*ATTENTION RESEARCH UPDATE*
*VOLUME 37, November 2000*
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In this issue.§ CAN TEENS WITH ADHD EVALUATE THE SUCCESS OF MEDICATION
TREATMENT?§ ADHD AND LANGUAGE DIFFICULTIES
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* CAN TEENS WITH ADHD EVALUATE THE SUCCESS OF MEDICATION
TREATMENT?Although stimulant medication can be an effective treatment for adolescents with ADHD, it is not uncommon for them to believe that they do not need medication and to refuse to take it. This can present difficult situations where both parents and clinicians may wonder whether ongoing medication benefits outweigh the costs associated with struggling to get an adolescent to take it.
An important consideration in such instances is whether adolescents can accurately evaluate the benefits of the medication treatment they are receiving. Surprisingly, there have been virtually no studies conducted on this interesting and important issue. It was encouraging to come across a well-conducted study addressing this question that appeared in the Journal of Consulting and Clinical Psychology (Smith, B.H. et al., 68, 489-499, 2000).
Participants included 36 (mostly male) adolescents with ADHD who attended an intensive summer treatment program over an 8-week period. Daily program activities included participation in academic classroom activities, study hall, therapeutic recreation, social skills and problem-solving groups, a Junior Achievement style business meeting, and a job period. All activities occurred in the context of an intensive behavior management system in which adolescents were given frequent feedback about their behavior from highly trained staff. Each adolescent's success in meeting the requirements of their behavior contract was used to determine access to various privileges.
Two weeks into the 8-week program, participants began a placebo-controlled medication trial that lasted for the next 6 weeks. During this period, either methylphenidate (the generic form of Ritalin) or a placebo was administered 3 times each day, and neither the adolescent, his counselors, nor his classroom teacher at camp were told when real medication and when the placebo had been received. At the end of the day, each adolescent, his counselors and teachers were asked to judge the adolescent's behavior during the day. These included judgments about:
1) Problems getting along with peers and staff;
2) The intensity of specific ADHD symptoms; and
3) A guess as to whether or not the adolescent was on medication or a placebo during that day.In addition, the frequencies of specific behaviors (such as the number of conflicts with peers and staff, and amount of time spent off-task in the classroom) were recorded each day by trained observers. These ratings are considered "objective accounts" of what happened during the day, and provide a basis for evaluating the accuracy of the judgments made by the staff and adolescents about their own behavior.
RESULTS
The authors first examined the accuracy of the guesses made each day by adolescents, counselors, and teachers as to whether the adolescent had received medication or a placebo that day. Overall, adolescents, their counselor, and their teacher responded correctly at a rate that was significantly better than chance. However, the counselors and teachers were more accurate than the adolescents.
Next, the authors examined how the ratings provided by adolescents, counselors, and teachers changed depending on whether or not the adolescent was on medication or placebo. Adolescents and their counselors both reported significantly fewer problems with peers and staff during active medication days. For specific symptoms of ADHD, however, adolescents' reports for the medication and placebo days did not differ. The ratings provided by each adolescent's counselor and teacher, in contrast, indicated substantial reductions in ADHD symptoms on days when medication was given.
Finally, the authors examined the relationship between the behavior judgments made by adolescents, counselors, and teachers, and the "objective accounts" made by trained observers. When an adolescent reported difficulties with peers on a certain day, the adult raters would report the same. This also was true for problems getting along with staff. When it came to ADHD symptoms in the classroom, however, the self-ratings provided by adolescents had no relationship to what actually occurred. Teacher ratings of ADHD symptoms, in contrast, corresponded to what was observed. Overall, the authors concluded that the ratings made by adolescents added relatively little to the information provided by their counselors and teachers.
SUMMARY AND IMPLICATIONS
The results of this study have potentially important implications for how the treatment of adolescents with ADHD is monitored. First, although the teens in this study showed a good ability to determine when they were on medication, the adults around them were more accurate at determining this. Thus, when a teenager argues that he no longer needs medication and that it "doesn't make any difference whether he takes it or not," this assertion needs to be considered in conjunction with feedback received from his teachers as well as other adults who observe him daily.
Second, most adolescents with ADHD may be better able to provide reports on how they are getting along with peers and teachers than on how well they are paying attention in the classroom. In this study, the adolescents did a pretty good job of rating how well they got along with peers and staff, but their ratings of specific ADHD symptoms, such as attending in the classroom, were not accurate. Based on these data, efforts to incorporate adolescents reports of treatment effectiveness should perhaps focus on their perceptions of maintaining cooperative relations with peers and teachers, rather than inquiring about particular symptoms of ADHD.
In reality, efforts to monitor the effectiveness of ADHD treatment for adolescents are more difficult than the situation faced by the authors of this study. Here, the adolescents were enrolled in a summer treatment program where the counselors and teaching staff spent considerable time with them each day. In most middle and high schools, however, adolescents generally have a different teacher for every class and there is often no adult who observes the adolescent during the day for more than a relatively brief time period. As a result, the feedback that teachers provide may often fail to be as accurate and reliable as is needed to make sound judgments. In my experience, this is a difficult issue and one for which there is no easy answer.
ADHD AND LANGUAGE DIFFICULTIES
One of the key aspects of ADHD for parents and clinicians to be aware of is that there are a number of other difficulties that often co-occur in children with ADHD. For example, children with ADHD are more likely to be diagnosed with other externalizing behavior problems such as Oppositional Defiant Disorder and Conduct Disorder. (For more information on other disorders that tend to occur with ADHD, please click here.
