Combining two medications with parent training appears to improve anger, irritability and violent tendencies in children whose attention-deficit/hyperactivity disorder (ADHD) is coupled with severe aggression, a new study suggests.
"Augmented" therapy that consists of stimulant and antipsychotic drugs, along with parent training in behavioural management techniques, was rated more effective by parents than "basic" therapy pairing only the stimulant and parent training, researchers found.
"An important finding of this study was that at the end of nine weeks, approximately half of all children receiving basic therapy were still rated by their parents as being impaired... with symptoms interfering with school or social functioning," said study author Kenneth Gadow, a professor of psychiatry at Stony Brook University in New York.
"In the augmented group receiving three interventions for aggression, about one-quarter still, at the end of nine weeks, were rated by their parents as being impaired, and that suggests, even with highly effective therapies, that many of these children still have unmet treatment needs" " he added.
The drugs used in the study, published in the September issue of the Journal of the American Academy of Child and Adolescent Psychiatry, included the widely prescribed ADHD stimulant Concerta (methylphenidate) and the antipsychotic Risperdal (risperidone).
Approximately 11 percent of American children aged 4 to 17 have been diagnosed with ADHD, which includes symptoms such as impulsivity, hyperactivity, and difficulty focusing and controlling behavior, according to the U.S. Centers for Disease Control and Prevention.
As many as half of children with ADHD also display significant, disruptive aggression, according to an editorial accompanying the new research.
"This is very common among kids with ADHD, but unfortunately it complicates the picture for treatment," said Erin Schoenfelder, a clinical psychologist at Seattle Children's Hospital and assistant professor of psychiatry and behavioural health at University of Washington.
"It really is staggeringly high."
In the new research, Gadow and his colleagues divided a group of nearly 170 children aged 6 to 12 with ADHD and aggression problems into two treatment groups, basic and augmented.
The basic group received Concerta and their parents underwent behavioral management training.
The augmented group received Concerta and parental training as well, but also took the antipsychotic Risperdal. Both groups were followed for nine weeks.
While both groups of children displayed marked reduction in symptoms, improvement ratings varied depending on whether parents or teachers were making the assessment.
Parents reported that children on augmented therapy were less likely to be impaired socially or academically by their anger and irritability than children on basic therapy.
On the other hand, teachers found few differences in these measures.
Instead, teachers of those on augmented therapy reported significant drops in ADHD symptoms, especially impulsiveness, compared with teachers of children on basic therapy.
Gadow and Schoenfelder agreed that the conflicting parent-teacher ratings demonstrate a familiar concept: that children's behaviours vary in different settings, whether or not they have ADHD.
"Just like adults, they adapt their behaviours to be more appropriate for the setting they're in," Gadow said.
"People do differ, however, in their ability to modify their behaviour from one setting to the next, and some children are much more variable [in this regard]."
Schoenfelder said long-term evidence is needed indicating that combining Concerta and Risperdal is safe in children, but "it appears from this study that the combination was well-tolerated and something practitioners could [adjust the dosage of] effectively."
"Folks trying this type of treatment should have close monitoring," she added. "This is a starting point. It's a combination doctors may try when they see this blend of aggressive and hyperactive behaviours. It certainly will require adjustment . . . but it's exciting to find something helpful for a significant proportion of the kids studied."
The study authors pointed out that their findings only apply to children with ADHD who exhibit severe irritability and peer aggression.
They noted that the study's findings are not an indication of the ADHD population as a whole.
More Information: "Risperidone Added to Parent Training and Stimulant Medication: Effects on Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, and Peer Aggression" http://www.jaacap.com/article/S0890-8567(14)00369-4/abstract
"Augmented" therapy that consists of stimulant and antipsychotic drugs, along with parent training in behavioural management techniques, was rated more effective by parents than "basic" therapy pairing only the stimulant and parent training, researchers found.
"In the augmented group receiving three interventions for aggression, about one-quarter still, at the end of nine weeks, were rated by their parents as being impaired, and that suggests, even with highly effective therapies, that many of these children still have unmet treatment needs" " he added.
The drugs used in the study, published in the September issue of the Journal of the American Academy of Child and Adolescent Psychiatry, included the widely prescribed ADHD stimulant Concerta (methylphenidate) and the antipsychotic Risperdal (risperidone).
Approximately 11 percent of American children aged 4 to 17 have been diagnosed with ADHD, which includes symptoms such as impulsivity, hyperactivity, and difficulty focusing and controlling behavior, according to the U.S. Centers for Disease Control and Prevention.
As many as half of children with ADHD also display significant, disruptive aggression, according to an editorial accompanying the new research.
"It really is staggeringly high."
In the new research, Gadow and his colleagues divided a group of nearly 170 children aged 6 to 12 with ADHD and aggression problems into two treatment groups, basic and augmented.
The basic group received Concerta and their parents underwent behavioral management training.
The augmented group received Concerta and parental training as well, but also took the antipsychotic Risperdal. Both groups were followed for nine weeks.
While both groups of children displayed marked reduction in symptoms, improvement ratings varied depending on whether parents or teachers were making the assessment.
Parents reported that children on augmented therapy were less likely to be impaired socially or academically by their anger and irritability than children on basic therapy.
On the other hand, teachers found few differences in these measures.
Instead, teachers of those on augmented therapy reported significant drops in ADHD symptoms, especially impulsiveness, compared with teachers of children on basic therapy.
Gadow and Schoenfelder agreed that the conflicting parent-teacher ratings demonstrate a familiar concept: that children's behaviours vary in different settings, whether or not they have ADHD.
"Just like adults, they adapt their behaviours to be more appropriate for the setting they're in," Gadow said.
"People do differ, however, in their ability to modify their behaviour from one setting to the next, and some children are much more variable [in this regard]."
Schoenfelder said long-term evidence is needed indicating that combining Concerta and Risperdal is safe in children, but "it appears from this study that the combination was well-tolerated and something practitioners could [adjust the dosage of] effectively."
"Folks trying this type of treatment should have close monitoring," she added. "This is a starting point. It's a combination doctors may try when they see this blend of aggressive and hyperactive behaviours. It certainly will require adjustment . . . but it's exciting to find something helpful for a significant proportion of the kids studied."
The study authors pointed out that their findings only apply to children with ADHD who exhibit severe irritability and peer aggression.
They noted that the study's findings are not an indication of the ADHD population as a whole.
More Information: "Risperidone Added to Parent Training and Stimulant Medication: Effects on Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, and Peer Aggression" http://www.jaacap.com/article/S0890-8567(14)00369-4/abstract
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