ADD Treatment Center - ADD/ADHD, Attention Deficit Disorder, Treatment

<body topmargin="0" leftmargin="0"> <p>This page uses frames, but your browser doesn't support them.</p> <table class=MsoTableGrid border=0 cellspacing=0 cellpadding=0 width="97%" style='border-width:0;border-collapse:collapse;mso-yfti-tbllook:480;mso-padding-alt: 0in 0in 0in 0in'> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;height:15.25pt'> <td width="100%" valign=top style='width:100.0%;background:red;padding:0in; height:20'> <p class=MsoPlainText><b><span style='font-size:12.0pt;font-family:"Times New Roman"; color:white'><span style='mso-spacerun:yes'> </span>Does ADHD Predict Early Drug Use?<o:p></o:p></span></b></p> </td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td width="100%" valign=top style='width:100.0%;padding:0in 0in 0in 0in'> <p class=MsoPlainText style='margin-top:5;text-indent:5; margin-left:5; margin-bottom:0'><b><span style='font-size:18.0pt;font-family:"Times New Roman"'>A</span></b><span style='font-size:12.0pt;font-family:"Times New Roman";mso-bidi-font-weight: bold'> widespread concern among parents of children with ADHD, as well as among clinicians who work with such children, concerns the degree to which it increases a child's risk of drug use.<span style='mso-spacerun:yes'> </span>For some, these concerns focus on whether treatment with medication - by itself – will lead children with ADHD to be more likely to use illicit substances later in life.<span style='mso-spacerun:yes'> </span>No evidence for this concern has been reported in several relevant studies, however.</span></p> <p class=MsoPlainText style='margin-top:5;text-indent:5; margin-left:5; margin-bottom:0'><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>Other parents and clinicians have concerns about the role of ADHD in eventuating later drug use irrespective of whether a child is being treated with stimulant medication. Evidence for an association between ADHD and later substance abuse has been mixed.<span style='mso-spacerun:yes'> </span>Some studies have reported increased rates of substance use and abuse among adolescents with ADHD while others have found no such association.<span style='mso-spacerun:yes'> </span>It is also not clear whether any association between ADHD and adolescent substance use or abuse that have been found can be attributed specifically to a child's ADHD symptoms, or whether the association between ADHD and substance use is explained by the other kinds of behavior disorders (i.e. Conduct Disorder - CD) that often go along with ADHD. Finally, little research has been conducted on the specific factors in the environment of children with ADHD that will act to protect them from becoming involved in substance use, or increase their risk for doing so.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>A study published in the Journal of the <st1:PlaceName w:st="on">American</st1:PlaceName> <st1:PlaceType w:st="on">Academy</st1:PlaceType> of Child and Adolescent Psychiatry (JAACP) was designed to answer these important questions (<span class=SpellE>Chilcoat</span>, H., & <st1:place w:st="on">Breslau</st1:place>, N. (1999). Pathways from ADHD to early drug use. JAACP, 38, 1347-1354).<span style='mso-spacerun:yes'> </span>In this study, <span class=GramE>a representative community sample of 717 children were</span> followed from ages 6 to 11.<span style='mso-spacerun:yes'> </span>At age 6, children's mothers were interviewed to determine whether or not their child had ADHD.<span style='mso-spacerun:yes'> </span>In addition, mothers completed ratings of aggressive, delinquent, and oppositional behavior problems in addition to the information they provided about specific ADHD symptoms.</span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>(An important strength of this study is that the children were all from a community context rather than being selected from a clinic population.<span style='mso-spacerun:yes'> </span>This allows one to have more confidence that the results are representative of children with ADHD in general, rather than to the relatively small subset <span class=GramE>who</span> are treated in mental health settings.<span style='mso-spacerun:yes'> </span>It would have been preferable, however, if diagnosis was based on information from teachers as well as mothers).<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>When children were 11, their own use of drugs, the drug use by their peers, and their perceptions of how closely parents monitored their behavior were all assessed in individual interviews with each child.<span style='mso-spacerun:yes'> </span>During these interviews, children were asked about their use of tobacco, alcohol, marijuana, and inhalants.<span style='mso-spacerun:yes'> </span>They were <span class=GramE>counted<span style='mso-spacerun:yes'> </span>as</span> drug users if they had ever used any of these substances (in the case of alcohol, they were not counted if the use had occurred with parental permission - e.g. a small glass of wine at a family celebration). Peer drug use items measured friend's use of these same substances, as well as friends' attitudes towards drugs, as reported by the children with ADHD who were the subjects in the study.<span style='mso-spacerun:yes'> </span>Items on the parent monitoring questionnaire concerned parents’ practices for supervising their child, and</span><span class=GramE><span style='font-size:12.0pt; font-family:"Times New Roman";mso-bidi-font-weight:bold'> their</span></span><span style='font-size:12.0pt;font-family:"Times New Roman";mso-bidi-font-weight: bold'> knowledge/surveillance of their child's whereabouts and behaviors outside their home.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>It is important to note that the definition for "drug use" in this study is a lenient one.<span style='mso-spacerun:yes'> </span>This is because the authors were specifically interested in whether or not ADHD is associated with the earlier use of any type of drug.<span style='mso-spacerun:yes'> </span>They did not address whether ADHD might also increased the risk of substance abuse rather than</span><span class=GramE><span style='font-size:12.0pt; font-family:"Times New Roman";mso-bidi-font-weight:bold'> just</span></span><span style='font-size:12.0pt;font-family:"Times New Roman";mso-bidi-font-weight: bold'> substance use.<span style='mso-spacerun:yes'> </span>In part, this is because children in their study were only 11 years old at follow up, an age before substance abuse problems would be expected to develop in very many children.<span style='mso-spacerun:yes'> </span>It should be noted, however, that early drug use is an extremely important predictor of subsequent substance abuse problems.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'><o:p> </o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><b><span style='font-size:12.0pt;font-family:"Times New Roman"; color:red'>RESULTS<o:p></o:p></span></b></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'><o:p> </o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>Of the 711 children with complete data, 137 (19.1%) had used drugs at least once.<span style='mso-spacerun:yes'> </span>Incidence was highest for tobacco and alcohol (10.6% and 10.1% respectively).<span style='mso-spacerun:yes'> </span>Of the 117 children who had used tobacco or alcohol, 31 had used both.<span style='mso-spacerun:yes'> </span>A small number - 3.8% - had used inhalants and only 7 children reported having used marijuana.<span style='mso-spacerun:yes'> </span>Interestingly, most of the children reporting inhalant use had not previously used tobacco or alcohol according to <span class=GramE>their self-reports</span>.</span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"> </p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'><b><font color="#FF0000">DID ADHD INCREASE THE RISK OF EARLY DRUG USE?</font></b><o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"> </p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>Simply stated, the answer to this question is yes.<span style='mso-spacerun:yes'> </span>The authors found that children with ADHD were about 1.7 times more likely than others to have been an early drug user.<span style='mso-spacerun:yes'> </span>In addition, the risk of early drug use seemed to vary in relation to the number of ADHD symptoms that mothers had reported when their child was 6.<span style='mso-spacerun:yes'> </span>There was a sharp increase in drug use in the 8+ symptom range that peaked at around 10 symptoms (Note: This study was done when the prior version of DSM was in effect and a total of 14 symptoms for ADHD were listed in the diagnostic criteria).<span style='mso-spacerun:yes'> </span>At this level of symptoms, more than one in three</span><span class=GramE><span style='font-size:12.0pt; font-family:"Times New Roman";mso-bidi-font-weight:bold'> children</span></span><span style='font-size:12.0pt;font-family:"Times New Roman";mso-bidi-font-weight: bold'> reported early drug use.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'><o:p> </o:p>The authors also examined whether treatment with stimulant medication was associated with different rates of early drug use in children with ADHD.<span style='mso-spacerun:yes'> </span>No such association was found.