Placebo Treatment of Inattentive ADHD

I ran into this study the other day while I was reading up on something else that I found kind of amazing. The researchers of the study were trying to figure out the degree of placebo effect that you were going to get when you gave individuals with ADHD a new drug treatment. 

The researchers used data gathered from a study on Strattera and determined that if you had never been given any drug treatment OR if you were predominantly inattentive, your response to a placebo was going to be pretty good.

It is important to gauge placebo effect when studying a new drug because if you give 10 people Strattera and ten people a sugar pill and the people on the Strattera report 40% fewer symptoms you might say, "Wow, this drug is fantastic, my patient is 40% better," until you realize that the people on the sugar pill (the placebo) also reported 40% fewer symptoms and the Strattera was no better than a placebo in reducing symptoms.

The researchers of the study found that if you were predominantly inattentive, or if you had never been treated with medicine for ADHD you were going to have 40% fewer symptoms when measured by the ADHD rating scale by simply taking a sugar pill. This was not true with people with combined type ADHD. They did not have a big response to the sugar pills. This was also not true of people who had previously been treated with stimulants.

This Inattentive ADHD finding reminds me a little of what Woody Allen has said about life. Ninety percent is just showing up. I believe that with Inattentive ADHD paying attention to the disease (just 'showing up' with a diagnosis) makes a good bit of difference. I believe that if you pay attention to inattentive kids, they do better. If you give them omega-3, vitamins, coffee, encouragement, respect, a mission or a task relevant to their lives... they do better.

Maybe all of these tactics help simply because of the placebo effect. Maybe they would do better if you just ask them to do better. I do not know but it makes sense to me that the first step to improving the symptoms of  Inattentive ADHD if the recognition of the problem and the formulation of a plan, any plan, that will address the inattention.

It may go without saying but it is also important to continuously remind the inattentive of what you are doing to encourage their focus and attention because if you do not set up a reminder system, those of us with Inattentive ADHD are like to forget.

Characteristics of Placebo Responders in Pediatric Clinical Trials of Attention-Deficit/Hyperactivity Disorder.

Newcorn JH, Sutton VK, Zhang S, Wilens T, Kratochvil C, Emslie GJ, D'Souza DN, Schuh LM, Allen AJ.

RESULTS: A subset analysis of patients completing 6 weeks of treatment (to eliminate the effects of early dropout) identified inattentive subtype and lack of previous stimulant experience as significant predictors of robust placebo response.

Journal of the American Academy of Child and Adolescent Psychiatry. 2009 Oct 23. 

Inattentive ADHD, Out in the Cold

I have told you many times about the great school that my children attend. It is a school that above all, KNOWS and genuinely LIKES kids. The teachers work in an environment where they are allowed to control the destiny of their classrooms. This makes teachers happy and happy teachers are more likely to have happy students. This school is pretty 'State of the Art” in many ways. It is, however, not perfect especially with regards to its knowledge of Inattentive ADHD.

It is not really the school's fault; there is precious little knowledge to be had about Inattentive ADHD. The current diagnostic criteria and treatment principals used for spotting and treating Inattentive ADHD are crude and poorly studied. Recently published information regarding this condition (1985 - 2010) tends to lump treatment options for Inattentive ADHD with the treatment options for Hyperactive/Impulsive ADHD. Older information, pre-1985, tends to lump the diagnosis of this condition with the diagnosis of Sluggish Cognitive Tempo.

When my eldest son's second grade teacher, a teacher who adores children and who has taught successfully for over 45 years, gave us this piece of paper with a profile of a kid that she thought was just like our son, a sheet of paper that explained, in kind of vague terms, why he needed ADHD medication, I realized that the 'State of the Art' school, that my kid's attended, knew little about Inattentive ADHD.   They knew that there were some kids that were inattentive, likely to be distracted, spaced out, somewhat impulsive and sluggish who needed to be evaluated for ADHD but that was about it.

I cannot tell you the number of parents of Predominantly Inattentive children, that I know, who have received, at their teacher conference, some ADHD like sheet of paper and have rejected the information in it outright. The information is these particular pieces of paper does not really describe a child with Inattentive ADHD, the materials more accurately describes something else. Sometimes the materials describe a child with Sluggish Cognitive Tempo who is also a bit impulsive. Sometimes the materials will describe a child who is impulsive and inattentive but not sluggish or a child that is hyperactive, inattentive, and impulsive.

The worse schools give no materials at all and do not even notice your inattentive child. These schools are happy to have a spaced out, quiet child sitting in the classroom. If that child manages to test in the average range for reading and math he will coast through his school life totally under the radar and whatever opportunity this child might have had to maybe learn something in school will be lost.

Not all people who are Predominantly Inattentive are also predominantly sluggish. Most people with Inattentive ADHD are neither impulsive nor hyperactive. Many of us are not sluggish at all and some of us are only a bit sluggish and on a sluggish to hyperactive bell curve would fall in the 'normally active' range. Most of us with inattentive ADHD are no more impulsive than would be considered normal. If you happen to have a child, like I have and a child like I was as a kid, that is Predominantly Inattentive and is NOT impulsive or predominantly Sluggish, these generic ADHD descriptive materials will not resonate with you and your child will likely not get any help.

