It was with great interest that I reviewed an Australian study looking at academic achievement in students with ADHD during the period from childhood to adolescence. Having spent the last twenty years speaking with researchers, parents, educators, school boards and Ministries of Education across Canada I firmly believe that this study highlights the same situation that we have here in Canada.
The study published in the Journal of Developmental and Behavioral Pediatrics showed that 40% of students with ADHD were not reaching minimum standards for literacy and numeracy in at least one academic area such as writing or math. Based on test results in year seven, which is equivalent to our grade seven, 73% of students with ADHD had a problem with writing and almost a quarter scored below the minimum standard. By year nine things had become worse; 54% of students still had difficulties, however now 37.5% did not reach the minimum standard. What was also interesting was the fact that boys had far greater difficulty with writing than girls. The lead researcher, Nardia Zendarski said that they had expected to see a gap in academic success for students with ADHD, but not such a large gap.
Professor Harriet Hiscock, a consulting paediatrician with the Murdoch Children's Research Institute that ran the study, said problems arose for students with ADHD particularly in English subjects, due to issues with writing, spelling and grammar. "They're quite sophisticated things that we learn how to do," she said. The frontal lobe of the brain, which we know is not as developed in children with ADHD, is used in this type of task.
Remarkably, 75% of children looked at in the study were on medication to increase their attention. This fact led Ms. Zendarski to state, "ADHD medication has its place but it doesn't seem to improve long-term academic outcomes … it doesn't address the core academic skills." She went on to say, "We should stop focusing on the argument around whether these kids should be medicated or not and start focusing on providing services and support that they need to reach their full potential. These programs could be used to support all kids with learning difficulties.”
"We need to look further back and see when the problems start — do these problems start for kids as early as grade one?" said Professor Hiscock. "And if they're not picked up and addressed, particularly in primary school, then these kids get into high school where it becomes harder, the work becomes more complex. So we're seeing the problems become worse."
Professor Hiscock went on the say, “The solution is not clear cut, but better support and training of teachers would be a good start. More support around literacy and numeracy teaching, probably it's got to be small groups, more individualised teaching."
Tracy-Ann Pettigrew a mother with two sons with ADHD went back to university to study special education in order to assist her sons with school. There's not a lot of understanding by mainstream teachers about how to teach kids with additional learning needs and it's a tough gig," she said. "I am hoping that this will facilitate some meaningful change, so that teachers can learn the skills that they need to learn to be able to support these kids."
Ms Zendarski closed by says, “As education is a key determinant of overall quality of life and health, I can't think of a better area to concentrate our efforts,"
Access the Institute’s REPORT
Access articles on the study:
Children with neurodevelopmental disorders like ADHD have been excluded from general guidelines on screen use by the Canadian Pediatric Society because children with these disorders are at greater risk for internet addiction. Dr. Umesh Jain, a Child and Adolescent Psychiatrist specializing in ADHD, believes that children with ADHD should only be in front of a screen for educational purposes. He believes that screen time can be addictive for children with ADHD with the same cravings and withdrawal effect as other addictions. He also believes that it deteriorates social skills of children with Autism since they quickly become dependent on the Internet for their social interaction. Dr. Jain states that screen time is altering the brain of children with ADHD by “softening and altering cortical structures”. He’s basing his recommendations on studies out of South Korea pointing to ADHD as the most common reason for Internet addiction under the age of 12.
Dr. Randy Kulman, a child clinical psychologist from Rhode Island, believes screen time for children with ADHD and ASD should be tailored to their learning challenges, but does recognize the increased risk to those with ADHD. Children with ADHD crave stimulation that these online interactions provide.
Access the entire article by Patricia Tomasi HERE
A large Danish study found that teens with ADHD were at least twice as likely as their peers without ADHD to become parents and have more children by the age of 25.
Early teen years were especially concerning since girls with ADHD were three and a half times more likely, and boys were almost two and a half times more likely to become parents between the ages of 12-15. Even researchers, who expected increased rates, where shocked at the extent of the increase.
Researchers looked at 2,698,052 people born between 1960 and 2001 in Denmark, including 27,479 who had been diagnosed with ADHD and grouped the data into a variety of age intervals. They analyzed the likelihood of becoming a parent during age intervals of 12-16, 17-19, 20-24, 25-29, 30-34, 35-39 and over 40. The age interval between 17 and 19 indicated at a rate at least twice as high for those with ADHD.
“It is well established that becoming a teenage parent, irrespective of your mental health status, is burdensome for both parents and children,” lead author Dr. Soren Dinesen Ostergaard, of Aarhus University Hospital in Denmark said. “It is also well known that parenting is often difficult for individuals with ADHD.” For this reason he and his colleagues suggest creating sexual education and contraceptive counseling programs tailored for adolescents with ADHD. Other experts commented that awareness of the issue and educating parents of teens with ADHD about this research was paramount.
Access more information HERE
A new study published on May 10 in the journal JAMA Psychiatry looked at ADHD, driving and medication. The study tracked more than 2 million American adults who had been diagnosed with ADHD for a period of 10 years. The data was accessed from health insurance claims from more than 100 health insurers and reviewed inpatient and outpatient hospital visits due to motor vehicle collisions (MVCs) and filled prescriptions.
