Download STIMULANT MEDICATION AND ADHD

ADHD
1
Below, you will find an example of a critical review of the literature.
Notes:
Green highlighting = SOP
Yellow highlighting = Critical Review of the Literature
Blue highlighting = Purpose & Hypothesis
P.S. Highlighting is being used here for instructional purposes. Do not highlight your own
literature review.
In the past decade, there has been a tremendous growth in the field of
psychopharmacology in general. With more and more drugs being put on the market, the types of
medication prescribed to children, as well as the rates of production and prescription, have
increased substantially (Barkley, 1991). In a 2002 study by Rappley et al., which examined
patterns of pediatric prescribing practices, it was concluded that medications for children are
prescribed in an inconsistent way. Rappley et al. found that 22 different medications were used
in 30 different combinations for 44 different patterns of disorders.
The increase in types and rates of medications being prescribed to children has led
researchers to examine both costs and benefits of the effects of psychoactive medications versus
psychotherapy in the treatment of mental disorders in children. A potential downside to
biological treatments for childhood disorders is the presence of numerable side effects patients
can experience from taking the medication- side effects that do not occur with psychotherapy. It
is interesting to note that once a drug has been approved by the FDA, doctors can prescribe it to
children, even though it has not yet been tested or approved for use in children. There are few, if
any, available studies that have examined long-term effects of psychoactive drug use, mainly
because the drugs that are being prescribed to adults and children have not been on the market
long enough for long-term side effects to appear (Jenson et al., 1999). Although previous
research has focused on the pros and cons of prescribing drugs to children, longitudinal studies
ADHD
2
examining differences between psychopharmacological treatments and psychotherapy for
childhood disorders have been few and far between.
A significant amount of research has been conducted on various short-term drug
effectiveness trials. Most of these studies have followed a randomized double-blind placebo
design. Fischer and Newby (1991) investigated children’s response to stimulant medication in a
clinical setting. A double-blind, randomized, placebo-controlled protocol was used. All of the
child participants were diagnosed with ADHD. Results of this study indicated a positive
stimulant response on most measures, including both questionnaire-based and observational
measures. By using a randomized, double-blind procedure, the authors were able to eliminate
several confounding variables such as experimenter bias, and the large sample size gives strength
to the results obtained. However, one of the weaknesses of the present study is that some of the
assessments were conducted in a laboratory setting. A laboratory setting is removed from the
normal stimuli of the outside world, and thus detracts from the generalizability of the results to
the normal environment. This is of particular importance with ADHD children, as novel
environments and stimuli do not produce as much hyperactivity and attention problems as does a
normal, more routine environment. The interpretation of the results must also take into account
the individual differences of each child. An additional weakness is that the order of the dosages
(low, high, placebo) may have caused a particular response in an individual child, and possibly
effect the overall results of the study.
In a study conducted by Pelham, Vodde-Hamilton, Murphy, Greenstein, and Vallano
(1991), 17 boys (aged 7-10) diagnosed with ADHD were compared to 17 adolescent boys also
diagnosed with ADHD. The participants were matched for sex, diagnosis, IQ, and reading
achievement scores. In addition, all participants were participating in a summer treatment
ADHD
3
program for children with behavior and/or learning problems. Results revealed equally beneficial
effects of methylphenidate for both younger and older boys. The authors concluded that when
used in conjunction with a behavioral intervention, methylphenidate appears to be a useful
treatment for youngsters diagnosed with ADHD. However, the small sample size yields limited
generalizability to the whole population of youngsters diagnosed with ADHD. In addition, the
response rate for adolescents to the methylphenidate was only 50%, a figure that is lower than in
the general population. This may suggest that the medication responsiveness of the boys is not
representative of the population of ADHD children. Another weakness that is found with almost
all studies involving drug effectiveness trials is that there are large individual differences in
response to medication, and these differences cannot be ignored.
Other studies have used vignettes to examine people’s attitudes of various treatments for
ADHD in children. Johnston and Leung (2001) conducted a study with mothers and fathers who
had sons diagnosed with ADHD. Participants were instructed to watch videos of children
exhibiting ADHD symptoms, compliance, and noncompliance to instructions. The participants
were either told that the children in the video were receiving medication, behavioral treatment, a
combination of both medication and behavior interventions, or no treatment. From the results
obtained, the authors concluded that parents rated children’s positive behaviors as more stable
and negative behaviors as less enduring over time as compared with other conditions (behavior
intervention or no treatment). However, by using videotaped scenarios, the attributions of the
parent participants cannot be generalized to the parents’ thoughts regarding their own children.
