Children with Attention Deficit Hyperactivity Disorder

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Children with Attention DeficitHyperactivity DisorderGeorge M. Batsche a & Howard M. Knoff aa University of South Florida , USAPublished online: 20 Oct 2008.

To cite this article: George M. Batsche & Howard M. Knoff (1995) Children withAttention Deficit Hyperactivity Disorder, Special Services in the Schools, 9:1, 69-95,DOI: 10.1300/J008v09n01_04

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Children with Attention Deficit Hyperactivity Disorder:

A' Research Review with Assessment and Intervention

Implications for Schools and Families

George M. Batsche Howard M. Knoff

University of South Florida

ABSTRACT. It is estimated that there have been over 4,000 articles in the literature on the subject of attentional problems, addressing its etiology, epidemiology, assessment, diagnosis, and treatment. This article reviews recent and relevant literature with an eye toward functional conclusions and linkages between assessment and intervention. The article concludes by providing a problem-solving model that integrates parent or teachers' referral concerns, reasons for these concerns, assessment methods, and intervention strategies. In the end, four definitive conclusions are drawn, and the importance of multirnodal strategies that collaboratively involve home, school, and community settings is emphasized.

Overactivity, impulsivity, and difficulty with sustained attention are characteristics of children who are of increasing concern to parents and teachers. These children often are labeled as having some type of "attention deficit disorder." The disorder has been identified through a number of labels, including "attention deficit," "attention

Address correspondence to: Dr. George M. Batsche, School Psychology Ro- gram, Department of Psychological Foundations, FA0 IOOU, Room 268, Univer- sity of South Florida. Tampa, FL 33620-7750.

Special Services in the Schools, Vol. 9(1) 1994 O 1994 by The Haworth Ress, Inc. All rights reserved. 69

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70 SPECIAL SERVICES IN THE SCHOOLS

deficit disorder" with (ADDlW) or without (ADDPO) hyperactivity (APA, 1980), "hyperactivity" or "hyperkinetic reaction" (Schaughency & Hynd, 1989), and/or "attention deficit hyperactivity disorder" (ADHD, APA, 1987). A variety of professionals are in- volved with the diagnosis and treatment/intervention of these children, including physicians, psychologists, mental health workers, nurses, educators, and parents. The definition of the disorder has changed over time, presenting a dilemma for professionals trying to a 5 on the presence or absence of the disorder and the appropriate methods of treatment. To add to the confusion, the disorder is identified differently based upon the setting in which the child is seen (e.g., medical, mental health, school). Regardless of the label, however, the characteristics of this disorder have been of concern to the parents, teachers, and other educators who interact with these children in home and school settings, respectively.

It is estimated that there have been over 4,000 articles in the Literature on the subject of attentional problems, addressing its etiology, epidemiology, assessment, diagnosis, and treatment (Barkley, 1990). Although these articles deal with a wide range of subjects, parents and teachers are most interested in how to provide develop- mentally appropriate and effective interventions that improve the social and academic progms of children with mention problems. Recently, anticipated Eha&es in psychiatric and educationd diagnostic systems have concentrated efforts to defme more clearlv the char- actehstics, assessment procedures, and intervention systems for children with attention disorders. Although it is not possible to review all of the research generated on the topic, this article will focus on recent and relevant developments related to the nature of the disorder, its assessment and classification in mental health and school settings, the cumnt dilemma in educational settings regarding who is eligible for services, and interventions of note. Throughout this article, the term "attention deficit hyperactivity disorder" (ADHD) will be used to represent the varied labels the disorder has been given.

NATURE AND CHARACTERISTICS

ADHD is one of the most frequent referral reasons (as high as 50%) cited in the intake reports of children seen by mental health

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George M. Bafsche and Howard M. Knoff 71

clinics in the United States (Frick & Lahey, 1991). The most widely used definition of the disorder (Table 1) is the one provided in the "

Diagnostic and Statistical Manual of the American Psychiatric Association, 3rd Edition Revised (APA, ,1987). There is general agreement that the essential features of ADHD include inappropriate levels of inattention, impulsivity, and motor hyperactivity for the given ageor developmental level of the child (Frick & Lahey, 1991). Significantly, Barkley (1990) cites deficiencies in the "regulation and maintenance of behavior by rules and consequences" (p. 71) as the primary problem that gives rise to diffkulties with inattention, impulsivity, and motor activity. Using this paradigm, the primary difference between children with and without ADHD may not be in the area of attention, but rather, in how the child regulates his or her behavior through the consequences of inatten- tive behavior. Because we do not yet conclusively h o w which problems (attention and/or regulation) are the primary symptoms in ADHD students, a current "best practices" approach is to address all of the symptoms when planning comprehensive interventions for these children (Frick & Lahey, 1991).

