In this issue...
* How well do parents
and teachers agree on the diagnosis
of ADHD?
* Recommended guidelines for medication treatment
* Patterns of brain activity linked
to positive medication
response
- Subscriber Question -
"My child is 8 and was put on
Ritalin by his pediatrician
at the very end of the school
year because of problems he
had with attention during the
year. The teacher didn't
notice much difference during
the last week of school and
we haven't either during the
summer. Now that school
will be starting again in a few
weeks, the doctor wants
to try bupropion since the Ritalin
did not seem to work.
Does this seem like a reasonable
thing to try?"
------------------------------------------------------------------
ISSUE OVERVIEW
Dear Subscriber:
I hope that you have been enjoying the summer.
This issue of ADHD RESEARCH UPDATE
reviews three interesting
studies and also addresses an important question from a parent about
medication. The first study reviewed - How
well do parents and teachers
agree on the diagnosis of ADHD?
-
looks at the important issue of
correspondence between parents and
teachers in their reports of a
child's ADHD symptoms. As
the results of this study make clear, the
correlation between what parents
and teachers report is often quite low,
and diagnostic decisions based on
one source alone are likely to be
inaccurate as a result. The
implications of these data for the ongoing
monitoring of a child who has been
properly diagnosed is also
considered.
The second paper reviewed - Recommended
guidelines for medication
treatment - is not a research
study. Instead, it presents the
recommendations from a team of ADHD
experts about a framework
for prescribing medication to treat
ADHD that is based on the best
research data available. These
guidelines are quite important to
review if you are considering medication
for your child, and can also
be helpful if your child's treatment
with medication has already been
initiated. I think it is reasonable
to speculate that the guidelines
presented are very different from
what often happens in clinical
practice, and hopefully they will
come to have an influence on what
physicians in this country actually
do.
The final study reviewed - Patterns
of brain activity linked to positive
medication response - is
a preliminary but very nice piece of research.
The authors of this study took a
careful look at what changes in brain
activity occur in children with
ADHD who show a positive response to
medication compared to children
who fail to respond. The data indicate
that in medication responders, there
is a decrease in slow wave
brain activity after taking medication
and an increase in higher
frequency brain waves. In
children who fail to show improvement
after medication, the reverse is
true. These data support the idea
that ADHD may often result from
underactivity in the prefrontal
cortex. For those who are
interested in neurofeedback treatment,
the data are also important because
this is exactly what neurofeedback
treatment teaches children with
ADHD to do - i.e. inhibit slow wave
activity and enhance higher frequency
activity.
Finally, I address an important question
from a subscriber about
medication for their child.
The subscriber's question illustrates
some important potential difficulties
with how children are often
given meds in ways that are inconsistent
with the newly published
guidelines reviewed in this article.
I hope that you enjoy the issue below.
Sincerely,
David Rabiner, Ph.D.
Licensed Psychologist
Duke University
* HOW WELL
DO PARENTS AND TEACHERS AGREE
ON THE DIAGNOSIS OF ADHD?
One of the
more frustrating experiences for parents that I have
encountered
is the extent to which their perceptions of their child's
behavior can
differ from that of their child's teacher. This seems
to generally
take the form of teachers reporting problems at school
that parents
do not observe at home, but the reverse situation
occurs as
well. A sometimes unfortunate consequence of these
different
parent and teacher perceptions is that communication
and trust
between parents and teachers can suffer. Parents can
come to believe
that the teacher must be mishandling their child
(which, of
course, can sometimes be the case). Teachers can
interpret
parents' report of no problems at home as reflecting
either deliberate
denial of their child's difficulty or an obliviousness
that results
from an absence of involvement. When such impasses
occur, it
is unfortunately the child who frequently suffers because
there is no
agreement between parents and teachers/school
about how
to proceed.
Just how well
do parents and teachers generally agree on information
related to
the diagnosis of ADHD? This was the question addressed
in a study
published recently in the Journal of the American Academy
of Child and
Adolescent Psychiatry (Mitsis, E.M. et al; (2000). Parent-
teacher concordance
for DSM-IV ADHD in a clinic referred sample.
Journal
of the American Academy of Child and Adolescent Psychiatry,
39,
308-313). The answer to this question has important implications
for the evaluation
and management of ADHD, and I believe the data
from this
study are quite instructive.
Participants
were 74 children (60 boys and 14 girls) from 7 to 11 years
old who were
referred to a clinic because of problems related to disruptive
behavior.
The parents and teachers of these children were interviewed
separately
via phone using a highly structured psychiatric interview
(the interview
used was the Diagnostic Interview Schedule for Children -
DISC) so that
the presence/absence of each specific symptom of ADHD
could be obtained
from both sources. These interviews enabled the
researchers
to determine whether the child qualified for a diagnosis
of ADHD, and
the specific subtype the child qualified for (i.e. Combined
Type, Inattentive
Type, or Hyperactive/Impulsive Type) according to
each source,
and when parent and teacher information was considered
jointly.
