********************************************************
ADHD RESEARCH UPDATE - Vol. 3, December, 1997
********************************************************In this issue....
** A presentation from Dr. Russell Barkley
** New evidence for the long term effectiveness of stimulant medication
** New data on long term outcomes for hyperactive boys
** How conduct disorder and oppositional defiant disorder effect ADHD
** Social skills training for children with ADHD
** A presentation by Dr. Russell BarkleyRecently, I had the opportunity to attend a talk by Dr. Russell Barkley. Dr. Barkley is perhaps the world's leading authority on ADHD and is an excellent speaker to boot. If you ever get a chance to attend one of his workshops, I would highly recommend it. He shared some very interesting and important information that I wanted to let you know about, and the majority of this issue will be devoted to relaying this information.
- On Treatment -
Dr. Barkley was very clear that the ONLY treatments for which there is any credible scientific support are stimulant medication (e.g. Ritalin) and behavioral therapy. He was also clear that stimulant medication is the treatment of choice for children with ADHD and that NO other form treatment will come close to equaling it's effectiveness for most children. (NOTE: Dr. Barkley is a clinical psychologist and not a physician, so he is not able to prescribe medication himself.)
Five years ago Dr. Barkley was of the opinion that the proper way to approach the use of medication was to try other interventions first, and only resort to using medication when these other interventions were not sufficiently effective. His thinking on this issue has come full circle in that he now suggests that medication be started initially, and that other interventions be implemented to target difficulties that may still remain even after the child is getting the maximum benefit possible from medication.
Obviously, this will not be a very popular position with many parents. It is, however, the opinion of probably the leading authority in the field and is coming from someone who can not even prescribe medication himself.
Dr. Barkley had several other important things to say about treatment. First, he emphasized the important of regarding ADHD as a condition that needs to be managed across a child's development rather than something that can be cured. To date, there is no known cure for ADHD, only ways to help manage the symptoms. When medication is stopped, the symptoms return to their prior level almost immediately.
The same is true for other types of interventions. He described a year long study in which children attended a special classroom in which state of the art behavioral techniques were employed. During the year, when the behavioral system was in place, most children did quite well. Within one week of ending the behavior system, however, children's problems returned to their original levels. his should come as no surprise to those of you who have implemented behavior plans yourself. Like medication, such interventions can be effective in helping to reduce a child's symptoms while they are in place, but appear to produce no lasting change in a child's behavior.
So, is there anything a parent can do that can have a lasting positive impact on a child with ADHD? Dr. Keith Connors, another leading ADHD expert who also participated in the workshop I attended, stressed the importance of parents helping their child to get involved in an activity that can provide them with a basis for good self esteem. Helping your child develop a skill or talent in any area, he feels, can be extremely important.
Now, this wouldn't be expected to have any direct effect on a child's primary ADHD symptoms, but seeing oneself as successful and competent in some area - be it sports, art, music, etc., - can be critically important according to Dr. Connors in protecting a child against the adverse effects that having ADHD can have on a child's developing feelings about self. This is something parents can do that may make a real difference in a child's long term outcome.
One other important thing that Dr. Barkley stressed is that for treatment to be effective, it must actually occur in the setting where the child is having problems. For example, if a child is having trouble with peer relationships, work on these difficulties needs to occur in the child's classroom or out on the playground - the places where the problems are actually occurring. He stressed that having a child work on social skills in a therapist's office - is unlikely to be effective because even though the child may display new skills in the therapists office, this is not likely to generalize to other settings.
Unfortunately, working on a child's problems in the actual setting where they occur can be a difficult thing to do. Mental health professionals really can't do this, generally, because it is difficult to leave the office and go out with a child to the environments where the child actually lives, works, and plays in. Parents are probably the only ones who can do this on any type of consistent basis. The most effective role for professionals, therefore, may be to coach parents on how they can try to work with and help their child in these real world settings.
- On Assessment -
Dr. Barkley stressed that the basis of a good assessment for ADHD is collecting information from parent and teachers - i.e. the individuals who are in the best position to have observed a child's behaviors and symptoms over an extended period of time. The use of standardized behavior rating scales such as the Connors Ratings Scales or the Child Behavior Checklist in collecting this information is very important. How a child behaves in a clinic setting - a new environment with an unfamiliar adult who is providing individual attention - can be absolutely irrelevant to the diagnostic process.
Gathering information directly from the child, particularly from a child of elementary school age, is often not particularly helpful. This is because many children with ADHD are relatively oblivious to their symptoms or may be unwilling to discuss difficulties that they experience. Interviewing the child directly, however, can be very important for evaluating the presence of other difficulties such as a mood or anxiety disorder which may mimic ADHD symptoms or which may need to be addressed directly in a child's treatment.
