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essay–psychological intervention

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First read widely about the topic so that you can get a good feel for the area. Think about an appropriate structure for this essay and introduce this structure at the beginning. Think about where you want to end up – which is evidence to support your final conclusion. A key feature of these questions is to draw on the evidence base. After you have introduced the nature of the problem for which treatment is needed, review the evidence for or against them. Consider areas in which research appears to be lacking or groups for which the treatment has been shown to be helpful – and those for whom it has not been examined or not found helpful. Make sure your conclusion can be backed by the research

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1. Clear introduction stating the background to the problem, the question, and how it will be addressed in the essay. 10%
2. Use of wide range of relevant research and reviews of research, and integration and synthesis of research findings (rather than describing each study in detail unless that approach is specifically warranted) 25%
3. Critical evaluation (strengths and weaknesses) of the available research relevant to the essay 30%
4. Conclusion that is justifiable on the basis of research findings 10%
5. Strong and coherent structure for the essay 10%
6. English expression and grammar, presentation, proof-reading and use of APA style 15%

4 Attention deficit hyperactivity

disorde

Margretta Nolan and Alan Carr

Definition

Attention deficit hyperactivity disorder, attention deficit disorder, hyper-
kinetic disorder, hyperkinesis and minimal brain dysfunction are some of the
terms used for a syndrome characterized by persistent overactivity, impulsiv-
ity and difficulties in sustaining attention (Barkley, 1990; Hinshaw, 1994;
Taylor, 1994)

Throughout this chapter preference will be given to the term
attention deficit hyperactivity disorder (ADHD) since this is currently the
most widely used term. In Figure 4.1 the DSM IV(APA, 1994) diagnostic
criteria for ADHD and the lCD 10 (WHO, 1992) criteria for Hyperkinetic
Disorder are presented. The most noteworthy feature of the syndromes
described in the two widely used classification systems is their similarity

Historically, a narrow definition of ADHD has been used in the UK and
defined in the lCD classification system, with great emphasis being placed
on the stability of the overactivity problems across home and school con-
texts. In contrast, in the US, this cross-situation stability has not been a
core diagnostic criterion within previous editions of the DSM (Hinshaw,
1994). In view of this historical difference, it is particularly noteworthy
that currently in both the North American DSM IV and the European lCD
10, it is stipulated that symptoms must be present in two or more settings
such as home and school for a positive diagnosis to be made.

Historically the following features have been used to subtype ADHD:

• The pervasivness of the problem
• Presence or absence of both inattention and hyperactivity
• Co-morbidity with conduct disorder

The occurrence of the symptoms both within and outside the home, presence
of both inattention and overactivity, and the presence of conduct disorder
are all associated with a more serious condition which is less responsive to
treatment and which has a poorer outcome (McArdle et al., 1995). Both
DSM IV and lCD 10 distinguish between subtypes of ADHD depending upon
the patterning of symptomatology or the presence of co-morbid conditions.

Copyrighted Material

Carr, A. (Ed.). (2001). What works with children and adolescents? : A critical review of psychological interventions with children,
adolescents and their families. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from latrobe on 2020-09-15 21:57:37.

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DSMIV
Attention deOcit hyperactivity disorder

A. Either 1 or 2.

1. Six or more of the following symptoms of inattention
have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level.

Inattention
a. Often fails to give close attention to details or makes
careless mistakes in schoolwork, work or other activities
b. Often has difficulty sustaining attention in tasks
or play activities
c. Often does not seem to listen when spoken to directly
d. Often does not follow through on instructions and
fails to finish schoolwork, chores or work duties
e. Often has difficulty organizing tasks and activities
f. Often avoids or dislikes tasks that require sustained
mental effort
g. Often loses things necessary for tasks or activities
h. Is often easily distracted by extraneous stimuli
i. Is often forgetful in daily activities

2. Six or more of the following symptoms of
hyperactivity-impulsivity have persisted for at least
6 months to a degree that is maladaptive and
inconsistent with developmental level.

Hyperactivity
a. Often fidgets with hands or feet or squirms in seat
b. Often leaves seat in classroom or in other situations
in which remaining seated is expected
c. Often runs about or climbs excessively in situations
in which it is inappropriate
d. Often has difficulty playing or engaging in leisure
activities quietly
e. Is often on the go or acts as if driven by a motor
f. Often talks excessively

Impulsivity
g. Often blurts out answer before questions have been
completed
h. Often has difficulty awaiting turn
i. Often interrupts or intrudes on others

B. Some of these symptoms were present before the
age of 7 years

C. Some impairment from the symptoms is present in
two or more settings (e.g. home and school

)

D. Clinically significant impairment in social , academic
or occupational functioning

E. Not due to another disorder

Specify:
Combined type if inattention and overactivity-impulsivity

are present ;

Inattentive type if overactivity is absent;

Hyperactive-impulsive type if inattentivness is absent

lCD 1

Hyperkinetic disorders

The cardinal features are impaired
attention and overactivity. Both are
necessary for the diagnosis and
should be evident in more than
one situation (e.g. home or school).

Impaired attention is manifested by
prematurely breaking off from tasks
and leaving activities unfinished . The
children change frequently from one
activity to another, seemingly losing
interest in one task because they
become diverted to another. These
deficits in persistence and attention
should be diagnosed only if they are
excessive for the child’s age and IQ.

Overactivity implies excessive
restlessness, especially in situations
requiring relative calm. It may,
depending upon the situation ,
involve the child running and
jumping around, getting
up from a seat when he or she was
supposed to remain seated, excessive
talkativeness and noisiness, or
fidgeting and wriggling. The standard
for judgement should be that the
activity is excessive in the context of
what is expected in the situation and
by comparison with other children of
the same age and 10. This behavioural
feature is most evident in structured,
organized situations that require a high
degree of behavioural self-control.

The characteristic behaviour problems
should be of early onset (before the
age of 6 years) and long duration.

Associated features include
disinhibition in social relationships,
recklessness in situations involving
some danger, impulsive flouting of
social rules, learning disorders, and
motor clumsiness.

Specify:
Hyperkinetic disorder with disturbance

of activity and attention when
antisocial features of conduct
disorder are absent;

Hyperkinetic conduct disorder when
criteria for both conduct disorder and
hyperkinetic disorder are met

Figure 4.1 Diagnostic criteria for attention and hyperactivity syndromes in
DSM IV and ICD 10.

Source Adapted from DSM IV (APA, 1994) and ICD 10 (WHO, 1992) .

Copyrighted Material
Carr, A. (Ed.). (2001). What works with children and adolescents? : A critical review of psychological interventions with children,
adolescents and their families. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from latrobe on 2020-09-15 21:57:37.
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Attention deficit hyperactivity disorder 67

In DSM IV the main distinctions are between cases where inattention and
overactivity are present or absent whereas co-morbid conduct problems are
the basis for subtyping in lCD 10.

Evidence summarized by Hinshaw (1994) indicates that the inattentive
and overactive subtypes of ADHD have distinct profiles. Children with the
inattentive subtype of ADHD are described clinically as sluggish, apathetic
daydreamers who are easily distracted and have difficulty completing
assigned tasks within school because of learning difficulties. Within their
family history there is a preponderance of learning disorders and emotional
disorders such as anxiety and depression. Those with the hyperactive-
impulsive subtype of ADHD are characterized by extreme overactivity,
oppositional and aggressive behaviours. Conduct problems are their most
notable school-based difficulties and they have a high rate of school sus-
pension and special educational placement. Within their family history
they have a preponderance of antisocial problems such as drug abuse and
criminality and children with the hyperactive-impulsive profile are at risk
for long-term antisocial behaviour problems and poor social adjustment.
Children with both the inattentive and hyperactive-impulsive subtypes of
ADHD have significant relationship difficulties with peers, school staff and
family members and both respond to psychostimulant treatment although
the inattentive subtype tends to respond to a lower dosage.

The primary distinction made in the lCD 10 system is between hyperkinetic
conduct disorder, where a co-morbid conduct disorder is present, and cases
where such co-morbidity is absent. Hinshaw (1994) in a review of differ-
ences between these two subgroups concluded that those children with co-
morbid conduct disorder show greater academic problems and suffer more
extreme relationship difficulties with peers, teachers and family members.
While they show some response to psychostimulant treatment, they rarely
respond to psychosocial individual and family interventions.

ADHD with co-morbid emotional disorders such as anxiety or depres-
sion, is not subclassified as a distinct condition within either lCD 10 or
DSM IV. Children with such co-morbid profiles have been found to have a
later onset for the disorder, fewer learning and cognitive problems and
to be less responsive to stimulant medication than youngsters without
co-morbid anxiety (Taylor, 1994).

ADHD is a particularly serious problem because youngsters with the core
difficulties of inattention, overactivity and impulsivity may develop a wide
range of secondary academic and relationship problems (Cantwell, 1996;
Gaub and Carlson, 1997; Hinshaw, 1994). Attentional difficulties may lead
to poor attainment in school. Impulsivity and aggression may lead to diffi-
culties making and maintaining appropriate peer relationships and devel-
oping a supportive peer group. Inattention, impulsivity and overactivity
make it difficult for youngsters with these attributes to conform to parental
expectations and so children with ADHD often become embroiled in chronic
conflictual relationships with their parents. In adolescence, impulsivity may

68 Margretta Nolan and Alan Carr

lead to excessive risk taking with consequent complications such as drug
abuse, road traffic accidents and dropping out of school. All of these risk-
taking behaviours have knock-on effects and compromise later adjustment.
As youngsters with ADHD become aware of their difficulties with regulat-
ing attention, activity and impulsivity and the failure that these deficits lead
to within the family, peer group and school, they may also develop low
self-esteem and depression. In light of the primary problems and secondary
difficulties that may evolve in cases of ADHD, it is not surprising that for
some the prognosis is poor (Hinshaw, 1994). For two-thirds of cases, the
primary problems of inattention, impulsivity and hyperactivity persist into
late adolescence and for some of these the primary symptoms persist into
adulthood. Roughly a third develop significant antisocial behaviour prob-
lems in adolescence including conduct disorder and substance abuse and
for most of this subgroup, these problems persist into adulthood leading to
criminality. Occupational adjustment problems and suicide attempts occur
in a small but significant minority of cases.

Epidemiology

Reviews of epidemiological studies of ADHD report overall prevalence
rates varying from 1 to 19 per cent depending upon the stringency of the
diagnostic criteria applied and the demographic characteristics of the
populations studied (Cantwell, 1996; Cohen et al., 1993; Gaub and Carlson,
1997; Hinshaw, 1994; McArdle et al., 1995). Using DSM IV criteria a pre-
valence rate of about 3-5 per cent has been obtained. The prevalence of
ADHD varies with gender and age. ADHD is more prevalent in boys than
girls and in preadolescents than in late adolescents. Co-morbidity for con-
duct disorder and ADHD is about 20 per cent in community populations
and possibly double this figure in clinic populations. Co-morbidity for emo-
tional disorders, such as anxiety or depression, and ADHD is about 10 per
cent in community populations. In clinical populations the co-morbidity
rate may be twice this figure. Virtually all children with ADHD have
attainment problems. However, co-morbid severe specific learning difficulties
have been estimated to occur in 10 to 25 per cent of cases. A proportion
of youngsters with ADHD have co-morbid developmental language delays
and elimination problems although reliable epidemiological data are
unavailable.

Previous reviews

Historically, individually oriented play therapy based on psychodynamic
or client-centred theories was widely used as a treatment for children with
ADHD. This tradition has yielded little empirical research and those studies
that have been conducted, while promising, have not employed control
groups. For example, Fonagy and Target (1994) found that of 69 per cent

Attention deficit hyperactivity disorder 69

of 93 cases who had disruptive behaviour disorders, after a year of psycho-
dynamic treatment showed clinically significant improvement. Children with
oppositional defiant disorder were most likely to improve, those with con-
duct disorder were least likely to improve and those with ADHD showed
improvement rates that fell between these two groups.

Working within the cognitive-behavioural tradition, Meichenbaum and
Goodman (1971) developed an individual approach to treatment – self-
instructional training- where children with ADHD were coached in the use
of self-instructions to control the way in which they deployed their atten-
tion and controlled their impulses to engage in high levels of activity.
Researchers within this tradition have expanded Meichenbaum’s original
treatment package to include other elements, notably social as well as
academic problem-solving skills training, and therapy-based contingency
management. However, the development of self-control through training
in the use of self-instructions remains the core feature of this treatment
approach. Extensive reviews of this literature have concluded that while
self-instructional training may have some effects on parent or teacher rated
behaviour problems, these effects are minimal and do not constitute clinic-
ally significant improvement (Abikoff, 1991; Hinshaw and Erhardt, 1991).
From their meta-analysis of this literature, Baer and Nietzel (1991) con-
cluded that self-instructional training is maximally effective if therapy focuses
on both academic and social tasks and involves therapy-based contingency
management.

Within the behavioural tradition, a contingency-management approach
to the treatment of children with ADHD emerged from the seminal work
of Patterson (1965). This involved therapy-based contingency management
implemented directly by therapists within therapy sessions or laboratory-
based specialist classrooms. Children with ADHD were reinforced for
deploying their attention in a focused appropriate way and for reduced
inappropriate activity levels. Response-cost systems were used where chil-
dren lost points for engaging in inappropriate behaviour. Such systems
have typically involved intensive schedules of reinforcement with therapists
or teachers prompting children to engage in appropriate behaviours and
administering reinforcement with high levels of frequency and immediacy.
While such approaches had the potential to strongly influence children’s
behaviour, they ran the risk of leading to low generalizability (DuPaul and
Eckert, 1997). That is, they entailed the possibility that treatment effects
would be confined to treatment sessions or specialist classrooms.

Behavioural parent training and school-based contingency management
were developed to deal with this problem (Braswell and Bloomquist, 1991).
In these approaches parents or teachers were trained by therapists in con-
tingency management procedures. They then implemented these contingency
management programmes to modify and normalize the behaviour of children
with ADHD in their home or classroom contexts. Typically parents and
teachers were trained to prompt and reinforce appropriate target behaviours

70 Margretta Nolan and Alan Carr

and to use response cost and time-out methods to reduce the frequency of
target negative behaviours. Typically such training procedures have been
referred to as behavioural parent training. While these programmes had the
benefit of increasing the possibility of generalization of appropriate beha-
viour to home and school contexts, they ran the risk of reduced potency
since typically reinforcement was delivered with lower levels of frequency
and immediacy than therapy or special class-based contingency management
programmes. Parents and teachers, due to other demands, were unable to
offer frequent prompts and to be available to administer reinforcement
immediately and frequently. In a review of studies of contingency manage-
ment approaches for the treatment of children with ADHD, Hinshaw eta/.
(1998) concluded that programmes implemented by therapists in treatment
sessions or specialist classrooms have profound immediate effects but these
are short-lived and do not generalize beyond the classroom setting to the
home or normal school context. Contingency management programmes
implemented by parents and teachers, in contrast, have in a limited number
of studies led to sustained clinically significant benefits.

Following the serendipitous discovery by Bradley (1937) of the positive
effects of stimulants on the conduct and academic performance of disturbed
children, more than a hundred controlled studies of the effects of stimu-
lants on children with attention and hyperactivity problems have been con-
ducted. Early studies examined the effects of dextroamphetamine, but the
bulk of recent studies have focused on methylphenidate.

Following a thorough review of this literature, Greenhill (1998) con-
cluded that stimulant therapy is effective in 70 per cent of cases in reducing
the core symptoms of ADHD. Stimulants have a greater effect on behaviour
than academic achievement. The effects of stimulants are short term and
evidence for their long-term effectiveness has not been established.

The idea that combined psychological and pharmacological therapies
might have synergistic effects has led to studies of the impact of combined
treatment packages. Typically these studies have evaluated the effects of
stimulant therapy combined with self-instructional training, behavioural
parent training and school- or therapy-based contingency management. In
these studies the effects of combined therapy packages have been compared
with those of psychological treatments, stimulant therapy and/or various
control conditions. Such control conditions have included placebo pills,
psychological support groups for children which have acted as attention
placebo conditions, and waiting list control groups. In a review of such
studies Hinshaw et a/. (1998) concluded that the short-term effects of
stimulant therapy are greater than those of behavioural parent training and
contingency management programmes. While contingency management
interventions add little incremental value to the short-term impact of high
dosage (.6-.8 mg/kg body weight) stimulant therapy, they may reduce the
requirement for high dosages by 50 per cent and they may lead to long-
term maintenance of treatment gains.

Attention deficit hyperactivity disorder 7

Method

The aim in this chapter was to review well-designed studies of the effects of
psychological interventions or combined psychological and pharmacological
interventions for children and adolescents with ADHD. A computer-based
literature search of the PsychLit database was conducted. Terms that
defined the disorder, such as attention deficit hyperactivity disorder, hyper-
activity, impulsiveness, inattention and hyperkinesis were combined with
terms that defined interventions such as treatment, therapy, intervention, con-
tingency management, behavioural parent training, self-instructional train-
ing, social skills training, behaviour therapy, cognitive-behaviour therapy,
family therapy, methylphenidate and stimulant therapy. The search, which
was confined to English language journals, covered the period 1977 to
1997 inclusively. A manual search through bibliographies of all recent re-
view papers on psychological interventions for ADHD was also conducted.
Treatment outcome studies were selected for inclusion in this review if they
contained a psychological or psychological and pharmacological treatment
condition or group and a control or comparison condition or group; if at
least five cases were included in the active treatment group; and if reliable
and valid pre- and post-treatment measures were included in the design of
the study. Single-case designs and studies reported in dissertations or con-
vention papers were not included in the review. Using these inclusion and
exclusion criteria twenty studies were selected.

Characteristics of the studies

Characteristics of the studies are set out in Table 4.1. All of the studies
were conducted between 1978 and 1993 and all were conducted in either
the USA or Canada. Of the twenty studies eleven evaluated the effects of
psychological interventions and nine examined the effects of combined
psychological and pharmacological interventions. Eighteen studies employed
comparative group designs and two used repeated measures designs where
the same group of cases participated in two or more different treatment
conditions sequentially. One thousand and ninety-six children were con-
tained in the 66 treatment groups or conditions of the twenty studies. Of
these 1096 children 862 were in treatment groups and 234 were in control
conditions. Participants’ ages ranged from three to eighteen years. For the
sixteen studies where gender data were given, 87 per cent of cases were
male and 13 per cent were female. Co-morbidity data were reported in only
eight studies and for these, oppositional defiant disorder and conduct dis-
order were the most commonly reported co-morbid conditions. For the
ten studies where referral information was given, schools and physicians
were the principal referring agents. Cognitive and/or behavioural treatment
interventions were evaluated in all of the studies selected. All of the pro-
grammes were conducted on an outpatient basis with two in community

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Carr, A. (Ed.). (2001). What works with children and adolescents? : A critical review of psychological interventions with children,
adolescents and their families. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from latrobe on 2020-09-15 21:57:37.
C
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74 Margretta Nolan and Alan Carr

settings; five in hospitals, six in university outpatient clinics, six in schools and
two in school-based summer treatment programmes. The number of sessions
of treatment ranged from six to 40 sessions over three to sixteen weeks.

Methodological features

Methodological features of the twenty studies included in this review are
presented in Table 4.2. All of the studies included in this review contained
control or comparison groups or conditions. All studies contained diagnost-
ically homogeneous groups which were assessed before and after treatment
on reliable and valid measures. In 60 per cent of studies parent ratings of
improvement were recorded and in 75 per cent of studies teacher ratings
of behavioural changes were made. Parent- and teacher-rated symptomatic
improvement after treatment and at follow-up were commonly assessed
with the Conners Parent Rating Scale or the Conners Teacher Rating Scale
(Conners, 1990), both of which contain a specific hyperactivity factor score.
Researcher-rated improvements, which were conducted in sixteen studies,
were based on observations of specific classroom behaviours such as on-
task and off-task behaviour or disruptive behaviour. Improvements in rela-
tionships within the child’s family system and social network were conducted
in only two of these twenty studies, but self-esteem was assessed in four
studies, attentional deployment in eleven, and academic achievement in eight.
The Piers-Harris Children’s Self-Concept Scale (Piers and Harris, 1969)
was commonly used to assess self-esteem and the Wide Range Achievement
Test (Wilkinson, 1993) to assess academic performance. To assess children’s
capacity to deploy attention in a sustained manner a range of laboratory
test were used and these included the Matching Familiar Figures Test (Kagan,
1966), the Continuous Performance Test (Conners, 1995) and the Porteus
Mazes (Porteus, 1955). In 70 per cent of studies cases were randomly
assigned to conditions. In 40 per cent of studies cases within conditions
were matched for co-morbidity. In 75 per cent of studies, groups were
demographically similar. In 50 per cent of studies follow-up assessments
were conducted two or more months following the end of treatment. In 50
per cent of studies deterioration was assessed and in 80 per cent, drop-out
rates were reported. In 20 per cent of studies information on engagement in
further treatment was given. In 45 per cent of studies information on both
statistical and clinical significance of treatment gains was reported. Experi-
enced therapists were used in 50 per cent of studies and in eight of the four-
teen studies (57 per cent) where two or more treatments were compared,
information given in the reports suggested that treatments were equally
valued by the research team. In 75 per cent of studies treatments were
manualized but in only 35 per cent of studies was information on supervision
given. In 55 per cent of studies treatment integrity was checked. Different
treatments compared were equally valued. In 80 per cent of studies informa-
tion on concurrent treatment was given but in only 10 per cent of studies

Ta
bl

2
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b
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76 Margretta Nolan and Alan Carr

was information on engagement in further treatment given. Overall this
was a methodologically robust group of studies.

Substantive findings

Effect sizes and other outcome results of the eleven studies which focused
exclusively on the effects of psychological treatments of ADHD are given in
Table 4.3. Results of studies of combined psychological and pharmacolo-
gical interventions are given in Table 4.4. A narrative summary of key
findings from all twenty studies is presented in Table 4.5. What follows is a
summary of these studies.

Psychological treatment

Eleven studies in this review examined the effects of psychological treat-
ment on ADHD in children and adolescents. Three of these studies were
concerned primarily with the effects of self-instructional training combined
with therapy-based contingency management (Kendall and Braswell, 1982;
Kendall and Finch, 1978; Kendall and Wilcox, 1980); one evaluated a
social skills training programme (Frankel et a/., 1997); three assessed the
effects of behavioural parent training (Anastopoulos eta/., 1993; Barkley et
al., 1992; Pisterman et al., 1992); and four examined the effects of multicom-
ponent programmes involving behavioural parent training, self-instructional
training and school-based contingency management (Abikoff and Gittleman,
1984; Bloomquist et al., 1991; Horn et al., 1987, 1990).

Self-instructional training and social skills training

In Kendall’s series of three investigations of self-instructional trammg,
the first study (Kendall and Finch, 1978) evaluated the effects of routine
self-instructional training. The six-session treatment programme involved
Meichenbaum and Goodman’s (1971) self-instructional approach com-
bined with a response-cost procedure. In the self-instructional training
the therapist demonstrated how to use increasingly covert self-instructions
from speaking aloud to engaging in covert self-talk to guide completing
particular tasks such as finishing a picture. There were five steps in this self-
instructional protocol: problem definition, problem approach, focusing
attention, selecting an answer and self-reinforcing for correct performance.
For this training, a standard set of materials was used over the six sessions
covering the areas of conceptual thinking, attention to detail, recognition
of identities, sequential recognition, visual closure and visual reproduction.
For example, with sequential recognition children had to work out what
comes next in a sequence from an array of alternatives. For the response-
cost procedure, children were given ten poker chips and informed that they
could buy items from a reinforcement menu with the chips after the session

Attention deficit hyperactivity disorder 77

but could lose chips for making mistakes during the session. Cases in the
control group covered the six-session curriculum but did not receive self-
instructional training or undergo response-cost procedures.

In Kendall’s second study (Kendall and Wilcox, 1980), similar self-
instructional and response-cost therapy techniques and teaching materials
were used over twelve sessions, but for one group, concrete self-instructions
which focused on the specific task at hand were used whereas for the
second treatment condition, children were coached in using abstract self-
instructions. For example, children in the concrete self-instructional training
group were taught to use task-specific self-instructions such as ‘I’m to find
the picture that doesn’t match; I must look at the pictures’. In contrast,
children in the abstract self-instructional training programme used more
general, conceptually based self-instructions such as ‘My first step is to make
sure that I know what I’m supposed to do; I should think about only what
I am doing right now’.

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training procedure initially helped the child to develop concrete self-
statements but later, more general abstract self-instructions were taught. In
addition, a broader curriculum was used which covered social as well as
academic problem solving. This treatment, combined with the response-
cost procedure used in the other two studies, was compared with a pro-
gramme that employed the use of response cost alone and a control condition
where neither self-instruction nor response-cost procedures were used.

For the self-instructional training programmes combined with therapy-
based response-cost procedures evaluated in these three studies, effect sizes
based on teacher-reported improvements ranged from 0.8 to 1.3, with the
highest effect size occurring in the group that received the abstract or con-
ceptually based self-instructional training. This indicates that from teachers’
perspective, the average child who participated in these programmes fared
better after treatment than 79 to 90 per cent of cases in the control group.
At four to twelve weeks’ follow-up, excluding the group who received con-
crete rather than abstract self-instructional training and who all relapsed,
effect sizes based on teacher-reported improvements ranged from 0.7 to 1.3.
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fared better than 76-90 per cent of cases in the control group on teacher-
rated improvements.

Effect sizes for therapist-rated improvement following treatment ranged
from 1.8 to 2.0 and at four to twelve weeks’ follow-up in the third study
the effect size based on therapists’ ratings was 1.8. These results indicate
that from therapists’ perspective the average treated case fared better after
treatment and at follow-up than 96 per cent of untreated cases.

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esteem, and reading achievement both following treatment and at follow-
up were small and ranged from -0.3 to 0.5. Effect sizes for performance on
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Carr, A. (Ed.). (2001). What works with children and adolescents? : A critical review of psychological interventions with children,
adolescents and their families. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from latrobe on 2020-09-15 21:57:37.
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la
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.
Carr, A. (Ed.). (2001). What works with children and adolescents? : A critical review of psychological interventions with children,
adolescents and their families. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from latrobe on 2020-09-15 21:57:37.
C
op
yr
ig
ht
©
2
00
1.
T
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ca
le

.
Carr, A. (Ed.). (2001). What works with children and adolescents? : A critical review of psychological interventions with children,
adolescents and their families. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from latrobe on 2020-09-15 21:57:37.
C
op
yr
ig
ht
©
2
00
1.
T
ay
lo
r
&
F
ra
nc
is
G
ro
up
. A
ll
rig
ht
s
re
se
rv
ed
.

