Post by healthy11 on Aug 20, 2013 16:53:52 GMT -5
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** Can adolescents tell when they are taking stimulant medication? **
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Although stimulant medication helps alleviate symptoms for many adolescents with ADHD, many adolescents refuse to take medication or choose to discontinue it. In fact, by age 18, it is estimated fewer than 10% of youth started on medication continue to receive it. Reasons commonly cited by teens for discontinuing medication include that they don't need it, that it is not helpful, and/or that they don't like how it makes them feel. The accuracy of these statements depends, at least in part, on assuming that they can actually tell when they are on medication. Surprisingly, virtually nothing is known about this basic question.
A study published online recently in the Journal of Attention Disorders [Pelham et al., (2013). Attributions and Perception of Methylphenidate Effects in Adolescents With ADHD. Journal of Attention Disorders published online 26 July 2013. DOI: 10.1177/1087054713493320] was designed to address this issue and extend research showing that children with ADHD are unable to reliably differentiate when they have received stimulant medication vs. when they had taken a placebo. Because adolescents have more advanced cognitive skills than children, and many have more extended experience on stimulant medication, the authors suggested that teens may be better able to distinguish real medication from placebo.
Participants in this study were 46 12-17 year old adolescents participating in an intensive summer treatment program for youth with ADHD. As part of the program, each adolescent received a placebo-controlled trial of stimulant medication (the medication used was methylphenidate) in which they received either of 3 different doses or a placebo on different days.
At the end of each day, participants received feedback from their counselors on how well they had met behavioral expectations for the day. The teens then rated the importance of different reasons for their performance that day, including their effort level, their ability, the difficulty of what they had been asked to do, how fairly they had been treated, how much the pills had helped them, and the fact that they had ADHD. They were also asked whether they had received real medication or a placebo and, if they answered 'real medication', whether they had received a small, medium, or large dose. Through this procedure the researchers sought to examine 3 basic questions. First, can teens reliably distinguish medication from placebo? Second, does this depend on the dose they received? And, finally, what reasons to teens provide for their behavior on 'good' and 'bad' days? The researchers were especially interested in the extent to which teens explained their behavior in terms of having ADHD and taking medication vs. their effort, ability, and how fairly they had been treated.
Results
Question 1 - Can teens reliably distinguish medication from placebo?
The answer to this question was clearly that they could not. Teens correctly identified 'real' medication days only 61% of the time. They correctly identified placebo days only 59% of the time. These figures become even less impressive when one realizes that participants would be correct some of the time just by random guessing; in fact, their accuracy rates did not reliably differ from random guessing. After correcting for chance, they correctly detected real medication only 38% of the time and placebo only 23% of the time.
Question 2 - Does teens' ability to detect medication depend on the dose they receive?
Overall, adolescents were more likely to correctly indicate they had taken real medication when they received a high dose relative to a low dose. However, even for the highest dose used in the study, they did not do much better than chance.
Questions 3 - What attributions do adolescents make for their behavior on both good and bad days?
On good days, i.e., those when participants had clearly met behavioral expectations, they were most likely to attribute this to their own effort and ability. The effect of medication and of having ADHD were rated as most important less than 1% of the time.
On bad days, the most frequently cited explanation was having been treated unfairly. Having ADHD was provided as an explanation less than 5% of the time.
There were no differences adolescents' attributions based on whether they received real medication or placebo.
Summary and implications
Results indicate that adolescents are no more accurate than children in differentiating when they have received active medication vs. placebo and their overall ability to make this determination was no better than chance. They tended to explain their behavior on good days as reflecting their own effort and ability level; on bad days, they tended to cite external factors, i.e., unfair treatment, as the reason. Thus, there was little evidence that they were prone to invoke ADHD or medication as explanation of either positive or negative behavior.
Of what relevance are these findings clinically? One important implication is that many adolescents may be unable to accurately judge whether or not they are actually benefiting from medication. Thus, the commonly stated request to discontinue medication because 'it is not helping' needs to be carefully considered and should not be taken at face value.
In such instances, a useful procedure may be to carefully monitor a teen's behavior on and off medication - including obtaining feedback from teachers when possible - so that behavior and school work productivity on and off medication can be assessed. When I was practicing, I found that some adolescents pressing to stop meds could be engaged in conducting such a trial to obtain 'hard' evidence about whether or not medication was doing anything useful. In cases where the data indicated that medication was making a positive difference - despite what they had thought - they would sometimes agree to continue.
There are several limitations of this study that are worth noting. First, the medication used was short acting methylphenidate, and whether teens are equally unable able to detect more current longer acting medications cannot be determined. The extent to which these findings would extend outside of the intensive summer treatment program in which the data were collected also cannot be known with certainty.
These limitations not withstanding, results from this study are both interesting - and, at least to me - a bit surprising. Given the significant impact that stimulant medication has on the behavior of many adolescents with ADHD, expecting that teenagers would be able to reliably detect its presence is not unreasonable. As discussed above, however, this does not appear to be the case and this may have important implications for dealing with requests to discontinue treatment.
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Sincerely,
David Rabiner, Ph.D.