Psychological tests - including computerized tests of sustained attention - were also of relatively little value, Dr. Barkley felt, in the diagnostic process. He noted that parents often pay hundreds of dollars or more for a battery of tests that contribute very little to making an accurate diagnosis of ADHD. Tests can be very useful for answering other questions - such as whether a child has a learning disability - but are often not directly helpful in establishing an ADHD diagnosis.
- On the Long Term Outcome of Children with ADHD -
Dr. Barkley shared preliminary results from a longitudinal study in which approximately 160 children with ADHD, along with an appropriate control group, have been followed over a 20 year period. His preliminary findings are quite interesting.
First, it appears that the continuity of ADHD from childhood to adulthood may be greater than previously thought. In the sample he followed, approximately 66% still had ADHD in adulthood when age appropriate diagnostic criteria and assessment procedures were used.
Second, data collected during subjects' adolescent years suggests that having ADHD is associated with a variety of behaviors that present clear risks to individuals' health. The findings include:
* ADHD subjects were significantly more likely to become smokers than match controls;
* ADHD subjects engaged in more alcohol and drug use;
* ADHD subjects had over 4 times as many speeding tickets and auto accidents. In additions, the accidents they had were more severe.
* ADHD subjects had more unprotected sex, increasing their risk for HIV and other sexually transmitted diseases. Not surprisingly, they were also more likely to have had a child during their teenage years.
Here is an astonishing statistic. Forty-two children were born to subjects in the ADHD group during adolescence compared to only 1 birth among control subjects.
An important implication of these findings is that because children with ADHD are at significantly greater risk for behaviors that can have negative health consequences, educating children about these risks may need to start earlier and be more concentrated. In adolescence, even greater emphasis may need to be placed on monitoring children's whereabouts and activities. Obviously, this needs to be done in a way that respects an adolescent's growing need for autonomy and independence. Balancing these competing needs can be quite difficult, and is an area where professional help can be quite useful.
In describing these findings, Dr. Barkley noted that although he had not yet completed the necessary analyses, he expected that many of these adverse outcomes would be more prevalent in ADHD subjects who had also developed serious behavioral difficulties such as Conduct Disorder. In other words, the developmental sequence may be as follows:
ADHD --------------> Behavior Disorder --------------> Negative Outcomes
ADHD --------------> No Behavior Disorder -----------> Positive Outcomes
This oversimplified path shows that having ADHD places children at risk for developing serious behavior disorders in childhood or adolescence, and that when this occurs, the outcomes during the teen or young adult years are much worse. When these behavior problems do not develop, however, the child with ADHD would be expected to do much better.
If Barkley's expectations are born out, and this would be consistent with other studies, it again emphasizes the importance of carefully attending to the behavioral and emotional difficulties that many children with ADHD develop. This is an area where parents can have a tremendously important influence.
***New Support for the Long Term Benefits of Stimulant Medication***
A study recently published in the Archives of General Psychiatry provides important evidence for the long term benefit of treatment with stimulant medication for children with ADHD.
In this study, which was conducted in Sweden, 62 children with ADHD were initially treated with medication for 1 month. After the optimal dose was determined for each child, subjects were then randomly selected to either continue receiving the medication or to be switched to a placebo. After this occurred, all subjects were followed for 15 months.
As predicted, improvements noted during the initial month of medication treatment were maintained among children who continued to receive medication. These improvements were still evident 15 months later according to both parent and teacher ratings.
Children in the placebo group, in contrast, soon returned to their prior level of difficulty. In fact, 71% of parents of these children terminated their child's participation within 12 months - usually within 3 months - because of the difficulties their child was having.
In addition to these behavioral differences between the 2 groups, there was also an indication of improved intellectual functioning in those children who had continued to receive medication. These children showed greater increase on an IQ test than did children in the control group.
Side effects of sustained medication use were also carefully monitored. Most side effects were reported at a low rate, and except for decreased appetite, did not differ for children in the two groups. For each month of stimulant medication treatment, weight gain was reduced by an average of .2 kilograms. The authors of this study, who were physicians, did not feel that this was a significant problem for the vast majority of subjects.
This study is important because it is the first to convincingly document long term benefits of stimulant medication in the treatment of ADHD. Although numerous other well controlled studies have clearly demonstrated the beneficial effects of stimulant medication, these have almost all been restricted to short term (1 month or less) follow up periods.
There are several important implications of these results. First, it needs to be emphasized that NO other form of treatment has demonstrated anything approaching the efficacy of stimulant medication in this type of controlled study.
