*******************************************************
ADHD RESEARCH UPDATE - Vol. 23, September, 1999
*******************************************************Announcements -
* Next on-line discusscussion group
* New subscription option for health care professionals
* A program for conducting careful medication trials
* Referral Appreciation Program
In this issue...
* The impact of ADHD on siblings
* Teachers' ratings of adolescents with ADHD: Do
different teachers see the same thing?* Does methylphendiate cause tics?
* The emotional experience of children with ADHD
- READER QUESTION -
"My child has been diagnosed with ADHD but I was
unable to obtain any special services at school for him
last year. What is the process for going about this?"
______________________________________________* NEXT ON-LINE DISCUSSION GROUP
The next on-line discussion group for subscribers to
ADHD RESEARCH UPDATE will be held on
Thursday, September 16th at 9:00 PM EST. To
receive instructions for participating in the chat,
just send an e-mail message to discussion@www.helpforadd.com
and they will be sent to you automatically.* NEW SUBSCRIPTION OPTION FOR HEALTH
CARE PROFESSIONALSIn response to several requests, I recently began a
new subscription option for health care professionals
that enables you to provide ADHD RESEARCH
UPDATE to all the families you work with at a
very reasonable rate.You can learn more about this option by clicking
here.If you decide to sign up for this option, just indicate
that you are a current subscriber where you are asked
if you were referrred by anyone, and your original
subscription charge of $19.95 will be credited
towards the new charge.Parents: Please let your child's physician know about this
option. If he or she decides to subscribe under the new
option, I will refund your original payment as well.
Just make sure he or she lets me know that you made
the referral.* REFERRAL APPRECIATION PROGRAM
I want to thank those of you who have recently referred
a friend to subscribe to ADHD RESEARCH UPDATE.
You should be receiving a message from me to confirm
that your own subscription will be extended by 4 months
in appreciation of your referral. If you did refer someone
who subscribed, and you do not hear from me about this,
please get in touch. Despite my best efforts to stay
organized, this does not always happen and I want to be
sure that you receive credit for your referral.
________________________________________________* THE IMPACT OF ADHD ON SIBLINGS
What is it like for a child when one of his or her
siblings has ADHD? What are the kinds of issues that
children in this situation tend to struggle with? This
is an extremely important area for parents and professionals
to attend to and almost no research on this topic exists.That is why I was so pleased to recently locate a study
in which this issue is examined (Kendall, J., Sibling
accounts of ADHD. Family Process, 38, Spring, 1999, 117-136).
I found this to be a wonderful study, even though the
information presented is somewhat upsetting.Because so little work has been done in this area, the
author elected to conduct a qualitative rather than a
quantitative investigation. Rather than collecting rating
scale data, or other kinds of data that could be translated
into numbers and then analyzed statistically, the approach
was to gather as much in-depth information as possible
about the experience of children who live with a sibling
who has ADHD.This was done by conducting a series of in-depth interviews
with children and parents in 11 families. These families
were participants in a larger study on the family experience
of living with a child with ADHD. Thirteen non-ADHD
siblings, 11 biological mothers, 5 biological fathers, 2
stepfathers, and 12 boys with ADHD each participated in
2 individual interviews and 2 family interviews. Eight of
the 13 non-ADHD siblings were younger than their ADHD
brother and 5 were older. Seven were boys and 6 were girls.
The average age of the boys with ADHD in these families was
10. None of the children with ADHD were girls. Five of
the boys diagnosed with ADHD had also been diagnosed with
Oppositional Defiant Disorder. Three of the families were
of low income and receiving federal assistance. The other
8 families were of either middle or upper middle socioeconomic
status.In addition to collecting data by interview, written diaries
were also kept by the non-ADHD siblings. These children were
asked to write in there diaries once a week for 8 weeks
regarding their account of a critical incident - either
particularly good or particularly bad - that related to
ADHD. These diaries, along with the interviews that were
were audiotaped and transcribed, formed the data base that
was used to examine common themes in the lives of siblings.
The goal was to identify the major themes that emerged
across the accounts of the 13 different siblings who
participated.The author emphasizes that the findings to emerge represent
only one possible account of the sibling experience, and
should be considered as tentative. Because these accounts
were provided spontaneously by siblings themselves, however,
it is reasonable to believe that they capture important
aspects of the experience for many children.From the massive amount of data collected - over 3000 pages
were transcribed - 3 major categories of the sibling
experience were identified. These categories were disruption,
effects of disruption, and strategies for managing disruption.
