*************************************************************
ADHD RESEARCH UPDATE - Volume 12, 1998
*************************************************************

In this issue....
 

* THE EFFECTS OF NUTRITIONAL SUPPLEMENTS ON ADHD

Probably the most frequent request I receive from subscribers is to publish studies on natural/nutritional/alternative treatments for ADHD. You have not seen any such studies reviewed in ADHD RESEARCH UPDATE, because I have not come across any studies on this topic that have been published in scientific journals. Recently, however, I finally found one.

This study was published in Volume 33 of Integrated Physiology and Behavioral Science, page 49-60. The study reports the effects of two nutritional products upon the severity of the symptoms in children with confirmed diagnoses of ADHD. One product tested was a glyconutritional product containing saccharides "known to be important in healthy functioning" and the other was a "phytonutritional product containing flash dried fruits and vegetables. (I'm sorry that I can not provide more information about these supplements but I really do not know much about them, and the way they are described is confusing to me. I am in the process of trying to learn more about this and will pass on what I find out in subsequent issues.)

In the study, 17 children with ADHD were recruited from local parent support groups - 12 of the children had been receiving medication and 5 had not. Over a 6 week period, all children received the glyconutritional product and their behavior was rated by parents and teachers both before the supplement began, and then 3 more times over a 6 week period. Of the 12 children who had been taking medication, 6 continued to received it throughout the study and 6 had their dose reduced by half after two weeks. Three weeks after the glyconutritional supplement had been started, the phytonutritional supplement was also introduced.

The authors report that the glyconutritional supplement decreased the number and severity of ADHD symptoms, and other behavioral symptoms, during the first two weeks of the study. In those children who had been taking medication, side effects were also reported to decline, although it was not really clear how this was evaluated. Further reductions in symptoms after the phytonutritional supplement was introduced were not observed. According to the authors, the degree of symptom reduction from the glyconutritional supplement did not differ for the children who were not receiving medication, those who had their dose reduced by half, and those who took their regular dose over the entire study. The authors conclude that symptoms of ADHD can be reduced by the addition of saccharides to children's diet.

Is this a reasonable conclusion? While I applaud the attempt made to begin investigating the benefits of this type of treatment for ADHD, this conclusion seems to be QUITE premature for several reasons. The questions/concerns that most physicians and mental health professionals would have about these results include:

* sample size is very small and probably not representative of children with ADHD.

Parents who volunteer to have their child test a nutritional product for treating ADHD may be predisposed to see such treatments as helpful;

* supplements were not administered in a "double -blind" manner.

Because parents, subjects, and probably teachers knew when the nutritional treatment was being implemented, the ratings made of children's behavior may have been biased. If you expect or at least hope that something will work, it is just very difficult to provide an unbiased, objective ratings of a child's behavior. Thus, one would have to questions the validity of the improvements reported here.

It is important to emphasize that the same thing is true for the use of medication in treating ADHD as well. This will be clearly illustrated in the case study reviewed below.

* short term improvements may not translate into long term benefits.

Even if the concerns noted above were addressed, one also has to be cautious about assuming that improvements that are noted over a short duration will translate into long term improvements in children's outcomes. The point to emphasize is that any treatment needs to be monitored over a sustained period with evidence that it results in meaningful improvements in a child's functioning over a meaningful time period.

Once again, this is not a critique limited to nutritional treatments, as the same holds true for medical and behavioral treatments of ADHD as well. To date, there is a real lack of good data on the long term benefits of any treatment for ADHD, although this may be because the well designed and required studies have not really been done. This type of important and essential work is currently underway and I will be sure to include results in future issues of ADHD RESEARCH UPDATE as these results are published.

The bottom line is that I would regard these results as perhaps a promising beginning for documenting the effectiveness of glyconutritional-   for some children with ADHD. This should really be considered a very preliminary pilot study, however. Unfortunately, I am sure that you will see data from this study being used on the internet to promote the use of some companies product based on the "published scientific evidence." Please be very cautious about any such claims.
 

