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One of the questions
asked most frequently is how parents can know whether medication particularly Ritalin
will help their child. It would
certainly be helpful to know in advance whether a particular child truly
will benefit from medication, what the magnitude of those benefits will be,
and what areas (e.g. behavior,
academics, etc.) will be most effected.
A
study appearing in an issue of the Journal of the
American Academy
of Child and Adolescent Psychiatry
takes a careful look at how well medication response can be predicted in
advance (Denney, C.B. & Rapport, M.D. (1999). Predicting methylphenidate
response in ADHD. Journal of the
American
Academy of Child and
Adolescent Psychiatry, 38, 393-401.)
In this study, 76 children with ADHD, Combined Type (i.e. they had
both inattentive and hyperactive/impulsive symptoms) received each of 4 doses
of methylphenidate (MPH - this is the generic form of Ritalin) in the context
of a double-blind, placebo-controlled medication trial. There were 66 boys in the sample and 10
girls.
Both
before and during the trial, careful measures of a number of behavioral and
academic variables were collected.
These included teacher ratings of inattention and hyperactivity using
standardized behavior rating scales; direct observations of children's
on-task behavior in the classroom made by observers blind to the child's
medication status; teacher ratings of children's self-control in both the
academic and social areas; and finally, a measure of academic efficiency
which was defined as the percentage of assigned work that the child completed
in an accurate manner. The authors were
particularly interested in whether any of the behavioral or academic measures
collected prior to the medication trial would prove to be helpful in
predicting whether or not the child showed a positive response to medication,
and whether it could predict the optimal dose for each child.
Although
there was some variation depending on what outcome measure was being
predicted (e.g. inattention, hyperactivity, self-control, academic
efficiency), overall, predicting whether an individual child would benefit
from medication based on any of the pretreatment variables was quite
difficult. There was some indication
that the more inattentive and/or hyperactive a child was to start with, the
more likely he or she is to show gains in these areas. In other words, children whose ADHD
symptoms were more severe were more likely to show positive effects from
medication.
What
seems to me to be a more interesting and important aspect of the results,
however, was the finding that behavioral improvements do not necessarily lead
to corresponding academic improvements. Thus, it was not uncommon for a child
to show clinically significant gains in the core ADHD symptoms, and yet not
to show corresponding gains in the academic efficiency measure. In other
words, for some children, their behavior improved but their academic
performance did not.
In
contrast to this pattern, gains in academic efficiency were almost always
accompanied by corresponding improvements in attention, hyperactivity, and
self-control. Thus, when children's school work improved, their primary ADHD
symptoms almost always improved as well.
Was
there any way to predict which children would show these important gains in
the academic efficiency measure? It turns out that there was, and that the
best predictor was how well a child was performing academically prior to
starting the medication trial.
Children whose pre-treatment academic efficiency scores fell in the
bottom 50% were much more likely to show improvements in academic functioning
than children whose pre-treatment academic scores were higher. These latter children, however, might still
show important gains in the areas of core ADHD symptoms.
What does this all
mean?
First,
the findings highlight that assessing a child's response to medication should
be a fine-grained process. One can not assume that gains in one area will
necessarily mean gains in all areas.
As this study demonstrated, there can be many children who show
important gains in behavior without corresponding gains in academic
performance.
For
each child, therefore, one has to carefully monitor the effects of medication
in multiple domains of functioning. Thus, you would want to know what impact
medication is having on behavior, social relations, and academic performance
to have a clear understanding of the child's unique response.
This
assessment of medication's impact on different areas should be evaluated in
comparison to the domains that were most problematic to begin with. Thus, if academic functioning is the chief
concern, it is very important to evaluate how the child's academic work is
changing in response to medication.
What you don't want to do is assume that just because your child may
be behaving better in class, that his or her school work is also better.
Parents
and teachers can be understandably elated that a child's behavior is under
better control, and the fact that the child's school performance is still not
very good manages to be overlooked.
When report card time rolls around, there can be some unfortunate
surprises in store.
By
the way, this same approach can, and should, be used to evaluate a child's
response to any type of treatment. Thus, if you are considering alternative
methods for treating your child (e.g. behavioral interventions, herbal
treatments, etc.) you would still want to carefully track what effect - if
any - the treatment is having in different areas. You would also want to pay careful
attention to whether the areas of real trouble are the ones that are being
positively affected.
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