In this issue...

Does ADHD predict early drug use?

Patterns of brain activity in children with ADHD

A new rating scale to assist in diagnosing ADHD in adults

A widespread concern among parents of children with ADHD, as well as among clinicians who work with such children, concerns the degree to which it increases a child's risk of drug use.  For some, these concerns focus on whether treatment with medication - by itself - will lead children with ADHD to be more likely to use illicit substances later in life.  No evidence for this concern has been reported in several relevant studies, however.

Other parents and clinicians have concerns about the role of ADHD in eventuating later drug use irrespective of whether a child is being treated with stimulant medication. Evidence for an association between ADHD and later substance abuse has been mixed.  Some studies have reported increased rates of substance use and abuse among adolescents with ADHD while others have found no such association.  It is also not clear whether any association between ADHD and adolescent substance use or abuse that have been found can be attributed specifically to a child's ADHD symptoms, or whether the association between ADHD and substance use is explained by the other kinds of behavior disorders (i.e. Conduct Disorder - CD) that often go along with ADHD. Finally, little research has been conducted on the specific factors in the environment of children with ADHD that will act to protect them from becoming involved in substance use, or increase their risk for doing so.

A study published recent in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACP) was designed to answer these important questions (Chilcoat, H., & Breslau, N. (1999). Pathways from ADHD to early drug use. JAACP, 38, 1347-1354).  In this study, a representative community sample of 717 children were followed from ages 6 to 11.  At age 6, children's mothers were interviewed to determine whether or not their child had ADHD.  In addition, mothers completed ratings of aggressive, delinquent, and oppositional behavior problems in addition to the information they provided about specific ADHD symptoms. (An important strength of this study is that the children were all from a community context rather than being selected from a clinic population.  This allows one to have more confidence that the results are representative of children with ADHD in general, rather than to the relatively small subset who are treated in mental health settings.  It would have been preferable, however, if diagnosis was based on information from teachers as well as mothers).

When children were 11, their own use of drugs, the drug use by their peers, and their perceptions of how closely parents monitored their behavior were all assessed in individual interviews with each child.  During these interviews, children were asked about their use of tobacco, alcohol, marijuana, and inhalants.  They were counted  as drug users if they had ever used any of these substances (in the case of alcohol, they were not counted if the use had occurred with parental permission - e.g. a small glass of wine at a family celebration). Peer drug use items measured friend's use of these same substances, as well as friends' attitudes towards drugs, as reproted by the children with ADHD who were the subjects in the study.  Items on the parent monitoring questionnaire concerned parents'practices for supervising their child, and their knowledge/surveillance of their child's whereabouts and behaviors outside their home.

It is important to note that the definition for "drug use" in this study is a lenient one.  This is because the authors were specifically interested in whether or not ADHD is associated with the earlier use of any type of drug.  They did not address whether ADHD might also increased the risk of substance abuse rather than just substance use.  In part, this is because children in their study were only 11 years old at follow up, an age before substance abuse problems would be expected to develop in very many children.  It should be noted, however, that early drug use is an extremely important predictor of subsequent substance abuse problems.

RESULTS

Of the 711 children with complete data, 137 (19.1%) had used drugs at least once.  Incidence was highest for tobacco and alcohol (10.6% and 10.1% respectively).  Of the 117 children who had used tobacco or alcohol, 31 had used both.  A small number - 3.8% - had used inhalants and only 7 children reported having used marijuana.  Interestingly, most of the children reporting inhalant use had not previously used tobacco or alcohol according to their self-reports.

Did ADHD increase the risk of early drug use?

Simply stated, the answer to this question is yes.  The authors found that children with ADHD were about 1.7 times more likely than others to have been an early drug user.  In addition, the risk of early drug use seemed to vary in relation to the number of ADHD symptoms that mothers had reported when their child was 6.  There was a sharp increase in drug use in the 8+ symptom range that peaked at around 10 symptoms (Note: This study was done when the prior version of DSM was in effect and a total of 14 symptoms for ADHD were listed in the diagnostic criteria).  At this level of symptoms, more than one in three children reported early drug use.

The authors also examined whether treatment with stimulant medication was associated with different rates of early drug use in children with ADHD.  No such association was found.  The rates of early substance use in children with ADHD who had and had not received stimulants was equivalent.

What role do other behavior problems play in the early onset of drug use for children with and without ADHD?

