In this issue...

A National Perspective on Treatment Services for ADHD

Preliminary report of a new medication to assist
children with ADHD and severe behavior problems

Does stimulant medication treatment improve self-esteem in
children with ADHD and peer problems?

The effect of arousal level on creativity and time estimation in children with ADHD

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What have been the important trends during the past decade in the type of care that children with ADHD typically receive in community settings?  As you can imagine, this is a difficult and complicated question to address.  The answer to this question is enormously important, however, for it will inform us about critical gaps in the provision of appropriate care that parents need to be aware of and that professionals and policy makers need to address.

A recent article from the Journal of the American Academy of Child and Adolescent Psychiatry (JAACP) provides the most comprehensive information yet available on this issue (Hoagwood, K. et al., (2000). Treatment services for children with ADHD: A national perspective. JAACP, 39, 198-206). There is a tremendous amount of interesting data presented in this paper, and I will try to highlight what seem to be the key findings below.

Data for this study come from two large national data bases that were established in the 1980s and updated annually since then.  These data bases include representative samples of pediatricians, family physicians, and psychiatrists who provide records of patient visits, diagnoses, and services provided at each visit.  (All information that could potentially identify any patient is removed so that records remain anonymous.) By comparing the kinds of services provided to children who had been identified as having a diagnosis of ADHD, and noting the types of services that these children received, trends in service provision over the recent past can be identified.  This is because these data are based on thousands of community physicians who treated thousands of children and teens for ADHD.  Even though the exact same physicians did not provide data in different years, the sample is large enough, and representative enough, to provide a good picture of what is actually going on.

Results

The results of this study are fascinating.  Here are some of the key findings:

* ADHD is being identified at a greater rate

The percentage of visits where ADHD was identified has risen from .74% in 1989 to 1.9% in 1996.  In addition, for physician visits where a mental health problem was identified as the primary reason for the visit, the percentage of children identified as having important attentional problems increased from 41% to 60% during this same period.

Note: Although these data indicate that ADHD is being identified at an increased rate, 2 points are important to keep in mind. First, these data tells us nothing about the accuracy of the diagnoses being made.  Second, the 1.9% rate for physician- identified ADHD in 1996 is still substantially below actual prevalence rates that have been determined from a number of different studies.  Overall, therefore, it may be that many instances of ADHD continue to go undiagnosed and untreated.

* Important changes are occurring in medication management

The percentage of visits for children with ADHD during which stimulants were prescribed increased from about 55% in 1989 to about 75% in 1996.   During that time, there was a corresponding decline in the prescription of other medications to treat ADHD - from about 15% in 1989 to about 7.5% in 1996.

Note: Because stimulant medication has been shown to be an effective treatment for most children with ADHD, the fact that more children are receiving it may reflect physicians' greater use of an empirically validated treatment approach.  Unfortunately, no data is available on the quality and care of the medication treatment being practiced.  As you may recall from the results of the MTA study (i.e. the largest and most comprehensive treatment study of ADHD conducted to date) there is good reason to believe that children treated with medication in the community typically do not derive as much benefit as they might were careful and systematic procedures followed.

I think it is encouraging that the rate of prescribing non-stimulant medications for children with ADHD has been cut dramatically. These reason for this is that non-stimulant meds are typically less effective and less is known about their long-term safety. In the MTA study, however, almost none of the children with ADHD required medications other than stimulants to effectively manage their symptoms.  This suggests that in many cases where other meds are prescribed, it may be because careful efforts to obtain the greatest possible benefits from stimulant medications were not used.  Thus, the 7.5% figure may still reflect a greater use of alternative medications than is really necessary.

* There has been an important decline in important follow-up care for children with ADHD

Between 1989 and 1996, the percentage of visits where follow-up care was recommended declined from 91% to 75%.  Thus, as recently as 1996, 25% of children identified as having ADHD are not scheduled for any follow-up care.

