* Is stimulant medication overprescribed?

* Concerta: A new medication for treating ADHD

* Do boys with ADHD overestimate their social competence?

* Parent and child report of sleep problems in children with ADHD
_________________________________________________

                              Issue Overview

Dear Subscriber:

I hope that the summer has been a good one for you.  If your
child is back in school now, I hope that the year is off to a
good start.

This month's issue of ADHD RESEARCH UPDATE reviews
several new studies that I found to be quite interesting.  The first -
Is stimulant medication overprescribed? - is one you may
have seen carried in the popular media.  In this study, the authors
examine the rate of stimulant medication treatment relative to the
diagnosis of ADHD in an entire county of western NC.  An initial
examination of the results of this study suggests that stimulants
are being widely overprescribed, and this is the way I have seen
this investigation portrayed.  In fact, however, when one examines
the study more carefully, the reasonableness of this conclusion
becomes more suspect.  Instead, it appears that undertreatment -
especially of females - is also a very important issue to consider.

Next, preliminary reports of a new medication called Concerta
are presented.  You may have heard of Concerta, which is
basically methylphenidate with a unique delivery system that
allows for effective symptom management with only
once-a-day dosing.  There are many children for whom this
medication may be a tremendous improvement, as the requirement
for multiple doses per day can lead to compliance problems.  This
is especially likely to the true for adolescents who often balk at
having to take medication while at school.  This does not mean,
however, that Concerta should be used for every child with
ADHD who is currently on meds, and some guidelines for
thinking about the issue of switching are discussed.

The next article - Do boys with ADHD overestimate their
social competence? - reviews an interesting experimental
study in which a possible non-behavioral explanation for the
social problems experienced by many children with ADHD
is explored.  The authors of this study report that boys with
ADHD often believed they were more successful socially than
was actually the case, and that they also tend to disavow
responsibility for the social outcomes - whether positive or
negative - that they experienced.  This may prevent them from
accurately recognizing how others are perceiving them, and
thereby reduce their motivation to alter their behavior.  Although
this would not be true certainly for all children with ADHD, these
data have implications that are important for parents and
practitioners to be aware of.

The final article - Parent and child report of sleep problems
in children with ADHD - provides another interesting look
at the issue of sleep difficulties in relation to ADHD.  This
study adds to current knowledge on this topic by obtaining  the
perspective of children themselves, rather than relying solely
on the reports of parents.  An interesting finding is that children
with ADHD were more likely than peers to report fears and
anxieties associated with going to sleep, which can certainly
have important clinical implications for some children.

Detailed accounts of these studies are provided below.  I hope
you enjoy the issue and find information in here that is useful
to you.

Sincerely,

David Rabiner, Ph.D.
Senior Research Scientist
Duke University
================================================

* IS STIMULANT MEDICATION OVERPRESCRIBED?

An article published in the recent issue of the Journal of the
American Academy of Child and Adolescent Psychiatry
(JAACAP) is sure to add to the ongoing controversy about
the possible overprescription of stimulant medication.  Upon
initially reviewing this paper, a clear case for dramatic overuse
of medication to treat ADHD seems evident.  A closer
inspection of the results, however, suggests that the issue is
not so straight-forward.  This is an important study that will
probably get plenty of press, so I wanted to include a careful
review of it in ADHD RESEARCH UPDATE.

In this paper (Angold, A. et. al., (2000). Stimulant treatment
for children: A community perspective. JAACAP, 39, 975-
984.) the authors examine the use of stimulant medication in
relation to a research-derived diagnosis of ADHD in a community
sample of children.  Participants in this impressive study were a
representative sample of 4500 children ages 9 to 16 from 11
different counties in western North Carolina.  Each year for
4 years, these children and their parents were administered
structured psychiatric interviews to enable careful diagnoses -
not just of ADHD, but of a variety of psychiatric conditions -
to be made.  Parents were also asked to provide information
on any treatment the child had received during the prior year
for a mental health condition, including treatment with stimulant
medication for ADHD.  In addition, the teachers of these children
were asked to complete a standardized behavior rating scale each
year.  Ratings from multiple teachers were collected whenever
possible.

A study of this magnitude is an enormous undertaking, and the
overarching objective was to obtain reliable estimates of the
frequency of a wide variety of psychiatric problems within a
community sample of children, the kinds of services for psychiatric
problems that children receive, and the match between the rate of
problems and available services.  In this particular paper, however,
the authors were interested in a much more circumscribed question.
Specifically, they were interested in how the rate of stimulant
medication treatment in this community compared to the community
rate of ADHD.  Their data would enable them to answer to the
these important questions:

1). What percentage of children with a verified diagnosis of
ADHD are actually being treated with stimulant medication?

