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Symptoms
Epidemiology
Etiology
Assessment
Treatment
Authors
Shane R. Jimerson, Berkley Bowers, & Gabrielle Anderson
University of California, Santa Barbara
The authors also note the important contributions of Barbara D’Incau, Robert Ngan and Sabrina Rhee, who provided information critical to the development of this website.
Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder (ADHD)
is the most commonly diagnosed behavioral disorders during childhood (Tannock
& Schachar, 1996; Shaywitz, Fletcher & Shaywitz, 1994; Shelton
& Barkley, 1994; Kavanagh & Lyon, 1994; Barkley, 1990b).
ADHD includes a heterogeneous array of symptoms which overlaps markedly
with oppositional defiant disorder, conduct disorder, affective disorders
such as depression, anxiety, learning disabilities, and communication disorders.
The most common age for diagnosis is between the ages of 7 and 9, although
symptoms may be apparent before the age of 3 (Cohen et. al., 1993).
According to DSM-IV-TR criteria, the onset of ADHD is before age 7, however,
many individuals are not diagnosed until a later age due to the prominent
expression of ADHD symptoms in the school setting. ADHD is characterized
by a persistent pattern of behavioral symptoms of inattention, hyperactivity,
and impulsivity (APA, 2000; Barkley, 1990a, 1990b). Children showing
behaviors that are characteristics of ADHD have been found to be highly
“at-risk” for maladaptive educational and social outcomes. Furthermore,
although a child may not meet full DSM-IV criteria for ADHD, subclinical
problems of inattention, impulsivity or hyperactivity may contribute to
deleterious outcomes such as low reading achievement (Warner-Rogers, Taylor,
Taylor & Sandberg, 2000). It is important for the school psychologist
or child clinician to provide accurate information about ADHD to children
and their parents as misperceptions about the disorder, such that it is
primarily a disorder of inattention or that that the ADHD child must display
symptoms of both inattention and hyperactivity are common. Controversial
debates continue with regards to etiology, diagnosis and the use of pharmacological
intervention for ADHD.
DSM-IV-TR Criteria for ADHD
Source:
The Diagnostic and Statistical Manual of Mental Disorders - Fourth
Edition, Text Revision (APA, 2000) lists diagnostic criteria for Attention-Deficit/Hyperactivity
Disorder (p. 85-93):
A. Either (1) or (2):
(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Inattention
(a) often fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to oppositional
behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys,
school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(I) is often forgetful in daily activities
(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which
remaining seated is expected
(c) often runs about or climbs excessively in situations in which it
is inappropriate (in
adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty paying or engaging in leisure activities quietly
(e) is often “on the go” or often acts as if “driven by a motor”
(f) often talks excessively
Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations
or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
Subtypes
Attention-Deficit/ Hyperactivity Disorder, Combined Type:
This subtype should be used if six or more symptoms of inattention
and six or more symptoms of hyperactivity-impulsivity have persisted for
at least 6 months to a degree that is maladaptive and inconsistent with
developmental level. Most children and adolescents with the disorder
have the Combined Type. It is not known whether the same is true
for adults with the disorder.
Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive
Type:
This subtype should be used if six or more symptoms of inattention
(but fewer than six symptoms of hyperactivity-impulsivity) have persisted
for at least 6 months to a degree that is maladaptive and inconsistent
with developmental level. Hyperactivity may still be a significant
clinical feature in many such cases, whereas other cases are more purely
inattentive.
Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive
Type:
This subtype should be used if six or more symptoms of hyperactivity-impulsivity
(but fewer than six symptoms of inattention) have persisted for at least
6 months to a degree that is maladaptive and inconsistent with developmental
level. Inattention may often still be a significant clinical feature
in such cases.
Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified:
This category is for disorders with prominent symptoms of inattention
or hyperactivity-impulsivity that do not meet the criteria for Attention-Deficit/Hyperactivity
Disorder. Examples include:
1. Individuals whose symptoms and impairment meet the criteria for
Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type
but whose age of onset is 7 years or after.
2. Individuals with clinically significant impairment who present with
inattention and whose symptom pattern does not meet the full criteria for
the disorder but have a behavioral pattern marked by sluggishness, daydreaming,
and hypoactivity.
EPIDEMIOLOGY
Attention deficit hyperactivity disorder is
the most commonly diagnosed behavioral disorder of childhood, estimated
to affect 3 to 7 percent of school-age children (American Psychiatric Association
2000; National Institute of Health, 1998). Increases in identification
during the school-age years may be a factor of the school environment rather
than increases in the actual incidences. More specifically, behavioral
symptoms of ADHD (i.e., easily distracted, difficulty sustaining attention
in tasks) are more often observed in classroom settings where formal structure
is warranted. Thus, children are more likely to be referred for an
ADHD diagnosis during the school-age years rather than the pre-school years
when certain behavioral norms are expected in the elementary classroom.
More often than not, symptoms of this disorder are evident beginning in
early childhood and extend into adulthood. Indeed, it has been reported
that 50 percent of children diagnosed with ADHD as preschoolers will either
receive a similar diagnosis at a later age (Campbell, 1990) and/or continue
to exhibit symptoms of this disorder into adulthood (Barkley, Fischer et.al.,
1990; Gittelman et.al., 1985; Weiss & Hechtman, 1993). Developmentally
the symptoms of ADHD typically attenuate or change in form as one matures
and grows older, though the severity and extensity of problems may remain
(American Psychiatric Association, 2000; Whalen & Henker, 1998).
The number of boys diagnosed with ADHD outnumber
girls by at least 4 to 1. The higher ratio of males in clinic samples
may be due to selective referral, rather than actual incidence. Furthermore,
females are more likely to exhibit internalizing symptoms that involve
mood, affect and emotion, whereas males usually display more externalizing
symptoms such as aggressive and antisocial behaviors. Thus referrals
initiated from the school environment are more likely to be due to overt
or disruptive behavior, symptoms found more often in males with this disorder.
Children who exhibit the Predominantly Inattentive Type are more likely
to be placed in special education classes for students with learning disabilities
despite that as a group they do not display significantly greater learning
deficits than children with the Combined or Predominantly Hyperactive-Impulsive
Types. Furthermore, children who exhibit the Combined and Hyperactivity-Impulsive
Types are more likely to be placed in special education classrooms for
children with emotional and behavioral disorders (Warner-Rogers,
Taylor, Taylor, & Sandberg, 2000).
Warner-Rogers, Taylor, Taylor, and Sandberg (2000) redressed
the lack of research focusing specifically on children who exhibit inattentive
behavior through an large, community-based epidemiological study of seven
year old boys. Comparisons were made between the developmental functioning,
social, and environmental backgrounds of children with pure inattentive
behavior to that of children with pure overactive behavior and combined
problems of inattentive and overactive behavior. The authors found
that children with pure inattentive behavior were more likely to have general
cognitive delays, especially in the area of language development, and were
more likely to come from families where the father was of low occupational
status.
This study underscores the importance for
educators, clinicians, and researchers to improve identification methods
for children displaying the Predominantly Inattentive Type. Although
purely inattentive children did not exhibit the magnitude of disruptive
behavior that the purely overactive or Combined Type children did, inattentive
behavior was highly associated with adjustment problems in the classroom
such as having reading impairments, possessing low self-esteem, and needing
directions repeated (Warner-Rogers, Taylor, Taylor & Sandberg, 2000).
Co-morbidity of ADHD with conduct disorder
(50 percent; Biederman et. al., 1991), oppositional-defiant behavior,
anxiety disorders, speech and language disorders (78 percent; Baker
& Cantwell, 1992), and learning disabilities (LD) (41-70 percent; Holborow
& Berry, 1986; Mayes, Calhoun & Crowell, 2000) is extremely high.
Estimates of the incidence of school-age children with partial ADHD syndrome
and one or more other problems present (i.e., anxiety, depression, etc.)
are 5 to 10 percent (www.chadd.org/facts). Comorbidity appears to
be more common in younger than in older children (Bird et. al., 1993; Russo
& Beidel, 1994).
Mayes, Calhoun, and Crowell (2000) explored
the overlap between ADHD and learning disabilities in a clinical sample
of 8 to 16 year olds. The authors found that a LD was present in
70 percent of the children with ADHD. Furthermore, a LD in written
expression was twice as common (65 percent) as a LD in reading, math or
spelling. No previous research studies examining the prevalence of
LD in children with ADHD assessed for LD in written expression. Furthermore,
children with both a LD and ADHD had more severe learning problems than
children who had a LD but not ADHD as well as had more severe attention
problems than children with ADHD but not a LD. Based on their observation
that children with ADHD who did not meet full criteria for a LD still experienced
learning difficulties, the authors conclude that learning and attention
problems are best conceptualized as existing on a continuum where they
usually are interrelated and coexist.
The symptoms of this disorder are closely
tied to behavioral difficulties. And as a result, it has been documented
that about 40 percent of referrals to child guidance clinics are associated
with children diagnosed with this disorder (Barkley, 1990). Over
60 percent of adolescents with ADHD have been documented to be defiant
in comparison to 11 percent of the non-ADHD population (Barkley, Fischer,
Edelbrock & Smallish, 1990). As adults, it has been estimated
that 33 percent will not complete high school, with only 5 percent completing
a college degree (Barkley, Fischer, et. al., 1990). Almost 1 in 4
of these individuals is likely to develop chronic maladaptive patterns
such as substance abuse, occupational instability, and interpersonal difficulties
(Barkley, Fischer, et. al., 1990). About one-third of this population
is estimated to be resilient, meaning they find adaptive means to cope
with the disorder (Barkley, 1990).
Gingerich, Turnock, Litfin, and Rosen (1998)
considered the epidemiology of diverse populations and ADHD. The
authors stress the importance of including diversity variables such as
ethnicity, age, gender, and SES in the assessment, diagnosis, and intervention
strategies of ADHD. Cross-cultural comparison of hyperactive behavior
must be understood and examined with caution as cultural factors may influence
both the demonstration of the disorder as well as the approach to intervention
strategies. These diversity variables may contribute to inappropriate
diagnosis as expected behavioral norms may fluctuate in these various groups.
A 1999 study in the Journal of the American Academy of Child and Adolescent
Psychiatry addressed the gender differences in the diagnosis of ADHD. The
authors suggest that the disorder frequently goes undiagnosed in girls
because they are less likely to behave disruptively, which is one of the
most common signs of the disorder. The study included 140 girls with
ADHD and 122 girls who did not have ADHD, ranging in age from 6 to 18 years
old. Results of this study imply that if the core problem of ADHD
is redefined from a behavior disorder to the issue of inattention, then
it is likely that the number of girls identified will increase.
Attention-deficit/hyperactivity disorder is
one of the most prevalent childhood disturbances in the United States,
affecting upward of 400 million children and adolescents. ADHD has received
much publicity in recent years and professionals should clarify misunderstandings
when working with children and their families. Children with ADHD
may have pronounced difficulties and impairments resulting from the disorder
across multiple settings. They may also experience long-term adverse
effects on academic performance, vocational success, social-emotional development
and peer relations. Males are diagnosed with ADHD at approximately
three times the rate of females which may be due the Combined and Predominantly
Hyperactive-Impulsive forms of the disorder being more common in males.
There is no conclusive evidence of the causes of this disorder, thus extensive
assessment measures should include various settings as well as informants
in order to understand the multiple factors that may contribute to the
symptoms. Given the overlap of ADHD with oppositional defiant disorder,
conduct disorder, antisocial personality traits, and learning disabilities,
psychologists need to assess related domains of functioning when addressing
a referral question regarding ADHD. Subclinical problems such as
learning difficulties, hyperactivity, and attention problems should also
be addressed when planning treatment interventions. Recent studies reveal
that there are wide variations in the diagnosis of the disorder, resulting
in under and over identification of ADHD within certain populations, thus
environmental and socio-cultural variables need to be considered during
assessment of the behavioral symptoms common in ADHD.
I. ETIOLOGY
The familial incidence of ADHD has long been
noted. Early investigations centered around biological hypotheses and “Minimal
Brain Dysfunction” was postulated in explaining the origin of the disorder.