<span style='mso-spacerun:yes'> </span>The <span class=GramE>rates</span> of early substance use in children with ADHD who had and had not received stimulants was equivalent.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"> </p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'><font color="#FF0000"><b>WHAT ROLE DO OTHER BEHAVIOR PROBLEMS PLAY IN THE EARLY ONSET OF DRUG USE FOR CHILDREN WITH AND WITHOUT ADHD? </b></font> <o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"> </p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>The answer to this question is that other kinds of behavior problems (e.g. aggression, defiance, argumentativeness, etc.) play a substantial <span class=GramE>role<span style='mso-spacerun:yes'> </span>in</span> predicting early drug use for children, regardless of whether they have ADHD.<span style='mso-spacerun:yes'> </span>These findings are important to examine in some detail.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'><o:p> </o:p>As expected, children with ADHD also had higher scores on maternal ratings of these other externalizing behavior problems than children without ADHD.<span style='mso-spacerun:yes'> </span>In relation to early drug use, however, what is <span class=GramE>VERY<span style='mso-spacerun:yes'> </span>IMPORTANT</span> to emphasize is that when these behavior problems were low, a child with ADHD was quite unlikely to be an early drug user.<span style='mso-spacerun:yes'> </span>Thus, by itself, ADHD did not appear to increase children's risk for early onset substance use.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>In a child with ADHD, however, even moderate levels of externalizing behavior problems were associated with a substantially increased risk for early drug use.<span style='mso-spacerun:yes'> </span>In fact, children with ADHD with externalizing problems just slightly above average were more than twice as likely as children without ADHD, but with similar scores for other behavior problems, to be early substance users.<span style='mso-spacerun:yes'> </span>At the highest levels of these behavior problems, risk of early drug use was high for children, regardless of whether they also had ADHD.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>The message here is an important one: children with ADHD but without even modest levels of other behavior problems are no more likely to become early substance users than anyone else.<span style='mso-spacerun:yes'> </span>When even modest levels of other behavior problems occur in a child with ADHD, however, there is an increased risk for early substance use.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"> </p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'><b><font color="#FF0000">ENVIRONMENTAL RISK/PROTECTIVE INFLUENCES ON DRUG USE</font></b></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"> </p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>How closely children reported they were monitored by their parents was a significant predictor of early drug use.<span style='mso-spacerun:yes'> </span>Children whose parents were reported to engage in a high level of monitoring of their whereabouts and behaviors were about half as likely to report early drug use than children who reported</span><span class=GramE><span style='font-size:12.0pt; font-family:"Times New Roman";mso-bidi-font-weight:bold'> low</span></span><span style='font-size:12.0pt;font-family:"Times New Roman";mso-bidi-font-weight: bold'> monitoring by parents.<span style='mso-spacerun:yes'> </span>This relationship held for children both with and without ADHD.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>Increasing levels of drug use by peers was also found to be a risk factor for early drug use.<span style='mso-spacerun:yes'> </span>Children who reported high levels of drug use by peers (i.e. in the top 33% of the scores) were SIX times more likely to be early drug users than children reporting low drug use by their peers.<span style='mso-spacerun:yes'> </span>Once again, this relationship held for both children with and without ADHD.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"> </p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><b><span style='font-size:12.0pt;font-family:"Times New Roman"; color:red'>SUMMARY AND IMPLICATIONS<o:p></o:p></span></b></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"> </p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>There are several very important messages in this study.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>First, ADHD in the absence of other behavior problems does not seem to increase a child's risk for early substance use.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>Second, even when accompanied by modest levels of associated behavior problems, however, a child with ADHD is at greater risk to be an early substance user. The types of behavior problems assessed by the authors included such things as defiance, verbal and physical aggression, irritability, blaming others for mistakes, argumentativeness, etc.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>Finally - and this is especially important - how carefully parents monitor their child's whereabouts and the kids their child spends time with - has enormous implications for whether or not their child is likely to be an early substance user.<span style='mso-spacerun:yes'> </span>Thus, for children with ADHD who are also showing other types of externalizing difficulties, careful parental monitoring is essential.<o:p></o:p></span></p> <p class=MsoPlainText style="text-indent: 5; margin-left: 5; margin-top: 5; margin-bottom: 0"><span style='font-size:12.0pt;font-family:"Times New Roman"; mso-bidi-font-weight:bold'>What I think is noteworthy about this is that parental monitoring was shown to be so important in regards to substance use even though the children in this study were not even teenagers when the follow up data was collected.<o:p> </o:p>Most parents would recognize the importance of careful monitoring for their adolescents sons and daughters, being careful to make sure their child is not hanging around with peers who are likely to get in trouble. What these data indicate, however, is that such monitoring is just as important when children are still in elementary school, as it can be a key factor in reducing a child's risk for beginning to experiment with illicit substances at a very early age.<o:p></o:p></span></p> </td> </tr> <tr> <td width="100%" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF" valign="top" colspan="2"> <hr color="#C0C0C0"> <p style="text-align: center; margin-top: 5; margin-bottom: 0"> <a target="_top" href="../../home.html" style="color: blue; text-decoration: underline; text-underline: single"> <font size="3">Home</font></a><font size="3"> | <a target="_top" href="../../addadhd.html"> ADD</a> | <a target="_top" href="../../diagnostic.html"> <span style="color: #0000FF; text-decoration: underline">Diagnostics</span></a> | <a target="_top" href="../../treatment.html">Treatments</a> | <a target="_top" style="color: blue; text-decoration: underline; text-underline: single" href="../../workshops.html">Workshops</a></font></p> <p style="text-align: center; margin-top: 5; margin-bottom: 0"> <font size="3"><a target="_top" href="../../faq.html"> <span style="color: #0000FF; text-decoration: underline">FAQ</span></a> | <a target="_top" href="../../clinics.html">Clinics</a> | <a target="_top" href="../../resources.html"> Resources</a> | <a target="_top" href="../../addquiz.html"> <span style="color: #0000FF; text-decoration: underline">Tests</span></a> | <a target="_top" href="../../messageboard.html"> <span style="color: #0000FF; text-decoration: underline">Testimonials</span></a></font></p> </td> </tr> <tr> <td width="101%" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF" valign="top" colspan="2"> <p align="center"><span class="f" id="foot">Copyright © 2005 ADD Treatment Centers All rights reserved.</span></td> </tr> </table>  <table class=MsoTableGrid border=0 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none;mso-border-alt:solid windowtext .5pt; mso-yfti-tbllook:480;mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-border-insideh: .5pt solid windowtext;mso-border-insidev:.5pt solid windowtext' width="97%"> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td width=655 valign=top style='width:100%;border:medium none windowtext; mso-border-alt:solid windowtext .5pt;background:red;padding-left:5.4pt; padding-right:5.4pt; padding-top:0in; padding-bottom:0in'> <p class=MsoNormal><b style='mso-bidi-font-weight:normal'><span style='font-size:12.0pt;color:white'>Do Co-morbid Conditions Impact How Children With ADHD Respond To Treatment?</span></b><span style='color:white'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td width=655 valign=top style='border-left:medium none windowtext; border-right:medium none windowtext; border-bottom:medium none windowtext; width:100%;border-top:medium none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt; padding-left:5.4pt; padding-right:5.4pt; padding-top:0in; padding-bottom:0in'> <p class=MsoBodyText><b style='mso-bidi-font-weight:normal'><span style='font-size:18.0pt'>M</span></b><span style='font-size:12.0pt'>any of you are already familiar with the results of the MTA study, the largest treatment study of ADHD every conducted.