An overview of the experiences represented by these different
categories is presented below. An extremely rich set of
descriptive data was presented, and I will do my best to
capture this for you.DISRUPTION
Disruption caused by the symptoms and behavior of their
brother with ADHD was the most central and significant problem
identified by the siblings. Children described their family
life as chaotic, conflictual, and exhausting. Living with
a sibling with ADHD meant never knowing what to expect next,
and children did not expect this to end.Seven types of disruptive behavior were identified. These
included: physical and verbal aggression, out-of-control
hyperactivity, emotional and social immaturity, academic
underachievement and learning problems, family conflicts,
poor peer relationships, and difficult relationships with
extended family. These are the different problem areas
that the siblings of ADHD brothers indicated as being most
disruptive to their lives and to their family.Although these types of disruption were reported consistently
across the 13 siblings, there were, of course, important
differences in the extent to which children reported themselves
to be adversely affected. Children who were most affected
lived in families where the sibling with ADHD was an adolescent,
with more than one sibling or a parent who had ADHD, and
where the sibling with ADHD was more aggressive which
went along with having ODD in addition to ADHD. Among
all siblings, however, it was clear that that the vast majority
of family disruptions were attributed to their brother with ADHD.There were several different types of disruptive patterns
that were identified. These included the child with ADHD
doing something that needed immediate attention, younger
siblings mimicking disruptive behavior, seeking revenge on
the sib with ADHD, or parents allowing the child with ADHD
to "run wild". Children described family life as focusing
on their sibling with ADHD and of constantly having to
adjust to the disruption and the negative effects it had on
themselves and family life.EFFECTS OF DISRUPTION ON SIBLINGS
The disruptive effects of their ADHD siblings were experienced
by children in 3 primary ways: victimization, caretaking, and
feelings of sorrow and loss. These are described below.Victimization
Siblings reported feeling victimized by aggressive acts from
their brothers with ADHD through overt acts of violence,
verbal aggression, and manipulation/control. Although the
most severe acts of aggression were reported by boys whose
ADHD sibling also met diagnostic criteria for Oppositional
Defiant Disorder, every sibling interviewed reported
feeling victimized to some degree by their ADHD brother.Although not all acts of aggression reported would be
considered severe, all were perceived by siblings to be
destructive to their sense of safety and well-being. They
also reported that parents often minimized and did not
believe the seriousness of the aggression. Thus, while
parents tended to attribute such behavior to normal sibling
rivalry, none of the children interviewed experienced their
brother's aggression in this way.Many children reported that they were easy targets for
their brother's aggression because their parents were either
too exhausted or too overwhelmed to intervene. Interestingly,
this impression was confirmed by many of the ADHD children
themselves, who noted that they could get away with hitting
their sibling while they would get in trouble for such
behavior at school.Overall, siblings of boys with ADHD tended to report feeling
unprotected by parents and were resentful of the degree to
which family life was controlled by their brother. They
often worried about the ADHD child "ruining" potentially
fun activities that were planned and no longer looked forward
to certain events because so much depended on how their
brother with ADHD would behave.Feelings of powerlessness was a commonly expressed sentiment.
As children became increasingly resigned to their situation,
many seemed to develop an image of themselves as unworthy
of attention, love, and care, and experienced feelings of
rejection from their parents.Caretaking
Many siblings reported that they were expected to act as
their brother's caretaker. Both younger and older siblings
talked about how parents expected them to befriend, play
with, and supervise the ADHD child. Among the caretaking
activities that children reported being expected to perform
were: giving medication, helping with homework, intervening
with other children and teachers on behalf of their brother,
keeping their brother out of trouble, and getting their
brother involved in activities when parents were exhausted.Although 2 of the 11 siblings reported positive feelings
and pride about taking on such a role, the others said this
was quite difficult because they were expected to care for
their brother even though they were frequent targets of his
aggression. They also reported feeling that although they
were supposed to provide relief for parents, they never
received any relief themselves.Children expressed resentment that they often felt responsible
for their brother's care even though they had no input into
the decision-making. Many felt caught in the middle - having
to care for and supervise their brother while being attacked
and victimized by him.It is important to note that parents tended to regard such
caregiving as what siblings do for one another, and did not
regard it as anything particularly difficult or extraordinary.