The answer to this question is that other kinds of behavior problems (e.g. aggression, defiance, argumentativeness, etc.) play a substantial role  in predicting early drug use for children, regardless of whether they have ADHD.  These findings are important to examine in some detail.

As expected, children with ADHD also had higher scores on maternal ratings of these other externalizing behavior problems than children without ADHD.  In relation to early drug use, however, what is VERY  IMPORTANT to emphasize is that when these behavior problems were low, a child with ADHD was quite unlikely to be an early drug user.  Thus, by itself, ADHD did not appear to increase children's risk for early onset substance use.

In a child with ADHD, however, even moderate levels of externalizing behavior problems were associated with a substantially increased risk for early drug use.  In fact, children with ADHD with externalizing problems just slightly above average were more than twice as likely as children without ADHD, but with similar scores for other behavior problems, to be early substance users.  At the highest levels of these behavior problems, risk of early drug use was high for children, regardless of whether they also had ADHD.

The message here is an important one: children with ADHD but without even modest levels of other behavior problems are no more likely to become early substance users than anyone else.  When even modest levels of other behavior problems occur in a child with ADHD, however, there is an increased risk for early substance use.

Environmental Risk/Protective Influences on Drug Use

How closely children reported they were monitored by their parents was a significant predictor of early drug use.  Children whose parents were reported to engage in a high level of monitoring of their whereabouts and behaviors were about half as likely to report early drug use than children who reported low monitoring by parents.  This relationship held for children both with and without ADHD.

Increasing levels of drug use by peers was also found to be a risk factor for early drug use.  Children who reported high levels of drug use by peers (i.e. in the top 33% of the scores) were SIX times more likely to be early drug users than children reporting low drug use by their peers.  Once again, this relationship held for both children with and without ADHD.

Summary and Implications

I think there are several very important messages in this study.

First, ADHD in the absence of other behavior problems does not increase a child's risk for early substance use.

Second, even when accompanied by modest levels of associated behavior problems, however, a child with ADHD is at greater risk to be an early substance user. The types of behavior problems assessed by the authors included such things as defiance, verbal and physical aggression, irritability, blaming others for mistakes, argumentativeness, etc.

Finally - and this is especially important - how carefully parents monitor their child's whereabouts and the kids their child spends time with - has enormous implications for whether or not their child is likely to be an early substance user.  Thus, for children with ADHD who are also showing other types of externalizing difficulties, careful parental monitoring is essential.

What I think is noteworthy about this is that parental monitoring was shown to be so important in regards to substance use even though the children in this study were not even teenagers when the follow up data was collected.

Most parents would recognize the importance of careful monitoring for their adolescents sons and daughters, being careful to make sure their child is not hanging around with peers who are likely to get in trouble.

What these data indicate, however, is that such monitoring is just as important when children are still in elementary school, as it can be a key factor in reducing a child's risk for beginning to experiment with illicit substances at a very early age.

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One important current theory about the biological basis for ADHD is that it results from underactivity in those brain regions that are most directly involved in behavioral inhibition (i.e. behavioral inhibition refers to the ability to refrain from acting immediately on behavior impulses - i.e. to "inhibit" one's behavior).  This theory of ADHD has been discussed at great length and eloquence by Dr. Russell Barkley and a summary of Dr. Barkley's ideas were presented in a prior issue of Attention Research Update.  The brain areas believed to be most important for behavioral inhibition are the regions of the frontal cortex.

Although there has been some support for this idea found in several studies in which brain activity in individuals with and without ADHD have been directly examined, this work has not yet been conducted in relatively young children.  There has also been little work to compare these brain activation patterns in boys and girls with ADHD.  Finally, some have questioned the findings of earlier studies by noting that many of the subjects with ADHD also had co-occurring behavior disorders like Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD).  These critics noted that any unusual patterns of brain activity that were found could just as likely be associated with behavior problems in general rather than to ADHD specifically.

A recently published study does a nice job of beginning to address some of these important issues (Baving, L., et al. (1999). Atypical frontal brain activation in ADHD: Preschool and elementary school boys and girls. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1363-1371. The neurobiology of ADHD is something that I do not know that much about, and there are technical details in this study that are well outside my own area of expertise.  I know that many subscribers have a keen interest in this type of work, however, so I wanted to include this interesting study in the newsletter.  This type of work is important in that it may ultimately be quite useful in developing more effective treatments for ADHD.  It is also important, however, to note the limitations of such neurobiological research in regards to more immediate assessment and treatment needs.  These limitations will be discussed below.