The incidence estimates of ADHD for the general population are placed at five to six percent of children and youth from ages 4 to 16. The male-female differences range from a ratio of 6:l (male to female) for clinic referrals (Barkley, 1990) to a 3:l ratio for non-referred children (Szatmari et al., 1989). However, recent research suggests that the frequency of inattention in girls is as frequent as in boys (McGee, Williams, & Silva, 1987), but that girls may go relatively unnoticed because they demonstrate fewer symptoms of hyperactivity and aggression than their male counterparts (Berry, Shaywitz, & Shaywitz, 1985). As with any disorder, the incidence figures vary according to the definition of the disorder and the methods of evaluating the presence or absence of the symptoms. However, these incidence figures are generally agreed upon at the

. . present time.

Currently, most investigators (Barkley, 1990) endorse a biological predisposition to ADHD in which hereditary factors play the largest role. Hynd, Hem, Voeller, and Marshall (1991) cite evidence from genetic, biochemical, neurobehavioral, and neuroimaging studies that suggests a neurological basis for this disorder in most

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TABLE 1. DSM-Ill-R Criteria for Attention Deficit Hyperactivity Disorder.

A. A disturbance of at least 6 months during which at least 8 of the following are present:

1.

2. 3. 4. 5. 6.

7. 8. 9.

10. 11.

12. 13.

14.

Note

Often fidgets with hands or feet or squirms in seat (in adolescents may be limited to subjective feelings of restlessness) Has difficulty remaining seated when required to do so Is easily distracted by extraneous stimuli Has difficulty awaiting turn in game or group, situations Often blurts out answers to questions before they have been completed Has difficulty following through on instructions from others (not due to oppositional behavior or failure of comprehension), for example, fails to finish chores Has difficulty sustaining attention in tasks or play act~aies Often shifts from one uncompleted activity to another Has difficuhy playing quietly Often talks excessively Often interrupts or intrudes on others, for example, buns into other children's games Often does not seem to listen to what is being said to him or her Often loses things necessary for tasks or adivities at school or at home (e.g., toys, pencils, books, assignments) Often engages in physically dangerous activities without mnsidering possible consequences (not for purpose of thrill-seeking), for example, runs into street without looking

The above items are listed in descending order of discriminating power based on data from a national field trial of the DSM-Ill-R criteria for Disruptive Behavior Disorders.

B. Onset before the age of seven

C. Does not meet the criteria for Pervasive Developmental Disorder

Note: Considera criterion met only if the behavior is awrsiderably more frequent than that of most people of the same mental we. From the agnostic and S f a t i s ~ l h n w l lor Mental Disorders (3d ed.. fee). 1987. Washinglon DC: American Psychiatric Assodation.

children. Although. some specific environmental factors such as lead poisoning have been associated with ADHD (Rummo, Routh, Rumrno, & Brown, 1979), there is little evidence to suggest that only social or environmental factors, including diet (Bieman & Furukawa, 1978) and food additives (Wender, 1984), are responsi- ble for the symptoms of ADHD (Barkley, 1990).

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George M. Batsche and Howard M. Knoff 73

An issue that continues to attract controversy in the literature is whether there is one type of attention deficit disorder (unidimensional) or two types-attention deficit disorder with and without hyperactivity (multidimensional). The DSM-III-R provides a "unidimensional" definition that represents the disorder as having components of impulsivity, problems with sustained attention, and/or excessive motor activity (APA; 1987). However, prior to the most recent revision of the DSM, the disorder was labeled "attention deficit disorder" with (ADD/%') and without (ADD/W/O) hyperactivity (APA, 1980). Critically, the DSM-Ill recognized that impulsivity and difficulty with sustained attention might occur in the absence of excessive motor behavior. Clearly, those children with excessive motor behavior are going to come to the attention of parents, relatives, educators, and ultimately, mental health workers because of the social effects of the hyperactivity. Children who have difficulties with sustained attention and impulsivity in the absence of motor excesses, however, are more "tolerable" and may go unnoticed.

There is a significant amount of evidence to support a multidimensional view of ADHD. First, factor analytic studies of behavior rating scales consistently identify two "groups" of children-those who demonstrate impulsivity and difficulties with sustained attention with motor excess and without motor excess, respectively (Lahey, et al., 1988). Second, the clinical characteristics of these two groups support a multidimensional view. Children who are identified as ADHD with hyperactivity have: (a) more conduct problems; (b) greater amounts of impulsivity and distractibility; and (c) are more socially rejected (Landau & Moore, 1991). Children who are identified as ADHD without the hyperactivity are more: (a) anxious; (b) shy; (c) sluggish and drowsy; and (d) Likely to daydream (Lahey et al., 1987; Neeper et al., 1990). Third, DuPaul, Barkley, and McMurray (1991) suggest that there are qualitative differences in cognitive processing between the two groups.

Recognizing that there are two distinct groups of students with attention disorders has its greatest implication in the area of interventions. When only students with attention disorders with hyperactivity are recognized, then access to services for the non-hyperactive group become limited or nonexistent and a significant number

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of children may be more vulnerable to resulting academic and social delays. Aside from these functional home and school implications, a subtle gender bias, relative to service delivery, may also result. Indeed, significantly more males manifest the symptoms of hyperactivity and aggression than do females, and significantly more males than females are actually identified (Barkley, 1990; Szatmari et al., 1989).

