Stimulant Medications, ADHD, Child Maltreatment – PediaCast 074

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Topics

• Do Stimulant Medications Stunt Growth?
• Long-Term Follow-Up of Children with ADHD
• Child Maltreatment Increases when a Parent is Deployed for Combat

Transcription

Announcer 1: This is PediaCast.

Dr. Mike Patrick: Bandwidth for PediaCast is provided by Nationwide Children's Hospital, For Every Child For Every Reason.

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0:00:21.9

Katie: Welcome to PediaCast, a pediatric podcast for parents, the Research Edition. And now direct from Birdhouse Studios, here is your host Dr. Mike.

Dr. Mike Patrick: Thanks, Katie. Hello everyone and welcome to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to your from Birdhouse Studio and it is Episode 74, our Research Edition for Thursday November the 1st 2007 and Happy November to all of you out there.

Our research topics this week, two of them have to do with ADHD and then we also have one on Military Deployment and how that affects moms and dads and kids. So we're going to talk about that.

0:01:07.3

Before we get started, I did want to mention that a couple of weeks ago I had told you that I went to my doctor and he told me basically I either need to loose weight or grow taller. [Laughs] That's a nice way to put it isn't it? And I was almost 200 pounds and for my height it's just too much and my blood pressure was a little high and so he said, "You need to do something." And he didn't want to get a blood work because he thought it would look too bad. So for the last couple of weeks, I guess two and a half weeks now,  I've maid real effort, Karen and I both have to exercise at least 30 minutes a day and to work up a sweat, you know when you're doing it; aerobic exercise and limit the snacks. And I just want to report in that I've lost eight pounds in two and a half weeks doing that.

This is not to brag although I'm a little proud, but the reason I mentioned it is because I felt like I was accountable since a couple of weeks ago I said I was going to do this. So I wanted to give you an update and it's also to encourage you because you can do it. Now 30 minutes, five times a week, you got to work up a sweat, you don't have to kill yourself. And you keep in mind too that how much weight you loose doing something like this, is going to depend a lot on your own metabolic rate which will be determined by your age and whether you're male or female and your genetics. So not everyone's going to be able to lose eight pounds in a couple weeks and some people will be able to lose twice that amount.

0:02:40.9

But also keep in mind that as you exercise you do build up muscle mass and muscle weighs more than fat, so you can just go strictly on how much you have lost or gained. So make sure you exercise either way.

I was so proud of it though that the receptionist at my doctor's office is actually, I take care of her kids; I'm their pediatrician. And when they came in, it has been a few days ago. I said, "Hey make sure you tell the doctor that I lost eight pounds." Or it's actually only six pounds at that point but you know I was proud enough of it that I wanted him to have an update, of course he gave me the lecture so wanted to let him know I guess that I took it seriously.

0:03:24.3

I should mention too with this being a medical podcast, you do want to check with your doctor before starting any exercise program 'cause I'm not your doctor, folks. Just a doctor friend. [Laughs]

OK. So in terms of the studies today; Do stimulant medications stunt growth? We're going to talk about that. Also; Long Term Follow Up of Children with ADHD, how long does the medicine work, how long do they need to be on it, that sort of thing. We have a study there. And then finally, Child Maltreatment Increases When a Parent is Deployed for Combat. So we're going to discuss that as well.

0:04:00.9

Don't forget if you have a topic you would like us to talk about, all you have to do is go to Pediacast.org and click on the Contact link, you can also e-mail me at pediacast@gmail.com or call the voice line at 347-404-KIDS.

Also don't forget the information presented in every episode of PediCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health and arrange a face-to-face interview and hands-on physical examination.

Also your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at Pediacast.org. And with that in mind, we'll be back with our Research Round Up right after this short break.

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0:05:21.9

All right. We are back and I do want to mention that I am doing this live on Stickam.com and I'd like to remind you if you would like to participate and to watch us record PediaCast and to listen as we do it live, you're more than welcome too. I'm doing a little bit later tonight, it's actually 11:00 Eastern Time and the reason for the late hour is because I was on-call and our office actually has evening office hours for the on-call doctor so, I just got home by the half hour ago. So we were seeing patients late into the evening in the office, so that's the reason. Although I have kind of toyed with the idea of making it a little bit later anyway. So we'll see how it goes.

