The core symptoms of ADHD are inattention and hyperactivity-impulsivity.  Although most children with ADHD struggle in both areas, and are diagnosed as having the combined subtype of ADHD, a substantial number show high levels of inattentive symptoms only.  These children are frequently described as having ADD rather than ADHD; technically, however, the correct term is ADHD, Predominantly Inattentive Type, or ADHD-I.

Some prominent ADHD researchers have suggested that although children with the inattentive and combined subtypes of ADHD both show high rates of attention difficulties, these are really very different disorders.  Children with the inattentive type tend of have more severe alertness/orientation problems, including more symptoms of sluggish cognitive tempo and slower processing speed.  Socially, they are less aggressive but more highly withdrawn and passive and may have even greater social difficulties.

Given the large number of ADHD treatment studies that have been conducted it is surprising to note how little work has focused exclusively on treatment for children with ADHD-I.  The limited evidence that is available for the treatment of ADHD-I is focused primarily on stimulant medication and initial results suggest that medication treatment is about as effective for these children as for children with the combined type of ADHD.

Behavioral interventions for children with ADHD-I, however, have not previously examined and this is an important gap in the literature.  The literature on behavior therapy for ADHD has focused on evaluating programs that have been for children whose ADHD includes both inattentive and hyperactive-impulsive symptoms.  These children have substantially greater problems with aggression and other forms externalizing behavior than children with ADHD-I and tend to have different types of social difficulties.  Thus, programs that may be effective for them may not adequately target the different types of problems experienced by children whose difficulties are restricted to inattention.

Given the absence of research on behavioral therapy for children with inattentive ADHD, a study published in a recent issue of the Journal of the American Academy of Child and Adolescent Psychiatry represents an important addition to the field [Pfiffner, L., et al. (2007). A randomized, controlled trial of integrated home-school behavioral treatment for ADHD, Predominantly Inattentive Type. JAACAP, 46, 1041-1050.] 

Participants were 69 2nd-5th grade children (23 females) all of whom were diagnosed with ADHD-I.  The sample had a good representation of minorities and included families from a wide range of socioeconomic backgrounds. Only 2 children were taking medication at the beginning of the study and none began medication during the 12-week program.

Participants were randomly assigned to the newly developed intervention called the CLAS Program (Child Life and Attention Skills) or to a "treatment as usual" control group. (Unfortunately, details on what treatment as usual consisted of are not provided.)  Unlike existing behavioral treatments for ADHD, The CLAS Program was designed to target the most prominent difficulties for children with ADHD-I and included the three inter-related components described below. 


- Teacher Consultation -

Each child's teacher was given an overview of behavioral interventions and classroom-based accommodations for ADHD-I, followed by 4-5 1/2 hour meetings of teacher, parent, child, and therapist over 12 weeks.  In addition, a daily report card system in which teachers rated key target behaviors for each child, e.g., completion of assigned work, accuracy of completed work, appropriate social behavior) was implemented so that parents were kept informed of their child's progress in these key areas.  This enabled parents to reward children on a daily basis for attaining important classroom goals. Environmental and academic accommodations such as preferential seating, reduction in assigned work, help with organization) were provided as needed to each child.


- Parent Training -

A 12-week parent-training program that included 6-8 families began with an overview of ADHD-I followed by a set of strategies for managing ADHD-I and associated impairments.  Strategies covered included the use of positive attention, rewards, establishing effective routines, planning activities, giving directions and commands, and using prudent negative consequences.

In contrast to parent training programs developed for children with the combined type of ADHD, where acting out behavior problems are more common, there was less focus on disciplinary strategies and greater focus on improving homework routines, independence, and organizational and time-management skills to improve academic performance.  Parents were also taught ways to promote and reinforce their child's use of social skills that were covered in the children's groups (see below).


- Child Skills Training -

The Child Skills Training Groups met concurrently with the parent training groups.  Child groups were divided into modules focused on skills for independence, e.g., academic, study and organizational skills) and skills for social competence, e.g., being a good sport, combating "spaciness", being assertive, dealing with teasing, and initiating friendships. 