Because current evidence suggests that carefully conducted treatment
with stimulant medication is an effective treatment approach - although
many children require additional interventions as well - the answer to
this question provides a crude indication of how often children
with ADHD are receiving an empirically supported treatment.

2). How often are children without a verified diagnosis of
ADHD being treated with stimulant medication?

To my knowledge, even the most ardent supporters of medication
treatment for ADHD do not endorse its use for children without
a carefully established ADHD diagnosis.  Thus, the answer to this
question provides some indication of how often stimulants are
being prescribed inappropriately.

Note: An important issue that was not really possible to address in
this study concerns the manner in which medication treatment is
carried out.  One can not assume that a child with a clear
diagnosis of ADHD who is prescribed medication is receiving
appropriate treatment.   This is because medication treatment in the
community is often carried out in a far from optimal manner, and is
often not combined with behavioral interventions that may be
necessary.

RESULTS

What is the rate of ADHD in this community sample?

The initial data presented by the authors concerns the rate of
ADHD diagnoses in this large and representative community
sample.  Of the children interviewed, 3.4% were regarded as
having a definite diagnosis of ADHD.  Boys (5.3%) were more
likely to have a definite diagnosis than girls (1.5%).  An additional
2.7% had sufficient impairment from ADHD to warrant the
diagnosis of ADHD-Not otherwise specified.  Boys were
over represented in this group as well (i.e. 4.4% vs. 1.0%).
(Note: ADHD-NOS is the term applied when a child does not
meet complete diagnostic criteria for ADHD but still has a number
of symptoms that are causing impairment.  For a review of
current official diagnostic criteria click here.)  Overall, therefore,
6.2% of the population were diagnosed with either definite ADHD
or ADHD-NOS.  This prevalence rate is consistent with what
has been found in other studies, and represents the % of the
population who were found to meet diagnostic criteria for
ADHD at any time during the 4-year study.

Note: One problem with the diagnostic procedure used in this
study that will have important implications to be discussed below
is that diagnoses were based solely on the parent interview data.
Thus, even though behavior rating scale data was collected from
teachers, ADHD diagnoses were assigned strictly based on what
parents reported.  The authors explain this choice by noting that
they did not have full diagnostic information from teachers, and
that parent reports are used for diagnosis in most "real world"
clinic settings.

Although these points are well taken, the absence of teacher-
reported information being used in the diagnostic process would
almost certainly result in a lower prevalence rate than
if it were included.  This is because teachers often observe ADHD
symptoms that parents do not.  I thus think it is quite likely that the
prevalence rates reported above underestimates the true rate in
the community.

What is the rate of stimulant medication treatment in this
community sample?

At one or more points during the 4 years of this study, 7.3%
of the children had been treated with stimulant medication.
This is over twice the number of children who received a
definite diagnosis of ADHD (although the caveat noted above
about the probable underidentification of ADHD is an
important one).  It is also slightly higher than the combined
rate of ADHD and ADHD-NOS.

This overall rate, however, does not tell us whether the children
receiving medication were the ones who actually had ADHD.
Instead, it just indicates the percentage of children in the
community who had received stimulant medication. When
the authors examined this important question, they found
that approximate percentage of children treated with stimulants
was 72%, 23%, and 5% for children with ADHD, ADHD-NOS,
and without ADHD or ADHD-NOS respectively.

Because this last group is so much larger than the others in
terms of absolute numbers (remember, the vast majority of
children had no ADHD diagnosis), it means that at any given
time, the number of children without ADHD in this community
who were being treated with stimulants was greater than the number
of children with ADHD who were being treated.  The authors
estimated, in fact, that 57% of the children who were treated with
stimulants did not have ADHD or even ADHD-NOS.  It is also
interesting to note that boys with ADHD were far more likely to be
treated with medication than girls with ADHD (80% of ADHD boys
vs. only 41% of ADHD girls).

What do these numbers say about the overtreatment vs.
undertreatment problem?

One unfortunate problem with data such as this is that it is
relatively easy to focus on numbers that support the point one
wants to make and ignore the bigger picture.  It is thus
important to carefully consider the implication of these
findings.

First, in regards to possible undertreatment, these data show
that almost 30% of children with a definite diagnosis of ADHD
did not receive stimulant medication treatment at any point
over the 4-year study period.  One possible explanation for
this is that although these children were diagnosed with ADHD
in the study, they were never diagnosed appropriately by their
physician in the community.  In this study, diagnostic information
was not routinely shared with parents nor were treatment
recommendations made by the research staff.  So, it is quite
possible that many children who clearly met diagnostic criteria
for ADHD were simply never diagnosed by their own health
care provider, and thus never received medication treatment.

