About 5 percent of school-age children have ADHD. Children with untreated ADHD have higher than normal rates of school problems, social problems, and even injury.
ADHD frequently co-occurs with other problems, such as depression and anxiety disorders, conduct disorder, drug abuse, or antisocial behavior.
Although ADHD is relatively common, our knowledge of the problem is fairly limited.
It is pretty common today for ADHD treatment to include a variety of approaches, such as drug therapy, counseling, supportive services in schools and communities, diet interventions, and alternative treatments such as Attend.
The medical literature offers many studies carried out over brief treatment periods to try to find out what the best treatment for ADHD really is.
Here are some samples of the dozens of articles available:
New York Times Syndicate
Judy Holland
October 02, 2000
WASHINGTON - Psychiatric leaders warned Congress Friday that too many educators are urging parents of problem children to give them prescription drugs rather than address their real problems at home or school.
Dr. Peter R. Breggin, director of the International Center for the Study of Psychiatry and Psychology, a nonprofit research group in Bethesda, Md., said school officials are pressing parents to give such children stimulant drugs such as Ritalin, Concerta, Metadate, Dexedrine and Adderall.
"Teachers, school psychologists and administrators commonly make dire threats about their inability to teach children without medicating them,'' Breggin told a panel of the House Committee on Education and the Workforce.
Brito GN, Pereira CC, Santos-Morales TR
Dev Med Child Neurol 1999 Nov;41(11):732-9
Departamento de Pediatria, Instituto Fernandes Figueira, Fundacao Oswaldo Cruz, Brazil. ccsgnob@vm.uff.br
Attempts at subtyping attention-deficit-hyperactivity disorder (ADHD) along the hyperactivity dimension are considered controversial.
This study addresses this issue by dividing a non-clinical sample of Brazilian children (mean age, 9.4 years; SD, 2.9), who were attending a mainstream school in the Greater Rio de Janeiro area, into four behavioral domain groups (
on the basis of teacher ratings on an ADHD scale.
The groups did not differ in intellectual level as determined by the Human Figure Drawing test.
Comparisons were made between groups along the factorial dimensions extracted from the Composite Teacher Rating Scale, academic performance and neuropsychological measures were then performed.
Our data showed that IA and C children are less independent and more prone to socialization problems than NO children, and that HI and C children are less anxious and fearful than IA children.
Furthermore, the groups differed in academic and neuropsychological performance.
The results could be considered consistent with the hypothesis that ADD with hyperactivity (ADD/+) and ADD without hyperactivity (ADD/-) represent singular nosological entities.
Arch Gen Psychiatry 1990 May;47(5):419-26
Kruesi MJ, Rapoport JL, Hamburger S, Hibbs E, Potter WZ, Lenane M, Brown GL
National Institute of Mental Health, Child Psychiatry Branch, Bethesda, MD 20892.
Cerebrospinal fluid levels of 5-hydroxyindoleacetic acid, a metabolite of serotonin, were measured in relation to aggression, impulsivity, and social functioning in 29 children and adolescents with disruptive behavior disorders.
The cerebrospinal fluid 5-hydroxyindoleacetic acid level was low compared with that of age-, sex-, and race-matched patients with obsessive-compulsive disorder.
Within the disruptive group, significant negative correlations with age-corrected 5-hydroxyindoleacetic acid level were seen for the child's report of aggression toward people and the expressed emotionality of the child toward his or her mother; other correlations of age-corrected 5-hydroxyindoleacetic acid level with measures of aggression were in the expected negative direction but did not reach statistical significance.
Impulsivity per se and socioenvironmental factors were not significantly related to cerebrospinal fluid 5-hydroxyindoleacetic acid concentration.
Author/s: Kimberly Hoagwood
Issue: Feb, 2000
ABSTRACT
Objective: To summarize knowledge on treatment services for children and adolescents with attention-deficit hyperactivity disorder (ADHD), trends in services from 1989 to 1996, types of services provided, service mix, and barriers to care.
Method: A review of the literature and analyses from 2 national surveys of physician practices are presented.
Results: Major shifts have occurred in stimulant prescriptions since 1989, with prescriptions now comprising three fourths of all visits to physicians by children with ADHD.
