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ADHD RESEARCH UPDATE - Vol. 2, October, 1997
********************************************************Welcome to the second issue of ADHD RESEARCH UPDATE, a newsletter devoted to helping parents stay informed on the latest research on ADHD and how these new findings may be used to assist their child. I am delighted that you have decided to subscribe and will do my best to provide you with information that is helpful to you. I welcome your feedback and suggestions.
In this issue I'll review several recent studies that present important data on medication in the treatment of ADHD, a study that demonstrates how parents can be helpful in improving their child's peer relationships, an interesting study in which the genetic basis of ADHD was examined, and preliminary results from an ongoing study of different treatments for ADHD.
Let's begin with the studies that examine the use of medication...
BUPROPION VS. METHYLPHENIDATE IN THE TREATMENT OF ADHD
I've received lots of questions lately on the use of Wellbutrin (i.e. Bupropion is the generic name) in the treatment of ADHD. Bupropion is a relatively new anti-depressant that has started to be used to treat some children with ADHD. In general, all anti-depressants would be regarded as a second line medication in the treatment of ADHD, and would typically not be used unless: a. stimulant medications such as Ritalin (i.e. methylphenidate) were not effective; b. a child experienced intolerable side effects to stimulant medication; or c. there were significant depressive and/or anxiety symptoms in addition to ADHD.
To date, there have been two controlled studies of the effectiveness and safety of Bupropion to treat children with ADHD, and both have provided encouraging results. In the first study, Bupropion was compared to a placebo - this type of drug/placebo comparison is essential to establish efficacy because many children with ADHD are reported to improve by their teacher when they have given only a placebo. In this study, Bupropion produced significant improvements in teacher rated hyperactivity and conduct problems, and on parent ratings of conduct problems and restless/impulsive behavior. Bupropion appeared to be tolerated well by most children, although 4 of 72 children were not able to tolerate the drug.
These encouraging results led to a second study in which Bupropion was specifically compared to methylphenidate (i.e. the generic name for Ritalin). The results of this study indicated that Bupropion was equally effective as methylphenidate and was no more likely to produce intolerable side effects. Significant improvements in behavior and academic functioning was observed on both types of medication.
These results suggest that Bupropion may offer an effective alternative for children with ADHD who do not respond to stimulant medication or who can not tolerate it. (By the way, although some children are starting to be prescribed Prozac (i.e. fluoxetine) to treat ADHD there has not yet been any controlled studies demonstrating efficacy.) Because the use of Bupropion to treat ADHD is quite new, however, your child's pediatrician may not be aware of this or may not feel comfortable prescribing this medication. As a result, parents may need to consult with a child psychiatrist if they are interested in this as an option for their child.
THE EFFECT OF METHYLPHENIDATE ON CHILDREN'S FUNCTIONING OVER TIME
Despite over 150 controlled studies which demonstrate the benefits of methylphenidate (i.e. Ritalin) on the behavior of children with ADHD, very few studies have examined the impact of medication over any kind of extended period. As a result, surprisingly little is known about the longer term effects of stimulant medication on children with ADHD.
The October 97 issue of the Journal of the American Academy of Child and Adolescent Psychiatry contains a study in which the behavioral effects of methylphenidate were carefully monitored over a 4 month period. Considering that many children receive stimulant medication for a period of years, 4 months may not seem like a particularly long follow up. Nonetheless, this is one of the few studies that have examined medication effects over more than several weeks, and the results have implications that are important to know about.
In this study, the optimum dose was carefully determined for each child, who then received two doses per day over the next 4 months (one dose before school and one dose at mid day). Control subjects received 2 daily doses of a placebo over this same 4 moth interval. The important findings of this study are as follows:
* Teacher ratings indicated significant reductions in both core ADHD symptoms (i.e. inattention & hyperactivity/impulsivity) and associated problems (i.e. oppositional behavior and aggression). These improvements were found to persist over the entire 4 month period.
* Parent ratings, in contrast, showed no significant advantage of medication over placebo. Because the medication would not be expected to be active after school when parents were with their child, this is not really surprising. It is clear, however, that beneficial effects that were evident at school DID NOT carry over to the home.
* Teachers did not report any increase in side effects over the 4 month period, while parents reported an increase in side effects over the 4 month period. The most frequently reported side effects were: appetite reduction, stomach aches, sadness, and crying. The latter two side effects were more likely to shown an increase over time. It should be noted that these side effects were evident despite careful efforts being made to keep them to a minimum through careful and continuous monitoring. Even so, only 5 children discontinued taking medication because of problems related to side effects.
Overall, it appeared that teachers were likely to see the benefits of medication but not the side effects, while parents were more likely to see the side effects but not the benefits.
