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ADHD RESEARCH UPDATE - Vol. 7, April, 1998
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** Differing Views on Beginning Treatment for ADHD **Differing views on beginning treatment
ADHD in adults: Difficulties in diagnosis
Is stimulant medication equally effective for children and teens?
Question from subscriber - Does treatment with Ritalin promote substance abuse? Over the years the condition known as ADHD has been one of the most controversial diagnoses in child mental health. I came across an interesting article recently in a publication called "Point-Counterpoint: Controversial Issues Confronting the ADHD Specialist" that clearly indicates how aspects of this controversy continue to be alive and well.
The article featured interviews with two of the world's leading authorities on ADHD - Dr. William Pelham, a psychologist who teaches and conducts research on ADHD at the State University of New York in Buffalo, and Dr. Joseph Biederman, a Professor of Psychiatry at Harvard Medical School.
The focus of the interviews with each expert was how they felt the treatment of children with ADHD should best be managed. Dr. Pelham stated quite strongly that he believes behavioral interventions should be implemented first, and that medication be used as a secondary treatment if necessary. He based his position on research which suggests that medication does not alter the long term outcomes for children with ADHD. Because medication has not yet been shown to have long term positive effects, he believes it should not be the first treatment implemented.
According to Dr. Pelham, parent training should be an important part of treatment for EVERY child with ADHD. In his parent training program, which lasts from 8-16 sessions, parents are taught how to give effective commands, how to use appropriate punishment strategies, and how to use positive rewards to encourage good behavior.
Dr. Pelham also believes that every child with ADHD should get a daily report card at school, in which he or she receives grades from the teacher on how well important goals (e.g. completing work, following class rules) have been met. This report card is brought home each day, and depending on the marks received, the child is able to earn privileges at home. For example, for each goal with a satisfactory daily grade, the child might earn 15 minutes of TV time or computer time.
Dr. Biederman advocates a very different approach to managing the treatment of children with ADHD. He feels that because ADHD is a "brain disorder" with a strong biological basis, medication therapy should be started immediately. He believes it is difficult to know what other interventions will be necessary until one sees how effective medication can be for a particular child. This is because some children, if they are placed on the appropriate medication and have a good response, may have their behavior normalized to such a degree that additional interventions are not required. Making sure the child is deriving the optimum benefit from medication, and then carefully monitoring how the child does over time, are critically important to promoting the child's long term success.
After the child's behavior has been stabilized as well as possible via medication, other treatments may then be necessary to target difficulties that still remain. For example, many children with ADHD will continue to have social difficulties and may require specific assistance in this area. Behavioral problems at home, and/or conduct problems at school may also need to be specifically targeted. Dr. Biederman also feels that some parents may benefit from supportive therapy to help them with their concerns about their child having a chronic illness. Children may also benefit from supportive therapy to verbalize the frustrations of dealing on a daily basis with difficulties with teachers and peers.
For whatever it's worth, my own personal feeling on this issue is more in keeping with Dr. Biederman. In my own work, I have seen many children who responded so well to medication that there really weren't any significant issues left to address. As long as the child continues to do well, it is not clear to me why any additional treatments are necessary. The ESSENTIAL thing, though, is to make sure that there are not difficulties that still remain to be addressed, and to carefully follow the child to be sure that such problems are addressed should they emerge. All too often, this kind of careful, ongoing monitoring is just not done, which may be one important reason for why the long term impact of medication on children with ADHD still needs to be clearly demonstrated.
It is also important to note that in today's era of managed care, there are often real world barriers to providing the kind of behavioral treatment that Dr. Pelham advocates. Many insurance companies will simply not authorize 8 sessions of behavioral parent training, let alone the 16 sessions that is sometimes required. I have certainly felt the squeeze in recent years from the managed care industry, and it can be incredibly frustrating for providers not to be able to offer the appropriate level of care. I also know how difficult and frustrating this is for parents.
Finally, it needs to be stressed that given the disagreement on this matter by such experts, what approach parents feel most comfortable with is a VERY important consideration. Some parents I work with prefer to begin with behavioral interventions alone and see how things go. Others prefer to start medication right away. BOTH of these choices are quite reasonable alternatives. Just make sure that whatever you decide to do, there is a careful system in place so you know how effective the approach you decide on with your child's health care provider is being. If it is not working as well as it needs to be, make sure that you become aware of other options to try.
** The Assessment of ADHD in Adults **
The June 1997 issue of Comprehensive Psychiatry included an article titled "Adult attention deficit hyperactivity disorder: Assessment guidelines based on clinical presentation to a specialty clinic" that highlights the difficulties and problems associated with "self-diagnosis" of adult ADHD.
The authors report on 143 adults between the ages of 18 and 64 who requested that they be evaluated for ADHD at a specialty clinic. Of these 143 individuals, all of whom believed that they had ADHD, 46 met diagnostic criteria for ADHD, 46 clearly did not meet criteria, and 51 had ADHD like features but did not meet criteria either because there was no history of childhood onset and/or because of complicating psychiatric disorders or substance abuse. Members of the 3 groups were similar in demographics, psychiatric symptom severity, and functional impairment.
Compared to patients not meeting diagnostic criteria for ADHD, those adults with ADHD had more frequent histories of learning disabilities in childhood, poorer reading scores on a standardized test of reading achievement, poorer scores on a laboratory test of sustained attention, and higher scores on a ADHD rating scale that has been developed specifically for adults. The rating scale used for adults was developed by Dr. Paul Wender from the University of Utah and looks specifically at 5 types of types of symptoms: emotional lability, emotional over activity, disorganization, impulsivity, and inability to complete tasks.