* IMPORTANCE OF CONDUCTING A CAREFUL MEDICATION TRIAL

A case study that appeared in the July 1998 issue of the Australia Family Physician (pages 103-105) highlights the importance and, in my opinion, necessity of conducting a careful trial for children with ADHD who are started on medication. Although this isn't really a research article, per se, I wanted to include it in the newsletter to highlight this important issue.

The subject of this case study was a 16 year old boy with learning and attention problems whose parents were convinced required medication. The child's physician was not so sure, so a double blind, placebo controlled medication trial was conducted. During the trial the child received either medication or a placebo over a period of several weeks, and ratings were obtained from the child's teacher concerning his behavior and academic performance during each condition. Because this subject was a teenager, he also completed self-ratings of his ability to concentrate during the medication and placebo conditions.

The results of this trial showed that this subject received no objective benefit from the medication. In other words, teacher ratings of behavior and school work and the subject's own ratings of his ability to concentrate were not appreciably different during the medication and placebo weeks. As a result, the subject did not go on to take medication for an extended period when there was apparently no real benefit from doing so.

For all these reasons, conducting the type of individual trial described in this article is important to do. Conducting such a trial is really extremely easy and provides the benefit of giving you and your child's doctor objective information to use in making long term decisions about the use of medication. Unfortunately, this type of trial is rarely done. As a result, there are many children who may be taking medication regularly who are deriving no objective benefit from it. Many more are probably receiving a dose or medication that is not really optimal for them.

If you are considering the use of medication for your child, I would recommend that you speak with your child's doctor about conducting this type of careful trial. I have developed a set of materials for conducting medication trials that make this quite easy and straight forward to do. I am pleased that a number of physicians in my state have started to use this program routinely. Please feel free to get in touch with me about this if you are interested. If you are a physician looking for a more rigorous and objective way to evaluate your patients' response to stimulant medication that you prescribe, this program would be quite helpful to you as well.
 

* DOES STIMULANT MEDICATION STUNT CHILDREN'S GROWTH?

Along standing concern about the ongoing use of stimulant medications such as Ritalin is that it will lead to growth deficits in children who take it for a sustained period. This concern has arisen because of the appetite loss that stimulant produce in some children, and there has been initial evidence presented that stimulant medications may inhibit childrens' growth - at least at some phases of their development.

The impact of stimulant medication on children's growth was the subject of a study that appeared in the August, 1998 issue of the journal Pediatrics (pages 501-506). In this study 124 subjects with ADHD, along with control subjects without ADHD were followed from early to late adolescence. Some of the teens with ADHD were receiving stimulant medications and some were not.

The authors report that small but significant height differences were found between children with and without ADHD. These height differences, however, were evident in early adolescence but were not present several years later. In addition, the height deficits in early adolescence that were found, were not related to the use of medication. In other words, young teens with ADHD who were not receiving medication were just as likely to show this small height differences compared to non-ADHD children as those who were. In addition, there was no evidence of weight deficits in children with ADHD relative to controls.

The results of this study suggest that ADHD may be associated with temporary deficits in height gain through mid-adolescence, but that ADHD teens appear to "catch up" later on. For parents who have been concerned about the effect that ongoing use of stimulants may have on their child's growth, it is important to note that stimulant medications did not seem to be responsible for even this temporary lag in growth. Apparently, there is something about the biology of ADHD itself that can lead to small and transient differences in growth patterns, and this does not seem to be exacerbated by the use of stimulants.

If you have been reluctant to use medication with your child because of growth-related concerns, this study will hopefully alleviate this concern. It is important to note, however, that although stimulant medication may not have the general effect of inhibiting children's growth, individual children may possibly be affected in this way. That is why it is important to discuss this issue with your physician and to pay attention to it with your child. As the results of this study demonstrate, however, this is quite unlikely to be a problem.
 

* ADHD and DEPRESSION

Several well conducted have shown that children with ADHD are more likely than others to become depressed at some time during their development. In fact, the risk for developing depression is as much as 3 times greater than for other children.