•
A

t
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sy
st

em
ic

l
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t

h
e
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is

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ay

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p

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c
=
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sh

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h

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o
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9
0

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P
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M
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1
2
7

1
>
2

=
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h

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c

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w
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m

en
t,

t
h
e
co
m
b
in
ed
t
re
at
m
en
t

(B
P

T
+
S
IT
+
S
B
-C

M
)

le
d

t
o

m
o

re
i

m
p
ro
v
em
en
t
th

an
e

it
h

er
B

P
T
o
r
S
IT
.
•

A
ll

h
re

e
tr

ea
tm
en
ts
l
ed
t
o
p
ar
en
t-
an
d

t
ea

ch
er
-r
at
ed

im
p
ro
v
em
en
ts
i

n
b

eh
av
io
u

r
fr

m
p

re
–

to
p

o
st

-t
es

t
o
n
t
h
e
C
B
C
L
a
n
d
t
h
e
C
T

R
S

.
•

N
o

n
e

o
f
th
e
tr
ea
tm
en

ts
l

ed
t

o
t
ea
ch
er
-r
at
ed

im
p
ro
v
em
en
ts
o
n
t
h
e
C

T
R

S
a

t
fo

ll
o
w
-u
p
.

•
N

o
n
e
o
f
th
e
tr
ea
tm
en
ts

h
ad

a
s

ig
n
if
ic
an
t
ef
fe

ct
o

ac
h
ie
v
em
en
t
te

st
(

W
R

A
T

)
sc

or
es

,
la

b
te

st
s
o
f
at
te
n
ti
o
n

al
d

p
lo

y
m
en
t

(C
P

T
),

o
r
se
lf

-c
o

n
ce

p
t.

Ta
bl
e
4.

5
(c

on
t’d

)
St
ud
y
St
ud
y
A
ut
ho
rs

Ye
ar

N
p
er
g
p
N

o.
o

f
G

ro
up

ey
f

in
di

ng
s

no
.

ty
pe

se
ss
io
n
s

di
ffe

re
nc

1
1

lo
o

m
q

u
is

t
et

a
/.
1
9
9
1

1.
B
P
T
+
S
B
-C
M
+
S
IT
=
1
1

2
9

1
>
2

>
3

•
T
h
e
m
u

lt
ic

o
m
p
o

n
en

t
p

ro
g
ra
m
m
e

2.
S

B
-C
M
=
1
2

( B

P
T
+
S
B
-C
M
+
S
IT

)
w

as
m

o
re

e
ff

ec
ti

ve
t

h
an
t
h

e
3.

c
=
1
3
S
B
-C
M

p
ro

g
ra

m
m

e
in

i
m
p
ro
v
in

g
o

n
-t

as
k

b
eh

av
io

u
r

(
)

in
s

ch
o
o
l
b
u
t
at
o
n
e-
m
o
n
th
f
o
ll
o
w
-u
p
t
h

is
e

ff
ec

t
w
as
h
ed
o

u
t.

~
•

T
h
e
p
ro
g
ra
m
m
es
h
ad

n
o

e
ff

ec
ts

o
n
t
ea
ch
er
o
r
ch
il
d

ra
ti
n
g
s
o

f
ad

ju
st

m
en
t.

<2 · 1 2 P I- S T C o h en e ta /. 1 9 8 1 1. S IT + S T = 6 2 0 1 = 2 = 3 = 4 • F o

r
k

in
d

er
g

ar
te

n
c
h
il
d
re
n
w
it
h

A
H

D
a

ll
t

h
re

e
:::

r
2.

S
IT
=
6

tr
ea
tm
en
t
p
ac
k
ag

es
w

er
e
n
o
m
o

re
e

ff
ec

ti
ve

t
h
an

Ci>

3.
S
T
=

8
n
o
t
re
at
m
en
t
o
n
p
ar
en
t
an
d
t
ea
ch
er
r
at
in
g
s
o
n
t
h
e

Q
.

4.
C

=
4

C
o
n

n
er

s’
s

ca
le

s,
l

ab
t

es
ts
o
f
at
te
n
ti
o
n
al
d

ep
lo

y
m
en
t

s:
(M

F
F
T
),
a
n
d
s
el
f-
co
n
ce
p
t.

Q
)

P
I-
S
T

ro
w

n
e

ta
/.

1
9
8
5

1.
S
IT
+
S
T
=
1
0

2
4

1
=
2
>
3

>
4

•
F
o
r
p

re
-a

d
o

le
sc

en
t

bo
ys

w
it

h
A

D
H

D
,

co
m
b
in
ed

….
..

2
.S

IT
=
1
0

IT
a

n
d
S
T
t
re
at
m
en
t
w
as

n
o

b
et
te
r
th
an
S
T

a
lo

n
e

~
3.

S
T
=
1
0

an
d

b
o

th
w

er
e
b
et
te
r
th
an
S
IT

.
4

.
c
=
1

0
•

Im
p

ro
v
em
en
ts
f

or
p

ar
en
t
an
d
t
ea
ch

er
r

at
in
g
s
o
n
t
h
e
C
o
n
n
er

s
sc

al
es

o
cc

u
rr

ed
f

or
t

he
S

IT
+
S
T
a
n
d
S
T

g
ro
u
p

•
S

IT
+
S
T
a
n
d
S
T
g
ro
u

p
s

im
p
ro
v
ed
t

h
ei

r
sc

or
es
o
n

la
b
t
es
ts
o
f
at
te
n
ti
o
n
al
d
ep
lo
y
m
en
t

(M
F

F
T
).

•
N
o
n
e
o
f
th

e
g

ro
u
p
s
im
p
ro
v
ed
o

n
m

ea
su

re
s
o
f

ac
ad

em
ic
a
ch
ie
v
em
en

t
(W

R
A

T
).

1
4

P
I-
S
T

in
sh

aw
e

ta
/.

1
9
8
4

1.
S
IT
+
S
T
=
1

1
6

1
>

2
•
T
h
e
S
IT
+
S

T
p

ac
k
ag
e
p
ro
d
u

ce
d

o
p

ti
m
a
l
ef
fe

ct
s.

2.
S
IT
+
P
=
1
0

D
ec

re
as

es
i

n
th
e
in
te
n
si
ty
o
f
b
eh
av
io
u
r
w
h

p
ro

v
o

k
ed

o
cc
u
rr
ed
a

s
a

re
su

lt
o

f
th
e
S

T
c

o
m
p
o
n
en
t
an
d
i
n
cr

ea
se

s
in
t
h

e
us

e
o

f
se

lf
-c

o
n
tr
o

l
st

ra
te

g
ie

s
w
h
en
p
ro
v
o
k
ed
o
cc
u
rr
ed
a
s
a
re
su
lt
o

f
S

IT
.

1
5

P
I-
S
T

A
b

ik
o

ff
a

n
d

1
9
8
5

1.
S
IT
+
S
T
=
2

1
3

1
=

2
=

•
F

o
ll
o
w
in
g
t
re
at
m
en
t
th
er
e
w
er
e
n
o

d
if

fe
re
n
ce

s
G

it
tl
em
an

2.
S
T
+
S

U
P

=
1
4

b
et
w
ee
n
t
h
e

th
re

e
co
n
d
it
io
n
s
o
n
p
ar
en
t
o
r
te
ac
h
er

3
.
S
T
=

1
5

b
eh
av
io
u

r
ra

ti
n

g
s,

l
ab
t
es

ts
o

f
at
te
n
ti
o
n
al

d
ep
lo
y
m
en
t
(M
F
F
T
)
o

r
ac

h
ie
v
em
en
t
te
st

s
(W

R
A

T
).

<2 ·

:::
r

Q
. ~ CD ~

1
6

P
I-
S
T

B
ro

w
n

e
t
a/
.
1
9
8
6

1
7

P
I-
S
T

F
ir

es
to

n
e
et
a/
.
1
9
8
6

P
I-
S
T

ar
ls

o
n
e
t
a/
.
1
9
9
2

1.
S
IT
+
S
T
=
9

2
.
S
IT
+
P
=
1
0
3.
S
T
+
S
U
P
=
8

4.
S

U
P

+
P

=
8

1.
B
P
T
+
S
T
=

3
0

2.
B
P
T
+
P
=
2
1
3.
S
T
=
2
2

1.
S
B
-C
M
+
H
i-
S
T
=
2

4
2.

S
B
-C
M

+
L

o-
S

T
=
2
4

3.
S
B
-C
M
+
P
=
2
4

4
.

H
i-
S
T
=
2

4
5.

L
o

-S
T
=
2

4
6.

p
=

2
4

R
ep
ea

te
d

m
ea

su
re
s
de
si
gn

2
2

4
0

1
=
2
=

3
=

1
=

3
>

F
o

r
cl

as
s

b
eh
av
io
u
r
1
=
2
=

4
=

5
>

3
=
6

F
o

r
o

n
-t
as
k

b
eh

av
io
u
r
1
=
2
=

4
>

3
=
5
>
6

F
o
r
ac
h
ie
v
em
en
t
1
=
2
=
4
=
5
>
3
=
6

•
A
ft
er
t
re
at
m
en
t
ch
il
d
re
n
c
ea
se

d
m

ed
ic

at
io
n
f

or
o

n
e
m
o
n
th
a
n

d
8

5
%
o
f
ch
il
d
re

n
r

es
u

m
ed

ic
at
io
n

u
e

o
e

x
ac

er
b

at
io
n
o

f
sy

m
p
to
m

at
o

lo
g
y
,
in
d
ic
at
in
g

at
S

T
d

o
es

n
o
t
gi
ve
c
h
il
d
re
n
w
it
h
A
D
H
D

s
ki

ll
s

re
q

u
ir

ed
f
o
r

re
la

p
se

p
re
v
en
ti
o
n
.
•
O
v
er
al
l

th
is

s
tu
d
y
s
h
o
w
ed
t

h
at

S
IT
a
n
d
S
T
a
lo
n

e
an

d
c
o
m
b
in
ed
a
re
i

n
ef

fe
ct

iv
e

in
t

re
at
in
g
A
D
H
D
.
•

In
t

h
is
s
tu
d
y

,
S

T
w

as
d

is
co

n
ti
n
u
ed
f

or
a

w
ee

k
b

ef
o

re
p

o
st
-t
es
ti
n

g
w

h
ic

h
r

ev
ea

le
d
n
o
g
ro
u
p

d
if
fe
re
n

ce
s

fo
r
p
ar
en
t-
o
r
te
ac
h
er
-r
at
ed

h
y
p
er
ac
ti
v
it
y
,
at
te
n
ti
o
n
al
d
ep
lo
y
m
en
t
(M
F
F
T
)
o
r
ac
h
ie
v
em
en
t
(W
R
A
T
).

•
A
ft
er
t
re
at
m
en
t
S
T
a
lo
n
e
an
d
i
n
co
m
b
in
at
io
n
w
it
h

B
P
T
w
as
s
u
p
er
io
r

to
B

P
T
i
n
im
p
ro
v
in
g
t
ea
ch
er

–
ra

te
d

h
y

p
er
ac
ti
v
it
y
,
p
ar
en
t-
ra
te
d
c
o
n
d
u

ct
p

ro
b

le
m

s
an

d
a

tt
en

ti
o
n
al

d
ep

lo
y
m
en
t
in
l
ab

o
ra

to
ry

t
es
ts

(d
el

y
ed

r
ea

ct
io
n
t

im
e)

,
b
u
t
n
o

t
ac

h
ie
v
em
en
t
te
st
s
co

re
s.

•

A
t

tw
o

-y
ea

r
fo

ll
o
w
-u

p
,

in
te

rg
ro

u
p
d
if
fe
re
n
ce
s
w
as
h
ed
o

u
t,

s
o
t
h

e
be

ne
fi

ts
o
f
S
T
w
er
e
sh
o

rt
t

er
m

.
•
T
h
e
o
v
er
al
l

fi
n

d
in
g
o
f
th

is
s

tu
d
y
w

as
t

h
at

h
ig

h
o

r
lo

w
d

os
e

S
T
c
o
m
b
in
ed
w
it

h
C

B
-C

M
h

ad
a

p
o

si
ti
v
e
im
p

ac
t

o
n

c
la

ss
ro

o
m
b
eh
av
io

u
r,

w
h

il
e

o
n

ly
S

(r
eg

ar
d

le
ss

o
f
th
e
d
o

sa
g

e)
h

ad
a
p
o
si
ti
v
e
im
p
ac
t
o
n

d
em

ic
p

er
fo
rm
an

ce
.

•
F
o
r

cl
as

sr
o

o
m

o
b

se
rv

at
io
n
s
o
f
o
n

-t
as

k
b

eh
av
io
u

r
an

d
d

is
ru

p
ti

v
e
b
eh
av
io
u
r
th
re
e
co
n
d
it
io
n
s
p
ro
d
u
ce
d

th
e
b

es
t

re
su

lt
s:

t
h

e
h

ig
h

S
T
c
o
n
d
it
io
n
a
lo
n
e
an
d
i

n
co

m
b

in
at

io
n
w
it
h
S
B
-C

M
a

n
d
t
he
L
o

w
S

T
c
o
n
d
it
io
n

in
c
o
m
b
in
at
io
n
w
it
h
S
B
-C

M
.

T
h

e
lo

w
S
T
c
o
n
d
it
io
n

an
d
t
he
S
B
-C
M
+

P
t

re
at
m
en
t
p
ac
k

ag
es

w
er

e
le

ef
fe
ct
iv

e
th

an
t

h
es

e
th

re
e

co
n
d
it
io
n

s
b

u
t
w
er
e
m
o
re

ef
fe
ct
iv
e
th
an
t
h
e
p

la
ce

b
o
c
o
n
tr
o
l
co
n
d
it
io
n
.
•
F
o
r
ac

ad
em

ic
a
ch
ie
v
em
en
t
an
d
c
h
il
d
re
n
‘s
s
el
f-
re
p
o
rt
s
o

f
ru

le
f
o
ll
o
w
in
g
a
n
d
a

ca
d

em
ic

a
d

ju
st
m
en

t
al

l
fo

u
r
co
n
d
it
io
n
s
in
v
o

lv
in

g
S

T
l

ed
t

o
m

o
re

im
p
ro
v
em
en
t
th
an
t
h
e
co
n
d
it
io
n
s
w
h
er
e
S
T
w
as
n
o

t
em

p
lo
y
ed
.
Carr, A. (Ed.). (2001). What works with children and adolescents? : A critical review of psychological interventions with children,
adolescents and their families. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from latrobe on 2020-09-15 21:57:37.
C
op
yr
ig
ht
©
2
00
1.
T
ay
lo
r
&
F
ra
nc
is
G
ro
up
. A
ll
rig
ht
s
re
se
rv
ed
.

(‘
) ~ <2·

::r
–
(i
)

0.
. ~

(i
)

~ ~

Ta
bl
e
4.
5
(c
on
t’d
)
St
ud
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Carr, A. (Ed.). (2001). What works with children and adolescents? : A critical review of psychological interventions with children,
adolescents and their families. ProQuest Ebook Central http://ebookcentral.proquest.com
Created from latrobe on 2020-09-15 21:57:37.
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Attention deficit hyperactivity disorder 87

ranged from 0.1 to 0.5 and at follow-up from 0.1 to 1.3. The high level of
variability in these results makes it difficult to draw firm conclusions about
the impact of treatment on attentional deployment.

Frankel et a/. (1997) examined the effects of social skills training on
children with ADHD. In the training sessions children were taught conversa-
tion and telephone skills; group entry skills for joining in peer activities;
procedures for managing play-dates where children visit a youngster’s home;
skills for the management of peer rejection or teasing; negotiation skills for
managing conflicts of interest; and skills for managing confrontations with
adults. Didactic input, modelling, rehearsal and therapy-based contingency
management were used throughout this social skills training programme.
Children were also directly coached in play skills. In dyads, therapists used
prompting and contingency management to facilitate the development of
rule-following and turn-taking behaviours. Concurrently, parents received
psychoeducation on the development of social skills in children. Following
treatment, effect sizes for parent- and teacher-rated improvement were 1.1
and 1.0 indicating that the average treated child fared better after treatment
than 84 to 86 per cent of untreated cases.

The results of these four studies of child-focused psychological interven-
tions for ADHD allow a number of conclusions to be drawn. First, both
self-instructional training and social skills training have positive effects on
pre-adolescent school-aged children with ADHD. Self-instructional training
where children learn both specific and general self-instructions combined
with therapy-based contingency management over six to twelve sessions is
probably effective in reducing school- and clinic-based behaviour problems,
but not achievement problems, behavioural problems in the home or atten-
tion deployment as assessed by laboratory tests of vigilance. However, cau-
tion in drawing these conclusions is warranted because Kendall’s studies on
which these conclusions are based were conducted before the introduc-
tion of stringent criteria for the diagnosis of ADHD were routinely used
in selecting cases for inclusion in treatment trials. A second conclusion is
that social skills training conducted over twelve sessions supplemented with
therapy-based contingency management and parental psychoeducation is
probably effective in reducing home- and school-based behaviour prob-
lems. The studies reviewed in this section provide evidence for the short-
term effectiveness of self-instructional and social skills training, but do not
address the issue of long-term improvement.

Behavioural parent training

Three studies included in this review examined the effects of behavioural
parent training offered as a self-contained treatment package (Anastopoulos
et al., 1993; Barkley eta/., 1992; Pisterman et al., 1992). Pisterman eta/.
(ibid.) evaluated the effects of a twelve-session behavioural parent training
programme for preschool children with ADHD. The programme offered

88 Margretta Nolan and Alan Carr

parents training in shaping and reinforcing compliance with parental
requests and on-task behaviour, and using time-out procedures for dealing
with non-compliance (Forehand and McMahon, 1981). Psychoeducation,
modelling, rehearsal and video-feedback were used in parent training.
Anastopoulos et a/. ( 199 3) examined the effects of a similar nine-session
parent training programme for pre-adolescent school-age children (Barkley,
1987, 1990). Following treatment, in Pisterman’s programme 65 per cent
of cases showed clinically significant change on researcher ratings of on-
task behaviour and in Anoustopoulos’ study 64 per cent of cases showed
clinically significant change on the ADHD rating scale (DuPaul, 1991). At
follow-up in both studies these gains were maintained. In Pisterman’s study
there were substantial improvements in parent-child interaction. Treated
cases fared better than 88 per cent of untreated cases following therapy and
at follow-up. In Anastopoulos’ study the parent-child system of the average
treated case fared better than those 73 per cent of untreated cases. Combined
deterioration and drop-out rates for both studies ranged from 20 to 21 per
cent. These two studies provide evidence for the efficacy of behavioural
parent training in leading to improvements in behaviour and parent-child
relationships for preschoolers and pre-adolescent children with ADHD.

In contrast to Pisterman and Anastopoulos, who were concerned with
children under twelve years of age, Barkley eta/. (1992) studied the impact
of behavioural parent training with adolescents. They compared the effect-
iveness of behavioural parent training with a programme of problem solving
and communication skills training and a programme of structural family
therapy. In each programme, ten sessions of therapy were offered. Clinically
significant gains were made by 20 per cent of cases receiving behavioural
parent training; nineteen of cases in the problem solving and communica-
tion skills training programme; and only 5 per cent of cases who engaged
in structural family therapy. Deterioration occurred in 10 per cent of the
behavioural parent training cases but not in the other two conditions.

From these three studies it may be concluded that nine to twelve sessions
of behavioural parent training is an effective treatment for a proportion of
children and adolescents from three to eighteen years old with ADHD.
Behavioural parent training leads to short-term positive changes in home-
based behavioural problems and parent-child relationships. These studies
provide no evidence for the long-term effectiveness of behavioural parent
training or its impact on attentional deployment, academic performance or
school-based behaviour.

Multicomponent treatment packages

In four studies the effects of behavioural parent training combined with
self-instructional training and/or school-based contingency management
were examined (Abikoff and Gittleman, 1984; Bloomquist eta/., 1991; Horn
eta/., 1987; Hornet a/., 1990). Hornet a/. (1987) compared the effects of

Attention deficit hyperactivity disorder 89

combined behavioural parent training and self-instructional training with
self-instructional training alone and behavioural parent training alone.
The behavioural parent training programme was similar to those described
earlier in this section and was based on Patterson’s (1976) approach.
The self-instructional training programme was similar to those described
in the previous section and was based on the approaches developed by
Meichenbaum (1977) and Camp and Bash (1981). In all there were nine-
teen treatment sessions: eight for behavioural parent training, eight for self-
instructional training and three for school-based contingency management.
Abikoff and Gittleman (1984) evaluated the effects of a combined beha-
vioural parent training programme (Becker, 1971; Patterson, 1975) and
school-based contingency management programme (O’Leary and O’Leary,
1972) in normalizing hyperactive children’s behaviour. In all there were
approximately fifteen sessions in this programme with eight devoted to
parent training and several devoted to school-based contingency manage-
ment. Horn et al. (1990) compared the efficacy of combined behavioural
parent training, self-instructional training and a school-based contingency
management programme with a behavioural parent training programme
and a self-instructional training programme. The behavioural parent training
programme was based on Barkley (1981), Patterson (1976) and Forehand
and McMahon’s (1981) manuals. The self-instructional training programme
was based on the clinical practices outlined in Camp and Bash (1981),
Kendall and Braswell (1985) and Meichenbaum’s (1977) texts. The school-
based contingency management programme involved consultations with
teachers and the use of a daily report card system (Ayllon et al., 1975). In
all there were 27 sessions: twelve for behavioural parent training, twelve
for self-instructional training and three for school-based contingency
management. Bloomquist et al. (1991) compared the effects of a combined
programme of behavioural parent training, self-instructional training and
school-based contingency management with a school-based contingency
management programme alone using treatment procedures detailed in
Braswell and Bloomquist (1991). In all there were 29 treatment sessions:
seven for behavioural parent training, twenty for self-instructional training
and two for school-based contingency management.

Across these four studies, for improvements in parent-reported behaviour
following treatment, effect sizes ranged from 0.2 to 0.6 and at follow-up
they ranged from -0.1 to 0.7. The largest sustained effects occurred in Horn
et al.’s (1990) study where the multicomponent treatment package, when
compared with the behavioural parent training and the self-instructional
training programmes after treatment and at follow-up yielded effect sizes
that ranged from 0.6 to 0. 7, indicating that the average case receiving the
combined package fared better than 73-76 per cent of cases who received
single component treatments. The worst results for combined treatments
compared to single component treatments occurred in Horn et al.’s earlier
( 1987) study where they found an effect size of -1.0 at one-month follow-up

90 Margretta Nolan and Alan Carr

on parent-rated behaviour. This showed that the average case receiving a
combined behavioural parent training and self-instructional training pack-
age was worse off than 84 per cent of cases who received self-instructional
training alone.

For teacher-rated behavioural improvement comparing combined treat-
ments with single treatments, effect sizes ranged from -0.6 to -0.1 follow-
ing treatment across the four studies. These results show that none of the
combined treatment packages were any better than single component
approaches in modifying school-based behaviour in the period immediately
following treatment. In fact they were marginally worse. At four to twelve
weeks’ follow-up, effect sizes for teacher-rated behaviour ranged from -0.5
to 0.5, with the worst and the best results occurring in Horn et al.’s later
(1990) study. The average case in the multicomponent programme fared
better at follow-up than 69 per cent of cases in the self-instructional train-
ing programme and worse than 69 per cent of cases in the behavioural
parent training programme.

Across the four studies, effect sizes for researcher ratings of children’s
behaviour ranged from 0.7 to above 2.0, with the largest effect sizes occur-
ring in Bloomquist’s (1991) study. The average case receiving a combined
programme of behavioural parent training, self-instructional training and
school-based contingency management fared better than 98 per cent of
untreated controls.

For children’s self-esteem, effect sizes across the four studies concerned
with the impact of combined treatments ranged from -0.2 to 0.9 following
treatment and from -1.0 to 1.1 at follow-up. Both the largest and smallest
effect sizes occurred in studies where a combined treatment package was
compared with self-instructional training. In Horn et al.’s earlier (1987)
study, effect sizes of 0.9 and 1.1 were obtained post-treatment and at follow-
up from a comparison of a combined progamme of behavioural parent
training and self-instructional training with self-instructional training alone.
In contrast, in Hornet al.’s later (1990) study, an effect size of -1.0 was
obtained after treatment and at follow-up from a comparison of a com-
bined programme of behavioural parent training, self-instructional training
and school-based contingency management with self-instructional training
alone. These conflicting findings make it difficult to draw firm conclusions
in this domain.

For laboratory tests of attentional deployment, effect sizes across the
four studies concerned with the impact of combined treatments after therapy
and at follow-up ranged from -0.7 to 0.4. These results suggest that, com-
pared with single component treatments, combined treatments did not
enhance attentional deployment and vigilance for children with ADHD.

For academic achievement tests of reading skills, effect sizes across the
four studies concerned with the impact of multicomponent programmes
after therapy and at follow-up ranged from -0.5 to 0.7. Both the largest and
smallest effect sizes occurred in studies where a multicomponent treatment

Attention deficit hyperactivity disorder 91

package was compared with behavioural parent training. In Horn et al.’s
earlier (1987) study, effect sizes of 0.5 and 0.7 were obtained after therapy
and at follow-up from a comparison of a multicomponent programme
with behavioural parent training alone. In contrast, in Horn et al.’s later
(1990) study, effect sizes of -0.5 and -0.3 were obtained after treatment
and at follow-up from a comparison of a multicomponent programme with
behavioural parent training alone. These conflicting findings make it diffi-
cult to draw firm conclusions in this domain.

In studies of multicomponent treatment programmes after therapy 36-
51 per cent of cases were classified as having made clinically significant
improvements or being indistinguishable from children without ADHD and
at follow-up these figures improved to 73 per cent. Caution is required in
interpreting this follow-up figure since it is based on a single study. In com-
parison, 9-25 per cent of cases who received single component treatments
made clinically significant improvements. The drop-out rate for combined
treatment packages was 23 per cent and for single component treatments,
drop-out rates ranged from 15-20 per cent.

In summary, the studies reviewed in this section suggest that multicom-
ponent treatment packages may be more effective than single component
packages in reducing home-based behaviour problems and researcher-
rated behaviour problems. For school-based behavioural and achievement
problems, self-esteem and attentional deployment as assessed by laboratory
tests of vigilance there was no compelling evidence that multicomponent
treatment packages were any better than single component treatments.
Effective multicomponent treatment packages included behavioural parent
training, self-instructional training and in some instances school-based con-
tingency management and spanned 17 to 29 sessions over eight to twelve
weeks.

Combined psychological and pharmacological treatment

Nine studies in this review examined the effects of combined psychological
and pharmacological treatments. Five of these involved self-instructional
training combined with stimulant therapy (Abikoff and Gittleman, 1985;
Brown et al., 1985, 1986; Cohen et al., 1981; Hinshaw et al., 1984). Four
involved stimulant therapy combined with either behavioural parent train-
ing, or school-based contingency management or multicomponent psy-
chological interventions (Carlson et al., 1992; Firestone et al., 1986; Horn
et al., 1991; Pelham et al., 1993).

