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ADHD RESEARCH UPDATE - Vol. 10, May, 1998
********************************************************In this issue...
Stimulant use and the potential for abuse
A warning about Pemoline/Cylert
Can massage help with ADHD?
Academic underachievement in ADHD subtypes...
The importance of peer relations in the outcomes for boys with ADHD...
Is ADHD a valid diagnosis in younger children?
* READER QUESTIONS *"Do you recommend private schools for children with ADHD?"
"Is there a medication that can help mornings go better - until the Ritalin kicks in the mornings can be awful."
** STIMULANT USE AND THE POTENTIAL FOR ABUSE **
There have been multiple reports in the media recently about the abuse potential of stimulant medications such as Ritalin, including stories about teens who are selling their medication at school. The June 1998 issue of the Journal of Development and Behavioral Pediatrics (pages 187-192) presented an interesting article related to this area of parental concern.
The purpose of the study, which was conducted in Wisconsin, was to describe stimulant use and abuse as reported by school administrators and by children diagnosed with ADHD/ADD. Five years after they were identified as responding positively to Ritalin, 161 children in middle school and high school were surveyed about their experiences taking medication. School principals were also surveyed about medication use policies in their schools.
The authors report that no child believed that stimulants as prescribed could lead to abuse. Sixteen percent of the children indicated, however, that they had been approached to sell, give, or trade their medication. Forty-four percent of children and 37% of the principals indicated that medication was stored unlocked at school, some schools did not have written policies regarding prescription drugs, and 10% of schools allowed children to carry their own medication.
I'm not sure what to make of these results, and it is certainly not possible to generalize from a relatively small sample that is confined to a single region with what is going on more generally in schools across the nation. Nonetheless, the number of children who indicate that they had been approached to sell or trade their medication is certainly disturbing. One thing this suggests is that for those of you who have middles school or high school age children who take medication, it may be important to discuss how they would handle this situation should it occur to them.
The fact that medication policy is also likely to be quite lax in many schools is also concerning. Certainly, making children responsible for taking their own medication - even for high school students - seems ill advised. I know that many of the children I have treated would just not remember to do this consistently, and it is unreasonable, in my opinion, for the school to expect this. Having children responsible for their own medication would also seem to increase the odds that they will be approached to sell or trade it. Finding out what the policy is at your child's school, and taking action to change it if it seems unreasonable and not in your child's best interest, would also be something to consider.
** A WARNING ABOUT PEMOLINE/CYLERT **
Pemoline, the generic name for Cylert, is one of the stimulant medications that is often used in treating ADHD. Like the other stimulants, it is often quite helpful in alleviating a child's primary ADHD symptoms.
A potential problem with Pemoline, however, are the adverse affects it can have on a child's liver functioning. The April, 21998 issue of the Annals of Pharmacotherapy presents a case study of a 9 year old boy who was treated with Pemoline, and developed signs and symptoms of liver failure that did not reverse after the medication was discontinued. Eventually, a liver transplantation was required.
The authors strongly recommend that Pemoline not be used as a first line treatment for ADHD. I have been surprised at the number of questions I have received from parents whose child had been prescribed Cylert as the very first medication that was tried. I have NO IDEA why this would be done, and if your child's physicians suggests this, be sure to obtain a very careful explanation as to why. The authors of this study recommend that prior to initiating therapy with Pemoline, baseline liver function tests should be obtained, that liver functioning should be carefully monitored, and that both parents and patients should be educated about the signs of symptoms of liver toxicity.
** CAN MASSAGE HELP ADHD? **
I certainly would never have expected this, but a study which appeared in the spring 1998 issue of the journal Adolescence (pages 103-108) provides tantalizing evidence of a very surprising evidence. The study was authored by Dr. Tiffany Field who is a very well known researcher in child mental health, and who has published a number of studies on the beneficial effects of massage for infants. In this study, 28 adolescents with ADHD were randomly selected to receive either massage therapy or relaxation therapy (i.e. relaxation therapy is a technique in which clients are taught specific skills to enable them to become more calm and relaxed and is often used in treating anxiety disorders) for 10 consecutive school days.
