In this issue.....
 

"Do you have any suggestions about the right way to explain taking medication to a 5-year old? We've tried 3 different medications, two did not work and one had bad side effects."

* ADDERALL VS. RITALIN IN THE TREATMENT OF ADHD

Although stimulant medications have been shown to be effective in treating ADHD in numerous studies (at least in the short term - data on the long-term effectiveness of stimulant medication treatment is still needed), the comparative effectiveness of different medications has not been widely studied. In fact, the generally held view is that no particular stimulant has been shown to be more effective than a different stimulant, even though some children may show a much better response to one medication than to another.

Because this can not be predicted in advance, however, there has been no data to suggest which medication would be the best to start with because it is most likely to produce the most positive response. As a result, physicians generally begin by prescribing Ritalin or methylphenidate (i.e. the generic form of Ritalin) because it has been the most widely studied and is what many physicians have the most experience with. If Ritalin is not effective, or produces adverse effects for the child, a different stimulant is often tried.

Data that was presented at the recent meeting of the American Academy of Child and Adolescent Psychiatry suggests, however, that Adderall may be a generally more effective medication for treating ADHD than Ritalin. In this study, 25 children (mean age 9.5 years) participated in a double-blinded placebo-controlled study in which the effects of 2 different doses of Ritalin (i.e. 10 mg and 17.5 mg) were compared to 2 different doses of Adderall (7.5 mg and 12.5 mg).

The study was conducted over a 24-day period at an intensive summer treatment program for children with ADHD in which both recreational and classroom activities were an important component. During the study, the medication and dose that subjects received changed on a daily basis. Thus, a child might receive the low dose of Ritalin one day, the high dose of Adderall the next, the placebo the next, etc. This was arranged so that over the 24 day trial, an equal number of days on each medication and dose was obtained for all participants. During the study, medication was administered at 7:45 AM and again at 12:15 PM. (Changing doses and medications this often is certainly not what is done in typical clinical practice, but was important to provide the fairest comparison between the different drugs and doses.)

Extensive behavioral, academic, and side effects ratings were obtained each day from children's counselors, teachers, and parents. The individuals completing these ratings were blind to what dose or medication the child had received each day, so they are not likely to be biased by any preconceived notions of which medication would be more effective, or even if medication would be more effective than placebo. In addition to these daily ratings, a recommendation at the end of the study was made for each child about which medication/dose appeared to be best for him/her. These recommendations were also made without any knowledge of what the child had received during each day of the study, hence they were also unbiased.

The general conclusions of the authors are as follows:
 

These more "research based" results translated into the following clinical recommendations regarding the medication and dose believed to be best for each individual child:

(Note: Number indicates the number of children for whom the recommendation was made and the % indicates the percent this represents of the total sample of 25)
 

Summary and Conclusions

Although this is a small study and its' results require replication, it is a very nicely done investigation and the results are quite instructive. Here are what I think are the important implications:

Not every child with ADHD should be on medication

As seen above, the recommendation for 20% of the children in the study was not neither Ritalin nor Adderall was advisable to continue. Of course, some of these children might wind up doing well on still another medication, but this would not be expected to be true for everyone.

Adderall may be a good alternative to Ritalin for many children

In this study, 75% of the children in this study were judged to have done better on Adderall than on Ritalin. Although this result requires replication with a larger sample, it does suggest that Adderall would be a good medication to include in an initial medication trial.

It is important to see how a child responds to different doses and perhaps different medications

I think this is the most important implication of all. Not all children respond the same way to the same medication and responses to different doses can also vary considerably. Finding the optimum dose and medication for a child requires carefully monitoring how the child responds to different medications and doses. For example, even though this study suggests that Adderall may be more effective in general that Ritalin (and remember, this result needs to be replicated) there were still some children who did better on the Ritalin.

To my knowledge, there is still no way to predict in advance what will be best for an individual child. Therefore, it is only by the type of careful analysis done in these type of trials that the optimum medication/dose combination can be ascertained.

Even if your child's doctor does not want to begin by comparing different medications, you would still want to carefully monitor the effectiveness of different doses. If a child's response is dramatically positive, there may be no need to try anything else (although carefully monitoring the ongoing effectiveness of the treatment - and making adjustments should problems emerge - is essential). However, if the initial medication tried does not yield as positive response as one might hope for, than switching to a different medication and evaluating its effects would definitely be warranted.
 

* READING COMPREHENSION IN CHILDREN WITH ADHD *

Unfortunately, many children diagnosed with ADHD go on to have important difficulties in their academic development. For example, prior research has shown that children with ADHD are more likely to have learning disabilities than other children, and are also more likely to be retained in grade at some point during their schooling.