(Note: It is important to remember that the figures reported
below refer
to the percentage of children in a sample referred to a
clinic for
behavior problems who met diagnostic criteria for ADHD.
These figures
are much higher, of course, than would be found in
a general
population.)
RESULTS
How well did
parents and teachers agree? As it turns out, not very
well.
Among the 74 children, 85% met criteria for any subtype of
ADHD according
to parent information (this means that 85% met
diagnostic
criteria for either the combined, inattentive, or hyperactive/
impulsive
subtypes according to parents). Using the information
gathered from
teachers, 76% met diagnostic criteria for one of the
ADHD subtypes.
Parents and teachers agreed on the presence vs.
absence of
any type of ADHD diagnosis (e.g. if diagnosis based on
parent data
was the combined type and diagnosis based on teacher
data was the
inattentive type it was considered an agreement) 74%
of the time.
This means they disagreed on the presence or absence
of ADHD more
than a quarter of the time. (This is not really very
impressive
when you consider that chance agreement alone would
be 50%).
Agreement for
the particular subtype of ADHD was especially poor.
Among 55 children
who met criteria for ADHD, Combined Type,
according
to parents or teacher, parents and teachers agreed on only
17 cases.
Agreement between parents and teachers for the ADHD,
Hyperactive/Impulsive
subtype was only 2 of 24 cases and for the
Inattentive
subtype it was only 2 of 20 cases.
The authors
also examined how diagnoses based on combined parent
and teacher
data compared to diagnoses based on each source alone.
These comparisons
are quite interesting and are shown in the chart
below. (Note:
ADHD-C=combined type; ADHD-H/I = hyperactive/
impulsive
type; ADHD-I = inattentive type).
=====================================================
Percentages of Diagnoses Based on Parent, Teacher, and
Combined Parent-Teacher Information
Parent Teacher Combined
no ADHD
15
24
7
ADHD-C
61
37
87
ADHD-H/I
15
19
4
ADHD- I
10
20
3
======================================================
(Note: The numbers in the table above reflect the percentage of children
who were diagnosed with each subtype of ADHD, or who were not
diagnosed with any subtype of ADHD, based on parents alone, teachers
alone, or the combination of parent and teacher information.
For example,
the first entry indicates that 15% of children were not diagnosed with
any
type of ADHD based on the parent report alone. The fact that
the percentage
of children diagnosed with the inattentive or hyperactive/impulsive
subtypes
in the combined column are so low reflects the fact that when both
parent
and teacher data is combined, almost every child diagnosed with ADHD
received the combined type diagnosis.)
Several things
are noteworthy here. First, it should be stressed that when
information
from parents and teachers is integrated in the diagnostic
process, children
are more likely to be diagnosed with ADHD of some
type (i.e.
only 7% had no diagnosis in the combined condition vs. 15%
and 24% for
parents and teachers respectively. This is probably because
each reports
certain symptoms that the other does not observe, and when
these reports
are then combined, a greater number of symptoms is
reported than
for either source considered separately.) It is also evident that
when combined
information is used, the combined subtype is by far
the most common,
and that relatively few children are diagnosed with
either of
the other two subtypes.
How do parents
and teachers compare directly? First, it is interesting
that using
teacher data alone was less likely to result in a child being
diagnosed
than using parent data alone (i.e. 24% of children received
no diagnosis
based on teacher data compared to only 15% using parent
data.).
Second, even though teachers are less likely to report ADHD
symptoms overall
than parents, they are more likely to see children as
being highly
inattentive (i.e. 20% of children diagnosed with inattentive
subtype according
to teachers compared to only 10% according to
parents).
This is most likely because teachers observe children in a
context where
problems with attention are much more likely to be
evident.
How do parent
reports of their child symptoms at school compare
to teacher
reports?
The data reported
above is based on parent report of symptoms they
observe in
their child at home. Parents were also asked, however,
about symptoms
they believed their child to display in school and these
were compared
to what teachers reported about the child. The
percent agreement
for each symptoms was assessed and ranged from
50-76% for
hyperactive/impulsive symptoms and from 43-78% for
inattentive
symptoms. This is not especially good when one would
expect agreement
to be 50% by chance alone. In fact, after correcting
for chance
agreement, it was found that parent and teacher agreement
on individual
symptoms was rarely better than chance. When reports
were treated
as a composite score using the different hyperactive/impulsive
and inattentive
symptoms, rather than considering each symptom
individually,
a modest but significant correlation was obtained. Thus,
there was
at least some significant consistency between parent and
teacher reports
of how the child behaves at school when a more global
rating of
hyperactive and inattentive behaviors was considered.
