****************************************************************
ADHD RESEARCH UPDATE - Vol. 22 August, 1999
****************************************************************In this issue...
* Announcements
- Next on-line discussion for subscribers scheduled for August 12th
- Referral Program
- Individual consultation
* Articles
* Is stimulant medication over prescribed?
* A comparison of Adderall and methylphenidate in treating children
with ADHD* A promising model for school-based behavioral treatment
* ADHD, Central Auditory Processing Disorder, and Learning Disabilities
* Reader Questions *
"Our child was diagnosed with ADHD this summer. My husband does
not want to tell his teacher because he is concerned that our son
will be stigmatized if we do. What do you suggest?""I read that there is no good evidence that Ritalin produces
long-tern gains for children with ADHD. If this is true, than
why should I have my child take it.?"
_______________________________________________________________________* ANNOUNCEMENTS *
NEXT ON-LINE DISCUSSION GROUP FOR SUBSCRIBERS
The next on-line discussion will be held on Thursday, August 12th
at 9:00 PM EST. For instructions about participating in the
discussion, just send an e-mail to discussion@www.helpforadd.com
and the directions will be sent to you automatically. I hope
that you will be able to participate.REFERRAL PROGRAM
I just wanted to remind you that if you refer someone who subscribes
to ADHD RESEARCH UPDATE I will extend your own subscription by 4
months in appreciation.If you have already referred someone, you should have received a
note from me thanking you and letting you know that I have extended
your subscription.If you have not received such a note, please let me know. Sometimes
people forget to indicate who referred them. Just give me the name
of the friend or colleague that you referred.INDIVIDUAL CONSULTATION
I continue to provide a short-term focused consultation services to parents
looking for suggestions about how to best help their child. To learn more
about this service, and whether it may be appropriate for your own
situation, click here.* IS STIMULANT MEDICATION OVER PRESCRIBED?
One of the frequent concerns raised by individuals and groups who oppose the
use of stimulant medication for treating children with ADHD is that such medications
are grossly over prescribed. In fact, some data about the use of such medications
is potentially consistent with this concern. For example, recent data indicates that
the number of methylphenidate prescriptions for adolescents increased by over
250% between 1990 and 1995. Does such an increase reflect the misuse and
overuse of stimulant medications, or does it reflect that more children who
need the assistance that medication can provide are now receiving it?This important question was addressed in a recently published study
(Jensen, et.al. (1999). Are stimulants over prescribed? Treatment of ADHD in four
U.S. Communities. Journal of the American Academy of Child and Adolescent
Psychiatry, 38, 797-803). In this study, the authors used epidemiological methods
to estimate the prevalence of ADHD among 1285 9 to 17 year-old children residing
in 4 different communities. They also gathered information on the frequency with
which stimulant medications were prescribed to children in these communities, as
well as the other types of services that children with ADHD were receiving.In this study, ADHD was diagnosed based on structured diagnostic interviews
that were administered to both a child's parent(s) and the child him or herself.
Unfortunately, it was not possible to obtain information from children's teachers.
Teachers, of course, are an important source of information in the evaluation process,
and the absence of this information is a regrettable limitation of the study.In any case, the rates of ADHD were found to vary widely across the 4 communities,
ranging from a low of 1.6 % for a community in San Juan, Puerto Rico, to a high
of 9.4% for Atlanta, Georgia. The average prevalence rate across the 4 communities
(the other 3 were Westchester, NY, and New Haven, CT) was 5.8%. Whether
the discrepancy in apparent rates of ADHD in the different communities reflects true
differences in the rate of the disorder, or different cultural thresholds about what
constitutes acceptable vs. deviant behavior is unclear.What is clear, however, is that despite widespread concerns about the overprescription
of stimulant medications, many children who have ADHD are receiving no such
treatment. In fact, in this epidemiological derived sample, only 12% of children who
were diagnosed with ADHD were being treated with stimulants. This means that fewer
than 1 out of 8 children with ADHD who comprised a representative sample from 4
diverse communities were receiving such treatment. In addition, only 1.4% of
children who did not meet diagnostic criteria for ADHD were being treated with stimulants
at the time of the study, and these children all showed high levels of ADHD symptoms
even though they did not meet full diagnostic criteria.These data are certainly not consistent with the notion that stimulant medications are being
widely over prescribed. In fact, if anything, they argue for the exact opposite conclusion.