It is also possible that many of these children were diagnosed in
the community and parents were informed of this treatment option
but elected not to consider it for their child.  Alternatively, some
parents of diagnosed children may never have been appropriately
informed of the possible benefits of medication.  This information
would be very interesting to have but was not presented in the
paper.

One conclusion that can be made with greater certainty, however,
concerns the undertreatment of girls with ADHD.  Recall that girls
with confirmed ADHD were half as likely as boys with ADHD to be
treated with medication.  Because medication has been shown to
be an effective treatment, the fact that girls with ADHD are less
likely than boys to receive it is problematic.  My hunch is that the
reason for this finding is the previously shown fact that physicians
are prone to miss the diagnosis of ADHD in girls.  In other words,
fewer girls with ADHD were treated with meds because fewer
girls who were diagnosed with ADHD by the researchers ever
received this diagnosis by their own physician.  This, of course,
is just speculation, but is seems plausible.  It would be interesting
to know if this were true, and even more interesting to know
whether girls were less likely than boys to receive meds even when
their physician had diagnosed them with ADHD.

Despite these uncertainties, the bottom line is that many children with
ADHD - and the majority of girls with ADHD - were not receiving
medication treatment in this community.  Of course, whether or not
this is a problem depends on the value one places on this treatment
modality.  It is also important to recognize that because the reliance
on parent data only to make diagnoses probably resulted in a number
of children with ADHD going undiagnosed, the actual number of
ADHD children who were not treated is probably higher - and may
have been substantially higher.

What about the overtreatment problem?  As noted above, about 5%
of children without ADHD were reported to have received medication
treatment.  In fact, at any given time, more children without ADHD
were on medication than children with ADHD.

Certainly, this is an important problem.  The magnitude of this problem,
however, may not be quite as great as it initially appears.  One very
interesting comparison the authors made looked at the children without
ADHD or ADHD-NOS who were receiving stimulants and those
who were not.  They found was that although the parents of
children in both groups reported few if any ADHD symptoms, the
interviewers observed ADHD symptoms in 50% of the children who
were treated with meds compared to only 10% in those not treated.
In addition, the ADHD symptom ratings from teachers was actually
higher in the non-ADHD children who were being treated than in the
children with definite ADHD.

So, in many cases, children who did not have ADHD according to
their parents were clearly displaying high levels of ADHD symptoms
according to their teachers.   These were the children in the study
"without ADHD" who were likely to be receiving medication treatment.
One would imagine that at least some of these children would have
turned out to have a confirmed diagnosis of ADHD if parent and
teacher information was combined - a procedure not implemented
in this study for the reasons noted above.  Thus, the number of
children treated with meds who did not have ADHD is probably
fewer than what is reported in this study.

(Note: It is important to emphasize that the data presented above,
although representative of the community in which they were
collected, still applies to this one community.  To what extent
similar patterns would be found in other communities across
the county is unclear, as it is well-know that prescribing patterns
can vary greatly across physicians.)

SUMMARY

It would not be surprising if the results of this study are presented
in the media as prima fascia evidence that children are often treated
with stimulants for "no good reason".  Unfortunately, this practice
certainly goes on, and it seems inevitable that far more children
receive stimulant medication than truly need it.  One only has to
consider studies reviewed in prior issues of ADHD RESEARCH
UPDATE in which it was reported that as many as 20% of
white male 5th graders in some communities are receiving
medication to know that this must be the case.

What can get lost in the understandable concern over such
findings is the equally concerning fact that large numbers of
children with ADHD are never identified or treated in any way
other than being punished repeatedly for their behavior.  In
the current study, almost a third of all children with ADHD never
received medication.  For females with ADHD, the odds of
being treated with meds were less than 50/50.  Once again,
this is a problem only to the degree that one believes stimulant
medication to be a safe and effective treatment for ADHD.
However, because research conducted to date indicates that
well conducted medication treatment is probably the most
effective treatment for ADHD currently available, it is not
unreasonable to be concerned about this finding.

The "safest" conclusion one can make from data such as this
is that at any given time, there are probably thousands of
children in the US who are treated with stimulants they
probably don't need and thousands of children with ADHD
who could benefit from stimulants but not receiving them.
The solution to this problem is to increase the ability of
community physicians to evaluate children for ADHD in
a careful and systematic manner, and to help them prescribe
medication when appropriate in a systematic manner that is
likely to provide the maximum possible benefit.