Following World War II, pediatricians, neurologists, and child psychiatrists
observed that brain-damaged children were often hyperactive, inattentive,
had learning difficulties, and displayed a wide variety of behavior problems.
This led to the original diagnostic concept of “minimal brain damage.”
However, subsequent large epidemiological studies of grossly brain-damaged
children did not support a link with excessive hyperactivity nor did more
recent imaging studies find evidence of gross brain damage in ADHD children.
Over time, the various characteristics including
hyperkinesis/hyperactivity, inattention/distractibility, and impulsive
responding became the focus of research in etiology, assessment, and treatment.
Whether or not attentional deficits are, in fact, a hallmark of this disorder
is currently debated. The great variability in symptomology, prognosis,
and comorbidity has made definite etiologic determinants elusive. As a
result, it has captured the interest of clinicians and researchers from
many different disciplines. Currently researchers are also investigating
and comparing the etiologies of different ADHD subtypes which indicate
that ADHD is a heterogeneous disorder. Moreover, an understanding
of the etiology of ADHD has important implications for treatment procedures.
Current hypotheses involve a complex transactional model which links genetic,
biological, familial, cognitive/ neurological, psychosocial, and developmental
contributors. The following sections of this paper will provide information
and current research regarding various etiological factors and their associations
with ADHD.
Genetic Contributors:
Research evidence suggests that ADHD is a trait
which is highly hereditary in nature, making heredity one of the most well-substantiated
etiologies for ADHD (Barkley, 1997). Consequently genetic research
has contributed to these studies in order to explain familiality, heritability,
mode of transmission, and gene locations (Tannock, 1998). Twin studies
have provided genetic researchers the opportunity to explore genetic as
well as shared and non-shared environmental factors in the identification
of ADHD.
Research has shown that if a parent has ADHD,
the risk to the offspring is 57 percent. As evidenced by recent twin
studies, the average heritability is .80 for symptoms of ADHD, suggesting
a strong genetic contribution (Barkley, 1997). Sprich, Biederman,
Crawford, Mundy and Faraone (2000) lent additional support to the genetic
hypothesis for ADHD etiology through their study examining the rates of
ADHD and associated disorders in the first-degree biological relatives
of ADHD children and adolescents. The authors found that 18% of the
biological parents of ADHD youths had ADHD compared to 6% of the adoptive
parents of ADHD youths and 3% of the biological parents of the non-ADHD
control youths. As the rate of ADHD in adoptive parents of adoptees
with ADHD did not differ significantly from the rate found in the biological
parents of the control subjects, the researchers conclude that there is
no increased risk for ADHD amongst the adoptive parents of adopted ADHD
youths. Furthermore, significantly higher rates of mood and anxiety
disorders were found in the biological parents of ADHD youths than in the
adoptive parents of ADHD youths. The authors suggest that these other
psychiatric disorders are manifestations of the same genes that influence
ADHD rather than parental disorders resulting from the stress of raising
a child who has ADHD.
In a review of molecular genetic studies of
AHD, Faraone (2000) proposes that ADHD comprises several disorders having
different genetic and nongenetic etiologies rather than a single, unitary
disorder. This proposition is supported by inconsistent results from
molecular genetic studies such as those investigating the influence of
the dopamine transporter gene (DAT) and the dopamine D4 receptor gene (DRD4)
on susceptibility to ADHD (Biederman & Spencer; Faraone, 2000).
Faraone highlights two other clinical features, psychiatric comorbidity
and long-term outcome, as evidence for the genetic heterogeneity of ADHD.
Faraone and his colleagues tested competing hypotheses about the comorbidity
of ADHD with other disorders and concluded that there appear to be two
types of ADHD families. There are families in which ADHD occurs with
bipolar disorder and/or conduct disorder and there are families in which
ADHD occurs without bipolar disorder or conduct disorder. Although
ADHD and major depression were found to share common familial vulnerabilities,
the researchers were unable to distinguish subforms of ADHD based upon
the presence of major depression in the family. Hence, in contrast
to bipolar disorder and conduct disorder, major depression appeared to
be a phenotypic rather than a genetic marker of heterogeneity in ADHD.
Anxiety and learning disorders showed weak associations with ADHD in the
families of this study. However, the authors stress the need for
more investigation in order to make conclusions about whether these disorders
share genetic causes with ADHD.
As long-term outcome may have further implicates
for genetic heterogeneity, Faraone cites evidence for the stronger influence
of genes on persistent ADHD than on remitting ADHD. Faraone, Biederman,
and Monuteaux (2000) found that the prevalence of ADHD in parents of youths
who continued to meet diagnostic criteria for ADHD in mid-adolescence was
16.3% compared to a 10.8% prevalence of ADHD in the parents
of youth whose ADHD had remitted by mid-adolescence. The prevalence
in their siblings was 24.4% and 4.6%, respectively. Faraone (2000)
interprets the data as suggesting that children and adolescents with persistent
ADHD have a more familial form of the disorder than those whose ADHD remits
by mid-adolescence.
Citing molecular biological studies of genes
affecting dopamine and serotonin as contributors to ADHD and Tourette Syndrome,
Comings (1997) considers the two disorders as hereditary spectrum disorders.
This work is said to supplement twin studies which have found that genetic
factors play a significant role in both ADHD and Tourette Syndrome, implying
a polygenetic inheritance pattern. The two conditions are best described
as spectrum disorders because of their appearance in multiple family members
as well as their association with several comorbid disorders including
drug and alcohol abuse and conduct disorder. Sherman and colleagues
found greater concordance for monozygotic than dizygotic twins in both
teachers’ and mothers’ ratings, providing evidence for the genetic contribution
to expression of ADHD (Sherman et.al., 1997). Twin studies can tell us
as much about environmental contributions as they do about genetic factors
affecting the expression of a trait. Across the twin studies conducted
to date, the results have been reasonably consistent in demonstrating that
the shared environment contributes little, if any, explanation to individual
differences in the trait underlying ADHD (hyperactive-impulsive-inattentive),
typically accounting for less than 5 percent of the variance among individuals.
In a study by Levy, Hay, McStephen, Wood, and Waldman (1997) shared environmental
factors included social class, family educational/occupational status,
general home environment, family nutrition, toxins that may be present
in the home environment (i.e., lead), and parental and child-rearing characteristics.
Biological Contributors:
The potentially causative factors associated
with ADHD that have received the most research support are biological in
nature; that is, they are known to be related to or to have a direct effect
on brain development and/or functioning (Barkley, 1997). Barkley
dismisses theories of social and dietary causes of ADHD as having weak
support, and instead focuses on the much larger body of empirical evidence
which supports the association of biological vulnerability toward poor
inhibitory control and ADHD. Children with pervasive ADHD showed
the least inhibitory control and greatest variability of responses compared
with a control group (Oosterlaan & Sergeant, 1996). In addition,
MRI scans have shown distinct physiological differences in brain regions
between ADHD and control children (Barkley, 1997).
Pregnancy, delivery and infancy complications
(PDIC’s) have been studied to determine correlates and/or predictors of
ADHD. Milberger, Biederman, Faraone, and Guite (1997) found a positive
association between ADHD and PDIC’s using linear and logistic regression
models in their study. In addition, very low birthweight children
have been found to have an increased prevalence of inattention and hyperactivity;
23 percent of very low birthweight children met research diagnostic criteria
for ADHD in contrast to 6 percent of normal birthweight peers (Bottin,
Powls, Cooke, and Marlow, 1997).
Milberger et al. (1996) investigated the role of maternal smoking during
pregnancy in the etiology of 6-17 year old boys with ADHD found that 22%
of the ADHD children had a maternal history of smoking during pregnancy,
compared with 8% of the comparison non-ADHD Subjects. This finding remained
significant after adjustment for SES, parental IQ, and parental ADHD status.
Hill, Lowers, and Locke-Wellman (2000) explored
the question of whether maternal cigarette smoking or drinking during pregnancy
places the child at risk for ADHD. The longitudinal study examined
the association between prenatal exposure to cigarettes and alcohol for
the etiology of childhood psychopathology including ADHD. The findings
revealed that prenatal exposure to alcohol was significantly associated
with the presence of ADHD although, after controlling for SES and parental
antisocial personality disorder, this finding did not remain significant.
Furthermore, the findings did not confirm the association between cigarette
use and ADHD reported by Milberger et al. (1996).
Family Contributors:
Research encompassing family contributors to
ADHD has included studies of parental psychopathology, parenting styles,
and parent-child interactions. Viewing family factors and their relation
to ADHD through the perspective of the transactional model has implications
for both the etiology and treatment of the disorder. The transactional
model proposes that maladaptive behaviors and/or disorders such as ADHD
can be viewed in terms of the “reciprocal effects of children on their
environmental contexts and contexts on children” (Sameroff & Chandler,
1975; Sameroff & Fiese, 1988).
Nigg & Hinshaw (1998) highlighted two significant findings in their
examination of the role of specific parental characteristics in relation
to ADHD; 1) boys with ADHD were more likely to have mothers with a major
depressive episode and/or marked anxiety symptoms in the past year, and
fathers with a childhood history of ADHD, and 2) boys with comorbid ADHD
and Oppositional Defiant or Conduct Disorder had fathers with lower Agreeableness,
higher Neuroticism, and more likelihood of having Generalized Anxiety Disorder.
Pfiffner, McBurnett, Lahey, Loeber, Green,
Frick, and Rathouz (1999) examined the relationship of parental psychopathology
to similar forms of comorbid psychopathology in children with ADHD (Pfiffner
et.al., 1999). Their findings suggest that type of child psychopathology
accompanying ADHD (internalizing and/or externalizing) is concurrently
predicted by the same type of parental psychopathology. This finding
contrasts with theories that comorbidity is simply a reflection of more
severe psychopathology among children with ADHD and instead supports specific
modes of familial transmission.
Johnston and Freeman (1997) assert that the social context within which
ADHD behaviors are displayed is an important etiological consideration.
In this study of children with and without ADHD and the parent-child relationship,
parents of ADHD children viewed the disorder as primarily internally caused,
beyond the child’s control, and as relatively stable over time. These
beliefs are consistent with a neurobiological etiology of ADHD.
Weinstein, Apfel, and Weinstein (1998)
examined personality traits and background variables of mothers and children
with and without ADHD. Mothers with ADHD had elevated scores on Neuroticism
and Conscientiousness. Furthermore, neuropsychiatric disorders, atypical
sexual events, and familial alcoholism were found with more frequency in
the group with ADHD mothers and ADHD children.
Woodward, Dowdney, and Taylor (1997) compared
child and family factors in clinically referred boys with ADHD and those
not referred. Results suggest that clinic referral is more likely
in children with hyperactivity when the parent is having difficulty coping
and the child is experiencing greater peer and emotional problems in school.
White (1999) points out the confluence of
findings from studies examining parent-child interactions suggests that
parents of ADHD children tend to provide more impulse-control directions,
encouragement, and disapproval than parents of non-ADHD children.
Research has indicated that these parent behaviors persist after the child’s
behavior improves. Thus, it is unclear whether these parental behaviors
are responses to the behavior problems of the child. The parent-child
relationship may be viewed through a transactional lens as an on-going,
reciprocal transaction. For example, raising a child with ADHD may
continuously stress the parent and, therefore, affect the quality of the
parent-child relationship, potentially impacting the child’s behavior (White,
1999).
Viewing these family factors and ADHD through
the transactional model has important implications for intervention strategies.
Treatment plans might address the familial context through interventions
such as parent-skills training, coping techniques. in order to modify
individual behaviors and contextual factors which may be contributing to
the increased rate of observable characteristics of ADHD.
Cognitive and Neurological Contributors:
The early onset of the symptoms in ADHD
and their relatively persistent nature over time, their association with
other developmental disorders believed to arise from neurological development
or impairment (i.e., learning disabilities, language disorders, motor abnormalities,
and IQ), their significant relationship to peri and postnatal adversities,
and their relatively dramatic improvement by stimulant medication have
served to repeatedly focus research attention on possible causal neurodevelopmental
factors (Barkley, 1997).
