******************************************************
ADHD RESEARCH UPDATE - Vol. 19, May, 1999
******************************************************In this issue...
* Pediatric practices in evaluating children for ADHD
* Predicting children's response to methylphenidate
* How do parent and child perceptions of stimulant medication
treatment compare?* The self perceptions of children with ADHD
- Question -
"My child is in the third grade and was diagnosed with
ADHD earlier this year. He has been taking Ritalin and
his behavior has been much better. His school work,
though, continues to be a real problem. Reading and
writing in particular are incredibly difficult for him
and have hardly improved at all. What should we do?"
UPCOMING SEMINAR FOR PARENTS
Do you live near Boca Raton, Florida? I will be giving
a seminar for parents on ADHD in Boca Raton, Florida,
on May 15th. For those of you who live in that area, and
who may be interested in attending, you can learn more
about the seminar by clicking here.If you attend, please be sure to introduce yourself.
* PEDIATRIC PRACTICES IN EVALUATING CHILDREN FOR
ADHDAlthough ADHD is regarded as a psychiatric disorder,
the vast majority of children suspected of having ADHD
are evaluated and treated by pediatricians rather than
by child mental health specialists. It thus becomes
quite important to learn how this task is typically
handled by pediatricians in general community practice.In the March, 1999, issue of Pediatrics, a large-scale
survey of pediatricians on their procedures for
evaluating ADHD is reported (Wasserman, R.C., et. al.;
(1999). Identification of attention and hyperactivity
problems in primary care: A report from pediatric
research in office settings and the ambulatory sentinel
practice network. Pediatrics, 103, pp. e38). The
results of this survey contain what I think is both
good, and not so good, news.In this study, 401 pediatric and family practice
clinicians in 44 states, Puerto Rico, and 4 Canadian
provinces were included. This is thus a very large and
representative sample of physicians. The results thus
provide us with a very good idea of how physicians in
the community are typically practicing.Participating physicians were asked to respond to
questions about 70 consecutive children between the
ages of 4-15 who visited their office for non-emergency
care. For each of these children, physicians were
asked whether there was a "new, ongoing, or recurrent
psychosocial problem present". They were also asked to
provide information on the assessment techniques they
used to determine the nature of the psychosocial
problem when such a problem was the focus of the visit.
These techniques included "parent interview", "child
interview", "school reports", "observation", and
"standardized assessment tools" such as behavior
checklists. Clinicians were also asked about their use
of DSM-IV criteria to diagnose psychosocial problems,
including ADHD. (DSM-IV contains the currently
recognized diagnostic criteria for all psychiatric
disorders.) In addition to collecting this information
from physicians, the parents or guardians of each child
was asked to completed a behavior rating scale to assess
symptoms as perceived by parents.Here is a summary of the important results:
* Almost 20% of all patient visits for children between
the ages of 4-15 involved children with psychosocial
problems.* Almost 10% of all patient visits were specifically
related to problems with attention and/or
hyperactivity. This underscores just how often
primary care physicians are called upon to help
children and parents with this important problem.Here is a finding that is encouraging:
* Despite concerns that racial and ethnic minorities
are more likely to be diagnosed with ADHD, clinicians
identified minority children
and those from low-income or poorly functioning
families as having significant problems with
attention and/or hyperactivity at the same rate as
other children.There was thus no evidence of any racial or ethnic
bias in physicians' tendency to diagnose children
with ADHD.Here are some findings that are less encouraging:
* Physicians reported using standard DSM-IV diagnostic
criteria for only 38.3% of their patients diagnosed
as having problems with attention and hyperactivity.* Physicians reported using standardized assessment
tools, such as norm-based behavior rating scales for
only 36.9% of these patients.* Despite the widely recognized importance of obtaining
direct information from a child's school in
evaluating ADHD, this was not done in almost half the
cases.The infrequent use of current diagnostic criteria,
standardized behavior rating scales, and the number of
children form whom no direct feedback from teachers was
obtained certainly raises important questions about
the adequacy and accuracy of many of the ADHD diagnoses
that are made.Here is another interesting and, I think, alarming
finding.* Even after controlling for the type and intensity of
symptoms that parents reported, boys were still
almost three times as likely to be identified as
having important problems with attention and
hyperactivity than girls.In other words, when parents of boys and girls reported
the same type of ADHD symptoms, girls were still much
less likely to be identified as needing help for
problems related to attention and hyperactivity.
