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ADHD RESEARCH UPDATE - Vol. 8, March, 1998
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In this issue...

New medication studies - Buspirone and Adderall

 

The relation between sleep disorders and ADHD

 

Are computerized tests for ADHD really helpful?

 

Question from subscriber: Should medication be used over the summer?

 

** NEW MEDICATION STUDIES **

Although Ritalin is still the most widely prescribed medication for treating ADHD/ADD, and the safety and efficacy of this medication are well established, not all children do well on this medication. Some children do not show the positive response that most do, and others experience side effects that make the ongoing use of Ritalin problematic.

For these reasons, new medications that can be effective in treating the symptoms of ADHD continue to be important to develop. In this issue of ADHD RESEARCH UPDATE I'd like to report on two recent studies that were conducted to test new medications for treating ADHD.

The April 1998 issue of the Journal of the American Academy of Child and Adolescent Psychiatry presents a study that offers some preliminary support for the use of Buspirone in treating ADHD. Buspirone has been used since 1984 to treat children and teens with anxiety disorders and it has been reported to be effective for such conditions. In addition, side effects (these include nausea, headaches, daytime tiredness and weight gain) to Buspirone are reported to be uncommon and to be only mild or moderate when they do occur.

In this study, 12 children with ADHD between the ages of 6-12 were treated with Buspirone over a 6 week period and systematic assessments of children's behavior were completed by parents on a weekly basis. All children received the medication twice per day. At the end of the 6 weeks, the medication was discontinued and a final set of parent ratings was obtained 2 weeks later.

The effectiveness of Buspirone in reducing core ADHD symptoms AND in reducing oppositional/aggressive behavior was quite impressive. By the end of the 6 week trial, all subjects were reported to have shown a reduction in symptoms of at least 50% on the behavior rating scales completed by their parents. In addition, significant and substantial in children's overall functioning was also reported. When the medication was discontinued temporarily for 2 weeks at the end of the trial, all 12 children showed a reemergence of symptoms within 2 weeks. During the trial, only 2 children reported any side effects at all (i.e. mild dizziness) and this abated after the first week.

These results are obviously quite promising, although as the authors readily acknowledge this is an initial demonstration only. Subsequent studies will need to include larger samples, an adequate control group, and should also include ratings from teachers as well as parents.

Hopefully, these necessary follow up studies will be conducted and reported shortly, because Buspirone may have several important advantages compared to stimulant medications in that it has a very favorable side effects profile and for parents who are concerned about this, it also has no reported abuse potential.

The May 1998 issue of the Journal of the American Academy of Child and Adolescent Psychiatry reports the results of a carefully designed study to test the effectiveness of Adderall, which is a relatively new type of stimulant medication   that is being used more frequently to treat ADHD.

Adderall was initially approved by the FDA for the treatment of obesity and "minimal brain dysfunction" in the 1960's. In 1994, Richwood Pharmaceuticals began marketing Adderall specifically to treat ADHD. Among the reported advantages relative to Ritalin are that it lasts longer - meaning that fewer doses per day are possible - and that children are less likely to show the "rebound effect" (i.e. a temporary increase in irritability and ADHD symptoms as the medication wears off).

Thirty-three children with a confirmed diagnosis of ADHD between the ages of 7 and 14 served as subjects in this study. All children who participated were currently being treated with methylphenidate (i.e. the generic name for Ritalin) and had been shown to have a good response to their medication. During the study, children were tried on 4 different doses of Adderall (i.e. 5 mg, 10 mg, 15 mg, and 20 mg.) They were also placed on a placebo for 1 week and were evaluated for one week on their regular dose of methylphenidate. Children received the different doses in a random order - in other words, some children might receive the highest dose during their first week while others might start with the lowest dose. This differs, of course, from the typical procedure of starting at the lowest possible dose and gradually building up to a level that yields a strong response.

During the trial, students participated in an experimental classroom that was designed to be similar to a typical classroom environment. The schedule of daily activities was tightly adhered to, however, so that children could be systematically observed performing particular tasks at set times after taking the medication in the morning. This enabled the researchers to track whether and how children's performance changed over the course of the day in a systematic manner. With this information, the duration of benefits provided by the medication could be carefully assessed.

