O’Malley on ADHD in FASD, Part II

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This post assumes you’ve read Part I of this review of Chapter 4 in Kieran O’Malley’s 2007 book, ADHD in Fetal Alcohol Spectrum Disorders. Here, I will overview his observations on pharmacology –using medication –to treat ADHD in a child who has been prenatally exposed to alcohol.

Remember this from the last post: many of us have adopted children with prenatal alcohol exposure do not have enough background information to know whether our adopted kids inherited ADHD (i.e., ADHD runs in the birth family), or if they acquired ADHD secondary to prenatal exposure (no birth family history of ADHD). O’Malley observes that while inherited and acquired ADHD manifest in similar behaviors in children, the underlying neurochemical pathways are not identical.  So kids with inherited ADHD respond differently to medication than those with acquired ADHD.

Therefore, when we parents talk about our experiences trialing ADHD meds with our children, there will never be consensus about what works because each child’s life history and brain chemistry is different.

As of 2007, only two controlled studies of ADHD medication in children with FASD had been published. One followed eleven kids; the other followed four. Both studies trialed several different stimulant medications. The sample sizes were too small to draw general conclusions. Yet O’Malley observes that the two independent trials shared a common finding: stimulant medication “significantly improved” parents’ ratings of the child’s behaviors at home while showing “no significant effect” on teacher’s ratings of the child’s attention span in school.

O’Malley’s summary begs questions: Did parents perceive any change in their child’s attention span? Did teachers note any change on the child’s behavior in school? Answering those questions is not the point of his article. I can only hope that more recent research may address them. We met with resistance from a professional who said our report of significantly easier to manage behavior at home was insufficient reason to continue trialing medication in the absence of clear evidence that Hope’s ADHD symptoms impacted her performance in school.

O’Malley notes evidence that children’s response to specific stimulants may change over time–specifically when trialed under age 5 vs. response at age 6 or 7 –and notes some evidence that children of differing ethnicities may metabolize the same medication differently. He also points to advancing genetic research that may eventually lead to being able to screen for genes that enable the transportation of dopamine, a neruochemical key to the expression of ADHD symptoms.

In Chapter 4, O’Malley helpfully summarizes reasons to be cautious about medicating ADHD. Beyond the fact that there are no medium or large-scale studies on ADHD in children with FASD, there is a well-established body of evidence that medication may have unintended adverse effects on the developing brain. “The developing brain of a child prenatally exposed to alcohol has already experienced neurotoxic damage…. Thus it is likely that a child with ‘acquired brain injury’ from prenatal alcohol exposure will show atypical responses to standard medications including psycostimulants [ADHD medication]. The atypical response may be intolerance, hypersensitivity, paradoxical reaction, over-sedation, as well as blunted cognitive ability, or the unmasking of a primary psychiatric familial disorder such as Bipolar disorder…” (p. 55)

O’Malley also cites research suggesting that the commonly noted side effect of weight loss may involve a depressive effect on growth hormones over time. He also points out that since prenatal alcohol adversely effects the child’s developing heart, kidneys, and liver, kids with FASD may be invisibly vulnerable to toxic effects of medication on those organs.

His discussion includes a very provocative question asked in 2001 by Benedetto Vitiello of the National Institutes of Mental Health,”whether the reduction of ADHD symptoms, achieved through pharmacological or behavioral intervention, will ultimately translate into better prognosis with respect to improved educational and occupational achievement and decreased risk of accidental trauma, anti-social behaviors and substance abuse.” O’Malley observes, “In the current climate of NO scientific pharmacological intervention research in children or adolescents with FASD [being able to answer this question] is  an important horizon far, far away.”

O’Malley is well aware of Striessguth’s thesis about guided early intervention with the goal of preventing secondary disabilities in FASD; he cites her research throughout this book. At the same time, he observes that the lack of longitudinal research is the elephant in the FASD living room. As the professional who pushed back about continuing Hope’s ADHD medication trials commented, “I just want to see more evidence that her symptoms are harming her. In this era we generally don’t medicate people just to make them easier to live with.”

O’Malley, cautiously, differs: “Within the constraints mentioned above it is worth acknowledging that stimulant medication can have a profound and sustained positive effect on children or adolescents with FASD (and thereby decrease parent stress) who present ADHD symptoms…. It does appear… that the dopaminergenic pathways are one of the areas most effected by prenatal alcohol and their disruption is commonly expressed in the neuropsychiatric disorder ADHD.” (p. 58)

He concludes with a proposed “Drug Algorithm” for ADHD in FASD based on the evidence available in 2007:

• First choice: dextroamphetamine (Adderall and derivatives)
• Second choice: methylphenidate (Ritalin and derivatives)

Third choice: Second generation, long acting derivatives of the above –which were only beginning to come into use at the time he wrote this article. It would be fascinating to see his updated opinion.

If you request the whole book, be sure to turn to Chapter 11 and read O’Malley’s summary, “5. Medication Therapy” which includes a list of drugs commonly prescribed for psychiatric disorders that may co-occur with FASD,  yet are contra-indictated as a drugs of choice in kids who have FASD.

source:http://daysofwonderandgrace.wordpress.com/2012/01/18/omalley-on-adhd-in-fasd-part-ii/

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