SUMMARY AND IMPLICATIONS
The results
of this study highlight the importance of obtaining information
from both
parents and teachers in the evaluation process. As is clear
from the data
above, parents and teachers do not necessarily agree on
the presence
or absence of sufficient number of symptoms to warrant
any type of
ADHD diagnosis in a large number of cases (i.e. 24% in
this sample).
This is the case even when parents have sought an
evaluation
because of behavior problems their child was displaying.
In cases where
parents are less concerned about their child's
functioning
- as often occurs when a child is having problems at
school but
not at home - one might expect that agreement between
parents and
teachers would be even lower.
Even in this
sample, however, the level of disagreement on specific subtypes
was surprising.
Having parents report on their child's behavior at school
in addition
to their child's behavior at home is no solution to this problem,
as agreement
with what teachers report observing for individual
symptoms is
often no better than chance. Even for more global measures
of ADHD symptoms,
agreement remains relatively modest.
The clear message
from these data is that relying on a single source
for diagnostic
purposes - in reality, this would generally be the parent -
runs the substantial
risk of misdiagnosis. These data suggest that
when only
one source is used, children who perhaps should have
been diagnosed
with some type of ADHD will not be. The concern,
of course,
is that this will preclude a child from receiving treatment
who really
needs it. Of course, the opposite is also possible - i.e.
relying on
a single source will result in a child being diagnosed with
ADHD who should
not be. The authors of this study argue that
the use of
data from both parents and teachers is essential to
arrive at
the most accurate diagnosis possible - a conclusion with
which I would
strongly agree. Unfortunately, we know that for a
variety of
reasons this often fails to happen and children are diagnosed
by physicians
when information has been obtained directly from
teachers.
It should also
be emphasized that obtaining data from both parents
and teachers
is also critically important for the ongoing monitoring
of how a child
who has been diagnosed is responding to treatment.
Knowing how
a child's treatment - regardless of what that treatment
consists of
- is affecting behaviors specifically targeted for
improvement
is critical for determining whether treatment is being
successful
or needs to be modified. As this study makes clear, a
treatment
provider who relies solely on parent reports for information
about a child's
behavior at school is likely to receive a different -
and probably
less accurate - account of what is going on than if
the data about
school behavior was obtained from the child's
teacher.
It is thus quite important for parents to insist that periodic
feedback from
the child's teacher be obtained and conveyed to
their child's
treatment provider so that appropriate decisions
about treatment
can be made. (Remember, this is what I developed
the ADHD Monitoring
System to do. If you have not yet
received your
copy, just send an email message to
monitor@www.helpforadd.com
and it will be sent to you automatically.)
Reprint requests to:
Dr. Jeff Halperin
Dept. of Psychology
Queens College
65-30 Kissena
Blvd.
Flushing,
NY 11367
* RECOMMENDED
GUIDELINES FOR MEDICATION
TREATMENT
Even though
stimulant medication treatment is generally believed to
be a safe
and effective treatment for most children with ADHD, based
on the results
of numerous studies, even proponents of such treatment
would agree
that they way in which meds are often prescribed is
problematic.
Among the problems that have been noted are: 1) the lack
of a careful
evaluation to establish that ADHD is a proper diagnosis
prior to initiating
treatment; and 2) failure to collect systematic information
on a child's
response to medication so that well-informed decisions
about continued
use can be made. As a result, many children are probably
placed on
stimulant medication who really do not have ADHD, and others
who really
have ADHD are not prescribed medication in a way that
is likely
to be as helpful as it could be. Evidence in support of the latter
were results
from the recent multi-modal
treatment study of ADHD, where
it was found
that children treated with medication as part of the study
did better
than children who were treated with medication by community
physicians.
In response
to the recognition that medication treatment for ADHD is often
not done in
a careful and systematic way, efforts are underway to
develop clear
guidelines that such treatment should follow. Recently, a
set of such
guidelines was published by a group of ADHD experts
(Plizka, S.R.
et.al., (2000). The Texas children's medication algorithm
project: Report
of the Texas Consensus Conference Panel on the medication
treatment
of childhood ADHD. Journal of the American Academy of
Child and
Adolescent Psychiatry, 39, 908-927). This is an important
effort
because the
authors attempt to provide - based on the best currently
available
evidence - a specific set of recommendations for how medication
should be
prescribed that is quite different from the far less-systematic
approach that
is generally used. These guidelines are summarized below.
Note:
The authors of these guidelines emphasize, of course, that the use
of medication
treatment is predicated on the fact that the diagnosis of
ADHD has already
been carefully established.
Also, the authors
do not specifically recommend that medication should
always be
the first or certainly the only treatment initiated, and specifically
emphasize
that psychosocial interventions (e.g. behavioral treatment) play
an important
role in the treatment of ADHD. Instead, if medication is
going to be
used, they try to lay out a careful and systematic procedure for
doing this
that can be feasibly implemented in most primary care
settings.
