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Greetings:
Below is an article that appeared in a prior issue of ADHD
RESEARCH UPDATE. The article summarizes an interesting study
on similarities and differences in how children and their
parents perceive the effects of medication treatment. I
think you will find the data reported below to be interesting,
as it has potentially important implications for parents whose
child is taking medication to treat his or her ADHD, or who
are considering medication for this purpose.
If you have been finding the information you have been receiving
about new research on ADHD to be helpful, I'd like to encourage
you to become a regular subscriber to ADHD RESEARCH UPDATE.
You'll find information about subscribing at:
https://www.helpforadd.com/subscribe.htm
and at the end of the article below.
Please feel free to forward this article to others you know
who may be interested in it.
Sincerely,
David Rabiner, Ph.D.
Duke University
==================================================================
* PARENT AND CHILD PERCEPTIONS OF STIMULANT MEDICATION
TREATMENT: HOW DO THEY COMPARE?
Although stimulant medication has been shown to be safe
and effective for most children with ADHD in numerous
studies, fewer studies have been conducted in which
children's own feelings about taking medication are
examined. How parent and child perceptions of medication
treatment compare has been examined even less frequently.
These are both important topics to investigate, because
child attitudes towards medications, and the match
between parent and child perceptions, can have potentially
important implications for the ultimate success of such
treatment.
A study published in a recent issue of the Journal of
Pediatric Child Health provides important information
on these questions (Jarman, E.D., & Barker, M.J. (1998).
Child and parent perceptions of stimulant medication
treatment in attention deficit hyperactivity disorder.
Journal of Pediatric Child Health, 34, 288-292.)
Participants in this study were 102 children between the
ages of 67 months and 179 months. The majority (over 80%)
had been diagnosed with ADHD,Combined Type (i.e. had
both inattentive and hyperactive/impulsive symptoms),
about 16% had the inattentive symptoms only, and about
1% had the hyperactive/impulsive symptoms only.
Ninety-three of the children were males and only 9 were
females. (The preponderance of males was not done
intentionally but reflected the referral pattern
in the clinic from which participants were drawn).
During the study, children received methylphenidate
(MPH - the generic form of Ritalin) or dexamphetamine
(DEX - the generic form of dexedrine) for 2 weeks in a
randomly assigned order. Neither children, their
parents, nor the investigators was aware of which
medication the child was receiving at any time. At the
end of each 2-week cycle, children were asked to rate
how they felt taking each medication on a 5-point scales
ranging from "much worse than usual" to "much better
than usual". They were also asked to rate how helpful
the medication was on a 5-point scale ranging from "not
at all helpful" to "very helpful". Parents were also
asked to complete ratings of their child's behavior
during each period as well as ratings of any side
effects that they thought they observed. By collecting
this data from parents and children, the investigators
would also be able to compare how parent and child
perceptions of response to medication compared - both
in terms of the medication's effectiveness and possible
side effects.
The results below show how children reported feeling
when taking either Ritalin or Dexedrine. The numbers
in the table represent the percentage of children who
responded as indicated. For example, the first entry
indicates that 4.9% of children indicated that they had
felt much worse than usual during the 2 weeks that
they were taking MPH.
Child reported feeling: MPH Dex
Much worse than usual 4.9 5.9
Worse than usual 7.8 12.9
About the same as usual 24.5 25.7
Better than usual 34.3 22.8
Much better than usual 28.4 22.8
Overall, therefore, almost two-thirds (62.7%) of children
taking MPH reported feeling better or much better than
usual and 55.5% of children reported feeling better or
much better than usual when taking Dexedrine. Conversely,
12.7% of children reported feeling worse or much worse than
usual when taking MPH and 18.8% reported similar feelings
when taking Dex. Although it appears that children were
somewhat more likely to report feeling better when taking
MPH than when taking Dex, these differences were not
significant. In other words, it is likely that the
differences observed were due to random factors
rather than to a "true" difference in how children feel
when taking the different medications.
Children's ratings of how helpful they felt each medication
was are shown below.
Child's rating MPH Dex
Very helpful 45.1 38.6
Helpful 28.4 24.8
Not sure 14.7 26.7
Not very helpful 3.9 5.0
Not at all helpful 8.0 5.0
Overall, almost three-quarters of children (73.5%)
reported that MPH was either helpful or very helpful to
them. The corresponding figure for Dex was 63.4%.
