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ADHD RESEARCH UPDATE - Vol. 16, February 1999
**********************************************************In this issue.....
Is ADHD over diagnosed?
Peer tutoring can be an effective education intervention
Medication treatment for ADHD adolescents with Conduct Disorder and Substance Use Disorders
Injuries to children with ADHD
ADHD symptoms in adults
- Reader Question -"I read somewhere about a study that showed behavioral treatment was not as good as medication and that adding behavioral treatment did not improve on the results of medication alone. Does this means that behavioral approaches don't work and are a waste of time and money?"
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Licensed Psychologist
* Is ADHD over diagnosed?
It is quite common to hear reports in the popular media about how ADHD is over diagnosed and how many children are taking medications like Ritalin for no good reason. A study that was published in the November 1998 issue of the Journal of Developmental and Behavioral Pediatrics (pages 162-168), however, clearly suggests that such reports are greatly exaggerated.
In this study, teachers in grades K-5 in 10 different schools serving over 4000 children completed standardized behavior rating questionnaires on their students. The questionnaires asked for information about ADHD symptoms, academic and behavioral problems, emotional symptoms, and whether the child was known to be receiving stimulant medication.
In this study, the prevalence of ADHD was estimated based on the teachers' reports of DSM-IV symptoms of ADHD. This, of course, is only one facet of a diagnostic evaluation and can not be used by itself to establish a diagnosis for any child. (For the components of a thorough evaluation, please click here. Even so, the percentage of children who were reported to display a sufficient number of symptoms to possibly warrant an ADHD diagnosis was quite high - 16% of the total sample.
Of course, the presence of ADHD symptoms by themselves does not necessarily result in the diagnosis of ADHD. This is because it is also necessary to show that the symptoms reported are related to "clinically significant impairment" in the child's behavioral, social, or academic functioning. Even when this additional criteria was employed, 7% of the population were still classified as having ADHD. (As noted above, however, this would not be considered a sufficient evaluation but the results are still quite instructive.)
What was particularly striking is the extent to which many of these children, all of whom were identified by their teacher as having significant difficulty in school functioning because of ADHD symptoms, had never been identified. The authors report that about 66% of these children had never been diagnosed and about 75% had never received stimulant medication. Even though the diagnosis of ADHD would be ruled out for some of these children based on a thorough evaluation, it is clear that many children who should have been identified and received assistance were not getting any help.
The results of studies such as this clearly suggest that under diagnosis of ADHD, rather than over diagnosis, is the bigger problem facing children today. Although it is certainly true that some children who do not have ADHD are misdiagnosed, and that some children are put on medication who do not have ADHD, it would be more helpful if media reports focused on how many children with ADHD fail to get help because they are never properly identified. Although definitive conclusions can not be drawn from a single study such as this one, it may be the case that as many as 50% or more of children with ADHD are never properly diagnosed and treated. If so, this is a pretty significant public health problem that needs to be addressed.
* Peer tutoring can be an effective education intervention
It is widely believed that children with ADHD do better with instructional methods that help to involve them more actively in the learning task. A study published in the Winter issue of the Journal of Applied Behavior Analysis (pages 579-5920 provides evidence that peer tutoring is one such method that can be helpful for many ADHD students.
In this study, typical instructional methods were contrasted with Classroom Wide Peer Tutoring (i.e. CWPT) for 18 children with ADHD in grades 1-5. CWPT is an instructional approach that requires students to take turns in teaching new material to a peer classmate. In a typical peer tutoring procedure, all students in a classroom are randomly paired with another classmate. Each child takes turns being the "tutor" and "tutee". The tutor is provided with a "script" of academic materials (e.g. 10 math problems) that is related to the current instructional content in the classroom. The tutor dictates the items orally to the tutee who then responds orally with the answer. The tutee receives 2 points for each correct answer, and the tutor provides the correct response when errors are made and gives the tutee opportunity to practice the correct response. (Thus, this process lends itself to drilling of factual information such as math problems, spelling words, historical facts, etc.) The list is presented as many times as possible for a defined time period. At the end of this period, the tutor and tutee switch roles.