Self-instructional training and stimulant therapy

Cohen et al. (1981) compared the outcome for kindergarten children with
ADHD who received self-instructional training combined with stimulant
therapy to that of children who received either of the treatment components

92 Margretta Nolan and Alan Carr

alone and a control group. The self-instructional training was based on the
protocols of Meichenbaum and Goodman (1971), Camp and Bash (1981)
and Douglas et al. (1976). Stimulant therapy involved 10-20 mgs per day
of methylphenidate. Children began medication one to two weeks before
the first assessment and remained on medication for the post-treatment
assessment. Brown et al. (1985), using a similar four-group research design
to that of Cohen et a/. (1981), examined the effects of self-instructional
training combined with stimulant therapy with school-aged children.
The self-instructional training programme was based on the work of
Meichenbaum and Goodman (1971) and Douglas et al. (1976). Stimulant
therapy involved 5-15 mgs per day of methylphenidate administered in
a divided dose and children remained on medication for post-treatment
assessment. Hinshaw et al. (1984) compared the effects of self-instructional
training combined with stimulant therapy to that of the same psychological
treatment combined with a pill placebo. The self-instructional training
addressed the management of academic problems and socially provocative
situations (Meichenbaum, 1977; Spivack and Shure, 1974; Douglas et al.,
1976; Kendall and Braswell, 1985). Stimulant therapy dosages of methyl-
phenidate ranged from 4-40 mgs. Abikoff and Gittleman (1985) compared
the effects of self-instructional training combined with stimulant therapy
to those of stimulant therapy alone or in combination with an attention
placebo psychological support treatment. The self-instructional training
addressed the management of academic and social problems (Douglas et al.,
1976; Meichenbaum, 1977; Spivack and Shure, 1974). Stimulant therapy
included up to 80 mgs of methylphenidate, 50 mgs of dextroamphetamine
or 50 mgs of pemoline per day given in a divided dose. Following sixteen
weeks of treatment, all cases on stimulant medication alone and 50 per cent
of those in the combined treatment group were placed on placebo pills and
subsequently, their requirement for further stimulant treatment assessed
regularly for a one-month period. Brown’s team in a four-group design
compared the effects of combined self-instructional training and stimulant
therapy with those of stimulant therapy combined with an attention placebo
psychological support treatment; self-instructional training combined with
a pill placebo; and a placebo control group (Brown eta/., 1985; Brown,
Borden et al., 1986; Brown, Wynne et al., 1986).

Self-instructional training followed Meichenbaum and Goodman’s (1971)
protocol and stimulant treatment involved 10-40 mgs of methylphenidate
per day in a divided dose.

Across these five studies, for combined self-instructional training and
stimulant therapy compared with self-instructional training alone or with a
placebo pill, effect sizes for improvements in parent-rated behaviour ranged
from 0.2 to 1.4 after treatment and the average effect size was 0.8, indicat-
ing that for parent-rated behaviour problems the average case receiving the
combined treatment fared better than 79 per cent of cases treated with self-
instructional training alone. However, these parent-rated behavioural gains

Attention deficit hyperactivity disorder 9 3

were not maintained at three months’ follow-up in all studies, where effect
sizes ranged from -0.5 to 0.8.

For combined self-instructional training and stimulant therapy compared
with self-instructional training alone or with a placebo pill, effect sizes for
improvements in teacher-rated behaviour ranged from 0.2 to 0.9 after treat-
ment and the average effect size was 0.6, indicating that for teacher-rated
behaviour problems the average case receiving the combined treatment
fared better than 73 per cent of cases treated with self-instructional training
alone. These teacher-rated behavioural gains, however, were not maintained
at three months’ follow-up in all studies, where effect sizes ranged from
-0.3 to 0.7.

For combined self-instructional training and stimulant therapy compared
with self-instructional training alone or with a placebo pill, effect sizes for
improvements in self-rated behaviour ranged from 0.1 to 0.3 after treat-
ment and from 0.3 to 2.4 at follow-up. Cases treated with the combined
treatment made negligible progress compared with cases treated with self-
instructional training alone over the course of treatment, but in one study
at follow-up substantial gains were made. However, the variability in re-
sults precludes firm conclusions being drawn in this domain.

For combined self-instructional training and stimulant therapy compared
with self-instructional training alone or with a placebo pill, effect sizes
for improvements in attentional deployment as assessed by laboratory tests
range from -0.9 to 1.0 after treatment and from -1.0 to 0.9 at follow-up.
Once again, as with the results on self-reported behavioural improvements,
those for attentional deployment have such a wide variability that drawing
firm conclusions about the benefits of combined self-instructional training
and stimulant therapy compared with self-instructional training alone in
this domain is not possible.

For combined self-instructional training and stimulant therapy compared
with self-instructional training alone or with a placebo pill, effect sizes
for improvements in academic achievement as assessed by standardized
reading tests ranged from 0.1 to 0.2 after treatment and from -0.3 to -0.1
at follow-up. These results suggest that combined self-instructional training
and stimulant therapy probably have few advantages over self-instructional
training alone in this domain.

In one study (Hinshaw et a/., 1984) compared with self-instructional
training alone or with a placebo pill, combined self-instructional training
and stimulant therapy led to significant gains in researcher-rated behaviour
when faced with interpersonal provocations in a laboratory situation.

Let us now consider the combined self-instructional training and stimu-
lant therapy compared with stimulant therapy alone or with an attention
placebo psychological support intervention. Across the four studies that
made such comparisons effect sizes for parent-rated, teacher-rated and self-
rated behavioural improvements ranged from -0.9 to 0.4 after treatment
and at follow-up. These results suggest that combined self-instructional

94 Margretta Nolan and Alan Carr

training and stimulant therapy probably has few advantages over stimulant
therapy alone in facilitating behavioural improvements at home or at school.
Effect sizes for attentional deployment and academic achievement ranged
from -0.5 to 0.6 after treatment and at follow-up. These results suggest
that combined self-instructional training and stimulant therapy probably
have few advantages over stimulant therapy alone in facilitating improved
attention and academic achievement.

In summary, compared with self-instructional training alone or with a
placebo pill, combined self-instructional training and stimulant therapy
led to short-term improvements in parent- and teacher-rated behaviour,
but such gains were not always maintained at follow-up. For self-reported
behavioural improvement, attentional deployment as assessed by laborat-
ory tasks requiring sustained vigilance, and for academic achievement as
assessed by standardized reading test, there was no firm evidence that
combined self-instructional training and stimulant therapy were routinely
more effective than self-instructional training alone or with a placebo pill.
Combined self-instructional training and stimulant therapy probably had
few advantages over stimulant therapy alone in facilitating behavioural
improvements at home or school or in facilitating improved attention and
academic achievement. Self-instructional training programmes examined in
these studies involved six to 32 sessions over three to sixteen weeks and
were offered on an outpatient basis. Stimulant therapy commonly involved
a daily divided dose of 5-40 mgs of methylphenidate.

Behavioural parent training, school-based contingency
management and stimulant therapy

Four studies included in this review investigated the effects of stimulant
therapy combined with either behavioural parent training, or school-based
contingency management or multicomponent psychological intervention
programmes (Carlson et al., 1992; Firestone et al., 1986; Hornet al., 1991;
Pelham et al., 1993 ). Firestone et a/. (ibid.) compared the effects of nine
sessions of behavioural parent training based on Patterson’s (1975) ap-
proach combined with stimulant therapy, with behavioural parent training
combined with a placebo pill. Children receiving stimulant treatment were
given 10-30 mgs of methylphenidate per day in a divided dose.

For combined behavioural parent training and stimulant therapy com-
pared with behavioural parent training plus a placebo pill, effect sizes for
improvements in parent- and teacher-rated behaviour were 0.7 and 0.8
after treatment, indicating that the average case receiving the combined treat-
ment fared better than 76 per cent of cases treated with behavioural parent
training and a placebo at home and better than 79 per cent at school.
However, these gains were not maintained when cases were followed up
three months later and effect sizes of -0.4 and 0.0 were obtained for sus-
tained improvements in parent- and teacher-rated behaviour respectively.

Attention deficit hyperactivity disorder 95

For attentional deployment on laboratory tests of vigilance an effect size of
0.6 was obtained following treatment and this increased to 0.9 at three
months’ follow-up. Thus, the average case receiving combined behavioural
parent training and stimulant therapy fared better on tests of attentional
deployment three months after treatment than 82 per cent of cases who
received behavioural parent training plus a placebo pill. Effect sizes for
performance on academic reading achievement tests following treatment
and three months later were 0.1 and 0.3, indicating that the differences
between groups were negligible. At two years’ follow-up, differences be-
tween cases who received combined behavioural parent training and stimu-
lant therapy and cases who received behavioural parent training plus a
placebo pill were negligible on all variables. Following treatment and at
three months’ and two years’ follow-up, differences between cases who
received combined behavioural parent training and stimulant therapy and
cases who received stimulant therapy only were negligible on all variables.
Thus it may be concluded from Firestone’s study that combined behavioural
parent training and stimulant therapy were more effective than behavioural
parent training without stimulant therapy in reducing parent- and teacher-
rated behaviour problems and in improving attentional deployment in the
short term but not the long term. However, the combined therapy was no
more effective in the short term than stimulant therapy alone and neither
had a significant impact on academic performance.

Carlson et al. (1992) compared the effects of school-based contingency
management combined with high and low doses of stimulant therapy, with
school-based contingency management combined with a placebo pill. In
addition, groups that received high and low doses of stimulant therapy and
a group that received a placebo pill without contingency management were
included in the six condition repeated measures design. Children received
treatment within the context of a summer day programme with 40 daily
sessions conducted over an eight-week period. There were twelve children
per class. The contingency management programme included a high level
of classroom structure, rules posted on classroom walls and teacher feed-
back on performance; a token and social reinforcement system; time out;
an honour roll system; and a daily home-school report card. High dose
methylphenidate stimulant therapy was based on 0.6 mg per kg body weight
and low dose therapy was based on 0.6 mg per kg body weight. Stimulant
therapy was given in a divided daily dose and the first dose was given
within two hours of the treatment sessions. Pelham et a/. (1993) used a
similar design, contingency management treatment procedures and stimulant
medication dosages for their study. They report that the for low stimulant
therapy the range was 5-15 mgs and for the high dose condition the range
was 10-23 mgs.

In these two studies, for researcher ratings of on-task behaviour and
disruptive behaviour three conditions produced the best results: the high
stimulant therapy condition alone and in combination with school-based

96 Margretta Nolan and Alan Carr

contingency management and the low stimulant therapy condition in
combination with school-based contingency management. When these three
conditions were compared with the low stimulant therapy condition and
the school-based contingency management plus placebo conditions, the
average effect size of 0.55 indicated that the average case in the top three
conditions fared better than approximately 70 per cent of cases in the other
two conditions. In Pelham et al.’s study (1993) 57 per cent of cases in the
high stimulant therapy condition alone and in combination with school-
based contingency management and the low stimulant therapy condition
in combination with school-based contingency management showed clinic-
ally significant improvement. In contrast only 46 per cent of cases in a low
stimulant therapy condition and the school-based contingency manage-
ment plus placebo conditions made such improvements. Thus, it may be
concluded that the addition of school-based contingency management to a
low dose of stimulant therapy made it as effective in improving classroom
behaviour as a high dose of stimulant therapy.

Hornet al. (1991) compared the effects of a multicomponent treatment
package containing behavioural parent training, self-instructional training
and school-based contingency management combined with high and low
doses of stimulant therapy, and the multicomponent treatment package
combined with a placebo pill. In addition, groups that received high and
low doses of stimulant therapy and a group that received a placebo pill
without the contingency management programme were included in the
six-group design. The behavioural parent training was based on manuals
by Patterson (1976), Forehand and McMahon (1981), Barkley (1981) and
Becker (1971). The self-instructional training component was based on
protocols developed by Kendall and Braswell (1985), Camp and Bash (1991)
and Meichenbaum (1977). The school-based contingency management
programme involved a daily home-school report card system such as that
described by Ayllon et al. (1975). In all there were 27 treatment sessions:
twelve of behavioural parent training, twelve of self-instructional training
and three of school-based contingency management. High dose methyl-
phenidate stimulant therapy was based on 0.8 mg per kg body weight and
low dose therapy was based on 0.4 mg per kg body weight. Nine-month
follow-up data following the withdrawal of stimulant medication was
published in a second paper (lalongo et al., 1993).

In this study, for teacher-rated behavioural improvement following
treatment, three conditions produced the best results: the high-stimulant
therapy condition alone and in combination with multicomponent treat-
ment package and the low-stimulant therapy condition in combination with
the multicomponent treatment package. When these three conditions were
compared with the low-stimulant therapy condition and the multicomponent
treatment package plus placebo conditions, the average effect size of 0.6
indicated that the average case in the top three conditions fared better than
approximately 73 per cent of cases in the other two conditions. From

Attention deficit hyperactivity disorder 97

post-test to nine-month follow-up, cases that received combined treatments
made improvements on parent-rated behaviour whereas those that received
stimulant treatment only did not.

In summary, the following conclusions may be drawn from the four
studies addressed in this section. Combined behavioural parent training
and stimulant therapy was more effective than behavioural parent training
without stimulant therapy in reducing parent- and teacher-rated behaviour
problems and in improving attentional deployment in the short term but
not the long term. However, the combined therapy was no more effective
in the short term than stimulant therapy alone and neither had a significant
impact on academic performance. The addition of school-based contingency
management or a multicomponent psychological intervention package to a
low dose of stimulant therapy made it as effective in improving classroom
behaviour as a high dose of stimulant therapy in the short term. Combined
stimulant therapy and a multicomponent psychological intervention treat-
ment package was more effective in leading to sustained improvements
over a nine-month period in home-based behaviour problems than stimulant
therapy alone.

Conclusions

From this review of twenty well-conducted studies, two broad conclusions
may be drawn about the effectiveness of psychological treatments alone or
in combination with pharmacological treatments for ADHD. First, a range
of psychological interventions have positive short-term effects on ADHD
symptomatology and related problems. These psychological treatments
include child-focused interventions (social skills training, self-instructional
training, therapy-based contingency management), family-based interven-
tions (behavioural parent training, problem solving and communications
training, family therapy), school-based interventions (school-based con-
tingency management), and multisystemic interventions where child, family
and school-focused interventions are combined into a multicomponent treat-
ment package. Second, the effects of these interventions may be enhanced
when they are combined with stimulant therapy. In addition to these broad
conclusions, a series of specific conclusions may be drawn from this review
about the effectiveness of particular interventions on particular features
of ADHD symptomatology and related clinical features. A consideration of
these follows.

Social skills training and self-instructional training were the principal
child-focused psychological interventions for ADHD addressed in this review
and the following conclusions concern these interventions. First, social skills
training conducted over twelve sessions supplemented with therapy-based
contingency management and parental psychoeducation is probably effective
in reducing home- and school-based behaviour problems in the short term.
Second, self-instructional, where children learn both specific and general

98 Margretta Nolan and Alan Carr

self-instructions combined with therapy-based contingency management
over six to twelve sessions is probably effective in reducing school- and
clinic-based behaviour problems, but not home-based behaviour problems,
achievement problems or attention deployment problems. Third, combined
self-instructional training spanning six to 32 sessions over three to sixteen
weeks and stimulant therapy involving a daily divided dose of 5-40 mgs of
methylphenidate is probably more effective than self-instructional training
alone in leading to short-term improvements in home- and school-based
behaviour problems but no more effective than self-instructional training
alone in improving achievement problems and attention deployment diffi-
culties. Fourth, combined self-instructional training and stimulant therapy
probably have few advantages over stimulant therapy alone in facilitating
behavioural improvements at home or school.

Behavioural parent training was the principal family-based psychological
intervention for ADHD addressed in this review and the following con-
clusions concern these interventions. First, behavioural parent training
conducted over nine to twelve sessions probably leads to short-term positive
changes in home-based behavioural problems and parent-child relation-
ships for children and adolescents from age three to eighteen with ADHD.
Second, behavioural parent training has little impact on attentional deploy-
ment, academic performance or school-based behaviour. Third, behavioural
parent training is probably as effective as problem solving and communica-
tion skills training and structural family therapy with adolescents. Fourth,
combined behavioural parent training and stimulant therapy is probably
more effective than behavioural parent training without stimulant therapy
in reducing home- and school-based behaviour problems and in improving
attentional deployment in the short term. Fifth, combined behavioural
parent training and stimulant therapy are probably no more effective than
stimulant therapy alone.

From this review, the following conclusions about the effectiveness of
multicomponent treatment packages may be drawn. First, multicompon-
ent treatment packages that include behavioural parent training, self-
instructional training and school-based contingency management and span
seventeen to 29 sessions over eight to twelve weeks are probably more effect-
ive than single component packages in reducing home-based behaviour prob-
lems in the short term. Second, multicomponent psychological intervention
packages combined with a low dose (0.3 mglkg) of methylphenidate stimu-
lant therapy are probably as effective as a high dose therapy (0.6 mglkg)
alone in improving school-based behaviour problems in the short term.
Third, multicomponent psychological intervention treatment packages
combined with stimulant therapy are probably more effective in leading to
sustained improvements in home-based behaviour over a nine-month period
than stimulant therapy alone.

In drawing out the implications of these conclusions for clinical practice,
service development and further research, it is important to keep in mind

Attention deficit hyperactivity disorder 99

the risks associated with psychological and pharmacological interventions.
Currently there are no sound reasons to suspect that any of the psycholo-
gical interventions addressed in this review have serious short- or long-term
negative effects on children’s health or development. In contrast stimulant
therapy has a number of well-documented side-effects, but unfortunately
there is little information on the long-term negative effects of protracted
stimulant therapy. In the short term methylphenidate may lead to insomnia
(59 per cent), decreased appetite (55 per cent), stomach aches (33 per cent),
headaches (30 per cent), and dizziness (12 per cent), motor and vocal tics
(1 per cent) and there is also some evidence that stimulant therapy may lead
to a reduction in growth velocity (Greenhill, 1998). These negative effects of
stimulant therapy warrant a cautious approach to the routine use of high
dosages.

The conclusions of this review suggest that in clinical practice for effect-
ive short-term treatment of ADHD, multisystemic interventions involving
multicomponent treatment packages combined with low dose stimulant
therapy are the treatments of choice. Multicomponent treatment packages
should include behavioural parent training, self-instructional training and
school-based contingency management elements and span seventeen to 29
sessions over eight to twelve weeks. Low dose methylphenidate stimulant
therapy should be based on 0.3 mg/kg body weight.

For effective long-term treatment, it is probable that a chronic care model
of service delivery is required. Children with ADHD and their families,
within such a model of service delivery, would be offered the option of
infrequent but sustained contact with a psychological and paediatric service
over the course of childhood and adolescence. It is likely that at transitional
points within each yearly cycle (such as entering new school classes each
autumn) and at transitional points within the life cycle (such as entering
adolescence, changing school, or moving house) increased service contact
would be required. Two of the studies reviewed in this chapter (Carlson
et al., 1992; Pelham et al., 1993) underscore the value of intensive summer
school day programmes as an option for service delivery and such annual
programmes could well form part of a chronic care model of service
delivery.

This review highlights the need for well-controlled large-scale long-term
studies to examine the effectiveness of multicomponent treatment packages
alone and in combination with low dose stimulant therapy offered within
the context of a chronic care model. Of course it would be essential for
such studies to take account of the design features outlined in Chapter 1
and in addition to include measures of classroom behaviour, academic
achievement, attention deployment and stimulant therapy side-effects. Within
the context of such studies there is also a need to examine the effects of
withdrawing stimulant therapy following normalization of behaviour and
achievement. Currently two such studies are nearing completion (Hechtman
and Abikoff, 1995; Richters et al., 1995) but more are required.

100 Margretta Nolan and Alan Carr

ASSESSMENT

Atkins, M., Pelham, W. and Licht, M. (1988). The development and validation of
objective classroom measures for the assessment of conduct and attention deficit
disorders. In R. Prinz (ed.), Advances In Behavioural Assessment Of Children
And Families (Vol. 4, pp. 3-33). New York: Guilford.

Cairns, E. and Cammock, T. (1978). Development of a more reliable version of the
Matching Familiar Figures Test. Developmental Psychology, 18, 555-60.

Conners, C. (1990). The Conners’ Rating Scales. North Tonawanda, NY: Multi-
Health Systems.

Conners, C. (1995). The Conners’ Continuous Performance Test. North Tonawanda,
NY: Multi-Health Systems.

Conners, C. (1996a). Conners’ Abbreviated Symptom Questionnaire. Odessa, FL:
PAR. Available from PAR, PO Box 998, Odessa, Florida, USA. Phone +1-800-
331-8378.

Conners, C. (1996b). Conners’ Rating Scales Computer Programme. Available from
PAR, PO Box 998, Odessa, Florida, USA. Phone +1-800-331-8378.

DuPaul, G. (1991). Parent and teacher ratings of ADHD symptoms: Psychometric
properties in a community based sample. Journal of Clinical Child Psychology,
20, 245-53.

DuPaul, G. and Barkley, R. (1992). Situational variability of attention problems:
Psychometric properties of the revised Home and School Situations Question-
naires. Journal of Clinical Child Psychology, 21, 178-88.

Gilliam, J. (1996). Attention Deficit Hyperactivity Disorder Test. Odessa, FL: PAR.
Available from PAR, PO Box 998, Odessa, Florida, USA. Phone+ 1-800-331-8378.

Ullmann, R., Sleator, E. and Sprague, R. (1984). A new rating scale for diagnosis
and monitoring of ADD children. Psychopharmacology Bulletin, 20, 160-4.

Wilkinson, G. (1993). WRAT-3: Wide Range Achievement Test (Third Edition).
Wilmington, Delaware: Wide Range Inc.

TREATMENT MANUALS AND RESOURCES

American Academy of Child and Adolescent Psychiatry (1991). Practice parameters
for the assessment and treatment of ADHD. Journal of the American Academy of
Child and Adolescent Psychiatry, 30, i-iii.

Barkley, R. (1987). Defiant Children: A Clinician ‘s Manual for Parent Training.
New York: Guilford.

Barkley, R. (1990). Attention Deficit Hyperactivity Disorder: A Handbook for
Diagnosis and Treatment (Second Edition). New York: Guilford .

Becker, W. (1971). Parents are Teachers: A Child Management Programme.
Champaign, Ill: Research Press.

Braswell, L. and Bloomquist, M. (1991). Cognitive Behavioural Therapy for ADHD
Children: Child, Family and School Interventions. New York: Guilford.

Camp, B. and Bash, M. (1981). Think Aloud: Increasing Social and Cognitive
Skills: A Problem Solving Program for Children. Champaign, Ill: Research Press.

Cantwell, D.P. (1994). Therapeutic Management of Attention Deficit Disorder: Par-
ticipant Workbook. New York: Guilford.

Attention deficit hyperactivity disorder 101

Feindler, E. and Ecton, R. (1985). Adolescent Anger Control: Cognitive-Behavioural
Techniques. New York: Pergamon.

Forehand, R. and McMahon, R. (1981). Helping the Non-compliant Child: A
Clinician’s Guide to Parent Training. New York: Guilford.

Gordon, M. (1995). How to Operate an ADHD Clinic or Subspecialty Practice.
Odessa, FL: PAR.

Kendall, P. and Braswell, L. (1985). Cognitive Behavioural Therapy for Impulsive
Children. New York: Guilford.

Meichenbaum, D. (1977). Cognitive Behaviour Modification. An Integrative Ap-
proach. New York: Plenum.

O’Leary, K. and O’Leary, S. (1972). Classroom Management: The Successful Use of
Behaviour Modification . New York: Pergamon.

Patterson, G. (1975). Families: Applications of Social Learning to Family Life.
Champaign, Ill: Research Press.

Patterson, G. (1976). Living with Children: New Methods for Parents and Teachers.
Champaign Ill: Research Press.

Pelham, W. (1994) . Attention Deficit Hyperactivity Disorder: A Clinician’s Guide.
New York: Plenum.

Robin, A. and Foster, S. (1989). Negotiating Parent-Adolescent Conflict. New York:
Guilford.

FURTHER READING FOR PARENTS

Barkley, R. (1995a) . ADHD: What do we know?; ADHD: What can we do?; ADHD
in the classroom: Strategies for teachers. These videos are available from PAR
Inc., PO Box 998, Odessa, Florida, USA. Phone +1-800-331-8378.

Barkley, R. (1995b). Taking Charge of ADHD: The Complete Authoritative Guide
for Parents. New York: Guilford.

Ingersoll, B. (1988). Your Hyperactive Child; A Parent’s Guide to Coping with
Attention Deficit Disorder. New York: Doubleday.

Patterson, G. (1976). Living with Children: New Methods for Parents and Teachers.
Champaign, Ill: Research Press.

Wender, P. (1987) . The Hyperactive Child, Adolescent and Adult. Attention Deficit
Disorder Through The Lifespan. New York: Oxford University Press.

199

In the next two chapters we discuss attention- deficit/
hyperactivity disorder (ADHD) or hyperkinesis, and
Tourette syndrome. These are seen as neuropsychiat-
ric disorders because of their frequent association with
central nervous system manifestations. Neurological
signs and symptoms are part of the definition of Tour-
ette syndrome; it is also frequently associated with hy-
perkinesis and learning difficulties. The situation with
the attention-deficit disorders (ADDs) varies depending
on the definitions used, but they are frequently associ-
ated with learning difficulties. There is other evidence
of brain involvement, such as epilepsy, clumsiness, lan-
guage delay, and a variety of syndromes (e.g., fragile X
syndrome, fetal alcohol syndrome). In this chapter we
review the clinical presentation of ADHD, then sum-
marize the literature on treatment. We refer only to the
more robust studies from the vast literature on ADDs

DefiNitioN

ADHD is characterized by reduced levels of concen-
tration or attention, impulsivity, and overactivity or
restlessness. There is no clear demarcation between
extremes of normality and truly abnormal degrees
of these behaviors (National Institute for Health and
Clinical Excellence [NICE], 2008; J. Williams, 2008).
ADHD has been variously named “minimal brain dys-

function,” “hyperkinesis,” “attention deficit disorder”
(ADD), “attention deficit disorder with hyperactivity”
(ADD-H), and “attention- deficit/hyperactivity disor-
der” (ADHD) at different times and in different loca-
tions. Opinions differ about the interchangeability of
these names. DSM-5, used in the United States and
Australia, refers to the diagnosis of “attention-deficit/
hyperactivity disorder.” In Europe, the ICD-10 (World
Health Organization, 1993) classification system refers
to “hyperkinetic disorder,” which, in practical terms, is
a narrower term describing a subset of individuals with
ADHD. Inattention is a required diagnostic criterion for
hyperkinetic disorder but not for ADHD. Pervasiveness
of the problems and absence of significant anxiety are
also criteria for hyperkinetic disorder. Children so di-
agnosed tend to have other neurodevelopmental delays
(E. Taylor, Sandberg, Thorley, & Giles, 1991). J. Wil-
liams (2008, p. 706) has proposed a relatively new con-
ceptual framework for understanding ADHD, which he
refers to as the “extended temporal difference model.”
He explains that “ADHD does not have a single, simple,
core problem, but rather . . . ADHD is a collection of
disparate neurodevelopmental problems, which mainly
cohere through the effectiveness of stimulants and the
practical need for a very small number of diagnoses.”
This theory is in contrast to that of Tripp and Wickens
(2008), who, like Antrop et al. (2006), note the atypi-
cal response of children with ADHD to positive rein-

c h a p t e r 6

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200 W h at Wo r k s f o r W h o m ?

forcement; these authors have proposed a “dopamine
transfer deficit” as an explanation. It remains to be
seen whether either of these models can fully explain
the features of ADHD and characteristic responses to
interventions.

