Attention-Deficit/Hyperactivity Disorder (ADHD)
Problems with attention, impulse control, and activity level are among the most common behavior difficulties exhibited by children and adolescents in the United States (Barkley, 2006). In fact, approximately 3 to 5 percent of school-aged children could be diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD), a psychiatric condition applied to individuals who exhibit developmen-tally inappropriate levels of inattention and/or impulsivity/ overactivity (American Psychiatric Association, 2000).
To meet DSM-IV-TR (American Psychiatric Association, 2000) criteria for ADHD, individuals must exhibit at least six inattention or at least six hyperactive-impulsive symptoms prior to the age of 7, for at least 6 months, and with concomitant academic and/or social impairment. Boys with ADHD outnumber girls with this disorder at about a 2:1 to 5:1 ratio (Barkley, 2006). Given that most public school classrooms in the United States include 20 to 30 students, approximately one to two students in every classroom will have ADHD. Further, ADHD symptoms typically persist from early childhood through at least adolescence for a majority of individuals (Barkley, Murphy, & Fischer, 2007). Thus, ADHD typically is viewed as a lifelong disorder that must be addressed through ongoing intervention that is developmentally appropriate and addresses the unique needs and specific impairment of individual children (DuPaul & Stoner, 2003).
Children and adolescents with ADHD typically exhibit a variety of difficulties with school functioning. First, students with this disorder frequently are inattentive and exhibit significantly higher rates of off-task behavior relative to their non-ADHD classmates (e.g., Vile Junod, DuPaul, Jitendra, Volpe, & Cleary, 2006). Second, hyperactive-impulsive behaviors that characterize ADHD typically lead to disruptive behaviors (e.g., talking without permission, bothering other students, and leaving assigned area) in the classroom and other school settings. Third, ADHD frequently is associated with deficits in academic skills and/or performance. On average, children with ADHD score between 10 to 30 points lower than non-ADHD control children on norm-referenced, standardized achievement tests (e.g., Barkley, 2006). In fact, approximately 20 to 30 percent of children with ADHD are classified as having learning disabilities because of deficits in the acquisition of specific academic skills (DuPaul & Stoner, 2003). Further, the results of prospective longitudinal investigations of children with ADHD into adolescence and adulthood indicate significantly higher rates of grade retention, placement in special education classrooms, and school drop-out relative to their non-ADHD classmates as well as significantly lower high school grade point average, enrollment in college degree programs, and socioeconomic status (for review, see Barkley et al., 2007).
Children and adolescents with ADHD are at higher than average risk for a variety of behavioral difficulties including defiance toward authority figures, physical and verbal aggression toward peers, and antisocial acts such as lying, stealing, and vandalism (American Psychiatric Association, 2000; Barkley, 2006). As a result of defiant and aggressive behavior, individuals with ADHD often have significant difficulty developing and maintaining positive relationships with peers, teachers, and other school personnel. Not surprisingly, several investigations have found children with ADHD to be less well-liked, more often rejected, and have fewer friends than their non-ADHD peers (e.g., Hoza, Gerdes, Mrug, Hinshaw, Bukowski, Gold et al., 2005).
The DSM-IV identifies three subtypes of ADHD: combined type, predominantly inattentive type, and predominantly hyperactive-impulsive type (American Psychiatric Association, 2000). Individuals with ADHD combined type exhibit significant symptoms of both inattention and hyperactivity-impulsivity, while those with predominantly inattentive and hyperactive-impulsive types display significant symptoms of only one of the two dimensions. Prevalence figures in the child population are approximately equal for ADHD combined and predominantly inattentive types, with these two subtypes outnumbering hyperactive-impulsive type by a 2:1 margin (Hudziak, Heath, Madden, Reich, Bucholz, Slutske et al., 1998).
Most of the research on ADHD conducted as of the early 2000s has focused on children and adolescents with ADHD combined type. Between 1985 and 2005, studies examining individuals with predominantly inattentive type have found that the latter are more likely to exhibit learning problems and possibly internalizing disorder symptoms, and less likely to have comorbid disruptive behavior disorders relative to children with ADHD combined type (Bark-ley, 2006), although these findings are not consistent across studies. Given that the predominantly hyperactive-impulsive type was not included in the DSM nomenclature until 1994, very little research has focused on this subtype. What little data are available suggest that the hyperactive-impulsive subtype may be more prominent in younger children and could be an early childhood manifestation of what eventually will be ADHD combined type (e.g., Riley, DuPaul, Pipan, Kern, Van Brakle, & Blum, in press). Importantly, very little research has examined differential treatment response across subtypes; thus, as of 2007, treatment components are not modified based on ADHD subtype.