The authors conclude that primary care physicians show
a strong tendency to overlook such problems in girls,
perhaps because they focus more on symptoms of anxiety
and sadness in females.Overall, the results of this study highlight that there
is still important progress to be made in the manner
with which children suspected of having ADHD are
evaluated in primary care settings. Far too many
children are not receiving the kind of systematic
and standardized evaluation procedures using current
diagnostic criteria and empirically validated
evaluation instruments. It is my understanding that
the American Academy of Pediatrics is in the process of
developing a set of standard practice guidelines for
the assessment and management of ADHD. Hopefully, such
guidelines will be widely adopted and contribute to
making better care more routinely available to children
with ADHD.
* PREDICTING CHILDREN'S RESPONSE TO METHYLPHENIDATE
One of the questions I am asked most frequently is how
parents can know whether medication - particularly
Ritalin - will help their child. It would certainly be
helpful to know in advance whether a particular child
truly will benefit from medication, what the magnitude
of those benefits will be, and what areas (e.g.
behavior, academics, etc.) will be most effected.A study appearing in this month's issue of the Journal
of the American Academy of Child and Adolescent
Psychiatry takes a careful look at how well medication
response can be predicted in advance (Denney, C.B. &
Rapport, M.D. (1999). Predicting methylphenidate
response in ADHD. Journal of the American Academy of
Child and Adolescent Psychiatry, 38, 393-401.) In this
study, 76 children with ADHD, Combined Type (i.e. they
had both inattentive and hyperactive/impulsive
symptoms) received several different doses of methylphenidate
(MPH - this is the generic form of Ritalin) in the
context of a double-blind, placebo-controlled
medication trial. There were 66 boys in the sample and
10 girls.Both before and during the trial, careful measures of a
number of behavioral and academic variables were
collected. These included teacher ratings of
inattention and hyperactivity using standardized
behavior rating scales; direct observations of
children's on-task behavior in the classroom made by
observers blind to the child's medication status;
teacher ratings of children's self-control in both the
academic and social areas; and finally, a measure of
academic efficiency which was defined as the percentage
of assigned work that the child completed in an
accurate manner. The authors were particularly
interested in whether any of the behavioral or academic
measures collected prior to the medication trial would
prove to be helpful in predicting whether or not the
child showed a positive response to medication, and
whether it could predict the optimal dose for each
child.Although there was some variation depending on what
outcome measure was being predicted (e.g. inattention,
hyperactivity, self-control, academic efficiency),
overall, predicting whether an individual child would
benefit from medication based on any of the pretreatment
variables was quite difficult. There was some indication
that the more inattentive and/or hyperactive a child
was to start with, the more likely he or she is to show
gains in these areas. In other words, children whose
ADHD symptoms were more severe were more likely to show
positive effects from medication.What seems to me to be a more interesting and important
aspect of the results, however, was the finding that
behavioral improvements do not necessarily lead to
corresponding academic improvements. Thus, it was not
uncommon for a child to show clinically significant
gains in the core ADHD symptoms, and yet not to show
corresponding gains in the academic efficiency measure.
In other words, for some children, their behavior improved
but their academic performance did not.In contrast to this pattern, gains in academic efficiency
were almost always accompanied by corresponding
improvements in attention, hyperactivity, and self-control.
Thus, when children's school work improved, their
primary ADHD symptoms almost always improved as well.Was there any way to predict which children would show
these important gains in the academic efficiency measure?
It turns out that there was, and that the best predictor
was how well a child was performing academically prior
to starting the medication trial. Children whose
pre-treatment academic efficiency scores fell in the
bottom 50% were much more likely to show improvements
in academic functioning than children whose pre-treatment
academic scores were higher. These latter children,
however, might still show important gains in the areas
of core ADHD symptoms.What does this all mean?