Anyway you're more than welcome to stop by in the future. We're there in the evenings on Sundays through Thursday, so feel free to stop by.

0:06:20.0

OK. So Do Stimulant Medications Stunt Growth?

This is a research article that was published in the journal of the American Academy of Child and Adolescent Psychiatry in August of 2007. The question before the researchers; the possibility of stimulant use Leading to decrease growth was reported 35 years ago and subsequent studies most of them retrospective have supported and refuted this hypothesis. So there have been studies that have shown, that yes there's a link between stimulant use for ADHD and decrease growth and there's been some that showed that there is not. But they are not great studies and they were all retrospective. Meaning you take some kids and you asked the parents, how much did they weigh and what medicines where they on? Rather than following the kids along and seeing how they actually grow while they're on the medicine.

0:07:17.0

So to address this growth controversy and to try to do a better design of a study, researchers analyzed follow up data from this think called the Multi Model Treatment Study of Children with ADHD. Now what that is, is basically just a big prospective, longitudinal study where you're looking at kids as they're on ADHD medicine for lots of different things. And so a subset of those kids were a part of this particular study. And what they did is they just looked at children who were ages seven to nine years of age, so we're going to be comparing who are about the same age and these kids were basically divided into four groups. One group which is your control group was pretty much, or not pretty much, in research you don't want pretty much. The control group was unmedicated throughout the study. So we followed the kids' growth who did not have any medication at all.

0:08:21.2

And then the second group or kids who at some point during the study were newly started on a stimulant medication, so you had a little bit of information about their growth and then they were started on the medicine and then after that, then you saw what happened with their growth. The third group was on medicine before the study really started. So they were just constantly on medicine the entire study and had been on it even before the study started. And then the fourth group were inconsistently medicated throughout the study. So sometimes they were on it then their parents would take them off and they were on it again, maybe off on the weekends, that kind of thing. [Clears throat] You have to excuse me folks. being around all the sick kids in the last couple of weeks, I've got a little cold.

0:09:08.4

OK. So then all four groups had their heights and weights measured serially, meaning they had the height and weight measured on a regular basis over many months. So what did they find, well there were two groups that had significant divergence in growth. Meaning there were two groups that were really really different, and those two groups were the newly started group. So the kids who during the course at some point they started ADHD medicine stimulants for the very first time and the group that was unmedicated and not on any stimulant medicine at all.

And the growth in the newly medicated group compared to growth in the unmedicated group, the newly medicated group, so the ones who had just started it, during the course of the study they averaged two centimeters less in height and 2.7 kilograms less in weight. So 2.7 x 2.2, I'll let you do the math to figure how many pounds that is. But suffice it to say it's almost 6, 7 pounds something like that.

0:10:20.6

So it's significant. There was a significant decrease in growth both height and weight for the kids who were newly started on ADHD medicine and the kids who are not on any medicine at all. Now this reduction in growth was greatest in the first year that they were on the medicine, less in the second year, and really absent in the third year. So by the third year that these kids were on ADHD medicine, they really did not seem to be as much of a decline in their growth anymore.

The inconsistently medicated group which was the ones that sometimes are on it, sometimes they're not and the consistently medicated group; meaning the ones who were on ADHD right from the get go and even before, did not show decreases in their growth rate at all.

0:11:10.8

So the authors concluded that stimulant medication does stall height and weight growth but the effect is limited to the first couple years of treatment. Now you have to keep in mind, OK so what does this mean? Well I don't think that it means that you don't treat for ADHD because the benefit of treating and having kids' behavior beyond a better control, controlling their impulse problems, helping them to do better in school and to stay out of trouble. I think the benefit certainly outweighs any problem with growth. And honestly I see a lot of kids, we talk about childhood obesity and one thing a lot of these kids are over weight and you put them on ADHD medicine and you stall their growth a little bit and you know they're coming down to the 50th percentile where they're supposed to be.

0:12:01.9

And of course it does also reinforce the need for frequent follow up with your doctor. I mean certainly if you have a kid who's dropping below where they should be or losing weight rapidly, you want to be following them along so that you catch that.

