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Greetings:

Below you will find a preview of the November 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 factors
associated with the development and persistence of Oppositional
Defiant Disorder in children with ADHD.

If you have been enjoying the information received in these
previews, please consider becoming a regular subscriber to
ADHD RESEARCH UPDATE. As a regular subscriber, you will
receive substantially more research based information for helping
children with ADHD to succeed. I have included information about subscribing at the end of the article below should you be interested.

Please feel free to forward this information to others you know
who may be interested in it.

I hope you are doing well.

Sincerely,

David Rabiner, Ph.D.
Duke University

*******************************************************
ADHD RESEARCH UPDATE - Preview of November issue
*******************************************************

In this issue...

* The course of Oppositional Defiant Disorder in children
with ADHD - REPRINTED IN FULL BELOW


The other studies reviewed for subscribers in this month's issue
were:

* The impact of ADHD symptoms and Conduct problems on
children's development

* Preliminary reports of a promising new medication

* How ADHD effects preschoolers' understanding of stories
_________________________________________________________________

* THE COURSE OF OPPOSITIONAL DEFIANT DISORDER IN
CHILDREN WITH ADHD

As discussed in several studies previously reviewed in ADHD
RESEARCH UPDATE, the development of significant behavioral problems
in children with ADHD is often associated with more negative
long-term outcomes. For this reason, understanding the factors
associated with both the development and persistence of important
conduct problems in children with ADHD is extremely important.

This issue was the focus of an interesting study published
in a recent issue of the Journal of the American Academy of
Child and Adolescent Psychiatry (August, G.J., Realmuto, G.M.,
Joyce, T. & Hektner, J.M. (1999). Persistence and desistance
of Oppositional Defiant Disorder in a community sample of
children with ADHD. JAACP, 38, 1262-1270). In this study,
the authors began with a sample of over 7000 children attending
22 different elementary schools in a suburban community, and
using a combination of behavioral screening procedures and
diagnostic interviews, identified those children who met
diagnostic criteria for ADHD alone, ADHD and Oppositional
Defiant Disorder (ODD), and neither diagnosis.

As you may recall from a prior issue of ADHD RESEARCH UPDATE,
the essential feature of ODD is a persistent pattern of
negativistic, defiant, disobedient, and hostile behavior towards
authority figures that persists for at least 6 months. Children
with ODD often lose their temper, argue with adults, actively defy
and refuse to comply with rules and other demands, deliberately
annoy others, appear angry and resentful, act spiteful, and blame
others for their mistakes and misbehavior. Although all
children may display such behaviors from time to time, in
children with ODD these behaviors occur much more often and
with greater intensity.

In this study, the authors were interested in learning several
things. First, they wanted to study what background factors differed
between children with ADHD alone, from those who were diagnosed
with ADHD and ODD. Second, they were interested in identifying
factors predicted the persistence of ADHD and ODD. Finally,
they wondered how often ODD escalated into Conduct Disorder (CD)
and what factors were associated with this progression. As you
may recall, CD is an even more serious behavioral disturbance
than ODD that often involves criminal type behavior (for a more
thorough discussion of ODD and CD go to
http://www.helpforadd.com/oddcd.htm.

The sample of children identified to study included 79
with ADHD alone, 43 with ADHD and ODD, and 111 children
with neither diagnosis who were included as a comparison group.
Children were approximately 9 year olds at the start of the study
and were from primarily middle-class backgrounds. The ratio of
boys to girls in the sample was about 4:1. This study was
conducted in Minnesota, and 95% of the sample were white.

At the initial assessment, several measures were collected
in addition to the diagnostic interview data that was obtained
for all participants. These additional measures included
basic demographic information on the families (e.g.. socioeconomic
status, single parent status vs. intact family), psychiatric
information on parents (i.e. whether parents had a history of
any psychiatric diagnosis), and parenting practices. This
latter factor was designed to evaluate parents' use of different
disciplinary practices and the authors were especially
interested in the use of what they considered to be "negative
practices" that involved inconsistent and punitive approaches
to managing children's behavior.