A study recently published in the Journal of Affective Disorders (January 1998, 113-122) examined the course of depression in 76 children with ADHD in order to learn more about the relationship between ADHD and depression. The authors were especially interested in whether depression in children with ADHD represents an actual clinical depression, or whether it may be better understood as a kind of "demoralization" that can result from the day to day struggles that children with ADHD often have.

Lets begin by reviewing what mental health professionals mean when they talk about depression. The important point to emphasize is that the clinical diagnosis of depression requires the presence of a collection of different symptoms - just because one is feeling down or depressed does not necessarily mean that the diagnosis of major depression would be appropriate.

According to DSM-IV, the publication of the American Psychiatric Association that lists the official diagnostic criteria for all psychiatric disorders, the symptoms of major depression are as follows:
 

For the diagnosis of depression to apply, 5 or more of the symptoms listed above need to be present during the same 2 week period (i.e. the symptoms must have persisted for at least 2 weeks), and at least one of the symptoms must be either 1) depressed mood (irritable mood in children can qualify) or 2) loss of interest or pleasure.

In addition, it must be determined that the symptoms cause clinically significant distress or impairment, are not due to the direct physiological effects of a medication or general medical condition, and are not better accounted for by Bereavement (i.e. loss of a loved one.)

As you can see, the important point is that true clinical depression is indicated by a collection of symptoms that persist for a sustained   time period, and is clearly more involved that feeling "sad" or "blue" by itself.

Let me also say a few words about depression in children. Research has shown that the core symptoms for depression in children and adolescents are the same as for adults. Certain symptoms appear to be more prominent at different ages, however. As already noted above, in children and teens the predominant mood may be extreme irritability rather than "depressed". In addition, somatic complaints and social withdrawal are especially common in children, and hypersomina (i.e sleeping too much) and psychomotor retardation (i.e. being extremely slow moving are less common).

What, then, would a "typical" depressed child look like? Although there of course would be wide variations from child to child, such a child might seem to be extremely irritable, and this would represent a distinct change from their typical state. They might stop participating or getting excited about things they used to enjoy and display a distinct change in eating patterns. You would notice them as being less energetic, they might complain about being unable to sleep well, and they might start referring to themselves in critical and disparaging ways. It is also quite common for school grades to suffer as their concentration is impaired, as does their energy to devoted to any task. As noted above, this pattern of behavior would persist for at least several weeks, and would appear as a real change in how the child typically is.

With this brief overview of depression behind us, lets get back to the study. The authors of this study started with 76 boys who had been diagnosed with both major depression and ADHD and followed them over a 4 year period. Because depression can be such a debilitating-   condition they were interested in learning what factors predicted persistent major depression, and how the course of depression and ADHD were intertwined.

The results of the study indicated that the strongest predictor of persistent major depression was interpersonal difficulties (i.e being unable to get along well with peers). In contrast, school difficulty and severity of ADHD symptoms were not associated with persistent major depression. In addition, the marked diminishment of ADHD symptoms did not necessarily predict a corresponding remission of depressive symptoms. In other words, the course of ADHD symptoms and the course of depressive symptoms in this sample of children appeared to be relatively distinct.

The results of this study suggest that in children with ADHD who are depressed, the depression is not simply the result of demoralization that can result from the day to day struggles that having ADHD can cause. Instead, although such struggles may be an important risk factor that makes the development of depression in children with ADHD more likely, depression in children with ADHD is a distinct disorder and not merely "demoralization".

Depression in children can be effectively treated with psychological intervention. In fact, the evidence to support the efficacy of psychological interventions for depression in children and adolescents is more compelling than the evidence supporting the use of medication.

The important point that can be taken from this study, I think, is that parents need to be sensitive to recognizing the symptoms of depression in their child, and not to simply assume that it is just another facet of their child's ADHD. In addition, if a child with ADHD does develop depression as well, treatments that target the depressive symptoms specifically need to be implemented. As this study shows, one should not assume that just addressing the difficulties caused by the ADHD symptoms will also alleviate a child's depression.

