**********************************************************Research clearly shows that families who have children with ADHD experience increased levels of parental
ADHD RESEARCH UPDATE - Vol. 14, December, 1998
**********************************************************In this issue...
* NIH Conference on the diagnosis and treatment of ADHD
* Alternative treatments for ADHD: What is their scientific status?
* Report of an effective new medication for adults
* Language difficulties in children with ADHD
READER QUESTIONS
If ADHD is a brain disorder, how can it truly be treated without medication?
Are there different levels of ADHD and is behavioral treatment only appropriate for milder cases?
* NIH Consensus Conference on ADHD
The National Institute of Health recently convened a conference on ADHD that was attended by leading authorities on this disorder from multiple disciplines. The purpose of this conference was to generate a widely shared agreement about the central facts about the diagnosis and treatment of ADHD based on the current research literature. Important directions for future research were also discussed.
The findings to come out of this conference represent the current state of knowledge in the field as agreed to by multiple experts. I will try to highlight the major conclusions reached by panel for the six different questions that they addressed. (Note: The information below is based on a Draft version of the consensus statement, and it is possible that the final version will contain modifications.)
What is the Scientific Evidence to Support ADHD as a Disorder?
As you may know, there are still many individuals who doubt that ADHD even exists. Even some health care professionals continue to regard ADHD as an excuse for poorly behaved child with parents who do not know how to discipline. Because of this continuing concern, the panel first considered evidence that supports the validity of ADHD as a disorder.
The panel concluded that there is validity in the diagnosis of ADHD, and that the diagnosis can be made reliably using well tested diagnostic interview methods. Evidence supporting the validity of ADHD includes the predictable course of ADHD over time, studies in different cultures that reveal similar characteristics for the disorder, and the fact that ADHD has been shown to have a strong genetic component.
Several cautions were also noted, however. As yet, an independent, valid test for ADHD does not exist. This means that there is not single procedure or "objective" test that can be routinely used to determine whether or not a child or adult has ADHD, and that a careful evaluation relying on information collected from multiple sources is still required. Furthermore, although prior research does indicate differences in brain functioning between individuals with and without ADHD, there is no conclusive evidence that ADHD is caused by a brain malfunction. (Note: There is certainly evidence which strongly suggests that this is the case, however. Scientists tend to have a very high standard for what constitutes "conclusive evidence" for something. We know, for example, that important differences in brain activity have been found for people with ADHD. This does not necessarily mean, however, that such differences are the actual cause of the disorder. I think this is probably what the panel had in mind.)
The consensus statement drafted by the panel also noted difficulties in differentiating ADHD from other behavioral problems, and the need to develop more reliable methods for doing this. It is also the case that the reported rate of ADHD in some countries is much lower than in the US. This indicates the need for better study of ADHD in different populations and better definition of the disorder.
Finally, it was noted that all formal diagnostic criteria for ADHD were designed for diagnosing young children. Diagnostic criteria that are sensitive to changes in how ADHD may appear in older children and adults need to be developed. If you look at what the formal diagnostic criteria for ADHD you will see that this is clearly true. Developing diagnostic criteria that are more appropriate for older individuals is clearly needed.
What is the Impact of ADHD on Individuals, Families and Society?
The statement issued by the panel notes the wide ranging effect that ADHD has on children, their families, and society. Many children with ADHD experience peer rejection and engage in a broad array of disruptive behaviors. They are more prone to accidents than other children and are at increased risk for developing serious behavioral disturbances such as conduct disorder. For many children, the adverse impact of ADHD continues into adulthood.
This clear description of the adverse impact that
ADHD can have on parents and families is important. In many
cases, even when a child is getting treatment, little
or no treatment/ support is provided to parents who are
contending with the frustrations and difficulties
that having a child with ADHD can cause. Research has shown that
this can take an important toll on parents' own
sense of well being.
For those of you who may be experiencing such stress,
it is important to know that this is a frequent complication
of the disorder and getting assistance to cope with
such stress, perhaps by participating in a parent support group
can be extremely helpful. Many physicians who treat
ADHD fail to consider the impact on other family members
and do not encourage parents to seek out the assistance
that they may also need.
