What is a Functional Behavior Assessment?

Before a behavior plan is written, it is essential that the team, including you as a parent, make a careful assessment of when, where, and why the behavior is happening. This process cannot be guesswork by one or two people. If you have a child with ADHD who exhibits inapproriate behavior, consider asking for a functional behavior assessment to lead key team members through a scientific process that can accurately determine these key factors: when, where, and why.

The reason for having several people on such an assessment team is simple. Each person will have key information that will provide pieces to the puzzle. As they work together they will be able to assemble the complete picture of what is happening to cause the behavior. That is why one person alone should not be assigned to conduct a functional behavior assessment. However, it is crucial to have a person leading the team who has had special training and experience in conducting a functional behavior assessment.

There can be one factor or a number of factors involved in the root cause of an inappropriate behavior. For instance, a child who gets into trouble by acting out during adaptive P.E. may be over-stimulated and overwhelmed by the noise element in a gym, or perhaps is easily overheated. By changing the environment of PE, the inappropriate behavior disappears. Sometimes the cause is much more complicated. But with careful analysis a team can find positive, workable solutions that will, over time, improve a behavior.

A meaningful functional behavior assessment collects measurable date and utilizes input from several team members and others who have knowledge of the child.

The process for an appropriate functional behavior assessment is much more involved than this brief overview. A great article on what is involved can be found here. You will see right away that a properly conducted fba should involve a number of people, a leader well versed in the fba process, and a scientific approach to the evaluation.

A functional behavior assessment must be a team effort.

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Executive functions are those functions that enable us to plan ahead, organize our work, make good use of time, break down tasks into workable units, consider consequences, and a host of other activities. Poor executive functions can appear at any time in life, among the elderly as well as symptomatic with a number of disabilities.

Common in children with certain disabilities

Children with particular disabilities, especially ADHD, often display a deficit in the area of executive functions. These deficits become more serious as a child grows older. More is expected in the way of independent work, making good use of time, having complicated assignments completed in the allotted time, managing academic multitasking, extracurricular activities, and remembering appointments and chores. Older children are expected to "be more responsible" by handling such tasks independently with little oversight. For some children that "responsibility" is impacted by their "incompetency" in expected performance.

Lack of supports can lead to school failure

It is important for adults to recognize that performance levels may be seriously impacted negatively for some children with poor executive functions. Without that recognition, children can begin to fail because there are no built in supports to help compensate for such deficits. When failure is viewed as a matter of willful noncompliance there is little hope of a turnaround.

Teach compensatory strategies, with careful adult oversight

On the other hand, if children are taught compensatory measures, with careful adult supervision and coaching, they can make steady progress towards more independent effective study habits and successful school performance. That progress should be carefully planned out in small, achievable steps. Those small steps can add up dramatically over a period of time. But just as we expect a small child to learn to walk before running, so progress in overcoming poor executive functions by learning compensatory tools must be looked at in smaller steps.

The neglect of this extremely important area of functioning has led to the downfall of otherwise serious, responsible students. The importance of addressing executive functions cannot be over estimated. Most schools do not understand this area of concern. It is often up to parents to bring it to the attention of school personnel.

What parents can do

If a child has such difficulties, parents might ask the school district to assess the executive functions. The tests are very simple, inexpensive, and can be given by a school psychologist. The approach must always be positive, never punitive. Positive reinforcement works wonders, especially as every child starts out wanting to be successful. School psychologists, however, are usually delighted when the subject comes up. Parents can usually depend on their cooperation and enthusiastic input.

If deficits are discovered, then there should be a written plan to be followed at school and at home, step by step. Parents and school personnel should work together as a creative team, to decide what steps will lead to more self sufficiency. If the deficits are causing a negative impact on a child's education then there definitely needs to be consideration of a formal 504 plan or even an Individualized Education Plan (IEP) with a formal goal in the area of executive functions. Children who already have an IEP could have such a goal/goals added to it.

By Judy Bonnell

Poor executive functions must be supported with compensatory strategies and adult coaching

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Among several very common comorbid, or co-existing conditions among children with ADHD (Attention Deficit Hyperactivity Disorder), is dyslexia. There is still considerable confusion with the general public and educators as to what truly defines a dyslexic child. Even more confusion surrounds how to teach these children with dyslexia to read proficiently.

Dyslexia is an inherited condition that makes it extremely difficult to read, write, and spell in your native language -- despite at least average intelligence. Dyslexia is a neurologically-based disorder which interferes with the acquisition and processing of language. Varying in degrees of severity, it is manifested by difficulties in receptive and expressive language, including phonological processing, in reading, writing, spelling, handwriting, and sometimes in arithmetic.

From my experience and considerable research, I have discovered that such children must have a multi-sensory approach of instruction. If children do not pick up the phonics along with other children by the third grade, they invariably are stuck at the second grade level of reading through the rest of their schooling. In my personal experience, I have not seen an exception to this observation. In one instance, the school insisted the child read on an early fourth grade level, but intensive, in-depth testing, revealed the child read at a second grade level.

Since reading is the basis for all learning, I urge parents to insist that schools address any lag in reading skills. Don't let it drag on and on. Your child cannot afford to lose precious months of meaningful instruction. While you, as the parent, cannot insist on a particular methodology of instruction, i.e. Orton Gillingham, Lindamood, you have every right to ask for instruction that teaches your child the way he or she learns. Any recommendation from the district should be a proven method or combination of multi-sensory methods. You have the right, under IDEA, (Individuals with Disabilities Education Act), to ask that your child's teacher have such training as to provide meaningful progress educationally. Ask for documentation demonstrating such success with the school's proposed program.

The reasons you may run into a brick wall are simple. First, districts have stonewalled parents of dyslexic children for years by claiming there is no such disability. Second, they may tell you that IDEA, (Individuals with Disabilities Education Act), does not include dyslexia as a disability. Or third, there is no real testing for dyslexia. These statements simply are not true. Any child who is substantially behind in reading skills shoud be suspected of having dyslexia. Simply put, dyslexia is a serious deficiency in written language skills.

