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DOCUMENT RESUME

EC 304 807

Attention Deficit Hyperactivity Disorder and theSchools. Task Force Report.

INSTITUTION Virginia State Dept. of Education, Richmond.PUB DATE [Feb 95]

NOTE 44p.; A separate seven-page communication dealingwith revisions caused by the new DSM-IV definition ofADHD, is appended.

PUB TYPE Information Analyses (070) -- Guides -.Non-ClassroomUse (055)

EDRS PRICE MF01/PCO2 Plus Postage.DESCRIPTORS *Attention Deficit Disorders; *Change Strategies;

Clinical Diagnosis; Definitions; DisabilityIdentification; *Educational Diagnosis; EducationalHistory; Elementary Secondary Education; FamilySchool Relationship; *Hyperactivity; Incidence;*Intervention; Medical Services; ParentParticipation; School Districts; State Boards ofEducation; Student Evaluation

IDENTIFIERS *Virginia

ABSTRACTThis report of a Virginia interdisciplinary task

force on children with attention deficit hyperactivity disorder(ADHD) in the schools reviews what is known about this disorder andpresents recommendations to the Virginia Department of Education andlocal school districts. Recommendations include the need to provide asystematic program of inservice education and revise state rules,regulations, and guidelines in specified ways. Recommendations tolocal school districts include development of plans for programingfor ADHD children and establishment of resource libraries.Incorporation of education regarding ADHD into all teacher trainingprograms in the state is urged. Sections of the report discuss: (1)

historical background of ADHD; (2) definition; (3) relationship tospecial education categories; (4) prevalence; (5) identification andassessment; (6) the schools' role in the assessment and diagnosticprocess for ADMD; (7) medical interventions; (8) school-basedinterventions; (9) parent/family issues; (10) controversialinterventions; and (11) conclusions. An attachment updates the ADHDdefinition based on the fourth edition of the Diagnostic andStatistical Manual of Mental Disorders. (Contains 41 references.)(DB)

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Reproductions supplied by EDRS are the best that can be madefrom the original document.

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U.S. DEPARTMENT OF EDUCATION()Ike or Eoucationzi hasearcn anu Improvement

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

a This document nas been reproduced as.l'aceiyed from the person or organizationoriginating it

0 Minor changes nave been made toimprove reproduction quatity.

Points of view or opinions stated in thisdocument clo not necessarily representofficial OERI position or policy. Task Force Report

A TION

HYPERAHYPERACTIVITY

HYP ORAND THE SCHOOLS

Virginia Department of Education

RFST CIIPY AVAILABLE

PERMISSION TO REPRODUCE ANDDISSEMINATE THIS MATERIAL

HAS BEEN GRANTED BY

ct.

TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)

TABLE OF CONTENTSAcknowledgements I

Members of the Task Force II

Recommendations III

Summary IV

Introduction 1

Historical Background 2

Current Definition 4

Relationship to Special Education Categories 6

Prevalance 9

Identification and Assessment 10

The Schools' Role in the Assessment and Diagnostic Process for ADHD 15

Medical Interventions 17

School-Based Interventions 20

Parent/Family Issues 23

Controversial Interventions 24

Conclusions 26

Re ferences 27

3

IAcknowledgements

ACKNOWLEDGEMENTSEach member of the task

force made significant contribu-tions to the content of thedocument through research andprofessional viewpoints. Specialrecognition is given to Dr. RonReeve, Associate Professor, CurrySchool of Education, Universityof Virginia. Dr. Reeve served asconsultant to the task force andwas responsible primarily for or-ganizing the content of thedocument. During the course ofthe field review of the report, weappreciated the many thoughtfulinsights given by parents,physicians, and school personnelwho have profound interest inservirig the needs of childrenwith attention deficit hyperactiv-ity disorders.

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Members of the Task Force!!

MEMBERS OF TASK FORCEPatricia White, Ed.D.Task Force ChairmanAssociate Director,Visiting Teacher/SchoolSocial Work, SchoolPsychology, and School Health ServicesDepartment of Education

Stephen Baker, Ed.D.Division SuperintendentHanover County Public Schools

Harriet Cobb, Ed.D.Associate Professor of PsychologyJames Madison University

Meena Hazra, M.D.Developmental PediatncianMedical College of Virginia and Children's Hospital

Mrs. Kathe KlareSupervisor, Due Process HearingsDepartment of Education

Jane Logan, Ph.D.Supervisor, School Food ServicesDepartment of Education

Delores Mick, Ph.D.Supervisor, Programs for the Learning DisabledDepartment of Education

Karen Rooney, Ph.D.Educational ConsultantMedical Counseling Associates

Mrs. Charlene StraleySupervisor of Special EducationCharlottesville City Public Schools

Austin Tuning, Ed.D.Director, Special Education ProgramsDepartment of Education

Ronald Reeve, Ph.D.Task Force ConsultantAssociate ProfessorCurry School of EducationUniversity of Virginia

Elizabeth Cluver, Ph.D.Associate Director,Special Educati on ProgramsDepartment of Education

Mrs. Ruth FinleyParent

William Helton, Ed.D.Administrative DirectorSpecial Education Programs and Pupil Personnel ServicesDepartment of Education

Lillian Lindemann, M.D.Child Psychiatrist

Miss Phyllis MayEducational ConsultantChildren's Hospital

Pamela Oksman, Ph.D.Supervisor, School PsychologyDepartment of Education

Mrs. Dorothy RoseboroSupervisor of Preschool and Child Find ServicesNewport News City Public Schools

Karen Trump, Ed.D.Director of Special ServicesGreene County Public Schools

Ms. Irene Walker-BoltonSupervisor, Programs for the Emotionally DisturbedDepartment of Education

III Recommendations

RECOMMENDATIONSI. The Virginia Department of

Education should embark ona systematic program of in-service education with thegoal of providing appropriateinformation regardingattention deficit hyperactivitydisorder (ADHD) to allpublic school personnel inthe Commonwealth. Thisshould include the following:

A. Wide distribution ofthis document.

B. Intensive training forchild study teams inidentification and man-agement of ADHDchildren.

C.Development of pro-grams/materials foreducation of all schoolpersonnel, physicians,and parents aboutADHD. In addition toin-service training,pamphlets should bedeveloped alertingteachers and parents tothe presence and char-acteristics of the disor-der.

U. The Virginia Department ofEducation should undertakewhatever revisions of staterules, regulations, andguidelines are necessary toclarify that:

A. "Other health impaired"is a categorical optionwhich may be used tofind ADI-ID studentseligible for specialeducation services when

the child's educationalfunctioning is impaired.

B. Appropriately certifi-cated teaching and/orpupil personnel servicesstaff may be designatedto provide educationalservices for ADHD stu-dents.

C.Services should beprovided through theregular educationprogram unless thechild is determinedeligible for specialeducation services.

III. Local school division per-sonnel should be required todevelop plans for program-ming for ADHD children,whether the children areplaced in special education orremain in the regular educa-tion program. The plansshould include guidelines forthe following:

A. Specifying membershipof Child Study teamswhen a child withattenton problems isunder consideration,

B. Identifying childrenwho have the disorder,including the assess-ment procedures to beutilized,

C. Working with physi-cians to monitor theeffects of medications,and handling of medi-cines in school,

D. Adapting regularinstructional programs

to meet the specialneeds of children withthis disorder, when ap-propriate. Possibleappropriate modifica-tions might include, forexample, reducing thevolume of requiredhomework, shorteningthe length of bus rides,and providing moretime for tests.

E. Making available toADHD children, theirteachers, and theirfamilies the support ofPupil Personnel Servicesstaff including schoolpsychologists, counsel-ors, visiting teachers,school social workers,and nurses for consulta-tion and direct service,when appropriate.

IV.Local school divisions shouldset up resource libraries toserve as clearinghouses forinformation for school per-sonnel, parents, and othercitizens regarding ADHD.Included should be selectedbooks and articles.

V. Education regarding thecharacteristics and manage-ment of ADHD should beincorporated into !he teachertraining programs of all thecolleges and universities ofthe Commonwealth.

SummaryIV

SUMMARYAttention deficit hyperac-

tivity disorder (ADHD) is aserious condition which affectsfrom 3-5% of the school popula-tion. Defining characteristics ofthe disorder include age-inap-propriate levels of motor activity,impulsivity, and inattention,with the attentional problemstypically being the most debili-tating. Differential diagnosis isdifficult since many otherphysical and psychologicalconditions share characteristicswith ADHD, including forexample hearing and auditoryprocessing deficits, drug abuse,and anxiety and depression.ADHD is not a separate handi-capping condition under currentspecial education law. However,many learning disabled, emo-tionally disturbed, or otherwisehandicapped children also canbe considered to have ADHD.When ADHD does not co-existwith another handicappingcondition such as LD or ED, yetthe condition is found to ad-versely affect school functioning,the child may be considered forspecial educational services inthe category of "other healthimpaired."

Appropriate assessmentshould be multidisciplinary innature. It involves gathering in-formation from multiple sources

(parents, teachers, and others),assessing in different settings atdifferent times of the day,looking at the multiple compo-nents of the condition (inatten-tion, impulsivity, and hyperactiv-ity), and using different types ofassessment procedures (inter-views, observations, behaviorrating scales, standard psychom-etric instruments, and specifictests of attention, impulsivity,and activity level).

When a child in schoolevidences difficulties in attention,activity level, and impulsecontrol, or when a child with amedical diagnosis of ADHD isbrought to the attention ofschool personnel, it is appropri-ate for the Child Study Commit-tee to become involved. TheCommittee can coordinate infor-mation gathering and prelimi-nary interventions, and candetermine whether or not furtherevaluation is appropriate. ForADHD children who have beendetermined to be handicappedunder PL94-142, the IEP shouldcontain additional provisions fordealing with problems resultingfrom the attentional difficulties.

Interventions for ADHDchildren often include medica-.tion. Positive effects of psychos-timulant medications such asRita lin occur in 60-80% of cases

P41

of ADHD. However, medicationalone is never sufficient to dealwith the problems associatedwith the disorder. In school,teachers may need to make avariety of alterations in theregular instructional program inorder for the ADHD child toachieve reasonable academicsuccess. Behavior modificationapproaches and changes in theclassroom environment toeliminate distractions haveproven to be helpful in somecases. Currently the mostpromising approach involves"cognitive behavior modifica-tion" (CBM). The child is taughtstrategies for self-control and forcoping with specific types ofschool work. ADHD childrenfrequently also experienceproblems in social skill acquisi-tion. A comprehensive treat-ment program must include helpfor the child in this area as well.

Families of ADHD childrentypically are under considerablestress as they attempt to copewith their child's behavior.School personnel can help byproviding accurate informationabout the disorder throughdeveloping a library of usefulmaterials as well as by encourag-ing parents with similarlyaffected children to interact andshare ideas.

1 Task Force Report

INTRODUCTIONIn almost every classroom

in America one or more childrenare present who experienceserious difficulty with inatten-tion, impulsivity, and/or hyper-activity. School personnel findthem to be difficult to teach; theydo not respond in the same wayas other children, and they oftenare disruptive. The childrenthemselves are at risk for majoracademic and social failureunless they are managed appro-priately. Clearly these children,whose condition is referred to asattention deficit hyperactivitydisorder (ADHD), presentchallenges to educators whichmust be met. However, for mostschool personnel, informationabout ADHD is not readilyavailable. What is available oftenis confusing and, not infre-quently, contradictory. Thepurpose of this document is toprovide an integrated source ofinformation which reflects themost current knowledge aboutADHD from medical, educa-tional, social, and psychological/psychiatric perspectives. It ishoped that this information willbe useful to educators, parents,and other involved individuals asthey seek to help children whohave this condition.