Although methodological problems make it hard to
define the precise costs of ADHD to society, it is clear that they
are huge. Additional public school expenditures
on behalf of students with ADHD exceeded $3 billion in 1995.
This is but a fraction of the dollars that are spent
each year on problems that are either directly or indirectly related
to ADHD.
What are Effective Treatments for ADHD?
The panel notes that available research data clearly
supports the efficacy of stimulant medication treatment and
certain types of behavioral treatment on the core
symptoms of ADHD (see the prior issue of ADHD RESEARCH
UPDATE for a more extended discussion of empirically
supported behavioral treatments).
There are a number of important questions and caveats that were also raised, however.
* Studies of treatment efficacy have been short term - generally 3 months or less.
Although it is hard to believe, there are no long
term studies testing stimulants or psychosocial treatments that last
several years. There is thus no conclusive information
on the long term outcomes of medication-treated children in
terms of educational and occupational achievements,
or other important areas of social functioning. It is important
to note, however, that several studies have been
conducted in which children taking stimulant medication were
followed for durations of 12-24 months. These studies
indicate that when prescribed properly, and when children
are carefully followed, the beneficial effects of
medication treatment seem to persist.
* Almost all treatment studies
have been conducted on children who show both inattentive and
hyperactive/impulsive symptoms.
Basically, there is very little treatment data on
children who show attention problems only without the hyperactive/
impulsive symptoms (i.e. children who are diagnosed
in the current system as ADHD, Predominantly Inattentive
Type). This is particularly important because this
subgroup of children with ADHD may contain a higher
percentage of girls. (In my own experience, I have
certainly found that stimulant medications are also effective for
children with the inattentive type of ADHD. Specific
research on this population is needed, however.)
* There is no conclusive data on treatment of ADHD in adolescents and adults.
Most of the treatment research has been conducted
with school age children, and the data base looking at
adolescents and adults is much smaller. As you have
seen in prior issues of ADHD RESEARCH UPDATE,
however, studies examining the efficacy of stimulant
medication treatment in adolescents does indicate that it is
effective, at least over the short term. More work
on medical and non-medical treatments for older individuals
with ADHD is clearly needed, however.
Preliminary evidence from a large scale, longer term
treatment study that promises to fill in important gaps in our
knowledge was also discussed. It was noted that
medication treatment that includes using systematic and intensive
monitoring methods over approximately one year may
be superior to an intensive set of behavioral treatments on
core ADHD symptoms (i.e. inattention, hyperactivity/impulsivity,
aggression).
(Unfortunately, in the real world, careful monitoring
of a child's response to medication over time is rarely done.
The ADHD Monitoring System that you should have
received as a bonus with your subscription provides a
reasonable method for doing this and I hope that
you are using it. If for any reason you did not receive this when
you subscribed, please let me know so I can send
it to you.)
Data from the large, ongoing treatment study noted
above is suggesting that the combination of medication and
behavioral treatment may result in improved social
skills for children with ADHD. In addition, parents and
teachers judged this combined treatment more favorably.
An important potential advantage for combined treatment
is the possibility of improving a child's functioning
with a reduced dose of stimulants, although existing data do not
permit any firm conclusions about this.
The panel also noted the long history of other treatments
for ADHD including dietary interventions, herbal
treatments, various vitamin or mineral regimens,
biofeedback, perceptual stimulation, etc. Their conclusion is that
the empirical evidence pertaining to these interventions
is generally sparse, and that the efficacy for all these other
treatments still remains to be established. It was
stated, however, that some of the dietary elimination strategies
(i.e. eliminating from a child's diet certain foods
or additives believed to exacerbate ADHD symptoms) have
shown some intriguing results that suggest future
research in this area should be pursued. (Note: This is the most
positive statement on dietary interventions from
a scientific panel that I have seen. I will be looking for research in
this area to present in future issues of ADHD RESEARCH
UPDATE.)
What are the Risks of the use of Stimulant Medication and Other Treatments?
The panel provides a very cautious statement on the
risks associated with the long term use of stimulant
medications.
