In this issue...

* The impact of ADHD symptoms and Conduct problems on
   children's development

* The course of Oppositional Defiant Disorder in children
   with ADHD

* Preliminary reports of a promising new medication

* How ADHD effects preschoolers' understanding stories
 

* THANKS FOR YOUR FEEDBACK

I want to thank those of you who sent feedback about the
possibility of establish CE credits in conjunction with
ADHD RESEARCH UPDATE for mental health professionals.
It seemed as though enough people were interested in this
possibility for me to push ahead and try to arrange this.  I
hope to have the details worked about to begin in the
new year and will keep you posted.

As a reminder, this will be a feature that can be taken
advantage of only if you would like.  For those of you who
have a child with ADHD, the CE option for mental health
professionals will not affect your subscription in any way.

* MEDICATION TRIAL PROCEDURE

If you have not already done so, please check out the
medication trial program I have developed for use by
either parents or health care professionals. If you are
a parent considering the use of medication for your child,
or a professional interested in a convenient and systematic
way to obtain objective data on medication effectivenss,
I think you will find this program to be quite beneficial.
 

* CONTACT INFORMATION TO REQUEST REPRINTS

In this issue I have added something that I should have thought
of a long time ago.  At the end of each article you will find
the contact information for the lead author of the study that
was reviewed.  If the study is of particular interest to you, you
can write to the author to request a reprint.  (If no contact
information is listed it is because it was not included in the
journal where the article was published.)

Although I do my best to provide a thorough review of the
studies included in each issue of the newsletter, and to
highlight what I think are the key elements, there is certainly
often more information in the complete article than I can
do a good job of conveying.  Thus, writing for the actual
paper can be a great way to build up your own collection
of studies that you are especially interested in.

My own experience over the past 12 years is that most
authors are pretty good about responding to requests for
reprints.  Don't be surprised, however, if it takes a long
time, or, in some cases, if it never arrives.  Including
a stamped, self-addressed envelope with your request
should certainly boost the odds of a prompt response.
Also, be sure to include the title and citation information
of the paper you are requesting.  You can get this, of course,
from the summary that I provide.

Sorry I didn't think to do this 25 issues ago.  Oh well,
better late than never.
 

* THE IMPACT OF ADHD SYMPTOMS AND CONDUCT
   PROBLEMS ON CHILDREN'S DEVELOPMENT

It has been shown in many different studies that children
with ADHD are at increased risk to develop significant
behavioral problems in addition to the primary ADHD symptoms
of inattention, impulsivity/hyperactivity.  Thus, many
children with ADHD will be diagnosed with Oppositional
Disorder (ODD) or Conduct Disorder (CD) at some time during
their development (for a description of these conditions go
here).  This is important because the outcomes for children with
ADHD who also develop significant behavioral disturbances -
especially CD - are generally much more problematic than outcomes
for children with ADHD alone.

In the October issue of the Journal of the American Academy
of Child and Adolescent Psychiatry (JAACP) there is an important
study reported that provides a careful examination of the
contributions made by ADHD symptoms vs. conduct problems to
the long-term outcomes for children with ADHD (MacDonald, V.M.,
& Achenbach, T.M. (1999. Attention problems vs. conduct problems
as 6-year predictors of signs of disturbance in a national
sample. JAACP, 38, 1254-1261).  This study is especially
important, I think, because it include large numbers of
females in the sample, and is able to look at the prediction
of developmental outcomes for both boys and girls.

Participants in this study were 1238 males and 1241 females
drawn from a representative sample of the US population.
Parents of these children completed a well-validated behavior
rating scale (i.e. the Achenbach, Conners, Quay Behavior Checklist)
of these children that provided data on the level of ADHD
symptoms that parents observed as well as the level of
behavior/conduct problems, and a variety of other types of
difficulties (e.g. social problems, emotional problems,
etc.)