If you have concerns about depression in your child, a thorough evaluation by an experienced child mental health professional is strongly recommended. This can be a difficult diagnosis to correctly make in children, and you really want to be dealing with someone who has extensive experience in this area.
 

* THE VARIABILITY OF TREATMENT RESPONSE IN DIFFERENT SETTINGS

This is a very important article that appeared in a recent issue of Behaviour Research and Therapy (1998, Vol. 36, 675-694). In this study, the authors examine the consistency and inconsistency of children's response to behavioral and medication treatment depending on the domain being assessed (i.e. classroom behavior, academic performance, getting along with adults, and getting along with peers), the setting in which treatment occurred (i.e. the child's regular school vs. an intensive summer treatment program), and treatment intensity (i.e. intensive behavioral treatment vs. more modest behavioral treatment). This is more of an extensive case study per se than a large scale research investigation, but it raises and emphasizes some very important points that are for parents to understand.

The purpose of this paper is to clearly demonstrate that children with ADHD can show either consistency or inconsistency in how they respond to treatment, depending on what outcome is being considered and what type of treatment is being implemented. For example, suppose one is examining how effective behavioral treatment alone - i.e. no medication - is for a particular child. One might find that for this child, a good behavioral plan is sufficient to help the child get along fine in several different domains (e.g. getting along with parents, teachers, and peers), but may be inadequate when it comes to the academic domain (i.e. the child is unable to complete assigned work and makes numerous careless mistakes).

For another child, the same type of treatment (e.g. behavioral treatment without medication) might result in adequate academic functioning but problems in the social domains (e.g. the child is unable to follow class rules or get along with peers). For still another child, all domains may be positively effected, or, the child may not function adequately in any domain. The same range of possibilities can occur with medication treatment alone, or even with the combination of medication and behavioral treatment.

In this excellent paper, the authors present fairly detailed case examples of three different children. All three children participated in treatment in both an intensive summer treatment program and in their regular classroom. All children were also receiving an appropriate dose of medication interspersed with a placebo, and in addition, received either intensive behavioral intervention (at the summer camp) and a more modest behavioral treatment program in their regular classroom. Through this design, the authors were able to establish whether medication improved children's functioning above and beyond the boost provided by behavioral treatment alone, and if so, what domains (e.g. academic vs. social) this was true for.

For one child, a consistent additive effect for medication was found across all domains (e.g. academics and social), settings (i.e. in the intensive summer treatment program and in the regular classroom), and treatment intensity (i.e. intensive vs. moderate behavioral intervention). That is, regardless of which domain was being assessed, which setting the child was in, or how intensive the behavioral treatment was, medication made a clear and important contribution to the child's functioning.

A second child also responded consistently to medication across different domains, but differed in his response to treatment depending on the setting or treatment intensity. That is, for this child, behavioral interventions alone were sufficient to produce a good response in academic and social domains during the intensive summer treatment program, but were not effective when the child returned to his regular classroom. In other words, even though this child functioned quite well without medication when at the summer treatment program, where more intensive behavioral treatment was readily available, he was unable to do well either academically or socially in his regular classroom without medication.

In the final case study presented, the child response consistently across the different settings (i.e. camp vs. school), but differed according to which domain was being assessed. Specifically, this child showed a positive response to behavioral alone in the social domain, and functioned adequately in this domain without medication in both the camp and classroom settings. Medication, however, provided a specific enhancement of this child's academic functioning in the classroom. In addition, during less structured classroom times, medication also had an incrementally positive effect on this child's behavior.

What this paper makes clear is that there is no simple answer to the question: "Is behavioral treatment effective for this child?" or "Is medication necessary for this child ?" The answer is that for many children with ADHD it depends - depends on what outcome is being considered (e.g. behavioral vs. academic), what setting is being considered (e.g. home vs. school) and what level of treatment intensity is being considered (e.g. highly structured behavioral treatment plan vs. more simplified behavioral contract).

