In this issue...

Adderall vs. methylphenidate in the treatment of ADHD

A new approach for handling "explosive" children

During the past year there have been two studies published in which Adderall - a relatively new medication used for treating ADHD - has compared favorably to methylphenidate (i.e. the generic form of Ritalin) for reducing the symptoms of ADHD.  In these studies, Adderall was found to yield a comparable - or even more favorable response - than methylphenidate for most children, and children required less frequent dosing with Adderall.

There were several important limitations of these prior studies, however, that mitigate the conclusions one can make about the superiority of Adderall.  First, both studies compared certain fixed doses of Adderall to fixed doses of methylphenidate.  What this means is that an individualized procedure to determine the optimum dose of medication for each child - based on feedback received about the child's performance on different doses - was not employed.  This is important because such a procedure helps to insure that a child is getting the maximum possible benefits from medication. This is also closer to what should happen in actual clinical practice.  Second, children in these studies were not randomly assigned to receive either Adderall or methylphenidate, but received one or the other - or both - based on a variety of considerations.  Random assignment (i.e. it is strictly chance whether a child gets placed on one medication or the other), however, is the best procedure to use for trying to determine whether one medication tends to produce a superior effect to the other.

A study published last month in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACP) takes an important step in addressing the limitations of prior work (Plizka, S.R. et al., (2000). A double-blind, placebo- controlled study of Adderall and methylphenidate in the treatment of ADHD. JAACP, 39, 619-626.)  The focus of this study was to provide the most thorough evaluation to date of the relative efficacy of Adderall vs. methylphenidate for the treatment of ADHD in elementary school children.

Participants in this study were 58 children diagnosed with ADHD, the majority of whom had received no prior medication treatment. The average age of children was approximately 8 years old and both boys and girls were included.  (Unfortunately, the breakdown of girls and boys in the sample was not provided). To participate in this study, parents had to provide consent for their child to be randomly assigned to receive either methylphenidate, Adderall, or a placebo (i.e. a placebo is something that looks like real medication but is really not) for a 3-week trial.  (The child received only one of these 3 possibilities during the entire 3-week trial.) Neither the child, the child's parents, nor the child's teacher were aware of what the child was receiving during the trial.

Prior to commencing the trial, baseline ratings of children's behavior were obtained from both parents and teachers. During the initial week of the trial, teachers completed behavior rating forms twice per day, each day - once to report on the child's behavior and academic performance during the morning and once to report on behavior and school work during the afternoon.  In addition, at the end of the week, parents were interviewed over the phone about their child's behavior during the after-school hours for that week.  Parents were also asked to rate the severity of a variety of possible side effects that they may have observed during the week.  These teacher and parent ratings were then reviewed by a psychiatrist who was also blind to the child's medication status.  Based on the ratings, this psychiatrist decided whether an adjustment to the child's medication needed to be made for the second week (e.g. increasing the dose, adding a second dose during the school day and/or after school).

So, for example, some children on Adderall may have done so well during the initial week that no adjustment to dosage was made after reviewing the first week's ratings.  Other children in Adderall, in contrast, may have had their dosage increased.  The same would be true for the children on methylphenidate.  Even for children on placebo, a recommendation for adjustment could be made (recall that the psychiatrist making the recommendation did no know whether the child was on a placebo), although this would result in nothing more than the placebo being administered for another week.

A similar procedure was followed during the second week, at the end of which another adjustment was made if warranted.  This procedure thus provided the opportunity to adjust the child's dosage for 2 successive weeks using carefully collected data from parents and teachers.  Finally, parent and teacher behavior ratings and parent side effect ratings were then collected once again at the end of the final week.  In addition, a psychiatrist who was blind to the child's medication status provided an overall rating of the child's improvement using a standardized scale designed to assess treatment improvement.  This rating was made based on an individual interview with the child and his/her parents, as well as reviewing the rating scale data collected during the trial.

In theory, this procedure for adjusting dosage after the first 2 weeks based on the behavior rating and side effects data should have resulted in the child being placed during the 3rd week on a dosage regime that was best suited for him or her.  Thus, this should allow for a "fair" comparison of the relative efficacy of Adderall vs. methylphenidate for treating ADHD symptoms in school-age children.

Results

For each source of outcome data (i.e. teachers, parents, and psychiatrist) analyses were conducted that compared children in the 3 groups (i.e. Adderall, methylphenidate, and placebo).  The results of these comparisons are summarized below.

Teacher behavior ratings showed - as expected - that children receiving either Adderall or methylphenidate did better than children on placebo.  This, of course, has been documented in numerous prior studies and the magnitude of the difference were comparable to what has been found before.

Of more interest, however, is that children receiving Adderall fared significantly better according to teachers than children receiving methylphenidate.  This was true for ratings of ADHD symptoms specifically and for ratings of aggressive/ disruptive behavior.

In contrast to the results for teachers, no significant difference was found when parents ratings were analyzed.  In other words, neither Adderall nor methylphenidate were found to be superior to placebo when parent ratings of children's behavior during the evening were analyzed.

This can not be explained by the fact that children were not receiving medication to cover the after-school hours when parents would have the opportunity to observe them.  The reason why this is not a viable explanation is that when parent ratings during week 1 or 2 indicated that problems related to ADHD were clearly evident during evening hours, an adjustment would have been made to provide the child with the additional dose needed to cover the after-school period.  Instead, the authors suggest that the reason no significant effect was found for the parent ratings is that there was such a large placebo effect for parents.  In other words, even parents whose children were receiving placebo reported substantial improvements relative to the initial ratings taken at baseline.  Because so much improvement was reported by parents for children receiving a placebo, it was difficult for the medication to look significantly better.

As noted above, a psychiatrist also provided an overall rating of each child's improvement based on an interview conducted with the child and family, and reviewing the behavior rating scale data.  Children were considered to have shown a positive response (i.e. significant improvement) during the trial based on the score they received on this rating.