One especially important area that has not been carefully studied is the effect that ADHD may have on children's reading comprehension. Because reading comprehension requires sustained mental effort and attention, it seems reasonable to expect that ADHD would have an adverse effect on this skill. An interesting study published in the Journal of Attention Disorders (Vol. 3, 1996, pages 173-185) provides an interesting and instructive initial look at this important question.

In this study, the reading comprehension abilities of 21 children in grades 4-6 with and without ADHD were compared. What is noteworthy about the children in this study is that the authors first made sure that the two groups were matched on their basic sight reading skills. In other words, the children with ADHD were selected so that their ability to read individual words did not differ from the non-ADHD children. This enabled the authors to determine whether children with ADHD have deficits in reading comprehension even when their more basic reading abilities (e.g. their ability to read and sound out individual words) are intact.

For the reading comprehension assessment, children were asked to read several passages of approximately 440 words in length from a 5th grade science text. After reading each passage, children were asked to rate on a 5-point scale how well they understood what they had just read. They were then asked to give the passage a good title and to identify the specific number of main ideas in the text and their accuracy in identifying the topic and main ideas present in each passage was evaluated.

As predicted, children with ADHD were less accurate than children in the control group in correctly identifying the different topics and main ideas in each passage. Children without ADHD were able to correctly identify about 50% more of the important topics and were twice as likely to correctly identify the main idea of the passage. Thus, even though children with ADHD were able to read the passages as well (recall that they were carefully matched to insure that their basic sight reading skills were equivalent) they were still less able to correctly comprehend the important aspects of what they had read. (It is interesting to note that some of the children in the ADHD group were on medication at the time of testing. These children did better on the comprehension tasks than the non-medicated children and did not differ in their comprehension results from the children without ADHD).

What are the implications of these results? First, the authors suggest that children with ADHD may have special reading instructional needs. Even when children with ADHD are able to sight read passages as well as other children - as the children in this study were selected to be able to do - they are still less able to construct meaning from the passages they have read. Thus, they will be at a disadvantage when asked to read for new learning. In other words, comprehending material read from a long chapter may be quite difficult for the student with ADHD. (This may ring a bell for you. I have had many children I work with who report that it is very difficult for them to read chapters in social studies or science books and then have to answer questions about what they have read.)

Special instruction in understanding and comprehending written material may thus be very important for the student with ADHD, even if he or she is a very good oral reader. (Recall, however, that the results of this study also suggest that medication may significantly improve reading comprehension in a child with ADHD, although this was based on a very small sample size. Therefore, any firm conclusions about the effects of medication on reading comprehension can not be made from these results alone.)

In regards to assessment, it may be quite important to use longer passages when evaluating the reading comprehension abilities of children with ADHD. The use of longer passages, as was done in this study, increases the demands for sustained attention and effort while processing the material. The most widely used tests to evaluate reading comprehension for students being assessed for possible learning difficulties, however, typically use much shorter passages. As a result, how a child with ADHD does on these reading achievement tests may overestimate how they will actually perform when required to read chapter books for school assignments. Because a child's score on these tests is one factor used to determine his or her eligibility for specialized reading instruction, some children with ADHD who actually require extra instruction in reading will not be selected to receive it.
 

* THE PSYCHOSOCIAL AJUSTMENT OF ADHD BOYS IN YOUNG ADULTHOOD *

Studies that trace the development over time in children with ADHD are especially important for understanding the impact that having this disorder can have on individual's lives. A study that appeared in the January 99 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (pages 165-171) provides some important new and hopeful information on this essential issue.

In this study, the psychosocial functioning of 18 young adult men who had been diagnosed with ADHD in childhood was compared to the functioning of 18 matched control subjects who had not been diagnosed with ADHD or any other psychiatric condition during childhood. The subjects had been followed for a 10 year period since their diagnosis and the average age at follow up was 21 years. Detailed clinical interviews conducted at age 21 were used to determine the young adults' educational, occupational, residential and marital status. Current psychological status and prior use of mental health services was also ascertained.

In some areas, the young adults who had been diagnosed earlier with ADHD appeared to be doing as well as the control subjects. Thus, they were just as likely to be working and to be living independently. Although fewer subjects with ADHD had graduated from high school (10 vs. 16) those who did not graduate often went on to receive their GED (i.e. graduate equivalency degree). Thus, the number of young adults with ADHD who had either graduated or gone on to obtain their GED did not differ from young adults in the control group.