This is really a critical point to pay attention to. In working to promote the healthy development of your child, it is often not sufficient to find an approach to treatment that works well in one setting or domain and assume that it will also be effective in other settings and domains. You need to carefully evaluate how your child is performing in the different settings and domains in their life that are important. Parents need to be aware that for their child to be as successful as possible in these different settings and/or domains, different treatments or combinations of treatments may well be necessary. Working with someone who understands this very important notion, and who can assist you in developing treatment strategies that may need to vary across domains and settings is a really helpful person to look for.

The other helpful point that follows from this discussion is that it can promote greater collaboration between the important adults in a child's life. Often times, I have seen parents and teachers get into an unnecessarily bad frame of mind about each other because they disagreed about what a particular child required to succeed. Parents may be successful with behavioral interventions alone at home and thus fail to understand why the child is not doing well at school. Often times, the assumption can be that the teacher must not be managing the child well. In actuality, however, the demands at school are quite different and behavioral methods by themselves may not be an adequate intervention at school, no matter how faithfully and skillfully they are implemented. Obviously, the reverse can also be true - teachers may not understand why the child is having such a hard time completing work at home when things at school seem to be going much better. When parents and teachers understand and appreciate that such discrepancies do not necessarily mean that one or the other is doing an inadequate job with the child, but instead may very well reflect the realities of how the child functions in different settings, a more helpful collaborative relationship can often take hold.
 


     * USING A HOME-SCHOOL REPORT CARD *

    (This originally appeared in a column I write for Brandi Valentine's newsletter "Added Attractions". Brandi's site
    is DEFINITELY worth a visit if you have not already been there.

    Now that school has started up again, one of the most important things parents can do to help make it a successful
    year for their child is to carefully monitor how their child is doing each day at school.

    An easy and effective way to do this is with something called a "home-school" report card. This is simply a little
    chart that makes it easy for your child's teacher to provide you with feedback each day on how your child did in
    key areas (e.g. completing work, following class rules, etc.). Based on how your child does each day, he or she
    will earn "special" privileges that afternoon/evening after school (e.g. t.v. time, computer time, getting to stay up
    30 minutes later, etc.).

    Here are suggested guidelines to follow in developing and using such a program. (Note: This program is most
    appropriate for elementary school children, and needs to be adapted for use with older students.)
 

    1. Discuss the plan with your child's teacher: Cooperation from your child's teacher is essential for this to work
    as he/she needs to fill out the ratings each day. Explain that you are trying to carefully monitor how your child is
    doing each day at school and that this will give you the information you need without requiring a lot of time from
    the teacher.

    2. Decide what behaviors to target: This should be done with input from the teacher. The idea is to focus on 2-3
    key areas that the teacher feels are most important. Examples of behaviors you might target are: completing
    assigned class work"; following class rules", treating peers with respect, waiting turn before talking.

    The idea here is to identify a few important areas that your child is having trouble with and where improvement is
    necessary. Don't try to focus on more than 2-3 things at a time and make sure they are stated in simple, straight
    forward language.

    3. Decide how your child will be "graded" for each item: Each day, your child's teacher will provide a rating
    indicating how your child did on each item being targeted. The rating system I generally use is a simple 1-5 scale
    where "1" indicates a very poor job on the specified behavior; "3" indicates an "okay job" and "5" indicates a
    "very good" job.

    Each day, therefore, the teacher would assign such a rating to each behavior that is being targeted.

    4. Make up the daily rating forms that will be used: This does not have to be fancy and can be as simple as the
    outline below:
 

    _________________________________________________________________________________________

                                  (SAMPLE DAILY RATING FORM)
 

    Please write a number 1-5 next to each behavior to indicate your rating for how the child did on the behavior
    today. The rating scale you should use is shown below.

    1. Completes assigned work

    2. Awaits turn before talking

    3. Treats peers with respect
 

    Rating scale: 1 = very poor; 2 = poor; 3 = okay; 4 = good; 5 = very good
    __________________________________________________________________________________________
 

    You would give your child's teacher a supply of these forms so she can complete one each day that your child
    brings home. As you can see, this should not take more than a minute or two.