<span style='mso-spacerun:yes'> </span>The goal of this study was to compare the effectiveness of carefully conducted medication treatment, intensive behavioral treatment, the combination of medication and behavioral treatment, and typical treatment for ADHD as practiced in community.<span style='mso-spacerun:yes'> </span>Participants in this study were 579 children between the ages of 7 and 9.9 who had been carefully diagnosed with ADHD, Combined Type.<span style='mso-spacerun:yes'> </span>Although children in all 4 treatment groups showed significant improvement, those in the medication-only group and the combined-treatment group had significantly greater improvement in their core ADHD symptoms than children given only intensive behavioral treatment or community care.<span style='mso-spacerun:yes'> </span>There was also evidence that combined treatment provided a modest incremental benefit compared to careful medication treatment alone. <o:p></o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>An important question not fully addressed in the initial analyses of = the MTA results is whether treatment response may vary as a function of the other conditions a child may have in addition to ADHD (i.e. co-morbid conditions). Unfortunately, it is well known that children with ADHD often have other conditions as well, including Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), mood disorders, and anxiety disorders. <o:p></o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>These co-morbid conditions can complicate a child’s treatment and tend to be associated with a poorer long-term prognosis.<span style='mso-spacerun:yes'> </span>Therefore, it is very important to carefully examine whether the presence of these other difficulties affects the type of impairments that children have, how they respond to treatment, and the type of treatment that is likely to be<span style='mso-spacerun:yes'> </span>most helpful. (Note: In the MTA study, medication and behavioral treatment were the only ones investigated because they are the interventions with the strongest empirical support at this time.)<o:p></o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'><span style='mso-spacerun:yes'> </span>(Note: Some of the children diagnosed with anxiety disorders had mood disorders as well.)<span style='mso-spacerun:yes'> </span>Diagnoses and assignment to the different groups were based on structured psychiatric interviews conducted with parents, and thus do not reflect children’s own reports of fears, worries, and other symptoms of anxiety.<o:p></o:p></span></p> <h1><span style='font-size:12.0pt;font-family:"Times New Roman"'>Results<o:p></o:p></span></h1> <p class=MsoBodyText><span style='font-size:12.0pt'>A number of different baseline and outcome measures were collected in this study, including core symptoms of ADHD, oppositional/aggressive behavior, academic achievement, anxiety and depression symptoms, social skills, and parent-child relations.<span style='mso-spacerun:yes'> </span>Although the results varied across these different measures, there are several important general conclusions that can be made.<o:p></o:p></span></p> <p class=MsoListBullet>Parents of children with ADHD and ODD/CD report greater difficulty with their child than parents of children with ADHD and an anxiety disorder.</p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>An important exception to this general pattern is that children with ADHD and an anxiety disorder were more likely to have academic problems and to be diagnosed with a learning disability.<o:p></o:p></span></p> <p class=MsoListBullet>Overall, children with ADHD and an anxiety disorder tended to be more treatment responsive than children with ADHD alone or children with ADHD and ODD/CD</p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>Children with ADHD and an anxiety disorder showed a positive response to all 3 MTA treatments (i.e. medication only, behavior therapy only, and combined treatment) and tended to show greater improvement than children in the other groups.<span style='mso-spacerun:yes'> </span>Thus, although children in the other groups also showed important benefits from treatment, the treatment gains for children with ADHD and an anxiety disorder tended to be slightly greater.<o:p></o:p></span></p> <p class=MsoListBullet>Behavioral interventions were particularly likely to be helpful for children with ADHD and an anxiety disorder.</p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>On a number of specific outcome measures, including measures of academic achievement, as well as an overall composite measurement of outcome, children with ADHD and anxiety were more likely to show a positive response to behavioral treatment than were children in the other groups.<o:p></o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>Unlike the children in the other groups, these children did as well with behavior therapy alone as they did with medication alone.<o:p></o:p></span></p> <p class=MsoListBullet>For children with ADHD only, or ADHD and ODD/CD, treatments with medication seem especially effective, while behavioral treatment alone may be less effective.</p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>Children with ADHD alone or ADHD and ODD/CD showed relatively little response to intensive behavioral therapy only.<span style='mso-spacerun:yes'> </span>The use of carefully conducted medication treatment thus seems especially important for these types of ADHD children.<o:p></o:p></span></p> <p class=MsoListBullet>For ADHD children who also have both an anxiety disorder and ODD/CD, the use of combined treatment (i.e. medication and behavior therapy) may offer substantial advantages.</p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>For these children with the most complex set of symptoms, overall outcome for combined treatment was significantly better than for either behavioral treatment or medication treatment alone.<o:p></o:p></span></p> <h1><span style='font-size:12.0pt;font-family:"Times New Roman"'>Summary and Implications<o:p></o:p></span></h1> <p class=MsoBodyText><span style='font-size:12.0pt'>These findings add substantially to the main results of the MTA study and have clinical implications that are potentially important for parents and clinicians.<span style='mso-spacerun:yes'> </span>First, it appears that children with ADHD and a co-morbid anxiety disorder may be especially likely to have concurrent academic problems and learning disabilities.<span style='mso-spacerun:yes'> </span>Thus, for these children, it would be especially important for this possibility to be carefully considered and investigated.<span style='mso-spacerun:yes'> </span>Although this is likely to occur in a comprehensive evaluation conducted by a child mental health specialist, this may be short-changed because of insurance-imposed limitations.<span style='mso-spacerun:yes'> </span>In addition, primary care physicians may not always have the training that enables a careful assessment of academic functioning and learning difficulties to be completed.<o:p></o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>Second, for children with ADHD and an anxiety disorder, carefully executed behavioral treatment may yield treatment gains that are equivalent to what would be provided by medication.<span style='mso-spacerun:yes'> </span>Thus, in situations where parents have strong concerns about the use of medication, where children do not benefit from it, or, cannot tolerate it, behavioral treatment alone can be a reasonable treatment choice for these children.<span style='mso-spacerun:yes'> </span>For these children, beginning treatment with behavior therapy alone and carefully monitoring their progress may alleviate the need for medication in many instances.<o:p></o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>Third, parents and clinicians should be aware that in children with ADHD alone, or ADHD with ODD/CD, the use of carefully conducted medication therapy is likely to be especially critical.<span style='mso-spacerun:yes'> </span>In the MTA study, these children did not respond well to medication treatment alone even though they showed robust responses to medication.<span style='mso-spacerun:yes'> </span>When an anxiety disorder is also present, however, the addition of behavior treatment may confer some important incremental benefits.<o:p></o:p></span></p> <p class=MsoNormal><span style='font-size:12.0pt'>As with any study, there are several important caveats to keep in mind.<span style='mso-spacerun:yes'> </span>First, these results apply specifically to children with the combined sub-type of ADHD between the ages of 7 and 10.<span style='mso-spacerun:yes'> </span>The extent to which they would generalize to children with other ADHD subtypes (i.e. inattentive or hyperactive-impulsive) and of different ages is unknown.<span style='mso-spacerun:yes'> </span>Second, there are always individual exceptions to results that are derived from comparing groups.<span style='mso-spacerun:yes'> </span>Thus, although these results indicate what is more likely to be true about a specific child (e.g. a child with ADHD alone is likely to respond better to medication treatment than to behavioral treatment), there are always exceptions at the individual level.