DEVELOPMENTAL COURSE AND FAMILY ISSUES

The behaviors associated with ADHD modify over time. These changes are important to understand because accurate identification is based on a clear defmition of the. disorder at different developmental levels. Teeter (1991) has provided an excellent summation of the developmental course of ADHD. The changes in the behavior of ADHD children over time is a function of both biological maturation and the different settings (home, community, school, voca- tional) in which the child functions. Most importantly, however, is the interaction effect described by Barkley (1981, 1990) between the child with ADHD and significant adults (parents, caregivers, teachers). The effects of that interaction often are negative, involving noncompliance and resistance by the child and increased stress and frustration by the adult. In addition, the effects of the behaviors associated with ADHD place the child at-risk for delayed academic and social development. These delays result when parents and teachers assume that the child is refusing to perform a task (performance deficit) and consequate it, rather than being unable to do the task (skill deficit) and functionally correcting it. Experientially, the frushation level of parents and teachers is significantly greater when they perceive the problem' as a performance rather than a skill deficit. Therefore, the nature of the problem (skill vs. performance) combined with the reaction to the problem affects how the solution to the problem is developed and what it focuses on.

In infancy, the most common characteristics of ADHD children include excessive crying and irritability, low levels of responsive- ness, difficulty with being soothed, and eating/sleeping problems (Campbell, Szumowski, Ewing, Gluck, & Breux, 1982; Weiss & Hechtman, 1986; Wender, 1987). During toddlerhood and pre-

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George M. Balsche and Howard M . Knoff 75

school years, noncompliance, high activity levels, inattention, and restlessness (Campbell, 1990, Palfrey, Levine, Walker, & Sullivan, 1985) predominate. ADHD children who demonstrate aggressive behavior begin to experience rejection by peers (Pelham & Bender, 1982) and the number of referrals for hyperactivity increase as the demands on the child (via adult commands and directions) increase (Weiss & Hechtman, 1986). However, Campbell's (1990) research has demonstrated that the majority of these behaviors decrease significantly within three to six months and that only 50% of the children who are severe enough to receive a diagnosis of ADHD during preschool years will have the same diagnosis by later childhood or early adolescence. In fact, Campbell demonstrated that, in a sample of difficult-to-manage three-year-olds, only those who maintained ADHD symptoms at age four were likely to demonstrate hyperactivity and conduct problems by ages six and nine years. Critically, Barkley (1990) cautions that both the severity and duration of symptoms must be taken into consideration during diagnosis, and he recommends that 12 months is a useful lennh of time when tracking the duration of symptoms and making di&oses.

During earlv and middle childhood. the behaviors associated with ADHD &e most likely to be seen'in difficulties with school tasks, social skills deficits, noncompliance and oppositional behavior, aggression, and risk-taking or dangerous behaviors (Barkley, 1989; Campbell, 1990; Landau & Moore, 1991; Swanson & Ma- lone, 1992; Wender, 1987; Whalen & Henker, 1985). During this time-period, referrals p r e d o h a t e in school settings, and the stress on families is increased by the verbalized concerns of educators. In adolescence, these problems persist and expand as the student with ADHD is at-risk for conflicts with adults over rules in both home and school, interpersonal problems with peers, academic problems in settings where there is little individual attention, restlessness and distractibility, and suspension or school drop-out (Barkley, 1989, 1990; Taylor, 1986; Wender, 1987).

It is clear that the symptoms of ADHD continue'over t i e and modify according to environmental factors and settings. The developmental course of ADHD is affected by the reaction of others to the behaviors of the ADHD child. The most profound effects on parents, caregivers, and teachers are increased frustration and

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stress. Indeed, researchers have identifled high stress levels, less frequent interactions, more commands, higher frequency of negative interactions, and less affection toward the child as characteristics of the parents of ADHD children (Barkley, 1990, Danforth, Barkley, & Stokes, 1991; Mash & Johnston, 1983). While Barkley (1985) concluded that parental stress was at its height when the child is between three &d six years of age, it must be noted that these parental reactions are responses to the behaviors exhibited by ADHD children-the reactions are not causing these child behaviors.

Although there are numerous studies that have identified characteristics of parents of ADHD children, there has been very little systematic investigation of the teacher-student interaction. While teachers of ADHD children are more interactive with these students, they also are more commanding and negative (Campbell, Endman, & Bemfield, 1977). The results of both parental and teacher studies suggest that the behaviors of ADHD children affect adults similarly in both school and home settings. From an intervention perspective, similar management skills are needed, once again, in both settings.

ASSESSMENT AND CLASSIFICATION

The purpose of assessment is to collect data in such a way as to develop effective interventions (Knoff & Batsche, 1991; Shapiro Kc Lentz, 1985). As part of this process, a "label" or diagnosis often is. applied to a child that can (a) open access to an environment (e.g., special education, pre-school program) in which interventions can be implemented, and/or, from a medical standpoint, (b) permit appropriate medical (e.g., medication) intervention. In either case, the process of conducting assessment is very important. Because assessment is critical to the availability of interventions and treatment, the process by which it is conducted has received a great deal of attention.

