********************************************************
ADHD RESEARCH UPDATE - Vol. 4, January, 1998
********************************************************In this issue...
*** Can medication help the severe behavior problems that often go along with ADHD?
*** When do ADHD symptoms have to emerge for it to be ADHD?
*** Can choosing assignments improve behavior and school performance of a child with ADHD?
*** How effective are behavioral interventions in the school setting?
** Can Stimulant Medication Help with Severe Behavior Problems? **
The December 97 issue of the Archives of General Psychiatry contained a very important study on the use of methylphenidate (i.e. the generic version of Ritalin) for treating children with ADHD who had also been diagnosed with Conduct Disorder (CD). Recall from last issue of ADHD RESEARCH UPDATE, that CD is a serious behavioral disturbance that involves major violations of social norms (i.e. stealing) and or aggression against others. The prognosis for children with ADHD and CD is especially worrisome, and conventional wisdom has been that stimulant medication is not appropriate or helpful for the treatment of children with CD.
Children between the ages of 6 and 15, many of who were duly diagnosed with ADHD and CD were randomly assigned to receive either methylphenidate or a placebo over a 5 week period. On average, children in the medication group were receiving 40 mg/day divided into a morning and afternoon dose. At the conclusion of treatment, ratings of children's behavior were obtained from their parents, teachers, and observers who came into the classroom. Both ADHD symptoms as well as behaviors specific to CD were assessed. The latter included obscene language, physically attacking others, property destruction, and deliberate cruelty. These latter behaviors are more severe than the type of oppositional and problematic behavior that is seen in children with ADHD alone.
The authors had expected that, as has been amply documented in prior studies, children in the medication group would show a substantial reduction in ADHD symptoms compared to subjects in the placebo group. This was the case in parent, teacher and observer ratings.
What was surprising, however, was the significant reduction in core CD behaviors and symptoms for children receiving medication. Parents reported clear reductions in such behaviors as cruelty to others, hanging around with bad companions, and stealing outside the home. Overall, the percentage of children rated as improved in the medication group and placebo group were 59% vs. 9% for mother's ratings, 78% vs. 27% for teachers' ratings, and 68% vs. 11% for observers ratings. The amount of improvement reported varied across individuals, but overall the reductions in antisocial behavior were substantial and clinically meaningful.
Although there is no clear explanation for why this would occur, the authors speculate that impulsivity is a key difficulty in both ADHD and CD. Impulsivity is specifically reduced by stimulant treatment, and it may be that in boys with CD, enhanced impulse control results in multiple positive secondary effects.
This is a very important finding, and one that represents a real conventional wisdom, based in part on prior research, has been that stimulant medication is not helpful in reducing core CD symptoms in children with or without ADHD. This study clearly suggests otherwise, however.
Several things are important to stress. First, the dose received by children in the medication group is probably higher than what is typically prescribed by pediatricians. Children in this study appeared to tolerate it well, however, and it may be that doses of this magnitude are required to ameliorate severe behavior difficulties rather than ADHD symptoms alone.
Second, although the reduction in CD behavior was impressive, it rarely eliminated the problems experienced by children in the study. Thus, children clearly got better but continued to engage in behaviors that would be considered problematic by any reasonable standard. Although clinical normalization is frequent among good responders with uncomplicated ADHD, this was not the case here.
Third, as the authors rightly point out, the treatment in this study was short term (i.e. 5 weeks). Both ADHD and CD tend to be chronic conditions, and the long term effectiveness of medication on the latter especially remains to be determined.
Fourth, it is interesting to note that even at the doses used in this study, children typically tolerated the medication quite well. The most common reported side effects were decreased appetite and delay of sleep. It is also noteworthy that almost half the children in the placebo group reported at least one adverse side effect. This finding underscores the need for placebo conditions to obtain accurate information on medication related side effects. Many times, what may appear to be a side effect of medication is nothing more than a placebo response.
Finally, although these results are encouraging, the results from any individual study need to be replicated.
Overall though, this is an important study to know about for parents whose child is displaying serious antisocial behavior in addition to ADHD symptoms. it may be that at the proper dose, stimulant medication can make a substantial contribution to reducing such behavior in addition to helping with the core symptoms of ADHD.