The Virginia Department ofEducation has received an in-creasing number of inquiriesfrom local school divisions,parents, and other citizens aboutADHD children. Questions suchas the following are askedrepeatedly: "If a child is diag-nosed as ADHD, does s/hequalify for special educationservices?" "How do teachers andother school staff get help forADHD children if they are notfound eligible for special educa-tion?" "Should school divisionpersonnel encourage parents toget medication for their ADHDchild?" "How should thesebehavior drugs be handled inschool, on field trips, etc.?" Thefrequency of these and otherrelated questions convinced theDepartment of the need to studythese issues and make informa-tion available to all schooldivisions.

In March,1988, a "TaskForce on ADHD and theSchools" was appointed. Mem-bers were chosen to representthe various disciplines which areconcerned professionally withADHD children, includingpediatrics, child psychiatry,clinical psychology, schoolpsychology, counseling, school

health, law, special education,and of course regular education.In addition parents of ADHDchildren and staff of the Depart-ment of Education were repre-sented. The Task Force met forone day-long initial session inMarch, at which time each mem-ber made short presentationsregarding issues which theybelieved should be included inthe document. More detailedpresentations also were maderegarding medical, educational,and psychological perspectiveson the disorder. Dr. RonaldReeve, a faculty member of theCurry School of Education at theUniversity of Virginia, was corn-miss:oned to serve as consultantto the Task Force and preparethe document. The Task Forcethen met in June to critique thedocument and to determinewhat additional informationshould be included. A seconddraft was reviewed by TaskForce members in the early fall.Their feedback was incorporatedinto a third draft, which was dis-tributed statewide in Novemberfor public comment. Two addi-tional meetings of the Task Forcewere held (February and March,1989) to decide on the contentand format of this final report.

Historical Background 2

HISTORICAL BACKGROUNDThe condition which today

is termed "Attention DeficitHyperactivity Disorder" (ADHD)has been recognized as an entityfor at least the last half-century.In fact, descriptions of theassociated behaviors have beenremarkably consistent over theyears. For example, Werner andStrauss (1941) characterized thegroup of children with whomthey were working as hyperac-tive, distractible, impulsive,emotionally labile, and persev-erative. What have changedevery few years are the namesemployed for the syndrome.Early terminology was based onassumptions about the causes ofthe disorder. In the 1930's and1940's, children with the behav-iors listed above were called"brain damaged" or "brain-injured" because it was knownthat brain damaged individualsshowed similar behaviors. In the1950's and 1960's it became clearthat many children exhibited thesame set of behaviors, thoughneither a definitive history ofbtain trauma nor the presence ofabnormal neurological signscould be documented. Theassumption was made thatneurological dysfur ict ionsnevertheless were at the root ofthe problems; they were just toosubtle to be detected with themedical procedures available.Therefore, the terms "minimalbrain damage" or "minimal braindysfunction" came into commonuse.

"Hyperactive" became theterm of choice for many profes-sionals for characterizing thesechildren by the 1960's. Theargument was made, especially'n education and psychologycircles, that diagnosis of theunderlying disorder was basedon behavioral criteria, not on anydocumentable medical evidence.Thus it made sense to use a termwhich was descriptive of theobservable behavior. Excessivemotor activity at that time wasconsidered to be the centralproblem evidenced by thesechildren, and hence the tennhyperactivity became widelyused. By the 1970's most profes-sionals were in agreement thatdifficulties in attention and con-centration were more criticalthan activity problems as cardi-nal symptoms of the disorder. Itwas primarily because they couldnot pay attention, rather thanbecause of their amount ofmovement, that these childrenexperienced so much social andacademic difficulty. Thischange in perspective was givenofficial recognition with thepublication of the third editionof the Diagnostic and StatisticalManual of Mental Disorders(DSM-I11) in 1980. The DSM,published by the AmericanPsychiatric Association, is the"Bible" for psychiatric terminol-ogy. In DSM-III, the term"hyperactivity" was replaced as adiagnostic category by "attentiondeficit disorder" (ADD). Two

basic kinds of ADD were sped-fied: ADD with hyperactivity,and ADD without hyperactivity.

The most recent terminol-ogy change, to "attention deficithyperactivity disorder" (ADHD),was made in the 1987 revision ofthe DSM, known as DSM-III-R.That change apparently resultedas a compromise. Some mem-bers of the committee workingon DSM-III-R felt that ADDcould not exist without hyperac-tivity, while others felt stronglythat hyperactivity often wasabsent in children with seriousattention deficits. The basiccharacteristics of ADHD, asdescribed in DSM-III-R, includeattention problems, impulsivity,and hyperactivity. However, it isnoted that these may occur invarious proportions in affectedchildren; thus it would bepossible for a given child to haveattention problems and impul-sivity, with only a tiny elementof hyperactivity, and still receivea diagnosis of ADHD. From thediscussion of the disorder whichis presented in DSM-III-R, it isclear that the committee contin-ued.to agree that attentiondeficits and impulsivity arerelatively more debilitatingaspects of the ADHD syndromethan is hyperactivity.

Though most professionalswill now use the term ADHD tocharacterize these kinds ofchildren, it can be expected thatthe older terms will continue topop up in the professional

3 Task Force Report

literature and especially in thepopular press and the media.This causes confusion forindividuals trying to make senseof research studies, and certainlyimpairs the ability of lay people

to understand this disorder. It isnot always clear that the differentterms are being used inter-changeably, and some subtledifferences do exist among theconditions described by the

different terms. However, forthe most part, "ADHD: "ADD,""hyperactive: "MBD," and even"brain injured" refer to the samecondition as viewed at differentpoints over the past 50 years.

1 6

Current Dermition 4

CURRENT DEFINITIONAccording to DSM-III-R

(1987), the essential features ofADHD are "... developmentallyinappropriate degrees of inatten-tion, impulsiveness, and hyper-activity" (p. 50). Recognitionthus is given to the fact thatyounger children have higherrates of each of these threecharacteristics than older chil-dren. Hyperactivity, in fact,appears to diminish steadilythrough the school years, andmay disappear altogether inadolescence. Attention problemsand impulsivity persist, however.While manifestations of thedisorder usually appear in everysetting (home, school, withpeers, etc.), it is recognized thatsigns "... may be minimal orabsent when the person isreceiving frequent reinforcementor very strict control, or is in anovel setting or a one-to-onesituation (e.g., being examinedin the clinician's office, orinteracting with a videogame)"(p. 50).

Associated features ofADHD include low frustrationtolerance and temper outbursts,low self-esteem, variable mood,and academic underachieve-ment. While the disorderusually is not actually diagnosedprior to school entry, problemsoften are noted before age 4.Boys are diagnosed at least threetimes more often than girls.There appears to be a significantfamilial component it is verycommon to find that relatives of

an ADHD child were consideredto be hyperactive and inattentivewhen in school.

A major goal of the authorsof DSM-III-R was to makediagnoses of disorders as objec-tive as possible by focusing onobservable characteristics. ForADHD, the diagnostic criteria(pp. 52-53) specify that the dis-turbance must have been ongo-ing for at least 6 months, and atleast 8 of the following 14behaviors must be present (atconsiderably greater frequencythan observed for most otherpeople of the same mental age):

(1) often fidgets with hands orfeet or squirms in seat (inadolescents, may belimited to subjectivefeelings of restlessness);

(2) has difficulty remainingseated when required todo so;

(3) is easily distracted byextraneous stimuli;

(4) has difficulty awaitingturn in games or groupsituations;

(5) often blurts out answers toquestions before they havebeen completed;

(6) has difficulty followingthrough on instructionsfrom others (not due tooppositional behavior orfailure of comprehension),e.g., fails to finish chores;

(7) has difficulty sustainingattention in tasks or playactivities;

(8) often shifts from oneuncompleted activity toanother;

(9) has difficulty playingquietly;

(10) often talks excessively;(11) often interrupts or in-

trudes on others, e.g.,butts into other children'sgames;

(12) often does not seem tolisten to what is being saidto him or her;

(13) often loses things neces-sary for tasks or activitiesat school or at home (e.g.,toys, pencils, books,assignments); and/or

(14) often engages in physicallydangerous activities with-out considering possibleconsequences (not for thepurpose of thrill-seeking),e.g., runs into streetwithout looking.

In addition to the abovebehaviors, DSM-III-R specifiesthat onset must have occurredprior to age 7. Based on thenumber and intensity of theobserved behaviors, the ADI-1Dadditionally can be classified as"mild," "moderate," or "severe."

Unfortunately, the behav-iors listed above are not limitedonly to the ADHD child. Forexample, children from disor-ganized, chaotic environmentsalso may have difficulty sustain-ing attention and behaving in agoal oriented manner. Likewise,depressed children, or those

5 Task Force Report

with a variety of other emotionaldisorders, may exhibit attentionproblems. Further, physicalillnesses, poor hearing and/orvision, and inadequate nutritionmay result in behaviors whichlook the same as those whichcharacterize ADHD. Differentialdiagnosis, thus, is not an easytask.

Though DSM III-R com-bines hyperactivity, inattention,and impulsivity into a singlesyndrome, many researchers andpractitioners in the field empha-

size that attention deficits existwith and without hyperactivity.Those with hyperactivity drawattention to themselves throughexternalizing behavior such asaggression, and they thereforeare diagnosed and treated at ahigher rate. Children withattention deficits without hyper-activity, however, may be atequal or greater risk for aca-demic and social difficulties. Forexample, in one study, 72% of agroup of ADD children withouthyperactivity were retained,

compared to only 17% of a groupof ADD children who werehyperactive (Lahey, Schaugh-ency, Strauss, & Frame, 1984).Those without hyperactivity tendto be more socially withdrawn,and their academic performancerelatively poorer. Thus, thoughless visible and therefore lessoften diagnosed than theirhyperactive counterparts, ADDchildren who are not hyperactivehave serious problems whichrequire assistance.

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RELATIONSHIP TO SPECIALEDUCATION CATEGORIES

Under current interpreta-tions of PI.. 94-142, ADHD is notconsidered a separate "handicap-ping condition" (Bellamy, 1987).However, if the child's educa-tional functioning is impaired bythe disorder, special educationservices must be provided in theleast restrictive environmentupon determination of eligibility.When ADHD coexists with otherhandicapping conditions, theservices may be provided asadjuncts to the child's programby making certain thatappropri-ate interventions are included inthe 1EP. When no other handi-capping condition is present, oneoption is to consider the childeligible for services in the "otherhealth impaired category.

Attention problems arecommonly occurring characteris-tics of several specific handicap-ping conditions, especiallylearning disabilities and seriousemotional disturbance. As such,their presence may lend support-ing information for determina-tion of eligibility for servicesunder those categories.

LEARNING DISABIUTIESDo all LD children also

have ADHD? The answer clearlyis "no." Children may be LDprimarily because of language-based problems, or due to visualor auditory perceptual difficul-ties, and have few symptoms ofADHD. However, many LDchildren do have substantialdifficulties with attention,

impulsivity, and hyperactivity, tothe extent that they can beconsidered ADHD as well. Itappears reasonable to estimatethat at least 33% of LD childrenare ADHD (Hallahan,1989).

