Multiple studies have established that stimulant medication treatment is effective for adolescents with ADHD, especially in reducing core ADHD symptoms. However, adolescents frequently stop taking medication, and by age 18, less than 10% continue to take it. This is problematic given that symptoms often persist into young adulthood and continued treatment can be essential.
One reason frequently expressed by teens for stopping medication is their belief that it is not helpful. However, teens may not be accurate judges of whether medication is helping them and may not even be able to detect when they are receiving medication.
The inability to distinguish active medication from placebo treatment has been demonstrated in children, but not previously examined for teens. A study published in the Journal of Attention Disorders examined this issue [Pelham et al., (2017) Attributions and perception of methylphenidate effects in adolescents with ADHD. Journal of Attention Disorders, 21, 129-136.]. In this study, 46 youth ages 12 to 17 participated in a summer treatment program that combined medication treatment, behavior therapy, and both academic and social skills training. For the medication component, each adolescent underwent a placebo-controlled medication assessment in which he/she was tested on 3 different doses of methylphenidate as well as a placebo. Medication or placebo was administered 3 times per day.
After each day, youth were asked whether they had received medication or placebo. If they responded medication, they were asked whether they had received a low, medium, or high dose. They were also asked to rate how much their behavior and academic performance during the day had been influenced by a variety of factors including: their ability, effort level, whether they had been treatment fairly, medication they had taken, and having ADHD. Counselors and teachers rated participants’ behavior and academic success during the day.
Did medication help?
The answer here was a clear yes. On average, adolescents’ behavior and academic work was significantly better on active medication days than on placebo days. Could adolescents tell when they were on medication vs. placebo? – No, they could not. In fact, their ability to correctly identify medication days vs. placebo days was not better than chance, i.e., guessing. This replicates a finding previously reported for children. Furthermore, even though their behavior/academics was significantly better during medication days, adolescents rarely reported that medication played an important role in their success. On good days, they were especially likely to rate their effort and ability as the primary determinant of their success. In contrast, medication was rated as the primary determinant of success less than 1% of the time. The most frequent explanation provided for bad days was that they had not been treated fairly.
Summary and implications
Although medication was objectively helpful, teen participants rarely saw it as a key factor in their success. And, their ability to correctly distinguish between active medication days and placebo was no better than chance. While attributing their success to effort and ability is a positive attribution, not recognizing the benefits provided by medication may contribute to why so many teens refuse to take it. After all, if you don’t believe medication is helping, why take it? Given that teens could not reliably tell when they had taken medication or placebo, it is not surprising that they would be similarly unaware of benefits that medication provided. This is important to keep in mind when a teen objects to continuing medication because they don’t believe it is helping. Although they may be right, one should not assume their report is accurate. There are several issues with this study to highlight. First, the sample was relatively small and teens were given regular methylphenidate rather than a longer-acting medication. Caution is thus required when interpreting these findings and there would be value in replicating the study with a larger sample and different types of medication. It should also be noted that although adolescents, on average, may have trouble detecting when they have received medication or how it affects them, this does not mean individual teens are unable to do this. Thus, one should not use these results to discount the reports of individual teens. Instead, the findings provide an important context for interpreting individual reports. Because teens often refuse medication because they don’t believe it is helping, an important clinical implication of these findings is the need to engage teens in a discussion of the issue. Why do they believe the meds aren’t helping? Might they actually be benefiting even if this is not evident to them? Would they consider an ‘experiment’ to try and get actual data on this question? These are conversations parents and health professionals can have with teens and a procedure to gather data on medication effectiveness can also be considered. For example, one could try alternating days on and off medication and seeing whether it makes a difference in getting school work done. Another option would be to have the teen complete a computerized attention test on and off medication to see whether their performance differs (one would need to work with a health care provider on this). Neither approach is a ‘perfect’ procedure, but the goal is not perfection. Instead, it is to engage the teen as a collaborative partner in an important discussion about their health and treatment and to gather information relevant to this decision. In any such discussion, involving the teen’s healthcare professional is essential.
Copyright © 2020 by David Rabiner
5 Dobbs Place
Durham, NC 27707