myADHD.com News • June 1, 2004
In this issue of MyADHD.com News:
Research Updates
- Sluggish congnitive tempo as a symptom of ADHD
- How well do ADHD children adhere to stimulant treatment over 5 years and what difference does it make?
- Does maternal smoking during pregnancy increase the risk for ADHD?
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Research Updates
Should symptoms of sluggish cognitive tempo be included in ADHD diagnosis? In the DSM-III, attention deficit disorder was categorized according to whether hyperactivity was present. This changed when the DSM-IV was published and listed three subtypes of ADHD: predominantly inattentive type; predominantly hyperactive-impulsive type; and combined type. This required the presence of six or more of nine inattentive symptoms, six or more of nine hyperactive-impulsive symptoms, or both, plus impairment.
There had been for a number of years interest as to whether symptoms that described "sluggish cognitive tempo" should be included in the list of the items making up the eighteen ADHD symptoms. Several studies of DSM-III subtypes had demonstrated that individuals diagnosed as having attention deficit disorder without hyperactivity had greater deficits in information retrieval and processing, lower levels of alertness, and more problems with memory/orientation. Factor analytic studies found these features formed a "sluggish cognitive tempo" (SCT) factor that was characterized by inconsistent alertness and orientation as suggested by symptoms of sluggishness, drowsiness, and daydreaming. These SCT items were deleted in the final version of DSM-IV due to their poor predictive validity.
There has been a recent resurgence of interest in SCT as a possible discriminating factor for subtypes of ADHD. Keith McBurnett et al. (2001) found that ADHD, predominantly inattentive type can be further described by whether those in this subtype exhibited SCT from those that did not. Other researchers have suggested that inattentive ADHD children with SCT may have higher levels of emotional problems, social dysfunction, and withdrawn behavior.
A recent article in the May, 2004 Journal of the American Academy of Child and Adolescent Psychiatry written by Richard Todd and colleagues looked at the impact of including SCT items on ADHD subtypes in boys and girls and attempted to replicate Keith McBurnett's earlier findings. The two SCT symptoms were "stares into space and daydreams" and "appears to be low in energy, sluggish or drowsy." They examined parent report of these two SCT items on 1,430 female twins and 1,414 male twins along with parent report of the 18 DSM-IV ADHD items. The inclusion of the two SCT items resulted in distinct factor structures for boys and girls. For boys there were separate inattentive, hyperactive-impulsive, and sluggish factors. For girls there were separate inattentive/sluggish, hyperactive, and impulsive factors. SCT items had minimal impact on the latent class structure of ADHD for both boys and girls. The authors were not able to replicate McBurnett's findings and concluded that the inclusion of SCT symptoms does not support the presence of additional discrete subtypes. Inclusion of SCT symptoms does not better discriminate subgroups of children than the 18 DSM-IV symptoms alone. Looking at stimulant treatment of ADHD over five years. There are few studies documenting the effectiveness of psychostimulant treatment for ADHD beyond a few months. Recent controlled studies of one to two years' duration indicate that stimulants continue to reduce the core ADHD symptoms, however, cumulative benefits in psychosocial, academic, and family functioning have not yet been documented. In fact, studies by Russell Barkley and others who report long-term outcomes support the notion that children with ADHD continue to have significant academic, social, and psychiatric impairment during adolescence, even with the substantial use of medications and other interventions.
Poor adherence to treatment may be one explanation for suboptimal long-term outscome for children with ADHD. Alice Charach, Abel Ickowicz, and Russell Schachar, Canadian researchers and clinicians, evaluated the impact of adherence and medication status on effectiveness and adverse effects of stimulant use in children with ADHD over five years. In earlier adherence studies by Schachar and colleagues they found that 74% of children with ADHD initially treated with stimulants took 50% or more of their pills over twelve months. About 52% continued to use stimulant medication for three consecutive years.
In a recent article in the May 2004 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, Charach et al. reported on a sample of seventy-nine of 91 participants in a 12-month randomized controlled trial of methylphenidate and parent groups enrolled in a follow-up study. Adherence to stimulants, treatment response, and adverse effects were evaluated annually for 5 years. Changes in teacher-reported symptoms and parent-reported adverse effects were compared over the five years. The results showed that at 2 years and at 5 years, those who adhered to stimulant treatment showed greater improvement in teacher-reported symptoms than those off medication. Clinically significant adverse effects were present for 5 years, most commonly loss of appetite. However, the adverse effects documented were, in general, relatively mild and of little health concern. The authors concluded that psychostimulants improve ADHD symptoms for up to 5 years, but adverse effects persist. Children who were using stimulant medication at consecutive annual evaluations showed ongoing benefit. Children who had more severe symptoms at baseline tended to be better adherents to medication treatment.
Maternal smoking in pregnancy and ADHD. A study by Thapar, et al. appeared in the American Journal of Psychiatry published in 2003 and was summarized in the ADHD Report (April, 2004). This study investigated the effects of maternal smoking and ADHD. Investigators looked at 2,054 twin pairs ages 5-16 and their families from the Manchester Twin Registry. Both mothers and teachers rated children's level of ADHD symptoms and mothers reported on the number of cigarettes they had smoked daily during their pregnancy. Results showed an association between maternal smoking and ADHD symptoms, regardless of the rater (mother or teacher). The authors concluded that maternal smoking increased risk for ADHD in offspring in addition to genetic and environmental factors.
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