During the peer tutoring process, the teacher's role is to monitor the behavior of tutoring pairs throughout the classroom and to provide assistance as necessary. The teacher also awards bonus points to pairs that are using proper instructional procedures with each other and exhibiting good behavioral control. At the end of the peer tutoring session, the teacher records the number of points received by each pair, and a cumulative record of points earned is kept throughout the week. To increase students' motivation, the class is usually divided into separate teams with point totals tallied for each team.
Using a peer tutoring procedure like the one described above, 50% of children with ADHD showed improvements in academic performance in both math and spelling during the CWPT condition as compared to the regular instructional methods. Overall, CWPT led to increases in active engagement in academic tasks and reductions in off-task behavior for most participants - including children without ADHD as well. These results suggest that peer tutoring methods can be an effective strategy for addressing some of the academic and behavioral difficulties associated with ADHD for many students.
Proponents of CWPT argue that it allows for an efficient use of teacher's time by placing him or her in a supervisory and monitoring role rather than having to exert more intensive efforts with individual students. In addition, students and teachers typically report a high level of satisfaction with this procedure. CWPT can be used for a variety of academic subjects and successful programs for both elementary and secondary school students have been developed. For a child with ADHD, it may also eliminate some of the "social stigma" that might be experienced if a teacher mediated behavioral program is administered on an individual basis.
It is also worth thinking about how the basis procedure used in CWPT could be modified for use at home to assist your child with homework. There is really no reason why you could not set up a situation where a parent and child are the "tutor" and "tutee" pair. The same framework as outlined above could be used with both parent and child earning points for correct answers and proper behavior. These points can be exchanged for a predefined "reward" at the end of the week - this could be a joint reward (e.g. a special outing that you and your child take together) or separate rewards for each of you.
I have actually recommended this procedure to parents and children that I have worked with and have had some good results. When implemented properly, it can turn some aspects of homework from ongoing power struggles to collaborative efforts that both parent and child enjoy. This is certainly not a solution for all the homework problems a child may be having, but it can definitely be a useful approach for parents to know about and to try out.
* Medication treatment for ADHD adolescents with Conduct Disorder and Substance Use Disorders
As has been discussed in several previous issues of ADHD RESEARCH UPDATE, adolescents with ADHD are more likely than other adolescents to also be diagnosed with Conduct Disorder (CD) and to abuse illicit substances. The need to develop effective treatments for such adolescents are particularly important, but there have been very few studies regarding pharmacological treatment of ADHD in such youths. A study that appeared in the December 1998 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (pages 1271-1278) provides preliminary information about a potentially effective medication for these teens.
In this study, 13 non depressed adolescents boys who had been diagnosed with ADHD, CD, and SUD (i.e. substance use disorder) were treated over a 5 week period with bupropion. Patients' doses were gradually raised over this period to a maximum daily dose of 300 mg. This was an open-trial meaning that placebo controlled, double blind procedures were not used.
Ratings of patients hyperactivity, inattention, and a global severity of illness were taken prior to initiating the treatment with bupropion and at the conclusion of the 5 week trial. Ratings of subjects' hyperactivity declined by 13%, inattention ratings declined by 10%, and global severity ratings declined by 39%. Declines in all these measures were statistically significant.
Although these are preliminary results, they suggest that bupropion may be an effective treatment for ADHD symptoms in adolescents who are also manifesting serious behavioral disturbance. Clearly, these results indicate that a controlled trial with a larger sample of such patients is warranted. In the meantime, bupropion should be considered as a possible pharmacological treatment for teens with this combination of difficulties who have not responded positively to other agents. It should be stressed, of course, that medication alone is unlikely to be a sufficient treatment for adolescents who are exhibiting these multiple problems. It may, however, be a very helpful component of an overall treatment approach.
* Injuries to children with ADHD
Parents of children with ADHD often express their concern about the accidents and injuries sustained by their child. The combination of inattention, hyperactivity, and impulsivity makes it quite difficulty for many ADHD children to "look before they leap" and the result may be an excessive tendency to hurt and injure themselves. A study published in the December 1998 issue of the journal Pediatrics (pages 1415-1421) indicates that the concerns of many parents are well founded.
The goal of this simple but important study was to determine where differences exist in the injuries sustained by children with and without ADHD who were admitted to a hospital as a result of their injury. Thus, this study did not examine whether children with ADHD were more likely to sustain serious injuries than other children. Instead, it looked at differences in the types of injuries that children with ADHD are likely to sustain.