Biederman and Spencer (1999) reviewed
neurobiological and pharmacological research in order to investigate the
hypothesis that a dysregulation of the central noradrenergic networks is
responsible for the pathophysiology of ADHD. The noradrenergic system
is believed to modulate higher cortical functions including attention,
especially the maintenance of arousal, a cognitive function that is believed
to be deficient in ADHD. Pharamocological studies provide strong evidence
that drugs with noradrenergic and dopaminergic pharmacological profiles
can be used to effectively treat ADHD. The authors conclude, “Although
there is no single pathophysiologic profile of ADHD, much data do implicate
dysfunction in the fronto-subcortical pathways that control attention and
motor behavior.” Researchers underscore the need for further research to
confirm empirical evidence which suggests that norepinephrine may play
a key role in the attentional and inhibitory abilities of the prefrontal
cortex (Biederman & Spencer, 1999; White, 1999).
Max, Arndt, Castillo, Bokura, Lindgren,
Smith, Sato, and Mattheis (1998) examined ADHD symptomatology and sequelae
after traumatic brain injury (TBI) in children and adolescents. A
significant correlation was found for ADHD symptomalogy and a measure of
family dysfunction when family psychiatry history, SES, and severity of
TBI were controlled. Results indicate that changes in ADHD symptoms
in the first two years after TBI was significantly related to the severity
of TBI, suggesting implications for a neurological basis of ADHD.
Sheppard, Bradshaw, Purcell, and Pantelis
(1999) suggest that the high level of comorbidity of both OCD and ADHD
in Tourette’s suggests that the gene responsible for Tourette’s Syndrome
may at least be responsible for an increased susceptibility to these two
disorders. The authors suggest this may be due to the neuropathological
overlap and/or a neurochemical imbalance. This examination of the
comorbidity among disorders is not meant to discount the idea that these
disorders can exist on their own with their own etiologies.
The broad definition of executive function
has guided current research towards the testing of various interpretations
of impulsiveness/response inhibition in ADHD. Such models include:
An underlying deficit in a central act of control; a dysfunction in the
energetical/state-regulation of motor control; and a deviant cognitive
style designed to reduce the subjective experience of delay (Tannock, 1998).
The following studies address the executive function process in individuals
with ADHD.
Carte, Nigg, and Hinshaw (1996) used a neuropsychological
battery to measure executive functioning in boys with and without ADHD.
When tasks required a slow pace, selective attention demand, and rapid
automatic naming, subjects with ADHD performed more poorly than controls.
Results are consistent with hypothesized deficits for ADHD in organization
and planning, possibly mediated by frontal systems, as well as with the
cognitive model of response organization.
Nigg (1999) considered the neuropsychological
executive functions of behavioral or response inhibitions as an etiological
factor in ADHD in a replication study. Results indicate that deficits
in motor inhibition processes are associated with the DSM-IV ADHD Combined
Type. However, whether the response inhibition is a frontal, behavioral
inhibition system or some other inhibition process remains to be explored.
While recent advances in structural and functional imaging techniques of
the brain are leading to a new understanding of disorders such as ADHD,
functional studies are necessary to determine which anatomical abnormalities
have functional sequelae, as well as to demonstrate abnormal cognitive
processes inferred from such neuropsychological studies (Tannock, 1998).
Psychosocial Contributors:
Sandberg and Garralda (1996) state that a number
of psychosocial factors are associated with the development of ADHD although
it seems unlikely that a direct causal relationship exists in this case.
Factors that are associated with ADHD include social conditions, family
stability and marital discord, psychiatric disorder in parents, parenting
styles, and the quality of family interactions. In particular, they
highlight social conditions and maternal depression as highly correlated
with ADHD.
Another factor that is well associated with
ADHD in the research literature is the relationship between ADHD and temperament
(White, 1999). A high level of activity or hyperactivity is perhaps
the most salient temperamental trait of ADHD children. These children
are generally markedly distractible and impulsive and, therefore, tend
to be most readily diagnosed due to their behavior frustrating teachers
and caretakers. One popular explanation offered to explain the impulsivity
that is characteristic of individuals with ADHD is that they are constitutionally
underaroused and thus seek external stimulation. This hypothesis
is supported by empirical evidence suggesting that children and adolescents
with ADHD are more likely than their non-ADHD peers to engage in risky
behavior. However, these youths not only tend to seek out arousing
experiences, they also have lower levels of inhibitory control when presented
with high levels of stimulation (White, 1999).
Temperamental difficulties related to disinhibition
are considered to relatively remain stable throughout the lifespan of the
individual with ADHD (White, 1999). In a study mentioned earlier
by Oosterlaan and Sergeant (1996), ADHD children demonstrated poorer inhibitory
control and a slower inhibitory process than control group children in
response to a stop signal task. It is interesting to note that aggressive
children showed a lack of inhibitory control and a slower inhibitory process
that were similar to the ADHD children.
Hinshaw, Zupan, Simmel, Nigg, and Melnick,
(1997) examined the predictive power of behavioral, internalizing, and
familial variables with respect to peer status in boys with and without
ADHD. Aggression, covert behavior, and authoritative parenting beliefs
were the independent predictors of both negative peer status and peer social
preference. Authoritative parenting beliefs were stronger predictors
in peer status in children with ADHD than in comparison youth.
Harvey (1998) studied how parent’s employment
influences conduct problems in children with ADHD. Results demonstrated
that time spent in employment indirectly affected childcare workload and
parental well-being for mothers only. The more time that mothers
spent at work, the lighter the childcare workload, which was then related
to mothers’ greater parenting well-being and fewer conduct problems for
the children.
The transactional model can again be used
in the domain of psychosocial contributors to explain the interacting effects
of the individual with ADHD and the given context. While the transactional
model may not explain the underlying causes of ADHD, it does offer explanations
as to how the individual and the environment effect one another in a reciprocal
manner. For example, a child’s temperament may solicit negative responses
from adult caretakers and peers, whose responses may, in turn, contribute
to future behavior problems. Consequently, throughout the individual’s
growth and development over time, their unique ADHD symptoms may fluctuate
depending on the surrounding environment and their interactions with it.
Developmental Contributors:
Combining several of the previously discussed
etiological factors of ADHD, Barkley suggests that ADHD is a “developmental
disorder of behavioral inhibition that impairs the development of self-regulation
(executive functioning) and is not, as its name implies, chiefly a disorder
of attention” (Barkley, 1997). Barkley defends this idea by suggesting
that not all forms of self-regulation are fully covert or internalized
in the early school-age years and may not be so until early adolescence.
Thus as one develops, their ability to control behavior shifts from an
external governance to an internal regulation.
The understanding of the development of ADHD
symptomatology is important because of the apparent relationships between
these symptoms and subsequent development of behavior problems and educational,
occupational, and interpersonal maladaptions. Olson (1996) states
“behavior deviance is the product of a continuous, dynamic interplay between
qualities that individual children bring to their social interactions and
characteristics of the immediate caregiving environment and its broader
social-ecological context”.
From this perspective, risk factors, vulnerability
factors, and resiliency factors are all essential in the understanding
of the eventual outcome of behavioral disorders. In the research
literature, positive outcomes for ADHD children are associated with higher
IQs, fewer health problems, an internal locus of control, physical health,
high self-esteem, positive coping skills, achievement orientation, and
social skills (White, 1999). Although these characteristics may serve as
protective factors for ADHD children, low levels of these same traits characterize
the disorder itself. ADHD children are more likely than non-ADHD
children to have inferior social skills, lower achievement orientation,
and an external locus of control. Hence, the less ADHD symptoms that
the child has, the more positive his or her trajectory is likely to be
(White, 1999). Furthermore, at the family level, high levels of cohesion,
support, and warmth as well as higher SES and two-parent families with
fewer children are predictors of positive, long-term outcomes for ADHD
children (Hechtman, 1996).
Seidman, Biederman, Faraone, Weber,
and Oullette (1997) extended studies on developmental processes in the
neurophysical investigation of ADHD. Related to developmental progression,
neuropsychological test performance generally improved with age for both
the ADHD and non-impaired samples. The youngest participants with
ADHD had the lowest performance scores for al groups. Significant
neuropsychological impairment continued to be present for the ADHD group
relative to controls, which contrasts with the idea that children “outgrow”
ADHD in the adolescent or adult years.
Nolan, Volpe, Gadow, and Sprafkin (1999) addressed
the developmental approach to the diagnosis of ADHD by examining age, gender,
and comorbidity differences in the three different subtypes. Results
indicate that hyperactive/impulsive behavior was more common in adolescents.
Subjects who exhibited symptoms of both inattention and hyperactivity/impulsivity
were more likely to show behaviors characteristics of oppositional and
conduct disorders, than those who were only considered inattentive.
II. DEVELOPMENTAL APPROACH
The developmental approach is a contemporary
framework for understanding psychopathology. A fundamental tenet
behind this approach includes descriptions of developmental deviations
in relation to normal patterns of functioning. Manifestation of psychopathology
is the result of life-long interactions between genetics, biological dispositions
and the social environment. Two undergirding principles within the
developmental psychopathology framework are equifinality, which refers
to the multiple paths that can lead to the same outcome, and multifinality,
which suggests there are various possible outcomes to similar developmental
pathways. Thus, according to this paradigm, an ecological and transactional
approach, which takes into account the influence of many factors (for example,
genetic, biological, social, and familial) throughout the developmental
process, would best be able to explain eventual outcome. It is extremely
difficult to tease apart the factors contributing to a specific trajectory.
White (1999) summarizes, “A complex cluster of biological, psychological
and situational factors appear to be related to the etiology and symptom
presentation of ADHD.”
Developmental psychopathology is a product
of ontogenetic, biochemical, genetic, biological, physiological, cognitive,
social-cognitive, socioemotional, environmental, cultural, and societal
influences on behavior (Cicchetti and Cohen, 1995). When considering
Attention Deficit Hyperactivity Disorder (ADHD), the multiple proposed
causal pathways and the inability of researchers to empirically account
for a single cause for this disorder is indicative of the notion of equifinality.
Further, the large number of identified symptoms (of which relatively few
are necessary for an ADHD diagnosis) will inevitably result in a wide variety
of profiles that are given the ADHD label. The heterogeneity of the
disorder appears to be consistent with the multifinality tenet of the developmental
approach. A developmental-systems perspective will need to take into
account the normal variation in development (e.g., in different domains
within an individual as well as variation in one domain of development
between individuals). This will require the use of multiple measures,
assessment of more than one domain of development, and the study of various
age-groups of children (Tannock, 1998).
Etiology of ADHD remains unclear, although
multiple factors such as genetic susceptibility, biochemical dysfunction,
and environmental interactions have been proposed. Accordingly, the
various etiological models have different implications for diagnostic assessment,
treatment, and management.
Extensive evidence exists which supports
a heritability factor for attention deficit hyperactivity disorder, with
greater risk of the disorder being found among family members. Biological
and neuroanatomical studies involving neuro-imaging have measured cerebral
blood flow as well as cerebral glucose metabolism and scanning techniques
have documented physical abnormalities in particular brain regions, especially
the frontal lobes, for adults and children with ADHD. In addition,
pregnancy and infancy complications can be an influencing factor.
Low birthweight children have been found to be particularly at risk for
ADHD and other learning disorders. Current attempts focus more on
a framework that incorporates a multiplicity of causal factors underlying
ADHD. The developmental perspective asserts the interactional nature
of the organism with environmental contexts. Although the preponderance
of evidence supports a genetic-neurobiological etiology, the developmental
perspective has emphasized the interactional nature of the organism with
environmental contexts. Neuropsychological testing has suggested
that while the developmental trajectory for ADHD is linear, normal brain
maturation processes may attenuate symptoms over time, although ADHD is
generally believed to be a lifelong disorder. Furthermore, the manifestation
of ADHD symptomatology may change over time. For example, hyperactivity
in childhood evolve into a subjective sense of restlessness in adolescence.
Considering the heterogeneity of children diagnosed with ADHD, such diverse
etiological evidence may facilitate an enhanced diagnostic structure with
greater specificity. That is, there may be distinct alternative pathways
towards a diagnosis of ADHD.