Four years after this initial assessment, a second diagnostic
evaluation was conducted, in which the authors were able to
reevaluate approximately 60% of the original sample.
Although it would have been preferable if they were able to
retain a larger portion of the original sample, analyses they
conducted indicated that participants who dropped out did
not differ significantly on most characteristics from those
who were reevaluated. Thus, it is reasonable to assume that
their findings are not unduly influenced by their having a
non-representative sample for the follow-up assessment.

Using this second round of diagnostic data, they were able to
look at changes in the symptom picture for each child, changes
in the overall rate of diagnosis, and to examine what types of
background factors were associated with these changes. The
major questions addressed and the results of their analyses
are summarized below.


What was the stability of the initial diagnoses?

Of the 79 children who were diagnosed with ADHD alone at the
initial evaluation and reevaluated 4 years later, 36 - about 46% -
continued to meet diagnostic criteria for ADHD and no additional
diagnosis. Another 21 - about 27% - continued to meet diagnostic
criteria for ADHD and were also now diagnosed with ODD as
well. The same number - 21 - no longer met ADHD diagnostic
criteria and received no diagnosis at the follow up.

This is certainly encouraging in that it indicates that a significant
number of children with ADHD do experience a diminishing
of symptoms over time to the point where they no longer qualify
for the diagnosis. It is important to be aware, however, that even
though a child/teen may no longer meet full diagnostic criteria,
he or she will often still be adversely affected by residual
symptoms of ADHD and continue to need extra help and
support. Not meeting full diagnostic criteria is definitely not
always the same as not having any difficulties related to
ADHD symptoms.

Of the 43 children initially diagnosed with both ADHD and ODD,
almost 50% retained these original diagnoses. Fifteen still met
diagnostic criteria for ADHD, but their behavioral symptoms had
improved to where they were no longer diagnosed with ODD.
Only 4 children from this group - about 10% - were not given either
diagnosis at follow up.


What factors predicted the emergence and persistence of ODD?

The authors first examined the factors associated with an ODD
diagnosis at the initial assessment. Specifically, their analyses
considered whether child IQ, socioeconomic status, history
of psychiatric difficulty in the child's family, gender, and
negative parenting practices increased the likelihood of the child
being diagnosed with ODD.

The results indicated that only negative parenting practices was
a significant predictor that a child with ADHD would also be
diagnosed with ODD. To put this in perspective, they found
that children whose parents scored in the top 15% of the sample
on a measure of negative parenting practices were about twice as
likely as other children to be diagnosed with ODD. Children from
families of lower socioeconomic status were somewhat more likely
to be diagnosed with ODD.

At the follow up evaluation, the strongest predictor of an ODD
diagnosis was whether or not the child had ODD at the initial
assessment. Such children were 8 times more likely than others
to be diagnosed with ODD at the second evaluation. In addition,
however, negative parenting practices was also an important
predictor of whether or not the ODD diagnosis would persist.
Thus, children with ODD at time 1 whose parents were in the
top 15% for the negative parenting practices measure were almost
twice as likely as other to still have ODD 4 years later.

In addition, children diagnosed with ADHD initially also tended
to be more likely to be diagnosed with ODD 4 years later than
the 111 comparison children who had no diagnosis at time 1. Thus,
this is an indication that the presence of ADHD increases the
likelihood that a child will develop important behavior problems
as well.

It is important to note that although these data indicate that
parenting practices are associated with the emergence and
persistence of ODD, they do not necessarily mean that negative
parenting practices were the initial "cause" of the child's ODD. Remember, all of these children were also diagnosed with ADHD
and children with ADHD present unique challenges to parents in
terms of behavior management issues.

Sometimes, the stresses that occur between parents and children
in response to a child's ADHD symptoms can precipitate a pattern
of negative exchanges that do contribute to the development of
important behavior problems. Thus, negative parenting practices
can emerge in response to the frustration associated with parenting
a child with ADHD, which is certainly different from arguing that
such practices are the original cause of a child's oppositional and defiant behavior.

It should also be noted that children with persistent ODD were
more likely than children whose ODD "desisted" to have extreme
problems with temper at the initial evaluation along with a tendency
to be spiteful. Thus, these particular symptoms appear to be
especially common in children who are likely to show persistent
behavior problems.