Here is another concerning aspect of the medication data. Children with ADHD who were
being treated with stimulants were showing virtually the same level of ADHD symptoms as
those children with ADHD who were not being treated. In other words, there was no
indication in the report of parents and children that the medication was producing any
observable positive effects on children's symptoms.These data should not be interpreted as indicating that stimulants don't work. There is
simply an abundance of well-designed studies which clearly indicate that they do. Instead,
I think these data again underscore the sad truth that medication is frequently not prescribed
in the careful and systematic way that is required to produce the maximum possible
benefits for each child. Stimulant medication has been shown repeatedly to result in
dramatic reductions in ADHD symptoms are related behaviors when it is prescribed
carefully and monitored properly. In actual community settings, however, this is often
not done, and, in the absence of careful procedures, the expected benefit is often
not attained.What about the other types of treatments that children with ADHD were receiving?
About 1/3 were receiving some type of psychosocial treatment (i.e. behavioral
treatment or some form of therapy). Less than 25% were receiving any type of
of special services at school. It is discouraging to note fewer than half of parents
who felt their child needed services at school reported that their child was receiving
any such services. In addition, under 40% who believed they needed assistance in
learning how to manage their child's behavior were receiving any help in this area.
In contrast, when parents believed their child need medication, they were able to
obtain this for their child over 85% of the time. Thus, it appears that medication is
the easiest type of assistance for parents to obtain for their child with ADHD.
Although medication treatment may be relatively easy for parents to obtain for
their child, as noted above, it is not easy for parents to find a physician who will
provide such treatment in a careful, thorough, and systematic manner.
School services, help with behavior management, and counseling for their child
are all more difficult for parents to arrange.This is an important study. Although any study such as this should be replicated
so that confidence in the conclusions one draws are strengthened, these data
clearly argue against the belief that stimulant medications are widely over prescribed.
It appears that the vast majority of children with ADHD are not receiving any such
treatment, and for those that are, this treatment is often done in a way that fails
to provide the greatest possible benefit. Although other interventions (i.e. behavioral
treatment and school-based services) may actually be provided more frequently to
children with ADHD, most parents who feel their child needs such service are
unable to obtain it. These are generally discouraging conclusions. Hopefully,
studies such as these will eventually result in improvements in the services that
are readily available for children with ADHD and their families.(For an introduction to the educational rights for children with ADHD, click
here.)* A COMPARISON OF ADDERALL AND METHYLPHENIDATE FOR
TREATING CHILDREN WITH ADHDIn a prior issue of ADHD RESEARCH UPDATE , I reported on a study that
compared the effectiveness of Adderall and Ritalin in the treatment of ADHD.
This study suggested that Adderall may be a more effective
medication for the majority of children with ADHD, although it was noted that
this would certainly not be true for all children with ADHD and that, in addition,
replication of these results was required. (Click here to view this article). Recently,
another study was published that suggests another potential advantage of Adderall for t
reating ADHD (Handen, B.L., et al.; (1999). Differential effectiveness of methylphenidate
and Adderall in school-age youths with attention deficit/ hyperactivity disorder.
Journal of the American Academy of Child and Adolescent Psychiatry, 38, 813-819.)In this study, 42 children with ADHD between the ages of 5 and 17 were treated with
Adderall - a relatively new stimulant medication for treating ADHD - and a matched
group of 42 children were treated with methylphenidate (i.e. MPH - the generic version
of Ritalin). All children in the study were evaluated using a 4-week, double-blind
placebo-controlled procedure. In each group, 19 children were diagnosed with ADHD,
Predominantly Inattentive Type (i.e. they displayed the inattentive symptoms only)
and 23 were diagnosed with ADHD, Combined Type (i.e. they displayed both inattentive
and hyperactive/impulsive symptoms).Three different doses of each medication were used (i.e. 5 mg, 10 mg, and 15 mg)
and these were administered in a random order such that children could receive
either the low dose or the moderate dose first, but would not receive the high dose
as their initial dose. In addition to these 3 medication weeks, there was also a
4th week of the trial during which children received a placebo. For children
receiving MPH, the medication was administered twice per day - at 8:00 AM
and again at noon during the school day. Children receiving Adderall were
given the medication in the morning only. At the end of each week of the
trial, parents and teachers completed ratings of children's ADHD symptoms and
other behavioral problems exhibited during that week using standardized behavior
rating scales. Ratings of possible side effects were also completed.At the end of the study, a judgment about the best dose for each child was made
based on the combination of parent ratings, teacher ratings, and clinical observation
by the child's primary clinician - either a child psychologist or a child psychiatrist.