I think there are several implications of these results
that are really quite important.First, the findings highlight that assessing a child's
response to medication should be a careful process.
One can not assume that gains in one area will necessarily
mean gains in all areas. As this study demonstrated,
there can be many children who show important gains
in behavior without corresponding gains in academic
performance.For each child, therefore, one has to carefully monitor
the effects of medication in multiple domains of functioning.
Thus, you would want to know what impact medication is
having on behavior, social relations, and academic
performance to have a clear understanding of the child's
unique response.This assessment of medication's impact on different areas
should be evaluated in comparison to the domains that
were most problematic to begin with. Thus, if academic
functioning is the chief concern, it is very important
to evaluate how the child's academic work is changing
in response to medication. What you don't want to do
is assume that just because your child may be behaving
better in class, that his or her school work is also
better.I can't tell you how many times I have seen this occur.
Parents and teachers can be understandably elated that
a child's behavior is under better control, and the fact
that the child's school performance is still not very good
manages to be overlooked. When report card time rolls
around, there can be some unfortunate surprise in store.By the way, this same approach can, and should, be used
to evaluate a child's response to any type of treatment.
Thus, if you are considering alternative methods for treating
your child (e.g. behavioral interventions, herbal
treatments, etc.) you would still want to carefully
track what effect - if any - the treatment is having in
different areas. You would also want to pay careful
attention to whether the areas of real trouble are the
ones that are being positively effected.
* PARENT AND CHILD PERCEPTIONS OF STIMULANT
MEDICATION TREATMENT: HOW DO THEY COMPARE?Although stimulant medication has been shown to be safe
and effective for most children with ADHD in numerous
studies, fewer studies have been conducted in which
children's own feelings about taking medication are
examined. How parent and child perceptions of medication
treatment compare has been examined even less frequently.
These are both important topics to investigate, because
child attitudes towards medications, and the match
between parent and child perceptions, can have potentially
important implications for the ultimate success of such
treatment.A study published in a recent issue of the Journal of
Paediatric Child Health provides important information
on these questions (Jarman, E.D., & Barker, M.J. (1998).
Child and parent perceptions of stimulant medication
treatment in attention deficit hyperactivity disorder.
Journal of Paeditric Child Health, 34, 288-292.)
Participants in this study were 102 children between the
ages of 5 and 16 years old. The majority (over 80%)
had been diagnosed with ADHD, Combined Type (i.e. had
both inattentive and hyperactive/impulsive symptoms),
about 16% had the inattentive symptoms only, and about
1% had the hyperactive/impulsive symptoms only.
Ninety-three of the children were males and only 9 were
females. (The preponderance of males was not done
intentionally but reflected the referral pattern
in the clinic from which participants were drawn).During the study, children received methylphenidate
(MPH - the generic form of Ritalin) or dexamphetamine
(DEX - the generic form of dexedrine) for 2 weeks in a
randomly assigned order. Neither children, their
parents, nor the investigators was aware of which
medication the child was receiving at any time. At the
end of each 2-week cycle, children were asked to rate
how they felt taking each medication on a 5-point scale
ranging from "much worse than usual" to "much better
than usual". They were also asked to rate how helpful
the medication was on a 5-point scale ranging from "not
at all helpful" to "very helpful". Parents were also
asked to complete ratings of their child's behavior
during each period as well as ratings of any side
effects that they thought they observed. By collecting
this data from parents and children, the investigators
would also be able to compare how parent and child
perceptions of response to medication compared - both
in terms of the medication's effectiveness and possible
side effects.The results below show how children reported feeling
when taking either Ritalin or Dexedrine. The numbers
in the table represent the percentage of children who
responded as indicated. For example, the first entry
indicates that 4.9% of children indicated that they had
felt much worse than usual during the 2 weeks that
they were taking MPH.Child reported feeling: MPH Dex
Much worse than usual 4.9 5.9
Worse than usual 7.8 12.9
About the same as usual 24.5 25.7
Better than usual 34.3 22.8
Much better than usual 28.4 22.8
Overall, therefore, almost two-thirds (62.7%) of children
taking MPH reported feeling better or much better than
usual and 55.5% of children reported feeling better or
much better than usual when taking Dexedrine. Conversely,
12.7% of children reported feeling worse or much worse than
usual when taking MPH and 18.8% reported similar feelings
when taking Dex. Although it appears that children were
somewhat more likely to report feeling better when taking
MPH than when taking Dex, these differences were not
significant. In other words, it is likely that the
differences observed were due to random factors
rather than to a "true" difference in how children feel
when taking the different medications.