<span style='mso-spacerun:yes'> </span>Most importantly, the results from the MTA study are based on both medication and behavioral treatment that can be considered state-of-the-art.<span style='mso-spacerun:yes'> </span>For example, children receiving medication treatment began with a = careful placebo-controlled trial to determine their optimum starting dose, and were then carefully monitored each month to determine when modifications to dosage or even type of medication were necessary.<span style='mso-spacerun:yes'> </span>Behavioral treatment included extensive work with parents, an 8-week summer program for children, and an intensive behavior management system at school.<span style='mso-spacerun:yes'> </span>Unfortunately, this is not the type of medication treatment or behavioral treatment that is typically provided in community settings.<span style='mso-spacerun:yes'> </span>In fact, one of the main findings of the MTA study is that children receiving medication treatment or combined treatment in the study did significantly better than those whose treatment occurred in the community.<span style='mso-spacerun:yes'> </span>Thus, one cannot assume, for example, that the behavior treatment most children have access to = would show the same positive impact on children with ADHD and an anxiety disorder that was shown in this study.<o:p></o:p></span></p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>Rather than being discouraged by this possibility, however, it is important for parents to learn as much as they can about what these state-of-the-art MTA treatments entailed, and to do their best to make sure that the treatment received by their child matches this to the extent possible.<span style='mso-spacerun:yes'> </span>With medication treatment, for example, even though the entire = placebo-controlled procedure would be hard to follow exactly, it is quite possible to incorporate several important elements of this procedure, including: testing a child on a full range of doses, obtaining systematic feedback from teachers on the child’s behavior and school work on each dose, and obtaining such feedback on a regular basis to determine when treatment modifications may be necessary.<span style='mso-spacerun:yes'> </span>These simple steps can make an important difference.<o:p></o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><b style='mso-bidi-font-weight:normal'><span style='font-size:12.0pt'>New Evaluation and Treatment Guidelines From an Expert Panel<o:p></o:p></span></b></p> <p class=MsoBodyText><span style='font-size:12.0pt'>The Journal of Attention Disorders recently published a special issue in which the results of a large-scale survey conducted with ADHD experts from medical and psychology backgrounds were reported.<span style='mso-spacerun:yes'> </span>The goal of this survey was to establish guidelines that address important clinical issues for which there may currently be little controlled scientific evidence, but for which there exists considerable experience in clinical practice.<span style='mso-spacerun:yes'> </span>By obtaining and summarizing the opinions of a large number of experts (i.e. 44 physicians and 47 psychologists, representing 86% and 94% of the individuals to whom a survey was sent), the results create a set of guidelines that can be informative to both parents and practitioners. <o:p></o:p></span></p> <p class=MsoNormal><span style='font-size:12.0pt'>As noted above, the survey was designed to obtain and synthesize expert opinion on issues that are not yet fully addressed in the research literature on ADHD.<span style='mso-spacerun:yes'> </span>The designers of the survey were themselves recognized ADHD experts (Keith Conners is the lead author) and are careful to note that because individuals with ADHD can vary so widely along multiple dimensions, the consensus recommendations will certainly not be appropriate in all circumstances.<span style='mso-spacerun:yes'> </span>They are also careful to note that the survey was financially sponsored by the pharmaceutical industry, and describe the steps taken to avoid having this bias the results.<span style='mso-spacerun:yes'> </span>The major effort here was to present data from every respondent so that readers can compare the summary guidelines with the raw data on which each guideline is based. <o:p></o:p></span></p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>It is also noted appropriately that the guidelines represent current expert opinion, and that expert opinion at any given time can be revealed by future studies to be wrong.<span style='mso-spacerun:yes'> </span>For example, future studies may indicate that treatments currently regarded as “alternative”, and thus not generally recommended, are actually quite helpful in many cases and should be considered to be important treatment options.<span style='mso-spacerun:yes'> </span>The important point here is that any set of recommendations can only be based on the best available evidence, and should this evidence change over time, so will the recommendations.<o:p></o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>Survey results were summarized to produce guidelines in multiple areas, including the assessment and treatment of ADHD, how these vary depending on the type of ADHD (i.e. combined, inattentive, or hyperactive-impulsive), and the age of the client.<span style='mso-spacerun:yes'> </span>Particular attention is given to important clinical issues such as what to do when treatment is only partially effective or even ineffective, what constitutes adequate monitoring, and how the current state of treatment for ADHD can be improved.<span style='mso-spacerun:yes'> </span>Reviewing the entire set of guidelines is beyond the scope of what can be presented here, and the focus in this issue will be on three particular points: selecting an initial treatment strategy, changing the treatment regimen when response is judged to be inadequate, and what constitutes appropriate ongoing care. <o:p></o:p></span></p> <h1><span style='font-size:12.0pt;font-family:"Times New Roman"'>Selecting an initial treatment strategy<o:p></o:p></span></h1> <p class=MsoBodyText><span style='font-size:12.0pt'>The question facing the experts here was how to sequence the treatments for ADHD—whether to begin with medication alone, psychosocial treatment alone, or a combination of both from the start.<span style='mso-spacerun:yes'> </span>Experts were told to assume that both types of treatment would be available, and to rank order their recommendations in terms from most to least preferred option.<span style='mso-spacerun:yes'> </span>It is reasonable to assume that by psychosocial treatment, the experts were referring to the types of non-medical interventions for ADHD for which empirical support has been shown, including parent training, clinical behavior therapy, skills-based training, psycho-educational interventions, etc.<o:p></o:p></span></p> <h1><span style='font-size:12.0pt;font-family:"Times New Roman"'>Psychosocial treatment alone<o:p></o:p></span></h1> <p class=MsoBodyText><span style='font-size:12.0pt'>Starting with psychosocial treatments alone was the consensus recommendation in situations where ADHD symptoms were judged to be mild and/or when the child was of preschool age.<span style='mso-spacerun:yes'> </span>In cases where there was a co-occurring internalizing problem (i.e. mood or anxiety disorder), beginning with a psychosocial intervention alone and beginning with a combination of medication and psychosocial treatment were rated equivalently.<o:p></o:p></span></p> <h1><span style='font-size:12.0pt;font-family:"Times New Roman"'>Combined treatments<o:p></o:p></span></h1> <p class=MsoNormal><span style='font-size:12.0pt'>Situations where combined treatment was viewed as an equally appropriate initial treatment strategy to medication or psychosocial intervention alone are described above.<span style='mso-spacerun:yes'> </span>In addition, combined treatment was regarded as the best initial option for individuals with the predominantly inattentive subtype of ADHD, for children and adolescents, and/or when there are co-occurring behavior disorders (i.e. Oppositional Defiant Disorder or Conduct Disorder).<span style='mso-spacerun:yes'> </span>The consensus opinion of these experts thus shows a strong preference for combined treatment.<span style='mso-spacerun:yes'> </span>For children and adolescents, this would be the preferred option except in cases where symptoms were judged to be mild (i.e., psychosocial treatment alone would be reasonable here), or when there is a strong preference for one treatment approach vs. the other.<span style='mso-spacerun:yes'> </span>The preference for combined treatment is consistent with MTA study results in which<span style='mso-spacerun:yes'> </span>the researchers found a modest, but statistically significant, advantage for combined treatments over medication alone for several specific outcomes and for an overall composite of the different outcomes considered.<o:p></o:p></span></p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><b style='mso-bidi-font-weight:normal'><span style='font-size:12.0pt'>Changing the treatment regimen<o:p></o:p></span></b></p> <p class=MsoBodyText><span style='font-size:12.0pt'>An issue closely related to the choice of initial treatment strategy is the appropriate time to change treatment regimens when the response has been inadequate.