June 10, 2009

Children With ADHD Drugs Score Higher on Tests

CHICAGO - Children on medicine for attention deficit disorder scored higher on academic tests than their unmedicated peers in the first large, long-term study suggesting this kind of benefit from the widely used drugs.

Wow.  WOW.  I get more actionable information from porn.


1. The comparison isn't between kids getting meds and "unmedicated peers" but kids with ADHD who get meds, and kids with ADHD who don't get meds.

1b.  "Both groups had lower scores on average than a separate group of children without ADHD."

2. The study indicates that the kids derived a benefit on test scores equivalent to 1/5 of an academic year, by 5th grade.  That would be two months.  (Still below non ADHD kids, though.)

2b.  In order to derive this benefit, kids needed to be on the medications for about 3 years consecutively; in other words, they had to "learn" while on meds.  Risk-reward?


3.
Our objective was to determine if reported medication use for attention-deficit/hyperactivity disorder is positively associated with academic achievement during elementary school.  CONCLUSIONS. The finding of a positive association between medication use...and test scores is important, given the high prevalence of attention-deficit/hyperactivity disorder and its association with low academic achievement.

You say,  "the study did find that stimulants were effective.  Wasn't that the whole point?" 

II. 

So that's the kind of study analysis they talk about in medical school but don't bother to teach.  See how awesome it is to look critically at the methodology of a study, differentiate clinical significance from statistical significance?    (Never mind that the study produced nothing new.)

This kind of analysis is the intellectual equivalent of turning a gun sideways.  Looks cool to anyone who's never actually held a gun, but dangerously unreliable when it matters most.

The question: what do the authors want to be true?


III. 

First of all, was this study really necessary, let alone important enough to end up in Pediatrics?

There are already plenty of studies examining, specifically, stimulants and school performance.  Here are seven:  1, 2, 3, 4, 5, 6, 7.

I'll admit that this study is unique in that it is prospective and long, but do we need a unique, prospective and long study of what we already know?   It isn't even important research in that it has been pretty much established that there aren't significant effects on academic performance overall in ADHD kids.  So why bother doing this study?

Or, you might ask me: "why does this study, in particular, bother you?"

The author names aren't important here, it's their degrees that are important.  6 authors-- only one an MD.  The rest are PhDs.

Do you think PhDs care about ADHD drugs?    The study isn't about the efficacy of medications; it's about the validity of ADHD.  "See?  We're studying a medical problem.  Can we get some grant money now?"

Don't send me back to my pirate ship yet.  The authors are from the Petris Center, which receives funding to examine healthcare policy.  They got $900,000 from NIMH to study this.  Was it worth it?   But if there's a million dollars out there to study something that could have been done with a review paper (or a blog post), then you're going to do it.

This is the basic problem with academic research.  Covering the same old ground, over and over, focusing on whatever is institutionally (or politically) popular. 

Given this kind of research, I have no expectation that any progress will be made in the "treatment of ADHD," let alone in improving anyone's academic performance.   I am entirely confident, however, that this lack of progress will cost millions and millions of dollars.








Comments

I've always wondered if doc... (Below threshold)

June 10, 2009 11:11 AM | Posted by Joseph Bergevin: | Reply

I've always wondered if doctors were nonplussed by all the "efficacy of enteral salicylic acid formulations on self-reported measures of cephalgia" type of studies being done. I know that it's good science to reproduce others' findings for the sake of validating those findings, but how many times need this be done? You're saying that it's done for money, which isn't hard to believe, but why is anyone impressed enough by these old chestnuts to give away $900K? Is it just that there aren't any seminal studies out there to support?

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You seem to be forgetting t... (Below threshold)

June 10, 2009 12:40 PM | Posted by Andrew Ator: | Reply

You seem to be forgetting the obvious solution of telling children that they're retarded, not giving them anything, and also forcing them to feed themselves. Personally, I would like to see the statistics relating performance while medicated with profiles of how much support the children were getting from parents and teachers. ADHD might not be a disease at all, but rather a devolution to mental playing fields where, when one has no choice one must take all choices... or at least run around a lot until they find one that sticks.

Relating this personally, because anecdotal evidence is the end all be all of evidence in what authors want to be true, every fucked up girl I have ever known has been diagnosed with some combination of mental illness. Seriously, looking through my past you can take your pick between bipolar, ADD, ADHD, absence of male or female figure within the house or both, or flat out rejection. Each one of these girls were beautiful and unique snowflakes that somehow managed to malign themselves when they fell from the sky and collided with all of the other snowflakes on the way down. Oh, and their parents. Having parents is a surefire way to grow up stupid this day in age.

I remember seeing something some time ago about a group of doctors banding together to promote the free-sale of cognitive enhancers. Perhaps this $900,000 wouldn't need to be spent in grant money if everything came with a label that said, "Warning, this product may or may not kill or otherwise affect your life and well-being." Also, if everything was legal. Except murder, because as infomercials tell us, not murdering people is a key to happiness. I digress. So does The Industry. Isn't the cannon of medical journals nothing more than advertising anyway? It's just filtered out for people that understand big words like cephalgia. No, I don't care enough to look that up on my own. I'm not the one being marketed, the doctors are. I'm just the one that gets marketed to by the doctors. I sure hope the doctors know how to set their content filters.