Using this criterion, 90% of the children in the Adderall group were judged to be responders.  This compares to 65% of children receiving methylphenidate and 27% of children who received placebo.  This difference in response rate between Adderall and methylphenidate was statistically significant, as was the difference between methylphenidate and placebo. (The fact that over 25% of children receiving placebo were rated as showing significant improvement highlights the need of conducting placebo-controlled trials to determine medication response.  Otherwise, children who get no real benefit from medication above and beyond a placebo response may be maintained on the meds for a sustained period of time.)

FINAL DOSING REGIMEN

In addition to looking at how the behavioral outcomes compared for children on Adderall and methylphenidate, it is also instructive to look at the dosing regimens that children were on at the end of the trial.  Seventy percent of the children receiving Adderall required only a single dose per day to cover the entire day, while 30% required a second dose after school to cover the evening hours. None of the children on Adderall were judged to have needed a second dose during the school day - an important finding in that taking medication at school can be a source of concern for some children and parents.

For the children on methylphenidate, 85% received 2 or more doses per day.  Of the 13 who were judged to be positive responders according to the psychiatrists ratings, 6 required a second dose during the school day. Thus, about half the children judged to have responded favorably to methylphenidate needed to take the medicine during school.

In terms of the total daily dose, children in the Adderall group received an average of 12.5  mg/day compared to 25.2 mg/day for children receiving methylphenidate.

SIDE EFFECTS

After each week of the trial, parents provided ratings of the most commonly reported side effects of stimulant medications.  For each of 11 side effects, the percentage of parents reporting that the adverse effect was either moderate or severe was a minority.  Although there was no significant difference in the number of children for whom parents reported moderate to severe side effects, there was a tendency for children receiving Adderall to show more stomach problems and mood changes (i.e. sadness and/or irritability).  Approximately 25% of children receiving Adderall were reported by parents to show such effects.

It was interesting to note the parent reports of the side effect "Gets wild when medication wears off", a relatively common complaint of parents whose children take stimulant medication.  Thirty-five percent of parents whose child received Adderall reported this concern as did 40% of parents whose child received methyl- phenidate.  This would seem like a real problem.  For children receiving placebo, however, this same concern was reported by 44% of their parents.  Thus, this also illustrates one of the potentially important benefits of conducting placebo-controlled medication trials: such trials can help to determine whether an apparent side effect of medication is really just a placebo effect.

Summary and Implications

The results of this study suggest that Adderall may be a better initial choice of medication for children with ADHD relative to methylphenidate.  In this study, the behavioral effects of Adderall were generally greater than those produced by methylphenidate, and they also lasted longer.  This means that most children treated with Adderall required less medication and fewer doses to achieve better results.  In particular, none of the children treated with Adderall needed to take a dose during the school day during this trial, something required by a number of children treated with methylphenidate.  One potential concern is the possibility that Adderall may possibly be more likely to lead to stomach aches and mood changes than methylphenidate.  Thus, these potential side effects would need to be monitored carefully.

These results should not be interpreted to mean that any particular child will do better on Adderall than methyl- phenidate, as this is clearly not the case.  Many children will do equally well on both types of medication, some will do equally poorly on both, and some will do better on methylphenidate than Adderall.  Instead, the data should be interpreted to suggest that if a child is going to be started on medication to treat ADHD - and this is an entirely separate decision - then Adderall is probably a good medication to begin with.  Replicating these results with a larger sample would lend even greater confidence to this recommendation.  It would also be nice if a study was done that directly compared Adderall to Ritalin, as there have been some reports that Ritalin may be superior to its generic form (i.e. methylphenidate).

If your child is currently on methylphenidate or Ritalin and is doing well, I would not take these data to mean that you should switch to Adderall.  For a child on a stable medication regimen and doing well, the only reason I am aware of to do this would be if the child needed to take medication during the school day, and this was a source of concern.  In this case, it appears that Adderall will often eliminate the need for this in school dosing.  Thus, should this be your circumstance, it may be an option worth discussing with your child's physician.  Remember, though, there is no guarantee that Adderall will prove to be as effective for your child, so one would need to carefully and systematically monitor how a child responded to the switch.

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One of the most frequent questions I receive from parents concerns how they should deal with their child's temper outbursts and "explosions".  Although such characteristics are not part of the core symptoms of ADHD (click here for complete diagnostic criteria), and can certainly occur for a variety of reasons besides ADHD, such explosiveness does seem to be more common among children with ADHD and is often a major source of concern.

I just finished an excellent book called The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, "Chronically Inflexible" Children. The book is authored by Dr. Ross Greene, a clinical psychologist on the faculty at Harvard Medical School.  I purchased this book hoping for some helpful insights for dealing more effectively with my own charming but difficult 3-year-old.  The approach described by Dr. Greene impresses me as a very thoughtful and useful approach that may be helpful to many parents, and I wanted to share his ideas with you.

WHAT ARE THE COMMON CHARACTERISTICS OF INFLEXIBLE-EXPLOSIVE CHILDREN?

It is important to begin by noting that the label "inflexible- explosive" is certainly not a diagnostic term recognized in DSM-IV - the official diagnostic guide for psychiatric disorders.  Instead, it is used by Dr. Greene to capture the key features of children who can be extremely difficult for parents to manage.  According to Dr. Greene, the key features of such children are the following:

1. A remarkably limited capacity for flexibility and adaptability and a tendency to become "incoherent" in the midst of severe frustration.

These children are much less flexible and adaptable than their peers, become easily overwhelmed by frustration, and are often unable to behave in a logical and rational manner when frustrated.  During periods of incoherence, they are often not responsive to efforts to reason with them, which can actually make things worse.

Dr. Greene refers to these episodes as "meltdowns", which strikes me as a very apt description.  Because a child's ability to think clearly during a meltdown is essentially nil, their behavior can appear exceedingly wild and irrational.  Cursing, screaming, breaking things, and physical aggression are quite common during these episodes, which can last from several minutes to several hours.  Dr. Greene believes that the child has little or no control over his/her behavior when in the midst of a meltdown.

