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ADHD RESEARCH UPDATE - Vol. 24 October, 1999
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In this issue...

ANNOUNCEMENTS

* Feedback requested about CE credits

* Medication trial program for professionals and parents

* Next on-line discussion group

ARTICLES

* New data on the possible overdiagnosis of ADHD

* ADHD in girls

* The relationship between medication treatment for ADHD and substance abuse

* ADHD as a public health problem: Report on recent meeting sponsored
  by the Center for Disease Control (CDC)
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FEEDBACK REQUESTED ABOUT CE CREDITS

If you are a mental health professional I'd appreciate your feedback
on this.

I have been approached by a company that provides CE credits to
licensed mental health professsionals.  They are interested in providing
CE credits in conjunction with ADHD RESEARCH UPDATE.

My understanding is that an on-line quiz would be prepared to cover
2 issues of the newsletter, and that one credit could be earned by those
who successfully completed the quiz.  Everything could be done
on-line and  your responses and payment ($15.00/credit) would go
directly to the company who would file the necessary forms with
your state licensing agency.

Is this something you would be interested in?  Whether you used the
CE credit option would be entirely up to you - but it would be
helpful for me to know if you think this would be of any use to you.

Your feedback on this would be most appreciated.  Please send me
a message and let me know what you think, along with any ideas you
have about how a CE program could work best for you.  If you could
type CE in the subject line of your message it will alert me to it.

Thanks!
 

MEDICATION TRIAL PROGRAM FOR PROFESSIONALS
AND PARENTS

I am excited to let you know about a program I have developed that
makes it easy to conduct careful placebo-controlled trials to obtain
objective data about a child's response to stimulant medication.

If you are a health care professional involved in medication treatment -
either as a physian prescribing medication or as a mental health
professional who consults physicians for this aspect of a child's
treatment - I think you will find this program to be quite useful to you.
I know that I have.  You can learn more about it here.

If you are a parent of a child with ADHD and are considering medication
treatment for your child, this program can be useful to you as well.  You
can learn more about the program and how it can be helpful to you here.

NEXT ON-LINE DISCUSSION

The next on-line discussion group for subscribers will be held on
Thurdsday, October 7th at 9:30 PM Eastern Standard Time.  You
can obtain directions for particpating in the discussion group by
sending a message to: discussion@www.helpforadd.com.

Just send a blank message to this address and the directions will
be sent to you automatically.  I hope that you will be able to make it
if you have specific questions and concerns that you would like to
chat about.
 

* NEW DATA ON THE POSSIBLE OVERDIAGNOSIS OF ADHD

In recent issues of ADHD RESEARCH UPDATE I have reviewed
several studies which suggest that the majority of children who have
ADHD are not being diagnosed, nor are they receiving any appropriate
treatment for their difficulties.  For example, in several studies in
which large-scale screenings have been done to identify a population
of children who, based on parent and/or teacher behavior ratings, seem
as though they would be likely to meet formal diagnostic criteria, as
many as two-thirds had not been previously identified or treated in
any way.  These data have led some to conclude - and I am personally
quite sympathetic with this view - that the underdiagnosis of ADHD
may very well be a bigger problem than over diagnosis and subsequent
inappropriate treatment with stimulant medication.

A study that was recently published, however, suggests that this
may not necessarily be the case (LeFever, G.B., Dawson, K.V., &
Morrow, A. (1999). The extent of drug therapy for Attention
Deficit-Hyperactivity Disorder among children in public schools.
American Journal of Public Health, 89, 1359-1364.)  In this very
impressive and well-conducted study, the authors' goal was to
determine the extent of medication use for treating ADHD in 2
different communities located in the state of Virginia.  All
students in grades 2-5 in these two communities (a total of
5767 in city A and 23, 967 students in city B) were included in
the study.

Based on the medical records that were made available to the
authors (all identifying information was first removed so that
students' identities remained confidential) by the public schools in
these two cities, they were able to a determine the percent of the
student population in each city who were receiving medication
treatment for ADHD.  Because every child who receives
medication at school needs to have authorization for this by
his or her physician in their school record, these records provide
a complete and accurate estimate of the students in these two
school systems who were being treated with medication for
ADHD.  Excluded from these figures would be students who
had also been diagnosed with ADHD but who were not receiving
medication at school, either because they were not being
treated with medication at all or because they were not taking it
during the school day.  In addition to looking at overall rates of
medication use, the authors were also able to look at whether this
varied significantly according to several basis demographic
characteristics of the students.