Children who
meet criteria for a manic episode, any psychotic
disorder,
or a pervasive developmental disorder would be excluded from
the recommendations
below.
It should also
be noted that separate algorithms were developed for those
children who
have an anxiety or depressive disorder in addition to ADHD.
The guidelines
presented below apply to children diagnosed with ADHD
but without
either of these other types of disorders. For children with
ADHD and either
depression or an anxiety disorder, the trial begins with
stimulant
medication as described below, and then recommends the use
of separate
meds to treat the depression and/or anxiety symptoms depending
on whether
or not these show improvement when the ADHD symptoms
are reduced.
Space considerations do not enable me to include
this entire
algorithm.
I expect that
other groups - particularly the American Academy of
Pediatrics
- may be issuing similar guidelines in the months ahead.
RECOMMENDED PROCEDURE
The guidelines
below are intended to apply to children with ADHD alone, as
well as to
those who have ADHD along with other types of conditions including
oppositional
defiant disorder or conduct disorder. The authors also note that
although the
recommendations below should be appropriate in the majority of cases,
any stage
can be skipped depending on the particular child's presentation.
Stage 1:
Medication treatment for ADHD should begin with one of the
stimulants.
Typically this would be Ritalin/methylphenidate (methylphenidate
is the generic
form of Ritalin) or amphetamine (e.g. Dexedrine or Adderall).
The authors
note that there are no current clinical predictors indicating
which child
will respond to which stimulant. Thus, the choice of which type
of stimulant
to begin with is up to the physician and parent. (Note:
Recently,
however, several
studies have been published to suggest that Adderall may
be a more
effective medication for the majority of children with ADHD and
also requires
fewer doses per day for most children. It may therefore
be reasonable
to begin a child's medication treatment with Adderall.)
The important
point to note here is that medication treatment for ADHD
should
almost always begin with one of the standard stimulants, rather than
with
other types of meds or with a combination of meds. There may
certainly
be situations that warrant an exception to this recommendation,
but
one would want to be clear about why a deviation from this generally
recommended
place to start was being made.
The guidelines
also specify the way in which medication should be prescribed
and how the
impact on the child's functioning should be monitored. A key
point here
is that a full range of doses should be used with the initial
medication
prescribed
because body weight can not be used to predict what will be
the best dose
for an individuals child.
What this means
specifically is that a child would be started on a low dose of
whichever
medication is tried initially, and each week the dose would be
increased
until a maximum recommended daily dose is reached. For example,
for methylphenidate
(MPH), the child would be started on a dose of 5 mg
twice per
day. Each week, the dose is raised by 5 mg so that in the 4th week,
(4 weeks is
the recommended length for this initial titration trial) the child would
be receiving
20 mg twice per day, with the possibility of a 3rd dose during the
day added
at the physician's discretion.
At the end
of each week, parent and teacher ratings of the child's behavior
(the recommended
scale is the Abbreviated Conners Rating Scale, a 10
item measure
of ADHD symptoms) and a side effects scale developed by
the authors.
As long as side effects are reported to be mild or non-existent,
the increase
to the next dose occurs - even if it appears that the child has
done well
on the current dose. The quantitative data from the Conners
Scales is
combined with clinical impressions to obtain an overall sense
of the child's
degree of improvement on a 1 ("very much improved")
to 7 ("very
much worse) scale. (This scale is called the Clinical Global
Impressions
Scale - i.e. CGI).
After the 4-week
trial is concluded, the child and parent meet with the
physician
to determine whether any of the doses used during the trial
yielded significant
benefits in the child's functioning (i.e. a CGI rating of
either 1 or
2), and, if so, what the most effective dose was. Assuming
no
intolerable
side effects were observed, this would be the dose the child is
maintained
on.
The really
important point here is that regardless of which medication
a parent
and physician choose to start the child on, there is an initial
4-week
trial in which a range of different doses are used and systematic
ratings
of the child's functioning is obtained from parents and teachers
after
a week on each dose.
The reason
this is so important is that physicians often stop a child's
trial at the
lowest dose that seems to produce benefits. Thus, if a child
is reported
to do better on the initial dose prescribed, this is the dose
the child
is often maintained on. The problem with this is that, in many
cases, even
though the child received some benefit on the initial dose,
he or she
would do substantially better were a higher dose to be tested.
As a result,
many children are maintained on doses of stimulant
medication
that really fail to provide the child with as much benefit
as would be
possible.
By trying a
child on a full range of doses, and comparing standardized
behavior ratings
on these different doses, the likelihood of finding the
best dose
for the child increases dramatically. Although not specifically
stated in
the guidelines, if a child's response to two different doses seems
to be equivalent,
one would generally maintain the child on the lower
dose.