The main reason for skirting the issue of appropriate instruction is the bottomline. A teacher must receive intensive instruction over a period of time to be fully certified to teach such a program. It is expensive for districts to train teachers. However, we must let districts know that the bottomline for our children is not a second grade level of reading proficiency. Ask your districts how many teachers are certified in such a program in your district. Ask how many are in training, and in what programs. Finally, ask how many teachers the district will be placing in such training in the coming year.

The cause of dyslexia seems as elusive as the cause for ADHD. However, they have discovered suspected genetic links for both conditions. It is neurological in origin, that is the source of the condition is in the brain, as is ADHD.

Future Articles on Dyslexia

Now I have the privilege of introducing to you Susan Barton, founder of Bright Solutions for Dyslexia. She has graciously agreed to write a series of articles for my site explaining what dyslexia is, and just as importantly, what it is not.

Susan Barton become interested in dyslexia as she watched her nephew struggle with the disability. She is an internationally recognized expert in the field of Dyslexia and Attention Deficit Disorder. As founder of Bright Solutions for Dyslexia, Susan devotes her time to educating parents, teachers, and tutors about the causes, the symptoms, and the appropriate remediation techniques for students with dyslexia and/or ADD. In addition to offering seminars to the public, she conducts in-service trainings throughout the Western United States.

Susan is also an instructor in Phonemic Awareness and Multisensory Teaching Methods at the University of California, and in Learning Disabilities at West Valley College. She has recently been the keynote speaker at conferences for the Canadian Dyslexia Association, California Literacy, and the California Learning Disabilities Association. Susan is also a member of the International Dyslexia Association, Ch.A.D.D., the Learning Disabilities Association, Parents Helping Parents, and the Association for Educational Therapists.

As Susan tutored children and adult students, and taught instructors, she realized there was a need for a more practical system to teach the teachers and tutors. She developed her own system, called Bright Solutions for Dyslexia.

I am most grateful for Susan's professional and practical input on this most important subject. Watch for more articles by Susan at this site. On behalf of all parents, thank you, Susan!

Susan's site can be found at Bright Solutions for Dyslexia .

Information at this site is not to be construed as legal advice. If you need such advice be sure to contact an attorney who specializes in special education matters.

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Learn how to be an effective advocate for your ADHD child.

I'd like to set aside some space and time to focus on advocating. I believe that learning to advocate is a must for any parent, especially those of us who have been blessed with special children. One of the most important skills one can have is proper communication. It's one thing to know what needs to be done and what services you need and its another thing to get your wants and wishes across. The last thing you want to do is alienate the very people you need to make your ADHD child's school experience a successful and positive one.

• First, educate yourself.
• Learn the laws.
• Know what your rights are as well as the responsibilities of the school district.
• Check out Special Education Rights and Responsibilities.

It is a 13 chapter manual that addresses every question imaginable for parents seeking special ed and section 504 rights and services for their children. At the end of each chapter you will find sample letters so you will know how to ask, in writing for services and hearings! Click here to check out this manual!

Next, learn how to communicate properly. For tips and ideas on how to effectively communicate with the school, The Special Ed Advocate has some very informative tips and ideas on how to write a letter. Here are some additional links with resources that should prove helpful:

• How to be an advocate for your child.
• Department of Education guide to IEP
• Questions Dealing with IEP's
• A great article on why so many smart kids with ADHD fail in school
• Article on legal issues, adhd, and education.

Special Education and Dealing with Your Child's School

While I realize that not all teachers and academic professionals are hard to deal with, or untrained in the area's of special education and attention deficit disorder, there are many parents who do have these types of people at their child's school. Here are some things that I have learned from my experiences. Over the years I have learned two very important things.

1. School districts tend to close ranks when there has been a serious error on their part. In the beginning, when I had a problem with the school, I used to follow the chain of command. Start with the teacher, then to the principal etc... Since then I've learned that when there is a serious issue at hand, the principal protects the teacher, the superintendent protects the principal, the board protects the superintendent and so on down the line. Not wanting a "reputation" I followed the chain of command until I realized that it is not always the best path to take. I learned to stop taking it right away. I have been lied to by principals, had my concerns belittled by superintendents and "politely disregarded" by the school board of supervisors. While it is not appropriate in all instances, when necessary, I abandon the chain of command, particularly if I know there will be no support from them and go straight to county and state agencies.

2. Schools could care less about lawyers and lawsuits and unless there is potential for large sums of monies to be won for damages, lawyers could careless about you and your problems with the school district. School districts don't even flinch when you threaten them with legal action simply because the tax payers pockets run deep and the cost incurred in legal battles does not concern the school, the principal or the district. Lawyers do not like taking these types of fights on in your behalf because, once again, the schools pockets run deep and they have the ability to tie things up in the court system for years so unless there is a possibility for large monetary amounts in the way of damages, lawyers just as soon decline your request for them to take your case. Forget large entities such as your civil rights organizations. It didn't take long to for me to learn that your issue must impact an entire group or minority, so unless your suit would affect the way schools deal with disabled children or add/adhd children across the U.S. I was told that there would be no help for them to give. So, what can a parent do? I have found that the following steps have helped me greatly. The thing to remember is that while you want to be aggressive and persistent, you want to do so in a polite manner. Schools/principals/districts tend to look at parents who actively seek services for their children as "combative, or problem parents." I for one am not out to win any awards for most pleasant parent. After a while, you get used to being known as "one of those parents" and not long after that, you begin to find a certain amount of pride in the fact that you are able to obtain the services your child needs or hold the school accountable for their actions.