As expected, however, there were also areas of important differences between the two groups. Young adults in the ADHD group were more likely to have fathered a child (5 vs. 0), to be utilizing psychological services (4 vs.0), to have experienced difficulties in their psychological functioning in the past 5 years (10 vs. 2) and to have been in trouble with the law (7 vs. 2). For most of the subjects who reported legal problems, however, the difficulties had occurred prior to age 18.

Overall, the authors suggest that their results provide a reason for guarded optimism for those who are involved in a parenting or treatment role for children with ADHD. Although many boys experienced legal difficulty and dropped out of high school during adolescence, the majority had overcome these problems by young adulthood. They suggest that these results should encourage adolescents with ADHD and their parents to adopt a more global, long-term outlook rather than focusing on difficulties and failures that may occur during the turbulent teen-aged years.

Apparently, many boys experiencing such troubles during adolescence will be able to return to a better developmental path by the start of young adulthood. An important key may thus be to help the teen with ADHD navigate the adolescent period without getting into circumstances that can be more difficult to recover from, such as a serious criminal offense or fathering a child. Both of these outcomes would be more likely to occur for teens who had also developed Conduct Disorder in addition to their ADHD.

The authors appropriately note that their sample size is relatively small, so the results must be considered with caution. It is also important to realize that the boys with ADHD in this study had all been referred for treatment in childhood or early adolescence and had received either counselling and/or medication treatment. Whether similar results would occur with boys who had never been referred or treated, therefore, can not be determined from this study.

Finally, a number of boys who had been diagnosed earlier with ADHD could not be located to participate in the follow-up study. It is certainly possible that these boys were having a more difficult time in young adulthood than the boys who were able to be contacted. Overall, however, the results imply that many boys with ADHD can return to satisfactory adjustments in young adulthood after having more difficult times during adolescence.
 

* THE IMPACT OF EARLY ATTENTION DIFFICULITES ON CHILDREN'S READING ACHIEVEMENT *

I'd like to share with you now some preliminary results from a study I have been working on that I think are quite interesting. These data have not yet been published, so this is a sneak preview of the findings. I wanted to let you know about these results because I think they have may important implications for parents and educators.

The study involves approximately 240 boys and girls who were recruited from four different cities around the county. Children were first contacted when they were in kindergarten, and then followed each year over the next 6 years. Thus, the data is available for the period covering elementary school (i.e., k-5). This data is from a much larger study that I was fortunate to be able to work on in my new position at Duke.

For each year of the study, teacher ratings of both attention problems and activity level were collected. In addition, assessments of children's reading achievement were gathered at the end of grades k, 1, 2, 3, and 5. What I was interested in looking at is whether very early attention problems - i.e those reported in grades k and 1 have a significant impact on the development of children's reading ability.

The results appear to be quite straight-forward and were a bit surprising to me. Here's what I found:
 

Now, here is what I think makes these results very concerning. In this sample at least, it turns out that reading achievement is quite stable between grades 1 and 5. In other words, if a child is doing poorly relative to peers after grade 1, there is a VERY GOOD chance that he or she will still be a relatively poor reader 4 years later. Thus, children who fall behind early seem to have a hard time - at least in the normal course of things - catching up.

We also know that attention problems are often not identified early on, especially when the child is not also showing more overt behavior problems. This means, unfortunately, that many children have attention difficulties that are interfering with their acquisition of fundamental reading skills during the kindergarten and first grade years. As a result, they are falling behind their peers in ways that seem quite difficult to catch up on. Perhaps identifying these children early, and providing them with appropriate assistance, could make an important difference. This would certainly seem like a reasonable thing to try, and I hope to do this over the next few years if I can get the funding to do so.

There are, of course, several important cautions to bear in mind. First, all studies need to be replicated. The link between attention problems and reading achievement has been reported before, however. What the current results may add to this knowledge base is that the adverse effects of attention problems are most pronounced very early in a child's schooling, and can result in deficits that are difficult to fully recover from.

I also want to stress that the children in this sample had not been diagnosed with ADHD. Instead, they were just a "typical" sample of kids, some of whom had important attention difficulties and most of whom did not. Personally, I think this makes the results more compelling because it highlights how important attentional functioning may be for children's academic achievement, regardless of whether or not they are formally diagnosed as having ADHD.

The implications of these results are fairly clear - early problems with attention can have lasting effects on academic achievement. I think we need to do a better job of identifying children with these problems and provide them with the extra assistance they may need. Perhaps this can make an important difference in the course of their school careers. I will keep you posted on additional findings from this data set as they emerge.