During the trial, ratings of children's behavior and attention were collected by independent observers in children's class- rooms. These observers did not know what dose children were receiving, or when they were on a placebo as opposed to real medication. This placebo condition is important because by comparing ratings for the real medication weeks with the placebo week one can then determine whether any improvements from medication are above and beyond what is produced by a placebo alone. In addition to ratings of attention and behavior, data was also collected on the percent of assigned math problems attempted and the percentage that were answered. Thus, the authors sought to evaluate the impact of Adderall not just on children's behavior, but also on the quality of their academic performance.

The authors first present data on side effects. As has been found in studies with other stimulant medications, reports of side effects were no more frequent or severe in most medication conditions than in the placebo condition. At higher doses, however, there were more reports of sleep difficulties and appetite reduction from children's parents. During the placebo week, children's behavior deteriorated significantly over the course of the day. Children also attempted fewer assigned problems and completed fewer problems correctly as the day wore on. In contrast to this decline during the day for behavior and school work, ratings of attention remained relatively constant over the day - i.e. they were equally problematic throughout.

During the medication weeks, the same decline in behavior and school work was not observed. Instead, children showed an initial improvement in both these areas that began to reverse as the medication wore off. As for academic work, children attempted more problems and answered a higher percentage correctly when on medication, although this also changed as the medicine wore off. Overall, greater benefits were obtained at higher doses, although the optimum dose for each individual child varied. Although the study was not designed to compare the effectiveness of Adderall and methylphenidate, overall children seemed to do equally well on both.

In comparing methylphenidate with Adderall, the authors reports that the peak effects (i.e. the time required to reach the greatest benefit of methylphenidate occurred quicker than for Adderall (i.e. 1.88 hours vs. 1.50, 2.60, 2.60, and 3.50 for the 5, 10, 15 and 20 mg doses respectively). The beneficial effects of methylphenidate were of shorter duration however (i.e. 3.98 hours vs. 3.52, 4.83, 5.44, and 6.40 hours for the different Adderall doses). It is important to note that these times represent group averages and can thus vary considerably between individual children.

What are the important clinical implications of these studies for parents trying to help their child? There are several. First and foremost, it is essential to realize that there are multiple medications that have been shown to have demonstrated efficacy for treating ADHD. For a child who does not respond well to the first medication tried (this is generally Ritalin) there are other options available. Unfortunately, there are many instances, I think, where failure to get good results with an initial medication is not followed by systematic efforts to find a medication that will be effective. As a result, many children who could really be deriving important benefits from medication are not getting treatment that could be quite helpful to them.

The same issue holds true for side effects. In my experience, if a child experiences side effects on the medication first tried parents are reluctant to try anything else. Just because a child has an adverse reaction to one type of medication, however, does not mean that similar problems will occur on a different medicine. In addition, in many cases what appear to be side effects to medication will actually be nothing more than a placebo effect. this is another reason why carefully conducted trials in which a child's response to medication is compared to placebo is so important.

Please do not interpret this to mean that I am advocating the use of medication for any child diagnosed with ADHD. As reported in the last issue of ADHD RESEARCH UPDATE there is still disagreement about this issue among experts, with some very well regarded psychologists advocating the use of behavioral interventions prior to any decision about the need for medication is made. If it does make sense to try medication for a child with ADHD, however, it is important to know what the different options are and what the best procedure is for determining the optimal dose and medication for each individual child.
 

* THE RELATION BETWEEN SLEEP DISORDERS AND ADHD *

Is there a connection between sleep disorders and ADHD in children. I recently came across a very provocative study that appeared in the December 1997 issue of the journal Sleep which suggests that this may be the case.

The authors of this study sought to determine whether children with higher levels of inattention and hyperactivity more frequently have symptoms of sleep related breathing disorders (SRBDs) or periodic limb movement disorders (PLMD) than children without these symptoms.

Parents of 70 children at a child psychiatry clinic and 73 children at a general pediatric clinic were interviewed to assess their child's behavior, snoring, complaints of "restless legs" at night, and daytime sleepiness. Standardized ratings of DSM-IV symptoms of ADHD were used to establish a whether a child had ADHD (this was really not a full diagnostic work up) and a validated pediatric sleep questionnaire was used to assess sleep difficulties.

