, the national
support group for children and adults with attention deficit disorder.
At the conclusion of this curriculum, only 7% of teachers continued to
believe that ADHD was caused by poor parenting, 5% still believed that
food additives were the primary culprit, and 34% still felt that medication
should only be used as a last resort. It is also interesting to note that
teachers who participated in the educational meetings reported that they
experienced significantly less stress from their students with
ADHD after learning more about ADHD and effective ways to help students
with this condition.
I think this study provides good initial evidence for how knowledge
about ADHD among teachers may continue to be very suspect, which is quite
unfortunate as it can make things much more difficult for children and
parents. The absence of cooperation between teachers and physicians is
also concerning. On the positive side, the results also suggest that many
teachers are open to changing their beliefs when provided with new information.
Perhaps working to organize an in-service workshop for teachers at your
child's school could be a helpful and important thing to do.
* SELF PERCEPTIONS AND SOCIAL RELATIONS OF
BOYS WITH ADHD *
As has been discussed in several prior issues of ADHD RESEARCH UPDATE,
peer relations are often an area of difficulty for child with
ADHD. An article that appeared in the September, 1997 issue of the Journal
of Clinical Child Psychology (pages 256-265) presents some interesting
new information on this important issue.
The authors of this study were intrigued by the fact that many children
with ADHD seem to offer inflated (i.e. overstated) accounts of their own
competence, and believed that such exaggerated self appraisals may serve
a self-protective function for many children. This is the hypothesis that
they wanted to test.
This was tested by examining the effects of positive feedback on the
self-perceptions and social interactions of boys with and without ADHD.
Eight to 11 year old boys were participated in two unstructured, cooperative
tasks with a same age peer whom they did not know. After the first interaction,
half of the boys were given feedback that they believed was from their
partner about how good a job they had done on the task and how much their
partner liked them. This feedback was actually made up and had nothing
to do with the other child's opinions.
After the first task - but before receiving the bogus feedback - boys
with ADHD reported an overly positive view of how much their partner actually
liked them. In other words, they believed that their partner liked them
more than their partner actually did.
After received the bogus positive feedback, an interesting change occurred:
boys with ADHD who received the feedback actually showed a decrease in
their self-perceptions. That is, they now reported that their partner liked
them less well than they did before, and the perceptions they now reported
were actually more accurate. For boys without ADHD, receiving the positive
feedback had the opposite and more expected effect in that their self-perceptions
actually increased.
The authors interpret these results as supporting their hypothesis that
children with ADHD often provide inflated self-perceptions to counter their
feelings of inadequacy. They believed that what was going on in their study
is that when the boys with ADHD were given the positive feedback, they
were able to relax their defensive post posture and provide more realistic
self-assessments. In other words, because the positive feedback helped
them to feel better about themselves, they no longer had the same need
to describe themselves in unrealistically positive ways.
This is an interesting and important finding that highlights the importance
of findings ways to provide your child with positive feedback and praise.
Although certainly not all children with ADHD may harbor inflated self-perceptions
to ward off feelings of in adequacy, it is certainly easy to understand
how tempting this may be for a child who is the recipient of negative feedback
and criticism both at school and at home for most of the day.
Something that is often helpful for parents that I work with is the
reminder to try and catch their child "being good" at least 5 times each
day and to be sure to point this out to their child. Positive feedback
and praise from parents - when it is deserved - is an important basis for
developing positive feelings about self that can reduce the need to latch
on to overly positive and unrealistic views.
An interesting and informative exercise to do is to keep track of the
ratio of positive to negative statements that you make to your child each
day. Many parents I have worked with are surprised at just how weighted
towards the negative side their communication with their child turns out
to be. This is easy to fall in to be- cause children with ADHD often behave
in ways that elicit such negative feedback from parents, teachers, and
others. That is why it can be so important to really make a deliberate
effort each day to notice positive things to focus on and to convey your
appreciation of these things to your child. The results of this study suggest
that this approach can actually result in the child becoming more open
to criticism and less defensive in how he or she reacts and relates to
you and to others.
* DOES LATE AFTERNOON RITALIN CAUSE INSOMNIA?