In addition, a direct comparison between the effectiveness of one dose per day of
Adderall vs. 2 doses per day of MPH was made. A summary of the important findings
is presented below.* The average daily best dose for MPH was 19.5 mg/day; for Adderall, the average
daily best dose was 10.6 mg/day.These data provide evidence suggesting that Adderall is substantially more potent
than an equivalent dose of MPH . (Note: I do not think it can be definitely concluded
that a similar result would be found if Ritalin - the non-generic form of MPH - were
used instead, although I believe it is quite likely.)* For both MPH and Adderall, both parents and teachers rated children's behavior as
significantly better on the child's best medication dose than on placebo.As has been demonstrated in numerous carefully controlled studies, stimulant medication
was shown to produce clinically significant improvement in children's behavior. It
is interesting to contrast these findings with those reported in the study above, where no
significant differences in ADHD symptoms were found for children treated with
medication by community physicians compared to children with ADHD who were not
receiving medication treatment.This again underscores the important of using a careful and systematic procedure to
determine a child's response to medication and to identify the optimal dose for a particular
child.* There were no significant differences between children treated with MPH and children
treated with Adderall.What this means, of course, is that children who received a single dose of Adderall before
school did as well as children who received 2 doses per day of MPH - one before school
and one during the school day.It is also important to note that 15 of the children in the Adderall sample were individuals
who had either not responded to prior treatment with MPH, or who were not able to
tolerate MPH because of adverse side effects. This suggests that Adderall may actually
be a superior medication for a number of children with ADHD.* There were no significant differences in side effects between children treated with MPH
and children treated with Adderall.In addition, side effects reported by parents and teachers did not differ for the best
medication dose and the placebo week. In other words, side effects were no more
likely to be observed when children were on medication as when they were on a placebo.Limitations and Clinical Implications
Every study has limitations and this study is no exception. Perhaps the most important
limitation is the absence of objective outcome data related to children's academic
performance. In addition, children's physicians made the initial decision about which
medication to prescribe, meaning that children could not be randomly assigned to
receive one medication or the other. It seems unlikely, however, that this would have
significantly influenced the results.The most important implication of these results, I think, is that they indicate that once-
a-day dosing with Adderall is likely to be as effective as twice-a-day dosing with
MPH. (This assumes, of course, that a careful trial has been conducted to determine
the optimal dose of these medications for an individual child.) In other words, children
are likely to get the same benefits with a lower daily dose and without having to
take medication at school. As noted above, I think it is likely that similar results would
have been obtained if Ritalin had been used because the vast majority of children treated
with Ritalin require 2-3 doses per day, but this can not be concluded with absolute
certainty.The latter can be especially important for several reasons. It is certainly not uncommon
for children to be embarrassed about taking medication at school, and depending on
how this issue is handled at school, it can become a fairly significant problem. In fact,
I have worked with a number of children who simply refused to take medication for
this reason. It is also not uncommon - at least in my experience - for a child to forget
to go to the office for his or her afternoon dose and for the teacher to forget to make
sure that this happens.If either of these are issues for your own child, than discussing a trial of Adderall
with your child's physician may be worth considering. Remember, there is no
guarantee that the results obtained in this study would occur for your child.
A careful evaluation of Adderall's effectiveness - including whether a single dose in the
morning was sufficient - would need to be made. Just switching to Adderall in the
belief that it will be better for your child - without using a careful procedure
to determine if this is in fact the case - is definitely not recommended.If you are a physician, these data should be given careful consideration in
deciding on the initial medication that you prescribe for your patients with ADHD.