Although it again appears that more children found MPH
to be helpful than Dex, these differences were not
statistically significant.
The authors next examined how parent and child response
to medication compared. This was done by looking at the
number of children where both child and parent rated the
response to medication as being positive; the number
where both parents and child agreed that there was not
a positive response; and the number where parents and
child disagreed about whether or not there had been a
positive response.
For MPH, parents and their child agreed on the child's
response to medication about 75% of the time
(i.e. regardless of whether it had been positive or
not) and disagreed about the child's response about 25%
of the time. For Dex, parents and their child agreed about
two-thirds of the time and disagreed about one-third of
the time. For both medications, about 75% of the disagreements
occurred when the parent(s) felt the child has shown a
positive response but the child did not agree. Thus,
on both types of medication, there was a substantial
number of instances in which parents and children
disagreed about whether or not the child had benefited from
the medication.
The only predictor of whether children perceived themselves
as benefiting was the severity of side effects that
were reported. Those children who did not perceive a
benefit to medication were the ones who had experienced
a greater number of side effects (unfortunately, it is
not completely clear in the article who - parent or
child - is providing information about the side effects
experienced.) Apart from this factor, none of the other
characteristics of the child that were known - including
gender, type of ADHD (i.e. combined type vs. predominantly
inattentive type), age, self-concept, nor the presence
of other emotional or behavioral problems) - was related
to whether or not the child reported a positive response
to the medication.
There is one important limitation to this study that
needs to be recognized, and that is the absence of a
placebo that was administered in addition to the 2 active
medications. It would have been very interesting to see
how children's reports about their response to medication
compared to what they reported when they were on the
placebo. This is especially important in relation to the
children who reported feeling worse than usual when they
were taking medication. The percentage of children who
reported feeling this way was not insignificant, and it
would be very interesting to know what percentage would
have reported feeling this way when they were taking a
placebo. The other point to note is that children's
reports were collected after only a 2-week period, and
it is not uncommon for side effects to dissipate over
time. Thus, it is quite possible that a smaller percentage
of children would have reported feeling "worse than
usual" if this data was collected several more weeks
down the road.
Despite, these limitations - which the authors also
acknowledge - I think this is a very important study
that has clear clinical implications. The results
of this study highlight that it is not uncommon for
children to report no response, or even to report a
negative response, to treatment by stimulant medication.
Furthermore, this can occur even in situations when
parents and teachers may observe important improvements
in the child's behavior and functioning. In some cases,
children who actually appear to have benefited
the most may have the strongest objections to continuing
medication.
This underscores the need to pay careful attention to
children's feelings about taking medication and their
perception of how it is effecting them. One reason this
is so important is that it can certainly influence
children's compliance with the medication regimen being
prescribed. A child who finds him or herself feeling
worse after starting on medication is unlikely to want
to continue taking it - even if parents and teachers
perceive it to be helpful to the child. When this child
gets a bit older, getting him/her to continue taking the
medication if it still seems to be necessary may
be difficult if not impossible. Therefore, paying
careful attention to the presence of such negative
feelings early on, and trying to deal with them in a
sensitive and respectful way if they are present, can
help to avoid a lot of difficulty and aggravation later
on.
In my own experience, I have found it to be extraordinarily
helpful when a child is started on medication to make
it clear that their feedback about how the medication
seems to be helping will be an important part of what
goes in to deciding whether it makes sense to continue
taking it. I try to let the child know that their
opinion about the medication, along with opinions from
their parents and teachers will all be taken into account
because all are important. In this way, one tries to
enlist the child as an active and cooperative collaborator
in the process of trying to determine whether medication
is an appropriate and helpful treatment. My own
experience has been that when approached in this way,
children are generally less likely to put up strong
objections to giving medication a try. It is also my
impression that they are less likely to report negative
effects of medication, but this is not based on any
systematic data. In any case, trying to develop the
feeling that this approach to treatment is something that
is done "with" the child as an important collaborator,
rather than something that is done "to" the child as
a passive recipient, seems to make a lot of sense to me.
______________________________________________________________________
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Dear Parent:
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Sincerely,
David Rabiner, Ph.D.
Licensed Psychologist
Duke University
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