<span style='mso-spacerun:yes'> </span>Several factors were deemed important to evaluate before making any such change.<span style='mso-spacerun:yes'> </span>Before making changes to medication treatment, the following steps were advised:<o:p></o:p></span></p> <p class=MsoListBullet><span style='font-size:12.0pt'>Ensure adequate dosage: In many instances, patients may be receiving a dosage that is too low to provide maximum benefit, and adjusting the dose can yield significant additional benefits.<span style='mso-spacerun:yes'> </span>This often occurs when researchers do not test a full range of during an initial trial, but instead use the first dose on which some improvements are evident as the maintenance dose.<o:p></o:p></span></p> <p class=MsoListBullet><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoListBullet><span style='font-size:12.0pt'>Evaluate for compliance problems: Being certain that medication is actually being taken as instructed is necessary before changing medications or deciding medication will not provide important benefits.<o:p></o:p></span></p> <p class=MsoListBullet><span style='font-size:12.0pt'>Ensure coverage across waking hours - It is important to make sure the type of medication and/or dosing schedule provides adequate coverage across the period of time when symptom management is critical.<span style='mso-spacerun:yes'> </span>(Note: Now that medications with longer durations have become available—e.g., Concerta—this may be easier to ensure than when multiple daily doses are required as with regular methylphenidate.)<o:p></o:p></span></p> <p class=MsoListBullet><o:p> </o:p></p> <p class=MsoBodyText><span style='font-size:12.0pt'>In regards to switching medications when a positive response to the initial medication choice is not obtained, the panel strongly recommended that several different stimulants be given a thorough trial before trying a different class of medication (e.g. switching to an anti-depressant).<o:p></o:p></span></p> <p class=MsoList><span style='font-size:12.0pt'>Adding new meds rather than trying another type of stimulant first was also not a preferred option. <o:p></o:p></span></p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>In cases where medication alone has been used to begin treatment, the consensus was that psychosocial treatment should be added when no response has been noted over a 5-week period of careful trials.<span style='mso-spacerun:yes'> </span>In situations where only a partial response (i.e. some symptoms clearly remain and impair functioning), it was recommended that psychosocial interventions be added after 7 weeks.<span style='mso-spacerun:yes'> </span>When psychosocial treatment alone has been the initial strategy, the experts advised adding medication when a month has elapsed with no response, and waiting between 6-7 weeks when at least a partial response has been obtained.<o:p></o:p></span></p> <h1><span style='font-size:12.0pt;font-family:"Times New Roman"'>What is an appropriate level of maintenance care?<o:p></o:p></span></h1> <p class=MsoBodyText><span style='font-size:12.0pt'>One of the real drawbacks in the care that many children with ADHD receive is the lack of adequate monitoring and follow-up.<span style='mso-spacerun:yes'> </span>In addition, those receiving medication often stop taking it prematurely.<span style='mso-spacerun:yes'> </span>The guidelines in this section are thus especially important to note.<o:p></o:p></span></p> <p class=MsoBodyText><span style='font-size:12.0pt'>For children/adolescents who respond well to medication, it is suggested that medication be maintained on the dosage determined to be most effective for 1-2 years before trying to taper it.<span style='mso-spacerun:yes'> </span>A typical duration of medication treatment for good responders ranged from 2-10 years.<span style='mso-spacerun:yes'> </span>For adults, it was recommended that those showing an excellent medication response continue to take it for 2-5 years before trying to taper or discontinue.<o:p></o:p></span></p> <p class=MsoList style='margin-left:3.2pt;text-align:justify;text-indent: 0in'><span style='font-size:12.0pt'>For individuals who have had an excellent response to medication treatment (i.e. symptoms have been fully normalized with no residual impairment), it was advised that follow-up visits be scheduled every 3 months.<span style='mso-spacerun:yes'> </span>In cases where only partial response has been obtained, the consensus opinion called for monthly visits.<span style='mso-spacerun:yes'> </span>Thus, ongoing monitoring of treatment response is seen as essential. For psychosocial interventions, weekly visits are recommended during the first 6 months of treatment.<span style='mso-spacerun:yes'> </span>A range of 7-20 visits would be held during this period depending on response.<span style='mso-spacerun:yes'> </span>This figure is for an “uncomplicated ADHD patient”, and would need to be increased when difficulties were more pronounced than is typical. 6-12 months after treatment has been initiated, booster sessions were recommended to be held every 1-3 months once symptoms have been fully normalized, and 1-2 times each month when there has been only a partial<o:p></o:p></span></p> <p class=MsoList style='margin-left:3.2pt;text-indent:0in'><span style='font-size:12.0pt'>response.<span style='mso-spacerun:yes'> </span>Sessions for ongoing monitoring beyond 12 months should take place 1 to 2 times per year for children and adolescents, and as needed for adults. <o:p></o:p></span></p> <p class=MsoNormal><span style='font-size:12.0pt'><o:p> </o:p></span></p> <h1><span style='font-size:12.0pt;font-family:"Times New Roman"'>Summary<o:p></o:p></span></h1> <p class=MsoNormal><span style='font-size:12.0pt'>The recommendations above are important in that they reflect the most widely held views among a large number of experts.<span style='mso-spacerun:yes'> </span>As noted above, these guidelines will not apply to every individual, and treatment decisions for specific individuals can be influenced by a wide variety of factors that no set of guidelines can fully capture.<span style='mso-spacerun:yes'> </span>In cases where treatment choices fall clearly outside of these guidelines, however, it would be important to be able to specify the factors that have resulted in what would be considered atypical recommendations.<o:p></o:p></span></p> </td> </tr> <tr> <td width="100%" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF" valign="top" colspan="2"> <hr color="#C0C0C0"> <p style="text-align: center; margin-top: 5; margin-bottom: 0"> <a target="_top" href="../../home.html" style="color: blue; text-decoration: underline; text-underline: single"> <font size="3">Home</font></a><font size="3"> | <a target="_top" href="../../addadhd.html"> ADD</a> | <a target="_top" href="../../diagnostic.html"> <span style="color: #0000FF; text-decoration: underline">Diagnostics</span></a> | <a target="_top" href="../../treatment.html">Treatments</a> | <a target="_top" style="color: blue; text-decoration: underline; text-underline: single" href="../../workshops.html">Workshops</a></font></p> <p style="text-align: center; margin-top: 5; margin-bottom: 0"> <font size="3"><a target="_top" href="../../faq.html"> <span style="color: #0000FF; text-decoration: underline">FAQ</span></a> | <a target="_top" href="../../clinics.html">Clinics</a> | <a target="_top" href="../../resources.html"> Resources</a> | <a target="_top" href="../../addquiz.html"> <span style="color: #0000FF; text-decoration: underline">Tests</span></a> | <a target="_top" href="../../messageboard.html"> <span style="color: #0000FF; text-decoration: underline">Testimonials</span></a></font></p> </td> </tr> <tr> <td width="101%" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF" valign="top" colspan="2"> <p align="center"><span class="f" id="foot">Copyright © 2005 ADD Treatment Centers All rights reserved.</span></td> </tr> </table>  <table class="MsoTableGrid" border="0" cellspacing="0" cellpadding="0" style="border-style:none; border-color:inherit; border-collapse:collapse;mso-border-alt:solid windowtext .5pt; mso-yfti-tbllook:480;mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-border-insideh: .5pt solid windowtext;mso-border-insidev:.5pt solid windowtext" width="97%"> <tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes'> <td width="100%" valign="top" style="border: medium none; mso-border-alt: solid windowtext .5pt; background: red; padding-left:5.4pt; padding-right:5.4pt; padding-top:0in; padding-bottom:0in"> <p class=MsoPlainText><b style='mso-bidi-font-weight:normal'><span style='font-size:12.0pt;font-family:"Times New Roman";color:white'>How Does Young Adult Outcome Relate To Childhood ADHD, Aggression, And Stimulant Medication Use? </span></b><span style='font-family:Arial;mso-bidi-font-family: "Times New Roman";color:white'><o:p></o:p></span></p> </td> </tr> <tr style='mso-yfti-irow:1;mso-yfti-lastrow:yes'> <td width="100%" valign="top" style="border: medium none; mso-border-top-alt: solid windowtext .5pt; mso-border-alt: solid windowtext .5pt; padding-left:5.4pt; padding-right:5.4pt; padding-top:0in; padding-bottom:0in"> <p class=MsoPlainText><b style='mso-bidi-font-weight:normal'><span style='font-size:18.0pt;font-family:"Times New Roman"'>T</span></b><span style='font-size:12.0pt;font-family:"Times New Roman"'>his important question was examined by researchers addressed in a study published recently in the Journal of Child and Adolescent Psychopharmacology (Paternite, Loney, Salisbury & Whaley, 1999, JCAP, 9 , 169-184).