If a child clearly did better on a higher dose, however, and no
adverse side
effects were reported, then it would make sense to continue
the child
on the dose that provided the greatest benefit. For some children
this will
be lower doses and for others it will be higher doses. Because
this can not
be determined in advance, a procedure like that recommended
here is essential.
(Note:
It should be noted that these guidelines do not advocate the use
of a placebo-controlled
trial in which parents, teachers, and children are
unaware of
when the child is on medication and when the child is on
a placebo.
The authors of these guidelines did not issue this recommendation
because they
did not feel it would be practical for physicians to routinely
implement
such a trial.
One especially
important benefit of using a placebo-controlled
trial, however,
is that sometimes what can seem to be side effects to
the medication
are actually reactions that occur during the placebo week
as well.
In the absence of a placebo trial, there is not really a good way
to detect
this. Unfortunately, when this occurs, a child's medication can
be stopped
because of apparent side effects that are really just a placebo
response.
In addition, sometimes what looks like a very positive
response to
medication is really just a placebo response as well.)
Stage 2:
If the child fails to respond to the first stimulant tried, or has side
effects that
make its long-term use inappropriate, the same procedure is
repeated using
a stimulant not used in Stage 1. The range of doses
appropriate
for that particular medication would be used across a similar
4-week trial
period.
The important
point here is that one does not give up on stimulants
if a
favorable response is not obtained to the initial stimulant tried.
In many
cases, a child who does not respond well to the first type
of stimulant
used - or who experiences adverse side effects - will
respond
quite well with no side effects to a different stimulant. So,
before
moving to an entirely different class of medications, or giving
up on
meds altogether, a second stimulant would first be tried.
Stage 3:
Some children will not respond favorably to either stimulant
tested in
the first 2 stages. In this case, the recommendation is to move on
to pemoline
(i.e. the brand name is Cylert) and use a similar titration
trial procedure
using the range of doses appropriate for this medication.
Because of
the concerns about the potential for adverse effects on
liver functioning,
the authors stress that pemoline requires that liver
functioning
must be monitored twice monthly. In addition, parents need
to be made
fully aware of the potential risks. And, the use of pemoline
would
only be suggested if the stimulants tried initially were not
effective
in managing the child's ADHD.
The authors
noted that as a result of these concerns, many parents
and physicians
will prefer to skip this stage and go directly to stage
4. (Note:
As new stimulant medications receive FDA approval and
come on the
market, the guidelines may change to trials of additional
stimulants
before moving on to a new class of medication.)
Stage 4:
In stage 4, it is recommended that the clinician and parent
select either
bupropion (i.e. a newer type of antidepressant; the non-
generic name
is Wellbutrin) or one of the tricyclic antidepressants
(e.g. TCAs,
imipramine or nortriptyline). There is no data currently
available
to suggest which of these antidepressants is more effective
for ADHD than
the other. If a TCA is prescribed, heart rate
monitoring
(i.e. ECG) at baseline and during treatment is indicated.
The authors
note that bupropion should not be used in children with
a seizure
disorder.
As with the
stimulant medications, a range of doses appropriate
for these
particular medications would be used. For the tricyclics,
parent and
teacher rating scales are collected after each week, and
the first
week where significant improvement is reported would be
the dose the
child is maintained on. Thus, on the tricyclics, one
does not necessarily
go through the full range of doses. For bupropion,
because it
can take as long as 4 weeks to obtain benefits, the
behavioral
rating data is not obtained until the end of the trial.
Stage 5:
If
the first antidepressant tried does not produce a
beneficial
result, or is accompanied by adverse side effects, a second
type of antidepressant
would be tried as the next step.
Stage 6:
If a positive response has still not been obtained, the final
recommendation
is a trial of clonidine. The authors note that the
safety and
efficacy data for the use of clonidine for the treatment of
ADHD is not
as well established as one would like. If clonidine
is tried,
they note that office visits are required each week to
monitor blood
pressure and pulse, and that these indices should be
obtained with
the child both lying down and standing. A child
would generally
take clonidine for 2 to 8 weeks at the maximum
dose tolerated
to assess its response, with a total daily dose
ranging from
.05 mg/day to 4 mg/day. After the child has been
on the maximum
dose tolerated for 3 to 4 weeks the behavioral
rating data
would be collected and the CGI rating made. If the
CGI score
is 1 or 2 (i.e. the child is rated as very much improved
or much improved)
and there are not troublesome side effects,
he or she
would be maintained on that dose.
SUMMARY and RECOMMENDATIONS
It is important
to emphasize once again that these guidelines are
not intended
to convey the impression that every child with ADHD
should necessarily
be treated with medication. The authors
note that
non-medication options can certainly be considered prior
to beginning
the medication algorithm, and that even if medication
treatment
is initiated, psychosocial interventions will often be
a very important
part of a child's treatment.