The children themselves, however, felt very differently
about this.Feelings of Sorrow and Loss
Many siblings of boys with ADHD reported feeling anxious,
worried, and sad. They yearned for peace and quiet and
mourned not being able to have a "normal" family life.
They also worried about their sibling with ADHD - about his
getting hurt by other people and getting into trouble.Children reported feeling that parents expected them to
be invisible - to not require too much of their attention
and help since they were consumed caring for their child
with ADHD. Many felt ignored and overlooked much of the
time. They reported trying not to burden their parents
any more then they were already burdened. They felt their
needs were minimized by parents because they seem so much
less significant than the needs of the ADHD child.Some of these sentiments, of course, could be considered to
be part of the competition for parental attention that is part
of many sibling relationships. The author suggests, however,
that these feelings are much more pronounced in siblings
of a child with ADHD. It would have been quite instructive
to collect similar data from children with non-ADHD siblings
to see how such feelings compare.Strategies to Manage Disruption
Three of the 10 siblings reported that they dealt with their
brother's behavior by fighting back. All 3 of these children
had been diagnosed with Oppositional Defiant Disorder. Whether
their aggressive behavior arose purely in response to the
attacks of their ADHD sibling, or reflected other important causes
as well, could not be determined.The majority of siblings, however, responded to the situation
with their ADHD brothers by learning to avoid and accommodate
themselves to their brother. The process they described was
a transformation of intense anger about how they were being
treated, to sadness and resignation. In some children, this
process appeared to result in clinical depression.Some of the statements that children made about dealing with
their sibling are really quite telling."I've learned to check and see how he's feeling before I
even say hi when I come home from school. If he looks upset
I don't say anything because I know he will yell at me. I
dread coming home sometimes.""I've learned not to talk to him about what's important to me
because he won't listen or he'll say its stupid. So, I only
talk to him about what he wants to talk about and that way
he won't get mad at me.""I just try to stay out of his way most of the time and go
with the flow."Overall, 10 of the 13 siblings interviewed in the study
thought they were severely and negatively affected by their
brother with ADHD.Implications
It is important to put the results of this study into the
proper perspective. As the author points out, these findings
are based on a small sample of ADHD children and their
siblings, and the experiences of the siblings in this study
may not necessarily be representative of what many children
experience. Certainly, one would expect that some children
with ADHD siblings have very positive relations with their
sib and within their family. One can and should not assume,
therefore, that children in one's own family are necessarily
having a similar set of experiences.As noted previously, it would be helpful to consider these
children's reports in comparison to what children who live
with non-ADHD siblings describe. This would help
differentiate what may be more typical feelings that children
with siblings have from what may be unique to children who
have a sibling with ADHD.The children in this study all had brothers with ADHD. One
can certainly not assume that the experience of children with
a sister who has ADHD would be similar. This would be a
very interesting and important issue to examine in future
research.It is also possible that children's reports of their experience
may not necessarily reflect the actual reality of their situation.
They may feel frequently victimized by their ADHD brother and
overlooked by their parents when this is not truly the case.
Certainly, it is not uncommon for children to feel they are
being treated unfairly by sibs and parents, and this could
certainly have contributed to what these children had to say
about their situation.These caveat aside, these data have important implications and
I think need to be taken quite seriously. The description provided
by the children in this study is certainly consistent with
what I have observed in many of the families I have worked
with.There are several things that parents can do to minimize the
likelihood of their child without ADHD having the type of
experience described here. An important place to start would
be to think carefully about how the experiences shared by the
siblings in this study fit with what may be going on for your
own children. It is difficult for any parent to recognize
that one of their children is being victimized - even when it
is by their other child. The parents in this study, as you
recall, tended to minimize the reports of siblings and to
attribute what was going on to normal sibling rivalry. The
children themselves, however, had a very different perspective.The same applies to taking a careful look at how much one is
expecting a child to care for his/her sibling. These children
tended to feel burdened by caretaking responsibilities when
parents believed it was what siblings do for each other. Asking
oneself what your own family's expectations are and whether or
not they are reasonable could be quite useful. I have to say reading
this provided an important wake up call to me.Sibling reports of aggression/violence need to be taken
seriously. There can be an almost reflexive reaction to
deny or minimize such accounts, which can leave a child feeling
very much alone and unprotected.As difficult as it can be in busy families, making the effort
to spend special time alone with the non-affected sibling can
be enormously helpful. These children were reluctant to
make demands of their parents because they saw them as so
overburdened trying to manage their sibling. They, of course,
need parental attention as well, and making sure that it is
provided can go a long way to helping a child feel better
about his or her situation in the family.For health care professionals, I think these results highlight
the importance of paying close attention to the siblings
of a child with ADHD in an overall evaluation and treatment
plan. A focus on how to maintain a reasonable family life
in spite of the disruption caused by behaviors related to
ADHD may be important for many families. Looking back on
my own practice, I now recognize how often I failed to consider
the needs and experiences of siblings as fully as may
be necessary.The impact on family members of children with ADHD, particularly
on siblings, is an important but under-researched area. This
qualitative study is an important initial step to learn more
about this. I am concerned that the findings of this study
may be disconcerting to some readers and sincerely hope that
if this is the case, you are able to take positive steps to
addressing issues that you feel are important.