Are all ADHD children LD?Again, the answer is "no." Whilesome have estimated the inci-dence of LD in attention deficithyperactivity disordered young-sters to be as high as 80%, theseestimates were based on childrenwho came into specialized clinicsfor help; certainly these are notrepresentative samples. Recent,carefully conducted epidemiol-ogical studies indicate that as fewas 10-20% of ADHD childrenmay qualify for LD services whencriteria include utilization ofregression formula-based apti-tude/achievement discrepancyprocedures (Shaywitz & Shay-witz,1987). Since the federal"Rules and Regulations" for LDrequire a "severe discrepancybetween achievement andintellectual ability,* the majorityof ADHD children will notqualify for LD diagnosis.

The substantial overlapwhich does exist between ADHDand LD is easy to understand. Inthe classroom, a child whocannot pay attention, or whocannot pay attention to theappropriate information, or whocannot overcome the impulse torespond before instructions arecompleted, obviously will not beable to learn efficiently. Gaps inthe acquisition of hierachically

structured skills such as readingand math, which build system-atically from simpler to morecomplex learnings, will becommon. Failure and theresulting frustration will build,eventually interfering withmotivation, and then withsubsequent performance, in anegatively spiraling fashion.

SERIOUS EMOTIONALDISTURBANCE

Many emotionally dis-turbed (ED) children demon-strate enough characteristics ofADHD to carry both diagnoses.likewise, many children who arediagnosed as ADHD exhibitserious social and emotionaldeficits. While the extent ofoverlap is difficult to pin down,investigators have reported co-occurrence of ED and ADHD inthe 30%-65% range (Loney,1987; Pelham & Murphy,1986).

Which is primary? Doesthe emotional difficulty lead toattentional problems, perhapsbecause the resulting anxietyinterferes with ability to concen-trate? Or is there somethingabout the nature of ADHD thatpredisposes children to developsocial/emotional difficulties?The answer is not at all clear,and there probably are instancesof both pathways to the eventualsituation where a child is ADHDand ED. However, a casecertainly can be made for ADHDbeing at the root of some subse-quent emotional problems.

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7 Task Force Report

Retrospective reports ofparents of ADHD childrenfrequently contain descriptionsof a difficult child from infancy,with irregular rhythms, pooradaptability, negative mood, andhigh intensity of behaviors (e.g.,Thomas, Chess, & Birch, 1968).What may then occur is aninteraction parents becomefrustrated when they recognizethat their efforts at child manage-ment are ineffectual. The childis less reinforcing to parents thanother children seem to be. By alloutward appearances the child isnormal; so there may be atendency to blame themselves,and therefore feel less competentas parents, rather than to acceptthat the child is different throughno fault of their own. Theattefitional problems and theimpulsivity may interfere withsuch basic emotional/socialprocesses as mother-childattachment.

In the homes of ADHDchildren we know that morenegative interactions occuramong family members (Sch-leifer et aL,1975). Both thechild's initial symptoms andfamily interactional patternsinfluence the child's outcome atschool age (Campbell, Breaux,Ewing, & Szumowski, 1986).Likewise, early peer interactions,which are precursors to latersocial satisfactions, are impairedin many ADHD children. Atpreschool ages ADHD children,especially those who exhibit

hyperactivity, are strikinglyunpopular (Rubin & Clark,1983). They seem to miss socialcues which other children pickup more or less automatically.They have difficulty modulatingbehavior; and switching fromone activity to another, or fromone setting to another, is seldomdone without incident. To theextent that the children areaware of the fact that others donot like them, their self-esteemmay be negatively impacted,with resulting lack of confidencein their ability to develop andmaintain rewarding relationshipsWith others.

SPEECH, LANGUAGE, ANDHEARING IMPAIRED

No direct relationshipbetween speech problems andADHD exists. Heating impairedindividuals do exhibit manybehaviors similar to those ofADHD children, including notseeming to listen to what is said,difficulty following directions,etc. For this reason, when anattention deficit is suspected, itmakes sense to check for audi-tory acuity to be certain that thechild can hear normally.

A more subtle condition,central auditory processingdisorder (APD), shares manymore symptoms, and therefore isvery easy to confuse, withADHD. Children with APDoften are described as "poorlisteners," have short auditoryattention spans, appear unable to

sustain attention to a task, andhave trouble following direc-tions, especially in noisy oracoustically poor settings. Thesechildren frequently also havehigh activity levels, though someare less active than normal, tothe point of lethargy.

Making a diagnosis of APDversus ADHD is not a simplematter. Many children with APDhave a history of hearing lossand/or of recurrent ear infec-tions. Such a history shouldsignal an evaluator to look evenmore closely for signs of thedisorder. Other indicatorsinclude difficulty with phonics,trouble recalling the sequence ofinformation heard, frequentrequests that information berepeated (many "Huh"? and"What?" questions), poor verbalcomprehension and vocabularyfor age, and slow or delayedresponse to verbal stimuli. TheAPD child may also have lan-guage problems, indicated bysuch things as misunderstandingthings said, confusing the orderof words when speaking, andincorrectly using words. Whenthis pattern of problems isencountered with a childthought to be ADHD, the childshould be referred to a specialistfor an evaluation of centralauditory processing skills.Highly trained audiologists mostfrequently perform these assess-ments, though other speech andlanguage professionals also maybe able to provide that service.


MENTAL RETARDATIONMany features of ADHD

may be present in mentallyretarded (MR) children due togeneralized intellectual delay.Thus, retarded children behavelike much younger children, andhigher levels of inattention,impulsivity, and motor activityare expected at younger ages. Inorder to be considered ADHD inaddition to being MR, therelevant symptoms must beexcessive for the child's mentalage.

OTHER HEALTH IMPAIREDChildren who manifest the

characteristics associated withthe diagnosis of other health im-paired may also have ADHD.This handicapping condition orcategory for special educationservices may be an option foraccessing services for childrenmanifesting ADHD symptoms.Other health impaired,according to state and federalregulations, means havinglimited strength, vitality or

alertness due to chronic or acutehealth problems such as heartcondition, tuberculosis, rheu-matic fever, nephritis, asthma,sickle cell anemia, hemophelia,epilepsy, lead poisoning, leuke-mia, or diabetes, which adverselyaffects a child's educationalperformance.

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9 Task Force Report

PREVALANCEEstimates of incidence rates

of ADHD vary widely, fromfewer than 1% to more than 20%of the population. This variationoccurs because of the impreci-sion of terms such as "overactiv-ity" and "impulsivity." Ascriteria for the disorder havebecome more objective, a clearerpicture of prevalance hasemerged. The best currentestimates are that between 3%and 5% of school age childrenhave this problem.

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I NTIFICATION AND ASSESSMENTThe actual diagnostic label

"ADHD" usually is given byphysicians (mosi. commonly bypediatricians and child psychia-trists, though sometimes byneurologists) and by psycholo-gists. Occasionally parents willinitiate the evaluation by one ofthese professionals on their own.However, the typical route is forschool personnel to note aconcern and recommend that theparents have the child formallyevaluated.

There is little consistencyamong professionals in the waythe assessment for ADHD isperformed. It is possible, how-ever, to identify principles andprocedures which, in most cases,should be followed in order toassure that the best diagnosticdecisions are reached.

Use multiple sourcesof information. In addition toevaluating the child directlythrough tests and observations, itis very important to get informa-tion from parents, teachers, andothers in the child's environ-ment. Hopefully these differentsources will be in concurrence.However, that often is not thecase. Parents, especially, maynot have an accurate perceptionof what is a developmentallyappropriate level of attention,impulsivity, and activity. Forexample, one recent study(Shaywitz & Shaywitz, 1987)revealed that 76% of the parentsof kindergarteners rated their

children as more active thannormal. Their own child may bethe only child of a given age withwhom parents have extensiveexperience. Teachers tend to bebetter.sources of informationbecause they have a built in"norm group" in front of themevery day. However, they toomay be subject to a variety ofbiases.

Get information aboutfunctioning in differentsettings. For many years theassumption was made that if achild was ADHD, s/he wouldexhibit the symptoms in everysituation. We now know that isnot necessarily true. In free playactivities, no differences inactivity levels can be seenbetween ADHD and normalchildren (Routh & Schroeder,1976). likewise, an ADHD childmay be able to sit and watch aninteresting IV show, or may beable to attend intensively to avideo game, for considerabletime periods. In simple tasksituations, many ADHD childrenalso do fine. It appears that thesymptoms are seen most oftenwhen the tasks are difficult (i.e.,the information load is high) andwhen they are asked to attendfor relatively long time periods.

Assess all three dimensionsof ADHD. The syndromeincludes attention problems,impulsivity, and hyperactivity.While there is an emerging

consensus that inattention andimpulsivity cause the child moreproblems than does overactivity,each of these should be evalu-ated. Obviously some overlapexists among these characteris-tics. However, each is a complexconstruct in its own right. Anassessment for ADHD would beincomplete if it did not include alook at each of these componentsof the disorder.

Further, it is important torecognize the complexity of theconstructs. Attention, forexample, includes at least thefollowing: being able to

1) focus, or come to atten-tion;

2) choose which stimulus tofocus on "selective at-tention";

3) resist distractors in theenvironment; and

4) sustain attention over areasonable time period"attention span." Assess-ment of each requireslooking at different kindsof information, or askingdifferent questions.

Get multiple types of data.Interviews, observations, ratingscales, psychoeducational tests,and specific tests for the assess-ment of attention, impulsivity,and activity all contribute to acomprehensive evaluation forADHD.

I. Interviews. Most formalevaluations begin with obtaininga thorough developmental

11 Task Force Report

history from the parents. Thisincludes information about anyprenatal or birth complications,illnesses (especially those accom-panied by high fevers), accidentsinvolving head trauma, eatingand sleeping patterns, acquisi-tion of developmental mile-stones, general temperament(especially compared to sib-lings), child care and educationalbackground, peer social status,parents' and siblings' social andacademic levels, and the pres-ence of any similar problemsamong family includingextended family members.Most of the information acquiredis considered important becauseof the assumed relationshipbetween neurophysiologicalinsults and later ADHD. Wenow know that the relationshipis not direct. Many childrenwith unfortunate histories ofbirth trauma, major illness, headinjury, late walking and talking,etc., manage to function quitewell. However, there are solidindicators that a disproportion-ate number of children withthese histories become ADHD(Shaywitz & Shaywitz, 1987).

Another purpose of inter-viewing the parents is to get asense of how the home is organ-ized, and of what expectationsare held for the child's behavior.Clearly there is an interaction be-tween what the child brings to asituation (in terms of geneticpredispositions to temperament,medical history, etc.) and the

environment of the home. Sdmechildren who would be pre-dicted to do very poorly on thebasis of their early developmen-tal indicators end up doing finebecause of the "goodness of fit"with their home environment.The opposite is also true. Fur-ther, it is important to have a feelfor the home environment inorder to select what treatmentoptions have the highest likeli-hood of working effectively.How much can the parents beexpected to participate in theintervention?

Interview information alsoshould be obtained from thechild's teacher(s), and from thechild him/herself. Teachers canindicate the severity of the prob-lem in comparison to otherchildren in the class, the situ-ations under which the behav-iors of concern seem relativelybetter or worse, and the extent towhich the problem is interferingwith academic productivity andsocial acceptability. Childrenoften can give surprisinglyaccurate descriptions of theirown behaviors, including thosenot directly observable bysomeone else. For example, theymay indicate what sorts of thingsgrab their attention, or what thenature of troublesome distrac-tions is (e.g., auditory versusvisual). They also often can ver-balize the extent to which theyfeel socially and academically in-competent, and how thosefeelings are affecting their

motivation and self-esteem.A number of structured

interviews are commerciallyavailable and/or have shown upin the literature. Homemadeones appear to be just as useful ifthey are thoughtfully done.When constructing the interviewformat, it is especially importantto include questions relating tothe 14 DSM-11I-R criteria listedearlier.

