In this issue....

* Can ADHD be prevented by early intervention?

* Is it safe to use stimulant medication for children with
  chronic tics?

* Combining medication treatment and behavior modification
  for children with ADHD and Oppositional Defiant Disorder

* Magnesium supplementation as a treatment for ADHD

-READER QUESTION -

"My son is finishing up the 4th grade and had by far his most
difficult year ever.  Does that mean his ADHD is getting worse?
What should we do?"
 

* CAN ADHD BE PREVENTED BY EARLY INTERVENTION?

Almost all of the work I have seen in helping children with ADHD
focuses on providing effective treatment after the disorder has
been diagnosed.  Studies on the possible prevention of ADHD, in
contrast, are few and far between.  Is it possible that early
intervention in children showing signs of being at risk for the development of
ADHD could prevent the development of the condition
when they are older?  This is an extremely interesting and important
question.

A study that appeared in Israeli Journal of Psychiatry and Related
Science provides an interesting initial look at this question
(Rappaport, G.C., Ornoy, A., & Tenenbaum, A. (1998). Is early
intervention effective in preventing ADHD? Israeli Journal of
Psychiatry and Related Science, 35, 271-279).  The authors of
this study note that ADHD is usually not diagnosed until after
a child begins school, even though evidence of ADHD symptoms
is often present at a much earlier age.  Clinicians are often
reluctant to diagnose ADHD in preschool age children - and
rightly so, in my opinion - because of the difficulty involved
in differentiating between normal and deviant behavior in
children this young.

On the other hand, some studies have shown a significant continuity
of ADHD symptoms from a very early age.  Thus, one research has
reported that 33% of children who were hyperactive at age 3 were
diagnosed as having ADHD at age 11.  The authors of the current study
had found in prior work that among 2-4 year old children who showed
signs of inattention, hyperactivity, and speech delay, approximately
80% were diagnosed as having ADHD upon reaching school age.  Based
on these earlier results, the authors reasoned that such symptoms in
young children might serve as early signs of ADHD, and wondered
whether early intervention by non-pharmacologic methods might
be effective in reducing the number of children showing these early
signs who go on to develop ADHD.

In this study, the authors identified 77 children between the ages of
2-4.5 who were showing problems with inattention, and who showed
evidence of speech and/or motor delay.  All of the children identified
were offered treatment, which consisted of occupational therapy and
speech therapy.  These treatments were individually administered at
least once a week over a period of at least 6 months.  The authors
hypothesized that improving children's speech and motor functioning
would also enhance their attention and concentration abilities, and
that this would reduce the incidence of ADHD in those children
receiving treatment.  About 60% of parents elected to provide
their children with the recommended treatment while about
40% did not.

Children were followed up an average of 5.5 years later when
they were 8-10 years old.  Fifty-one of the original 77 children
were able to be contacted, and a comprehensive evaluation of
ADHD was performed at this time.  Of the children who were
evaluated  for ADHD, 31 had received the early speech and
occupational therapy evaluation and 20 had not.  Did the rates
of ADHD differ in these two groups?

Of the 21 children who had not received the early intervention,
10 (48%) were diagnosed with ADHD at the follow up assessment.
(These follow up evaluations were done by examiners who were
not aware of whether or not the child had received prior treatment.)
In contrast, only 33% of children who had received the early
Intervention were diagnosed with ADHD at this time.  These
results are in the expected direction, but were not statistically
significant.  This means that differences of this magnitude could
have occurred by chance reasons alone.

When looking at children according to whether or not there was a
family history of ADHD, however, the results are more striking.
Every child who was from a family where another member had ADHD
and who did not  receive the intervention, was diagnosed with ADHD
at follow up.  In contrast, only 37% of children who had the same
family history but who received the early intervention developed
ADHD.  The differences between these rates was statistically
significant, meaning that they were unlikely to reflect chance
factors alone. When there was not any family history of ADHD,
whether or not a child received early intervention services was not
related to whether or not he/she developed ADHD.