DSM-5 describes three types of ADHD:

• Predominantly inattentive (six or more symptoms of
inattention present up to age 16, or five or more symp-
toms for adolescents ages 17 and older and adults.
Symptoms of inattention must have been present for
at least 6 months and are inappropriate for the devel-
opmental level).

• Predominantly hyperactive– impulsive (six or more
symptoms of hyperactivity– impulsivity present up to
age 16, or five or more symptoms for adolescents ages
17 and older and adults. Symptoms of hyperactivity–
impulsivity must have been present for at least 6
months to a level that is disruptive and inappropriate
for the developmental level).

• Combined (both sets of symptoms).

Several symptoms must have been present before age
12 and some must have been present in two or more
settings (in the DSM-IV description, some symptoms
must have been present before age 7 and have persisted
longer than 6 months). ICD-10 requires an age of onset
before age 6.

Perceptions of hyperactivity may vary across cul-
tures (E. M. Mann et al., 1992). However, Prendergast
et al. (1988) found that if a diagnosis is based on the re-
spective criteria of the DSM and ICD classification sys-
tems, there is agreement on “caseness.” In other words,
clinicians on either side of the Atlantic could be trained
to use the other side’s criteria.

Since the vast majority of the relevant literature
on attention deficit problems comes from the United
States rather than Europe, in this chapter we use the
term ADHD, as defined in DSM-5, to describe ADDs.
It should be noted that inclusion criteria for studies will
refer to DSM-IV (or earlier) criteria as the research re-
viewed was conducted before DSM-5 was published.

PrevAleNce

Suspected hyperkinesis or ADHD is a frequent rea-
son for referral to child and adolescent mental health
services in the United States. Similarly, in the United
Kingdom, the numbers of cases diagnosed and treated

have been increasing over the years. For example, in
2006, the total annual cost of prescribed stimulants and
other drugs for ADHD in England was approximately
£29 million, an increase of 20% on the previous year’s
cost (National Health Service (NHS) Health and So-
cial Care Information Centre, 2006; NHS Information
Centre, 2007).

Prevalence varies according to the diagnostic sys-
tem and criteria used. The American Psychiatric As-
sociation (1994) estimated the prevalence of ADHD in
school- age children at between 3 and 5%. E. Taylor et
al. (1991) found that 1.7% of 7-year-old boys in a Lon-
don population survey fulfilled criteria for the more
restricted diagnosis of hyperkinetic disorder. The au-
thors commented that this probably overestimated the
true prevalence of hyperkinetic disorder in the general
population, because it is more common in boys and in
urban areas, and 7 years is the peak age for recognition
of the disorder. They suggested that a hyperkinetic dis-
order prevalence of at least 0.5% in the general popula-
tion may be more accurate. Studies of the prevalence of
the less restricted diagnosis of ADD-H or ADHD indi-
cate a prevalence in children in the range of 4.2–12%
(August, Ostrander, & Bloomquist, 1992; Bergeron,
Valla, & Breton, 1992; NICE, 2008; Polanczyk et al.,
2007). In the United Kingdom, Ford, Goodman, and
Meltzer (2003) reported a prevalence of 2.23% for
“any ADHD.” In adolescents, the prevalence of ADHD
is in the range of 1.5–5.0% (Bergeron et al., 1992;
Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993).

ADHD is thought to occur much more frequently in
males. The American Psychiatric Association (1987)
reports a male:female ratio in clinic- referred samples
ranging from 9:1 to 6:1. This contrasts with a ratio of
3:1 from population- based studies (Szatmari, Offord,
& Boyle, 1989).

cliNicAl PreseNtAtioN

The authors recommend reading the American Acad-
emy of Pediatrics clinical practice guideline on the
diagnosis and evaluation of ADHD (Subcommittee on
Attention- Deficit/Hyperactivity Disorder et al., 2011)
and the NICE (2008) clinical guidelines on ADHD.

Children with ADHD and, to a greater extent, hy-
perkinesis show impaired functioning in most areas of
their lives, including home and school settings. Their
impulsivity and inattention lead to frequent criticism
from relatives, peers, and teachers, and their hyperac-

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Attention‑Deficit/Hyperactivity Disorder 201

tive and often aggressive behavior leads to peer rejec-
tion.

The peak age of referral for ADHD or hyperkinesis
is between 7 and 9 years, but peak age of onset appears
to be in the preschool period at around 3 years. The
onset of the more restricted diagnosis of hyperkinetic
disorder is probably earlier, at age 2 or 3 years, because
of the associated neurodevelopmental problems (Thor-
ley, 1984). Children with attention problems without
hyperactivity have later onset at around 6 years (S. M.
Green, Loeber, & Lahey, 1991).

A meta- analysis of 18 studies, describing differences
based on relevant variables, highlighted gender differ-
ences in presentation (Gaub & Carlson, 1997). Clinic-
referred girls with ADHD have lower levels of hyperac-
tivity and fewer externalizing behavior problems than
boys, but greater intellectual problems. The sexes did
not differ in terms of impairment due to inattention,
internalizing behavior, peer aggression, and being dis-
liked. Among nonreferred children, however, boys with
ADHD were more likely to be impaired by inattention,
internalizing behavior problems, and peer relationship
difficulties. These findings suggest that many of the
gender differences may be attributable to referral bias;
that is, there may be different thresholds for the referral
of boys and girls. Boys are more likely to be referred
for treatment than girls because of the increased rate
of disruptive externalizing behavior problems in boys.
This could mean that although boys with ADHD are
generally more severely impaired than girls, studies of
clinic samples fail to detect these differences, because
only the most severely affected girls are referred. As
mentioned earlier, the ratio of boys:girls attending treat-
ment clinics with ADHD ranges from 6:1 to 9:1, despite
the lower ratio of ADHD-affected boys:ADHD-affect-
ed girls in the community of 3:1 (R. T. Brown, Madan-
Swain, & Baldwin, 1991). Further research is needed
to determine whether boys and girls with ADHD are
receiving appropriate services.

The behaviors causing impairment in ADHD are dif-
ficult to measure. Although there is an understanding of
the behaviors that must be present for the diagnosis to
be made, recognizing the point at which the behaviors
in question become abnormal can be problematic, espe-
cially in very young children. ADHD often has its onset
in the second or third year of life, but since children
this age are normally active and have a short attention
span, diagnosis in this age group is more problematic
than in older children. The varying presentation of
ADHD also adds to the difficulty of accurate diagnosis.

The etiology for the primary problems of inattention
and hyperactivity is heterogeneous (Curran & Taylor,
2000). In many cases, multiple secondary factors, such
as parental disharmony, bullying, and additional learn-
ing difficulties, produce the behavior problems that
lead to referral.

At assessment, the parents and child should be in-
terviewed. Interviews should include an inquiry about
possible comorbidity and environmental causes of the
problems. It is also important to ask about the home
situation (e.g., parental conflict, financial hardship,
parental mental disorder), and about the child’s educa-
tional progress. This information can be obtained with
use of standardized rating scales and an open report
from the school; classroom observations are also in-
formative. A variety of questionnaires are available:
the best validated are the Child Behavior Checklist
(Achenbach, 1991; Achenbach & Edelbrock, 1983),
which includes a teacher report form, and the Conners
Parent and Teacher Rating Scales (Goyette, Conners, &
Ulrich, 1978). Children should be medically examined
and have a comprehensive assessment of their learning
abilities, including reading and writing. A helpful study
of the performance of 621 children in neuropsychologi-
cal testing found only 61.9% reliability from such tests
(Pineda, Puerta, Aguirre, Garcia- Barrera, & Kam-
phaus, 2007); these should therefore be used with cau-
tion as an aid to diagnosis, although they can be helpful
in identifying cognitive deficits. The clinical practice
guideline (Subcommittee on Attention- Deficit/Hyper-
activity Disorder et al., 2011) states that the evaluation
of children and adolescents presenting with possible
ADHD should include assessment for other emotional/
behavioral, developmental, and physical (e.g., tics or
sleep apnea) conditions that may be comorbid with
ADHD.

There is no evidence that screening for ADHD is
beneficial. An article by Sayal et al. (2010) described
a 5-year follow- up of a school- based randomized con-
trolled trial (RCT) exploring the benefits of screen-
ing (followed by an educational program for teachers
of children identified as having significant features
of ADHD) in children ages 4–5 years. The authors
screened 1,662 children from 332 participating schools.
There was no evidence of benefit in terms of long-term
symptomatology; in fact, the authors suggested that
the children who were identified to their teachers as
having ADHD problems fared worse than children
for whom nothing was done. The authors suggest that
if school personnel decide to screen for ADHD, they

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202 W h at Wo r k s f o r W h o m ?

should make further detailed assessments for learning
difficulties or other comorbid psychiatric problems in
any child identified by screening, because these other
problems may be missed, and the child could easily be
wrongly labeled by screening in this way.

comorbiDitY

Biederman, Newcorn, and Sprich (1991) reviewed the
literature and reported that comorbidity with ADHD
is high: 30–50% of children with ADHD have comor-
bid conduct or oppositional disorders, 15–75% have a
mood disorder, and 25% have an anxiety disorder. The
type of comorbid problem seems to vary between two
subtypes of ADHD: Those with hyperactivity are more
likely to have a comorbid conduct disorder, while those
without hyperactivity are more at risk of internalizing
symptoms, such as anxiety and depression (Barkley,
DuPaul, & McMurray, 1990a; D. P. Cantwell & Baker,
1992).

It has been reported that 50% of children with ADDs
have speech or language impairments (Love & Thomp-
son, 1988). Similar numbers go on to have reading and
writing difficulties. Visuomotor problems and clumsi-
ness are also common (Losse et al., 1991; E. Taylor et
al., 1991). Hellgren, Gillberg, Gillberg, and Enerskog
(1993) found that visuomotor problems persist into
adolescence, placing the young person at higher risk
of accidents than those in a control group. E. Taylor et
al. (1991) similarly reported a higher rate of accidents
in pervasively hyperactive youngsters. Richters et al.
(1995) reported that 10–25% of children with ADHD
have comorbid learning disorders. Problems with so-
cial relationships are often associated with ADHD. T.
Clark, Feehan, Tinline, and Vostanis (1999) reported a
retrospective case study in which 65–80% of 49 sub-
jects with ADHD reported significant difficulties in
social interaction and communication.

GeNetic fActors

Several multicenter studies have now confirmed the
significant impact of genetic factors, with estimates of
heritability ranging between 60 and 90% (Asherson et
al., 2007). Studies to clarify the exact genotypic abnor-
malities are still under way. Asherson et al. reported the
significant contribution of a gene affecting dopamine
transport, DAT1, although the contribution is likely to

be fairly small. Lowe, Barry, Gill, and Hawi (2006)
presented a list of genes that are possibly involved
(multiple susceptibility genes), including several dopa-
minergic and serotonergic genes, and the gene encod-
ing synaptosomal- associated protein-25 (SNAP-25).

Polanczyk et al. (2007) reported a study demonstrat-
ing the involvement of the alpha2A adrenergic recep-
tor. In this study, methylphenidate was used as a treat-
ment in children with ADHD symptoms who had the
ADRA2A-1291 C → G polymorphism (the “G allele”)
in the alpha2A receptor gene. There was a significant
interaction effect between the presence of the G allele
and treatment with methylphenidate over time, leading
the authors to conclude that the (nor)adrenergic ner-
vous system must be involved in modulating the action
of methylphenidate. Studies are still under way to iden-
tify the genes involved in the etiology and treatment
response.

Studies are beginning to emerge that describe abnor-
malities on brain scans of subjects with ADHD. Castel-
lanos et al. (2002) reported smaller brain volumes in all
areas apart from the caudate nucleus and suggested that
these abnormalities were persistent and nonresponsive
to treatment. Overmeyer et al. (2001) reported grey-
matter deficits in the right frontal and posterior cin-
gulate gyri and the basal ganglia on both sides. There
were also some white- matter deficits.

NAtUrAl historY

Up to 80% of school- age children diagnosed with
ADHD or hyperkinesis will have the same diagno-
sis 5 years later or in adolescence (see Dreyer, 2006,
for a helpful review of the continuity of ADHD from
the preschool years and the reliability of the diagno-
sis based on DSM-IV criteria). The disorder will per-
sist into adulthood in up to 65% of cases (G. Weiss
& Hechtman, 1993). At least one-third will be diag-
nosed with a conduct disorder and/or have increased
rates of substance abuse in adolescence, with problems
persisting into adulthood in the form of trouble with
the police and personality disorder. Mannuzza, Klein,
and Moulton (2002) reported a 10.0- to 12.6-year
follow- up study of 250 boys with ADHD and found
that boys with pervasive problems (apparent in all set-
tings) and those with problems identified by teachers
only had worse outcomes in terms of antisocial behav-
iors (29% had antisocial disorder) than those who had
problems reported only by parents (no cases had anti-

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Attention‑Deficit/Hyperactivity Disorder 203

social disorder). The factors most highly predictive of
poor outcome include a family history of ADHD or
hyperkinesis, psychosocial adversity, and comorbidity
with conduct, mood, and anxiety disorders (Bieder-
man et al., 1996). Biederman, Wilens, Mick, Spencer,
and Faraone (1999) compared the rate of substance use
disorder in adolescence in subjects with ADHD who
had received medication (mean duration of treatment
1.7–7.1 years) and in those who had not. None of those
treated with medication were receiving treatment at
follow- up. The authors found that the untreated sub-
jects were at significantly increased risk for substance
misuse at follow- up compared with the controls. Medi-
cation with stimulants reduced the risk of substance
misuse, even in the subjects with ADHD and a comor-
bid conduct disorder.

In an important meta- analysis of the impact of
ADHD on academic achievement, T. W. Frazier,
Youngstrom, Glutting, and Watkins (2007) reported
a moderate to large discrepancy between individuals
with ADHD and controls. Standardized reading mea-
sures were the most impaired.

treAtmeNt

Relative to many other areas of child mental health
difficulties, a large number of RCTs have examined
the ADDs; these have been predominantly of physical
treatments but also of nonphysical interventions. How-
ever, the majority have been short-term and have as-
sessed the response to a single treatment intervention,
making it difficult to compare effectiveness in a given
population. The Multimodal Treatment of Attention
Deficit Hyperactivity Disorder (MTA) study, which we
discuss first, was an attempt to improve on the length
of follow- up and to enable between- group comparisons
on a larger scale than had been attempted previously. It
also included comparison with psychological interven-
tions, although there are some concerns about the study
design, which we discuss later in the chapter.

the mtA study

The MTA study, an 8-year, multimodal treatment study
involving six sites, was set up by the National Institute
of Mental Health (NIMH) to address unanswered ques-
tions about ADHD and the possible benefits of multi-
modal treatments for the disorder, compared with med-
ication alone. Findings at 14 months (at the end of the

treatment phase of the study), 24 months, 36 months,
and 96 months have been reported. Due to confusion
over the results, there have been many discussions of
the findings. The first official report (MTA Cooperative
Group, 1999a) describes a sample of 539 children with
carefully diagnosed DSM-IV combined- type ADHD.
The children were randomly allocated to 14 months of
treatment in one of four possible groups: (1) medica-
tion; (2) intensive behavioral management involving
the parents, child, and school; (3) these two treatments
combined; or (4) standard care provided by a commu-
nity team.

The parent training component of the behavioral in-
tervention (Wells et al., 2000) was based on programs
developed by Barkley (1987) and Forehand and Mac-
Mahon (1981). There were 27 group sessions, with
six families per group, plus eight individual sessions
per family. The therapist also provided consultation to
the school. The child- focused behavioral work was a
summer treatment program developed by Pelham and
Hoza (1996) as a summer camp and provided in a group
format (Pelham et al., 2000). The same therapist who
provided the parent training and school consultation
supervised the child- focused work. The school- based
intervention consisted of a part-time, behaviorally
trained classroom assistant working directly with the
child in the classroom, using methods suggested by J.
M. Swanson (1992), and fortnightly consultation be-
tween the therapist and the teacher targeting classroom
behavioral management strategies, as described by Pel-
ham and Waschbusch (1999).

Medication management in the MTA study began
with a double- blind titration of methylphenidate to
identify the optimal dose. For children who did not
respond adequately to any tested dose of methylphe-
nidate, alternative medications (dextroamphetamine
[dexamfetamine; see “Methylphenidate and Dexamfet-
amine” section later in the chapter], pemoline, imipra-
mine and, if necessary, others) were titrated. The care-
fully titrated medication treatment, when compared
with standard care or behavioral management, was
optimal for parents’ and teachers’ ratings of inatten-
tion, and teachers’ ratings of hyperactivity– impulsivity.
There were no other differences between medication
and behavioral management. The combined interven-
tion was also superior to behavioral intervention alone
on the previously described parameters. Moreover, it
was significantly better than behavioral intervention
alone in three particular areas: parent- rated opposi-
tional/aggressive behaviors, internalizing symptoms,

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204 W h at Wo r k s f o r W h o m ?

and reading achievement scores. The authors conclude
that “Combined behavioral intervention and stimulant
medication— multimodal treatment, the current cri-
terion standard for ADHD interventions— yielded no
significantly greater benefits than medication manage-
ment for core ADHD symptoms” (MTA Cooperative
Group, 1999a, p. 1078). However, the combined treat-
ment was superior to the standard community treat-
ment in respect of internalizing symptoms, opposi-
tional behaviors, peer relationships, and parent– child
interactions. The authors concluded that there is evi-
dence that long-term (14 months) stimulant medication
is beneficial and safe, and that “carefully monitored”
drug treatment may render intensive behavioral inter-
ventions unnecessary.

A second article (MTA Cooperative Group, 1999b)
reported on the moderators of treatment response. In
the presence of comorbid anxiety (present in 34% of
the sample) there was a trend toward a better response
to the combined treatment than to medication alone,
and behavioral intervention alone was better than the
standard community care. The presence of comorbid
anxiety reduced the relative advantage of medication
over the other treatments, but it did not reduce the rate
of response to medication. The presence of comorbid
oppositional or conduct problems had no impact on
the response rate. The authors conclude that improve-
ments in ADHD symptoms resulting from medication
can lead to a reduction in anxiety symptoms; therefore,
some of the anxiety present in ADHD-affected chil-
dren may be generated by their distress about problems
resulting from their ADHD.

In the first commentary on the responses to the find-
ings, P. S. Jensen (1999) suggested that the findings do
not mean that behavioral treatment is ineffective. Pel-
ham (1999) made a similar argument. First, he noted
that the behavioral treatment had a large effect size
(ES) improvement (0.9–1.3) from baseline to end point
across all measures. Second, he pointed out that the
medical management in the MTA study did not differ
from withdrawn behavioral treatment (which faded out
several months before the 14-month review) for most of
the measures. Third, there was no difference between
the behavioral treatment and standard community
treatment for all of the measures. On this basis, he con-
cluded that behavioral treatment is nearly as effective
as ongoing medical management.

Hinshaw et al. (2000) analyzed in more detail the
changes in parenting that led to an improvement in chil-
dren’s social behaviors at school, and found a signifi-

cant correlation between the reduction in negative/inef-
fective parental discipline and reduction in children’s
school- based disruptive behaviors. Hoza et al. (2000,
p. 569) also reported that, based on the MTA study
sample, “Low self- esteem in mothers, low parenting
efficacy in fathers, and fathers’ attributions of noncom-
pliance to their ADHD child’s insufficient effort and
bad mood” were all associated with a poorer outcome
of treatment for the child. Pelham (1999) pointed out
the relevance of this finding for parents, who often pre-
fer the combined or behavioral approaches. Another
important finding, supported by previous studies, was
that the combined approach required a 20% lower dose
of medication than the dose required when the medica-
tion was used alone. The fact that the beneficial effects
of the behavioral treatment appeared to persist several
months after treatment ceased supports the notion that
combining treatments may allow earlier discontinua-
tion of medication.

At 24 months (i.e., 10 months after treatment cessa-
tion), the groups of children who had received carefully
monitored medication management (either medication
alone or combined medication and behavioral treat-
ment) showed significantly greater improvements in
ADHD and oppositional defiant disorder (ODD) symp-
toms than the groups that had received behavioral in-
terventions only or the standard community treatment.
The combined treatment group was still showing sig-
nificantly greater reductions in internalizing symptoms,
and better teacher- rated social skills, parent– child re-
lations, and reading achievement, compared with the
community treatment and behavioral treatment groups.
The medication- only group did not fare significantly
better than these two groups in these domains. Howev-
er, the ESs were reduced by approximately 50% at the
14-month follow- up. P. S. Jensen et al. (2007) reported
that an analysis of treatments the groups were receiving
at the time of the 24-month follow- up revealed changes
in status, such that children originally assigned to the
behavioral group may have commenced medication,
and those originally assigned to the medication and
combined groups may have stopped medication. The
authors suggest that this finding could explain the re-
duction in ES and between- group differences.

P. S. Jensen et al. (2007) also reported on the 36-
month follow- up. At that time, there were no differ-
ences between the treatment groups in relation to the
five outcome measures of parent- and teacher- rated
ADHD and ODD symptoms, reading achievement, so-
cial skills, and functional impairment. However, there

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Attention‑Deficit/Hyperactivity Disorder 205

were large improvements in all the groups, with the fol-
lowing ranges of ESs for improvement from baseline
to 36 months: 1.6–1.7 for ADHD, 0.7 for ODD, 0.9–1.0
for impairment, 0.8–0.9 for social skills, and 0.1–0.2
for reading. Unfortunately, in the absence of a no-
treatment control group, it is difficult to know whether
this represents a natural tendency to improve; the lack
of such a control group has been the main reason for
criticism of the otherwise well- designed MTA study.

Molina et al. (2007) reported on rates of delinquency
and emerging substance use 36 months after the end of
treatment in the MTA study. At that point, the children
were between 11 and 13 years of age and were there-
fore still at the age where experimentation, rather than
substance dependence, was more likely. Delinquency
rates in the MTA sample were significantly higher than
those of local control children (27.1 vs. 7.4%) at 36-
month follow- up. There was also a significant differ-
ence in substance use rates in the MTA study subjects
compared with controls, with 11.7% of children in the
MTA study reporting lifetime use of any substance at
24 months, compared with 5.6% of controls unaffect-
ed by ADHD. By 36 months, 17.4% of children in the
MTA study reported lifetime use, compared with 7.8%
of controls. Twenty-five percent of the original sample
evidenced moderate or severe delinquency at 36-month
follow- up. There had been a significant decrease in the
delinquency rate during the initial 24 months of the
study (i.e., 14 months of treatment and 10 months of
follow- up). The increase had therefore occurred in the
last 12 months of follow- up. It was determined that pre-
scription medication was not a risk factor for substance
misuse. The children who had received the intensive
behavior therapy reported less severe substance misuse
at 24 months, but not at 36 months. There were no other
differences between treatment groups.

Summary of MTA Study Findings

Table 6.1 summarizes findings from the MTA study,
comparing the four treatment groups: (1) intensive med-
ication, which required close monitoring of medication
and titration of optimal dose; (2) behavioral approach,
which combined behavioral work with children, parent
training, school consultation, and behavioral input in
the classroom; (3) combination of behavioral interven-
tion and medication; and (4) usual community treat-
ment. Table 6.1 shows the aggregated findings reported
at 14 months (end of treatment) and at 24 months (10-
month follow- up).

tABle 6.1. summary of findings
from the mtA study

Parameter Finding

Parent-rated

Hyperactivity No difference between groups

Impulsivity No difference between groups

Inattention Intensive medication best, but no
benefit of combined treatme

Aggression and
oppositional behaviors

Combined treatment significantly
better than behavioral only

Parent–child
interactions

Combined treatment significantly
better than behavioral only

Teacher-rated

Hyperactivity Combined treatment and intensive
medication best

Inattention Combined treatment and intensive
medication best

Impulsivity Combined treatment and intensive
medication best

Peer relationships Combined treatment best

Child/adolescent and parent report

Delinquency and
substance use

No differences between treatments
in delinquency rates; substance
misuse reduced with intensive
medicati

Researcher observations

Internalizing disorders Combined treatment best

Reading ability Combined treatment best

Comorbid anxiety
effec

Combined treatment best;
behavioral treatment alone better
than routine care; intensive
medication often as effective as
in nonanxious children, but effect
size lower

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206 W h at Wo r k s f o r W h o m ?

By the 36-month follow- up, the differences between
treatment groups had disappeared. It is hypothesized
that this was due to significant movement between
types of treatment as patients returned to their usual
community care; for example, those who had previous-
ly received medication went on to receive behavioral
treatment, and vice versa.

At 6–8 years (96-month follow- up; Molina et al.,
2009) the type or intensity of the original 14-month
treatment no longer had a significant effect on outcome
measures analyzed. The authors found that prognosis
was determined by symptom severity, with children
with the DSM-IV ADHD combined type (inattention
and hyperactivity) faring worse. This suggests that any
between- group differences were lost when the intensive
interventions ended. Most children showed some im-
provement, but this was not to the degree required for
normalization. It is not possible to say whether long-
term intensive medication would have provided an ad-
vantage. In fact, 62% of the children taking medication
at 14 months post-MTA treatment had stopped medi-
cation at the 6- to 8-year follow- up point. The authors
comment on the need to look at motivational issues for
adolescents in a bid to improve adherence to medica-
tion. They also suggest the need for periodic psychoso-
cial interventions.

Physical treatments

Psychostimulants

Methylphenidate and Dexamfetamine

Stimulants are the drugs most frequently prescribed
for children with ADHD. They have been shown to be
effective in the control of hyperactive and aggressive
behavior. Two stimulants are available, methylpheni-
date and dexamfetamine (also known as dexamphet-
amine or dextroamphetamine). They are both fast- or
immediate- acting drugs; after oral ingestion, they
begin to work within the first hour. Effects last no more
than 4 hours. Several authors (reviewed by Wilens &
Biederman, 1992) have reported that the serum concen-
tration and onset of action of methylphenidate are simi-
lar, with a half-life for both concentration and action of
approximately 3 hours. In contrast, the blood level of
dexamfetamine peaks at 4 hours and consequently has
a longer half-life of 6–8 hours.

Short‑ Acting Stimulants. Methylphenidate remains the
most frequently used psychostimulant (J. M. Swanson,

Lerner, & Williams, 1995), despite little evidence for
its superiority over other stimulant preparations. It has
a short half-life, which often necessitates several doses
throughout the day. Up to 40% of children with ADHD
do not respond to methylphenidate, although they may
respond to other stimulants; however, there is no way
of predicting which child will respond to which stimu-
lant preparation. In a summary of practice parameters
for the use of stimulant medication, Greenhill et al.
(2001a) reported that, at the time of writing, 152 RCTs
indicated that 65–75% of patients improve with stimu-
lants, compared with 5–30% of patients treated with
placebo.