Children's ratings of how helpful they felt each medication
was are shown below.
Child's rating MPH Dex
Very helpful 45.1 38.6
Helpful 28.4 24.8
Not sure 14.7 26.7
Not very helpful 3.9 5.0
Not at all helpful 8.0 5.0
Overall, almost three-quarters of children (73.5%)
reported that MPH was either helpful or very helpful to
them. The corresponding figure for Dex was 63.4%.
Although it again appears that more children found MPH
to be helpful than Dex, these differences were not
statistically significant.The authors next examined how parent and child response
to medication compared. This was done by looking at the
number of children where both child and parent rated the
response to medication as being positive; the number
where both parents and child agreed that there was not
a positive response; and the number where parents and
child disagreed about whether or not there had been a
positive response.For MPH, parents and their child agreed on the child's
response to medication about 75% of the time
(i.e. regardless of whether it had been positive or
not) and disagreed about the child's response about 25%
of the time. For Dex, parents and their child agreed about
two-thirds of the time and disagreed about one-third of
the time. For both medications, about 75% of the disagreements
occurred when the parent(s) felt the child has shown a
positive response but the child did not agree. Thus,
on both types of medication, there was a substantial
number of instances in which parents and children
disagreed about whether or not the child had benefited from
the medication.The only predictor of whether children perceived themselves
as benefiting was the severity of side effects that
were reported. Those children who did not perceive a
benefit to medication were the ones who had experienced
a greater number of side effects (unfortunately, it is
not completely clear in the article who - parent or
child - is providing information about the side effects
experienced.) Apart from this factor, none of the other
characteristics of the child that were known - including
gender, type of ADHD (i.e. combined type vs. predominantly
inattentive type), age, self-concept, nor the presence
of other emotional or behavioral problems) - was related
to whether or not the child reported a positive response
to the medication.There is one important limitation to this study that
needs to be recognized, and that is the absence of a
placebo that was administered in addition to the 2 active
medications. It would have been very interesting to see
how children's reports about their response to medication
compared to what they reported when they were on the
placebo. This is especially important in relation to the
children who reported feeling worse than usual when they
were taking medication. The percentage of children who
reported feeling this way was not insignificant, and it
would be very interesting to know what percentage would
have reported feeling this way when they were taking a
placebo. The other point to note is that children's
reports were collected after only a 2-week period, and
it is not uncommon for side effects to dissipate over
time. Thus, it is quite possible that a smaller percentage
of children would have reported feeling "worse than
usual" if this data was collected several more weeks
down the road.Despite, these limitations - which the authors also
acknowledge - I think this is a very important study
that has clear clinical implications. The results
of this study highlight that it is not uncommon for
children to report no response, or even to report a
negative response, to treatment by stimulant medication.
Furthermore, this can occur even in situations when
parents and teachers may observe important improvements
in the child's behavior and functioning. In some cases,
children who actually appear to have benefited
the most may have the strongest objections to continuing
medication.This underscores the need to pay careful attention to
children's feelings about taking medication and their
perception of how it is effecting them. One reason this
is so important is that it can certainly influence
children's compliance with the medication regimen being
prescribed. A child who finds him or herself feeling
worse after starting on medication is unlikely to want
to continue taking it - even if parents and teachers
perceive it to be helpful to the child. When this child
gets a bit older, getting him/her to continue taking the
medication if it still seems to be necessary may
be difficult if not impossible. Therefore, paying
careful attention to the presence of such negative
feelings early on, and trying to deal with them in a
sensitive and respectful way if they are present, can
help to avoid a lot of difficulty and aggravation later
on.In my own experience, I have found it to be extraordinarily
helpful when a child is started on medication to make
it clear that their feedback about how the medication
seems to be helping will be an important part of what
goes in to deciding whether it makes sense to continue
taking it. I try to let the child know that their
opinion about the medication, along with opinions from
their parents and teachers will all be taken into account
because all are important. In this way, one tries to
enlist the child as an active and cooperative collaborator
in the process of trying to determine whether medication
is an appropriate and helpful treatment. My own
experience has been that when approached in this way,
children are generally less likely to put up strong
objections to giving medication a try. It is also my
impression that they are less likely to report negative
effects of medication, but this is not based on any
systematic data. Along these lines, letting a child know
that it may take a while to "get used" to taking the
medication can also be helpful to do. In any case, trying to
develop the feeling that this approach to treatment is something
that is done "with" the child as an important collaborator,
rather than something that is done "to" the child as
a passive recipient, seems to make a lot of sense to me.