*
Parents and physicians are often reluctant to have children take a 3rd
dose of stimulant medication after school because of concerns about the
adverse effect this can have on the child's sleep. In many situations,
a 3rd dose may seem necessary to help the child get through homework and
to reduce behavioral difficulties as well. Nonetheless, this often not
provided because of the concerns noted above. This concern is an important
one, particularly because recent studies suggest that children with ADHD
may be more prone to sleep difficulties, and, that sleep difficulties may
exacerbate the symptoms for many such children (see Volumes 8 and 9 of
ADHD RESEARCH UPDATE for reviews of recent studies on this topic.) A study
published several years ago in the journal Pediatrics (August, 1995;
pages 320-325) suggests that this concern - namely, that methylphenidate
(i.e. the generic name for Ritalin) administered in the late afternoon
will adversely affect a child's sleep - may be unfounded. In this study,
12 children with ADHD received a 4 PM dose of either 15 mg MPH, 10 mg MPH,
or placebo in a randomized order for 12 consecutive days. Children in this
study were inpatients at a child psychiatric hospital which allowed the
researchers to monitor their sleep very carefully. Ratings of the children's
behavior from the 4 PM dose through bedtime were also carefully recorded.
Results indicated that MPH, in either the 10 or 15 mg doses, yielded
marked improvements in children's behavior compared to placebo. In regards
to the effect on children's sleep, no change in sleep latencies
(i.e. how long it took the children to fall asleep) were recorded. On the
10 mg dose of MPH, children were rated as less tired upon awakening compared
to either the 15 mg dose or the placebo.
This study's findings show that children with ADHD derive substantial
symptom reduction from medication administered in the late afternoon, without
there necessarily being an adverse effect on their sleep. Although the
sample size is small, and the study should be repeated, there does not
seem to be any a priori reason for an afternoon dose to be ruled out because
it will ruin a child's sleep.
I have had many parents tell me that their physician was unwilling to
prescribe medication for after school hours because of this very concern.
This can be unfortunate, because without medication, some children are
just very difficult to manage at home and getting homework done in any
reasonable way can seem almost impossible.
Please note that what can not be concluded from a study like this is
that your child will also tolerate afternoon medication well and that it
will not effect his or her sleep. As has been emphasized repeatedly in
prior issues of ADHD RESEARCH UPDATE, children's response to medication
- including how a late afternoon dose may affect their sleep - is highly
individualistic. A study like this one only suggests that it is unlikely
that your child would have their sleep disrupted, not that it can not possibly
happen.
What guidelines, then, should be used to decide whether a child who
is receiving medication should receive a dose in the later afternoon? First,
I would want to know whether the problems with behavior and/or getting
work done are severe enough to possibly warrant this. If a child is doing
reasonably well in the afternoon without medication, then there may certainly
be no clear reason to administer it. Second, I would want to know whether
appropriate, behavioral strategies to deal with problems caused by a child's
symptoms have been implemented without a sufficient level of success. Finally,
it would be important to carefully monitor how a late afternoon dose affected
this child's sleep - some children may really have their sleep affected
in an adverse way even though this may be uncommon among children overall.
If these questions are all addressed in a thoughtful and deliberate manner,
than the odds that you are making the best choice for your own child will
certainly be enhanced.
* WHAT IS CONDUCT DISORDER? *
In Volume 5 of ADHD RESEARCH UPDATE a discussion, I presented as overview
of Oppositional Defiant Disorder (ODD), a behavioral disorder that children
with ADHD are at increased risk for developing eloping. In this issue,
I would like to present a similar over view of Conduct Disorder (CD), which
is a more severe type of behavioral disorder that is also unfortunately
more likely to develop in children with ADHD.
According to DSM-IV, the publication of the American Psychiatric Association
that provides current diagnostic criteria for all recognized psychiatric
disorders, the essential feature of CD is "...a repetitive and persistent
pattern of behavior in which the basic rights of others or age-appropriate
social norms or rules are violated." These behaviors fall into 4 main groupings:
Aggressive behavior that causes or threatens to cause harm;
Examples: initiating fights; cruelty to people or animals;
Non-aggressive conduct that causes property loss or damage;
Examples: fire setting with intent to cause damage; deliberate destruction
of property;
Deceitfulness or theft;
Examples: shoplifting; breaking into someone's house; frequent lying
to obtain goods or avoid obligations;
Serious violation of rules;
Examples: truancy from school; running away from home; staying out
at night prior to age 13;
For the diagnosis of CD to be correctly assigned, at least 3 of the specific
symptoms must have occurred during the prior 12 months, with at least one
criterion present in the last 6 months. In addition, the disturbance in
behavior must clearly result in clinically significantly impairment
in the child or teen's social, academic, or occupational functioning.
These criterion are intended to assure that the diagnosis is not assigned
for an isolated antisocial act, but is instead reserved for youth who show
a pattern of antisocial behavior over a significant period of time.
