------------------------------------------------------------------- This mailing is being sent to over 12,900 parents and professionals interested in keeping up with new research on ADHD. If you are no longer wish to receive this information, just mailto:[EMAIL PROTECTED] and type unsubscribe preview in the body of your message. For information on becoming a regular subscriber to ADHD RESEARCH UPDATE, please visit https://www.helpforadd.com/subscribe.htm ------------------------------------------------------------------ Greetings: I hope that you and your family had a safe and happy holiday. Below is an article that appeared in a prior issue of ADHD RESEARCH UPDATE. The article summarizes an interesting study on the use of medication and behavioral treatment for children with both ADHD and Oppositional Defiant Disorder (ODD). I hope that you enjoy it. Let me apologize if you recently sent in an unsubscribe request and are receiving this. 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To switch to this list, just mailto:[EMAIL PROTECTED] and I will make the change. ================================================================ * COMBINING MEDICATION TREATMENT AND BEHAVIOR MODIFICATION FOR CHILDREN WITH ADHD AND OPPOSITIONAL DEFIANT DISORDER Children with ADHD often develop other behavioral disorders such as Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD), and such conditions are associated with more negative long-term outcomes. Learning about the most effective ways to treat children who show these types of behavior disorders in addition to ADHD is thus an extremely important task for parents, clinicians, and researchers. A recent study appearing in the Journal of the American Academy of Child and Adolescent Psychiatry (Kolko, D. J., Bukstein, M.D., and Bafron, J. (1999). Methylphenidate and behavior modification in children with ADHD and comorbid ODD or CD: Main and incremental effects across settings. Journal of American Academy of Child and Adolescent Psychiatry, 38, 578-585) provides interesting and important data on this issue. Before getting in to the specifics of this study, let me briefly review the symptoms of ODD and CD. Listed below are DSM-IV symptoms for ODD: 1. often loses temper; 2. often argues with adults; 3. often defies or refuses to comply with adult requests or rules; 4. often deliberately annoys people; 5. often blames others for mistakes or misbehavior; 6. is often touchy or easily annoyed by others; 7. is often angry and resentful; 8. is often spiteful and vindictive; For ODD to be an appropriate diagnosis, at least 4 of the symptoms listed above must be present for at least 6 months; the behavior must occur more frequently than is typical for a child of comparable age, and the behavior must create significant impairment in a child's social or academic functioning. In addition, the oppositional behavior can not occur only during times when a child is depressed. An important difference that you will note from the symptoms of ADHD is that none of the ADHD symptoms involve behavior that is considered to be deliberate and willful. Thus, although children with ADHD often engage in behavior that annoy others and fail to follow through on requests, such behavior is not deliberately and willfully initiated. Conduct Disorder (CD) is a more severe form of behavioral disturbance. According to DSM-IV, the publication of the American Psychiatric Association that provides current diagnostic criteria for all recognized psychiatric disorders, the essential feature of CD is "...a repetitive and persistent pattern of behavior in which the basic rights of others or age-appropriate social norms or rules are violated." These behaviors fall into 4 main groupings: * Aggressive behavior that causes or threatens to cause harm; Examples: initiating fights; cruelty to people or animals; * Non-aggressive conduct that causes property loss or damage; Examples: fire setting with intent to cause damage; deliberate destruction of property; * Deceitfulness or theft; Examples: shoplifting; breaking into someone's house; frequent lying to obtain goods or avoid obligations; * Serious violation of rules; Examples: truancy from school; running away from home; staying out at night prior to age 13; For the diagnosis of CD to be correctly assigned, at least 3 of the specific symptoms must have occurred during the prior 12 months, with at least one criterion present in the last 6 months. In addition, the disturbance in behavior must clearly result in clinically significantly impairment in the child or teen's social, academic, or occupational functioning. These criterion are intended to assure that the diagnosis is not assigned for an isolated antisocial act, but is instead reserved for youth who show a pattern of antisocial behavior over a significant period of time. It is very important to recognize that the symptoms of ODD and CD are quite different from those of ADHD. When one of these disorders is present in addition to ADHD (note that if a child meets diagnostic criteria for both ODD and CD, which is almost always true for children with CD, only the CD diagnosis is assigned because it is the more severe condition), making sure that this is a clear target of treatment is critical. I mention this because I have seen many instances where parents whose child had one of these conditions in addition to ADHD was not aware of this, and was not pursuing anything other than medication treatment for the primary ADHD symptoms. Now back to the study. In this investigation, 16 children with ADHD and one of these other behavior disorders completed a randomized placebo-controlled study examining the separate and combined effects of 2 dose of methylphenidate (i.e. MPH, the generic form of Ritalin) during a partial hospitalization program. During the study, which took place over a 6 week period, children received two administrations daily of either a placebo, or a low or higher dose of methylphenidate. In addition, every other week a comprehensive behavioral treatment was added to the mix. Thus, over the 6 week study, children were observed both with and without behavioral treatment in place, and with and without medication. To make things a bit more complicated, separate observations were made when children were in a classroom environment and a non-academic environment. Children were rated on a variety of dimensions including ADHD symptoms, oppositional behavior, peer conflicts, overt aggression, and positive mood. By comparing ratings of children's behavior both with and without medication, and with and without behavioral treatment, the researchers were able to examine both the individual and combined effects of these 2 treatment approaches. As one might expect from a complicated study like this, the results are not entirely straight forward. Basically, the authors were able to look at whether medication and behavior modification - when administered without the other treatment present - produced gains in each outcome area, and, whether the addition of either treatment to the other resulted in any incremental benefits. This breaks down into 4 different questions: 1. Does medication alone produce gains? 