3. KNOW YOUR RIGHTS! I can not stress this enough. I have been in many situations where school officials have given me inaccurate information. I believe that there are some school professionals who expect parents to accept whatever they are told in "blind faith". After all, "Whose the professional here?". I have dealt with more school personnel that DON'T know what my child is entitled to then you would believe and there are schools that DO NOT under any circumstance what to cut lose with any of that money to pay for the services your child needs. The ONLY way you are going to get past this is to KNOW YOUR RIGHTS so empower yourself. Do the research. DOCUMENT EVERYTHING! Meetings, phone calls, conversations with your child, your child's teacher etc. Be prepared to explain the requests you've made, the interventions you've tried to take, the instructions you given your child's teacher in handling your child etc. I was once told that when an employee comes up for promotion or review, the powers to be at the district office review the employees file, and that the ONLY way these supervisors find out that there is an employee who perhaps shouldn't be working with certain children or has problem area's is when they run across letters of complaints in the employees file. I've also taken to filing formal complaints with the district and other agencies if applicable, such as the County Office of Special Education rather than turning to attorneys. Once you start the formal complaint process, each district has certain guidelines they must follow which include timelines and in some cases, a chance for the employee in question to respond to the complaint in writing which I was entitled to a copy of. In my case, the employee hung herself in her written statement making my case stronger and a little bit easier for me to get my issues addressed. Plus, having it cross filed with other agencies, left little room for the district to sweep the incident under the rug and also left the district answering to other entities besides myself. The district had to deal with the issue and the employee and the entire incident was documented in the employees record. The other thing I've learned with particularly hard to deal with districts, while they laugh at the mere mention of an attorney, they absolutely hate publicity and dealing with agencies outside their realm of control. This is where state and county offices, congressmen, city councilman, newspapers, etc come in handy. Go here for some informative tips on advocating for your ADHD child.

Why Bother to File A Complaint Against the School District

Why bother to take the district on and put up with the frustration and headache that goes along with the process? Because in the long run, it makes a difference. It puts the school employees, the school, the district, and the board on notice that they had better mind their p's and q's. Because it creates a paper trail, a trail that will be on file and follow the employee where ever they go and that will be reviewed by their peers every time they come up for promotion or an employee evaluation. A trail that will be there when the next parent or child needs help. A paper trail that eventually is going to back the district into a corner of which they will not be able to get out of. They will not be able to claim they didn't know, or they had no idea that there was a weak link in the chain and while it may not help your child today, it will help the children who come tomorrow. Another thing is that above all things, the school system is geared to survive. They survive by protecting each other, they survive by limiting the amount of information they give to parents they survive by being close knit and by telling parents only the things they need to know. The parent that advocates for their child is a threat to the way they have been dealing with children and parents and because they pose a threat, the school and the district is going to have to pay closer attention to how they deal with you and your child. And last but not least if we don't band together, join forces and tell our schools that the way they treat our children is unacceptable, it will never change. I can't stress how important it is to take the time to file a complaint with the district if the situation warrants it and there is a policy or employee that needs to be looked at. Filing a complaint in writing creates a paper trail into the employees file and according to the Asst. District Superintendent, is often the only way they know when an employee is not doing there job well when their employee record comes under review. Also, as my mother pointed out, the teachers and admin people certainly have no problem issuing citations, suspensions, and expulsions to our children for inappropriate behavior which become part of their records so why shouldn't we call them on theirs? For tips and ideas on how to effectively communicate with the school, The Special Ed Advocate has some very informative tips and ideas on how to write a letter. IT'S HERE!!! Special Education Rights and Responsibilities is a 13 chapter manual that addresses every questions imaginable for parents seeking special ed and section 504 rights and services for their children. At the end of each chapter you will find sample letters so you will know how to ask, in writing for services and hearings! Click here to check out this manual! If you are having problems viewing the manual or would like a copy of the manual, I have made a zip file of all the chapters in text form.

What are we? ADVOCATES OR TROUBLEMAKERS?

Now that statement varies depeding entirely upon who you are speaking to at the time. When you are speaking to families we have helped: we are more than just advocates. We are some one who has been there and gone through it and survived. Someone who can relate to every ounce of energy it takes, just to make it through another day. Most definitely there are those who think we are trouble makers the minute we walk into a building. Thinking we are there to find fault in the way they are teaching our children. I mean, after all, they are the professionals. If you define troublemakers as a person who advocates for a child who can not speak for it's self as a trouble maker,

SO BE IT.

When you find a child that needs to have it's lessons read to them and you do something about it. Then they call you a troublemaker. SO BE IT. The really odd part about all of this trouble making business is; they should have already been doing those things in the first place. My friend, That is Advocacy. NOW WHO IS THE TROUBLEMAKER.? Thank you and Hugs to Steve Metz for sending this to me.

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A new national survey indicates that there are three major barriers to improved quality of life for people with schizophrenia and for their caregivers -- stigma of mental illness, inadequate insurance and access to treatment and services.

The results of this National Mental Health Association survey were presented in a press conference on May 20^th at the Annual Meeting of the American Psychiatric Association. In the U.S., about 2.2 million people have schizophrenia.

"While it is the case that treatment and services are widespread in our country, persons with this illness often have trouble navigating the system, dealing with access and stigma issues and getting on the right drug therapy," said presenter and investigator Peter Weiden, MD, Director of Schizophrenia Research Service, professor of psychiatry, SUNY Downstate Medical Center, in New York. "Good drugs exist but only if a patient can get to them or get help developing a plan of treatment that will work for that individual."

Harris Interactive Inc. conducted the "Barriers to Recovery" survey from October 29 through December 19, 2002. They interviewed 1,087 adults ages 18 and older, including 403 persons categorized as "aware of mental illness in general," representing 90% of the total adult U.S. population.

The survey results identified 202 participants as knowing "someone with a mental illness other than schizophrenia"; 201 knew "someone with schizophrenia"; and 200 were identified as being unpaid caregivers for people with schizophrenia.

Eighty-one participants recruited through the National Mental Health Association had been diagnosed with schizophrenia.

Regarding stigma, 58% of people with schizophrenia and 47% of caregivers say that they believe schizophrenia can be treated successfully, while among other respondents, 27% hold this view.

Among respondents who did not have schizophrenia and did not know anyone with the condition, 50% said they believe people with depression can hold jobs and 49% believe people with depression can raise families, but only 14% of these same respondents believe that people with schizophrenia can do either successfully.

Seventy percent of respondents with schizophrenia said it is difficult to keep a positive attitude while dealing with illness-related stigma.

The survey results also shows that 48% of people with schizophrenia think adequate services exist for people with mental illness, and 35% of caregivers feel adequate services exist for families and friends dealing with mental illness. Likewise, 52% of people with schizophrenia and 21% of caregivers believe that insurance coverage for mental illness is on a par with coverage for physical illness.