<span style='mso-spacerun:yes'> </span>This is one of the few studies yet conducted in which the long-term effects of stimulant medication treatment have been examined and is thus an important addition to the treatment literature on ADHD. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>These authors were interested in determining how ADHD symptoms, aggression, and a child's history of stimulant medication treatment related to outcome in young adulthood. This type of longitudinal work - i.e. following a group of children identified with ADHD over time - is critically important for understanding the long-term impact of ADHD and how medication treatment may effect children's outcomes.<span style='mso-spacerun:yes'> </span>This latter question is especially important because although many studies have documented the short-term benefits of medication, and more recent work has indicated that such benefits persist beyond a year (see the MTA study as an example of this - http://www.helpforadd.com/mta.htm), there is virtually no research to indicate that medication treatment during childhood results in meaningful improvements in young adult functioning. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>Participants in this study were 121 boys who were initially diagnosed with ADHD when they were between 4 and 12 years old.<span style='mso-spacerun:yes'> </span>These boys were diagnosed back in the 1970's, and the diagnostic criteria in use at that time were substantially different then they are today.<span style='mso-spacerun:yes'> </span>In fact, in the official terminology in use at that time the boys were diagnosed with either hyperkinetic reaction of childhood (HK) or minimal brain dysfunction (MBD).<span style='mso-spacerun:yes'> </span>Using detailed information about specific symptoms contained in boys' medical charts, however, the authors estimated that proximately 71% of these boys would have qualified for a diagnosis of ADHD using today's diagnostic criteria. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>All 121 boys were treated with stimulant medication (i.e. methylphenidate) and their treatment with medication was initiated between 1967 and 1972.<span style='mso-spacerun:yes'> </span>(It would have been preferable, of course, if girls were also included in this sample.<span style='mso-spacerun:yes'> </span>Several decades ago, however, females were probably even less likely to be recognized as having ADHD than they are today, so it is not surprising that only boys were available to follow.) Based on information contained in these boys' medical records, the authors created scores for each boy that provided an indication of the strength of both ADHD symptoms (i.e. inattention and hyperactivity/impulsivity) and aggression.<span style='mso-spacerun:yes'> </span>These ratings were made based on information from parents, teachers, and the boys themselves that were included in the boys' charts.<span style='mso-spacerun:yes'> </span>Because prior research has clearly shown that ADHD symptoms and aggression both make independent contributions to children's long-term development, these two aspects of children's behavior were considered separately.<span style='mso-spacerun:yes'> </span>(The authors actually hypothesized that childhood aggression would be more strongly associated with negative outcomes in young adulthood than would ADHD symptoms.) <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>As noted above, all participants in this study were treated with stimulant medication at some point.<span style='mso-spacerun:yes'> </span>Thus, the authors were not comparing the long-term outcomes of children with ADHD according to whether or not they had received medication.<span style='mso-spacerun:yes'> </span>Instead, they carefully reviewed boys' medical records to document the characteristics of the medication treatment that was provided. They then examined how important aspects of medication treatment - i.e. overall response to medication, dose of medication received, and duration of medication treatment - were related to various outcomes in young adulthood. These ratings were based on information contained in the boys' charts and were made by raters who were blind to how the boys were doing in young adulthood. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>The young adult assessment occurred when participants were between 21 and 23 years old.<span style='mso-spacerun:yes'> </span>Approximately 80% of the original sample participated in the young adult evaluation, and those who did were representative of the sample as a whole. A wide variety of<span style='mso-spacerun:yes'> </span>measures were collected at this assessment including information on psychiatric diagnoses, overall level of functioning in important life areas, intellectual functioning, academic achievement, and overall life circumstances (i.e. social, educational, and<span style='mso-spacerun:yes'> </span>employment circumstances). Within each of these broad domains, a number of different measures were included so the overall number of outcome measures considered was quite large.<span style='mso-spacerun:yes'> </span>This assessment thus provided a comprehensive account of how participants were faring at this point in their lives. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p></span><b style='mso-bidi-font-weight:normal'><span style='font-size:12.0pt;font-family:"Times New Roman"'>Results<o:p></o:p></span></b></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'>The basic questions of interest in this study are as follows: <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>1. How do childhood levels of ADHD symptoms relate to functioning in young adulthood? <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'>2. How does childhood level of aggressive behavior relate to functioning in young adulthood? <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'>3. Does young adult outcome relate to a child's overall response to stimulant medication, the magnitude of the dose a child typically received, and/or the duration of medication treatment? <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>This last question is actually quite important as there are distressingly few long-term studies of the effect of stimulant medication treatment on important outcomes for children with ADHD.<span style='mso-spacerun:yes'> </span>As noted above, the authors of this study were not comparing outcomes for children with ADHD depending on whether they were treated with medication.<span style='mso-spacerun:yes'> </span>Instead, they were interested in how important aspects of medication treatment (i.e. overall response, dose, and duration) predicts important life outcomes over a number of years. Because of the large number of outcome measures collected, it is perhaps more important to look at the overall pattern of results rather than focusing on specific outcome variables.<span style='mso-spacerun:yes'> </span>When the results of the study are considered in this way, they are really quite clear.</span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'>Overall, childhood aggression was a stronger predictor of problems in young adulthood than was childhood ADHD. The authors reported that aggression was uniquely related to 38% of the outcomes they considered while ADHD symptoms predicted only 10% of these outcomes.<span style='mso-spacerun:yes'> </span>Among the specific outcomes predicted by childhood aggression were depression, drug abuse, antisocial personality disorder, and a variety of functional impairments.<span style='mso-spacerun:yes'> </span>ADHD symptoms, in contrast, predicted only lower levels of employment and greater general levels of impairment.<span style='mso-spacerun:yes'> </span>Thus, these results clearly indicate that high levels of aggression during childhood poses significantly greater risks to a child's long-term development than do ADHD symptoms alone. Children who had a better overall response to medication, who received higher doses, and who were treated for a longer duration, had better outcomes in a variety of different areas. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>The aspects of medication treatment the authors examined - i.e. overall response, dose, and treatment duration - were not related to all of the different outcomes considered. For 11 different outcome measures, however, these aspects of medication treatment were found to be significant predictors, and in every case but one, results were in the direction of indicating significant benefits for medication. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'>Thus, it is reported that better overall response to medication was associated with lower depression scores and better social functioning in young adulthood.