These results need to be considered cautiously, as they were
obtained with a small sample of children and certainly require
replication with a larger sample.  Even so, I think they are quite intriguing.
What they suggest is that for children who are showing
early signs of ADHD, and who have a family member who has this
disorder,  early intervention may be effective in reducing the odds
of their developing ADHD later on. Perhaps other types of intervention,
or similar interventions applied for a longer  time, might prove
similarly helpful for children showing early signs of ADHD but do
not have a positive family history.

In terms of the practical application of these results, I think the
most important message is that when a young child is showing signs of
difficulty, efforts should be made to determine the best ways to
address that difficulty.  I have been involved in many situations
where a parent felt certain that their child was not developing in
ways that they felt comfortable with, but were told that the child
was too young to diagnose and would probably just grow out of the
trouble.

Although I agree that diagnosing a 2 year-old with ADHD is not
appropriate, that does not mean that treatment/assistance should not
be provided to a child that age who is showing problems in their
development.  The important thing, I think, is to provide a young
child with the assistance he or she may need to help get their
development back on a healthy trajectory.  When the difficulties
really are interfering with their developing the skills and abilities
they need, then waiting until they "outgrow" them, or not providing
any assistance because they are too young to diagnose with ADHD, does
not seem like a particularly helpful position to take.
 

* IS IT SAFE TO USE STIMULANT MEDICATION IN CHILDREN
  WITH CHRONIC TICS?

An ongoing controversy in the use to stimulant medication treatment
is whether it is safe to use in children with ADHD who also have
chronic and multiple tics.  Many physicians continue to be reluctant
or unwilling to prescribe medication like Ritalin to such children
because of the concern that it will make the child's tics worse, and
that this exacerbation may not reverse even if the medication is discontinued.

A recent study from the Archives of General Psychiatry provides
the most comprehensive look to date at this important question
(Gadow, K.D., Sverd, J., Sprakin, J.C., Nolan, E.E.,  & Grossman, S. (1990).
Long-term Methylpenidate therapy in children with comorbid
ADHD and chronic Multiple tic disorder. Archives of General Psychiatry, 56,
330-336).  In this study, 34 pre-pubertal children (31 boys and 3 girls) diagnosed
with ADHD and either chronic multiple tic disorder or Tourette Disorder were
treated with stimulant medication over a 2 year period, and carefully evaluated
every 6 months.  The dose they received during this time was determined by the
results of an initial placebo controlled trial in which several different doses were
tested, and the most effective dose for each child was selected.

Every 6 months a comprehensive re-evaluation to assess ADHD symptoms,
tic severity, medication side effects, and other behavioral and
emotional difficulties was conducted.  This included data collection
via standardized behavior rating scales completed by parents along
with direct observation of the child in a simulated classroom
environment while the child was receiving medication.

Over the entire 2 year period, there was absolutely no indication
that ongoing treatment with methylphenidate (i.e. the generic form
of Ritalin) results in the exacerbation of either motor tics of vocal tics.
There was one child for whom this had been thought to be true,
but when a careful analysis of the severity of the child's tic during
a placebo condition and medication condition was conducted, the
resulting data did not support this conclusion.

The authors did find that over the 2 year period, there was
considerable fluctuation in the frequency and severity of tics
in children who were receiving the maintenance medication therapy.
This suggests that in children with chronic tic disorder or
Tourettes, spontaneous exacerbation of tics are a natural occurrence,
and this may explain many of the reports of stimulant induced tic exacerbation
in children with ADHD and tic disorder.

The authors are very careful to point out that just because there was
no evidence that methylphenidate increases tics in this group of
children with ADHD and a tic disorder, that just not mean that this
can not occur in individual cases.  One would still want to be careful about
this possibility.  The important implication of this research, however, is
that there is no reason to rule out stimulant medication treatment for a
child who may benefit from it because of  the fear that it will cause a
possible irreversible increase in tics.

