Updates on ADHD
Updates on ADHD
Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article - October, 2004
Copyright © 2004 Dr. Sam Goldstein - All Rights Reserved
Rather than focus on a specific topic in this month's article, I wanted to convey information about four important issues relative to ADHD that have found their way into the media over the past month.
ADHD and Lost Income
This past month, Dr. Joseph Biederman and his research group at Harvard announced the results of a 2003 survey of 500 adults with ADHD relative to a variety of lifestyle issues. The study reported that lost income for adults with ADHD averages 77 billion dollars a year and pointed to job loss, lower income, higher divorce rates and more driving accidents as contributing factors. ADHD would appear to be one of the costliest medical conditions that has been researched. By comparison it is reported that the direct and indirect costs of drug abuse in adulthood are estimated to be about 58 billion a year, depression 44 billion a year and alcohol abuse 86 billion a year. The figures from the ADHD survey were based on the lower incomes reported by adults with ADHD compared to the general population. A 3% to 5% incidence rate was utilized for adult ADHD.
The researchers reported that high school graduates with ADHD had household incomes approximately $10,800 lower than those without the condition. For college graduates, incomes were about $4,300 lower. As has been reported in other research studies, adults with ADHD were less likely to have finished high school, attend or finish college and less likely to be employed in jobs consistent with their educational background.
Stimulants for Healthy Children
A Food and Drug Administration Ethics Panel has decided that the advancement of science outweighs the risks of giving a stimulant to healthy children as young as nine years of age. The eleven member pediatrics ethics subcommittee panel reviewed a proposal by respected researcher Judith L. Rapoport, M.D. to give a single 10 mgs. dose of dextroamphetamine to 78 children and then use Magnetic Resonance Imaging to reveal brain patterns as the children completed specific academic tasks. The goal of this study is to determine whether the brains of children with ADHD respond to stimulant medications in fundamentally different ways from normal children. Such research might lead to more efficient and effective diagnostic protocols and treatments.
In the proposed study, half the children ages 9 to 18 years would have a diagnosis of ADHD. The other half would be unaffected or healthy children. It was suggested to the panel that the dose of dextroamphetamine proposed was roughly equivalent to 50 to 75 mgs of caffeine, about five cups of average coffee. Dr. Rapoport reported that household surveys have demonstrated that many healthy school children are exposed to such doses of caffeine by drinking soda daily. Despite the subcommittee's recommendation, there were a number of concerns raised, including the inability to predict that a particular child may have a significant adverse reaction to the dose of stimulant and that the researchers were offering families $570 to participate in this study in exchange for about eleven hours of the child and family's time. Concern was raised that families at lower incomes might be lured to participate in the study, exposing their children to unnecessary risk.
This panel's recommendation was used by the FDA Pediatric Advisory Committee to grant approval two weeks ago to Dr. Rapaport to begin her study. The FDA also suggested that families receive not more than $110 for participating in the study plus reimbursement for expenses such as meals.
Green for ADHD
In the past few years I have pleasantly spent a number of hours per week on golf courses. I enjoy the time spent outdoors. Now a number of researchers are questioning whether outdoor activities, specifically exposure to green space, may prove therapeutic for children with ADHD. In the September issue of the American Journal of Public Health, researchers Drs. Frances Kuo and Andrea Faber Taylor examined the impact of relatively green or natural settings on ADHD symptoms across diverse sub-populations of children. Parents nationwide rated the aftereffects of forty-nine common after school and weekend activities on children's symptom severity. Aftereffects were compared for activities conducted in green outdoor settings versus those conducted in both built outdoor and indoor settings. As a basis for their study, the researchers cited three previous studies suggesting that disruptive behavior in general could be reduced in inner city children with exposure to green space. In particular for children with ADHD in these studies, parents suggested that their children's symptoms were better than usual after activities in relatively green settings. Further, they reported the improvements generalized for a period of time afterwards. The present study was uniquely completed using a website and incentives for parent participation including a list of recommendations for coping with ADHD based on the study's findings and the chance to win a gift certificate. The final study was based on 452 completed surveys from parents throughout the country. The findings appeared consistent regardless of the child's age, gender, income, community size, region of the country, case severity and comorbid conditions. Surprisingly the benefits of green space exposure were also found even for the group of children within the sample who, according to parents, had not been formally diagnosed as suffering from ADHD.