Reprint requests:

Dr. Adrian Angold
Center for Developmental Epidemiology
Duke University Medical Center
Box 3454
Durham, NC 27710

* CONCERTA: A NEW MEDICATION FOR TREATING
   ADHD

For parents who have a child taking medication to help
manage ADHD symptoms, a frequent source of difficulty
is the need for multiple doses each day.  Among children who
take Ritalin (the generic is methylphenidate), a second dose
while at school and a third dose in the late afternoon
is often necessary to provide good control of symptoms
over the course of the day.  Administration during the
school day can be associated with complications, and is
often a source of concern or embarrassment for the child.
As children move into adolescence, this can frequently lead
to a refusal on the part of the teen to continue on meds, even
though medication may still be necessary to help manage the
child's symptoms and help with behavior and academic
performance.

Although sustained release forms of Ritalin last longer and can help
somewhat with this problem, the additional duration of benefit
provided by a single dose varies substantially across children.
Adderall, a more recently approved stimulant medication for
treating ADHD, also has a therapeutic effect that lasts longer
than Ritalin, and many children on Adderall can get by with
a single dose during the school day.   Even with Adderall,
however, a second dose in the afternoon is often required.

Recently, a new medication called Concerta was approved
by the FDA for the treatment of ADHD and is expected to be
widely available very shortly.  Concerta is simply methylphenidate
in which a unique and patented system is used to maintain a
smooth and optimal level of medication in a child's system
throughout the entire day.  In fact, the benefits of Concerta are
reported to persist throughout the school day and into the evening.
This would make the administration of medication to children with
ADHD much more convenient, and should help to eliminate many
of the problems associated with multiple daily doses.

Results of a study on the effectiveness of Concerta was presented at
the May meeting of the American Academy of Pediatrics.  This study
was supervised by Dr. James Swanson from the University of California
at Irvine, a leading researcher in the field of ADHD.   His work
has included studies of both medication and behavioral treatment so
I believe he has a broad perspective on the treatment of ADHD.

Participants in this study were 64 6-to-12 year old children with a
confirmed diagnosis of ADHD, all of whom were being treated
currently with methylphenidate.  During the study each child
received 3 different treatments: methylphenidate on their regular
dose 3 times per day, Concerta once per day, and a placebo.  Each
treatment was received for 7 consecutive days and neither parents,
teachers, nor children were aware of what treatment the child was
receiving each week.  At the end of each week, standardized
behavior rating forms were completed by parents and teachers,
as were ratings of possible adverse side effects.  (To be sure
that participants would not know when the child was on the
Concerta, one "real" dose and 2 placebo pills were given each
day.  This way, 3 "doses" each day were required during every
week of the trial.)

Results indicated that both Concerta and the 3 daily doses of
methylphenidate resulted in significantly lower symptom ratings
compared to placebo from both parents and teachers.  The two
medications, in contrast, did not differ from one another.  This
means, of course, than a single daily dose of Concerta was as
effective as 3 doses of regular methylphenidate in managing the
symptoms of ADHD.  Side effects were reported to be mild
and were quite similar to regular methylphenidate.  Only 3 side
effects were reported to occur in over 2% of the children - abdominal
pain, headaches, and fever - and these all occurred in less than
5% of the participants.

Overall, parents reported preferring Concerta to the methylphenidate
used during the study and to the treatment their child had been receiving
prior to the study.  Remember, this preference for Concerta was reported
even though during the study, all children received 3 doses per day.
(During the time they were receiving Concerta, it was just the first
dose each day that was real medication.  The second two "doses"
were actually placebos.)  The most likely reason for this, I think, is
that with Concerta, the smoother release of medication throughout
the day may have resulted in more consistent management of
symptoms than regular methylphenidate.

A SECOND STUDY OF CONCERTA

I also recently saw a press release describing a second study
involving Concerta.  A larger number of participants - 407
children with a confirmed diagnosis of ADHD - were included and
these children were followed over the course of an entire school
year.  Children in the study ranged in age from 6 to 13 and had
previously completed a short-term controlled study that included
regular methylphenidate, Concerta, and placebo conditions.
In this second study, children were assigned to one of three dosing
levels - 18, 36, or 54 mg. - based on the dose level administered
in the short-term study.  Data on the results of this study are not yet
published in a peer reviewed journal, but were presented at a recent
meeting of the American Psychiatric Association.