Based on these behavior ratings, 4 different groups of
subjects were created.  The first group consisted of children
who scored high for ADHD symptoms (i.e. in the top 10% for
their age and gender) but not for conduct problems.  The
second group scored in the top 10% for their age and gender
on conduct problems but not for attention problems.  A third
group was high on both ADHD symptoms and for conduct problems.
Finally, a fourth group was created that included children
scoring high on a variety of other difficulties (e.g. social
problems, physical complaints, emotional symptoms, etc.)
but who were in the "normal" range for both attention
problems and conduct problems.  This group was created to
determine whether any difficulties predicted by attention
problems and/or conduct problems were unique to these types
of difficulties, or would also be found in children who
displayed other types of symptoms as well.  It is important
to note that this "control" group was not problem free, but
simply had other types of problems than either ADHD symptoms
or conduct problems.  Thus, this should be considered a
"clinical" control group rather than a "normal" control
group.

Three years after the parent behavior ratings were collected,
parents were interviewed to learn whether their child had
shown any of the following signs of disturbance during the
prior 3 years: 1. special education services - received
special education services for academic or emotional problems;
2. school behavior problems - had school behavior problems
or was suspended or expelled; 3. received mental health
services; 4. displayed suicidal behavior; 5. got in trouble
with the police.

A second interview with parents was conducted 3 year after
this one - thus 6 years after the initial behavior ratings
had been collected.  At this interview, slightly different
areas were probed with parents whose child was between
10-18 and those whose "child" was now a young adult (i.e.
18-22).  For the former, the same 5 areas listed above were
inquired about as were questions about substance abuse.  For
parents of older participants, additional questions were
included to cover: alcohol abuse, drug abuse, unwed pregnancy,
being fired from jobs, and dropping out of school.

With this large and nationally representative data set the
authors sought to address 3 basic and important questions:

1. Which signs of disturbance are specifically predicted by
   ADHD symptoms, conduct problems, or both?

2. Do the types of problems predicted by ADHD symptoms and
   conduct problems differ for boys and girls?

Given the scarcity of research that has been conducted on
ADHD in girls, the latter is a particularly important question.

RESULTS

In a study of this magnitude there are almost always more
interesting and important results than can be easily summarized.
Nonetheless, I will try to present an overview of what the
authors found and focus on those results that seem to be
especially noteworthy.

* Compared with children who were initially high on conduct
problems or on other types of problems, those high on
attention problems alone were more likely to have received
special education services over the next 6 years.

This was the only outcome that was more frequent among
children who had scored high on ADHD symptoms only and
highlights the particular risk to academic performance for
children with ADHD.

* Compared to children initially high on attention problems
or to the clinical controls, subjects high on conduct
problems subsequently had more school behavior problems,
police contacts, and suicidal behavior.

Thus, the outcomes for children with conduct problems
were both different, and in important ways, more severe
than for children having attention problems only.

* The combination of attention problems and conduct problems
was predictive of the most serious and varied difficulty
over the next 6 years.

These children had more school behavior problems, mental
health service use, substance abuse, suicidal behavior, and
total number of different signs of disturbance than did
children in any of the other 3 groups.

Clearly, children who displayed both attention problems and
conduct problems were at the greatest risk for important
difficulties in their development.

It was especially interesting to find that when conduct problems
were broken down into aggressive and non-aggressive behaviors
(i.e. the latter include such behaviors as lying, stealing,
skipping school, hanging out with bad companions, cheating, etc.)
it was the latter that were more closely linked to several of
the negative outcomes studied.  Thus, even though these
non-aggressive behavior problems may create fewer problems
early on for children than high levels of overtly aggressive
behavior, those displaying a number of such delinquent type
behaviors may be at particular risk for negative developmental
outcomes.

As noted above, one of the important strengths of this study
was the large number of females that were included.  In general,
many similarities in outcomes for both genders.  There were,
however, some findings that were unique to females that are
important to note.  Girls with both attention and conduct
problems were significantly more likely to drop out of school
than girls with attention problems alone (i.e. 45% vs. 7%).
For boys, in contrast, those with attention problems alone
were as likely to drop out as boys who had both types of
difficulties.  In addition, girls with attention problems
and conduct problems were more likely than girls with attention
problems only to become pregnant out of wedlock (59% vs. 27%).

