Article for Category: ‘ADHD’

Does medication improve reading ability?

September 05th, 2016

The Journal of Child and Adolescent Psychopharmocology has published an article by Shaywitz et al that investigated the affects of the drug atomoxetine (sold as Strattera) on reading and attention in children with dyslexia, ADHD and comorbid dyslexia + ADHD.

My understanding is that the experiment was part of a broader study on the effectiveness of atomoxetine as a treatment for ADHD. The study appears to have been funded by Eli Lilly and the second author is reportedly an employee and minor shareholder in Eli Lilly.

Children were defined as having dyslexia if (a) there was at least a 22-point discrepancy (approx. 43 percentile ranks) between IQ and word-reading ability (defined by the WJIII Word Attack test OR the Word Identification OR the WJIII Basic Reading Cluster – an average of Word Attack and Word Id) or (b) the child had a standard score of 89 or lower on at least one of the WJIII tests.

The first thing that springs to mind is that these criteria are not particularly stringent. A standard score of 89 represents the 23rd percentile. It is still within a standard deviation of the mean. Further, the discrepancy criterion presumably means that a child with an IQ score of 122 and a reading score of 100 (exactly average) met criteria for the dyslexia group.

Using these criteria, 209 children who were allocated at random to an atomoxetine or placebo group. Numbers in each group were: dyslexia only (n = 29 atomoxetine, n = 29 placebo), ADHD + dyslexia (n = 64 atomoxetine, n = 60 placebo) and ADHD only (all of whom received atomoxetine).

The drug trial lasted for 16-weeks. Changes in reading skills were measured by:

WJIII Word Attack and Word Identification tests

WJIII Spelling

WJIII Reading Comprehension and Reading Vocabulary

Comprehensive Test of Phonological Processing (CTOPP)

Gray Oral Reading Tests-4 (GORT-4)

Test of Word Reading Efficiency (TOWRE)

It is unclear why but on many variables the Placebo group had higher pre-treatment reading/spelling skills than the Atomoxetine group. For example, within the Dyslexia only group the Placebo sub-group had an average standard score on the Word Attack subtest of 88.05 while the Atomoxetine group had an average score of 84.11. It was 83.86 vs 80.47 for Word Identification, 83.32 vs 77.32 for Spelling. This may seem a minor point but consider the effect of regression to the mean http://www.understandingminds.com.au/blog/2012/02/. The more extreme a score is at pre-test the more likely it is to “bounce’ back towards average at post-testing. Thus, the Atomoxetine group was more likely to “benefit” from regression effects than the Placebo group.

A summary of the interesting bits of the results:

  • Children with dyslexia who were treated with atomoxetine made greater gains than children with dyslexia given the placebo treatment on WJIII Word Attack, WJIII Basic Reading Cluster and WJIII Reading Vocabulary.
  • Children with dyslexia + ADHD who were treated with atomoxetine made greater gains than children with dyslexia + ADHD given the placebo treatment on the CTOPP Elision test (a peripheral/distal reading sub-skill).

So what?

  1. At first glance it seems odd that children with dyslexia would respond better to a medication designed for ADHD than children who actually had ADHD. However, there are reasonable explanations. First, medication isn’t a panacea. It doesn’t cure ADHD. It improves symptoms. It is possible that the ADHD + dyslexia remained more impaired than the dyslexia group even when given medication. Second, children with dyslexia often have sub-threshold symptoms of ADHD that may in fact respond better to medication than the more severe symptoms seen in children actually diagnosed with ADHD.
  2. It is possible that at least some of the effects were due to greater regression to the mean in the Atomoxetine vs Placebo group (see above).
  3. It is possible that the medication simply improved test behaviour rather than reading ability per se.

The data are arguably the beginning of a research journey. They provide some preliminary support for the idea that psycho-stimulant medication can improve academic skills even in children without ADHD. However, I am sceptical about this. I can see how medication might improve test-taking behaviour in some children. I can also see how it might “smooth out” the inconsistency seen in children with attention problems and with dyslexia. However, medication doesn’t teach. It doesn’t matter how good your attention is; if you don’t know it you don’t know it.

