- Email: [email protected]
Psychosocial and Medical Histories of Stimulant-Treated Children
Psychosocial and Medical Histories of Stimulant-Treated Children PETER S. JENSEN, M.D., MAJ, MC, ROBERT E. SHERVETTE III, M.D., LTC, MC, STEPHEN N. XENAKIS, M.D., COL, MC, AND MICHAEL W. BAIN, M.D., LTC, MC Abstract. Medical records of all children (N = 38) being treated with psychostimulants for attention deficit disorder at one general hospital clinic were screened from birth to point of diagnosis. Frequency of medical and psychosocial conditions, including hospitalizations, perinatal distress, chronic medical illness, separation from caregivers, family turmoil/divorce, and abuse/neglect were recorded and compared with control records matched for sex. Results indicated that stimulant-treated children had significantly more histories in all categories; also, stimulant-treated children had more than twice as many actual medical and psychosocial events felt to be significantly threatening to a child. Results suggest that stimulant-treated children comprise a group at risk for a variety of medical and psychosocial adversities, but these factors do not appear to be considered during routine clinical management of these children. J. Am. Acad. Child Adolesc. Psychiatry, 1988,27,6:798-801. Key Words: attention deficit disorder, psychostimulants, medical trauma, psychosocial events. Frequent controversy has surrounded discussions of attention deficit disorder (ADD) in the past two decades. These debates have ranged from questioning the validity of the syndrome (Barkley, 1981; Ross and Ross, 1982; Shaffer and Greenhill, 1979), its distinction from other psychiatric conditions (Rutter, 1983), and the lack of scientifically established long-term efficacy of any treatment modality (Weiss et al., 1985), to the ethical problems arising from medicating a child to meet other persons' social and behavioral expectations (Cole, 1975; Eisenberg, 1971; Lennard et aI., 1970). However, the growing weight of evidence indicates that ADD can be distinguished from a range of normal conditions (Conners and Wells, 1986; Taylor, 1986). Furthermore, preliminary evidence suggests that ADD differs from other psychiatric conditions of childhood (Hinshaw, 1987; Taylor et aI., 1986a; Taylor et aI., 1986b; Werry et al., 1987). Also, recent followup studies indicate that certain multi-modal (combined) treatments may indeed be effective even alter several years (Satterfield et aI., 1987). Despite the progress in our understanding and treatment of ADD, researchers have noted that in actual clinical practice, multi-modal treatments are not frequently prescribed (Bosco and Robin, 1980; Gadow, 1983; Plomin and Foch, 1981). Older, single-source models of causality (e.g., genetic, psychologic, perinatal-traumatic) may still guide clinicians' actual treatment practices for ADD patients (Whalen and Henker, 1980). Reasons for this include the fact that pediatricians are not systematically trained to provide multi-modal treatments. In clinical practice, the clinician's task is made much more
difficult if he/she has to consult with schools, facilitate special education arrangements, and coordinate a range of behavioral and counseling strategies for the child and parents. Furthermore, the short-term effectsof medication may be so dramatic that both the pediatrician and parent may take a "wait and see" attitude about the implementation of other treatments. The possible stigma of seeing a child psychiatrist or other mental health professional may contribute to this reluctance; the lack of availability of these professionals may also playa part. In addition, reliable information about any child's behavior is difficult to gather and actual agreement between various raters of a child's behavior is poor. For example, correlations between parent-, teacher-, and clinician-completed ratings of child behaviors are as a rule quite low, with Pearson correlations usually about .30 (Achenbach, 1978). Obtaining adequate historical data in the developmental and medical histories of ADD children is likely to be quite unreliable as well, as parents that have children with significant handicaps tend to selectively remember events in order to figure out "what went wrong." Given the evidence of these difficulties in the routine clinical evaluation and management of children with ADD, better understanding of the factors preceding the clinician's diagnosis and treatment of a child for ADD is needed. Parent recall of the child's developmental physical and psychosocial events is highly suspect, therefore more reliable means of determining this information are necessary. Such information could enhance our understanding about the early events possibly related to the development of behavioral problems and eventual treatment for ADD. For these reasons, we sought to screen medical records from birth to the point of beginning treatment for ADD. Our hospital pharmacy utilizes a computerized prescription system that allows us to identify all cases of children being treated with psychostimulants for ADD. Based on our clinical experience, we hypothesized that these children's medical records, compared with other pediatric records matched for sex, would show an increase not only in histories of perinatal physical stressors (low birth weight, low APGAR scores, etc.), but also in number of other developmental stressors (psychological and physical), reflecting adverse environmental conditions.
Accepted April 19. 1988. From the Dept. I?( Psychiatry and Neurology, Eisenhower Army Medical Center. Fort Gordon. and the Dept. 0/ Psychiatry and Health Behavior. Medical College ofGeorgia, Augusta, Ga. The opinions and assertions contained herein are the private views ofthe authors and are not to he construed as official or as reflecting the views ofthe Department ofthe Army or the Department 4 Defense. The authors wish to thank Mrs. Rosina Martinez for her careful editing and preparation ofthe manuscript. Reprints may he requested from MAJ Peter S. Jensen. MC, P.D. Box 342. Eisenhower Army Medical Center. Fort Gordon. GA 309055650. 0890-8567/88/2706-0798$02.00/0© 1988 by the American Academy of Child and Adolescent Psychiatry.