** Is it still ADHD when symptoms emerge after age 7? **
One of the current diagnostic criteria for ADHD is that impairment from symptoms must be evident prior to age 7. This means children whose symptoms emerge at a later age can not be diagnosed with ADHD, and it is assumed that their symptoms are reflective of some other condition or are secondary to school failure. (For a complete discussion of diagnostic criteria click here.
This age of onset criteria was included in DSM-IV because ADHD has always been considered a disorder that arose during early childhood. When symptoms emerged beyond the early childhood years, it was believed that this could not be ADHD, but instead reflected behavior arising in response to failure at school and/or the development of another psychiatric condition (e.g. depression).
A study recently appearing in the Journal of the American Academy of Child and Adolescent Psychiatry casts doubt on the validity of this belief. In this study, 380 children between the ages of 4 and 17 who met symptomatic criteria for ADHD were compared according to whether the initial impairment from their ADHD symptoms was evident prior to age 7.
Results indicate that the validity of the age of onset criteria depends on what type of ADHD the child was diagnosed with. Recall that the core symptoms groups for ADHD are problems with attention and problems with hyperactivity/impulsivity. According to current diagnostic guidelines, children who show attention problems but not hyperactive/impulsive problems are diagnosed with ADHD, Predominantly Inattentive Type. (This is what used to be called ADD, a term which is no longer technically correct). Children with hyperactive/impulsive symptoms but not attention symptoms are diagnosed ADHD, Predominantly Hyperactive/Impulsive Type. Children who display symptoms of each type are diagnosed with ADHD, Combined Type.
Results indicated that nearly all subjects diagnosed with the hyperactive/impulsive subtype of ADHD first showed impairment from their symptoms prior to age 7. Nearly 20% of the combined group and 43% of the inattentive group, however, did not show impairment by this age. These were all children that trained clinicians agreed had "true" cases of ADHD, and imposing the age of onset criteria would thus have reduced the accurate identification of these cases.
These results question the usefulness of requiring an early age of onset for diagnosing ADHD, especially for the combined and predominantly inattentive subtype. My own experience is that for children who display only the attention problems, difficulties often do not emerge until late elementary school or even middle school.
This is probably because children with attention symptoms only are generally not behavior problems, and are often able to get by in the early grades when the academic demands are not that great. This is especially true for a child who is above average inability because they can often do okay in their school work even if they have trouble attending.
As children move in to the later grades, however, academic demands and the need to sustain attention increase considerably. Children also begin to get more homework. At some point, it doesn't matter how smart you are - you simply need to be able to sustain attention and concentration in order to do well academically. In middle school, children also change from having a single teacher to having multiple teachers. When this occurs, it becomes increasingly difficult to stay organized and keep track of assignments from multiple classes. As a result, a child who did okay in prior grades can suddenly start to struggle in a major way.
Many times, because a child has done well in earlier grades, the assumption is made that he or she must now be unmotivated or lazy. As a child starts to struggle and do poorly, they often can lose their motivation as a result. Parents and children can start butting heads and get locked into an escalating power struggle and conflict as a result.
It is important for parents to be aware that ADHD symptoms, and the difficulty these symptoms cause, will vary tremendously depending on the context. In some situations, a child with ADHD will appear indistinguishable from his or her peers. In other situations, the symptoms will be quite apparent and create significant difficulties. Unfortunately, the classroom environment is often one of these latter situations, and this is especially true of how most middle schools are structured. Trying to alter these environments in ways that make it more likely for a child with ADHD to be successful can thus become a critically important aspect of a child's treatment.
It should also be stressed that although requiring a strict cut off like age 7 apparently reduces diagnostic accuracy, it is important to be very careful when diagnosing ADHD in a child whose symptoms do not create significant impairment until a later age. When this occurs, it is usually the case that there would have been some clear indication of symptoms at an earlier age, even if the difficulties they created were not especially severe. Thus, teachers may have noted that the child had trouble completing assignments, or seemed to daydream and be off task more than peers.
When ADHD symptoms first emerge in an older child without their being ANY prior evidence that they were present, however, it is likely that these symptoms do reflect a different type of problems. For example, a 12 year old who had NEVER displayed any prior attention problems is suddenly observed to have real problems with sustained attention and stops completing assigned work. This situation would be more likely to reflect some type of emotional disorder rather than ADHD and would warrant a careful evaluation in which all alternative possibilities were carefully considered.
** Providing Choice can Enhance Cooperation and Schoolwork **
A study that recently appeared in the Journal of Applied Behavior Analysis provides preliminary evidence that permitting children with ADHD to choose their assignments can enhance their cooperation and performance.