2. Obsenutions. Obser-vations of the child's behavior inthe naturalistic environment(especially the home and school)can provide the most directindications of the presence orabsence of the symptoms ofADHD. Interviews and ratingscales are indirect, and theysuffer from possible reporterbiases. Tests given to the childare direct, but they usually aregiven in novel settings, usuallyon a one-to-one basis, and theytypically involve novel taskswhich thus may be more inter-esting to the child being testedthan s/he would ordinarilyconfront; therefore, tests aremore reactive, and they mayprovide unreliable indications ofhow the child does in the "realworld.* Careful observationsavoid these problems. Theirbiggest disadvantage is theamount of time they require.

It seldom is possible toobserve in the home environ-ment, and even when it is, thepresence of the observer some-times interferes with the normal


behavioral flow of the family tosuch an extent that the validityof the observation is compro-mised. Therefore, most formalobservations are done in theschool setting. However, whenobtainable, home observationscan be quite valuable. Visitingteachers and school socialworkers have specialized trainingwhich makes them especiallygood resources for obtaininginterview and observational data.

School observations shouldbe done with careful thought tothe time of day (Does the childdo better/worse in the morning,or after lunch, than at othertimes?), and to the type ofactivity (recess, lunch, lecture,seatwork, group versus individ-ual work, math versus readingversus writing, and complexityversus simplicity of the tasks).Usually the teacher can providegood information to aid theobserver in targeting appropriatetimes of the day and activitiesduring which the child is likelyto exhibit the behaviors ofconcern for the evaluation.

Observation methodologycan vary from merely watchingthe child to using complex,multiple behavior, multiplechild, time sampling procedureswhich have been developed andused widely for the purpose. Inorder to make the observation asefficient as possible, it is impor-tant to have it planned and or-ganized. Target behaviors whichcan be observed and counted

should be specified in advance.For example, if attention is thefocus, an independent seatworkactivity time might be chosen.The observer could operationallydefine attention as "looking atthe materials and appearing to beengaged." Then, using a stop-watch, the observer would check"yes" for every time the child wasseen to be paying attention atpre-set times, e.g., every time 15seconds passed. In order to get a"normative" sense for how thetarget child compared withothers, one or two classmatescould be observed in the samemanner. In one 25 minuteperiod, this observer would have100 possible times at which thebehavior was observed. It thenwould be a simple matter toconvert the results to a percent-age of time on task, and tocompare that with the norm forthe class (as represented by theother classmates observed).

Among the more sophisti-cated classroom observationprocedures which are used forthe assessment of ADHD are theRevised Stony Brook Observa-tion Code (Abikoff, Gittelman-Klein, & Klein, 1977) and theClassroom Observation System(Whalen, et al.,1978).

3. Rating scales. Ratingscales are the most popularmethods of assessing children'sADHD-like behavior. That isbecause rating scales are quickand inexpensive; they can beobtained from a variety of

individuals who have observedthe child in different contextsover extended time periods;several of the popular measureshave accumulated normativedata for comparison purposes;and evidence regarding theirreliability and validity often isavailable, and frequently is quiteimpressive compared to othertypes of assessment methods.For these reasons rating scalesoften are administered at differ-ent points in time for purposessuch as evaluating the effects ofinterventions (like drug trials).

In format, rating scalestypically consist of a statementregarding a behavior, e.g., "Hasdifficulty completing assign-ments,' or "Has many friends."The rater usually is asked tocheck on a two through fivepoint scale the extent to whichthat behavior is descriptive of thechild. Two point scales consistof categones for "yes" and "no,"or *true" and "not true." A fivepoint scale would have catego-ries such as "always," "usually,""sometimes," "seldom," and"never." Typically the good orpositive direction of items isvaried to avoid tendencies torespond with the same answer torepeated questions. The two ex-amples above ("difficulty com-pleting assignments" and "manyfriends") are reversed. Connersand Barkley (1985) provide agood review of child behaviorrating scales relevant for use withADHD children.


Informants for rating scalesusually are parents or teachers.Parents can give excellentinformation since they haveobserved the child's behavior ina variety of situations across anextended time frame. They alsoare highly motivated. However,the objectivity of their ratingsmay be compromised by theirlack of exposure to other chil-dren of the same age, their desireto respond in socially desirabledirections, and by any responsetendencies they may bring to theratings. Teachers tend to bemore objective, though theyusually are less invested in theprocess, and they have morelimited exposure to the child'sbehavior.

a. Parent scales. TheConners scales have been themost widely used. Originallyconsisting of 93 items, therevised version (Goyette, Con-ners, & Ulrich, 1978) has 48items. There also is a 10 item"Abbreviated Symptom Ques-tionnaire" (ASQ), sometimescalled the "Hyperkinesis Index"(Conners,1973), which can begiven to parents or teachers. The48 item scale yields scores for"Impulsive-Hyperactive," "Learn-ing Problem," and "ConductProblem," though these are notas distinct as one might wish forADHD identification purposes.For example, the LearningProblem scale contains inatten-tion items like "distractible" and"fails to finish things."

Two other popular parentrating scales are the RevisedBehavior Problem Checklist(RBPC) (Quay & Peterson,1983)and the Child Behavior Checklist(CBCL) (Achenbach & Edel-brock, 1983). The RBPC has an"Attention Problems-1mmaturity"scale which contains severalitems relevant to ADHD, but alsoincludes immaturity items (e.g.,"acts younger") which mayconfuse the issue. The CBCL hasa Hyperactivity factor, and theoverall scale is comprehensiveand well normed. However, theHyperactivity scale does notinclude items directly related toinattention; it focuses almostexclusively on excessive motoricactivity.

A newer parent rating scale,the Yale Children's Inventory(YCI) (Shaywitz, Schnell, Shay-witz, & Towle,1986), wasdeveloped explicitly for theassessment of ADD (as defined inDSM-III). Among the 11 scalesare "Attention," "Impulsivity,"and "Activity." While the scale isrelatively new, early researchresults are encouraging regardingits usefulness for assessing thesetypes of problems.

b. Teacher scales. Aswith the parent scales, theConners Teachers Rating Scalesare the most widely used. The39 item version (Conners,1969)has a 6 item 'Hyperactivity"factor which has been used oftenin research studies.

A newer instrument,

developed with DSM-III criteriain mind, is the ADD-H Compre-hensive Teacher Rating Scale(ACTeRS) (Ulmann, Sleator, &Sprague, 1984). Four empiricallyderived scales are included:"Attention," "Hyperactivity,""Oppositional Behavior," and"Social Problems." Good relia-bility and construct validity datahave been reported, though thescale is too new for much data tohave accumulated regardingpredictive or concurrent validity.

4. Psychoeducationaltests. Many of the tests given aspart of the routine psychoeduca-tional eValuation proceduresperformed in schools and clinicsprovide some information whichcan be useful in assessingADHD. For example, both theWechsler Intelligence Scale forChildren-Revised (WISC-R) andthe Wechsler Adult IntelligenceScale-Revised (WAIS-R) havesubtests which contribute to a"Freedom from distractibility"factor. Likewise, the KaufirianAssessment Battery for Children(K-ABC) and the Stanford-BinetIntelligence Scale: Fourth Editionhave short term memory taskswhich are sensitive to attentionand concentration problems.Unfortunately, poor scores onthese measures also may occurfor other reasons. For example,anxiety can lower performanceon these tasks, as can short termmemory difficulties. Also, asnoted earlier, auditory process-ing problems can interfere with


functioning on those itemswhich are presented verbally.Thus, results from standardpsychoeducational tests can beused to signal the possibility ofADHD-type problems, but mustbe interpreted cautiously. -

5. Specific tests of atten-tion, impulsivity, and hyperac-tivity. Tests of sustained atten-tion have been in use for anumber of years. Of these, the"continuous performance tests"are best known. The child isasked to attend over a set periodof time to a series of visual orauditory stimuli, and to indicatewhen a prearranged, low fre-quency stimulus occurs and torefrain from giving a responsewhen it does not occur. Forexample, the child may bepresented with a whole pagefilled with randomly orderedsingle digit numbers. S/he is toproceed row by row, circling any9 which is preceded by a 5.

Errors of omission and commis-sion are noted. Recently, severalcomputerized versions of con-tinuous performance tests havebeen marketed for the purposeof identifying ADHD children.For example, the GordonDiagnostic System (Gordon,McClure, & Post, 1986) containsa vigilance task in addition to adelay task to measure impulsiv-ity.

The most popular instru-ment for assessing impulsivityhas been the Matching FamiliarFigures test (MFF) (Kagan,Rosman, Day, Albert, & Phillips,1964). The test requires thechild to choose which of sixhighly similar figures is exactlylike a standard figure. Bothlatency of response and accuracyare recorded. Impulsive re-sponders are those who haveshorter response times combinedwith more errors. Twelve and20 item forms are available.

Copies of the norms are availablefrom Neil Salkind at the Univer-sity of Kansas.

Several procedures havebeen used to measure hyperac-tivity. For example, childrenhave been observed in play roomsituations where the room ismarked off into quadrants.Activity can be rated by thenumber of quadrant changes andby such things as the number ofdifferent touches of toys by thechildren. Recently, the develop-ment of an "actometer" thatmeasures truncal activity over aprolonged period has provided astandard assessment procedure(Porrino et al.,1983). However,it seems unlikely that such so-phisticated procedures arenecessary in most instances,especially given the fact thathyperactivity seems to be arelatively unimportant aspect ofthe ADHD child's symptomatol-ogy.

24


THE SCHOOLS' ROLE IN THEASSESSMENT AND DIAGNOSTICPROCESS FOR ADHD

In the majority of cases,concerns about a child's atten-tion and activity levels will arisefirst in the context of school.This occurs because schoolplaces greater demands on thechild than sthe previously hasexperienced both for durationand intensity of attention. Instill other cases, parents will bethe first to express concern, butthey will indicate their concernto school personnel rather thanproceeding directly to a physi-cian. How should the situationbe handled from that point?

All schools in Virginia arerequired to have Child StudyCommittees to receive referralsand discuss alternatives forworking with individual stu-dents. The focus of the ChildStudy Committee is on helpingthe child succeed in the regularclassroom environment. Mem-bership on the Committee variesfrom school to school, but is toinclude the Principal (or desig-nee), the referring source,regular classroom teachers, andspecialists who have expertiseapplicable to the case. Given thecomplexities associated withADHD, knowledgeable staffshould participate in making rec-ommendations concerningADHD children. This wouldeliminate inappropriate referrals.These knowledgeable profession-als may include the psychologist,school nurse, counselor, andspeech/language specialist whenattention deficits are suspected.

Parental involvement should besought as well during the ChildStudy process. A "case manager"should be appointed to keeptrack of the case, including themanagement of contacts withmedical personnel. Guidelinesfor Child Study have beenprepared by a task force of theVirginia Department of Educa-tion (1986). As with all otherreferrals, the goal of the ChildStudy Committee with ADHDchildren is to make sufficientalterations in the regular schoolenvironment so that the ADHDchild can function well.