Compared to children without ADHD, children with ADHD were more likely to be injured as pedestrians (28% vs. 18%) or bicyclists (17% vs. 14%). They were more likely to sustain injury to multiple body regions (57% vs. 43%), to sustain head injuries (53% vs. 41%), and to be severely injured (13% vs. 5%). In addition, they were more likely to be admitted to an intensive care unit as a result of their injury (37% vs. 24%). These comparisons are based on large numbers of children who were treated at more than 70 hospitals, so it is likely that the results are quite representative of the general population of children with and without ADHD.
Overall, the authors conclude that children with ADHD are more likely than other children to sustain severe injuries. They also point to the need to develop injury prevention efforts that are specifically targeted to children with ADHD. In the meantime, parents probably should be especially vigilant about emphasizing safety precautions for their children with ADHD. For example, setting up an incentive/reward system to encourage such important precautions as wearing a helmet for such activities as bicycle riding and roller blading would be worth considering.
* ADHD in girls
An important limitation in the research literature on ADHD is that the vast majority of studies have been conducted using boys as the subjects. As a result, considerably less has been documented about ADHD in girls, and whether any significant differences exist in how ADHD appears in girls versus boys. The effects of medication treatment on girls specifically has also not been studied nearly as extensively.
An article that appears in the January 1999 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (pages 40-47) address this important gap in the literature by specifically comparing girls and boys who have been diagnosed with ADHD. Forty-two girls and 56 boys meeting DSM-IV diagnostic criteria for ADHD, Combined Type were compared on a number of different measures to determine whether there are any important differences in ADHD related to gender.
For the most part, boys and girls with ADHD were remarkably similar. The only differences reported were that boys tended to display symptoms at a slightly earlier age than girls (2.8 years vs. 3.6 years), and to have greater problems with hyperactivity. Girls, on the other hand, were rated by their parents - but not by their teachers - as showing more difficulties with attention. Girls with ADHD also scored lower on a standardized test of reading achievement.
The authors also examined whether the parents and siblings of girls and boys with ADHD differed in any important ways. There were no differences found in the likelihood of any psychiatric diagnosis - including ADHD - in parents. Mothers of girls with ADHD, however, were more likely than mothers of boys to report elevated levels of ADHD symptoms when they were children (62% vs. 31%). In addition, a significantly higher percentage of siblings of girls with ADHD were identified as having definite or probably ADHD compared with siblings of boys (50% vs. 16%). This was true regardless of whether the sibling was male or female.
The second portion of this study involved a placebo-controlled double blind study of medication effectiveness in girls with ADHD. This is an important contribution because almost all the published research on medication treatment of ADHD has been conducted with boys. Both methylphenidate (the generic version of Ritalin) and dextroamphetamine (the generic form of Dexedrine) were compared to a placebo. The results of this trial are both interesting and instructive.
At the end of each week, overall ratings of "improvement" were completed for each child based on information obtained from both parents and teachers. During the placebo week, 16% of the girls were rated as either "much improved" or "very much improved". Sixty-nine % of girls were rated as showing similar levels of improvement on both methylphenidate and dextroamphetamine- . In addition, 9 out of 10 girls who did not improve on one stimulant showed good improvement on the other. Thus, the response either stimulant was a full 97% for the girls in this sample. In other words, almost every girl was rated as either much improved or very much improved on one or both of the medications used.
There are several aspects of this portion of the study that are instructive. First, the results appear to clearly indicate that stimulant medication is as effective for girls with ADHD as it is for boys. Second, the results highlight the importance of conducting placebo controlled trials to evaluate a child's response to medication. Recall that 16% of girls were rated as "much improved" or "very much improved" while on placebo alone. This is not an insignificant percentage and highlights how it is only by comparing a child's behavior and school work during medication and placebo weeks that the true benefits of medication can be ascertained.
Finally, it is very important to note that while only 69% of girls showed a positive response to the first medication prescribed, almost all girls responded positively to one of the two medications tested. This highlights the importance of trying different medications if the first one tried is not helpful, or if the response is not as substantial as hoped for. In many cases - 9 out of 10 in this study - a second medication can result in a very positive effect. Too many times, I think, parents who may be ambivalent about medication in the first place get discouraged if the first type prescribed fails to provide a significant benefit. As a result, a child who might derive substantial and needed benefits from another medication is not tried on something else.