III. ADHD WEBSITES
Top Ten Websites
www.aap.org/policy/ac0002.html
Title: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity
Disorder (AC0002)
Author: American Academy of Pediatrics
This website features practice guidelines for the assessment,
diagnosis, and treatment of school-aged children with attention-deficit/hyperactivity
disorder (ADHD). Although these guidelines are intended for primary
care clinicians working in primary care settings, mental health care professionals,
educators, and students may find this site informative, as the youth’s
primary care provider is an integral member of the evaluation team.
The Committee on Quality Improvement of the American Academy of Pediatrics
selected a panel of experts in pediatrics, neurology, psychology, child
psychiatry, development, epidemiology, and education in order to develop
an evidence base of research literature, which was used to formulate these
recommendations. Major themes include child and family assessment,
school assessment, and comorbidity. These practice guidelines were
published in the May 2000 edition of Pediatrics.
www.add.about.com/health/add/ OR www.add.miningco.com/health/add/
Title: Attention Deficit Disorder
Both addresses will link you to a website containing a wide variety
of practical resources for ADHD. The website is also an excellent
search engine for ADHD research abstracts/summaries (e.g., the NIMH Nultiodal
Treatment Study of Children with Attention Deficit Hyperactivity Disorder)
and journal articles. For example, there are links to research journals
such as the Journal of Abnormal Child Psychology as well as to abstracts
from the National Institute of Health (NIH) conference. The website
also contains other ADHD topics for parents such as Ritalin, the presentation
of ADHD at different age levels, special education, advocates/attorneys,
and book reviews. One unique feature of this website is summaries
of ADHD subtopics in Spanish. This may be a good resource for Spanish-speaking
parents.
www.addinschool.com
This website provides interventions and resources for parents
and education professionals. Practical tips and advice are presented
separately for elementary and middle/high school level students.
Examples of topics include: Classroom set-up and ADHD students, presenting
lessons to ADHD students, giving tests to ADHD students, improving the
socials skills of ADHD students, assisting the ADHD students with organization,
increasing the on-task behavior of ADHD students, and dealing with the
impulsive behaviors of ADHD students. This is website may serve as
a valuable resource for parents and education professionals seeking accommodations
for ADHD students that can be incorporated into the everyday classroom
routine without a great deal of effort.
www.addwarehouse.com
This website provides abundant information on assessment and evaluation
procedures currently used by school psychologists and other professionals.
The ADDwarehouse website provides the most current information available
on attention deficit disorders. Teachers, health-care professionals,
parents, and children and adults with ADD can get information about a broad
selection of products and quality service. Qualified professionals can
order assessment measures through this website such as the BASC, Conners
Rating Scale, ACTeRS, All Child and Adolescent Symptom Inventories, Attention-Deficit
Scales for Adults, The Continuous Performance Test products, Gordon Diagnostic
System, and T.O.V.A.
www.chadd.org
Title: Children and Adults with Attention Deficit Disorders
Written by parent advocates for parents, this web site contains an
introduction to the disorder ADHD, an empirically sound discussion of both
helpful and controversial treatments, and behavioral interventions for
parents who have or believe they may have a child with ADHD. CHADD
is a national organization, which has local chapters in many cities.
This website provides current information on medical, scientific, educational
and advocacy issues. The literature includes position papers, government
publications, current research studies (mostly on treatment issues), fact
sheets (e.g., legal rights for children with ADD), ADD in the media, and
current events pertaining the organization. CHADD also has a quarterly
magazine for people with ADHD.
www.kidsource.com/LDA-CA/ADD_WO.html
Title: Attention Deficit Disorder Without Hyperactivity: ADHD, Predominantly
Inattentive Type
Authors: Jennifer Wheeler, M.A., and Caryn L. Carlson, Ph.D.
of the University of Texas at Austin
Source: The Learning Disabilities Association of California
This website provides a detailed description of Attention Deficit
Disorder Without Hyperactivity, Predominantly Inattentive Type (ADHD, IA).
The authors begin with a discussion of ADHD, IA as a valid DSM diagnostic
category. The contents also discuss etiology, activity level, accompanying
disorders, peer relationships, school performance, and treatment as they
relate to ADHD, IA. This article was found on the Kid Source Online
database. Kid Source Online (www.kidsource.com/) advertises itself
as “the source for in depth and timely education and healthcare information
that will make a difference in the lives of parents and their children.”
www.medscape.com
Title: Attention Deficit Hyperactivity Disorder
Medscape is an excellent resource for the latest medical research
on the etiology of ADHD as well as other ADHD subtopics. Searches
can be limited specific dates including the last twelve months. The
database includes articles, conference summaries, treatment updates, clinical
management modules, practice guidelines, and textbooks. Searches can also
be made on other databases such as MEDLINE, News, Drugs by Name, and Drugs
by Disease. After filling out a brief online survey, use of the database
is free.
www.schoolpsychology.net/p_01.html
Title: School Psychology Resources Online
The School Psychology Resources Online website allows psychologists,
parents, and educators to research a variety of developmental psychopathological
disorders including ADHD. Example search results for ADHD included
reviews and links to websites such as diagnosis and evaluation recommendations
from the American Academy of Pediatrics, a Scientific American article
by Russell Barkley, and school-based ADHD accommodations for a 504 plan.
www.scientificamerican.com/1998/0998issue/0998barkley.html
Title: Attention Deficit Hyperactivity Disorder
Author: Russell Barkley- Director of Psychology and Professor of psychiatry
and neurology at the University of Massachusetts Medical Center.
He has numerous publications, including two books: ADHD and the Nature
of Self-Control (1997) and Attention Deficit Hyperactivity Disorder: A
Handbook for Diagnosis and Treatment (1998).
This website provides various etiological information with an emphasis
on a neurological basis. General topics include: Search for a cause
of ADHD, From
genes to behavior, Prescribing self-control, Diagnosing ADHD, A psychological
model of ADHD, Illustrations of the brain, Further reading, and Related
links. More specifically, in the search for a cause section there
is a focus on neurological imaging techniques and genetics. Information
also includes discussions about the different regions of the brain, as
well as genetic research focusing on heritability and twin studies.
The main premise of this website is impaired behavioral inhibition and
self-control are the central deficits in ADHD.
www.surgeongeneral.gov/library/mentalhealth/chapter3/sec4.html
Title: Mental Health: A Report of the Surgeon General-Chapter 3
Source: The United States Surgeon General
This website is a subsection of the U.S. Surgeon General’s mental health
report outlines the following ADHD subtopics: Prevalence, causes (etiology),
pharmacological treatment, psychostimulant treatment, psychosocial treatment,
behavioral approaches to treatment, Cognitive-Behavioral Therapy, psychoeducation,
multimodal treatments, treatment controversies, overprescription of stimulants,
and safety of long-term stimulant use.
OTHER WORLD WIDE WEBITES ON ADHD
www.aacap.org/clinical/adhdsum.htm
Title: Summary of the Practice Parameters for the Assessment and Treatment
of Children, Adolescents, and Adults with Attention-Deficit/Hyperactivity
Disorder
Author: American Academy of Child and Adolescent Psychiatry
This website makes specific recommendations for clinicians faced with
the assessment, differential diagnosis, and treatment of children, adolescents,
and adults who present with symptoms of ADHD. Specific recommendations
are based on an extensive review of the scientific literature and clinical
consensus among experts on ADHD. Comorbidity with other disorders is also
described.
www.addclinic.com
The website provides links to ADHD resources such as support
groups and an internet search engine for ADHD. Many of the websites
featured on the homepage advertise alternative treatment products and services
for ADHD (e.g., dietary supplements instead of stimulants).
www.add.org
Title: National Attention Deficit Disorder Association
The National Attention Deficit Disorder Association is a nonprofit
organization, built around the needs of adults and young adults with ADHD.
Information on research, treatment, books on ADD, family issues, legal
issues, support groups and personal interviews, and weblinks are available.
A nice way of presenting information is that there
are areas devoted to specific groups (e.g., children, women, and teens)
as well as various contexts (e.g., school, work and career).
www.ahcpr.gov/clinic/adhdsutr.htm
Title: Diagnosis of Attention-Deficit/Hyperactivity Disorder
Author: Agency for Health Care Policy and Research (AHCPR)
This website is a technical review summarizing current scientific
evidence related to ADHD as well as the value of various evaluation methods
for the diagnosis of ADHD. The sections of the website include Overview,
Reporting the Evidence, Methodology, Findings, Future Research, and Availability
of Full Report. The author of this website is the Agency for Health
Care Policy and Research (AHCPR). AHCPR describes itself as “developing
scientific information for other agencies and organizations on which to
base clinical guidelines, performance measures, and other quality improvement
tools, under the Agency's Evidence-based Practice Initiative, which was
launched in the fall of 1996.”
www.adhd.com.au/ADHDaeti.html
Title: The etiology of ADHD: Evidence of a neurobiological basis and
treatment implications
Author/Affiliation: Jacques Duff- Behavioral Neurotherapy Clinic
This website concludes that ADHD is caused by inherited factors that
are manifest in abnormal brain morphology, and associated with an underlying
neurological disregulation and underarousal of the frontal lobes.
Information provided at this site was helpful because an historical account
for various explanations of ADHD were stated along with available empirical
evidence to support their claims. Sections in this website are divided
as follows: Toxins, Family and environmental factors, Perinatal factors,
Genetic evidence, Brain morphology, and Neurotransmitter activities.
A significant amount of information is provided on neurobiological treatment
interventions.
www.btinternet.com/~black.ice/addnet/
Title: Collaborative Management of Students with ADHD
The department of education in conjunction with specialist medical
practitioners provides information to support teachers and schools to effectively
manage students with ADHD. The information provided in this website
are practical guidelines for teachers and school personnel to modify the
educational environment and/or instructional approaches in order to enhance
the opportunities for these students. Topics which are covered include:
problem solving, organization, sustained attention, social skills, impulsive/aggressive
behavior, non-compliance, and off-task behaviors.
www.cdipage.com/adhd.htm
Title: About Attention Deficit Hyperactivity Disorder- ADHD/ADD
This website provides information about attention deficit hyperactivity
disorder, including diagnosis, treatment, classroom management, parent
education, behavior modification, communication, and family relationships.
The information is updated as needed to reflect current research on ADHD.
www.eegspectrum.com/
Title: EEG Spectrum- Mental Fitness Training: Neurofeedback Research
and Clinical Services
This website provides extensive information about EEG training
and its application to individuals diagnosed with ADHD. Background
information describing the training procedures, as well as its clinical
application to a variety of conditions are outlined. The authors
imply that neurofeedback can be used for many conditions and disabilities
in which the brain is not functioning normally. Clinical neurofeedback
services, clinical and scientific articles, professional training courses,
as well as general news and announcements are covered under the primary
topics.
www.findarticles.com
This website can be used to search for research journal articles
related to ADHD in addition to other topics. An example of an article
related to the assessment and diagnosis of ADHD that is available on the
site is a study by Weiler (1999) published in the Journal of the American
Academy of Pediatrics entitled “Mother and teacher reports of ADHD symptoms:
DSM-IV questionnaire data.” This article examines the component structure
and distribution of scores of the Diagnostic Rating Scales, which are brief,
DSM-IV-referenced parent and teacher questionnaires designed to screen
children for ADHD symptoms.
www.gsi-add.com/default.asp
Title: ADD/ADHD Attention Deficit Hyperactivity Disorder (Dr. Gordon)
Dr. Gordon along with GSI Publications, Inc. and Gordon Systems,
Inc. has created this website to provide resources on information and products
about ADHD. Many of the materials are useful for clinicians and licensed
professionals. The web site provides a comprehensive list of assessment
devices (i.e., rating scales, and structured interviews). Furthermore,
the research referenced is categorized as such: General, longitudinal,
ADHD in adults, medication, and educational issues. Likewise, there
is an extensive list of books/videos (e.g., books in Spanish for parents
and children).
www.health-center.com
This website can be used to search for a variety of subtopics
related to ADHD. Subtopics are organized in folders according to
their utility for kids, parents, physicians, teachers, teens, therapists,
adults, etc. The site also features the ADHD Living Guide Project,
providing information on dealing with ADHD at school and home, funded by
the Agency for Healthcare Quality and Research. In addition, the
website features a discussion bulletin board, a link to Medline, and page
viewing in Spanish.
www.info@adhd.com.au
Title: Behavioural Neurotherapy Clinic
The authors of this website asserts that a particular treatment modality
called neurotherapy appears to provide an effective treatment for ADHD,
based on the studies reviewed. The authors discuss their study which will
use sophisticated SSVEP (Steady State Visually Evoked Potential) Functional
Brainmapping, IQ testing, neuropsychological assessment and behavioural
measures before and after Neurotherapy to evaluate the effectiveness of
specific Neurotherapy protocols as treatment for ADHD and Learning Difficulties.
