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ADHD RESEARCH UPDATE - Vol. 5, February, 1998
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In this issue...

Problems with how medication is often prescribed.

 

What is Oppositional Defiant Disorder and how does it differ from ADHD?

 

Why did you do that?: Differences in how parents of children with and without ADHD explain their child's behavior.

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* Problems with how medication is often prescribed: Children's size does not predict medication response *

The decision to place a child on medication is a difficult one for most parents and if you are going to have your child take medication, you want to be sure that he or she is deriving the maximum benefit possible. Unfortunately, a commonly used procedure that physicians employ to decide on the dose to prescribe - basing the dose on the child's body mass - appears to be problematic.

A recent study in the Journal of the American Academy of Child and Adolescent Psychiatry conclusively demonstrates that a child's size CAN NOT be used to determine what dose of medication the child should receive.

In this study, 76 children with ADHD received different doses of methylphenidate (i.e. the generic version of Ritalin). The doses used in the study were 5, 10, 15, and 20 mg. Children received each dose in for one week and also received a placebo for one week. Careful assessments of each child's attention, schoolwork, and classroom behavior were made during each week of the trial. Children, teachers, and adult observers who rated children's behavior were unaware of what dose the child was on each week.

The results clearly indicated that children's body mass WAS NOT related to their response to the different doses. Children's response to the different doses was quite idiosyncratic and the optimal dose for each child (i.e. the one that child did best on) was not related at all to the child's size. Thus, the commonly used practice of basing the dose a child is to receive on their weight is quite unlikely to yield the best possible dose for each individual child.

What procedure should be used, then, to determine the appropriate dose. The procedure used and recommended at leading ADHD treatment clinics around the country involves a careful trial that typically lasts for 3-4 weeks. During a 4 week trial, the child would be tried on 3 different doses. There would also be a placebo week. For a 3 week trial, two different doses and a placebo week would be used. Teachers are asked to complete ratings of ADHD symptoms, academic performance, and side effects at the end of each week. Similar ratings may also be completed by parents.

By comparing the ratings at the end of the trial, you can determine if medication really helped (i.e. did child do better on medicine than on placebo), what the best dose was, whether there were any possible side effects, and what problems may remain even if the medication was helpful. Once the optimal dose has been identified, ongoing monitoring of the child's behavior and academic performance is required to be certain that medication is continuing to provide necessary benefits and to determine whether any changes or adjustments to a child's treatment are necessary.

I offer a program that is used by many physicians to conduct this type of careful trial. If you are interested in learning about it just send an e-mail to me at addhelp@mindspring.com and type "medication trial procedure" in the subject line.

Let me also emphasize that after the optimal dose has been determined, it is really very important to monitor how the child is doing on an ongoing basis. The ADHD Monitoring System that you received with your subscription is a good way to do this (if you didn't get the monitoring system, send me your address and I will get it to you.)

The reason this is important is that a child's response to medication can change over time, and what starts out as being effective may be less helpful weeks or months down the road. Other things can be going on in or out of the classroom that can also make a child's symptoms more difficult to manage.

As a result, it is not uncommon for children who are receiving medication to still be having real difficulty because their symptoms are not being managed as effectively as they could be. For example, I saw a child last week who had been receiving medication for several years. Feedback gathered from his teacher, however, made it clear that his ADHD symptoms were still quite prominent despite the medication he was receiving.

Now, it may be that this is a child who won't do better on a different dose or a different medicine. The important point, however, is that had his parents been aware of how prominent his symptoms were, they could have tried to do something about it before more than a year had gone by. What was done could include trying alternative medications, trying a different dose, and OF COURSE, looking at additional, non-medical interventions.

In my experience, this is more likely to occur with children who have the inattentive symptoms only, and who do not display hyperactive/impulsive behaviors. This is because these children are often not behavior problems, in the classroom, and it is thus much easier for them to "fall through the cracks". Carefully monitoring how they are doing - and not assuming that no news is necessarily good news - will prevent this from happening.

By the way, I think the above applies just as fully for children whose symptoms are being managed via non-medical means. It is still critical to get regular systematic feedback about how prominent ADHD symptoms are in the classroom and how these are affecting the child's work and behavior. This will let you know whether the intervention being used - whatever it is - being effective, or whether changes and/or modifications are necessary.
 

** WHAT IS OPPOSITIONAL DEFIANT DISORDER AND HOW DOES IT DIFFER FROM ADHD **

I've received several questions after last month's issue concerning the article on how parents of children with ADHD interpret their child's behavior. Recall that the article described a study in which parents were found to hold children with ADHD less responsible for core ADHD behaviors (i.e. inattentiveness and overactivity) than parents of children without ADHD. In addition, parents of children with ADHD also believed their child had less control over behaviors that were more deliberately oppositional and perhaps reflective of Oppositional Defiant Disorder ODD).

The authors of this study speculated that believing that ADHD children were not able to exercise control over these latter behaviors might make parents less likely take appropriate steps to correct these behaviors. Conceivably, this could contribute to these behaviors becoming more prominent.

Several subscribers sent messages describing how their child seemed to be much more oppositional when not on Ritalin, and that the medication helped both primary ADHD symptoms AND behaviors that appeared more oppositional in nature. They wondered whether this meant that their child also had ODD in addition to ADHD. I thus thought I tried to address this important question more completely in this issue of the newsletter.

Listed below are DSM-IV symptoms for ODD:

1. often loses temper;
2. often argues with adults;
3. often actively defies or refuses to comply with adult requests or rules;
4. often deliberately annoys people;
5. often blames others for mistakes or misbehavior;
6. is often touchy or easily annoyed by others;
7. is often angry and resentful;
8. is often spiteful and vindictive;

For ODD to be an appropriate diagnosis, at least 4 of the symptoms listed above must be present for at least 6 months; the behavior must occur more frequently than is typical for a child of comparable age, and the behavior must create significant impairment in a child's social or academic functioning.  In addition, the oppositional behavior can not occur only during times when a child is depressed.