Participants in this study were 66 children who were 4.5 years old and 51 8-year-old children.  Forty-seven of these children had been diagnostic with ADHD, Combined Type, using a structured diagnostic interview.  The remaining 70 children had never displayed any type of disorder and were used as controls.  Among the 4.5-year-olds with ADHD, 20 were boys and 8 were girls.  Among the 8- year-olds, there were 12 boys with ADHD and 7 girls.  About two/thirds of the children with ADHD were also diagnosed with ODD while the others did not have this additional behavior disorder.

All children participated in a non-invasive EEG procedure to assess their patterns of brain activity.   None of the children were on stimulant medication at the time the EEG recordings were made, and only 3 of the children had ever received stimulants at all.  (The study was conducted in  Europe where the use of stimulant medication for treating ADHD is much less common. In fact, stimulant medication is not even available in a number of European countries.)  In making these recordings, the researchers were specifically interested in the relative amounts of neural activity occurring in frontal brain area in the right vs. left hemispheres.

RESULTS

The analysis of the results of these EEG recordings revealed clear and significant differences in brain activity between children with and without ADHD.

Boys with with ADHD showed significantly reduced neural activity in the right hemisphere compared to boys without ADHD. This was true for both 4.5 and 8-year-old boys.  It was also true for boys who had ADHD alone, as well as for boys who had been diagnosed with both ADHD and ODD.

Interestingly, for girls the pattern was exactly reversed.  That is, girls with ADHD showed significantly reduced neural activity in the left frontal region than girls without ADHD. In fact, brain activity in girls with ADHD was very similar to boys without ADHD while brain activity in boys with ADHD was very similar to girls without ADHD.

The reasons for these gender differences is apparently not well understood, although they do point towards the importance of including both boys and girls in studies of ADHD so that potentially important gender differences are not missed or obscured.

Summary and Implications

The authors suggest that the differential pattern of brain activity that they observed between children with and without ADHD suggests that "..ADHD is the final stage of a disorder in the development of regulation."  In other words, they are hypothesizing that brain regions that are involved in the regulation of behavior and emotional arousal work differently in individuals with ADHD, and that this is the neurological basis of the condition.

Although I am not able to fully understand some of the nuances conveyed in this paper, the study seems important to me for several reasons.

First, it provides yet additional evidence that there really does appear to be a neurological basis to ADHD, at least in some children who receive this diagnosis.  Because there are unfortunately so many people who continue to doubt the reality of ADHD, research that points to real differences in brain functioning in children and  adults with ADHD is important in combating this unreasonable opinion. This study makes a useful contribution to this body of literature.

In fact, this study goes further in this regard than earlier work in this area in a variety of ways.  First, significant differences in patterns of brain activity were found in children with ADHD as young as 4.5 - this is a younger age group than has been included in much other neurobiological work.  This is important because some scientists have noted - with good cause - that finding such differences among adults with ADHD is hard to interpret.  This is because differences in brain activity in adults may just as likely reflect a consequence of having ADHD as opposed to something that may have been influential in the development of the individual's ADHD to start with.  This argument is more difficult to make when differences are found in such young children, although it still can not be entirely ruled out as a possibility.

This study is also important because almost none of the participants with ADHD had ever been treated with stimulant medication.  Again, some have contended that differential brain activity observed in adults or teens who have received medication over extended periods may, perhaps, reflect the long-term consequences of taking the medication.  That can not be used as a critique of these results - both because the children were so young and because none of the 4.5 year olds had ever received medication.

Finally, in this study, differential brain activity patterns was found for children with pure ADHD, as well as for children with both ADHD and ODD.  Thus, it is hard to argue that the differences observed would be found in children with any type of behavior disorder, rather than being specific to ADHD.  It would have been helpful, of course, if children with ODD but not ADHD had been included and no differences between them and control children on the EEG recordings were found.  This would have made the case for the findings being specific to ADHD even stronger.

Despite all the strengths of the study noted above, it is important to consider these results in the context of the very real limitations of such work.  With this study - as in all studies of this type that I have seen - there is a fair amount of overlap between brain functioning in children with and without ADHD.  In other words, some of the children with ADHD showed patterns of brain activity in this study that were characteristic of non-ADHD children and vice versa.  Thus, even though the group averages for children with ADHD differ from the group average for non-ADHD children, there is a fair amount of variability that is seen in individual children.