Associated Features
In addition to these core diagnostic criteria, individuals with CD often
display a number of associated features as well. They often have little
empathy or concern for the feelings and wishes of others; they are prone
to often misperceive other's intentions towards them as being hostile which
can lead them to overreact in a retaliatory, aggressive manner; guilt and
remorse over clear misdeeds are often absent, other than feeling badly
about having been caught; poor frustration tolerance and irritability are
often present, and self esteem is often poor even though an image of "toughness"
is often presented.
CD is often also associated with the early onset of sexual behavior,
substance use and abuse, excessive risk taking, and school suspension.
Self-destructive behavior, including suicide, also occur at higher than
expected rates. Not surprisingly, school suspensions, dropping out, and
poor achievement are also quite common in individuals with CD.
NOTE: It is important to recognize that the explicit symptoms of CD
do not really share any overlap with diagnostic criteria for ADHD (see ).
These two disorders certainly share many of the "associated features",
but the actually symptoms that are used to make the diagnosis for each
condition are really quite distinct. This is why if a child with ADHD is
also displaying the types of behaviors that may warrant a CD diagnosis,
it is important not to attribute the antisocial behavior to just another
facet of the child's ADHD. The danger in doing this is that the child may
not receive the necessary and appropriate treatment as a result.
Subtypes of Conduct Disorder
Two different types of CD are currently recognized. The Childhood- Onset
Type is defined by the onset of at least on symptom of CD prior to age
10. Thus, even though a child may not meet full diagnostic criteria before
age 10, if these criteria are met when the child is 12, and at least one
symptom was present (e.g. running away) before 10, the Childhood-Onset
Type would apply. Almost all children who meet criteria for childhood-onset
CD would have previously been diagnosed with Oppositional Defiant
Disorder.
The second subtype of CD is called the Adolescent-Onset Type. This type
is applicable to individuals who current meet the diagnosis for CD but
who showed no symptoms of CD prior to age 10. Individuals with adolescent-onset
CD are less likely to display aggressive behavior and are more likely to
have decent peer relationships. Of utmost importance is that adolescent-onset
CD less likely to persist into adulthood.
Although CD may occur in children as young as 5-6, it's onset is usually
in late childhood or early adolescence. The course of CD is variable: in
a majority of individuals, the disorder remits by adulthood. Nonetheless,
a substantial percentage continue to display sufficient antisocial behaviors
into adulthood to warrant the diagnosis of antisocial personality disorder
as young adults. This is most likely to be true as noted above, for individuals
whose CD begins early in life and is marked by aggressive behavior.
What is the association between ADHD and CD?
Data collected in numerous studies indicates that about 50% of children
with ADHD will also develop ODD (i.e. Oppositional Defiant Disorder) or
CD at some point during their development. An inter- finding
has been that although "pure" ADHD (that is, ADHD without either ODD or
CD) is quite common in children, the reverse is almost never that case.
In other words, it appears that virtually all children under age 12 who
meet criteria for ODD or CD will also be diagnosed with ADHD. In these
cases, it appears that the impulsivity and over activity that is characteristic
of ADHD children, and the ensuing difficulties this creates in parent-
child, teacher-child, and peer relationships, increases the risk for the
kind of conflictual interactions that promote the develop of
these other disruptive behavior disorders.
THIS IS WHY IT IS SO IMPORTANT THAT PARENTS LEARN ABOUT THE KINDS
OF SPECIALIZED BEHAVIOR MANAGEMENT STRATEGIES THAT ARE OFTEN HELPFUL AND
NECESSARY FOR CHILDREN WITH ADHD.
Probably the most important thing a parent can do to help promote
their child's long term success is to make sure that the proper steps are
taken to prevent the development of these more severe behavior disorders
that often develop in response to the problems that primary ADHD symptoms
can cause.
Here's why. The long term outcomes of children with pure ADHD and ADHD/CD
are very different. For example, in one study in which samples that followed
two samples of ADHD children - one with high levels of aggressive behavior
and the other without - there were no cases of drug or alcohol abuse at
age 14 in the ADHD only group, while for the ADHD aggressive group, over
30% had engaged in substance abuse. In a similar study using different
samples of children, approximately 1/3 of ADHD/CD boys had committed multiple
crimes as teenagers compared to fewer than 4% of boys who had been diagnosed
with ADHD alone.