There are several other results from this study that are important to note.
First, the gains that resulted from medication treatment during
the initial 8 week titration trial were maintained over the course of
the 2 years.  This was especially true for the observations made of children
during the simulated classroom observation sessions.  In addition to sustained
reduction in ADHD symptoms, improvements in oppositional behavior were
also sustained over the 2 year period.  These results are important in that they
provide additional evidence for the persistent benefits that are associated with
well administered and carefully monitored medication treatment.

A final issue the investigators looked at was the presence of any
adverse drug reactions over the 2 year study.  Parent ratings of medication
side effects did not show any significant increase
compared to ratings provided during the initial placebo trial over
the entire study.  At the end of 2 years of treatment there were small changes
in blood pressure compared to the initial placebo
trial, an average increase in heart rate of about 10 beats per minute.
I am not a physician and am thus unable to comment on the significance of this,
but according to the authors, who are physicians,  this is not considered to be
clinically significant.  On average, children showed slightly reduced gains in weight
and height than would have been expected (.72 kg and .67 cm less than expected).
Once again, the authors believe that such modest reductions would be of marginal
concern for most children.

Overall, therefore, the results of this study indicate that treatment with stimulant
medication should not be automatically ruled out for children with ADHD and a
co-occurring tic disorder.  Although an exacerbation of tics in such children may
occur on an individual basis, and should be monitored carefully, apparently this is
not a common occurrence.  The results also provide additional evidence that stimulant
medication treatment - when administered properly - is associated with clinically
meaningful improvement in children's functioning over a sustained
period of time.
 

* COMBINING MEDICATION TREATMENT AND BEHAVIOR MODIFICATION
   FOR CHILDREN WITH ADHD AND OPPOSITIONAL DEFIANT DISORDER

Children with ADHD often develop other behavioral disorders such as Oppositional
Defiant Disorder (ODD) or Conduct Disorder (CD), and such conditions are associated
with more negative long-term outcomes.   Learning about the most effective ways to
treat children who show these types of behavior disorders in addition to ADHD is thus an
extremely important task for parents, clinicians, and researchers.
A recent study appearing in the Journal of the American Academy of
Child and Adolescent Psychiatry (Kolko, D. J., Bukstein, M.D., and
Bafron, J. (1999). Methylphenidate and behavior modification in
children with ADHD and comorbid ODD or CD: Main and incremental
effects across settings. Journal of American Academy of Child and Adolescent
Psychiatry, 38, 578-585) provides interesting and important data on this issue.

Before getting in to the specifics of this study, let me briefly
review the symptoms of ODD and CD.  Listed below are DSM-IV symptoms
for ODD:

1. often loses temper;
2. often argues with adults;
3. often actively defies or refuses to comply with adult requests or rules;
4. often deliberately annoys people;
5. often blames others for mistakes or misbehavior;
6. is often touchy or easily annoyed by others;
7. is often angry and resentful;
8. is often spiteful and vindictive;

For ODD to be an appropriate diagnosis, at least 4 of the symptoms
listed above must be present for at least 6 months; the behavior must occur
more frequently than is typical for a child of comparable age,
and the behavior must create significant impairment in a child's
social or academic functioning.  In addition, the oppositional
behavior can not occur only during times when a child is depressed.

An important difference that you will note from the symptoms of ADHD
is that none of the ADHD symptoms involve behavior that is considered
to be deliberate and willful. Thus, although children with ADHD often
engage in behavior that annoy others and fail to follow through on requests,
such behavior is not deliberately and willfully initiated.

