*ATTENTION RESEARCH UPDATE**
VOLUME 36, October  2000
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In this issue.

§ TEACHER KNOWLEDGE OF ADHD

§ A PROCEDURE FOR PREDICTING RESPONSE TO STIMULANT MEDICATION
   TREATMENT
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Dear Subscriber:

This issue of Attention Research Update contains summaries of two recent studies that I found interesting. The first article, Teacher Knowledge of ADHD, highlights ongoing misconceptions about ADHD among teachers. Contrary to oft-recurring concerns that teachers are too quick to label a child as ADHD, results from this study suggest the opposite. In addition, many teachers attribute the problems experienced by children with ADHD to environmental factors such as inadequate attention and support from parents. Although the sample of teachers in this study is small, the results highlight the need for a more systematic examination of teacher knowledge about ADHD, and how important gaps in that knowledge can be addressed.

The second study reviewed -- A Procedure for Predicting Response to Stimulant Medication Treatment -- presents intriguing data suggesting that a procedure called Quantitative Electroencephalography (QEEG), which measures patterns of electrical activity in the brain, may help identify individuals who will respond positively to stimulant medication treatment and those who will not. In this study, the medication benefits obtained by individuals with ADHD were closely linked to a QEEG result that indicated reduced activity in the prefrontal cortex, a pattern referred to as "cortical slowing". Nearly every participant with ADHD who showed this pattern obtained substantial benefits from medication, while none of the participants without evidence of cortical slowing on their QEEG obtained similar benefits.
 

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TEACHER KNOWLEDGE OF ADHD

Teachers vary dramatically in their ability to work effectively with students who have ADHD. Some teachers are extremely knowledgeable about ADHD, the special difficulties it creates for children, and effective strategies for helping children with ADHD succeed. Many other teachers, however, are severely lacking in this important knowledge. As a result, children with ADHD often fail to receive the assistance they need to be successful in school, which is a tremendous source of frustration to children and parents alike. For this reason, documenting the knowledge and understanding that teachers have about ADHD is an important task, as a systematic examination of the gaps in this knowledge can hopefully promote more routine training in these areas for teaching professionals.

The extent of teachers' knowledge of ADHD and effective strategies for helping children with ADHD succeed were examined in a recently published study in the Journal of Attention Disorders (Frank, E.A. et al., 4, 91-101, 2000).  Although the results from the study are based on a relatively small sample of teachers (21 teachers from 3 different communities), they still highlight major gaps in teacher knowledge of ADHD and identify challenges that the education profession needs to address.

All but one of the teachers in this study taught elementary school children. The majority worked in grades K-3. Teachers were interviewed about a child in their classroom who exhibited inattention, distractibility, and/or hyperactivity in order to learn about the special efforts they made to help students with these characteristics.

It is important to note that these students were not specifically labeled as having ADHD, as researchers were interested in the explanations that teachers provided for this type of behavior. However, all children were displaying behaviors that were strongly consistent with an ADHD diagnosis, and the majority was diagnosed with ADHD by the conclusion of the study.

Specific topics that were covered in the interviews included:
1) attributions the teacher made for the child's behavior;
2) strategies used by the teacher to manage the child;
3) other school or community resources that were available to support the child;
4) and the teacher's opinion of strategies and resources that would help the child.

After this initial interview was completed, teachers were given feedback about the results and interviewed again. During the second interview, they were asked more directly about their familiarity with ADHD symptoms and treatment options.

RESULTS

There is a wealth of qualitative data that the researchers gleaned from the summary of the teacher interviews. Below are some especially interesting results.

Teachers infrequently attributed the child's behavior to ADHD.

Although concerns are frequently raised that teachers are too quick to label a child with behavioral difficulties as having ADHD, such concerns were not supported by the results of this investigation. In fact, only 6 teachers mentioned ADHD as a possible explanation for the symptoms the child was displaying, despite the fact that the children were highly symptomatic. Several teachers said that the child they were asked about could not be ADHD because he was not highly disruptive. This indicates a lack of awareness that some children with ADHD are highly inattentive and do not show hyperactive-impulsive symptoms. This may contribute to the under-identification of many children with the inattentive subtype of ADHD, and the failure of these children to obtain the assistance and services they require to succeed.

Teachers often suggested alternative explanations for children's symptoms that were environmentally based.

When asked why they failed to mention ADHD as a possible explanation for children's symptoms, a variety of explanations were provided. The majority of teachers offered environmentally based explanations, including: a disruptive family environment, lack of discipline, single parenthood, overprotective mothers, lack of parental support for the child's education, and neglect.