Here are the highlights of what they found:

* Overall, the rate of medication use was quite similar in the 2 cities -
   8% in one and 10% in the other.

   Now, these rates are 2-3 times what the commonly accepted prevalence
   rate for ADHD is of between 3-5%.  The 3-5% prevalence rate, however,
   may or may not be entirely accurate.  In fact, many professionals argue
   that we still do not have an accurate estimate of what the prevalence rate
   for ADHD actually is.

* There was substantial variability in the use of medication between
   genders and ethnic groups.

   Not surprisingly, about 3 times as many boys were being treated with
   medication as girls.  ADHD is widely believed to be more common in
   boys than in girls, so this may accurately reflect those differences.  This
   may also reflect the fact, however, that ADHD may be less likely to
   be accurately identified in females even when it is present.

   White children were about twice as likely to be receiving medication
   treatment as black children.  To my knowledge, there is no evidence
   to suggest that ADHD is actually more prevalent in whites than in
   blacks, so it seems very unlikely that a difference of this magnitude
   in medication treatment could accurately reflect the numbers of
   white and black children who had ADHD.  Instead, it suggests that
   either: a. white children were being overdiagnosed; b. black children
   were being underdiagnosed; c. black parents were less willing or
   able to provide medication treatment for their child than parents of
   white children.  It should be noted that this difference in the use of
   medication between black and white children was found even after
   controlling for such possible contributing factors as household
   income.

* Children's age was significantly related to medication use.

   The percentage of children treated with medication for ADHD was
   found to increase with grade.  Here is a statistic that I found to be
   shocking: Among male 5th graders, 18% of white boys in city A
   and 20% of white boys in city B were being treated with medication.

   It is unlikely given what is generaly believed about the prevalence of
   ADHD that such a high percentage of this subgroup of students actually
   had ADHD.  Although no information was collected in this study about
   the accuracy of the diagnoses of ADHD in these children, a question is
   certainly raised about whether many of these children had been incorrectly
   diagnosed.

   Here is a statistic that was especially surprising. One of the characteristics
   the authors looked at was each child's age in relation to the expected
   age for the child's grade.  Thus, they were able to identify children
   who were younger than expected for their current grade as well as
   children who were older then expected.  In each city, approximately
   4% of students were either a year older than expected for their
   grade or a year younger than expected.  For example, in city B, 770
   out of the nearly 24,000 students whose records were examined were
   considered to be young in age relative to their grade mates.

   In city A, they found that students who were old for grade were
   about 60% more likely than other students to be receiving medication
   treatment for ADHD.  In city B, however, 62.7% of the young-for-
   grade students - 483 out of 770 children who were considered young
   for their grade - were being treated with medication for ADHD.
   Compared to other students, those who were young-for-grade
   were 21 times more likely than students who were not young-for-
   grade to be receiving medication.

   Clearly, it seems unreasonable to believe that nearly 2/3s of young-for-grade
   children in this city actually had ADHD.  Instead, one can not help but wonder
   whether the expectations that were held by parents and professionals in this
   community for children who were slightly younger than their classmates were
   somehow inappropriate, and contributed to this dramatically high prevalence
   rate in this subgroup of children.  For example, one can speculate that when
   children who were young-for-grade began kindergarten, they may have been
   somewhat more active and inattentive than their older classmates.  Perhaps
   this resulted in many of these children being incorrectly diagnosed with ADHD
   and started on medication, and they simply continued to take it with no
   ongoing evaluation of the appropriateness of, or need for, this treatment.
   This is the explanation for these results that the authors of the study suggested -
   as a speculation - when I discussed this with her recently.

What can be concluded from results such as these?

The high prevalence rates that were found suggest that ADHD
was overdiagnosed and over-treated among some groups of children -
especially older white boys and children in one of the cities who were
young relative to their grade mates.

Please keep in mind that these findings should not be used to aruge that this is
occurring all over the country in a systematic way.  Recall other studies
reviewed in this newsletter where it has been found that a large percentage of
children who are likely to have ADHD are not receiving any treatment at all.

This is very important to keep in mind when results such as those from
the current study are used to argue what a problem overdiagnosis of ADHD
and overtreatment with medication is in this country.