2. An extremely low frustration tolerance threshold.

These children often become overwhelmingly frustrated by what seem like relatively trivial events.  Because their capacity to tolerate frustration does not develop at the same rate as their peers, the child often experiences the world as an extremely frustrating place filled with people who do not seem to understand what they are experiencing.

3. The tendency to think in a concrete, rigid, black- and-white manner.

These children fail to develop the flexibility in their thinking at the same rate as peers, and tend to regard many situation in an either-or, all-or-none, manner.  This greatly impairs their ability to negotiate and compromise.

4. The persistence of inflexibility and poor response to frustration despite a high level of intrinsic or extrinsic motivation.

In other words, even very salient and important consequences do not necessarily diminish the child's frequent, intense, and lengthy "meltdowns".  This means that typical approaches of consistently rewarding a child for desired behavior and punishing negative behavior may not make a dent in the child's tendency to "fall apart".  According to Dr. Greene, traditional behavioral therapy approaches for such children often don't work at all and can actually make things worse.  

In addition to these key features, Dr. Greene notes that a child's "meltdowns" often have an "out-of-the-blue" quality, occurring in response to an apparently trivial frustration even when the child has been in a good mood.  As a result, parents never know what to expect - i.e. all hell can break loose at seemingly any moment.  These children may have a specific issue about which they are especially inflexible (e.g. the food they will eat, the order in which certain things need to be done), or can be this way about multiple issues.

WHAT "CAUSES" A CHILD TO BE THIS WAY?

According to Dr. Greene, there are a variety of "pathways" that a child may move along towards developing these "inflexible and explosive" characteristics.  For the most part, he seems to believe that all of these pathways are predominantly biological in nature, and that most children who become extremely inflexible and explosive do not do so in response to "poor parenting".  How parents respond to these biologically- based vulnerabilities in their child, however, can have important implications for how well their child is able to master his or her problems over time.

Below is a brief description of the different characteristics that are identified as predisposing a child to become highly inflexible and explosive.  Bear in mind that this is probably not an exhaustive list (some would suggest that allergies - espcially food allergies - should be on this list) that not every child with any of these characteristics will display the kinds of problems that Dr.Greene describes, and that some children will possess more than one of these "predisposing" attributes.

Difficult Temperament - By nature, some infants come in to the world being more finicky, emotionally reactive, and more difficult to soothe than others.  For example, with my younger daughter, almost anytime she was awake during her first 6 months she was crying.  Calming her down and soothing her was all but impossible with anything other than letting her nurse.  As she grew older, she continued to get upset easily, to be virtually impossible to distract when she got her mind on something (which is a real problem when it is something she can't have or do), and to display her negative emotions in intense and persistent ways.  Undoubtedly, we've made mistakes in how we have tried to deal with these difficulties, and these have probably contributed to their ongoing nature.  The bottom line, however, is that this was essentially how she came into the world.  These "innate" aspects of personality are what psychologists refer to as temperament.  (Note: It is important to recognize that even very difficult temperaments can be modified over time and this in no way "dooms" a child to a life of ongoing difficulty and struggle.)

ADHD and Executive Function Deficits

Many children with difficult temperaments also wind up being diagnosed with ADHD at some point.  As discussed in a prior issue of Attention Research Update, current conceptualizations of the core difficulties associated with ADHD focus on deficits in a crucial set of thinking skills called "executive functions".  Although there is no universal agreement on the specific skills that constitute executive functions, the typical list of such skills would include such things as: organization and planning skills, establishing goals and being able to use these goals to guide one's behavior, holding information in memory, selecting strategies to accomplish these goals and monitoring the effectiveness of these strategies, being able to keep emotions from overpowering one's ability to think rationally, and being able to shift efficiently from one cognitive activity to the next.

Deficiencies in these skills are believed to help explain not only the core symptoms of ADHD (i.e. inattention and hyperactivity/impulsivity), but also to the poor tolerance for frustration, inflexibility, and explosive outbursts that are seen in "inflexible-explosive" children.  For example, if a child has difficulty shifting readily from one activity to the next because of an inherent cognitive inflexibility, it may explain why he or she becomes so frustrated when parents request that he/she stop playing and come in for dinner.  Such a child may not be intentionally trying to be non-compliant, but their non- compliance may instead reflect trouble with shifting flexibly and efficiently from one mind-set to another.

Language processing problems

Language skills set the stage for many critical forms of thinking including problem solving, goal setting, and regulating/managing emotions.  Thus, it is not surprising that children with less well- developed language abilities - either in receptive language (i.e. taking in and understanding what is said) and/or expressive language (i.e. communicating their thoughts and ideas clearly to others) would be at risk for dealing effectively and adaptively with frustration.  Dr. Greene believes that such language difficulties often contribute to the problems displayed by children he describes as "explosive".

Mood difficulties

Some children are born predisposed to perpetually sunny and cheerful moods; others, unfortunately, tend to experience sustained periods of irritability and crankiness.  Clearly, our moods are effected by what actually happens to us in the world.  Green notes, however, that there is an important biological component to one's general mood state.  This is not just true for children who experience full-blown mood disorders such as depression or bipolar disorder, but can apply to "sub-clinical" mood difficulties as well.

Imagine for a moment how you tend to handle things when feeling cranky and irritable.  If you're like most people, you probably become frustrated more easily and lose your temper more readily as well.  So, for children who are prone to these kinds of moods, more chronic difficulties with frustration and temper are likely to be evident.

What can parents do?

How does a parent go about helping their "explosive" child become less explosive, and thereby create a better quality of life for everyone in the family?

Dr. Greene begins by describing common recommendations from the mental health field that often fail to bring the desired relief. First, of course, is the use of medication. Dr.Greene does not appear to be anti-medication, and we certainly know that for children with ADHD, properly prescribed medication often helps, not just with the core symptoms of ADHD, but also with the associated behavior problems such as the explosive outbursts that are the focus of this book. For a number of children with ADHD, however, and certainly for children who are prone to explosions for a variety of the other possible reasons outlined above, medication may often fail to provide a significant benefit. In the book, Dr. Greene describes a number of children he worked with who had been tried on a variety of different meds with limited or no success.