- Questions -

"Do you have any suggestions about the right way to explain things to a 5-year old? We've tried 3 different medications, two did not work and one had bad side effects. I may try another one soon, but I am dreading the 'mommy has a new pill' talk. I am not sure how much he understands of all this. On the last med he understood it was a 'pill' to make me stop fighting. (Later, when he flung a chair at his older brother, big bro said, 'hey, that pill is not working'!) I try to tell him I understand he has trouble controlling himself and remembering the rules so these medicines should help. With a fourth drug trial coming up, I fear my credibility is endangered. He gets counseling at school but I do not think the counselor talks to him about meds, he's too busy playing checkers with him. Can you please tell me how much a 5 year old should know about ADHD. And how I should approach the medication issue?"

This is a really important question as it concerns the often neglected issue of discussing medication with children. Let me start by commending you on two counts. First, your attention to helping your child understand why he is taking medication is exemplary. I can not tell you how many times I have encountered children who had been taking medication for years without ever really understanding why. In my opinion, this is a really critical oversight. Second, the fact that you have already tried several different medications suggests that you and your child's physician are paying careful attention to how the medication is impacting your child's behavior, and making adjustments when the results obtained are not adequate. In many situations that I have seen, a child is often continued on a medication that is not really helping or parents/physicians don't try something else if the first medication tried does not yield the desired effects.

Now, as far as what to say... First, a caveat. I do not know your child and thus can not really provide specific suggestions about what would be best. Instead, I'll present a set of general guidelines that can be modified to be most appropriate to your child's specific situation. I have found that even children this young are generally receptive to a straight-forward explanation about why medication is being tried and what it can do. For a 5 year old with ADHD, I would say something like the following: (What follows is much more of a monologue than would generally occur and it is always important to give the child plenty of opportunity to ask questions.)

"You know, kids your age differ in lots of ways. Some are short and some are tall. Some are really fast and others are not so fast. Some can read really well and some have a harder time learning to read. There are just lots of ways that kids differ.

Kids can also differ in how energetic they are and in how their mind works. Some kids don't seem to have very much energy - they just like to sit around. Other kids have so much energy, though, that it is very hard for them to sit still. Having all this energy can be great for some things, but when you have to sit still and pay attention to something - like you have to do at school - it can make things difficult. Some kids are also able to really concentrate and think about one thing for a long time. For other kids, though, their mind sort-of jumps from one idea to the next. Having all these different ideas can be great, but when you have to focus on just one thing at a time, it can make things hard.

Sometimes kids with so much energy and so many different ideas need some help being able to sit still and focus on one thing at a time. One of the things that can help a lot with this is a kind of medicine. What the medicine can do is make it easier for you to stay in your seat and pay attention when you need to at school. It can also make it easier to slow down a bit so that you can make good choices about the kinds of things you do.

Now, your doctor and I think it makes sense to see whether some medicine can make these things easier for you. That way, you will be able to use all your energy and ideas to get the things done that you need to and to make good choices about your behavior and the things you do. The medicine should make it easier for you to do these things, but we'll also need you to keep trying really hard as well.

Now, there are several different medicines that kids can take to help with this. Not every medicine works for every child and we may have to try a few different ones to try and find one that is best for you. If we stick with it, though, there is a very good chance that we will find a medicine that can help with some of the challenges you have been having at school (note: this assumes that the child is aware of the difficulty they have been having and that this has been discussed with them. Presumably, this would be the rational given for why they were seeing the doctor in the first place.)

A few other things to mention. First, as hopefully comes through above, I try to convey to the child that the medicine is not a "magic pill" and that the child has to also try to follow rules and make good choices. After all, if medication works, all it does is to help the child have more control over his or her behavior, but how the child chooses to exercise that control is still up to them. A child can make thoughtful decisions about not to comply just as easily as impulsive ones. What you want to convey is a sense that the child is responsible for his or her behavior and that if they do better it is just as much because of their efforts as the medication alone.

One other thing. I would be careful about presenting medication as something being tried to help a child "stop fighting." You don't want to convey a sense that aggressive behavior is something that is outside of a child's control because this can make it more difficult to hold them accountable for their actions. Instead, I would say that the medicine may make it easier for them to stop and think about what they are doing, so that they will be able to make better choices about how they behave. This is a subtle difference, but I think it is an important one.

Anyway, I hope this is helpful and that you will be able take from the above what seems to fit for your child. Let me also mention that a number of good books have been written on this topic. You can find them at the A.D.D. Warehouse site.
 

That's all for this month...

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Sincerely,

David Rabiner, PhD
Licensed Psychologist

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Copyright 1999 David Rabiner, PhD and ADHD RESEARCH UPDATE