Overview

Attention Deficit Hyperactivity Disorder (ADHD) is a very complex disorder and for

many individuals suffering from ADHD, their daily struggle with this disorder can be

very frustrating and debilitating at times. Throughout the years, it has been known that

genetics has a strong link to the cause ADHD as well as the psychotropics being

prescribed by Mental Health Professionals to assist in the management of ADHD.

However, data supports in the past decade there has been an explosion with ADHD

individuals, specifically children being treated by the pharmacological modality

rather than the behavioral modification or family psychotherapy. The old analogy of take

two pills and call your doctor in the morning is becoming the norm in today’s society.

This Reflective Paper will provide a multi-systemic approach which addresses the following

topics: (1) the genetic link to ADHD, (2) population trends of psychotropic use, (3) concerns for

the safety and efficacy of children have risen due to the lack of studies.

The Genetic Link to ADHD

Several decades of study has shown Attention Deficit Hyperactivity Disorder (ADHD)

to be a neurobiological disorder. Research has shown other contributing causes of ADHD

can be caused by environmental (home, school etc.), brain dysfunction and toxins found

in food additives, yet strong supporting data can be found in genetic studies too. Researchers

have concluded the phenotypic display of ADHD is attributed by the abnormal amounts

of neurotransmitters such as serotonin, gamma-amino butyric acid (GABA) and

dopamine which controls, sleep, learning, mood and attention (Faraone, & Asherson, P,

2005). Link between ADHD 3

Studies show that on the average, 25% of all families who have a member diagnosed

with ADHD are usually not alone. When clinicians review family medical history, it’s

not uncommon to find other family members who have been formally diagnosed with

ADHD or demonstrate signs and symptoms. To support the genetic link to ADHD, the

strongest genetic data comes from twin studies, yet more studies are needed to assess the

specifics of the overlapping between familial and genetic neurocognitive impairments of

ADHD. However, many mental health professionals continue to support the cause of

ADHD is mainly environmental or family dynamics driven. The belief that children

demonstrating signs and symptoms of ADHD come from a home with poor family

dynamics. Specifically, these parents lack the parenting skills necessary to appropriately

parent their child or children. Once a child demonstrates behaviors of ADHD, research

data reflects school educators or psychologist immediately address the type of family

dynamics that child is living around. Other factors reviewed are, possible drug use or

abuse issues (emotional/physical) which would distract a child and increase anxiety in a

school settings. For many children who have been diagnosed and are being treated for

ADHD, on the average, their family dynamics will not be consistent nor will there be a

high level of parenting skills being demonstrated by parents. The high probability of one

or both parents experiencing adult ADHD is very high. Given this fact, it’s vital the

research continues in confirming that ADHD is caused by genetic factors and not entirely

on environment.

In the meantime, the dilemma and challenge for children experiencing ADHD appears

to be; how to function daily with characteristics such as, inattentive, fidgety,

Link between ADHD 4

difficulty in playing quietly or waiting their turn, excessive talkativeness and interrupts

others. Until more data can be gathered, Mental Health Professionals continue to

prescribe different types of psychotropics (Ritalin, Adderall or Concerta) to children

resulting in contraindications such as dizziness, headaches, increased anxiety,

gastrointestinal problems and cardiac issues.

The growing number of children being prescribed psychotropics to help manage their

ADHD symptoms is a concern for families as well as professionals. Currently, research

is being done in the prescribing trends done by the child’s provider and the actual

populations that use psychotropics most frequently.

Who are the new users of psychotropics? In recent years, the psychiatry community has been turning their focus to ethical issues of pharmacotherapy intervention concerning aspects of the increased use of antipsychotic. The specific areas of concern cited were: a trending increase in prescription writing since 1996, the population using antipsychotic medications and the diagnosis associated with the need for antipsychotics, safety and efficacy. It was determined that second generation antipsychotics were rapidly making up the new population of psychotropic users (Bellonci and Henwood, 2004). According to the Food and Drug Administration (FDA), there has also been an increase in psychotropic usage with individuals who’ve been diagnosed with bipolar disorder as well as a significant increase in off-label usage. While the psychotropic medication spending is on the upward swing and continues to rise higher than any other medication (17% vs 21%)