At the end of the treatment, students who received massage, but not those who had received the relaxation treatment, rated themselves as feeling happier and observers rated them as being less fidgety and active following the sessions. Even more impressive is the fact that teachers rated these students as spending more time on task and showing less hyperactive behavior in the classroom (teachers did not know which students had received which treatment).
This is certainly an interesting result, even if it is unclear - at least to me - what the explanation for this effect would be. It is also important to keep in mind that as with any new treatment approach, avenues that seem initially promising do not always hold up to repeated study and investigation. That is why it is so important for studies such as this to be replicated, ideally with larger samples, before it is reasonable to recommend new approaches as a reasonable alternative to treatments with previously established efficacy. For ADHD, it is especially important to know how long the apparently beneficial effects from any form of treatment actually last and what impact does the treatment have on children's long term success and development.
I'll certainly keep you posted about any additional studies of this intriguing finding that I come across.
** ACADEMIC UNDERACHIEVEMENT IN ADHD SUBTYPES **
This study appeared in the November 1997 issue of the Journal of Learning Disabilities (pages 635-642). The objective of authors was to compare the academic performance of children with ADHD, Combined Type (i.e. children who had both hyperactive and inattentive symptoms) with children who were diagnosed with ADHD, Predominantly Inattentive Type (i.e. children with inattentive symptoms only).
Recall that an article reviewed in the previous issue of ADHD RESEARCH UPDATE that the difficulties associated with the Combined Type diagnosis were generally greater than for children with inattentive symptoms only, particularly in regards to behavioral problems such as oppositional defiant disorder (ODD) and conduct disorder (CD). The authors of this study report, present data which suggests that, at least in regards to academic functioning, children with the inattentive subtype may be at greater risk in certain areas.
Compared to the other children with ADHD, inattentive children had significantly lower levels of math achievement. The authors speculate that these children's difficulties with attention interferes with their ability to master abstract symbol systems, especially with the acquisition of basic arithmetic skills in the primary grades.
For parents whose child has the inattentive type of ADHD, these results highlight the importance of attending to how well your child is acquiring basic academic skills in the early grades. I have often found that because children with inattentive symptoms only are less likely to present significant behavior problems in the classroom, their difficulties are more likely to be overlooked. These children may not be acquiring the basic academic skills they will need for success in later grades, but this can be overlooked or not noticed because the child was relatively well behaved. Pay careful attention to this throughout the school year, and at the very least, if your does not perform well on end of grade standardized achievement testing, be sure to get a thorough evaluation of your child's academic functioning. Information about ways to go about this can be found by clicking here .
** PEER RELATIONS AND THE OUTCOMES FOR BOYS WITH ADHD **
This is a very interesting study that was published in the October 1997 issue of the Journal of Consulting and Clinical Psychology (pages 758-767). The study highlights the importance of a child's peer relations in their long term successful adaptation.
In this study, the authors followed boys who had been diagnosed with ADHD over a 4 year period. At the beginning of the study, careful assessments were made of the boys emotional state, aggressive behavior, and conduct disorder symptoms. The authors also paid close attention to the quality of the boys' peer relations - e.g. . how well accepted were they by their peers; did they have a close friend. Boys who fared poorly on these assessments of social functioning were considered to have a "social disability". (It is important to note that this peer relations variable was evaluated independently from children's behavioral and emotional functioning. Thus, some boys who were doing well socially were showing emotional and/or behavioral problems while others did not show these latter difficulties but were struggling in their relations with peers.)
Two questions were of primary interest. First, the authors wanted to know if social disability at the beginning of the study was a significant predictor of severe longer outcomes 4 years later when the boys were now adolescents (e.g. substance abuse). Second, they wanted to determine whether being "socially disabled" (i.e. having important difficulty in one's relations with peers) made a unique contribution to boys' long term outcomes. That is, do social problems play an important role in children's adjustment as adolescents even when other difficulties such as emotional and behavioral problems are taken into consideration.