The study will be conducted over a period of twelve months, and will involve
60 ADHD children. Lastly, several large international clinical studies
are
underway, some sponsors include EEGSPECTRUM, and the Biofeedback Foundation
of Europe. The Brain Sciences Institute (Swinburne University) is also
conducting a scientific investigation of the effectiveness of Neurotherapy.
This innovative treatment approach and the related literature seem to be
interesting and unique.
www.ldonline.org/ld_indepth/add_adhd/ael_success.html
Title: ADHD- Building Academic Success
Author: Appalachia Educational Laboratory (based on information provided
by the Office of Educational Research and Improvement- OERI)
The information provided in this website advocates a multimodal
approach of treatment in the educational environment. The authors
adopt the idea that often times there is a mismatch between school environments
and children with ADHD which may contribute to school failure. In
an attempt to address this problem, the following topics are discussed:
ADHD and school failure, The mismatch of ADHD and school, School’s response
to academic failure, School-Child Relationships: A transactional model,
Multimodal treatment: Sharing responsibility for learning, Specific, individual
accommodations, Comprehensive changes in school environments, and Monitoring
performance.
www.newideas.net/attention_deficit/treatment_options/overview.htm
Title: The Attention Deficit Hyperactivity Disorder Information Library
Author: Dr. Douglas Cowan
This Attention Deficit Hyperactivity Disorder Information Library
is a part of the NewIdeas.Net family of ADD ADHD related websites. This
website presents information in a straightforward manner suitable for parents.
Treatment options, interventions, diagnostic information and other resources
are discussed. The website claims to glean its information from ADD/ADHD
research findings as well as from the observations of professionals working
in the field.
www.newideas.net/p0000392.htm
Title: ADHD- Diagnosing ADD & ADHD in Children and Teens (Dr. Doug
Cowan)
The information provided on this website is from a clinical perspective
and appears to be written for parents. The author states two main
problems in the diagnosis of ADHD: 1) the over-diagnosis, which is a result
of incomplete assessment procedures and 2) under-diagnosis, which he describes
the school psychologists’ reports which include information appearing to
describe many characteristics of ADHD, yet no formal diagnosis or label
is prescribed to the child. The author addresses several components
in a thorough ADHD assessment: a) physical exam, b) in-depth parent interview,
c) parent and teacher rating scales, d) clinical interview with the child,
e) psychological testing, and f) TOVA.
www.nyspsych.org/cybercol/sept97/perry.html
Title: Attention Deficit Hyperactivity Disorder (ADHD) Causes
Author: Richard Perry, M.D.
This article reiterated the uncertainties with regards to the etiology
of ADHD which points to the necessity for further investigations in this
area. According to the author, it is the general opinion from those
in the field today that the causes of ADHD lie within the abnormalities
of certain regions of the brain. However, and as stated by the author
in this case, conclusive evidence to support this aim has yet to be found.
On the other hand, evidence to demonstrate the genetic component to this
disorder appears to be well established based on twin studies and studies
of close family and close relatives of those with this disorder.
Finally, considerations must likewise be given to other factors such as
pre- and perinatal complications and family situations.
VI. CONCLUSIONS
Etiology of ADHD remains unclear, although
multiple factors such as genetic susceptibility, biochemical dysfunction,
and environmental interactions have been proposed. Accordingly, the
various etiological models have different implications for diagnosis, treatment,
and management.
Extensive evidence exists which supports a
heritability factor for attention deficit hyperactivity disorder,
with greater risk of the disorder being found among family members. Biological
and neuroanatomical studies involving neuro-imaging have measured cerebral
blood flow, cerebral glucose metabolism, and scanning techniques have documented
physical abnormalities
in particular brain regions, especially the frontal lobes, for adults
and children with ADHD. In addition, pregnancy and infancy complications
can be an influencing factor. Low birthweight children have been
found to be particularly at risk for ADHD and other learning disorders.
Current attempts focus more on a framework that incorporates a multiplicity
of causal factors underlying ADHD. The developmental perspective
asserts the interactional nature of the organism with environmental contexts.
Although the preponderance of evidence supports a genetic-neurobiological
etiology, the developmental perspective has emphasized the interactional
nature of the organism with environmental contexts. Parental attributions,
parental psychopathology, and behavioral management techniques have been
found to be significantly related to the severity of expression of ADHD
behaviors. Neuropsychological testing has suggested that while the
developmental trajectory for ADHD is linear, normal brain maturation processes
may attenuate symptoms over time, although ADHD is generally believed to
be a lifelong disorder. Considering the heterogeneity of children
diagnosed with ADHD, such diverse etiological evidence may facilitate an
enhanced diagnostic structure with greater specificity. That is,
there may be distinct alternative pathways towards a diagnosis of ADHD.
I. ASSESSMENT
The assessment of behavioral disorders, such
as ADHD, must be guided by research on the classification and core features
of the disorder. Multiple sources and multiple varieties of information
are necessary because the level of agreement among sources and between
types of information is relatively low (Forbes, 1998). The current research
strongly suggests that an optimal assessment protocol relies upon several
methods, utilizing several different sources of information obtained from
different settings and informants (Barkley & August, 1998). ADHD
diagnosis is increasingly common. The driving force behind an ADHD
diagnosis must not be to qualify a student to receive medical treatment
to improve behavioral disruptions in the classroom or to receive extended
time on standardized tests. To circumvent these problems, direct
and frequent communication between school personnel, medical professionals
and family members needs to occur during assessment and treatment. Furthermore,
assessment results should be used to design intervention strategies.
The first diagnostic task in the classification
of ADHD is ruling out alternative causes or establishing the primary problem
(e.g., head injuries, metabolic or endocrine disorders, learning disabilities,
substance abuse, and giftedness). Secondly, the situational variations
of problems directs that multiple sources of information be obtained from
the different domains of the child’s life (e.g., home, school). Thirdly,
it is necessary to consider developmental issues (e.g., age of the child,
maturity). Various assessment methods have been utilized to determine whether
a child is displaying behaviors characteristic of ADHD at a developmentally
inappropriate level and to a problematic or symptomatic degree. These
methods of assessment include: Interviews, standardized child behavior
rating scales, peer-referenced assessment, laboratory measures, and direct
observation. Multi-method
Interviews:
The clinical interview is an essential component
of the assessment process in diagnosing ADHD (Hechtman, 2000). Several
interview schedules have been developed for use with children and adolescents
as well as with primary caregivers. Interviews may be conducted with
a child’s teachers, parents and others such as school staff or childcare
providers.
Teachers provide important observations of the child’s behavior, social
skills, and academic performance. It is especially helpful when teachers
are able to identify which situations trigger problematic behaviors as
well as what type of consequences result. Furthermore, teacher reports
about what instructional and intervention strategies that have been effective
or ineffective is essential for both assessment and intervention planning
(Brown, 2000).
There are several advantages to a well-conducted,
comprehensive interview such as building rapport and coverage of a broad
range of topics related to ADHD diagnosis and treatment planning (Brown,
2000). Hechtman (2000) outlines the important parameters that can
be assessed in the clinical interview, which include: An extensive family
history that explores family history of ADHD symptomatology as well as
other psychiatric disorders, the family situation, parental stress level,
and psychosocial adversity (family conflict, social support, poverty, etc.).
Other relevant subjects to cover in the interview are details of the referral
concerns; medical and developmental history; and academic performance and
experience; behavior problems and peer relationships. Furthermore, diagnostic
interviews are typically tied to the most recent revisions of the DSM.
Some disadvantages may be that they are time
consuming, and may not provide norm-referenced information. In addition,
the reliability of child self-report interviews (before age 9) may be questionable.
Children, particularly over age 10, tend to be reliable in reporting internalizing
symptoms such as depression, whereas they tend to underreport externalizing
symptoms such as aggression. Although parental reports of their children’s
behavior are generally reliable, excessive stress may result in increased
reports of behavior problems (Brown, 2000). A list of the more
common interview schedules in provided as well as recent studies researching
the use of such instruments. Popular instruments include the Diagnostic
Interview Schedule for Children (DISC-R; Schwab-Stone, Fisher, Piacetini,
Shaffer, Davies, and Briggs, 1993), the SCICA (Structured Interview for
Children and Adolescents (SCICA; McConaughy & Achenbach, 1994), the
Diagnostic Interview of Children and Adolescents (DICA-R; Boyle, Offord,
Racine, and Szatmari, 1996), and the Structured Developmental History (SDH)
of the multidimensional Behavior Assessment System for Children (BASC)
(Kamphaus, Reynolds, & Hatcher, 1999).
The use of structured interviews adds a standardized,
quantifiable dimension to the clinical assessment (Hechtman, 2000).
Brown (2000) recommends the use of two widely used structured interviews,
the Diagnostic Interview Schedule for Children (DISC) and the Semistructured
Clinical Interview for Children and Adolescents (SCICA) due to their specific
diagnostic criteria and relatively high reliabilities.
Schwab-Stone, Fisher, Piacetini, Shaffer,
Davies, and Briggs (1993) examined the test-retest reliability and internal
consistency of the Diagnostic Interview Schedule for Children (DISC-R).
Forty-one adolescents and thirty-nine of their parents were administered
the DISC-R. Test-retest reliability for symptom scales was excellent
for the parent DISC-R and good for the child version, except for Oppositional
Defiant Disorder. Internal consistency was satisfactory for symptom
items comprising most diagnoses.
McConaughy and Achenbach (1996) tested the
predictive power of the Semistructured Clinical Interview for Children
and Adolescents (SCICA), combined with a standardized parent scale, the
Child Behavior Checklist (CBCL), and a standardized teacher scale,
the Teacher's Report Form (TRF), for children with emotional and behavioral
disorders (EBDs) or learning disabilities (LDs) and nonreferred children.
The authors found that the majority of SCICA, CBCL, and TRF scales were
able to significantly discriminate between subjects with EBDs and nonreferred
subjects. Several scales were also able to discriminate between subjects
with EBDs and LDs.
Another structured interview that is
commonly utilized for ADHD assessment is the Diagnostic Interview for Children
and Adolescents (DICA-R). Boyle, Offord, Racine, and Szatmari (1996) compared
the reliability and validity of the DICA-R and theOntario Child Health
Study Scales, (OCHS-R), a self-administered checklist, on two administration
occasions, 1-3 weeks apart. Differences in test-retest reliability
between the two instruments were small. Validity coefficients were
slightly better for the checklist classifications of disorders listed in
the DSM-III-R. Differences in reliability and validity were also
small between the two measures.
A structured diagnostic clinical interview
with the child’s primary caregiver is also useful (Ammerman, Hersen, &
Last, 1999). One instrument that can be used or this purpose is the
Structured Developmental History (SDH). The SDH is one component
of the multidimensional Behavior Assessment System for Children (BASC).
The SDH is an extensive history and background survey that may be used
as either part of an interview with the child’s primary caretaker administered
by the clinician. This comprehensive questionnaire systematically
gathers diagnostic information including developmental events, medical
problems, social history, and family problems that may affect the child’s
behavior (Kamphaus, Reynolds, & Hatcher, 1999).