The study looked at over 2 million patients identified with ADHD, over the age of 18, with half over the age of 33. The study found that men’s risk of a motor vehicle accident decreased by 38% during the months they filled their prescriptions and women’s risk decreased by 42%.
The study team also estimated that 22 % of accidents could have been avoided if people with ADHD were on their medication during the entire study period.
The lead author Zheng Chang, of the Karolinska Institute in Stockholm, Sweden stated that the study most likely underestimated the effect of medication on car crashes because only those accidents serious enough to warrant medical intervention through a hospital were included in the numbers. The data also did not include car crashes were someone died.
Considering the high prevalence of ADHD and its association with motor vehicle collisions along with the high rate of MVCs resulting in injury or death these findings should be looked at very seriously.
To access further details
Study published in JAMA Psychiatry. Published online May 10, 2017.doi:10.1001/jamapsychiatry.2017.0659
http://www.livescience.com/59047-people-taking-adhd-medications-may-have-fewer-car-accidents.html
A recent study has found that use of antidepressants by the mother during early pregnancy did not significantly increase the risk of poor fetal growth or the child’s risk of developing Autism or ADHD as previously thought. As well, only a slight increased risk for premature birth was found. This is the largest study to date, looking at over 1.5 million infants, using all live births in Sweden from 1996 to 2012. The information was matched to data on antidepressant use, mostly SSRIs, and autism and ADHD diagnoses. The study was led by Indiana University with analysis collaboration between the researchers at Karolinska Institute in Sweden and Harvard T.H. Chan School of Public Health.
This study’s results is of particular interest, not only for its size, but that researchers were able to compare outcomes in siblings when the mother was taking medication for depression and when she was not treated. The study looked at the use of antidepressants in fathers as well as use in mothers prior to pregnancy and found increased rates of both Autism and ADHD leading researchers to believe that genetics and a history of depression were a factor rather than the use of antidepressants.
Read more about the study HERE
A new Huffington Post article is talking about changes coming to the BC Special Education Guidelines that will allow students with ADHD, who present learning needs, to be identified under the learning disability (LD) category. This may not seem like a huge change, but parents of children with ADHD in BC and CADDAC have long been advocating for this change. In fact, CADDAC has been advocating for this change to occur in Ontario since our inception in 2005.
What does this change mean and why did it come about?
In the past system, students with ADHD in BC, who were struggling at school, were denied recognition as exception students (learners) because ADHD was not listed under a category. This recognition allows students access to special education resources and an Individual Education Plan (IEP). By placing ADHD under the LD category the Ministry of Education in BC has acknowledged recent changes in the DSM 5 (the document that defines mental health and neurological disorders) which now categorizes ADHD as a neurodevelopmental disorder, rather than a behaviour disorder. Learning disabilities have long been recognized as neurodevelopmental disorders. Although ADHD is not an actual learning disability it can significantly impair learning even without an LD being present.
Unfortunately, CADDAC continues to receive countless calls from parents in Ontario frustrated that their children are still being barred from being recognized as exceptional learners, many also being denied an IEP. Although a 2011 Ontario Ministry Memorandum states that a student with ADHD presenting learning needs should not be barred from being recognized as an exceptional learner, this is still routinely occurring.
You see, school boards are entitled to set the bar of learning impairment (how impaired a student must be to be recognized as an exceptional learner) wherever they like. There is no requirement for school boards to document this, so decisions are often quite arbitrary and difficult for parents to challenge. This is resulting in little consistency across boards or even within the same school board. Even though the Ministry’s 2011 memorandum exists, we continue to receive calls from parents who are told that their board does not recognize students with ADHD, period. The latest parent I spoke with, who also happened to be a teacher, just told me that their principal was totally unaware of the memorandum and when it was brought to their attention was sure that it must be out dated.
So here is my “ask” of you. If your child with ADHD is struggling at school and continues to be denied an IEP or recognition as an exceptional student in the Ontario School System and you would like to share your story with us to further advocacy efforts in Ontario, please contact heidi.bernhardt@caddac.ca
Access the article HERE
Results of the largest ADHD brain imaging study of its kind was released this week in The Lancet Psychiatry. MRIs of 1713 people with ADHD were compared to a control group of 1529 people without ADHD, between the ages of 4 and 63, across 9 countries.
Some of the study’s findings were:
Why are these findings of interest?
To listen to our interview click HERE
To view more access, CBC Lancet ScienceDaily
A recent study by the Institute for Clinical Evaluative Sciences found almost 12 per cent of children and youth with attention deficit hyperactivity disorder, or ADHD, were prescribed antipsychotics like Risperdal, Zyprexa and Seroquel. Since the study found that 5% of Ontario children have ADHD, this means that .06% of children may be receiving antipsychotic medications. The study went on to report that 20% of children with ADHD were also receiving antidepressants for depression or anxiety which the lead researcher Dr. Paul Kurdyak, head of the mental health and addictions program at ICES, did not find surprising since these disorders frequently coexist with ADHD. However, the researchers did find it surprising, that children with ADHD would be receiving antipsychotic medications when these medications have not been shown to treat ADHD.