CLINICAL IMPLICATIONS

The implications of this important study are clear and
straight forward: children with ADHD alone who do not also
display significant conduct problems have substantially
more positive developmental outcomes than children showing
both types of difficulty.  In children with ADHD alone, the
greatest risk seems to be academic performance.  This, of
course, is an enormously important aspect of children's
lives and is one that can certainly be critical to a child's
future.  Nonetheless, the finding that children with ADHD
symptoms alone are not necessarily more likely to have a host
of other important difficulties is certainly reassuring.

I think these data really underscore the importance of
preventing the development of significant conduct problems in
children with ADHD, and in treating such problems aggressively
should they emerge.  Often times, however, a child's behavior
problems tend to get "lumped together" with their primary
ADHD symptoms and regarded as just another aspect of the
ADHD.  When this occurs, there may be no specific interventions
implemented to target the behavioral difficulties, and parents
can believe that if their child is receiving medication for
treating the ADHD, than they are doing all that can be
done.

As this study points out, however, serious behavior problems
can be assessed independently of ADHD symptoms and are associated
with different long-term risks. In addition, as has been found in
a number of studies - including a study reviewed below - this is
an area where parenting practices can often make an important
difference.  Thus, even though parents may be unable to impact
their child's primary ADHD symptoms through their disciplinary
strategies and practices, they can have a substantial effect
on reducing a child's tendency towards other types of conduct
difficulties.  In so doing, parents can play an incredibly
important role in promoting their child's healthy development.
Working with a good mental health professional on this aspect
of a child's treatment can be a vital supplement to any medical
treatment that is also being received.

Reprint request  to:

Dr. T.M. Achenbach
Psychiatry Dept.
University of Vermont
1 S. Prospect Street
Burlington, Vt. 05401

* THE COURSE OF OPPOSITIONAL DEFIANT DISORDER IN
   CHILDREN WITH ADHD

As discussed in the article above, and in several other studies
previously reviewed in ADHD RESEARCH UPDATE, the development of
significant behavioral problems in children with ADHD is often
associated with more negative long-term outcomes.  For this reason,
understanding the factors associated with both the development and
persistence of important conduct problems in children with ADHD
is extremely important.

This issue was the focus of an interesting study published
in a recent issue of the Journal of the American Academy of
Child and Adolescent Psychiatry (August, G.J., Realmuto, G.M.,
Joyce, T. & Hektner, J.M. (1999). Persistence and desistance
of Oppositional Defiant Disorder in a community sample of
children with ADHD. JAACP, 38, 1262-1270).  In this study,
the authors began with a sample of over 7000 children attending
22 different elementary schools in a suburban community, and
using a combination of behavioral screening procedures and
diagnostic interviews, identified those children who met
diagnostic criteria for ADHD alone, ADHD and Oppositional
Defiant Disorder (ODD), and neither diagnosis.

As you may recall from a prior issue of ADHD RESEARCH UPDATE,
the essential feature of ODD is a persistent pattern of negativistic, defiant,
disobedient, and hostile behavior towards authority
figures that persists for at least 6 months.  Children with
ODD often lose their temper, argue with adults, actively defy and
refuse to comply with rules and other demands, deliberately annoy
others, appear angry and resentful, act spiteful, and blame
others for their mistakes and misbehavior.  Although all
children may display such behaviors from time to time, in
children with ODD these behaviors occur much more often and
with greater intensity.

In this study, the authors were interested in learning several things.
First, they wanted to study what background factors differed between
children with ADHD alone, from those who were diagnosed with
ADHD and ODD.  Second, they were interested in identifying factors
predicted the persistence of ADHD and ODD.  Finally, they wondered
how often ODD escalated into Conduct Disorder (CD) and what factors
were associated with this progression.  As you may recall, CD is an
even more serious behavioral disturbance than ODD that often involves
criminal type behavior (for a more thorough discussion of ODD
and CD go here.

The sample of children identified to study included 79
with ADHD alone, 43 with ADHD and ODD, and 111 children
with neither diagnosis who were included as a comparison group.
Children were approximately 9 year olds at the start of the study and
were from primarily middle-class backgrounds.  The ratio of
boys to girls in the sample was about 4:1.  This study was
conducted in Minnesota, and 95% of the sample were white.

