Preschool children with attention-deficit/hyperactivity disorder: impairments in behavioral, social, and school functioning.

OBJECTIVE: To examine differences in home, school, and medical functioning between preschool-age children with attentiondeficit/hyperactivity disorder (ADHD) and normal control children. METHOD: A sample of 94 children (58 with ADHD, 36 normal controls) between 3 and 5 years old participated. Dependent measures included parent and teacher ratings of problem behavior and social skills, parent ratings of stress and family functioning, medical functioning data, observations of parent-child interactions and classroom behavior, and a test of preacademic skills. RESULTS: Young children with ADHD exhibited more problem behavior and were less socially skilled than their normal counterparts according to behavior ratings. Parents of children with ADHD experienced greater stress and were coping less adaptively than parents of non-ADHD children. Children with ADHD exhibited more noncompliant and inappropriate behavior than normal controls, particularly during task situations. Parents of children with ADHD were more likely to display negative behavior toward their children. Children with ADHD exhibited more negative social behavior in preschool settings and scored significantly lower on a test of preacademic skills. No significant differences in injuries or utilization of medical services were found. CONCLUSIONS: Preschool-age children with ADHD are at significant risk for behavioral, social, familial, and academic difficulties relative to their normal counterparts.

Self-report of ADHD symptoms in university students: cross-gender and cross-national prevalence.

Little research has examined the structure and prevalence of attention-deficit/hyperactivity disorder (ADHD) symptoms in university students, including whether symptom structure conforms to the bidimensional (i.e., inattention and hyperactivity-impulsivity) conceptualization of the Diagnostic and Statistical Manual of Mental Disorders (DSMV-IV; American Psychiatric Association, 1994) and whether self-reported symptoms vary across gender and country. A sample of 1,209 university students from three countries (Italy, New Zealand, and the United States) completed a 24-item self-report measure (the Young Adult Rating Scale) tapping ADHD symptomatology. Factor analyses within the U.S. and New Zealand samples supported a bidimensional symptom structure, whereas weaker support for this conceptualization was provided by the Italian sample. Participants did not vary significantly by gender in symptom report; however, Italian students reported significantly more inattention and hyperactivity-impulsivity symptoms than students from the United States, and students from New Zealand reported more inattention symptoms than students from the United States. The prevalence of self-reported ADHD symptoms beyond DSM-IV thresholds for diagnosis ranged from 0% (Italian women) to 8.1% (New Zealand men). The implications of these results for the use of DSM-IV criteria in identifying university students with ADHD are discussed.

Psychoeducational interventions for children and adolescents with attention-deficit/hyperactivity disorder.

Children with attention-deficit/hyperactivity disorder (ADHD) are at risk for impaired functioning in most areas related to school success. Despite the benefits of psychostimulants and other medications to alleviate problem behaviors associated with ADHD, these therapies are unable to completely ameliorate behavior problems for all children with this disorder. Additionally, whereas pharmacologic therapies do impact behavioral functioning they have not been shown to improve academic achievement. Therefore, attention needs to be directed toward psychoeducational interventions and their ability to increase the successful functioning of children with ADHD. The purpose of this article is to highlight some of the most prominent and empirically validated classroom intervention strategies for children with ADHD. Additionally, this article discusses the importance of choosing psychoeducational interventions based on functional assessment data. Finally, this article describes progress monitoring strategies that should be used to determine the efficacy of intervention strategies.

Adolescent suicide prevention: acceptability of school-based programs among secondary school principals.

High school principals' acceptability ratings of three school-based programs for the prevention of adolescent suicide were examined. From a random sample of members from the 1994-1995 membership directory of the National Association of Secondary School Principals (NASSP), a total of 185 (40%) respondents completed the Suicide Prevention Program Rating Profile (SPPRP), a measure designed to evaluate the acceptability of suicide prevention programs, after reading a description of a particular prevention program. Programs evaluated for their acceptability included (1) curriculum-based programs presented to students, (2) in-service presentations to school staff, and (3) student self-report screening measures. The results indicated that the curriculum-based and staff in-service programs were significantly more acceptable to principals than was the schoolwide student screening program. No significant differences between the acceptability of curriculum-based and inservice programs were found. Limitations of the study and implications for practice and research are discussed.

Self-management as a strategy to improve the classroom behavior of adolescents with ADHD.