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For one, this goes against ... (Below threshold)

June 10, 2009 2:19 PM | Posted by Diego Navarro: | Reply

For one, this goes against the recently popular idea that "pediatric bipolar" might be misdiagnosed as ADHD. You'd guess that whatever is the pediatric equivalent of stimulant-induced mania would wildly increase school absenteeism, let alone negatively influencing test scores.

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I've never quite understood... (Below threshold)

June 10, 2009 10:21 PM | Posted by Kat: | Reply

I've never quite understood why MDs feel such smug superiority and contempt when it comes to their PhD counterparts, especially in the research field. I work as a research assistant in the department of psychiatry at a medical-research university and many of the MDs I work with have chosen to become full-time researchers; their salaries depend upon continued grant funding from the NIH.

I entirely agree that most psychiatric research - whether funded by pharmaceutical money or government money - is redundant, irrelevant, and nauseatingly biased. But this has very little to do with whether the investigators have MDs or PhDs and very little to do with whether they are also in private practice. Off-label prescribing is the rule rather than the exception as it is.

In clinical practice, psychiatrists and psychologists would both benefit if diagnostic categories were to expand. Take Borderline Personality Disorder, for example. There is a fairly aggressive push to move the diagnosis from Axis II to Axis I in the upcoming DSM-V, under the new name "Emotion Dysregulation Disorder." Since insurance companies will only cover psychotherapy or psychopharmacology for "biologically based conditions," psychologists who specialize in DBT and psychiatrists who write prescriptions for a condition where all prescriptions written to manage symptoms of the illness are (by definition) off-label will all get to breathe a huge sigh of relief if this happens, since they will no longer have to fight for therapy reimbursement or argue for medication coverage - or, more realistically, no longer have to cheat the system by inappropriately diagnosing Bipolar II instead of BPD.

Academic researchers are acting like cats in a bag right now within their own departments, competing for funds with one another and pulling rank in order to gain priority ... but REALLY, what IS it with MDs and their contempt for PhDs? Is it some sort of projective identification resulting from the fact that PhDs are far more innovative and creative than MDs? Is it resentment related to the fact that the PhDs always seem to come up with the best ideas and the MDs are forced to actually implement those ideas? Or is it just that psychiatrists always need to feel superior to someone else for all the times they were accused of not being "real doctors"?

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Its that PHDs are devoid fr... (Below threshold)

June 10, 2009 11:48 PM | Posted by Anonymous: | Reply

Its that PHDs are devoid from reality 75% of the time, have an even worse understanding of the marketplace than MDs, and often get all worked about about issues that are an inane was our valuable time. Having said that, MDs often fail to appreciate many of the nuances that are needed for many of the hard sciences (ie medicinal chem, physical chem., biophysical chem, molecular bio, etc) to work right. All those soft science PHDs are a waste of space. Period.
~~A jaded medical student.

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Oh, and it should be "an in... (Below threshold)

June 10, 2009 11:54 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Oh, and it should be "an inane waste of our..." so I can look retarded and jaded all at once ;). I also would like to add that I'm going into radiology to hopefully can grab a fellowship in interventional. Thus, rest assured that the air of superiority you complain about is not just limited to the psychiatry community.

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I have my own theory about ... (Below threshold)

June 11, 2009 2:18 PM | Posted, in reply to Kat's comment, by Aleks Milosevic: | Reply

I have my own theory about why MD psychiatrists have contempt for Ph.D. psychologists - both academically and clinically. I am speaking as a Ph.D. candidate in clinical psychology who has worked in medical school settings and hospitals in the U.S. and in Canada, and who has a brother who is a "real" physician - an endocrinologist. First, I think you are absolutely correct when you suggest that psychiatrists feel like they are not "real" physicians. Psychiatry, as I have been told by various physicians, continues to be regarded as the medical speciality that is the lowest on the totem pole. This is particularly true because psychiatry does not rely on the body/brain to render diagnoses, essentially making psychiatry a largely non-biological speciality. I believe the inferiority psychiatrists feel relative to other physicians is evident when psychiatrists say "Oh, you aren't even a real doctor" to psychologists working with them (See Frederick Goodwin, M.D. say "you're not a physician" to psychologist Jeffrey Schaler, Ph.D. in their debate on depression being/not being a disease, and Sally Satel, M.D., saying psychologists are below psychiatrists on the totem pole for examples). As if medical-biological knowledge informs our understanding of patients with psych conditions - it doesn't in 95%+ of patients. I do believe psychiatrists, despite the fact psychologists are professionally and legally capable of making the EXACT same psychiatric diagnoses, NEED to believe they are better than psychologists simply because they prescribe medications (which, by the way, have questionable efficacies). Can a psychiatrist truly face the reality that they completed a 4-year undergraduate degree in a natural science, and 4 years of medical school learning about real diseases of the body, only to rarely use any of that information when making diagnoses or providing treatments to their patients? Second, the academic issue... In my experience, psychologists (particularly experimental and social psychologists) have infinitely greater knowledge of research design than psychiatrists do. I think that is beyond question given that these types of psychologists spend 5 or more years devoted solely to learning how to conduct research, whereas academic psychiatrists devote more time during their training on activities that distract them from focusing purely on research. I have attended research group meeting with psychologists and psychiatrists and the psychologists tend to know quite a bit more about research design, statistics, etc. than psychiatrists. The entrance of clinical psychologists into the domain of psychiatry (i.e., psych diagnostics, psychotherapy) several decades ago has left psychiatrists scrambling to maintain their unique identity (hence, "biological" psychiatry because if it's biological than it's medical and medical doctors own it!). It's a shame because the ultimate consequence of this kind of turf warring is that patients are over-drugged for their "diseases" and do not get any form of help that is non-biological (but then again they are now saying psychotherapy is a "biological" intervention because brain scans light up more normally after successful psychotherapy).