Note: This is a very concerning finding.  Because ADHD typically effects children over many years, one of the most important aspects of treatment is carefully monitoring a child's development over time.  Just because a child's symptoms are being managed effectively at one point in time does not, unfortunately, mean that this will persist. Difficulties often emerge and require that adjustments to a child's treatment be made.  It is virtually inconceivable that effective care could be provided in the absence of regular and periodic follow-ups. (The ADHD Monitoring System that you received can be an effective tool to help you monitor your child's progress and functioning over time, although this gets more difficult to do when children move into middle school and begin to have multiple teachers).

The authors also examined how the type of services that children with ADHD received varied according to whether the provider was a pediatrician, family physician, or psychiatrist.  These results are based on the most recently available data, which was from 1996.

The major findings here are that family physicians are more likely than the other providers to prescribe stimulant medication for treating ADHD (i.e. 95% vs. about 75% for pediatricians and psychiatrists).  Conversely, family physicians were less likely to utilize any type of formalized diagnostic services in their visits with children identified as having ADHD (i.e. 33% vs. 64% for pediatricians and about 80% for psychiatrists).  Family physicians were also less likely to recommend specific follow-up care (i.e. 46% vs. 79% for pediatricians and 89% for psychiatrists). Family physicians were also far less likely to provide any type of mental health/behavioral counseling services during visits - only 7% of the time - than were pediatricians (44%) or psychiatrists (67%).

Although this study does not include any data that enables one to determine the appropriateness of services being provided, it does appear that the care a child receives depends greatly on the type of physician doing the treatment. In particular, although family physicians were more likely to prescribe stimulant medication, they were less likely to use any formalized diagnostic services, to provide any type of counseling, or to even recommend follow-up care.  Even among pediatricians and psychiatrists, follow- up care often failed to be recommended, and it seems highly unlikely that this was because no such care would have been needed.

Overall, the authors conclude that in at least 50% of the cases, guidelines for care that have been recommended by the American Academy of Child and Adolescent Psychiatry for the treatment of ADHD are not being followed.  This is not  good news.

BARRIERS TO CARE

The final issue examined in this study concerned what primary care physicians (i.e. pediatricians and family physicians) perceived as the major obstacles to making mental health referrals they may have felt were needed for their patients with ADHD.  Listed below are some of the barriers they identified along with the % of the physicians surveyed who reported each barrier:

Barriers                                               % reporting

Lack of specialists                                        64%

Difficulty getting appt.                                   64%

Restrictions on who could be                        48% referred to because of insurance company

Authorization procedures                              39%

Financial disincentives                                   35%

Burdensome paperwork                               30%  

The two most commonly reported barriers, mentioned by nearly two-thirds of participating physicians, reflect the perceived lack of clinicians who are specially trained to work with child behavior problems (e.g. child psychiatrists, child psychologists, developmental pediatricians).  The other commonly reported barriers to care appear to be direct outgrowths of the restrictions placed on mental health treatment by many of today's health maintenance organizations.   It is particularly striking to me that over one-third of the physicians surveyed reported that financial disincentives limited the number of mental health referrals they made for children.  Although these data do not provide direct evidence that the quality of care that children receive as a result of HMO regulations has been compromised, it is certainly consistent with this hypothesis.

Summary and Implications

The most important implication of this study according to the authors is as follows:

"Although at least 2 professional associations have written guidelines or parameters of practice with these children (American Academy of Child and Adolescent Psychiatry and American Academy of Pediatrics), and though evidence-based reviews have been completed, these guidelines are not yet influencing care as delivered in real-world practices."

To this conclusion I would add that these data strongly suggest that changes in the insurance industry and the restrictions these changes have placed on many physicians is likely to be having a negative effect on the quality of care that many children with ADHD - as well as children with other types of emotional and behavioral problems - receive.

To me, this highlights how important it is for parents to be as informed as possible about how ADHD can affect children's development and what are the best ways to promote the long-term success of children with ADHD.

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One of the questions I receive most frequently from parents concerns how to help their child who, in addition to having ADHD, is also demonstrating significant behavior problems. As you are aware, other behavior disorders such as oppositional defiant disorder (ODD) or conduct disorder (CD) frequently develop in children with ADHD, and managing these children is much more difficult. ( For a discussion of ODD and CD click here).