Lack of access means people with schizophrenia do not always receive the latest standard of care medications for their specific illness, said Dr. Weiden. The researcher reported that 70% of both caregivers and people with schizophrenia express satisfaction with the results of their current pharmacotherapy. But only 50% of caregivers and 62% of people with schizophrenia are satisfied with their access to effective medications that do not have significant side effects.

As for the economic effects of schizophrenia, 63% of caregivers indicated difficulty in working full-time due to their role as a caregiver. The survey results also showed that the average caregivers' household income is 13% lower than that of the general public, despite parity in age and education.

In a press release distributed at the briefing, Chuck Ingoglia, vice-president of research and services at the National Mental Health Association, in Washington, D.C., said, "This survey proves what people with schizophrenia and caregivers already knew regarding the barriers to an improved quality of life. Now we need to reduce the barriers that people with schizophrenia and caregivers face every day. A good start includes public education, improved insurance legislation, and better access to appropriate services and treatments."

The survey was supported by an unrestricted grant from Bristol-Myers Squibb Co. and Otsuka America Pharmaceutical, Inc.

My 2 Cents on Medication

Medication is a serious issue. It's one that Parents do not take lightly and is one of the hardest decisions to make regarding the treatment of ADHD.

As Parents, we agonize over whether or not we should medicate our child. We weigh the pros and cons, look at the the short and long term side affects, consider our lifestyle and the welfare of our child and make a decision based on the best information we can.

As a parent who has chosen to medicate their child, for whatever reason, you will one day run into that family member, news story, friend, stranger, teacher or...whoever, who will take it upon them self to inform you as to how horrible of a parent you are. They will question your motives for medicating your child, they will tell you that you are killing your child, turning him/her into a dope fiend, that you are shirking your duties as a parent and so on. Not only do they send you on a guilt trip but they back your bags for you.

How does one handle these situation? How do I handle these situations?

• I handle these situations by letting these people know that

  IT IS NONE OF THEIR BUSINESS!

• How I treat my child's ADHD is a personal and private matter, not open to discussion to anyone except myself and my child's doctor. Whether I choose traditional methods, alternatives, diet and nutrition or wave crystals and chant, it is MY decision based on what is right for myself, my child, and our lifestyle. If it works who are they to question my motives or my child's Dr.? Learn to distance yourself from those who offer criticism rather than support.
• Unless the newspaper, magazine article, sales literature etc, concerning medication is based on facts and not the ramblings of a reporter, opportunist or other individual who is spouting personal opinion, bias and faulty information, use it to train the new puppy, or line the bird cage. If an article concerns you, discuss it with your dr. before jumping to conclusions or changing how you treat your child.
• Be wary of any school official, teacher, principal, counselor etc, that tells you your child needs medication. While these people may very well be looking out for your child's best interest the truth is that none of these people have a degree in medicine and have no business suggesting that your child needs medication. These same people also have no business diagnosing your child with any medical condition. Again, they do not have the training to do so. If I had listened to the professionals at my son's school, he would be labeled as "psychotic" today instead of diagnosed and treated as ADHD. If your child's teachers have come to you with concerns, use the tools at the school (Special ed Testing) and use the results to help your pediatrician or Dr. seeing your child make the best possible diagnosis possible.
• Also Be Wary of any professional who suggests that you treat your child indiscriminately with powerful drugs such as Ritalin, cylert etc under the guise of, "if this medication helps, then your child has ADHD". I do not believe that haphazardly medicating your child is the proper way to make a diagnosis.
• Please keep in mind that there are many, many other disorders and issues that can cause symptoms that mimic ADHD. Aspergers syndrome, bi-polar, depression, post traumatic stress, allergies to food and environment, and even gifted children who are unidentified and going unchallenged in class can all exhibit symptoms of ADHD. It takes an experienced and well trained Dr. to make an accurate diagnosis.
• Please remember that medication, no matter how appropriate is not a "magic bullet". Children diagnosed with ADHD are often candidates for the co-existence of other disorders such as depression. Counseling and/or group therapy can excellent tools in teaching your child the skills and tools they need to be successful social and behaviorally.
• If you are having trouble deciding whether or not medication is the right route to take in treating your child's ADHD, one option is to explore alternatives. Knowing that you tried other avenues before choosing medication may help alleviate any issues you have regarding using medication.

In view of all of this, let me say that the better informed you are, the better decisions you will make concerning your child. There are a lot of issues to take into consideration before you decide on a method of treatment. With the right information, you will make a decision that is right and in the best interest of your child. As mothers, we have a 6th sense about our children..... call it instinct or guts, whichever you choose, always take time to listen to it and your heart. When you take all this into consideration, how can you go wrong? And when you think about it, how can someone, who doesn't know your child like you do, or care about your child like you do, know what's best for your child? I don't believe they do.

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Long-term study shows once-a-day Concerta effectively controls ADHD symptoms in children.

A study of children with Attention Deficit Hyperactivity Disorder (ADHD) who had previously responded to treatment with methylphenidate demonstrates that once-a-day Concerta(R) (methylphenidate HCl) CII effectively controls ADHD symptoms and maintains a consistent safety profile over one year. The study, an interim analysis of one of the longest studies to date of continued use of stimulant medication, indicates that children with ADHD are likely to continue to respond to Concerta for up to 12 months. The findings were published in the April issue of the Journal of the American Academy of Child & Adolescent Psychiatry.

The findings also add to the literature in countering some long-standing beliefs about the effect of methylphenidate, the active ingredient in Concerta, as a long-term ADHD treatment. Investigators reported that Concerta did not adversely affect growth (weight and height); did not appear to induce or worsen tics; did not adversely affect vital signs (i.e., blood pressure, pulse); and had no clinically meaningful effect on a wide range of blood tests (i.e., red and white blood cell count, liver function tests). Additionally, despite its extended-release pharmacokinetic profile and long duration of action, Concerta apparently had little impact on parental perception of sleep quality.