Between 1989 and 1996, related services, such as health counseling, for children with ADHD increased 10-fold, and diagnostic services increased 3-fold. Provision of psychotherapy, however, decreased from 40% of pediatric visits to only 25% in the same time frame. Follow-up care also decreased from more than 90% of visits to only 75%.
Family practitioners were more likely than either pediatricians or psychiatrists to prescribe stimulants and less likely to use diagnostic services, provide mental health counseling, or recommend follow-up care.
About 50% of children with identified ADHD seen in real-world practice settings receive care that corresponds to guidelines of the American Academy of Child and Adolescent Psychiatry.
Physicians reported significant barriers to service provision for these children, including lack of pediatric specialists, insurance obstacles, and lengthy waiting lists.
Conclusions: The trends in treatment services and physician variations in service delivery point to major gaps between the research base and clinical practice.
Clinical variations may reflect training differences, unevenness in the availability of specialists and location of services, and changes in health care incentives.
J. Am. Acad. Child Adolesc. Psychiatry 2000, 39(2):198-206. Key Words: services, treatments, attention-deficit hyperactivity disorder.
Author/s: Bertrand G. Winsberg
Issue: Dec, 1999
ABSTRACT
Objective: This study attempted to relate the alleles of the [D.sub.2] (DRD2), [D.sub.4] (DRD4), and dopamine transporter (DAT1) genes to the behavioral outcome of methylphenidate therapy.
Method: African-American children with attention-deficit hyperactivity disorder were treated with methylphenidate in doses not in excess of 60 mg/day.
The dosage was increased until behavioral change was achieved, using a decrement in scores of less than or equal to 1 on a commonly used rating scale or until the maximum tolerated dose was achieved.
Blood samples were obtained at that point, and genotypes for polymorphism at the respective genes were identified.
Results: Genotypes were then tested by [X.sup.2] to assess the significance of any association with drug response. Only the dopamine transporter gene was found to be significant.
Homozygosity of the 10-repeat allele was found to characterize nonresponse to methylphenidate therapy (p = .008).
Conclusions: While the results suggest that alleles of the dopamine transpor ter gene play a role in methyiphenidate response, replication in additional studies is needed.
J. Am. Acad. Child Adolesc. Psychiatry 1999, 38(12):1474-1 477. KeyWords: attention-deficit hyperactivity disorder, drug response, dopamine transporter, molecular genetics.
Children with attention deficit hyperactivity disorder (ADHD), the most common of the psychiatric disorders that appear in childhood, are often the subject of great concern on the part of parents and teachers. Children with ADHD are unable to stay focused on a task, cannot sit still, act without thinking, and rarely finish anything. If untreated, the disorder can have long-term effects on a child's ability to make friends or do well at school or in other activities. Over time, children with ADHD may develop depression, lack of self-esteem, and other emotional problems.
Experts estimate that ADHD affects 3 to 5 percent of school-age children and two to three times as many boys as girls. Children with untreated ADHD have higher than normal rates of injury. ADHD frequently co-occurs with other problems, such as depression and anxiety disorders, conduct disorder, drug abuse, or antisocial behavior.
Although ADHD is relatively common, our knowledge of the problem is incomplete. Current ADHD treatment includes a mix of approaches, such as drug therapy, counseling, supportive services in schools and communities, and various combinations of the three. The medical literature offers many studies carried out over brief treatment periods (3 months or less), but a pressing question remains: what is the best kind of help we can offer children with ADHD over a longer term?
To answer this question, NIMH is sponsoring an ongoing, multisite, cooperative agreement treatment study of children with ADHD entitled The Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder. The first findings from this study, which were published in December 1999, provide important guidance for physicians and parents of children with ADHD and are discussed below. Ongoing follow-up reports will be published, with an additional 10-15 papers expected to be released in calendar year 2000.
Questions and Answers
Q. What is the Multimodal Treatment Study of Children with ADHD?
A. The Multimodal Treatment Study of Children with ADHD–"MTA" for short–brought together 18 nationally recognized authorities in ADHD at 6 different university medical centers and hospitals to evaluate the leading treatments for ADHD, including various forms of behavior therapy and medications. The study has included nearly 600 elementary school children, ages 7-9, randomly assigned to one of four treatment modes: (1) medication alone; (2) psychosocial/behavioral treatment alone; (3) a combination of both; or (4) routine community care.