After I got the ADHD materials from my son's teacher, I started thinking about the lack of information available about Inattentive ADHD and I started thinking that I wanted to learn more about the materials available for teachers. There is very little available. Teachers need better material and need to be educated regarding the differences between inattentive ADHD and the other types of ADHD. They need to know that NOT all children with Predominantly Inattentive ADHD are predominantly sluggish.  Teachers are often the first step in the process of getting help for a person with Inattentive ADHD but teachers need better resources than are currently available.

If the American Psychiatric Association (APA) gives Inattentive ADHD a category of their own in the DSM V (The manual that mental health providers use for diagnosing), people with Predominantly Inattentive ADHD may finally travel out of the cold woods and into a warm classroom. Teachers, like my son's second grade teacher, will have better resources to distribute to parents of children with Inattentive ADHD and these same teachers will be better able to guide parents towards community resources where the parent can find the further help that they will need.

I am hoping, for the sake of the many people with Inattentive ADHD who have gone through life thought of as lazy, mentally slow and incompetent that the APA does not bury this condition in with the Hyperactive or Impulsive types of ADHD as it did in the DSM IV. We know, from our current experience that this approach has left most ADHD-PI kids and  their families all alone, out in the cold, searching for answers.

Let's Drink More Coffee!!!

The scientific ADHD community in Brazil has been studying caffeine and ADHD for a  while and they have recently published yet another study (see below) confirming that in animal models, caffeine really helps ADHD symptoms especially those seen in Inattentive ADHD.  Interestingly, in this animal study, caffeine worsened memory in 'normal' rats but improved memory skills in ADHD rats.

I find that coffee helps me focus and makes me infinitely more productive.  My inattentive son drinks coffee and it helps him focus tremendously.  A cup in the morning and a cup at homework time is usually enough to keep him on track.

This study used 3mg per kilogram.  My inattentive son weighs about 30 kg so that would translate to an amount of about 90 mg every 6 hours which is just about one cup of coffee every 6 hours.  The symptoms of Inattentive ADHD can often be treated with something like coffee because these patients have focus problems but are often not otherwise different than other non-ADHD folks.

My younger son does not drink coffee but I believe that this is kind of beside the point.  The symptoms of his Hyperactive/Impulsive ADHD are, unfortunately, much more difficult to treat.  ADHD when there is an impulsive behavior component is a multifaceted, intrusive and often destructive problem that can require counseling, medication and an attentive risk management approach to care.  The co-morbidities (self esteem and depression problems, substance abuse risks, behavioral and conduct disorders, etc) associated with Impulsive ADHD makes the treatment of Impulsive ADHD folks, in my opinion, much more difficult.  

Caffeine in Impulsive ADHD may help memory but caffeine's inability to treat the other symptoms of Impulsive ADHD, makes it not a great option for non-Inattentive ADHD

Behav Brain Res. 2010 Dec 20;215(1):39-44. Epub 2010 Jun 25.
Chronic caffeine treatment during prepubertal period confers long-term cognitive benefits in adult spontaneously hypertensive rats (SHR), an animal model of attention deficit hyperactivity disorder (ADHD).
Pires VA, Pamplona FA, Pandolfo P, Prediger RD, Takahashi RN.
Departamento de Farmacologia, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Campus Universitário Trindade, 88049-900 Florianópolis, SC, Brazil.

Abstract

The spontaneously hypertensive rat (SHR) is frequently used as an experimental model for the study of attention deficit hyperactivity disorder (ADHD) since it displays behavioural and neurochemical features of ADHD. Increasing evidence suggests that caffeine might represent an important therapeutic tool for the treatment of ADHD and we recently demonstrated that the acute administration of caffeine improves several learning and memory impairments in adult SHR rats. Here we further evaluated the potential of caffeine in ADHD therapy. Female Wistar (WIS) and SHR rats were treated with caffeine (3mg/kg, i.p.) or methylphenidate (MPD, 2mg/kg, i.p.) for 14 consecutive days during the prepubertal period (post-natal days 25-38) and they were tested later in adulthood in the object-recognition task. WIS rats discriminated all the objects used, whereas SHR were not able to discriminate pairs of objects with subtle structural differences. Chronic treatment with caffeine or MPD improved the object-recognition deficits in SHR rats. Surprisingly, these treatments impaired the short-term object-recognition ability in adult WIS rats. The present drug effects are independent of changes in locomotor activity, arterial blood pressure and body weight in both rat strains. These findings suggest that chronic caffeine treatment during prepubertal period confers long-term cognitive benefits in discriminative learning impairments of SHR, suggesting caffeine as an alternative therapeutic strategy for the early management of ADHD symptoms. Nevertheless, our results also emphasize the importance of a correct diagnosis and the caution in the use of stimulant drugs such as caffeine and MPD during neurodevelopment since they can disrupt discriminative learning in non-ADHD phenotypes.