Children with ADHD also are more likely to experience difficulties with depression and anxiety, and to have specific learning difficulties. Such co-occurring problems are not evident in all children with ADHD, and a variety of factors contribute to why some children with ADHD experience one or more of these additional difficulties while others do not. Correctly identifying these additional problems is essential to providing effective treatment as they often play an important role in the long-term success experienced by children with ADHD, and may not be substantially helped by interventions that are typically prescribed for ADHD alone.
Another reasonably common, but often overlooked, problem that can go along with ADHD is language impairment. Language difficulties (significant problems in either the production or understanding of language) are more common in children with a wide variety of psychiatric disorders, and this is also the case in children with ADHD. In addition, both ADHD and language difficulties are likely to play a role in the academic struggles that many children with ADHD experience. Therefore, it is important to know which difficulties that are typically experienced by children with ADHD are specific to ADHD alone, and which reflect language impairment. Such knowledge could prove helpful in ensuring that a child receives treatments that are most likely to meet his or her needs.
Examining the academic and cognitive functioning in ADHD children with and without a co-occurring language deficit was a fundamental issue addressed in a paper published in the Journal of Child Psychology and Psychiatry (Cohen N.J., et al., 41, 353-362, 2000). Participants in this study included 166 children between the ages of 7 and 14 (approximately 75% boys) who had been brought by their parents to a mental health center. Of these children, 105 were diagnosed with ADHD, and the remaining 61 were diagnosed with some other psychiatric disorder. As part of the evaluation process, participants were also administered a number of standardized tests of language functioning to determine whether or not they also met criteria for a co-occurring language impairment. Of the 105 children with ADHD, 36 were diagnosed with a language impairment as well. Among the 61 children with a psychiatric diagnosis besides ADHD, approximately 50% had a co-occurring language disorder. The specific nature of the language deficits was not described, but problems in both expressive and receptive language were included.
Following this battery of language tests, participants were given a series of tests designed to evaluate their academic and cognitive functioning. These included tests of reading, spelling, math achievement, IQ, and working memory. The authors then compared the performance of children in 4 different groups: those with ADHD and no language impairment; those with ADHD and a language impairment; those with a psychiatric diagnosis besides ADHD with no language impairment, and those with a psychiatric diagnosis besides ADHD and a language impairment. These comparisons enabled the authors to determine which academic and cognitive difficulties may be specific to ADHD, which may be specific to language difficulties, and which are specific to neither ADHD nor language impairments, but which are likely to occur in children with any type of psychiatric problem.
RESULTS
For the academic achievement measures, ADHD and language difficulties were both significantly associated with lower achievement scores. Thus, children with ADHD did worse than children with a psychiatric diagnosis besides ADHD, and children with ADHD and a language impairment did worse than children with another psychiatric diagnosis as well as a language impairment.
Of particular interest, however, are comparisons between the ADHD groups with and without a language impairment. For each academic achievement area, ADHD children with a language impairment did substantially worse than those without. The figures are shown below. (Note: On the tests administered, a score of 100 is average, and any score between 90 and 109 is considered to fall within the average range. In the table below, LI stands for language impairment. Basic reading refers to the ability to sight read single words. Word attack refers to the ability to correctly sound out nonsense words such as "glurp".)
ADHD alone ADHD + LI
Basic reading 109 88
Reading comprehension 102 85
Spelling 97 82
Math computation 95 86
Word attack 94 74For children with ADHD alone, the average achievement scores for each area fell within the normal range. In contrast, scores for children with ADHD who also had a language disorder were substantially below average. In all cases, the magnitude of the difference between the groups is significant.
Similar results were found for intellectual ability. Children with ADHD alone had significantly higher IQ scores than those with ADHD and a language impairment (108 vs. 96). This was largely because the ADHD + LI children received poor results on the verbal portions of the IQ test. Children with ADHD + LI also performed worse on the various memory tests that were administered.
SUMMARY AND IMPLICATIONS
The results of this study highlight the importance of screening for language difficulties among children who are being evaluated or treated for ADHD. Compared to ADHD children who did not have language difficulties, children with ADHD + LI performed significantly worse on measures of academic achievement, intellectual functioning, and working memory. Although not directly tested in this study, it is reasonable to hypothesize that successfully addressing the academic difficulties of children with ADHD + LI requires interventions that focus directly on their language impairment in addition to difficulties attributed to their primary symptoms of ADHD. Thus, for these children, bringing their ADHD symptoms under control is not expected to be a sufficient intervention. For some children with ADHD alone, in contrast, interventions that focus more exclusively on the core ADHD symptoms of inattention, hyperactivity, and impulsivity could be quite adequate.
Screening for associated language difficulties is not a frequent component in ADHD evaluations, and is most often excluded when primary care physicians conduct the evaluation. Should parents have any concerns about their child's expressive or receptive language functioning, a thorough screening for language difficulties is worth pursuing. In addition, for children already being treated for ADHD but who continue to struggle academically, results from this study suggest that language difficulties may be a contributor to this problem. A speech and language evaluation may be worth considering in such instances.
******I hope you enjoyed the above reviews of recent attention studies and found them informative. If you know of friends or colleagues who would enjoy keeping up with newly published research on ADHD, please let them know that they can sign up to receive the newsletter at http://www.helpforadd.com******
Sincerely,
David Rabiner, Ph.D.
Senior Research Scientist
Duke University