Q. Why is this study important?
A. ADHD is a major public health problem of great interest to many parents, teachers, and health care providers. Up-to-date information concerning the long-term safety and comparative effectiveness of its treatments is urgently needed. While previous studies have examined the safety and compared the effectiveness of the two major forms of treatment, medication and behavior therapy, these studies generally have been limited to periods up to 4 months. The MTA study demonstrates for the first time the safety and relative effectiveness of these two treatments (including a behavioral therapy-only group), alone and in combination, for a time period up to 14 months, and compares these treatments to routine community care. The children involved in the study will be tracked into adolescence to document and evaluate long-term outcomes.
Q. What are the major findings of this study so far?
A. The MTA results published in December 1999 indicate that long-term combination treatments as well as medication-management alone are both significantly superior to intensive behavioral treatments and routine community treatments in reducing ADHD symptoms. The study also shows that these differential benefits extend as long as 14 months. In other areas of functioning (specifically anxiety symptoms, academic performance, oppositionality, parent-child relations, and social skills), the combined treatment approach was consistently superior to routine community care, whereas the single treatments (medication-only or behavioral treatment only) were not. In addition to the advantages provided by the combined treatment for several outcomes, this form of treatment allowed children to be successfully treated over the course of the study with somewhat lower doses of medication, compared to the medication-only group. These same findings were replicated across all six research sites, despite substantial differences among sites in their samples' sociodemographic characteristics. Therefore, the study's overall results appear to be applicable and generalizable to a wide range of children and families in need of treatment services for ADHD.
Q. Given the effectiveness of medication management, what is the role and need for behavioral therapy?
A. As noted in the NIH ADHD Consensus Conference in November 1998, several decades of research have amply demonstrated that behavioral therapies are quite effective. What the MTA study has demonstrated is that on average, carefully monitored medication management with monthly follow-up is more effective than intensive behavioral treatment for ADHD symptoms, for periods lasting as long as 14 months. All children tended to improve over the course of the study, but they differed in the relative amount of improvement, with the carefully done medication management approaches generally showing the greatest improvement. Nonetheless, children's responses varied enormously, and some children clearly did very well in each of the treatment groups. For some outcomes that are important in the daily functioning of these children (e.g., academic performance, familial relations), the combination of behavioral therapy and medication was necessary to produce improvements better than community care. Of note, families and teachers reported somewhat higher levels of consumer satisfaction for those treatments that included the behavioral therapy components. Therefore, medication alone is not necessarily the best treatment for every child, and families often need to pursue other treatments, either alone or in combination with medication.
Q. Which treatment is right for my child?
A. This is a critical question that must be answered by each family in consultation with their health care professional. For children with ADHD, no single treatment is the answer for every child; a number of factors appear to be involved in determining which treatments are best for which children. For example, even if a particular treatment might be effective in a given instance, the child may have unacceptable side effects or other life circumstances that might prevent that particular treatment from being used. Furthermore, findings indicate that children with other accompanying problems, such as co-occurring anxiety or high levels of family stressors, may do best with approaches that combine both treatment components, (i.e., medication management and intensive behavioral therapy). In developing suitable treatments for ADHD, each child's needs, personal and medical history, research findings, and other relevant factors need to be carefully considered.
Q. Why do many social skills improve with medication?
A. This question highlights one of the surprise findings of the study: although it has long been generally assumed that the development of new abilities in children with ADHD (e.g., social skills, enhanced cooperation with parents) often requires the explicit teaching of such skills, the MTA study findings suggest that many children can often acquire these abilities when given the opportunity. Children treated with effective medication management (either alone or in combination with intensive behavioral therapy) manifested substantially greater improvements in social skills and peer relations than children in the community comparison group after 14 months. This important finding indicates that symptoms of ADHD may interfere with their learning of specific social skills. It appears that medication management may benefit many children in areas not previously well known to be salient medication targets, in part by diminishing symptoms that had previously interfered with the child's social development.
Q. Why were the MTA medication treatments more effective than community treatments that also usually included medication?