"While it is generally agreed that pharmacological treatment of ADHD may be needed for extended periods, few treatment studies of ADHD extend beyond a few months," said study lead author Timothy Wilens, M.D., Director of Substance Abuse Services in the Pediatric and Adult Psychopharmacology Clinics at Massachusetts General Hospital. "This 12-month analysis of a longer-term study establishes the safety and efficacy of Concerta over one year, and addresses some concerns about the effects of long-term methylphenidate treatment on growth (height and weight), tics, vital signs, and sleep quality. Given the chronic nature of ADHD, it is comforting to know that medications such as Concerta continue to work in reducing ADHD and associated impairment."

About the Study

The study was designed to evaluate the effectiveness and tolerability of Concerta administered openly over a period of up to 24 months. It involved one of the largest samples of stimulant-treated ADHD children followed systematically for at least one year.

A total of 407 children, ages six through 13, who had participated in one of the previous efficacy or pharmacokinetic studies for Concerta participated in this multicenter, open-label nonrandomized study.

Subjects were initially assigned to one of three daily dosing levels of once-a-day Concerta (18, 36, or 54 mg) based on their dose in the previous study. Doses could be adjusted upward or downward in 18 mg increments if considered appropriate by the investigator, and participants were permitted to stop taking the medication for weekends or non-school days, or to have medication holidays.

At the beginning of the study, 116 (28.5%) subjects were taking the 18 mg dose, 193 (47.4%) were taking the 36 mg dose, and 98 (24.1%) were taking the 54 mg dose. At the end of treatment (last dose before completing or withdrawing from study), 61 (15.0%), 163 (40.0%), and 183 (45.0%) subjects were taking the 18 mg, 36 mg, and 54 mg doses, respectively. During this period, 39.8% of children had no dose change, 19.7% had dose increases only, and 38.4% of subjects experienced both increases and decreases.

"Increases in dosage of ADHD medications over time is not unusual, and in line with the published literature," explained Dr. Wilens. "The findings from this research suggest that a 20 percent upward titration of Concerta may be appropriate for some children to receive the full benefit of the medication," he added.

Children's ADHD-related behavior in school and at home were rated at various intervals of the study by parents and teachers, using established tools such as the IOWA Conners Ratings Scale. Researchers reported that teacher and parent/caregiver monthly IOWA Conners scores remained relatively consistent throughout the 12-month period.

"The results of this study coupled with results from short-term clinical studies support the usefulness of this once-daily preparation of OROS(r) MPH for ADHD," said Dr. Wilens. "Further studies of Concerta in adolescents, adults, and subgroups of individuals with ADHD, and with concurrent psychosocial treatments are warranted to determine the impact of this long- acting stimulant preparation on the long-term outcome of ADHD." The majority of adverse events reported during the study were judged mild in severity and consistent with the known safety profile of methylphenidate. There were no unusual or unexpected adverse events.

Of the 407 subjects who received study medication, 289 (71 percent) completed 12 months of treatment. Of the 118 subjects who discontinued treatment prior to 12 months, 31 subjects (7.6%) discontinued for lack of effectiveness, 30 of whom were taking the 54 mg dose. Other reasons for discontinuation included adverse events (n=28), lost to follow-up (n=16), noncompliance or protocol violation (n=14), personal reasons (n=11), female reaching menarche (n=6), and other (n=12).

About Concerta

Concerta is an extended-release formulation of methylphenidate for ADHD treatment that is designed to last through 12 hours, with just one morning dose. Concerta uses an advanced OROS(R) extended-release delivery system. The OROS(R) trilayer tablet is designed to release the medication in Concerta in a controlled pattern providing symptom management throughout the day.

Concerta was approved by the U.S. Food and Drug Administration in 2000. It is marketed in the United States by McNeil Consumer & Specialty Pharmaceuticals. For more information about Concerta, call 1-888-440-7903 or visit http://www.concerta.net/.

Source: McNeil Consumer & Specialty Pharmaceuticals, manufacturers of Concerta

Anxiety is common, but not inevitable after a heart attack. If left untreated, it may impair a patient's recovery.

There is a mismatch between patients' own descriptions of anxiety after a heart attack and the way it is recorded and treated by their doctors. Anxiety is common - but not inevitable - after a heart attack. Left untreated, it may impair a patient's recovery.

Researchers at Ohio State University have looked at the experience of a group of 101 heart attack patients. Anxiety levels varied from none to severe. Nearly half of those who rated themselves as being extremely anxious had not had a clinical assessment of anxiety. Nor had more than half of those saying they were moderately or mildly anxious. Slightly less than a third of those reporting no anxiety had been evaluated.

Three quarters of the participants had received some treatment for anxiety - such as tranquilizing drugs or relaxation therapy - but a prior clinical assessment had only been done in less than half of cases. It was rare for any follow up to be done to see if the treatments were effective.

The researchers are developing an easy-to-administer tool that can accurately measure the patient's level of anxiety after a heart attack. This will help doctors administer the correct treatment, if any is needed and this should aid the patient's recovery.

Source:
Ohio State University press release, March 12, 2003.

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The public's understanding of bipolar disorder is often flawed, especially when it hits celebrities.

At first glance, legendary music producer Phil Spector and Oakland Raiders center Barret Robbins may seem to have little in common, but they both apparently struggle with bipolar disorder. Not that the condition has made the two celebrities behave in the same way.

Robbins had reportedly been hospitalized and placed on suicide watch shortly after he was suspended from playing this year's Super Bowl against the Tampa Bay Buccaneers. In the hours leading up to the big game in late January, there were accounts of the 29-year-old going on a drinking binge, missing crucial team meetings, and being disoriented and utterly depressed.

Spector, 62, supposedly resisted arrest in early February, minutes after police found the bloodied body of B-movie actress Lana Clarkson in the foyer of his Los Angeles mansion. The record producer, responsible for more than a dozen Top 40 Hits in the 1960's ("Be My Baby," "You've Lost That Lovin' Feelin'"), was accused of shooting Clarkson in the face and faces first-degree murder charges.

Although Spector has been notorious for his drunkenness and violent behavior over the decades, Rolling Stone reports that in the months before the murder, colleagues had found him sober, pleasant, and productive.