During the course of the year, children were evaluated with varying
frequency using standardized ratings of behavior and attention.
Results indicated sustained improvement in behavior and attention
over the course of the year.  In a global assessment of treatment
effectiveness obtained at the end of the study, over 60% of teachers
and 84% of parents rated treatment as good or excellent.  Thus,
it appears from these results that the once per day treatment with
Concerta provide effective symptom management over the course
of the entire year.  Side effects reported were similar to those
that have been reported before for regular methylphenidate.

Note: I was previously advised by a subscriber to note when studies
reporting effective medication treatment have been funded by
the pharmaceutical company who manufactures the drug.  I
believe this is the case here.  While some would argue that this
means the results are suspect, I do not personally feel this to be
correct.

Such medication studies are typically conducted by independent
academicians, and I have several colleagues who are routinely
involved in pharmaceutical trials.  The clinic where they work is paid by
the drug company to conduct the study, but this does not influence -
in my opinion - the integrity with which the data is collected and reported.
It is also important to be aware that there is not really an alternative
to the drug company paying for such studies.  These studies are
necessary to obtain FDA approval and no one else is going to fund
studies of a medication that has not yet been approved by the FDA.

Should you make the switch to Concerta for your child?

The answer to this question is not necessarily straight forward.
If your child is currently taking another medication that is
working well, and having to take multiple doses each day is
not a problem, there may be no good reason to switch.  Basically,
why tinker around if everything is going fine?

If you and your child's physician do elect to try Concerta, you
should be aware that because Concerta is methylphenidate that is
being delivered in a way that maintains a steady dose over the entire
day, children doing well on  regular methylphenidate should do well
on Conerta.  If your child has been on another type of medication
such as Adderall or Dexedrine, however, one could not necessarily
assume that Concerta would be equally effective in managing
ADHD symptoms. It is possible, for example, that your own child's
symptoms would not be managed as well if the switch were made.

If your child's current medication seems to be working well,
but he/she requires multiple doses each day which is resulting
in compliance problems, than discussing a switch to Concerta
with your child's physician should be considered.  As noted above,
the need for only once-a-day dosing may be especially helpful
with teens who often balk at needing to take medication during
the school day.

If your child is not currently taking medication to manage ADHD
symptoms, but this is something you are considering, it may
be worth asking your doctor about starting out with Concerta.
So far, it appears to be as effective as regular methylphenidate in
managing ADHD symptoms, and to produce no additional side
effects.  The caution to keep in mind, however, is that it has not
yet been studied as extensively as regular methylphenidate or even
Adderall, and there can be no guarantee that these initially encouraging
results will hold up to further study.  There is no compelling
reason, however, to think that they will not.  My own personal
expectation is that they will.

One other issue that I think is important in the decision to use
Concerta is whether a child really needs medication throughout the
entire day, which is what Concerta  provides.  For example, some
children require medication primarily to assist with academic functioning
during the school day, and really do not need it except for these times.
For these children,  a single morning dose of methylphenidate or Adderall
may be all they require.  In such instances, it seems like a
legitimate question to ask is whether Concerta would really be preferable.

In summary, although Concerta appears like it will be an extremely helpful
and valuable new medication for many children with ADHD, it is not
necessarily going to be the best choice for everyone.  As always,
carefully evaluating what is required by each individual child is still
required to make the best decisions about medication.
 

*  DO BOYS WITH ADHD OVERESTIMATE THEIR
    SOCIAL COMPETENCE?

One of the most common problems for children with ADHD is
the difficulty they experience in relationships with peers.  In fact,
some authors have noted that social problems are so pervasive
among ADHD children that they ought to be included in the
diagnostic criteria.  Of these problems, rejection by peers is the
most widely documented and the source of greatest concern.
The reason for this concern is that a number of studies have
linked peer rejection in childhood to a number of adjustment
problems later in life.

Why do children with ADHD tend to have such consistent
difficulty in establishing friends and getting along with peers?  One
contributing factor is clearly the behavior that is closely
linked to ADHD symptoms.  Just as such behavior can be aversive
to adults, it can be equally aversive to children.  Another factor
that may contribute to the social problems of ADHD children is
the that may they frequently misperceive the quality of their
interactions with peers. Some researchers have suggested that
children with ADHD are prone to overestimate how much peers
like them, and to be relatively unaware of how they actually
come across. In addition, boys with ADHD have been
shown to be less likely than peers to accept personal responsibility
for social failures.  If children with ADHD have difficulty recognizing
their problems, and tend to attribute problems they do recognize
to something other than themselves, motivation for corrective
action could be quite low.  This raises the possibility that a
positive and illusory bias could be as important an impediment to
developing better peer relations as are behavioral factors.