I am more interested in how medication affects response to reading intervention. The graph below shows data from a single case seen in my clinic. The case is of a male with ADHD + mixed dyslexia. He was receiving reading intervention delivered 4/week. See here http://sgo.sagepub.com/content/spsgo/1/2/2158244011420452.full.pdf and here http://sgo.sagepub.com/content/early/2011/11/01/2158244011428159 for descriptions of the program.

 

The data points represent a weekly nonword reading test. The test items were constructed using the grapheme-phoneme conversion rules taught in the intervention program. If the student learns ~4-5 new GPCs weekly they should be able to read ~5 extra nonwords each week. The “flat lines” represent data from 2 x baseline periods and 2 x treatment periods in which the participant was receiving reading intervention only. One can see that not much progress was being made. It wasn’t that the boy wasn’t learning new things. It was more than his “recall” was inconsistent and his test-taking behaviour was poor.

Upwards growth in test scores were seen almost immediately upon beginning to take a stimulant medication. Later data, not shown in the graph, showed that removing the reading intervention so the only treatment was medication resulted in a return to a flat line. That is, the medication didn’t teach skills.

We have seen this pattern in several cases now; although the results of other cases have not been as dramatic as this first case.  (I should also point out that the skeptic in me thinks that these data are too perfect and I need to see them replicated before I truly “believe” them).

Our very preliminary conclusions are that attention is necessary for new learning to take place and that the medication helps set the conditions for learning to happen (the batter into which the teaching is stirred if you will). However, medication will probably not make you a good reader sans the teaching.

At this point there is no justification for trialling medication in students who just have dyslexia. However, we hope to see a larger trial of the response of students with ADHD + dyslexia to reading intervention versus medication + reading intervention.

For help with dyslexia, ADHD, autism spectrum disorders and other developmental and learning disorders in the Gold Coast and Tweed regions contact the Understanding Minds Clinic.

 

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Behavioral sensitivity to changing reinforcement contingencies in attention-deficit hyperactivity disorder

May 05th, 2016
  • Attention-deficit hyperactivity disorder;
  • response allocation;
  • reinforcement;
  • change

Background

Altered sensitivity to positive reinforcement has been hypothesized to contribute to the symptoms of attention-deficit hyperactivity disorder (ADHD). In this study, we evaluated the ability of children with and without ADHD to adapt their behavior to changing reinforcer availability.

Method

Of one hundred sixty-seven children, 97 diagnosed with ADHD completed a signal-detection task in which correct discriminations between two stimuli were associated with different frequencies of reinforcement. The response alternative associated with the higher rate of reinforcement switched twice during the task without warning. For a subset of participants, this was followed by trials for which no reinforcement was delivered, irrespective of performance.

Results

Children in both groups developed an initial bias toward the more frequently reinforced response alternative. When the response alternative associated with the higher rate of reinforcement switched, the children’s response allocation (bias) followed suit, but this effect was significantly smaller for children with ADHD. When reinforcement was discontinued, only children in the control group modified their response pattern.

Conclusions

Children with ADHD adjust their behavioral responses to changing reinforcer availability less than typically developing children, when reinforcement is intermittent and the association between an action and its consequences is uncertain. This may explain the difficulty children with ADHD have adapting their behavior to new situations, with different reinforcement contingencies, in daily life.

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A randomized controlled trial into the effects of neurofeedback, methylphenidate, and physical activity on EEG power spectra in children with ADHD

May 04th, 2016
Journal of Child Psychology and Psychiatry

Journal of Child Psychology and Psychiatry

Background

The clinical and neurophysiological effects of neurofeedback (NF) as treatment for children with ADHD are still unclear. This randomized controlled trial (RCT) examined electroencephalogram (EEG) power spectra before and after NF compared to methylphenidate (MPH) treatment and physical activity (PA) – as semi-active control group – during resting and active (effortful) task conditions to determine whether NF can induce sustained alterations in brain function.