This article reports on the application of a self-management strategy for improving the classroom behavior of students with attention-deficit/hyperactivity disorder (ADHD). Based on the work of Rhode, Morgan, and Young (1983), the intervention focuses on teaching students to systematically rate their own behavior according to the rating of their teacher. Although, historically, self-management strategies based on cognitive control have not been found to be effective for students with ADHD, strategies based on contingency management have not been widely reported in the literature. A description of the intervention and two case study illustrations are provided. Potential limitations and implications for research in using this strategy are discussed.

Assessing culturally different students for attention deficit hyperactivity disorder using behavior rating scales.

Behavior rating scales are commonly used in the assessment of attention deficit-hyperactivity disorder (ADHD). However, there is little information available concerning the extent to which scales are valid with culturally different students. This study explored the use of the ADHD-IV Rating Scale School Version with male Caucasian (CA) and African American (AA) students from ages 5 to 18 years. Teachers rated AA students higher on all symptoms across all age groups. LISREL analysis indicated that scale does not perform identically across groups. This was supported by the results of multidimensional scaling with suggested that there is a different relation between items across groups. Implications for research and practice are discussed.

Classroom-based functional and adjunctive assessments: proactive approaches to intervention selection for adolescents with attention deficit hyperactivity disorder.

The present investigation evaluated the utility of classroom-based functional and adjunctive assessments of problem behaviors for 2 adolescents who met diagnostic criteria for attention deficit hyperactivity disorder (ADHD) and comorbid oppositional defiant disorder (ODD). For children with ADHD-ODD, environmental classroom variables, when systematically manipulated by teachers, were related to the occurrence and nonoccurrence of problem behaviors. Classroom interventions derived from information that was obtained during functional and adjunctive assessments and from subsequent analyses resulted in substantial reductions in problem behaviors. Teacher and student consumer satisfaction ratings indicated that the interventions were effective and feasible in the classroom setting.

Peer tutoring for children with attention deficit hyperactivity disorder: effects on classroom behavior and academic performance.

We investigated the effects of classwide peer tutoring (CWPT) on the classroom behavior and academic performance of students with attention deficit hyperactivity disorder (ADHD). Typical instructional activities were contrasted with CWPT for 18 children with ADHD and 10 peer comparison students attending first- through fifth-grade general education classes. CWPT led to increases in active engagement in academic tasks along with reductions in off-task behavior for most participants. Of students with ADHD, 50% exhibited improvements in academic performance in math or spelling during CWPT conditions, as measured by a treatment success index. Participating teachers and students reported a high level of satisfaction with intervention procedures. Our results suggest that peer tutoring appears to be an effective strategy for addressing the academic and behavioral difficulties associated with ADHD in general education settings.

Attention deficit disorder and methylphenidate: normalization rates, clinical effectiveness, and response prediction in 76 children.

OBJECTIVE: To evaluate the magnitude and clinical significance of methylphenidate (MPH) effects on the classroom behavior and academic performance of 76 children with attention deficit disorder/hyperactivity (ADDH). METHOD: A double-blind, placebo controlled, within-subject (crossover) experimental design was used to evaluate acute MPH effects at four dose levels (5 mg, 10 mg, 15 mg, and 20 mg) on children's attention, academic functioning, and behavior in regular classroom settings. Results were contrasted with a normal control sample. RESULTS: Standard statistical analysis revealed MPH effects on classroom functioning that were primarily linear. Analysis of the clinical significance of effects indicated that large proportions of treated children exhibited significantly improved or normalized classroom functioning; however, a large subset of them failed to show improved academic functioning. Overall, children failing to respond at lower dose levels have a high probability of improving or becoming normalized as a function of increasing dose. CONCLUSIONS: For a majority of children with ADDH, MPH results in significantly improved or normalized attention and classroom behavior. A significant subset, however, fail to realize gains in their academic functioning and will require supplemental interventions.

Response of children with ADHD to methylphenidate: interaction with internalizing symptoms.

OBJECTIVE: The purpose of this study was to examine differences in methylphenidate (MPH) response between groups of children with attention-deficit hyperactivity disorder (ADHD) who exhibited varying degrees of internalizing symptoms. METHOD: A sample of 40 children with ADHD was subdivided into three groups based on the severity of comorbid internalizing symptoms. Differential effects of three doses of MPH (5 mg, 10 mg, 15 mg) were evaluated in a double-blind, placebo-controlled fashion using multiple outcome measures across home, school, and clinic settings. RESULTS: Children with ADHD and comorbid internalizing symptoms were significantly less likely to respond positively to MPH than were their noninternalizing counterparts according to teacher ratings and behavioral observations during a clinic-based academic task. CONCLUSIONS: Children who exhibit comorbid symptoms of ADHD and internalizing disorder are less likely to respond to MPH in classroom settings and on academic tasks. A significant minority of children with comorbid conditions may be at a higher risk for an adverse medication response relative to patients with ADHD who are not exhibiting internalizing symptoms. Further research is necessary to delineate the characteristics of possible adverse responders.