Technically, ADHD is a psychiatric diagnosis with no equivalent label in any educational diagnostic system (Teeter, 1991). The DSM-III-R is the most commonly used diagnostic system for childhood disorders at the present time and provides criteria for the diagnosis of ADHD. An accurate diagnosis of ADHD requires the

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George M . Batsche and Howard M . Knoff 77

documentation of the existence of certain overt behaviors and, therefore, can be identified as a "behavioral diagnosis." Over the years, there have been a number of labels assigned to the pattern of behavior currently identified as ADHD, each of which has its own criteiia for the types of behaviors that must be present in order to "qualify" for the diagnosis. These range from Minimal Brain Dys- function (MBD), "hyperactivity," "hyperkinetic reaction," and "attention deficit disorder," to the current "attention deficit hyperactivity disorder" (APA, 1968, 1980, 1987; Schaughency & Hynd, 1989). New labels and definitions sometimes result in changes af- fecting who is eligible for the diagnosis, the methods of assessment, and the availability and even implementation of interventions and services. Accurate diagnoses of ADHD, as evidenced by satisfacto- ry levels of agreement between independent evaluators, has been a problem in the field for two reasons. First, the behaviors that define ADHD are not always consistent across settings and diagnostic criteria Second, the methods of collecting information necessary for identification are not free of error.

Researchers have addressed the effects of the different defmi- tions on the incidence rates of ADHD and the extent to which children retain diagnoses of attention deficit disorder across different labels and definitions. Lahey et al. (1990) compared the diagnostic criteria of DSM-Ill-R (ADHD) with that of DSM-III (ADD/H) and found that more children met the former definition than the latter. In addition, they found a strong overlap between the number of children who met the defmition of ADD W/O and those who met the criteria for ADHD.Newcom et al. (1989) conducted a similar study and also found that a greater number of children met the criteria for ADHD than met the criteria for ADD/H. The results of these studies suggest that both a greater number of children and those with a wider range of behavioral symptoms would be identified using the ADHD definition. Therefore, how ADHD is opera- tionalized (i.e., as a unidimensional or a multidimensional condition) impacts who is eligible for services and, ultimately, the breadth of possible services required. Clearly, the issue of whether or not hyperactivity is a necessary prerequisite for a diagnosis must be resolved across medical, mental health, and educational settings.

Behavioral assessment is the method by which children with

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ADHD are identified and diagnosed. The method uses multiple informants and a variety of different procedures, including review of records, interviews, observations, and testing (Mash & Terdal, 1988). This "multimethod" approach provides the opportunity to determine the consistency of a child's behavior, as perceived by multiple individuals across multiple settings. In addition, it allows comparisons of the data collected through a variety of methods, thereby increasing the incremental validity of the diagnosis. Criti- cally, the accuracy and the consistency of results across informants and methods is directly related to the level of confidence in the final diagnosis. Thus, the influence exerted by a single individual or method should be minimized, and a confluence of positive indica- tors should predominate.

The clinical interview is the most frequently used component in the assessment process. Relative to this, the most recent research suggests that inter-evaluator reliability is enhanced by using a structured or semi-structured interview format rather than an informal one (Gutterman, O'Brien, & Young, 1987). Currently, a number of interview schedules are available that incorporate the DSM criteria for ADHD. Examples include the Diagnostic Interview Schedule for Children (DISCDISC-P; Costello, Edelbrock, & Costello, 1985) and the Diagnostic Interview for Children and Adolescents (DICADICA-P; Weiner, Reich, He janic, Jund, & Amado, 1987). The use of these procedures permits a more systematic, standard- ized method of obtaining information that typically reduces the perceptual variance between evaluators ( ~ u t t ~ r m a n et al., 1987). However, the majority of these procedures use the DSM-111 criteria for ADD/H rather than the more recent DSM-Ill-R (ADHD) criteria (Schaughency & Rothlind, 1991).

The extent to which structured interview procedures correctly identify children with ADHD has been examined by Weiner et al. (1987) and Carlson, Kashani, de Fatima Thomas, Valdya, and Dan- iel (1987). These studies concluded that these interview procedures had moderate reliability (Weiner et al., 1987) and high levels of agreement between the results of the interview procedures used and previously assigned labels of ADHD. However, when compared to a diagnostic summary, the use of the structured interview scales alone resulted in a higher number of children identified as ADHD

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George M. Batsche ond Howard M. Knof 79

(Carlson et'al., 1987; Weiner et al., 1987). Thus, diagnostic interviews appear to be clinically sensitive, but they may result in over- diagnoses (i.e., false positive decisions) when used in isolation. Interview schedules should be used within the context of a multimethod assessment approach; they should not be used in isolation.