I will say one criticism with this is they didn't look at different forms of stimulants. It'd be interesting to see like the kids who are on plain Ritalin, the kids who are on Adderall, the kids on Concerta, Medodate, Focalin, Vyvanse; all of these different stimulant ADHD medicines that are out there, is there a difference from one medicine to another? And that wasn't really addressed, so that would have been an interesting thing to add to this. And maybe they'll end up doing that as they continue to follow these kids.

0:12:45.8

OK. Our second study also has to do with ADHD and really the same set of kids were followed for this one as well. So this again is published in the journal of the American Academy of Child and Adolescent Psychiatry in August 2007. In 1999 results from a randomized control multi model treatment study of children with ADHD, so this is still this big group of kids they've been following for years. And in 1999 these kids were basically divided a a group of these kids, 579 of them altogether between the ages of seven and nine years old. And they divided them into three groups. This time they divided them into kids who were on stimulant medicine by itself, kids who are on medicine plus had some kind of behavioral management counseling type thing going on, and then the third group were the kids who just had behavioral management counseling with no stimulant medication at all.

0:13:49.6

They follow these kids along for quite a while and after 24 months the two medication groups had significantly ADHD symptoms compared to the group that just had behavioral management alone. So it seemed like the medicine really helped this kids. Again this is in 1999 that they were doing this. This is just sort of the precursor for this study. Also the medication and behavior group, that group in particular, the group that had the stimulant medicine and behavioral management, they had improvements in coexisting anxiety, disruptive behaviors and improved parent and teacher satisfaction ratings compared to the medication alone and the behavioral management alone group.

0:14:42.3

So it seems like the best course of treatment was the medication plus the behavioral management. Now again this was after just 14 months of treatment. Then they followed these kids out another 24 months and basically there was persistent benefit in the two medication groups but the effects were reduced to half of those seen at 14 months. So basically what this means is that the kids who had ADHD symptoms who were on a stimulant medicine with behavioral management as part of the treatment did quite a bit better especially in the first 14 months and not quite so much at the 24 month period.

0:15:29.7

So what this research study was, they wanted to look at these kids over a longer period of time than just two years. So these particular kids, what they ended up doing is they followed them along for 36 months, so this is going to be over a three year period to see if these observations still held true. And they not only looked at the kids' behavior, they also looked at their school work, they talked to the parents, had the parents fill out surveys, had the teachers fill out surveys, so it really did a better job at making sure that they were looking at these kids from bunches of different angles. And what they found is that all the groups did show some improvement in their ADHD symptoms. But now it seemed that the medication group in this particular study did not differ significantly from the behavior only group on any of the outcome measures.

0:16:30.6

So now it seems that with this study over a longer period of time that the kids who did not have medicine also could do a good job just with behavioral management. And some of that maybe that counselors are getting better at teaching kids how to deal with ADHD without medication. So that's kind of an interesting thing I think. Factors associated with worst outcomes were more severe initial symptoms; boys usually did worse than girls, the presence of oppositional and disruptive behaviors, also if the family was receiving any public assistance and any diagnosis of ADHD and the parent, all of those groups of kids were more likely to have significant problems regardless of which group they were in. Whether it was medicine by itself, medicine plus behavioral therapy, or behavioral therapy on its own.

0:17:29.3

So again I think the take home here is that, for a lot of kids medicine is still important way of controlling ADHD. But there is a growing number of kids especially those with  milder ADHD that counseling can help them to learn to deal with their impulse issues, with their inability to concentrate. And you know some of that is, let's figure out a different way for them to do school, let's figure out a different way for them to do their homework so that they can concentrate on things for a shorter amount of time rather down sitting down for an hour and working on Math problems for an hour.

0:18:07.6

So you know there's different strategies in dealing with life and you know there's so many adults with ADHD who are untreated and to some degree as adults you pick your profession based on your personality and how you handle these kind of issues. For instance, I am sure that I have ADHD, definitely component of it and I control mine personally with caffeine and also with just being able to control my schedule. You know as a pediatrician I'm in one room for a few minutes and we're talking about ear infections and then I'm looking at a small baby who just was born and being seen for their very first visit and that might last maybe a 10 minute visit, 15 minute visit, and then you see a kid for ADHD and then you see a kid with a sore throat. So I mean you're moving from room to room and going from place to place and that really makes it easy for someone who has some attention issues.