Based on the studies that have recently been published, evidence is accumulating to
suggest that Adderall is a good initial option for children with ADHD. Adderall
appears to be at least as effective as MPH and it may yield comparable benefits
with fewer daily doses.* A PROMISING MODEL FOR SCHOOL-BASED BEHAVIORAL TREATMENT
For many children with ADHD, behavioral treatment will be an important part
of their overall treatment plan. Effective behavioral treatment at school, particularly
for children who do not respond to medication, or who continue to have problems
despite obtaining some benefits from medication (or alternative treatments), can
play an enormously important role in promoting a child's long-term success.What is involved in setting up an effective school-based behavioral intervention
for children with ADHD? A recently published paper describing a program
developed by Dr. James Swanson at the University of California at Irvine describes
one promising approach (Kotkin, R. (1998). The Irvine paraprofessional program:
Promising practice for serving students with ADHD. Journal of Learning Disabilities, 31,
556-564.) Although this program may be more intensive than what can be easily
implemented in many public school settings, it provides an excellent model to emulate,
and offers a good idea of what effective behavioral treatment may need to include.The program is designed to serve students with ADHD in grades K-6 and has
these primary components:1. Training paraprofessionals to work directly with ADHD children in the
classroom an to serve as instructional aides under teacher supervision;2. Consultation by the school psychologist with teachers about developing
and implementing the behavioral plan with each child. These school psychologists
have received specialized training about how to provide this consultation effectively;3. Implementing a behavioral point system in the classroom by the paraprofessional
aide and the child's teacher;4. Twice-weekly skills training sessions with students;
5. Follow-up with the child's next year teacher.
The backbone of this approach is a very intensive and systematic point system that is
implemented in the child's classroom by the trained paraprofessional. In designing
this program for each child, the school psychologist, paraprofessional, and teacher
first decide on the specific behaviors that will be targeted on the child's "daily
report card". These "target" behaviors are determined based on direct observation
of the child's behavior and the completion of standardized ratings scales. The goal
is to identify those specific behavioral that are most problematic for the individual
child, and which most-strongly compromise the child's ability to succeed.This careful attention to identifying the specific behaviors that are most problematic
for the child being treated, and documenting the pretreatment (i.e. baseline) severity
of those behaviors should be a part of any child's behavioral treatment. There is
no "one size fits all" approach that can or should be used.Before treatment is initiated, the child is informed about the specific behaviors that
are being targeted (e.g. not talking out of turn, completing assigned work, etc.). It is
explained to the child that he/she can earn points for demonstrating the desired
behaviors (or refraining from the undesired ones) and that these points can be used
to obtained different kinds of rewards.When treatment is first initiated, the child receives feedback about each target
behavior EVERY 15 MINUTES. Thus, every 15 minutes the child is informed
about whether he or she earned points for the behavior (up to 4) on their daily
report card. In addition to earning points, the child is prompted or praised
verbally a predesignated number of times during each 15-minute interval. This
feedback is provided by the trained paraprofessional as it is not realistic to
expect the classroom teacher to provide this level of feedback. When the
paraprofessional is not in the classroom, similar feedback is provided by the
classroom teacher at 60-minute intervals, which is a more reasonable schedule
for teachers to adhere to.This very-frequent feedback, which includes a combination of something tangible
(i.e. points on the report card) and intangible (i.e. attention and verbal praise),
is another key element of effective behavioral treatment for elementary school
children with ADHD. Less-frequent feedback is unlikely to be as effective in
shaping the child to engage in more of the desired behaviors.Daily points earned on the report card are turned in for reinforcement during
the last 20 minutes of the school day. The school principal assigns a staff
member to design, implement, and maintain a daily reinforcement program to
be used with targeted children as part of the behavior management program.
Children bring their report cards to the "reinforcement center" and exchange
their points for the opportunity to participate in a 20-minute activity of
their choice. The number of points required to earn each different activity
would, of course, have been worked out in advance.The opportunity to earn short-term rewards for meeting behavioral expectations
is another hallmark of behavioral treatment for children with ADHD. The
short-term time horizon helps to maintain children's motivation to succeed and
will be much more effective than requiring a long interval (e.g. a week) before
the reward can be earned.As noted above, this is how the program begins. It would clearly not be
possible, however, to maintain this level of treatment over an entire school
year. For this reason, the Irvine program employs a "level system" that
children move through as they experience success. These levels are as
follows:Level 1 - The child receives feedback and points every 15 minutes from
the paraprofessional as well as verbal prompts and social reinforcement
(i.e. praise) for each targeted behavior during each interval. When the
paraprofessional is not available, teachers provide this feedback on
a 45-60 minute schedule.When the child has earned an average of 90% of possible daily points over
a 10-day period, they move up to level 2.Level 2 - Feedback and points are provided every 30 minutes as are
verbal prompts and social reinforcement. The child also begins to set
goals for each interval (e.g. "I think I can finish 2 pages of math, work
quietly, and get along with other kids") and attempts to match the para-
professional's evaluation when the feedback for that interval is given.
