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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 or 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 them.
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 that addressed this question. This study was presented
in the Journal of Consulting and Clinical Psychology (Smith, B.H. et
al., 68, 489-499, 2000).
The
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-members. 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 the real medication
or when the placebo had been received. At the end of each day, each adolescent,
his counselors and his 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 the 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, the adolescents, their
counselors, and their teachers 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, the 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 was also
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 this 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, the efforts to monitor the effectiveness of ADHD treatment for
adolescents are more difficult than the situations 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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