Schachter, Pham, King, Langford, and Moher (2001)
reported a meta- analysis of studies (not including the
MTA) of short- acting methylphenidate. They included
62 randomized trials involving 2,897 children and ado-
lescents up to the age of 18 with DSM-III-diagnosed
ADDs, with diagnosis made in a systematic and re-
producible way. The average length of the trials was
3 weeks, with some lasting up to a maximum of 28
weeks. The overall ES, as reported by teachers, was
0.78 (95% confidence interval [CI] [0.64, 0.91]). The
ES reported by parents was 0.54 (CI [0.40, 0.67]). The
adverse- event profile (expressed as number needed to
harm [NNH]) showed that four children needed to be
treated to get one with drug- induced appetite suppres-
sion; 22, for the side effect of headache; 26, for insom-
nia; and 367, for drowsiness.

A more recent meta- analysis by Faraone and Buite-
laar (2010) of RCTs of stimulant therapy for ADHD,
published since 1979, identified 23 trials meeting cri-
teria of the meta- analysis. The trials studied 11 drugs
and used 19 outcome measures related to core ADHD
symptoms; the authors therefore had to use some com-
plex statistical analyses for the meta- analysis. They
found that the ESs for amphetamine products were sig-
nificantly larger than those for methylphenidate. Trans-
lating this into the number needed to treat (NNT) in
order for there to be a significant benefit compared with
placebo, two patients needed to be treated with amphet-
amine, compared to 2.6 patients with methylphenidate.

A helpful review by Pietrzak, Mollica, Maruff, and
Snyder (2006) summarizes the findings of 40 studies
of the cognitive effects of immediate- release stimulant
medication. The authors report that 63.5% of studies
showed some improvement in cognitive functioning.

Long‑Term Stimulant Treatment. Hechtman and Green-
field (2003) reported a review of RCTs of stimulant use

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Attention‑Deficit/Hyperactivity Disorder 207

for up to 2 years. Review of two long-term multimodal
studies indicated that well- titrated stimulant medica-
tion continued to be beneficial for at least 14 months.
Even with treatment, subjects with ADHD had less
favorable outcomes than nonaffected controls, but the
authors note that the treated ADHD group had fewer
car accidents and better social skills and self- esteem
compared to untreated affected subjects.

Long‑ Acting Methylphenidate. A long- acting formula-
tion of methylphenidate (Concerta), designed to provide
cover for 12 hours, has been compared with immediate-
release methylphenidate in 68 children between ages 6
and 12 years, in structured and unstructured settings,
over a trial period of 3 years (Pelham et al., 2001). The
study found no significant differences in responses to
the two drug preparations, apart from significantly bet-
ter parent- reported behavior in the evening for the chil-
dren taking the long- acting preparation, compared with
those taking the immediate- release preparation. There
were no significant side effects from either preparation.

Equasym XL, a controlled- release preparation of
methylphenidate similar to Concerta, has been found
to be equivalent to immediate- release preparations in
onset of action. The peak plasma concentrations are at
1.5 and 4.5 hours (V. R. Anderson & Keating, 2007).
Clinical efficacy and high levels of tolerability have been
demonstrated in two well- designed placebo- controlled
studies (Findling et al., 2006a; Greenhill, Findling,
Swanson, & ADHD Study Group, 2002). In the study
by Findling et al. (2006a), 318 children between ages
6 and 12 years with a DSM-III-R diagnosis of ADHD
were randomized to receive placebo, immediate- release
methylphenidate (Ritalin), or controlled- release meth-
ylphenidate (Equasym XL). There were equally signifi-
cant clinical improvements in the two treatment arms.
Overall, the number of children with adverse reactions
reported was highest in the placebo group. Adverse
reactions leading to withdrawal occurred in 3% of the
group receiving the immediate- release preparation and
2.2% of the controlled- release group. The most fre-
quent side effect for both preparations was headache.
One child treated with the controlled- release prepara-
tion developed neutropenia, but this was not thought to
be related to the treatment.

Banaschewski et al. (2006) carried out a meta-
analysis of studies (published and unpublished) on
the use of long- acting medications in ADHD and hy-
perkinetic disorder. They discuss the four long- acting
methylphenidate hydrochloride preparations available,

namely, Ritalin LA, Equasym XL, Concerta XL, and
Medikinet retard, all of which provide a combination
of immediate- release and delayed- release methylphe-
nidate. The authors report that, in summary, Equasym
XL was more effective than Concerta XL early in
the day, while Concerta XL was more effective than
Equasym XL later in the day. The authors emphasize
that the drugs should be used to meet patients’ needs
according to their preferences and that no stimulant
drug is superior to another overall. Mean ESs were very
similar, between 0.8 and 1.0. The ES for atomoxetine
and modafinil (both discussed later in this chapter) was
lower, at 0.6. However, the atomoxetine study results
may have been adversely affected by the fact that the
“clinician rating” used in most studies was parent inter-
views, and in one study (M. Weiss et al., 2005) teacher
reports, whereas the stimulant studies used direct clini-
cian observations.

Further studies are required, particularly using iden-
tical methodology, so that more direct comparisons can
be made. Better designed quality- of-life studies are
also needed but, based on the findings outlined earlier,
Concerta may be beneficial when children need to be
medicated in the evenings and compliance is poor.

Table 6.2 summarizes information regarding the
profiles of the slow- release stimulants in comparison
with immediate- release methylphenidate.

Long‑ Acting Dexamfetamine. Lisdexamfetamine, an
amphetamine prodrug, is a compound of dexamfet-
amine and the amino acid lysine that is inactive until
digested and absorbed into the bloodstream. It has been
licensed for the treatment of ADHD in 6- to 12-year-
olds in the United States since 2007, in Canada in the
same age group since 2009, and in the United Kingdom
in children 6 years and older since early 2013. Lisdex-
amfetamine is converted to dexamfetamine by hydro-
lytic enzymes located on erythrocytes. This leads to an
onset of action 1–3 hours after taking the drug. The du-
ration of action has been reported to be up to 13 hours.
Lisdexamfetamine was developed due to its lower po-
tential for abuse compared with dexamfetamine (see
Blick & Keating, 2007, for a helpful review). It is given
once a day at doses of 30–70 mg.

Elbe, MacBride, and Reddy (2010) have reported a
literature review of five RCTs demonstrating the effi-
cacy of lisdexamfetamine. Two of the larger trials were
reported by Biederman and colleagues (2007a; Bieder-
man, Krishnan, Zhang, McGough, & Findling, 2007b),
who describe a study of the use of lisdexamfetamine

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208 W h at Wo r k s f o r W h o m ?

dimesylate in 290 school- age children. The efficacy
and side effects in this study were comparable to those
in a trial of 584 children (Biederman, Lopez, Boellner,
& Chandler, 2002) using extended- release mixed am-
phetamine salts (Adderall XR; see below), and also to
those of other controlled- release stimulants. The drug
performed well over 8 hours at doses of 30–70 mg. A
further RCT by Findling et al. (2011) investigated the
treatment of 265 adolescents ages 13–17 years and,
similarly, demonstrated significant improvements with
doses of between 30 and 70 mg per day, without sig-
nificant adverse effects. Unfortunately, the study lasted
only 4 weeks.

As with all stimulants, monitoring of the patients’
height and weight is essential. This has recently been
emphasized in a study by Faraone, Spencer, Kollins,
and Glatt (2010), in which 281 children ages 6–13 years
receiving lisdexamfetamine dimesylate treatment were
followed up over a 15-month period. There was no
control group. There was a significant reduction in the
children’s weight, body mass index (BMI), and height
relative to age- appropriate standards, although the au-
thors commented that overall, the children entering the
study were taller and heavier than the average for the
population.

Adderall

Adderall, a long- acting amphetamine compound, is a
75:25 ratio of dextro- and levoamphetamine. It has been
shown to have a longer half-life than methylphenidate
(J. Swanson et al., 1998), which may be advantageous
in reducing the frequency with which the drug needs to

be taken during the day. It is available as immediate-
release and extended- release preparations.

Ahmann et al. (2001) reported an RCT of the use
of Adderall in 154 children and adolescents ages 5–18
years. The subjects all fulfilled criteria for DSM-IV di-
agnosis of ADHD (hyperactive– impulsive, inattentive,
or combined) using standardized measures such as the
Conners Parent and Teacher Rating Scales (Conners,
1989), the ADD-H Comprehensive Teachers’ Rating
Scale (Ullman, Sleator, & Spraugue, 1988), and the
Child Behavior Checklist (Achenbach, 1991). In this
study, Adderall was found to be very effective, with
side effects similar to those of other stimulants. Bieder-
man et al. (2002) have similarly reported the benefits
of Adderall XR (the extended- release formulation) in
an RCT of 509 6- to 12-year-olds with DSM-IV diag-
nosed ADHD. This study used standardized assess-
ment scales such as the Conners Rating Scales.

Faraone and Biederman (2002) reported a meta-
analysis of six studies of Adderall and confirmed its
efficacy, compared with placebo, in reducing ADHD
symptoms and aggression. In a second report, Faraone,
Biederman, and Roe (2002) reported a meta- analysis
comparing Adderall with methylphenidate. They found
that, on the basis of results from four small studies, cov-
ering a total of 186 subjects, Adderall is significantly
superior to methylphenidate in terms of reduction of
ADHD symptoms and aggression.

Methylphenidate Patches

Several studies have shown the benefit of methylpheni-
date patches. The literature on methylphenidate patches

tABle 6.2. Profiles of slow‑release stimulants in Comparison to immediate‑release methylphenidate

Methylphenidate
IR BID Concerta XL Equasym XL Medikinet retard Adderall XR

Formulation 100% IR 22% IR, 78% ER 30% IR, 70% ER 50% IR, 50% ER 50% IR, 50% ER

Duration of action 8 hours 12 hours 8 hours 7 hours 8–10 hours

Dosage 1.6 mg/kg/day;
maximum 60 mg/
d

2 mg/kg/day;
maximum 72 mg/
day

2 mg/kg/day;
maximum 72 mg/
day
2 mg/kg/day;
maximum 72 mg/
day

10–30 mg/day;
maximum 30 mg/
day

Time course of
action/serum
concentration

Peaks at around 2
hours and 6 hours;
trough at 5 hours

Peaks at 2 and 10
hours

Larger effect in
first 4–5 hours and
peak at 5 hours

Peak at 2 hours;
larger effect in
first 4–5 hours

Peak at 7 hours

Note. IR, immediate release; ER, extended release; BID, twice daily.

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Attention‑Deficit/Hyperactivity Disorder 209

has been well reviewed by V. R. Anderson and Scott
(2006), who give helpful advice on dosage, which is
dependent on patch size. The patches are effective for
9 hours, with the smallest patch (12.5 cm) releasing a
10-mg dose and the largest (37.5 cm) releasing a 30-mg
dose. They report that there have been at least two
randomized controlled multicenter studies confirming
the efficacy of the patches, which have been approved
by the U.S. Food and Drug Administration for use in
children ages 6–12 years. One of the studies to which
they referred was a poster presentation. The other, a
published study by McGough et al. (2006b), was fairly
well designed, with 80 participants between ages 6 and
12 years showing significant improvement with patch
treatment compared to placebo. Unfortunately, side
effects were not assessed, although “pinkness” at the
patch site was common.

Faraone and Giefer (2007) reported that although
there was no evidence of serious side effects among 127
children ages 6–12 after 36 months of methylphenidate
patch treatment, there was significant slowing of gains
in height and weight, particularly in children who were
taller or heavier than average for the population at the
start of the study; the same was not true for smaller
children with lower centiles for weight, height, and
BMI at baseline. The reduction in growth was greatest
in the first 12 months of the study; after that, there was
attenuation of the losses, particularly for weight and
BMI and to a lesser degree for height.

Treatment Protocols, Dosage, and

Side Effects

There appears to be reasonable consensus among ex-
perts on both sides of the Atlantic (Greenhill, 1992;
NICE, 2008; Subcommittee on Attention- Deficit/
Hyperactivity Disorder et al., 2011; J. M. Swanson et
al., 1993; E. Taylor, 1994) about the treatment proce-
dure for stimulants. Treatment should commence with
a suboptimal dose (5 mg methylphenidate or 2.5 mg
dexamfetamine in school- age children) in order to re-
duce the risk of side effects. There is great individual
variation in responsiveness: Greenhill et al. (2001b)
described the findings of the MTA study in relation
to optimal dosages for children ages 7–10 years with
DSM-IV-diagnosed ADHD (combined type) and found
that 22% of subjects responded to 15 mg/day or less,
25% responded to 16–34 mg/day, and 30% responded
to 35 mg/day or more. The dose should be increased
gradually while monitoring for effectiveness and any
adverse reactions. The recommended average daily

dose of methylphenidate is 10–40 mg per day, divided
between two and six doses; the maximum dose is 60
mg. An adequate trial period for immediate- release or
slow- release preparations is between 4 and 8 weeks.

Overall, 20–25% of patients who respond poorly to
one treatment will respond well to another (Dulcan,
1990). Side effects are common and dose- related but
rarely serious. Probably the most severe side effect
is precipitation of a psychosis (A. S. Bloom, Russell,
Weisskopf, & Blackerby, 1988), but this is rare. Pos-
sible adverse reactions include appetite suppression,
insomnia, irritability, mood changes, nausea and vom-
iting, growth suppression, and an increase in heart rate
and/or blood pressure. Interestingly, Barkley, McMur-
ray, Edelbrock, and Robbins (1990b) reported a high
(> 50%) rate of side effects with placebo; some of these,
such as anxiety and sadness, decreased with stimulant
treatment. Height and weight should be monitored reg-
ularly. Studies have demonstrated a significant negative
impact of methylphenidate on the weight and height of
treated children relative to untreated peers (Charach,
Figueroa, Chen, Ickowicz, & Schachar, 2006) and to
children who had annual drug holidays (R. G. Klein,
Landa, Mattes, & Klein, 1988). The seriousness of the
effects on weight and height depend on the individual’s
baseline weight and height. Pulse and blood pressure
should be monitored after an increase in dose. Some
children may have a behavioral rebound 5 hours after
the last dose. In the case of a severe rebound, adding
clonidine may be necessary. Alternatively, a small dose
of stimulant given late in the afternoon may reduce the
rebound effect.

Effect on the Primary Symptoms

Over 100 medication trials have confirmed the benefi-
cial effects of stimulants for the treatment of inattention,
hyperactivity, and impulsivity. In the United Kingdom,
the first NICE (2000) review of the evidence for meth-
ylphenidate treatment concluded that methylphenidate
is recommended for children with a diagnosis of severe
ADHD or hyperkinetic disorder. In the most recent
NICE (2008) guidelines, stimulants are still the recom-
mended first-line treatment for severe ADHD. There is
no doubt that stimulant medication relieves the primary
symptoms, at least in the short term. There is less cer-
tainty, however, regarding the extent of the benefit. In
a helpful review of the literature, J. M. Swanson et al.
(1993) reported that there is fairly good consensus that
the ES of stimulant treatment on the primary symptoms

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210 W h at Wo r k s f o r W h o m ?

of ADHD or hyperkinetic disorder is 0.8, and that 70%
of treated children respond. In contrast, the ES on aca-
demic performance is approximately 0.4. The placebo
response rate appears to be approximately 30%.

Some studies have looked at laboratory measures
of the symptoms of ADHD, such as impulsivity. Two
types of impulsivity have been described in the litera-
ture. “Behavioral impulsivity” refers to a disregard for
the consequences of an action and a lack of tolerance
for any delay in gratification. “Cognitive impulsivity”
refers to a tendency to give answers without adequate
consideration to their accuracy. The Matching Familiar
Figures Test (Kagan, Rosman, Day, Albert, & Phillips,
1964) was developed to assess cognitive impulsivity.
Unfortunately, it is unclear whether inaccuracy alone,
or a fast and inaccurate response, is characteristic of
children with ADHD. Other tests have been developed,
such as the Continuous Performance Test (Rosvold,
Mirsky, Sarason, Bransome, & Beck, 1956) and the
Test of Everyday Attention for Children (T. Manly,
Robertson, Anderson, & Nimmo-Smith, 1998), but
these are thought not to be specific to impulsivity.
Using the Matching Familiar Figures Test, several au-
thors have reported a decrease in errors when the child
is treated with a stimulant (Losier, McGrath, & Klein,
1996; Tannock, Schachar, & Logan, 1995). Similar ap-
proaches have used other test paradigms, such as M.
A. Malone and Swanson’s study (1993) using a word-
matching test, and a study by Bedard, Ickowicz, and
Tannock (2002) using the Stroop Color and Word Test
(C. J. Golden, 1978). As a result of these studies, re-
searchers concluded that control children made fewer
impulsive errors than children with ADHD who are
receiving placebo. Children with ADHD who were on
medication performed nearly as well as the nonaffected
control group, and significantly better than untreated
children with ADHD.

More recently, studies have examined the response to
medication by monitoring brain performance using im-
aging techniques. Akay et al. (2006) reported a single-
photon emission computed tomography (SPECT) study
of children with DSM-IV-diagnosed ADHD. The
SPECT technique detects variations in cerebral blood
flow. Akay et al. (2006) summarized the findings to
date on reduced blood flow in the prefrontal and tem-
poral cortices and the cerebral hemispheres. In their
small study of nine patients, they found that there was
a visually increased perfusion of the frontal and right
lateral temporal cortices during 2 months of stimulant
treatment and up to 2 months after treatment discon-

tinuation. However, this apparent increase in perfusion
was not confirmed by semiquantitative analyses, and
the authors hypothesized that variability in D2 dopa-
mine receptor availability and the small sample size
affected the analysis.

The influence of genetics on response to treatment
with stimulants has been explored by Cheon, Kim, and
Cho (2007). In this study, 83 Korean children with a
DSM-IV diagnosis of ADHD were treated with meth-
ylphenidate for 8 weeks. Between 71.1 and 80.0% of
those with a good response to treatment had the 4/4
genotype at DRD4 (the gene that encodes dopamine
receptor D4); in contrast, between 31.6 and 37.7% of
poor responders had the 4-repeat allele. Children who
were homozygous for the 4-repeat allele had most
severe ADHD symptoms at the start of the trial and
showed the greatest response to treatment. D. L. Gilbert
et al. (2006) looked at short- interval cortical inhibition
(SICI) in the motor cortex, measured by transcranial
magnetic stimulation; SICI is reduced in children with
ADHD compared with controls. These authors inves-
tigated whether a genetic variation in the dopamine
transporter gene (DAT1), a site of action of methylphe-
nidate, would influence the effect of methylphenidate
and atomoxetine on SICI. Both medications increased
SICI in individuals heterozygous for the gene variant
but not in homozygotes.

Influence of Age on Response
to Stimulant Treatment

Adolescents. Studies relevant to this age group have
been reviewed by P. Hazell (2007), who reported that
a meta- analysis of eight RCTs between 1988 and 1991,
which included 199 participants ages 12–18 years with
DSM-IV-diagnosed ADHD, found an ES of 0.94. He
points out that since 1996, several new slow- release
preparations have been shown to be equally effective in
adolescents and also notes that use of stimulant medi-
cation does not predispose adolescents to substance
misuse. In a meta- analysis of six follow- up studies (two
with follow- up in adolescence and four in young adult-
hood), Wilens, Faraone, Biederman, and Gunawardene
(2003) reported that stimulant treatment of ADHD led
to a reduced rate of substance misuse in adolescence.
In another meta- analysis of seven studies (five prospec-
tive) with 766 subjects, 98% of whom had been treated
with stimulants, Faraone and Wilens (2003) suggested
that not only was there no increased risk of substance
misuse, but the treatment also reduced the risk of sub-

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Attention‑Deficit/Hyperactivity Disorder 211

stance misuse. However, S. M. Gordon, Tulak, and
Troncale (2004) found that approximately 20% of pa-
tients will misuse or sell their medication; these authors
recommend switching such patients to a nonstimulant
treatment. In a small controlled study of the subjective
response to methylphenidate in adolescents, C. A. Mar-
tin, Guenthner, Bingcang, Rayens, and Kelly (2007)
concluded that abuse potential is a risk because a sig-
nificant number of adolescents in this study reported
subjectively feeling better when taking stimulants.

D. J. Cox et al. (2006) reported a study of 35 adoles-
cents in which they compared slow- release methylphe-
nidate, dexamfetamine, and placebo. They found that
extended- release methylphenidate, at a dose of 72 mg,
led to significant improvements in driving skills and
safety.

Preschool Children. In a literature review of all stud-
ies of treatments for this age group, McGoey, Eckert,
and DuPaul (2002) concluded that stimulant treatment,
parent training, and classroom behavior management
are all effective. However, at that time, there were only
14 nonpharmacological studies in the literature. Con-
nor (2002) reported a review of stimulant medication
studies in preschoolers and suggested that there is rea-
sonable evidence to support using stimulant medication
in this age group if behavioral approaches, including
parent training, have failed. Greenhill et al. (2006b)
reported the results of the NIMH multisite study of
preschoolers with a DSM-IV consensus diagnosis of
ADHD. This study of children ages 3.0–5.5 years with
ADHD examined the response to three daily doses
of immediate- release methylphenidate. A total of 303
preschoolers were enrolled. There was a significant
improvement with stimulant medication compared to
placebo. The daily maintenance dose of methylpheni-
date ranged from 7.5 to 30 mg. However, the ESs were
smaller than those reported for older children. Parents
reported an ES of 0.35 for preschoolers compared with
0.52 in school- age children, and teachers reported
an ES of 0.43 in preschoolers compared with 0.75 in
school- age children. The authors reported higher rates
of emotional lability in the preschoolers.

An additional aspect of this study, reported by Mc-
Gough et al. (2006a), was an attempt to identify a
genetic contribution to the response. Possible associa-
tions were found for the DRD4 promoter and SNAP-
25. The SNAP-25 variant was associated with tics and
buccal– lingual movements, in addition to irritability.
The DRD4 variant was associated with picking. Fur-

ther studies are clearly required to confirm these ge-
netic influences on the response to stimulant treatment
in preschoolers.

Ghuman et al. (2007) showed that, when comorbid
disorders are present, the response to stimulants in pre-
schoolers is reduced, as is the case in other age groups.
In this study, the children in a high- comorbidity sub-
group had an ES of –0.37 with a 7.5-mg dose of meth-
ylphenidate three times a day (relative to placebo),
compared with high ESs of 0.89 in children with no
comorbidity, 1.00 in those with low comorbidity, and
0.56 in children with moderate levels of comorbidity.

Abikoff et al. (2007) explored the outcomes for the
same sample in more detail. Unfortunately, there was a
dropout rate of 45% in the placebo group and 15% in
the methylphenidate group, due to deterioration in be-
havior. This may have adversely affected the power of
the study; hence, the treatment effect reported may be
an underestimate. The authors suggest that the 4-week
treatment phase may have been too short and the dose
of medication too low. They also recommend adding a
parenting program in future studies.

In summary, regardless of age, 75% of children with
ADHD show normalization of inattention, hyperactiv-
ity, and impulsivity when treated with stimulants. It
is not possible to predict reliably which children will
show a good response. In addition, 70% of children
with ADHD and comorbid aggression show significant
improvement in aggressive behaviors. However, proso-
cial behaviors do not improve.

Stimulant Use in the Presence
of Comorbid Disorders

Ter- Stepanian, Grizenko, Zappitelli, and Joober (2010)
found that most children with ADHD have comorbidi-
ties. In this study of 267 children ages 6–12 years, in
which boys were overrepresented (77.9% of the sam-
ple), 40.8% had ODD, 27.7% had conduct disorder,
47.2% had an anxiety disorder, and 7.9% had a depres-
sive disorder.

Internalizing Disorders. T. Spencer et al. (1996) re-
viewed the findings from 11 studies that examined the
response of children with ADHD and comorbid inter-
nalizing symptoms to stimulant medication. Most of
these studies reported that the presence of a comorbid
internalizing disorder, such as anxiety or depression,
reduced the response to stimulant medication. In a
well- designed trial with a sample of 40 children with

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212 W h at Wo r k s f o r W h o m ?

ADHD and varying degrees of internalizing symp-
toms, DuPaul, Barkley, and McMurray (1994) found
that significantly fewer children in a high- internalizing
group exhibited a positive response to methylphenidate
compared to subjects with fewer internalizing symp-
toms. Fifty percent of the children with significant co-
morbid internalizing symptoms either failed to respond
or had an adverse reaction to methylphenidate; 25%
of the children with a comorbid internalizing disorder
showed deterioration in behavior (based on teacher
reports of classroom behavior) with stimulant use,
compared with 9% in the groups with fewer internal-
izing disorder symptoms. The study by Ter- Stepanian
et al. (2010) confirmed the poor response of children
to methylphenidate when comorbid anxiety was pres-
ent. In contrast, there was a positive response in the
presence of comorbid conduct disorder, although this
latter result must be interpreted with caution because
the duration of the study was only 2 weeks, comprising
1 week of placebo followed by crossover to 1 week of
methylphenidate.

Analysis of the data from the MTA study by J. S.
March et al. (2000) revealed no adverse response to
stimulant medication in children with comorbid inter-
nalizing disorders, but it did highlight the need for ad-
ditional psychosocial interventions for this group.

More recently, Goez, Back- Bennet, and Zelnik
(2007) found that some children with DSM-IV-diag-
nosed ADHD and anxiety improved with stimulant
medication, and a larger proportion (58.62%) worsened
(a bimodal distribution). They found similar results in
children with comorbid ODD. They suggested that in
these children the inattention is secondary to the other
problems; hence, this represents a separate group re-
quiring different interventions.

In summary, while earlier studies suggested that only
50% of children with ADHD and comorbid depression
and/or anxiety significantly benefited from stimulant
treatment, and that there was an increased risk of ad-
verse reactions and deterioration in mental state, more
recent findings suggest that, at least for comorbid anxi-
ety, this may not be the case. The findings from the
MTA study also suggest that when ADHD is comor-
bid with internalizing disorders, additional behavioral
interventions may be appropriate and more beneficial
than when ADHD is present on its own.

Manic Symptoms. There is considerable debate about
how to diagnose children with ADHD who present
with manic symptoms such as irritability and lability

of mood but do not show all the symptoms of a bipolar
disorder. Galanter et al. (2003) reported on the sample
used for the MTA study (579 children ages 7.0–9.9
years). Children in the sample with symptoms of mania
showed a good response to stimulant treatment. Galant-
er et al. and Sarampote, Efron, Pearl, Robb, and Stein
(2002) have suggested that the high reported rates of
manic symptoms in individuals with ADHD may be
due to stimulant rebound. There was no evidence to
support this suggestion in the study by Galanter et al.
(2003), and they concluded that, on the basis of their
short-term study (4 weeks), there was no contraindica-
tion to a trial of methylphenidate in the presence of pos-
sible bipolar symptoms. They recommend a carefully
monitored trial of stimulant medication.

