Meds & BT for Adolescents with ADHD

Ritalin, Behavior Modification Make the Grade for ADHD

Teens With Disorder See Boost in Grades With Drugs, Guidance
By Neil Osterweil

WebMD Medical News

Reviewed by Dr. Tonja Wynn Hampton

May 31, 2001 -- Here's some good news, for a change, about teens and drugs: Junior high school students with attention deficit hyperactivity disorder (ADHD) who took the drug Ritalin, and who also got help with their behavior, had improvement in academic scores -- enough to boost their scores by one or two letter grades.

The students were both more likely to complete assignments and to get them done more accurately when they were taking Ritalin than when they were taking a look-alike placebo drug, report Stephen W. Evans, PhD, and colleagues in a study published in the journal Experimental and Clinical Psychopharmacology.

"We believe very strongly that what this shows is that you need to combine medication on top of appropriate behavioral interventions for teens, just like lots of studies have shown to be true for younger kids," says co-author William E. Pelham Jr., PhD, professor of psychology, pediatrics, and psychiatry at SUNY at Buffalo, in an interview with WebMD

The study also showed that for kids with ADHD who benefit from taking Ritalin, increasing the dose does not necessarily improve academics -- and could even hurt performance, the authors say.

Children who are diagnosed with ADHD generally have trouble paying attention, are easily distracted, impulsive, and hyperactive -- in other words, they just can't seem to keep still or to focus on the task at hand. The disorder is frequently broken down into three subcategories according to whether the child is hyperactive and impulsive alone, inattentive alone, or a combination of all three.

"ADHD children suffer from serious impairment in relationships with parents, teachers, peers, and siblings, as well as major difficulties in academic functioning. Although it has been well established that such difficulties continue into young adulthood for individuals with ADHD, there has been very little research directed at the nature of these impairments in adolescents with ADHD," Evans and colleagues write.

To determine whether specific doses of Ritalin had an effect on classroom behavior and academic performance in teens, the researchers looked at 45 adolescents diagnosed with ADHD -- 40 boys and five girls -- who were enrolled in an intensive summer treatment program at the University of Pittsburgh.

The students received either placebo or Ritalin three times per day during the eight weeks of the study. Each student received a different dose of the drug or a placebo each day of the study, allowing the researchers to compare how the students behaved and performed academically at each dose.

The students also received behavior modification therapy aimed at helping them to control their behavior and function better in settings such as school. Instruction included tips on better note-taking, social skills, and problem-solving.

The researchers looked at the quality of the students' notes, performance on daily quizzes, writing assignments, in-class worksheets, and how often they completed assigned homework. The students were also monitored for signs of ADHD-related behavior in the classroom.

About 80% of the students showed some degree of academic improvement while taking Ritalin. The biggest improvement occurred at the smallest drug dose (10 mg), with lesser improvements seen when the dose was doubled or tripled.

Pelham tells WebMD the study focused only on daily productivity in the classroom, and not long-term effects on academic performance. In fact, says an education specialist who was not involved in the study, it's not clear whether taking Ritalin now will help with a student's chance of getting into a good college later.

Judith Wiener, PhD, professor of human development and applied psychology at the University of Toronto, tells WebMD studies have shown Ritalin to have inconsistent effects on academic performance.

"What seems to be the case is that if you look at long-term outcomes of kids with ADHD who have or have not been on Ritalin, that you get no differences," she says. "On the other hand, if you look at things like task engagement -- short-term gains on specific tasks while they're taking the drugs vs. not -- then you tend to get better results from the Ritalin group."

Wiener suspects Ritalin has no effect on long-term academic performance because over time, other factors interfere with academic achievement.

Still, Pelham tells WebMD, behavior modification -- working with children in the classroom to provide positive incentives for appropriate behavior and penalties for inappropriate behavior -- may be all that some children or teens with ADHD need to work well in school.

"If a parent wants to take a conservative approach, behavior modification is all you need -- that's simple to do and it doesn't put a drug in the child's brain," he says. "For a lot of other kids, they need something beyond that; I don't ever think they need something instead of that. So you train parents to be good behavior modifiers, you intervene in the schools and work with the kids, and if that's not enough you add medication."

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