798
799
PSYCHOSOCIAL AND MEDICAL HISTORIES OF ADD CHILDREN
Method Thirty-eight charts of children (32 boys, 6 girls) being treated with psychostimulants for ADD at one general hospital clinic were screened from birth to the present for the frequency of medical conditions, hospitalizations, and other information in the medical record (these medical records are unique in that in the military system the child's medical record from birth follows the child from site to site, as the father is transferred in his military duties; thus, a longitudinal record of the child's medical history is readily available). The 38 charts comprised all cases of children being treated with stimulants during a 3-month time period. The events screened in the medical record included complications at birth and during the newborn period (defined as infant needing resuscitation, APGAR scores of less than 5/8, infant needing continued hospitalization 4 or more days after the birth, perinatal infections, or congenital deformities), history of asthma, history of repeated ear infection or chronic otitis (defined as 3 or more ear infections during childhood), history of one or more hospitalizations, history of medical treatment for problems with the genitalia (e.g., torsion of the testicle, circumcision after the perinatal period), trauma requiring sutures or extensive/painful procedures, evidence in the chart of prolonged separations from caregivers (e.g., medical record documentation of power of attorney being given to someone else to care for the child, evidence of foster care placement), history of alternating caregivers (e.g., child being brought in by daycare worker or a family member other than a parent for treatment), deaths of caregivers, evidence of divorce of parents, documentation in the record of fights between parents, evidence of parent-child conflicts, documented child abuse or neglect, and suspected abuse or neglect. The frequency of these conditions was compared with 38 control records gleaned from a regular pediatric outpatient setting where children come in for routine medical appointments. These records were matched for sex of child with the index charts. Children's average age did not differ between cases and controls (9.2 vs 9.4 years, respectively; range 5 to 14 years). Results Frequency of conditions were compared between the cases (children being treated with stimulants) and controls using the Chi square statistic. Results are presented in Table I. Those events that conceptually appeared as potentially threatening to the child (e.g., events that may increase the child's anxiety or threaten the stability of the relationship between the parent and the child) were defined as threats to the security of parent-child relationship or threats to attachment. All of these events (see Table I) were summed for each child to determine the total number of threatening events that the child had experienced. Children being treated with psychostimulants had an average number of 4.6 events, while control children had an average of 2.2 events (T = 3.53 p < 0.00 I). One or more threatening events were recorded for 94.7% of the ADD cases (36 of 38 children), while only 47.4% of controls had one or more threatening events (18 of 38) (x 2 = 20.73, p < 0.(01). To further clarify the relationship between the background
TABLE I.
Frequency of EventsGleanedfrom Records ADD Cases (N= 38)
Complications of birth/ newborn period History of asthma Chronic otitis History of one or more hospitalizations" Medical treatment of genitalia" Trauma requiring sutures, hospitalization, or extensive/painful procedures" Alternating caregivers" Separation from caregivers" Deaths of caregivers" Ingestions" Divorce of parents" Fights between parents" Conflicts with child" Documented abuse" Suspected abuse/neglect"
Controls (N= 38)
x2
%
N
%
N
26.3 18.4 39.5
10 7 IS
10.5 10.5 28.9
4 4 II
3.15 0.96 0.94
36.8
14
28.9
II
0.54
39.5
15
18.4
7
4.09
68.4 18.4
26 7
39.5 2.6
IS
6.41· 5.03·
23.7 5.3 13.2 21.1 36.8 23.7 10.5 55.3
9 2 5 8 14 9 4 21
2.6 2.6 7.9 0 2.6 0 2.6 15.8
I I
I
3 0 I
0 I
6
7.37·· 0.35 0.56 8.94·· 14.04·· 10.21·· 1.93 12.93··
" Threat to attachment. • p < 0.05, •• p < 0.01.
psychosocial and medical factors and "caseness," the variables were separated into three categories: (I) medical variables (complications of birth/newborn period, history of asthma, chronic otitis, history of hospitalization(s), medical treatment ofthe genitalia, and trauma requiring sutures, etc.); (2) parentrelated variables, possibly reflecting the nature of the caretaking environment (alternating caregivers, separations from caregivers, death of caregivers, ingestions, divorce, marital conflicts, parent-child conflicts, suspected and documented abuse); and (3) child-related variables, possibly reflecting the nature of the child's disorder (trauma requiring sutures, etc., ingestions, parent-child conflicts, and suspected abuse). We deliberately allowed several items to be tallied in two categories (e.g., ingestions), because it was not possible to determine whether such incidents reflect the nature of the home environment/parental supervision, the severity of the child's disorder, or both. Children treated with psychostimulants did not differ from controls in the average number of medical events/conditions (2.7 vs 1.9, respectively; T = 1.56, NS). In contrast, cases differed from controls in the number of presumably parentrelated conditions (2.2 vs 0.4, respectively; T = 5.01, p < 0.00 I). Also, there was a trend for cases to have more childrelated events in their medical records (3.2 vs 2.1, T = 1.65, p = 0.10). Discussion Several cautions are necessary to put our findings in perspective. First of all, there was no independent validation of the diagnosis of ADD in these children; thus, our findings may apply only to children who are presumed to have ADD
800
JENSEN ET AL.