At the initial assessment, several measures were collected
in addition to the diagnostic interview data that was obtained
for all participants.  These additional measures included
basic demographic information on the families (e.g.. socioeconomic
status, single parent status vs. intact family), psychiatric
information on parents (i.e. whether parents had a history of
any psychiatric diagnosis), and parenting practices.  This
latter factor was designed to evaluate parents' use of different
disciplinary practices and the authors were especially
interested in the use of what they considered to be "negative
practices" that involved inconsistent and punitive approaches
to managing children's behavior.

Four years after this initial assessment, a second diagnostic
evaluation was conducted, in which the authors were able to
reevaluate approximately 60% of the original sample.
Although it would have been preferable if they were able to retain
a larger portion of the original sample, analyses they
conducted indicated that participants who dropped out did
not differ significantly on most characteristics from those
who were reevaluated.  Thus, it is reasonable to assume that
their findings are not unduly influenced by their having a
non-representative sample for the follow-up assessment.

Using this second round of diagnostic data, they were able to
look at changes in the symptom picture for each child, changes in
the overall rate of diagnosis, and to examine what types of
background factors were associated with these changes.  The
major questions addressed and the results of their analyses are
summarized below.

What was the stability of the initial diagnoses?

Of the 79 children who were diagnosed with ADHD alone at the
initial evaluation and reevaluated 4 years later, 36 - about 46% -
continued to meet diagnostic criteria for ADHD and no additional
diagnosis.  Another 21 - about 27% - continued to meet diagnostic
criteria for ADHD and were also now diagnosed with ODD as
well.  The same number - 21 - no longer met ADHD diagnostic
criteria and received no diagnosis at the follow up.

This is certainly encouraging in that it indicates that a significant
number of children with ADHD do experience a diminishing
of symptoms over time to the point where they no longer qualify
for the diagnosis.  It is important to be aware, however, that even
though a child/teen may no longer meet full diagnostic criteria,
he or she will often still be adversely affected by residual
symptoms of ADHD and continue to need extra help and
support.  Not meeting full diagnostic criteria is definitely not
always the same as not having any difficulties related to
ADHD symptoms.

Of the 43 children initially diagnosed with both ADHD and ODD,
almost 50% retained these original diagnoses.  Fifteen still met
diagnostic criteria for ADHD, but their behavioral symptoms had
improved to where they were no longer diagnosed with ODD.
Only 4 children from this group - about 10% - were not given either
diagnosis at follow up.

What factors predicted the emergence and persistence of ODD?

The authors first examined the factors associated with an ODD
diagnosis at the initial assessment.  Specifically, their analyses
considered whether child IQ, socioeconomic status, history
of psychiatric difficulty in the child's family, gender, and negative
parenting practices increased the likelihood of the child being
diagnosed with ODD.

The results indicated that only negative parenting practices was
a significant predictor that a child with ADHD would also be
diagnosed with ODD.   To put this in perspective, they found
that children whose parents scored in the top 15% of the sample
on a measure of negative parenting practices were about twice as
likely as other children to be diagnosed with ODD.  Children from
families of lower socioeconomic status were somewhat more likely
to be diagnosed with ODD.

At the follow up evaluation, the strongest predictor of an ODD
diagnosis was whether or not the child had ODD at the initial
assessment.  Such children were 8 times more likely than others
to be diagnosed with ODD at the second evaluation.  In addition,
however, negative parenting practices was also an important
predictor of whether or not the ODD diagnosis would persist.
Thus, children with ODD at time 1 whose parents were in the
top 15% for the negative parenting practices measure were almost
twice as likely as other to still have ODD 4 years later.

In addition, children diagnosed with ADHD initially  also tended to be
more likely to be diagnosed with ODD 4 years later than the 111
comparison children who had no diagnosis at time 1.  Thus, this is an
indication that the presence of ADHD increases the likelihood that a
child will develop important behavior problems as well.

It is important to note that although these data indicate that parenting
practices are associated with the emergence and persistence of
ODD, they do not necessarily mean that negative parenting
practices were the initial "cause" of the child's ODD.  Remember,
all of these children were also diagnosed with ADHD and children
with ADHD present unique challenges to parents in terms of
behavior management issues.  Sometimes, the stresses that occur
between parents and children in response to a child's ADHD
symptoms can precipitate a pattern of negative exchanges that do
contribute to the development of important behavior problems.
Thus, negative parenting practices can emerge in response to the
frustration associated with parenting a child with ADHD, which
is certainly different from arguing that such practices are the
original cause of a child's oppositional and defiant behavior.