Another common approach - and one that is especially likely to be recommended by child psychologists - would involve behavioral intervention. The basic idea is that by consistently rewarding a child for good behavior, and consistently "punishing" them when they "explode" (e.g get angry, throw stuff, curse, etc.) the child will eventually learn that their tantrums fail to produce any desired consequences for them and these tantrums would then diminish. Essentially, through this approach, children learn that they need to obey parents when commands are given because things go better for them when they do then when they don't.

Certainly, behavioral approaches can be enormously helpful for many children and parents. The literature on the benefits of well executed behavioral treatment is voluminous, and this is one of the best-validated psychosocial interventions that exists. For children whose explosiveness stems from one or more of the reasons that Dr. Greene identifies, however, behavioral interventions may not be effective. In fact, he thinks that they can actually make things worse in many cases - increasing rather than decreasing the frequency with which a child loses control.

Here's why. According to Dr. Greene, a child who is developmentally compromised in the skills of flexibility and frustration tolerance may have difficulty switching from their agenda to their parents' agenda (i.e. responding to a parental command) regardless of how enticing the reward or how aversive the punishment is. So, if I'm a child who currently lacks the capacity to behave logically and coherently when frustrated, then punishing me for telling you to "shut up" when I've become frustrated may make you feel better because you "didn't let me get away with it", but it won't make me any less likely to do the same thing next time. Why? Because the threat of consequences simply can't have an effect on a child who is in a state of mind where they are so upset that the liklihood that they will consider the consequences of their actions is nil. The analogy is that punishing a child with a reading disability for doing poorly on a reading test won't result in better performance on the next test.

It is important to note that this notion runs counter to what many parents and professionals instinctively believe to be true. The widely held belief is that if a child misbehaves, then he or she needs to be punished. If the child is not punished, they will simply not be deterred from continuing to misbehave, and even to get worse. Thus, Dr. Greene's thesis here is a controversial one. I am certainly not suggesting that these ideas are "correct", but do think this is a very useful perspective to consider. From my own experience, I can honestly say that no matter how consistently I might "punish" my younger daughter for getting angry and telling me to "shut up", the impact this has had on helping her to stay in better control - or at least to refrain from telling me to "shut up" when she loses control - has been a BIG FAT ZERO. Perhaps this is not an unfamiliar situation for some of you as well.

If these options don't work, than what?

Developing an effective approach to dealing with explosive children is the heart and soul of Dr. Greene's book, and I can not really do justice to it in this brief review.  I will, however, try to convey the basics of his approach to provide you with a general understanding of the framework that he recommends. Specific strategies about what to do are provided in abundant detail in his excellent book.

The first step is to develop a clear understanding of the reasons for your child's explosiveness.

This is the key first step.  To the extent that parents - and others - regard a child's explosiveness as reflecting deliberate and willful attempts to "get what they want", the overwhelming tendency will be to respond in punitive ways.  As noted above, however, punishments will not be successful with a child who lacks the skills to handle frustration more adaptively and, who, when frustrated, can not possibly use the anticipation of punishment to alter their behavior.

When one's mindset changes from "my child is acting like a spoiled brat" to "my child needs help in learning to deal with frustration in a more flexible and adaptive manner", one can move from a punishment-oriented approach to a skills-building approach.

Dr. Greene talks about how parents can create a "user- friendly" environment for their child that can dramatically reduce the number of explosive outbursts.  Doing so involves a combination of steps including:

* Making sure that all adults who deal with the child have an accurate understanding of the child's unique difficulties, especially those that contribute to the child's explosiveness.  (Note: Consultation with a mental health professional to get an accurate understanding of these difficulties can be absolutely essential.)

* Parenting goals are judiciously prioritized such that the demands for flexibility and frustration tolerance that are placed on the child are reduced.

In other words, parents have to make a concerted effort to make life easier and less frustrating for their child.  Just like a child with a reading disability requires accommodations in what they are expected to do academically, a child with a "disability" in tolerating frustration requires analogous accommodations.  This can be difficult for parents - and teachers - to do, particularly as long as the child's behavior continues to be regarded as deliberate and willful. Specific recommendations that Dr. Greene provides to accomplish this task are presented below.

* Efforts are made to identify in advance the specific situations that tend to trigger inflexible- explosive episodes.

Although not all explosions can be predicted, parents can often get a very clear picture of the situations that tend to be consistently difficult for their child to handle (e.g. going shopping, having to do homework, getting ready for bed.) Once these triggering situations are identified, parents can decide whether they can be avoided altogether to reduce the child's frustration, which can be altered in ways that make it easier for the child to deal with, and which are, unfortunately, unavoidable.  For example, for a child who has meltdowns in a store when he/she can't get what she wants, simply not taking them with you as infrequently as possible can be quite helpful until they develop the skills to handle their frustration better.  With homework, accomodations can often be made in terms of the amount of work the teacher requires the child to do.

* Parents recognize that a child's behavior during meltdowns for what they really are: incoherent behaviors.

When a child has begun to lose control - or has already lost control - and starts screaming and cursing at a parent, it can be excruciatingly difficult not be become angry and hurt.  As a result, it is all too easy for parents to get drawn into making a punitive response, or a demand on their child ("You apologize now!") that only serve to add fuel to the fire.

As tempting as such responses are, Dr. Greene suggests that parents carefully consider whether they really accomplish anything positive.  For example, he talks about asking many parents whether their history of punishing their child for such behavior has had any effect at all in reducing the likelihood of such behavior occurring the next time the child becomes frustrated.  When many parents consider this question, they realize that it has not.  So, if the primary reason for punishing a child is to change the child's behavior, and this is clearly not working, one can legitimately question the utility of punishment.