It is important to stress that ADHD is a disorder that requires a childhood onset. An key consideration in making this diagnosis in adults is thus to determine that an adult did actually have ADHD in childhood. This can be difficult to do, and a comprehensive evaluation can require direct input from an adult's parents as well as an examination of old school records. There are many other reasons why an adult can experience difficulties with concentration and can feel fidgety and impulsive, but unless these difficulties were also evident in childhood, the explanation for current problems can not be ADHD.
The results of this study suggest that many adults who experience symptoms that make them feel they have ADHD are unlikely to have this disorder. In my opinion evaluating adults for ADHD is actually more difficult than evaluating children, because obtaining the information about childhood history is often quite difficult. Finding a practitioner who has specific expertise in adult ADHD is strongly recommended for individuals who wish to learn whether difficulties they experience are the result of ADHD. Self-diagnosis using "ADHD tests" floating around on the Internet is not a good substitute for a thorough evaluation.
* Does the effectiveness of stimulant medication decrease in adolescence? *
One of the concerns that many parents have about their child receiving stimulant medication is that children develop a "tolerance" for medicine, and that medication may thus not be as effective for teenagers as for pre-pubertal children. A study that was just published in the March 98 issue of the Journal of the American Academy of Child and Adolescent Psychiatry titled "Equivalent effects of stimulant treatment for ADHD during childhood and adolescence" suggests that these concerns are unwarranted.
In this study, children who attended a summer treatment program for ADHD completed careful placebo-control medication trials when they were children (i.e. 8 to 11 years old) and again when they were adolescents (i.e. 12 to 14.5 years old). Careful measures of subjects' academic performance and social behavior were obtained on each occasion, and the magnitude of medication effects were computed for each child at each time. By comparing the effect size for subjects when they were children with the effect size obtained several years later when they were teenagers, the researchers could determine whether the effectiveness of medication diminished with advancing age.
The results indicated that for most children, effect sizes for medication were judged to be in the moderate to large range, and that this was true at both assessments. Thus, there was no indication that the effect of medication diminished as subjects moved from childhood to adolescence. This was true even though the doses being administered on these two occasions were IDENTICAL. In other words, just because the subjects were bigger, a larger dose was not required to produce equivalent benefits. This is perhaps not surprising given that other research has not indicated any relation between body mass and response to different doses (see the prior issue of ADHD RESEARCH UPDATE).
Now, it certainly often seems that a child with ADHD experiences greater difficulties upon entering middle school, and a common response from treatment providers is to increase the amount of medication the teen receives. The authors of this study argue that their results indicate that stimulant medication is equally effective with children and adolescents IF they are engaged in similar activities, and suggest that a change in environmental demands may often explain why the functioning of adolescents with ADHD appears to worsen.
I think they are likely to be correct about this. Just consider how the academic demands of middle school - when students often have 5 or more different teachers - compare to the demands of elementary school, when a single teacher is generally responsible for each student. If a student appears to be struggling to a greater degree when he or she enters middle school, it is often because the demands they have to meet are greater, and not because their ADHD has gotten "worse".
This line of reasoning suggests that increasing the amount of medication the student receives rather than looking to make appropriate and necessary accommodations in the academic environment may not be the best course to pursue. Once the optimal dose of medication has been determined for an individual child using a careful medication trial procedure, treatment providers should "rigorously examine environmental causes to problems before prescribing higher doses of stimulants to adolescents with ADHD who exhibit a worsening in functioning."
In such instances, increasing the dose of medication, or perhaps changing the medication may turn out to be the answer, but it should not automatically be assumed that this is what needs to be done. When such a change is contemplated, controlled, individualized dose-response trials should be implemented to document whether the medication change is really helpful.
* Question from subscriber *
I received this question recently from a subscriber to ADHD RESEARCH UPDATE.
"I wondered if you could find me any information on an article that what printed in a paper called the 'Daily Mail' (As you may already know I live in the U.K. Is there any truth in this?
Children's drug 'just like cocaine'.
A 'MIRACLE drug' given to thousands of hyperactive children increases the risk of drug addiction in later life, scientists have warned.
They claim youngsters who take Ritalin are more likely to smoke in adulthood and three times as likely to abuse cocaine.
The findings which are disputed by other scientists, will add to fears about the drug given to 6,000 British children but described by some as a 'chemical cosh'.
One of the unfortunate ideas about stimulant medications such as Ritalin is that children who take Ritalin are more likely to become substance abusers during their adolescent years. As the excerpt from the above newspaper article that was recently printed in England makes clear, this concern continues to persist.
I am not aware of ANY published research that supports this view. As best I can surmise, there continues to be some uncertainty about whether ADHD alone, in the absence of any co-occurring condition such as conduct disorder, major depression, or bipolar disorder actually increase the risk of later substance abuse. Some studies seem to indicate that it does, while the results of other studies suggest that increased rates of substance abuse among individuals with ADHD are better attributed to the other difficulties that often go along with ADHD, rather than to ADHD itself.
What the article quoted above suggests is that among children with ADHD, those who were treated with stimulant medications like Ritalin are more likely to develop problems with substance abuse than children who do not receive medication as part of their treatment.
I was unable to locate the study cited to support this conclusion but want to emphasize that this is quite in- consistent with other research that has looked at this issue. There is no evidence that I am aware of that children treated with stimulants are more likely to abuse drugs or alcohol in later years. In fact, available research suggests that if anything, it is the reverse that is likely to be true.
copyright 1998 ADHD RESEARCH UPDATE.
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David Rabiner, PhD
Licensed Psychologist