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ADHD RESEARCH UPDATE - Vol. 6, March, 1998
********************************************************In this issue...
**ADVERSE RESPONSE TO CLONIDINE**Health concerns about a frequently prescribed medication
The adaptive aspects of ADHD from an evolutionary perspective
Is biofeedback an effective treatment?: Results from 2 recent treatment studies
The first article to review this issue may not effect many of you, but it is quite important so I wanted to include it. This article appeared in the April, 97 issue of the Journal of the American Academy of Child and Adolescent Psychiatry.
The authors of this study begin by noting that Clonidine, either alone or in combination with methylphenidate (i.e. the generic form of Ritalin) is being used with increasing frequency. They voice several important concerns about this including:
The bottom line that I would take away for this is that I would not put my child on Clonidine unless:there is an absence of controlled studies that document the efficacy of clonidine in combination with methylphenidate for treating behavioral disorders in children and adolescents;
some children taking Clonidine - either alone or in combination with a stimulant medication have had extreme adverse reactions. In 4 cases, in fact, the child actually died. (The authors note that the contribution of medication to these deaths is unclear, however.)
As a result, the following guidelines were suggested:
Children and adolescents with preexisting cardiac or vascular disease SHOULD NOT receive Clonidine therapy for behavioral disorders like ADHD;
Careful monitoring of blood pressure and pulse rate needs to be obtained prior to starting the medication, each week as the proper dose is being determined, and every 4-6 weeks thereafter.
Clonidine dose change should be done gradually and it should not be terminated abruptly. This can increase the risk of adverse reactions.
If your child is already taking Clonidine, I would suggest discussing these issues with your child's physician. He or she can consult the April 97 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, pages 539-544 for the complete article.I had exhausted all other possibilities - which would include other medical as well as non medical treatments - none of which worked.
My child's difficulties were creating a level of impairment that DEFINITELY needed to be addressed.
I was working with a physician who was experienced in using this medication with children and who was knowledgeable about the possible complications.
** ADHD AS A DISORDER OF ADAPTATION **
Dr. Peter Jensen, the chief of child and adolescent psychiatry at the National Institute of Mental health (NIMH), published an interesting paper in the December, 97 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. In this paper, Dr. Jensen and his colleagues try to understand and explain ADHD from the perspective of evolutionary biology, and argue that certain characteristics of ADHD may have conveyed important adaptive advantages even though they appear to reflect a "disorder" as our environment has changed.
Dr. Jensen begins by noting that ADHD has a strong genetic basis and is believed to occur in 3-5% of the population. Drawing on principles of evolutionary biology, he argues that it is unlikely that such a "disorder" would be so prevalent if it did not convey certain advantages in addition to the difficulties that are associated with this condition.
He goes on to argue that the core ADHD symptoms of inattention, hyperactivity, and impulsivity can be adaptive in some instances, and that the environmental conditions that our ancestors lived in were ones where such characteristics may have had an important adaptive value.
Dr. Jensen suggests that in many ancestral environments, humans' survival depended on: being able to rapidly scan the environment for threats as opposed to sustaining attention to particular stimuli; being able to pounce or flee quickly - that is, responding rapidly to environmental cues without necessarily considering alternative responses to those cues; and, being motorically hyperactive (e.g. foraging for food, migrating as the climate changed.
Dr. Jensen describes individuals with these characteristics as "response ready", and argues that within a hunter- gather society individuals with these "response-ready" characteristics would likely have been more successful "...warriors on a primitive battlefield while those with more contemplative characteristics would have been valued for longer term planning..."
He points out, though, that as society has changed these "response ready" characteristics have become less adaptive. Thus, as success depends more and more on planning and analytic strategies, restraint of impulsivity, and the controlled deployment of energies, the response ready characteristics of individuals with ADHD have become increasingly problematic.
What are the practical implications of understanding ADHD from this evolutionary perspective? Dr. Jensen argues that current school environments could hardly be more difficult for a "response-ready" child. Most school environments favor the "problem solving" individual who is able to maintain problem solving activity without physical movement, who can sustain attention, and delay responding until all aspects of a situation have been analyzed.
Specialized classroom environments tailored to the "response ready" child could be potentially beneficial. Such classrooms incorporate self-paced computer learning, active self-monitoring, more frequent work periods of shorter duration, opportunities for moving around, tailoring assignments to student's individual needs, and the consistent use of reinforcement. For an excellent book on this topic, see "School-Based Assessments and Interventions for ADD Students" by Dr. James Swanson.
Working with your child's teacher to provide reasonable accommodations that are well matched for his or her character is-is can be extremely important. In my experience, some teachers are quite willing and able to do this while others are simply not. This often explains why a child with ADHD can have a pretty good school year in one grade and then have a miserably difficult time the next. It is not necessarily that the child's ADHD symptoms are actually getting worse; rather, the child may simply be in the type of classroom environment that is particularly mismatched for their characteristics and which makes their symptoms more prominent.