Although the factors listed above can contribute to behavioral and academic difficulties, the majority of children whom teachers were interviewed about had confirmed diagnoses of ADHD. For children with ADHD, such environmental factors should have already been ruled out as a primary determinant of their symptoms. It is striking that these findings suggest that teachers may be prone to unreasonably implicate "poor parenting" as a chief causal factor in the difficulties experienced by a child with ADHD.

Teachers also noted that "labeling" a child does not help solve problems, and were reluctant to suggest ADHD as a possible explanation for the child's difficulties for that reason.

Teacher strategies for classroom management

Teachers reported a variety of strategies for managing the behavior of disruptive students, including behavioral interventions such as point systems to promote desired behavior, instructional modifications (one-on-one instruction; the use of peers as tutors), and environmental modifications (preferential seating). Most teachers described the use of multiple strategies that cut across these different categories.

Although this sounds positive, the authors indicate that most teachers did not have a consistent and coherent plan of action for dealing with disruptive and inattentive students. The types of behavioral interventions that teachers frequently described were not expected to have a positive impact on many children with ADHD. There were a variety of reasons for this, including: inconsistent implementation, the absence of frequent feedback (frequent feedback is generally required on their behavior and ability to meet short-term goals), and failing to identify appropriate behaviors to try and modify. Teachers also seemed to have a strong preference for management strategies that did not require very much of their time.

SUMMARY AND CONCLUSIONS

This study presents a combination of encouraging and discouraging news. On the positive side, there was no indication that teachers are overly prone to label children with ADHD. Thus, these data do not support the notion that ADHD is the first explanation that teachers assume when a child in their class is struggling.

On the other hand, the majority of children these teachers were asked about had in fact been diagnosed with ADHD, and teachers rarely mentioned this as an explanation for the child's problems. This was the case even when teachers were aware that the child had already been diagnosed. Instead, teachers frequently noted environmental causes that tended to focus on a specific parenting problem. This suggests that teachers may erroneously blame parents for difficulties that a student with ADHD is experiencing. It also suggests that teachers may fail to take an active role in helping to identify students with ADHD who could benefit from appropriate evaluation and intervention services.

Another concerning finding was the relative lack of knowledge of appropriate behavioral interventions and other classroom strategies to help facilitate the success of students with ADHD. As a result, teachers were attempting interventions that were unlikely to succeed.

These findings need to be considered cautiously because they are based on a relatively small sample of teachers.  However, they underscore the need for a larger-scale version of this study so that a more complete understanding of these important issues can be obtained. In all likelihood, results from such a study would underscore the need for increased training and education of teachers on identifying students requiring a comprehensive ADHD evaluation, and how to develop and implement classroom-based interventions that are effective in helping students with ADHD succeed.  It would be wonderful if such training was implemented routinely in school systems across the country.
 

A PROCEDURE FOR PREDICTING RESPONSE TO STIMULANT MEDICATION TREATMENT

When considering the use of stimulant medication treatment for their child, parents often wonder whether it is possible to know in advance if it will work and if there will be any adverse side effects. To date, the answer to this question has been that it is not possible to determine such outcomes. Thus, although most children with ADHD will show clear reductions in ADHD symptoms when stimulant medication is administered appropriately, results from prior research suggest that predicting the response for individual children is not possible. The same holds true for predicting which children may experience unpleasant side effects.

Making accurate predictions would be useful for several reasons. First, if parents reluctant to consider medication could be assured that it would help their child, they might be more willing to give it a try. Second, for those children who were unlikely to benefit and were likely to experience adverse reactions to the medication, an unpleasant and ineffective treatment experience could be avoided

A study appearing in a recent issue of the journal Biofeedback provides intriguing evidence that such predictions may be possible (Monastra, V., vol. 28, 2000). A bit of background information is necessary before discussing these important findings.

In an issue of Neuropsychology, Dr. Monastra and his colleagues demonstrated that individuals with ADHD showed a distinctive pattern of results on a quantitative electroencephalography (QEEG) reading.

QEEG is a procedure in which the pattern of electrical activity in different brain regions is recorded and measured. The research of Dr. Monastra and others indicates that most individuals diagnosed with ADHD via traditional methods, such as diagnostic interviews and standardized behavior rating scales, show a QEEG pattern that indicates under-activity in prefrontal brain areas. It is suggested, although not yet confirmed, that under-activity in this brain region causes the behavioral symptoms that individuals with ADHD display. In contrast, very few individuals not showing the behavioral symptoms characteristic of ADHD showed this same pattern of cortical under-activity. Of course, because ADHD is currently diagnosed based on the presence of observable behaviors rather than any particular QEEG pattern, not all individuals who meet diagnostic criteria for ADHD show this pattern of cortical slowing in their QEEG results. This fact is the basis for the current study.

