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The Informed Parent

A.D.D. And the Medical Literature Over the Past Two Years: A “Scanning the Journals” Feature Article

by John H. Samson, M.D., F.A.A.P.
Published on Jan. 01, 1997

Attention Deficit Disorder papers form a significant part of the pediatric and adolescent psychiatry medical literature. This topic frequently appears in the media, sometimes spreading panic with partial reporting. At other times the media educates the public on important facts about this controversial subject.

Here is an update on significant articles that appeared in print over the past two years. This is an attempt to present notable papers that shed light on important aspects of A.D.D. It is not meant to be an exhaustive listing of all the publications printed. If some articles have been overlooked it was unintentional. If any reader feels that I have missed a significant paper, please send me a reference so that I can review the article for presentation in a future "Scanning the Journals".

This feature is dedicated to the parents of A.D.D. patients who bear the slings and arrows of relatives and friends critical of their management of these difficult children.

In August of 1996 the Journal of the American Academy of Child and Adolescent Psychiatry (for conciseness I will refer to this journal as J.A.A.C.A.P. in the remainder of this feature) printed an article by Dennis Cantwell,M.D., entitled "A.D.D.: A review of the Past Ten Years". This is a classic paper beautifully summarizing the fund of knowledge collected over the preceding ten years. Anyone wanting an overview of this topic should read this work.

In addition, a superb two-part review on A.D.D. appeared in the December 1993 and January 1994 issues of Pediatrics in Review. Although four years old, these two papers also provide a benchmark allowing parents to assess the current level of care they are receiving for their A.D.D.children. These references and the ones to follow would be available from your local medical library or various internet medical literature sources.

Non medical literature can provide good information to parents on medical topics. One of the best examples is an article printed in the Los Angeles Times on November 20, 1997, in the Science File section. It provides a concise and easily understood view of the role of the P.E.T. scanner, in studying A.D.D. Although it is not medically profound, the reader will find it very informative.

Understanding the mechanisms of the causation of A.D.D. has been a much studied but somewhat elusive pursuit. An example is the March 1997 issue of J.A.A.C.A.P. (36:3), an article entitled "Implication of Right Frontostriatal Circuitry in Response Inhibition and Attention Deficit Hyperactivity Disorder" by B.J. Casey, et al. This article indicates that the right frontal aspect of the brain suppresses responses to irrelevant stimulating events, while an area in the base of the brain executes these behavioral responses. Nine months later in December 1997, the same journal presented a paper by J.M. Halperin, Ph.D., et al, entitled "Nonadrenergic Mechanisms in A.D.H.D. Children with and without Reading Disabilities". This provided the reader with a neurochemical look at A.D.D. It showed a neurochemical variation that correlates with the patient's academic achievement, but not attention or impulsive behaviors.

These two representative articles show the complexity of mechanisms involved in this condition. Only the tip of the iceberg has been seen. In years to come we will find that there are many distinct conditions currently included under the umbrella diagnoses of A.D.D./A.D.H.D. When diagnoses becomes more precise, treatment will be more specifically relevant.

Therapy is always of great interest to parents and patients alike. An article appeared in The Journal of Child and Adolescent Psychopharmacology, Vol. 7:2, 1997, entitled "Effects of Methylphenidate and Behavioral Contingencies on Sustained Attention in Attention-Deficit Hyperactivity Disorder: A Test of the Reward Dysfunction Hypothesis" by M.V. Solanto, Ph.D., et al. It showed that Ritalin was effective in sustaining attention while certain behavior modifications were not. This supports the general clinical view that true primary or neurogenic A.D.D. behavior syndrome needs medication to achieve good results. Behavior modification methods alone do not create sustained control of inattention or impulsivity.

The question of the efficacy of stimulant medication in preschoolers is addressed in the J.A.A.C.A.P. 36:10, October 1997 issue. It is the paper by L.M. Musten, Ph.D., et al. entitled "Effects of Methylphenidate on Preschool Children with A.D.H.D.: Cognitive and Behavioral Functions".It shows that Ritalin therapy can improve behavior in preschool as well as school age children. This is something appreciated by clinicians, and it is nice to see it in print.

Therapy for the A.D.H.D. patient who also suffers from Tourette's Syndrome is a significant problem. Stimulant therapy may aggravate the tics and cause outbursts in the Tourette's patient. In a small percentage of patients such therapy may unearth the latent symptoms of a subclinical Tourette's syndrome. This seemingly bleak picture of tic emergence was made brighter by a study that appeared in J.A.A.C.A.P. 36:5, May 1997, entitled "Controlled Stimulant Treatment of A.D.H.D. and Comorbid Tourette's Syndrome: Effects of Stimulant and Dose". In the paper, authored by F.X. Castellanos, M.D., et al., investigators showed that the majority of A.D.H.D./Tourette's Syndrome patients treated with Ritalin experienced improvement in the A.D.H.D. symptoms with acceptable effects on tics. It also showed that the increasing tic side effects were all reversible on cessation of medication. The majority of these patients were on other medications to control the tic activity. This gives the clinician a reasonable prognosis when faced with the difficult patient who suffers from tics and A.D.H.D. behavior.