Parent training for attention-deficit hyperactivity disorder: its impact on parent functioning.

This study examined changes in parent functioning resulting from parental participation in a behavioral parent training (PT) program specifically designed for school-aged children with attention-deficit hyperactivity disorder (ADHD). Relative to wait list controls, subjects who completed the nine-session PT program showed significant posttreatment gains in both child and parent functioning, which were maintained 2 months after treatment. In particular, there were PT-induced reductions in parenting stress and increases in parenting self-esteem, which accompanied parent-reported improvements in the overall severity of their child's ADHD symptoms. In addition to their statistical importance, these findings are discussed in terms of their clinical significance, utilizing methods developed by Jacobson and Truax (1991).

Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: a 3- to 5-year follow-up survey.

OBJECTIVE: To determine whether teenagers and young adults with attention deficit hyperactivity disorder (ADHD) have more motor vehicle citations and crashes and are more careless drivers than their normal peers. DESIGN: A comparison of two groups of teenagers and young adults (ADHD and normal) followed up 3 to 5 years after original diagnosis. SETTING: A university medical center clinic for ADHD patients. PATIENTS: Thirty-five subjects with ADHD and 36 control subjects between 16 and 22 years of age, all of whom were licensed drivers. MAIN OUTCOME MEASURES: Parent ratings of current symptoms of ADHD, oppositional defiant disorder, and conduct disorder, a survey of various negative driving outcomes, and a rating scale of driving behavior. RESULTS: Subjects with ADHD used less sound driving habits. This deficiency was associated with greater driving-related negative outcomes in all categories surveyed. Subjects with ADHD were more likely than control subjects to have had auto crashes, to have had more such crashes, to have more bodily injuries associated with such crashes, and to be at fault for more crashes than control subjects. They were also more likely to have received traffic citations and received more such citations than control subjects, particularly for speeding. The sub-group of teenagers with ADHD having greater comorbid oppositional defiant disorder and conduct disorder symptoms were at highest risk for such deficient driving skills/habits and negative driving-related outcomes. CONCLUSIONS: ADHD, and especially its association with oppositional defiant disorder/conduct disorder, is associated with substantially increased risks for driving among teenagers and young adults and worthy of attention when clinicians counsel such patients and their parents.

Does methylphenidate normalize the classroom performance of children with attention deficit disorder?

The present study examined the degree to which methylphenidate (MPH) normalized the classroom behavior and academic functioning of 31 children with attention deficit disorder (ADD). Subjects with ADD participated in a double-blind, placebo-controlled trial in which children received each of four doses (5, 10, 15, and 20 mg) of MPH and a placebo following baseline measures. Children with ADD were compared with a group of 25 normal control children on teacher ratings of social conduct, direct observations of on-task behavior, and academic efficiency. At a group level of analysis, MPH exerted a significant effect on classroom measures of attention and academic efficiency to a point where they were no longer statistically deviant from scores obtained by normal control children. Nevertheless, when examined at the individual level, 25% of the sample failed to show normalized levels of classroom performance, thus implying the need for ancillary school-based interventions.

Parenting stress among families of children with attention deficit hyperactivity disorder.

Prior research has shown that parenting stress levels can be quite high among families of children with attention deficit hyperactivity disorder (ADHD). This study investigated the degree to which such stress was related not only to the child's ADHD, but also to various other child, parent, and family-environment circumstances. Multimethod assessments were conducted on 104 clinic-referred children with ADHD. Data collected from these subjects were entered into hierarchical multiple-regression analyses, utilizing the Parenting Stress Index as the criterion. The results showed that the child and parent characteristics accounted for a substantial portion of the variance in overall parenting stress. The child's oppositional-defiant behavior and maternal psychopathology were especially potent predictors. The severity of the child's ADHD, the child's health status, and maternal health status also emerged as significant predictors. These findings are discussed in terms of their impact upon the clinical management of children with ADHD.

Frontal lobe functions in attention deficit disorder with and without hyperactivity: a review and research report.