At this point, there have been several studies that have demonstrated that stimulant medications, when prescribed properly, often help with these co-occurring behavior problems in addition to a child's primary ADHD symptoms.  For example, in the MTA study - the largest treatment study of ADHD ever conducted -  it was found that carefully prescribed and monitored medication resulted in significant reductions in children's oppositional and aggressive behavior.

Non-medical interventions have also been shown to have important benefits for children demonstrating severe behavior problems.  Such interventions generally involve the development of systematic behavioral plans designed to promote more prosocial behavior in children combined with strategies to help children learn more appropriate ways to resolve disagreements with others (i.e. teaching children more effective social problem-solving skills).

What can be done, however, when these approaches that are often helpful do not seem to work?  This important question was the subject of a preliminary report of a new medication for treating children with ADHD and severe behavior problems that was published recently in the Journal of the American Academy of Child and Adolescent Psychiatry (Kewley, G. (1999). Risperidone in comorbid ADHD and ODD/CD. JAACP, 38, 1327-1328.)

The author of this brief report is a child psychiatrist who directs a clinic in England that specializes in the evaluation and management of children and adolescents with ADHD.  He describes his experience in using Risperidone to treat 30 child and adolescent/young adult clients between the ages of 6 and 21.  All these individuals had been diagnosed with ADHD, combined with severe behavior difficulties (they had been diagnosed with either ODD or CD) that had started relatively early in their lives.  In addition, most of the individuals in this sample were also diagnosed as having bipolar disorder.

According to the author, these individuals had all been treated with stimulant medications without substantial benefits.  Other medications such as clonidine had also failed to provide good results, as had a variety of psychosocial interventions. (Unfortunately, no information is provided about the type, intensity, or quality of the non-medical interventions that had been implemented.) Although details about the treatments received are lacking given the brief nature of this report, it is evident that the patients being discussed are those who presented with severe problems for which the most frequently used treatments supported by the best empirical evidence is available were inadequate.

Only after more traditional treatment approaches were proven unsuccessful were the clients started on risperidone.  Risperidone is a relatively recently developed antipsychotic medication that is most frequently used to treat schizophrenia, a severe mental disorder that has no relation to ADHD.  In children, risperidone has been shown to be helpful to children with schizophrenia (a very rare diagnosis for a child) and it has also been used effectively to assist children with Tourette's disorder.  There have been no prior reports, however, in the use of risperidone for treating ADHD.

According to the author, 20 of the 30 patients showed a "very significant" improvement in symptoms (both ADHD symptoms and behavioral symptoms as well) , 5 showed a "moderate" improvement, and in 5 the risperidone was stopped, either because it yielded no improvement or because of side effects.  (No information is provided about how significant or moderate improvement was defined or measured). The most commonly reported side effect was excessive weight gain which occurred in 10 patients.  The author reports that the patients have continued to be maintained on risperidone - some for up to 4 years - with ongoing positive results.  Attempts to withdraw the medication have typically resulted in a recurrence of symptoms.

The author is very careful to stress that this is a preliminary study only.  This is not a controlled trial in which the effects of risperidone are compared to the effects produced by a placebo, and can thus only be considered the initial stage in establishing the efficacy of this medication for children with severe ADHD and associated difficulties who have not been able to be helped by other means.

These considerations aside, I wanted to include a summary of this work in ADHD RESEARCH UPDATE because it provides an avenue that may be worth considering in circumstances where a variety of other treatment options have been exhausted. It is important to stress that in the absence of effective intervention, the prognosis for the children described in this report is unfortunately not very positive.  In these situations, consulting with an experienced child psychiatrist (this would not be the type of medication treatment that most pediatricians would feel comfortable handling) about the possible use of risperidone may be a reasonable option.  I will be sure to include more comprehensive follow up studies to this work in the newsletter as they are published.

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How does treatment with stimulant medication effect a child's self-esteem?  Many parents are concerned that taking medication will cause their child to feel badly about him or herself, and are reluctant to consider medication use because of this concern.

A team of researchers (Frankel, F., Cantwell, D., Myatt, R. & Feinberg, D.) set out to answer this question in an independent study conducted at the UCLA Department of Psychiatry. Their results were recently published in an article of the same name in the Journal of Child and Adolescent Psychopharmacology, 9, pp. 185-194.