Link between ADHD 5

there have been barriers found in the treatment and cost of prescribing this type of medication in the mental health field (Bellonci, Henwood (2004). One particular study was done by the Florida Medicaid Program and involved a population of youths and adolescents up to the age of 18. The results produced from this study found a significant amount of use between the years of 2002 -2004, within the sub-group of 13-18 years and the least was 0-5 years old. Aripipazole and risperidone was reported the two highest prescribed psychotropic’s in 2005 for 13-18 year olds. The method used in this study was fee for service claims submitted for psychotropic payment. This data taken was from a population of 1.2 million second generation children enrollees in the fiscal years 2002 – 2005. The population then was broken down into three sub-groups (0-5, 6-12 and 13-18 years). In order to control for variances in enrollment, researchers examined the sub-groups in numbers containing 1,000 enrollees. “Trends in antipsychotic use were analyzed by using piecewise regression with time in months as the independent variable and monthly users per 1,000 enrollees as the dependent variable” (Bellonci and Henwood, 2004). During this study many side-effects were also noted, cardiac problems, weight gain, increased chances of diabetes and dyslipidemia. Researchers at Florida Medicaid Program cited more research is needed not only the second generation population but in how youths are being diagnosed that are requiring psychotropic’s and the specific symptoms being targeted with the psychotropic. Lastly, what is the projected length of time a youth will use psychotropics. Results from the Florida Medicaid study confirmed the new psychotropic users are second generation but this is just the tip of the iceberg. Link between ADHD 6

With the second generation youths and adolescents relying on a broad number of psychotropics daily to reduce their erratic moods and promote better behavior. Many studies have been written about the effects second generation psychotropic users may experience. South Carolina Medicaid program identified cases of youth and adolescents associated with an event of cardiovascular or metabolic disturbance and treated with antipsychotics. The data came from outpatient and inpatient medical services and pharmacy claims submitted through the
South Carolina Medicaid program January 1, 1996 through December 31, 2005. The treatment group encompassed 4140 youth and adolescents of 1 of 5 atypical or 2 conventional antipsychotics while a random sample of 4500 youth and adolescents not treated for with psychotropic medications (Domino, M., Swartz, M. (2008). Somatic conditions were cited in both groups and the prevalence rates for obesity, type 2 diabetes mellitus, dyslipidemia, cardiovascular and cerebrovascular events, hypertension, and orthostatic hypotension. The random samples of results were much lower than the controlled group (see Figure 1). Random Sample Controlled Sample Increased Chance Obesity 2.13 2.28 +15
Type 2 Diabetes Mellitus 3.23 2.36 -87
Dyslipidemia n/a 5.26 +5.26
Cardiovascular Events 2.70 4.34 +1.64
Cerebrovascular Events n/a 1.57 +1.57 Hypertension n/a 1.77 +1.77 Figure 1 Link between ADHD 7 The conclusion of this study made by South Carolina’s Medicaid program were the youth and adolescents in the controlled group who had been taking psychotropic’s experienced several metabolic and cardiovascular events, especially when multiple antipsychotics or classes of psychotropics are prescribed for youth and adolescents with high risk factors (3).
Many researchers and others are concerned with the fact of Medicaid programs having an enormous amount of children and youths enrolled who are currently being prescribed multiple class of psychotropic’s for their emotional and behavioral issues. A few years ago, Dr.
Hennessy who is with the U.S. Department of Health and Human Service along with three of his colleagues wrote an article citing their concerns with Medicaid beneficiaries receiving psychotropics in their pharmacological regimen. His article used populations from ten states
(Alabama, Arkansas, Delaware, Georgia, Kansas, Kentucky, New Hampshire, New Jersey,
Vermont and Wyoming) that currently received Medicaid benefits and were diagnosed with either Schizophrenia or an affective disorder and taking psychotropic medications.
The samples of this study was adults between the age of 21 and 64 and recipients of Medicaid only. No dual Medicaid and Medicare) coverage beneficiaries were accepted. From the sampling of the ten states, a total of 185,791 Medicaid enrollees used some type of mental health services or chemical abuse treatment service. Of these 14% (26,256) were diagnosed with schizophrenia or schizoaffective disorder. While 17% (32,192) were diagnosed with an affective disorder. Dr. Hennessey and his colleagues concluded from their research; 84% of all Medicaid beneficiary classified with schizophrenia were being prescribed an antipsychotic while 74% used antipsychotic medications with a classification of an affective disorder (McIntyre R, Terrell, J (2008). See figure 2. Link between ADHD 8

80
70
60
50
40
30
20
10
0

Anti-Depressants Anti-Psychotics Barbiturates Benzodiazepines Lithium Multiple Drugs No Drugs

It’s becoming increasingly alarming that the number of Medicaid beneficiaries throughout the
United Stated that are being prescribed some type of psychotropic medication at young ages.
Supporting research of massive over prescribing, increased dosage rates, and multiple class of psychotropic’s being prescribed to the second generation is astounding. The health ramifications from long-term psychotropic use have only recently been a topic of interest and not a priority for the pharmaceutical companies who manufacture these drugs. Link between ADHD 9