The authors
are also careful to note that the management procedure
they outline
always need to be used in the context of the individual
clinical situation
and the clinician's judgment about what is most
appropriate
for an individual patient. Thus, these guidelines are
not published
with the intent that they be rigidly followed in every
situation.
Instead, the
value of these guidelines is that they provide physicians
with a systematic
approach to medication treatment that should result
in a greater
likelihood that such treatment can provide the child
with the maximum
gains from medication that are possible. They
also educate
parents about an approach to medication treatment
that has been
developed by experts in the field based on the best
data currently
available. Should your child's medication treatment
for ADHD be
substantially different from what is discussed in these
guidelines
(for example, your child is being treated simultaneously
with multiple
medications) it would seem reasonable to inquire about
the reasons
for this with your provider.
If your child
is taking a conventional stimulant medication, but was not
initially
tested with a full range of different doses, you should consider
the possibility
that the dose your child is being maintained on would not
be the optimal
one. You may also wish to discuss this with your child's
physician.
(Note: If you are using the ADHD Monitoring System to
track how
your child is doing at school on a regular basis you should
be in a good
position to evaluate how well your child's symptoms are
being managed.
If they are clearly being managed quite well, there
would generally
not be any reason to consider an adjustment to
treatment.
If they are not, however, then such adjustments would
be important
to consider with your child's physician.)
New data that
may influence the guidelines described above may
certainly
be published in the future, of course, and new and hopefully
more effective
medications for treating ADHD are being developed.
As these changes
occur, the guidelines for medication treatment will
change as
well. (You can find the web site where such changes would
be posted
by going here,
although when I recently checked, the ADHD
treatment
algorithm was not yet posted.)
One important
aspect of medication treatment not covered in these
guidelines
is the need to monitor a child's treatment on an ongoing
basis even
after a maintenance type and dose of medication has been
decided on
using an approach such as that described. Remember,
even when
a child's symptoms are being managed well, this can
change over
time for a variety of different reasons. Thus, the fact
that a particular
medication is working well at one point in time does
not guarantee
that things will still be going well later on. Monitoring
a child's
functioning over time in a consistent and systematic way
can thus be
critical to promoting a child's healthy long-term development.
Reprint requests to:
Dr. Steven
Plizka
UTHSCSA
Dept. of Psychiatry
Mail Code
7792
7703 Floyd
Curl Drive
San Antonio,
TX 78229-3900
* PATTERNS
OF BRAIN ACTIVITY LINKED TO POSITIVE
MEDICATION RESPONSE
A recent issue
of the journal Biological Psychiatry contains a brief but
very interesting
report that relates patterns of brain activity in children
with ADHD
to a positive response to medication. This study is
interesting
for at least 2 reasons. First, the finding that only children
with ADHD
who show a particular change in brain activity in response
to medication
show behavioral improvement supports a current
theory that
ADHD is associated with underactivity in the prefrontal
cortex.
Second, the findings to be discussed below also provide
support for
the theory and practice that underlies the use of
neurofeedback
treatment for ADHD.
Before describing
the study, some brief background information will
be useful
to review. First, current theories of ADHD, such as the
recent theory
proposed by Dr. Russell Barkley, suggest that the
symptoms of
ADHD reflect a pattern of underactivity in the prefrontal
cortex.
It is this region of the brain that is believed to be primarily
responsible
for what Barkley and others refer to as "behavioral
inhibition"
- i.e. the ability to inhibit or refrain from one's immediate
response tendencies
so that situations can be thought through and
various options
considered. In Barkley's theory, this core deficit
in behavioral
inhibition leads to a variety of other difficulties and
eventually
to the observable symptoms of ADHD.
There have
been several recent studies in which EEG measures
in individuals
with and without ADHD have been compared and
found to differ.
(An EEG is a procedure for measuring the pattern
of activity
in different brain regions.) Studies using this procedure
have found
that children with ADHD exhibit an excess of slow
wave activity
(these types of brain waves are referred to as
theta or alpha
depending on their exact frequency) and a reduced
amount of
beta (these are higher frequency brain waves that are
associated
with attention and concentration). The basic idea is
that children
with ADHD demonstrate a pattern of underactivity
in the prefrontal
cortical areas, and that this is the basis within the
central nervous
system for many of the symptoms they display.
Some support
for this hypothesis was provided in a study
reviewed
in the April
issue of ADHD RESEARCH UPDATE,
in which
measures of
prefrontal cortical activity was found to do a very
accurate job
of differentiating individuals with ADHD from those
without the
diagnosis.
Studies such
as these that report an association between particular
patterns of
brain activity and ADHD symptoms are an initial step
in determining
whether such EEG patterns play a causal role in
a child's
- or adult's - symptoms of ADHD. Merely demonstrating
that these
things are related, however, is not sufficient to establish
causality.