Methods

Using a multicentre three-way parallel group RCT design, 112 children with a DSM-IV diagnosis of ADHD, aged between 7 and 13 years, were initially included. NF training consisted of 30 sessions of theta/beta training at Cz over a 10-week period. PA training was a semi-active control group, matched in frequency and duration. Methylphenidate was titrated using a double-blind placebo controlled procedure in 6 weeks, followed by a stable dose for 4 weeks. EEG power spectra measures during eyes open (EO), eyes closed (EC) and task (effortful) conditions were available for 81 children at pre- and postintervention (n = 29 NF, n = 25 MPH, n = 27 PA). Clinical trials registration: Train Your Brain? Exercise and Neurofeedback Intervention for ADHD, https://clinicaltrials.gov/show/;NCT01363544, Ref. No. NCT01363544.

Results

Both NF and MPH resulted in comparable reductions in theta power from pre- to postintervention during the EO condition compared to PA (ηp2 = .08 and .12). For NF, greater reductions in theta were related to greater reductions in ADHD symptoms. During the task condition, only MPH showed reductions in theta and alpha power compared to PA (ηp2 = .10 and .12).

Conclusions

This study provides evidence for specific neurophysiological effects after theta/beta NF and MPH treatment in children with ADHD. However, for NF these effects did not generalize to an active task condition, potentially explaining reduced behavioural effects of NF in the classroom.

 

For help with dyslexia, ADHD, autism spectrum disorders and other developmental and learning disorders in the Gold Coast and Tweed regions contact the Understanding Minds Clinic.

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ADHD virtual issue of Child & Adolescent Mental Health

February 07th, 2013

Child & Adolescent Mental Health (CAMH) has a virtual issue that pulls together a number of papers published in CAMH in recent years that have focused on ADHD. The issue distils key clinical practice and research messages from articles that were published prior to and since the publication and dissemination of the NICE ADHD guidelines. Together the articles (reflecting expert commentary, review articles, and original research) provide a comprehensive guide across a full range of debate around identification, recognition, associated problems, assessment, service organisation, and interventions for children and adolescents with ADHD.

Editorial: Attention-deficit Hyperactivity Disorder (ADHD)
Kapil Sayal

Teachers’ Recognition of Children’s Mental Health Problems
Maria E. Loades, Kiki Mastroyannopoulou

Teachers’ recognition of children with ADHD: role of subtype and gender
Maria Moldavsky, Carla Groenewald, Victoria Owen, Kapil Sayal

On the intersection between AD/HD and DCD: The DAMP Hypothesis
Edmund J. S. Sonuga-Barke

Undertreatment of Motor Problems in Children with ADHD
Ellen A. Fliers, Barbara Franke, Nanda N.J. Lambregts-Rommelse, Marieke E. Altink, Cathelijne J.M. Buschgens, Maria W.G. Nijhuis-van der Sanden, Joseph A. Sergeant, Stephen V. Faraone and Jan K. Buitelaar

The Social Competence of Children with Attention Deficit Hyperactivity Disorder: A Review of Literature
Elizabeth Nixon

Evaluation of Screening in Children Referred for an ADHD Assessment
Kapil Sayal, Nicole Letch, Samaa El Abd

The Diagnostic Utility of Executive Function Assessments in the Identification of ADHD in Children
Joni Holmes, Susan E. Gathercole, Maurice Place, Tracy P. Alloway, Julian G. Elliott, Kerry A. Hilton

Early identification of stimulant treatment responders, partial responders and non-responders using objective measures in children and adolescents with hyperkinetic disorder
Carsten Vogt and Tim Williams

Attention Deficit Hyperactivity Disorder: New Ways of Working in Primary Care
Gill Salmon, Amanda Kirby

ADHD: A survey of psychiatric and paediatric practice
Gill Salmon, Alison Kemp

Young People’s Experience of ADHD and Stimulant Medication: A Qualitative Study for the NICE Guideline
Ilina Singh, Tim Kendall, Clare Taylor, Alex Mears, Chris Hollis, Martin Batty, Sinead Keenan

The Impact of Governmental Guidance on the Time Taken to Receive a Prescription for Medication for ADHD in England
David M. Foreman

Five years on: Public Sector Service Use Related to Mental Health in Young People with ADHD or Hyperkinetic Disorder Five Years after Diagnosis
Tamsin Ford, Tom Fowler, Kate Langley, Naureen Whittinger, Anita Thapar

Effects of attentional/hyperactive and oppositional/aggressive problem behaviour at 14 months and 21 months on parenting stress
Anne-Claire E. Beernink, Sophie H.N. Swinkels, Rutger Jan Van der Gaag, Jan K. Buitelaar

A randomized controlled pilot study into the effects of a restricted elimination diet on family structure in families with ADHD and ODD
Lidy M. Pelsser, Daphne J. van Steijn, Klaas Frankena, Jan Toorman, Jan K. Buitelaar and Nanda N. Rommelse

For help with ADHD on the Gold Coast and in the Tweed region contact Understanding Minds.