The FDA originally approved this classification of drugs for a limited time of use for individuals needing to take Risperdal, Seroquel, Zyprexa, Geodon or Abilify just to mention a few. It’s no secret many professionals are paid large sums of money to support a drug within their professional community. Matter of fact in August of 2007, the Associated Press reported various drug companies spending a large amount of money on members of the Minnesota advisory panels that help choose the drugs which patient’s will be covered through Medicaid benefits. The pharmaceutical companies mentioned in this article were, Eli Lilly who manufactures Zyprexa and Astra Zeneca who makes Seroquel (DeAngelis, 2004). It poses the question, is our children being sold out due to greed from a selected number of health professionals sitting on high- powered State Boards making decisions that could affect American families for generations to come. In a few years are we looking at the “third generation” of psychotropic users? A new study was just published in BioMed open access journal Child and Adolescent
Psychiatry and Mental Health claiming children in the United States are “approximately three times more likely to be prescribed psychotropic’s than the children in Europe” (BioMed Central;
American kids most medicated 2008). Julie Zito led the team of researchers and came to the conclusion, antidepressants and stimulants usage was three or more times greater in the United
States than in the Netherlands and Germany. She attributes the increased use of psychotropics to the differences in diagnostic classification systems and cultural beliefs. Zito cited the US trend of increasing bipolar diagnosis in children and adolescents which does not reflect the European practice. Zito concluded by saying, “The increased use of medication in the US also reflects the individualist and activist therapeutic mentality of US medical culture" (Hennessey, Hennessey-
Green and, Miller, 2007). Link between ADHD 10

Conclusion

It’s undeniable; children living in the United States today are vulnerable to being diagnosed

with Attention-Deficit Disorder (ADHD), it has become a “blanket” diagnoses. The data found

in this Reflective Paper supports that ADHD is genetically driven and mental health

professionals are treating second generation patients diagnosed with ADHD. More and more

professionals today question the efficacy of psychotropics and are looking for alternatives to

assist their patients in managing their ADHD symptomology.

It’s time the bar is raised by mental health community in confirming the last piece of the genetic

puzzle for the sake of our clients and future clients.

Link between ADHD 11

References

Faraone, S., and Asherson, P., (2005), The Molecular Genetics of ADHD: A View From the IMAGE Project, retrieved on 12/01/09 from http://www.psychiatrictimes.com

Zonfrillo, Penn, Leonard (2005) Pediatric Psychotropic Polypharmacy. Psychiatry MMC, Retrieved October 18, 2008 from http://www.psychiatrymmc.com

Bellonci, Henwood (2004) Use of Psychotropics Medications in Child Welfare. Retrieved October 19, 2008, from http://www.hunter.cuny.edu/socwork/nrcfcpp/Psychotropic-Medications

Murat C, Nahit M. (2008). Possible Risperidone-Related Gastrointestinal Bleeding or Epistaxis in Two Pediatric Cases. Journal of Child and Adolescent Psychopharmacology, 18(3), 299-300. Retrieved November 1, 2008, from Research Library database. (Document ID: 1501025401).

Domino, M., Swartz, M. (2008). Special Section on Implications of CATIE: Who Are the New Users of Antipsychotic Medications? Psychiatric Services, 59(5), 507-14. Retrieved November 1, 2008, from Research Library database. (Document ID: 1488756331).

Constantine, R., Rajiv T. (2008). Changing Trends in Pediatric Antipsychotic Use in Florida's Medicaid Program. Psychiatric Services, 59(10), 1162-8. Retrieved November 1, 2008, from Research Library database. (Document ID: 1576210571)

McIntyre R, Terrell, J (2008). Metabolic and Cardiovascular Adverse Events Associated With Antipsychotic Treatment in Children and Adolescents. Archives of Pediatrics & Adolescent Medicine, 162(10), 929. Retrieved November 1, 2008, from Research Library database. (Document ID: 1582078201)

Hennessey K.,Hennssey-Green, .S, Buck, J.,Miller, K (2007) Use Of Psychotropic’s in Mentally Ill by Medicaid Beneficiaries, Retrieved October 30, 2008 from http://psychservices.psychiatryonline.org/cgi/content/full/53/9/1070

BioMed Central; American kids most medicated. (2008, October). NewsRx Health,17. Retrieved November 1, 2008, from Research Library database. (Document ID: 1565638811)

Pringle, E. (2007) Psychotropic Drug Makers Bankroll Prescribing Shrinks Retrieved October 19, 2008 from http://psyrights.org

DeAngelis, T., ( 2004), Should Our Children be Taking Psychotropic’s? retrieved October 31, 2008 from http://www.apa.org/monitor/dec04/psychotropics.html
Faraone, S., and Asherson, P., (2005), The Molecular Genetics of ADHD: A View From the IMAGE Project, retrieved on 12/01/09 from http://www.psychiatrictimes.com