* SELF-PERCEPTIONS IN CHILDREN WITH ADHD
Because children with ADHD often struggle in their
school work, peer relations, and ability to follow rules
at home and at school, it is reasonable to hypothesize
that their feelings of competence would suffer as a result.
A recent study in which the self perceptions of
children with ADHD were specifically examined highlights
the importance of paying attention to this area (Dumas,
D., & Pelletier, L. (1999). A study of self-perception
in hyperactive children. American Journal of Maternal
and Child Nursing, 24, 2-9).In this study 57 children with ADHD between the ages of
6-11 (20 girls and 37 boys) and 59 children without ADHD
(25 girls and 34 boys) served as participants. Each
child completed a standardized measure to assess his or
her self perceptions in a number of dimensions including
perceived scholastic competence, social competence,
behavioral competence, and athletic competence. Children's
score on each of these dimensions reflects how competent
they perceive themselves to be in each area. (The measure
that was used was called the Self-Perception Profile for
Children).The results indicated that as a group, children with ADHD
perceived themselves to be less competent than children
without ADHD in all areas except for athletic competence.
Thus, the self perceptions of children with ADHD were
lower than those of other children in regards to how they
felt about their behavior, their ability to get along
with others, and their ability to succeed in school.
As in any study that compares children in different groups,
not every child with ADHD rated their competence in these
areas as being low. On average, however, children with
ADHD perceived themselves as less competent than the
other children.The results of this study highlight the need to pay
attention to the feelings that a child with ADHD has
about him or herself. In many instances, particularly
when parents are struggling to manage their child's
difficult behavior, it can be easy to lose sight of the
effects that ADHD can have on some children's self-esteem.
When one considers how much negative feedback a child
with ADHD may have to contend with on a regular basis,
however, it is not difficult to imagine how this could
come to adversely affect a child's feelings about him or
herself. Also, it is important to recognize that
questioning one's competence in scholastic, behavioral,
and social areas may be quite realistic for a child who
is really struggling in these domains.What can parents do to help their child to feel more
competent? The first thing, I think, is to make sure
one's child is getting the best treatment possible so
that he or she can actually be more successful in school,
more successful with peers, and more successful with
meeting behavioral expectations. Although it is not
always the case, children's self-concept is often closely
linked to their actual success in different important
domains. So, the more successful they can actually be
in those domains, the more competent they are likely to
feel.Another thing that can be quite helpful is providing a
child with the opportunity to talk about his or her
feelings - even when those feelings are negative. Thus,
trying to engage one's child in discussions about how
he feels things are going at home, at school, with peers,
etc. can provide you with a great opportunity to learn
whether your child is feeling down and discouraged.
Talking about such feelings alone may not solve the problem,
but talking can help a child develop more control over
strong negative feelings. It can also lead to a problem-
solving discussion about how to try and help things go
better. I know from my own experience that it can be
hard to really listen to one's child saying negative things
about him or herself and that it is a natural reaction to want
to try and help your child feel better "right away" by
pointing out all the positive things they may be overlooking.
Unfortunately, this can have the effect of keeping a child
from really getting the chance to express what is on her
mind, and may short circuit a necessary sharing of
feelings. A really good book to look at in this regard
is called How to Talk so Kids will Listen and Listen
so Kids will Talk by Adele Faber and Elaine Mazlish.
