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ADHD RESEARCH UPDATE - Vol. 9, April, 1998
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In this issue...
 

Another look at sleep disturbances in children with ADHD

 

Difficulties with emotion recognition in children with ADHD

 

How effective is medication for preschoolers?

 

Similarities and Differences between ADHD subtypes

 

Behavioral reinforcement in children with ADHD

** Subscribers Questions **

- Hypnotherapy for ADHD? -

- Teens who refuse meds -
 

**SLEEP PROBLEMS AND ADHD**

After reviewing a study on the association between sleep difficulties and ADHD in the last issue of ADHD RESEARCH UPDATE, I became curious about prior research in this area. Recall that the study indicated that a significant percentage of children with ADHD had some form of sleep difficulty, and suggested that treating their sleep problem could also be an effective treatment for their ADHD symptoms.

It is important to note that a study like this merely establishes that a correlation may exist between sleep difficulties and ADHD, and documenting this correlation does not mean that sleep problems cause ADHD. It is just as likely that ADHD causes the sleep difficulties or that some other factor contributes both to the child's ADHD symptoms and to their sleep difficulties.

What I was interested in learning is whether any research has been done where treating the sleep difficulties of a child with ADHD was found to reduce their ADHD symptoms. I was surprised to find only two published case studies on this issue. The first was as far back as 1976 and appeared in the Journal of Behavior Therapy and Experimental Psychiatry. In this report, the insomnia of a 7 year old boy with ADHD was treated via behavioral therapy. The treatment was successful in eliminating the boy's insomnia and it was reported that significant reductions in hyperactivity were also obtained. These reductions were sustained over a 6 month period. The only other study I found appeared in the Journal of Pediatric Psychology (1991, Vol. 16). This was another case study in which behavioral interventions were used to treat insomnia in a 10 year old girl. Successful treatment of the girl's insomnia led to better peer interactions, and increased academic productivity at school. These gains were maintained over a 4 month follow up period.

Obviously, 2 case studies are not nearly sufficient to establish the efficacy of any form of treatment, and it is surprising to me that more research has not been conducted on this provocative topic. Until such work is done, no definitive statements about the efficacy of treating sleep difficulties as a treatment for ADHD can be made. Even so, work in this area highlights the importance of considering the role that sleep problems may play in a child's behavioral difficulties. This is an area that most mental health and medical professionals don't routinely inquire about, and it may be an important factor for at least some children with ADHD. Thus, even though the nature of sleep difficulties in children with ADHD is not yet clearly established, behavioral treatment of these difficulties may provide symptom relief for some children, and improve their relationships with peers and family members. If your child seems to have consistent difficulty getting a good nights sleep, this may be very important to take a careful look at.
 

**DIFFICULTIES WITH EMOTION RECOGNITION IN CHILDREN WITH ADHD**

It is well established that children with ADHD often have difficulty in their peer relationships. One reason for this is that the hyperactive/impulsive and/or spacey behavior that frustrates parents and teachers can also be alienating to peers. Children with ADHD can also have difficulty attending to, or accurately reading, social cues. This latter difficulty is the topic of an interesting study that appeared in the April 1998 issue of Behavior Modification.

The authors of this study were interested in testing how well children and adolescents with ADHD were able to identify the emotions conveyed by others. This is an important component of effective social functioning because consistently misreading others' emotions can lead to behavior that seems inappropriate. For example, a child who does not recognize that his friend feels sad would be unlikely to provide the kind of empathic and supportive response his friend might desire. Overtime, consistently misreading the friend's emotions could have important negative repercussions on the friendship.

In this study, 50 children and adolescents with ADHD were shown photographs of faces portraying a different basic emotion, and stories portraying those emotions were read to them. After each story, the subject was asked to point to the photograph that depicted the emotion described.

Compared to results that have been previously reported for children without ADHD, the subjects with ADHD were less accurate in identifying the correct emotion, suggesting that children with ADHD are less competent at identifying emotions in others. (It would have been better if a control group of children without ADHD was used in the current study, rather than just comparing the results of the subjects with those obtained from non ADHD children in earlier studies.) What are the clinical implications of these results? First, it is important to stress that not every child with ADHD would be expected to have this difficulty. Thus, the first step would be to think whether your child has difficulty reading others' emotions. If so, and if this sometimes results in inappropriate behavior, it may be a skill that you want to work on with your child.

There are several ways you could do this. You could start by simply talking about the different feelings people have, the things that make people feel different ways, and how to tell what another person is feeling. This kind of talking can increase a child's attention to, and knowledge of, people's emotions. Looking at books or magazines that have pictures of different people, talking about what the people might be feeling, and discussing how you can tell this may also enhance your child's skill at emotion recognition. It would be important to present this as a fun thing to do rather than as a remedial exercise, and this really can be a fun way to spend time with your child. Of course, if you think that your child has real difficulty in this area, than speaking directly with a mental health professional about ways to address this problem would also be recommended.
 