The issue that this article addresses is an important one.  Children with ADHD often have difficulty making and maintaining friends. Studies have shown that peers of children with ADHD are less likely to endorse them as friends, and frequently these children are the victims of peer teasing.  As a consequence of these and other influences, children with ADHD tend to have lower self-esteem compared to children without ADHD.  The same is true among adolescents, where a greater number of ADHD symptoms have also been found to be associated with lower self-esteem.

Although stimulant medications - the most common treatment for children and teens with ADHD - has been shown to produce a wide variety of benefits for many children, the impact of medication treatment on self-esteem has not been studied very carefully. Because some researchers believe deficits in self-esteem are among the more enduring problems for children with ADHD, the absence of research on the relation between medication treatment and self-esteem in children with ADHD is an important gap in the literature.

Previous research that is related to this issue has yielded inconclusive results.  One study evaluated whether children with ADHD who took medication ascribed their improvement to pills instead of to their own abilities and found some indication that children with ADHD tended to attribute their improvement to their medication.  The authors argued that this attribution might lead to feelings of helplessness and lower self-esteem because children were not taking full credit for their own improvement, although they did not measure self-esteem directly.

In a second study on this issue, it was reported that children with ADHD who were prescribed stimulant mediation reported higher academic self-esteem than unmedicated children.  However, the majority of children in the study were either receiving special education services or were repeating at least one grade, which is a highly specialized sample.  Thus, the results may not necessarily be representative of the majority of children with ADHD.  In addition, the study was limited to the assessment of academic self-esteem, which is only one aspect of self-esteem that would be important to examine. For example, it is also important to know how medication treatment may influence not only how a child feels about his or her academic competence, but also their feelings of competence in social and behavioral domains.

The current study was designed to fill in some of these important gaps. The authors attempted to answer two main questions related to the effects of medication in children with ADHD and peer difficulties: 1) Does medication improve self-esteem, and if so 2) does this improvement correspond to the amount of medication taken?

Participants in the study were 39 boys and 17 girls between the ages of 7 and 12 who were in regular school classes without a history of repeated grades. All 56 children were diagnosed with ADHD, with half obtaining the additional diagnosis of Oppositional Defiant Disorder (ODD).  All participants were also clinic-referred for peer problems.  The most frequent parental complaint was that their child was having difficulty making or keeping friends.  Also common were complaints of peer rejection and peer teasing.

In this study, children were divided into two groups.  The larger group contained 38 children,  and all of these children were prescribed stimulant medication for the study. The smaller group consisted of the remaining 18 children, who were either non-responders to medication, were seeking alternative sources of treatment, or were newly diagnosed in the context of the study.  During the study, none of these children received medication.

ADHD diagnoses were made using a structured diagnostic interview completed with the child's parent(s). The mothers of these children also completed two questionnaires to assess their child's behavioral and emotional functioning, as well as their ability to establish friendships and get along with their peers. (The specific behavior rating scale instruments used were the Child Behavior Checklist and the Social Skills Rating System (SSRS). The children themselves were administered the Piers-Harris Self- Concept Scale (PHS), one of the most widely used and extensively researched instruments used to measure self-esteem in children. Unfortunately, the amount of time that children were receiving medication prior to the self-esteem assessment was not indicated.

Results

The results of this study indicated that children who received stimulant medication reported mildly higher self-esteem than children who did not take medication. The relationship between self-esteem and medication was complex, however.  Medicated children either with or without ODD reported feeling smarter and more accepted by peers then the children who did not receive medication.  Only children with ADHD and ODD, however, (i.e. those who demonstrated more behavior problems) reported feeling that they were better behaved.  In addition, among all children that were medicated, higher self-esteem in the behavioral academic, peer, and physical domains was associated with higher doses of medication.

The authors suggest two alternative explanations for these results. The first is that children receiving medication reported higher self-esteem because they perceived that their behavior was under better control, thus leading them to feel more positively about themselves.  They explained the dose-response relationship by suggesting that children receiving higher doses may have experienced stronger "internal sensations" from the medication, and this may have led them to have greater hope for positive social outcomes.  Of course, it higher doses may have resulted in greater improvement, which could also explain the results.