"Although little information concerning the long-term
effects of psychostimulants, there is no conclusive evidence
that careful therapeutic use is harmful. When adverse
drug reactions do occur they are usually related to dose.
Effects associated with moderate doses may include
decreased appetite and insomnia. These effects occur early in
treatment and may decrease with continued dosing.
There may be negative effects on growth rate, but ultimate
height appears not to be effected."
How are we supposed to interpret this statement and
what does it really mean about the long term safety of
treatment with stimulant medication? I find the
statement to be distressingly vague, although it is as strong a
statement as can be made based on currently available
evidence. Basically, the available data on the long term
effects of stimulant medication does not permit
one to conclude that there is no possibility of adverse health effects,
but there is also no evidence that they are harmful.
It would be nice to be able to make a stronger conclusion than
this, and given how long stimulant medications have
been prescribed, it is surprising that more long term data is
not available. Clearly, however, there is not sufficient
concern about safety among the panel for them to suggest
that long term use is not advisable. Overall, the
conclusion seems to be that the ratio of potential benefits to
potential risks is highly favorable. It should be
noted, however, that although this may have been the consensus
view, not everyone agreed with this conclusion.
Several important concerns were raised, however.
The panel stated that psychostimulants do have abuse potential
and that very high doses can result in central nervous
system damage, cardiovascular damage, and hypertension.
Unfortunately, what constitutes a "very high" dose
was not defined, although it is my understanding that this is
certainly above what should be required to produce
a therapeutic response in most children. If you are concerned
about your own child's dosage, please be sure to
discuss your concerns with your child's doctor.
The panel noted that the degree of assessment and
follow up by primary care physicians who prescribe stimulant
medication varies significantly. In many cases,
appropriate procedures for these important functions are just not
used. My own opinion about this is that this results
in many children taking medication who may derive no real
benefit from it, or, who are maintained on a less
than optimal dose.
The panel suggested that little is currently known
about the illicit use of stimulant medication, but that there is little
evidence that current levels of availability have
had a substantial effect on abuse. The need to be vigilant in
monitoring the use and possible abuse among high
school students was emphasized.
What are the Existing Diagnostic and Treatment Practices,
and What are the Barriers to Appropriate
Identification, Evaluation, and Intervention?
The panel was actually quite critical about the way
ADHD is often diagnosed. They noted that there is wide
variation in the frequency of diagnosis made by
different types of providers (e.g. pediatricians, family physicians,
psychologists, neurologists, psychiatrists), and
that diagnoses are often made in an inconsistent manner. As a result,
many children are misdiagnosed - either being identified
as having ADHD when they do not or not being properly
identified when they do.
The panel noted that some practitioners do not use
any standardized procedures for making the diagnosis - either
structured interviews, or standardized behavior
rating scales. They were particularly concerned about how often
the diagnosis is made without the practitioner obtaining
any direct information from the child's teacher. It was
noted that pediatricians, family physicians, and
psychiatrists tend to rely on parent input only rather than also
collecting information from the child's school and
teacher. (For more detailed information on what I think is a
reasonable approach to evaluating a child for ADHD,
click here.)
Just as the diagnosis is often made without direct
input from the child's school, the panel also noted that there is
often poor communication concerning a child's response
to treatment. They note that follow up is often "inadequate
and fragmented", and stress the importance of careful
monitoring to determine how treatment is working and to
detect any adverse effects of treatment. It is really
a shame how infrequently this is done - most children are simply
put on medication with little or no systematic procedure
in place to determine how effective the medication is
being, and what difficulties may still need to be
addressed via other means even if the medication is helping with
the core ADHD symptoms.
The panel implied that the quality of the evaluation
a child receives and the type of treatment recommended may
depend on the type of provider doing the evaluation.
They stated that primary care practitioners (e.g. pediatricians
and family physicians) are less likely to recognize
the other difficulties that often go along with ADHD (e.g.
behavioral, social, emotional, and academic problems).
This can result in a child failing to receive the
comprehensive treatment approach that may be necessary.