** HOW EFFECTIVE IS STIMULANT MEDICATION WITH PRESCHOOLERS? **

Although stimulant medication has been shown to reduce a child's ADHD symptoms in numerous studies, virtually all of this work has been conducted using school age children. Considerably less is known, therefore, about effectiveness of stimulant medication treatment for preschoolers.

A study that appeared in the October 1997 issue of the Journal of the American Academy of Child and Adolescent Psychiatry takes a careful look at this important question. In this study, 31 children with ADHD between the ages of 4 and 6 participated in a double blind placebo controlled study in which they received either a placebo or methylphenidate (i.e. the generic form of Ritalin) twice a day. In this double blind study, neither the child nor parents knew whether placebo or medication had been taken. Any improvements that were observed in children's functioning could thus be attributed to a real effect of the medication, and not to a placebo effect.

In both the placebo and medication conditions, children were given tests of attention and impulsivity, and parents were asked to completed standardized ratings of their child's behavior. As has been repeatedly demonstrated in studies with older children, medication produced improvements on cognitive tests of attention and impulsivity, as well as on certain behaviors assessed by the parent rating scales. An important exception to these generally positive findings, however, was that no improvements were observed in children's tendency to comply with parental requests. In other words, children's tendency to be defiant did not show substantial improvement.

The results of this study highlight both the benefits and limitations of stimulant medication treatment for ADHD. In regards to the former, the study provides good initial documentation that methylphenidate can play an important role in the management of primary ADHD symptoms (i.e. attention problems and impulsivity) for younger children.

These results also highlight the fact that for many children with ADHD, medication is only part of an overall treatment plan. Recall that children's tendency to comply with parental requests did not improve with medication. This difficulty would need to be targeted by other means, and specialized behavior management programs for children with ADHD have been developed and shown to be effective in increasing children's compliance.

If you are having difficulty managing your child's behavior it is VERY important to consult with a knowledgeable mental health professional to learn about the strategies that can make this easier. In addition to helping things go more smoothly in the present, this can be extremely important for preventing the development of more serious behavior problems down the road.
 

** SIMILARITIES AND DIFFERENCES BETWEEN ADHD SUBTYPES **

In the current diagnostic scheme for ADHD, 3 different subtypes have been identified. ADHD, Predominantly Inattentive Type is the diagnosis assigned to children who display multiple inattentive symptoms, but few hyperactive/impulsive symptoms. These are the children who used to be diagnosed as ADD without hyperactivity. Children who display multiple hyperactive/impulsive symptoms but few inattentive symptoms are classified as ADHD, Predominantly Hyperactive/Impulsive Type while those who show both sets of symptoms are diagnosed with ADHD, Combined Type. (For a complete list of diagnostic criteria for each subtype click here.

A study published in the February 1998 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (pages 185-292) takes a careful look at the similarities and differences between children with these different subtypes of ADHD. This is a very interesting article and here are some of the highlights:
 

The combined type group is the most common, occurring in 61% of identified cases compared to 30% for the inattentive type and 9% for the hyperactive impulsive type.

 

For each subtype, there was a significant time lag from when symptoms were first evident to when the child was referred for treatment. This ranged from 1.9 years for the hyperactive/impulsive type to 4.4 years for the inattentive type.

This is an extremely important and disturbing finding because it indicates that most children with ADHD do not receive any treatment for several years until after their symptoms were first apparent. As a result, both children - and parents - are struggling unnecessarily for an extended period before any professional help is obtained. I'm trying to figure out why this is the case - any ideas?
 

Children with the Combined Type had higher rates of behavior disorders (i.e. Conduct Disorder and Oppositional Defiant Disorder) than the other two subtypes. They also had higher rates of bipolar disorder. Even children who had the inattentive symptoms only, however, still had higher rates of these disorders than children without ADHD.

 

Children in the different groups did not differ in how often they were diagnosed with an anxiety disorder. Children with the Combined Type or Inattentive Type were more likely to be depressed than children with the Hyperactive/Impulsive subtype.

 

All three groups scored lower - on average - than non ADHD children on measures of intellectual , academic functioning, and social functioning. Children with different subtypes of ADHD did not differ from one another on any of these dimensions.

This study is valuable for several reasons. First, it provides validation for the current diagnostic system in which 3 different types of ADHD are listed. Because differences in children's functioning was related to which type of ADHD they had, the different diagnostic groupings actually reflect important differences between children and not just labels that don't relate to anything that really matters.