I would really recommend this.Parents can also play a very important role in helping
to protect a child's self-esteem by helping their child
to develop a real area of skill and ability. For example,
helping your child to get involved - and stay involved -
in an activity where they can see themselves as improving
and developing can be a real source of satisfaction and
pride. I don't even think it matters that much what
the activity is - art, music, sports, dance, etc. - the
main thing, I think, is that a child gets the opportunity
to develop an area of skill and competence. This can
provide an important buffer when a child may be struggling
in other important areas of their daily life.I went to a talk last year in which this point was stressed
by Dr. Keith Connors - one of the world's leading authorities
on ADHD - as a very important contribution that parents
can make to their child's development. To my knowledge,
there is not yet any research data to support this idea.
It makes a tremendous amount of sense to me based on clinical
experience, however, and I believe it is a potentially
very useful idea for parents to consider and pursue.
- READER QUESTION -
"My child is in the third grade and was diagnosed with
ADHD earlier this year. He has been taking Ritalin and
his behavior has been much better. His school work,
though, continues to be a real problem. Reading and
writing in particular are incredibly difficult for him
and have hardly improved at all. What should we do?"
This is an important question and describes a scenario
that occurs fairly often: a child with ADHD is started
on medication and the child's behavior improves but
their school work continues to be problematic. How
should this type of situation be handled?First, as reported in the article above, research has
documented that behavioral improvements in response to
medication often do not translate into academic gains.
There are several different reasons why this might occur.
These reasons include the following:The child's academic performance is not being used as
the outcome to which medication response is being targeted.As has been discussed in prior issues of ADHD RESEARCH
UPDATE, medication often has different impacts on different
domains of a child's functioning. In some cases, the
medication and/or dose that is effective in producing
behavioral improvements will not necessarily be what is
required to generate academic improvements. Thus, if
the primary concern is improving a child's academic
performance, one has to carefully evaluate medication
response in relation to that outcome. It is possible
that a more positive impact on academic performance would
be obtained with a different medication and/or dose.
So, this is one option that could be considered. In
these situations - where a medication adjustment can make
an important difference - we are generally talking about
a child where their academic struggles really are secondary
to their ADHD symptoms rather than reflecting a more primary
learning difficulty.No behavioral intervention is being used to improve academic
productivity and accuracy.In many instances, even the most carefully prescribed
medication will not be adequate to address a child's
academic struggles. (Note: Again, I am talking here about
a child with ADHD where the ADHD symptoms are the primary
cause of the academic problems rather than another issue
like a learning disability).Thus, it will often be necessary to incorporate a behavioral
plan targeted to improving work completion and the quality
of work the child is doing. I can't get into the details
of such interventions here, but basically, they involve
making access to desired privileges contingent on the
amount and quality of the work being completed by the
child. The idea is to provide an additional source of
motivation to encourage better academic performance.
Such programs can be quite helpful, and can produce
benefits above and beyond the benefits a child may
already be deriving from medication.There are also other reasons a child with ADHD may struggle
academically, not all of which have anything to do
necessary with ADHD itself. These include the following:The child may have a specific learning disability
Children can have specific learning disabilities in reading,
written language, math, etc. that will make it extremely
difficult for them to succeed academically regardless of
how well their ADHD symptoms are being managed. One
needs to be especially careful about this in children
with ADHD because learning disabilities do seem to be more
common in such children.How can you tell if your child has a learning disability?