A topic that has come to the forefront in the A.D.H.D. literature in the past several years is that of combined or associated psychiatric or behavioral disorders existing in the patient at the same time as the A.D.H.D.It is critical to diagnose these associated conditions if true symptom amelioration is to exist. So often the signs and symptoms overlap. The parent, physician and psychologist team miss the complexity of the problem. They focus on the A.D.H.D. When desired effects are not achieved, the parental part of the team abandons therapy for some ineffective fringe treatment modalities.

As informed parents, always remember that two primary conditions may coexist, necessitating multiple forms of therapy to achieve acceptable results.Three papers appearing in J.A.A.C.A.P. point out clearly that neuropsychiatric and behavioral disorders can coexist. They can make the symptom expression much worse, management more difficult and prognosis more guarded. The three articles are: "Comorbidity in A.D.H.D.: Implications for Research, Practice, and DSM-V" by P. Jensen, M.D., et al., J.A.A.C.A.P. 36:8, August 1997, "Attention-Deficit Hyperactivity Disorder With Bipolar Disorder: A Familial Subtype?" by S.Faraone, Ph.D., et al., J.A.A.C.A.P. 36:10, October 1997, and "Impact of Comorbid Oppositional or Conduct Problems on Attention-Deficit Hyperactivity Disorder" by M. Kuhne, M.A., et al, J.A.A.C.A.P. 36:12, December 1997. In general, if the treatment for A.D.D./A.D.H.D. does not get desired results one must consider the presence of a coexisting condition, or perhaps the original diagnosis was incorrect. From a practicing clinician's view point, many other conditions may masquerade as A.D.H.D. Managing patients with this potential diagnosis takes more than just a quick history and a prescription for Ritalin or Dexidrine.

A frequently confused diagnostic situation is exemplified by the article of Richard Perry, M.D. which appeared in J.A.A.C.A.P. 37:1, January 1998 entitled "Misdiagnosed A.D.D./A.D.H.D.; Rediagnosed P.D.D.". This paper points out the ease of which A.D.H.D. can be misdiagnosed for a condition like autism or pervasive developmental delay. The commonality of signs and symptoms of attentional problems and other serious conduct disorders can be very confusing to the most experienced clinician. The lack of effectiveness of therapy should raise a question for the original diagnosis.

Partial failure of a therapeutic program to control all the symptoms should force the clinician to pursue other possible diagnoses. As parents you must understand that the changing or adding of additional diagnoses to your child's case does not indicate the inadequacy of your child's practitioner. In fact, the perseverance to a correct diagnosis and, thus, more complete amelioration of the signs and symptoms, indicates the thoroughness of your child's clinician.

Many parents and teachers fail to realize that attentional disorders are not always associated with hyperactivity. The non-hyperactive type is more commonly seen in females. In my own experience the incidence of A.D.D. without hyperactivity is almost the same in both genders. In the A.D.H.D. category the male is effected 10 to 15:1 over females.This is substantiated in the work of M.Gaub, B.A., and C.L. Carlson, Ph.D., entitled "Gender Differences in A.D.H.D.: A Meta-Analysis and Critical Review", J.A.A.C.A.P. 36:8, August 1997. As they point out, there are clear gender differences in the expression of A.D.H.D. behaviors. Girls showed lower levels of inattention, hyperactivity and aggression. The authors themselves indicate that more work is needed in this area in order to get a more complete analysis.

The final article reviewed deals with the progression of hyperactive boys to adolescent and adult criminal behavior. Work in this field leaves the impression that many teenage and adult criminals are hyperactive or true A.D.H.D. patients. This is a frightening concept to the parents of A.D.H.D. children. The paper entitled "A Prospective Study of Hyperactive Boys With Conduct Problems and Normal Boys: Adolescent and Adult Criminality", authored by J.H. Satterfield, M.D. and Anne Schell, Ph.D. appearing in J.A.A.C.A.P. 36:12, December 1997 points out, "Hyperactive children who do not have conduct problems are not at increased risk for later criminality". They indicated that those children who exhibited high ratings in "lies", "takes things from other children", and "takes money from members of his family" had significantly higher adult expression of criminality.The encouraging factor, however, was that those boys who had therapy for their conduct problems had a 50% reduction in juvenile arrests. Therefore, A.D.H.D. alone does not lead to criminality, and, furthermore, if aberrant conduct is addressed and controlled the adult criminality rate is greatly reduced.

Keep in mind that if the hyperactive behavior is controlled, and the child achieves success in school which assures good self-esteem, problems later in life are avoided. Scanning of the A.D.H.D. medical literature from the past two years will hopefully make you a well informed parent.

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