Instead, I think these data clearly indicate that there are important regional
variations - or, community-by-community variations - in the extent to which
either under-identificiation and under-treatment or over-identification and
over-treatment of ADHD may be occurring.  To a large extent, this may depend
on the procedures the school system has in place for identifying children
with ADHD, as well as the inclination of the medical professionals in that
community who would ultimately make the diagnosis and prescribe
medication when they felt that was appropriate.

As was reported in the May, 1999 issue of ADHD RESEARCH UPDATE,
however, current pediatric practices do not provide good reason to
be optimistic about the thoroughness with which these evaluations and
treatment decisions are often made.  A systematic survey conducted on
a nationally representative group of pediatricians indicated that fewer
than 40% used current DSM criteria when making their diagnoses
(for a list of current criteria click here).  In addition, barely 50% obtained
any kind of systematic behavior rating scale data from parents and
teachers.  In fact, the majority reported that no direct feedback from
teachers was obtained at all in the evaluation process.

So, as the current study points out, we still have a long way to go to
insure that children who are diagnosed with ADHD are done so using
appropriate procedures.  Both underdiagnosis and overdiagnosis are
problems that exist today and which clearly needs to be addressed.

* ADHD IN GIRLS

One of the important shortcomings of most of the research based information
on ADHD is that the vast majority of studies have been conducted solely
on boys, or, have included very few girls in the sample.  As a result, the
scientific literature on ADHD is almost exclusively based on male subjects.

Recently, a study funded by the National Institute of Mental Health on a
large group of girls both with and without ADHD was published in the
Journal of the American Academy of Child and Adolescent Psychiatry
(Biederman, J. et al., (1999). Clinical correlates of ADHD in females:
Findings from a large group of girls ascertained from pediatric and
psychiatric referral sources.   Journal of the American Academy of Child
and Adolescent Psychiatry, 38, 966-975.  In this study, the authors
examined the clinical correlates of ADHD in girls so that similarities
and differences with what has been found among boys with ADHD could
be ascertained.  This study represents the largest and most comprehensive
study of girls with ADHD that has been published to date.

Participants in this study were girls between the ages of 6 and 18.  There
were 140 girls who had been diagnosed with ADHD based on structured
psychiatric interviews conducted with the child's parent(s).  In addition,
122 girls of similar ages and other backgrounds who did not have ADHD
were included as comparison subjects.  These two groups of girls were
compared on a wide variety of characteristics so that the researchers
could learn about the problems associated with ADHD in females
specifically.  The major findings are summarized below.

* Among the girls who were diagnosed with ADHD, 59% had the
combined type (i.e. both inattentive and hyperactive/impulsive
symptoms), 27% had the Predominantly Inattentive type, and
only 7% had the Predominantly Hyperactive/Impulsive type.

Overall, a significantly greater proportion of symptoms of inattention
were present according to parents relative to either hyperactive or
impulsive symptoms.

* Girls with ADHD were significantly more likely to be diagnosed with
other disorders as well.

Compared to girls without ADHD, girls with ADHD were more likely
to be diagnosed with co-morbid conduct disorder, oppositional defiant
disorder, mood disorders, anxiety disorders, and substance use
disorders.  Tic disorders and enuresis (i.e. bed wetting or day-time
wetting) were also more common in the girls with ADHD.

Overall, 45% of the girls with ADHD were diagnosed with at least one
other condition.  Only 4% of the girls with ADHD had more than 2
co-morbid disorders, however.

Although the rate of co-morbid behavior disorders in girls with
ADHD was high, it was still no more than half of the rate that has
been previously reported for boys.   Because disruptive behavior
disorders are one of the main reason that children get identified and
referred for treatment, the authors speculate that the lower incidence
of these problems in girls with ADHD may partially explain the marked
gender differences that are often found in children with ADHD who
are receiving clinical treatment.

The rate of mood and anxiety disorders in girls with ADHD was quite
similar to what has been previously found in boys.  Contrary to what
some have suggested, there was thus no evidence in this sample of
children that girls with ADHD are more likely than boys to have problems
in these areas.  There was, however, an indication that problems with
substance use were more common among girls with ADHD than has
been previously found to be true for boys.  For example, girls with
ADHD were about 4 times as likely to be smokers.