In the Raiders camp, some teammates publicly criticized Robbins for bailing out on the team in the Super Bowl, where Raiders lost to the Bucs 48-21. Despite the center's record of missed games and unexplained absences, guard Frank Middleton says he and many fellow players never knew Robbins as a depressed guy.

What happened to Robbins and Spector, and how did people working closely with them miss what was really going on? Psychiatric experts say a number of factors contribute to society's misconceptions about bipolar disorder and make treatment of it all the more difficult.

The Anatomy of Inner Turmoil

According to the American Psychiatric Association (APA), people with bipolar disorder, commonly known as manic depression, usually suffer extreme mood swings, cycling from mania to depression.

In the manic phase, they usually feel invincible, euphoric, hyperactive, and very productive. This could lead to excessively risky behavior, grand delusions, uncontrollable thoughts and actions, irritability, rage, and insomnia. In the depressed phase, they can experience intense sadness, despair, fatigue, insomnia, difficulty concentrating, changes in appetite, and constant thoughts of suicide.

Robbins once described his problem as 'a battle within your head.' Spector explained his as 'devils inside that fight me.' These are two examples of the emotional challenges affecting the lives of millions of people. The Depression and Bipolar Support Alliance (DBSA) reports that 2.5 million adult Americans suffer from the chronic disease; other countries reportedly have similar rates.

The good news is that effective treatments exist for manic depression, including medication, counseling, and sometimes a mix of both. The bad news is that many people don't take this life-altering remedy because they are either in denial about their illness, think nothing can help them, or they're misdiagnosed -- usually with depression. It is also common for those who are on drugs to relapse because they stop taking their prescription, often because they think they're getting better.

The stigma attached to psychiatric illness doesn't help either. Many people think only violent and insane-acting individuals could possibly have a mental disorder. Though it is true that mania could cause someone to become more aggressive and do illegal things, most of the time, people with serious psychiatric problems end up to be victims of crime.

"They are not as good at defending themselves because they tend to be loners, and vulnerable," says Robert Hirschfeld, MD, chairman of the department of psychiatry and behavioral sciences at the University of Texas Medical Branch in Galveston. He says many tend not to know what manic depressives go through unless they experience the disorder themselves, or know someone close to them who is suffering.

Otherwise, most people think sufferers can 'pull it together,' when that's not usually the case, says David Dunner, MD, director of the Center for Anxiety and Depression at the University of Washington in Seattle. He explains that mental illness isn't usually viewed in the same vein as the flu, pneumonia, heart disease, or broken bones. Yet, he says, "The same kinds of physical things are wrong when someone has depression or a manic episode."

Medical experts aren't yet certain of the exact cause of bipolar disorder, but a biological cause is the prime suspect since it seems to run in families. APA figures indicate that 80% to 90% of individuals with manic depression have a relative with either depression or bipolar disorder, a rate 10 to 20 times higher than in the general population.

A person's environment can also contribute to the disease, says Hirschfeld, pointing to both early and current experiences as possible factors.

Silent Suffering, Public Misunderstanding

Spector and Robbins' woes with manic depression may both have played out on the national stage, but based on reactions of shock to their plight, it seems their recent emotional anguish went relatively unnoticed or were ignored until it was too late.

The same thing can happen to ordinary citizens, testifies Dan Gunter, who has endured bipolar disorder for nearly a decade. The Opelika, Ala., resident says before he was accurately diagnosed with the illness, he cycled from mania to depression to the point that he hurt many people close to him and quit a good-paying healthcare job.

When he first sought help, doctors thought he had depression and prescribed him antidepressants. The drugs, he said, made his manic episodes worse.

Once the bipolar disorder was correctly identified and he was able to take the right medication, however, Gunter says his life improved dramatically. Now he not only works as an announcer for a group of radio stations, he has started his own coaching business -- helping other people with manic depression.

Although he considers the damage to his marriage irreparable, Gunter says his new life under treatment has helped him cope with many emotional difficulties. He considers himself fortunate that many of his family and friends have been understanding about his disease.

Gunter worries about the people who do not receive appropriate treatment, pointing to DBSA figures that say roughly seven in 10 consumers are misdiagnosed by doctors at least once. Also, more than a third (35%) of the misdiagnosed suffer for more than 10 years before they are accurately diagnosed with bipolar disorder.

The problem, Gunter says, is that most people will only report some symptoms, and many physicians don't take the time to do a comprehensive evaluation. "So bipolar disorder is very often misdiagnosed as depression, as schizophrenia, and other disorders," he says.

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Mood stabilizers should lower the risk of episode recurrence, reduce symptoms overall, and improve our patients' daily function - Journal of Family Practice, March, 2003 by Paul E. Keck, Jr., MD

Bipolar disorder is a persistent, severe, sometimes lethal, and lifelong illness. Therefore, it is important to prevent recurrent mood episodes and suppress intercurrent symptoms. (1) Evidence from randomized, controlled trials supports the efficacy of lithium, carbamazepine (Tegretol), divalproex (Depakote), olanzapine (Zyprexa), and lamotrigine (Lamictal) in long-term treatment of patients with bipolar disorder. As more treatments become available, expectations increase regarding the potential impact of mood stabilizers--in combination with psychotherapeutic interventions--on patients' lives.

Lithium

Alter more than 50 years, lithium remains the cornerstone of bipolar disorder treatment. (2) Lithium is one of the best-studied drugs in acute and long-term treatment, and it remains useful for many patients. On the other hand, new drugs are being developed for maintenance treatment of bipolar disorder because lithium is not effective for everyone and is associated with bothersome side effects for many patients. (2,3)

Goodwin and Jamison found about one-third of patients on lithium monotherapy remained episode-free for about 2 years. (4) Other naturalistic outcome studies of lithium maintenance therapy found somewhat more pessimistic results. A substantial subgroup of patients with bipolar disorder does well on lithium, but we now see greater numbers of patients who do not respond.

These findings imply the question, "What do we expect from mood-stabilizing drugs?" Do we expect complete prevention of mood episodes? These agents are certainly more useful if we define efficacy as a relative reduction in risk of episode recurrence, overall symptom reduction, and improvement in function.