and are treated with psychostimulants. Findings may not apply to children with ADD who are treated with other means (it was not possible to locate ADD-diagnosed children who did not receive stimulants, since our case-finding method was the hospital pharmacy computer system that tracked medication prescriptions). Secondly, although military medical records may have the advantage of being more complete than civilian records, the data available to us were only as good as each physician's examination and recording practices. Also, it is possible that some of the children in this study (cases and/or controls) received treatment outside the military system. An additional concern is that the direction of causality is not clear in our results. Possibly, some of the psychosocial turmoil these families experienced was a result of the child's ADD symptoms. Alternatively, the apparent relationship between the psychosocial stressors and the child's ADD could be the result of a third, underlying etiologic factor (e.g.,genetic mechanisms in both the child and parent). Nonetheless, interesting trends emerge from this review of records, which are consistent with initial hypotheses. Events reflecting presumably anxiety-proving events to the child (e.g., medical treatment of the genitalia, trauma requiring sutures or hospitalization, or other extensive and/or painful procedures) and events reflecting potential anxiety-arousing issues in the relationship between the child and his/her caretakers are more frequent in stimulant-treated children than controls. All of these events occurred before the diagnosis of ADD and the initiation of treatment with stimulants. It is of interest to note that children being treated with stimulants had twice as many of these potentially threatening events than non-ADD children. Possibly, the reason for the more frequent documentation of these events in the charts of stimulant-treated children is that when such children experience behavioral problems and difficulties with attention, pediatricians may be more likely to elicit and document information in the records about caregiver stability, death of caregivers, family and home conflicts, as well as look for evidence of abuse and/or neglect. Thus, the nature of the predromal symptoms of ADD (prior to the actual diagnosis and treatment of ADD) elicits more pediatrician questions about these discrete events. Nonetheless, the nature of the events reflect the kinds of psychosocial conditions in the histories of those with emerging conduct disorder (Wolkind and Rutter, 1985; Wolff, 1985). This finding may reflect the possibility that in general hospital settings pediatricians tend to use stimulants as a means of general behavioral management for parent-child relationship problems, rather than for clearly diagnosed ADD (Plomin and Foch, 1981). This is potentially quite troublesome, since treatment with stimulants alone may obscure the extent and nature of the child's and family's difficulties and delay more appropriate treatment. In a related finding, an audit of these same records revealed that only 20 (52.6%) of the 38 cases showed adequate evidence of appropriately diagnosed ADD (as indicated by the physician's report of any two of three ADD symptoms of inattention, impulsivity, and hyperactivity); furthermore, only 13 (34.2%) of these cases received any treatment other than stimulants (e.g., school interventions
and/or behavioral home management and counselling). Of course, the availability of resources to which children can be referred will affect which treatments they actually receive. However, the widespread availability of psychologic, social work, and psychiatric services (both in the military medical care system and through civilian CHAMPUS providers) suggests that other explanations underlie pediatricians' failure to consider multi-modal treatments; these findings are consistent with those of previous researchers (Bosco and Robin, 1980; Gadow, 1983; Ploman and Foch, 1981). An alternative explanation is that ADD and conduct disorders are best characterized as a single disorder, representing a continuum of behavioral responses to adverse psychosocial environments in a child who is otherwise at risk due to constitutional/genetic factors. Thus, threats to the child's sense of security (or "threats to attachment" to significant care-taking figures) may result in increased behavioral problems, characterized by distractibility, inattentiveness, impulsivity, and aggression. The nature of the psychosocial environment and the quality of the child's attachments to significant others may help discriminate between children with attention deficit disorder with emerging conduct disorder and aggression from those children with attention deficit disorder without aggressive behavior and with long-term benign outcomes. This hypothesis is consistent with the findings of researchers who have demonstrated importance of "personenvironment" interactions in the assessment, treatment, and outcome of children with ADD (Barkley and Cunningham, 1979; Lambert and Hartsough, 1984; Mash and Johnston, 1982; Milich and Loney, 1979; Weiss et aI., 1985; Whalen and Henker, 1980). Analysis of the records of the early developmental histories ofa number of these children is interesting, in that it indicates that the ADD symptoms and hyperactivity may represent undiagnosed anxiety disorders in some children with presumed ADD. Several children manifested overt behavioral problems only after potentially traumatic events (e.g., circumcision at age 3, dog bite to the face at age 4, etc.). Although it is possible that these children would have developed ADD anyway, these findings suggest that an atypical anxiety disorder should be considered as a part of the differential diagnosis of ADD, especially when ADD-like symptoms demonstrate a recent and sudden onset, with no prior history consistent with ADD. These findings also indicate that ADD symptoms may result from adverse events in the home environment (e.g., divorce, marital conflicts, child abuse/neglect, etc.). Some children may become anxious and insecure about the availability and quality of their caretaking relationships and manifest behavioral responses to this anxiety by increased inattentiveness, hyperactivity, and decreased responsiveness to guidance and structure from others. Interestingly, depression and separation anxiety have been reported as a side effect of stimulant treatment of ADD (Barcai, 1969; Dulcan, 1985). A paradoxical relationship between ADD and separation anxiety has also been described during the successful psychotherapeutic treatment of ADD: as ADD symptoms begin to subside, separation anxiety symptoms may emerge (Jensen, 1985). An interesting canine model of hyperkinesis responsive to stimulants, but etiologically related to separation distress