* Cognitive, school, and family functioning

Girls with ADHD had scores on measures of intellectual functioning
and academic achievement that were modestly lower than what was
found in the non-ADHD girls.  They were also about 2.5 more likely
to be diagnosed with a learning disability, more than 16 times more
likely to have repeated a grade in school, and almost 10 times as
likely to have been placed in a special class at school.  It is perplexing
why girls with ADHD were so much more likely to have repeated a
grade given that the difference in the academic achievement test scores
were, although lower, not so dramatically different from other girls.
I think this may reflect that fact that achievement testing - which is
done on an individual basis - tends to reflect the highest level of work
that children are capable of.  In many instances, this is quite a bit
higher than the level that a child with ADHD actually performs at
on a day to day basis.  So, these data may reflect the debilitating effect
that ADHD has on a child's typical school performance, which can
result in grade retention and special class placement even for children
who are quite bright and capable.

The parents of girls with ADHD also described their family life as
less cohesive and reported greater amounts of conflict with their
daughters.

CLINICAL IMPLICATIONS

The results of this study make clear that ADHD in girls is as serious a
condition and has a comparably large negative impact on children's
functioning and adjustment as it does in boys.  Overall, the correlates
of ADHD in girls were remarkably similar to what is known to be
true for boys.  Among the few differences found were that girls were
less likely to be diagnosed with a co-morbid behavior disorder than
boys (i.e. oppositional defiant disorder or conduct disorder) and perhaps
more likely to have problems related to substance use.   Rates of mood
and anxiety disorders, and impairment in academic functioning appeared
to be quite comparable.

The lower rates of disruptive behavior problems, along with the
preponderance of inattentive symptoms relative to hyperactive/impulsive
symptoms, may partially explain why ADHD in girls may often not be
recognized.  Because rates of mood and anxiety disorders were similar to
what has been found in boys, the authors speculate that in conjunction with
the lower levels of disruptive behavior and hyperactive/impulsive symptoms,
this may lead clinicians to diagnose girls with the former types of disorders
rather than ADHD.   As you may recall from a study recently reviewed in
ADHD RESEARCH UPDATE, pediatricians were significantly more likely
to diagnose boys with ADHD than girls, even when the problems described
by parents were quite comparable.

The authors stress that clinicians need to be aware that, despite their
lower rates of disruptive disorders, ADHD in girls is a serious condition
associated with impairment in multiple areas of children's functioning.
Thus, there is no reason to assume that the treatment of girls with ADHD
should be any less aggressive or comprehensive than that of boys.

Parents need to be aware that their daughter with ADHD is at significantly
increased risk for a variety of other conditions as discussed above.  In
fact, in this study, almost 50% of girls with ADHD had at least one other
diagnosable disorder.  It is thus essential that as is true for boys, evaluation
of girls for ADHD take a broad look at their emotional, behavioral, social,
and academic functioning so that a comprehensive treatment plan addressing
all areas of important difficulty can be developed and implemented.  Too
often, even if ADHD in females is identified, necessary attention to areas
of difficulty apart from core ADHD symptoms may not be targeted in a
child's treatment, or may not be addressed in the most helpful way.  In
particular, given the indication of possible increased risk of substance use
in girls with ADHD, this may be an area that is especially important for parents
to monitor.

There are several limitations to this study that the authors acknowledge.
First, the girls with ADHD were referred from both psychiatric and
pediatric facilities/practitioners, and the degree to which they are
representative of girls with ADHD in the general community can not
be determined with any certainty.  Thus, it is quite possible that the
girls in this study were more impaired than would be girls with ADHD
from the general population.

In addition, it is clear that research on treatment specifically in girls with
ADHD is sorely needed.  Currently, most of the data on both medical
and non-medical treatment of ADHD is also based predominantly on
boys.  To my knowledge, there is currently no clear indication of any
known differential effect for various treatments that is specifically
related to gender, but this may be partially because the studies that
are required to carefully look at this issue have not really been done.
As such studies are published, I will certainly be sure to include them
in the newsletter.

* THE RELATIONSHIP BETWEEN MEDICATION TREATMENT
   FOR ADHD AND SUBSTANCE  ABUSE

An ongoing source of concern for many parents and clinicians about
the use of stimulant medication for treating children with ADHD is
that it will increase the risk that these youth will develop SUDs
(i.e. substance use disorders) later in life.  Given the documented
potential for abuse of stimulant medications, and the widespread use
of this form of treatment, such concerns are understandable.