It should also be noted that children with persistent ODD were
more likely than children whose ODD "desisted" to have extreme
problems with temper at the initial evaluation along with a tendency
to be spiteful.  Thus, these particular symptoms appear to be
especially common in children who are likely to show persistent
behavior problems.

What factors were associated with an initial diagnosis of ADHD
or the persistence of ADHD?

These results provide an interesting contrast to the results discussed
above for ODD.  At the initial evaluation, none of the family background
factors  - e.g. socioeconomic status, single parent vs. intact family etc. -
was  associated with whether a child had ADHD, nor was
the negative parenting practices variable.  Compared to parents
of children without ADHD, however, parents of children with ADHD
were more likely to have ADHD themselves, either currently or at
an earlier time in their lives.

In addition, the only significant predictor of whether a child was
diagnosed with ADHD at follow-up was whether he or she was
given the diagnosis originally.  Thus, parenting practices did not
seem to be related to whether a child was diagnosed with ADHD
initially, or whether the child developed ADHD over the subsequent
4 years.

IMPLICATIONS

I think there are several important implications that emerge from this
study.  First, the fact that almost 75% of children diagnosed with
ADHD initially were still diagnosed with ADHD 4 years later indicates
both that:

1. the disorder tends to be relatively stable over time, but

2. for a significant percentage of children, symptoms diminish over
time to a point that the diagnosis no longer applies.

At this point, it is still not possible to accurately predict which of these
possibilities will be true for a particular child. It is also important to
note that even among children who no longer meet full diagnostic
criteria for ADHD, in many instances they can continue to struggle with
symptoms of the condition.  Thus, no longer meeting full diagnostic
criteria is not the same thing as a complete remission from the difficulty
that ADHD can cause.

The reason I think this point is so important is because I have seen some
teens and their parents who were confused by the fact that they had
been told the teen no longer "had ADHD" and yet it was clear that the
adolescent was continuing to struggle in significant ways.  Even when
the full diagnosis no longer applies, therefore, it can be critically important
to continue to provide the structure, assistance, and support that is
often needed.

The findings pertaining to the emergence and persistence of ODD are
also quite interesting.  Recall that the primary predictor of ODD was
the degree of negative parenting practices that parents engaged in.
These would include such practices as overly harsh and punitive
discipline, inconsistent enforcement of limits and rules, overly
restrictive rules, unrealistic behavioral expectations, and failing to reward
appropriate behavior.

As discussed above, these findings should not be interpreted as proving
that parenting is the fundamental cause of ODD.  What these data
do clearly suggest, however, is that this is an area where parents have
the potential to have a substantial and important impact on their
child's development.  From this study alone, we do not know what
the long-term outcomes for children with persistent ODD will be.
Although few such children developed conduct disorder - a more
serious behavioral disturbance - during the course of the study, it
is certainly reasonable to speculate that the outcomes for those with
persistent ODD are likely to be more problematic.

The fact that such persistent behavior problems are associated with
a higher degree of negative parenting practices clearly implies that
altering such practices can play a critical role in promoting better
behavioral adjustment in one's child.  Thus, getting professional
assistance in learning the types of child management strategies that
can help to accomplish this can be an enormously useful step
for parents to take.  I've got an introduction to behavioral interventions
posted here and would also recommend a book called "Your Defiant
Child" by Dr. Russell Barkley.  These resources can help get you
started, but if this is a real concern of yours, then consultation with
an experienced child mental health professional in your area would
be highly recommended.

Reprint requests to:

Dr. Gerald August
Division of Child and Adolescent Psychiatry
Box 95 Mayo Building
University of Minnesota
Minneapolis, MN  55455
 

* PRELIMINARY REPORTS OF A PROMISING NEW MEDICATION
  FOR USE IN TREATING CHILDREN WITH ADHD

One important problem with the use of Ritalin is that even for children
for whom the medication results in substantial reductions in ADHD
symptoms and associated problematic behaviors, the effects typically
last for 4 hours or less.  As a result, most children taking Ritalin
require 2 to 3 doses per day, which involves the need to take medication
when at school.  Although this is handled well in many schools, it
can also create discomfort and embarrassment for a child - especially
as that child becomes older.  In fact, in my own experience, the need to
take medication during the school day was an important factor for
many adolescents who expressed a strong desire to discontinue their
medication.

