ADHD drugs work, but not the way experts thought
The stimulants Ritalin and Adderall have been used for decades to treat attention deficit hyperactivity disorder (ADHD), but research shows they don’t act on the brain’s attention circuits as long thought.
Instead, the drugs primarily target the brain’s reward and arousal centers, according to a new study published in the journal Cell. The research, which used brain imaging data from nearly 5,800 children aged 8 to 11, also highlighted the important role that lack of sleep plays in the disorder.
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“When I first saw the results, I thought I had made a mistake because none of the attention systems changed here,” said Benjamin Kay, one of the study’s authors and a professor of neurology at Washington University School of Medicine in St. Louis.
It’s not that stimulants are ineffective.
“The paper clearly shows that they help,” said Nico Dosenbach, another of the authors and a professor of neurology at the university. “They help kids who have an ADHD diagnosis do better in school and on tests, and they help kids who don’t get enough sleep – and many Americans don’t get enough sleep.”
Although ADHD is often considered a childhood illness, an estimated 15.5 million American adults are diagnosed with this condition; about half of them received the diagnosis as adults. This disease affects approximately 7 million children aged 3 to 17. Prevalence among American children increased from 6.1 percent in 1997 to 1998 to 10.2 percent in 2015 to 2016, according to one study.
The exact cause of ADHD remains unknown and there is no single test for this condition.
“Despite its name ‘attention deficit disorder,’ ADHD is a multifaceted disorder in which difficulty focusing attention is only one component,” Maggie Sweitzer, a professor of psychiatry and behavioral sciences at Duke University School of Medicine, who did not work on the study, said in an email.
“It is important to remember that ADHD is not a benign illness: people with ADHD are not only at risk for academic problems during childhood, but also for occupational, social, physical and mental health problems throughout their lives. For many people, these medications are transformative.”
The brain images used in the Cell article published last month came from children enrolled in the Adolescent Brain Cognitive Development (ABCD) study, which began in 2015.
Researchers compared images of children who took prescription stimulants on the day of their exam with those of children who did not.
By studying the connections that allow different regions of the brain to communicate with each other, scientists found that stimulants promoted increased activity in the arousal and reward regions, but not in the attention regions.
Dosenbach said stimulants “pre-reward our brains and allow us to continue working on things that wouldn’t normally hold our interest,” like a class at school that feels like a chore.
Stimulants “don’t stimulate cognition,” Dosenbach said. “They don’t make you smarter, I don’t think. In fact, they don’t pay you better attention.”
Researchers found that stimulants not only helped children with ADHD, but also those who slept less than the recommended nine hours per night.
Stimulants did not lead to better academic performance in children who did not have ADHD and were not sleep deprived.
Psychiatrists have said that some non-stimulants are used to treat ADHD, such as atomoxetine.
The new study supports a growing body of research that points to lack of sleep as a contributing factor to ADHD.
“Sleep disorders are incredibly common in ADHD, affecting about three in four children and adolescents with the disorder,” said Jessica Lunsford-Avery, a professor of psychiatry and behavioral sciences at Duke University School of Medicine, who was not involved in the study.
“It is increasingly clear that clinicians and families should view ADHD as a 24-hour persistent disorder. Unfortunately, sleep problems are rarely recognized or adequately treated in children and adolescents with ADHD.”
Sinan Omer Turnacioglu, acting head of the division of neurodevelopmental pediatrics and neurogenetics at National Children’s Hospital, said that while sleeping pills may be prescribed for children with ADHD, it is also important to address “behavioral management,” including limiting light exposure and time spent in front of a computer screen before bed. He suggested that people “have some sort of bedtime routine to really dial down the level of stimulation” before falling asleep.
Turnacioglu and other experts have pointed out that giving prescription stimulants such as Ritalin or Adderall to children is not the same as giving them a 5-hour energy dose. Prescription stimulants, he says, “don’t act on the nervous system in exactly the same way.”
Sweitzer said the study suggests that clinicians and families should discuss sleep, behavioral strategies and medication options to treat ADHD.
Max Wiznitzer, professor of pediatrics and neurology at Case Western Reserve University School of Medicine and board member of the nonprofit Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), said research has shown the condition can shorten life expectancy.
“Because they are impulsive, they don’t necessarily make good choices,” Wiznitzer said. “They don’t think about taking their medication. They sometimes eat too much. There is more obesity, more cardiovascular disease, more diabetes.”
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