Behavior Rating Scales:
Behavior rating scales (teacher or parent)
have become more commonplace in child assessment of ADHD and are designed
to gather information about ADHD symptoms, general social competence, comorbid
disorders, and situational variability in behaviors. These instruments
are practical and cost-efficient, although they have been criticized for
their limited interpretive value. The Behavior Assessment System
for Children (BASC- Parent & Teacher forms-PRF & TRF; Reynolds
& Kamphaus, 1992) and the Achenbach Child Behavior Checklist (CBCL-
Parent & Teacher scales- PRS & TRS; Achenbach & Edelbrock,
1983) appear to be the most widely used and have the most support for reliability
and validity. Other available behavior rating scales include: Connors’
(CTRS 39, 28 and CPRS-R; Connors, 1989); the ADHD Symptoms Rating Scale
(ADHD-SRS; Holland, Gimpel, and Merrell, 1998); the Devereux Scales of
Mental Disorders (DSMD; Smith, Wigenfeld, Hilsenroth, Reddy, and LeBuffe,
2000); Attention Deficit Disorder Evaluation Scale (ADDES; McCarney, 1989);
ADD-H Comprehensive Teacher Rating Scale (ACTeRS; Ullmann, Sleator, and
Sprague, 1991); and the AD/HD Rating Scale-IV (Teacher and Parent forms;
DuPaul, Anastopoulos, Power, Murphy, and Barkley, 1996). Following
are research studies regarding the use of various scales.
Kamphaus, Reynolds, and Hatcher (1999) review recent research on the
use of BASC and found that most of the studies focused on the assessment
and diagnosis of clinical populations such as ADHD. The confluence
of finding suggests that the BASC is comparable to the CBCL for the diagnosis
of ADHD Combined Type. However, the BASC appears to be superior
to the CBCL for diagnosing children with externalizing disorders, specifically
ADHD Primarily Inattentive Type. Researchers identify the rational derivation
of the BASC scales as another advantage of the BASC over the CBCL.
Vaughn, Riccio, Hynd, and Hall (1997) compared
the effectiveness of discriminating ADHD subtypes using the Parent Rating
Scale and the Teacher Rating Scale of the Behavior Assessment System for
Children (BASC) and the Parent Report Form and the Teacher Report Form
of the Achenbach Child Behavior Checklist (CBCL). Their results indicated
that correlations were significant for a number of scales. Discriminant
analysis did not strongly favor either measure in differentiating children
with ADHD from those who did not meet diagnostic criteria. The authors
stated that results show the BASC Teacher Rating Scale has better predictive
ability for children who do not meet ADHD criteria. For subtypes
of ADHD, specifically the predominantly inattentive type, results show
an advantage for the use of the BASC.
Connors, Sitareios, Parker, and Epstein (1998)
evaluated the factor structure, reliability, and criterion validity of
the revised Connors Parent Rating Scale (CPRS-R). Exploratory and
confirmatory factor-analytic results revealed a seven-factor model including
the following factors: Cognitive Problems, Oppositional, Hyperactivity-Impulsivity,
Anxious-Shy, Perfectionism, Social Problems, and Psychosomatic. The
psychometric properties of the revised scale seem to demonstrate good internal
reliability
coefficients, high test-retest reliability, and effective discriminatory
power. Advantages of the CPRS-R include a corresponding factor structure
with the Connors Teacher Rating Scale-Revised and comprehensive symptom
coverage for ADHD and related disorders.
Holland, Gimpel, and Merrell (1998) investigated
the reliability and validity of the ADHD Symptoms Rating Scale (ADHD-SRS)
used by 1006 participants. The results indicate that the ADHD-SRS
possesses strong internal consistency reliability and test-retest reliability
and moderate cross-informant reliability. In addition, this instrument
was shown to have strong content validity. The authors state several
advantages of the use of this instrument over many currently existing rating
scales. One advantage is that the items are based on the DSM-IV classification
of ADHD and its symptomatology. In addition, with 56 items designed
to purely assess for ADHD characteristics, this instrument generates a
more thorough and complete assessment.
Smith, Wigenfeld, Hilsenroth, Reddy, and LeBuffe (2000) evaluated
the validity of the Devereux Scales of Mental Disorders to discriminate
between children and adolescents with ADHD, Conduct Disorder (CD), and
no clinical diagnosis. The results of the study did support the use
of the DSMD for distinguishing between clinical and nonclinical subjects.
However, the DSMD Total, Composite and Scale score did not differentiate
between the ADHD and the CD youths. Although the DSMD appears to
perform as well or better than other behavior rating scales at differentiating
clinical from nonclinical groups, the DSMD is not as able to make subtle
distinctions between disorders. However, the participants with ADHD
scored higher on the number of ADHD-related items endorsed and the participants
with CD scored higher on the number of CD-related items endorsed.
Thus, clinicians using the DSMD may be able to differentiate between these
two highly related disorders by examining the number of disorder-specific
items endorsed.
Peers:
Ammerman, Hersenand, and Last (1999)
suggest that “when social problems are a primary concern, peer measures
such as positive and negative nomination procedures, peer rating scales,
and/or peer reputation measures are useful in providing important information
about the extent and types of peer problems” (p. 67). Schaughency
and Rothlind (1991) also suggest the use of peer nominations in assessments
of ADHD. Specific items such as “can’t pay attention, can’t wait
turn, and can’t sit still” correlated well with teacher and observer measures
of inattention and hyperactivity.
Cornett-Ruiz and Hendricks (1993) investigated
the effects of labeling and ADHD behaviors on peer judgments. Fourth
through sixth grade subjects watched a brief video of a child displaying
stereotypical ADHD behaviors or normal behaviors and was labeled as either
ADHD or normal. Then, the peer raters completed first-impressions
rating scales, made predictions regarding subsequent success, and evaluated
a hand-written essay. Findings revealed that the ADHD behavior but
not the label resulted in a significant negative impact on the peer raters’
first-impressions and prediction scales.
Although peer ratings may make a valuable
contribution to diagnostic assessment, the evaluation team should consider
the effect that a sociometric instrument may have on the child. For
example, the peer rankings may result in increased anxiety or may encourage
teasing.
Behavioral Observations:
Behavioral observations provide opportunities
to compare the child’s behavior in a variety of settings in order to gain
a more holistic view of the child and a more objective sense of his or
her functioning. However, conducting observations can be expensive and
time consuming, and are limited in the ability to observe an adequate sample
of behavior. Examples of behavioral observation instruments include the
Behavioral Assessment System for Children-Monitor for ADHD (BASC- Student
Observation System SOS; Reynolds and Kamphaus, 1992) and the Child Behavior
Checklist (CBCL- Direct Observation Form DOF; Reed & Edelbrock, 1983
).
Assessors can also maximize time spent conducting
assessment by incorporating observations during testing into the evaluation
report. Glutting, Robins, and De Lancey (1997) compared the test
session behaviors of children with ADHD to unclassified children from the
GATSB standardization samples. The ADHD children were matched to the control
children according to the background characteristics of age, race, gender,
parent educational attainment, and overall cognitive ability. Test-taking
behaviors were rated according to the Guide to the Assessment of Test Session
Behavior (GATSB) for the Weschler Intelligence Scale for Children-Third
Edition (WISC-III) and the Weschler Individual Achievement Test (WIAT)
following the administration of the WISC-III. Results indicated that ADHD
children could be distinguished from the matched GATSB control children
on the test behavior variables of Inattentiveness, Avoidance and Uncooperative
Mood. The inattentiveness dimension of the GATSB best differentiated between
the two groups.
Valid ADHD diagnosis is complicated by heavy
reliance upon parent and teacher reports as well as children’s performance
on tasks which may be confounded by comorbid learning difficulties. In
lieu of a standard assessment technique, Costantino, Colon-Malgady, Malgady,
and Perez (1991) “applied an old technique to a new problem by examining
attention to projective stimuli.” A structured thematic apperception technique,
the Tell-ME-A-Story (TEMAS), was utilized to measure attention to pictorial
stimuli depicting characters, events, settings, covert psychological conflicts.
The TEMAS was administered to Black, White and Hispanic ADHD and non-ADHD
school-age children. The results revealed that the ADHD children
were significantly more likely that than the non-ADHD children to omit
information in the stimuli about characters, events, settings, and psychological
conflicts. Furthermore, prompting with structured inquiries by test
examiners was three times more likely to be required for the ADHD children
than the non-ADHD children.
Handen, McAuliffe, Janosky, and Feldman (1998)
observed children in a laboratory playroom setting to determine whether
children identified as ADHD or controls differed on activity and attentional
measures. Children with ADHD were further divided into ADHD + conduct
problems (ADHD + CD) and ADHD-only subgroups. Results indicated that
the ADHD-combined group was significantly more vocal and engaged in a significantly
greater number of toy changes than controls during independent play.
Significant group differences were also noted during the restricted academic
task, with the ADHD-combined and ADHD + CD groups more off-task and engaging
in a greater number of toy touches than controls.
Laboratory Measures:
Laboratory measures have been used to obtain
direct core features of ADHD (e.g., attention span, impulsivity, and motor
activity). While other assessment measures may be criticized for
their validity (e.g. unclear comparison standards of children of the same
age, cultural variations) and/or subjectivity (e.g., child ratings versus
parent ratings), laboratory measures are able to account for these inconsistencies
by the objective nature of the assessment. However, some limitations
may involve standardization issues, normative data, and generalization
to other contexts. Specifically, a computerized assessment of attention
and impulsively may not relate to assessments of a child’s adaptive behavior
in broader social contexts such as home, school, and peer groups.
Thus, greater research is needed in this area to determine its generalization
utility.
The Continuous Performance Test (CPT) is probably the most widely
used instrument for attention span or vigilance. There have been
several variations on the basic method of the original CPT, but most researchers
continue to follow the design of presenting a series of random letters
and requiring the participant to respond when a specific letter, usually
an X, appears or when a specific letter, usually an A, is followed by another
specific letter, usually an X. Failure to respond to the specified
letter or letter sequence is usually interpreted as a result of inattention.
Responses to incorrect letters or letter sequences are usually interpreted
as impulsivity (Forbes, 1998).
Widely used laboratory measures for ADHD are:
The Continuous Performance Test (CPT; Rosvold, Mirsky, Sarason, Bransome,
and Beck, 1956), Connors’ Continuous Performance Test (CPT; Connors, 1995),
Matching Familiar Figures Test (MFFT; Kagan, 1964), and Test of Variables
of Attention (TOVA; Greenberg, 1991).
Corkum and Siegel (1993) reviewed research
studies that employed the CPT in order to examine the possibility of sustained
attention deficits in children with ADHD. The authors concluded that
there is no compelling evidence for a sustained deficit in ADHD children.
An alternative theoretical model for understanding the results of CPT performance
in ADHD is also provided.
Mirsky, Pascualvaca, Duncan, and French (1999)
present a neuropsychological model of attention based on a factor analysis
of data derived from more than 600 children and adults. The model
divides attention into different elements or factors including the capacities
of encoding, focusing, executing responses, sustaining attention, shifting
attention, and a measure of response stability. A description is
also given of an on-going investigation of children referred to an inner-city
family clinic for evaluation of ADHD. The findings of this ADHD study
indicate that several aspects of attention are impaired in children with
ADHD and that these impairments are probably not attributable to learning
disorders.
The authors also present an Attention Battery,
modified for children, derived from neuropsychological tests in order to
assess the various elements of attention. Preliminary findings from
the current study suggest that ADHD children are impaired in various elements
of attention as compared to control children: The capacity to focus on
a task when distracted and to execute brisk, efficient responses (The Trail
Making B Test and the Stroop Word Test); the ability to shift attention
in a flexible, efficient manner (the Wisconsin Card Sorting Test); and
the ability to sustain attention in both the visual and auditory modalities
(CPT); and the capacity to maintain a stable response rhythm in the auditory
modality (CPT). In addition, the preliminary results suggest that
ADHD children tended to have more rapid responses than control subjects,
yet the responses tend to be more impulsive and more poorly regulated.
For instance, the ADHD children had more CPT commission errors as well
as increased Reaction Time (RT) Variance on the auditory CPT in comparison
to control children.
In order to address the question of the possible
contributions of learning disabilities to documented attention deficits,
the authors also compared the assessment results between the subgroup of
children diagnosed with ADHD alone (ADHD) with the subgroup of children
diagnosed with ADHD and a learning disability (ADHD+LD). The only
significant difference found between the groups was on the Word and Color
naming subtests of the Stroop Test, which appears to be consistent with
generally poor reading abilities. Thus, the authors conclude that the impaired
attentional elements in the ADHD population are not generally attributable
to learning disabilities.