In response to this concern, medications that last longer are often tried,
including the sustained release form of Ritalin, and a more recently
approved medication for treating ADHD called Adderall.  The
sustained release form of Ritalin has certainly proven to be helpful
for many children, but significant inconsistency in duration of benefits
from child to child has been noted.  In regards to Adderall, several
recent studies that were reviewed in prior issues of ADHD RESEARCH
UPDATE have provided data that it is at least as helpful as Ritalin for
most children, and that it lasts significantly longer.  As a result,
a single dose before school of Adderall may be as helpful for many
children as Ritalin that is administered both before school and during
the school day.  Although these data suggest that Adderall represents
an excellent medication option for many children with ADHD, not
all children will respond positively to Adderall, and some children may
experience problematic side effects to both medications.  Because of these
factors, there remains an important need to develop new medications
that are safe, effective, and provide long lasting benefits that reduce or
eliminate the need for multiple daily dosing.

Data from two studies of a new medication called ATTENADE that were
presented by Dr. James Swanson at the recent annual meeting of the
American Academy of Child and Adolescent Psychiatry provides
initial evidence that this may become an excellent medication choice for
children and adolescents with ADHD.   As I currently understand it,
ATTENADE is a somewhat modified form of methylphenidate
(i.e. the generic form of Ritalin).

In these studies, more than 200 children participated in two
multi-center trials. Both trials compared ATTENADE to a placebo,
a necessary step to demonstrate that a new medication provides
benefits that are clearly above and beyond what can be attributed
to placebo effects alone. In the second trial, the new medication
was also directly compared to methylphenidate (e.g. the generic
form of Ritalin).

In the study comparing ATTENDADE and methylphenidate, the
results indicated that ATTENDADE  demonstrated a statistically
significant longer duration of action for ATTENADE. ATTENADE
controlled the symptoms of  ADD/ADHD at  all times measured in
the study while dl-methylphenidate did not control the symptoms
at the last measurements which were between 5.5 and 6.5 hours
after the medication had been taken.

In both trials, both behavioral and objective measures were examined.
ATTENADE produced significant and substantial declines in teacher
ratings of children's ADHD symptoms.  As noted above, these
improvements were maintained for a longer period of time than the
gains that were provided by methylpenidate.  Side effects of the new
medication were reported to be low, and only reports of appetite reduction
and mild abdominal pain showed significant increases relative to the
placebo.

The studies reported were part of the testing required before ATTENADE
can be approved by the FDA for use in treating ADHD.  Thus, this
medication is not yet available for regular use.  According to the
reports I have seen, it may become available - provided new and
unexpected adverse information do not emerge in additional testing -
sometime during the latter part of next year.  As I become aware of
new information about this medication, I will include it in the newsletter.

Please note that as has been discussed repeatedly in ADHD RESEARCH
UPDATE, even when a medication has been clearly demonstrated to be
effective for children with ADHD, there is no guarantee that it will be
helpful for an individual child.  In all cases where medication is being
considered as a treatment option, a carefully conducted trial that incorporates
the use of a placebo-controlled procedure and systematic assessments of a
child's behavior and academic performance on different doses, should be
conducted to establish the most effective dose and medication for each child.
In addition, this needs to be followed up with ongoing monitoring of the
medication's effectiveness.
 

* HOW ADHD EFFECTS PRESCHOOLDERS' UNDERSTANDING OF
   STORIES

One of the most profound effects that ADHD can have on children's
development is in the area of academic performance.  Numerous
studies - several of which have been reviewed in ADHD RESEARCH
UPDATE - have documented that children with ADHD are at
substantial risk for academic difficulties, and that the majority fail
to achieve at a level that is consistent with their academic ability.
As indicated in the study reviewed above, children with high levels
of attention problems but not high levels of conduct problems were
at specific risk for academic difficulty over a 6-year period and to
require special educational services.  In my own work, I have found
that attention problems specifically - and not hyperactive/impulsive
symptoms - exert substantial negative effects on the development of
children's reading skills.