The very clear and important implication of these results is that medication during the school day alone is not likely to produce any improvements in the child's behavior at home. This makes it clear how important it is for additional interventions to improve the child's behavior at home to be implemented. The authors suggest that for some children, the benefit of a third dose for after school hours should be carefully explored. Behavioral interventions to help parents learn more effective ways to manage their child's challenging behavior is another direction that would be important to pursue. Unfortunately, in many cases, medication during the school day is the ONLY form of intervention that children with ADHD ever receive. For most children, this is clearly an inadequate approach to treatment and parents need to aggressively pursue additional options.
This study also points out the important possibility that some children may not develop adverse reactions to medication until they have already been receiving it for several months. Because of this, such reaction may often not be recognized as being medication side effects. Apparently, however, this possibility needs to be considered.
IMPROVING THE SOCIAL SKILLS OF CHILDREN WITH ADHD
For many children with ADHD, difficulty in establishing and maintaining friendships with peers is one of the most difficult aspects of the disorder. Unfortunately, the kinds of behaviors that children with ADHD frequently engage in and which are aversive to adults, can also be aversive to peers. As a result, many children with ADHD have few friends and may be actively rejected and disliked by their peer group. This is an especially important area for children to receive help in, because numerous studies have clearly documented that children who are rejected by their peers are at increased risk for a variety of negative outcomes as they develop. Helping children with ADHD establish better peer relationships can thus be critically important in promoting their long term success.
Social skills training is a form of treatment that is specifically designed to help improve the peer relationships of unpopular children. The idea behind social skills training is quite simple: it is assumed that the ability to make and maintain friendships is a skill like any other skill, and that children can improve their skill in this area with teaching and practice. In a typical social skills training program, children are instructed in a number of skills that are necessary for good peer relationships (e.g. sharing and cooperating; being a good listener; learning how to enter groups; learning how to resolve conflicts; etc.). Opportunities to practice these skills in real work settings and to receive feedback on how they are doing is also provided.
Unfortunately, prior investigations of social skills training with children who have ADHD and associated peer difficulties have not yielded very positive results. The authors of a recently published study argue, however, that this may be because most prior studies have failed to involve parents effectively in the skills training process. Because parents play such a large and important role in scheduling and supervising children's play experiences, it was predicted that providing parents with specific training in how to help their child get along better with peers would enhance the effectiveness of a traditional approach to social skills training.
Treatment consisted of 12 hour long sessions. Separate meetings were conducted for children and parents, although parents and children participated together for a portion of each meeting. Children received instruction in the kinds of skills noted above while parents received basic information about children's social relationships as well as specific information about how to help their child develop and practice the necessary social skills. The importance of arranging play dates with a peer of their child's choosing was emphasized, and parents were instructed on how to monitor their child's use of practiced skills during these play sessions. The important difference from previously reported studies of social skills training, therefore, is that parents were made active participants in their child's treatment. They were taught the kinds of skills their child needed to develop, how to help their child develop those skills, and how to provide effective practice opportunities for their child.
The results of this study were clear. Children with ADHD showed significant improvement in both teacher and parent reports of peer adjustment, and the amount of improvement reported was similar to that of children without ADHD. Overall, the average child who received treatment was doing better at the end of the study than over 80% of children who had not received the social skills training.
There are several factors that are important to consider in evaluating these results. First, no measures were taken from children's peers, so it can not be definitely assumed that the improvements noted by parents and teachers would also be reported by peers. Second, it is very important to emphasize that all children in this study who had ADHD were receiving stimulant medication throughout the study. The authors felt this was important because their prior work had indicated that impact of social skills training on children with ADHD is facilitated when children are receiving medication. In fact, they do not believe that social skills training in the absence of medication would be effective for most children with ADHD. Finally, it is unclear as to how long the benefits reported would be maintained after the social skills training program ended.
The very important point to be taken from this study is that if your child is having difficulty making friends, social skills training may be an important and effective intervention. In many schools, guidance counselors run this type of group for children, and checking about this at your child's school would be a good first step. Some child psychologists also offer social skills groups for a children on a private basis. Checking with your state's psychological association to see about the availability of this in your area may also provide to be helpful. If your child is working individually with a private therapist, you may want to discuss how any social difficulties your child is having are being targeted and how you can play a more active role in helping your child in this areas. It is really very hard to improve a child's social skills in a one on one meeting with an adult, and this study has shown that by getting parents involved more directly in their child's social encounters can be a very effective way to help promote a child's success with peers. There is a very good book that was recently published called "Skills Training for Children with Behavior Disorders: A Parent and Therapist Guidebook" by Michael Bloomquist that covers specific ways that parents can help their child develop social skills. The book addresses a number of other important areas as well and I believe you would find it to be a useful resource.
