Although ADHD is diagnosed based on the presence of inattentive and
hyperactive-impulsive symptoms (see
http://www.helpforadd.com/criteria.htm
for full diagnostic criteria), problems that often co-occur with these
symptoms can be larger concerns for parents and teachers. For
example, many children with ADHD have difficulty maintaining positive
relations with peers and parents and many struggle with their academic
performance. In fact, difficulties in these areas may be more
closely linked to long-term outcomes than core ADHD symptoms themselves.
When core ADHD symptoms improve significantly, what happens to
children's functioning in other important areas? It is tempting
to conclude that normalizing inattentive and hyperactive-impulsive
symptoms will assure meaningful improvement in important areas.
However, this is not necessarily the case as other difficulties may not
have been caused by ADHD symptoms in the first place or may persist
even when ADHD symptoms are well-controlled. Surprising as it may
seem, the relationship between normalizing core ADHD symptoms and
improvements in other important areas has not been carefully studied.
Because this is such a critical question, I was pleased to recently
locate a study that begins to address it [Karpenko et. al., (2009).
Clinically significant symptom change in children with ADHD: Does it
correspond with reliable improvement in functioning?
Journal of Clinical Psychology, 65,
76-93.]. Participants were 417 children from the Multimodal
Treatment Study of ADHD (MTA Study), the largest ADHD treatment study
ever conducted. In this study, children were randomly assigned to
received either intensive medication management, intensive behavior
therapy, a combination of the two, or routine community care. The
children included in the current study were those from one of the first
three treatment groups. You can find a complete summary of the
initial MTA Study findings at
http://www.helpforadd.com/mta-study/
These 417 children were grouped according to whether their core
symptoms of ADHD and ODD (Oppositional Defiant Disorder) were
normalized according to parent and teacher ratings 14 months after
treatment began. Children's symptoms were considered 'normalized' when
the ratings averaged across all symptoms and across parents and
teachers corresponded to their being present either "just a little" or
"not at all". Fifty-five percent (n=231) had ratings that fell in
the "normalized" group while 45% (n=186) had ratings that remained
elevated.
Next,the authors computed the percentage of children in the
'normalized' and 'elevated' groups who showed meaningful improvement in
several key areas of functioning: parent-child relations, social
skills, homework problems, behavior at home, and overall
impairment. These were measured using parent and/or teacher
rating scales. Improvement was determined by subtracting the ratings
obtained at 14 months from those obtained at baseline. A
statistical formula was then used to determine whether the change on
each measure for each child was large enough to be reliable, i.e.,
unlikely to reflect chance fluctuation. The authors then compared
the percentage of children in "normalized" and "elevated" groups who
showed clinically reliable change in each area.
-
Results
-
Social skills - Based on parent ratings, 66% of children in the
normalized group made reliable improvements in social skills compared
to 52% of those in the elevated group. When using teacher
ratings, the percentages were 78% and 49% respectively. In both
cases, the difference between the groups was statistically significant.
Homework problems - According to parents' ratings, 66% of 'normalized'
children showed reliable reductions in homework problems compared to
45% of children whose symptoms remained elevated. This difference
was significant.
Parent-child relationship - Two dimensions of parent-child relations
were examined: power assertion and closeness. Higher scores on
power assertion reflect more problems in the relationship while higher
scores on closeness reflect a stronger parent-child bond. Based
on parent ratings, reliable reductions in power assertion was found for
19% of normalized children vs. 15% for the elevated group. For
closeness, the percentages were 21% and 13% respectively. This
latter difference was significant.
Ratings completed by the children themselves yielded non-significant
group differences: 17% vs. 13% for closeness and 20% vs. 16% for
power assertion.
Overall impairment - Forty-four percent of 'normalized' children
compared to 25% of 'elevated' children showed reliable reductions in
their overall impairment rating; this difference was statistically
significant.
The authors also examined the total number of domains in which reliable
improvement was found for each group. On average, children with
normalized symptoms showed reliable improvement on 4 of 9 functional
measures. For children whose symptoms remained elevated,,
reliable changed occurred on average in 2 of 9 measures.
-
Summary
and Implications -
The results of this study are important and informative. On the
one hand, it is clear that when core ADHD symptoms are normalized,
children are more likely to show reliable improvements in several
important functional areas including social skills, homework, and
overall level of impairment. On the other hand, a substantial
percentage of children fail to show meaningful improvement even when
their ADHD symptoms have been normalized. Furthermore, improvements in
key aspects of parent-child relations were not related to ADHD symptom
normalization, although the authors note that this may reflect
limitations in the measure of parent-child relations that was used.
These findings highlight the need to move beyond core ADHD symptoms
when evaluating children's response to treatment as even the
normalization of core symptoms - which often fails to occur - does not
guarantee meaningful improvement in key functional areas. In
addition, the fact that many children without normalized symptoms also
showed reliable change in key functional outcomes further underscores
that ADHD symptom normalization and functional improvement are not
tightly linked. Thus, as emphasized in ADHD treatment guidelines
from the American Academy of Pediatrics, the primary goal of ADHD
treatment should be to maximize children's functioning rather than
simply minimizing core symptoms.
There are several limitations to this study that should be
recognized. First, the authors did not examine how normalization
of symptoms was related to children's academic achievement and daily
academic success at school, a very important outcome to consider.
Second, children in the 'normalized' group not only had ADHD symptoms
normalized but ODD symptoms as well. Thus, what the results would
have been if normalization was based on ADHD symptoms exclusively is
not known. It is reasonable to assume, however, that fewer
children would have shown reliable improvement in the areas assessed.
Thus, the findings likely overstate the benefits that would accrue from
normalizing inattentive and hyperactive-impulsive symptoms exclusively.
It should also be noted that the sample was limited to 7-9-year-old
children diagnosed with the combined type of ADHD; these were the youth
included in the MTA Study. How the results would generalize to
older children, or to children with the inattentive subtype of ADHD is
thus unknown.
These limitations not withstanding, this study addresses an important
topic that has not been previously studied. One hopes that future
work by these authors and others will build on this initial examination
of how change in core ADHD symptoms relates to children's adjustment in
important functional areas as this has important implications for how
we think about successfully treating ADHD.