McGee, Clark, and Symons (2000) found that
children with Reading Disorders (RD) had higher scores than both ADHD children
and control children on the Connors’ CPT. Furthermore, the ADHD children
did not have significantly higher CPT overall index scores than the control
children did. Phonological awareness tests, consisting of two auditory
and two visual subtests from the Woodcock-Johnson Psychoeducational
Battery--Revised, distinguished the RD children from both the ADHD
and the control children. This finding may be due to the Connors’ CPT requiring
rapid identification of letters, which is basic deficit in RD children.
The authors point out the danger that RD children could be falsely diagnosed
with ADHD if the Connors’ CPT overall index is used as diagnostic tool.
ADHD children who did fail the Connors’ were rated as more hyperactive
by their teachers. The Connors’ CPT did demonstrate several strengths in
this study. There were no age, order or fatigue effects. CPT
performance was uninfluenced by visual-motor integration, fine motor speed,
visual processing speed--with the exception of reaction time--or SES.
In agreement with other studies, the authors found that CPT scores do not
consistently identify attention in ADHD children. In conclusion,
the utility of the Connors CPT for differential diagnosis of ADHD is questioned.
Some clinicians believe that the CPT measures
psychomotor speed function rather than sustained attention. In order
to examine this relationship, Chae (1999) conducted a correlation
study between the Performance IQ (PIQ) of the WISC-III and the TOVA, which
is commonly used as a CPT. The relationships between the Freedom
from Distractibility (FD) and Processing Speed (PS) indexes of the WISC-III,
which are often included in ADHD assessment, with the TOVA were also examined.
The results of forty ADHD children studied indicate that there was no correlation
between the TOVA and the PIQ of WISC-III. Furthermore, the insignificant
correlation between the WISC-III Symbol Search subtest, which is regarded
as simply measuring psychomotor speed, and Response Time of TOVA supports
the conclusion that the TOVA is not a simple of psychomotor speed for the
evaluation of ADHD. It appears that the PIQ and the TOVA measure
different qualities of psychomotor functioning. In addition, the
significantly negative correlation between the Object Assembly (OA) and
Picture Arrangement (PA) subtests with the TOVA Inattention indicates that
ADHD children will not do well in the tasks that require sustained attention.
Hence, the OA and PA WISC-III subtests may be useful screening tools for
ADHD.
Forbes (1998) conducted clinical tests of
the TOVA to distinguish between referred children with ADHD/ADD and “other”
clinical diagnoses. The ADHD group differed from the “other” group
on TOVA variables and most measures from the Revised Connors Teachers Rating
Scale (RCTRS) and ADD-H Comprehensive Teacher’s Rating Scale (ACTeRS).
These results indicate these instruments are measuring relevant but different
dimensions of attention deficit disorders. The TOVA classification
criterion of any one variable correctly identified 80 percent of the ADDHD/ADD
group and 72 percent of the “other” group. In addition, cases misclassified
by teacher ratings were often correctly classified using TOVA. The
authors note that, because the rating scales and the TOVA have inherent
differences (e.g., differences in populations studied, differences in diagnostic
criteria, differences in scoring), making meaningful comparisons is difficult.
Thus, both appear to be contributing significant amounts of unique information
to an ADHD assessment.
A recent study assessed the usefulness of
the CPT, the MFFT, and the actigraph (an acceleration-sensitive device
with a solid-state memory used to count and store the number of times accelerations
change above a certain threshold per unit time) used in combination to
differentiate boys with ADHD from control subjects and to classify them
into subtypes (Inoue, Nadaoka, Oiji, Morioka, Totsuka, Kanbayashi, and
Hukui, 1998). In this study, the actigraph measured motor activity
in the subject’s trunk area. Regarding the MFFT, the authors
suggest that the “fast inaccurate” category is an important diagnostic
sign in ADHD as 16 out of the 20 participants with ADHD were classified
in this category. The participants with ADHD and the controls
were differentiated with enough high sensitivity and specificity by the
actigraph and the CPT.
Marks, Himelstein, Newcorn, and Halperin (1999)
identified ADHD subtypes using actigraphs and CPTs with a clinically referred
sample of participants ranging in ages from 7-11 years old. Results
indicate that the hyperactive-inattentive group was impaired on measures
of intellectual functioning and academic achievement relative to the other
3 groups. In addition, the impulsive-inattentive group was generally
rated as more aggressive, although this difference was not statistically
significant for all measures. The authors conclude that these results
suggest that such laboratory-based measures may be an effective strategy
to categorize diagnostic subgroups of ADHD.
Silberstein, Farrow, Levy, Pipingas, Hay,
and Jarman (1998) used a novel brain electrical imaging method to investigate
rapid and continuous changes in brain activity during the CPT in 17 boys
(ages 1-14 years) with ADHD and 17 matched-aged controls. In the
interval between the appearances of the A and the X of the correct trials
of the CPT-AX, control boys showed transient reductions in steady-state
visually evoked potential (SSVEP) latency at right prefrontal sites.
By contrast, boys with ADHD showed no changed or an increase in prefrontal
SSVEP latency at right prefrontal sites. The use of these laboratory
measures in this study provide evidence for neurological differences in
children with ADHD. Specifically, these results suggest an increased
speed of prefrontal neural processing in children without ADHD following
a priming stimulus, and a deficit in such processes in children with ADHD.
II. DEVELOPMENTAL PERSPECTIVE
Utilizing a developmental framework is a useful
practice in the assessment of ADHD. ADHD can be viewed as a developmentally
relative disorder as findings indicate that ADHD symptoms decline significantly
in prevalence and/or change in expression with age across childhood and
adolescence. Furthermore, what we presume to be subtypes of ADHD
(ADHD-HI and ADHD-C) may be viewed instead as two different developmental
stages of the same disorder (Barkley, 1998).
As ADHD children tend to progress at a relatively
constant rate but with delays in both social development and cognitive
tasks when compared to their non-ADHD peers, Mirsky, Pascualvaca, Duncan,
and French (1999) speculate whether ADHD represents a developmental delay.
The authors point out that the hypothesis that this “developmental lag”
does not necessarily mean that ADHD children will eventually catch-up with
their peers is supported in the research literature. In fact, follow-up
studies indicate that approximately 70 to 80 percent of children diagnosed
with ADHD continue to present symptoms of inattention and impulsivity into
adolescence and early adulthood. As it is likely that the developmental
course and outcome of ADHD children depend on the specific nature of their
attention deficits, the authors underscore the importance of assessing
specific elements of attention (see Laboratory Measures). Although it is
clear that “the diagnosis of ADHD is given to a group of children who show
marked variability in their clinical presentation and response to treatment”,
little is known about the possible differences in developmental trajectories
and outcomes between ADHD subgroups.
When assessing for ADHD, one must gather historical,
behavioral, and socio-emotional information about an individual from multiple
sources, informants and contexts. Furthermore, as indicated in the
DSM-IV-TR, it is critical that the evaluation team considers whether the
child’s behaviors are developmentally inappropriate and that there is clear
evidence of significant impairment in social and/or academic functioning.
Thus, reflected in the assessment process is a regard for the importance
of the interactional nature of biological, environmental and developmental
constituents. Current objectives for refining assessment methods
should emphasize the importance of developmentally sensitive measures.
At this time, behavior rating scales and some structured interview schedules
seem to incorporate this aspect best because of their extensive normative
base.
Using CPTs and actigraphs, Inoue, Nadaoka,
Oiji, Morioka, Totsuka, Kanbayashi, and Hukui (1998) considered the developmental
perspective in the analysis of their findings. Results suggest that
younger elementary schoolchildren are more hyperactive, inattentive, and
impulsive. Therefore, the authors suggest that ADHD should be diagnosed
taking into consideration the age of the child.
Age and sex relationships were examined with
measured performance in the CPT in a study by Lin, Hsiao, and Chen (1999).
The participants were 341 randomly selected school children between the
ages of 6 and 15. Results revealed that the hit rate, false alarm
rate, and sensitivity of the CPT measures were associated with age.
These findings underscore that failing to take variables such as age and
gender into consideration may result in misdiagnosis or misinterpretation
of assessment results.
Fisher, Barkley, Edelbrock, and Smallish (1990)
studied various outcomes in adolescence of children diagnosed as hyperactive.
One hundred hyperactive children (aged 12-14 years) were tested on measures
of academic skills, attention and impulse control, and select frontal lobe
functions and, then, were tested in follow-up eight years later.
Follow-up results indicated that hyperactive subjects demonstrated impaired
academic achievement, impaired attention and impulse control, and greater
off-task, restless, and vocal behavior, compared with control subjects.
Thus, it was concluded that hyperactive children may remain chronically
impaired in academic achievement, attention, and behavioral disinhibition
well into their late adolescent years.
Barkley (1997) addresses several problems
in diagnosing ADHD across the lifespan using the DSM-IV items. First
he states that much of the content of the inattention items actually refers
to the persistence of goal-directed responding and resistance to distraction
(interference control). He argues that the term inattention, is in
many ways misleading, as distraction and impersistence have nothing to
do with perception of information processing, which is usually associated
with
attention. A second argument is that the items reflecting poor
behavioral inhibition are underrepresented relative to their importance
in identifying the disorder. Barkley notes that even though the symptoms
of inattention become useful discriminators of ADHD in school-age children,
they may become increasingly less useful by adulthood. Thus, only
the more serious cases of ADHD would be more likely to be detected by these
inattention items, and, even then, not particularly well (Barkley, 1997).
Barkley offers suggestions to address the
problem of the developmental insensitivity of these assessment instruments,
by doing what has already been done in the diagnosis of mental retardation
or learning disabilities such as reading disorders. Specifically,
he proposes that a wide range of items must be used that represent the
broad developmental span for the cognitive impairment of interest.
In addition, a flexible cutoff score must be chosen that is developmentally
referenced in order to continue to reflect the same degree of deviance
at all ages (Barkley, 1997).
The developmental perspective is an essential
piece in the assessment of ADHD as many of the symptoms tend to be subjective
measures (i.e. difficulty sustaining attention, easily distracted, etc.)
as evidenced by inconsistency between informants. Furthermore, the
history of its classification in the different versions of the DSM illustrates
the inconsistencies and confusion in the agreement of ADHD. In addition,
failing to incorporate one’s developmental level in the assessment procedures
may lead to misdiagnosis as measured by the DSM.
III. OPTIMAL ASSESSMENT BATTERY
To date, ADHD, like any other mental disorder,
cannot be firmly diagnosed by one medical or objective procedure (August,
1998). The best approach for evaluating individuals for ADHD is a
comprehensive, multi-method, multi-informant behavioral assessment that
addresses the specific referral questions. As a best-estimate approach,
the following assessment strategies, also mentioned above, should be used
in a standard ADHD assessment: Diagnostic interview, behavioral rating
scale, behavioral observations, and laboratory measures that examine different
elements of attention. In addition, a peer sociometric measure may
be of use if the child is having social difficulties. Research has
shown that many of the available methods do not correlate highly with one
another, which lends support to the rationale for incorporating more than
one method.
The assessment practice of ADHD has included
the use of diagnostic interviews, behavioral rating scales, peer-referenced
measures, behavioral observations, and laboratory measures. An undergirding
theme in assessing for ADHD is the developmental perspective, which is
a reflection of the developmental underpinnings associated with this disorder.
At the present time, it is recommended that measures that have a solid
normative base such as that found in most behavioral rating scales and/or
diagnostic interviews remain a necessary component of the broad assessment.
Currently, the most effective method for ADHD assessment is conducting
a comprehensive behavioral assessment that utilizes multiple methods and
informants. While assessments may be conducted by school personnel
and/or medical professionals in the school environment or clinical settings,
it is imperative that these professionals and informants communicate and
work together as an evaluation team to discuss the students’ situation.
Furthermore, the evaluation team should discuss the confluence of assessment
results as well as the developmental level of the child when attempting
to interpret findings and make a diagnosis. Failure to establish
effective communication may result in misdiagnosis.