The authors report that habitual snoring was more common among the children with ADHD (33%) than among other children from either the psychiatric clinic (11 %) or pediatric clinic (9%). Associations between ADHD symptoms and the other sleep difficulties assessed (e.g. restless legs, daytime sleepiness) were also found, although these results were not as strong as for snoring.

The authors suggest that their results SRBDs and perhaps some other sleep disorders could be a cause of ADHD in some children. (It is important to note, however, that nothing about this study established any causal connection between snoring and ADHD. In other words, these results suggest that snoring is associated with ADHD but it can not be concluded that this sleep difficulty is a cause of ADHD.) If a causal connection were to be established, the authors suggest that as many as 25% of children with ADHD could have their ADHD eliminated if their habitual snoring and any associated sleep difficulty were successfully treated.

This is a very interesting study and replicates prior work in which an association between sleep difficulties and ADHD has been documented. Although it is premature, in my opinion to suggest that sleep difficulties are an important cause of ADHD for some children, this information can still have important clinical implications.

For example, other work in this area has found a link between children's sleep and their cognitive functioning (see the March 1996 issue of the Seminar in Pediatric Neurology). Apparently, inadequate sleep results not only in tiredness, but also can produce difficulties with focused attention, irritability, and difficulty modulating impulses and emotions. Clearly, this mimics some of the symptoms of ADHD, and it would appear prudent to rule out sleep problems as the source of a child's difficulties when making the diagnosis.

It may be thus be quite important to assess whether your child or patient with ADHD experiences the type of sleep difficulties that were found to be more frequent among the children with ADHD in this sample. Even if these sleep problems are not the cause of a child's ADHD symptoms, it is certainly the case that inadequate sleep is likely to make things worse. Treating these sleep problems could potentially have a beneficial effect on the ADHD symptoms for some children. In my own practice, I have found this to be true on several occasions. Discussing this issue with your child's physician would be a good thing to do.
 

* COMPUTERIZED TESTING FOR ADHD - HOW USEFUL IS IT? *

The recent issue of Child Psychiatry and Human Development (Vol 28, 1998) included an article on the diagnosis of ADHD using "objective" laboratory based measures. Many professionals and parents have been hopeful that a reliable and objective method for diagnosing ADHD can be developed, and this article provides a good opportunity to revisit this issue.

An important concern that many have about the diagnosis of ADHD is that it depends to a large degree on subjective judgments of parents, teachers, and physicians. After all, all children display problems with attention, activity level, and impulsive behavior at some times, so at what point does "typical" childhood behavior become "atypical" and result in a meaningful and accurate diagnosis. (For specific information about diagnostic criteria click here. This situation can be more difficult when parents and teachers see the child in different ways, and parents worry about their child's teacher providing inaccurate or biased observations of their child's behavior.

For such reasons, efforts have been made for many years to develop an "objective" procedure that could be used to diagnose ADHD in a reliable and valid manner. The most promising candidate for this is something called a Continuous Performance Test or CPT for short. The way this test basically works is to have a child sit in front of a computer terminal on which various letters, numbers, and/or symbols are repeatedly displayed. The child is instructed to either respond, or to refrain from responding, depending on what appears on the screen.

Unlike your typical computer game, CPT tests are designed to be extremely repetitive and boring. Doing well requires paying careful attention so that careless and impulsive mistakes are avoided . In theory, by comparing a child's score with the scores that are typically received by a child the same age, one can tell whether the child's ability to carefully attend and refrain from making careless, impulsive mistakes is deficient relative to his or her peers. If it is (i.e. if the child does worse on this task than the vast majority of same age children) than the diagnosis of ADHD might reliably be assigned.

In this study, 20 boys who had been diagnosed with ADHD were compared with 52 boys without ADHD on the CPT. The scores of these two groups of boys were compared to see whether the children with ADHD performed significantly worse on the CPT than the control subjects. As has been found in many other studies using this procedure, as a group, boys with ADHD did worse than control subjects.

Now, does that mean that such a test can be used as a good instrument for diagnosing and individual child? Unfortunately, this is not necessarily the case. To use the CPT to diagnose individual children requires that scores above a certain level are considered to indicate ADHD while scores below this level are "normal". When used in this way, the authors report that boys with ADHD were differentiated from the control subjects with "sensitivity and specificity" above 75%.