Many factors associated with acute response to lithium--reviewed by Dr. Frye et al in this monograph--are also associated with long-term response. Patients with bipolar I illness--especially with euphoric or elated mania--tend to have better long-term outcomes with lithium than do other patients. Those who have done well on lithium in the past tend continue to do well on lithium, although the number of prior episodes is an important predictor of response.

Carbamazepine

Numerous studies have examined the use of carbamazepine in bipolar disorder maintenance treatment. (6) In a critical analysis by Dardennes et al of maintenance trials comparing carbamazepine with lithium, three of four studies found the agents comparable in efficacy, and one found lithium more effective than carbamazepine. (7) Limitations inherent in these early maintenance trials led to two recent studies.

Denicoff et al compared the efficacy of carbamazepine, lithium, and the combination in 52 outpatients with bipolar I disorder. (8) Patients received randomized, double-blind treatment with carbamazepine or lithium in year 1, were crossed over to the alternate agent in year 2, and received the combination in year 3. Adjunctive use of antipsychotics, antidepressants, and benzodiazepines was permitted.

Mean time to a new manic episode was significantly longer with combination therapy (179 days) compared with lithium (90 days) and carbamazepine (66 days) alone. Patients were significantly less likely to experience a manic episode during the combination phase (33%) than with lithium (11%) or carbamazepine (4%). Most patients required adjunctive treatment during each study phase.

Greil et al compared lithium and carbamazepine in an open-label, randomized trial for up to 2.5 years. (9) Some interesting differences between the two medications were noted:

* no significant difference in hospitalization rate, though more carbamazepine-treated patients (55%) than lithium-treated patients (37%) required hospitalization.

* a trend suggesting that carbamazepine was not quite as effective as lithium in preventing recurrence--59% versus 40% (Figure 1).

On the other hand, lithium-treated patients had better outcomes on two measures:

* number of patients who had mood episode recurrence or required an antimanic or antidepressant drug

* mood episode recurrence, need for additional medicine for manic or depressive symptoms, or dropout because of adverse effects.

A post hoc analysis found that patients with bipolar II illness or atypical features--mood incongruence, psychiatric comorbidity, psychotic symptoms and dysphoric mania--tended to do better with carbamazepine than with lithium. (10) These findings are interesting because relatively few predictors of response are found in the literature for carbamazepine maintenance treatment. Taken in total, this study suggested that lithium overall was associated with a better long-term outcome than carbamazepine.

Valproate

Three studies have addressed long-term efficacy of valproate formulations in treating patients with bipolar disorder.

Lambert and Venaud conducted an open comparison trial of valproinide versus lithium in >140 patients. (11) During 18 months, the number of episodes per patient was slightly lower with valpromide (0.5) than with lithium (0.6).

Bowden et al conducted the only placebo-controlled, randomized, maintenance study of valproate in patients with bipolar I disorder (Figure 2). (12) In this 1-year trial, patients received divalproex, lithium, or placebo. The primary outcome measure was time to relapse of any mood episode.

The inclusion of patients with relatively mild bipolar illness probably explains the lack of any significant difference in efficacy among the three treatment groups. Approximately 40% of the patients had never been hospitalized for a manic episode.

Post hoc analysis found divalproex was significantly more effective than placebo in preventing relapse among patients who started divalproex before randomization and then were randomized to divalproex or placebo. This group is representative of clinical practice.

The third maintenance study, which compared divalproex with olanzapine, is described later in this article. (13)

Summary. Predictors of response to valproate are not as well established as for lithium. Predictors of response for maintenance treatment are similar to those identified for acute treatment. Thus far, the evidence suggests that most bipolar illness subtypes--including rapid cycling and mixed mania--have comparable response rates to valproate compared with lithium, leading to the suggestion that valproate may be a broad-spectrum antimanic agent. However, most of these data regarding predictors of response are from open longitudinal studies, not from randomized controlled trials. (14)

Olanzapine

Three randomized, controlled trials have examined olanzapine's efficacy in bipolar disorder maintenance treatment.

Tohen et al compared olanzapine with divalproex over 47 weeks in patients who responded to acute treatment during an initial 3-week trial. (13) Manic symptoms were reduced markedly in the first 3 weeks with both agents, followed by a cumulative reduction in manic symptoms over time following hospital discharge. Throughout the trial, manic symptoms were reduced significantly more in patients receiving olanzapine than divalproex. Depressive symptoms improved similarly in the olanzpaine and divalproex treatment groups.

The second olanzapine maintenance study addressed whether patients who respond to olanzapine plus lithium or valproate should be maintained on the combination. (15) Patients who responded in a 6-week acute treatment trial could either stay on combination treatment or resume monotherapy with lithium or valproate.

A significantly lower relapse rate was found with combination treatment (45%) than with monotherapy (70%). Time to relapse of manic symptoms was significantly longer with combination therapy than with lithium or valproate alone. (15) Combination therapy was significantly more effective in preventing manic relapse but not in preventing depressive relapse (P = 0.07).

Insomnia was significantly more common in the monotherapy group. Weight gain was more common in the combination group (19%) than the monotherapy group (6%).

This is the first large study to compare the efficacy of combination mood-stabilizer treatment with monotherapy over time. A small, 1-year pilot trial comparing lithium plus divalproex versus lithium alone also suggested that combination therapy was more effective. (16)

The third maintenance study of olanzapine was a 1-year comparison with lithium in >400 patients with bipolar I disorder. (17) Patients had clinically significant baseline manic symptoms--YMRS score >20--and at least two manic or mixed episodes within 6 years prior to study entry.

The rate of manic recurrence with olanzapine or lithium did not differ significantly for the first 150 days of the trial, but thereafter the rate was significantly lower for the olanzapine group. Overall, 27% of patients receiving lithium relapsed into mania, compared with 12% of those receiving olanzapine. Fewer patients receiving olanzapine (14%) than lithium (23%) required inpatient admission for relapse. Depression relapse rates did not differ significantly.

Significantly more patients receiving lithium reported insomnia, nausea, and manic symptoms. Significantly more patients receiving olanzapine reported depressive symptoms, somnolence, and weight gain.

