Stimulants for ADHD: Placebo for Parents?

Stimulants like Adderall and Ritalin may have more of an effect on parents and teachers than they do on the children with ADHD who take them, according to a recent study by pediatric psychologists at the University of Buffalo.

It seems that when parents and educators think that a child is on an ADHD drug, the child gets better, even if he or she is not actually taking medication, reported Daniel A. Waschbusch, PhD.

"The act of administering medication, or thinking a child has received medication, may induce positive expectancies in parents and teachers about the effects of that medication, which may, in turn, influence how parents and teachers evaluate and behave toward children with ADHD," said Dr. Waschbusch. Caregivers who think kids are on medication, tend to view those children more favorably and treat them more positively, whether or not medication was actually involved.

Dr. Waschbusch and his colleagues reviewed data from several placebo controlled studies of stimulant medications in elementary school aged children with ADHD, looking specifically at 'responders' in the placebo groups.

While there is little evidence that placebos produce any significant actual changes in behavior or cognition of kids with ADHD, the aggregated evidence suggests that parents and teachers tend to evaluate children with ADHD more positively when they believe the child has been given stimulant drugs, even if they have not (Waschbusch DA, et al. J Dev Behav Pediatr. 2009; 30(2): 158-68).

The investigators suggested four possible ways that placebos might affect the interaction between children and their caregivers:

Through the child's expectation of change: If a child believes he or she is under a treatment that is supposed to improve his attention and behavior, he may behave differently in accordance with the expectations. Dr. Waschbusch's analysis did not show evidence supporting this proposed mechanism.

By changing how caregivers perceive children thought to be on treatment: Parents or teachers assume that the "medication" will produce improvements, and they interact more positively with the children based on the expected behavioral changes. The data suggest that this is a significant factor accounting for the observed outcomes.

By producing changes in how caregivers behave: Educators or caregivers who interact with the kids based on an assumption of improved behavior may actually induce some of those improvements through their language, tone, body signals when communicating with the children. The analysis supported this hypothesis.

• Caregivers may be influenced through classical conditioning: Parents who routinely give their children active medication in pill form and then see rapid improvements in cognition or behavior, unconsciously learn to connect the giving of a pill with improved child behavior. These expectations connected with the "ritual" of giving medication change how the parents communicate and interact with the children, producing positive changes in and of themselves.

Dr. Waschbusch and his colleagues are hoping to develop a study that directly observes parents and children interacting under three different conditions: after children received a pill with real medication, after children received an identical placebo, and after children didn't receive any pill. The idea is to identify changes in the communication and interaction patterns that might influence how the children respond.

"We speculate that the perception that a child is receiving ADHD medication may bring about a shift in attitude in a teacher or caregiver. They may have a more positive view of the child, which could create a better relationship. They may praise the child more, which may induce better behavior."

The impact of placebos on the behavior of children with ADHD and related conditions is a subject of increasing interest among pediatric psychologists in recent years. Two years ago, researchers at the Mission Children's Hospital, Asheville, NC, published a study looking at placebo-based dose reduction protocols in 70 children with ADHD.

Children randomized to the dose reduction program, which is based on gradually replacing actual medication doses with placebos, showed strong treatment responses to the placebos that were well maintained over time (Sandler A, et al. Child Care Health Dev. 2008; 34(1): 111-20). "Most parents reported treatment benefits, and 80% of the children found the placebo to be useful," the authors reported. What is really interesting about these findings is that the parents and children were all aware that they were getting placebos.

"Disclosure of the placebo to parents and children did not appear to negate the placebo's effectiveness. Participation effects and changes in caregiver behavior may have contributed to positive treatment outcomes," they note. The authors conclude that open-label placebo-based dose reductions represent an innovative, ethical way of harnessing the power of placebos in clinical therapeutics.

The issue has considerable health and economic significance, given that between 2 and 3 million school-age children in the US are prescribed stimulant medications, and the numbers have been rising steadily (Zuvekas SH, et al. Am J Psychiatry 2006: 163; 579-585). This is despite the fact that there are no long-term studies definitively demonstrating the efficacy or safety of stimulant medications in children. The longest published outcomes studies are only of 4 weeks' duration.

There is also considerable concern over stimulant drug abuse not only among the kids for whom they are prescribed but also among their non-diagnosed peers. Up to 30% of students surveyed report diverting their stimulant prescriptions. Up to 9% of kids in grades 1-12, and up to 35% of all college students surveyed reported using non-prescribed stimulants at some point (Wilens TE, et al. J Am Acad Child Adol. 2008: 47 (1): 21–3).

It certainly makes sense to eliminate unnecessary stimulant use among school-aged children.

 
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