Update See NYTimes - previous article
NY Times Which will it be — the berries or the chocolate dessert? Homework or the Xbox? Finish that memo, or roam Facebook?
NY Times Which will it be — the berries or the chocolate dessert? Homework or the Xbox? Finish that memo, or roam Facebook?
Such quotidian decisions test a mental
ability called cognitive control, the capacity to maintain focus on an
important choice while ignoring other impulses. Poor planning, wandering
attention and trouble inhibiting impulses all signify lapses in
cognitive control. Now a growing stream of research suggests that
strengthening this mental muscle, usually with exercises in so-called
mindfulness, may help children and adults cope with attention deficit hyperactivity disorder and its adult equivalent, attention deficit disorder.
The studies come amid growing disenchantment with the first-line treatment for these conditions: drugs.
In 2007, researchers at the University of
California, Los Angeles, published a study finding that the incidence of
A.D.H.D. among teenagers in Finland, along with difficulties in
cognitive functioning and related emotional disorders like depression,
were virtually identical to rates among teenagers in the United States.
The real difference? Most adolescents with A.D.H.D. in the United States
were taking medication; most in Finland were not.
“It raises questions about using medication as a first line of treatment,” said Susan Smalley, a behavior geneticist at U.C.L.A. and the lead author.
In a large study published last year in The
Journal of the American Academy of Child & Adolescent Psychiatry,
researchers reported that while most young people with A.D.H.D. benefit
from medications in the first year, these effects generally wane by the third year, if not sooner.
“There are no long-term, lasting benefits from taking A.D.H.D. medications,” said James M. Swanson,
a psychologist at the University of California, Irvine, and an author
of the study. “But mindfulness seems to be training the same areas of
the brain that have reduced activity in A.D.H.D.”
“That’s why mindfulness might be so important,” he added. “It seems to get at the causes.” [...]
The article you posted is really just building on an earlier piece in the NYT written by ALAN SCHWARZ @ http://www.nytimes.com/2013/12/30/health/adhd-experts-re-evaluate-studys-zeal-for-drugs.html
ReplyDeleteTHAT article is the real eye-opener.
They're basically saying that an $11 million study funded by the NIMH, going by the fancy title "Multimodal Treatment Study of Children With A.D.H.D.", was totally biased.
This, based not on some outside anti-establishment figures, byt rather on the enlightened reassesment of some of the principal researchers in the original study!!!
To understand what went wrong, a piece in The Carlat Psychiatry Report , might be educational.
They're basically saying that:
1) The original results claiming little gain from behavior therapy were based on the the researchers biases that had them ignore non-adhd symptoms like: "oppositional/aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading achievement". Medication did NOT help for all of these & therapy DID - but the original research ignored that "little" fact.
2) The MTA’s “medication-only” treatment protocol for the "medication only" group (no therapy) included a lot of extra care and monitoring than a typical ADHD kid doesn't receive in the doctor’s office, Injcluding:
• Clinicians prescribing medication were required, according to written algorithm, to continue titrating the dose of stimulants up to the point of optimal effectiveness.
• Medication visits were monthly and lasted a full half-hour.
• Clinicians provided “support, encouragement, and practical advice” without providing the behavioral therapy that was being tested in other arms of the study.
• Parents were given readings about ADHD.
• Each month, clinicians reviewed information on the child’s symptoms from both parents and teachers.
To quote the carlat Report:
"I suspect that there aren’t many readers out there who schedule monthly half-hour medication visits for stimulant monitoring, who make sure to get teacher evaluations at every session, who give out special psychoeducational material to parents, and who use a research-driven algorithm to ensure the stimulant dose gets high enough, quickly enough."
For the full article, see @ http://pro.psychcentral.com/2013/therapy-vs-meds-for-adhd-lessons-from-the-mta-study/002344.html
In any case - how many heimishe parents and children are still suffering because their pediatricians were fooled by the original study results?
Whether medication is the right choice and whether its costs outweigh its benefits is one question. But I can't believe that taken alone, performance enhancing drugs don't enhance performance. Amphetamines are used both legally and illegally outside of the ADHD context as well. If it works there, why would it not also help people with ADHD?
ReplyDeleteI am not a doctor or a chemist and I don't doubt that drugs have helped many children and teens to cope with ADHD. What I do know is that I have a child who was diagnosed as being ADHD and as parents, we had a long talk with the specialist about options. She suggested medication as the easiest route, but admitted that at the time (this was 20 years ago) there were no reliable studies about the long-term effects of these drugs.
ReplyDeleteSo we opted for the harder route, which was basically to work harder with our child and get the school on board. Our daughter was very bright, as many of these children are. She also had no learning issues (these also seem to often go hand in hand with the ADHD diagnosis which obviously complicates the issue for many).
This meant speaking to teachers before the year started and getting them on board to consider strategies to deal with this high-energy child. Some teachers were receptive to suggestions, some thought of things on their own, and some were resentful that we were making their jobs more difficult (these are the ones who use the same stencils and projects for twenty years running...)
We fought with the school principal, a brilliant lady from another century, who insisted that we had it all wrong, despite bringing our physician into the school to meet with her. After a few years, she insisted on bringing in the school's own consulting physician to assess our daughter and have a meeting with all parties. Her physician agreed with us.
Lesson learned? Parents must advocate for their kids. And parenting is hard and takes effort and hours and both parents. And some kids need more strategy and patience than others.
Schools are interested in all the kids to be sure, but also in making life as easy as possible for their teachers. So they will first advocate medicating the students, rather than having their teachers utilize the teaching skills that they supposedly have.
If you are faced with this, find one person in the school who will also advocate for your child, someone who she can go to for help, guidance or a kind word when the frustration builds. We found such a person, who told us young worried parents at the time that our daughter will one day excel and prove us right.
She graduated university with honors and is married with a baby.
There will be some kids whose ADHD is chronic and will need meds , but ultimately Medication should not be seen as a long term solution or at least doctors should try to reduce dosage. Thanks Ploni for sharing the criticism of the MTA study. There are other studies which seem to support the MTA = Abikoff . My take was that the social skills training was top-down in a classroom, and therapy could be the traditional ADHD approach – behavior modification which imho is not the best approach. Approaches which encourage thinking, reflecting, planning, collaborative problem solving g etc as with Mindfulness change the brain – neuroplasticity . Shure and Aberson used ICPS approach – I can problem solve approach with ADHD kids in a research project with good results.
ReplyDeleteOf course , teachers will never reflect if what they are teaching or the tasks they give to kids are worth paying and giving much attention. If school is boring and not engaging I don't blame kids for being inattentive.
The comparison between Finland and the USA is interesting. Imho, it could be that the Finnish educational system with not much frontal teaching and a popular high powered vocational training for older kids – so kids learn by doing is a possible reason that kids need less medication.
If I'm not mistaken, Abikoff's current approach uses task analysis & not just meds, & I think that ask analysis per se DOES have a robust effect. Purely behavioral strategies have also been shown to have a positive effect on neuroplasticity.
ReplyDeleteTo quote the MTA study, the behavioral leg included participation in a Summer training program that taught "sports and social skills and gave them an opportunity to practice and refine their academic skills" Doesn't sound like behavior modification.