When behavior that occurs in the midst of a meltdown is seen instead as incoherent behavior that the child can not currently control, a different mind set is possible.  One can focus instead on how to help the child regain control, which will inevitably lead to the end of the behavior that parents find so upsetting and offensive.

A critical belief that underlies this approach is that the vast majority of explosive children really do want to behave better and feel badly about their outbursts.  Thus, they are already motivated to change their behavior but just lack the skills to do it.  Therefore, they don't need more motivation to behave better (increasing motivation is what rewards and punishments are supposed to do).  Instead, they need to acquire the skills that will help them to achieve something they are already motivated to accomplish.

THE "BASKET" APPROACH

When a child is experiencing frequent meltdowns, the toll on the child, parents, and siblings can be enormous. Unfortunately, I speak from some experience on this topic, as my younger daughter is prone to the types of episodes that Dr. Greene describes.

Because such explosions are so difficult for everyone in the family to endure, the primary objective in working with such children is to first reduce the frequency of such episodes.  For example, just reducing the number of meltdowns from several per day to one per day, and eventually to just a handful per week, can make an enormous difference in the quality of family life.  Initially, this is accomplished largely by reducing the demands to tolerate frustration that are made on the child.  Dr. Greene refers to this as the "basket" approach.

Basket A

Some behaviors are clearly so important that they have to remain non-negotiable, even if enforcing them will result in setting off a meltdown.  Initially, Dr. Greene suggests that the only behaviors to be placed in Basket A are those that are clear safety issues (e.g. wearing a seat belt in the car; not engaging in dangerous or harmful behaviors such as hitting others).  These core behaviors that have clear safety implications are where parents must continue to stand firm and require compliance on.

As important as these Basket A behaviors are, it is also important to note the kinds of things that may not initially be placed in Basket A.  Dr. Greene suggests that these can include such things as homework, not yelling at parents, brushing one's teeth, etc.  To make it into Basket A, 3 criteria must be met:

1. The behavior must be so important that it is really worth enduring a meltdown to enforce:

2. The child must be capable of exhibiting the behavior on a fairly consistent basis.

For example, Dr. Greene would argue that there is no point insisting that completing assigned homework be placed in Basket A when there is little chance that he or she has the skills and frustration tolerance to do this consistently.

3. It must be something that you are actually able to enforce.

There are many things we wish our child would do that we are simply in no position to control.  For example, you may want to insist that your child not hang out with certain peers during the school day, and there may be some very legitimate reasons for this.  This, however, is not something that most parents are in any position to be able to enforce.  As a result, you can wind up triggering meltdowns for no real reason and wind up undermining your credibility to boot.

Simply by greatly reducing the number of behaviors for which compliance is non-negotiable to those that are really essential, that the child is capable of performing, and that the parent is capable of enforcing, the number of exchanges that are likely to set off explosive episodes is drastically reduced.

Basket B

Basket B - the most important basket according to Dr. Greene - contains behaviors that really are high priorities but are ones that you are not willing to endure a meltdown over.  These can include such items as completing school- work, talking to parents with respect, complying with reasonable expectations, etc.

It is around Basket B behaviors that Dr. Greene believes that critical compromise and negotiation skills can be taught to your child.  For example, suppose your child is watching tv and you know it is time to stop and get started on homework.  You tell your child to turn off the tv and get started, and he refuses.

The temptation here would be to insist on immediate compliance and to threaten punishment (e.g. no tv for the rest of the week) if your child does not comply.  But, in Dr. Greene's framework, this is not a safety issue, and thus should not be placed in Basket A.  He would ask what is likely to happen if you make such a response? One likely consequence is that your child's frustration will increase, he or she will lose control, and a full-fledged meltdown will ensue.

Is this worth it?  Now, if standing firm and tolerating this meltdown really made it more likely that your child would readily comply the next time you made such a demand, the answer might be yes.  If, however, standing firm and triggering the meltdown in no way increases the likelihood of future compliance or decreases the likelihood of future meltdowns, Dr. Greene would suggest it was definitely not worth it.  Unfortunately, this can often be the case.

What to do instead?  Dr. Greene argues that these Basket B behaviors provide wonderful opportunities to try and engage your child in a compromise and negotiation process. In the scenario above, the parent could say something like, "I know that it is important to you to keep watching tv.  I would like for you to be able to do this, but I also know that you have homework that needs to get done.  Let's try to come up with a compromise where you'll get some of what you want, and I'll get some of what I want."

The goal here is not just to get the child to give in and do what you want, but to begin to help your child learn the compromise and negotiation skills that will contribute to his or her gradually becoming more flexible over time. Dr. Greene points out how this process can be extremely difficult for inflexible-explosive children, and that it is not unusual for them to become increasingly agitated when trying to negotiate a solution.

As a parent, if you observe this starting to occur, and sense your child is getting closer to a meltdown, the goal becomes trying to diffuse the tension so that a meltdown does not take place.  This can mean offering compromise solutions for the child in an effort to help things calm down.  When this does not work, Dr. Greene suggests just letting things go so that the meltdown is avoided.  In the example above, should the efforts to negotiate fail and lead the child to the verge of a meltdown the parent might say, "Well, I can see you are getting really upset about this.  I appreciate that you tried to work out a compromise with me but we have not been able to come up with a good one yet.  So, why don't you just watch a bit more tv for now and we can try again in a little while to work out a good compromise."

This can be very difficult to do.  Certainly, many parents - and mental health professionals - would be concerned that such actions would result in teaching the child that he or she can get what she wants simply by refusing to give in and becoming upset.  This is certainly what a traditional behavioral therapist would argue.  From Dr. Greene's perspective, however, insisting that the child turn off the tv when a compromise was not reached would accomplish little more than triggering a meltdown that would also prevent homework from getting started on and be much more upsetting for everyone.  So, instead, you do your best to help your child develop some much needed negotiation skills, but drop things when it is clear that an explosion is imminent.  Later, when the child has settled back down, you can resume your efforts to negotiate. (By the way, this can also be quite beneficial in helping parents to keep their composure as well - it has certainly been that way for me.)