PSYCHOSOCIAL AND MEDICAL HISTORIES OF ADD CHILDREN
in the animals has been reported as well (Corson et al., 1980). It is not clear whether the relationship between ADD and anxiety symptoms is paradoxical, or if the anxiety symptoms merely become more apparent once the ADD symptoms are treated. This intriguing question must await further research. Additional research on ADD must be done to tease out the differences between subgroups of ADD children with and without aggression, with and without adverse psychosocial environments, and with and without associated psychiatric symptoms and disorders (e.g., depression, anxiety, and learning disorders). As Fish (1971) has noted, the "one child, one drug," hypothesis of hyperactivity and ADD is truly a myth. Etiologies as diverse as perinatal, traumatic, genetic, environmental, post-traumatic, and gene-environment interactions are all possible. Much more work needs to be done to tease out the various possibilities and subtype children in terms of etiology, treatment responsiveness, and outcome. Unfortunately, in terms of subtyping ADD children, most research to date has focused on treatment responsiveness. With one exception (Taylor et aI., 1986b) strong evidence has not been forthcoming that ADD children can be reasonably subtyped on the basis of clinical response. If the evidence presented here is borne out in future studies, more research needs to address the potential overlap of ADD with anxiety and depressive conditions, and the associations of these conditions with concurrent family stressors, the quality of parent-child relationships, parental psychopathology, and children's self-reports of depression and anxiety. References Achenbach, T. M. (1978), The classification of child psychopathology. Psychol. Bull., 85:1275-1301. Barcai, A. (1969), The emergence of neurotic conflict in some children after successful administration of dextroamphetamine. J. Child Psychol. Psychiatry, 10:269-276. Barkley, R. A. (1981), Hyperactive Children: A Handbook for Diagnosis and Treatment. New York: Guilford Press. - - Cunningham, C. E. (1979), The effects of methylphenidate on the mother-child interactions of hyperactive children. Arch. Gen. Psychiatry, 36:201-208. Bosco, J. J., & Robin, S. S. (1980), Hyperkinesis: prevalence and treatment. In: Hyperactive Children: The Social Ecology ofidentification and Treatment, eds. C. K. Whalen & B. Henker. New York: Academic Press, pp. 173-178. Cole, S. O. (1975), Hyperkinetic children. Am. J. Orthopsychiatry, 45:28-37. Conners, C. K., & Wells, K. C. (1986), Hyperkinetic Children: A Neuropsychosocial Approach. Beverly Hills, Calif.: Sage Publications. Corson, S. A., Corson, E., Becker, R. E. et al. (1980), Interaction of genetics and separation in canine hyperkinesis and in differential responses to amphetamines. Pavlov. 1. BioI. Sci., 15:5-11. Dulcan, M. K. (1985), The psychopharmacologic treatment of children and adolescents with attention deficit disorder. Psychiatr. Ann., 16:59-86. Eisenberg, L. (1971), Principles of drug-therapy in child psychiatry with special reference to stimulant drug. Am. 1. Orthopsychiatry,
801
41:371-379. Fish, B. (1971), The "one child, one drug" myth of stimulants in hyperkinesis. Arch. Gen. Psychiatry, 25: 193-203. Gadow, K. D. (1983), Pharmacotherapy for behavior disorders. Clin. Pediatr., 22:48-53. Hinshaw, S. P. (1987), On the distinction between attentional deficits/ hyperactivity and conduct problems/aggression in child psychopathology. Psychol. Bull., 101:443-463. Jensen, P. S. (1985), Separating psychological factors from brain trauma in treating a hyperactive child. Hosp. Community Psychiatry, 36:711-713. Lambert, N. M. & Hartsough (1984), Contribution of predispositional factors to the diagnosis of hyperactivity. Am. J. Orthopsychiatry, 54:97-109. Lennard, H. L., Epstein, L. J., Bernstein, A. & Ransom, D. C. (1970), Hazards implicit in prescribing psychoactive drugs. Science, 169:438-441. Mash, E. J. & Johnston, C. (1982), A comparison of the mother-child interactions of younger and older hyperactive and normal children. Child Dev., 53:1371-1381. Milich, R. S. & Loney, J. (1979), The role of hyperactive and aggressive symptomatology in predicting adolescent outcome among hyperactive children. J. Pediatr. Psychol., 4:93-112. Plomin, R. & Foch, T. T. (1981), Hyperactivity and pediatrician diagnoses, parental ratings, specific cognitive abilities, and laboratory measures. J. Abnormal Child Psychol., 9:55-64. Robin, S. S. & Bosco, J. J. (1980), Hyperkinesis as a pathology and as a social metaphor. In: The Ecosystem of the "Sick" Child, eds. S. Salzinger, J. Antrobus & J. Glick. New York: Academic Press, pp.167-184. Ross, D. M. & Ross, S. A. (1982), Hyperactivity: Current Issues, Research and Theory (2nd Edition). New York: Wiley. Rutter, M. (1983), Syndromes attributed to "minimal brain dysfunction" in childhood. Am. J. Psychiatry, 139:21-33. Satterfield, J. H., Satterfield, B. T. & Schell, A. M. (1987), Therapeutic interventions to prevent delinquency in hyperactive boys. J. Am. Acad. Child Adolesc. Psychiatry, 26:56-64. Shaffer, D. & Greenhill, L. (1979), A critical note on the predictive validity of the "hyperkinetic syndrome." J. Child. Psychol. Psychiatry,20:61-72. Taylor, E. A. (1986), Childhood hyperactivity. Br. J. Psychiatry, 149:562-573. - - Schachar, R. & Wieselberg, M. (1986a), Conduct disorder and hyperactivity. Br. J. Psychiatry, 149:760-767. - - Everitt, B., Thorley, G., Rutter, M. & Wieselberg, M. (l986b), Conduct disorder and hyperactivity. Br. J. Psychiatry, 149:768777. Weiss, G., Hechtman, L., Milroy, T. & Perlman, T. (1985), Psychiatric status of hyperactives as adults. J. Am. Acad. Child Adolesc. Psychiatry, 24:211-220. Werry, J. S., Reeves, J. C. & Elkind, G. S. (1987), Attention deficit, conduct, oppositional, and anxiety disorders in children. I. A review of research in differentiating characteristics. J. Am. Acad. Child Adolesc. Psychiatry, 26:133-143. Whalen, C. K. & Henker, B. (1980), The social ecology of psychostimulant treatment. In: Hyperactive Children: The Social Ecology of Identification and Treatment, eds. C. K. Whalen & B. Henker. New York: Academic Press, pp. 3-51. Wolff, S. (1985), Non-delinquent disturbances of conduct. In: Child and Adolescent Psychiatry, eds. M. Rutter & L. Hersov. Oxford: Blackwell Scientific Publications, pp. 401-413. Wolkind, S. & Rutter, M. (1985), Separation, loss, and family relationships. In: Child and Adolescent Psychiatry, eds. M. Rutter & L. Hersov. Oxford: Blackwell Scientific Publications, pp. 34-57.