Instead, to get closer to making any causal conclusion
about patterns
of brain activity and ADHD symptoms, one would
want to try
and change these underlying EEG patterns, and then
observe where
there is any corresponding change in ADHD
symptoms.
This is essentially
what the authors of this interesting preliminary
investigation
attempted to do (Loo, S.K. et.al.; (1999). EEG
correlates
of methylphenidate response among children with
ADHD: Preliminary
findings. Biological Psychiatry, 45, 1657-
1660).
Participants in this study were 10 children (8 boys and
2 girls) between
the ages of 8 and 13 who had a confirmed
diagnosis
of ADHD. Children in the study were brought to
the lab on
2 separate days that were about 1 week apart.
On each day,
EEG recordings were taken two separate times.
The first
time was a baseline reading to obtain a measure of
the child's
typical EEG activity. The second time was about
1.5 hours
after taking either a 10 mg. tablet of methylphenidate
or a placebo.
There was one
other important step in this study. Right
after the
second EEG recording, children were given the Conners
Continuous
Performance Test (CPT), a computerized measure
of sustained
attention and impulsivity. In this test, the child sits
in front of
a computer terminal and is instructed to press the
space bar
each time any letter except X is presented on the
screen.
A variety of measures are computed from this test
including
reaction time, errors of omission (i.e. failing to press
the space
bar when letters besides X are displayed; such
omissions
are associated with failing to pay attention), and
errors of
commission (i.e. pressing the space bar when an
X is displayed;
such errors of responding when one has been
instructed
not to is associated with impulsivity).
Prior research
has documented that children with ADHD perform
differently
from children without ADHD on the Conners
CPT, and this
measure is often used to assist in the diagnostic
process.
In addition, a child's CPT performance has been
shown to improve
significantly in response to stimulant medication
treatment.
Thus, by comparing the CPT results that each
child obtained
after taking the placebo pill with the results
obtained after
taking the actual medication, children could be
classified
as "responders" or "non-responders" to the medication
(i.e. those
classified as responders had significantly better
CPT results
after medication than after placebo while the
CPT results
for non-responders did not show any significant
change.)
Then, by comparing the EEG changes after
medication
for the responders and non-responders, the authors
could examine
what specific changes in brain activity were
associated
with a positive response to medication.
(Note:
In this study, the authors were using CPT results alone
to decide
whether or not a child was a medication responder.
In actual
clinical practice, of course, it would be important to
confirm that
medication was also associated with positive changes
in the child's
behavior and academic performance. Improvement
in a lab based
measure without corresponding improvement in
the child's
functioning in the "real world" of home and school is
not going
to do the child any good. For the purposes of this
study, however,
the methods employed by the researchers are
adequate.)
RESULTS
When response
vs. no response to medication was determined
as described
above, 7 of the 10 children were found to have
a positive
medication response. The crucial question, then, is
how EEG changes
following medication in the responders
compared to
EEG changes in the non-responders. The prediction
would be that
medication responders would show a decrease
in slow wave
activity (i.e. alpha and theta) because these wave
patterns are
associated with daydreaming and lack of concentration
and an increase
in beta activity which is associated with better
attention.
For the non-responders, no such changes should have
been evident.
In general,
this is exactly what was found. Responders showed
small but
consistent decreases in alpha and theta activity and
increases
in beta activity. Non-responders, in contrast, showed
the exact
opposite pattern. As the authors note "...medication
appears to
increase cortical arousal and increase high frequency
activity (i.e.
beta) associated with concentration and attention
among children
who are positive medication responders."
The authors
also examined the correlation between changes in
CPT performance
between the medication and placebo
condition
and changes in beta activity during these conditions.
This correlation
was strongly positive which means that
children who
showed the most improvement on the CPT
were those
who showed the greatest increase in beta activity.
This suggests
- but does not prove - that increased beta
activity is
what caused the better CPT performance.
SUMMARY and IMPLICATIONS
Because of
the small sample size, the results of this study
certainly
needed to be considered preliminary, and replication
with a larger
sample would be an important extension of
this work.
With this caution in mind, however, this is potentially
a very important
study.
This study
demonstrated that children who responded
positively
to stimulant medication as assessed by their
CPT performance
were those whose EEG results indicated
increased
beta and reduced alpha and theta activity following
medication.
Thus, the children who improved showed
increased
cortical activity after medication. This supports
current views
that ADHD reflects lower levels of cortical
activity (some
have referred to this as a "sluggish brain"),
and that increasing
this activity is associated with improvement
in ADHD symptoms.
The results
of this study also have potentially important
implications
for the use of neurofeedback as a treatment
for ADHD.