A study published recently in the Journal of Clinical Child Psychology
provides an extremely interesting look at how ADHD can have an
adverse impact on skills related to academic performance even
before academic problems are likely to be evident.  In this study
(Sanchez, R.P., Lorch, E.P., Milich, R., & Welsh, R. (1999).
Comprehension of televised stories by preschool children with ADHD.
Journal of Clinical Child Psychology, 28, 376-385), the authors
looked at how preschool children with and without ADHD might
differ in their understanding of televised stories.

Televised stories- actually, they used a series of clips from Sesame
Street - were used because the children were young enough so that
most of them would not yet be expected to be reading.  In addition,
the benefits of using television to examine young children's comprehension
of stories is that it is a familiar context for children, it captures children's
attention at an early age, and can provide a less-monotonous context
than do many laboratory tasks that are used to investigate ADHD.  It
is certainly a common experience for parents to observe that their child
with ADHD can attend faithfully to his or her favorite tv shows for
an extended period of time, even though the same level of attending
to homework is rarely evident. Children's ability to understand and
comprehend televised stories can thus serve as a useful medium to learn
about their comprehension of story material more generally.  If
problems are evident in this context - which probably captures children
with ADHD operating at their best in terms of attending - then it can
inform parents, educators, and clinicians about the struggles that are
even more likely to occur in a classroom context.

Participants in this study were 27 boys and girls with ADHD between
4 and 6 years old and 52 comparison children without ADHD.  About
75% of the children in each group were male and almost 90% were
Caucasian.  All the participants with ADHD had been diagnosed
with ADHD, Combined Type.  Thus, they had the inattentive and the
hyperactive/impulsive symptoms as opposed to the inattentive symptoms
only.  Although many children were being treated with medication at
the time of the study, care was taken to be sure that children were
medication-free when actually tested.

All children viewed a 23 minute videotape that consisted of 13 separate
segments of Sesame Street.  Four segments that were embedded in this
larger group of segments were the actual target stimuli for the study.
All of the target segments had conventional story structures and were
narrative in nature.  In other words, they were typical of Sesame Street
stories.

Children were assigned at random to one of two viewing conditions.
Half of the children in each group viewed the segments with
attractive toys present and available to play with; the other children
viewed the tape without any toys around to serve as potential
distractors.

Each child was videotaped while watching the Sesame Street stories.
This tape was used to identify the amount of time that participants
were actually focusing their attention on the screen where the tape
was playing.  Thus, an accurate record of the visual attention of
each participant was available.  Each child watched the videotape
individually, so that other children were not present as another
possible source of distraction

Children were told that they would be watching a tv program and
that afterwards, they would be asked some questions about what
they had watched.  In the condition where toys were present, it
was simply mentioned that they could play with the toys if they
wanted to.  Thus, they were neither specifically encouraged to
play with the toys or discouraged from doing so.

After the tape was over, the experimenter returned to ask each
child questions about the stories they had watched.  Questions
were asked about the 4 targeted stories in the order that these
stories had appeared on the tape.  Pictures of the characters from
each story were presented to the child, and the names of each
character was provided to try to help cue their recall of what
they had watched.

Two types of questions were asked: factual questions (e.g. What
does the man do with the fish he catches?") and causal relation
questions (e.g. Why does the man kiss the fish?")  The former
questions thus test for children's recall of specific events that
occurred in each story.  The causal relation questions, in contrast,
required the child to draw upon several different elements in
the story and to recall the relationship between these elements.
Between 12 and 15 questions were asked for each story, and
these were divided equally between the factual and causal
relation type questions.

* RESULTS

The first question the authors examined is how children in the
two groups compared in terms of how attentive they were to
actually watching the videotape and whether this varied
according to whether toys were present.  Overall, as might
be expected, children without ADHD were more attentive
(i.e. actually spent more time looking at the screen) than
children without ADHD.  In the no-toy condition, the % of
time children in these groups were observed to be "observing
the screen" were 90.4% and 80.3% respectively.