Unfortunately the article implies that these medications are being used to treat simple ADHD, while at the same time conceding that these medications have a sedating effect and assist with disruptive behaviour. Unfortunately what the researchers did not mention is that some children with a more severe presentation of ADHD can also have extreme forms of emotional dysregulation, in some cases so severe that they are unable to attend school or be involved in normal family life without experiencing episodes of emotional “meltdown” and sometimes aggression. This would be the common profile of the majority of children who are receiving these medications. Normal levels of ADHD disruptive behaviour would not commonly warrant a prescription of antipsychotic medication.
In addition, it makes perfect sense that more people who see a psychiatrist have these medications prescribed. It is child and adolescent psychiatrists who generally see these more severe cases. General practitioners and paediatricians refer these more difficult cases to child and adolescent psychiatrists, when they have been unable to successfully treat the child themselves. Of course, better education for front line physicians on how to assess, diagnosis and treat ADHD appropriately may be helpful as well. We know that the sooner we diagnose and treat ADHD the better chance we have of reducing co-existing disorders and the long term consequences of ADHD.
No one would argue that if there is a choice antipsychotic medication should never be given to children and that psychotherapy should always be the first choice of treatment. Unfortunately it is also true that affordable family, child and youth mental health therapy is very difficult to access across this country resulting in a two tier mental health system. However, after speaking with many of these families and the physicians who treat these children it is clear that even when parents do everything right and therapy is implemented, for some children and youth it is still not enough.
Also, no one would disagree that many of these medications have significant side effects and should not be a first line treatment. However, at this time there are no medications that have been approved to specifically treat these symptoms in children and youth so physicians are forced to use these medications off label. Obviously more research is required.
One new medication, Intuniv, has been approved by Health Canada for treating children and youth with ADHD and has been found to be very helpful for many children with emotional dysregulation and aggression issues. This medication is not an antipsychotic medication and can be prescribed along with ADHD stimulant medication or on its own for those who have difficulty tolerating stimulant medication, or have not found stimulant medication to be effective. While Intuniv does have some mild side effects, as do all medications, they seem to be far fewer than those of antipsychotic medications.
For this reason CADDAC is currently asking the Ontario Public Drug Program to include this medication on their list of approved medications making it accessible to families receiving their medication through this program. Advocacy on this issue in other provinces is also on the agenda. As this study indicates not many children will require this medication, and while it will not work for all children with these symptoms, I have spoken to many families who have indicated that it has changed their child’s life and their family’s quality of life.
Of course, better access to newer more easily tolerated once-a-day ADHD medications being covered on provincial drug programs would be helpful and may actually help to decrease prescribing of antipsychotic medication. Coverage across Canada is sporadic leaving vulnerable families unable to access a wide variety of ADHD medications. The more choices we have in ADHD medication the better chance we have of being able to achieve the best treatment options for each child and adolescents with mental health disorders. Unfortunately mental health medications are definitely not a one-size fits all scenario.
My major concern about articles on this particular study such as this CBC article, and often articles on other ADHD topics, is that writing about these very complex issues superficially and with an aim to sensationalize only increases misunderstanding about childhood mental health and the way we treat it. They also result in increased stigma, confusion and fear for parents and care givers trying their best to make informed decisions on treatment for their children.
This past week, a follow-up letter was received from Marion Law, the Director General of Health Canada’s Therapeutic Products Directorate (TPD) addressing discussions during the Oct 31 meeting with Janssen, CADDAC and ADHD medical experts.
The letter noted that:
CADDAC will continue to communicate with Health Canada, monitor the situation and report back to our stakeholders.
On October the 31st CADDAC and CADDRA, as well as other stake holders, met with Health Canada to present our activities over the past six years and express our continued concerns in regards to the bioequivalency, or more accurately the lack of therapeutic equivalence, of the generic forms of the brand name ADHD medication Concerta. Heidi Bernhardt President and Executive Director of CADDAC presented information on past advocacy efforts, patient feedback and patient surveys carried out to obtain patient feedback on this issue. In addition she addressed the continued challenges CADDAC is experiencing in having patients and caregivers report on adverse events such as the decrease in symptom control and increase in side effects of these medications. Dr. Doron Almagor, President of CADDRA, reviewed the individual and societal impact of ADHD and summarized Canadian and US adverse events and lack of efficacy reporting on these generic medications. Dr. Murray Ducharme covered the different processes and timing of absorption, peaking and elimination of the brand versus generic medications and why they are not therapeutically equivalent or bioequivalent. Dr. Judy van Stralen presented on three studies which demonstrated the difference between Concerta and the TEVA generic product. In addition she spoke about the additional wait times this issue has added to her clinic. Several of the presenters also shared specific troubling patient cases with bad outcomes due to substitution by the generic medication.
At the close of the meeting all were informed that we would receive a decision within the next month on what the Health Canada’s next steps might be.