The results obtained were quite interesting. At the 4 year follow up period, boys with ADHD who had been identified as socially disabled higher rates of mood, anxiety, behavioral, and substance use disorders than ADHD boys who were not socially disabled or than boys without ADHD. In addition, statistical analyses indicated that having a social disability at the beginning of the study significantly increased the risk of developing later conduct disorder and substance use disorders even after earlier emotional and behavioral functioning was taken into consideration. In other words, difficulty with social relationships appeared to be making a unique contribution to many boys, adjustment as adolescents.
How can this information be useful to you? The very important conclusion that emerges from this study is just how important children's peer relations are to their long term development. Children's peer relations are the area in which I have done much of my own research, and it is clear that children who have difficulty making friends and getting along with peers - regardless of whether or not they also have ADHD - are at increased risk for a variety of negative developmental outcomes.
Sometimes, it is easy for parents to focus primarily on children's grades and their behavior at home and with other adults, and to lose sight of how their child is succeeding or not succeeding in the peer arena. Paying attention to how your child is faring socially, and trying to get him or her help in this area if they are struggling, however, can be one of the most important and helpful things that parents can do.
There are several ways that parents can be helpful to their child in this regard. First, you may have to take an active role in trying to arrange play activities for your child (this applies more for younger children, of course, than for adolescents). This can be quite helpful in assisting your child in developing a good friendship. If you know that your child has difficulty with the social skills - e.g. sharing, compromise, turn taking, etc. - that are important, you may need to actively supervise the play times to try and make sure that things go okay and to help get things back on track when they start going downhill. Reviewing with your child the kinds of things that will help him or her to be a better friend - both before and after the play session - can also be helpful in getting your child to try and focus on these important issues.
You should also be aware that their is a specialized type of treatment called "social skills" training that is specifically geared towards helping children learn the kinds of skills they will need to do well socially. (Note that recent studies of social skills training for children with ADHD were reviewed in volumes and of ADHD RESEARCH UPDATE.) In my area, the school guidance counselors often run social skills groups in which children who are struggling with peers get together on a weekly basis to try and both learn and practice new skills. In many communities, these groups are offered on a private basis by child psychologists.
The point to emphasize is how important it is to pay close attention to how your child is doing with friends and with peers. Helping your child to make and keep even a single good friend can make a significant difference to your child's development. If it is clear that your child is having difficulty with making and/or keeping friends, this may be a VERY IMPORTANT problem for you to attend to.
** IS ADHD A VALID DIAGNOSIS IN YOUNG CHILDREN? **
The younger children are, the more likely they are to seem overactive, impulsive, and inattentive. Just compare the attention span and activity level of your typical 4 year old with a typical 10 year old. For this reason, it can be more difficult to make the diagnosis of ADHD in younger children and some professionals have even questioned whether it makes sense to make this diagnosis in preschoolers. I'm sure that some of you may have experienced this first hand when your initial concerns expressed to physicians were responded to with "He's just an active boy."
Professionals have become particularly concerned with this question because the current diagnostic criteria set forth in DSM-IV permits children who display no inattentive symptoms and only hyperactive-impulsive symptoms to be given the diagnosis (i.e. such a child would be diagnosed ADHD, Predominantly Hyperactive/Impulsive Type). Many of these children would not have been diagnosed with ADHD using the prior set of guidelines and concern has been expressed that this might increase the diagnosis being given to active but otherwise unimpaired preschool and primary school children.
A study which appears in the July 1998 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (pages 695 -702) takes a careful look at this important question. In this study 126 3-7 year old children who met current diagnostic criteria for ADHD were compared with 126 same age children who did not. The authors were interested in determining how these children were functioning in important life areas such as peer relations, behavior at school, impairment reported by parents, and early academic functioning.