Conduct Disorder (CD) is a more severe form of behavioral disturbance.
According to DSM-IV,  the publication of the American Psychiatric Association
that provides current diagnostic criteria for all recognized psychiatric disorders,
the essential feature of CD is "...a repetitive
and persistent pattern of behavior in which the basic rights of others
or age-appropriate social norms or rules are violated." These
behaviors fall into 4 main groupings:

* Aggressive behavior that causes or threatens to cause harm;

  Examples: initiating fights; cruelty to people or animals;

* Non aggressive conduct that causes property loss or damage;

  Examples: fire setting with intent to cause damage; deliberate
  destruction of property;

* Deceitfulness or theft;

  Examples: shoplifting; breaking into someone's house; frequent
  lying to obtain goods or avoid obligations;

* Serious violation of rules;

  Examples: truancy from school; running away from home; staying out
  at night prior to age 13;

For the diagnosis of CD to be correctly assigned, at least 3 of the
specific symptoms must have occurred during the prior 12 months,
with at least one criterion present in the last 6 months. In addition, the
disturbance in behavior must clearly result in clinically significantly
impairment in the child or teen's social, academic, or occupational
functioning. These criterion are intended to assure that the diagnosis is
not assigned for an isolated antisocial act, but is instead reserved for
youth who show a pattern of antisocial behavior over a significant period
of time.

It is very important to recognize that the symptoms of ODD and
CD are quite different from those of ADHD.  When one of these
disorders is present in addition to ADHD (note that if
a child meets diagnostic criteria for both ODD and CD, which is
almost always true for children with CD, only the CD diagnosis is
assigned because it is the more severe condition), making sure that
this is a clear target of treatment is critical.  I mention this
because I have seen many instances where parents whose child had
one of these conditions in addition to ADHD was not aware of this,
and was not pursuing anything other than medication treatment for the primary
ADHD symptoms.

Now back to the study.  In this investigation, 16 children with ADHD
and one of these other behavior disorders completed a randomized
placebo-controlled study examining the separate and combined effects
of 2 dose of methylphenidate (i.e. MPH, the generic form of Ritalin)
during a partial hospitalization program.   During the study, which
took place over a 6 week period, children received two administrations
daily of either a placebo, or a low or higher dose of methylphenidate.
In addition, every other week a comprehensive behavioral treatment was
added to the mix.  Thus, over the 6 week study, children were observed
both with and without behavioral treatment in place, and with and
without medication.

To make things a bit more complicated, separate observations were
made when children were in a classroom environment
and a non-academic environment.  Children were rated on a variety of
dimensions including ADHD symptoms, oppositional behavior, peer
conflicts, overt aggression, and positive mood. By comparing ratings
of children's behavior both with and without medication, and with and
without behavioral treatment, the researchers were able to examine
both the individual and combined effects of these 2 treatment
approaches.

As one might expect from a complicated study like this, the results
are not entirely straight forward.   Basically, the authors were
able to look at whether medication and behavior modification - when
administered without the other treatment present - produced gains
in each outcome area, and, whether the addition of either treatment
to the other resulted in any incremental benefits.  This breaks down
into 4 different questions:

1. Does medication alone produce gains?
2. Does behavior modification alone produce gains?
3. Does adding behavior modification to medication treatment result
   in greater benefits than medication alone?
4. Does adding medication to behavior modification treatment result
   in greater benefits than behavioral treatment alone?

In some ways, it is the last two questions that are most interesting.
I will try to summarize the major findings below as I understand them:

1. In the classroom environment, medication alone was associated with
reductions in ADHD symptoms, and improvements in mood and positive
behavior.  In the non-classroom setting, medication was found to
improve ADHD symptoms, oppositional behavior, peer conflicts,
and mood.

2. In the classroom environment, behavioral treatment alone was
associated with reductions in ADHD symptoms, oppositional behavior,
and peer conflicts, and an increased in positive mood ratings.  In
the non-classroom setting, behavioral treatment resulted in significant
improvement only for oppositional behavior.

3. Behavioral treatment did not add significantly to the gains produced
by medication alone for any of the outcomes studied.  When added to behavioral
treatment, however, medication had significant incremental effects (i.e. children
did better than they were doing with behavioral treatment alone) on several of
the outcomes.