difficult if he/she has to consult with schools, facilitate special education arrangements, and coordinate a range of behavioral and counseling strategies for the child and parents. Furthermore, the short-term effectsof medication may be so dramatic that both the pediatrician and parent may take a "wait and see" attitude about the implementation of other treatments. The possible stigma of seeing a child psychiatrist or other mental health professional may contribute to this reluctance; the lack of availability of these professionals may also playa part. In addition, reliable information about any child's behavior is difficult to gather and actual agreement between various raters of a child's behavior is poor. For example, correlations between parent-, teacher-, and clinician-completed ratings of child behaviors are as a rule quite low, with Pearson correlations usually about .30 (Achenbach, 1978). Obtaining adequate historical data in the developmental and medical histories of ADD children is likely to be quite unreliable as well, as parents that have children with significant handicaps tend to selectively remember events in order to figure out "what went wrong." Given the evidence of these difficulties in the routine clinical evaluation and management of children with ADD, better understanding of the factors preceding the clinician's diagnosis and treatment of a child for ADD is needed. Parent recall of the child's developmental physical and psychosocial events is highly suspect, therefore more reliable means of determining this information are necessary. Such information could enhance our understanding about the early events possibly related to the development of behavioral problems and eventual treatment for ADD. For these reasons, we sought to screen medical records from birth to the point of beginning treatment for ADD. Our hospital pharmacy utilizes a computerized prescription system that allows us to identify all cases of children being treated with psychostimulants for ADD. Based on our clinical experience, we hypothesized that these children's medical records, compared with other pediatric records matched for sex, would show an increase not only in histories of perinatal physical stressors (low birth weight, low APGAR scores, etc.), but also in number of other developmental stressors (psychological and physical), reflecting adverse environmental conditions.
Accepted April 19. 1988. From the Dept. I?( Psychiatry and Neurology, Eisenhower Army Medical Center. Fort Gordon. and the Dept. 0/ Psychiatry and Health Behavior. Medical College ofGeorgia, Augusta, Ga. The opinions and assertions contained herein are the private views ofthe authors and are not to he construed as official or as reflecting the views ofthe Department ofthe Army or the Department 4 Defense. The authors wish to thank Mrs. Rosina Martinez for her careful editing and preparation ofthe manuscript. Reprints may he requested from MAJ Peter S. Jensen. MC, P.D. Box 342. Eisenhower Army Medical Center. Fort Gordon. GA 309055650. 0890-8567/88/2706-0798$02.00/0© 1988 by the American Academy of Child and Adolescent Psychiatry.
798
799
PSYCHOSOCIAL AND MEDICAL HISTORIES OF ADD CHILDREN
Method Thirty-eight charts of children (32 boys, 6 girls) being treated with psychostimulants for ADD at one general hospital clinic were screened from birth to the present for the frequency of medical conditions, hospitalizations, and other information in the medical record (these medical records are unique in that in the military system the child's medical record from birth follows the child from site to site, as the father is transferred in his military duties; thus, a longitudinal record of the child's medical history is readily available). The 38 charts comprised all cases of children being treated with stimulants during a 3-month time period. The events screened in the medical record included complications at birth and during the newborn period (defined as infant needing resuscitation, APGAR scores of less than 5/8, infant needing continued hospitalization 4 or more days after the birth, perinatal infections, or congenital deformities), history of asthma, history of repeated ear infection or chronic otitis (defined as 3 or more ear infections during childhood), history of one or more hospitalizations, history of medical treatment for problems with the genitalia (e.g., torsion of the testicle, circumcision after the perinatal period), trauma requiring sutures or extensive/painful procedures, evidence in the chart of prolonged separations from caregivers (e.g., medical record documentation of power of attorney being given to someone else to care for the child, evidence of foster care placement), history of alternating caregivers (e.g., child being brought in by daycare worker or a family member other than a parent for treatment), deaths of caregivers, evidence of divorce of parents, documentation in the record of fights between parents, evidence of parent-child conflicts, documented child abuse or neglect, and suspected abuse or neglect. The frequency of these conditions was compared with 38 control records gleaned from a regular pediatric outpatient setting where children come in for routine medical appointments. These records were matched for sex of child with the index charts. Children's average age did not differ between cases and controls (9.2 vs 9.4 years, respectively; range 5 to 14 years). Results Frequency of conditions were compared between the cases (children being treated with stimulants) and controls using the Chi square statistic. Results are presented in Table I. Those events that conceptually appeared as potentially threatening to the child (e.g., events that may increase the child's anxiety or threaten the stability of the relationship between the parent and the child) were defined as threats to the security of parent-child relationship or threats to attachment. All of these events (see Table I) were summed for each child to determine the total number of threatening events that the child had experienced. Children being treated with psychostimulants had an average number of 4.6 events, while control children had an average of 2.2 events (T = 3.53 p < 0.00 I). One or more threatening events were recorded for 94.7% of the ADD cases (36 of 38 children), while only 47.4% of controls had one or more threatening events (18 of 38) (x 2 = 20.73, p < 0.(01). To further clarify the relationship between the background
TABLE I.