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Now, if they would study AD... (Below threshold)

June 11, 2009 3:37 PM | Posted by Whatever: | Reply

Now, if they would study ADHS kids whose grades improved with non-pharmaceutical solutions vs. kids who's grades improved through speed, then I might be a little interested. I'd be more interested in their depression rates.

But even if they'd come out saying that drugged kids got the better grades it still wouldn't change my mind. Know plenty of people who had great grades (incl. myself) yet never amounted to much of anything. Know plenty of non-medicated ADHS kids who eventually learned a practical trade and went on to productive lives.

Prefer the second for my kid.

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I agree that this is an ins... (Below threshold)

June 11, 2009 9:59 PM | Posted by BenB: | Reply

I agree that this is an insipid study, but I can't help but be amused by the continued sniping between PhDs and MDs (particularly shrinks). I am neither a PhD nor an MD, but I've worked with both and am familiar with the training that each receives.

MDs: Guess what? You're not researchers! The average Psych PhD or MPH has a better grasp of research design, stats, etc. than you have. Deal with it. It's not what you're trained for.

PhDs: Guess what? You're not doctors! Putting everything into medical terminology and referring to yourself as "doctor" when you make restaurant reservations isn't going to change that.

Psychiatrists are holding on to the very bottom of the medical ladder with their hands and perching their feet on the very top rung of the psych ladder. They struggle mightily not to get kicked off the medical ladder by the "real doctors" while at the same time fighting off attempts by the psychologists to crawl over them on the psych ladder.

And now, stupidly enough, psychologists appear to want to skip the top of the psych ladder altogether and join the psychiatrists on the medical ladder. With prescription priveleges, they're looking to add a new little rung to the medical ladder and earn their Junior Psychiatrist badges.

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"I'll admit that this study... (Below threshold)

June 12, 2009 10:57 AM | Posted by Janka: | Reply

"I'll admit that this study is unique in that it is prospective and long, but do we need a unique, prospective and long study of what we already know?"

I am too lazy/busy to go through your references now, so this should not be taken as a comment on if this particular study on this particular topic was necessary, but in general, my answer to this question would be YES. If we only know what we know from short-term, non-prospective studies and a hunch, I think we in most cases do benefit from verifying that in prospective, long studies before considering it completely confirmed.

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What about the treatment of... (Below threshold)

June 19, 2009 6:51 PM | Posted by Rodney : | Reply

What about the treatment of ADHD in a correctional setting. I'll be starting in an inpatient correctional facility and am aghast at the high number of misdiagnosed kids with "bipolar" or "psychosis NOS" given large amounts of "rispalin" or some other mood stabilizer/antipsychotic that neither stabilizes mood, treats a psychosis that doesn't really exist and causes obesity and diabetes. At the same time, there is a huge amount of undiagnosed ADHD and i was wondering if you really wanted to see a study worth while, it would be in a correctional setting, because if there truly are cases of ADHD kids self medicating with THC by the time they become adult criminals they will NEVER get access to a prescribed stimulant based on their drug abuse history and the facility a convict has in abusing stimulants. So, absent millions of dollars. How would you design a prospective study for adolescents in a correctional facility or forensic unit that could provide helpful information in the rapid diagnosis and treatment of ADHD before these kids become adult criminals/drug abusers?

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it's my graduate research. ... (Below threshold)

July 11, 2009 1:09 PM | Posted by Psikolog Uğur Dalan: | Reply

it's my graduate research. ADHD and drug score have a coleration.

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you can see my research <a ... (Below threshold)

July 11, 2009 1:11 PM | Posted by Çocuk Psikolojisi: | Reply

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Thank you

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@ the whole PhD/MD debate..... (Below threshold)

April 15, 2011 5:38 AM | Posted by oh-one: | Reply

@ the whole PhD/MD debate...


Waaaiiiit, can't you, like, get a PhD in the field of psychiatry?

http://www.canadian-universities.net/Universities/Programs/Graduate-Studies-Psychiatry.html

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thank you. this is so good ... (Below threshold)

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