This interesting hypothesis was examined in a study published recently
in Child Development, perhaps the leading journal in developmental
psychology.  In this study (Hoza, et al., (2000). Attention-deficit/
hyperactivity disordered and control boys' responses to social success
and failure. Child Development, 71, 432-446.) the authors looked at
how boys with and without ADHD responded to experiences of social
success and social failure.  They were especially interested
in how accurate boys with ADHD were in their evaluation of their
interactions with peers, and the degree to which they assumed personal
responsibility for their positive and negative social experiences.

Participants in this study were120 7 to13-year-old boys with ADHD (average
age was 9.5 years) and 65 boys without ADHD who served as control
subjects.  Unfortunately, no girls were included in this study, which the
authors clearly recognize as a limitation.  The ADHD boys were
participating in an intensive 8-week summer treatment program.  At the
time of the study to be described below, children were not receiving
medication.

The procedure used in this study was interesting and a bit
complicated. The study used a social acquaintance task in a controlled
laboratory setting in which participants interacted briefly with a child
whom they did not know.  Prior to this interaction, each participant was
told that the experimenter needed his help in recruiting a new child to
participate in the summer camp program next year.  He was thus instructed
to "try and get him to like you" and "try to talk him into coming to camp
here".

Unbeknownst to the subjects, however, the unfamiliar child they were
introduced to was actually  a "confederate" of the experimenter who had
been instructed to act in particular ways.  In one condition, the confederate
was instructed to behave in a friendly manner towards the child and to
express his interest in attending the camp next summer.  Thus, this
condition was intended to provide study participants with a clear
experience of social success.  In the other condition, confederates
were told to behave in the opposite manner.  They behaved in ways that
clearly indicated they were not enjoying themselves and expressed a strong
desire not to attend camp the following summer.  The intent was to
create an experience in which children would feel they had not been
successful in getting the other child to like them or to want to attend camp.
(Note: After these negative interactions, children were always provided
with a positive social experience with that same confederate before leaving
to ensure that all interaction sessions ended on a positive note.)

Each child participated in both the success and failure interaction task.
The different conditions occurred on separate days during the summer.
The order of these tasks - i.e. success followed by failure or failure
followed by success - occurred equally often for ADHD and control
children.

After both the success and failure interaction, boys were asked a
number of different questions to learn about their perceptions
for what had occurred.  One set of questions focused on having the
boys evaluate their performance by asking them to rate how well
they did at getting the other child to like them and to want to attend
the camp.  They were also asked how much they liked the boy they
had just met.  A second set of questions asked the boys to explain
why they believed they had either succeeded or failed on the task.
These explanations focused on ability (e.g. "I failed because I'm not
good at getting kids to like me."), task difficulty (e.g. "It's not hard to
get kids to want to come to a camp like this."), effort (e.g. "He didn't
like me because I didn't really try that hard to make him like me."),
or luck ("I guess it was just lucky that he liked me.").  As you can
see, these 4 types of attributions (i.e. explanations for what happened)
either involve something about the child himself (i.e. ability and effort
attributions) or something that has little to do with the child himself
(i.e. task difficulty and luck).

In addition to asking boys these questions, their interactions with
the confederate were videotaped so their behavior during the sessions
could later be studied and analyzed.  Boys' behavior was rated by
adult raters who were unaware of whether or not the child being rated
had ADHD.  They were asked a number of different questions about
each boys' performance during both the success and failure interaction tasks.
Ratings of individual questions were collapsed to provide summary
scores for 2 general factors: how effective each boy was at the task
(i.e. how effective was their behavior for getting another child to
like them to want to attend camp) and how frustrated and helpless
each boy appeared during the interaction.

RESULTS

The results of this study were quite interesting. As expected, boys
with ADHD were rated by observers as being less effective than
control boys in being able to act in ways that would get the other
child to like them and want to attend the camp.  Despite being seen
as less effective, however, they were also regarded as appearing
less frustrated and helpless.  This was true regardless of whether the
confederate was acting towards them in a friendly or unfriendly
manner.

One reason ADHD boys may have appeared to feel less frustrated
and helpless is that in their own self-evaluations, they rated themselves
as doing significantly better at accomplishing the goals than control
boys.  Thus, even though they were judged by objective observers
to be less effective, they rated their own performance as more
effective.  This suggests that boys with ADHD are prone to overestimate
the success of their social overtures towards peers, and may also
misperceive others' feelings towards them.