Another possible interpretation for the dose-response relationship is that these improvements may be, in part, a function of the severity of the child's symptoms.  A child with more severe symptoms will generally take higher doses of medication, and will also have greater room for improvement. Greater improvement would be expected to translate into greater gains in self- esteem, thereby accounting for the association found between dosage and self-esteem that was found.

Summary and Implications

Despite the encouraging findings of this study, you should be aware of several limitations that may have influenced the results.  This includes a design that did not randomize children into treatment groups, thereby leaving the possibility that the two groups differed in some ways other than medication status and that these differences could account for the results.

Another important factor not taken into account in this study is what parents tell their children about their medication and how this might effect their children's self-esteem.   It may be that the expectations and interpretations that children on medication make, as well asthe way peers respond to them, vary as a function of the amount of time they have been taking the drug.  Future studies should address these concerns to form a more complete and informative understanding of the effects of stimulants on self-esteem in children with ADHD.  Finally, this article did not specify the amount of time children had been taking medication before their self-esteem was evaluated. This is an important oversight.

These concerns not withstanding, I think there are several implications of these results are quite important. First, it is important to emphasize that medication is not a "magic pill" that improves a child's self-esteem. Most psychologists would argue that a child's self-esteem depends, to a large extent, on how that child is performing in important life areas (i.e. academics, getting along with peers, teachers, and family members) and the feedback the child receives in that area.  The fact that medication was associated with improvements in self-esteem thus probably reflected the very real impact that it had on a child's ability to do better in these different areas.  One would expect that any type of intervention - whether that be medical, behavioral, etc. - that yielded significant improvements in child functioning would also result in corresponding self-esteem gains.

A second important implication is that contrary to a concern that has been expressed by many parents and professionals, medication treatment did not seem to be harmful to how children felt about themselves.  In fact, the exact opposite was found to be the case. In my own experience, I have worked with a number of parents who were reluctant or unwilling to try medication with their child because they were convinced that this would cause the child to feel badly about him or herself.  While this may certainly occur in individual instances, and is a possibility that one should be aware of, the current data would seem to indicate that this would not be expected to occur very often.

Finally, I think it is really important to emphasize again the link between how a child is faring in academic, social, and behavioral domains and how the child feels about him or herself in these different areas.  For most children, improving their feelings about themselves in these areas will require helping them to have more consistently successful experiences in school, with peers, and at home.  Well-conducted medication treatment is one important way of helping many children experience such success, but other types of interventions can clearly play an important role in accomplishing this as well.

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Getting bored quickly - particularly in the classroom - is one of the most common features of children with ADHD.  Some have proposed that this observed behavior is related to cortical underarousal in individuals with ADHD - i.e. certain regions in the brains of people with ADHD tend to be underactive relative to what is found in those without ADHD.  As a result, researchers have suggested that people with ADHD are especially likely to be underaroused during dull tasks which impairs their actual performance during these conditions.  This is certainly one plausible factor that could contribute to the difficulty that many students with ADHD experience in the classroom.

If underarousal is at least part of the basis for difficulties experienced by students with ADHD than, in theory, some of the performance differences that are evident between students with and without ADHD during low arousal conditions should disapper under conditions of high arousal. This interesting question was the subject of a paper published recently in Developmental Neuropsychology (Shaw, G., & Brown, G. (1999). Arousal, time estimation, and time use in attention-disordered children. Developmental Neuropsycholgy, 16, 227-242.

This study was conducted with students in an English high school. As you may know, ADHD is diagnosed much less frequently in England than in the US, not I think because of any actual difference in how many children are affected by ADHD in the two countries, but instead, because of very different attitudes towards the disorder in England and the US.  Thus, none of the participants in the study to be described had actually received a formal diagnosis of ADHD.