For both groups, the presence of toys substantially reduced
their level of attention.  The % of time attending dropped
to 30% on average for children without ADHD, and all
the way to 7% for children with ADHD.  In other words,
even though the toys were a substantial distracter for both
groups of children, the adverse impact on attending to what
they needed to was even greater in children with ADHD.
Thus, this is experimental evidence of the far greater
distractibility in children with ADHD, which, after all, is
one of the core symptoms of inattention.

Here is something even more interesting.  Even though
children without ADHD reduced their attending behavior
when toys were present from 90% to 30%, the proportion
of questions that they answered correctly DID NOT
CHANGE.  This strongly suggests that these children were
"strategic viewers" who could systematically divide their
attention between the tv stories and the toy play such that
their ability to recall and comprehend the stories did not
suffer.

For children with ADHD, however, the findings were
quite different.  When toys were not present, children
with ADHD were about as accurate as comparison
children in their responses to factual questions.  Thus,
in the absence of distraction, they answered factual
items every bit as well.  In the toy-present condition,
however, their performance was adversely affected such
that they now did much worse than comparison children.
In this condition, in fact, they answered correctly to
about 50% fewer questions.

What is important here is that even though the comparison
children also "paid less attention" to the stories when
toys were present, they were still somehow able to
divide their attention between toys and the stories such
that their recall was not hurt.  Children with ADHD,
however, apparently could not do that.  Thus, not only did
they attend less when distractors were present, but they
were unable to divide their attention in such a way that
their level of performance was preserved.

Results for the causal relation questions were somewhat
different.  Here, the children with ADHD did worse
than the comparison children regardless of whether toys
were present as a distracter.   Thus, even when their
visual attention to the program was high, children with
ADHD still did not do as well in responding to
questions that required an understanding of how the
different elements in a story fit together.

It would be quite interesting to know whether similar results
would have been obtained for the comprehension items
even if the children with ADHD had been receiving their
medication when testing occurred.

* IMPLICATIONS

The results of this interesting study have potentially
important implications for educating children with ADHD.

First, as has been demonstrated in the past, the presence
of distracting stimuli appear to have a significantly greater
adverse impact on the performance of children with ADHD
than of other children.  Not only is a child with ADHD
less likely to pay attention to what he or she is supposed to
when an attractive alternative stimulus is present, but he or
she is also apparently less able to effectively allocate attention
to competing activities in ways that help maintain a good level
of performance.

These data support the benefits of arranging the environment
for many children with ADHD in such a way that potential
distractions are minimized.  In a classroom setting, of course,
this is not always easy to do, particularly without isolating a
child in a way that can be stigmatizing.  At home, however,
when it comes to getting homework done, this type of
intervention may be easier to accomplish.  Please note, however,
that although reducing distractions may be helpful for many
children with ADHD, there will always be exceptions.  Thus,
evaluating whether such environmental modifications are
helpful for a particular child always needs to be carefully
evaluated.

The comprehension results seem especially important.  These
data indicate that comprehension may be an area of particular
difficulty for children with ADHD, and that such difficulty
may be evident as early as the preschool years.  This result
is consistent with another study of reading comprehension in
children with ADHD that was reviewed in an earlier issue
of ADHD RESEARCH UPDATE.  Careful assessment of
the comprehension abilities of a child with ADHD, even for
a child whose basic reading skills or ability to recall factual
information about stories appears adequate, may thus be
quite useful in identifying necessary targets for intervention.
This, however, is rarely done.

When difficulties in this area is identified, specific training to
help a child with ADHD understand cause-and-effect relations,
both in stories and in real-life social situations, may be quite
helpful.  This may be best done by a reading specialist who
is aware of specific techniques and strategies to assist children
in their comprehension skills.  Such training may have benefits
not only for academic performance, but for a child's social
relationships as well.

Reprint request to:

Dr. Elizabeth Pugzles Lorch
Dept. of Psychology
University of Kentucky
Lexington, KY 40506-0044

That's all for this month...

I hoe that you enjoyed this issue of ADHD RESEARCH
UPDATE and found it to be informative.

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See you next month.

David Rabiner, Ph.D.
Licensed Psychologist
Duke University

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