I. TREATMENT
A variety of interventions have attempted to ameliorate the cognitive, behavioral, academic and social disturbances, which accompany ADHD. Among the most popular treatments are pharmacological, behavioral, cognitive-behavioral and multi-modal strategies. All treatments have demonstrated some promise, but a single effective treatment has not been identified. The heterogeneity of symptoms and frequent co-occurrence with other behavioral and psychological conditions contribute to the difficulty in treating ADHD. Few studies have examined the efficacy of treatments across developmental stages. Despite the evidence that various symptoms of the disorder seem to improve somewhat with age, psychologists know little about which treatments address the salient features of this disorder across different stages of the life span. Listed below are examples of research literature, which examine the effectiveness and/or ineffectiveness of various treatment approaches that have been utilized for ADHD.
Studies of Pharmacotherapy for ADHD:
Psychostimulants are one of the most common
treatments for ADHD in children and include methylphenidate (MPH, also
commonly known as Ritalin), clonidine, dextroamphetamine, and Adderall
among the most commonly prescribed in the United States (Manos, Short,
& Findling, 1999). While several studies have demonstrated their
effectiveness, the use of psychostimulants with children continues to be
controversial.
Little information exists concerning the long-term
effects of psychostimulants, however, there is no conclusive evidence that
careful therapeutic use is harmful (National Institute of Health, 1998).
Because the behavioral and side effects of stimulants can vary significantly
across dosages and individuals, the importance of evaluating the medication
response should be stressed (Roberts & DuPaul, 2000). Evaluations
should include repeated assessment of child behavior across dosages including
placebo and/or non-medication conditions (as a basis of comparison) in
order to ensure that the child is not receiving inappropriate dosages.
Despite its controversy, this type of treatment has been used in children
as young as two years old. Research has shown that clinical improvement
in behavior occurs in as many as 75-92 percent of those with the hyperactive-impulsive
form of ADHD and results in normalization of behavior in approximately
50-60 percent of these cases on average (Barkley, 1997).
Studies have estimated that 3 percent
of US schoolchildren take medication for ADHD, while as many as 7 percent
of US children may have the disorder (Lang, 1997). Recently, public
concerns have been raised about the dramatic rise in ADHD diagnosis and
stimulant prescription. Jensen et al. (1999) investigated the rates
of ADHD diagnosis and treatment in four U.S. communities (Atlanta, Georgia;
New Haven, Connecticut; Westchester, New York; and San Juan, Puerto Rico).
The epidemiological procedures used for the study entailed two lay interviewers
separately interviewing children (ages 9-17) and their primary caretakers
in their homes using a computer-assisted version of the National Institute
of Mental Health Diagnostic Interview Schedule for Children (NIMH-DISC-2.3).
Only the children for whom the DISC data permitted an ADHD diagnosis were
included in the analyses. The researchers found a low overall prescription
rate, only 12% of children with ADHD received stimulant treatment.
There were no significant differences in prescription rates between the
four sites. Although half of the children who were taking stimulants
did not meet full diagnostic criteria for ADHD, this may have been a function
of a positive response to stimulant treatment. However, these children
had high levels of ADHD symptoms. The authors conclude that concerns
about overprescription were not supported by the study data. Furthermore,
more ADHD children received school-based or psychotherapeutic services
(one-fourth to one-third) than medication (one-eighth). The authors
underscore the lack of services provided to ADHD children, with these findings
paralleling previous reports that only about one-third of children in need
of mental health services actually receive care.
LeFever, Dawson, and Morrow (1999) attempted
to determine the extent of medication use for ADHD among children enrolled
in public schools in two different cities in Virginia. The study
population included all students enrolled in grades 2 through 5 in city
A (n=5767), and city B (n=23967). Results indicated that 8-10 percent
of the students received medication for ADHD. The majority (90 percent)
of children receiving medication were prescribed MPH, and 5 percent received
MPH in combination with other drugs. The percentage of students receiving
ADHD medication generally increased with grade; the increase from second
to fifth grade was from 7-9 percent and 7-10 percent in cities A and B
respectively. The percentage was highest in fifth grade, in which
18 percent and 20 percent received medication in cities A and B, respectively.
The study also included sex and race differences: 17 percent of Caucasian
males, 9 percent of African-American males, 7 percent of Caucasian females,
and 3 percent of African-American females received ADHD medication (these
findings were consistent between the two districts). The difference
between the findings of this study and the previous study indicate that
both overprescription and underprescription occur and are likely to be
region-, community-, and provider-specific (Jensen et al, 1999).
While the the LeFever, Dawson, and Morrow
(1999) study included school-aged children, psychotropic medical use has
also been studied in younger children. Rappley, Mullan, Alvarez,
Eneli, Wang, and Gardiner (1999) investigated the diagnosis and treatment
methods used in very young children with ADHD. Their study included
223 children aged 3 years or younger who had a clinical diagnosis of ADHD.
In addition, many had conditions commonly comorbid with ADHD (44 percent),
other chronic health conditions (41 percent), and injuries (40 percent).
More than half of the children received psychotropic medication (57 percent)
while 26 percent received psychological services. Among those receiving
psychotropic medications, 54 percent received one medication and 45 percent
received a combination of medications. Twenty-two different medications
were used by children included in this sample, with MPH and clonidine hydrochloride
among the most frequently used. The authors do point out that, “the
use of psychotropic medications as described for these children is not
approved by the FDA” (Rappley, et.al., 1999).
The research described previously highlights the prevalence of
psychotropic medical use in children with ADHD. We will now turn
to studies that highlight different effects of such medications.
One commonly reported side effect of psychostimulant
use is sleeping difficulties. Stein (1999) compared the parental
perceptions of sleep problems in stimulant treated children with ADHD,
untreated children with ADHD, and a control group children receiving routine
pediatric care. Thirty percent of the stimulant treated children
with ADHD versus 10 percent of the untreated children with ADHD reported
delayed sleep onset or insomnia every night. The stimulant treated
children with ADHD were three times more likely to report severe sleeping
problems than the untreated children with ADHD. The authors point
out that the findings of this study concur with previous studies indicating
that children with ADHD who take stimulant medications are at increased
risk for insomnia as well as other sleeping difficulties.
Schachar, Tannock, Cunningham, and Corkum
(1997) studied the long-term effects of MPH in children’s behavior as well
as the medication side effects as reported by teachers and parents.
The study duration was scheduled for 12 months, with this interim report
covering the first four months of treatment. The findings include
differences in adherence to treatment, with more families and children
in the placebo group discontinuing treatment due to ineffectiveness.
Medication side effects were the primary reason for discontinuing use in
the medication group. Teacher ratings revealed greater behavioral
improvement for the MPH group. In contrast, parents reported no difference
between the groups (both groups improved overall).
Another study included observations of student’s
behavior and academic performance in response to the effectiveness of Adderall
with ADHD children. Swanson, Wigal, Greenhill, Browne, Waslik, Lerner,
Williams, Flynn, Agler, Crowley, Finberg, Baren and Cantwell (1998) included
30 children in their study to compare the effectiveness of 5, 10, 15, and
20 mg of Adderall to the best dose of Ritalin. Results indicated
that all doses of the two medications were superior to the placebo.
However, higher doses of Adderall lasted longer than lower doses of Adderall
and Ritalin, and these effects were apparent in the children’s behavior
and academic performance. This longer lasting effect is of particular
interest because it has been reported that higher doses of Ritalin give
a more powerful effect instead of a longer lasting effect.
Another study was conducted comparing the
effectiveness of MPH and Adderall in children ranging in age from 5 to
17 years. More specifically, the study was designed to compare the
effectiveness of Adderall given once in the morning and that of MPH given
in the morning and at noon. All forty-two participants met the DSM-IV
criteria for ADHD and were assigned to one of three groups (Adderall, MPH
and control). Teacher reports, parent ratings as well as standardized
measures of the side effects were included in the measurement procedures.
Results indicated that both MPH and Adderall are effective treatments as
measured by the teacher and parent ratings of behavior. In addition,
a single-dose treatment of Adderall was shown to be as effective as two
daily doses of MPH. These results may increase the possibility of
managing treatment without having to involve the school in medication administration.
As the majority of stimulant response studies
have been conducted on children, there is a paucity of studies examining
stimulant efficacy for adolescents with ADH. Barkley, Connor, and
Kwasnik (2000) evaluated the utility of employing systematic assessment
of stimulant response with adolescents (ages 12-17) with ADHD in a routine
outpatient clinical setting. Thirty-five teenagers with ADHD rotated
through five blind drug conditions: Two daily doses of Adderall (5 mg and
10mg), MPH (5mg and 10mg), and a lactose placebo. Results revealed
no significant effects of the medication on parent or teacher ratings between
groups. The authors note confounding variables such as the teachers
completing less than half of the weekly ratings across the five weeks of
the study. Subjects taking 10mg of Adderall made significant improvements
on an inhibition control task (Stroop Color Word Association Test) but
not on an attention task (CPT). Teens reported less severe side effects
for the 10mg dose of Adderall than the 5mg dose of MPH. Non-blinded
global clinical judgements of stimulant response, based upon multiple sources
of information, suggested that both Adderall (46%) and MPH (40%) appear
to be clinically effective in the treatment of adolescents with ADHD.
However, 14% did not respond to either stimulant. The authors discuss
several logistical problems with conducting this type of study using rating
scales in typical outpatient practice and offer recommendations (e.g.,
a daily report card presented to each teacher by the teenager) for future
studies.
Frankel, Cantwell, Myatt, and Feinberg (1999)
used the Achenbach Child Behavior Checklist (CBCL), the Social Skills Rating
System (SSRS), and the Piers-Harris Self-Concept Scale (PHS), to assess
the self-esteem of children with ADHD medicated with stimulants and those
who were unmedicated. Results showed that stimulants were associated
with significantly higher self-esteem and children reported feeling more
intelligent and more popular than unmedicated children with ADHD did.
Significant correlations indicated that higher doses were associated with
higher levels of self-esteem. The authors highlighted two possible
interpretations for these results. First, subjects reported higher
self-esteem because they perceived that their behavior was under better
control (and perhaps they were drawing less criticism from others).
Second, the dose-response correlations reflect stronger internal sensations
caused by stimulants at higher doses and perhaps a greater hope for positive
social outcomes.
Kemptom, Vance, Maruff, Luk, Costin,
and Pantelis (1999) attempted to measure executive function in medicated
and non-medicated children with ADHD by using a computerized battery.
Results from the study indicated that the unmedicated ADHD children showed
impairment on tasks of executive function, including planning ability,
movement time, attentional set shifting, and spatial working memory.
However, the group of medicated ADHD children showed no impairment on any
of the executive function tasks, with the exception of poor performance
on the spatial recognition memory task. Results from this study are
consistent with neuropsychological attributes of ADHD in specific regions
of the brain.
Thomson and Varley (1998) conducted
a multivariate analysis with several predictor variables (age, gender,
SES, family structure type, adoptive status, and neurological status) and
response to medication in 336 children with ADHD from 3-16 years old.
All children underwent a 3-week, double blind trial of MPH and a placebo.
Three conditions were assigned to each child: a) 1 week of placebo, b)
1 week of .5 mg/kg daily of MPH in two divided doses, and c) 1 week of
1.0 mg/kg daily of MPH in two divided doses. The CBCL and the Wechsler
Intelligence Scale for Children (WISC-R) were completed before the drug
trial period. In addition, the Connors Abbreviated Symptom Questionnaires-
Parent and Teacher forms and narratives regarding the child’s functioning
were collected daily during the medication trial for the determination
of response. Results indicate that neurologic status, inattention,
and overactivity were found to be most likely to predict good response
to psychostimulants, whether rated by parents or teachers. Although
a number of variables predicted a positive psychostimulant response, the
strength of the predictive associations suggests only a minimal clinical
usefulness.
Cognitive-Behavioral Therapy for ADHD:
A variety of cognitive-behavioral interventions have been used to treat ADHD in children. Ervin, Bankert, and DuPaul (1996) discuss several of these methods including: Cognitive-based interventions (i.e., self-instruction training and social problem-solving training), contingency-based interventions (i.e., self-monitoring, self-evaluation, self-reinforcement, and correspondence training), and cognitive-behavioral therapy (self-management) combined with other interventions. The authors use empirical studies to examine the e