The assessment of children and adolescents suspected of having ADHD involves the use of multiple assessment tools (e.g., rating scales and diagnostic interviews) to obtain information on symptomatic behavior and associated functioning from the perspectives of multiple individuals (i.e., parent, teacher, and child) (Barkley, 2006). No single assessment method or source alone is adequate for making the diagnosis; clinicians must examine child functioning as comprehensively as possible (American Academy of Child and Adolescent Psychiatry, 2007).
The assessment process can be viewed as a five-stage process, including screening, multimethod assessment, interpretation of data, treatment design, and treatment evaluation (DuPaul & Stoner, 2003). The goal of this assessment process is not only to determine if an individual has ADHD, but also to identify possible comorbid conditions, delineate potentially effective treatment strategies, and evaluate whether intervention is successful.
The first stage of the assessment process is screening for ADHD symptoms in all cases where an individual is reported to have problems with attention, impulsivity, or activity level. Typically, screening entails obtaining parent and/or teacher report on the extent to which ADHD symptoms are evident in home or school settings. For example, the parent or teacher could complete an 18-item rating scale that contains the DSM-IV ADHD symptoms. If a significant number of inattentive and/or hyperactive-impulsive symptoms are reported, then more assessment data will be gathered at the next stage of the process.
The multimethod assessment stage involves gathering extensive information about symptoms of ADHD and other psychopathological disorders; the child's developmental, medical, and family histories; and the extent to which academic and social functioning are impaired by symptoms (Barkley, 2006; DuPaul & Stoner, 2003). A major component of the assessment is a diagnostic interview with the child's parent (and teacher, if possible). There are various interview formats available, but the key information to obtain is parental perception of the frequency and chronicity of ADHD symptoms, presence of symptoms of other disorders (e.g., oppositional defiant disorder), prior attempts to treat these difficulties, developmental history, and family history (Barkley, 2006). Behavior ratings also must be obtained from parents and teachers. Ideally, rating scales that assess a broad band of psychopathological behaviors (e.g., Child Behavior Checklist; Achenbach, 1991) and a narrow band of behaviors related to ADHD (e.g., ADHD Rating Scale-IV; DuPaul, Power, Anastopoulos, & Reid, 1998) should be used. If possible, direct observations of classroom behavior should be used to assess the degree to which ADHD-related behaviors are evident as compared to classroom peers as well as to identify possible environmental factors that could be eliciting and/or maintaining challenging behaviors. Finally, data regarding social (e.g., Social Skills Rating Scale; Gresham & Elliott, 1990) and academic (e.g., curriculum-based measurement probes) functioning should be gathered to determine the degree of impairment associated with ADHD symptoms.
It should be noted that traditional psychological and neuropsychological tests (e.g., Wechsler scales) have limited value in the assessment of ADHD symptoms. Although individuals with ADHD may perform below their non-ADHD peers on some of these instruments, score profiles specific to ADHD have not been identified and these data have limited ecological validity (Barkley, 2006). In similar fashion, medical assessment procedures (e.g., MRI, EEG) do not provide specific data to inform diagnostic decisions at the individual level.
The next stage in the assessment process is to interpret the data obtained through multiple measures. Specifically, one must determine the degree to which clinically significant ADHD symptoms are evident across settings and the degree to which these symptoms are associated with academic, social, and/or occupational impairment. Further, alternative hypotheses for the display of apparent ADHD symptoms should be considered. For example, attention difficulties may be due to an anxiety or depressive disorder. Finally, possible comorbid diagnoses should be considered given that most individuals with ADHD will have one or more additional disorders (Barkley, 2006). The disorders most commonly associated with ADHD include oppositional defiant disorder, conduct disorder, and learning disabilities.
The final two stages of the assessment process are designed to move beyond diagnosis and are focused on treatment development and evaluation. Assessment data are used to determine the most appropriate course of action for intervention. For example, the more severe the ADHD symptoms and the more these symptoms are associated with multiple comorbid disorders, the more likely that a combination of psychotropic medication and behavior modification will be necessary (Jensen, Hinshaw, Kraemer, Lenora, Newcorn, Abikoff et al., 2001). Also, data regarding the antecedent and consequent events that serve as a context for classroom disruptive behavior can aid in determining the function of target behaviors and, ultimately, can lead to the development of an intervention that directly addresses this behavioral function (DuPaul & Stoner, 2003). Finally, once a treatment plan is developed and put into action, assessment data are collected periodically to determine whether the plan is successful and to delineate potential treatment modification.
The two primary interventions for ADHD are psychostimulant medication (e.g., methylphenidate) and behavior modification strategies implemented in home and school settings (Barkley, 2006). These intervention strategies have been found to reduce ADHD symptoms and associated behavior difficulties (e.g., noncompliance and aggression) as well as enhance peer interactions and academic performance for most study participants (for review see Barkley, 2006).