They also mention data that indicates family
practitioners are more likely to prescribe stimulant
medication than other types of physicians.
My own experience certainly indicates that these
concerns are valid ones. There are, of course, many pediatricians
and family physicians who do an absolutely outstanding
job of evaluating children for behavioral disorders such as
ADHD and who make certain that all necessary and
appropriate forms of treatment are considered. I hope that you
have been fortunate in being able to find such a
person.
In regards to barriers to appropriate identification,
evaluation, and treatment, the primary one described is the lack
of adequate insurance coverage. Many health insurance
policies simply do not provide sufficient coverage for an
adequate evaluation and families often can not afford
the out of pocket expenses that are required.
A perfect example of this is that few if any plans
will reimburse a provider for visiting a child's school to observe
the child in the classroom and to consult directly
with his or her teacher. In many cases, this can be one of the most
important things for the therapist to do, but there
is no insurance coverage for this and parents can not afford to bear
the expense.
What are the Directions for Future Research?
A number of important research questions and areas were identified including:
Developing age appropriate diagnostic criteria for adolescents and adults;
Studies of the inattentive type of ADHD, especially since girls may be overly represented in this subtype;
Studies of long term treatment with a focus on the
risks and benefits of long term treatment with stimulant
medications;
Studies on the effects of different educational/instructional
methods on the academic achievement of children
with ADHD;
Studies to determine whether the combination of stimulants
and behavioral treatments can improve functioning
with a reduced dose of stimulants;
Studies to determine the risks and benefits of treating children younger than 5 with stimulants;
The panel also emphasized that work needs to be done in the following areas:
Developing a more consistent set of diagnostic procedures and practice guidelines;
Model projects should be developed to demonstrate
methods of training teachers to recognize and provide
appropriate special programs for children with ADHD;
Developing and incorporating classroom strategies that effectively serve a greater variety of students;
Determining the extent to which individuals with
ADHD are being served in post secondary education (i.e.
college), how successful they are being, and what
types of accommodations are necessary to help enhance their
success.
I hope the above summary of this important conference
provides you with a good appreciation for the current state
of knowledge and practice in the field. (Remember,
this is a "draft" statement, and it is certainly possible that
changes will be made for the final version, although
I would not expect any major revisions.) As is evident, there
are some important gaps in our knowledge of how
to best evaluate and treat ADHD, and the gaps between what
should be done and what is often done is even more
concerning. For the complete text of the consensus statement
drafted by the panel click here
The Scientific Status of Alternative
Treatments for ADHD
At the NIH Consensus Conference noted above, Dr.
Eugene Arnold, an emeritus professor of Psychiatry from the
University of Ohio, presented a very interesting
talk in which he summarized the current scientific evidence for a
variety of alternative treatments for ADHD. I know
this is an area that many people have interest in, so I wanted to
present his paper in some detail.
Based on his review of the existing research literature,
Dr. Arnold rated the alternative treatments presented on a
0-6 scale. It is important to understand this scale
before presenting the treatments. (Note that this is one person's
opinion based on the existing data - other experts
could certainly disagree). The scale he used is presented below:
0 - no supporting evidence and not worth considering further;
1 - based on a reasonable idea but no data available;
These would be treatments not yet subjected to any real
scientific study;
2 - Promising pilot data but no careful trial; These
would be treatments where very preliminary work appears
promising but where the treatment approach is in
the very early stages of investigation.
3 - Supporting evidence beyond the pilot data stage
but carefully controlled studies lacking; This would apply to
treatments where only "open" trials and not double-blind
controlled trials have been done.
(Let me briefly review the difference between an
"open" trial and a double-blind trial because this is a very
important distinction. Say you are testing the effect
of a new medication on ADHD. In an open trial, you would just
give the medication to the child, and then collect
data on whether the child improved from either parents or
teachers. The child, the child's parents, and the
child's teacher would all know that the child was trying a new
medication.
In a double-blind trial, the child would receive
the new medicine for a period of time and a placebo for a period of
time. Neither the child, parents, nor teacher would
know when medication or placebo was being received. The
same type of outcome data as above would be collected
- during both the medication period and the placebo
period.