Please note that these areas are not specific symptoms of ADHD, but are life areas that children with ADHD often have trouble in. The logic of the study was to determine if even at a young age, children who show the primary symptoms of ADHD (i.e. inattention, impulsivity, and overactivity) are also showing early signs of struggle in these important areas. If they are, it would indicate that ADHD is a valid diagnosis in young children because it is associated with significant impairment in important life areas. If, however, the children who showed the primary ADHD symptoms were not having trouble in these areas, it would suggest that the diagnosis of ADHD in young children is problematic. After all, if a child is doing fine socially, academically, and behaviorally, what sense does it make to say that he or she has a disorder?
The results were striking and clear cut. Even after controlling for other psychiatric symptoms (i.e oppositional defiant disorder (ODD), conduct disorder (CD), depression, and anxiety) the children with ADHD were faring less well than their counterparts at an early age. Children who met criteria for each subtype of ADHD were rated by teachers as being liked by fewer classmates and ignored by more classmates than comparison children. They were also rated by teachers as being less prosocial and less assertive. Mirroring the teachers' reports, the children themselves indicated that they were experiencing friendship difficulties, and this was true regardless of which subtype (i.e. hyperactive/impulsive, inattentive, or combined) the child had been diagnosed with. (Note: for a complete discussion of current diagnostic criteria you can click here .
Academically, young children with ADHD were already showing signs of difficulty. This was assessed by determining the difference between children's IQ results and their achievement test results. In general, achievement test scores and IQ scores should be roughly equivalent - when they are it indicates that a child is learning about as well as he/she should based on how smart they are. When achievement test scores start dropping significantly below a child's IQ score, it indicates that the child is not learning at a level that is consistent with his potential. In math, children with ADHD had significantly lower math scores relative to their intelligence than did control children. A similar trend was found for reading, but the results were not quite as strong. Finally, even at this young age, children with ADHD (at least those who had started school) were already more likely to be in special education classes for learning and/or behavior problems.
These are very compelling results and clearly indicate that ADHD - when it is diagnosed properly - is a very real and important condition in preschool and beginning elementary school children. As was clearly demonstrated, young children who are carefully diagnosed with ADHD are not just children who are a bit more active and inattentive than their peers. Rather, they are already having trouble making friends, behaving prosocially, and achieving at a level that is consistent with their potential.
The implications of these results are equally clear. It is just not appropriate to do nothing for a young child whose symptoms are consistent with an ADHD diagnosis. It is still fairly common practice for treatment to be withheld until a child begins school in the hope that he or she will "grow out of it." In other cases, the concerns expressed by parents are dismissed as reflecting their inability to manage and discipline their child. Many children this will not "outgrow" their symptoms, however, and in the meantime, months and years are passing where a child is really struggling without any help. The longer a child's struggles go unaddressed, and the further he or she falls behind in the social and academic arenas, the more difficulty it generally is to get back on track.
Understandably, many physicians are reluctant to prescribe medication to preschool children, and parents of young children displaying these problems are then often left with nothing to do. It is essential to be aware that there are alternative psychological and behavioral approaches to help with the difficulties that preschoolers with ADHD display and the decision not to treat with medication does not need to mean a decision not to treat at all. Even if one is reluctant to label a child as having ADHD at a very young age (personally, I do not feel comfortable making this diagnosis prior to kindergarten) that does not mean that help can and should not be provided to parents and children who are having a difficult time.
- READER QUESTIONS -
I have been able to respond to just about everyone who submitted a question a while back but realize that there are some of you who have still not received a reply. Once again, I apologize for this but between a full time job, getting out the newsletter, and spending time with my family, I have been unable to answer more than a few questions each day. I'm working on it though, and if you have not yet heard back from me, you will soon.
"My child had a very difficult time in school last year. Do you think he would be better off in a private school?"
I get asked this question often by parents, and there is not a clear cut answer that is possible. It really depends on the private school being considered. In my experience in many such situations, I have found that some private schools are actually poorer matches for children with ADHD than the public school that the child switched from.
