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Greetings:
I hope the new year has gotten off to a safe and happy
start for you and your family.
Below you will find a preview of the January issue of
ADHD RESEARCH UPDATE that was recently sent out to
subscribers.
The preview contains the full text of one of the articles
from this month's issue, along with a listing of the other
studies that were reviewed this month. The article included
in this month's preview is an interesting study of the types
of other disorders that often accompany ADHD.
If you have been enjoying these previews and finding the
information helpful, why not take advantage of special offer
to start the New Year for subscribers who sign up prior to
1/31/00? You'll find details after the article below.
** FREE GIFT **
Have you received the ADHD Monitoring System yet?
I have developed a system that makes it easy for parents
to monitor how their child is doing at school and to
determine when changes to their child's treatment may
be necessary.
In the past, I have provided the ADHD Monitoring System as a
for new subscribers, but I'd be happy to send it to you regardless
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This can be enormously helpful to you and I hope that you
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in elementary school rather than for middle school and
high school students.
Please feel free to forward this information to others you
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Sincerely,
David Rabiner, Ph.D.
Duke University
**********************************************************
ADHD RESEARCH UPDATE - Vol. 27, January, 2000 PREVIEW
**********************************************************
In this issue...
* WHAT OTHER DISORDERS TEND TO GO ALONG WITH DIFFERENT SUBTYPES
OF ADHD?
REPRINTED IN FULL BELOW
* RESULTS OF THE MULTI-SITE TREATMENT STUDY OF ADHD
This is an extensive summary of 2 papers published recently on
what is widely regarded as the most important treatment study
of ADHD ever conducted. In this study, the relative effectiveness
of careful medication treatment, intensive behavioral treatment,
combined medication and behavioral treatment, and regular
treatment by community providers is compared.
* HOW EFFECTIVE IS CLONIDINE AS A MEDICATION FOR TREATING ADHD?
This medication is prescribed quite often - what is the evidence
that it works?
______________________________________________________________________
* WHAT OTHER DISORDERS TEND TO OCCUR WITH THE
DIFFERENT SUBTYPES OF ADHD?
An extremely important issue in promoting the healthy development
of a child with ADHD is paying careful attention to the other
behavior and/or emotional difficulties that often co-occur with
ADHD. These can include such other conditions as Oppositional
Defiant Disorder (ODD), Conduct Disorder (CD), Major Depressive
Disorder (MDD), and various types of anxiety disorders. Thus,
for many children with ADHD, the most effective treatment is
likely to require that specific attention be focused on these
"co-occurring" problems, in addition to the primary ADHD symptoms
of inattention and hyperactivity/impulsivity.
In a recently published study (Willcutt, E., et al., (1999).
Psychiatric comorbidity associated with DSM-IV ADHD in a
nonreferred sample of twins. Journal of the American Academy
of Child and Adolescent Psychiatry, 33, 1355-1362) some very
interesting data is presented on the types of other psychiatric
disorders that are more likely to be present depending on the
subtype of ADHD that a child has been diagnosed with.
As you may be aware, the current diagnostic criteria for ADHD
specify 3 distinct ADHD subtypes. ADHD, Predominantly
Inattentive Type, is the diagnosis given to children who display
prominent inattentive symptoms but relatively few symptoms of
hyperactivity/impulsivity. These are the children who people
sometimes refer to as "ADD", although it should be noted that
the term ADD or Attention Deficit Disorder is no longer technically
correct.
ADHD, Predominantly Hyperactive/Impulsive Type applies to
children who show high levels of hyperactive/impulsive behavior
but relatively few inattentive symptoms. Finally, there is a
final category called ADHD, Combined Type that is used for
children who display high levels of both inattentive behaviors and
hyperactive/impulsive behaviors. (For a complete presentation of
current diagnostic criteria for these subtypes go to
http://www.helpforadd.com/criteria.htm).
THE CURRENT STUDY
The participants in this study were part of an ongoing study of
learning disabilities in a large sample of twins. Parents of all
known twins from 27 school districts within a 150 mile-radius
of the Boulder/Denver, Colorado, area were contacted about
participating. For parents who consented, an initial screening
based on teacher behavior ratings was used to identify potential
cases of ADHD. These children then received a thorough
diagnostic evaluation to determine whether the child actually
had ADHD and which subtype was the appropriate diagnosis.
In addition, these children were given tests to estimate their
level of intellectual ability, and information was obtained from
parents, teachers, and children themselves to determine whether
CD, ODD, MDD, or Generalized Anxiety Disorder (GAD) were
also appropriate diagnoses for the child. (GAD is a type of
anxiety disorder that is characterized by persistently excessive
levels of anxiety/worry about a variety of different areas
including worries about school performance, getting along with
others, performance in extracurricular activities such as
sports or music, etc.).
The characteristics of the final sample are shown below. The
important thing to note is that this is a sample of children
obtained from the community rather than from a clinical setting.
Thus, the data reported are more likely to be representative of
children with ADHD in general community settings as opposed to
children with ADHD who are seen in a specific mental health setting. There
is some question, however, about whether data obtained from
a sample of twins can be generalized to children with ADHD who
are not twins. (HI stands for hyperactive/impulsive).
Control Inattentive HI Combined
Gender 49 boys 37 boys 10 boys 25 boys
46 girls 21 girls 5 girls 7 girls
Mean age 10.8 11.1 9.8 10.7
Mean IQ 115 98 117 99
As can be seen above, the hyperactive/impulsive subtype (HI)
is clearly the least frequently occurring subtype in this
community sample. This results replicates findings from
several other studies that have been published recently.
