Imagine if your child was diagnosed with attention deficit disorder (ADHD) and was started on a course of stimulant psychiatric medications (like Ritalin), a standard treatment used for ADHD.
Now imagine that suddenly, your child dies for no apparent reason.
Your child would be in a very small but significant group of children who die while on stimulant medications. I cannot emphasize this enough, however — this is a tiny, tiny group. This fact is likely to be glossed over in many mainstream media reports about this study.
Gould et al. (2009) studied state vital statistics from 1985-1996 and found that in 564 cases of sudden death in children ranging from ages 7 through 19, 10 (1.8%) of the sudden unexplained death cases were treated with a stimulant at the time of their death, as compared with only two (0.4%) of the motor vehicle accident victims.
Ten victims over an eleven year period hardly seems like the stuff of headlines. And it wouldn’t be, except that the rate was four times higher than the rate of the motor vehicle accident victims. This is a significant difference, despite the small numbers involved.
Remember, we’re talking about an extremely rare event here. The finding is of greater interest in trying to understand why it’s occurring at all, not for anyone to make a treatment decision based upon it.
The accompanying editorial highlights some of the important limitations of this study:
However, important confounders may remain. For example, the methods did not allow the investigators to learn whether, independent of stimulant treatment, ADHD itself increased the risk for sudden unexplained death. This is a plausible hypothesis given the association between ADHD and engagement in high-risk behaviors, such as substance abuse. Although history or postmortem toxicological evidence of substance abuse was reason for exclusion from the study, the sensitivity of these screening procedures is not perfect, and other drugs could have been ingested or inhaled. Furthermore, the parents of 40% of eligible cases could not be found or would not provide information. As the investigators point out, there is also a risk of inequality in the effort to search for medical explanations (including medication use) in sudden unexplained death, given its unexplained nature, compared to death from motor vehicle accidents, so that stimulant use might have been missed in the motor vehicle accident comparison population.
If the Gould et al. study reminds us of anything, it’s that psychiatric medications are not like candy, nor are they not without their downsides. It reminds us, too, that ADHD is a diagnosis that is probably the most over-used and mis-diagnosed malady affecting children today. Many children are being prescribed stimulants who do not meet the diagnostic criteria for ADHD.
Additionally, children on stimulants should be regularly monitored by the doctor that prescribed the medication, especially for heart issues.
The new study shows an unmistakable link, however, of sudden unexplained death and the stimulant medication used to treat ADHD. However, such deaths are very rare events and this is the very first study to look at this issue across such a large-scale child population.
Concerned? Talk to your doctor further about the study, or check it out yourself at the link below.
Read the full editorial accompanying the article: Stimulant Treatment of ADHD and Risk of Sudden Death in Children
Reference:
Gould MS, Walsh BT, Munfakh JL, Kleinman M, Duan N, Olfson M, Greenhill L, Cooper T. (2009). Sudden death and use of stimulant medications in youths. Am J Psychiatry, 166, 992 — 1001.
15 comments
“Although history or postmortem toxicological evidence of substance abuse was reason for exclusion from the study, the sensitivity of these screening procedures is not perfect, and other drugs could have been ingested or inhaled.” You are definitely reaching for justifications, and I would also like to point out that according to the FDA(!), more than 103 children just between the ages of 5-9, who took Abilify, DIED. Maybe it won’t be “sudden death.” Maybe it will be something else, like… attempted and completed suicide?
You want the facts on the drugs you might be taking? Check out cchrint.org, the Psychiatric Drug Adverse Effect machine. It is all based on FDA reported side-effects and deaths.
I look forward to a certain regular commenter to spin this as no reason to be wary of taking meds for ADD. I would like to be pre-emptive and just ask, if such comments do follow mine minimizing meds risks, is what do you say to the parents of a child who died from potential overmedicating?
Sorry, tough break?
I will be waiting with profound interest to what follows here.