Like us on Facebook for updates on ADHD related matters, information on other developmental disorders like dyslexia, language and communication problems, and autism spectrum conditions, as well as general mental health info.


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Autism, Asperger’s, Disability and related blogs

January 30th, 2013

Abnormal Diversity
Action for Autism
Adventures In Extreme Parenting
Along The Spectrum
Andrea’s Buzzing About
The Art of Being Asperger Woman
Ask An Aspie
The ASMan
Asperger Square 8
Asperger’s Conversations
Aspergers Parallel Planet
Aspie Dad
Aspie Home Education
ASPIES
Aspies For Freedom
Autiemom Speaks Out
Autism All The Time
Autism & Computing
Autism Blog
The Autism Crisis: Science & Ethics of Autism Advocacy
Autism Diva
Autism Natural Variation
Autism Podcast
Autism Squeaks
Autism Street
Autism Vox
Autism Watch
Autism’s Edges
Autismland
AutisMusic
Autistic Adults Picture Project
Autistic Advocacy
Autistic Conjecture of the Day
Autistic Dad
Autistic Health
Autistics.org
Ballastexistenz
Bartholomew Cubbins on Autism
Biodiverse Resistance
Chewing the Fat
Club 166
Commentary on the State of the World
Countering Age of Autism
Deconstructing Neurelitism
Desperately Seeking Ethics & Reason
Detritus
dkmnow
Ed’s Blog
The Family Voyage
Greener Pastures
Grey Matter/White Matter
Hard Won Wisdom
Hazardous Pastimes
Hollywood Spectrum
Homo Autistic
Hyperlexia
Hypnagogic Malcontent
I Speak of Dreams
Ian Johnson’s neurodiversity blog
in regione caecorum rex est luscus
Incorrect Pleasures
Interverbal
iRunman Blog
Jedi Workshop
Jenny McCarthy Body Count
The Joy of Autism
Killer of Sacred Cows
The Kingdom of Laurentius Rex
Left Brain/Right Brain
Life in the New Republic
A Life Less Ordinary
The Life That Chose Me
Mainstream Parenting
Memory Leaves
meow meow meow… blah blah blah
Misadventures from a Different Perspective
The Misbehaviour of Behaviourists (Discussion Board)
Mom Not Otherwise Specified
Mom to Mr. Handsome
More Than a Label
Mother of Shrek
My Act of Combating Neurobigotry
My Son Has Autism
My Son’s Autism
Neurotypicals Are Weird
No Autistics Allowed
Not Mercury
OASIS
Odd One Out
Oddizms
One Dad’s Opinion
Parenting a Complex Special Needs Child
PosAutive
Pre-Rain Man Autism
Processing in Parts
The “R” Word
Radio Calico
Ragged Edge
Random Reminiscing Ramblings
The Rettdevil’s Rants
Room 36
Sam I Am
Shh… Mum Is Thinking
Silver Cuckoo
Slurping Life
Snippets: Short Takes on Autistic Topics
So Much For Mercury
Stop. Think. Autism.
Susan Senator
Sweet Perdition
This Mom
This Mom
This Way of Life
A Touch of Alyricism
Touched by an Alien
Touched By An Alien
Translating Autism: Autism Research
29 Marbles
Unstrange Minds
Victoria’s Corner
We Go To School To Think
What Sorts of People…?
Whirled Peas
Whitterer on Autism
Whose Planet Is It Anyway?
Wikipedia on Neurodiversity
Zoe Notes

For help with autism spectrum conditions, ADHD and dyslexia on the Gold Coast and Tweed regions contact Understanding Minds.

Like us on Facebook for updates on developmental disorders like autism spectrum disorders, Asperger’s, dyslexia and ADHD, and general mental health info.

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