Conduct Disorder and Aggression. T. Spencer et al.
(1996) reported on 17 controlled studies of stimulant
treatment in ADHD. They concluded from their review
of these studies that stimulants produce significant
improvement in ADHD symptoms in children with
comorbid aggression. They also found that stimulants
reduce both verbal and physical aggression in these
individuals. A meta- analysis of 28 studies by Connor,
Glatt, Lopez, Jackson, and Melloni (2002) similarly
confirmed the benefits of stimulants in reducing ag-
gression in children or adolescents below age 18 years.

In a well- designed RCT of 85 children and ado-
lescents ages 6–16 years, Sinzig et al. (2007) showed
that long- acting methylphenidate was effective in the
treatment of ADHD and comorbid DSM-IV-diagnosed
oppositionality and aggression. Symptomatic improve-
ment was more favorable in school than in the home.

In summary, 70% of children with ADHD and co-
morbid aggression show a significant reduction of ag-
gressive behaviors when treated with stimulants. How-
ever, prosocial behaviors do not improve. For further
discussion of this topic, see Chapter 4.

There has been one pilot study on supplementation
of stimulant medication with risperidone for the treat-
ment of aggression in children (Armenteros, Lewis, &
Davalos, 2007). However, this study had several limita-
tions, particularly its short duration (4 weeks), which
may have led to an underestimation of side effects, and
the small sample size (25 children ages 7–12 years). A
well- designed controlled study is needed before defi-
nite recommendations can be made.

Learning Disabilities. ADHD and hyperkinesis are ap-
proximately four times as prevalent in children with

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Attention‑Deficit/Hyperactivity Disorder 213

learning disabilities as in non- learning- disabled chil-
dren (Biederman et al., 1991). There is no consistent
view in the literature regarding the efficacy of medi-
cation in children with ADHD and comorbid learning
disabilities, because most studies have excluded such
children from their sample. The few that have includ-
ed learning- disabled subjects have tended to contain
only those with mild deficits. Three studies (Aman,
Kern, McGhee, & Arnold, 1993; Handen, McAuliffe,
Janosky, Feldman, & Breaux, 1995; Payton, Burkhart,
Hersen, & Helsel, 1989) have reported a response rate
averaging 65%, which, although useful, is lower than
the rate of 70–80% reported in the literature for school-
age children without learning disabilities. Aman, Bui-
can, and Arnold (2003) pointed out that the response
of children with DSM-III-diagnosed ADD and addi-
tional learning disabilities is more variable than that
of children with normal IQ. Handen, Feldman, Lurier,
and Murray (1999) also reported a small (11 subjects)
RCT that confirmed preschool children with learning
disabilities respond to methylphenidate at a rate simi-
lar to that of school- age children, although there was a
suggestion of a higher rate of side effects in the younger
age group.

An important subgroup is children with fragile X
syndrome, most of whom have ADHD or hyperkinesis.
Hagerman, Murphy, and Wittenberger (1988) reported
a double- blind crossover study of a small sample (N =
15) of children with ADHD and fragile X syndrome
who were treated with methylphenidate, dexamfet-
amine, or placebo. The children showed significant
behavioral improvement in response to stimulant medi-
cation.

Stimulants are therefore often beneficial in the pres-
ence of a comorbid learning disability; however, the
more severe the learning disability, the poorer the re-
sponse.

Specific Learning Disabilities. Many children with
ADHD or hyperkinesis have a comorbid specific
learning disability, such as a specific reading disabil-
ity. Bental and Tirosh (2008) reported on a study of
25 boys ages 7.9–11.7 years with DSM-IV-diagnosed
ADHD and reading disorder, who participated in a
double- blind study of methylphenidate and placebo.
The authors found a significant improvement in word
accuracy, nonword accuracy, and rapid naming with the
active drug. However, in another study, Grizenko, Bhat,
Schwartz, Ter- Stepanian, and Joober (2006) found that
children with a mathematics disability had a poorer

response (37%) to methylphenidate than those with a
reading disability (67%); those with no disability had a
75% response to methylphenidate. The authors suggest
that the explanation is that children with mathematics
disabilities have higher executive dyscontrol than do
children with pure forms of ADHD.

In summary, in the presence of ADHD and a spe-
cific learning disability, stimulant therapy facilitates
improvement in the learning disability.

Pervasive Developmental Disorders. Two studies (Bir-
maher, Quintana, & Greenhill, 1988; Handen, Johnson,
& Lubetsky, 2000) have suggested that moderate to
severe social withdrawal can be an outcome of higher
doses of stimulants (0.6 mg/kg) and recommend the
lower dose of 0.3 mg/kg. However, a more recent report
(Posey et al., 2006) of an open-label study of atomox-
etine use in sixteen 6- to 14-year-olds with DSM-IV-
diagnosed ADHD and autism, Asperger syndrome, or
pervasive developmental disorder (PDD) not otherwise
specified found that 14 of the 16 subjects benefited.
A second study by Posey et al. (2007), describing a
4-week blinded crossover study of methylphenidate in
66 children with a mean age of 7.5 years, showed sig-
nificant benefit without significant side effects. These
more recent findings support the use of these treatments
when ADHD is comorbid with autistic spectrum disor-
ders. In Posey et al.’s second study, six of the original
sample of 72 subjects were excluded because they could
not tolerate methylphenidate. Therefore, it would be ad-
visable initially to use a low test dose in this group of
children and adolescents. Further studies are required
in this area.

Seizure Disorders. Until recently, the use of stimulants
was avoided in children with ADHD and comorbid
seizures, because stimulants were thought to lower the
seizure threshold. Some clinicians would prescribe
dexamfetamine but not methylphenidate, because it
was thought that dexamfetamine raised the seizure
threshold. An extremely helpful review of the treatment
of ADHD and comorbid epilepsy (Torres, Whitney, &
Gonzalez- Heydrich, 2008) highlights the fact that the
majority of studies to date have evaluated the risks and
benefits of stimulant medication when the two condi-
tions coexist. The authors emphasize the need for good
communication between the clinicians treating the epi-
lepsy and the ADHD, as well as the child’s caregivers
and school. The studies report a 70% response rate to
stimulants. They recommend the use of stimulants first,

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214 W h at Wo r k s f o r W h o m ?

because these treatments have the most evidence for ef-
ficacy, with atomoxetine next, and clonidine or guanfa-
cine as third-line treatments.

Stimulant Use with Comorbid Tics and Tourette Syn‑
drome. The use of stimulant treatment in children with
ADHD and comorbid tics or Tourette syndrome is dis-
cussed in Chapter 7.

Adaptation to Psychosocial Environments

Social Relationships. Children with ADHD and hy-
perkinesis usually have serious social difficulties, but
there have been few studies of the effects of stimulants
on social relationships. The studies that exist suggest
a benefit in this area, showing that children who re-
spond positively to stimulant medication receive in-
creased warmth and decreased maternal criticism, with
increased frequency of maternal contact (Schachar,
Taylor, Wieselberg, Thorley, & Rutter, 1987; Whalen &
Henker, 1991). In support of the suggestion that medi-
cation alone improves social relationships, several au-
thors have reported a decreased incidence of arguments
and fighting in stimulant- treated boys with ADHD
(Barkley, McMurray, Edelbrock, & Robbins, 1989).
Children also become more popular with their peers,
but often some social difficulties remain (Gadow,
Nolan, Sverd, Sprafkin, & Paolicelli, 1990; Whalen et
al., 1989). Approximately 70% of children and adoles-
cents treated with medication show a good response.
Nevertheless, J. M. Swanson et al. (1993) concluded
that although stimulants may reduce negative behav-
iors, they do not increase positive prosocial behaviors;
other therapies are required if social relationships are
to be fully normalized.

Academic Performance. Discussion of the benefits,
if any, of stimulant medication in relation to learning
in children with ADHD has been ongoing for many
years. In a meta- analysis of 135 studies, Kavale (1982)
found moderate positive effects favoring drug treat-
ment. The results revealed a 15% increase in achieve-
ment for those treated with methylphenidate. Rapport,
Denny, DuPaul, and Gardner (1994) evaluated the ef-
fects of methylphenidate on the classroom behavior
and academic performance of 76 subjects ages 6–11
years. Standardized statistical assessments showed that
medication significantly improved attention, academic
efficiency, and teacher ratings of classroom behavior.
Doses of 10 mg or above significantly increased per-

formance in all three areas compared to placebo or a
5-mg dose.

Overall, 76% of the sample showed either improved
or normalized attention (72% normalized), with 24%
showing no change; 53% showed improved or normal-
ized academic efficiency (50% normalized), and 47%
showed no change in academic efficiency. Academic
accuracy stabilized at the dose of 10 mg and did not im-
prove further at higher doses. In contrast, the numbers
of children with normalized attention and classroom
behavior increased as the dose of methylphenidate was
increased toward 20 mg. Hence, for some children,
academic performance may not improve in line with
changes in behavior. Moreover, the children who failed
to show improvements in academic accuracy were less
likely to show improvements in attention.

Some authors (Alto & Frankenberger, 1995; C. L.
Carlson, Pelham, Swanson, & Wagner, 1991) have
suggested that mathematical skills are particularly
improved by methylphenidate. However, Zentall and
Ferkis (1993) failed to find evidence to support this
finding. Another question is the effect of the dose on
learning; J. M. Swanson, Cantwell, Lerner, McBurnett,
and Hanna (1991) have suggested that high doses of
stimulant may produce such an “overfocusing” effect
that it impedes learning. These authors suggest that
higher dosages may maximize achievement in some
tasks and lower dosages may optimize other tasks, such
as those demanding greater cognitive effort.

Longer-term follow- up studies have often failed to
confirm the beneficial effects of stimulants on aca-
demic performance. Weber, Frankenberger, and Heil-
man (1992) studied 22 subjects with ADHD and used
a group achievement test before and after 1–2 years of
methylphenidate or control treatment to assess the re-
sponse to treatment. They concluded that methylpheni-
date did not improve achievement.

Alto and Frankenberger (1995) reported a study of
17 children ages 7–8 years with ADHD. Each child
was matched with a control child by age, gender, and
cognitive abilities. The authors found that even when
subjects were matched on verbal cognitive scores, they
showed significantly lower achievement than controls
in the areas of word analysis and reading. The perfor-
mance of subjects with ADHD in mathematics showed
an increase in rate of learning approaching significance
when compared with the control group. Listening skills
were more likely to respond to medication than vocabu-
lary. Increasing the dosage further increased listening
but had the opposite effect on vocabulary. The authors

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Attention‑Deficit/Hyperactivity Disorder 215

concluded that although the children with ADHD were
behind their normal peers in most areas of learning at
the start of the study, once placed on methylphenidate
their learning rate was equal to that of the controls,
so that they did not fall further behind, although they
did remain behind in reading skills. The study lasted 1
year; it was not possible to assign the children to a pla-
cebo treatment, because the parents and teachers were
reluctant to consent.

In practice, medication alone is unlikely to be ad-
equate for optimal academic achievement. Studies such
as that by Pelham, Milich, and Walker (1986) reveal
that when behavioral approaches incorporating a re-
ward system were combined with methylphenidate,
performance was maximized.

In summary, although attention and output during
academic tasks improve by 70% with stimulant medi-
cation, efficiency and accuracy show only approximate-
ly 50% improvement. In the long term, subjects with
ADHD receiving stimulant medication do not achieve
as much as nonaffected control children, probably be-
cause they are too far behind to catch up fully. Further
studies are required to verify this as the cause of poorer
long-term academic progress.

Summary

Stimulant treatment achieves normalization of inatten-
tion, hyperactivity, and impulsivity in 75% of children
with ADHD. It is not possible to predict with certainty
which children will show a good response. Attention
and output during academic tasks improve by 70% with
stimulant medication, but efficiency and accuracy show
less improvement. Prosocial behaviors do not improve.

The outcome of ADHD is still uncertain, but it ap-
pears to be better with treatment than without it. Indi-
viduals with ADHD who are treated with stimulants
still do not achieve as much as nonaffected individuals
in the long term, probably because they have already
fallen too far behind their unaffected peers to catch
up. Nevertheless, young adults treated for ADHD with
stimulants in childhood and adolescence have fewer ac-
cidents, improved social skills, and happier childhood
memories compared with individuals whose ADHD
was not treated.

When comorbid problems are present, stimulant
medication is beneficial to varying levels depending on
the comorbidity. In the case of conduct disorder, 70%
of children with ADHD show significant improvement
in both aggressive behaviors and ADHD behaviors

when treated with stimulants. In contrast, the consen-
sus until recently was that when ADHD is comorbid
with depression and/or anxiety, only 50% of children
significantly benefit from stimulant treatment. In addi-
tion, there was a presumed increased risk of adverse re-
actions and deterioration in mental state. The findings
from three more recent studies have concluded that, at
least in the case of anxiety, this is not so.

Stimulants are also often beneficial in the presence
of a comorbid generalized learning disability; however,
the more severe the learning disability, the poorer the
response. They also lead to improvements in the learn-
ing problems of some specific learning disabilities.
Children with PDD and ADHD have recently been
found to benefit from stimulant therapy without show-
ing an increase in stereotypies. Stimulants are safe to
use in the presence of epilepsy as long as the underlying
seizure disorder is appropriately treated.

Atomoxetine

Atomoxetine is a highly selective norepinephrine
reuptake inhibitor. It has been shown to be effective
in several studies. Kratochvil et al. (2006) reported a
meta- analysis of long-term atomoxetine treatment in
272 children ages 6 and 7 years who met diagnostic
criteria for a DSM-IV diagnosis of ADHD. Atomox-
etine was found to be beneficial over 2 years of treat-
ment with no significant risk of major side effects. In
another meta- analysis of atomoxetine, Cheng, Chen,
Ko, and Ng (2007) found that the NNT for treatment
response was 3.4, and the NNT for relapse preven-
tion was 10.3. Patients with more pronounced baseline
ADHD symptoms had the greatest reduction in symp-
toms. The groups showing the least response were male
children with hyperactive– impulsive subtype ADHD
and comorbid ODD. The most common side effects
were appetite suppression (NNH = 8.81), abdominal
pain (NNH = 22.48), vomiting (NNH = 29.96), and
dyspepsia (NNH = 49.38). Side effects were worse in
younger children and those with more severe baseline
hyperactive– impulsive symptoms. Oppositional symp-
toms reduced and quality of life improved.

Newcorn et al. (2006) reported an RCT of long-term
treatment of ADHD with atomoxetine and found that a
low dose of 0.5 mg/kg body weight was as effective as
a higher dose of 1.2–1.8 mg/kg. This study involved 459
children, ages 6–16 years, with a DSM-IV diagnosis of
ADHD. Treatment was initiated at the higher dose; 229
children responded positively and were subsequently

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216 W h at Wo r k s f o r W h o m ?

randomized either to continue on the higher dose or
move to the lower dose. The only significant difference
in adverse reactions was a higher rate of affective labil-
ity in the lower dose group.

G. A. Carlson et al. (2007) reported a small study
of 25 children ages 6–12 years who met diagnostic
criteria for a DSM-IV diagnosis of ADHD. The study
investigated a combination of atomoxetine and meth-
ylphenidate and showed that this was safe and effec-
tive in those who did not respond to atomoxetine alone.
However, it is difficult to draw conclusions given the
small sample.

Given that there have been reports of suicidal ideation
and depression as side effects of atomoxetine treatment,
Bangs et al. (2008b) undertook a meta- analysis com-
paring suicidal ideation in atomoxetine- treated patients
and placebo- treated controls. The authors compared 12
placebo- controlled studies of atomoxetine, with a treat-
ment duration of 6–18 weeks, and five trials of meth-
ylphenidate, with a duration of 6–9 weeks. The mean
daily dose of atomoxetine in the trials was 1.3–1.6
mg/kg. The mean daily dose of methylphenidate was
0.9–1.1 mg/kg. The age range of the children and ado-
lescents in these studies was 6–17 years. Although sui-
cidal ideation was uncommon in the studies, it was sig-
nificantly more common in atomoxetine- treated than in
methylphenidate- treated groups. However, there was
no difference between atomoxetine and methylpheni-
date in terms of the risk of inducing suicide.

Comorbid ODD

Dittman et al. (2011) reported an RCT of atomox-
etine in 181 German children ages 6–17 years with
ADHD and comorbid ODD. Both ADHD and ODD
improved during 9 weeks of atomoxetine treatment.
The authors reported that both ODD and ADHD be-
haviors significantly improved. However, a high rate
of side effects— sleep disorders, fatigue, nausea, and
gastrointestinal complaints— was reported in the first
3 weeks of treatment, occurring in 60% of cases re-
ceiving fast- titration atomoxetine treatment and 44%
of cases receiving slow- titration treatment. Partici-
pants in the fast- titration schedule received 0.5 mg/
kg atomoxetine for 7 days and a subsequent increase
to the target dose of 1.2 mg/kg. Participants in the
slow- titration schedule received 0.5 mg/kg for 7 days,
followed by 0.8 mg/kg for 7 days and thence 1.2 mg/
kg. The findings suggest that a slow- titration schedule
is preferable— possibly with an even slower increase

than the “slow titration rate” described in this study.
The authors suggest that the effect of atomoxetine on
ODD may be direct rather than secondary to the re-
duction in ADHD symptoms.

Bangs et al. (2008a) reported a study of 226 children
ages 6–12 years who met diagnostic criteria for a DSM-
IV diagnosis of ADHD. The children were randomized
to atomoxetine or placebo. There were significant im-
provements in both oppositionality and ADHD symp-
toms at 2 and 5 weeks postbaseline, but not at 8 weeks.
Biederman et al. (2007c) reported similar findings
from a meta- analysis of studies of comorbid ADHD
and ODD.

Comorbid Depression

In an RCT, Bangs et al. (2007) studied the effects of
atomoxetine in 142 adolescents ages 12–18 years with
DSM-IV-diagnosed ADHD and moderate depression.
They found atomoxetine to be as effective in reducing
ADHD symptoms over the 9 weeks of the trial as it had
been shown in trials in adolescents with ADHD and no
comorbid depression. The atomoxetine had no impact
on the depression. There was no precipitation of mania,
worsening of depression, or significant increase in sui-
cidal ideation, although the latter did increase a little.

Comorbid

Anxie

D. Geller et al. (2007) reported a well- designed RCT
in 176 children and adolescents ages 8–17 years with
ADHD and comorbid anxiety. The children met DSM-
IV criteria for a diagnosis of ADHD and generalized
anxiety disorder, separation anxiety disorder, and/or
social phobia. The authors reported a significant reduc-
tion in symptoms of both ADHD and anxiety.

Side Effects

D. Michelson et al. (2007) reported on a large, inter-
esting, well- conducted study exploring the influence
of genetics on the response to atomoxetine. The study
investigated the effect of variation in the gene for cyto-
chrome P450 2D6 (CYP2D6), the enzyme pathway that
breaks down atomoxetine, in a sample of children and
adolescents ages 6–18 years (589 receiving atomox-
etine and 294 receiving placebo). The authors reported
that poor metabolizers had highly significant superior
responses to medication compared with better metabo-
lizers. However, unsurprisingly, the poor metabolizers

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Attention‑Deficit/Hyperactivity Disorder 217

had more severe side effects, with significantly (p < .001) increased heart rate and diastolic blood pressure, and smaller increases in weight (p < .05). The authors concluded that tolerability was good in both genetic groups and, in particular, there was no significant ad- verse effect on the cardiac QTc interval.

Wang et al. (2007) reported a multicenter study of a
large sample of 330 children ages 6–16 years who met
criteria for a DSM-IV diagnosis of ADHD. The chil-
dren were randomly allocated to treatment with either
atomoxetine or methylphenidate. The authors reported
no differences in outcome using standardized outcome
measures, but the atomoxetine group reported signifi-
cantly more frequent side effects: anorexia (37.2 vs.
25.3%, p = .024), nausea (20.1 vs. 10.2%, p = .014),
somnolence (26.2 vs. 3.6%, p = .0001), dizziness (15.2
vs. 7.2%, p = .024), and vomiting (11.6 vs. 3.6%, p < .001). Unfortunately, there was no control group; in ad- dition, atomoxetine treatment was initiated at a faster rate than is usually recommended (titrated to 1.2 mg/ kg on Day 5). The impact of this more rapid initiation of medication on side effects is uncertain, but it may be relevant.

Summary

Atomoxetine can be useful if stimulant treatment has
been found to be ineffective or when stimulants are
contraindicated due to substance misuse in the fam-
ily, when there is comorbidity with tics and/or anxiety,
patient preference, or when a 24-hour response is es-
sential. Atomoxetine should commence at a dose of 0.5
mg/kg and, after a minimum of 7 days, be increased
gradually to the recommended dose of 1.2 mg/kg. Side
effects may be reduced by giving atomoxetine in the
evening. Alternatively, it can be divided into morning
and evening doses.

Common side effects of atomoxetine are nausea and
appetite loss. Insomnia and constipation may occur.
Earlier concerns about potential liver problems appear
to have been related to a serious idiosyncratic (allergic-
type) reaction, which can also occur with stimulants;
none of the recent studies has identified further cases.
Atomoxetine can precipitate seizures in someone al-
ready predisposed to them, but there is no evidence that
it is contraindicated in the presence of well- controlled
seizure conditions.

Table 6.3 summarizes information for clinicians
regarding the use of stimulants and atomoxetine in
ADHD.

Tricyclic Antidepressants

The tricyclic antidepressants are the most frequently
used alternatives to stimulants and atomoxetine in
ADHD treatment. T. Spencer et al. (1996) reviewed
the literature on their use in ADHD or hyperkinesis
and reported that 24 of the 26 (92%) studies of tricy-
clic antidepressant treatment of ADHD in latency- age
children indicated significant behavioral improvements
compared to placebo. Twelve studies evaluated the re-
sponse to imipramine; nine, to desipramine; three, to
amitriptyline; four, to nortriptyline; and one, to clomip-
ramine. Other studies that have tended to use higher
dosages report a better outcome than the earlier studies
(Biederman, Gastfriend, & Jellinek, 1986; Gastfriend,
Biederman, & Jellinek, 1985; Wilens, Biederman,
Geist, Steingard, & Spencer, 1993). However, electro-
cardiography (ECG) should be carried out regularly
and with each significant increase in dose, due to the
risk of arrhythmias. Several children receiving tricy-
clic antidepressants have died suddenly, although this
rate may be no higher than the sudden death rate in
the general population. Both parents and teachers have
reported that behavioral symptoms improve as well
with tricyclic antidepressants as with stimulants. Four
studies, including two controlled trials, have included
preschool children, and have shown significant im-
provements. Similarly, eight studies that included ado-
lescents (Gastfriend et al., 1985; Wilens et al., 1993)
reported a similar degree of benefit.

Biederman, Baldessarini, Wright, Knee, and Har-
matz (1989) reported one of the largest RCTs of de-
sipramine in 62 children ages 6–17 years, of whom 43
had responded poorly to stimulants. Treatment was 6
weeks of either desipramine or placebo. Significant be-
havioral improvements occurred at an average dose of
4.6 ± 0.2 mg/kg. Sixty-eight percent of desipramine-
treated subjects were considered very much or much
improved, compared with only 10% of those treated
with placebo. In a second study, Biederman, Baldes-
sarini, Wright, Keenan, and Faraone (1993a) reported
that improvement was seen even in cases with comor-
bid conduct disorder, depression, or anxiety. Cases with
“pure” ADHD showed a trend toward a lesser placebo
response and a greater difference between desipramine
and placebo.

Possible benefits of the tricyclic antidepressants, com-
pared with stimulants, are longer duration of action and
improved response in children with comorbid anxiety
and depression (McClellan, Rubert, Reichler, & Sylves-

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218 W h at Wo r k s f o r W h o m ?

ter, 1990). Other advantages include the use of a single
daily dose, lower risk of medication abuse, and lower
risk of an afternoon rebound in hyperactive behavior.

Baseline blood pressure, pulse, and ECG, to rule out
any preexisting conduction anomalies, should be re-
corded before tricyclic antidepressants are prescribed.
These parameters should also be monitored regularly
during treatment and with each dose increase.

In summary, tricyclic antidepressants have been
shown to be beneficial in the treatment of the primary
symptoms of ADHD in 70% of children of all ages. Al-
though children with “pure” ADHD are likely to show
the most improvement with stimulant treatment, it may
be preferable to use a tricyclic antidepressant in those
with comorbid depression, anxiety, or aggression, es-
pecially if the anxiety and/or depression worsens with

tABle 6.3. summary of stimulants and Atomoxetine

Stimulants Atomoxetine

Product names Methylphenidate: Ritalin, Equasym (IR or XL),
Medikinet (IR or XL), Concerta XL

Dexamfetamine (Dexamphetamine): Dexadrine,
Lisdexamfetamine, Adderall

Straterra

Dosage See Table 6.2 for details of slow-release preparations.

Methylphenidate: 10–60 mg/day

Dexamfetamine: 5–30 mg/day

0.5 mg/kg for the first week, then
increase gradually over 4–6 weeks to
1.2 mg/kg

Onset of action Same day (see Table 6.2) 4 weeks for full effect

Route and form of
administration

Oral tablet or capsule. Some can be sprinkled in food
and drink. Methylphenidate skin patches are also
available

Oral capsule; can be sprinkled in food or
drink

Frequency of
administration

Slow release: once a day

Immediate release: 2–6 times per day

Once a day; divide into two doses per day
if side effects are seen with daily dosing

Indications ADHD with impairment together with behavioral
strategies for parent and child, in addition to
behavioral approaches in school

Second-line treatment if stimulants are
ineffective, insufficient, or if side effects
are seen

Substance misuse

Anxiety

Investigations prior to or
during administration

Baseline and ongoing: height, weight, blood pressure
and pulse

Others dependent on full medical history and physical
examination

Baseline and ongoing: height, weight,
blood pressure and pulse

Others dependent on full medical history
and physical examination

Contraindications Substance misuse

Untreated epilepsy

Psychosis

Severe anxiety

Children who have not already tried
stimulants if safe

Reluctance to take on a daily basis

Allergy to atomoxetine

Side effects Reduced appetite

Insomn

Precipitation of seizures

Nausea and reduced appetite

Insomnia

Constipation

Suicidal ideation

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Attention‑Deficit/Hyperactivity Disorder 219

stimulant therapy. Tricyclic antidepressants may also
be indicated in cases in which there is a severe rebound
with stimulant treatment. Careful monitoring of car-
diac status with ECGs is essential, and advice must be
given to parents/caregivers about the dangers of this
medication in overdose.

Children with ADHD and a comorbid mood disorder
are sometimes treated with the combination of a stimu-
lant and an antidepressant. This practice seems to be
more prevalent in the United States than in the United
Kingdom. There is no good evidence to support this
type of drug combination.

Nontricyclic Antidepressants

Barrickman, Noyes, Kuperman, Schumacher, and
Verda (1991) reported an open-label trial of the selec-
tive serotonin reuptake inhibitor (SSRI) fluoxetine in
children and adolescents with ADHD. Sixty percent of
subjects improved moderately, and there were few ad-
verse reactions.