We review 22 neuropsychological studies of frontal lobe functions in children with attention deficit disorder with and without hyperactivity (ADD/+H, ADD/-H). Some measures presumed to assess frontal lobe dysfunctions were not reliably sensitive to the deficits occurring in either form of ADD. Tests of response inhibition more reliably distinguished ADD/+H from normal children. Where impairments were found on other tests between ADD and normal subjects, they were highly inconsistent across studies and seemed strongly related to age of the subjects and possibly to the version of the test employed. Other methodological differences across studies further contributed to the discrepant (LD) and conduct problems, with ADD may be an additional confounding factor in some, though not all, of these studies. In a separate reports. The co-morbidity of other disorders, such as learning disabilities (LD) and conduct problems, with ADD may be an additional confounding factor in some, though not all, of these studies. In a separate study, children with ADD/+H (n = 12) were then compared on frontal lobe tests to three other groups: ADD/-H (n = 12), LD but no ADD (n = 11), and normal children (n = 12) statistically covarying for differences in conduct problems across groups. Most measures did not distinguish among these groups. Both ADD groups made more omission errors on a Continuous Performance Test (CPT) than the normal group. All three clinical groups performed more poorly on the word and interference portions of the Stroop Test. Thus, while both types of ADD share some apparent similarities in deficits on a few frontal lobe tests in this study, the totality of existing findings suggests an additional problem with perceptual-motor speed and processing in the ADD/-H group.

Stimulant medication and parent training therapies for attention deficit-hyperactivity disorder.

The present article provides a brief overview of the clinical use of two of the most commonly used and effective therapies for Attention Deficit-Hyperactivity Disorder (ADHD) in children: stimulant medication treatment and training parents in child behavior management skills. The clinical issues involved in the use of each treatment, as well as their limitations, are reviewed, along with evidence for their efficacy. It is concluded that ADHD is a developmental disorder of attention, impulse control, and regulation of activity level that requires multiple treatment methods, which must be applied over long time intervals if they are to produce an impact on the outcome of children with ADHD.

Attention deficit disorder with and without hyperactivity: clinical response to three dose levels of methylphenidate.

The response of 23 children with attention deficit disorder (ADD) with hyperactivity (+H) and 17 children with ADD without hyperactivity (-H) to three doses of methylphenidate (5, 10, and 15 mg twice a day) was evaluated in a triple-blind, placebo-controlled cross-over design using parent and teacher ratings of behavior, laboratory tests of ADD symptoms, and behavioral observations during academic performance. Results indicated that the children with ADD+H were rated as having more pervasive behavioral problems at home and more pervasive and severe conduct problems at school than the children with ADD-H. Laboratory tests found the children with ADD+H to be impaired in behavioral inhibition and vigilance whereas children with ADD-H were more impaired in the consistent retrieval of verbally learned material Drug effects were noted on the parent and teacher ratings and on most laboratory measures, with all three doses typically producing significant changes but rarely differing among themselves in effectiveness. The groups were not found to differ significantly on any measures in their response to methylphenidate. However, more children with ADD-H were clinically judged as having either no clinical response (24%) or responding best to the low dose (35%) of medication. In contrast, most ADD+H (95%) children were judged to be positive responders and most were recommended to receive the moderate to high dose (71%).

Comprehensive evaluation of attention deficit disorder with and without hyperactivity as defined by research criteria.

Children with attention deficit disorder with hyperactivity (ADD+H; N = 48) were compared with those without hyperactivity (ADD-H; N = 42), as well as with learning disabled and control children, on an extensive battery of interviews, behavior ratings, tests, and direct observations. ADD+H children had more externalizing and internalizing symptoms by parent and teacher report, were more off task during vigilance testing, and had more substance abuse, ADD+H, and aggression among their relatives than did the other groups. ADD-H children were more day-dreamy and lethargic by teacher report, more impaired in perceptual-motor speed, and had more anxiety disorders among their relatives than did ADD+H children. Results indicate that these 2 types of ADD may be separate, distinct childhood disorders rather than subtypes of a common attention deficit.

Attention deficit disorder with hyperactivity and methylphenidate: the effects of dose and mastery level on children's learning performance.

This investigation examined the relationship between methylphenidate (MPH) and the learning and recall of paired associations by children with attention deficit disorder with hyperactivity (ADDH). Forty-five children with ADDH were randomly assigned to one of three groups (novel, partial mastery, and mastery learning) that varied in the amount of previous learning of paired associations and participated in a double-blind, placebo-control, repeated-measures-across-dose (crossover) design. Each child received four doses of MPH (5 mg, 10 mg, 15 mg, and 20 mg) and a placebo in a random, counterbalanced sequence. The results indicated that both the rate of acquisition and accuracy in learning paired associations were significantly, but differentially, affected by MPH dose and the degree of learning mastery. The implications of these results for psychopharmacological research and the monitoring of psychostimulant effects on children's learning performance in academic settings are discussed.