Sometimes the Child StudyCommittee will determine thatthe problems are beyond thescope of what regular educationcan provide. In those cases,referral for formal assessment ofeligibility for special education isappropriate. If an evaluation ispursued, it must include the fourcomponents required by statespecial education regulations:educational, psychological,medical, and sodocultural. Theeligibility committee mayrecommend to the parents thatthey consult a medical specialistwith particular expertise inADHD. Generally, developmen-tal pediatricians, pediatric neu-rologists, and child psychiatristsare most familiar with ADHDissues, though many pediatri-cians have considerable experi-ence with this disorder. If thereare a number of appropriatemedical personnel available in

the community, it is customaryto give parents the names,addresses, and phone numbersof at least three. School person-nel will need to bt come in-formed about physicians in thismedical specialty. The MedicalSociety of Virginia can listphysicians practicing in aspecific area of the state. Localmedical societies or academies,where they exist, can provideinformation about specialty areasof practice. Of course, if parentsdo not wish to have the medicalevaluation done privately, theschool division is responsible forsecuring the medical component.When ADHD is considered apossibility, school personnelshould be certain that the physi-cian conducting the evaluationhas expertise with the disorder.

It is important for schoolpersonnel to communicate withthe physician, especially in caseswhere some evaluation alreadyhas been done in the schoolcontext, in order that the diagno-sis and subsequent treatmentplans may be coordinated andcomprehensive.

In a number of localitiesaround the nation local schooldivision personnel have beensued over issues related todiagnosis and treatment ofADHD. Typically the complaintshave arisen when parentsperceived that they were beingforced to get medication for theirchild by school personnel. Theyhave charged that, in effect,

22

The Schools' Role in the Assessment and Diagnostic Process for ADHD

school staff were practicingmedicine without a license. It iscritical that personnel in schoolsrecognize that the medicaldiagnosis of ADHD, and theprescription of drugs such asRitalin, are appropriately to beleft in the hands of trainedphysicians.

The special educationEligibility Committee mustdetermine whether or not thechild is eligible to receive specialservices. In order to qualify, thechild must be "handicapped,"and the handicap must impairschool functioning. Since thereis no separate ADHD conditionspecified under PL94-142 (asthere is for LD, visually im-paired, etc.), the situation can becomplicated. Many ADHDchildren also will be found

eligible for special education asLD, and some as "seriouslyemotionally disturbed." In thosecases, a child who also is ADHDcan be served in existing pro-grams, with the IEP expanded toinclude provisions necessitatedby the attentional problems.

What if the EligibilityCommittee determines that thechild does have ADHD and thedisorder is interfering withschool functioning, but the childdoes not qualify as LID, ED, etc.?The category "other healthimpaired" may be an option forconsideration. As with otherchildren found to be handi-capped and in need of services,an IEP then would be developedto specify annual goals andobjectives for intervention,including the extent to which the

child would continue to partici-pate in regular prograins and theanticipated duration of services.

With ADHD children whoare found to be handicapped, theprogram modifications specifiedon the IEP often will be evenmore individualized than is thecase with other handicappedchildren. For example, longertime to take tests, or provision ofsocial skills training, or altera-tions in the transportationarrangements may be consid-ered. The school staff memberwho is most appropriate foroverseeing implementation ofthe 1EP may not be a teacher,especially if academic skillacquisition is not a problem forthe particular ADHD child inquestion.

2 3,


MEDICAL INTERVENTIONSPHARMACOTHERAPIES

Medication, whether usedalone or in combination witheducational and psychological/psychiatric interventions, clearlyis the most widely used proce-dure for management of ADHD.Drug treatment has been quitecontroversial for many years, andit remains so today.

As early as the 1930's it wasnoted that stimulants improvedthe functioning of hyperactivechildren, appearing to calm themdown. At one time this effectwas considered to be "paradoxi-cal* in view of the fact thatstimulants generally werethought to make normal indi-viduals more active. In fact, onecommon suggestion for deter-mining if a child was reallyhyperactive was to give a stimu-lant drug on a trial basis; if theeffect was calming, then thechild was considered hyperac-tive. It is now recognized,however, that normal childrenalso respond positively tostimulant medications, withimproved attention and concen-tration reported for normalchildren and adults in a numberof studies (e.g., Rapoport et al.,1980; Werry, 1982). Anotherprominent misconception had todo with the effects of puberty onchildren taking stimulants. Thisbelie f was influenced considera-bly by Laufer and Denhoffs(1957) assertion that the symp-toms of hyperactivity "...wanespontaneously and disappear,"

thus indicating that ADHD isonly a childhood disorder. Asstated earlier, while motoricactivity does abate, inattentionand impulsivity continuethrough adulthood. Stimulantmedications appear to maintaintheir usefulness at least throughadolescent years.

How helpful are stimulantmedications? Careful researchstudies, using control groupsand "double blind" procedureswith placebos so that there wasno way for the child, the parents,or the teachers to determinewhen a child was and was notreceiving medication, clearlyindicate that stimulant drugshave a positive effect in 60-80%of diagnosed ADHD children(e.g., Barkley, 1977; Shaywitz &Shaywitz, 1987). These effectsinclude improved attention,lessened quantity and intensityof motoric activity, improvedcompliance to parents' andteachers' requests, increasedappropriate social interaction,higher efficiency at problemsolving tasks, and increasedacademic productivity.

How do the drugs work?While this remains a question forfurther research, it generally isbelieved that most ADHDchildren have a neurochemicalimbalance in which the neuro-transmitters which carry im-pulses in the brain are affected.This results in an underarousal.The drugs appear to stimulatethose parts of the brain involved

in transmitting information,especially at the neural synapses,so that the brain functions moreefficiently.

Three drugs account for thevast majority of prescriptions forADHD. All three are stimulants.Since these are seen so fre-quently, information about eachwill be provided.

NIETPLPHENIDATEHYDROCHLORIDE - "RITAUN."Ritalin is the trade name for thedrug which is, by far, the mostcommonly used. In fact, consid-erable concern has been ex-pressed that Ritalin may be beinggrossly overprescribed, at anever-increasing rate, with theeffect that far too many childrenare "drugged" in school. Data donot support these concerns. Thebest estimates available indicatethat prevalence rates for anydrug treatment for ADHD rangefrom 0.75% to 2.6% of theschool population, depending onage of the children and onlocation in the United States. Acareful analysis of the amount ofRitalin ordered by pharmacistsand the amount produced by thepharmaceutical company (CIBA)indicated that there was little in-crease from 1980-86 (Shayw Liz &Shaywitz, 1987). Of course thesedata do not preclude the possi-bility that some physicians insome locations are prescribingthe medications to an excessiveextent.

Medical Interventions18

Rita lin comes in 5,10, and20 milligram (mg.) doses. Therecommended initial dose isbased on how large the child is.Usually, .3 mg for each kiiogramof body weight is the startingdosage, to be given once or twicea day. Since a kilogram is a littleover two pounds, an 70 poundchild might be started with a 10mg dose. The maximum dose isusually .8 mg/kg. Ritalin's effectsoccur very quickly. Typically itbegins to take effect within 30minutes, and it reaches its peaklevels within 2-3 hours. Thus, ifit is given at around breakfasttime, it will be exerting its effectsby the time the child is involvedin school work. It lasts no morethan 4-6 hours for most chil-dren. Therefore, a second doseat around lunch time may benecessary, especially if theacademic load is heavy in theafternoon. Generally, it is best toplace the child in the moreacademic subjects in the morn-ing so that the attentionalprocesses will be maximal whenthey are most needed.

A slow release Rita lin(Rita lin-SR) has been introducedin the past few years. It comesin 20 mg doses. It was hopedthat this would allow the child toavoid having to take a seconddose during the school day.Initial reports about this drughave been disappointing, how-ever. Apparently, the release ofthe drug is variable, dependingto a considerable extent on the

individual child's metabolism.Thus, Rita lin-SR is not pre-scribed as often as the othertypes, unless there are reasonswhy the child cannot or will nottake the drug at school.

DEXTROAMPHETAMINE -"DEXEDRINE." Dexedrine isused considerably less often thanRitalin, apparently in partbecause of the reputation whichis in the public's mind of thedrug being an often abused streetdrug ("speed"). However, thereare indications that Dexedrine isequally as effective as Ritalin.Dosage levels generally are onehalf that of Ritalin. Dexedrine isabsorbed at about half the rate ofRitalin, so it may be necessary totake the initial dose a little earlierin the morning.

PEMOUNE - "CYLERT." Cylert isa newer drug. Research indi-cates improvement rates similarto Ritalin atid Dexedrine forattention problems. One disad-vantage to Cylert is that thedrug's full effects require severaldays or even weeks to be seen,and once stopped, it is not fullyeliminated from the system forseveral more days. This makes itmore difficult to evaluate howmuch of any change in behaviorwhich occurs is due to the druge ffects.

Dosage levels of Cylert areunusual. It comes in capsules of18.75, 37.5, and 75 mg. Initialdosage is .5 mg/kg, with a

normal maximum dose of 3 mWkg. It is given only once a day,in the morning, which is anadvantage since neither the childnor school personnel must beinvolved in a second dose duringthe day.

At this point, Cyiertappears to be prescribed in caseswhere side effects were notedwith Ritalin and/or Dexedrine, orin situations where the issue oftaking a medication at schoolwas seen as problematic.

Side effects. The two mostcommon side effects of stimulantmedications are loss of appetiteand difficulties in sleeping.Sometimes involuntary move-ments occur, and some reportsof depression have been noted.There was fear that these drugswould result in growth retarda-tion. However, more recentresearch indicates that long termeffects are quite minimal atnormal dosage levels (Shaywitz

Shaywitz, 1987). Stimulantmedications can exacerbate thesymptoms of other disorders,including multiple tic disorderssuch as Tourette's Syndrome andpsychiatric disorders such as de-pression and schizophrenia.However, there are no indica-tions that the drugs cause thesedisorders. Usually these sideeffects can be managed byreducing the dosage level, or byswitching to another drug.

An important finding fromresearch studies of the last fewyears is that the ideal dosage

r r.4;


level for cognitive effects such asattention and memory is sub-stantially lower than that re-quired for changes in activitylevel (e.g., Shaywitz & Shaywitz,1987; Sprague & Sleator, 1977).Thus, if the assessment of thedrug's effects is based only onhow much the activity level isdecreased, there is a goodpossibility that the dosage will betoo high to achieve positiveeffects on school performance.

"Drug holidays," periodssuch as weekends and summervacations when the child is notgiven the medication, often arerecommended. The idea is tomaximize the effect of the drugwhen it is given, and to mini-mize the possibility of growthretardation to the extent pos-

sible. This generally is a goodidea unless the child's behaviorduring the time off the medica-tion is such that it interferes withfamily or other social function-ing. If the family is taking a triptogether in a car, for example,they may find that the negativeinteractions among familymembers which may be spurredby the ADHD child far outweighthe positive effects of the drugholiday.

While there can be littledoubt about the positive effectsof stimulant medications inincreasing attention for themajority of ADHD children, thisintervention is extremely limitedin scope. For one thing, thereremain 20-40% of children forwhom the positive effects are not

seen. More importantly, whenthe drugs are effective, theymerely make it possible for thechildren to behave and to learnmore normally in the future.The drugs do not cure poorsocial skills or negative behaviorpatterns which have beenlearned in the past; nor do theymake the child smarter; nor willthe child suddenly be able to domath problems which they didnot understand because theycould not pay sufficiently goodattention when the concept wastaught a year or two earlier.Thus, it is critical that a compre-hensive treatment program beimplemented for the ADHDchild. Such a program mustinclude school and home.