Frequency of EventsGleanedfrom Records ADD Cases (N= 38)
Complications of birth/ newborn period History of asthma Chronic otitis History of one or more hospitalizations" Medical treatment of genitalia" Trauma requiring sutures, hospitalization, or extensive/painful procedures" Alternating caregivers" Separation from caregivers" Deaths of caregivers" Ingestions" Divorce of parents" Fights between parents" Conflicts with child" Documented abuse" Suspected abuse/neglect"
Controls (N= 38)
x2
%
N
%
N
26.3 18.4 39.5
10 7 IS
10.5 10.5 28.9
4 4 II
3.15 0.96 0.94
36.8
14
28.9
II
0.54
39.5
15
18.4
7
4.09
68.4 18.4
26 7
39.5 2.6
IS
6.41· 5.03·
23.7 5.3 13.2 21.1 36.8 23.7 10.5 55.3
9 2 5 8 14 9 4 21
2.6 2.6 7.9 0 2.6 0 2.6 15.8
I I
I
3 0 I
0 I
6
7.37·· 0.35 0.56 8.94·· 14.04·· 10.21·· 1.93 12.93··
" Threat to attachment. • p < 0.05, •• p < 0.01.
psychosocial and medical factors and "caseness," the variables were separated into three categories: (I) medical variables (complications of birth/newborn period, history of asthma, chronic otitis, history of hospitalization(s), medical treatment ofthe genitalia, and trauma requiring sutures, etc.); (2) parentrelated variables, possibly reflecting the nature of the caretaking environment (alternating caregivers, separations from caregivers, death of caregivers, ingestions, divorce, marital conflicts, parent-child conflicts, suspected and documented abuse); and (3) child-related variables, possibly reflecting the nature of the child's disorder (trauma requiring sutures, etc., ingestions, parent-child conflicts, and suspected abuse). We deliberately allowed several items to be tallied in two categories (e.g., ingestions), because it was not possible to determine whether such incidents reflect the nature of the home environment/parental supervision, the severity of the child's disorder, or both. Children treated with psychostimulants did not differ from controls in the average number of medical events/conditions (2.7 vs 1.9, respectively; T = 1.56, NS). In contrast, cases differed from controls in the number of presumably parentrelated conditions (2.2 vs 0.4, respectively; T = 5.01, p < 0.00 I). Also, there was a trend for cases to have more childrelated events in their medical records (3.2 vs 2.1, T = 1.65, p = 0.10). Discussion Several cautions are necessary to put our findings in perspective. First of all, there was no independent validation of the diagnosis of ADD in these children; thus, our findings may apply only to children who are presumed to have ADD
800
JENSEN ET AL.
and are treated with psychostimulants. Findings may not apply to children with ADD who are treated with other means (it was not possible to locate ADD-diagnosed children who did not receive stimulants, since our case-finding method was the hospital pharmacy computer system that tracked medication prescriptions). Secondly, although military medical records may have the advantage of being more complete than civilian records, the data available to us were only as good as each physician's examination and recording practices. Also, it is possible that some of the children in this study (cases and/or controls) received treatment outside the military system. An additional concern is that the direction of causality is not clear in our results. Possibly, some of the psychosocial turmoil these families experienced was a result of the child's ADD symptoms. Alternatively, the apparent relationship between the psychosocial stressors and the child's ADD could be the result of a third, underlying etiologic factor (e.g.,genetic mechanisms in both the child and parent). Nonetheless, interesting trends emerge from this review of records, which are consistent with initial hypotheses. Events reflecting presumably anxiety-proving events to the child (e.g., medical treatment of the genitalia, trauma requiring sutures or hospitalization, or other extensive and/or painful procedures) and events reflecting potential anxiety-arousing issues in the relationship between the child and his/her caretakers are more frequent in stimulant-treated children than controls. All of these events occurred before the diagnosis of ADD and the initiation of treatment with stimulants. It is of interest to note that children being treated with stimulants had twice as many of these potentially threatening events than non-ADD children. Possibly, the reason for the more frequent documentation of these events in the charts of stimulant-treated children is that when such children experience behavioral problems and difficulties with attention, pediatricians may be more likely to elicit and document information in the records about caregiver stability, death of caregivers, family and home conflicts, as well as look for evidence of abuse and/or neglect. Thus, the nature of the predromal symptoms of ADD (prior to the actual diagnosis and treatment of ADD) elicits more pediatrician questions about these discrete events. Nonetheless, the nature of the events reflect the kinds of psychosocial conditions in the histories of those with emerging conduct disorder (Wolkind and Rutter, 1985; Wolff, 1985). This finding may reflect the possibility that in general hospital settings pediatricians tend to use stimulants as a means of general behavioral management for parent-child relationship problems, rather than for clearly diagnosed ADD (Plomin and Foch, 1981). This is potentially quite troublesome, since treatment with stimulants alone may obscure the extent and nature of the child's and family's difficulties and delay more appropriate treatment. In a related finding, an audit of these same records revealed that only 20 (52.6%) of the 38 cases showed adequate evidence of appropriately diagnosed ADD (as indicated by the physician's report of any two of three ADD symptoms of inattention, impulsivity, and hyperactivity); furthermore, only 13 (34.2%) of these cases received any treatment other than stimulants (e.g., school interventions
