Children with Attention Deficit Hyperactivity Disorder

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  • This article was downloaded by: [University of Toronto Libraries]On: 05 November 2014, At: 07:24Publisher: Taylor & FrancisInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

    Special Services in the SchoolsPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wzss20

    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

    To link to this article: http://dx.doi.org/10.1300/J008v09n01_04

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    http://www.tandfonline.com/page/terms-and-conditions

  • 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 inter- vention. The article concludes by providing a problem-solving mod- el 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 par- ents 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) hyperactiv- ity (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 chil- dren, 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 identi- fied 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 etiolo- gy, 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 diagnos- tic systems have concentrated efforts to defme more clearlv the char- actehstics, assessment procedures, and intervention systems for chil- dren 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 inappropri- ate 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 "regu- lation 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-re- ferred 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 biologi- cal 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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  • 72 SPECIAL SERVICES IN THE SCHOOLS

    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 (unidimen- sional) or two types-attention deficit disorder with and without hyperactivity (multidimensional). The DSM-III-R provides a "uni- dimensional" definition that represents the disorder as having com- ponents 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) hyperac- tivity (APA, 1980). Critically, the DSM-Ill recognized that impul- sivity 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 multidi- mensional 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 atten- tion 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 inter- ventions. When only students with attention disorders with hyper- activity are recognized, then access to services for the non-hyperac- tive group become limited or nonexistent and a significant number

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  • 74 SPECIAL SERVICES IN THE SCHOOLS

    of children may be more vulnerable to resulting academic and so- cial delays. Aside from these functional home and school implica- tions, 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 develop- mental 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 matu- ration and the diff...

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