Observational methods of data collection offer both advantages and disadvantages over other procedures. The advantages are that the child can be observed in natural settings (home, school), more objective information can be obtained, and more direct information, not available through interview and rating scale methods, can be collected (Barkley, 1990; Shaywitz & Shaywitz, 1988). The primary disadvantages'of observational methods are that access to the natural environment may be difficult at times, a "new" observer may change the behavioral ecology and thus the behavioral reactiv- ity of the target child (and others), and ultimately, the sample of behavior observed may not be representative of the best or worst behavior of the child. In the end, behavioral observation is highly dependent on the integrity of the observation system and protocol used, and on the quality of observer training and follow-through to maximize the accuracy and minimize the bias of the behavior viewed (Kazdin, 1994). In the fmal analysis, the reliability, validity, and cost- and time-effectiveness of behavioral observation, as con- trasted with other assessment approaches, must be weighed against its potential to provide objective low-inference data.

currently, behavior observation protocols have been developed to assess: (a) the child -directly (e.g., Alessi & Kaye, 1983; Madsen & Madsen, 1974); (b) child-parent interactions (Barkley, 1987); and (c) child-teacher interactions (Madsen & Madsen, 1974). Another behavior observation protocol (Achenbach, 1986) has been developed where a referred child is observed in the classroom, and then a behavior rating scale is completed based on the observations. The direct observation behavior protocols noted above are highly useful in the confirmation of behavioral data collected during parent or teacher interviews, and they can be used in the identification of behavioral contingencies in the environment and in generating possible intervention directions. The Achenbach approach is interest- ing, but it is largely untested and requires additional validating research. It is more inferential in nature, and it requires good clini-

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cal skills and judgment on the part of the observers in order to be effective. Clearly, observational procedures add a unique and important dimension to the assessment of children's attentional problems. However, as with the other methods, observational procedures should not be used in isolation (Barkley, 1990), and their strengths and weaknesses should be considered as part of the diagnostic process.

Critically, when contrasting direct observation and indirect observation (i.e., via behavior rating scales), there is a greater level of agreement between two different rating scales completed on a sin' gle child than between a rating scale and an observation of that child. Behavior rating scales are used extensively in the assessment of children with ADHD. Behavior rating scales present a number of advantages. For example, they (a) m cost effective (Young, O'Brim, Gutterman, & Cohen, 1987); (b) provide a convenient way to com- bine information about a child from different settings and informants; (c) assess aspects of chid behavior that are difficult to obtain through other procedures, while providing normative data based upon age, gender, setting, and informant; and (d) provide a prelpost method of evaluating the effects of interventions.

Among the disadvantages of rating scales are the fact that they: (a) represent the perceptions of raters and share the biases inherent in those perceptions; (b) fail to assess events that occur before and after the problem behavior occurs; and (c) have the potential to misidentify a student as ADHD due to the presence of conduct problems (Schaughency, Frick, Christ, Neeper, & Lahey, 1990). Rating scales rely on the perceptions of parents, teachers, significant adults, and the child him or herself across home, school, and testing environments. Although high correlations exist between different scales rated by the same informant, lower agreement is noted between raters, particularly between parents and teachers (Barkley, 1990). While this may be a function of the child demonstrating different behaviors across settings, based upon the demands of the setting, it also may be due to respondent tolerance, support, intervention skill, and chid outcomes. In addition to respondent characteristics, the presence of conduct problems may artificially inflate behavioral ratings due to the overlap of questions on scales that measure these seemingly different dimensions (Goyette, Comers, &

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George M. Barsche and Howard M. Knofl 81

Ulrich, 1978). Indeed, on the Revised Behavior Problem Checklist (Quay & Peterson, 1987). the Conduct Disorder scale correlates .52 with the Motor Excess scale and .51 with the Attention Roblems- Immaturity scale.

As with other assessment ~~@ods, rating scales should not be used alone. Critically, given the assumption that rating scales are completed most often when a pmnt and/or teacher perceives an attentional problem with a child, using only rating scales for the assessment likely will result in the overidentification of ADHD children.

In summary, current research supports a multi-method, multi-setting, multi-rater approach to the assessment of children with ADHD. Although differences may exist in the behavior of children across settings, results generally converge around issues of impulsivity, difficulty with attention, difficulties with rule-governed behavior, andlor motor excess behaviors. Schaughency and Rothlind (1991) present an excellent model for diagnosing ADHD children, emphasizing the multimethod assessment process. Their model is based upon the DSM system and focuses on four basic questions using the assessment methods cited in this article. The four questions to be answered are: (1) Does the child meet the DSM-III-R diagnostic criteria? (2) Does an alternative diagnosis account for the problem behavior? (3) Are the behaviors displayed to a develop- mentally inappropriate extent? and (4) Do the behaviors significantly interfere with the child'ssocial, academic, or home functioning? Answering these questions using a multimethod assessment process should result in higher levels of reliability and validity in the identification of children with ADHD, and less inference as assessment is linked to intervention and treatment programs are developed.

THE EDUCATIONAL DILEMMA

The behaviors that comprise ADHD often are inconsistent with a child's successful adaptation and performance in school. Infact, it is not uncommon for ADHD children to experience their first "failure" experience in school despite the fact that many of them 'al- ready have demonstrated such behavioral difficulties at home as noncompliance, verbal and physical aggression, and the inability to stick to a task. While lower levels of aggression typically occur at

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school, all of these behaviors are less tolerated by both teachers and peers. Indeed, teachers often are frustrated by the amount of time it takes to "manage" children with ADHD, and by the delayed academic progress of these students. While parents and teachers share the same desire for effective interventions, when school officials call parents with reports of their child's academic and social problems, the stress on the family increases significantly.

