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Can Stimulant Medication Help with Severe Behavior Problems?
The December 97 issue of the Archives of General Psychiatry contained a very important study on the use of methylphenidate (i.e. the generic version of Ritalin) for treating children with ADHD who had also been diagnosed with Conduct Disorder (CD). Recall from last issue of ADHD RESEARCH UPDATE, that CD is a serious behavioral disturbance that involves major violations of social norms (i.e. stealing) and or aggression against others. The prognosis for children with ADHD and CD is especially worrisome, and conventional wisdom has been that stimulant medication is not appropriate or helpful for the treatment of children with CD.
Children between the ages of 6 and 15, many of who were duly diagnosed with ADHD and CD were randomly assigned to receive either methylphenidate or a placebo over a 5 week period. On average, children in the medication group were receiving 40 mg/day divided into a morning and afternoon dose. At the conclusion of treatment, ratings of children's behavior were obtained from their parents, teachers, and observers who came into the classroom. Both ADHD symptoms as well as behaviors specific to CD were assessed. The latter included obscene language, physically attacking others, property destruction, and deliberate cruelty. These latter behaviors are more severe than the type of oppositional and problematic behavior that is seen in children with ADHD alone.
The authors had expected that, as has been amply documented in prior studies, children in the medication group would show a substantial reduction in ADHD symptoms compared to subjects in the placebo group. This was the case in parent, teacher and observer ratings.
What was surprising, however, was the significant reduction in core CD behaviors and symptoms for children receiving medication. Parents reported clear reductions in such behaviors as cruelty to others, hanging around with bad companions, and stealing outside the home. Overall, the percentage of children rated as improved in the medication group and placebo group were 59% vs. 9% for mother's ratings, 78% vs. 27% for teachers' ratings, and 68% vs. 11% for observers ratings. The amount of improvement reported varied across individuals, but overall the reductions in antisocial behavior were substantial and clinically meaningful.
Although there is no clear explanation for why this would occur, the authors speculate that impulsivity is a key difficulty in both ADHD and CD. Impulsivity is specifically reduced by stimulant treatment, and it may be that in boys with CD, enhanced impulse control results in multiple positive secondary effects.
This is a very important finding, and one that represents a real conventional wisdom, based in part on prior research, has been that stimulant medication is not helpful in reducing core CD symptoms in children with or without ADHD. This study clearly suggests otherwise, however.
Several things are important to stress. First, the dose received by children in the medication group is probably higher than what is typically prescribed by pediatricians. Children in this study appeared to tolerate it well, however, and it may be that doses of this magnitude are required to ameliorate severe behavior difficulties rather than ADHD symptoms alone.
Second, although the reduction in CD behavior was impressive, it rarely eliminated the problems experienced by children in the study. Thus, children clearly got better but continued to engage in behaviors that would be considered problematic by any reasonable standard. Although clinical normalization is frequent among good responders with uncomplicated ADHD, this was not the case here.
Third, as the authors rightly point out, the treatment in this study was short term (i.e. 5 weeks). Both ADHD and CD tend to be chronic conditions, and the long term effectiveness of medication on the latter especially remains to be determined.
Fourth, it is interesting to note that even at the doses used in this study, children typically tolerated the medication quite well. The most common reported side effects were decreased appetite and delay of sleep. It is also noteworthy that almost half the children in the placebo group reported at least one adverse side effect. This finding underscores the need for placebo conditions to obtain accurate information on medication related side effects. Many times, what may appear to be a side effect of medication is nothing more than a placebo response.
Finally, although these results are encouraging, the results from any individual study need to be replicated.
Overall though, this is an important study to know about for parents whose child is displaying serious antisocial behavior in addition to ADHD symptoms. it may be that at the proper dose, stimulant medication can make a substantial contribution to reducing such behavior in addition to helping with the core symptoms of ADHD.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.