This is a treatment approach whose efficacy
is still not
considered firmly established by most ADHD
experts, but
which has yielded promising results in a
number of
studies. In neurofeedback treatment, children
with ADHD
are specifically taught how to decrease
slow wave
activity (i.e. alpha and theta) and to increase
higher frequency
beta activity. Several studies have
demonstrated
that a majority of children with ADHD can
be taught
to produce these changes. In addition, unlike
such changes
which result from medication and last only
a matter of
hours, neurofeedback-induced changes are
reported to
persist over time. The results of the current
study appear
supportive of neurofeedback treatment
because they
show that EEG changes associated with a
positive medication
response are the same types of
changes that
are targeted by neurofeedback.
This is certainly
not "proof" that neurofeedback treatment
works,
but it does suggest that the premise underlying such
treatment
- i.e. train children to decrease slow wave brain activity
and increase
higher frequency activity - is a plausible account
of what successful
treatment may involve.
Reprint requests to:
Dr. Sandra
Loo
Univ. of Colorado
Health Sciences
4200 E. Ninth
Ave.
Box C-268-68
Denver, Co
80262
- Subscriber Question -
"My child is 8 and was put on
Ritalin by his pediatrician
at the very end of the school
year because of problems he
had with attention during the
year. The teacher didn't
notice much difference during
the last week of school and
we haven't either during the
summer. Now that school
will be starting again in a few
weeks, the doctor wants
to try bupropion since the Ritalin
did not seem to work.
Does this seem like a reasonable
thing to try?"
There are several issues here that
would be important to consider
and discuss with your child's physician.
First, although you do not mention
this, I will assume that your
child received a comprehensive evaluation
for ADHD and it
was determined that the attention
problems during the last
school year were determined to reflect
ADHD and not some
other issue. If this were
not done, of course, you would want
to have such an evaluation before
initiating any further
treatments. For a general
discussion of what is involved in
such an evaluation click here.
Based on what you describe, there
are several things that I
would wonder about. First,
if your child was put on meds
during the final week of school,
this is unfortunately not a good
time to evaluate their impact.
Typically, the last week of a
school year is quite different from
the rest of the year. In
many classrooms, the amount of work
required is reduced
and children are having end-of-year
parties and getting ready
for the summer. Because of
the reduced academic demands,
the demands for sustained attention
are also reduced. Thus,
this is not a good time to obtain
good data on how medication
may effect a child's inattentive
symptoms. (Also, as noted
above in the article on medication
guidelines, you would typically
want a 4-week trial in which your
child was observed on a
range of different doses.
Clearly, this can not be done when
the meds do not start until the
last week of school.)
You also noted that you and your
husband did not notice
much change in your son during the
summer. I would be
cautious about interpreting this
to mean that the Ritalin was
not effective. The reason
for this is that you stated in your
question that your child's problems
were primarily with attention
and did not mention hyperactivity/impulsivity.
If this is the
case, and your child has the inattentive
type of ADHD, his
symptoms would typically be much
more evident at school
than at home. This is because
the demands for sustained
attention at school are generally
greater than they are at home.
As a result, you may simply not
have the opportunity to
observe your child in a context
where his attention problems
are most evident, and thus you would
also not be able to
observe any positive impact the
Ritalin may have had on his
attention problems.
Because of these concerns, I would
be cautious about
moving to try an antidepressant
medication like bupropion
at this time. As reviewed
in the guidelines above, it is generally
recommended that at least 2 different
stimulant medications
be tried before moving to antidepressants.
Based on your
description, it does not sound as
though even the initial
stimulant has been given an adequate
trial. So, it may make
more sense to make sense to do a
careful trial with several
of the stimulant medications before
moving on to an
entirely different class of medications.
On other point to keep in mind is
that the very beginning
of the school year can also be a
difficult time to obtain
good information about how a child
has responded to
medication for treating ADHD.
The reason for this is that
many children with ADHD begin the
year reasonably well,
and do not start to really struggle
until a month or more has
gone be. This may be because
the novelty of a new classroom
environment helps them to maintain
better behavior and
focus early on. In addition,
it often takes teachers at least
several weeks to get to know a child
well enough that the
feedback they provide about a child's
response to medication
would be most valid.
Because of these factors, it may
make sense to start the
school year without your child on
medication and see how
things go. After 2-4 weeks
have gone by, it would be good
to have his teacher fill out a standardized
behavior rating form
such as the Child Behavior Checklist
- Teacher Version or the
Conners Ratings Scale to determine
whether he/she is observing
important problems with ADHD symptoms.
If this turns out to
be the case, then a careful medication
trial and/or other types
of interventions could then be implemented.
Once again, please remember that
this should not be construed
as medical advice. Your child's
physician is in the best position
to advise you and the discussion
above is presented as options
for you and your child's physician
to consider. Remember, the
authors of the guidelines note that
these are general
recommendations only, and that the
situation of a particluar child
may justify altering them.
________________________________________________
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