* TEACHERS' RATINGS OF ADOLESCENTS WITH ADHD:
DO DIFFERENT TEACHERS SEE THE SAME THING?When children move into middle school, they generally go from
having a single primary teacher to as many as 5 different
teachers for core subjects. As one might expect, the relationships
established with different teachers often differs, and a child may
get along well in several classes but have important difficulties
in others. This can be especially frustrating for parents who
have a teen ager with ADHD, because the behavior and
academic performance of students with ADHD tends to be more
erratic and inconsistent to begin with. Knowing what to make of
these sometimes very different reports can be particularly
important when it comes to treatment issues and to determining
whether any modification/adjustment to a child's medication may
be warranted.Just how closely do the behavior ratings that teachers provide
of students with ADHD agree? This important question was examined
in a recently published study (Molin, B.S., Pelham, W.E.,
Blumenthal, J., & Galiszewski, E. (1998). Agreement among
teachers' behavior ratings of adolescents with a childhood
history of ADHD. Journal of Clinical Child Psychology, 27,
330-339.In this study, behavior ratings of 66 adolescent boys were
obtained from multiple teachers using standardized behavior
ratings scales. The ratings scales used were the Teacher
Report Form, the Iowa/Abbreviated Conners, and the Disruptive
Behavior Disorders Rating Scale. Ratings from 2 to 5
teachers were collected for each child. At the time that
the teacher ratings were collected, the boys ranged in age
from 13 to 18. All had received a diagnosis of ADHD several
years earlier. Whether they still carried a diagnosis of
ADHD at the time of the study was not indicated, and information
on the treatment adolescents were receiving at the time is not
noted. I would assume, however, that since these teens were
part of an ongoing study, that the majority were receiving
some type of treatment at the time.The teachers completing the rating scales included both regular
education teachers (78%) and special education teachers (22%).
Teachers of primary academic courses (68%) and specialty courses
such as art and music were included (32%).Although the precise level of agreement between different
teachers varied somewhat depending on the particular behavior
rating scale examined (i.e. TRF, Iowa/Conners, or DBDRS)
the general level of agreement between teachers was generally
no better than moderate.In general, agreement between teachers that a student was not
displaying clinically significant problems with attention and/or
hyperactivity was pretty good. Thus, the majority of students
were rated as being in the "normal" range by their different
teachers who provided the ratings. This probably reflects the
fact that the children's symptoms were being managed well by
the treatment they were receiving, as well as the possibility
that the symptoms of some students had diminished over the
years to the point that they were no longer creating clinically
significant impairment.What about the agreement between a child's different teachers
when at least one of the teachers rated the child as showing
clinically significant problems? In this case, the level
of agreement was not very good, ranging from between 17 to
38% for randomly selected pairs of teachers. In other words,
when one teacher reported the student to show significant problems
with inattention and/or hyperactivity/impulsivity, the likelihood
that another teacher also reported clinically significant problems
was considerably less than 50%. The level of disagreement was
higher for attention problems than for hyperactive/impulsive
behaviors. Even for the latter, however, the level of agreement was
not very good.Overall, the authors conclude when teacher ratings are used to
discern whether a student's behavior is sufficiently impaired to warrant
a diagnosis or clinical attention, the agreement between teachers is
not that much better than what would be obtained by chance. What
are the implications of these results for evaluating teens for ADHD
and managing the treatment of students previously diagnosed?In regards to diagnosis, these data highlight how difficult
this task can be with older students. Now, for children
with hyperactive/impulsive symptoms, the diagnosis will
almost always have occurred years earlier, so this is not
usually an issue. This is because the difficulties these students
have are generally quite obvious during elementary school and
even before.For some students with the inattentive symptoms only, however,
problems are not always so obvious earlier on. This is especially
true for children who are bright, who may be able to get by reasonably