0:19:06.1

If I had to sit down for an hour and work on accounting or on someone's tax forms, I would go nuts doing it. But there are people who can do that, so to some degree you pick your profession based on your personality and whether you have attention issues or not as part of that. And so I think in today's age these behavioral management and counseling is helping kids deal with the kind of personality traits that they have more than they used to. So I think that's the take home with that particular one.

0:19:40.2

All right let's go ahead and move on, enough about ADHD because if I have it I can't talk about it for too long or you know I go off on these rants and tensions and now that I've admitted that I probably have adult ADHD that's not treated all the way, you're starting to understand the show a little bit more. [Laughs]

OK. Finally, Child Maltreatment Increases When the Parent is Deployed for Combat. This was reported in the journal of the American Medical Association in August of 2007. During times of war military families face tremendous stress. More than 1 million military families in the United States have kids younger than 18 and some studies in the past have suggested that child maltreatment increases during a parent's deployment.

0:20:28.3

So what researchers did in this case is they compared the rates of substantiated child maltreatment during periods of deployment and non-deployment in the military. And basically their definition of substantiated child maltreatment were cases of reported neglect, physical abuse, emotional abuse, and sexual abuse. They looked at 1,771 families, all of them had enlisted US army soldiers as a parent, as one parent and then all of them were combat deployed to either Afghanistan or Iraq at some time between 2001 and 2004. A total of 3,334 incidents of child maltreatment were reported which involves 2,968 children and 1,858 parents. So obviously there were more incidents of child maltreatment then there were families, so there were reported incidents in some families of more than one occurrence.

0:21:32.1

Now if you look at the kids who were reported being abused or maltreated in some way, more than half of the offending parents were non-hispanic whites 54% and then the victims were equally split between boys and girls. If you look at which parent was more likely to be the offender, well it depended a little bit on whether a parent was deployed or not. So during periods of active deployment, civilian mothers accounted for 83% of abuse offenses and civilian fathers were only 6% of abuse offenses. Now that doesn't mean that the mothers are more abusive than the fathers. It just means probably that more fathers were deployed and there were mothers at home with the opportunity [Laughs] to maltreat their children.

0:22:25.4

During periods of non-deployment, the soldier father was responsible for the abuse 54% and the civilian mothers, it was 35%. Only 28% of all incidents occurred during deployment but the percentage of kids having at least one incident was 42% higher during deployment. I'm sure you're getting a little confused here in your mind because as I'm reading these figures I'm getting a little bit confused. So I'm going to stop here a minute. I'll not try to go on too long of attention this time.

So they say 28% of all incidents occurred during deployment. That's because you're not deployed forever and so there were more times when parents weren't deployed than when they were. So only 28% happened during deployment but there were lot more opportunity for people to be home and maltreating their kids when they weren't deployed. But if you looked at all the kids of deployed parents and all the kids of the non-deployed parents at any given time, the percentage of kids who have at least one incident of maltreatment was 42% higher during deployment compared to non-deployment. So more kids were being maltreated during deployment even though there were more incidences overall during non-deployment 'cause more kids were in that bucket. Hope that makes sense.

0:23:57.2

This is kind of interesting, the rate of moderate or severe incidents however was also really higher during deployment. So during when the one parent was away in combat, the rate of moderate or severe incidences were higher. Also neglect incidents were three times more common among civilian mothers when the soldier father was deployed and while neglect rates by civilian fathers did not significantly changed during the deployment of soldier mothers. So if the dad was away, mom was tended to be three times more neglectful than when dad was home. On the other hand if it was mom who is deployed and dad was there, there was not a significant change between deployment and non-deployment in terms of how many cases of neglect were there.