The best way is with a thorough psychoeducational evaluation,
that involves a combination of individually administered
IQ testing and achievement testing. Such testing can be
performed by the child's school, although it often takes
very long to have done. It can also be done privately by
a child psychologist but is expensive and often not covered
by health insurance. In many instances, however, it is
absolutely essential to help develop the best educational
plan for a child.In terms of things a parent can look for, the academic problems
for a child with ADHD alone will generally look quite
different from the problems of a child who has both ADHD and
a learning disability. A child with ADHD alone can generally
understand the concepts being taught - at least if he or
she can be made to pay attention to what is going on. Work
may be very inconsistent - some days pretty good and other
days horrible - but at least you have the sense that the
child can grasp the basic concepts.In a child who also has a learning disability (i.e. LD), the
situation is quite different. This child will often not be
able to understand things no matter how well he or she is
able to pay attention. Thus, even if medication has brought
the child's primary ADHD symptoms under control, they are
still unable to get down basic concepts. A classic example
is with children who are LD in reading, who just can't
seem to learn to sound out words and sometimes appear as
if they are just guessing randomly at letter-sound
combinations.So, if your child's ADHD symptoms are being managed well,
and academic struggles are still quite prominent, it is
possible that one or more learning disabilities is an
important part of the problem. A thorough professional
evaluation would be definitely recommended.Child may not have LD but may have missed out on basic
skills and conceptsThis is a bit different from the scenario just described.
Imagine a child with ADHD who is now in 5th grade. Suppose
this child had the inattentive symptoms only, and was not
identified as having ADHD until the end of grade 4. At
that point the child was given appropriate treatment, and
his ability to attend and focus in the classroom improved
considerably. His academics, however, continue to be a
real problem.Even though this child may not have a specific LD, it is
quite likely that going through most of elementary school
with untreated ADHD meant that there was just lots of
important material that he was never able to master.
Problems with attention would have interfered with mastering
basic skills in reading, math, and written language. Thus,
there would be important gaps in this child's knowledge
base - leaving him quite unprepared to do 5th grade work.In this case, the child would need lots of remedial help
to acquire the important building blocks that he missed
out on in earlier grades. A good place to start would also
be with a thorough psychoeducational evaluation to see
what the child's current achievement level is in different
areas, and to help in developing a plan that is
specifically target to meet his needs.The child may be struggling because of intellectual factors
Finally, a child with ADHD whose symptoms are being well-
controlled may still struggle academically because of
intellectual factors alone. Just like children without
ADHD, many children with ADHD are quite intellectually
gifted. However, just as non-ADHD children can have
intellectual limitations that make school work hard for
them - no matter what they or anybody else does - the
same can be true for children with ADHD.For example, if a child has a low-average IQ, than school
work is just going to be difficult no matter how well
his or her ADHD symptoms are being managed. This will
be especially true as the child moves into the higher
grades where the work becomes more challenging.Several years ago a parent approached me because her child
was doing terribly in school and she was certain that it
was because the child had ADHD. As part of the evaluation,
IQ and achievement testing were completed and it turned
out this child had an IQ that was in the bottom 2%
of the population. This meant that there was just no
way that this child was going to be able to be successful
in a regular academic high school program. It was very
difficult for the child's mother to accept this, but she
eventually did, and was able to help her daughter get
into a program that was more appropriate for her and
where she had a chance to succeed.Again, I want to emphasize that having ADHD in no way
means that a child has basic intellectual limitations.
This can be a factor in some situations, however, and thus
may need to be considered and explored as a possible
explanation when other possibilities have been ruled out.
Emotional and/or behavioral problems can be interfering
with academic performanceOther emotional and/or behavioral problems can also effect
a child's schoolwork. For example, if a child is depressed
his or her schoolwork is likely to suffer. This would be
true regardless of whether the child also had ADHD.Alternatively, poor school work and lack of effort could
be part of a more pervasive problem with oppositional
behavior. Again, this could be the case regardless of
whether the child also had ADHD. The main point here is
that these could be reasons why a child with ADHD still
was doing poorly academically even if there ADHD symptoms
were being managed well.In any event, the above is a discussion of some of the
issues to consider as far as academic performance goes.
I hope that the above discussion gives you an understanding
of the different factors that can be involved. Sorting
these different factors out is a challenging task, however,
and is one where working with an experienced child mental
health professional can be absolutely essential.
That's all for this month...
I hope you enjoyed this issue of ADHD RESEARCH UPDATE and
found it to be informative.Please feel free to share information in this issue with others
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My address is: www.helpforadd.comI hope things are going well for you.
Sincerely,
David Rabiner, PhD
Licensed PsychologistP.S. I am continuing to offer consultation via telephone to
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