Can Teens with ADHD Evaluate The Success of Medication Treatment?

Although stimulant medication can be an effective treatment for adolescents with ADHD, it is not uncommon for them to believe that they do not need medication and to refuse to take it. This can present difficult situations where both parents and clinicians may wonder whether ongoing medication benefits outweigh the costs associated with struggling to get an adolescent to take it. 

An important consideration in such instances is whether adolescents can accurately evaluate the benefits of the medication treatment they are receiving. Surprisingly, there have been virtually no studies conducted on this interesting and important issue. It was encouraging to come across a well-conducted study addressing this question that appeared in the Journal of Consulting and Clinical Psychology (Smith, B.H. et al., 68, 489-499, 2000).

Participants included 36 (mostly male) adolescents with ADHD who attended an intensive summer treatment program over an 8-week period. Daily program activities included participation in academic classroom activities, study hall, therapeutic recreation, social skills and problem-solving groups, a Junior Achievement style business meeting, and a job period. All activities occurred in the context of an intensive behavior management system in which adolescents were given frequent feedback about their behavior from highly trained staff. Each adolescent’s success in meeting the requirements of their behavior contract was used to determine access to various privileges.

Two weeks into the 8-week program, participants began a placebo-controlled medication trial that lasted for the next 6 weeks. During this period, either methylphenidate (the generic form of Ritalin) or a placebo was administered 3 times each day, and neither the adolescent, his counselors, nor his classroom teacher at camp were told when real medication and when the placebo had been received. At the end of the day, each adolescent, his counselors and teachers were asked to judge the adolescent’s behavior during the day. These included judgments about:

1.      Problems getting along with peers and staff;

2.      The intensity of specific ADHD symptoms; and

3.      A guess as to whether or not the adolescent was on medication or a placebo during that day. 

In addition, the frequencies of specific behaviors (such as the number of conflicts with peers and staff, and amount of time spent off-task in the classroom) were recorded each day by trained observers. These ratings are considered "objective accounts" of what happened during the day, and provide a basis for evaluating the accuracy of the judgments made by the staff and adolescents about their own behavior.

Results

The authors first examined the accuracy of the guesses made each day by adolescents, counselors, and teachers as to whether the adolescent had received medication or a placebo that day. Overall, adolescents, their counselor, and their teacher responded correctly at a rate that was significantly better than chance. However, the counselors and teachers were more accurate than the adolescents. 

Next, the authors examined how the ratings provided by adolescents, counselors, and teachers changed depending on whether or not the adolescent was on medication or placebo. Adolescents and their counselors both reported significantly fewer problems with peers and staff during active medication days. For specific symptoms of ADHD, however, adolescents’ reports for the medication and placebo days did not differ. The ratings provided by each adolescent’s counselor and teacher, in contrast, indicated substantial reductions in ADHD symptoms on days when medication was given. 

Finally, the authors examined the relationship between the behavior judgments made by adolescents, counselors, and teachers, and the "objective accounts" made by trained observers. When an adolescent reported difficulties with peers on a certain day, the adult raters would report the same. This also was true for problems getting along with staff. When it came to ADHD symptoms in the classroom, however, the self-ratings provided by adolescents had no relationship to what actually occurred. Teacher ratings of ADHD symptoms, in contrast, corresponded to what was observed.  Overall, the authors concluded that the ratings made by adolescents added relatively little to the information provided by their counselors and teachers.

Summary And Implications

The results of this study have potentially important implications for how the treatment of adolescents with ADHD is monitored. First, although the teens in this study showed a good ability to determine when they were on medication, the adults around them were more accurate at determining this. Thus, when a teenager argues that he no longer needs medication and that it "doesn’t make any difference whether he takes it or not," this assertion needs to be considered in conjunction with feedback received from his teachers as well as other adults who observe him daily. 

Second, most adolescents with ADHD may be better able to provide reports on how they are getting along with peers and teachers than on how well they are paying attention in the classroom. In this study, the adolescents did a pretty good job of rating how well they got along with peers and staff, but their ratings of specific ADHD symptoms, such as attending in the classroom, were not accurate. Based on these data, efforts to incorporate adolescents reports of treatment effectiveness should perhaps focus on their perceptions of maintaining cooperative relations with peers and teachers, rather than inquiring about particular symptoms of ADHD.

In reality, efforts to monitor the effectiveness of ADHD treatment for adolescents are more difficult than the situation faced by the authors of this study. Here, the adolescents were enrolled in a summer treatment program where the counselors and teaching staff spent considerable time with them each day. In most middle and high schools, however, adolescents generally have a different teacher for every class and there is often no adult who observes the adolescent during the day for more than a relatively brief time period. As a result, the feedback that teachers provide may often fail to be as accurate and reliable as is needed to make sound judgments. In my experience, this is a difficult issue and one for which there is no easy answer.

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