What does this really mean?  First, even if it could be clearly established that the differences in brain functioning documented in this study were a "cause" of ADHD, this would only be true for some children with ADHD and not others.  This is because - as discussed above - not all children with ADHD showed the characteristic pattern.  Thus, at most, the authors may have identified a neurological basis of ADHD for some children but not others.  Children can manifest the behavioral symptoms of ADHD regardless of whether or not they show the pattern of brain activity identified in this study, suggesting that that there are likely to be multiple causes of ADHD, as opposed to a single cause.

This is especially important when it comes to the utility of such neurological assessments in the evaluation/diagnosis of ADHD.  A great hope - among both parents and professionals - when the initial studies documenting differences in brain functioning in individuals with ADHD were published was that the procedures used to document such differences could also be used to provide an "objective" basis for diagnosing ADHD.

The problem with this - and I think it is likely that this problem will always exist - is that the kind of variability discussed above suggests that these tests may not have tremendous utility for making individual diagnostic decisions.  If a child is clearly showing all the behavioral manifestations of ADHD but not the pattern of brain activity thought to be diagnostic of ADHD, does that mean the child "does not really have the disorder"?  Similarly, if  a child does not show the behavioral symptoms but not the underlying pattern of brain functioning, does this child have ADHD even though the symptoms are not evident?

These are the kinds of issues that are very important to keep in mind when one see reports in the media about new studies demonstrating important differences in brain structure or function in people with ADHD.  These differences do not apply to everyone who shows the symptoms of ADHD - there are probably multiple factors that are responsible for the development of ADHD, and multiple factors may be involved even for an individual child.

So, this work can be extremely valuable in helping us to better understand the biological underpinnings of ADHD in some individuals, and, ultimately, may progress to the point where it can help to inform both diagnosis and treatment. At this point, however, we still have a ways to go before getting there.

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Although as recently as the 1980s it was widely believed that ADHD was a self-remitting condition that would invariably abate following puberty, it is now been clearly demonstrated that ADHD often persists beyond adolescence and into adulthood.  In fact, it has been shown in several longitudinal studies that between 50-65% of children diagnosed with ADHD continue to demonstrate symptoms as they reach adulthood, while upwards of 30% continue to show the full syndrome (i.e. continue to meet full diagnostic criteria).

As the awareness of ADHD among adults has grown, so has the number of individuals seeking evaluation and treatment for this condition.   More and more, professionals are being called upon to evaluate adult patients for ADHD. The problem is, making the diagnosis in adults is even more demanding, many believe, than making the diagnosis in children.

There are several reasons for this.  First, our understanding of the phenomenology of ADHD in adulthood (i.e. what does ADHD really "look like" in adults and what areas of adult functioning are affected) is still evolving.  Certainly, it would not be surprising if how ADHD is manifested in adults would be quite different from how it presents in a school-age child.  Second, the official diagnostic criteria presented in DSM-IV were developed on the basis of field testing with 4-16 year olds. Thus, many of the items listed in the diagnostic criteria may not really be appropriate for use with adults.  Third, in a comprehensive evaluation of a child, information from multiple sources is collected - generally parents, teachers, and from the child his or herself. With adults, however, collecting multiple sources of information on the adult's symptoms can be complicated.  For example, performance at work might be a critical dimension in establishing the diagnosis, but, understandably, many adults would be reluctant to have their physician or psychologist speak to their boss or coworkers, or to even ask their co-workers to fill out a report on their behavior.  Finally, there is the need to establish that the ADHD symptoms an adult is manifesting were clearly evident earlier in life (i.e. the current criteria require that there be evidence of some impairment from symptoms prior to age 7).  When such symptoms emerge for the first time later in life, with no prior evidence of their occurrence, the diagnosis of ADHD would not be made. The best way to corroborate this is through direct interviews with an adult's parents, and, from examining school records from as far back as they are available.  This, too, can be difficult and objectionable to many adults seeking assistance.

Another obstacle to careful diagnostic evaluations for adults is the relative absence of empirically validated rating scales to use as aids in the evaluation process.  Several such behavior rating scales are available for use with children and teens - the most commonly used being the Child Behavior Checklist, the Conners Rating Scales, and the Behavioral Assessment System for Children.  For adults, however, no such well-validated instrument has been available.

