ADHD RESEARCH UPDATE - New Issue Preview

[David Rabiner, Ph.D.]

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Greetings:

Below you will find a preview of the April 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 summarizes a study in which the
relationship between childhood ADHD, aggression, and stimulant
medication treatment were related to boys' functioning
in young adulthood. Although the study has several limitations -
as does any piece of research - it is important in that it
is one of the few efforts that I have seen in which the long-term
impact of stimulant medication treatment has been evaluated.
As you will read, there is some indication of important benefits
that may be related to aspects of medication treatment.

If you have been enjoying the information received in these
previews, please consider becoming a regular subscriber to
ADHD RESEARCH UPDATE. By becoming a regular subscriber you will
receive substantially more information about important studies
that have been published recently in the leading medical and
psychology journals. I have included information about subscribing
at the end of the article below should you be interested. You
can also find this information at:

https://www.helpforadd.com/subscribe.htm

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


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ADHD RESEARCH UPDATE - NEW ISSUE PREVIEW
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In this issue...

* How does young adult outcome relate to childhood
ADHD, aggression, and stimulant medication use?

REPRINTED IN FULL BELOW


Here are the other articles that subscribers received
this month...


* AN OBJECTIVE PROCEDURE FOR ASSESSING ADHD?

Exciting information on the development of a potential
objective procedure for aiding in the diagnosis of ADHD.


* INCREASING USE OF STIMULANT MEDICATION TREATMENT FOR PRESCHOOLERS

This is the study that received so much attention in the
national press. What do the trends in the use of medication
for young children really look like?


* THE CONTINUITY OF BEHAVIOR PROBLEMS AND ADHD SYMPTOMS FROM
PRESCHOOL THROUGH EARLY ADOLESCENCE

Do most children really tend to "grow out of" early
difficulties? When should parents be concerned about
early behavior problems and what can be done?
_____________________________________________________

HOW DOES YOUNG ADULT OUTCOME RELATE TO CHILDHOOD ADHD, AGGRESSION,
AND STIMULANT MEDICATION USE?

This 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). 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.

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. 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.

Participants in this study were 121 boys who were initially diagnosed
with ADHD when they were between 4 and 12 years old. 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. 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). Using detailed information
about specific symptoms contained in boys' medical charts, however,
the authors estimated that approximately 71% of these boys
would have qualified for a diagnosis of ADHD using today's
diagnostic criteria.

All 121 boys were treated with stimulant medication
(i.e. methylphenidate) and their treatment with medication was
initiated between 1967 and 1972. (It would have been preferable,
of course, if girls were also included in this sample. 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. These ratings were made
based on information from parents, teachers, and the boys
themselves that were included in the boys' charts. 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. (The authors actually hypothesized
that childhood aggression would be more strongly associated
with negative outcomes in young adulthood than would ADHD
symptoms.)

As noted above, all participants in this study were treated with
stimulant medication at some point. Thus, the authors were not
comparing the long-term outcomes of children with ADHD
according to whether or not they had received medication. 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.

The young adult assessment occurred when participants were
between 21 and 23 years old. 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 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 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. This assessment thus provided a comprehensive account of
how participants were faring at this point in their lives.


RESULTS

The basic questions of interest in this study are as follows:

1. How do childhood levels of ADHD symptoms relate
to functioning in young adulthood?

2. How does childhood level of aggressive behavior
relate to functioning in young adulthood?

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?

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. As noted above, the authors
of this study were not comparing outcomes for children
with ADHD depending on whether they were treated
with medication. Instead, they were interested in how
important aspects of medication treatment (i.e. overall
response, dose, and duration) predicts important life
outcomes over a 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. When the results of the study are
considered in this way, they are really quite clear.

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. Among
the specific outcomes predicted by childhood aggression were
depression, drug abuse, antisocial personality disorder, and
a variety of functional impairments. ADHD symptoms, in
contrast, predicted only lower levels of employment and
greater general levels of impairment.

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.

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.

Thus, it is reported that better overall response to medication
was associated with lower depression scores and better
social functioning in young adulthood. 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. 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. This is a perplexing finding given
the overall pattern of results, and may represent a chance finding
that would not be replicated. In general, however, medication
treatment tended to have positive effects long after it had
been discontinued.

IMPLICATIONS AND LIMITATIONS

What seems fairly clear from these results is that childhood
aggression as measured in this study is associated with poorer
young adult outcomes. Also, MPH treatment is associated
with better young adult outcomes. 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.

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. There are several different reasons why such
caution is necessary. First, no information is provided about the
families of these patients or the total number of clinical visits
each child made. 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. Conceivably, the child's improvement could be a
consequence of this investment rather resulting from more
extensive treatment with medication.

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. 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. Finally, there
were no girls included in the sample so the extent to which
these findings would generalize to girls is completely unknown.

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. This
replicates findings that have been reported in prior work,
and underscores the importance of carefully attending to
this aspects of children's behavior. 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.

In regards to medication treatment, these data do provide
important initial support that such treatment is associated
with long-term benefits. 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.

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. I look forward to future publications from these authors
and will include summaries of their work in ADHD RESEARCH UPDATE as it
appears.

_______________________________________________________________

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Sincerely,

David Rabiner, Ph.D.
Licensed Psychologist
Duke University
http://www.helpforadd.com





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