and/or behavioral home management and counselling). Of course, the availability of resources to which children can be referred will affect which treatments they actually receive. However, the widespread availability of psychologic, social work, and psychiatric services (both in the military medical care system and through civilian CHAMPUS providers) suggests that other explanations underlie pediatricians' failure to consider multi-modal treatments; these findings are consistent with those of previous researchers (Bosco and Robin, 1980; Gadow, 1983; Ploman and Foch, 1981). An alternative explanation is that ADD and conduct disorders are best characterized as a single disorder, representing a continuum of behavioral responses to adverse psychosocial environments in a child who is otherwise at risk due to constitutional/genetic factors. Thus, threats to the child's sense of security (or "threats to attachment" to significant care-taking figures) may result in increased behavioral problems, characterized by distractibility, inattentiveness, impulsivity, and aggression. The nature of the psychosocial environment and the quality of the child's attachments to significant others may help discriminate between children with attention deficit disorder with emerging conduct disorder and aggression from those children with attention deficit disorder without aggressive behavior and with long-term benign outcomes. This hypothesis is consistent with the findings of researchers who have demonstrated importance of "personenvironment" interactions in the assessment, treatment, and outcome of children with ADD (Barkley and Cunningham, 1979; Lambert and Hartsough, 1984; Mash and Johnston, 1982; Milich and Loney, 1979; Weiss et aI., 1985; Whalen and Henker, 1980). Analysis of the records of the early developmental histories ofa number of these children is interesting, in that it indicates that the ADD symptoms and hyperactivity may represent undiagnosed anxiety disorders in some children with presumed ADD. Several children manifested overt behavioral problems only after potentially traumatic events (e.g., circumcision at age 3, dog bite to the face at age 4, etc.). Although it is possible that these children would have developed ADD anyway, these findings suggest that an atypical anxiety disorder should be considered as a part of the differential diagnosis of ADD, especially when ADD-like symptoms demonstrate a recent and sudden onset, with no prior history consistent with ADD. These findings also indicate that ADD symptoms may result from adverse events in the home environment (e.g., divorce, marital conflicts, child abuse/neglect, etc.). Some children may become anxious and insecure about the availability and quality of their caretaking relationships and manifest behavioral responses to this anxiety by increased inattentiveness, hyperactivity, and decreased responsiveness to guidance and structure from others. Interestingly, depression and separation anxiety have been reported as a side effect of stimulant treatment of ADD (Barcai, 1969; Dulcan, 1985). A paradoxical relationship between ADD and separation anxiety has also been described during the successful psychotherapeutic treatment of ADD: as ADD symptoms begin to subside, separation anxiety symptoms may emerge (Jensen, 1985). An interesting canine model of hyperkinesis responsive to stimulants, but etiologically related to separation distress
PSYCHOSOCIAL AND MEDICAL HISTORIES OF ADD CHILDREN
in the animals has been reported as well (Corson et al., 1980). It is not clear whether the relationship between ADD and anxiety symptoms is paradoxical, or if the anxiety symptoms merely become more apparent once the ADD symptoms are treated. This intriguing question must await further research. Additional research on ADD must be done to tease out the differences between subgroups of ADD children with and without aggression, with and without adverse psychosocial environments, and with and without associated psychiatric symptoms and disorders (e.g., depression, anxiety, and learning disorders). As Fish (1971) has noted, the "one child, one drug," hypothesis of hyperactivity and ADD is truly a myth. Etiologies as diverse as perinatal, traumatic, genetic, environmental, post-traumatic, and gene-environment interactions are all possible. Much more work needs to be done to tease out the various possibilities and subtype children in terms of etiology, treatment responsiveness, and outcome. Unfortunately, in terms of subtyping ADD children, most research to date has focused on treatment responsiveness. With one exception (Taylor et aI., 1986b) strong evidence has not been forthcoming that ADD