That is why I was so pleased to come across two studies published in the October, 1999 issue of the Journal of Attention Disorders that describes the development of a self-report rating scale for ADHD in adults. (Conners, C.K., et al., (1999). Self-ratings of ADHD symptoms in adults I: Factor structure and normative data. Journal of Attention Disorders, 3, 141-151.  Study 2: Self-ratings of ADHD symptoms in adults II: Reliability, validity, and diagnostic sensitivity. Journal of Attention Disorders, 3, 153-158).  I wanted to include a summary of this work in Attention Research Update not only because it may be useful for you to know about this instrument, but also because this work sheds important light on how ADHD presents in adulthood.

To construct the rating scale, the authors began by identifying 9 different domains of functioning that they believed would be impaired in adults with ADHD.  These domains were: 1) Inattention/problems with concentration, 2) Hyperactivity/ Restlessness, 3) Impulsivity/problems with concentration, 4) Problems with organization, time awareness, and planning, 5) Problems with memory, 6) Problems with self-concept 7) Interpersonal problems, 8) Problems with learning, and 9) Problems with mood - this included poor frustration tolerance, irritability, and a tendency to overreact emotionally.

After identifying these different domains, the authors then wrote approximately 10 different questionnaire items for each domain. For example, for domain 1 - Inattention/problems with concentration - they wrote 10 items that they felt tapped into the way these types of difficulties would show up in adults.  This resulted in an initial pool of 93 items that were derived from various sources including DSM-IV, rating scales that are used for children and teens, clinical impressions, and current conceptualizations of ADHD in adults.

Once the item pool was developed, the "test" was administered to 839 "normal adults" (slightly more females than males) as well as to 167 adults who had been carefully evaluated to confirm  a diagnosis of ADHD (97 males and 70 females). The responses provided by this sample of adults was then "factor analyzed" to identify which items would be retained for use on the final scale. (Factor analysis is a statistical technique that enables one to determine how individuals items in a test should be combined into groups of items that appear to be measuring a common attribute.  The groups of items that people tend to respond to in a similar manner are called "factors".   By examining the individual items in the factor and seeing what they have in common, you can then make a judgment about what attribute the different items are measuring.  Items that do not seem to "fit" well with any factor - this is also determined statistically - are then dropped from the test.)

RESULTS

The factor analysis resulted in the identification of 4 separate factors that contained 43 of the original 93 items.  These 4 factors - you can think of them as individual scales - represent the "domains of functioning" that emerged as the most important from the original pool of items. I will list each factor and the abbreviations of the items below because this provides a good picture of the types of difficulties that are characteristic of adults with ADHD. (Note: Each item was rated by participants on a 0 for "not at all true" to 3 for "very much true" scale).

Factor 1-  Inattention/Memory Problems

disorganized; forgets to remember things; lose things; I need don't plan ahead; depend on others for order; hard to keep track of several things; don't finish things; need deadline to get things done; trouble getting started; change plans/jobs midstream; absent-minded; misjudge time

Factor 2 - Hyperactivity/restlessness

squirm or fidget; can't sit still; up and on the go; feel restless when still; always moving; hard to stay in one place for long; effort to sit still; like to do active things; bored easily; risk-taker; don't like quiet activities; seek out fast-paced activities;

Factor 3 - Impulsivity/emotional lability

say things without thinking; short fuse; blurt out things; easily frustrated; often wish I could take back comments; annoy other people; throw tantrums; step on people's toes; moods unpredictable; interrupt others when talking; things set me off; easily irritable

Factor 4 - Problems with self-concept

not sure of self wish I had greater confidence get down on self act ok outside but unsure of self hard to believe in self avoid new challenges

(Note: Please be aware that although these items seemed to do a good job of discriminating between adults with and without ADHD, this should in no way be used as a means for self-diagnosis.  An adult's self-report on a measure like this is only one part of a thorough diagnostic evaluation, and can not be used in isolation for diagnostic purposes.  If you believe that many of these items are characteristic of you, and describe problems that you are experiencing, then consulting with a mental health professional is an option to consider.)

It is interesting to compare the content of the items above with the official diagnostic criteria in DSM-IV.  When you do this, you will see that although there is certainly some important similarities between the two sets of items, there are also items found on this new adult rating scale that are quite different from the items that had been developed on a much younger population.  This, of course, is not surprising as one would expect that ADHD would not necessarily appear identical in adults as it does in children.