28


SCHOOL-BASED INTERVENTIONSCLASSROOM ALTERATIONSSince it is in the school environ-ment that the majority of ADHDchildren experience their mostserious difficulties, it is obviousthat alterations to the typicalsetting and instructional pro-gram of the schools will berequired if the ADHD child is tosucceed. Of course many ADHDchildren also are identified as LDor ED. For those childrenspecial environments such as selfcontained or resource classes,with specially trained teachers,may already be part of theeducational program. Manydiagnosed ADHD children arenot eligible for formal specialeducation services, however. Re-gardless of the nature of theclassroom and of the training ofthe teachers, many of the sugges-tions offered below (adaptedfrom Cobb, 1987) can be useful.These suggestions can beadapted to meet the needs ofmiddle and high school studentsas well as elementary students.Middle and high school studentsoften require extra assistance andunderstanding because of theirpoor study and organizationalskills.

I. Place the child in the leastdistracting location in theclassroom. This may be inthe front of the classroom,but should be away fromdoors and windows. Itmay be necessary to havethe child face a blank wall,or to provide a special

work place away from thegroup.

2. Provide as much structureand routine as possible.Keep the routine the samefrom one day to another.When transitions orunusual events are tooccur, try to prepare thechild for what is to comeby explaining the situationand describing appropriatebehaviors in advance.

3. For individual seat work,help the child get started.It may prove helpful tohave the child verbalize toyou what the task is andhow they are to approachit. Check back periodi-cally to see if the child isstill on track.

4. Make frequent contactwith the child by touchingor by speaking the child'sname. Be sure that youhave his or her attentionbefore speaking.

5. Generally, multiple mo-dalities of instruction willbe more effective in main-taining attention andincreasing learning. Thuscombining a visual tactileapproach with verbalinstruction will be prefer-able to verbal instructionalone.

6. Adapt work sheets so thatless material is on eachpage.

7. Break assignments intosmaller chunks. Do not

expect that the child willbe able to work independ-ently for lengthy timeperiods.

8. Give the child extra timeto work on assignmentswhen needed, withoutcriticism or fanfare.

9. If the child has troublestaying in one place forlong periods of time,alternate desk, standing,group, and moving aroundactivities throughout theday.

10. Use learning aids such ascomputers, typewriters,calculators, tape recorders,etc. These seem to struc-ture learning, and theyalso maintain interest bytheir nature.

11. If note taking is a prob-lem, arrange to have amore attentive classmateshare notes by photocopy-ing or using carbon paper.

12. Use multiple choice testsor one-on-one oral tests todetermine the child'smastery of content.

13. Give regular feedback, andpraise success.

Three major models forschool based interventions havebeen used frequently. One isstimulus reduction, based onthe belief that eliminatingdistractors in the environment isthe best way to ensure that theADHD child will focus on theappropriate stimuli. Placing the

27


child in study carrels to avoidvisual distractions and using earplugs to eliminate auditorydistractors are examples of thistechnique. The stimulus reduc-tion procedures seem to workwell with some children, thoughcertainly they are insufficient bythemselves to manage the ADHDchild's educational program.Another set of techniques whichhave proven useful in managingthe behavior of ADHD childrencome from behavior modifica-tion, including systematicrewards as well as non-aversivepunishments such as "time out"and "response cost" programs.

Both stimulus reductionand behavior modification havebeen criticized on the groundsthat they foster dependence oncontrived and externally con-trolled events. Research hasindicated that many ADHDchildren accept a passive posturewhen confronted with academictasks. They rely on adults tostructure situations for them andto provide them with problemsolving strategies. There isconcern that setting up a non-distracting environment for thechild, providing tangible rein-forcements, and perhaps admini-stering drugs to the child en-courage the ADHD child'sdependence and passivity by notallowing or requiring the child todevelop and use his or her ownstrategies.

Over the past decade or so,the most prominent. approach to

teaching academic and socialbehavior to ADHD children hasbecome cognitive behaviormodification (CBM). CBMprocedures attempt to make thechildren consciously aware oftheir own thinking processes andstrategies, and to give themresponsibility for their ownreinforcement. An example isprovided by Hallahan, Lloyd,and Stoller (1982). They de-scribe a self-monitoring programfor improving attention. Afterdescribing the purpose of theprogram to the child and givingsome practice, the child goes towork on a regular seatworkassignment. When the childhears a piano note (pre-recordedon a tape recorder to go off everyso many seconds or minutes),the child is to ask, "Was I payingattention?" The child thenmarks "yes" or "no" on a paperattached to the top of the desk.If the answer is "yes," the childcongratulates him/herself, if"no," statements are verbalizedabout why and how to attend.This type of intervention hasbeen very effective for specificbehaviors such as paying atten-tion during seatwork. Broaderapplications of CBM approachesalso have been developed to aidthe child in generating problemsolving strategies for all types ofacademic tasks as well as forapproaching homework, socialsituations, etc.

No single approach,including CBM (see Abikoff,

1987), has been uniformlysuccessful. Since ADHD chil-dren present with multipleproblems, combined rather thanalternative treatments are neces-sary.

An important function ofschool personnel is to serve asthe eyes and ears for the physi-cian when stimulant medicationshave been prescribed. Initialprescriptions always are subjectto modifications, with the goal offinding the best fit for an indi-vidual child. However, mostphysicians are quite limited intheir capability to follow up todetermine how a specific dosageof a given drug is affecting achild's behavior in the schoolenvironment. While someschool personnel feel it ispresumptuous of them to initiatecontact with physicians for thepurpose of feedback, such linksare very important in the totalmanagement of the ADHD child.It is a rare physician who wouldnot welcome the information.Once contacts are established,future relationships are muchmore likely to be cooperative,and that certainly will benefitchildren. The designated contactperson between the schools andthe physician also should makesure that parents are included inthe 'feedback loop." In manycases, it will be simplest for theschool's contact person toacquire and communicate parentperceptions regarding medica-tion effects at the same time that

1

144

..


school information is providedto the physician. Of courseparents need to know what ishappening at school as well.

When ADHD childrenmust take medication at school,it is very important that schoolpersonnel handle the situationsensitively. In most schools,drugs must be administeredthrough the school office or theschool nurse. Teachers mustavoid embarassing the child byannouncing, in front of thewhole class, "Time to go takeyour medicine." likewise, officestaff must be sensitized to thepotential emotional harm whichcan come from singling out theADHD child in this way. Themedication should be handleddiscretely, with respect for theprivacy and dignity of the child.

A related issue has to do with thecommon mistake made byteachers and parents of givingthe medication too much creditor blame for the child's behavior.When the child is misbehaving,s/he slibuld not be asked, "Haveyou taken your pill? Suchquestioning, associated thatdirectly with bad or goodbehavior, fosters the belief in thechild that s/he is not responsiblefor the behavior.

Since the social skill deficitsof ADHD children may be asdebilitating to their ftmctioningas are academic deficiencies,many school divisions haveinstituted interventions in thisarea, too. Some teachers includesocial skills information as partof their curriculum. Morecommonly, counselors, school

psychologists, or social workerswill work directly with ADHDchildren around these issues.Sometimes this is done one-to-one, but more often small groupsprovide a better setting for thetraining. The best approach isdirect instruction with plenty ofopportunity for modeling andpractice with feedback. Topicscan be as simple as "making eyecontact when talking to some-one" or "how to shake hands."Other topics typically includerecognizing emotions, what todo when you are angry, how tomake friends, etc. Several socialskill programs are commerciallyavailable. These provide usefulinstructional aids such as handpuppets, stimulus pictures, andvignettes of social situations.


PARENT/FAMILY ISSUESRaising children is a trying,

humbling experience for parentsin the best of situations. Thereare times in every family whenstress levels are elevated to thebreaking point. For familieswith an ADHD child, the task isparticularly difficult. The childis not as reinforcing as are otherchildren s/he is harder tolove, and the pressure is moreconstant. To a much greaterextent than with other children,parents must oversee every partof the ADHD child's life. Athome, the child's room typicallyis messy and disorganized:getting dressed and ready forschool often requires direct helpfrom the parent, and may turninto a battle at any time; struc-tured situations such as meal-times can be disastrous; andfamily outings may turn intoembarassing fiascos at any time.Peer interactions have to bemonitored, and sometimescontrived, due to the unpopular-ity of the child. Homeworkfrequently is not completedwithout regular supervision. Yet,

with all this, the child looksnormal and seems intelligent. Itwould be easier, perhaps, toaccept the behavior if the under-lying problem were moreevident.

For many parents, having aclear and definitive diagnosis isthe first step toward learning tocope with the difficulties. It isimportant that parents be givenas much accurate information aspossible about the disorder.They may benefit greatly fromreading about the problem andhow others have dealt effectivelywith it. Physicians and schoolpersonnel can be sources if theywill educate themselves andmake material available. Openand frequent communicationwith teachers and others in-volved in the child's educationalprogram is essential.

Often parents and otherfamily members can benefit fromcounseling/therapy with quali-fied mental health professionalswho have an understanding ofADHD. Child management

issues frequently are topics ofconcern, but all kinds of othernormal problems of living maybe exacerbated by living with anADHD child.

Many parents have found itvery helpful to get their childinvolved in activities outside thehome. Sports may be one goodoutlet for the child. Generally,ADHD children have consider-able trouble with sports likebaseball which are highly rule-governed and which require thatthe player concentrate evenwhen no overt action is occur-ring. Sports like soccer usuallyare better choices because oftheir constant action and more"free form" nature.

In some locations, parentsof ADHD children have formedsupport groups which seem tohave great benefit. Since parentsmay not know who else is in asimilar situation, school person-nel or physicians may need toserve some initial coordinatingfunctions in helping to get suchgroups started.

30

Controversial Interventions 24

CONTROVERSIAL INTERVENTIONSAll sorts of other therapies

have been proposed for childrenwith attention deficit hyperactiv-ity disorder. Those discussedbelow are among the morepopular. They have severalshared characteristics: theirintroduction often is through thepopular media rather than inscientific journals; their theoreti-cal justification is inconsistentwith current scientific knowl-edge; studies which do notsupport the therapy are ex-plained away by refering to thehesitancy of the scientific andmedical establishment to acceptnew ideas; the danger of adverseside effects is minimized bynoting that the treatment relieson the use of *natural" sub-stances (special diets, vitamins),simple manipulations of thebody, or exercises; and layorganizations often emergewhich proselytize for the treat-ment (Shaywitz & Shaywitz,1987).

DIETARY ALTERATIONSThe best known therapy of

this type is the Feingold Diet, afood-additive free diet. In 1975Feingold wrote a book (WhyYour Child is Hyperactive) basedon anecdotal experiences fromhis pediatric practice. Since thencountless families have at-tempted to implement the diet inhopes of improving their child'sfunctioning. However, in areview of 13 controlled studiesutilizing the Feingold Diet,

Wender (1986) concluded thatfood colorings and other addi-tives had little or no effect on thehyperactive behavior of children.To date, no carefully designedstudies have supported the diet.

More recently, concernsabout the relation of sugar andADHD have received greatpublicity. Practicing physicians(45% in one surveyBennett &Sherman, 1983) often recom-mend low sugar diets to theirADHD patients. Research usingdouble-blind, placebo methodol-ogy has produced no convincingevidence to establish a relation-ship between sugar and adversebehavior of ADHD children.

Massive doses of vitamins(megavitamin therapy) have beensuggested as another dietaryintervention. However, noresearch support for this proce-dure exists, either.