An important difference that you will note from the symptoms of ADHD is that none of the ADHD symptoms involve behavior that is considered to be deliberate and willful. Thus, although children with ADHD often engage in behavior that annoy others and fail to follow through on requests, such behavior is not deliberately and willfully initiated.

So, what does it mean if a child with ADHD is much less oppositional when on their medication? First, as far as diagnosis goes, it should be emphasized that the diagnosis of ODD is made based on whether the symptomatic criteria described above are met, and not whether medication is effective in eliminating or substantially reducing the difficulties. This is of course true for ADHD as well - the diagnosis is made if the criteria are met and not whether a child has a good response to medication.

When ODD symptoms are significantly reduced by stimulant medication, it is probably because for that child, it is his or her impulsivity and overactivity that precipitates much of their oppositional behavior. For example, a child may lash out verbally in response to a parent's demand because their impulsivity makes it difficult for them to stop and think about what they are about to say. Or, running around in the store may precipitate a conflict with a parent that turns into a major argument. When medication helps the child to control such behaviors - to be less impulsive and hyperactive - the kinds of interactions with parents that can deteriorate into major oppositional power struggles are just less likely to get started. This is probably the most plausible explanation for why ODD symptoms may be reduced by stimulant medication. For these children, it is probably unlikely that they would meet full diagnostic criteria for ODD to begin with.

Other children, however, may be severely oppositional and defiant for reasons that have very little to do with impulsivity. Their oppositional behavior is more deliberate and premeditated. They may or may not also have ADHD, but even if they do, their oppositional behavior is still quite prominent when they are on medication, EVEN if the medication helps with the primary ADHD symptoms.

Such children can certainly not be treated effectively by medication alone. Behavioral interventions, and in some cases, individual or family therapy may be necessary to more fully address the difficulties of such children. Several excellent books have been written for parents on behavioral interventions for oppositional behavior. You may want to look at "1-2-3 Magic - Training Your Child to Do What You Want" by Dr. Thomas Phelan or "Behavior Management at Home - a Token Economy Program for Children" by Dr. Harvey Parker. Both are available from ADD Warehouse.

These kinds of difficulties are critically important to bring under control as soon as possible, because such behavior becomes more entrenched and difficult to change the longer it persists. In addition, children with ODD are at significant risk for the development of the more severe kinds of behavioral disturbance that is characteristic of Conduct Disorder, and the long term outcomes for children with Conduct Disorder are especially worrisome.
 

** "Why did you do that?: Differences in how parents of children with and without ADHD understand their child's behavior." **

A recent study in the Journal of Consulting and Clinical Psychology presents interesting findings on how parents of children with and without ADHD understand their child's behavior.

In this study, the authors studied parents attributions for (i.e. why their child did it) and reactions to behaviors reflecting inattentiveness/overactivity, oppositionality and defiance, and pro social actions.

Compared to parents of children without ADHD, parents of a child with ADHD believed that inattentive and overactive behavior was less controllable by their child and reflected a stable characteristic. In other words, they were less likely to "blame" their child for behaving in these ways. Even so, however, they reported that they would feel more frustrated and upset with their child.

Similar results were found for oppositional and defiant behavior. This is interesting because such behavior does not necessarily reflect core ADHD symptoms and may, in fact, be more under the child's control. As before, parents of children with ADHD indicated that they would react by feeling more frustrated and upset.

When it came to pro social behavior, parents of an ADHD child believed their child was less likely to be the "cause" of such behavior and that it was less likely to reflect a stable characteristic of their child. Instead, they were more likely to attribute such behavior to circumstances.

The authors of this study offer some interesting speculations about the possible implications of these results. First, they note that although parents of children with ADHD do not hold their child responsible for the behaviors that directly reflect ADHD symptoms - which is in keeping with current beliefs about the biological basis of these symptoms - they still report feeling more frustrated and upset by such behavior than parents of children without ADHD. While not observed directly in this study, they wonder about the possible negative effect on the parent-child relationship of expressing anger over something the parents recognizes is hard for their child to control.

The authors also note that parents of a child with ADHD were less likely to believe their child had control over oppositional and defiant behaviors. Deliberate defiance is not a core symptom of ADHD (it is more likely to reflect ODD), and may be behavior that a child with ADHD can choose to control more readily. Perhaps the experience of seeing their child behave in ways that are difficult to control leads parents to assume that non ADHD behaviors are also outside of their child's control. The authors suggest that this might make parents less likely to employ effective discipline strategies because they feel such behavior can not be controlled by their child. This could potentially lead to an increase in such behavior and is an issue that should be addressed in future studies.

Finally, the authors also wonder about the impact of believing that pro social behaviors are attributable situational factors rather than being deliberately initiated by the child. Could this result in such behavior being less likely to be praised and rewarded? If so, it would reduce the likelihood of such behavior increasing in frequency.

Please note that this study definitely does not imply that anything about how parents respond to their child's behavior is the cause of ADHD symptoms. The attributions that parents make for childrens' behavior can influence how they respond to their child, and may have important implications for the development of both problematic and pro social behaviors.

This study underscores the importance of examining the attributions that we all make about our children's behavior. Blaming children for behavior that is legitimately difficult for them to control can create difficulties, while not holding them responsible for behaviors that they can more easily exercise control over, can also be problematic. Of course, making these distinctions can be a difficult thing to do but is a task that deserves careful and ongoing effort and attention.

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