Second, aside from an increased likelihood of appetite reduction, and a corresponding small decrease in expected weight gain, there was no evidence of adverse side effects. Children in the placebo group were just as likely to exhibit other apparent "side effects" as were children receiving medication. Parents and physicians thus need to be careful before concluding that problems they observe are necessarily the result of medication.
** Long term follow up of Hyperactive Boys **
This study appears in the December 97 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. 89 subjects identified as hyperactive between the ages of 6-12 and 87 normal control subjects were followed over a period of up to 23 years to determine how they fared in adolescence and adulthood. (Note: When this study began, "hyperactive" was the diagnostic term used. The subjects would be expected to meet current diagnostic criteria for ADHD, however.)
During adolescence, 46% of the hyperactive subjects vs. 11% of the control subjects had been arrested; the rates of incarceration were 22% vs. 1%. In addition to being arrested more frequently, hyperactive subjects were also arrested at an earlier age.
During adulthood, 11 hyperactive subjects vs. 0 control subjects had been incarcerated. Almost all hyperactive offenders had been arrested more than once prior to turning 18. The adult arrest rates for hyperactive subjects with 0,1, 2, and 3 or more juvenile arrests were 2%, 0%, 38%, and 83% respectively.
The authors next looked at the childhood factors that differentiated hyperactive subjects who became offenders during adolescence and adulthood and those who did not. Children were group according to whether they were rated high or low by parents and teachers on the following conduct problems: "often gets into fights with other children", "lies to get out of trouble", "steals from other children", and "takes money from family members".
The results were striking. Of 16 hyperactive subjects without serious conduct problems in childhood as assessed by parents and teachers, only 2 committed a single offense during adolescence and all 16 were non-offenders in adulthood.
For the 73 hyperactive boys with childhood conduct problems, in contrast, 13 were single offenders in adolescence, 26 committed multiple offenses, and 34 were non-offenders. All of the adult offenders but one came from the group who had committed multiple offenses in adolescence.
This study has very important implications. Of special importance is that there is a clear distinction in the adolescent and adult criminality outcomes for ADHD children with and without conduct problems. In fact, being high on even one of the conduct problem items listed above placed the child at increased risk for antisocial behavior in adolescence and adulthood.
This underscores the importance of distinguishing between ADHD and other behavior problems. None of the childhood conduct problems predicting poor adult outcome in this study are symptoms of ADHD. These are separate difficulties that need to be addressed in their own right.
Too often, it seems, these kinds of problems are confused as being just another part of ADHD, and are not aggressively treated. Physicians sometimes compound this problem by prescribing medication as the sole form of treatment, and not alerting parents to the importance of addressing other behavioral difficulties via other means.
The authors of this study suggest that "... every child with ADHD should be evaluated for these early conduct problems, and that specific treatments should be targeted to treat these problems during childhood when behavior is more malleable." This seems like a very sensible and important recommendation to me.
** Impact of Oppositional Defiant Disorder or Conduct Disorder on ADHD **
This December 97 issue of the Journal of the American Academy of Child and Adolescent Psychiatry also has a very nice study examining how the presence of ODD (e.g. Oppositional Defiant Disorder) or CD (e.g. Conduct Disorder) influences the daily functioning of children with ADHD.
Let's begin with a brief overview of what ODD and CD are. The essential feature of ODD is a "...recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that has persisted for at least 6 months." Symptoms include excessive arguing, temper outbursts, willful disobedience, deliberately annoying others, blaming others for mistakes or misbehavior, being touchy and easily annoyed, spitefulness, and being angry and resentful. Note how these symptoms all reflect aversive behaviors that have very little to do with the symptoms that define ADHD.
CD is a more severe behavioral disturbance where the "...essential feature is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated." Behaviors indicative of CD fall into 4 main groupings: Aggressive behavior that harms or threatens to harm other people or animals; nonaggressive behavior that causes property damage or loss (i.e. vandalism); deceitfulness or theft; and serious violation of rules such as staying away from home all night or truancy from school.
In this study, the authors compared the behavioral, social, academic, and emotional functioning of three groups of children between the ages of 5 and 12: those with ADHD only, those with ADHD and ODD, and those with ADHD and CD (NOTE: almost all boys with ADHD and CD also would qualify for the diagnosis of ODD). As in prior studies, it was found that the majority of children with ADHD - about two thirds - were also diagnosed with either ODD or CD.
As one would expect, children with ADHD and either ODD and CD were doing poorer in most areas than children with ADHD alone. In general, children in the latter two groups were more disruptive and aggressive, were more difficult for parents and teachers to manage, and had greater difficulty getting along with peers and siblings.
Two findings were somewhat surprising , however, First, children with ADHD and ODD seemed to be doing better in school than children with ADHD alone. It is not at all clear why this should be the case, and this may be one of those findings that is difficult to replicate.