Research Professor
Dept. of Psychology & Neuroscience
Duke University
Durham, NC 27708
** Can adolescents tell when they are taking stimulant medication? **
*****************************************************************************************************************************
Although stimulant medication helps alleviate symptoms for many adolescents with ADHD, many adolescents refuse to take medication or choose to discontinue it. In fact, by age 18, it is estimated fewer than 10% of youth started on medication continue to receive it. Reasons commonly cited by teens for discontinuing medication include that they don't need it, that it is not helpful, and/or that they don't like how it makes them feel. The accuracy of these statements depends, at least in part, on assuming that they can actually tell when they are on medication. Surprisingly, virtually nothing is known about this basic question.
A study published online recently in the Journal of Attention Disorders [Pelham et al., (2013). Attributions and Perception of Methylphenidate Effects in Adolescents With ADHD. Journal of Attention Disorders published online 26 July 2013. DOI: 10.1177/1087054713493320] was designed to address this issue and extend research showing that children with ADHD are unable to reliably differentiate when they have received stimulant medication vs. when they had taken a placebo. Because adolescents have more advanced cognitive skills than children, and many have more extended experience on stimulant medication, the authors suggested that teens may be better able to distinguish real medication from placebo.
Participants in this study were 46 12-17 year old adolescents participating in an intensive summer treatment program for youth with ADHD. As part of the program, each adolescent received a placebo-controlled trial of stimulant medication (the medication used was methylphenidate) in which they received either of 3 different doses or a placebo on different days.
At the end of each day, participants received feedback from their counselors on how well they had met behavioral expectations for the day. The teens then rated the importance of different reasons for their performance that day, including their effort level, their ability, the difficulty of what they had been asked to do, how fairly they had been treated, how much the pills had helped them, and the fact that they had ADHD. They were also asked whether they had received real medication or a placebo and, if they answered 'real medication', whether they had received a small, medium, or large dose. Through this procedure the researchers sought to examine 3 basic questions. First, can teens reliably distinguish medication from placebo? Second, does this depend on the dose they received? And, finally, what reasons to teens provide for their behavior on 'good' and 'bad' days? The researchers were especially interested in the extent to which teens explained their behavior in terms of having ADHD and taking medication vs. their effort, ability, and how fairly they had been treated.
Results
Question 1 - Can teens reliably distinguish medication from placebo?
The answer to this question was clearly that they could not. Teens correctly identified 'real' medication days only 61% of the time. They correctly identified placebo days only 59% of the time. These figures become even less impressive when one realizes that participants would be correct some of the time just by random guessing; in fact, their accuracy rates did not reliably differ from random guessing. After correcting for chance, they correctly detected real medication only 38% of the time and placebo only 23% of the time.
Question 2 - Does teens' ability to detect medication depend on the dose they receive?
Overall, adolescents were more likely to correctly indicate they had taken real medication when they received a high dose relative to a low dose. However, even for the highest dose used in the study, they did not do much better than chance.
Questions 3 - What attributions do adolescents make for their behavior on both good and bad days?
On good days, i.e., those when participants had clearly met behavioral expectations, they were most likely to attribute this to their own effort and ability. The effect of medication and of having ADHD were rated as most important less than 1% of the time.
On bad days, the most frequently cited explanation was having been treated unfairly. Having ADHD was provided as an explanation less than 5% of the time.
There were no differences adolescents' attributions based on whether they received real medication or placebo.
Summary and implications
Results indicate that adolescents are no more accurate than children in differentiating when they have received active medication vs. placebo and their overall ability to make this determination was no better than chance. They tended to explain their behavior on good days as reflecting their own effort and ability level; on bad days, they tended to cite external factors, i.e., unfair treatment, as the reason. Thus, there was little evidence that they were prone to invoke ADHD or medication as explanation of either positive or negative behavior.
Of what relevance are these findings clinically? One important implication is that many adolescents may be unable to accurately judge whether or not they are actually benefiting from medication. Thus, the commonly stated request to discontinue medication because 'it is not helping' needs to be carefully considered and should not be taken at face value.
In such instances, a useful procedure may be to carefully monitor a teen's behavior on and off medication - including obtaining feedback from teachers when possible - so that behavior and school work productivity on and off medication can be assessed. When I was practicing, I found that some adolescents pressing to stop meds could be engaged in conducting such a trial to obtain 'hard' evidence about whether or not medication was doing anything useful. In cases where the data indicated that medication was making a positive difference - despite what they had thought - they would sometimes agree to continue.
There are several limitations of this study that are worth noting. First, the medication used was short acting methylphenidate, and whether teens are equally unable able to detect more current longer acting medications cannot be determined. The extent to which these findings would extend outside of the intensive summer treatment program in which the data were collected also cannot be known with certainty.
These limitations not withstanding, results from this study are both interesting - and, at least to me - a bit surprising. Given the significant impact that stimulant medication has on the behavior of many adolescents with ADHD, expecting that teenagers would be able to reliably detect its presence is not unreasonable. As discussed above, however, this does not appear to be the case and this may have important implications for dealing with requests to discontinue treatment.
***********************************************************************************************************************
Sincerely,
David Rabiner, Ph.D.
Research Professor
Dept. of Psychology & Neuroscience
Duke University
Durham, NC 27708