    5. Discuss the plan with your child: It is very important that your child understand that this plan is not intended as
    a punishment but, instead, will provide him/her with the opportunity to earn extra privileges for doing a good job
    each day at school.

    You need to make sure that your child understands exactly what is expected of him/her to earn a good score in each
    area being targeted. In other words, using the sample chart above, what does he/she need to do in order to be given
    a score of "5" for "treating peers with respect". Ideally, the teacher would explain to your child the reason for the
    ratings that were assigned each day.

    Your child also needs to understand what extra privileges he/she will be able to earn each day after school for
    doing a good job, and what score needs to be achieved to qualify for these rewards.

    * Your Child Needs to Succeed *

    It is important that your child is successful with this program early on. If not, children can quickly become
    discouraged and lose interest. I might thus start out by requiring the child to earn a total of 9 points to receive their
    daily reward. This would mean that the child achieved an average score of 3 (or "okay") on the different items,
    which is presumably an improvement over what had been their typical level of behavior. Once this score is being
    earned consistently, you may want to require a higher score in order to earn the reward, but do not set the standard
    so high that your child is unable to achieve it with some consistency as this can quickly result in a loss of interest
    and effort.

    These are the basics to consider in implementing this simple behavioral plan. This system can be helpful because it
    provides you with daily feedback about how your child is doing in important areas and provides your child with
    short term incentives for good behavior. It also requires very little time from your child's teacher. Here are some
    other things to keep in mind when designing and implementing this program:

    * The more input your child has in developing this program the better.

    It is good to get your child involved in setting the goals to work on as this can get him/her thinking about their
    behavior in a serious way. Also, letting your child have input into the daily rewards they are trying to earn (e.g. t.v.
    time, computer time, getting to stay up 30 minute later, etc.) can help them become more invested in doing well. *
    Consider a long term reward as well as daily rewards for good scores.

    I often suggest that in addition to the daily rewards a child can earn for a good report card, that a longer term
    incentive be used as well. For example, if the child earns a certain number of points during the week, a somewhat
    "bigger" reward can be earned on the weekend (e.g. getting to rent a video, lunch out with parents, trip to park,
    etc.)

    (Note - Some parents have concerns that a program like this is simply "bribing" their child for things he/she should
    do anyway. I do not think this is the case. If your child is behaving in a more mature and cooperative manner,
    shouldn't he or she have access to privileges that would otherwise not be available?)

    * Try to keep this plan on the "top" of your child's mind.

    It is a good idea to remind your child each morning before school what behaviors they are working on, what they
    need to do to earn a good "score" and what reward they are working to earn for that evening and end of the week. If
    the teacher does this as well, and gives your child feedback about how he/she is doing as often as possible during
    the day, this will also be very helpful.

    * Try to keep your child interested in the program.

    Parents often complain that their child with ADD/ADHD shows initial interest in a program like this but soon loses
    interest. This happens as children with ADHD tend to become bored with things quickly.

    The best way to work against this is to frequently praise your child for doing well and setting things up so he/she
    can be successful. Remember, don't make the standards too high starting out - if your child is not able to earn the
    rewards on a regular basis they are unlikely to work harder - instead, they will probably just lose interest.

    It also helps to rotate the rewards frequently so your child is always working to achieve something different and
    new. This takes some effort and creativity but is important to try.

    If you are not already using a program similar to that described above, this can be well worth giving a try. If it
    does not seem to be working for you, then consulting with a child psychologist to figure out how to modify the plan
    to be more successful would be advisable.

    Remember, just like medication is not a "cure" for ADHD, either is a behavioral plan like this. Most parents find
    that this type of plan is helpful while it is implemented, but once it is stopped, the child's behavior often returns to
    how it was before. The goal of this type of program is thus to help manage a child's symptoms more effectively,
    and expecting this to provide a long term "cure" is, unfortunately, an unreasonable expectation.
 

    * That's all for this month...

    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