well in elementary school even though they have important problems
with attention simply because the academic demands are not
that great. Thus, even though they would not be doing as
well as they could be, they are managing to get by.With the transition to middle school, however, and the increased
organizational and academic demands this generally entails,
the teen may start to struggle in much more noticeable
ways. It is not necessarily because their difficulties
with attention are more pronounced, but may instead reflect
the increased level of demands they confront. In this case,
the student may not even be evaluated for possible ADHD prior
to middle school.The results of this study clearly indicate that in such
instances, a diagnosis of ADHD can not be made based on
symptoms observed by a single teacher, even when those
problems are in a clinically elevated range. Instead,
multiple sources of information, including reports provided
by parents, by the adolescent him or herself, and data
gleaned from psychological tests may all be required.In my own experience, I have seen situations where a teen was
started on medication based on the problems reported by
a single teacher. The current study highlights what important
problems there can be with such an approach to diagnosis.
It is essential to remember that for a diagnosis of ADHD
to apply, there needs to be some evidence of impairment in
more than one setting. Thus, impairment in only a single
class, with no real problems anywhere else, should not be
assumed to reflect ADHD.These data also highlight the need to obtain feedback from
multiple teachers to obtain an accurate picture of how an
adolescent is handling the demands of school. It is clear
that different teachers will observe different levels of
strengths and difficulties. As a result, relying on feedback
from a single teacher - whether it is positive or negative -
will often provide a limited and inaccurate understanding of
the child's overall adjustment at school.It is also important to recognize that when one teacher
reports a child to be struggling, while other teachers
observe the child to be doing fine, it does not mean that
someone is right and someone is wrong. Children can and
do behave differently with different teachers and there are
a variety of reasons for this. These reasons can range from
a teacher and student being a poor match to a child's
having a particularly hard time with certain material and
acting out in response.So, the most productive approach, I think, to such discrepant
teacher reports is to systematically examine the possible
reasons why the teen is struggling in a particular class. Is is
problems in how the teacher is managing the student? Is it
a class that the teen is not interested in so his/her
ADHD symptoms appear much more pronounced? Is it a class
where the child struggles with the material and deals
with frustration by acting out?These are not necessarily easy issues to sort out, and it
may not always be possible to sort things out with complete
certainty. Rather than backing away from this complexity,
however, the more careful the efforts that parents and clinicians
make to understand the reasons for a teen's inconsistent
performance with different teachers, the more likely it
is that an effective approach to intervening where needed
can be made.* DOES METHYLPHENIDATE CAUSE TICS?
An ongoing concern about the use of stimulant medications
such as methyphendiate (i.e. the generic form of Ritalin) is
that they can exacerbate or even cause tics in children who
receive it. A recently published study provides additional
evidence that this unlikely to be the case, and highlights the
important of conducting careful placebo-controlled medication
trials to evaluate whether apparent medication side effects
really are reactions to medication (Law,S.F., & Schachar,
R.J. (1999). Do typical doses of methylphenidate cause tics
in children treated for ADHD? Journal of the American
Academy of Child and Adolescent Psychiatry, 38, 944-951.Participants in this study were 91 children with ADHD who
had no prior medication treatment for ADHD and no prior
treatment for tics. Seventy-four were boys and 17 were
girls. The average age of participants was 8.4 years. At
the beginning of the study, approximately 30% had pre-existing
tics. These were generally in a mild to moderate range.Children were randomly assigned to a medication group or
a placebo group for what was intended to be a one-year
study. After this random assignment was made, each child
went through a careful 3- or 4-week medication trial during
which the dose of MPH or placebo was administered in
the morning and at lunch. At the end of this trial, children
in the medication group continued on their optimal dose.