Participants in this study included 144 individuals between the ages of 6 and 20 who were diagnosed with ADHD using DSM-IV diagnostic criteria.  QEEG recordings were then conducted with these individuals. As expected, the majority (103) demonstrated the anticipated cortical slowing on their QEEG. The other 41 individuals did not. Remember, all 144 had already shown a sufficient number of inattentive and/or hyperactive-impulsive symptoms to warrant a diagnosis of ADHD. The difference between the two groups was not in the behavioral symptoms they displayed, but rather, whether a particular type of QEEG result was received.

After the diagnostic and QEEG procedures, all patients received a careful trial of stimulant medication. Participants were started on a low dose of methylphenidate (the generic form of Ritalin) two times per day and were given up to a maximum dose of 20 mg twice per day as needed. If methylphenidate was not helpful, a switch was made to Adderall, and the titration procedure began again. Careful measures were taken to determine whether each individual obtained clinically significant benefits from stimulant medication. Those who responded to medication (either medication or any dose) received behavior ratings on an ADHD rating scale from parents and teachers that placed them in a non-clinical range, and they obtained a "normal" score on a computerized test of sustained attention while on medication. Individuals who did not attain such benefits on either medication were classified as non-responders.

RESULTS

Of the 103 participants who showed the cortical slowing pattern on their QEEG, 96 responded positively to stimulant medication. In contrast, of the 41 participants who showed no cortical slowing on their QEEG, none responded positively to methylphenidate or Adderall. (Remember, a positive medication response was defined as normalized behavior ratings from parents and teachers as well as a "normal" performance on a computerized test of sustained attention.  The criterion for determining positive responders was quite strict.)  In addition, each of these 41 non-responders exhibited at least 3 of the following side effects: headaches, increased irritability, sedation, rapid speech, increased impulsive behaviors, or increased hyperactivity.  These side effects were rarely reported among those who responded positively to medication.

When efforts were made to predict medication response according to the number and severity of ADHD symptoms or performance on the computerized attention tests, no accurate predictions were achieved. Thus, it was only the indication of cortical slowing on the QEEG that enabled accurate predictions to be made.

SUMMARY AND IMPLICATIONS

The results of this study are impressive. Although almost every participant with ADHD who showed cortical slowing obtained substantial benefits from medication, those showing the behavioral symptoms of ADHD without this QEEG pattern never obtained a similar benefit. While these results require careful replication, they are exciting. Not only may QEEG prove to be a useful tool to assist in the ADHD diagnostic process, but it may also help to identify individuals showing the behavioral manifestations of ADHD who are (and are not) likely to benefit from stimulant medication.

As noted earlier, this would be quite helpful for treatment planning purposes. Although not examined in this study, it is also possible that individuals not showing the cortical slowing pattern would have responded to a different class of medication, such as an antidepressant. This would be an interesting question to explore in subsequent research.

These results also highlight something that is important for clinicians and parents to be aware of: the behavioral symptoms of ADHD can have different origins. Typically, recently published research suggests that individuals diagnosed with ADHD using the current behavioral criteria will show the pattern of cortical slowing that researchers like Dr. Monastra have identified. However, other individuals showing the ADHD behaviors will not. This suggests that some individuals with ADHD have developed their symptoms for other reasons. Accurately identifying those reasons may be key to providing appropriate treatment.

There is other published research which suggests that dietary factors, elevated lead levels, deficiencies in trace minerals like iron and magnesium, along with a variety of other factors may be important contributors to ADHD symptoms in individuals without the pattern of cortical slowing. When specific causes are identified for an individual, it is often directly linked to a specific treatment. For example, providing magnesium supplementation to children with ADHD found to be deficient in magnesium. This is an area where additional research is needed, and it is important to note that such ideas are not widely accepted within the medical and scientific community. I will include such studies in future issues of Attention Research Update as I become aware of them. Should you be aware of work in these areas that I may have missed, I would appreciate your letting me know.
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That's all for this issue.

I hope you enjoyed this issue of Attention Research Update and found it to be informative. If you know of friends or colleagues who would also 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 or http://www.attention.com.

The next issue will be sent to you in next month. Take care until then.

Sincerely,

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