I think this study is badly flawed. There seems to be no evidence that they controlled for the general health of their subjects, and this is very important. It is well known that children who are disabled or in bad health are also more likely to be prescribed stimulants. These children are also at a higher risk of heart defects and sudden cardiac death. The stimulants may be a completely irrelevant factor.
The control group was a cross-section of the population unlucky enough to be killed in auto accidents–not a cross-section of the sort of child that is likely to be prescribed stimulants.
This is almost certainly a spurious correlation. It is like predicting the amount of crime in a square-mile area by counting the number of refrigerators–which can be done, and is fairly accurate, simply because more people own more refrigerators and commit more crimes. In this case, children with disabilities are prescribed more stimulants and die suddenly due to undiscovered heart defects more often.
Incidentally, you simply can’t say that there were “ten victims over a ten-year period”. That statement assumes that the stimulants these children were taking was the causal factor in their deaths, which is still completely unproven.
Repeat after me: Correlation does not imply causation.
Don’t know why my post I submitted 3 days ago has not yet appeared, so I’ll try from another computer…
My original post spoke along with that Callista is stating. The study was conducted back in the mid 80s to mid 90s when less was known medically than we do now. I have not had a chance to read the full study but I would hope that the authors took into account pre-existing medical conditions as possible factors in these deaths, and not just attribute them to medications.
For example – ADHD medications and prolonged QTC syndrome. Pharma wont admit to it (I’ve talked to many reps who claim to know nothing about it), but the suggested current guidelines call for continual cardiac monitoring for children with known heart problems on ADHD medications. How many children in the study had undiagnosed cardiac problems? I dont think we will ever know, but I would venture a guess that its a very low number.
Submitted my last post too quickly…
I wanted to add that since pre-existing conditions may be responsible, the risk of death due directly to the medications (if such a risk exists), is likely even lower than what is being claimed. Heck, it may even approach the risk of death due to motor vehicle accidents.
Two things I keep in mind when reviewing articles: 1) correlation is not causation and 2) numbers can be deceiving
“It reminds us, too, that ADHD is a diagnosis that is probably the most over-used and mis-diagnosed malady affecting children today.”
Dr. Grohol needs to check his facts before continuing to promote the bias against AD/HD that seems to be present in all his articles on the subject. The “overdiagnosis†of AD/HD is a myth that has long since been refuted. While AD/HD may possibly be overdiagnosed or misdiagnosed in certain populations, particularly hyperactive elementary school boys, research has found that these instances are counteracted by the fact that it is UNDERDIAGNOSED in other populations, particularly inattentive girls. For example, see Sciutto and Eisenberg, “Evaluating the Evidence For and Against the Overdiagnosis of ADHD,†published in the September 2007 issue of Journal of Attention Disorders (Volume 11 No. 2).
Well, I am not too concerned about speed; it’s all relative, I guess. My son almost died from Abilify, and became bipolar from Luvox. (which is to say that the Luvox came first, understandably) Luckily, he got into trouble, and which led to him being taken off the Luvox after six years? A case worker had to call the psychiatrist, and tell her that.
Re Kate’s above comment:
While it is not better to underdiagnose, I’d rather do that for the moment than overdiagnose, because the latter can drive patients in true need of treatment away from providers after experiencing an iatrogenic problem, ie one from a treatment intervention. Having met patients who were diagnosed as Bipolar and put on these absurd polyphamaceutical regimens that basically did nothing but cause side effects, and for several made the diagnosis impossible to at least get further insurance coverage for mental health care as the “preexisting condition” was determined as ‘too risky to cover’, they were at the very least wary to meet with me for care.