Dr. Jensen also suggests that by reframing the child who has ADHD as "response ready" rather than as "disordered", and by emphasizing the child's experience-seeking, energetic, and "ready to act" characteristics, the child and family can be counseled to recognize situations in modern society that favor such an individual. In other words, in addition to trying to help the child develop skills for success in environments that are a poor fit for his/her characteristics, the child and parents should be encouraged to seek out situations where "response ready" traits are more adaptive. In childhood, this may include different types of athletic pursuits. In terms of long term choices, he suggests that professions such as air-traffic controller, salesman, entrepreneur, etc.
Although this is an interesting and potentially important way of thinking about ADHD, Dr. Jensen is careful not to "romanticize" the child with ADHD as simply being mismatched with his or her environment, since many children with ADHD experience significant difficulties across a wide range of different settings. The value of this conceptualization, I think, is that it highlights the potential adaptive features of this condition, and encourages parents and professionals to work towards creating the types of environments that can help children with ADHD succeed.
**READER REQUESTS**
BIOFEEDBACK AND ADHD
I had a request to present information on research examining biofeedback as a treatment for ADHD. The idea behind this treatment is that biofeedback can be used to train children to produce the type of brain activity that is associated with sustained attention.
In the last 3 years, I was able to locate two published studies on this treatment approach for ADHD. The first was published in March '95 issue of Biofeedback and Self Regulation. In this study 23 children and adolescents from 8-19 years participated in a 2-3 month intensive neurofeedback (i.e. another term for biofeedback) training program. The authors report that children receiving the training showed: improvement on a laboratory test of sustained attention; decreases in parent ratings of ADHD symptoms; and increases in IQ scores.
In a second study, published in the March 96 issue of the same journal, 18 children with ADHD were randomly assigned to a neurofeedback training group or a control group (i.e. subjects in the control group received no treatment.)
Treatment consisted of 40 45 minute sessions of neurofeedback training which occurred over a 6 month period. At the conclusion of treatment, children receiving treatment showed a significant increase in IQ compared to the control group and a significant reduction in inattentive symptoms as rated by parents. No significant reduction in hyperactive/impulsive symptoms or oppositional behavior was found.
These results are certainly promising, but several caveats need to be kept in mind. First, the number of subjects in these studies is quite small - 23 in the first and 18 (9 of whom received the treatment) in the second. As a result, I think it is prudent to regard these as promising pilot studies that need to be replicated with substantially larger samples.
Second, this is a lengthy and expensive treatment approach. In my area, a course of biofeedback treatment for ADHD runs about $3,000, and I doubt that many insurance companies would cover this. I would personally be careful about spending this kind of money for a treatment whose efficacy has not yet been demonstrated more convincingly.
Third, in the study that used a control group, no significant benefits of biofeedback for hyperactive/impulsive symptoms or for oppositional behavior were found. As you are aware, stimulant medication has been clearly shown to help with both of these aspects of ADHD. It may be that biofeedback proves to be helpful for children with the inattentive subtype of ADHD, but is less effective for children who also have hyperactive and impulsive symptoms.
For me, the bottom line is that compared to the hundreds of studies that have demonstrated clear benefits of medication and behavioral therapy for most children with ADHD, the empirical support for biofeedback training is not nearly as clear. This does seem to be a promising approach, however, and hopefully we will be seeing more large scale studies of this method being published in the near future. I will be sure to include such studies in the newsletter if they are published.
**QUESTIONS**
In response to the article last issue on Oppositional Defiant Disorder (ODD) a reader asked how one differentiates ODD from bipolar disorder (BPD - for a discussion of BPD symptoms, see the first issue of ADHD RESEARCH UPDATE.
This is a good question and also an important one, for one would not want to misdiagnose a child with BPD as ODD, and provide in-appropriate treatment as a result.
The key distinction between ODD and BPD is that ODD is primarily a behavioral disorder - the major problem is what the child actually does - while BPD is a mood disorder - the primary problem is a disturbance of mood. Where these conditions can seem to overlap is that children with ODD often show extreme irritability and moodiness as well.
Here, though, are some key differences. First, the mood fluctuations in a child with BPD are likely to be much more extreme. Frequent and rapid transitions from an unusually and inappropriately elated and giddy mood to appearing depressed and/or angry are common. According to Dr. Barbara Geller, an expert in childhood BPD, a child with BPD may be having a laughing fit one minute and then suddenly become miserable and talk about killing themselves.
Second, the thinking of children with BPD is often illogical and grandiose. Children with BPD may feel they would do a better job than their teacher of teaching the class, and may purposefully fail because the class is being taught "incorrectly". Children with BPD often get into trouble because they do not believe rules should apply to them. This is not just inside the home - as may be true of children with ODD, but outside the home (e.g. stealing expensive items) as well.
Children with BPD often display "pressured speech" which is intense, rapid talking which they feel they can not stop. This has a very different quality than the excessive talking that often goes along with ADHD. They also describe "racing thoughts" that can not be controlled.
Another key difference is that it is not uncommon for a child with ODD to have their problematic behavior restricted to a single setting, generally the home. Their behavior problems often occur with parents and no one else. For a child with BPD, however, the difficulties described above are much more likely to cut across multiple settings (i.e. home, school, peer group, etc.)
That's all for this issue. I hope that the new format of shorter but more frequent issues is working for you. Feel free to forward information in the newsletter to people you know who may be interested - I would just appreciate your letting them know where it cam from so I can send them information about subscribing if they are interested.
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