Particpants in the study were all 12 years old.  Teacher ratings of children's ADHD symptoms were used to identify 2 groups of 12 students each.  One group (10 boys and 2 girls) received extremely high ratings of ADHD symptoms using a standardized behavior rating scale.  As noted above, none of these students had been formally diagnosed with ADHD and none were receiving any type of medical treatment.  Their scores were well within the range of those obtained by children with ADHD, however, and it is likely that many of these children would have qualified for the diagnosis.  At the very least, they were certainly displaying very high levels of inattentiveness and hyperactive/ impulsive behaviors according to their teachers.  A comparison group - matched on a variety of characteristics including gender composition - was created from students who received very low ratings on this scale.

The design of this study was actually quite interesting.  The experimenters were especially interested in how students' arousal level effected their ability to accurately estimate time (problems with time estimation has been proposed by Dr. Russell Barkley to be an important problem in those with ADHD) and their performance on tasks that assess creativity. Arousal level was manipulated by having students watch both a "boring" and an "arousing" videotape (i.e. a high speed car chase scene).  After watching each tape, students were asked to estimate the amount of time each clip had lasted.  They were also then asked to perform two tasks that are believed to assess creativity.  These creativity "tests" presented students with various types of stimuli on paper that the students were asked to use to develop as many different figures or pictures as possible.  In addition to collecting these data, the authors also collected data on a variety of other issues.  This included students' self-reports of ADHD symptoms, their tendency to seek out "risky" types of activities, and their own assessment of their ability to use time wisely.  Teachers provided estimates of students' ability to use time wisely as well (e.g. being on time for activities, being able to plan the right amount of time to finish work, etc.).

(Note: Pulse rate data collected on students after the low and high arousal videotapes indicated significantly higher pulse rates after students viewed the latter tape.  Thus, the manipulation of arousal level was confirmed to be successful.  An assumption is made that this increased physiological arousal would also be reflected in cortical activity level, although this was not directly measured.)

Results

A number of interesting and potentially important results are reported. As one would expect, students in the ADHD group (remember, these are not students who had actually been diagnosed with ADHD but those whose teachers had rated them as showing high levels of ADHD behaviors) reported much higher levels of ADHD symptoms than the comparison group.  Thus, at least on this dimension, they seemed to be aware of their difficulties.  Also consistent with expectations, the students with ADHD described themselves as being more interested in seeking out high stimulating (i.e."risky") types of activities.

For self-reports of ability to use time wisely (e.g. "Can I plan the correct amount of time to complete my homework?) the results were quite different.  Here, the ADHD students reported that they were just as competent as students in the comparison group.  This was true even though the teachers reported that these children had substantial deficits in their time-planning abilities.  This contrast is interesting and a bit perplexing - i.e. the students are aware of and acknowledge their high levels of ADHD behaviors but seem oblivious to the difficulties they have in structuring and organizing their time.

The data pertaining to time estimation and creativity under the low and high arousal conditions are especially interesting.  After watching the low arousal video, children in the ADHD group reported that the video lasted significantly longer than children in the comparison group.  Time estimates for the high arousal video did not differ between the two groups.  In this condition, the students with ADHD were just as accurate.  For the creativity tasks, the scores received by children in the two groups did not differ for the task performed after the low arousing video was watched.  After watching the high arousal video, however, the students with ADHD obtained significantly higher scores.

Summary and Implications

The results of this interesting study indicate that how the performance of students with ADHD compares to their peers can vary significantly depending on their arousal level. When aroused, their ability to correctly estimate the passage of time did not differ from comparison children and their performance on a test designed to estimate creativity was actually better.

Although these data certainly do not prove the hypothesis that cortical underarousal may be the neurological underpinning of ADHD, they are consistent with this proposition.  The data also imply that when evaluating the ability of students with ADHD to perform certain tasks, estimates that are made in low-arousal conditions may given an inaccurate impression of their abilities.  Unfortuantely, this is often the context in which such performance estimates are obtained in educational settings.

As the authors note "...although most students are able to organize themselves and function effectively under low levels of stimulation, this is not true of ADHD students." Thus, developing ways to make the school environment a more "interesting and arousing" one may be especially important for improving the performance of students with ADHD.  Figuring out reasonable ways to accomplish this provides an interesting and important challenge for parents and educators alike.  I would hope that research on this issue is currently underway and will be published in the near future.

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(c) 2000 David Rabiner, Ph.D.