Interestingly, despite reporting that they were more successful
than they actually were, boys with ADHD tended not to give themselves
credit for that success.  In the condition where confederates had
been instructed to act in a friendly manner, ADHD boys were more
likely than controls to say that they succeed either because the task
was an easy one or because they were lucky.  After failing in the
task, however, (i.e. the condition in which confederates were not
friendly) they were less likely than controls to attribute the failure
to their own lack of effort.  Together, these findings suggest that
boys with ADHD may have a tendency to deny responsibility for
both their social success and social failure.

SUMMARY AND IMPLICATIONS

This study adds to our understanding of the social difficulties of
boys with ADHD by documenting what may be important non-
behavioral reasons for their problems.  The results of this study
suggest that boys with ADHD tend to overestimate their actual
social competence, are less prone to experience frustration and
helplessness in social situations, and tend to attribute their social
successes and failures to factors outside themselves.  One can
imagine how this combination would not promote a child's motivation
to act differently towards peers in an effort to improve one's social
situation.  After all, if you overestimate how well you are doing,
experience little social frustration, and tend not to feel responsible for
what happens anyway, then why bother trying to change?

Despite the interesting nature of these results, it is important to
note the limitations of a study such as this.  First, as noted above,
because only boys were included as participants there is no way
of knowing whether these findings would generalize to girls with
ADHD.  It is probably safer to assume that they do not until
a similar study with females is conducted.

Second, although the findings reported above characterized boys
with ADHD overall, one should not take this to mean that every
boy with ADHD would display a similar pattern.  In fact, that
would certainly not be the case.  Many children with ADHD tend
to feel quite negatively about their social competence and to
blame themselves - often unfairly - for the difficulties they
experience.  What is important, therefore, is to try and determine
whether the issues highlighted in this study are applicable to
an individual child, and if so, to develop an appropriate way
for addressing these issues.  Doing this effectively is likely to
require high levels of sensitivity and skill, and may best be
approached in consultation with an experienced child mental
health professional.

It is also important to emphasize that the pattern of results obtained
were found after boys with ADHD had a relatively brief encounter
with an unfamiliar child.  Thus, the tendency to overestimate success
and deny responsibility for both positive and negative outcomes
may be restricted to new relationships and may not necessarily
persist in situations where children know each other for a longer
period of time.  For example, one can imagine how an initial
tendency to believe that one is better-liked by a child than is
actually the case would eventually crumble in the face of repeated
negative feedback.  Of course, that would still not mean that these
findings are not important in the social problems of some boys
with ADHD.  This is because misreading the reality of a relationship
early on can eventuate problems that make developing a positive
relationship with a new peer less likely.

Finally, this study was conducted when children were not on
medication.  As medication is the most commonly prescribed
treatment for ADHD, it would be interesting to know whether
similar results would be obtained in ADHD children who were
medicated.

In summary, this study should be regarded as in interesting initial
effort to obtain a more comprehensive understanding of the social
difficulties experienced by many children with ADHD.  Additional
research addressing these interesting issues is certainly required to
help translate these findings into more effective interventions.  In
the meantime, the study acts as an effective reminder to parents
and practitioners of how important it is to attend to the peer
relationships of children with ADHD, and provides interesting
insights about issues to consider when trying to help a child with
ADHD become more successful with peers.

Reprint requests to:

Dr. Betsy Hoza
Dept. of Psychological Sciences
Purdue University
West Lafayette, IN 47907-1364

* PARENT AND CHILD REPORT OF SLEEP PROBLEMS
IN CHILDREN WITH ADHD

In prior issues of ADHD RESEARCH UPDATE studies in which
sleep difficulties among children with ADHD were investigated have
been  reviewed.  These studies have found that parents of children with
ADHD are more likely to report sleep difficulties in their children.  This
is an important finding for two reasons.  First, some investigators have
suggested that in some cases, significant sleep difficulties may explain
the ADHD symptoms that a child is displaying.  In other words, some
apparent cases of ADHD may reflect an undiagnosed and untreated
sleep disorder.  Second, even when this is not the case, inadequate
sleep could exacerbate symptoms in a child who truly has ADHD.
Addressing these sleep problems appropriately could thus play an
important role in reducing some of the child's difficulties.

In a recently published study in the Archives of Pediatric and Adolescent
Medicine interesting new data ion this important issue is presented
(Owens, J. eta., (2000). Parental and self-report of sleep in
children with ADHD. Archives of Pediatric and Adolescent
Medicine, 154, 549-555.)  This study adds to existing knowledge in
this area because it provides information about sleep difficulties
from children with ADHD themselves, rather than relying exclusively
on the report of their parents.