Overall, females made up about 32% of the children who were
found to have ADHD. Thus, the ratio of boys to girls with ADHD
was about 2:1. About 66% of the girls with ADHD were diagnosed
with the inattentive subtype while about 50% of the boys were
diagnosed with the inattentive type of ADHD.
Although there were no significant differences in socioeconomic
status (SES) between any of the ADHD groups and the control
participants, some very interesting differences in IQ were found.
Children with both the inattentive and combined type of ADHD
had lower IQ scores - on average - than did children in the
control group. The average IQ score for children with the
hyperactive/impulsive subtype of ADHD, however, was actually
slightly higher than children in the control group.
(It is important to note that the lower average IQ scores for
children with the inattentive and combined subtypes of ADHD
does not mean that these children tend to be less "bright" than
other children. The average scores for children in these groups
was almost exactly 100, which is the score that falls at the
exact mid-point for children taking this test. Thus, the children
in the control group and the HI group actually had scores that
were significantly above average, although why this would be the
case is unclear.)
Next, the authors examined the percentage of children in each
group who had any of the other diagnoses that were assessed. These
results are shown below. The number on left of the "/" indicates
the actual number of children in the group who had the diagnosis
and the number on the right side of the "/" indicates the % of
children in the group that this represents. For example, the
entry of 9/10 in the upper left-hand corner indicates that 9
children in the control group, which represents approximately
10% of that group, were diagnosed with ODD.
Control Inattentive HI Combined
ODD 9/10 23/40 8/53 21/66
CD 2/2 20/34 4/27 15/47
MDD 1/1 14/24 0/0 7/22
GAD 13/14 12/21 2/13 6/19
Several aspects of these results are noteworthy. First, for the
diagnoses of ODD and CD - the two types of disruptive behavior
disorders - children with any subtype of ADHD were more likely
to receive the diagnosis than control participants (i.e. those
without ADHD). Children with the Combined Type of ADHD, however,
were even more likely than children with the Inattentive Type or
the Hyperactive/Impulsive Type to receive these diagnoses. (For
a more thorough discussion of ODD and CD go to
http://www.helpforadd.com/oddcd.htm).
For the 2 types of emotional disorders - MDD and GAD - the
results were different. For GAD, it actually turned out that
children with ADHD were not significantly more likely to
receive this diagnosis than were control participants. Thus,
even though the percentages look a bit higher for the Inattentive
and Combined Types relative to the control group, these differences
are no greater than what would be expected by chance.
Children with the Inattentive Type of ADHD and children with the
Combined Type of ADHD were both more likely to be diagnosed
with depression than were control children. Interestingly, they
were also more likely to be diagnosed with depression than were
children with the HI subtype of ADHD, none of whom were diagnosed
with depression.
It is also very important to note that when examining children's
own reports about the amount of sadness and distress they
experienced, it was only children in the Inattentive group who
reported high levels of distress.
SUMMARY AND IMPLICATIONS
Overall, the results of this study clearly indicate that
children with ADHD are at increased risk for other behavioral
and emotional disorders. Thus, it is quite important when
evaluating a child for ADHD that careful attention is given
to obtaining a comprehensive assessment of the child's overall
emotional and behavioral functioning, rather than focusing
exclusively on the question of whether or not the child has ADHD.
This would hold true when evaluating adolescents and adults for
ADHD as well.
It also appears that the inattentive and hyperactive/impulsive
symptoms of ADHD are associated with increased risk for
different types of problems. Symptoms of hyperactivity/
impulsivity and the HI subtype are primarily associated with
symptoms of other disruptive behavior disorders. In contrast,
symptoms of inattention and the Inattentive type of ADHD are
associated with an increased risk of depression and perhaps
with lower levels of cognitive functioning. (It should be noted
that other researchers have reported that it is problems with
attention, and not problems with hyperactivity/impulsivity,
that are most strongly associated with academic difficulties in
children with ADHD).
This latter finding seems especially important given the fact that
many children with the inattentive subtype of ADHD often do
not display major behavior problems. As a result, these children
are more likely to "fall through the cracks" and receive no
treatment at all, or, to be treated by primary care physicians
alone rather than by mental health specialists.
The concern here is that prior research on the care provided
by primary care physicians to children with ADHD suggests that
they often do not conduct the type of thorough evaluation that is
required to identify a non-obvious problem like depression.
Thus, many children with the Inattentive subtype of ADHD who
are also depressed may fail to get the type of help that they
require. I think the important take-home message here is to pay
very careful attention to the emotional functioning of children
and teens with the Inattentive subtype of ADHD, about 1 in 4 of
whom may be depressed based on the data from this study. When
a child is depressed, consultation with a child mental health
professional is important to pursue.
For children with the Combined type of ADHD this is also quite
important. Because these children often have important co-occurring
behavior problems like ODD or CD, their depression may tend to
be overlooked for a different reason - i.e. everyone is so focused
on the ADHD symptoms and behavior problems that the child or
teen's depression gets overlooked. This can also result in the
child's receiving incomplete and less than optimal treatment. Thus,
in both cases, the best remedy for these potential problems is to
be certain that a thorough and comprehensive evaluation is
conducted in the first place. For a set of suggested guidelines
of what such an evaluation would entail, go to
http://www.helpforadd.com/evaluate.htm. You can
also find a discussion of depression in children at
http://www.helpforadd.com/depression.htm.
______________________________________________________________________
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David Rabiner, Ph.D.
Licensed Psychologist
Duke University
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