If, in fact, a link between treatment of ADHD with stimulant medication
and an increased risk of SUDs were found, it would have enormous
implications.  In this case, parents and clinicians would need to weigh
the potential benefits of stimulant medication treatment against the
potential increased risk of SUDs.  Although longitudinal studies
conducted to date have not indicated any increased risk for SUDs
among ADHD youth who were treated with stimulant medication,
the designs of these studies have not permitted strong conclusions -
especially long-term conclusions - about this important issue to be
made.

A recently published study, however, provides the most compelling
data to date on this important issue (Biederman et al.; (1999).
Pharmacotherapy of ADHD reduces the risk for substance use
disorder. Pediatrics, 104, p. e20.).  Although the title of this paper
makes the authors' conclusion pretty clear, these are very important
data and warrant a careful look.

In this study, the authors began with 140 children who met strict
diagnostic criteria for ADHD.  These children were between the
ages of 6-17 at the time of the initial assessment and 75% were
receiving, or had previously received, medication treatment for
ADHD.  One hundred and twenty other children of similar age
without ADHD were identified as control subjects.  All participants
were evaluated at this time for a wide range of emotional and
behavioral difficulties, including problems related to substance
abuse.  Comparable information from the parents and siblings
of these children were also obtained.

Four years later, a follow up assessment was conducted.  Although
a wide variety of outcome data was collected at this time, the
outcomes of particular interest in this paper were problems related
to substance use that had developed during the prior 4 years.
The rates of various types of SUDs were compared and contrasted
among 3 different groups: 1. children with ADHD who were being
treated with medication at the initial assessment; 2. children with
ADHD who were not receiving medication treatment at the initial
assessment and had not received such treatment in the intervening
4 years, and, 3. non-ADHD control children.

As might be expected, the gender and age composition of the children
in these groups was not equivalent.  To correct for these demographic
differences, the authors elected to limit their analyses to children
in each group who were males, and who were at least 15 years old
at the time of follow up.  This resulted in a final sample of 56 children
with ADHD in the medication group, 19 children with ADHD in the
nonmedicaiton group, and 137 children in the control group.

What were the rates of different types of SUDs in these 3 groups?
The data are presented below with the entries indicating the % of
teens in each group with the particular SUD.

                            Medication       No Medication        Control

Alcohol                        25%                    75%                    18%

Marijuana                    16%                    68%                    15%

Stimulants                     2%                       5%                       0

Cocaine                        2%                     16%                       1%

Tobacco                      34%                    32%                    16%
 

As is clearly evident in the figures above, children with ADHD who
had not been treated with medication had higher rates of substance
use problems than those who had been treated.  Rates of substance
use for children who had received medication treatment was not
appreciably different from control subjects (i.e. marijuana, stimulants,
and cocaine).

In addition to these descriptive analyses, rigorous statistical tests
were conducted so that other factors that could possibly explain
different rates of SUDs between the 3 groups could be controlled
for.  Specifically, these analyses examined whether significant
differences in SUDs were still found after controlling for rates
of Conduct Disorder, socioeconomic status, baseline problems
with substance use/abuse, and parental history of substance use.
By comparing rates of SUDs between medication-treated and
nontreated youth after controlling for all these different factors, the
authors are able to have greater confidence in whether differences
that remain can be attributed to the different treatment that they
received.

The results of these analyses were clear.  Even after controlling
for these other factors, youth with ADHD who had received
medication treatment were significantly less likely to show
problems with substance use at follow-up than the untreated
children.  In fact, children who had not received medication
treatment were about 6 times as likely to have some type of
SUD as were treated youth.

IMPLICATIONS AND LIMITATIONS

These data should provide some measure of comfort to parents
and clinicians by showing that it is unlikely that medication treatment for
ADHD will increase the risk of a child becoming a substance abuser
during adolescence.  In fact, it appears that medication treatment
may actually protect children with ADHD from developing these
types of problems.

Although these results are quite encouraging, there are limitations
to the study that should be considered.  First, the sample size
is relatively small.  In particular, there were only 19 subjects
with ADHD who had not received medication treatment.  Even
though statistical tests take sample size into account, it would
still be important to replicate these results with a larger sample.
Of course, the need to replicate results, particularly important
results such as these, is true for any study.

Second, because the study was limited to males, one can not
assume that similar reductions in SUDs for girls with ADHD
who were treated with medication would be found.  This
is an especially important issue given the findings reported
above which suggest that females with ADHD may be even
more likely than boys with ADHD to develop substance use
problems.  In addition, one can not assume that the findings
would generalize to an older group of subjects.  Thus, whether
the reduced rate of SUDs in medication treated subjects would
be found if a second follow up assessment were conducted
when subjects were older, is an open question.

