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Preliminary Report of a New Medication to Assist Children with ADHD and Severe Problems
One of the questions I receive most frequently from parents concerns how to help their child who, in addition to having ADHD, is also demonstrating significant behavior problems. As you are aware, other behavior disorders such as oppositional defiant disorder (ODD) or conduct disorder (CD) frequently develop in children with ADHD, and managing these children is much more difficult.
At this point, there have been several studies that have demonstrated that stimulant medications, when prescribed properly, often help with these co-occurring behavior problems in addition to a child's primary ADHD symptoms. For example, in the MTA study - the largest treatment study of ADHD ever conducted - it was found that carefully prescribed and monitored medication resulted in significant reductions in children's oppositional and aggressive behavior.
Non-medical interventions have also been shown to have important benefits for children demonstrating severe behavior problems. Such interventions generally involve the development of systematic behavioral plans designed to promote more prosocial behavior in children combined with strategies to help children learn more appropriate ways to resolve disagreements with others (i.e. teaching children more effective social problem-solving skills).
What can be done, however, when these approaches that are often helpful do not seem to work? This important question was the subject of a preliminary report of a new medication for treating children with ADHD and severe behavior problems that was published recently in the Journal of the American Academy of Child and Adolescent Psychiatry (Kewley, G. (1999). Risperidone in comorbid ADHD and ODD/CD. JAACP, 38, 1327-1328.)
The author of this brief report is a child psychiatrist who directs a clinic in England that specializes in the evaluation and management of children and adolescents with ADHD. He describes his experience in using Risperidone to treat 30 child and adolescent/young adult clients between the ages of 6 and 21. All these individuals had been diagnosed with ADHD, combined with severe behavior difficulties (they had been diagnosed with either ODD or CD) that had started relatively early in their lives. In addition, most of the individuals in this sample were also diagnosed as having bipolar disorder.
According to the author, these individuals had all been treated with stimulant medications without substantial benefits. Other medications such as clonidine had also failed to provide good results, as had a variety of psychosocial interventions. (Unfortunately, no information is provided about the type, intensity, or quality of the non-medical interventions that had been implemented.) Although details about the treatments received are lacking given the brief nature of this report, it is evident that the patients being discussed are those who presented with severe problems for which the most frequently used treatments supported by the best empirical evidence is available were inadequate.
Only after more traditional treatment approaches were proven unsuccessful were the clients started on risperidone. Risperidone is a relatively recently developed antipsychotic medication that is most frequently used to treat schizophrenia, a severe mental disorder that has no relation to ADHD. In children, risperidone has been shown to be helpful to children with schizophrenia (a very rare diagnosis for a child) and it has also been used effectively to assist children with Tourette's disorder. There have been no prior reports, however, in the use of risperidone for treating ADHD.
According to the author, 20 of the 30 patients showed a "very significant" improvement in symptoms (both ADHD symptoms and behavioral symptoms as well) , 5 showed a "moderate" improvement, and in 5 the risperidone was stopped, either because it yielded no improvement or because of side effects. (No information is provided about how significant or moderate improvement was defined or measured). The most commonly reported side effect was excessive weight gain which occurred in 10 patients. The author reports that the patients have continued to be maintained on risperidone - some for up to 4 years - with ongoing positive results. Attempts to withdraw the medication have typically resulted in a recurrence of symptoms.
The author is very careful to stress that this is a preliminary study only. This is not a controlled trial in which the effects of risperidone are compared to the effects produced by a placebo, and can thus only be considered the initial stage in establishing the efficacy of this medication for children with severe ADHD and associated difficulties who have not been able to be helped by other means.
These considerations aside, I wanted to include a summary of this work in ADHD RESEARCH UPDATE because it provides an avenue that may be worth considering in circumstances where a variety of other treatment options have been exhausted. It is important to stress that in the absence of effective intervention, the prognosis for the children described in this report is unfortunately not very positive. In these situations, consulting with an experienced child psychiatrist (this would not be the type of medication treatment that most pediatricians would feel comfortable handling) about the possible use of risperidone may be a reasonable option. I will be sure to include more comprehensive follow up studies to this work in the newsletter as they are published.
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.