The study also highlights that children with the Combined Type diagnosis (i.e. those who show both inattentive and hyperactive/impulsive symptoms) are likely to be at greater risk for other psychiatric disorders (specifically conduct disorder, ODD, and bipolar disorder). Parents whose child has the combined type diagnosis need to be especially vigilant about these other kinds of difficulties. Speaking specifically with your child's physician and/or psychologist about ways to minimize the chances of these other conditions developing can be quite important.

I want to emphasize again that for children with ADHD, it is often the behavior disorders, emotional problems, academic struggles, and social difficulties that develop in response to difficulties caused by the primary ADHD symptoms that have the most negative long term impact on the child's development.

If your child is showing important struggles in any of these area, it is essential that these difficulties be specifically addressed in treatment. Although ADHD often contributes to the development of these problems, such problems are not the same thing as ADHD. I have seen many parents who believed that all their child's problems were part of their ADHD, and that since their child was already taking medication, nothing else could be done. This is definitely not the case. Making sure that such difficulties are specifically addressed in a child's treatment is one of the most important things parents can do to promote their child's healthy long term development.
 

** BEHAVIORAL REINFORCEMENT STRATEGIES FOR CHILDREN WITH ADHD **

The April 1998 issue of Behavior Modification (pages 143-166) includes an interesting article on the effectiveness of different reinforcement strategies for children with ADHD. The study provides very important data that can be used by parents and teachers to develop more effective behavioral interventions.

In this study, the authors investigated how two types of reinforcement strategies - partial reinforcement and continuous reinforcement - effected children's learning a list of spelling words. In the continuous reinforcement condition, children were reinforced (i.e. receive a desired reward) after each word that they spelled correctly. In the partial reinforcement condition, the rewards were administered on an intermittent basis rather than after each correct response.

Twenty-two children with ADHD and 20 children without ADHD participated in the study. During the spelling task, the authors monitored children's facial expressions to assess their frustration level, the number of words they learned to spell correctly, and their degree of persistence. This allowed the authors to determine whether the two types of reinforcement schedules - partial or continuous - had similar or different effects on the frustration, learning, and persistence of children with and without ADHD.

The results were clear cut: children with ADHD who received partial reinforcement displayed higher levels of frustration and lower levels of persistence than children in any other group (i.e. children with ADHD who received continuous reinforcement or children without ADHD who received either partial or continuous reinforcement.) For children without ADHD, the type of reinforcement did not have a significant impact on their performance. Although ADHD children spelled fewer words correctly than control children regardless of which reinforcement they received, those given partial reinforcement learned the fewest words of all.

What do these results imply for parents day to day efforts to effectively manage their child's behavior? The biggest implication, I think, is that these results underscore the need for children with ADHD to receive VERY frequent positive feedback in order to encourage and sustain good behavior. If you are trying to promote the development of a particular behavior in your child (e.g. complying with your requests) it is important that he or she receive some type of reinforcement virtually each and every time they comply. Providing reinforcement on a more intermittent or partial basis will not be as effective in promoting the behavior you are trying to develop.

This is one reason why it can be so difficult and frustrating for parents who are trying to teach their child appropriate behavior. Obviously, it is difficult and demanding to reward a child each and every time they do something right. For children without ADHD, this continuous reinforcement is not necessary (i.e. recall that they did just as well in the partial reinforcement condition as in the continuous reinforcement condition). For a child with ADHD, however, it really can be.

This is also why it is common for parents to feel that strategies which worked well with their other children do not work at all for their child with ADHD. This study demonstrates that the conditions under which children with ADHD learn most effectively are very different from the conditions required by other children.

For this reason, it is often very important for parents to learn the specialized child management strategies that are often helpful and necessary to promote better behavior in children with ADHD. Discussing this in detail is beyond what I can do in the newsletter, and consulting with an experienced child mental health professional to assist you in developing a behavioral plan that is targeted to your child's unique needs can be a tremendous benefit. This can be quite helpful in preventing the development of more serious behavioral difficulties down the road.
 

** QUESTIONS FROM SUBSCRIBERS **

"What do you know about hypnotherapy as a treatment for ADHD?"

I was unable to find any published studies on this topic, and have not heard of anyone in my area who uses hypnosis to treat ADHD. I would not expect this to be very effective and would certainly recommend treatments for which there is good empirical support before trying something like this.

Having said this, the important thing with any type of treatment, regardless of whether it has empirical support or not, is to be as vigilant as possible about evaluating it's effectiveness for your child. Just because stimulant medication is helpful for most children with ADHD does not mean it will be effective for your child. Conversely, just because dietary interventions do not seem to help most children with ADHD does not guarantee that your child will not benefit. So, if you are going to try something like hypnotherapy, make sure that you get good data about whether it is having any effect. Obviously, you will observe your child's behavior at home but you also need to get good feedback from the teacher.