An earlier study (Zametkin, Rapaport, Murphy, Lin-
noila, & Ismond, 1985) was the first to consider the use
of the monoamine oxidase inhibitor (MAOI) group of
antidepressants. This 12-week double- blind crossover
study compared the effects of an MAOI with dexamfe-
tamine in a sample of 14 boys ages 7.7–10.7 years with
ADHD. Tranylcypromine sulphate or clorgyline was
given twice a day in 5-mg doses. Dexamfetamine dos-
age was 10 mg in the morning and 5 mg at lunchtime.
Low- tyramine diets were required, because of the risk
of a hypertensive crisis associated with disruption of
tyramine metabolism by MAOIs, and blood pressure
was measured weekly. There were no significant ad-
verse reactions. The MAOIs and dexamfetamine im-
proved disruptive behavior, as rated by both teachers
and parents, to an equivalent degree. Attention also
improved with both types of medication. There were
no significant differences between the treatments. This
small, well- designed study suggests that the newer,
more selective MAOIs may provide a promising alter-
native to stimulant treatment.

Akhondzadeh et al. (2003) investigated a type B
MAOI, selegiline, which is metabolized to amphet-
amine and methamphetamine stimulant compounds,
in 28 children between ages 4 and 9 years who met
criteria for a DSM-IV diagnosis of ADHD. In a small,
4-week RCT, they compared selegiline at doses of
5 mg/day (for children under 5 years of age) and 10
mg/day (for children over 5 years) with methylpheni-
date. The two treatments showed equal efficacy and

side effects. Further studies of longer duration are re-
quired.

Barrickman et al. (1995) reported a double- blind
crossover study contrasting the effectiveness of bu-
propion and methylphenidate in 15 subjects ages 7–17
years with ADHD. Bupropion is an antidepressant
whose pharmacological profile is similar to that of the
stimulants. According to parental reports, methylphe-
nidate was significantly more effective than bupropion
in improving attention. The two treatments did not dif-
fer significantly in relation to improvement of conduct;
both treatments significantly improved conduct above
the baseline behavior.

Side effects of bupropion include skin reactions,
which abate after stopping the drug. Bupropion lowers
the seizure threshold at a frequency similar to that of
the tricyclic antidepressants. Because it is a weak do-
paminergic agent, there is a small risk that it may pre-
cipitate a psychotic illness. Four such cases have been
reported in the literature (mentioned by Barrickman et
al., 1995).

The scarcity of studies of treatment with nontricyclic
antidepressants in ADHD makes it impossible to advise
about their use, other than to comment that they are
worth consideration if stimulants and tricyclic antide-
pressants are contraindicated.

Clonidine

D. R. Palumbo et al. (2008) and Daviss et al. (2008)
have reported a well- designed multicenter study of
clonidine treatment in 122 children ages 7–12 years
fulfilling criteria for a DSM-IV diagnosis of ADHD.
In two successive 4-week titration periods, clonidine
or matching placebo (in the first period) was compared
with clonidine plus methylphenidate, methylphenidate
on its own, or placebo (in the second period). The two
titration periods were followed by an 8-week mainte-
nance period. Clonidine showed significant benefits on
Conners Parent Rating Scales and clinicians’ ratings
of impairment (Children’s Global Assessment Scale).
However, there was no benefit based on Conners Teach-
er Rating Scales for clonidine treatment alone. At the
end of the study, the mean ± SD doses of the medi-
cations in each group were as follows: clonidine, 0.24
± 0.11 mg/day; methylphenidate, 30.2 ± 18.9 mg/day;
combined regimen, clonidine 0.23 ± 0.13 mg/day plus
methylphenidate 25.4 ± 18.2 mg/day. There was one se-
vere adverse reaction in the combined treatment group,
with the development of a prolonged QTc interval and
left ventricular hypertrophy on ECG, but no clinical

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220 W h at Wo r k s f o r W h o m ?

symptoms or findings on echocardiography. Sedation
was the main side effect with clonidine, but this de-
creased after Week 8. The ESs were as follows: methyl-
phenidate versus no methylphenidate, –0.49; clonidine
versus no clonidine, –0.24; combined treatment versus
placebo, –0.73.

In summary, clonidine appears to be as beneficial as
the tricyclic antidepressants in the treatment of ADHD
symptoms and should be a second- line treatment for
those who cannot be treated with stimulants or atom-
oxetine. The authors recommend an ECG before and at
regular intervals during treatment, although a statement
from a committee of pediatric cardiologists, accepted
by the American Heart Association, stated that ECGs
are not required (Gutgesell et al., 1999). The risk of a
hypertensive rebound means that this treatment must
not be stopped suddenly. Two children treated with
methylphenidate and clonidine in the United States and
one in Australia have died. Sudden cessation of cloni-
dine may have been the cause, although this is unprov-
en. Clonidine also frequently causes drowsiness. Al-
though no definite recommendations can be made about
the combination of clonidine and stimulant medication
until there is more scientific information regarding the
safety of their combined use, the rate of prescribing
of clonidine, both separately and in combination with
methylphenidate, has greatly increased (Swanson, Con-
nor, & Cantwell, 1999; Swanson et al., 1996; Wilens,
Spencer, Swanson, Connor, & Cantwell, 1999). Until
more is known about the safety of this drug combina-
tion, an ECG should be obtained at the start of treatment
and with each dose change (Daviss et al., 2008).

Guanfacine

Guanfacine is related to clonidine but has a longer half-
life and is less sedating. It is also more selective in its
binding to the alpha- adrenergic receptors and does not
bind to alpha1 receptors.

Biederman et al. (2008) have reported a placebo-
controlled study of an extended- release formulation of
guanfacine. A total of 345 patients ages 6–17 years, who
met criteria for a DSM-IV diagnosis of ADHD, were
randomly assigned to treatment with placebo or guanfa-
cine at 2-, 3-, or 4-mg doses for a period of 8 weeks. All
doses showed significant benefit by Week 5. There were
more side effects in the treatment groups, with som-
nolence correlating with higher doses. There were no
significant ECG changes. However, when the response
rate according to age was examined, adolescents failed

to show significant improvement, whereas younger
children did. The authors hypothesize that adolescents
would require a higher dose. The treatment ESs were
0.58 for a dose of 0.05–0.08 mg/kg, 1.19 for 0.09–0.12
mg/kg, and 1.34 for 0.13–0.17 mg/kg. These ESs are
similar to those of other nonstimulant medications.

Faraone and Glatt (2010) recently reported a review
of three clinical trials of the extended- release prepara-
tion, including the study of Biederman et al. (2008).
The authors concluded that longer term treatment is as-
sociated with less sedation. In other words, persevering
with the treatment, if possible, often leads to decreases
in the side effect of somnolence.

Modafinil

Modafinil is a treatment used for narcolepsy. Amiri et
al. (2008) summarized the current knowledge about
this treatment. Its mechanism of action is not fully un-
derstood, but it is thought to activate the hypothalamus
by altering the balance of gamma- aminobutyric acid.

Greenhill et al. (2006a) reported a 9-week placebo-
controlled study of modafinil in 128 children and adoles-
cents ages 7–17 years, who fulfilled criteria for a DSM-
IV diagnosis of ADHD. The dose range for modafinil
was 170–450 mg once per day. There was significant
improvement (p < .0001) with modafinil compared with placebo. Although there was a significantly higher rate of side effects (insomnia, headache, decreased appetite, weight loss) with modafinil, there was no increase in dropout rates compared with placebo.

Amiri et al. (2008) reported an RCT comparing
modafinil (200–300 mg once a day) and methylphenidate
(20–30 mg per day) in 60 children and adolescents ages
6–15 years, who fulfilled DSM-IV diagnostic criteria for
ADHD. The treatment period was 6 weeks. There were
no significant differences in treatment response or drop-
out rates. Methylphenidate was associated with signifi-
cantly more common side effects of decreased appetite
and difficulty falling asleep compared with modafinil
treatment. There was no increase in side effects associ-
ated with modafinil relative to methylphenidate.

Carbamazepine

Silva, Munoz, and Alpert (1996) conducted a meta-
analysis of carbamazepine use in patients with ADHD.
They found reports of seven open studies involving a
total of 189 patients, and three double- blind studies
including a total of 53 patients. Overall, 71% of those

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Attention‑Deficit/Hyperactivity Disorder 221

treated with carbamazepine in the controlled studies
showed significant improvement, compared with 26%
of those treated with placebo. There was an ES of 1.01
for the drug– placebo comparison in the double- blind
studies. The meta- analysis confirmed that carbamaze-
pine was significantly more effective than placebo in
controlling ADHD symptoms. A similar response rate
was found in the open studies.

Monitoring of the leukocyte count is required during
carbamazepine treatment due to the risk of leukopenia.
Liver function should also be tested regularly because
of the risk of liver damage. Other side effects include
rashes, ataxia, and drowsiness.

Antipsychotics

Antipsychotics should be used only if all the other
groups of drugs we discussed earlier have been tried
and the child is extremely disturbed. The child should
be reassessed first to ensure that the diagnosis of
ADHD is correct. Antipsychotics must be used only in
the short term and at low dosage, because of the risk of
side effects. On the whole, the risks are so great that
antipsychotics should probably be avoided in ADHD
treatment, although no good studies have evaluated the
risks and benefits of this class of drug.

Other Medications

Davari- Ashtiani, Shahrbabaki, Razjouyan, Amini,
and Mazhabdar (2010) have reported a 6-week RCT
in Iran with 34 children ages 6–12 years, comparing
methylphenidate and an anxiolytic drug, buspirone.
Both treatments significantly reduced ADHD symp-
toms from the second week of treatment. The outcome
measure was teacher and parent ADHD rating scales.
Side effects were also monitored. The maximum dose
of methylphenidate was 60 mg per day, and that of bus-
pirone, 45 mg per day. Although both drugs had a posi-
tive effect and no significant side effects, methylpheni-
date was significantly more effective than buspirone in
terms of reductions in teacher- rated inattention scores.
Buspirone was reported to have an anxiolytic effect,
but no rating scale was used to assess this. There was
no placebo comparison; therefore, the results need to
be interpreted with caution.

Table 6.4 summarizes information for clinicians
regarding the use of tricyclic and nontricyclic antide-
pressants, clonidine, guanfacine, modafinil, and carba-
mazepine in treatment of ADHD.

Dietary Interventions

Exclusion Diets

It has been suggested that certain food additives may
increase behavioral problems in normal and hyperac-
tive children. A meta- analysis by B. Bateman et al.
(2004) found that elimination diets reduced hyper-
activity symptoms (standardized mean difference of
0.80). Children showed adverse behavioral responses
to a range of substances, but most frequently chocolate,
wheat, and dairy products, and the pattern was individ-
ual to the child. This has been supported by Pelsser et
al. (2011) in an RCT in the Netherlands and Belgium of
one hundred 4- to 8-year-olds placed on a strict elimi-
nation diet. This study is part of the Impact of Nutri-
tion in Children with ADHD study. When challenged
with their usual diet, 19 of 30 children (63%) in the
sample relapsed. This study supports the finding that
some children can benefit from changes to their diet.
However, there is no good evidence for more rigorous
exclusion diets. Contrary to popular belief, there is no
evidence for the benefit of large doses of vitamins or
herbal remedies.

Polyunsaturated Fatty Acids

Omega-3 and omega-6 fatty acids are “essential” fats
that the body cannot make. The concentrations of these
fatty acids are higher in the brain than in other parts of
the human body. Benton (2007) reviewed the studies
of supplementation with polyunsaturated fatty acids in
ADHD and found no evidence that they are beneficial.
In another review, B. M. Ross, Seguin, and Sieswerda
(2007) reached the same conclusion. However, a recent
RCT of 92 children ages 7–12 years reported a signifi-
cant improvement in oppositionality and concentration
after 15 weeks of omega-3 and omega-6 supplementa-
tion among children who showed less hyperactivity and
impulsiveness at baseline (Gustafsson et al., 2010). The
intervention was not effective for those with more se-
vere hyperactivity and impulsiveness, so that when the
group of children was considered as a whole, the inter-
vention was ineffective. On the basis of these findings,
some children may benefit, but those with the most se-
vere ADHD symptoms do not appear to do so. Larger
studies are required. Transler, Eilander, Mitchell, and
van de Meer (2010) have reviewed the findings from
studies to date and recommend further research, be-
cause it is unclear whether fatty acid supplementation
is beneficial.

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222

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223

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224 W h at Wo r k s f o r W h o m ?

Iron Supplementation

Konofal et al. (2008) reported a small pilot study of 23
children ages 5–8 years, who met criteria for a DSM-IV
diagnosis of ADHD and had serum ferritin (a measure
of iron stores) levels below 30 ng/ml. None of the chil-
dren was clinically anemic. The children were random-
ized to receive iron supplementation or placebo. There
was a significant improvement in children treated with
ferrous sulphate at a dose of 80 mg/day. This study sug-
gests that ferritin levels should be measured in children
with ADHD. It is unclear whether the low serum fer-
ritin levels were significantly associated with a history
of poor diet.

Pycnogenol

Pycnogenol is a polyphenolic standardized extract of
French maritime pine bark with antioxidant properties.
Several case reports have suggested it is of benefit in
ADHD. A group in Slovakia (Chovanova et al., 2006;
Dvorakova et al., 2007) used pycnogenol supplemen-
tation to reduce the damage to DNA that they found
in children with ADHD, compared with controls. The
authors explain that damage to DNA and other cellu-
lar substances results from the production of oxygen-
derived free radicals inside the cells, and presume
that in ADHD, the cells are under particular stress
from this process. The study was a placebo- controlled
trial involving 61 children and adolescents ages 6–14
years. The authors did not report how the diagnosis of
ADHD was made. They found a significant reduction
in ADHD symptoms during the treatment (a period of
1 month), but relapse occurred 1 month after the treat-
ment was stopped. Further research in this area may be
worthwhile.

Homeopathy

A Cochrane review (Coulter & Dean, 2007) reported
that there is currently little evidence for the efficacy of
homeopathy in the treatment of ADHD.

Neurofeedback

Leins et al. (2007) reported a comparison study of a
small (N = 38) number of children and adolescents ages
8–13 years, fulfilling criteria for a DSM-IV diagnosis
of ADHD, who were randomized to two experimental
groups that received two different neurofeedback train-

ing protocols (theta–beta frequencies and slow cortical
potentials). The participants were blind to intervention
type, but those providing the treatment were not. The
aim was to assess for improvements in behavior and
cognition. Both protocols led to improvements, which
were sustained at 6-month follow- up. An earlier small
study (Levesque, Beauregard, & Mensour, 2006) of 20
children, with a small control group of 5 children, also
suggested that neurofeedback was beneficial, as did a
study of 34 children ages 8–12 years (Fuchs, Birbau-
mer, Lutzenberger, Gruzelier, & Kaiser, 2003). These
studies need repeating with a larger sample size and
a placebo group. In a review of neurofeedback stud-
ies, Vernon, Frick, and Gruzelier (2004) emphasized
the need for a standardized package of neurofeedback
training if this potential treatment is to be effectively
and consistently researched and implemented.

Melatonin for Sleep Problems

Van der Heijden, Smits, Van Someren, Ridderinkhof,
and Gunning (2007) reported the first RCT of mela-
tonin versus placebo treatment in 105 six- to 12-year-
olds who fulfilled criteria for a DSM-IV diagnosis of
ADHD and also had chronic sleep-onset insomnia.
This was a well- designed study with several outcome
measures. The doses of melatonin used were 3 mg for
children weighing less than 40 kg and 6 mg for those
weighing more than 40 kg. Actigraphy was used to
measure sleep. Sleep logs were used to verify the ac-
tigraphy recordings; these recorded sleep onset, sleep
latency (time from lights out to sleep onset), wake up
time, total time asleep, sleep efficiency, and moving
time (the percentage of time spent moving during the
presumed sleep period). The results confirmed the ben-
efits of melatonin, with a significant improvement in
time of sleep onset compared with placebo treatment.
There was also a significant increase in the mean total
time asleep with melatonin, and significant decreases
in sleep latency and sleep restlessness.

An additional measure used by the authors, dim
light melatonin onset (DLMO), the time at which the
endogenous melatonin level starts to rise, is a mea-
sure of the biological clock rhythm. Samples of saliva
were obtained hourly by having the subjects chew on
a cotton bud. Only dim light was permitted during the
measurement. Children treated with melatonin showed
a significant advance in DLMO compared with con-
trols, and there was a linear relationship between the
pre- and posttreatment levels, such that more delayed

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Attention‑Deficit/Hyperactivity Disorder 225

DLMO levels at baseline were associated with greater
improvements in sleep onset after melatonin treatment.
There was no significant difference in adverse reactions
between the placebo and melatonin treatments. None of
the children needed treatment for the side effects, and
none withdrew from the trial.

Psychosocial treatments

We recommend a useful review and summary of the
literature by Barkley (2002), which suggests a program
for psychosocial treatments and urges that these should
be “maintained over extended periods of time.” Such
an approach would require the commitment and col-
laboration of everyone involved in the child’s care. The
article describes components of behavioral parenting
approaches and training of teachers in classroom man-
agement. Several other authors have also reviewed the
benefits of these interventions, and their findings are
summarized below.

Behavioral Therapies

An individual behavioral therapy approach was a
component of the multimodal treatment provided in
the MTA study described earlier in this chapter. The
behavioral approach consisted of a summer treatment
program developed by Pelham and Hoza (1996). In the
MTA study, the therapist who supervised the individual
behavioral therapy with the child also provided par-
ent training and school- based consultation. Although
the impact of each of these individual aspects of the
treatment cannot be separated out, the children who
received the combined behavioral approach required
less medication than those who did not receive it. Very
few authors have reported good- quality studies of an
individual behavioral approach in treatment of ADHD.

Pfiffner et al. (2007) reported posttreatment findings
and 3- to 5-month follow- up of a controlled study of the
response of the inattentive subtype of ADHD to a be-
havioral program. Sixty-nine children ages 7–11 years
were involved. The program, referred to as the Child
Life and Attention Skills Program (CLAS), was com-
pared to a wait-list control or a treatment- as-usual con-
trol. The CLAS program consisted of parent training
(eight to 10 sessions) and child skills treatment (eight
to 10 sessions and added family sessions), which were
manualized. There was a significant reduction (50%)
in inattentive behaviors for the treated group versus
the controls (p = .0004). Parent- and teacher- rated im-

provements in social functioning and organizational
skills were significant. The authors reported high lev-
els of parent, teacher, and child satisfaction with the
program. However, this was a small sample, and most
of the ratings were undertaken by parents and teachers
who were not blind to the treatment group in which the
child was placed, so it is possible there was some bias.
Despite these shortfalls, this intervention seems prom-
ising, although it targets inattentive children, who are
often not highly represented in the clinic population.
As in this study, they would be best referred by schools.

Progress in this area has been summarized in a re-
view by the American Academy of Child and Adoles-
cent Psychiatry (AACAP; Pliszka & AACAP Work
Group on Quality Issues, 2007). Although behavioral
approaches are less effective than medication in reduc-
ing the primary symptoms of ADHD, they have been
shown to improve the targeted behaviors to a degree, in
addition to improving social skills and academic per-
formance.

As summarized in the AACAP review (Pliszka &
AACAP Work Group on Quality Issues, 2007), the
main shortcomings of behavioral management in
ADHD are that improvements in behavior tend not to
be sustained over time and they generalize poorly to
situations other than those in which the training oc-
curred. Booster sessions, and training in the setting
where the behavioral improvement is required, should
help to remedy these problems.

In summary, behavior therapy alone is less effective
than stimulant medication. Combining behavior ther-
apy with a low dose of stimulants, however, may lead
to sufficient behavioral improvement, so that a higher
dose of medication is not required. Behavioral therapy
is most likely to lead to improvements in on-task be-
havior and a reduction in disruptive and rule- breaking
behavior. Improvements in academic performance usu-
ally require medication. It is likely that an individual
behavioral approach needs to be combined with parent
training and school consultation; this is the first-line in-
tervention for mild and moderate ADHD recommend-
ed by the NICE (2008) guidelines for the treatment of
ADHD.

Cognitive‑Behavioral Therapy

Cognitive- behavioral therapy (CBT) combines the
techniques of behavioral management with training in
problem solving and self- monitoring. Several studies
have failed to confirm benefits from CBT. R. T. Brown,

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226 W h at Wo r k s f o r W h o m ?

Wynne, and Medenis (1985) reported a study in which
30 boys between 6 and 12 years of age, with a diagno-
sis of ADD-H, were randomly assigned to one of three
treatment groups: methylphenidate therapy, cognitive
training, or both interventions combined. There was a
no- treatment control group of 10 children on the wait
list (nonrandomly assigned). The treatment lasted 12
weeks and was provided as two 1-hour sessions a week
(24 sessions in total). The methylphenidate group im-
proved significantly compared with the cognitive train-
ing and no- treatment groups. There was no significant
improvement on academic measures, with the excep-
tion of the Durrell Subtest of Listening Comprehen-
sion. The combination of methylphenidate and CBT
had no significant advantage over methylphenidate
treatment alone. CBT alone produced some improve-
ment in attention, but the benefits were not as large as
with methylphenidate.

As with behavioral therapy, there is a problem with
teaching children to generalize any problem- solving
strategies they master to different settings and in get-
ting them to use them spontaneously. The view of ex-
perts in the field (Abikoff, 1991; Pliszka & AACAP
Work Group on Quality Issues, 2007) is that CBT is
only occasionally beneficial for children with ADHD,
and even then is less efficacious than medication.

In summary, CBT appears to be less effective
than medication in treating the primary symptoms of
ADHD; however, the majority of studies in the field
so far have been limited in design. CBT has no advan-
tages over behavioral therapy in relation to academic
performance, and medication appears to be preferable
to these psychological approaches. CBT may improve
self- control, although most studies to date have failed
to confirm this.

Parent Training

A course of parent training normally comprises six to 12
sessions and is best carried out when the child is prepu-
bertal. Children with more severe behavioral problems
will require treatment with medication first. Booster
training sessions are usually necessary. Sonuga-Barke,
Daley, Thompson, Laver- Bradbury, and Weeks (2001)
reported an RCT of parent training in 78 preschool
children. The parent training comprised a structured,
manualized, 8-week program of weekly home visits by
a specially trained health visitor therapist who provid-
ed one-to-one advice about reducing defiant behaviors
and increasing attention and organizational skills. The

preschool- age children were assessed to have ADHD
behaviors. Parent training was compared with a wait-
list control group and a parent counseling and support
group. The authors reported that ADHD behaviors
were significantly reduced, and mothers’ sense of well-
being was increased in the parent training group rela-
tive to the other two groups. The beneficial effects of
the intervention were maintained 15 weeks posttreat-
ment. Importantly, this study showed that primary care
staff can be trained to provide the intervention.

K. Jones, Daley, Hutchings, Bywater, and Eames
(2007) reported on use of the Incredible Years parent
training program (see also Chapter 4) for preschool
children showing signs of developing ADHD. Use of
the program led to a significant improvement in paren-
tal reports of problem behaviors (52%), compared to
wait-list controls (21%). These results are similar to
those of Sonuga-Barke et al. (2001), who reported that
53% of participants showed significant improvement,
and Bor et al. (2002), who reported 80% improvement.

Webster- Stratton, Reid, and Beauchaine (2011) have
reported similar results from an RCT of a combined
parenting and child program intervention based on the
Incredible Years program. The study included 99 chil-
dren diagnosed with ADHD (hyperactive or combined
subtypes) ages 4–6 years. The intervention comprised a
20-week program of weekly, 2-hour sessions for parents
with a separate “Dinosaur School” children’s program
running in parallel. Mothers and independent observ-
ers reported significant improvements in the children’s
behavior; mothers, but not fathers, reported improved
parenting behaviors. The authors did not seek teachers’
reports. Another weakness is that because the control
group was a wait-list control, there may have been some
bias in the mothers’ reports, although the independent
observers’ reports agreed with the mothers’ reports.
Overall, this hopeful finding confirms the benefits of
a group-based parenting intervention with a program
encouraging children with their social development.
Longer-term follow- up is required in future studies to
confirm whether the benefits persist.

van den Hoofdakker et al. (2007) have reported a
useful study of how behavioral parent training (BPT)
can be incorporated into routine clinical care (RCC).
In this study from the Netherlands, 94 children be-
tween ages 4 and 12 years, who met diagnostic criteria
for DSM-IV ADHD, were randomly assigned to RCC
alone or RCC with additional BPT. RCC in both groups
may have included medication. Follow-up was conduct-
ed 25 weeks after the cessation of the BPT program.

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Attention‑Deficit/Hyperactivity Disorder 227

The BPT was a manualized program that comprised
twelve 2-hour sessions of group parent training ad-
ministered by two psychologists. There was no differ-
ence between the two groups with respect to outcome
of ADHD symptoms. However, at follow- up, there was
a significant difference in favor of BPT plus RCC for
individually targeted externalizing behavior problems
in the children. The combined treatment also led to a
greater reduction in internalizing symptoms.

There was no significant difference between the
treatment groups in the dose of stimulant medication
required, but children in the RCC-only group were sig-
nificantly more likely to be prescribed an additional
treatment (clonidine, risperidone, or citalopram in this
study). Interestingly, families in the RCC-only group
had significantly more contact with clinical staff. There
was no benefit from BPT in relation to parental stress;
this finding is similar to that reported from the MTA
study (discussed earlier in this chapter). The authors
suggest that parental stress levels may already have de-
creased significantly with the initial RCC. They recom-
mend further studies to clarify which families require
the BPT intervention.

Corcoran and Dattalo (2006) reported a meta-
analysis of studies involving parents in treatments for
ADHD. They found that only 16 studies met the re-
quired inclusion criteria. In these studies, involving
parents had significant benefit only for academic per-
formance (ES = 0.8204), the child’s family functioning
(0.67), and internalizing problems (0.635). Teacher-
reported ESs were the largest (0.75) and child- reported
ESs were the smallest (0.11). The ES for ADHD symp-
toms was 0.397; that for externalizing problems was
0.361. Social competence showed the lowest ES of
0.071.

In the United Kingdom, NICE (2008) has similarly
reviewed the literature and concluded that parent train-
ing based on accepted programs for the treatment of
conduct disorder (see Chapter 4) is beneficial. They
suggest that, apart from some additional psychoeduca-
tion around the diagnosis of ADHD, not much needs to
be changed in these manualized and well- researched
programs. The NICE Guidance Group also recom-
mends that parent training, with a group treatment
approach, and possibly individual behavioral therapy,
should be the first treatment of choice in mild to moder-
ate ADHD.

Adding parent training in the home setting to medi-
cation treatment has also been shown to be beneficial
(Tutty, Gephart, & Wurzbacher, 2003). In this RCT

there was an improvement in ADHD symptoms and the
use of parenting discipline strategies. However, there
was no improvement in teacher ratings or in the child’s
ability to pay attention in the treatment group com-
pared with the controls.