By the way, it is worth noting that these same types of issues applies to side effects. It is not uncommon for children who are receiving placebo to develop apparent "side effects". This means that some children who appear to be having side effects to medication, may be showing nothing more than this type of placebo reaction. This can also result in parents and/or physicians stopping the medication when it is not really necessary. Thus, it is hard to tell a real side effect from a placebo effect unless children are observed on both medication and placebo as well. It is also true that when the side effects really are an adverse response to the drug, a different medication may yield excellent results without the side effects. These are important points to consider.
* ADHD symptoms in adultsIt has only been relatively recently that research attention has focused on ADHD in adults. In large part, this may be due to the fact that it had long been believed that ADHD was something that children invariably "outgrew" during adolescence, and that the disorder rarely persisted into adulthood. As it has become increasingly clear that this is not true for many individuals with ADHD, researchers have begun studying ADHD in adults, and how the disorder in adults may be both similar and dissimilar to how it appears in children.
A study published in the October 97 issue of the Journal of Attention Disorders provides information about the types of ADHD symptoms that are most prevalent in adults with ADHD. (This is a relatively new and very interesting journal that is entirely devoted to studies on ADHD. You can learn more about this journal by visiting it's web site).
Participants in this study were 149 adults who had been previously diagnosed with ADHD using structured diagnostic interviews. These interviews were used both to assess the presence of ADHD symptoms in adulthood, and were also used retrospectively to assess the presence of the identical symptoms in these adults when they were children.
The authors were interested in learning how frequently the different symptoms of ADHD occurred in a group of adults with this disorder. In addition, they were interested in trying to learn about changes in the frequency of different symptoms and symptom groups (i.e. inattentive vs. hyperactive) that may have occurred over time. This was done by comparing the symptoms reported by participants as adults with what they reported as being present during childhood. (Note that this study was done prior to the publication of DSM-IV, so the symptoms assessed were those used in the prior diagnostic criteria. The current diagnostic criteria - are not identical to the prior version but there is a lot of overlap.)
The results were quite interesting. What was striking to me was that in this sample of adults with ADHD, all of the inattentive symptoms were as prevalent, or more prevalent, than all of the hyperactive/impulsive symptoms. For example, at least 70% of this group indicated the presence of each inattentive symptom, and several of the inattentive symptoms were reported by more than 90% of the sample. The proportion of adults reporting the hyperactive symptoms, in contrast, ranged from a high of 70% to a low of 35%. The 3 most prevalent inattentive symptoms were "difficulty following directions", "difficulty sustaining attention", and "frequently shifting activities". For the hyperactive symptoms, the 3 most frequently reported were fidgeting, interrupting others, and speaking out of turn.
The reports of individual symptoms from both childhood and adulthood were also used to identify the participants as having ADHD Combined Type (both inattentive and hyperactive/impulsive symptoms), ADHD Predominantly Inattentive Type (inattentive symptoms only) and ADHD Hyperactive/Impulsive Type (hyperactive/ impulsive symptoms only). These classifications were made based on what was reported for childhood and what was reported for adulthood. Comparing the childhood subtypes to the current adult subtypes, 14% of ADHD adults had an increase in the inattentive subtype and 19& had a decrease in the Combined subtype. The latter was primarily because in these individuals too few hyperactive symptoms were reported to still qualify for the combined subtype diagnosis.
What are the implications of these results? First, the data seem to clearly suggest that in adults, it is problems with attention that are generally a more prominent part of the ADHD picture. Difficulties with remember things, keeping track of appointments, and planning/organizational skills are likely to be especially problematic. Although such difficulties can create significant problems for an individual, they are still more subtle and difficult to detect than the hyperactive/impulsive behavior of a younger ADHD child. As a result, it is likely that adults with ADHD who were not previously diagnosed as children will continue to go undiagnosed and untreated. Perhaps even more so than with children, the problems experienced by an adult with ADHD will be attributed by others to laziness, not caring, and lack of motivation.
Second, for parents of children with ADHD, it is important to be aware that in many cases, as your child grows older his or her symptoms of ADHD will become less obvious and dramatic. Eventually, almost everyone starts to slow down a bit and become less impulsive - even the most overactive "act now think later" youngster. Sometimes, this can result in the erroneous belief that the child is "no longer ADHD" when, in fact, what has occurred is simply the diminishing of more overt symptoms that often occurs with age. If this results in the cessation of necessary treatment and special assistance at school, it is a real shame.