It is also the case that one can not be certain whether it was
medication treatment itself that resulted in lower SUD rates
among children in this group.  For instance, it is possible
that parents who provided their child with medication
treatment also did other things for their child that the other
parents did not.  Perhaps it was these other treatments that
the children received that reduced their risk of developing
substance use problems.

Finally, because information on the type of medication that
children had received was not provided, differences between
stimulants and other forms of medication in relation to SUDs
can not be ascertained.  Because the vast majority of children
with ADHD are treated with stimulants, however, it is certainly
reasonable to assume that this would be true for the children
in this study as well.

These considerations aside, the results of this study clearly
suggest that rather than increasing the risk of substance use
problems for children with ADHD, medication treatment
may actually reduce the chances that this will occur.

As noted above, this should provide some measure of relief
for parents who have struggled with this concern.  In my
opinion, this study is a very important addition to the literature
on the risks and benefits associated with medication treatment of
ADHD.

* ADHD AS A PUBLIC HEALTH PROBLEM: REPORT ON
   A RECENT MEETING SPONSORED BY THE CENTER FOR
   DISEASE CONTROL (CDC)

Last week I attended a meeting in Atlanta that was sponsored by
the Centers for Disease Control (i.e. the CDC).  The meeting
was attended by individuals from the medical, mental health,
and educational fields, as well as by a number of advocates for
children and adults with ADHD.  Presenters at the meeting included
many of the most well regarded researchers on ADHD in both
children and adults.

There was a tremendous amount of interesting and important
information covered at this meeting.  I will try to convey what I
think are some of the important highlights.
 

The CDC regards ADHD as a significant public health problem
and seems committed to funding research and programs to
address this.

This was quite encouraging.  Although there may be areas in
the country where ADHD may be overdiagnosed and overtreated
(Note: the article reviewed above was discussed several times),
the consensus among presenters was that the majority of children
with ADHD are never identified and do not receive any
appropriate treatment.

There was general agreement that there is little accurate information
on what the costs to children, families, and society are for
untreated and/or improperly treated ADHD.  This is more than
an academic issue: several people involved in policy making
stressed how an accurate assessment of these cost figures are
important for getting the attention of policy makers and government
agencies to provide increases in research and treatment funding.

The CDC appeared interested in funding such studies along with
efforts to educate the public about appropriate evaluation and
treatment options for individuals with ADHD.
 

Although ADHD can be reliably and accurately diagnosed when
a thorough and competent evaluation is performed, there is
tremendous variability in the adequacy of the evaluations that
children receive.

Many participants seemed to believe - at least this is how it
seemed to me - that the standard of care received by many children
with ADHD is not nearly as high as it should be.  This includes
initial diagnostic procedures and subsequent treatment and treatment
monitoring.  Among the concerns cited were:

* Inconsistent use of DSM-IV criteria or any standardized diagnostic
criteria;

* Failure to use standardized behavior rating measures and to obtain
feedback directly from children's schools in the evaluation process;

* The absence of attention to carefully evaluating children for comorbid
conditions (more on this below);

* The lack of systematic procedures for evaluating children's response
to treatment and for monitoring children's treatment over time.
 

The American Academy of Pediatrics is in the midst of preparing a set
of evaluation and treatment guidelines to be used by practitioners.
Hopefully, the dissemination of these guidelines will lead to more uniform
and better quality care.
 

The biggest risk to the long term development of children with ADHD
seems to be the development of comorbid conditions - particularly
Conduct Disorder.

Very compelling data was presented by Dr. Rachel Klein of the New York
State Psychiatric Institute on a long-term follow up study of children who had
been diagnosed with ADHD and then followed into young adulthood.

The results of this study were quite clear and equally striking:

Children with ADHD were substantially more likely to develop Conduct
Disorder than children without ADHD.  (For a description of Conduct
Disorder and the diagnostic criteria for CD go here.)

Children with ADHD who developed CD were at substantial risk for
young adult criminal behavior and substance abuse.  In contrast, children
with ADHD who did not also develop Conduct Disorder were no
different from children without ADHD on these outcomes.