In fact, I saw a patient yesterday who presented with anxiety issues but related a questionable diagnosis of ADD as a youth and felt he had a negative response with meds, but was focused on the anxiety and need for a benzo prescription. After much discussion, I asked him to reconsider the ADD as at least part of his presenting issues and look at a retrial with an ADD med, but I respected his hesitance, albeit the treatment was as a child with his parents playing a sizeable role in the meds administered. We left it that he will read a chapter from a book explaining ADD and see if he has features now, and discuss risks/benefits on the next visit. What made the topic related here was the patient’s child was recently diagnosed as ADD, which appears a legitimate diagnosis from what little was noted in the office to me, and yet the patient was so taken aback by the quick push to medicate the child after just a 45 minute eval. So, even if stimulants present less than a 1% risk factor for cardiac consequences in children, as I asked in my first comment here at this posting, what do you say to the parents of a child who has a negative event after starting meds, like death!?
Least to most invasive, that is what I remember being taught in medical school and reinforced in residency. Meds alone, which is the mantra by many in my field and by these alleged consumer advocates commenting in support of ADD, is a disservice to patients. That is what I take home from Dr Grohol’s comments here.
Quick fixes. What is the message? Years of struggles can be eradicated with a tablet? Pathetic and unacceptable to sell without expecting challenges by those on the front line who have seen otherwise. Meds are part of the process, do not misread my perspective, but come on, how many people have heard a psychiatrist or pediatrician mention other interventions besides meds after diagnosing ADD?
Have a nice weekend!
I sometimes wonder, that if I had to do it over again, would I treat my son with stimulants, or better, have him be treated with such again. He is now 19, and he was six when he started.
Yes, I think I would, although I am not 100% certain. But with him, stimulants literally did work like magic, from the first moment on. His biological father still needed them at age 64, and was unbearable without them. He did not use stimulants though, but preferred pot. It did seem to help, but so did the stimulants, and better.
Except, with my son, there were side effects over time, and there are many side effects that are rarely mentioned. Like Tourettes symptoms? Difficulty doing sports and running?
I also do believe on a positive side, that as addicting as stimulants are and can be, that for those who need them it does help them not to get into other drugs. My son still takes the stimulants, although he needs less then he used to. He would rather not take them, mostly because both my kids do not like taking ‘pills’, not even Tylenol. But I do wonder if he had gotten into other drugs by now if it were not for this medicine. he even started smoking at the age of 17 and then quit cold turkey six months later without pressure from elsewhere.
I really do like your attitude though about prescribing, etc, and what you have said over time. You have been very consistent even if I do not understand some of your comments. (when you get really disgusted with people, you often fail to explain your point and seem to think everyone will get it, when that is not so true.)
Only one of my son’s has mental problems and I think this may be because his father had the same and his brother’s father has none.
The one clearly has ADHD but the moment we were referred to a psychiatrist, it was Luvox on top of the stimulants, and which really worked great until it turned him bipolar, and then I will never forget those horrible trials with mood stabilizers and which were so dangerous and damaging, and the psychiatrist was just adding and adding stuff so carelessly, like she wanted him to take Risperdal for the Tourettes stuff and which made him spin like crazy, and on and on.
And I am serious about him becoming bipolar from the Luvox and six years of hell for the whole family. And after it was stopped….an order through the nurse by phone call….the whole thing was never once discussed although we all knew what had happened.
The above comment was for ‘skillsnotpills’; your name did not show up!
Are you people serious?? I am a single mother of 3 who’s 5yr old son has adhd..i will exhaust every option available to me.. i will not even consider medicating my child on these “convenience” drugs being pushed on just about every child in America who seems “too” active. Get a grip people..these drugs are basically a regulated form of crystalmeth…you might as well go to your nearest drug dealer & get your child some…read the ingredients you idiots….what do you think teachers & parents did 50 years ago before we all these drugs….my grandmother raised 13 kids without..soooo…i am certain my child will survive….if i have to home school him to achieve that..i’ll do it…
Great article…thanks for your insight. I also have a strong interest in the area of ADD and APD. Please visit our site and read my article Attention Deficit Disorder Verses Auditory Processing Disorder – A Big Difference at http://www.learningsolutionsathome.com. Thanks and take care, Lucy Barlow
Most children display elements of ADHD behavior as they are developing, which is why it can sometimes be hard to distinguish between normal childhood behaviors and ADHD.