When examining the scores on these factors for all participants (i.e. this includes subjects in the normative group as well as those adults who had been diagnosed with ADHD), there were some very interesting differences with respect to gender and age that were found.  Across 4 different age ranges (i.e. 18-29; 30-39; 40-49, and 50+), a decline in participants' scores was found for self-reported problems with inattention, hyperactivity, and impulsivity.  In other words, older participants tended to report fewer problems in these areas than younger participants.

Regarding gender differences, males reported significantly more problems with inattention, hyperactivity, and impulsivity.  Females, however, reported greater problems than males in the area of self-concept.  (Note: Remember, these results are based on all participants - both those in the normative group and those adults with ADHD.  For reasons that I don't understand, age and gender results specifically for those participants with ADHD are not presented).

The final aspect of the study was an attempt to validate the newly created measure by seeing how well scores on the measure were able to differentiate between adults with and without ADHD.  This portion of the study included 39 adults diagnosed with ADHD (these adults were not part of the group used to create the measure) and 39 adults from the initial pool who were matched on age and gender. There were 16 females in each group.

Not surprisingly, the adults with ADHD reported significantly greater difficulty in all 4 areas: attention/memory problems, hyperactivity/restlessness, impulsivity/emotional lability, and problems with self-concept.  The authors also performed a statistical test called discriminant function analysis to determine how accurately individuals would be classified as being ADHD or control subjects based on their responses to the rating scale items. Of the 39 adults who were diagnosed with ADHD via other means (i.e. a structured psychiatric interview) 32 were classified as having ADHD based on their scores.  Of the 39 adults without ADHD, only 5 were classified as having ADHD based on their responses.  This degree of sensitivity and specificity is actually quite good for these types of instruments.  The misclassifications that result, however, point out the real problems with basing a diagnostic decision on behavioral rating scale data alone, and highlight the importance of conducting a comprehensive evaluation of which such rating scale data is just one component.

SUMMARY AN IMPLICATIONS

In addition to providing clinicians and researchers with a reliable instrument to assist in the diagnosis of ADHD in adults, another useful contribution of this work is the light it sheds on the variety of ways that ADHD tends to be experienced during adulthood.  The item list presented above - although it should not be used for the purpose of self-diagnosis - provides a good overview of the types of problems that adults with ADHD frequently experience.  Some of these "symptoms" are quite similar to what characterizes ADHD among children and adolescents, but others appear to do a much better job of capturing how ADHD may continue to impact the functioning of many adults.

As the authors note, there is additional work on the validation of this measure that remains.  In particular, it will be important to contrast the responses of adults with ADHD on this scale not just to other adults without ADHD, but also to adults with other types of psychiatric diagnoses (e.g. depression) to be certain that the scale is useful in distinguishing between ADHD and other types of psychiatric difficulties.  I imagine that such work is ongoing.

For practitioners interested in using this newly developed instrument in their own work, information about ordering it can be found at www.mhs.com.

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Over the past decade researchers have studied techniques for training individuals to pay better attention.  Initially, these attempts were focused on adults with traumatic brain injuries who regularly demonstrate poor attention.  More recently, researchers have applied similar techniques used with these adults to help children diagnosed with ADHD.  A recently published study evaluates the effectiveness of one such attention training tool called Pay Attention! (Kerns, K., Eso, K, & Thomson, J. (1999). Investigation of a Direct Intervention for Improving Attention in Young Children With ADHD.  Developmental Neuropsychology, 16, 273-295. This is a small scale study that is best thought of as a pilot investigation. The study addresses an interesting and important topic that has been the subject of virtually no prior research, however.  For these reasons, I wanted to include it in this issue of Attention Research Update.

The authors provide a compelling rational for efforts to directly train children with ADHD to improve their attention skills.  They note that although medication treatment is helpful to the majority of children with ADHD, many children continue to experience residual difficulties with attention.  Thus, non-medical means to improve children's ability to attend could be quite useful for many children with ADHD.  They also note that non-medical interventions for ADHD typically attempt to either 1) use behavioral strategies to increase a child's attentive behavior by providing incentives for better attending, or 2) provide children with compensatory strategies for dealing with their attention difficulties through such means as teaching better self-control or problem-solving strategies.  Efforts to directly improve children's attention skills through a systematic training procedure, in contrast, has been the subject of virtually no research.