THE ROLE OF GENETIC FACTORS IN THE DEVELOPMENT OF ADHD
In recent years, a growing body of evidence has pointed towards the important role of genetic, as opposed to family environment factors, in the development of ADHD. Recently published data based on the results of an extremely large scale twin study in Australia adds more confirmation to this view.
In this study, children from almost 2000 families with twins were contacted and all children in the family were evaluated for ADHD using standardized behavior rating scales. The authors than examined the similarity of ADHD ratings in monozygotic twins (i.e. these are identical twins who have the same genetic make up) and dizygotic twins (i.e. fraternal twins who are not identical genetically). By comparing the similarity in ADHD symptoms among children who are more or less similar in their genetic make up, the relative contribution of genetic and environmental factors in the emergence of ADHD can be determined.
The authors report that identical twins were similar with respect to the diagnosis of ADHD 82% of the time; in non-identical twins the diagnostic correspondence was only 38% In other words, identical twins were more than twice as likely to share the same status with respect to ADHD (i.e. either both have it or neither has it) as were non-identical twins. Through a series of statistical analyses, the authors went on to determine that the heritability of ADHD is .91, while the effect of environmental factors was only .13. What this means is that primary determinant of whether a child develops ADHD are genetic factors; environmental factors are much less important in the emergence of this disorder.
The implications of this study are clear: parents should not blame themselves if their child has ADHD. Available data strongly points towards genetic factors as the primary reason for why some children develop ADHD and others do not. This does not mean, of course, that how parents interact with their child can not have an important influence on how that child develops. In fact, although parenting factors do not seem to be influential in the development of ADHD, it is clear that parents can play an extremely influential role in helping to minimize the negative impact of ADHD on their child's development.
Another important implication of this study is that because heredity plays an important role in ADHD, parents of children with ADHD are more likely to have ADHD themselves than other parents. In my own clinical experience, it is common for a parent to note how they had all the same type of difficulties as their child when they were growing up. Because much less was known about ADHD 20 years ago, however, it was more likely for children displaying such symptoms to simply be regarded as trouble makers and "bad kids".
Parents who have questions whether they may have grown up with undiagnosed ADHD should consider pursuing an evaluation of this question. It is clear that for many individuals with ADHD, the symptoms can persist into adulthood and continue to create difficulties. Effective treatments for adults are available, however, and can make important differences in the lives of adults as well as children.
PRELIMINARY RESULTS FROM MULTIMODAL TREATMENT STUDY
For the past several years a large, ongoing study funded by the National Institute of mental health has been underway to examine the effectiveness of treatment for ADHD. This study is being carried out at several sites around the country. Children in this study are assigned to 1 of 3 different groups: medication management alone; medication management plus supportive counseling and education for parents; or intensive multimodal treatment including medication management, academic skills training, remedial tutoring when needed, social skills training, parent training, individual psychotherapy, and a home-based daily report card reinforcement program for school behavior. The purpose of this study is to learn whether this much more extensive - and expensive - treatment program yields clearly superior long term results for children with ADHD and whether children who have received such treatment will be able to eventually function adequately without medication.
After 2 years of this ongoing study, preliminary results are surprising- at least to me. Basically, early indications are that the intensive multimodal-modal treatment is NOT superior to medication alone and that children receiving the intensive treatment have not been able to be withdrawn from medication without relapse. Although longer term differences between the effectiveness of these treatments are still possible, so far, such differences have not been evident.
These preliminary results indicate just how important the use of medication can be for children with ADHD. It is also VERY IMPORTANT to stress that in this study, the "medication only" group received a level of careful management that is far different from customary practice. Each child initially received a careful trial to determine their optimal dosage in which weekly feedback from parents and teachers was obtained; there were also monthly 30-45 minute sessions to monitor medication efficacy and side effects, and to provide clinical management, education, and support. Regular feedback from teachers via standardized rating scales was also obtained.
This level of attention is clearly way beyond what most children receive, which is often nothing more than cursory "medication checks" on a monthly or even less frequent basis in which little or no systematic efforts are made to evaluate ongoing medication effectiveness. Children's response to medication can and does change over time, and the only way to be certain that a child is continuing to receive the maximum benefit possible is to conduct careful period evaluations.
I have developed a procedure that makes it easy to conduct period reevaluations of a child's need for medication and to also monitor it's ongoing effectiveness. This procedure can also be used to conduct initial evaluations of a child's response to medication. Let me know if you'd like to receive information on this.
copyright 1997 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