Ohio State study shows 2 drugs help adolescents with ADHD, aggression
Prescribing both a stimulant and an antipsychotic drug to children with physical aggression and attention-deficit/hyperactivity disorder (ADHD), along with teaching parents to use behavior management techniques, reduces aggressive and serious behavioral problems in the children, according to a study conducted by researchers at The Ohio State University Wexner Medical Center.
The study was conducted in conjunction with the University of Pittsburgh, Stony Brook University in New York and Case Western Reserve University in Ohio. The findings published online this week ahead of publication in the January issue of the Journal of the American Academy of Child and Adolescent Psychiatry.
“Combination pharmacotherapy is becoming common in child and adolescent psychiatry, but there has been little research evaluating it,” said first author Michael Aman, director of clinical trials at Ohio State’s Nisonger Center and emeritus professor of psychology. “Our findings may be considered somewhat controversial because they appear to support the use of two drugs over one for treating children with aggression and disruptive behavior when things do not seem to be going well. Many practitioners have been taught to ‘Keep things simple and safe’ in their medical training. In general, this is good advice.”
For the “Treatment of Severe Childhood Aggression (TOSCA) Study,” 168 children ages 6 to 12 who had been diagnosed with ADHD and displayed significant physical aggression were divided into two groups. All study participants received a psychostimulant drug called OROS methylphenidate and their parents received behavioral parent training for nine weeks. The researchers called this treatment combination “basic” because both are evidence-based and have been shown to be helpful for improving both ADHD and aggression.
Researchers wanted to see if they could expand or augment this treatment by adding a second medication. If there was room for improvement at the end of the third week, a placebo was added for the “basic group,” while the antipsychotic drug risperidone was added for participants in the “augmented group.”
Attention deficit hyperactivity disorder (ADHD) is one of the most common mental disorders in children and adolescents. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and very high levels of activity. Studies show that the number of children being diagnosed with ADHD is increasing, but it is unclear why.
- Different types of psychotherapy are effective in treating ADHD. Behavioral therapy helps teach practical skills such as how to organize tasks and manage time to complete homework assignments. It also helps children work through difficult emotions. Therapists also teach children social skills such as how to wait their turn, share toys, ask for help, or respond to teasing.
Studies show that interventions that include intensive parent education programs can help decrease ADHD problem behavior because parents are better educated about the disorder and better prepared to manage their child’s symptoms. They are taught organizational skills and how to develop and keep a schedule for their child. They are also taught how to give immediate and positive feedback for behaviors they want to encourage, and how to ignore or immediately redirect behaviors they want to discourage.
- The Multimodal Treatment Study of Children with ADHD (MTA study) is helping to inform long-term treatment decisions. For example, MTA researchers found that medication works best when treatment is regularly monitored by the prescribing doctor and the dose is adjusted based on the child’s needs. As children with ADHD mature, treatment decisions should adapt to the demands of adolescence and take into account long-term academic and behavioral problems commonly associated with ADHD.
- ADHD likely stems from interactions between genes and environmental or non-genetic factors. Several genes have been implicated in the risk for developing ADHD. One study showed that brain areas controlling attention were thinnest in children with ADHD who carried a particular version of a gene associated with brain development. However, these brain areas normalized in thickness during the teen years, coinciding with clinical improvement. Although this particular gene version increased risk for ADHD, it also predicted better clinical outcomes and higher IQ than two other versions of the same gene in youth with ADHD.
Compared to the “basic group,” the “augmented group” who received the stimulant drug and parent training plus risperidone showed significant improvement (on average with moderately better behavior) on the Nisonger Child Behavior Rating Form (NCBRF) Disruptive-Total Scale, the NCBRF Social Competence subscale and the Reactive Aggression part of the Antisocial Behavior Scale.
While there is always some risk with the addition of a second drug to the treatment package, the two drugs seemed to neutralize some of each other’s potential side effects. For instance, children in the augmented group did not seem to have as much trouble falling asleep, once the risperidone was added, Aman said.
“We conducted this study because we viewed the combination of ADHD and significant physical aggression – especially the aggression – as a serious situation,” Aman said. “It is not uncommon to use more than one medicine for other serious situations, such as when treating cancer or epilepsy for instance. Although doctors have often used stimulants and antipsychotics together in recent years, we did not have good evidence until now that they would work more effectively when carefully staged and given together.”
Other researchers include Oscar G. Bukstein, Robert L. Findling, Kenneth D. Gadow, L. Eugene Arnold, Brooke S.G. Molina, Nora K. McNamara, E. Victoria Rundberg-Rivera, Xiaobai Li, Heidi Kipp, Jayne Schneider, Eric M. Butter, Jennifer Baker, Joyce Sprafkin, Robert R. Rice, Jr., Srihari S. Bangalore, Cristan A. Farmer, Adrienne B. Austin, Kristin A. Buchan-Page, Nicole V. Brown, Elizabeth A. Hurt, and Sabrina N. Grondhuis.
This study was supported by grants from National Institute of Mental Health to The Ohio State University (R01 MH077907). The project was supported by a National Institutes of Health General Clinical Research Center grant (M01RR10710) and Clinical and Translational Science Awards from the National Center for Advancing Translational Sciences grant (8UL1TR000090-05).
Research confirms that children with ADHD are more likely to experiment with substances and start at an earlier age.
Factors that make your child more likely to use substances:
having friends who use drugs and alcohol
being aggressive, impulsive and not considering consequences.
To avoid this:
get to know your teen’s friends, and subtly encourage friendships with those who don’t use alcohol or drugs
keep your teen’s aggression under control – if necessary, ask your GP to help
read up on the signs of substance misuse, eg money going missing or ‘holes’ in spending, lying or secretive behaviour, sudden mood changes, loss of appetite, and loss of interest in school, work or friends
teach your teen about substance misuse – be accurate and don’t use scare tactics
if ADHD medication has been prescribed, try to make sure that it’s been taken. This will help to reduce impulsive behaviour and promote forward thinking behaviour. There’s no evidence that ADHD medicines increase the risk of substance misuse, rather the opposite. Taking medication as prescribed may well be protective.
If your teen does start using drugs or abusing alcohol:
don’t nag
let them know that you’re worried about them and you love him – it’s the behaviour you don’t like
help them get professional help to quit.
The Nisonger Center, a University Center for Excellence in Developmental Disabilities, is part of The Ohio State University Wexner Medical Center and was founded in 1966 to provide assistance to people with disabilities and their families, service providers and organizations by promoting inclusion of people with disabilities in education, health, employment and community settings.
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Contact: Eileen Scahill, Wexner Medical Center Public Affairs and Media Relations, 614-293-3737, or .(JavaScript must be enabled to view this email address)