A. There were substantial differences between the study-provided medication treatments and those provided in the community, differences mostly related to the quality and intensity of the medication management treatment. During the first month of treatment, special care was taken to find an optimal dose of medication for each child receiving the MTA medication treatment. After this period, these children were seen monthly for one-half hour at each visit. During the treatment visits, the MTA prescribing therapist spoke with the parent, met with the child, and sought to determine any concerns that the family might have regarding the medication or the child's ADHD-related difficulties. If the child was experiencing any difficulties, the MTA physician was encouraged to consider adjustments in the child's medication (rather than taking a "wait and see" approach). The goal was always to obtain such substantial benefit that there was "no room for improvement" compared with the functioning of children not suffering from ADHD. Close supervision also fostered early detection and response to any problematic side effects from medication, a process that may have facilitated efforts to help children remain on effective treatment. In addition, the MTA physicians sought input from the teacher on a monthly basis, and used this information to make any necessary adjustments in the child's treatment. While the physicians in the MTA medication-only group did not provide behavioral therapy, they did advise the parents when necessary concerning any problems the child may have been experiencing, and provided reading materials and additional information as requested. Physicians delivering the MTA medication treatments generally used 3 doses per day and somewhat higher doses of stimulant medications. In comparison, the community-treatment physician generally saw the children face-to-face only 1-2 times per year, and for shorter periods of time each visit. Furthermore, they did not have any interaction with the teachers, and prescribed lower doses and twice-daily stimulant medication.
Q. How were children selected for this study?
A. In all instances, the child's parents contacted the investigators to learn more about the study, after first hearing about it through local pediatricians, other health care providers, elementary school teachers, or radio/newspaper announcements. Children and parents were then carefully interviewed to learn more about the nature of the child's symptoms, and rule out the presence of other conditions or factors that may have given rise to the child's difficulties. In addition, extensive historical information was gathered and diagnostic interviews were conducted to establish whether or not the child exhibited the long-standing pattern of symptoms characteristic of ADHD across home, school, and peer settings. If children met full criteria for ADHD and study entry (and many did not), informed parental consent with child assent and school permission were received; the children and families then were eligible for study entry and randomization. Children who had behavior problems but not ADHD were not eligible for study participation.
Q. Where is this study taking place?
A. Research sites include:
* New York State Psychiatric Institute at Columbia University, New York, N.Y.
* Mount Sinai Medical Center, New York, N.Y.
* Duke University Medical Center, Durham, N.C.
* University of Pittsburgh, Pittsburgh, PA.
* Long Island Jewish Medical Center, New Hyde Park, N.Y.
* Montreal Children's Hospital, Montreal, Canada
* University of California at Berkeley, CA.
* University of California at Irvine, CA.
For More Information on Mental Disorders in Children, Contact:
Public Information and Communications Branch, NIMH
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513
TTY: 301-443-8431
FAX: 301-443-4279
Mental Health FAX 4U: 301-443-5158
E-mail: nimhinfo@nih.gov
NIMH home page address:
http://www.nimh.nih.gov
March 2000
Issue: Feb, 2000
ABSTRACT
Attention-deficit/hyperactivity disorder (ADHD) is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem.
Despite progress, ADHD and its treatment have remained controversial, especially the use of psychostimulants for both short- and long-term treatment.
Although an independent diagnostic test for ADHD does not exist, there is evidence supporting the validity of the disorder.
Studies (primarily short-term, approximately 3 months), including randomized clinical trials, have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Because of the lack of consistent improvement beyond the core symptoms and the paucity of long-term studies (beyond 14 months), there is a need for longer-term studies with drugs and behavioral modalities and their combination.
Although trials are under way, conclusive recommendations concerning treatment for the long term cannot be made at present. There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants, and thus the need for improved assessment, treatment, and follow-up.
Furthermore, the lack of insurance coverage, preventing the appropriate diagnosis and treatment of ADHD, and the lack of integration with educational services are substantial barriers and represent considerable long-term costs for society.
Finally, after years of clinical research and experience with ADHD, knowledge about the cause or causes of ADHD remain largely speculative.
Consequently, there are no documented strategies for the prevention of ADHD.