<span style='mso-spacerun:yes'> </span>They were more likely to be living independently of their parents, and to be either married or engaged. Similarly, children treated with higher doses were less likely to be diagnosed with alcoholism in young adulthood and had made significantly fewer suicide attempts. Finally, the longer a child was treated with medication the higher his IQ and academic achievement in reading and math was likely to be.<span style='mso-spacerun:yes'> </span>The only clear negative finding was that children who had a better overall response to medication treatment were less likely to graduate from high school.<span style='mso-spacerun:yes'> </span>This is a perplexing finding given the overall pattern of results, and may represent a chance finding that would not be replicated.<span style='mso-spacerun:yes'> </span>In general, however, medication treatment tended to have positive effects long after it had been discontinued. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p></span><b style='mso-bidi-font-weight:normal'><span style='font-size:12.0pt;font-family:"Times New Roman"'>Implications And Limitations <o:p></o:p></span></b></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>What seems fairly clear from these results is that childhood aggression as measured in this study is associated with poorer young adult outcomes.<span style='mso-spacerun:yes'> </span>Also, MPH treatment is associated with better young adult outcomes.<span style='mso-spacerun:yes'> </span>Specifically, positive outcomes occur in psychiatric, cognitive, academic, and social domains when considered in children who respond well to early treatment and who were treated with higher doses for a greater period of time. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>These results, although informative and potentially influential, should be viewed with caution in regards to what can be concluded about the long-term benefits of stimulant medication treatment.<span style='mso-spacerun:yes'> </span>There are several different reasons why such caution is necessary.<span style='mso-spacerun:yes'> </span>First, no information is provided about the families of these patients or the total number of clinical visits each child made.<span style='mso-spacerun:yes'> </span>It may be that more frequent visits to the doctor - which would be likely to correlate with a greater duration of medication treatment - is indicative of a more concerned family, or a family that is more invested in their child's well-being.<span style='mso-spacerun:yes'> </span>Conceivably, the child's improvement could be a consequence of this investment rather resulting from more extensive treatment with medication. <o:p> </o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'>It is also important to keep in mind that the diagnostic criteria for ADHD in use at the time the children in this study were first diagnosed were quite different than they are today.<span style='mso-spacerun:yes'> </span>Thus, not every child in this study would be diagnosed with ADHD using current guidelines and the degree to which these data would apply to children diagnosed today is not completely clear. In establishing the long-term effects of medication treatment, it would also be important to compare outcomes for children who did, and did not, receive treatment with medication. That was not done in the current study, although the authors indicate that they have additional papers on using this data set in which such comparisons are described.<span style='mso-spacerun:yes'> </span>Finally, there were no girls included in the sample so the extent to which these findings would generalize to girls is completely unknown. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>Despite these limitations, the value of this study is clear. The keys points to emphasize is that aggression during childhood appears to be a better predictor of negative long-term outcomes than ADHD symptoms alone.<span style='mso-spacerun:yes'> </span>This replicates findings that have been reported in prior work, and underscores the importance of carefully attending to this aspect of children's behavior.<span style='mso-spacerun:yes'> </span>When a child has both ADHD and aggressive behavior problems, parents and professionals need to be especially vigilant to make sure that interventions which address the aggressive behavior problems are an important part of the child's treatment. <o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>In regards to medication treatment, these data do provide important initial support that such treatment is associated with long-term benefits.<span style='mso-spacerun:yes'> </span>When children have a good response to meds, receive an adequate dose, and are maintained on medication over a longer period of time, these data suggest that there can be important long-term benefits.<o:p></o:p></span></p> <p class=MsoPlainText><span style='font-size:12.0pt;font-family:"Times New Roman"'><o:p> </o:p>This is not conclusive proof by any means that stimulant medication produces meaningful long-term gains, but it is consistent with this hypothesis and is a step in the right direction of establishing such proof.<span style='mso-spacerun:yes'> </span>I look forward to future publications from these authors and will include summaries of their work in ADHD RESEARCH UPDATE as it appears. </span><span style='font-family:Arial;mso-bidi-font-family: "Times New Roman"'><o:p></o:p></span></p> </td> </tr> <tr> <td width="100%" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF" valign="top" colspan="2"> <hr color="#C0C0C0"> <p style="text-align: center; margin-top: 5; margin-bottom: 0"> <a target="_top" href="../../home.html" style="color: blue; text-decoration: underline; text-underline: single"> <font size="3">Home</font></a><font size="3"> | <a target="_top" href="../../addadhd.html"> ADD</a> | <a target="_top" href="../../diagnostic.html"> <span style="color: #0000FF; text-decoration: underline">Diagnostics</span></a> | <a target="_top" href="../../treatment.html">Treatments</a> | <a target="_top" style="color: blue; text-decoration: underline; text-underline: single" href="../../workshops.html">Workshops</a></font></p> <p style="text-align: center; margin-top: 5; margin-bottom: 0"> <font size="3"><a target="_top" href="../../faq.html"> <span style="color: #0000FF; text-decoration: underline">FAQ</span></a> | <a target="_top" href="../../clinics.html">Clinics</a> | <a target="_top" href="../../resources.html"> Resources</a> | <a target="_top" href="../../addquiz.html"> <span style="color: #0000FF; text-decoration: underline">Tests</span></a> | <a target="_top" href="../../messageboard.html"> <span style="color: #0000FF; text-decoration: underline">Testimonials</span></a></font></p> </td> </tr> <tr> <td width="101%" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF" valign="top" colspan="2"> <p align="center"><span class="f" id="foot">Copyright © 2005 ADD Treatment Centers All rights reserved.</span></td> </tr> </table>  <table border="0" cellpadding="0" cellspacing="0" style="border-collapse: collapse" width="97%" bgcolor="#FFFFFF" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF"> <tr> <td width="100%" bgcolor="#FF0000" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF" height="20"> <font color="#FFFFFF"><span style="font-weight: 700"> Neurofeedback</span></font></td> </tr> <tr> <td width="100%" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF"> <p> <b> <font size="5"> <img border="0" src="../../images/wavedisplay.jpg" align="left" width="150" height="100" vspace="3">N</font></b>eurofeedback, or EEG Biofeedback, is a relatively novel breakthrough in the world of clinical psychology.  This type of treatment, which is an alternative for chemical interventions, offers new hope for various conditions.  Supported by 30 years of research, Neurofeedback is slowly gaining widespread acceptance and utilization among clinicians.  In order to gain a better concept of how neurofeedback works, one must first understand the context from which it was developed. <p> Neurofeedback is a form of operant conditioning that trains specific cortical areas to function normally. "Traditional biofeedback training brings to one's awareness signals from the body that are not normally sensed.  Neurofeedback is a type of biofeedback that demands specialized skills and understanding of neurophysiology on the part of the technician or researcher. Highly sensitive computerized instruments measure, filter, and amplify EEG (electroencephalographic) signals from appropriate areas of the head (cerebral cortex). The computer then feeds back to the client specific and/or desired brainwave patterns known to correlate with positive brain states. Over time, brainwaves are "shaped" or systematically changed in such a way as to facilitate such things as increased attention, decreased pain, and emotional stability." (1)<p>Generally speaking, the roots of neurofeedback stem from the operant conditioning paradigm and biofeedback research.  Operant conditioning, also known as instrumental conditioning,  is a method for changing behavior through the repeated presentation of rewards or punishments.  For example, a rat that is taught to push a lever in order to gain a reward (food pellet), can learn to do so if the pairing of behavior and reward are consistently repeated.  