The "sensitivity" of a test refers to it's ability to correctly identify individuals with a certain condition. In this case a sensitivity of approximately 75% means that 75% of the boys with ADHD (i.e. 15 of 20) scored above the level that is believed to indicate the presence of ADHD. Five boys (i.e. 25%) scored in the "normal" range.

The "specificity" of a test refers to it's ability to only identify as having the disorder individuals who really do. 100 percent specificity would mean that ONLY children who actually have ADHD achieve scores above a certain level and that children without ADHD NEVER DO. In this case, a specificity of 75% means that 75% of the non ADHD children scored in the normal range. This also means, however, that 25% of children without ADHD (about 14 of 52) did as poorly on the test as a child with ADD is supposed to do.

When looked at in this way, you can see the difficulty with using this test for making diagnoses. If one were to rely on a child's CPT score alone to decide whether he or she had ADHD, as many as 25% of children with ADHD would be misdiagnosed as "normal". An equal percentage of children without ADHD would be mistakenly diagnosed as having this disorder. Obviously, both types of diagnostic errors can create real problems.

It is for this reason that many professionals believe that "objective" measures like the CPT should be used only as "adjunctive" methods for diagnosis. The backbone of a good diagnostic work up remains a thorough and well conducted clinical interview with a child's parents and gathering information from the child's teacher. The value of inter viewing the child him or herself for establishing the presence of ADHD symptoms is debatable - especially for young children who often are not accurate reporters - but can be essential for evaluating whether other conditions (i.e. problems with mood or anxiety) may be present. You can go to for a more complete discussion of suggested evaluation guidelines.

Until objective tests like the CPT can be refined to show much higher levels of sensitivity and specificity they should be used cautiously and judiciously. Sometimes, computers can add an aura of "scientific accuracy" that is really not justified. I have heard of parents paying several hundred dollars for such tests that are then used as the primary basis for diagnosing their child. In my opinion, and the opinion of many mental health professionals, this is a misuse of such tests.
 

* Question from subscriber: Should my child stay on medication over the summer? *

For a child who receives medicine to help with school, the question of whether it should continue to be taken during the summer months is an important one. This is definitely something that should be carefully discussed with a child's doctor, although the guidelines below may be useful to take into account.

Until relatively recently, most physicians recommended that medication for treating ADHD be discontinued on weekends and over the summer. The reasoning behind this stance was that medication was intended to help children function more effectively in school, and there was thus no need for medicine when school was not in session. Concerns about the health consequences of continued use of medication were also involved in this decision.

Unfortunately, for many children with ADHD, the ability to succeed in activities outside of school is greatly reduced with the assistance provided medication. For example, some children are not able to do well with peers or to participate in organized peer activities without medication. Problems getting along with parents are also often helped substantially by medication - I've had many parents tell me how much easier it is to have a good time with their child when he or she is on medication and that they are able to spend time together in ways that are just not possible otherwise.

Success with peers and good relations with parents are extremely important in promoting a child's healthy development. Being excluded or disliked by peers and having frequent conflictual exchanges with parents can take a toll on a developing child's feelings about himself and others. Overt time a history of unsuccessful and conflictual interactions can create as much difficulty for a child as the primary symptoms of ADHD.

For these types of reasons, many mental health professionals now advocate that medication be continue year round for children who need it to be successful outside of school. Thus, if you recognize that your child gets along much better with peers, is able to participate more appropriately in various activities, and does better at home when on medication, than the use of medication during the summer months should be considered. For a child with ADHD who is able to do well in these contexts without medication, however, and who requires it primarily to assist with focusing on school work, it may not be necessary at all over the summer. In my experience, this is more likely to be the case for children who have the inattentive symptoms only and who do not also have problems with hyperactive and impulsive behavior.

Please note that suggesting medication can be appropriate to use over the summer does not mean that other interventions to assist a child with peer relations and social behavior are not important. For example, at summer camp programs that are designed to provide specialized treatment to children with ADHD, well designed behavioral interventions and social skills training are important parts of the curriculum. Even so, many of the children who attend continue to receive medication so they can participate more effectively.

Just like during the school year, medication can play a useful role for some children as part of their overall treatment plan. If a child needs mediation to be successful in the many activities he or she participates in over the summer I do not think it should be withheld, even as other efforts are being made to help the child be more successful. As noted above, this is a very important issue to discuss with your child's doctor.
 

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