Developing these skills to compromise and tolerate frustration don't happen right away.  Dr. Greene points out that progress in these areas can be painstakingly slow, but that over time, the approach he recommends can lead to substantial gains for explosive children.

Basket C

Basket C contains those behaviors that once seemed like a high priority but have since been downgraded considerably. These are behaviors that you simply don't mention anymore let alone endure meltdowns over.  By placing a number of previously important behaviors in Basket C, the opportunity for conflict producing meltdowns between parents and their child is greatly diminished.

What kinds of things belong in Basket C?  This depends on the specifics of each situation but may include such things as what a child will and will not eat, what clothes they wear, how they keep their room, etc.  The question to ask in determining whether a particular behavior falls into Basket C is "Is this so important that it is really worth risking a meltdown over?" If not, and you've already identified a number of behaviors that seem more important and worth negotiating over (i.e. those in Basket B), then into Basket C it goes.

Isn't this just giving in to a tyrannical child?

Not necessarily.  Dr. Greene points out that there is an important difference between giving in and deciding what behaviors are important enough to stand firm on.  It remains the responsibility and prerogative of parents to be clear about what is non-negotiable, when compromise is a reasonable way to go, and what things to let slide for the time being.  As the child becomes better able to tolerate frustration and learn much-needed compromise and negotiation skills, more and more behaviors can be moved from Basket C into Basket B, thus providing your child with increasing opportunities to practice learning to compromise.

DOES THIS APPROACH WORK?

It is important to emphasize that although Dr. Greene is a well- regarded researcher in child psychology, the approach described in this book is based primarily on his own clinical experience. He does not cite any studies in which the approach he recommends has been rigorously evaluated.  So, the data to support this system is not yet available to the best of my knowledge.

That being said, I will say that I found many of his ideas to be quite sensible and compelling.  For children who are prone to frequent explosions, the goal of reducing the frustration in their lives to decrease the frequency of their outbursts is critical.  Also, recognizing that these explosions often reflect a real lack of ability to handle themselves more adaptively rather than being willful and intentional certainly applies to many children with these difficulties.  If you buy this premise, then it is reasonable to argue that punishments won't be effective in altering this behavior. Instead, such children need to learn the skills that can help them maintain better control.

I have been trying this approach for the past several weeks with my own child and have been encouraged with the change in her behavior that has occurred so far.  Things are a little better.  The number of explosions has diminished and this has seemed like a major blessing.  Hopefully, this progress will continue.

If you have a child who shows the characteristics that Dr. Greene describes, I would strongly recommend that you go out and purchase his book.  It is thoughtful, well-written, and offers a set of ideas for helping your child that may be quite different from what you have considered.  I think that it is certainly worth a careful look.

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As you are probably aware, the current diagnostic criteria for ADHD identifies 3 distinct subtypes. Children with both inattentive and hyperactive/impulsive symptoms are diagnosed with ADHD, Combined Type. Those with predominantly inattentive symptoms but few hyperactive/ impulsive symptoms are diagnosed with ADHD, Predominantly Inattentive Type. When the opposite is true, the diagnosis would be ADHD, Predominantly Hyperactive/Impulsive Type. (Click here for a complete discussion of diagostic criteria.).

Since the criteria for these different subtypes were published in 1994, researchers have sought to identify meaningful differences between them in addition to differences in the primary ADHD symptoms that children with different subtypes of ADHD display. This is important not only to establish the validity of this subtyping scheme (after all, if children in the different groups do not differ on any important dimensions other than the symptoms used to define each subtype, the utility of such classification would certainly be questioned), but also to establish what may be the particular difficulties associated with the different subtypes to which treatment could be directed. In other words, by identifying meaningful differences in functioning between children with the inattentive, hyperactive/impulsive, and combined subtypes of ADHD, it might be possible to develop treatments that could be specifically tailored to these subtype specific problems.

An interesting study published in a recent issue of the Journal of Child Clinical Psychology is a good example of the work being done in this area (Maedgen, J.W. & Carlson, C.L. (2000). Social functioning and emotional regulation in the ADHD subtypes. Journal of Child Clinical Psychology, 29, 30-42.)   In this study, the authors examined whether children diagnosed with different subtypes of ADHD might differ in the primary reason for social difficulties that they experienced.

For example, some children who have difficulty getting along with peers actually lack the knowledge of ways to get along better - i.e. they really don't know more appropriate ways of interacting. These children have what the authors refer to as social knowledge deficits. Other children with peer difficulties know what they should do, but have difficulty putting this knowledge into practice. For these children, social performance deficits is a more apt description of their difficulties. The authors hypothesized, based on some preliminary work in this area, that children with ADHD, Combined Type and children with ADHD, Predominantly Inattentive Type would have social performance deficits, but that only the latter would also show deficits in social knowledge. (Note: Children with the hyperactive/ impulsive subtype were not included because this is a very infrequently occurring subtype among school-age children, and is more typically found in preschoolers.)

In addition to examining children's social functioning, the authors were also interested in studying how emotion regulation skills might differ between the ADHD subtypes. Children with problems in emotion regulation tend to be overly intense in their displays of emotion and frequently overreact to emotionally provoking situations. In his recent theory of ADHD, Dr. Russ Barkley hypothesizes that deficits in emotional regulation represent one of four primary areas of impairment in children with the combined subtype of ADHD. Problems with emotion regulation can also contribute to difficulties in children's relations with peers. The authors predicted that children with the combined subtype of ADHD would display significantly greater difficulties in this area than inattentive ADHD children.

Participants in this study were 16 children diagnosed with ADHD, Combined Type, 14 children with ADHD, Inattentive Type, and 17 children without ADHD (i.e. control subjects). Most of the participants were being treated with medication at the time of the study.  All children were between the ages of 8 and 11 and about 30% in each group were girls.