2. Does behavior modification alone produce gains? 3. Does adding behavior modification to medication treatment result in greater benefits than medication alone? 4. Does adding medication to behavior modification treatment result in greater benefits than behavioral treatment alone? In some ways, it is the last two questions that are most interesting. I will try to summarize the major findings below as I understand them: 1. In the classroom environment, medication alone was associated with reductions in ADHD symptoms, and improvements in mood and positive behavior. In the non-classroom setting, medication was found to improve ADHD symptoms, oppositional behavior, peer conflicts, and mood. 2. In the classroom environment, behavioral treatment alone was associated with reductions in ADHD symptoms, oppositional behavior, and peer conflicts, and an increased in positive mood ratings. In the non-classroom setting, behavioral treatment resulted in significant improvement only for oppositional behavior. 3. Behavioral treatment did not add significantly to the gains produced by medication alone for any of the outcomes studied. When added to behavioral treatment, however, medication had significant incremental effects (i.e. children did better than they were doing with behavioral treatment alone) on several of the outcomes. 4. When examining the outcomes for individual children, it was evident that for some outcomes in some settings, some children did better with the combination of medication and behavioral treatment than they did with either treatment alone. IMPLICATIONS In sifting through the results of this study, there are several general conclusions that are worth highlighting. First, the results indicate that both medication and behavioral treatment can be effective for children with ADHD and co-occurring behavior disorders. Although this may vary somewhat between the two approaches in different settings, some improvement in primary ADHD symptoms, and in oppositional behavior and peer relations can be expected. Second, it seems more likely that medication will add to the gains produced by behavioral treatment than the reverse. Nonetheless, the latter clearly does occur for some children. Third, and I think this is especially important, the complexity of these results indicate that questions like "Is medication an effective treatment for ADHD?" or "Is behavioral treatment effective for ADHD?" are in some ways too general to help develop the most effective treatment for an individual child. At a broad level, the answer to such questions is "Yes". But, what studies such as this highlight is that the effect of any treatment can vary depending on what outcome you are looking at (e.g. academics vs. oppositional behavior) and what setting you are examining that outcome in (e.g. classroom vs. home). This means that what is most effective for a child in terms of one outcome or setting may not be as helpful in alleviating problems in a different area or setting. Thus, you may find that medication helps a child's academic work at school but does not result in meaningful behavioral improvements at home. Or, you may find that behavioral treatment enhances a child's behavior with adults but does not produce similar gains with peers. Developing the most effective treatment for an individual child thus requires carefully evaluating how the child is doing in different domains (e.g. academics, behavior, peer relations, mood) and in different social contexts (e.g. classroom, home, peer group). One should not assume that just because a particular treatment such as medication is producing important benefits in one domain and setting, that this will necessarily translate into gains in all domains in settings. If it does not, than the task becomes one of determining what needs to be done to try and achieve similar gains in these other domains and settings. Although this may seem complicated, but it really doesn't need to be. As long as you are observant to how your child is functioning in the different important areas of his or her life, you will get a picture of how some things are going better than others. If you identify areas that continue to be problematic, even if other things have gotten much better with treatments that have already been initiated, you would want to speak with your child's health care provider about ways to try and address the difficulties that you still observe. This type of vigilance and effort should really pay off in the long run. ______________________________________________________________________ "SUBSCRIBE TO ADHD RESEARCH UPDATE PRIOR TO 12/31/99 AND SAVE 25% OFF THE REGULAR SUBSCRIPTION PRICE!" Dear Parent: IS KEEPING UP WITH NEW RESEARCH ABOUT HELPING CHILDREN WITH ADHD SUCCEED IMPORTANT TO YOU? HAVE YOU FOUND IT DIFFICULT TO FIND THIS INFORMATION IN A CONVENIENT AND RELIABLE MANNER? Most parents I have worked with answer "Yes!" to both of these questions. That is why I began publishing ADHD RESEARCH UPDATE over 2 years ago - to provide parents like yourself with convenient access to the latest published research about the best ways to help children with ADHD succeed. As a clinical child psychologist and research professor at Duke University, I am fortunate to have two luxuries that most parents - and even most health care providers do not: easy access to all the medical and psychology journals where important new research on ADHD is published and the time to spend reading new studies that are published each month. For each issue of ADHD RESEARCH UPDATE I select 4-5 studies that seem most important for parents to know about, and provide you with a comprehensive and objective summaries of these studies. A wide variety of studies are reviewed, ranging from studies of new medications to studies of alternative treatment strategies. My only criterion for selecting studies is that they be published in peer reviewed journals and that they have adequate scientific merit. "YOU WILL NOT FIND THIS COMPREHENSIVE COVERAGE OF IMPORTANT NEW RESEARCH ON ADHD ANYWHERE ELSE ON THE INTERNET." By becoming a regular subscriber you will be assured of receiving the most current information on ADHD that can make an important difference for you and your child. This is information that your child's health care provider will often not be aware of, is not provided elsewhere on the internet, and will enable you to be a much better informed advocate for your child. "SUBSCRIBE PRIOR TO 12/31/99 FOR ONLY $14.95 - A 25% SAVINGS FROM THE REGULAR SUBSCRIPTION RATE!" You can subscribe on-line at my secure order page located at: https://www.helpforadd.com/subscribe.htm If you prefer to subscribe by sending a check, you will find directions there for doing so as well. Parents from around the world have found that ADHD RESEARCH UPDATE is a valuable resource for them. I am confident that you will as well and encourage you to become a regular subscriber. Best wishes, David Rabiner, Ph.D. Licensed Psychologist Duke University ----------------------------------------- To unsubscribe send an email to: [EMAIL PROTECTED] with UNSUBSCRIBE PREVIEW in the BODY of the message.