Each module provided children with knowledge about the specific skills being addressed as well as providing ample opportunity for rehearsal and practice.  Children were helped to become more "alert" by group-reinforced attention checks during which the children were prompted to repeat the last comment made or the last activity that had occurred.  Role-plays of common problem situations for children with ADHD-I were included in each module.  Each week children brought in a record of rewards they had earned at home and school to exchange for rewards in the group setting.  This was done both to motivate the children and to promote the generalization of desired behaviors across settings.


- Measures -

A wide variety of measures were collected before, immediately following, and approximately 4-6 months after treatment ended to evaluate the impact of the CLAS program.  The primary outcome measure was the average ratings made by parents and teachers for the 9 inattentive symptoms of ADHD.  Parents and teachers also completed ratings of behavior indicative of "sluggish cognitive tempo", e.g., daydreaming, lost in a fog, sluggish/drowsy, which were also averaged.

In addition to these primary outcomes, parents and teachers rated each child's social skills, organizational skills, and overall degree of improvement.  As with the primary outcome measures, parent and teacher ratings for these secondary measures were averaged.


- Results -

Compared to the treatment as usual group, children in CLAS showed a significant decline in DSM-IV inattentive symptoms.  Both groups started with an average of approximately 6.3 symptoms (out of 9) before treatment.  Immediately following treatment this had dropped to 3.0 symptoms for the CLAS group and to 5.1 symptoms for the control group.  Symptoms levels at follow up were 3.2 and 4.4 respectively.  Following treatment, 55% of the treated group had scores in the normal range compared to only 27% of the control group.  Similar results were found for ratings of sluggish cognitive tempo.

In addition to these positive results for the primary outcome measures, children in the CLAS group were also rated as showing greater improvement in social skills, organizational skills, and on overall impressions of improvement. 

Finally, all parents rated their overall level of satisfaction with the CLAS program as "very satisfied" and all but one rated their child's attention problems as improved.  More than 90% rated the strategies and skills taught as either "useful" or "very useful".  The vast majority of children - roughly 80% - reported enjoying the program and that it helped them to do better at home and school.


- Summary and Implications -
 
Results from this study support the efficacy of behaviorally based psychosocial treatment for children with ADHD-I.  As noted above, the CLAS Program "...led to statistically and clinically significant reductions in attention problems and improvement in organizational and social skills relative to the control group, and these reductions were maintained at follow-up."  The magnitude of the effect on inattentive symptoms was similar to what has been reported in studies of stimulant medication treatment for children with ADHD-I.

These are extremely encouraging results and the authors are to be commended for developing and beginning to evaluate a psychosocial intervention specifically geared to children with ADHD-I.  There are several important limitations to this study, however, several of which are acknowledged by the authors, which makes it premature to consider this an established treatment.

First, there is limited information provided on the services received by children in the treatment as usual control group.  We are told that only 2 of these children began medication during the study, which is a strikingly low rate.  How results for the CLAS Program would compare to children who received adequate medication treatment is thus unknown. 

Second, because the authors averaged parent and teacher ratings for all outcomes, it is not possible to know whether similar improvements were observed by both parents and teachers, or whether the overall effects were primarily attributed to greater improvements seen by only one of these groups.  In particular, because parents committed significant time to the program, it is possible that they were "biased" to see improvement in their child.  If both parents and teachers observed similar improvements, this would be quite impressive but the data is not presented in a way that enables this to be determined.

Third, there were no objective measures provided of children's academic performance.  Thus, whether the program resulted in tangible gains in children's academic success is unknown.

Despite these important limitations, results from this study are certainly encouraging and suggest that a psychosocial intervention that specifically targets the difficulties experienced by children with ADHD-I can be effective.  As the authors note, "future randomized, controlled trials are needed to compare and contrast the CLAS Program and medication treatment and examine their combination in multimodal approaches to identify the most efficacious approach to treating ADHD-I over time."  As such studies are hopefully published, I will be sure to include them in future issues of Attention Research Update.