The American Heart Association (AHA) has issued recommendations that call for cardiovascular screening before prescribing stimulant treatment for all children diagnosed with attention-deficit hyperactivity disorder (ADHD).
The guidelines are meant to address mounting fears that these medications can raise the risk for cardiac complications among those with underlying heart disease.
"This is new, and it is a shift in our policy," says Dr. Victoria L. Vetter, at the University of Pennsylvania School of Medicine.
"But we're not recommending that every child in the country have these heart screenings, rather that they be used as a reasonable tool for this small, particular group of children about to take ADHD medications, so we can ensure the treatment proceeds as safely as possible," she explains.
The recommendations were published in Circulation, a journal of the AHA.
The following is recommended: the taking of a detailed patient and family medical history, particularly regarding heart disease; a full physical exam, including blood pressure and heart beat monitoring; an electrocardiogram (ECG); and a pediatric cardiologist consultation prior to treatment if evidence of heart disease is uncovered.
After treatment begins, the AHA says that children should continue to have blood pressure check-ups once every one to three months, as well as routine health check-ups every six to 12 months.
The AHA notes that ADHD is the most common neurobehavioral disorder among American children.
Estimates show that between 4 percent and 12 percent of American school-aged children have the condition.
Currently, more than 2.5 million children in the US are being prescribed ADHD medications, the AHA says.
According to the National Institutes of Health (NIH), the most effective ADHD medications typically belong to the "stimulant" class of drugs, which includes amphetamines, methylphenidates, and dextroamphetamines.
Some of the names under which these drugs are marketed include Adderall®, Concerta®, Dexedrine®, Focalin®, Ritalin®, Ritalin SR® or LA®, and Metadate ER® or CD®.
The new recommendations refer to all of these stimulants, as well as to a newer drug known as Strattera®, which was recently approved by the US Food and Drug Administration (FDA) as a non-stimulant treatment for ADHD.
Though ADHD stimulants increase a child's heart rate and blood pressure, the NIH noted that no evidence has indicated that such medications are addictive, and side effects do not typically pose any danger for most healthy children.
However, children with underlying heart disease who take stimulants for ADHD appear to face an increased risk for sudden cardiac arrest, the AHA notes.
This risk association is particularly troublesome for young ADHD patients, because heart disease often goes undiagnosed in children and may be present without noticeable symptoms.
The AHA also pointed to a number of studies that suggest that between 33 percent and 42 percent of pediatric heart patients also have ADHD.
FDA data collected for the period 1999 through 2004 revealed that 19 children following an ADHD prescription regimen had died suddenly, while 26 experienced heart complications such as stroke, heart attack, and/or heart palpitations.
Dr. Vetter notes that, in 2005, the Canadian equivalent of the FDA - Health Canada - decided to place a ban on Adderall, an amphetamine-based ADHD medication designed for kids over the age of three.
The Canadian decision was actually based on a review of FDA records concerning 12 reported deaths among American children taking ADHD medications.
Dr. Vetter points out that the Canadian decision was based on an assessment of collected data based on family self-reports (sometimes in the absence of autopsy records), rather than a complete scientific analysis.
"But the reality is that we were faced with some kids who had ADHD who suddenly died," she says. "And a lot of them were exercising at the time, which is when most of the kids who have electrical malfunctions of the heart would have a sudden cardiac death. So we have to assume they experienced a cardiac death."
In February 2007, the FDA ordered makers of ADHD medications to develop guidelines that alert patients to the heart risks associated with their treatments.
"But it's not that these are dangerous medicines," stresses Dr. Vetter. "But by adding the ECG, and by being aware of possible heart disease, and monitoring the kids once you prescribe the medications, one can go ahead and treat the ADHD. And these kids can be very happy."
Dr. Andrew Adesman, at Schneider Children's Hospital in Hyde Park, New York, agrees that the point of expanded screenings is to identify a child's underlying heart complication, not to look for problems with the stimulants themselves.
"Serious cardiac complications from stimulant medications are very rare," says Dr. Adesman. "But because there are concerns on the part of parents and some physicians, routine ECG screenings will provide greater reassurance for the vast majority of patients for whom ADHD medications are being considered."
Always consult your child's physician for more information.
ADHD is one of the most researched areas in child and adolescent mental health.
However, the precise cause of the disorder is still unknown. Available evidence suggests that ADHD is genetic.
It is a brain-based biological disorder. Low levels of dopamine (a brain chemical), which is a neurotransmitter (a type of brain chemical), are found in adolescents with ADHD.
Brain imaging studies using PET scanners (positron emission tomography; a form of brain imaging that makes it possible to observe the human brain at work) show that brain metabolism in adolescents with ADHD is lower in the areas of the brain that control attention, social judgment, and movement.
Estimates suggest that about 2 million children (3 percent to 5 percent) have ADHD. Boys are two to three times more likely to have ADHD than girls.
Many parents of adolescents with ADHD experienced symptoms of ADHD when they were younger. ADHD is commonly found in brothers and sisters within the same family.
Most families seek help when their adolescent's symptoms begin to interfere with learning and adjustment to the expectations of school and age-appropriate activities.
The symptoms of ADHD vary with age. In general, hyperactive behavior in children is less conspicuous, as, at this age, children are less likely to be required to sit still, pay attention for long periods of time, etc.
As children mature, though, symptoms become more conspicuous.
In early school-aged children, symptoms present differently, and involve more gross motor activity, such as climbing, running, fidgeting, inability to sit still, trouble remaining seated, tapping, etc.
These symptoms often affect class work. During late childhood and early adolescence, these types of symptoms are less common, and more restlessness sets in.
In adolescence, there is often more impulsive behavior, breaking of rules, and problems with relationships.
ADHD is the most commonly diagnosed behavior disorder of childhood.
A pediatrician, child psychiatrist, or a qualified mental health professional usually identifies ADHD in adolescents.
A detailed history of the adolescent's behavior from parents and teachers, observations of the adolescent's behavior, and psychoeducational testing contribute to making the diagnosis of ADHD.
Further, because ADHD is a group of symptoms, often diagnosis depends on evaluating results from several different types of evaluations, including physical, neurological, and psychological.
Certain tests may be used to rule out other conditions, and some may be used to test intelligence and certain skill sets.
Always consult your child's physician for more information.
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