation of how it can affect somebody in different parts of life. It was originally defined as hyperactive motor activity, and it was considered primarily a school problem. If a boy had to sit in his seat and sit all day, that was difficult and for school, you may need a medication, especially if they called out or were disruptive or that kind of thing. As we’ve grown to appreciate that there are problems with focus distention with this disorder, we’ve also grown to appreciate that it can affect the ability to get along with other kids, not just in a disruptive or belligerent manner, but some kids just have a hard time listening to other kids, they’re a little bit abrupt. It can affect maturity. It can affect the ability to get along with parents, with authorities, with other kids, and so the general sense is that we’re asking all clinicians to ask about all parts of life, not only school, but home, hobbies, and that sort of thing, a person’s entire day. There are recent treatment studies that used longer treatment into the day, 12 hours of treatment, that found much better improvement in social function, in self-esteem, and those kinds of issues than focused treatments just on school. So, for some kids at least, more thorough treatment is more helpful.

Does it affect the non-hyperactive?

Dr. Spencer: Absolutely. When you do the trials and when you’re using rating scales, hyperactive features -- the ability to sit in the chair, to not fidget, and that kind of thing, to be less impulsive, to jump to different stimuli  -- all the meds, the stimulants and this new Strattera, they work on that, but they also work for inattention, distractibility, organization and focus. Some people who have only that disorder, they’re not hyperactive at all, it will work as well on them. They don’t tend to have as many symptoms, so they’re usually a little better at baseline.

Does it also work on adults?

Dr. Spencer: We’ve actually done a lot of work on adults. Adults were one of the sort of missed areas. Adults were thought to have all grown out of it, but it turns out that inattention tends to persist and there are people with sort of hidden hyperactivity. They feel restless. They, even though life is working out for them, they kind of get bored and change, get divorced or change jobs even when they’re working pretty well, and the medicines that work for kids work just as well for adults. You just have to be a little more developmentally sensitive to what’s the issue in adults. Some of the issues in adults are the so-called executive functions -- time management, planning, administration, those kinds of things.

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END OF INTERVIEW

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc., or any medical professional interviewed. Ivanhoe Broadcast News, Inc., assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

If you would like more information, please contact:

Thomas Spencer, M.D.
Massachusetts General Hospital
725 ACC Building
Boston, MA 02114