Although ADHD is diagnosed based on the presence of inattentive and hyperactive-impulsive
symptoms (see http://www.helpforadd.com/criteria.htm
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
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,
, 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.
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.
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