Pay Attention! is an attention training program specially designed for use with younger children (targeting ages 5-10 years) in an ADHD sample. The materials are modeled after the Attention Process Training (APT) system developed for adults a decade ago.  It is based on the idea that there are several different components to attention.  There are lower levels of attention, including basic functions such as being able to focus attention and sustain attention over time, and there are higher levels of attention, such as being able to alternate attention quickly between tasks, or to divide attention in order to perform multiple tasks.  According to the theory behind the APT, higher levels of attention are dependent upon smooth lower level functioning. Pay Attention! was designed to train multiple levels of attention.  In theory, then, this would target the different types of problems with attention that a child with ADHD may have.

The Tasks in Pay Attention! cater to the knowledge, skills, and concepts that are established in younger children. In an attempt to make the materials interesting and engaging to younger children, they are colorful and visually interesting.  They also focus on familiar concepts such as family relationships (e.g., siblings, parents, grandparents), features of people (e.g., hair color, sex, clothing), and household characteristics (e.g., the purpose of particular rooms). Other constructs considered are the concepts of same and different, relative size, comparisons of visual features, and basic counting.  Both visual and auditory stimuli are used, and the treatment tasks have been graded to determine whether or not the individual should move onto more challenging tasks.

In this study the authors were interested in examining the extent to which children's attention improved following a series of training sessions using the Pay Attention! program.  The authors began with 2 groups of 7 children.  Each group was comprised of children diagnosed with ADHD, and consisted of 4 boys and 3 girls.  Five of the seven children in each group were taking stimulant medication throughout the study.  (This is obviously a very small sample, which is why it is best to regard this study as a pilot investigation.)

Both groups participated in pre- and post-treatment testing on measures thought to reflect attentional functioning at the beginning and end of the study.  A variety of measures of attention were collected, ranging from laboratory-based measures of attention to the more-commonly used method of having children's parents and teachers complete ratings of the child's attention.  Both groups also participated in 2 half-hour sessions after school each week over the course of 8 weeks, with one group receiving the Pay Attention! training program and the other group participating in various types of computer game activities (see below).

During the half-hour sessions the group receiving treatment with the Pay Attention! program performed a variety of attention-training tasks such as quickly sorting cards into categories based on the color and picture presented on them.  This was an activity that demanded careful attending in order to be successful.  As the child accomplished these tasks they would be made progressively more difficult, so that ever- increasing demands for careful, sustained attention were made on the child.  Auditory tasks followed a similar procedure (e.g., buzzing whenever the word ball is heard, versus buzzing whenever the name of something you might see in the sky is heard).  These tasks also required the child to exercise careful sustained attention to be successful, and the tasks again became more difficult - and thus required greater focus - over time.  The basic premise underlying the Pay Attention! program is that attentional abilities can be improved by providing structured opportunities for exercising and practicing particular aspects of attention.

The non-treated comparison group participated in computer based activities. This was a task that was interesting to children, and which required them to focus their attention.  It did not, however, include a systematic effort to specifically provide training that would lead to improved attention abilities.

RESULTS

Did the program work?

The results of this study are encouraging.  Although the groups did not differ in IQ or performance in pre-testing, they both demonstrated improved performance on posttest measures of attention, particularly selective attention.  This suggests the impact of a practice effect.  However, children in the attention training treatment group demonstrated significant improvement above and beyond that of the comparison group on 4 of 6 groups of measures considered sensitive to attentional functioning. Both groups also demonstrated significant improvement on a measure of academic efficiency called Math Worksheets. Once again, however, the children receiving the Pay Attention! program showed significantly greater improvement than children assigned to the computer game condition.  Children receiving the attention training program also tended to be rated as showing improvement in attentional functioning by their teachers. (The teachers did not know which group a child had been assigned to so these ratings should not have been biased).

In weighing the results of this study, there are several issues to be considered.  First, as noted above, the very small number of children participating in this study clearly indicates the need for a replication with a much larger sample.  Having said this, however, it is important to note that it is actually harder to obtain statistically significant results with such a small sample. The fact that several such results were found is thus impressive. It is also impressive to note that some significant improvements in attention were found even though the majority of children who participated were already on medication.  The gains made, therefore, were above and beyond the benefits that children were presumably already receiving from their medication.  Thus, combining this type of attention training program with medication treatment may offer potential benefits to many children.

Certainly, these results are encouraging enough to support the need for future investigations of this interesting program. In addition to employing larger samples, it will be important to include a longer follow up period to determine whether any initial improvements in attention as a result of the treatment are sustained over time.