0:24:57.6

Again you just have to just sort of infer some of this, this was not part of the study; my guess on that is that the mom is the primary care taker and so is going to be in the position to maltreat the children, whereas if mom is deployed, dad probably has a job and the kids are with a sitter or with the aunt or an uncle and so is not necessarily in dad's custody as much as when it's mom that's home with them and therefore that moms then again have more opportunity to maltreat the children.

0:25:31.3

Also the rate of physical abuse was actually lower during deployment but the incidents during employment of physical abuse were more severe. And I guess the good news with the study is sexual abuse was extremely uncommon and the rate of this did not differ at all between deployment and non-deployment.

I know it's a little confusing with all the statistics. Basically the bottom line and what the authors concluded is that military deployment is stressful for families and there are higher rates of child maltreatment during military deployment especially in the form of neglect by civilian mothers when a soldier father is away. And you know it's not too surprising. And I think the take home with this one is we need to do a better job of helping these families cope with this tremendous stress of a parent being deployed overseas. I mean we need to do a better job as a society, our government, our military needs to do a better job with this and as families. If we have extended family who's in the situation, we all need to do what we can to help pitch in and if you have some nieces or nephews and the dad is away and mom is just all stressed out, take the kids for a weekend and go do something fun, let mom have some mom time, you know what I mean?

0:26:53.0

I think as a society and as family we need to think about these folks. And now it would be interesting I think to compare the rates of child maltreatment that were seen in this study to other stressful situations, not just military deployment. So what's the rate of child maltreatment for single moms living alone versus single moms with boyfriends versus different work combinations; mom at home, where the boyfriend's working, boyfriend at home or mom's working, you know and then who is more likely to be the abusive one, the single mom or the boyfriend. Step parents, non-broken families but with different work combinations; both parents working, mom at home, dad at home, you know if you have an alcoholic parent , if you have a parent who's addicted to drugs. All of these different kinds of family interactions, what's the rate of maltreatment for all these kind of things. And of course this kind of study is a sociologist dream, I mean this is basically Sociology right?

0:27:55.9

I think families find themselves in tough situations all the time regardless of what your definition of a family is. And if we as a society want families to work, I think we have to figure out a way to support them during times of hardship, otherwise the cycle of abuse and neglect goes round and round as these kids grow up and the abuse and neglect carries on to their own children. OK I'm not a socialist, I actually lean more toward the conservative usually, but families are important and they're the foundation of our culture even in all of their messed up varieties. So if you know a family that's stressed out or for whatever reason, give them a hand. OK I'll stop there. Sociology class is dismissed. [Laughs] Just teasing.

All right. We are definitely out of time and we're going to wrap things up. I'll be back to wrap up the show right after this.

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0:29:16.2

All right. Thanks go out to Nationwide Children's Hospital for providing the bandwidth for this program. If you're wondering where in the world Nationwide Children's Hospital is located, it is in beautiful downtown Columbus Ohio. Also thanks to Vlad over at Vladstudio.com for providing the artwork for the feed and the website. We're very appreciative to him. So please support Vlad at Vladstudio.com. Thanks for all of you for tuning this day. I was going to say this week, but yeah I'm doing this everyday. Also thanks to my family because this of course takes up a lot of time. But Karen's great and of course she takes care of us on the blog side over at Pediascribe.com, so it's a great parenting blog. I highly recommend you check that out. iTunes reviews, I think last check we had 139, I'd really like to try to get 200 within the next month or two. iTunes reviews are just so important in terms of staying on the Featured Page and staying at the top where people see the program and really our advertising budget at this point is limited to where you see us and word of mouth. So the iTunes reviews really are helpful and I just want to thank everyone, all 139 of you who have taken the time at some point or another to jot down a few nice lines for us. I really, really, really do appreciate that.

0:30:38.4

Tomorrow we're going to wrap up the week with another listener edition. Yeah there're no interviews this week, but we do have some line up in the pipe so stay in tune for those, including a return visit from Dr. Michelle to talk about measles, that will be coming up, if all goes well next week. She's been under the weather and so we've had to postpone that a little bit. So hopefully next week we'll have Dr. Michelle on and we'll talk about measles.

So until tomorrow, this is Dr. Mike saying, "Stay safe, stay healthy, and stay involved with your kids." So long everybody.

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