What factors were associated with an initial diagnosis of ADHD
or the persistence of ADHD?

These results provide an interesting contrast to the results
discussed above for ODD. At the initial evaluation, none of
the family background factors - e.g. socioeconomic status,
single parent vs. intact family etc. - was associated with
whether a child had ADHD, nor was the negative parenting practices variable. Compared to parents of children without ADHD, however,
parents of children with ADHD were more likely to have ADHD
themselves, either currently or at an earlier time in their lives.

In addition, the only significant predictor of whether a child
was diagnosed with ADHD at follow-up was whether he or she was
given the diagnosis originally. Thus, parenting practices did
not seem to be related to whether a child was diagnosed with ADHD
initially, or whether the child developed ADHD over the subsequent
4 years.


IMPLICATIONS

I think there are several important implications that emerge from
this study. First, the fact that almost 75% of children diagnosed
with ADHD initially were still diagnosed with ADHD 4 years later
indicates both that:

1. the disorder tends to be relatively stable over time, but

2. for a significant percentage of children, symptoms diminish
over time to a point that the diagnosis no longer applies.

At this point, it is still not possible to accurately predict
which of these possibilities will be true for a particular child.
It is also important to note that even among children who no
longer meet full diagnostic criteria for ADHD, in many instances
they can continue to struggle with symptoms of the condition.
Thus, no longer meeting full diagnostic criteria is not the same
thing as a complete remission from the difficulty that ADHD can
cause.

The reason I think this point is so important is because I have
seen some teens and their parents who were confused by the fact
that they had been told the teen no longer "had ADHD" and yet
it was clear that the adolescent was continuing to struggle in
significant ways. Even when the full diagnosis no longer applies, therefore, it can be critically important to continue to provide
the structure, assistance, and support that is often needed.

The findings pertaining to the emergence and persistence of ODD are
also quite interesting. Recall that the primary predictor of ODD
was the degree of negative parenting practices that parents engaged
in. These would include such practices as overly harsh and punitive
discipline, inconsistent enforcement of limits and rules, overly
restrictive rules, unrealistic behavioral expectations, and failing
to reward appropriate behavior.

As discussed above, these findings should not be interpreted as
proving that parenting is the fundamental cause of ODD. What
these data do clearly suggest, however, is that this is an area
where parents have the potential to have a substantial and
important impact on their child's development. From this study
alone, we do not know what the long-term outcomes for children
with persistent ODD will be. Although few such children developed
conduct disorder - a more serious behavioral disturbance - during
the course of the study, it is certainly reasonable to speculate
that the outcomes for those with persistent ODD are likely to
be more problematic.

The fact that such persistent behavior problems are associated with
a higher degree of negative parenting practices clearly implies that
altering such practices can play a critical role in promoting better
behavioral adjustment in one's child. Thus, getting professional
assistance in learning the types of child management strategies that
can help to accomplish this can be an enormously useful step
for parents to take. I've got an introduction to behavioral
interventions at http://www.helpforadd.com/behtreat.htm and would
also recommend a book called "Your Defiant Child" by Dr. Russell
Barkley. These resources can help get you started, but if this
is a real concern of yours, then consultation with an experienced
child mental health professional in your area would be highly
recommended.
______________________________________________________________________

"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?"


Dear Parent:

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 do my best to
provide 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.

Although there is lots of good information on ADHD available on
the Internet - I have an extensive information section on my
own site at http://www.helpforadd.com/info.htm if you have not
already visited - there is NO other source I am aware of
that will keep you as informed about important new research.
In addition to summarizing new studies for you, I always include a discussion of how the results can be applied to help children
with ADHD succeed so that you can use the information to help
your own child be more successful at home and at school.


"GET THE MOST CURRENT INFORMATION ON ADHD AVAILABLE!"

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Parents from around the world have found that ADHD RESEARCH UPDATE
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well and encourage you to become a regular subscriber.

Best wishes,

David Rabiner, Ph.D.
Licensed Psychologist
Duke University

P.S. Health care professionals can find subscription options at:


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