Dr. Klein was quite clear that, in her opinion, much of the long-term
risk associated with ADHD is carried by these co-morbid
conditions.  The hypothesized developmental path is that ADHD
increases the likelihood of serious behavior disorders like
CD, and that once such behavior disorders develop, the child is at
substantially increased risk for all kinds of negative outcomes.

A key goal to focus on in the treatment and management of children with
ADHD therefore, is to prevent the development of these comorbid
conditions.

Unfortunately, as noted above, it was stressed that primary care
physicians - who treat the majority of children with ADHD in this
country - often fail to pay close attention to this aspect of children's
development.

In fact, it was suggested that the failure to carefully evaluate children
for comorbid difficulties (these include not just CD, but Oppositonal
Defiant Disorder (ODD), mood disorders, anxiety disorders, and learning
disabilities) is one of the most important gaps in how children with ADHD
are cared for.

This is why it is important for parents to be aware of what is involved in
a careful and comprehensive evaluation for ADHD.  (You can find a
discussion of suggested evaluation guidelines here.)  Also, it is essential
to be clear with your child's treatment provider how specific problems
that your child may be having are going to be addressed and targeted in
treatment.

For example, it is important to clearly identify all the important aspects
functioning where a child is having difficulty (e.g. academics, peer
relationships, self-esteem, behavior) and being certain that the child's
treatment is actually targeting these different areas.  For some children,
a good response to medication may address many or even all of the
child's difficulties.  For other children, however, this will not be the
case at all.  This is why carefully monitoring a child's progress in
different domains is so essential: if a child continues to struggle in
some areas even though things are improving in others, than additional
interventions specifically focused on the still problematic areas
need to be incorporated.

Despite the demonstrated efficacy and safety of stimulant medications
for treating children with ADHD, there are important gaps in
knowledge in this area that need to be addressed.

Several areas of potential concern were noted here including:

1. The long-term efficacy of stimulant medication treatment is unknown.

It is important to note that a main reason for this is that the impact of
well conducted stimulant treatment over a period of many years
has not been conducted.  It is not the case, as is sometimes suggested
by opponents of medication treatment, that such studies have been
conducted and have found no benefits for long-term medication
treatment.

To date, the longest period of time that children receiving well-
conducted medication treatment have been followed is 14 months.
This is the initial data from the NIMH Multi-Site Treatment Study
that will be published shortly.  In this study, significant and
substantial benefits of medication treatment over this period have
been found.

What is needed, however, is a study which follows children who
are treated with medication into adolescence and beyond to
document meaningful gains in important life outcomes.  Note
that there is already suggestive evidence of such benefits as
indicated in the study reviewed above on substance abuse and
medication treatment.

2. Although stimulant medications are considered to be quite safe,
we do not know much about the following:

a. What is the impact, if any, on adult stature for children who
take medication for an extended period, including during their
growth spurt?  Although the ultimate effects on adult stature are
believed to be negligible, there were questions raised about
whether larger effects could occur for children who were
maintained continuously on medication across their high
growth years.

For many children, this may be a reason why medication
holidays over the summer should be strongly considered if
the child is able to manage reasonably well without medication
when not in school.  This would certainly be a reasonable
issue to discuss with your child's doctor.

b. Stimulant medications are being increasingly used to treat
preschool children.  It was emphasized that very little is known
about the possible impact on brain development in preschool
children.

c. Stimulant medications are being increasingly prescribed in
combination with other psychiatric medications.  It was stressed
that there is no documented evidence for the efficacy of combined
medication treatments and there was concern that this "poly-pharmacy"
approach is being used too often.  Questions about the long-term
safety of combined medication regimes also need to be carefully
considered.

I think it is important for parents to be very careful about having their
child treated with multiple medications.  Personally, I would want my
child's doctor to be extremely clear about why h/she thought multiple
medications were needed, and how we were going to be able to
evaluate the effect of the different medications being used.

These were some of the major themes of the meeting.  There is likely
to be a follow up to this meeting, or an official report that will be
issued.  I'll be on the look out for this and will include relevant
information in future issues of ADHD RESEARCH UPDATE.

Thats all for this month...

I hoe that you enjoyed this issue of ADHD RESEARCH
UPDATE and found it to be informative.

As always, please feel free to share this information
with others you know who may be interested in it.
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See you next month.

David Rabiner, PhD
Licensed Psychologist
Duke University

P.S. I continue to offer individual consultation via
phone for parents who are seeking suggestions about
ways to deal with specific questions and concerns that
they have.  You can learn more about this service by
clicking here.