On average, children were maintained on a dose of .5mg/kg.
Children in the placebo group were maintained on the placebo.
Even though the double-blind trial to establish the initial
dose was over, children, parents, teachers, and research staff
remained blind as to what each child was receiving.During the one-year follow-up period, the dose of medication
that children received was adjusted as needed based on weekly
feedback obtained from parents and teachers. The importance
of complying carefully with treatment recommendations was
stressed. Parents were asked to use their own judgment about
the use of medication on weekends and holidays.Parents and teachers were interviewed about the presence of
tics in children before the study began, after the initial
medication trial to establish dosage, and then after the 4th,
8th, and 12th month of treatment. When tics were reported,
their severity was rated on a 10-point scale and then grouped
into 4 categories ranging from "no tics reported" to "severe
tics (defined as frequent, persistent, and markedly impairing).During the one-year study, parents of 60% of the children
in the placebo group requested a change of "medication"
because they observed no behavioral improvement. (Remember,
these parents did not know that their child had actually
been receiving a placebo.) No parent of a child in the
medication group requested a medication change.The results in regards to the development and exacerbation
of tics were quite interesting. During the one-year study,
approximately 19% of children treated with MPH who had
no prior history of tics were reported to develop tics by
either their parent of teacher. This sounds like a real problem
until one examines results for the placebo group where
approximately 16% of children were reported to develop
tics during the study. The difference between these 2 figures
is not statistically significant which means that is likely to
reflect a chance difference that would not be found if the
study were repeated.What about the impact on children with pre-existing
tics? For both children receiving medication and
children receiving placebo the results were virtually
identical: they were reported to get worse in about
one-third of the children and to stay the same, get better,
or completely remit in the other two-thirds.The results of this study indicate that it is not uncommon for
school-age children to develop tics over the course of a year,
regardless of whether or not they are receiving stimulant
medication. Thus, in many cases, children who appear to
have developed tics while being treated with medication for
ADHD are likely to have developed them anyway. This
means that the tics could not really be considered a side effect
of the medication.The data are important for several reasons. First, they
highlight the need to do careful placebo-controlled trials
when initiating treatment with stimulant medication not just
to determine medication efficacy and proper dose, but also
to determine whether apparent side effects are really
attributable to medication. Clearly, the emergence of
tics which are present both during medication weeks and
placebo weeks is unlikely to reflect an actual adverse reaction
to medication. When such a procedure is not used, a
decision that is made to discontinue medication treatment
because of side effects may be an error that deprives the
child of access to treatment that could be quite valuable and
important. Although one could argue that medication may
have resulted in tics emerging well after the medication was
discontinued, I am aware of know evidence to suggest this is
a likely possibility.What about a situation where a child who has been treated
with medication suddenly seems to develop tics? That happened
fairly often in this study, as 40 % of the children treated with
MPH who developed tics during the year did so after at least
4 months of treatment. In these cases, the procedure used during
this study was to reduce the dose of medication in 5-mg steps
until the tics disappeared or decreased to at least a mild
severity. In the few cases where moderate to marked tics
persisted, the medication was discontinued or an alternative
medication was introduced. All children were able to be
maintained on medication and none had to completely discontinue
medication treatment for ADHD because of tics.The authors conclude that MPH treatment at a dose determined
by a careful trial to maximize behavioral improvement
and minimize side effects, does not cause or exacerbate tics in
children with or without prior tics more often than placebo
treatment. For children with a prior history of tics, this conclusion is
limited to those whose tics were no more than moderate to begin
with. Different results for children with severe pre-existing
tics could be very different, as could be true for children who
are treated with much higher doses.These important caveats aside, this study is important because it
suggests that stimulant medication treatment can still be used
effectively for many children with ADHD who have pre-existing
tics, and that the emergence of tics during a course of medication
treatment is not necessarily cause to terminate the treatment.
* THE EMOTIONAL EXPERIENCE OF CHILDREN WITH ADHD
Because the behavioral symptoms of ADHD are generally so
problematic, it can be easy to overlook the emotional experience
of children who have ADHD. How do the emotional lives
of children with ADHD compare to those of children without
ADHD and how can attending to this information be useful
in both evaluation and treatment planning?This important set of questions was the subject of a study that
recently appeared in the Journal of Attention Disorders
(Kitchens, S.A., Rosen, L.A., & Braaten, E.B. (1999).