Relative to services, students with academic and social difficulties in public school settings have been limited to special education placements and the services of pupil support teams (school psychologists, counselors, social workers). However, in order to access the special education system, a student must be identified as disabled according to state criteria that are based on the federal Individual with Disabilities Education Act (IDEA). For children with ADHD, this has historically meant that, in order to qualify for special education services, the effects of the ADHD have been manifested pri- marily as a learning disability or a severe emotional disturbance. Although approximately 30% of ADHD students demonstrate a learning disability (Barkley, 1990) and up to 45% of ADHD children meet the DSM criteria for Oppositional Defiant Disorder and Conduct Disorder, it is estimated that only 35% of students with ADHD actually are receiving special education services in the public schools (Barkley, 1990).

Critically, there is no educational diagnosis that parallels the DSM diagnosis of ADHD. Therefore, children with ADHD must meet criteria for another category in order to receive special education services. While there have been attempts over the years create a diagnostic category for ADHD in the IDEA legislation, these have been unsuccessful. Recently, however, as a result of the combined efforts of a number of professional organizations and parent groups (e.g., Children with Attention Deficits, CHADD), the United States Department of Education issued a policy memo addressing the needs of ADHD children in the public schools (U.S. Department of Education, Office of Special Education Programs. September 16, 1991). This memo outlined a number of avenues through which ADHD students might receive services. These include: (a) meeting one of the diagnostic criteria set forth in the IDEA; (b) qualifying for services as a "handicapped person" under Section 504 of the

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George M. Balsche and Howard M. Knoff 83

Rehabilitation Act of 1973 where elementary and secondary education programs must address the needs of children who have a physical or mental impairment that limits one or more of their major life activities (i.e., learning); and (c) receiving services as state and local educational agencies train regular education teachers and other personnel to adapt regular education programs to address the needs of students with ADHD. In essence, this memo identified ADHD as a disorder that threatens educational progress and provided a number of avenues (through special education or regular education) for intervention. The memo reinforced the concept that intervention for children with ADHD is a joint responsibility between regular and special education, and that adaptations to regular education programs are necessary components of treatment. Although education, whether in the schools or in Washington, D.C., has not fully resolved the issue of assessment and diagnosis, an emphasis on interventions, implemented jointly and preventively by home and school, offers the best hope for ADHD children.

INTERVENTIONS

While ADHD is a condition that has neurological or organic. origins, its manifestations are affected by maturation and external environmental conditions. Significantly, the characteristics and developmental course of ADHD clearly require a comprehensive, multi-modal approach to intervention that must begin early in the development of the child. Such a comprehensive, multi-modal ap- 'proach to intervention includes consideration of the following components: medication, parent training, behavioral and social skills training in school, and academic strategies (Whalen, 1991). In the end, the specific intervention must continue until the child's symptoms or outcomes moderate to such a degree that they no longer interfere significantly with academic, social, and voca- tional &ks.

The use of psychostimulant medication is the most frequent treatment for ADHD children, with methylphenidate (MPH, Ritalin) being the prescription of choice in over 90% of the children receiving medication (Safer & Krager, 1988). Although alternative med- ications (tricyclic antidepressants, clonidine, and M A 0 inhibitors)

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are used in the treatment of ADHD, their effects are less well understood (DuPaul, Barkley, & McMurray, 1991). However, it has been demonstrated that the effects of stimulant medication are enhanced when medication is used in combination with behavioral interventions and parent training (Barkley, 1990; Gittelman-Klein et al., 1980). Stimulant medication has itsgreatest effect on improving sustained attention to tasks (Barkley, 1990), inhibiting impulsivity (Rapport et al., 1987), reducing task irrelevant movements (Cun- ningham & Barkley, 1979). and reducing disruptive and noncompliant behavior (Barkley, Karlsson, Strezelecki, & Murphy, 1984). In addition, the effects of medication on improving children's expecta- tions for success (Whalen, Henker, Hinshaw, & Heller, 1991) and on modifying their attributions regarding reasons for failure and success -(Milich, Carlson, Pelharn, & Licht, 1991) have been evaluated. Although early studies indicated that academic performance was not significantly improved through the use of stimulant medication (Barkley & Cunningham, 1978), more recent studies have indicated that academic productivity and accuracy may be improved (Rapport et al., 1987, 1988). The relationship between productivity, accuracy, and traditional measures of achievement (e.g., grades and test scores), however, has not been clearly established. DuPaul, Barkley, and McMurray (1991) suggest that both academic success as well as behavioral control should be considered when selecting a medication dosage. Thus, the methods used to evaluate the outcomes of medication should include measures of sustained attention to task, compliance, academic productivity, and academic accuracy.