The latter is considered to be a much more rigorous
test of a new treatment - whether it be a new medication, a
dietary intervention, or some other alternative
- because it enables researchers to determine whether any changes
reported/observed are above and beyond what can
be attributed to a placebo effect. In an open trial, you can not be
certain that any changes reported are actually the
result of the treatment, as opposed to placebo effects alone. It is
also the case that it is very hard for anyone to
provide objective ratings of a child's behavior when they know that a
new treatment is being tried. For these reasons,
"open" trials - even if they yield very positive results - are
considered to be only preliminary evidence in support
of any new treatment.)
4 - One significant double-blind controlled trial
that requires replication; (Note: Replicating a favorable
double-blind study is very important. The literature
is full of initially promising reports that could not be
replicated.)
5 - Convincing double-blind controlled evidence but
needs further refinement for clinical application. This rating
would be given to treatments where replicated double-blind
trials are available, but where it is not completely
clear who the treatment is best suited for. For
example, a treatment may be known to help children with ADHD, but
it may be effective for only a minority of the ADHD
population and the specific subgroup it is effective for is not
clearly defined.
6 - A well established treatment for the appropriate subgroup.
Of the numerous alternative treatments reviewed by
Dr. Arnold, no treatments received a rating of 6 and only one -
dietary treatments that involve placing children
on diets that eliminate their exposure to certain foods or food
additives that they have allergic reactions to.
Dr. Arnold concludes that there is convincing scientific evidence that
some children who display symptoms of ADHD can derive
significant benefits from appropriate dietary
treatments. The important task, as he sees it, is
to determine what percentage of the ADHD population dietary
responders constitute (i.e. is it a very small minority
of a larger proportion; the general view is that the percentage
is quite small) and to better identify the child
who is likely to respond to dietary treatment. Preliminary evidence
suggests that the type of child most likely to respond
is a preschooler with a history of prominent irritability and
sleep disturbance. Dietary interventions are also
more likely to be helpful if there is a family history of migraines,
or if a parent can give a definite example of a
food/behavior change connection.
There were two alternative treatments for which a
rating of 4 was assigned (i.e. a convincing double blind trial
that requires replication). This treatment involves
relaxation training using a type of biofeedback procedure (i.e.
EMG biofeedback). There is some preliminary evidence
that relaxation training does result in reductions in ADHD
symptoms (recall a recent article reviewed in ADHD
RESEARCH UPDATE about the possible benefits of
massage) and Dr. Arnold believes that this treatment
approach warrants further investigation. It is not clear what
the magnitude of the benefits are nor how long they
would be expected to last.
The second treatment for which some positive data
from controlled, double-blind trials exist is "deleading" (i.e.
reducing lead levels in the bloodstream). Positive
effects are restricted to those children who have elevated blood
lead levels to begin with; for such children, Dr.
Arnold argues that deleading would be the treatment of choice. To
how low a blood lead level this treatment should
extend is currently unknown.
Several alternative treatments received ratings of
"3", indicating promising results from initial studies, but for
which the necessary double-blind controlled studies
are lacking. Several studies have found that essential fatty
acids tend to be lower in children with ADHD, and
some preliminary data suggests that supplementing fatty acids
in children with ADHD who have been shown to have
low levels of these substances may result in behavioral
improvement. Controlled trials of fatty acid supplementation
should be pursued, although one would expect any
beneficial effect to be restricted to those children
with ADHD who are first shown to be deficient in their levels of
these substances.
Promising data from open trials of providing glyconutritional
supplements (glyconutritional contain basic
saccharides necessary for cell communication and
formation of glycoproteins and lipids) have also been obtained.
These results are from only 2 studies, however,
with small sample sizes. Once again, placebo controlled trials are
necessary.
Promising initial results using several types of
mineral supplements have also been reported. Iron supplementation
has been associated with improvements in parent
behavior ratings for ADHD boys, although no comparable
improvement in teacher ratings was found. Magnesium
supplementation has also yielded some promising
preliminary results for children with ADHD who were
also none to be deficient in magnesium. No double blind
trials of either type of supplementation have been
conducted.