Differences in anger, aggression, depression, and anxiety
between ADHD and non-ADHD children. Journal of
Attention Disorders, 3, 77-84). Participants in this study
were 29 children who met diagnostic criteria for ADHD,
Combined Type and 30 children without ADHD between
the ages of 6 and 12. Approximately 3/4's of the children
were males and the vast majority were white. The diagnosis
of ADHD was made on the basis of behavior rating scales
completed by children's parents and teachers. None of
the children who participated were currently receiving
treatment with medication.To evaluate the emotional experience of children with
ADHD, the researchers had children, parents, and
teachers complete a number of different rating scales.
Children completed the Child Depression Inventory
(CDI) a self-report measure of depressive symptoms
in children that has been shown to be both reliable
and valid. They also completed the Pediatric Anger
Scale (PANG) to evaluate their typical level of
angry feelings and the Pediatric Anxiety Scale
(PANX), a self-report measure of anxious personality
traits. Parents and teachers completed standardized
rating scales to evaluate the level of depressive and
anxiety symptoms that they observed the child to
display.Based on the self-report data, children with ADHD
reported themselves to be significantly more angry
than non-ADHD children and to also be significantly
more depressed. Differences between children with
and without ADHD on these measures were not
extremely large, but clearly indicate that, on average,
children with ADHD experience greater levels of
anger and depressive feelings. No significant
differences were found in the amount of anxiety
that children in each group reported.Parents and teachers also reported that children
with ADHD appeared more depressed than other
children. Teachers, but not parents, also observed
the children with ADHD to display more symptoms
of anxiety.IMPLICATIONS
It is important to put these results in the appropriate
context. The fact that children with ADHD report
more anger and depressive symptoms than other
children certainly does not mean that they are all
extremely angry and depressed. Like virtually all
studies that compare individuals with and without
ADHD, there was substantial amounts of variation
between individuals. Thus, a number of the children
in the ADHD group reported very few problems in
these areas while some children without ADHD
indicated that they struggled with high level of
anger and depression.The appropriate conclusion to draw from these
results is that children with ADHD are more likely
than others to be troubled by feelings of anger
and depression. This has several important implications
for the evaluation and treatment of children for
ADHD.First, ADHD evaluations should routinely incorporate
an assessment of children's emotional experience.
Regardless of the reasons why children with ADHD are
likely to be angrier and less happy than other children,
it is important not to overlook this aspect of children's
lives in the evaluation process. Too often, in my
opinion, ADHD evaluations are restricted to simply
answering the question of whether or not a child has
ADHD and other important aspects of a child's
experience are overlooked. This can result in an
overly narrow view of the issues that may need to be
addressed in a child's treatment. If this occurs, the
unfortunate result is that a child's treatment is incomplete
and does not address all the important issues that it needs
to.The implications for treatment follow directly from the
above. For many children with ADHD, treatment
may need to address issues of anger management and
depressive symptoms, in addition to managing
the primary ADHD symptoms of inattention and
hyperactivity/impulsivity. It is important to be aware
that improvement in the core ADHD symptoms will
not necessarily translate into comparable improvements
in these other areas. Should this be the case, these
aspects of a child's difficulties will need to be addressed
directly, and specific treatments to deal with anger
and depression in children have been developed.
Although some would certainly disagree, my reading
of the research literature is that specific psychological
treatment approaches have so far proven to be more
helpful to children with difficulties in these areas than
has medication treatment. This, is different from what
studies comparing medication and behavioral treatment
for ADHD have suggested.In summary, I think this is an important study in that
it reminds parents and health care providers about the
importance of attending to the emotional experience of
children with ADHD. These data suggest that this is
another important area where a child with ADHD may
be struggling, and where careful consideration of how
to best help the child is needed.- READER QUESTION -
"My child has been diagnosed with ADHD but I was
unable to obtain any special services at school for him
last year. What is the process for going about this?"
If you believe that your child may require special
services at school because of problems related to
ADHD, it is important to understand the process
by which these services can be obtained. Public
schools have certain procedures that must be
followed prior to providing special services for
any child. These procedures are outlined below.
(Note: The information below is based on what
occurs in the location that I live in. Procedures
in your community may differ somewhat, but should
be similar to what is described here because much
of these guidelines are stipulated by federal
regulations.)Parents can request that their child be evaluated by
the school to receive special services at any time.