Tardive dyskinesia. One other essential question about the safety of olanzapine and any other atypical antipsychotic in bipolar disorder maintenance treatment is whether these agents produce tardive dyskinesia (TD). A 1-year open-label study of olanzapine involving 98 patients with bipolar I disorder found no cases of TD. (18)

Lamotrigine

Two studies--almost identical in design--indicated that lamotrigine was more effective than placebo in delaying time to relapse into bipolar depression. (19,20) The first study randomized patients to lithium, lamotrigine, or placebo after a manic episode was stabilized. (19) The second study used the same randomization scheme but enrolled patients after a bipolar depressive episode was stabilized. (27)

In the first study, lithium and lamotrigine were significantly more effective than placebo in prolonging time to intervention for any mood episode: (20)

* Lamotrigine--but not lithium--was significantly more effective in preventing or extending time to intervention for depression.

*Lithium--but not lamotrigine--was significantly more effective than placebo in delaying time to intervention for a manic episode.

In the second study, lamotrigine and lithium were significantly more effective than placebo in prolonging time to intervention for a mood episode, with no difference between the agents. (27) Only lamotrigine was significantly more effective than placebo in time to intervention for depression. Lithium--but not lamotrigine--was significantly more effective than placebo in time to intervention for mania.

Summary

Data from randomized, controlled trials support the efficacy of lithium, lamotrigine, and olanzapine as foundational agents in long-term treatment of patients with bipolar disorder. Less substantial evidence supports the efficacy of carbamazepine and valproate. Lamotrigine appears to have greater efficacy in preventing bipolar depressive episodes, whereas lithium may have greater efficacy in preventing bipolar manic episodes.

Olanzapine was more effective than lithium in preventing bipolar manic episodes. Olanzapine's efficacy in preventing bipolar depressive episodes requires clarification in placebo-controlled trials. In the few available controlled trials, combination maintenance strategies were more effective in preventing relapse than mood-stabilizer therapies alone.

About the author: Paul E. Keck, Jr., MD is professor of psychiatry, pharmacology and neuroscience, and vice chairman for research in the Department of Psychiatry at the University of Cincinnati College of Medicine. This article appeared in the Journal of Family Practice, March, 2003.

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References

(1.) Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002;59:530-7.

(2.) Keck PE, Jr. McElroy SL. Treatment of bipolar disorder. In: Schatzberg AF, Nemeroff CB (eds). The American Psychiatric Textbook of Psychopharmacology (3rd ed). Washington, DC: American Psychiatric Publishing (in press)

(3.) Hirschfeld RM, Bowden CL, Gitlin MJ, et al. Practice guideline for the treatment of patients with bipolar disorder (rev). Am J Psychiatry 2002; 159(suppl):1-50

(4.) Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford University Press, 1990.

(5.) Frye MA, Gitlin MJ. Altshuler LL. Treating acute mania. Current Psychiatry 2003; 3(suppl 1):10-13.

(6.) Keck PE, Jr, McElroy SL, Nemeroff CB, Anticonvulsants in the treatment of bipolar disorder. J Neuropsychiatry Clin Neurosci 1992;4:395-405.

(7.) Dardennes R, Even C, Bange F, Heim A. Comparison of carbamazepine and lithium prophylaxis of bipolar disorders. A meta-analysis. Br J Psychiatry 1995;166:378-81.

(8.) Denicoff KD, Smith-Jackson EE, Disney ER, Ali SO. Leverich GS, Post RM. Comparative prophylactic efficacy of lithium, carbamazepine, and the combination in bipolar disorder. J Clin Psychiatry 1997;58:470-8.

(9.) Greil W, Ludwig-Mayerhofer W, Erazo N. et al. Lithium versus carbamazepine in the maintenance treatment of bipolar disorders: a randomised study. J Affect Disord 1997;43:151-61

(10.) Kleindienst N, Greil W. Differential efficacy of lithium and carbamazepine in the prophylaxis of bipolar disorder: results of the MAP study. Neuropsychobiology 2000;42(suppl 1):2-10.

(11.) Lambert P, Venaud G. Comparative study of valpromide versus lithium in the treatment of affective disorders. Nervure 1992;5:57-62

(12.) Bowden CL, Calabrese JR, McElroy SL, et al. A randomized, placebo-controlled 12-month trial of divalproex and lithium in treatment of outpatients with bipolar I disorder. Divalproex Maintenance Study Group. Arch Gen Psychiatry 2000;57:481-9.

(13) Tohen M, Baker RW, Altshuler LL, et al. Olanzapine versus divalproex in the treatment of acute mania. Am J Psychiatry 2002;159:1011-7.

(14.) Calabrese JR, Faremi SH, Kujawa M, Woyshville MJ. Predictors of response to mood stabilizers. J Clin Psychopharmacol 1996;16(suppl 1):S24-31.

(15.) Tohen M, Chengappa KNR, Suppes T, et al. Olanzapine combined with lithium or valproate in the prevention of recurrence in bipolar disorder: an 18-month study (paper presentation). Boston: U.S. Psychiatric and Mental Health Congress annual meeting, 2001.

(16.) Solomon DA, Ryan CE, Keitner GI, et al. A pilot study of lithium carbonate plus divalproex sodium for the continuation and maintenance treatment of patients with bipolar I disorder. J Clin Psychiatry 1997;58:95-9.

(17.) Tohen M. Marneros A, Bowden CL, et al. Olanzapine versus lithium in relapse prevention in bipolar disorder: a randomized double-blind controlled 12-month clinical trial (paper presentation). Freiburg, Germany: European Stanley Foundation Bipolar Conference, 2002.

(18.) Sunger TM, Grundy SL, Gibson PJ, Namjoshi MA, Greaney MG, Tohen ME Long-term olanzapine therapy in the treatment of bipolar I disorder: an open-label continuation phase study. J Clin Psychiatry 2001;62:273-81.

(19.) Calabrese JR, Shelton MD, Rapport DJ. Kimmel SE, Eljah O, Long-term treatment of bipolar disorder with lamotrigine J Clin Psychiatry 2002;63(suppl 10):18-22.

(20.) Bowden CL. Lamotrigine in the treatment of bipolar disorder. Expert Opin Pharmacother 2002;3:1513-9

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