It is premature to hypothesize as to the exact meaning of this research. From my perspective there are numerous methodological flaws, including relying only on parent report absent efforts to actually quantify and observe children's behavior. Nonetheless, as human beings it would not be unexpected for our behavior and emotions as well as attitudes and perhaps even beliefs to be modified by specific types of environmental exposure. Based upon this study, I would not suggest that parents and professionals prescribe "green time" for children with ADHD. However, I also don't believe that double blind controlled research is necessary to encourage all children, and adults for that matter, to participate in outdoor activities, even golf.
Behavioral Therapy vs. Medication in the Treatment of ADHD?
In last month's article, I reviewed a series of studies suggesting that in children with ADHD who are positive stimulant responders, psychosocial interventions did not add significant improvement to behavior or academic functioning. In that article I briefly mentioned a number of studies presented at professional meetings by Bill Pelham and his colleagues. Dr. Pelham suggests that consistent and appropriately administered doses of behavioral therapy are as effective as medication for symptom reduction in ADHD. In an interview with a Buffalo Newspaper, Dr. Pelham took the offensive, suggesting that "doctors and professionals in the ADHD field over-emphasize the role that medication should play in the treatment of children." He also noted that because of this, "Unfortunately the end result is that many parents of ADHD children are not made aware that there is a well-established, evidenced based alternative to medication-behavior therapy." His basic message - there is an effective alternative to medication for treating ADHD. Dr. Pelham has published a series of articles beginning in 1997 summarizing research from his summer treatment program for ADHD. Two of the most recent studies published in the Journal of Behavior Therapy, according to Dr. Pelham, continue to report the benefits of a comprehensive psychosocial treatment program. Dr. Pelham reported that children who receive behavioral therapy in advance of drug treatment required much lower doses than children who were put on drugs without first undergoing behavioral therapy. Further, only about a third of behavioral treated children subsequently were taking medications two years later.
Dr. Pelham suggests that unlike drug therapy, behavioral therapy may produce long-term benefits for children with ADHD such as teaching coping and behavioral skills that can generalize and be taken into adulthood. Medicine then is seen as symptom relieving while behavioral intervention is proposed to change long-term outcome. It should be noted, however, that Dr. Pelham's research as with studies involving stimulant medication, may demonstrate symptom relief but have yet to longitudinally demonstrate long-term, significant positive changes in children with ADHD. Dr. Pelham commented in this article that "more parents would opt out of using medication as the first line or sole treatment if they were provided with this information and if physicians did not opt for medication first." Dr. Pelham concluded, "every mental health professional in the country can do behavioral parent training and parents and pediatricians need to push for it in their community if it doesn't appear to be available."
I urge professional readers to review Dr. Pelham's studies. As I noted last month, the psychosocial intervention proposed is extensive and costly. As far as I am aware, neither managed care, community mental health nor the schools are willing to foot the expense for this type of service. Most parents cannot afford to pay out of pocket. Most professionals cannot afford to stay in business and not participate in managed care. Participants in Dr. Pelham's programs were not charged, as far as I am aware, because his research was funded. Thus, while these interventions may be effective, we have yet to determine how to translate this cost effectively into clinical practice. This is not a reason to abandon these treatments. I believe it is one of the reasons that medication is often first offered and accepted by parents. However, as I have pointed out repeatedly, stimulant medication as well as behavior management may lead to effective short term symptom relief but neither has been demonstrated to lead to long-term life changes for those with ADHD.
I don't have a solution for the managed care and community funding problem for these types of programs. As I noted in my article last month, the debate about medicine versus psychosocial treatment versus combination of the two is likely to continue to heat up in the coming year. As a clinician I have found it extremely difficult to consistently implement the kind of behavioral therapy suggested by Dr. Pelham with the majority of families with whom I work. The road blocks are not just time and funding, but often the family's ability to follow through. I am most concerned that Dr. Pelham's opinion that "behavior modification is the fabric of good parenting" may lead to parent bashing if parents of children with ADHD are unable to consistently follow through with the level of behavioral management required.