What about herbal treatments, an approach that is
frequently touted? Two open trial studies using a "Chinese herbal
cocktail" have reported extremely positive results,
including the complete disappearance of all symptoms in 23 of
80 subjects with no recurrence for 6 months, and
improvement reported in 90% of participants. Careful, controlled
trials of Chinese herbal treatments are certainly
warranted. (Interestingly, Dr. Arnold could not find any systematic
data for using pycnogenol for treating ADHD, even
though this is widely marketed via the Internet and other
vehicles.)
Other treatments for which encouraging preliminary
support has been reported include biofeedback, meditation,
and some forms of perceptual stimulation and training.
Controlled trials of all these approaches are lacking,
however, and research on the latter two approaches
has not been published in over 10 years.
A number of alternative treatments were assigned
ratings of 0 by Dr. Arnold, indicating that he views them as
being not worth pursuing. Among these treatments
are: eliminating sugar from children's diets, vitamin
supplementation, amino acid supplementation, and
hypnosis.
There would seem to be several general conclusions
that can be drawn from Dr. Arnold's excellent review of
alternative treatments for ADHD? First, in contrast
to the more standard treatments of stimulant medication and
behavioral therapy, there are no alternative treatments
for which comparable empirical support exists. Thus, there
is really no alternative treatment that one could
responsibly recommend prior to trying more standard treatments
(exceptions may be deleading for children with high
blood lead levels and thyroid treatment for children with
known thyroid dysfunction.)
Second, there are a number of promising alternative
approaches that would be reasonable to consider if more
standard treatments are not effective. Although
the necessary data to support the more routine use of these
alternatives does not yet exist, one hopes that
the required double blind studies that provide support for these
approaches will soon be available. Given some of
the encouraging initial results reported for several approaches,
it is somewhat surprising that more work in these
areas has not been conducted.
Finally, it should be noted that several alternative
treatments reviewed, if they are clearly demonstrated to be
effective, are likely to apply to only a subgroup
of the ADHD population. For example, it would not make sense to
provide nutritional or mineral supplementation to
a child who is not deficient in either area to begin with.
* Tomoxetine: Helpful new medication for adults with ADHD
This article appeared in the May, 1998 issue of the
American Journal of Psychiatry (pages 693-695) and reports on
a study testing the effectiveness of Tomoxetine
for treating ADHD in adults.
Participants in the study were 22 adults with clear
diagnoses of ADHD. During a 3 week trial, participants
received both Tomoxetine and a placebo, and a variety
of behavioral and laboratory measures of attention an
impulsivity were collected. The average dose of
the medication was 76 mg/day and few participants experienced
any adverse side effects.
During the placebo condition only 2 of 21 participants
showed any improvement, compared to 11 of 21 who
showed significant improvement when receiving Tomoxetine.
Although these results are regarded as preliminary
by the authors, they are promising nonetheless, and follow up
research on this medication using a larger sample
and a more extended treatment period is being planned. For
adults struggling with ADHD symptoms, this may prove
to be an important treatment alternative if other
medications are not successful.
* Language Difficulties in Children with ADHD
This study appeared in the October 1998 issue of
the Journal of Child Neurology (pages 493-497). The authors of
this paper call attention to the frequent presence
of language difficulties in children with ADHD - an important
problem that is often overlooked.
From an initial sample of 3208 children who were
screened for ADHD, just over 5% were identified as having
ADHD. These children, along with a randomly selected
sample of the non- ADHD children, were then given IQ
tests and language evaluations. Among the children
with ADHD, 45% were identified as having language
difficulties, and this occurred more often in girls
than in boys. The percentage of children with language problems
was much higher, of course, than for children without
ADHD. In fact, children's performance on the language
evaluation was more discrepant for the ADHD and
non-ADHD children than was their performance on a routine
IQ test. This is important because the authors note
that the language difficulties for many children with ADHD were
not reflected in their IQ test results.