Assessment of children's social functioning

Children's social performance - i.e. how they actually behave in a variety of different situations - was assessed in several ways.  First, each child's parent(s) and teacher completed a measure called the Children's Assertiveness Behavior Scale (CABS).  This measure consists of 27 items that describe different social situations that are important and relevant for children in this age range.  For each item, the parent and teacher were required to select from several options the way they believed the child would most likely respond in the sitatuation described.  Either competent responses (i.e. assertive) or incompetent responses (i.e. passive or aggressive types of responses) could be selected.

For each child, separate passive, aggressive, and passive + aggressive scores were computed based on the number of times these options were chosen.  These scores were computed separately for the parent and teacher ratings.  Thus, each child's scores provide an index of how likely his or her parent(s) and teacher believe the child is likely to enact incompetent responses in social situations - passive or aggressive - as opposed to more competent - i.e. assertive - responses.  Previous research has indicated that children's scores on the CAB provide valid estimates of their actual behavior with peers.

In addition to these data on children's social performance, parents and teachers were also asked to provide estimates of how well-liked the child was by his or her peers.  These ratings were used to estimate the proportion of peers who were thought to dislike the child, like the child, or be more or less indifferent to the child (i.e. ignore him or her).

In addition to obtaining these data about social functioning from parents, children themselves were also asked to provide ratings of their social performance and social knowledge skills.  This was obtained using the CABS measure described above.  To assess each child's estimate of their social performance ability, they were asked to select the response they would be most likely to enact in each of the situations described.  To assess social knowledge, they were asked to choose what was the best response to make, even though this might be different from what they felt they would do themselves. This enabled the researchers to examine whether children were able to recognize the most appropriate response in different situations (i.e. social knowledge) even if they reported that they would behave differently in that situation (i.e. social performance).

Assessment of emotion regulation

Children's emotion regulation skills were assessed in a creative and clever way.  Children were told that they would be receiving prizes for their help in the study, were shown 10 potential prizes to choose from, and asked to rank these prizes from least to most desired.  The impression conveyed was that they would receive their highest rank prize.  After completing the measures of social knowledge and social performance described above, they were presented instead with the lowest-ranked prize choice.  This was done by a second examiner who presumably would not have been aware of the child's rankings.

Children's reactions to receiving their least-favorite prize were videotaped (children had been informed that they would be taped during the session), and these tapes were later reviewed so that each child's reaction to receiving the disappointing prize could be carefully observed.  Judges who were blind to child's diagnosis (i.e. ADHD Combined, ADHD Inattentive, or control) rated each child for the intensity of the child's emotional display and the child's effectiveness at regulating his or her emotional display.  Thus, this procedure enabled the authors to observe how strongly children reacted to a disappointment and how well they were able to manage/ regulate their negative emtions.  (At the end of the study, of course, children were informed about the reasons for the procedure and presented with their highest ranked prize.)

Results

As is generally the case with an elaborate study such as this, there are  more data presented in the results section than can be fully reviewed here.  Below, however, are the findings from this study that seem most important.

* Children with ADHD, Combined Type, were less popular with peers according to parents and teachers.

The results on the peer liking issue were consistent and straight forward.  As a group, children with ADHD, Combined Type were regarded by parents and teachers as having great difficulty getting along with peers.  In fact, they were not only perceived to be liked less by peers than children without ADHD, but were also seen as less liked than children with the inattentive subtype of ADHD.  The inattentive ADHD children, in contrast, were not regarded as less well liked than control children by either parents or teachers.

* Children with both types of ADHD had social performance deficits according to parents and teachers, but the nature of these deficits was very different.

As discussed above, social performance was assessed in this study by having parents and teachers identify how they believed the child would respond to a variety of different social situations. Incompetent responses could take the form of either aggression or passivity.

As one might expect, children diagnosed with ADHD, Combined Type, were rated by parents and teachers as more likely than inattentive children or controls to enact aggressive responses.  The magnitude of this difference was exceedingly large - about 3-4 times higher for these children than for other children.  It must be noted that teacher ratings of aggressive behavior were this high even though most of these children were being treated with medication, and teachers had rarely observed them when not on meds.

For passive responses (i.e. just letting things go without taking appropriate steps to deal with the situation), the results were exactly the opposite.  Here, both parents and teachers indicated that inattentive children were far more likely to respond in passive ways than children in the other 2 groups.  The magnitude of these differences, although not quite as large as those noted above, were also substantial.

* Children's ratings of their own performance and knowledge skills did not show substantial differences between the groups.

As discussed above, each child was asked how he or she would act in the identical situations rated by parents and teachers.   They were also asked what the most appropriate response was - even thought this might be different from what they would actually do.  The former was used to assess children's self- appraisal of their social performance and the latter assessed their knowledge of appropriate social behavior.

In contrast to the clear differences between the 3 groups of children described above, virtually no differences were found for children's own reports.  In other words, even though parents and teachers reported that children with ADHD, Combined Type, were far more likely than others to enact aggressive responses, these children did not indicate that they would act aggressively.  And, children with ADHD, Inattentive Type, did not indicate that they would be more likely than others to respond to these situations in a passive manner.

There was, however, one interesting difference in regards to children's social knowledge.  Here, children with the inattentive type of ADHD were slightly less knowledgeable about the most socially appropriate ways to respond compared to control children. Children diagnosed with ADHD, Combined Type, however, did not show this same deficiency in their social knowledge.

* Emotion Regulation

As discussed above, children's ability to regulate their emotions was evaluated by observing how they reacted when presented with their least favorite prize.  Specifically, the researchers were interested in the intensity of the negative reaction they displayed and how well they were able to manage their disappointment.

Interesting differences on this task were found.  Consistent with what had been predicted, children with ADHD, Combined Type, displayed significantly more negative behavior, this behavior was judged to be of greater intensity, and they were less able to effectively mask or regulate their disappointment.  Thus, not only did they seem to become more upset than others, but they were also less willing/able to keep their negative emotions in check. In contrast, children with the inattentive type of ADHD did not differ in their emotion regulation skills as assessed by this task relative to the control children.