4. When examining the outcomes for individual children, it was evident that for
some outcomes in some settings, some children did better
with the combination of medication and behavioral treatment than they
did with either treatment alone.
 

In sifting through the results of this study, there are several general conclusions that
are worth highlighting.

First, the results indicate that both medication and behavioral
treatment can be effective for children with ADHD and co-occurring behavior
disorders.  Although this may vary somewhat between the two approaches in
different settings, some improvement in primary ADHD symptoms, and in
oppositional behavior and peer relations can be expected.

Second, it seems more likely that medication will add to the gains produced
by behavioral treatment than the reverse.  Nonetheless, the latter clearly
does occur for some children.

Third, and I think this is especially important, the complexity of
these results indicate that questions like "Is medication an
effective treatment for ADHD?" or "Is behavioral treatment
effective for ADHD?" are in some ways too general to help develop
the most effective treatment for an individual child.

At a broad level, the answer to such questions is "Yes".  But, what studies
such as this highlight is that the effect of any treatment can vary depending
on what outcome you are looking at (e.g. academics vs. oppositional behavior)
and what setting you are examining that outcome in (e.g. classroom vs. home).
This means that what is most effective for a child in terms of one outcome or
setting may not be as helpful in alleviating problems in a different area or setting.
Thus, you may find that medication helps a child's academic work at school but
does not result in meaningful behavioral improvements at home.  Or, you may
find that behavioral treatment enhances a child's behavior with adults but does
not produce similar gains with peers.

Developing the most effective treatment for an individual child thus
requires carefully evaluating how the child is doing in different
domains (e.g. academics, behavior, peer relations, mood) and in
different social contexts (e.g. classroom, home, peer group).
One should not assume that just because a particular treatment such
as medication is producing important benefits in one domain and
setting, that this will necessarily translate into gains in all
domains in settings.  If it does not, than the task becomes one
of determining what needs to be done to try and achieve similar
gains in these other domains and settings.

Although this may seem complicated, but it really doesn't need to be.
As long as you are observant to how your child is functioning in the different
important areas of his or her life, you will get a picture
of how some things are going better than others.  If you identify
areas that continue to be problematic, even if other things
have gotten much better with treatments that have already been
initiated, you would want to speak with your child's health care
provider about ways to try and address the difficulties that you
still observe.  This type of vigilance and effort should really
pay off in the long run.
 

* MAGNESIUM SUPPLEMENTATION AS A TREATMENT FOR ADHD

I recently received an advertisement touting magnesium supplements
as an effective treatment for ADHD.  The person sending me the
ad indicated that this treatment was supported by scientific
research.  Because of the interest that I, and so many people
have in alternative ADHD treatments, I decided to see what I
could find on this.

Based on my search of the literature, I would say that the
scientific support for this treatment is a bit thin.  I was
able to locate one study in which magnesium supplements for ADHD was
investigated  (Kozielec, T., & Starobrat-Hermelin, B. (1997).
Assessment of Magnesium levels in children with ADHD. Magnesium
Research, 10, 143-148).  The study was conducted by scientists
in Poland, where it is interesting to note that stimulant medications
for treating ADHD are not available.  (By the way, this is apparently
the case in a number of European countries.)

These researchers examined hair, red cell, and serum magnesium
levels in 116 children diagnosed with ADHD and found that 95%
were deficient in magnesium.  (Note that there was no control
group - these children were judged to be deficient based on normative
data that was used in comparison.)  Fifty of these children were
assigned to a 6 month trial of magnesium supplementation (200 mg/day)
in addition to their usual treatment and 30 children were assigned
to receive the typical treatment without magnesium.  (It is interesting
to note that because stimulants are not available in Poland, the
typical medications children are treated with are drugs that would
hardly ever be used in the US.)  At the end of the trial, the
children whose treatment included magnesium supplements showed
significant reductions in parent and teacher ratings of ADHD symptoms
compared to the children who had not received the supplements.