NEUROPHYSIOLOGICALPATTERNING

Doman and Delacato(Delacato,1966) proposed aregimen designed to restoreintegtated neurological function-ing in children whose behaviorswere assumed to be the result ofbrain-injury. The therapyinvolves externally manipulatingthe child into body patterns(e.g., crawling) thought to becharacteristic of the level of thedamaged brain, imposinghemispheric dominance andlaterality, administering carbondioxide therapy, and stimulating

the senses to improve bodyawareness. The regimen requiresa great deal of time and, often,specialized equipment. Afterevaluating the research evidence,a number of organizations joinedthe American Academy ofPediatrics (1965) in their conclu-sion that patterning has nospecial merit, the claims of itsadvocates are unproven, and thedemands on families are so greatthat harm may result from itsUSC.

NEGATIVE EFFECTSInterventions such as

dietary therapies and patterningare obviously appealing to someparents and professionals.While perhaps not helpful, atworst these have been consid-ered harmless. However, it isimportant to recognize thepotentially adverse effects ofsuch approaches. Most clear isthe harm from diverting parents'energies from well-documentedmethods to non-productiveregimens. If parents believe thatfollowing a specialized diet,which may require extra shop-ping and more preparation time,is critical, they are less likely tohave the energy or time to seethat their child's teacher isproviding an optimal classroomenvironment. Further, otherchildren in the family may beforced to eat the same food,increasing their resentment fortheir ADHD sibling. Also, thereoften is considerable expense

31


involved in these unproventreatments.

While thought to beinnocuous, idiosyncratic thera-pies may later be shown to haveunexpected side effects. Oxygen

therapy for treating respiratoryproblems in premature infantsalso was felt to be safe wheninitially instituted. Oxygen is anatural substance, but it is nowknown that its use with infants

can produce blindness and otherproblems. Controversial thera-pies for ADHD also may beshown to be dangerous with thepassage of time.

32

Conclusions 26

CONCLUSIONSADHD is a complex,

frequently misunderstoodcondition which impacts allparts of the affected child's life.Optimal school functioning canbe achieved only when profes-sionals in and out of the schoolenvironment and the child'sparents develop a comprehensiveunderstanding of the disorderand work together to meet thechild's needs.


REFERENCESAbikoff, H. (1987). An evaluation of cognitive behavior therapy for hyperactive children. In B. B. Lahey & A.

E. Kazdin (Eds.), Advances in clinical child psychology (Vol. 10, pp. 171-216). New York: Plenum.

Abikoff, H., Gittelman-Klein, R., & Mein, D. F. (1977). Validation of a classroom observation code forhyperactive children. Journal of Consulting and Clinical Psychology, 45, 772-783.

Achenbach, T., & Edelbrock, C. S. (1983) Manual for the Child Behavior Checklist and Revised Child Behav-ior Profile. Burlington, VT: T. A. Achenbach.

American Academy of Pediatrics (1965). Executive board statement. American Academy of Pediatrics Newslet-

ter, December 1, 1965.

American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.).Washington, DC: Author.

American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised).Washington, DC: Author.

Barkley, R. A. (1977). A review of stimulant drug research with hyperactive children. Journal of Child

Psychology and Psychiatry, 18, 137-165.

Belamy, G. T. (1987). Response to inquiry from the Tennessee Department of Education. Education for theHandicapped Law Report, 211:472.

Bennett, F. C., & Sherman, R. (1983). Management of childhood "hyperactivity" by primary care physicians.Journal of Developmental and Behavioral Pediatarics, 4, 88-93.

Campbell, S. B., Breaux, A. M., Ewing, L. J., & Szumowski;E. K. (1986). Correlates and predictors of hyper-activity and aggression: A longitudinal study of parent-referred problem preschoolers. Journal of Abnor-

mal Child Psychology, 14, 217-234.

Cobb, E. (1987). The role of the teacher in attention deficit disorders. Bear in Mind (A newsletter for parentsfrom Children's Hospital, Richmond), 5, (3).

Conners, C. K. (1969). A teacher rating scale for use in drug studies with children. American Journal ofPsychiatry, 126, 152-156.

Conners, C. K. (1973). Rating scales for use in drug studies with children. Psychopharmacology Bulletin,

(special issue), 24-29.

Conners, C. K., & Barkley, R. A. (1985). Rating scales and checklists for child psychopharmacology. Psy-chopharmacology Bulletin, 21, 809-812.

Delacato, C. H. (1966). Neurological organization and reading. Springfield, IL: Charles C. Thomas.

Feingold, B. (1975). Why your child is hyperactive. New York: Random House.

Gordon, M., McClure, F. D., & Post, E. M. (1986). Interpretive Guide to the Gordon Diagnostic System. DeWitt,

NY: Gordon Systems.

34

References 28

Goyette, C. H., Conners, C. K, & Ulrich, R. B. (1978). Normative data on revised Conners Parent andTeacher Rating Scales. Journal of Abnormal Child Psychology, 6, 221-236. Hallahan, D. P. (in press).Special education: specific learning disabilitiesattention disorders. In T. Husen & N. Postlethwaite(Eds.). International encyclopedia of education: Research and studies supplement (Vol. I). London: Perga-mon Books.

Hallahan, D. P., (1989). Attention disorders: specific learning disabilities. In. T. Husen and T. N. Postleth-waite (Eds.), The international encyclopedia of education: Research and studies (Suppl. Vol. 1, pp. 98-100),New York: Pergamon.

Hallahan, D. P., Lloyd, J. W., & Stoller, L. (1982). Improving attention with self-monitoring. Charlottesville:University of Virginia Learning Disabilities Research Institute.

Kagan, J., Rosman, B. L., Day, D., Albert, J., & Phillips, W. (1964). Information processing in the child:Significance of analytic and reflective attitudes. Psychological Monographs, 78, (1, Whole No. 578).

Lahey, B., Schaughency, E., Strauss, C., & Frame, C. (1984). Are attention deficit disorders with and withouthyperactivity similar or dissimiliar disorders? Journal of the American Academy of Child Psychiatry, 23,302-309.

Laufer, M., & Denhoff, E. (1957). Hyperkinetic behavior syndrome in children. Journal of Pediatrics, 50, 463-474.

Loney, J. (1987). Hyperactivity and aggression in the diagnosis of attention deficit disorder. In B. B. Lahey &A. E. Kazdin (Eds.), Advances in clinical child psychology (Vol 10). New York: Plenum Press.

Pelham, W. E., & Murphy, H. A. (1986). Attention deficit and conduct disorders. In M. Herson (Ed.),Pharmocological and behavioral treatment: An integrative approach (pp.108-148). New York: John Wiley& Sons.

Porrino, L. J., Rapopoort, J. L., Behar, D., Sceery, W., Ismond, D. R., & Bunney, W. E., Jr. (1983). A natural-istic assessment of the motor activity of hyperactive boys. I. Comparison with normal controls. Archivesof General Psychiatry, 40, 681-693.

Quay, H. C. & Peterson, D. R. (1983). Revised Behavior Problem Checklist. Coral Gables, FL: Author. (Uni-versity of Miami)

Rapoport, J. L., Buchsbaum, M. S., Weingartner, H. P., Zahn, T. T., Ludlow, C., & Mickkelsen, E. J. (1980).Dextroamphetamine. Its cognitive and behavioral effects in normal and hyperactivity boys and normalmen. Archives of Journal Psychiatry, 37, 933-943.

Routh, D. K., & Schroeder, C. S. (1976). Standardized playroom measures as indices of hyperactivity. Journalof Abnormal Child Psychology, 4,199-207.

Rubin, K. H., & Clark, M. K. (1983). Preschool teachers' ratings of behavioral problems: Observational,sociometric, and social-cognitive correlates. Journal of Abnormal Child Psychology,11, 273-286.

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Schleifer, M., Weiss, G., Cohen, N. J., Elman, M., Cvejic, H., & Krueger, E. (1975). Hyperactivity in pres-choolers and the effect of methylphenidate. American Journal of Orthopsychiatry, 45, 38-50.

Shaywitz, S., Schnell, C., Shaywitz, B., & Towle, V. R. (1986). Yale Children's Inventory (YCI): A newlydeveloped instrument to assess children with attentional deficits and learning disabilities. I. Scale devel-opment and psychometric properties. Journal of Abnormal Child Psycholog y, 14, 347-363.

Shaywitz, S. E., & Shaywitz, B. A. (1987). Attention Deficit Disorder: Current Perspectives. A report to thecongress of the United States presented at the National Conference on Learning Disabilities, Bethesda,MD: National Institute of Chiid Health and Human Development (NIH), January 13, 1987.

Sprague, R. L., & Sleator, B. K. (1977). Methylphenidate in hyperkinetic children: Differences in dose effectson learning and social behavior. Science, 198, 1274-1276.

Thomas, A., Chess, S., & Birch, H. G. (1968). Temperament and behavior disorders in children. New York: NYUPress.

Ullmann, R. K., Sleator, E. K., & Sprague, R. L. (1984). A new rating scale for diagnosis and monitoring ofADD children. Psychopharmacolov Bulletin, 20, 160-164.

Virginia Department of Education (1986). A proposal for Child Study in public schools in the Commonwealthof Virginia. Richmond, VA: Department of Education.

Wender, E. H. (1986). The food additive-free diet in the treatment of behavior disorders: A review. Journal ofDevelopmental and Behavioral Pediatrics, 7, 35-42.

Werner, H., & Strauss, A. A. (1941). Pathology of the figure-background relation in the child. Journal ofAbnormal and Social Psychology, 36, 236-248.

Werry, J. S. (1982). An overview of pediatric psychophamiacology. Journal of American Academy of ChildPsychiatry, 21, 3-9

Whalen, C. K., Collins, B. E., Henker, B., Alkus, S. R., Adams, D., & Stapp, S. (1978). Behavior observationsof children and methylphenidate (Ritalin) effects in systematicallyy structured classroom environments:Now you see them, now you don't. Journal of Pediatric Psychology, 3,177-184.

COMMONWEALTH of VIRGINIADEPARTMENT OF EDUCATION

P.O. BOX 2120RICHMOND 23216-2120

TO: Reader

FROM: Harley Tomey, SpecialistLearning Disabilities

DATE: February 6, 1995

RE: New DSM-IV Definition of Attention-Deficit/Hyperactivity Disorder

Recently, the American Psychiatric Association published its fourth edition of the Diagnostic

and Statistical Manual of Mental Disorders (DSM-1V). This new edition replaces the DSM

III-R and includes a revision of the criteria for Attention-Deficit/Hyperactivit7 Disorder (pp.

78-85). The attached three page document is to replace the Current Definition section

found in this publication, ttention I ef cit I. eractivi IsT a Sc

If you have any questions or would like more copies of this publication or Supts. Memo. No.

1, dated October 2 1991, Oarification of es ons'bili to cl s the Needs o dren

with Attention Deficit Hyperactivity Disorder. Please call me at (804) 371-8283.

HAT/htattachment

CURRENT DEFINITION

According to DSM IV (1994) the essential feature of ADHD is "a persistent pattern ofinattention and/or hyperactivity-impulsivity that is more frequent than is typically observedin individuals at .a comparable level of development" (p.78). These symptoms may bemanifested in academic, occupational, and/or social situations. It is believed that mostindividuals will have symptoms of both inattention and hyperactivity-implusivity. However,there are some individuals who will have symptoms that are predominantly those ofinattention while others will have symptoms that are predominantly those of hyperactivity-impulsivity. The appropriate determination should be based on the predominant symptompattern for the past 6 months. Thus, the three subtypes of ADHD are

ADHD, Combined Type. This subtype should be used if six or more symptoms ofinattention and six or more symptoms of hyperactivity-iznpulsivity have persisted forat least 6 months.

ADFID, Predominantly Inattentive Type. This subtype should be used if six or moresymptoms of inattention but fewer than six symptomsof hyperactivity-impulsivity havepersisted for at least 6 months.