You can use the ADHD Monitoring System that you received as a bonus with your subscription to do this. Just compare the ratings of your child's behavior and academic functioning at school before and after the treatment begins, and see if there is any real difference. Ideally, your child's teacher should not know that the treatment has been implemented so that the likelihood of his/her ratings being biased will be minimized.
 

"What can be done with an adolescent who refuses medication?"

This is a very tough issue and one that comes up fairly frequently. In my experience, one reason for this is that many children are never receive a good explanation about what it means to have ADHD and why they are taking medication in the first place. I have seen many children who have been taking medication regularly for years without really understanding why. In these instances, it is not surprising that a child would start refusing to take medication in adolescence.

One way to try and prevent this problem is to make sure that when your child begins medication, he or she understands why. Ask your child's physician to explain this to your child and get their advice/suggestions about how you can talk with your child about this. There are also many good books that have been written for children that explains what ADHD is and how medicine can help.

A very good book for older children and adolescents is called Distant Drums and Different Drummers - A Guide for Young People with ADHD by Dr. Barbara Ingersoll. Another good choice is I Would if I Could - A Teenagers Guide to ADHD/Hyperactivity by Dr. Michael Gordon For younger children, a very good book is Otto Learns About his Medicine All these books are available from ADD Warehouse in the Kids section.

If a teenager refuses to take medication, here is the approach that I take. First, I would really listen to what concerns the teen has about the medication. Trying to engage your son or daughter in a dialogue about their concerns so that you can more fully understand them is the first step. Inevitably, acquiring this understanding will be essential in helping decide how to best address this issue. If engaging your child in this dialogue is difficult, your child's physician may be able to help. If your child has been seeing a counselor, this person should also be able to help with this.

Something that can almost always be helpful to do is to try and engage your child in an "experiment" to see if he or she continues to need and benefit from the medication. There are two ways to do this. One way is to actually discontinue medication for a period of time - say several weeks or more. Before doing this, discuss with your child how you and he/she will judge the outcome of this "experiment". Be clear about what changes in your child's grades and behavior at school would indicate that the medication is still needed. If your child is able to maintain his or her performance at the expected level for this period without medication, then perhaps it is no longer required. If their grades and/or behavior decline, it would suggest that the medication needs to be resumed.

The problem with this approach is that an entire grading period can go down the drain as the results are being gathered. For this reason, I often try to arrange a shorter trial to see how helpful the medication continues to be. This trial covers a 3 week period during which I try to get the best feedback I can about the child's behavior and academic productivity at school . During the first week, the child is on medication as usual. During the second week , the medication is discontinued, and during the final week the medication is resumed. At the end of each week, the child's teachers are asked to complete ratings of the child's behavior and school work for the week. Similar ratings can be completed by the teen him or herself. Once again, the ADHD Monitoring Forms are a good choice to use for this.

Make sure your child understands that the value of the trial is to see whether the medicine is still helpful. I would present it like this: "Why don't we do a careful experiment to see whether the medicine is still being helpful to you? At the end of the experiment we can go over the results with your doctor. This will help all of us to decide whether it still makes sense for you to take medication or whether you may no longer need it." The important thing is to secure your child's cooperation with the proposed study. If this is not possible, than having your child talk with his/her physician or counselor about this is probably necessary.

Two important points. First, for this to be helpful, the teachers need to understand the importance of what they are being asked to do. Try to pick a couple of teachers who know your child well and whose cooperation you can count on. Because middle school and high school students typically only spend 50 minutes per day with each teacher, you really need a teacher who will observe your child carefully and fill out the forms conscientiously.

It is also best to do this kind of trial in such a way that your child does not know when he or she is not getting medication. If they simply stop taking their meds for one week, they may act differently at school simply because they know they are not on meds - certainly, their self ratings for this week could be biased.

The way around this problem is to have your pharmacist prepare identical capsules to be used during the trial. They do this by grinding up the medication and placing it in an opaque gel cap. For the non-medication week, your child receives identical capsules that are filled with an inert substance such as lactose. This way, your child does not know when they are getting medication and when they are not. (Note: You may need your physicians help in arranging this with the pharmacy.)

I know this seems like a lot of trouble but at the end of the trial you should have is some pretty objective data about the impact of medication for your child. In cases where medication is still needed, what you see is that the child received much better ratings for behavior and/or work during the medication weeks than during the placebo week. What if this is not the case and your child did as well during the placebo week as during the medication weeks? If so, then your child may be right - perhaps medication is not necessary.

The thing to do is to sit down and review the findings with your child. I'd suggest getting the physician involved here. If it looks like the medication was helpful, this may convince your child that they should continue to take it. Of course, this still may not happen, but then talking with your child about why they want to deny themselves something that really helps would need to be done, often with the assistance of a physician or psychologist. Trying to force medication on a teenager who simply does not want it is likely to create more problems than it solves. This is why the kind of experimentation described above in which your child is involved as a willing participant is preferred.
 

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