Parent training is a critical component in the comprehensive intervention process for ADHD children for a number of reasons. First, parents are one of the few constants in their child's life. Second, as their child's first "teacher," parents can begin the training process early in the developmental process. Regardless, because some ADHD children's behaviors are very intense, making it difficult for both parent and child in social and other situations, most parents welcome assistance with the academic and behavioral needs of their ADHD child. This assistance may provide parents access to skill-training sessions, as well as opportunities to share their concerns and frustrations with other parents of ADHD children. Parent

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George M. Balsche and Howard M. Knoff 85

training programs try to help parents: (a) to develop an understanding for the causes of their child's behavioral problems; (b) to identify and manage the family stress resulting from these problems; (c) to deal with noncompliance while teaching compliance; and (d) to increase the quality of adultchild interactions. The majority of parent training programs use procedures that employ reinforcement, punishment, skill training, and communication strategies. Numer- ous studies have demonstrated the efficacy of parent training in general (Barkley, 1981, 1990), with preschool children (Blackman, Westervelt, Stevenson, & Welch, 1991; Erhardt & Baker, 1990; Pisterman, McGrath, Fiestone, & Goodman, 1989; Strayhorn & Weidman, 1991) and in a group format (Barkley. 1986). The re.sults of these and other studies reinforce the importance of parent training as part of the intervention process.

The use of behavioral interventions and social skills training, particularly in the school setting, are essential components .of an intervention program. In general, interventions for ADHD children have focused on operant principles as applied to school settings (Kazdin, 1994; Rosen, O'Leary, Joyce, Conway, & Pfiffner, 1984). Although previous studies have emphasized the importance of both praise and reprimands in the control of behavior (Madsen, Becker, & Thomas, 1968), recent research has indicated that the strategic use of reprimands is more effective in controlling the behavior of ADHD students. More specifically, the most effective reprimands are those that are immediate (Abramowitz, O'Leary, & Futtersak, 1988; Rosen et al., 1984). short in duration; given in a calm, fm manner, and given with eye contact and in close proximity to the child (Van Houten, Nau, MacKenzie-Keating, Sameoto, & Cola- vecchia, 1982). Abramowitz and O'Leary (1991) concluded that the most important factor may be giving the reprimand immediately to the child. Although research has suggested that adding praise to reprimands does not increase on-task behavior (Acker & O'Leary, 1987). the effects of a "reprimand only" approach on self-esteem have not been adequately investigated. Common sense would suggest that praise and reprimands should be combined in order to insure the maintenance of both behavioral control and self-esteem.

Additional behavioral interventions such as token reinforcement systems (Pfiffner & O'Leary, 1987), group contingencies involving

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peer attention (Shapiro& Goldberg, 1990), and time-out from positive reinforcement (Branmer & Doherty, 1983) also have been used with ADHD students. The impact of these general behavioral interventions with ADHD children has been limited, and a sigruficant research base with ADHD c h i l d c m t l y does not exist (Landau & Moore, 1991). Cognitive behavior modification using self-instruc- tional strategies and self-evaluation procedures has been combined with behavioral interventions such as positive reinforcement and time-out. The long-term effects of these procedures also have yet to be documented (Whalen, Henker, & Hinshaw, 1985). although reinforced self-monitoring and self-reinforcement appear to increase the success of these behavioral interventions. Finally, the use of social skills training programs is becoming increasingly popular, and a number of curricula are available that teach a wide range of prosocial skills. However, the specific utility of these programs with ADHD students has yet to be demonstrated.

Another intervention area for ADHD children involves the cre- ation of academic environments that maximiz' success. This requires a conscious effort on the teacher's part such that academic tasks are organized effectively, and classroom management shate- gies, using the procedures outlined earlier in this article, are used continuously. Frequent and specific feedback, judicious use of praise and reprimands, peer attention, and externally prompted self- monitoring and reinforcement all can improve the academic environment for ADHD students. Directions given in a firm, calm manner with teacher proximity also maximize the extent to which ADHD students respond positively to the teacher and class setting.

Abramowitz and O'Leary (1991), abstracting from research conducted with a wide range of students, suggest that teachers should consider the following factors when organizing the academic environment for ADHD students. First, classroom noise, difficult tasks, and tasks paced by others result in more off-task behavior. Second, while the research on optimal seating arrangements is inconsistent, seating plans should be linked to the learning tasks and activities most prevalent in the classroom. For instance, "clustered seating" increases social interaction, but reduces productivity. "Circle" seating generally increases on-task behavior during teacher-led discus- sion. Third, greater task structure and increased use of stimulating

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George M . Batsche and Howard M . Knoff 87

materials (e.g., by adding color, shape, movement, or texture to a task) may increase attention, however, their impact on productivity and accuracy is not yet known. Finally, novelty and stimulation appear to improve learning outcomes for easy tasks, but not for more difficult tasks.

