by Karen Barrow

(Sept. 26, 2005) -- Just after the Centers for Disease Control reported that 2.5 million children and 1.5 million adults are currently taking myriad medications for attention deficit disorder (ADHD), a drug first approved for narcolepsy could be the latest addition. While one might question the connection between treating a sleep disorder and an attention problem, this newest finding highlights the confusion over how to determine which of the many options is the best choice for treating ADHD.

"Few studies pit one stimulant against another in a head-to-head comparison," said Dr. Marian McDonagh from the Oregon Evidence-based Practice Center at the Oregon Health and Science University.

The Newest in a List of Drugs for ADHD

This problem can be seen with the most recent study confirming the positive effects Provigil (modafinil) has on kids with ADHD. Provigil, is approved as a "wake-promoting agent" for those sluggish from a lack of sleep, specifically for shift workers. Logically, it seems to follow that the same drug would also help those who have trouble staying attentive during the day.

After early studies showed that Provigil helped adult patients with ADHD, Cephalon, the company that manufactures the drug, created a pediatric version to be tested for widespread use.

During a nine-week-long study, which was presented at the 2005 Annual Meeting of the American Psychiatric Association (APA), the pediatric version of Provigil was shown to improve children's scores on a standardized test.

"This study not only shows that this medication is effective and rapid in onset for the treatment of pediatric ADHD," said lead researcher Dr. Joseph Biederman, chief of pediatric neuropsychopharmachology at Massachusetts General Hospital, "It also gives the clear signal that we have a medication that can be used…to treat ADHD in children who cannot tolerate amphetamines."

Even if Provigil did have a positive effect, in the study it was only compared to a placebo, not to Ritalin nor any other drug for that matter.

"Short-term trials do not provide clear evidence that any one stimulant is any more tolerable than another," said McDonagh.

Comparing the Options

With almost 20 drugs being used for the treatment of ADHD, ranging from stimulants to antidepressants, things can get confusing. Most doctors simply prescribe the popular stimulants Ritalin, Concerta or Adderall. But if the patient doesn't respond to these drugs or if the side effects are intolerable, as is the case 60 to 80 percent of the time, an alternative method needs to be tried.

The problem is finding an option that seems to work best.

Of the 2,287 papers that McDonagh reviewed for her analysis, published in September 2005 by the Drug Effectiveness Review Project, the only drug ever used in comparison studies is Ritalin, the drug recommended by the American Academy of Pediatrics as a first-line against ADHD.

But even in those studies, the vast majority were short-term with limited numbers of mostly Caucasian participants, leaving almost none that looked at the long-term effectiveness, side effects or possible ethnic differences to show if one treatment truly worked better than another.

"The bottom line is that [choosing a drug for treatment] is trial and error," says Dr. John Santa, medical director of the Drug Effectiveness Review Project, a program dedicated to analyzing the data on various types of drugs to determine the safest and most helpful option.

Shaping the Future of ADHD Treatment

Santa and his colleagues were astounded by the gaping holes in the understanding of ADHD treatment and large number of studies that did not produce any new data. It seems that many more studies will be necessary to first determine the true pros and cons of the traditional mediations before even beginning to determine whether Provigil, or any new drug for ADHD, is truly better or worse than another.

"We are drowning in information, starved for knowledge," he says.

Looking towards the future, the biggest problem, according to Santa, is that the medical community doesn't require head-to-head trials before a drug goes to market.

"We need to look within ourselves because we don't require or reward comparison studies," said Santa.

Karen Barrow is a copyeditor/writer for Healthology. Previously, Karen has written for the New York Sun, Science World, Super Science and The Jewish Week. She obtained a master's degree in biomedical journalism from New York University and a bachelor's degree in biology from Cornell University.

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