In addition, as permitted, the child gets to mark his or her points on the
report card while the paraprofessional supervises. The child returns to
Level 1 if fewer than 75% of possible points are earned on average over
a 10-day period. When over 90% of possible points are earned over
this period, the child advances to Level 3.Several important behavioral treatment principles are illustrated here.
First, as success is experienced, an effort is made to gradually "fade"
the frequency with which feedback is provided. The goal is to gradually
reduce the child's dependence on external feedback. Second, efforts
are made to have the child set behavioral goals and to monitor his or
her own behavior. This represents an effort to have the child begin
to carefully attend to his/her own behavior and its consequences.
Finally, careful records are kept (i.e. the daily report card) of the
child's success - there are actual points than can be counted up
rather than relying on a more general impression of how things
are going. If treatment is not going well, an alteration is made
(i.e. the return to level 1). If it is going well, new requirement are
made on the child (i.e. the move to level 3).It is also important to note that the target behaviors may not be the
same ones as they were at level 1. The goal is to focus on the behaviors
that one is trying to promote, and these may change over time. As
during level 1, points continue to be exchanged for rewards at the
end of the day. This would be an ongoing part of the program and
apply to the levels listed below as well.Level 3 - The frequency of feedback is increased to every 45 minutes and
the feedback is now routinely provided by both the paraprofessional
and the classroom teacher. The child continues to be required to set
clear behavioral goals for each interval, and to provide ratings of his
or her own behavior that match those of the paraprofessional. If fewer
than 75% of possible points are earned over a 10-day period, the child
drops back to level 2. When over 90% of points are earned over this
interval, the child moves to the "challenge" level.Increasing the time interval continues in an effort to reduce the child's
reliance on external feedback. The teacher becomes more directly
involved in providing feedback so that the paraprofessional can be
a less important part of the program in preparation for the teacher
taking over. Continued attention is placed on goal setting and
monitoring one's behavior.Challenge level - This is identical to level 3 except that feedback is
now provided at 60-minute intervals. If fewer than 75% of possible
points are earned over a 5-day period, the child returns to level 3.
When 90% of points are earned over a 5-day period, the program moves
to the "transition level".Transition level - At this level, the teacher alone is responsible for
implementing the program. The teacher alone provides feedback about
points earned or not earned, and does so at 90-minute intervals, a realistic
schedule to adhere to.Ideally, movement to the transition level would occur during a 12-week
period. At this point, the paraprofessional is removed from the classroom
(unless there is another child to implement the program with). Next, the
child's treatment plan would be modified as needed in consultation with the
school psychologist. The teacher and school psychologist would
meet with the child's new teacher at the start of a new year in order to
help adapt the plan to the new teacher's classroom program.Over time, the goal has been to bring the child's behavior under sufficient
control so that the regular classroom teacher alone can fully manage it
by him or herself. Note that specific feedback continues to be provided
to the child, as it is not reasonable to expect that such feedback could be
completely eliminated for the vast majority of children with ADHD. Also
note that careful attention is paid to providing some continuity in how
teachers are dealing with the child from year to year.
The program described above has been shown to produce significant
behavioral improvements in children with ADHD in several evaluation
studies. It is my understanding that this program served as the model for
the school-based behavioral intervention that was implemented in the large
NIMH multi-site treatment study of ADHD.There is little doubt that a well-designed program like this one would be
helpful to the vast majority of students with ADHD. Even so, however, it
is important to remember that current evidence suggests that well-executed
medication treatment is likely to be more effective for most children with
ADHD. For children who do not respond to medication, who refuse to take
medication, or who continue to display important behavioral problems even
if medication is helpful, however, a program such as this can be very, very
important.As noted at the beginning of this article, the vast majority of school systems
do not have a program such as this available to students. This is unfortunate
because this program can be implemented in a cost-effective way and make
an important difference for children, parents, and teachers.Even if your child's school does not have such a program, however, the general
principals on which this program is based can be used to guide the development
and implementation of behavioral interventions for any child with ADHD. I hope
this summary was helpful in delineating those principles, and in providing an
overview of a very promising model for helping children with ADHD to
succeed at school.* ADHD, CENTRAL AUDITORY PROCESSING DISORDER, AND LEARNING
DISABILITIESIn recent years, several researchers have suggested that there is considerable
overlap between ADHD and Central Auditory Processing Disorder (CAPD).