ADHD with co-occurring CD also reported lower self esteem and higher amounts of anxiety than children with ADHD alone. Thus, those children who are creating the most difficulty for those around them, and in the process alienating many of the important people in their lives, also seem to be struggling the most emotionally. These children are not just hurting others but are also in emotional distress themselves. For a parent and teacher struggling to manage an extremely difficult child, this may not always be easy to see.
This study also highlights the importance of not confusing the behavior problems associated with ODD and CD with ADHD. As noted above, there are many cases where virtually all of a child's difficulties are attributed to "their ADHD", even when these problems reflect completely separate diagnoses. If the ADHD symptoms are being treated with medication, parents sometimes assume that whatever can be done is being done.
The authors of this study argue that the problems experienced by a child with ODD and CD in addition to ADHD are quite different from the problems experienced by a child with ADHD alone. These other difficulties need to be addressed via interventions targeted specifically to these problems. In most cases, the best source to consult for such assistance would be a child psychologist or child psychiatrist. Psychologists will generally be more experienced, however, in developing the kinds of behavioral interventions that these types of problems often call for, and the efficacy of medication in treating either ODD or CD is not very impressive.
** Social skills training with parent generalization: treatment effects for children with attention deficit disorder **
The last study to be reviewed in this issue appeared in the October 97 issue of the Journal of Consulting and Clinical Psychology. In this study, the authors examined the effectiveness of social skills training, both with and without parental involvement, in improving the social skills and peer relationships of children with ADHD.
How children get along with their peers turns out to be one of the best predictors we have as to which children will do well as they develop and which children are more likely to struggle in various ways. In general, children who have trouble making friends and who are rejected by their peers are at greater risk for a variety of negative outcomes as they develop.
Unfortunately, problems with peer relationships is often the case for children with ADHD. The behavior that is often irritating to adults is frequently aversive to peers as well, and children with ADHD are often rejected by peers as a result. Such difficulties compound the daily struggle for a child with ADHD and can make school an even more difficult experience.
As described in the last issue of ADHD RESEARCH UPDATE, social skills training is an approach designed to help children who are struggling with peers start to do better by teaching them the specific skills they need to make and keep friends. These skills often include learning how to join a group, conversational skills, learning how to manage anger and conflict, learning how to be assertive, and social problem solving skills.
In this study, the authors examined the effectiveness of social skills training for children who participated in a structured 8 week skills training program either with or without concurrent participation by their parents. The idea was to learn whether involving parents directly in helping their child learn better social skills would be more effective than having the child work with a professional alone. It was hoped that including parents in the skill building process would facilitate greater gains because it would enable parents to work more effectively with their child at home.
Results indicated that both groups who received social skills training improved in their knowledge of social skills relative to the control group (i.e. a group of children with ADHD who did not receive the treatment). In addition, parents of both groups of children reported that their child was demonstrating better social behavior at home and was less disruptive, and these gains were maintained over a 4 month period. Unfortunately, the evidence that the children's improved social skills and behavior also transferred to the school setting was much more modest.
These results are consistent with Dr. Barkley's comment, reported above, that for interventions to be successful they need to take place in the setting where the child's difficulty is occurring. In this study, social problems at school were not helped very much, perhaps because the skills training did not occur in a school based context. Many schools now have social skills training groups that are run by a guidance counselor, or other school staff, and these may be good options for a child with ADHD who is having social difficulties.
This study represents one of many efforts - and actually attained more successful results than most - to improve the peer relationships of children with ADHD via social skills training. Because of the difficulty in accomplishing this, home of the leading researchers in this area have actually started to take a somewhat different approach.
Rather than trying to improve a child's ability to be better accepted by a group of peers overall, several recent efforts have focused instead on helping a child to develop and maintain just a single positive friendship. The idea is that it may be easier to help a child make and keep a single friend than to work on having the child become better liked by his or her entire peer group.
This may prove to be a very fruitful approach. There is research which has shown that even when a child may be unpopular overall, children who have even a single friend experience less loneliness, depression, and anxiety than those without any friends at all. Just knowing that there is someone at school who is a friend can serve as an important buffer against the distress that can be caused by being disliked more generally.
Here is an area where parents really can help their child. If your child is struggling socially, taking an active role to help him or her cultivate and maintain a friendship can be enormously important. This may require arranging play dates and being there to supervise at first to help make sure that things go well. It can also involve helping your child patch things up after a conflict, rather than having the friendship end right there.
In my own work with parents and children, this is something I often focus on and have found to be extremely helpful. If your child is having a tough time socially, the effort required to help him or her build a close friendship can be well worth it.
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