ADHD, Predominantly Hyperactive-Impulsive Type. This subtype should be used ifsix or more symptoms of hyperactivity-impulsivity but fewer than six symptoms ofinattention have persisted for at least 6 months. However, inattention may often still

be a significant feature.

The diagnostic criteria for ADHD (pp. 83-85) is based upon observable characteristics. Itspecifies that the following occur:

Either A or B:

A. Six or more of the following symptoms of inattention have been persistent forat least 6 months to a degree that is maladaptive and inconsistent with thedevelopmental level of the individual:

1. often fails to give close attention to details or makes careless mistakesin schoolwork, work, or other activities

Z. often has difficulty sustaining attention in tasks or play activities

3. often does not seem to listen when spoken to directly

4. often does not follow through on instructions and fails to finishschoolwork, chores, or duties in the workplace (notdue to oppositionalbehavior or failure to understand instructions)

5. often has difficuhy organizing tasks and activities

35

6. often avoids, dislikes, or is reluctant to engage in tasks that requiresustained mental effort (such as school work or homework)

7. often loses things necessary for tasks or activities (e.g., toys, schoolassignments, pencils, books, or tools)

8. is often easily distracted by extraneous stimuli

9. is often forgetful in daily activities

B. Six or more of the following symptoms of hyperactivity-impulsivity have been

persistent for at least 6 months to a degree that is maladaptive and

inconsistent with the developmental level of the individual:

Hyperactivity

1. often fidgets with hands or feet or squirms in seat

2. often leaves seat in classroom or in other situations in which remaining

seated is expected

3. often runs about or climbs excessively in situations in which it is

inappropriate (in adolescents or adults, may be limited to subjectivefeelings of restlessness)

4. often has difficulty playing or engaging in leisure activities quietly

5. if often "on the go" or often acts as if "driven by a motor"

6. often talks excessively

Implusivity

7. often 6iurts out ansWeTs bekri qjistióiiihabàeñ completed

8. oftcn has difficulty awaiting turn

9. often interrupts or intrudes on others (e.g., butts into conversations or

games)

In addition to the above behaviors, DSM-IV specifies that

some hyperactive-impulsive or inattentive symptoms that caused the impairment must

be present prior to the age 7, even though many individuals are diagnosed after the

symptoms have been prosent for a number of years,

3

some impairment from the symptoms is present in two or more settings (e.g., at

school or work, at home and/or in social situations). However, it is very unusual for

an individual to display the same level of dysfunction in all settings orwithin the same

setting at all times. In fact, signs of the disorder may be minimal or absent when the

individual is under very strict control, in a novel setting, engaged in &specially

interesting activities, in a one-on-one situation, or while the individual experiences

frequent rewards for appropriate behavior,

there must be clear evidence of clinically significant impairment in social, academic,

or occupational functioning, and

the symptoms do not occur exclusively during the course of a psychotic disorder and

are not better accounted for by another mental disorder (e.g., Mood Disorder,Anxiety Disorder, or a Personality Disorder).

NOTE: Those individuals (especially adolescents and adults) who currently have

significant symptoms that cause functional impairment but no longer meet thefull criteria can be diagnosed as ADHD-In Partial Remission.

Those individuals with prominent symptoms of inattention or hyperactivity-

impulsivity but do not currently meet the full criteria for ADHD and it isunclear whether criteria for ADHD has previously been met, can be diagnosed

as ADHD-Not Otherwise Specified.

Some of the associated features of ADHD, which vary depending on age and developmental

stage, may include low frustration tolerance, temper outbursts, bossiness, stubbornness,

excessive and frequent insistence that requests be met, mood lability, demoralization,rejection by peers, and poor self-esteem. Academic achievement is often impaired and

devalued, which may lead to conflict with family and school authorities. Also, inadequate

self-application to tasks that require sustained effort may be interpreted by others as

indicating laziness, a poor sense of responsibility, and oppositional behavior. Family

relationships are often characterized by resentment and antagonism, especially because

variability in the individual's symptomatic-status-often- leads parent to believe that all the

troublesome behavior is willful.

Finally, while the disorder is not usually diagnosed prior to school entry, problems are often

noted before age 4. Boys are diagnosed at least three times more often that girls. There

appears to be a significant familial component it is very common to find that relatives of

a child with ADHD were considered to be hyperactive and inattentive when in school

American Psychiatric Assocaition (1994). Diagnostic and satistical manual of mental

disorders (4th ed.) Washington, DC: Author.

40

TO:

COMMONWEALTH of VIRGINIADEPARTMENT OF EDUCATION

P.O. BOX 2120RICHMOND 23216-2120

Directors of Pupil PersonnelDirectors of Special EducationPrincipalsParent Resource Centers

FROM: Harley Tomey, SpecialistLearning Disabilities.

DATE: February 6, 1995

RE: New DSM-IV Definition of Attention-Deficit/Hyperactivity Disorder, ADHD

As noted in Supts. Memo. No. 14, Informational dated January 27, 1994, the purpose of thememo is to alert you to the new definition of ADM recently published in the AmericanPsychiatric Association's fourth edition of the Diagnostig and Statistical Manual of MentalDisorders (DSM-IV) and to make sure that parent, teachers, support personnel, andadministrators are informed. This memo is not to endorse or refute the new DSM-IVdefinition but to make sure that you have this information since it will be used byprofessionals when determining if an individual has AMID.

DSM-IV which replaces the DSM III-R includes a revision of the criteria for Attention-Deficit/Hyperactivity Disorder (pp. 78-85):'This ñw ition dèiidisciiision of thediagnostic features of ADHD; the three subtypes; associated features and disorders; specificculture, age, and gender features; prevalence of ADHD; fanulial patterns; and differentialdiagnosis. The diagnostic criteria are provided for each subtype of ADHD. There is also

a discussion of the use of two new diagnoses, ADHD In Partial Remission and ADHD NotOtherwise Specified.

The attached four page document is to replace the Current Definition section found in theDepartment of Education's publication, Attention Deficit Hyperactivity Disorders and theSchools. If you have copies of this document, please make sure to include a copy of theattached document when you distribute it. This will inform parents, teachers andadministrators of the most current DSM-IV definition and criteria for the diagnosis ofADHD.

41.

ANALYSIS OF CHANGES IN CRITERIA FOR ADHD

The following are the major changes in the criteria for ADHD.

Three subtypes are identified, each with their own criteria. They are:

ADHD, Predominantly Inattentive Type;ADHD, Predominantly Hyperactive-Impulsive Type; andADHD, Combined Type.

NOTE: In DSM-III-R the diagnosis was only ADHD, however, the 14 DSM-III-Rbehavior discriptors are found in the three subtypes either verbatim or in a modifiedform in DSM-IV also four new behavior discriptors have been added.

"Some impairment from the symptoms is present in two or more settings (e.g., atschool or work, at home and/or in social situations)."

NOTE: In DSM-III-R cross settings impairment was implied but not as clearly statedas it is in DSM-IV.

There must be "clear evidence of clinically significant impairment in social, academic,or occupational functioning."

NOTE: In DSM-III-R there was a range of severity from mild to moderate to severewhich is not included in DSM-IV.

The symptoms do not occur exclusively during the course of a psychotic disorder andare not better accounted for by another mental disorder (e.g., Mood Disorder,Anxiety Disorder, or a Personality Disorder).

NOTE: In DSM-III-R the only criterion is "does not meet the criteria for a PervasiveDevelopmental Disorder" even though the importance of a differential diagnosis wasdiscuued.

Individuals (especially adolescents and . adults) who currently, lave significantsymptoms that caute functionalimpairmint but nolonger meet the full critezia -canbe diagnosed as ADHD-In Partial Remission.

NOTE: In DSM-MR this could have been included under UndifferentiatedAttention-Deficit Disorder.

4 2

Those individuals with prominent symptoms of inattention or hyperactivity-impulsivity,but who do not currently meet the full criteria for ADHD and where it is unclearwhether the criteria for ADHD have previously been met, can be diagnosed asADHD-Not Otherwise Specified.

NOTE: In DSM-III-R this could have been included under UndifferentiatedAttention-Deficit Disorder.

AMERICAN PSYCHIATRIC ASSOCIATION REVISION PROCESS

The American Psychiatric Association reports that its revision process went through a three-stage empirical process that included:

Comprehensive and Systematic Review of the Published Literature: The goal of theDSM-IV literature reviews was to provide comprehensive and unbiased informationand to ensure that DSM-IV reflects the best available clinical and research literature.To assist the work groups in this endeavor conferences were provided to helparticulate for all work groups a systematic procedure for finding, extracting,aggregating and interpreting data in a comprehensive and objective manner.

Reanalysis of Already-Collected Data Sets: When a review of tbe literature revealeda lack of evidence or conflicting evidence for the resolution of an issue, twoadditional resources were used to help make final decisions. These were reanalysesand field trials. Researchers at different sites collaborated by subjecting their datato the questions posed by the DSM-IV work groups. These questions concernedcriteria included in DSM-III-R or potential criteria to be included in DSMIV. Asa result, the data reanalysis made it possible to generate several criteria sets thatwere then examined in DSM-IV field trials.

Extensive Issue-Focused Field Trials: The DSM-IVfield trials allowed the workgroups to compare alternative options and to study the possible impact of suggestedchanges. The field trials compared DSM.III, DSM-III-R, InternationalClassificationof Diseases and Related Health Problems-10th edition (ICD-10) and the proposedDSM-IV criteria. The field trials collected information on the reliability andperformance characteristics of each criteria set as a whole as well as of specific itemswithin each criteria set. These trials also helped to bridge the boundary betweenclinical research and clinical practice by determining bow well suggetions for changethat are derived from clinical research finding apply in clinical practice. The 12 fieldtrials included more than 70 sites and evaluated more than 6,000 subjects.

It should be noted that according to the authors of DSM-IV, the threshold for maltingrevisions in DSM-IV was set higher than that for DSM-III and DRAzta. Decisions bad

be substantiated by explicit statements of rationale and by the systematic review of

43

relevant empirical data. If empirical data justified it, criteria sets were clarified andsimplified. Also there was an attempt to strike a balance in DSM-IV with respect tohistorical tradition as embodied in DSM-III and DSM-III-R, compatibility with ICD-10,evidence of literature reviews, analysis of unpublished data sets, results of field trials, andconsensus of the field. Also, the authors noted that major changes to solve minor problemsrequired more evidence than minor changes to solve major problems. For more informationon the process used you may either contact the American Psychiatric Association, 1400 KStreet, N.W., Washington, DC 20005 or read the introduction of the fourth edition of theDiagnostic and Statistical Manual of Mental Disordert (DSM4V).

Finally, while this memo is to be informative, one needs to remember that a school division

may not refuse to evaluate a student for the need for special education and related servicessolely by reason of a prior medical diagnosis of ADHD, and conversely, a school division cannot require a medical diagnosis of ADHD prior to the evaluation for the need for specialeducation and related services. Each school division has an affirmative obligation toevaluate a child who is suspected of having a disability to determine the child's need forspecial education and related services. The evaluation must be conducted in accordancewith Part B regulations of IDEA and the Regulations GoverningSpeciaLEducation Programsfor Children with Disabilities in Virginia. If you have any questions regarding ADHD orwould like copies of the Department's publication, Attention Deficit HyperactivilvDisordersand the Schools, and Supts. Memo. No. 1, dated October 2, 1991, Clarification of

t1 e g a., stDisorder. Please call me, Harley Tomey, at (804) 3714283.

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