In fact, some have questioned whether CAPD and ADHD are really
distinct disorders, or have suggested that children diagnosed with ADHD
often have CAPD instead. A recently published study takes a careful look at
this issue (Gomez, R., & Condon, M. (1999). Central auditory processing ability
in children with ADHD with and without learning disabilities. Journal of Learning
Disabilities, 32, 150-158.Since many people are unfamiliar with CAPD (at least I was until relatively
recently), I'll begin with a brief overview of what this condition actually is.
CAPD is defined as a deficiency in one or more of the following processes:
sound localization and lateralization (i.e. being able to determine where
sounds are coming from), auditory discrimination (i.e. being able to detect
differences between sounds), auditory pattern recognition (i.e. being able
to correctly identify/recognize patterns of sounds), temporal aspects of
audition (i.e. being able to identify the ordering of different sounds), and
auditory performance decrements in the presence of competing sounds
(i.e. being able to screen out extraneous auditory stimuli to correctly
identify important sounds).Deficits in one or more of these areas are believed to adversely affect an
individual's speech and language functioning. Thus, someone with CAPD
may have unusual difficulty being able to accurately process spoken language,
particularly in the presence of background noise, and thus have a difficult time
comprehending what is being said. One can certainly see how such a problem
would make it difficult for a child sitting in a crowded and noisy classroom, and
how this child might display symptoms of inattention and hyperactivity
as a result. This is why some professionals, professional speech and language
specialists, suggests that CAPD may often be misdiagnosed as ADHD. (Note
that it is certainly been shown than speech and language problems are
more common in children with ADHD.) Prior studies have shown that
children with ADHD tend to perform poorly on central auditory processing
tasks and that as many as 50% of children diagnosed with CAPD also have
ADHD.The authors of this study were interested in examining what might account for
the considerable overlap between ADHD and CAPD, and hypothesized that
the common link may be learning disabilities (LD). Children with ADHD and
children with CAPD both have significantly higher rates of LD than is found
in the general population. Although learning disabilities are defined in several
different ways, a commonly used procedure for identifying a child as LD is
to determine the discrepancy between the child's IQ score and achievement
test scores using standardized IQ and achievement tests. When a child is
achievement at a level that is significantly below what the child should be
capable of based on their intellectual level, the child is considered to have
a learning disability (i.e. the learning disability is what is hypothesized to
prevent the child from achieving at the level he/she should be capable of).
Learning disabilities can occur in a number of areas including basic reading
skills, reading comprehension, math, and written language. A child may have a
LD in one area but not others, or may have multiple learning disabilities.In the study, the authors began with 3 groups of 15 school-age children. One
group was comprised of children with ADHD alone; a second group included
children with ADHD with a learning disability in reading; the third group
was made up of children without either diagnosis. The ration of boys to girls
in each group was about 3:1. (Note: It would have been nice if they included
a fourth group comprised of children diagnosed with CAPD but not ADHD,
and a final group of children with both CAPD and LD as this would have
allowed for a more complete set of comparisons).Each child was given several different tests of central auditory processing
ability. These included being required to completed words that were
presented with portions missing; an auditory discrimination task in which
participants were asked to repeat words that are presented with background
noise; a dichotic listening tasks in which different words are presented in
each ear, and participants have to repeat both words in a specified order;
and an auditory conceptualization task in which children had to discriminate
different speech sounds (e.g. the sound of /p/ from the sound of /b/,) and to
perceive and compare the number and order of sounds within a pattern. All
these tasks are elements of determining whether an individual child has
CAPD. All testing was done individually, and care was taken to be sure
that children with ADHD had not received any medication for at least 48
hours prior to testing.The results were really quite clear-cut. Based on a composite score derived
from the different auditory processing tests, children with ADHD alone did
not differ from the control group. Children with both ADHD and LD, however,
scored significantly lower than both control children, and children with ADHD.