Summary and Implications

There are a number of interesting findings to emerge from this study.  First, children with the combined subtype of ADHD are having significantly greater difficulty getting along with peers than inattentive children according to their parents and teachers. This is probably because these children are more likely to act aggressively towards peers, who naturally dislike being the victims of this aggression.  These children are also apparently more prone to intense displays of negative emotion and have difficulty regulating their negative emotions compared to other children their age. Certainly, problems with emotion regulation could contribute to their being disliked by peers.

Given these findings, it is somewhat surprising that the children with ADHD, Combined Type, were not deficient in their social performance skills based on their own reports.  Thus, relative to parents and teachers, these children tended to dramatically underestimate their proclivity to behave towards others in an aggressive manner.

Because actual observational studies have clearly demonstrated that children with ADHD, Combined Type, are indeed more prone to act aggressively, it seems likely that the parent and teacher ratings were more accurate than children's own ratings.  One possible explanation for children's more positive ratings is that they were responding in ways to make themselves "look good" - that is, they were deliberately providing inaccurate assessments of their behavior.  Alternatively, many of these children may be relatively oblivious about the ways that they typically behave.  That is, they may be truly misinformed about how frequently they behave towards others in an aversive manner.

Regardless of which explanation is correct - and each may apply to different children - the absence of any social knowledge deficits suggests that these children do know how they should act even though they may often fail to do so.  This is consistent with Barkley's suggestion that for many children with ADHD, the problem is getting them to do what they already know (i.e. a performance deficit) rather than making sure they know what to do (i.e. a knowledge deficit).

It also bears repeating that the peer difficulties teachers reported for children in the ADHD, Combined Type group was so pronounced even though teachers had typically not observed these children except when they were on medication.  Clearly, this implies that medication was not being effective in managing important aspects of these children's difficulties.  Whether this was because medication was not being administered in the most efficacious way, or whether these were children who clearly required additional interventions beyond medication is not clear. The important point, however, is that most of these children were having difficulties that were not being addressed adequately in the treatment they were receiving.

For the inattentive children, the social problems were less severe and were of a different sort.  These children were seen as more passive by parents and teachers, and their social knowledge tended to be somewhat lower than that of children without ADHD. Surprisingly, however, they were not regarded by parents and teachers as being less well-liked by their peers.

This latter finding is somewhat inconsistent with what has been reported in previous studies and thus needs to be considered quite cautiously. One possible explanation is that because these children are highly passive rather than aggressive, the kinds of social difficulties they have with peers are of the type that adults are less aware of.  If this were true, then these children's peers might report that they did not like them very much even though adults tend to be unaware of this fact.

It is also possible that for inattentive ADHD children, difficulties getting along with peers do not emerge until later in their development.  Perhaps peers do not become as aware of these children's difficulties until older ages - after all, their problems are certainly less obvious than those of children with the combined subtype of ADHD - and it is only then that these children begin to have problems in their peer relationships.  As the demands of peer relationships become more complex with advancing age, it is plausible to hypothesize that children with the inattentive subtype of ADHD would experience increasing difficulty. This would be an interesting developmental question to examine in subsequent research.

In regards to the immediate implications of these results, there are several things that come to mind.  First, the results tentatively suggest that children with ADHD, Combined Type, and children with ADHD, Predominantly Inattentive Type, may benefit from different treatment approaches.  Children with ADHD, Combined Type, are more likely to require interventions that address their difficulties with emotion regulation, as these difficulties may often contribute to their behaving aggressively.  As evidenced by the results of this study, medication as typically prescribed is not likely to sufficiently address the social difficulties that these children have.  Children with the inattentive type of ADHD, in contrast, may benefit more from an approach that encourages appropriately assertive behavior with peers as an antidote to their frequent passivity.  This type of assistance can be provided to children in a well-designed social skills curriculum.

(Note: I'd like to suggest an excellent book that can be used by parents who are interested in trying to help their child with his or her peer relationships.  It is called Socially ADDept -  A Manual for Parents of Children with ADHD and/or Learning Disabilities and it is written by Dr. Janet Giler.  I think you will find that this is really helpful in your efforts to assist your child in getting along better with peers.  Professionals will find that this book can be quite helpful to them as well, especially in working with parents to help their child.)

The findings that children with ADHD Combined Type, were regarded as being relatively disliked by peers also underscores the need to pay attention to children's peer relationships.  Often times, this is not an area that physicians will target in a child's treatment, being content instead to rely on medication alone to treat the primary ADHD symptoms.  As seen in this study, however, these children continued to be regarded as unpopular even though most were receiving medication.  This is really quite important because being disliked and rejected by peers can be a very difficult experience for children.  In addition, other research has shown that as children who are disliked by their "mainstream" peers get older, they tend to hang around with more "devaint" and less socially competent kids because these are frequently the only peers who will accept them.  This process of gravitating towards deviant peers, which becomes especially problematic as children move into middle school and beyond, can lead in many cases to the development of increasingly deviant and antisocial behavior.

This developmentat progression underscores the need for parents to take an active role in trying to help their child who may be struggling with peer relations.  Perhaps the most direct way to help with this is to work hard to try and make sure that your child develops and maintains even a single good friendship.  Having a friend - even if one is generally disliked by other children - has been shown to make an important difference in how children feel about themselves, and in helping them feel less lonely and more positive. Working with an experienced child mental health professional can also be important for developing a good approach to assisting your child in developing more positive peer relations.

It is important to emphasize, of course, that a particular child with ADHD may not necessarily fit the pattern of behavior suggested by group findings such as these.  For example, these data suggest that most children with ADHD, Combined Type, know how to behave socially even though they often fail to act accordingly. Even so, however, a particular child may still have important social knowledge deficits that underlie his or her difficulties and addressing these deficits would be an important aspect of that child's treatment.  This is why it is so important that treatment decisions about what is best for each child with ADHD be based on a thorough and individualized assessment of that child's strengths and weaknesses.