Such requests may also be initiated by a child's
teacher. (When parents initiate a request, it is a
good idea to do this in writing and to retain a
dated copy.) If the evaluation is initiated by the
school, parents should be notified of the screening
procedures to be conducted and will be asked to
provide their written consent for this to be done.The initial stages of a school-based evaluation
will generally include hearing and vision
screenings, classroom observations of the child,
and intellectual and academic screening tests. The
child's teacher will complete a standardized
behavior rating form, and parents will often be
asked to complete a similar form. Parents may also
be interviewed about their child's developmental
history. Referral for a medical evaluation to help
determine whether ADHD is an appropriate
diagnosis may also be recommended.In addition to gathering this information, there will
also be two specific interventions implemented
within the child's regular classroom for a 4-6
week period. These interventions will be designed
to target behaviors specifically related to the
suspected ADHD (i.e. not completing assignments,
not following class rules). It should be noted that
public schools will generally require that these
interventions be implemented prior to providing
any additional services, even if the child has already
been diagnosed with ADHD by a physician. The reason
for this is that the school wants to learn whether a
child's educational needs can be effectively
addressed within the context of the regular
classroom.At the conclusion of this 6-week period, members
of the Student Assistance Team (i.e. those
individuals at the school who are responsible for
making determinations about the need for special
services) will review the information collected to
decide on the next step. If the child has been
diagnosed with ADHD by a physician, and the
interventions tried within the classroom were
successful, it is likely that an "accommodation"
plan will be written for the child. This plan will
describe the accommodations that need to be made
for the child to be successful in the regular
classroom. For example, the child may be required
to be seated near the teacher, to have reduced
assignments, to have extra time on exams, to have
teachers review and initial a daily homework log,
etc. Once this plan is written, the child's teachers
are required to implement it. Parents should be
active participants in the meeting where this plan
is developed, and should receive a copy of it in
writing.If the interventions which were implemented were
not successful, the Assistance Team is likely to
decide that additional evaluation is necessary, and
parents will be asked to sign a second consent
form to allow this to occur. The purpose of this
additional evaluation will be to determine whether
the child is eligible to receive special educational
services because of ADHD under the Other Health
Impaired category. It should consist of an in-depth
educational evaluation to evaluate the child's
current level of academic functioning, and may
also include an individually administered IQ test.
In addition, if a medical evaluation has not yet
been completed, this will be required as the
diagnosis of ADHD must ultimately be made by a
physician. Your child's physician will be required
to provide his or her diagnosis in writing to the school.It is important to be aware that if the Assistance
Team decides that a full evaluation is not
necessary because the child's needs are being
adequately met, but you disagree, you have the
right to appeal the decision. The school is required
to provide you with information about appeal
procedures.Federal guidelines stipulate that this second part of
the evaluation, which includes all necessary
testing and the development (when deemed
necessary) of an Individual Education Plan (IEP),
must be completed within 90 days of when parents
signed the consent form allowing it to occur. This
90-day clock does not stop when school ends for
the summer, and the evaluation can be completed
during the summer when required.After the evaluation is complete, the information
gathered will be used to determine a child's
eligibility for special services under the OHI
classification. There should generally be
agreement between parents and the school about
this, but parents have the right to appeal any
decisions they disagree with.When the consensus is that special educational
services are required, an IEP will be developed.
The IEP is a document that spells out educational
goals for your child, procedures to attain those goals,
and methods for evaluating their attainment. The IEP
is a legal document, and once its contents have been
agreed on, it can not be changed without your permission.
Either you or the school can request that changes
be made at any time, however. Your child's IEP
should be reviewed each year so that it's continued
appropriateness can be determined, and any
necessary modifications can be made.I hope this information is helpful to you.
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.
If you know someone who would like to receive the
newsletter on a regular basis, however, please ask them
to contact me about becoming a regular subscriber.If you maintain a web site related to ADHD, I would
welcome your selecting an article from this issue that
you would like to share with visitors to your site. Please
mention that it appeared in ADHD RESEARCH UPDATE
and include a link to http://www.helpforadd.com so
that folks who are interested in learning more about
the newsletter are able to do so.See you next month.
David Rabiner, PhD
Licensed Psychologist
Duke UniversityP.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.