This clearly suggests that problems in central auditory processing ability
are associated with LD and not ADHD. It is also provides strong evidence
that ADHD and CAPD are truly different disorders, rather than being slightly
different expressions of the same basic disorder.Now, even though these results suggest that ADHD and CAPD are distinct
conditions, it is still quite possible that some children with CAPD are
misdiagnosed as having ADHD. If this were to occur, it seems less likely
that proper treatment would be unlikely to be instituted, although there is
some data to indicate that stimulant medication is helpful to children with
CAPD. These results also suggest that children with ADHD who are also
learning disabled in reading may be especially likely to have CAPD. For
such children, a careful evaluation of this possibility may prove to be
quite helpful in developing the most effective treatment plan.- Reader Questions -
"Our child was diagnosed with ADHD this summer. My husband does
not want to tell his teacher because he is concerned that our son
will be stigmatized if we do. What do you suggest?"A number of parents that I have worked with have expressed this
type of concern. Unfortunately, it is certainly true that this
can happen. A teacher can expect to have difficulty with a child
who has ADHD, and perhaps not give the child a fair chance as a
result.All I can say is that in my experience, this is the exception
rather than the rule, and most teachers I have dealt with have
tried very hard to help their students who have ADHD.Children with ADHD most often do require extra attention and
certain accommodations to help them be successful in the classroom,
and this will not happen unless the teacher is aware of the
child's situation. Also, the educational rights that children
with ADHD are legally entitled to
(see http://www.helpforadd.com/educational-rights/) require that the child
be officially identified with ADHD by the school system. Otherwise,
the schools can not develop a 504 plan or, perhaps, and Individual
Education Plan (IEP) that can help address the child's educational
needs.So, I have always advised parents that in order for their child
to get the services that may be needed to help them succeed, there
is no choice but to have the child identified by the school as
having ADHD. If your child is able to be successful at school
without any such extra assistance or educational accommodations,
than this may not be necessary. When this is not the case, as
is true for most students with ADHD, I believe that the potential
benefits of having the child identified outweigh the possible
risks that your husband is concerned about."I read that there is no good evidence that Ritalin produces
long-tern gains for children with ADHD. If this is true, than
why should I have my child take it.?"This is another excellent and important question. I believe
you are probably referring to studies in which children with
ADHD have been followed from childhood into adulthood. In general,
these studies have not indicated that children who were treated
with medication had any better outcomes than children who were
not. This had led many to question whether there really are
any long term benefits to be gained from medication treatment
of ADHD. So, if there are no documented long-term benefits, than
why initiate such treatment in the first place.In beginning to address this question, it is important to note that
there have been several recent studies that do indicate long-term
gains from medication treatment. Now, these studies have not yet
followed children into young adulthood and beyond. Instead, children
have been followed for between 1 and two years, and it seems that
the gains associated with medication have been maintained over this
length of time. Whether these gains will be sustained over a longer
time period, and result in meaningful improvements in long-term
outcomes, still remains to be seen.I also think that the absence of long-term treatment benefits that
have been reported are not that surprising. As has been discussed
many times in ADHD RESEARCH UPDATE, the way that medication is
typically prescribed and monitored is so careless and haphazard
that the absence of long-term benefits is easy to understand.
Children are often not maintained on the right medication or dose
for them, and often stop taking their medication after a relatively
short period of time. How good meaningful long-term improvements
be expected from this?Here is how I think about it. It is clear that when a careful trial
is done to establish the optimum dose for a child, and the child
is carefully monitored to evaluate the ongoing effects of medication,
than the vast majority of children with ADHD experience meaningful
and sustained reductions in their symptoms. As long as these reductions
in symptoms persist, the child will be doing better than he or she
would otherwise be doing. If this goes on over a period of years,
it is difficult to imagine that the child will not be better off than
if his/her symptoms were significantly interfering with their
behavior and school work over this period.I believe that as children who are being carefully treated with
medication are followed over increasingly longer periods, that we
will begin to see evidence of even longer-term benefits derived
from medication treatment. Of course, until this data is actually
produced, we can not be certain that this will be the case. So,
the best any parent or health care provider can do is to make
sure that the child's symptoms are being managed as effectively
as possible on a day-to-day basis.For many children, currently available data indicates that medication
treatment is the best way to do this. This is not true for every child, however,
so finding what is best for each individual child is the key thing to focus on.That's all for this month...
I hope you enjoyed this issue of ADHD RESEARCH UPDATE and found it
to be useful to you.As always, please feel free to share information from this newsletter
with others you know who may benefit from it. If someone you know
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please suggest that they get in touch with me about subscribing.
I can be reached at addhelp@mindspring.com.If you manage an ADHD related site on the internet, or are part of
a group or organization devoted to helping people with ADHD, I would
be delighted for you to select an article from this issue to post
on your site or to distribute to your group's members in whatever
way works best. Please let people know the article came from
ADHD RESEARCH UPDATE, and that they can learn more about the
newsletter at http://www.helpforadd.com.I hope you are doing well.
David Rabiner, PhD
Licensed Psychologistcopyright 1999 David Rabiner and ADHD RESEARCH UPDATE