This type of data suggests that magnesium supplementation may be
a useful approach in children with ADHD who are confirmed to be
deficient in magnesium to begin with.  What percentage of the ADHD
population this is is unknown.  In addition, it must be noted that
the study conducted here would be considered an "open" trial rather
than a placebo-controlled double-blind trial.  In other words,
everyone knew who was receiving the magnesium supplements and who
was not.  This certainly has the potential to effect the ratings
of outcome that parents and teachers provided.  The next step, of
course, would be to try and replicate these findings using a
randomized, placebo-controlled double blind trial.  Until such a
study is conducted, there would not really be a convincing scientific
basis on which to recommend such a treatment.  One would also need
to be careful about providing extra magnesium to children who are
not deficient in magnesium to begin with, because there is some
evidence from animal studies that this could have an adverse effect.

I'll be looking for follow-up studies to this interesting work and
will let you know about it if such studies are published.
 

-READER QUESTION -

"My son is finishing up the 4th grade and had by far his most
difficult year ever.  Does that mean his ADHD is getting worse?
What should we do?"

There can be a variety of reasons why a child's ADHD symptoms can
seem to become more severe, or to create more difficulty for the
child.  One possibility, that occurs with some frequency, is that
as children move into higher grades, and the academic demands
become more rigorous, the difficulties created by ADHD symptoms
become more pronounced.  For instance, when the amount of assigned
homework becomes greater, it just becomes that much more difficult
for a child to get through.  Also, the demands for organizational
and planning skills are greater in later grades, and this also is
an area of difficulty for most children with ADHD.  Thus, a child's
symptoms may not be getting "worse" in an absolute sense.  Instead,
it is often just that the demands on the child are increasing so it
looks like the symptoms are suddenly worse.

Several other possibilities should also be considered.  First, some
teachers are simply better at working with children with ADHD than
others.  It is possible that the teacher your child had this year
was not as effective in working with him as were his previous
teachers.  This does not mean that he/she is not a good teacher, of
course, just that he/she may not have worked as well with your son.
It is always a good idea to try and learn which teachers work
most effectively with children who present the types of challenges
that a child with ADHD does, and to then put in a request for that
particular teacher.

Another possibility is that the increase in difficulties this year
occurred for other reasons besides ADHD.  It is possible that your
child developed other types of behavioral difficulties, or that
there were emotional issues (e.g. stress, anxiety) that made this
year a more difficult one.  Remember, just as there are multiple
factors that can have an adverse impact on the school performance
of children without ADHD, the same is true for a child with ADHD.

As far as planning for next year goes, an essential first step is
to try and figure out what factor(s) were most responsible for the
increase in problems this year.  In most cases, I would really
recommend consulting with a good child psychologist to help you
to sort things through.  What is most appropriate to help deal with
the increased problems will depend on what the likely "causes" are.
Potential solutions could include one or more of the following:

* getting your child placed next year with a teacher who will be
  the best match for his needs;

* developing or modifying a behavior plan to encourage better
  performance at school;

* adjusting the dose of medication your child is receiving or
  perhaps even trying a different medication;

* addressing any other emotional/behavioral problems that are
  contributing to the problems;

* getting the school to make accommodations in the amount of
  homework that is required for your child;

These are only a few of the many interventions could be necessary
and helpful.  Once again, consulting with an experienced professional
to determine the best steps to take would be strongly recommended.
 

That's all for this month...

I hope you enjoyed this issue of ADHD RESEARCH UPDATE and found it
to be helpful to you.

Please feel free to share this information with others you know who
may be interested in it.  If someone would like to receive the
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The next on-line discussion group for subscribers will take place
in the next few weeks.  I'll be sending out a confirmed date
and time shortly.

Sincerely,

David Rabiner, Ph.D.
Licensed Psychologist