J. Am. Acad. Child Adolesc. Psychiatry, 2000, 39(2):182-193. Key Words: attention-deficit/hyperactivity disorder, diagnosis, treatment, psychostimulants, risks, barriers.
Neuropsychopharmacology 1987 Dec;1(1):55-62
Stoff DM, Pollock L, Vitiello B, Behar D, Bridger WH
Medical College of Pennsylvania, Eastern Pennsylvania Psychiatric Institute, Department of Psychiatry, Philadelphia.
Binding characteristics of tritiated imipramine on blood platelets were determined in daytime hospitalized prepubertal children who had mixed diagnoses of conduct disorder (CD) plus attention deficit disorder hyperactivity (ADHD) and in inpatient adolescents who had a history of aggressive behavior.
The number of (3H)-imipramine maximal binding sites (Bmax) was significantly lower in the prepubertal patient group of CD plus ADDH; the dissociation constant (Kd) was not significantly different.
There were significant negative correlations between Bmax and the Externalizing or Aggressive factors of the Child Behavior Checklist when the CD plus ADDH prepubertal patients were combined with their matched controls and within the adolescent inpatient group.
We propose that a decreased platelet imipramine binding Bmax value, as an index of disturbed presynaptic serotonergic activity, is not specific to depression and may be used as a biologic marker for the lack of behavioral constraint in heterogeneous. populations of psychiatric patients.
Author/s: Jaap Oosterlaan
Issue: June, 1998
Attention deficit/hyperactivity disorder (AD/HD) has been conceptualized as a disorder which arises from a deficit in the capability for response inhibition (e.g., Barkley, 1994, 1997; Douglas, 1989; Newman & Wallace, 1993; Pennington & Ozonoff, 1996; Quay, 1988a, 1988b, 1997; Wender, 1972). That is, a failure to suppress inappropriate responding has been postulated to underlie the inattentive, hyperactive, and impulsive behavior that characterizes AD/HD.
Recently, however, the primacy of the response inhibition deficit has been called into question (e.g., Sonuga-Barke, 1995). That is, the possibility exists that the impairment in response inhibition in fact is only one aspect of a more general dysfunction. For example, it has been suggested that poor response inhibition originates from a frontal lobe deficit (Barkley et al., 1992; Pennington & Ozonoff, 1996; Shue & Douglas, 1992) or a lag in the development of the cognitive functions (Barkley, 1997; Barkley et al., 1992; Shue & Douglas, 1992). In the present study, we examine the possibility that poor response inhibition in AD/HD children actually is one of the many manifestations of a disinclination to invest effort, or stated differently, reflects a motivational deficit.
Different lines of research seem to converge in indicating that AD/HD children do not have the same motivational set as normal children. One line of research, aimed at localizing possible deficits in the information processing system, suggests that AD/HD children do not expend the effort necessary to perform optimally (see for reviews, Sergeant & Van der Meere, 1990a, 1990b, 1994; Van der Meere, 1996).
A second line of research suggests that the performance of AD/HD children seems to rely more strongly on the presence of contingencies than the performance of normal children (e.g., Douglas, 1985, 1989; Haenlein & Caul, 1987; Newman & Wallace, 1993; Quay, 1988a, 1988b, 1997; Wender, 1972).
Journal of Clinical Psychology
Volume 54, Issue 4, 1998. Pages: 461-476
Published Online: 6 Dec 1998
Ability of the Test of Variables of Attention (TOVA) to distinguish between referred children with attention-deficit/hyperactivity disorder (ADHD) and other (OTHER) clinical diagnoses were studied.
The ADHD group differed from the OTHER group on TOVA variables and most measures from the Revised Conners Teacher Rating Scale (RCTRS) and ADD-H Comprehensive Teacher's Rating Scale (ACTeRS).
The criteria of any one TOVA variable > 1.5 standard deviations from age and sex adjusted means correctly identified 80% of the sample with attention deficit disorders and 72% of the sample without attention deficit disorder.
Cases misclassified by teacher ratings were often correctly classified by the TOVA and conversely. The TOVA makes a unique and important contribution to diagnostic evaluations.
J Clin Psychol 54: 461-476, 1998.
http://www3.interscience.wiley.com/cgi-bin/abstract/31228/START