Psychotropic Medication. Central nervous system (CNS) stimulants are the most common and widely studied class of psychotropic medication used in the treatment of ADHD (Connor, 2006). In fact, methylphenidate and other CNS stimulants are the single most effective treatment for reducing ADHD symptoms in children (MTA Cooperative Group, 1999, 2004). Further, numerous studies have shown methylphenidate and amphetamine compounds to improve classroom attention, behavior control, and interactions with peers and authority figures as well as enhance productivity and accuracy on academic tasks and curriculum-based measurement probes (for review, see Brown, Antonuccio, DuPaul, Fristad, King, Leslie et al., 2007; Connor, 2006). Alternatively, long-term effects on academic achievement (as measured by standardized achievement tests) have been either very small or non-existent (e.g., Jensen, Arnold, Swanson, Vitiello, Abikoff, Greenhill et al., 2007; MTA Cooperative Group, 1999, 2004). Because some individuals may experience limited success and/or adverse side-effects with CNS stimulants, several non-stimulant medications have been studied. For example, atomoxetine (Spencer et al., 2002) and clonidine (Connor, Fletcher, & Swanson, 1999) have been successful in reducing ADHD symptoms. The effects of non-stimulants on academic performance and social interactions with peers have not been studied extensively and are as of 2007 essentially unknown.
Interventions Based on Behavioral Principles. Contingency management interventions that manipulate consequences to change specific target behaviors are widely used to treat ADHD symptoms and comorbid behavioral difficulties. The two consequence-based interventions that have the strongest empirical support are token reinforcement and response cost (Pelham, Wheeler, & Chronis, 1998). Token reinforcement programs involve providing individuals with immediate reinforcement in the form of tokens contingent on the display of appropriate behavior (e.g., Pfiffner, Rosen, & O'Leary, 1985). Alternatively, response cost involves the removal of token reinforcers following the display of inappropriate behavior (Rapport, Murphy, & Bailey, 1982). Both of these strategies have been found to reduce inattentive, disruptive behaviors to a significant degree relative to baseline conditions. When possible, behavioral interventions should be designed using functional assessment data (O'Neill, Horner, Albin, Sprague, Storey, & Newton, 1997). In fact, several single subject design studies that included students exhibiting ADHD symptoms (e.g., Eckert, Martens, & DiGennaro, 2005) have indicated the value of an assessment-based approach to the design of behavioral interventions.
Combined Medication and Behavioral Intervention. Investigations systematically comparing the combination of CNS stimulants, behavioral interventions and their combination (i.e., multimodal treatment) have found stimulants to be superior to behavioral treatments in reducing ADHD symptoms (MTA Cooperative Group, 1999, 2004). Alternatively, the greatest effects on problems associated with ADHD (e.g., oppositional behavior and social performance difficulties) typically are obtained with the combination of stimulants and behavior modification (Conners, Epstein, March, Angold, Wells, Klaric et al., 2001). Further, children with multiple comorbid disorders (Jensen et al., 2001) and individuals from ethnically or socioeconomically diverse backgrounds (Arnold, Elliott, Sachs, Bird, Kraemer, Wells et al., 2003) are most successful when these treatment modalities are combined.
Academic Interventions. Stimulants and behavioral interventions are associated with small effects, at best, on academic achievement. Although academic interventions for students with ADHD have not been as widely studied as behavioral treatments, studies in the late 1990s and early 2000s have provided preliminary support for instructional and remediation strategies. Specifically, computer-assisted instruction (Mautone, DuPaul, & Jitendra, 2005), classwide peer tutoring (DuPaul, Ervin, Hook, & McGoey, 1998), home-based parent tutoring (Hook & DuPaul, 1999) or homework support (Power, Karustis, & Habboushe, 2001), self-regulated strategy for written expression (Reid & Lienemann, 2006), and directed note-taking (Evans, Pelham, & Grudberg, 1995) are associated with improvements in specific academic skills and outcomes. Further, a large scale examination of consultation-based academic strategies found significant growth in reading and math skills for elementary students with ADHD (DuPaul, Jitendra, Volpe, Tresco, Lutz, Vile Junod et al., 2006).
Children and adolescents with ADHD experience significant academic, social, and behavioral difficulties in home and school settings. The assessment of ADHD involves collection of data across settings and sources to identify whether significant symptoms are present, whether these are better accounted for by other disorders, and what environmental variables can be altered as part of the treatment protocol. Empirical studies support the use of psychotropic medication (most notably stimulants and atomoxetine), behavioral strategies in home and school settings, and modifications to academic instruction in reducing ADHD symptoms and enhancing academic and social functioning. Nevertheless, there are many important gaps in the extant treatment literature, including the need (a) to evaluate effects on academic and social functioning, (b) to assess treatment integrity and acceptability, and (c) to document how the combination of stimulant medication and behavioral interventions can be optimized.
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