There can be several reasons for this. First, some private schools are really quite rigid in how they work with their students and are simply unwilling to make the accommodations that may be necessary for a child with special needs. If your child is able to do well with the system they have in place, things are fine. If he or she can not, than trying to get the school to make the changes necessary to help your child be successful may just not be possible. At least in the public schools, children with ADHD are guaranteed certain educational rights under the law that the schools have to try and meet (at least in theory). For a discussion of the educational rights for children with ADHD, click here.
Second, public schools tend to draw a population of students that are, on average, from wealthier and better educated families than your typical public school population. As a result, the students tend to have higher test scores and to be more advanced educationally than students in the public school system. (Please recognize that there are, of course, all kinds of exceptions to this gross generalization).
I have worked with many children with ADHD who attended private schools and were extremely discouraged at being unable to keep up with their peers academically. Many of these students would have done quite well in their local public school, but felt inadequate in a classroom full of hard working high achievers. This can be another difficulty with some private school settings for a child with ADHD who is struggling academically.
Of course, there can be important benefits to private schools for students with ADHD as well. Smaller classrooms, increased attention and structure, a better behaved group of peers - these things can all be quite helpful. Some private schools will bend over backwards to do everything they can to help their students succeed, and, of course, there are schools that specialize in helping students with ADHD and/or learning disabilities.
The bottom line, I think, is that the way to approach this issue is to clearly identify the type of educational environment that your child would be most likely to do well in and what types of extra support and accommodations he/she may need to succeed. Then, if private school is an affordable option, try to determine which schools - including the public school - would be best equipped and most willing to work with your child in the way that is needed.
Try to speak with the teachers about your child and what they would be able/willing to do to help your child be successful. Whenever possible, sit in on classes and see what the classroom environment is like. Personally, before I would commit to spending thousands of dollars to have my child attend a private school I would try to spend a reasonable amount of time their to see what it is really like. I would also want to talk with parents who also have a child with ADHD and see what their experience with the school has been. These folks can be your most helpful informants.
"My child does pretty well once his medication kicks in, but until it does, the mornings can be horrible. Is there a kind of medication that children with ADHD take that helps them stay on a more even keel?"
First, it is important to state that this problem - having the mornings go smoothly - is one that really can be targeted by behavioral intervention. Start by clearly explaining to your child what is expected in the morning, and then write it down in contract form and have you and your child sign it. The contract should spell out clear rewards that can be earned on a daily and weekly basis for doing a good job in the morning and fulfilling the contract. When set up correctly, this type of approach can really make a difference. Review the agreement and what is expected frequently and place it somewhere so your child can read it as soon as he/she gets up. Even putting on a play and having your child act out what is good and bad behavior in the mornings can make a nice contribution. These are all general ideas that can be generally helpful, but what is best in your specific situation should be determined in consultation with an experienced child mental health professional or physician.
As far as medication goes, antidepressants differ from the stimulant medications like Ritalin in that the they take longer to build up to a therapeutic level (often several weeks) and they then stay in the child's system on a more continual basis. In theory, this should result in fewer of the ups and downs that can accompany stimulant medication. In actuality, however, I know of no research that has really looked at this issue so I imagine it is probably a fairly individual thing. Also, you should be aware that antidepressants are generally considered a second line medication for treating ADHD and are usually used only after a comprehensive trial of stimulant medications has not produced good results.
So, at least as far as I know, there is not a medication that has been clearly shown to prevent the morning difficulties described in the question. I would talk with my child's doctor though, to see if he/she is aware of something that I am not.
copyright 1998 ADHD RESEARCH UPDATE.
Please feel free to share this information with others who may benefit from it. If they would like to receive this newsletter on a regular basis, however, please suggest that they contact me about subscribing at addhelp@mindspring.com. Thank you.
David Rabiner, PhD
Licensed Psychologist