Treatment
I'll try to cover treatment of CD and ADHD/CD in a subsequent issue
of ADHD RESEARCH UPDATE. For now, it is important to note that in several
double-blind, placebo-controlled studies, children with ADHD/CD show an
equally robust response to stimulant medication as do children with ADHD
alone. In addition, there is some evidence that not only primary ADHD symptoms
are reduced, but that antisocial behaviors themselves such as aggression
and stealing are also reduced. It is widely believed that children with
ADHD/CD as well as children with CD alone clearly require more intensive
behavioral and psychosocial interventions than children with ADHD alone,
but the research data that exists on this question is somewhat limited
at this time. Studies are currently underway that promise to begin providing
answers to these important questions, and I will certainly include them
in the newsletter as they begin to be published.
- READER QUESTIONS -
"My child was recently diagnosed with ADHD. I'm reluctant to tell
new teacher this because I'm concerned he will get labeled as a problem
student. What do you recommend?"
I've actually had this concern expressed by many of the parents I have
worked with. It is certainly the case that there may be some teachers who
would respond to learning that one of their students has ADHD by doing
the kind of labeling in their own mind that this parent is concerned about.
The teacher may expect certain behaviors from the student and not give
the child the benefit of the doubt or be as open minded with this student
as with others. As seen above, it is even possible that a teacher would
erroneously believe that the child's ADHD has resulted from poor parenting,
and thus have similar preconceptions about dealing with the child's parents.
For these reasons, some parents are reluctant to share their child's diagnosis
with the school. On the other hand, most students with ADHD really do need
certain accommodations at school in order for them to maximize their success.
Preferential seating, untimed tests, help with keeping track of assignments,
etc. are just some examples of what may be required. Students with ADHD
may be entitled to these types of accommodations as well as many others
based on guidelines outlined in two federal laws. Unless the child's diagnosis
is made known to the school, however, the extra assistance the child may
need is less likely to be forthcoming as the child must be officially identified
as having ADHD before the federal laws would apply. My own feeling on this
issue is that if a teacher reacts negatively to learning about a child's
diagnosis, and is unable or unwilling to modify their attitude and behavior
towards the child, parents must take active steps to have their child removed
from this teacher's class. I really think it is essential for a child's
teacher and school to be aware of the child's diagnosis so that the appropriate
steps to provide the child with the extra assistance that is necessary
can be taken. Without this assistance, many children with ADHD are simply
going to have a much more difficult time in the classroom. As time goes
on, hopefully fewer and fewer teachers will engage in the negative labeling
that parents are concerned about so that this will become less of an issue.
"I'm trying to encourage good behavior in my child at school this year
by promising him a reward on the weekend if he has a good week at school.
After only 2 weeks, though, it is clear that this does not seem to be working.
Any suggestions?" The main problem that may exist with the plan you are
using is that having to be "good" for an entire week in order to earn a
desired reward is simply too long a time period for most children with
ADHD. It is just very hard for most children with ADHD to stay focused
on long term goals, so this may not be providing the type of incentive
you need. For behavioral plans to be effective for children with ADHD,
much shorter time intervals between the behavior you are trying to encourage
and the privilege they will earn are usually required. One "typical" program
might provide a reward midway through the school day for good behavior
in the morning; the opportunity to earn an extra privilege at home in the
afternoon for good behavior during the second part of the school day; and,
a somewhat larger reward that can be earned on the weekend for an overall
good per- performance during the week. With this type of schedule, the
child is consistently working to attain more short terms goals and rewards,
and this is also tied in to a longer term goal as well. In addition to
providing this type of short term incentive, there are several other things
that are important to keep in mind when developing this type of behavior
plan for a child with ADHD. These include:
clearly defining the behaviors you expect of the child - it is essential
that the child fully understand what he or she has to do in order to earn
their desired reward;
focusing on only a few things at a time - I never try to target more than
2 or 3 behaviors at any one time;
providing the child with frequent reminders of what is expected of them
and what rewards they are working to earn;
letting the child take an active role in helping to design the program
- i.e. getting the child's input on what they need to work on, what rewards
they would like to earn, etc.
changing the incentives frequently so that the child does not get bored
with the program;
setting the program up so that the child has an excellent chance to be
successful with it early on - you can always make the required standards
to earn rewards more stringent as things progress, but if the child does
not experience some early success, he or she may quickly become discouraged
and lose interest.
Try incorporating some of these suggestions into the behavior plan you
are trying and you may find that it is more successful. If things continue
to be a struggle, consulting with an experienced child mental health professional
to help develop a good behavior plan is strongly recommended.
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