In addition, parents’ experiences with medication or behavior intervention with their children
might have had an effect on their attributions of such treatments and children’s behaviors.
ADHD
4
Another study, conducted by Stinnett, Crawford, Gillespie, Cruce, and Langford (2001),
examined future teachers’ assessments of two common treatments for children with ADHD,
namely special education placement and medication. Results showed that participants from a
rural high school were more accepting of treatments than those from urban high schools. The
results also suggested that the label of ADHD elicits more negative judgments. In addition, those
children in the vignettes that were not labeled with ADHD, but who were said to be taking
Ritalin, were judged by the participants as having greater attention difficulties as those unlabeled
children who were said to be in a special education placement at school.
Results of the study by Stinnett et al. (2001) cannot be generalized to the population. The
majority of the participants were White. In addition, all the participants were college students
studying to become teachers, and were not actually licensed professional teachers. Not only can
these results not be generalized to teachers’ attributions in the general population, but the results
cannot be generalized to teachers at all, as none of the participants were experienced teachers.
Another weakness of the present study involves measurement and instrumentation used. The
TRS was used to assess attention and social problems in children. The results could have been
more meaningful and useful if the authors had used instruments that are used in the schools (not
the TRS). There was inadequate preoperational explication of constructs, and as a result, the
authors failed to collect reliable demographic data from the participants. All of the data collected
was gathered from self-report, and this is a weakness because this information should have been
more clearly defined. As a result, the variables of rural and urban settings were not operationally
defined
An extensive amount of research has been collected regarding prescribing practices of
psychotropic medication to children. Angold, Erkanli, Egger, and Costello (2000) examined the
ADHD
5
use of prescribed stimulants in relation to ADHD symptoms in a sample of 4500 children in the
Smokey Mountain area of North Carolina. Results of the interviews showed that over a period of
four years, three-fourths of children with a diagnosis of ADHD received stimulant medication.
However, stimulant medication was also used as a treatment for a variety of other disorders.
The results obtained in the study conducted by Angold et al. (2000) have little
generalizability because the study was conducted on children from a single rural area: different
areas of the country could have different treatment practices. It cannot be claimed that these
results are representative of stimulant use with children across America. Another important
limitation to the present study is that the research conducted by Angold et al. (2000) looked only
at stimulant prescribing rates. No prior treatment histories, measures of dosages given, or any
information as to why the children had been started on such stimulant treatment were measured
or obtained. This information is valuable in generating prevalence rates on stimulant use with
children.
In their 1999 study, Jenson et al. looked at national pediatric prescribing practices. They
used two different national databases to gather and collect information. Results of the analysis
indicated that stimulants are the most common prescribed psychotropic medication to children.
However, the databases used for the analysis did not take into account the compliance of
patients, or other factors that could affect prescribing practices. The databases also do not
provide information about the duration or dosages of medications prescribed. But Jenson et al.
(1999) also state that longitudinal data on pediatric medication prescription practices are needed
because most childhood psychological disorders tend to be long-lasting and severe. “In addition,
long-term risks associated with psychotropics may be underrecognized, underreported, and
understudied” (p. 562). Also, Jenson et al. (1999) argue that developmental effects of
ADHD
6
psychotropic medications are not known, and therefore long-term medication treatments need to
be studied to determine if medication produces sustained improvement of childhood disorders, or
produces developmental toxicity in child patients.
Purpose
It has been commonly argued in previous research that there is a lack of longitudinal data
concerning effective treatment strategies for children with ADHD. In addition, there is a shortage
of data regarding long-term use of stimulant medication to treat children with ADHD, and the
potential side effects long-term use of stimulant medication may have on children. There has
been a substantial amount of research conducted that point to the conclusion that a combination
of behavioral interventions and stimulant medication is the most effective treatment for children
diagnosed with ADHD (Pelham et al., 1991). The purpose of the proposed study is to gather
longitudinal data on two different types of treatment interventions for children diagnosed with
ADHD: behavioral intervention and methylphenidate (Ritalin) medication treatment. In addition,
the present study was designed to determine which of these two treatments is more effective.
Based on previous research, it is hypothesized that the behavioral intervention will be a more
effective treatment that methylphenidate (Ritalin) treatment.