children can be reasonably subtyped on the basis of clinical response. If the evidence presented here is borne out in future studies, more research needs to address the potential overlap of ADD with anxiety and depressive conditions, and the associations of these conditions with concurrent family stressors, the quality of parent-child relationships, parental psychopathology, and children's self-reports of depression and anxiety. References Achenbach, T. M. (1978), The classification of child psychopathology. Psychol. Bull., 85:1275-1301. Barcai, A. (1969), The emergence of neurotic conflict in some children after successful administration of dextroamphetamine. J. Child Psychol. Psychiatry, 10:269-276. Barkley, R. A. (1981), Hyperactive Children: A Handbook for Diagnosis and Treatment. New York: Guilford Press. - - Cunningham, C. E. (1979), The effects of methylphenidate on the mother-child interactions of hyperactive children. Arch. Gen. Psychiatry, 36:201-208. Bosco, J. J., & Robin, S. S. (1980), Hyperkinesis: prevalence and treatment. In: Hyperactive Children: The Social Ecology ofidentification and Treatment, eds. C. K. Whalen & B. Henker. New York: Academic Press, pp. 173-178. Cole, S. O. (1975), Hyperkinetic children. Am. J. Orthopsychiatry, 45:28-37. Conners, C. K., & Wells, K. C. (1986), Hyperkinetic Children: A Neuropsychosocial Approach. Beverly Hills, Calif.: Sage Publications. Corson, S. A., Corson, E., Becker, R. E. et al. (1980), Interaction of genetics and separation in canine hyperkinesis and in differential responses to amphetamines. Pavlov. 1. BioI. Sci., 15:5-11. Dulcan, M. K. (1985), The psychopharmacologic treatment of children and adolescents with attention deficit disorder. Psychiatr. Ann., 16:59-86. Eisenberg, L. (1971), Principles of drug-therapy in child psychiatry with special reference to stimulant drug. Am. 1. Orthopsychiatry,
801
41:371-379. Fish, B. (1971), The "one child, one drug" myth of stimulants in hyperkinesis. Arch. Gen. Psychiatry, 25: 193-203. Gadow, K. D. (1983), Pharmacotherapy for behavior disorders. Clin. Pediatr., 22:48-53. Hinshaw, S. P. (1987), On the distinction between attentional deficits/ hyperactivity and conduct problems/aggression in child psychopathology. Psychol. Bull., 101:443-463. Jensen, P. S. (1985), Separating psychological factors from brain trauma in treating a hyperactive child. Hosp. Community Psychiatry, 36:711-713. Lambert, N. M. & Hartsough (1984), Contribution of predispositional factors to the diagnosis of hyperactivity. Am. J. Orthopsychiatry, 54:97-109. Lennard, H. L., Epstein, L. J., Bernstein, A. & Ransom, D. C. (1970), Hazards implicit in prescribing psychoactive drugs. Science, 169:438-441. Mash, E. J. & Johnston, C. (1982), A comparison of the mother-child interactions of younger and older hyperactive and normal children. Child Dev., 53:1371-1381. Milich, R. S. & Loney, J. (1979), The role of hyperactive and aggressive symptomatology in predicting adolescent outcome among hyperactive children. J. Pediatr. Psychol., 4:93-112. Plomin, R. & Foch, T. T. (1981), Hyperactivity and pediatrician diagnoses, parental ratings, specific cognitive abilities, and laboratory measures. J. Abnormal Child Psychol., 9:55-64. Robin, S. S. & Bosco, J. J. (1980), Hyperkinesis as a pathology and as a social metaphor. In: The Ecosystem of the "Sick" Child, eds. S. Salzinger, J. Antrobus & J. Glick. New York: Academic Press, pp.167-184. Ross, D. M. & Ross, S. A. (1982), Hyperactivity: Current Issues, Research and Theory (2nd Edition). New York: Wiley. Rutter, M. (1983), Syndromes attributed to "minimal brain dysfunction" in childhood. Am. J. Psychiatry, 139:21-33. Satterfield, J. H., Satterfield, B. T. & Schell, A. M. (1987), Therapeutic interventions to prevent delinquency in hyperactive boys. J. Am. Acad. Child Adolesc. Psychiatry, 26:56-64. Shaffer, D. & Greenhill, L. (1979), A critical note on the predictive validity of the "hyperkinetic syndrome." J. Child. Psychol. Psychiatry,20:61-72. Taylor, E. A. (1986), Childhood hyperactivity. Br. J. Psychiatry, 149:562-573. - - Schachar, R. & Wieselberg, M. (1986a), Conduct disorder and hyperactivity. Br. J. Psychiatry, 149:760-767. - - Everitt, B., Thorley, G., Rutter, M. & Wieselberg, M. (l986b), Conduct disorder and hyperactivity. Br. J. Psychiatry, 149:768777. Weiss, G., Hechtman, L., Milroy, T. & Perlman, T. (1985), Psychiatric status of hyperactives as adults. J. Am. Acad. Child Adolesc. Psychiatry, 24:211-220. Werry, J. S., Reeves, J. C. & Elkind, G. S. (1987), Attention deficit, conduct, oppositional, and anxiety disorders in children. I. A review of research in differentiating characteristics. J. Am. Acad. Child Adolesc. Psychiatry, 26:133-143. Whalen, C. K. & Henker, B. (1980), The social ecology of psychostimulant treatment. In: Hyperactive Children: The Social Ecology of Identification and Treatment, eds. C. K. Whalen & B. Henker. New York: Academic Press, pp. 3-51. Wolff, S. (1985), Non-delinquent disturbances of conduct. In: Child and Adolescent Psychiatry, eds. M. Rutter & L. Hersov. Oxford: Blackwell Scientific Publications, pp. 401-413. Wolkind, S. & Rutter, M. (1985), Separation, loss, and family relationships. In: Child and Adolescent Psychiatry, eds. M. Rutter & L. Hersov. Oxford: Blackwell Scientific Publications, pp. 34-57.