Of course, for a large percentage of children with ADHD, symptoms do diminish to the point where they no longer create significant impairment and the diagnosis no longer applies. The important point, however, which is highlighted by this study, is that the way that ADHD manifests itself often changes with development and maturity. Being vigilant to how your child's symptoms may be changing over time, and how they may be interacting with new developmental challenges, can help you to better understand how to assist and support your child throughout their transition into adolescence and young adulthood.
- Reader Question -
"I read somewhere about a study that showed behavioral treatment was not as good as medication and that adding behavioral treatment did not improve on the results of medication alone. Does this means that behavioral approaches don't work and are a waste of time and money?"
This is a really good and important question. The study you are referring to is the largest and most extensive treatment study of ADHD ever conducted. It is sponsored by the NIMH (i.e. National Institute of Mental Health) and involves 576 children being treated at four different research sites across the county. The major goal of this study was to compare and contrast 3 different treatment approaches: state of the art medication treatment alone; state of the art behavioral treatment alone; and combined medication and behavioral treatment. Children were assigned to one of these 3 groups and the effects of the different types of treatment have been studied over about a 14 month period. In addition, a comparable group of children who were treated by community practitioners were also followed.
Let me first say that the results of this study have not yet been published. They have been presented at a recent psychiatric meeting, and the reports in the media have been based, I assume, on this presentation. Actual published results, however, are not yet available for close scrutiny.
With that important caveat in mind, the general description of the results that I have seen indicates that medication alone was superior to behavioral treatment alone, and was not appreciably different from the combination of medication and behavioral treatment. (Please keep in mind that these general conclusions are not the same thing as being able to carefully examine published results that have been through the editorial review process). In other words, extensive behavioral treatment was found to be less helpful than carefully prescribed medication, and did not add significantly to the beneficial effects produced by medication alone. It is also interesting - and very important - to note that children who received medication as part of the study were doing much better than children who received their medication from community physicians. This is probably because children in the study were followed much more closely than is typical, and changes/adjustments to medication were made whenever difficulties began to emerge. In addition, children in the study were receiving 3 doses per day, 7 days per week which is also different from what is typically done.
Now, if these general conclusions are accurate, does this mean that behavioral treatments are unnecessary and a waste of time/money? I think the answer to this is it depends. It is important to recognize that studies like this compare the effect of different treatments on groups of children. If one children in one group did better overall than children in another group, this does not mean, however, that every child in one group did better than every child in the other.
For example, it is easy to imagine that there was a child in the combined treatment group who did not have an extremely positive response to the medication. For this child, the additional behavioral treatments may have made a very big difference. For children who showed a very positive response to carefully prescribed medication, however, which would be the vast majority, the behavioral treatments would not be expected to make much of a difference. After all, if medication alone eliminates the vast majority of a child's difficulty, what else is left for behavioral treatments to address?
Here is what I think is a reasonable way to think about these preliminary results, which others may certainly disagree with. If the published reports really do support the summaries that have been floating around, it would suggest that a reasonable approach to treatment would be to start by finding the optimal medication and dose for each individual child, making sure that no problematic adverse reactions are produced. The child needs to be followed carefully and regularly, with frequent feedback obtained from teachers and parents about the ongoing functioning of the child at home, at school, and with peers. If everything is going well, and there are no indications of difficulty in any of these areas, than adding anything to the medication treatment may not be necessary. If problems with behavior, school work, peer relationships, etc. are apparent, however, even if the medication is helping in important ways, than developing and implementing adjunctive treatments that specifically target these residual difficulties should be pursued. The key thing is to monitor how your child is doing on an ongoing basis, and make sure that if difficulties emerge treatment adjustments are made to address these problems. For, many children, I believe that treatment approaches besides medication will continue to be an important part of their overall management.
Let me say that I am really looking forward to seeing the published papers that come out of this study, and anticipate that there will be much to be learned here beyond the general summaries that have been available so far. I will certainly include reviews of these papers as they become available.
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David Rabiner, PhD
Licensed Psychologist
Copyright 1999 David Rabiner, PhD and ADHD RESEARCH UPDATE
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