Through this relationship, the rat is able to associate its behavior (pushing the lever) to the reward (food pellet) and become better at generating the desired response.  <p>This type of association can also be found in the feedback relationship between the client and the neurofeedback instrumentation.  During a neurofeedback session, the client is able to observe representations of their brainwave activity and modify their mind-state accordingly to obtain the desired results (i.e., increased attention, decreased pain, less seizures, etc.).  Through practice, the client  forms an association between the desired mind-state (reward) and the brainwave activity (behavior) necessary to achieve this state.<p>In addition to the influences of operant conditioning, biofeedback research has also played a significant role in the development of neurofeedback. Biofeedback is a technique for teaching individuals how to consciously control specific bodily activities.   By exposing clients to their own electrophysiological signals, biofeedback clinicians create a feedback loop that encourages the client to generate the proper behavioral responses.  This technique has grown dramatically from its meager beginnings into a science that continues to widen its range of applications.  <p>Biofeedback's experimental history stems as far back as 1901, which marks the first known record of biofeedback with instrumentation.  In 1901, J.H. Bair created an instrument that allowed people to gain control of their ear muscles.  He recorded the results of his experiment in a report he entitled "Development of Voluntary Control".  In 1934, E.D. Adrain and B.H.C. Matthews wrote the first report on brainwave biofeedback.  While trying to replicate Hans Berger's groundbreaking EEG work, Adrain discovered that he could generate and sustain alpha frequency (8-11 Hz) brainwaves by closing his eyes.<p>The field of modern biofeedback emerged around the 1950s and 60s. This field emerged out of great interest in stress research and the explosion in electrical technology after World War II.  Walter B. Cannon was one of the most influential stress researchers of this time.  His experiments investigated the effects of adrenaline and stress on human behavior.  Through his experimentation with cats, Cannon discovered that stress can halt digestive systems and adrenaline can increase heart rate and blood pressure.  He was also responsible for coining the term "fight or flight".  Early stress studies, such as these, spurred the creation of instruments that could measure stress in order to reverse its adverse effects. <p>In the 1960's, a book entitled "Muscles Alive" was released, which documented the experimental work of John Basmajian.  In his book, Basmajian describes how he trained subjects to consciously control a single motor unit that innervates a few thumb cells.  By using tiny needle-like electrodes, he was able to monitor and amplify invisible electrical activity within this single motor unit.  Basmajian used a loud speaker to create representations of his subjects' physiological responses, which allowed them to mimic certain sounds (i.e., drum rolls and horse trotting).  Aside from this ingenious experiment, Basmajian is also known for his role in the invention of the electromyograph (EMG), which became the primary instrument for traditional biofeedback.<p>Almost simultaneous to Basmajian's work was the landmark study of Joe Kamiya (1958), who inspired an explosion in neurofeedback research.  Kamiya was interested in people's perception of different brainwave states.  More specifically, he was interested in the brainwave state associated with introspection.  Kamiya designed an experiment in which his subject, a graduate student by the name of Richard Bach, was asked to distinguish between different brainwave ranges.  For this experiment, Kamiya chose the alpha frequency (8-12 Hz) as his target range.  He played a series of tones and asked his subject, after each tone, if he was in the alpha state.  For the first test day, his subject was able to get half of his answers correct.  After the fourth day of training, Bach was able to provide an almost perfect score.  Kamiya then asked Bach to enter into the alpha state when he heard a single bell tone; and again Bach was perfectly successful.  The results of this monumental study were later published in <i>Psychology Today</i> (1968) and the research in neurofeedback grew tremendously.<p>As a result of Kamiya's findings, psychological researchers became increasingly interested in neurofeedback, particularly alpha training.  Many researchers began studying alpha brainwaves in an attempt to find a cure for stress and anxiety.  Some believed that alpha training would be a cure-all that could alleviate all stress and normalize bodily functions.  Subjects reported feelings of clear-headedness, tranquility, and relaxation.  This growing interest in brain biofeedback spurred the creation of the Biofeedback Research Society (1969), which is now called the Association for Applied Psychophysiology and Biofeedback.<p>One prominent founder of this society was Barry Sterman, who studied beta frequency brainwaves (12-18 Hz) despite the popularity of alpha training.  While conducting his neurofeedback research with cats, Sterman discovered that the frequency range of 12-15 Hz has its own distinct properties.  He renamed the frequency SMR, or "sensorimotor rhythm", because of its prevalence in the sensorimotor strip of the prefrontal cortex.  This discovery enabled Sterman to stumble upon the alleviating effects that SMR training has on seizures.  Sterman discovered that training cats to increase SMR would make them resistant to a seizure-causing chemical.  Amazed by these findings, Sterman continued to study this topic and apply his findings to a human population.  Aside from demonstrating a drastic decrease in his subjects' seizures, Sterman's later findings also revealed a significant decrease in hyperactivity among the hyperactive participants.  These later findings unveiled more possibilities for the application of neurofeedback.<p>In the early 1970's, Joel Lubar conducted neurofeedback studies on children with ADD and ADHD.  By training SMR, Lubar successfully decreased the hyperactivity within his hyperactive population.  In addition to generating a decease in hyperactivity, Lubar was also able to improve his subjects' attention by training them to increase beta (15-18 Hz) and decrease theta (4-7 Hz) brainwaves.  To this day, Lubar's work continues to inspire neurofeedback studies concerning ADD and ADHD.<p>From the brief historical summary provided above, it is clear that neurofeedback training offers new hope for  various psychophysiological disorders.  Since its introduction to the clinical setting, neurofeedback has been used to treat seizure disorder, ADD/ADHD, Autism, Tourette's Syndrome, drug addiction, stress, depression, closed head injury, and Obsessive Compulsive Disorder.  Neurofeedback's range of applications continues to grow each year as more research is undertaken.  While computer technology and functional brain-mapping techniques continue to grow in exponential rates, it will be fascinating to see what neurofeedback has to offer in the future.<p>By James Macion<p><u>References</u><p>1.  Schummer, G. J.  <i>What is Neurofeedback ?</i><p><i>2.  </i>Evans, J., Abarbanel, A. (1999).  <i>Introduction to Quantitative EEG and Neurofeedback</i>. San Diego: Academic Press.          <p>3.  Robbins, J. (2000).  <i>A Symphony in the Brain: the evolution of new brainwave biofeedback (1st ed.).</i> New York: Atlantic Monthly Press.<p><i>4.  </i>Sears, W., Thompson, L. (1998). <i>The A.D.D. Book: new understandings, new approaches to parenting your child</i> (1st ed.). Canada: Little, Brown and Company.</td> </tr> <tr> <td width="100%" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF" valign="top" colspan="2"> <hr color="#C0C0C0"> <p style="text-align: center; margin-top: 5; margin-bottom: 0"> <a target="_top" href="../../home.html" style="color: blue; text-decoration: underline; text-underline: single"> <font size="3">Home</font></a><font size="3"> | <a target="_top" href="../../addadhd.html"> ADD</a> | <a target="_top" href="../../diagnostic.html"> <span style="color: #0000FF; text-decoration: underline">Diagnostics</span></a> | <a target="_top" href="../../treatment.html">Treatments</a> | <a target="_top" style="color: blue; text-decoration: underline; text-underline: single" href="../../workshops.html">Workshops</a></font></p> <p style="text-align: center; margin-top: 5; margin-bottom: 0"> <font size="3"><a target="_top" href="../../faq.html"> <span style="color: #0000FF; text-decoration: underline">FAQ</span></a> | <a target="_top" href="../../clinics.html">Clinics</a> | <a target="_top" href="../../resources.html"> Resources</a> | <a target="_top" href="../../addquiz.html"> <span style="color: #0000FF; text-decoration: underline">Tests</span></a> | <a target="_top" href="../../messageboard.html"> <span style="color: #0000FF; text-decoration: underline">Testimonials</span></a></font></p> </td> </tr> <tr> <td width="101%" bordercolorlight="#FFFFFF" bordercolordark="#FFFFFF" valign="top" colspan="2"> <p align="center"><span class="f" id="foot">Copyright © 2005 ADD Treatment Centers All rights reserved.</span></td> </tr> </table>  </body>