Participants in this study were 46 unmedicated school-age children
(mean age 89 months; 74% male) diagnosed with ADHD who had
been screened for severe symptoms of a sleep-related breathing
disorder and 46 matched controls.    None of the ADHD
children were reported to have a comorbid diagnosis of depression
or an anxiety disorder, and very few were reported to have an
additional disruptive behavior disorder (i.e. Conduct Disorder or
Oppositional Defiant Disorder). The relative absence of these
other diagnoses in a population of children with ADHD is somewhat
unexpected given the substantially higher rates of such conditions
that are generally reported, and suggests that the severity of the
symptoms of children in this sample may have been on the mild
side.

It is instructive that nearly 20% of the original sample of children with
ADHD were excluded because they were determined to have
marked symptoms of sleep disordered breathing.  These children
were excluded because of the concern that this sleep difficulty
could possibly explain the ADHD symptoms that they had been
displaying, and the authors wanted to examine reports of sleep
problems in children with ADHD for whom this potential confound
had been eliminated.  The fact that such a substantial proportion
of ADHD subjected were found to have these strong symptoms
of disturbed sleep underscores the importance of attending to
such issues in a child's diagnostic evaluation.)

The design and procedures used in this study were quite simple.
Parents of ADHD and control children completed the Children's
Sleep Habits Questionnaire (CSHQ), a measure that surveys
parents about a wide variety of children's sleep behaviors and
problems and which has been validated in prior studies.  In
addition, a corresponding self-report sleep measure was developed
to assess many of these same issues from the child's perspective.

RESULTS

PARENT REPORT

The CSHQ contains 8 different subscales including: bedtime
resistance, sleep-onset delay, sleep duration, sleep anxiety,
night wakings, parasomnias (e.g. wetting the bed, sleep walking,
nightmares), sleep-disordered breathing, and daytime sleepiness.
Parents of children with ADHD reported more problems than
parents of control children in every area except for sleep
disordered breathing.  (The absence of group differences on this
scale is to be expected given that children with ADHD who had
clear sleep disordered breathing difficulties had already been
screened out.)

CHILD REPORT

The self-report measure for children was completed by 36
children with ADHD who were at least 7 years of age and
by 24 control children.  Children with ADHD also reported
themselves to have more sleep-related difficulties than other
children, and the areas of difficulty they reported are quite
interesting.

First, and not surprisingly, children with ADHD reported
more fighting with parents around the issue of bedtime.  This
may be related to the more-frequent struggles that children
with ADHD and their parents are likely to engage in about a
variety of issues, and may not necessarily be specific to
bedtime.  In any event, it does highlight that this is perceived
as an area of difficulty by many children with ADHD, and
suggests that this may need to be a particular focus of treatment
in many families.

Somewhat surprisingly - at least to me - the other sleep-
related difficulties that children with ADHD reported
centered around fears/anxieties associated with bed time and
going to sleep.  Children in the ADHD group were more likely
to report that they needed a parent in the room with them to
fall asleep, that they were afraid of the dark, and that they
were bothered by nightmares.  Thus, it appears that children
with ADHD may be more likely than others to view the
period around sleep onset as one "...that frequently engenders
anxiety and is often difficult and unpleasant".  In fact, these
results leads one to wonder whether for some children with
ADHD, the struggles that occur around going to bed may
partially reflect their fear and anxiety about sleeping alone.

SUMMARY AND IMPLICATIONS

Although the authors of this study are careful to note that their
relatively small sample size requires that the results obtained
be viewed with caution, the finding that sleep-related fears and
worries may be more common in children with ADHD is an
important one.  What the reason for this may be is unclear, but
it does suggest an avenue to explore when a child with ADHD
is consistently struggling with parents around bedtime or is
having problem getting sufficient sleep.

Another important issue highlighted by this study is the importance
of screening all children who have symptoms suggesting
ADHD for sleep problems.  As noted above, this is because in
some causes, serious sleep difficulties (i.e. sleep disordered
breathing problems such as obstructive sleep apnea) may play
an important causative role in those symptoms, while in other
cases they may certainly exacerbate the severity of a child's
symptoms.  Treatment strategies for children with ADHD do
not routinely focus on sleep difficulties, and treatment with
stimulant medication can actually produce sleep problems as
a side effect in some children.  Carefully attending to a child's sleep,
and making sure that appropriate interventions are in place to address
problems that may be apparent, can thus be an important component
in the overall treatment plan for many children with ADHD.

Reprint requests to:

Dr. Judith Owens
Division of Pediatric Ambulatory Medicine
Rhode Island Hospital
593 Eddy St.
Providence, RI 02903
________________________________________________

Thats' all for this month...

I hope 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, Ph.D.
Licensed Psychologist
Duke University