In summary, interventions for ADHD children should be comprehensive and multi-modal. Medical, home, school, and child interventions must be combined in such a way as to minimize the effects of specific deficit areas, while building adaptive academic and social behaviors. In order to accomplish this in an effective manner, consistent interventions must be applied across settings (home, school, community) by individuals trained in behavioral and academic management strategies (parents, teachers, and other caregivers). In. order to accomplish this goal, communication and collaboration between home, school, and community is critical. The differences that exist in the structure and communication patterns of these settings often result in poor collaboration and discontinuous and inconsistent applications of intervention strategies. Medical and mental health professionals should assume a "case manager" role for young, preschool ADHD children, while school professionals should assume this role for school-age children. The major responsibility of these professionals is to facilitate treatment and intervention plans for the ADHD child and his or her family, while providing support and resources for the professionals who work directly with the child (e.g., teachers). The failure to achieve this integrated service delivery often results in the poor social and academic progress of children with ADHD, when much more positive outcomes can be attained.

A PROBLEM-SOLVING MODEL

One consistent problem in service delivery for ADHD children and their families has been the effective linking of referral concerns, assessment information, and successful academic and social interventions. Teeter (1 991) presents a psychoeducational paradigm that integrates diagnosis, assessment, and intervention. Batsche (1984) and Knoff and Batsche (1991) have developed a model of consultative problem-solving that incorporates some of the information

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from Teeter's model and should prove useful in linking the needs of ADHD children to effective interventions. The Referral Question Consultation (RQC) model integrates referral concerns, msons for those concerns, assessment methods, and intervention strategies. Briefly, the model has six steps.

Step One. Problem identification and definition, and the specifi- cation of desired, appropriate behaviors.

Step Two. The development of hypotheses that explain why the problem behavior exists. Hypotheses may be related to and can occur in six areas:

a Child characteristics (e.g., attention, impulsivity, skill level) b. Peer Characteristics (e.g., peer attention, rejection) c. Curriculum Characteristics (e.g., difficulty level, stimulus value) d. Teacher Characteristics (e.g., management style, teaching

style) e. Classroom Environment Conditions (e.g., seating, noise level,

lighting) f. Home/Community Conditions (e.g., parenting skill, peers,

family issues)

Step Three. The development of predictions that relate the problem behavior to specific hypotheses. For example: "Johnny is unable to stay on-task during assignments that require open-ended written responses." Or, "Lisa follows directions more accurately when the teacher establishes eye contact and is in close proximity." Or, "Bill will demonstrate longer periods of on-task behavior and higher academic completion rates when on stimulant medication compared to off medication."

Step Four. Assessment to determine if the prediction is true. In the above examples one could compare the academic productivity and accuracy of open-ended versus single word (cloze) type written activities. Direct observation can verify the optimal student-teacher interaction style in the second example and the on-task, productivity, and accuracy rates in the thud example.

Step Five. The development of interventions based on the outcome of assessments to confirm or reject the hypotheses. If the hypotheses are written correctly, the intervention should be obvious for those hypotheses that are verified. In the examples above,

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Johnny could be given cloze-type written assignments, Lisa's teacher should give directions with eye contact and using proximity control, and Bill should consistently be on stimulant medication.

Step Six. The evaluation of the outcomes of interventions. This involves both formative and, eventually, summative evaluations of the impact of the interventions implemented. These evaluations should focus on product outcomes (e.g., Did the intervention effect a change of behavior in the desired direction?) and process outcomes (e.g., Was the teacher satisfied with the intervention process and the degree of support and resources available during intervention implementation?).

The benefits of the RQC model are: (a) both the problem and replacement behaviors are addressed, with a primary focus on interventions; (b) the six hypothesis areas comprehensively cover the areas that must be considered when working with ADHD children, their families, and teachers; (c) the hypotheses are based upon the empirical literature in each of the areas ,noted above; (d) the assessment methods selected are functional and require a minimal amount of inferential interpretation; (e) interventions evolve directly from confirmed hwotheses; (f) intervention efficacy can be evaluated using the sa&e that were used dur& problem solving; and (g) the model facilitates collaboration and communication between professionals and,parents.

CONCLUSIONS

The task of reviewing the research on ADHD is a difficult one. This article has attempted to address issues in the identification, assessment, classification, and intervention with ADHD children. Although differences of opinion certainly exist regarding how to define, conceptualize, and assess ADHD, recently developed mod- els and improved assessment techniques have increased the effectiveness of the process. In addition, the use of meta-analytic statistical procedures enable researchers to evaluate the relative effectiveness of &ous interventions.

The dramatic increase in the amount of intervention research with ADHD children bodes well for the delineation of effective strategies. Although the research in this area continues to raise

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90 SPECIAL SERVICES IN T H E SCHOOLS

controversies and disagreements, a few defmitive conclusions can be drawn. First, ADHD is a condition that has its greatest impact on families and on the social and academic development of children. Second, although there have been changes in the definition of ADHD, researchers are smving for and reaching a consensus on the best methods of assessing the disorder. Third, the most effective method of intervention uses comprehensive, multi-modal strategies that involve home, school, and community settings in a collabora- tive model of service delivery. Fourth, the greatest threats to successful intervention are not the differences described above in the definition, assessment, or intervention areas, but in the failure of parents, educators, medical, and mental health personnel to work together. Hopefully, this last conclusion will be the fust conclusion that these individuals draw as they begin their work with the ADHD child.

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Documents

Children with Attention Deficit Hyperactivity Disorder