In this case study (i.e. a case study is a study of a single individual) an 8 year old student with ADHD was allowed to choose from among 3 assignments during designated work periods. The assignments re identical in length and difficulty and were matched to the work assigned to the rest of the class. Available choices were rotated to insure that all necessary work would be completed during the week.
Prior to implementing this choice procedure, the student was observed to be off task and disruptive almost 80 % of the time. When assignment choice was allowed, this dropped to 20%. Thus, although some difficulty remained, the amount of improvement was substantial.
Why might this procedure be effective? It is well known that children with ADHD are less likely to display their symptoms when engaged in a task that they are interested and invested in. By allowing an ADHD child to choose his or her assignment, the likelihood of their being interested in the task should increase. Their behavior and performance improves as a result.
This strategy of providing options is one that parents and teachers can experiment with right away. For example, providing a child with a list of chores to choose from may enhance cooperation. (Note that the choice is not whether or not to do a chore, but which chore to complete.) Breaking up daily homework into separate units and letting the child choose which unit to complete first may also prove helpful. Permitting the child to choose the time designated to complete homework can also be tried.
Discussing the choice procedure with your child's teacher may also prove worthwhile. Although it may take the teacher some extra time to work out the appropriate choices to present, if the procedure is effective it can significantly reduce the time she must spend trying to make sure the work gets done.
No procedure will work for every child with ADHD, and this is certainly no exception. you may also find that it works sometimes but not others. Even so, this technique can be an important strategy for parents and teachers to have in their overall repertoire, and is a relatively easy procedure to implement.
** The Effectiveness of Behavioral Interventions at School **
An article in a recent edition of School Psychology Review provides a comprehensive summary of studies testing different types of behavioral interventions in the classroom for students with ADHD.
Results from 137 studies conducted over the past decade were examined. Three types of behavioral interventions were considered. Contingency Management Interventions (CMI) are those where rewards or punishments are used to try and alter the child's behavior. Academic Interventions (AI) are those where modifications in the teaching process (e.g. using peers as teachers; providing choice of assignments) are employed. Thus, rather than providing consequences contingent on the child's behavior, the interventions alter the way material is presented and taught. Finally, Cognitive Behavioral Interventions (CBI) are those that attempt to teach the child specific thinking skills. For example, children may be taught how to self-monitor their behavior to reduce impulsivity or how to solve social problems without becoming aggressive.
Overall, the studies reviewed provide clear evidence that behavioral interventions can be quite effective. The authors note, however, that the effects typically achieved were less than what is generally provided by medication.
Results also indicated that certain interventions are more likely to be effective than others. Contingency Management Interventions and Academic Interventions tended to produce greater benefits than Cognitive Behavioral Interventions. In other words, trying to teach children with ADHD new cognitive skills to help them manage their behavior differently on their own, was less effective than the other approaches. This finding is consistent with Dr. Russell Barkley's contention that trying to teach new cognitive skills to children with ADHD is not likely to be effective (see the prior issue of ADHD RESEARCH UPDATE.)
It also appeared that behavioral interventions were more effective in improving children's classroom behavior than in enhancing their academic performance. Although statistically significant improvements in academic functioning were obtained, the actual magnitude of the improvements were disappointingly small.
This nice review paper has several important implications. First, it is clear that well designed behavioral interventions work and can be an important part of many children's treatment. For a child with a relatively mild case of ADHD, behavioral interventions alone may be sufficient to enable that child to succeed. For other children who do not respond to medication, or who experience adverse side effects, behavioral interventions can be an effective alternative. Even for children who respond positively to medication, there are often problems which remain that can be addressed using behavioral strategies.
This paper also underscores the importance of not confusing behavioral improvement with academic improvement. Sometimes, when treatment results in a child's being less disruptive, their can be the unwarranted assumption that everything is going better. The quality of a child's work can still be problematic, however, although parents often don't learn about this until report card time. Carefully monitoring academic performance - even when their classroom behavior is okay - is thus absolutely essential for promoting the long term success of students with ADHD.
Finally, it is important to stress that an effective behavioral intervention has to be designed on a child by child basis. There is no "programmed intervention" that can be applied to all children with ADHD. Consulting with an experienced child psychologist to help in developing a good behavioral plan is strongly recommended. (For a more thorough overview of behavioral treatment principles click here.
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