In discussing these results, the authors indicate
that undiagnosed, and hence, untreated language difficulties may
contribute substantially to the academic difficulties
experienced by many children with ADHD. They argue,
therefore, that language evaluations should be part
of the routine assessment of children with ADHD.
This is the first study that I have seen of this
issue, but it is a well conducted study and the concern it raises about
unaddressed language problems in children with ADHD
is certainly an important one. If you have concerns about
possible language difficulties in your child that
may be contributing to difficulties with academic functioning,
pursuing an evaluation of your child's language
functioning should be considered. This can generally be obtained at
no charge through the public school system.
- READER QUESTIONS -
If ADHD is a brain disorder, how can it truly be treated without medication?
First, as noted above, the conclusion of the NIH
Consensus Panel is that evidence that ADHD is caused by a brain
malfunction does not yet exist. This strikes many
as a very conservative statement, given the results of several
studies which have documented differences in certain
aspects of brain functioning between individuals with and
without ADHD. I think the panel took this position,
however, because the fact that finding such differences does not
necessarily mean that they are the actual "cause"
of ADHD. For example, these differences could possibly be the
result of having ADHD rather than the cause, or
may be associated with some other factor that actually "causes" the
disorder.
Even if ADHD is eventually shown to be clearly and
unambiguously caused by differences in brain function,
however, this does not necessarily mean that medication
must be the only treatment. For example, many cases of
depression are known to be associated with changes
in brain chemistry, and yet psychotherapy without medication
is clearly an effective treatment for many individuals
who suffer from depression. Psychosocial treatments can
actually alter brain chemistry in ways similar to
medication induced changes, as potentially, can other substances
besides stimulant medication. Thus, there is no
a priori reason why medication would need to be the only effective
treatment for ADHD, or any other psychiatric disorder
for that matter, regardless of whether a clear biological
cause has been identified.
Are there different levels
of ADHD and are behavioral treatments alone appropriate for mild forms
of
ADHD only?
There are definitely different levels of severity
of ADHD. For some children, even though they meet the criteria for
the diagnosis, their symptoms are relatively mild.
Other children , in contrast, display symptoms of much greater
intensity and are significantly more difficult to
manage.
It is also important to recognize that the severity
of a child's symptoms can vary significantly over time, and even at
the same point in time across different settings.
Thus, some children experience a diminishing of their symptoms as
they grow older - many times to the point where
the symptoms no longer cause significant impairment and the child
- who may now be a teen or young adult - no longer
would be diagnosed with ADHD. (At this point, it is not
possible to predict, as far as I know, who this
will occur for and who it will not.)
A child's symptoms can also show varying levels of
severity across different settings. For example, it is not
uncommon for a child's symptoms to be much more
evident and impairing at school then they are at home. Even
within the school setting, a child's symptoms can
even be more severe with one teacher than another because of
differences in how the two classrooms may be structured
and differences in teaching style. This is why it is so
important for parents to work hard to try and make
sure their child gets a teacher each year who works well with
children who have ADHD. In my own experience, I
have seen many times what an enormous difference having the
right teacher can make for the success of a child's
school year.
In relation to whether behavioral treatments are
appropriate for children with "mild" case of ADHD only, I am not
aware of any studies that have looked specifically
at the success rate for behavioral treatments in relation to the
severity of a child's symptoms. I believe the general
view among the medical and mental health professions is that
the more severe a child's symptoms, the more likely
it is that medication will need to be a part of the child's
treatment. Of course, the more severe a child's
symptoms, the more likely it is that other forms of intervention -
including behavioral treatments - will play an important
role in the child's overall treatment plan.
That's all for this month...
I hope you enjoyed this issue of ADHD RESEARCH UPDATE and found it to be informative.
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be interested. If people send a request for sample
issues to addhelp@mindspring.com I will be delighted to send
them several issues to review.
Take care.
Sincerely,
David Rabiner, Ph.D.
Licensed Psychologist
P.S. I continue to offer consultation via telephone
to subscribers who would like to discuss their questions and
concerns about their child's development in detail.
If you are interested in learning more about this service, and
whether it may be helpful for you, please get in
touch.
copyright ADHD RESEARCH UPDATE, 1998