Social Skills Training

Children with ADHD unquestionably show social defi-
cits that are nearly always impairing, but the basis of
these difficulties is not yet fully understood. Attempts
have been made to correct them by social skills train-
ing (reviewed by Cousins & Weiss, 1993), which com-
bines many of the behavioral and cognitive- behavioral
approaches discussed earlier. Unfortunately, several
studies have shown that despite improvements in be-
havior observed by parents, teachers, and research-
ers, they often are not perceived by peers; this has led
several authors to suggest the involvement of peers in
social skills treatment programs. This is an important
area for further research, because impaired social skills
appear to be the most disabling and persistent deficit in
children with ADHD (Hechtman, Weiss, Perlman, &
Amsel, 1984).

Interventions with Teachers

Miranda, Presentacion, and Soriano (2002) reported
an RCT of an approach whereby teachers in Spanish
schools were trained to help pupils with self- evaluation
techniques and with implementing a token economy.
The study involved 50 children ages 8–9 years, fulfill-
ing criteria for a DSM-IV diagnosis of ADHD. There
was a reduction of hyperactive and impulsive behaviors
and a significant improvement in self- control. However,
most of the children still required other interventions,
such as medication.

Multimodal Interventions

There has been increasing interest in multimodal thera-
pies for ADHD, because treatments of any kind rarely
produce a complete “cure” with generalization of be-
havioral improvements to all settings (Pelham & Mur-
phy, 1986). There have been few well- designed stud-
ies in this area, and the conclusions have been mixed.
Majewicz- Hefley and Carlson (2007) provided a very
helpful review of combined psychosocial and pharma-
cological treatments. This rigorous meta- analysis re-
quired qualifying studies to have adequate quantitative

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228 W h at Wo r k s f o r W h o m ?

data to enable calculation of ESs. It described outcomes
in terms of the following five criteria: inattention, hy-
peractivity, impulsivity, social skills, and academ-
ics. Out of a possible 26 articles describing combined
treatments, eight studies adequately met the inclusion
criteria. The meta- analysis of psychological and phar-
macological interventions confirmed that combined
treatments had large ESs on the core features of ADHD
(1.27 for inattention and hyperactivity, and 0.91 for im-
pulsivity), as well as the peripheral feature of social
skills (0.90). It found a small ES for academics (0.19).
All the studies employed behavioral management as
one of the comparison groups; one also included social
skills training.

A major problem is that all of these studies followed
the children for only short periods. One long-term
follow- up study of a large sample of boys, which, un-
fortunately, lacked a control (Satterfield, Satterfield,
& Cantwell, 1981; Satterfield, Satterfield, & Schell,
1987), found that combined treatments were more ef-
ficacious than medication alone when the subjects
were ages 14–21 years. The treatments included par-
ent training, group therapy, psychotherapy, and educa-
tional interventions. Choice of the combination of treat-
ments depended on the needs of the child and family,
very much like the situation in clinical practice. The
sample, which comprised boys ages 6–12 at the start of
the study, was divided into two groups: one receiving
only drug treatment and the other receiving multimodal
therapy. The children who continued with multimodal
therapy for 2–3 years responded best, with significantly
lower levels of delinquency than the medication- only
group. These findings support the use of multimodal
therapy and long-term treatments for this group of chil-
dren. However, in this study, allocation to therapy was
not randomized, and the treatments were not standard-
ized. Although the complexity and variation of cases
means that this is often the reality of case management
in clinical practice, these results must be interpreted
with caution.

Family Therapy

There have been very few outcome studies of family
therapy in this group of children. Bjornstad and Mont-
gomery (2005) reviewed the literature and concluded
that two studies addressed this issue. Both used a
structural behavioral approach. They concluded that a
manualized family therapy approach may be as useful
as usual medical management, but not more effective.

Family therapy per se may not be the most efficacious
treatment for ADHD, but a systemic approach to the
impact of the disorder on family and school functioning
is important (Bernier & Siegel, 1994).

Psychodynamic Therapies

There have been no trials of the use of psychotherapy in
children and adolescents with ADHD, but the relatively
poor insight of these children (Pelham et al., 1993) sug-
gests that it is unlikely to be particularly beneficial.

Consultation between schools and mental
health Professionals

Consultation with schools and teachers by mental
health professionals is crucial. Social workers also
need the opportunity to discuss children with whom
they are involved. There is a need for clinical practice
guidelines regarding the management of children with
ADHD, because the problem is so highly prevalent
and professionals from many different backgrounds
become involved in case management. A clinical ex-
ample, reported by Langberg et al. (2008), concerns
data from the MTA study (discussed in detail earlier
in this chapter). In this study, the severity of symptoms
in the ADHD group declined with increasing age as
a result of developmental changes. However, this de-
cline temporarily slowed over the year that coincided
with the children’s transition to middle school at age
11–12 years. It therefore seems important to advise
children, their caregivers, and teachers that additional
support should be made available in school during the
transition year. It may be possible to reduce some of
this support the following year as the ADHD symptoms
again resume their developmental decline. This is the
first study to describe clear evidence for the disruptive
impact of transition, a problem that caregivers, teach-
ers, and clinicians have been describing for some time.

sUmmArY

The evidence suggests that ADHD is a disorder that ex-
ists along a continuum and has a heterogeneous etiol-
ogy, and its severity relates to the long-term outcome.
Depending on the definition, its prevalence is 1–5% of
school- age children. Genetic factors are now known to
be important, and the fact that families may therefore
have several members with ADHD (including one or

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228 W h at Wo r k s f o r W h o m ?
data to enable calculation of ESs. It described outcomes
in terms of the following five criteria: inattention, hy-
peractivity, impulsivity, social skills, and academ-
ics. Out of a possible 26 articles describing combined
treatments, eight studies adequately met the inclusion
criteria. The meta- analysis of psychological and phar-
macological interventions confirmed that combined
treatments had large ESs on the core features of ADHD
(1.27 for inattention and hyperactivity, and 0.91 for im-
pulsivity), as well as the peripheral feature of social
skills (0.90). It found a small ES for academics (0.19).
All the studies employed behavioral management as
one of the comparison groups; one also included social
skills training.
A major problem is that all of these studies followed
the children for only short periods. One long-term
follow- up study of a large sample of boys, which, un-
fortunately, lacked a control (Satterfield, Satterfield,
& Cantwell, 1981; Satterfield, Satterfield, & Schell,
1987), found that combined treatments were more ef-
ficacious than medication alone when the subjects
were ages 14–21 years. The treatments included par-
ent training, group therapy, psychotherapy, and educa-
tional interventions. Choice of the combination of treat-
ments depended on the needs of the child and family,
very much like the situation in clinical practice. The
sample, which comprised boys ages 6–12 at the start of
the study, was divided into two groups: one receiving
only drug treatment and the other receiving multimodal
therapy. The children who continued with multimodal
therapy for 2–3 years responded best, with significantly
lower levels of delinquency than the medication- only
group. These findings support the use of multimodal
therapy and long-term treatments for this group of chil-
dren. However, in this study, allocation to therapy was
not randomized, and the treatments were not standard-
ized. Although the complexity and variation of cases
means that this is often the reality of case management
in clinical practice, these results must be interpreted
with caution.
Family Therapy
There have been very few outcome studies of family
therapy in this group of children. Bjornstad and Mont-
gomery (2005) reviewed the literature and concluded
that two studies addressed this issue. Both used a
structural behavioral approach. They concluded that a
manualized family therapy approach may be as useful
as usual medical management, but not more effective.
Family therapy per se may not be the most efficacious
treatment for ADHD, but a systemic approach to the
impact of the disorder on family and school functioning
is important (Bernier & Siegel, 1994).
Psychodynamic Therapies
There have been no trials of the use of psychotherapy in
children and adolescents with ADHD, but the relatively
poor insight of these children (Pelham et al., 1993) sug-
gests that it is unlikely to be particularly beneficial.
Consultation between schools and mental
health Professionals
Consultation with schools and teachers by mental
health professionals is crucial. Social workers also
need the opportunity to discuss children with whom
they are involved. There is a need for clinical practice
guidelines regarding the management of children with
ADHD, because the problem is so highly prevalent
and professionals from many different backgrounds
become involved in case management. A clinical ex-
ample, reported by Langberg et al. (2008), concerns
data from the MTA study (discussed in detail earlier
in this chapter). In this study, the severity of symptoms
in the ADHD group declined with increasing age as
a result of developmental changes. However, this de-
cline temporarily slowed over the year that coincided
with the children’s transition to middle school at age
11–12 years. It therefore seems important to advise
children, their caregivers, and teachers that additional
support should be made available in school during the
transition year. It may be possible to reduce some of
this support the following year as the ADHD symptoms
again resume their developmental decline. This is the
first study to describe clear evidence for the disruptive
impact of transition, a problem that caregivers, teach-
ers, and clinicians have been describing for some time.
sUmmArY
The evidence suggests that ADHD is a disorder that ex-
ists along a continuum and has a heterogeneous etiol-
ogy, and its severity relates to the long-term outcome.
Depending on the definition, its prevalence is 1–5% of
school- age children. Genetic factors are now known to
be important, and the fact that families may therefore
have several members with ADHD (including one or

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A Critical Review of Treatments for Children and Adolescents
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Attention‑Deficit/Hyperactivity Disorder 229

both parents) may have an impact on their response
to interventions and engagement with services. The
disorder is often persistent throughout childhood and
adolescence, and may require continuing treatment in
adulthood. The literature shows that there are often
high rates of diagnoses of comorbid conduct disorder,
attachment disorder, mood disorder, and specific learn-
ing disabilities. Early diagnosis and treatment of ADDs
improves the prognosis. ADDs are particularly persis-
tent in the presence of a family history, psychosocial
adversity, and comorbidity.

Physical treatments

• There is limited evidence (due to a limited number of
studies and small sample sizes) that favors the use of
stimulant medication to improve the working memo-
ry of children and adolescents with ADHD.

• There is no evidence that prosocial behaviors in-
crease with stimulant or atomoxetine use, although
aggression and oppositionality are significantly re-
duced.

• There is conflicting evidence on the impact of stimu-
lants on academic performance in the absence of
school and behavioral interventions.

• There is no evidence of serious, irreversible side ef-
fects from stimulant treatment. However, two studies
have confirmed a small reduction in actual relative to
predicted height after long-term (more than 2 years)
use at higher doses. One study that explored the use
of drug holidays reported that they protect against
the height reduction. There is conflicting evidence re-
garding the increased risk of depression and suicidal
ideation with stimulants and atomoxetine.

• There is strong evidence for the use of tricyclic anti-
depressants in children and adolescents with ADHD,
with or without anxiety, depression, or aggression,
if stimulants and atomoxetine have been ineffective
or caused side effects. Careful monitoring of cardiac
status is required.

• There is limited evidence (due to the number of stud-
ies) for the use of nontricyclic antidepressants in chil-
dren and adolescents with ADHD.

• There is limited evidence (due to the number of stud-
ies) for the use of clonidine, with or without stimu-
lants, in some children with ADHD who have not
responded to stimulants or atomoxetine alone.

• There is limited evidence (due to the number of stud-
ies) for the use of guanfacine in some children with
ADHD who have not responded to stimulants or ato-

moxetine, if they can tolerate the side effect of som-
nolence, which is common in the first few weeks of
treatment.

• There is limited evidence (due to the number of stud-
ies) for the use of modafinil in some children with
ADHD who have not responded to stimulants or ato-
moxetine.

• There is limited evidence (due to the small sample
sizes of studies) for the use of carbamazepine in
some children with ADHD who have not responded
to stimulants or atomoxetine.

• There is no evidence for the use of buspirone in the
treatment of ADHD in children and adolescents, be-
cause there has been no comparison with placebo
treatment as yet.

• No studies have investigated whether there is im-
proved effectiveness of antipsychotics or tricyclic an-
tidepressants in combination with stimulants.

• There is no evidence as to who will respond well to
medication for ADHD, and no evidence about when
to stop medication.

ADHD and Comorbid Difficulties

• There is strong evidence for the use of stimulants or
atomoxetine in children and adolescents with impair-
ing ADHD (including inattention, hyperactivity, and
impulsivity in the classroom), irrespective of age,
and with any comorbid condition except anxiety and
depression.

• There is strong evidence that treating ADHD with
stimulants and other forms of treatment reduces the
risk of drug misuse in adolescents with ADHD. Evi-
dence suggests that medication should not be with-
held when treating ADHD in substance- misusing
youth.

• There is conflicting evidence (with some studies
showing benefit and others not) for the use of stimu-
lants in children and adolescents with ADHD and
comorbid anxiety. Some studies have shown that pro-
viding a behavioral intervention as well as the stimu-
lant treatment confers additional benefit.

• There is limited evidence (one RCT) supporting the
use of atomoxetine in children and adolescents with
ADHD and comorbid anxiety.

• There is strong evidence for the use of stimulants in
children and adolescents with ADHD and comorbid

aggression, including ODD and conduct disorder.

• There is strong evidence for the use of stimulants in
children and adolescents with ADHD and comorbid

EBSCOhost – printed on 9/16/2020 1:10 AM via LA TROBE UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use

230 W h at Wo r k s f o r W h o m ?

generalized learning disability. However, the more
severe the learning disability, the less effective the
medication will be.

• There is conflicting evidence (one study showing
benefit and another no benefit) for the use of stimu-
lants in children and adolescents to improve the out-
come of specific learning disabilities.

• There is strong evidence for the use of stimulants in
children and adolescents with ADHD and comorbid
epilepsy, as long as the epilepsy is well controlled be-
fore initiating stimulant treatment.

Dietary Interventions

• There is limited evidence (due to a small number of
studies) for the use of an elimination diet in individ-
ual children if they appear sensitive to certain foods,
but there is no evidence to support the blanket exclu-
sion of additives and colorings in children’s diets.

• There is no evidence (due to the lack of RCTs) for the
use of omega-3 and omega-6 fatty acids, iron supple-
mentation, or pycnogenol in the treatment of ADHD
in children and adolescents.

Other Treatments

• There is no evidence (due to the lack of RCTs) for the
use of homeopathy or neurofeedback in the treatment
of ADHD in children and adolescents.

Psychosocial treatments

• There is strong evidence for the use of a behavior-
al parenting approach plus advice to the child and
teaching staff in treating children and adolescents
with mild ADHD.

• There is strong evidence for the use of a multimodal
approach for children and adolescents with impairing
ADHD. This comprises a parent behavioral group
approach, a child behavioral approach, and a school
consultation and behavioral approach, together with
medical treatment with frequent initial monitoring
and titration of medication by a doctor with specialist
knowledge of ADHD.

• There is strong evidence that behavior therapy on its
own is less effective than intensely monitored stimulant
medication, but it can prevent a need for higher doses of
medication. Behavior therapy improves on-task behav-
ior and reduces disruptive behavior, but studies have
reported little generalization across settings.

• There is conflicting evidence from a small number of
studies (some showing benefit, others not) to support
the use of CBT; the behavioral component may be the
effective component.

• When intense medication monitoring is unavailable
and there is the possibility of only infrequent ap-
pointments (standard medical care) in children and
adolescents with impairing ADHD, there is strong
evidence for the use of either the behavioral approach
(including approaches aimed at the parents, the child,
and school consultation, as described above) or stan-
dard medical care.

• There is some evidence (small number of studies)
that social skills interventions produce no significant
benefit in peer relationships.

• There is no evidence (no studies) for the effectiveness
of systemic or psychodynamic therapies.

imPlicAtioNs

service Provision

• The outcome of attention deficit problems, which are
common, is poor if they are untreated. However, ef-
fective treatments exist and can significantly improve
quality of life. Therefore, adequately resourced ser-
vices should be made available across the lifespan.

• Intervention should commence earlier rather than
later in order to reduce the risk of development of co-
morbid problems, including depression and low self-
esteem, as well as learning difficulties and conduct
disorders.

• Multiagency training is required to enable early and
accurate recognition of ADHD and to promote refer-
ral to appropriate services.

• Given that evidence supports a multimodal (and mul-
tiprofessional) approach, clear pathways to assess-
ment and treatment services need to be identified so
that resources can be most efficiently allocated.

• Services should be organized so that adequately
trained staff members can assess and treat patients
and monitor their treatment over long periods, con-
tinuing throughout the school years and into adult-
hood. There should be medical input from a psy-
chiatrist who treats children/adolescents and/or a
pediatrician with specialist training in ADHD.

• There needs to be a protocol for transition from child
to adult services, and provision of adequately trained
staff members who are able to work with adults af-
fected by ADHD.

EBSCOhost – printed on 9/16/2020 1:10 AM via LA TROBE UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use

Attention‑Deficit/Hyperactivity Disorder 231

Clinical

• Assessment should look beyond the core symptoms
of ADHD to include associated psychiatric comor-
bidities, as well as physical and educational function-
ing and social contexts. It is important to exclude
other reasons for problem behavior.

• If a child or adolescent is only mildly impaired by
ADHD, the recommended treatment is a behavioral
parenting approach and advice to the child and the
teaching staff.

• If diagnostic criteria are met, and the behavior prob-
lems are pervasive and severe in at least two different
types of setting, then a trial of medication is indicat-
ed as the first line of intervention, but with the addi-
tional behavioral (parent and individual) and school
interventions put in place as soon as possible.

• As assessment under the age of 6 years is likely to
be less reliable, medication normally should not be
used routinely as the first-line treatment in this age
group. However, evidence does support the effective-
ness of stimulant medication for the core symptoms
of ADHD in 4- to 5-year-olds.

• Medication should still be given when there are co-
morbid problems such as conduct disorders, autistic
spectrum disorders, learning disabilities, Tourette
syndrome, anxiety, depression, substance use dis-
order (in such cases, modified- release stimulants or
atomoxetine should be used), and epilepsy (when
stable). Interventions for the comorbid conditions
need to be available within the same service, or there
needs to be good communication between services
treating the comorbid conditions.

• As it is not possible to predict which dose will be ef-
fective, dosage should be increased within safe limits
until an effect is achieved. Effective monitoring of
dose titration is needed to minimize adverse effects
of drug treatment. In the MTA study, this involved
monthly monitoring appointments.

• There should be annual trials of drug holidays to see
whether stimulant medication is still required.

• In the case of high-dose stimulant medication, regu-
lar drug holidays are recommended to prevent growth
retardation.

• Stimulants may impact on a range of symptoms.

There is no evidence that the trial of other drugs dur-
ing initiation of stimulant treatment is particularly
helpful. If there is no, or only partial, resolution of
symptoms with stimulants, other medication should
be considered, such as discontinuing the stimulants
and replacing them with atomoxetine, tricyclic anti-
depressants, clonidine, or SSRI antidepressants. Evi-
dence is lacking in either direction for augmentation
of stimulant medication rather than replacement.

• If stimulants aggravate emotional problems (anxiety
or depression), then tricyclic antidepressants should
be considered instead.

• If there are marked adverse reactions to specific
foods, then evidence suggests considering a trial of
exclusion of that particular food or food type. If spe-
cific reactions have not been noticed, then evidence
suggests that the effort and restrictions involved in
imposing a selective exclusion diet are not warranted.

• There is evidence that additional educational input is
required to help children with delayed attainments to
catch up, but there is no evidence for specific educa-
tional approaches.

research

• Given the significant proportion of children whose
ADHD does not respond to methylphenidate, fur-
ther studies exploring pharmacological augmentation
strategies should be undertaken.

• While it is known that methylphenidate and other
medications are effective, it is less clear for how long
treatment should continue. Systematic outcome stud-
ies of longer term medication and its withdrawal are
required.

• Given the evidence for better prognosis following
early diagnosis and treatment, studies should focus
on evaluating early recognition protocols and early
interventions.

• Research is needed to examine effective educational
interventions that address the educational difficulties
experienced by many children with ADHD.

• Given the impact of the core symptoms of ADHD
on families, further research into systemic family
therapy interventions is required.

EBSCOhost – printed on 9/16/2020 1:10 AM via LA TROBE UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use

PeterFonagyDavi_2015_6AttentionDeficitHype_WhatWorksForWhomSecon
PeterFonagyDavi_2015_Summary_WhatWorksForWhomSecon

College of Science, Health and Engineering

School of Psychology and Public Health

PSY3PIN Psychological Interventions
Critical Essay Topics 2020

Dr. Kirstie McKenzie-McHarg – Post-Traumatic Stress Disorder following Childbirth.
You have a new job as a psychologist working in the maternity department of your local
hospital. You have a meeting with the head of midwifery and one of the senior obstetricians.
They tell you that they are concerned about the number of women who are going on to
develop post-traumatic stress disorder following childbirth. They would like you to do a
review considering how they can reduce the number of women who develop the disorder,
with a specific focus on prevention of perinatal/maternal PTSD.

Starting reading (which you can choose to include/not include in your report):

• Hollander, M. H., van Hastenberg, E., van Dillen, J., van Pampus, M. G., de Miranda, E.,
& Stramrood, C. A. I. (2017). Preventing traumatic childbirth experiences: 2192
women’s perceptions and views. Archives of Women’s Mental Health 20(4), 515-
523. doi: 10.1007/s00737-017-0729-6

Tips:

• Wherever possible, utilise the best quality research. This means that if meta-analyses

and systematic reviews exist on the topic, these would be the first to consider in order

to answer this question, supplemented by more recent or particularly high-quality and

relevant randomised controlled trials. If you can’t find these type of studies, focus on

larger sample sizes and work down from cohort studies to case studies, always noting

in your discussion if studies are of lesser quality/size

• Remember that this question is focused on prevention of perinatal PTSD, not

treatment

• Keep your focus on perinatal or maternal PTSD, not PTSD more broadly, although it is

acceptable to use more general research on PTSD to ‘set the scene’ if necessary

Professor Jordana Bayer – Child Attention Deficit Hyperactivity Disorder
You are required to review and critique literature on psychological interventions to treat child
attention deficit hyperactivity disorder. It will be important to explain what makes treatment
studies ‘well-designed’. It is essential to reach a conclusion about the most appropriate
treatment to recommend for a 10-year-old boy who is inattentive, overactive and aggressive,
at school and at home.

Starting Readings:

• Nolan, M. & Carr, A. (2000). Attention deficit hyperactivity disorder. In A. Carr (Ed.),
What Works for Children and Adolescents? A critical review of psychological
interventions with children, adolescents and their families (pp. 65-101). London:
Routledge.

https://link.springer.com/article/10.1007/s00737-017-0729-6

Page 2/2

• Fonagy, P., Cottrell, D., Phillips, J., Bevington, D., Glaser, D., & Allison, E. (2015). What
Works for Whom? A critical review of treatments for children and adolescents (2nd ed.,
pp. 199-231). New York: Guilford Press.

• Readings available via the PSY3PIN library reading list

Professor Eleanor Wertheim – Mindfulness-Based Stress Reduction
You are assisting at an Outpatient Clinic. A female, adult client has come to the Clinic. During
the assessment process she has been diagnosed with a depressive disorder. She mentions
that she has heard that mindfulness-based interventions may be a way to improve her
symptoms. You decide to review the evidence for Mindfulness-based Stress Reduction and
Mindfulness-based Cognitive Therapy to decide whether you would like to go ahead with such
an approach. Use the research evidence to guide your discussion of what you would
recommend and why. Remember in answering the question to read the literature to
understand which therapeutic approach is likely to be most effective for a particular type of
client with a particular type of problem.

Starting reading (for your information, but you do not need to include this in your essay):

• Baer, R. (2003). Mindfulness training as a clinical intervention: A conceptual and

empirical review. Clinical Psychology-Science and Practice, 10(2), 125-143.

doi:10.1093/clipsy.bpg015

Tips:

• If meta-analyses and systematic reviews exist on the topic, these would be your first

types of papers to look at to answer this question, potentially supplemented by more

recent or particularly high-quality and relevant randomised controlled trials.

• In your analysis of these articles, look at effect sizes to see how large they are. Note

that different types of effect sizes mean different things. Think about if the effect size

is just looking at pre-post differences in scores, or if it is comparing pre-post changes

between two conditions (such as between the MBSR intervention and a wait list

control group, or another type of intervention). These will mean different things. An

important question is not only whether a particular treatment works, but if it is better

than other options.

• Look at moderators of effects. In other words, see if effect sizes differ depending on

characteristics of the client, the type of disorder or the type of outcome of the

intervention. This can help you decide what type of client to use a particular

treatment with and what sorts of outcomes you can expect to achieve.

https://rl.talis.com/3/latrobe/lists/FFF1C191-08E7-42E8-2C9C-C1A4B3982497.html

https://doi-org.ez.library.latrobe.edu.au/10.1093/clipsy.bpg015

PSY3PIN 2020 Critical Essay Marking Rubric (40%)
Due Date: 9am Friday 9th October 2020 (Week 11) via turn-it-in

CRITERIA

A
Excellent (>80 %)

B
Very good (70–79%)

C
Good (60 – 69%)

D
Fair (50 – 59%)

N
Poor (<50%)

1. Clear introduction
stating the
background to the
problem, the
question, and how it
will be addressed in
the essay.

A strong introduction that
clearly covers the
importance of the topic,
background, direction of
essay & main arguments.
All key terms are defined.

Introduction covers the
importance of the topic,
background, direction of
essay & main arguments.
Key terms are defined.

Introduction attempts
to cover the
importance of the
topic. Background,
direction of essay &/or
main arguments are
addressed. Most key
terms are defined.

Introduction does not
adequately cover the
importance of the
topic. Several key
requirements (e.g.,
background, direction
of essay &/or main
arguments, key terms)
are missing.

Little to no attempt
to introduce the
importance of the
topic, including
background,
direction of essay
&/or main
arguments, key
terms.

2. Use of wide range
of relevant research
and reviews of
research, and
integration and
synthesis of research
findings (rather than
describing each
study in detail unless
that approach is
specifically
warranted).

Arguments are very well
supported with ample
evidence from credible,
current and peer reviewed
sources. Evidence is
cohesively integrated with
effective paraphrasing &
summarising.

Arguments are usually
supported with sufficient
evidence from credible,
current and peer
reviewed sources.
Evidence is
paraphrased/summarise
d effectively & usually
well-integrated.

Arguments are usually
supported with
evidence, but some
sources may be
inappropriate &/or of
poor quality.
Paraphrasing/summari
sing is mostly effective
but not always well-
integrated.

Arguments not
always supported by
evidence. Sources
are often not
appropriate &/ or of
poor quality. There
is an over-reliance on
the original wording
in paraphrasing or
summarising, &/or
evidence is poorly
integrated.

Little to no attempt
to support
arguments with
evidence from the
research literature.
Little to no attempt
to
paraphrase/summa
rise & integrate
evidence.

3. Critical evaluation
(strengths and
weaknesses) of the
available research
relevant to the essay

Strong critical evaluation
with topic & literature.
Demonstration of a
comprehensive
understanding of the key
arguments/ perspectives
(e.g., strengths and
weaknesses) of the
selected topic.

Demonstration of critical
evaluation of topic &
literature. Demonstration
of a good understanding
of the key arguments/
perspectives (e.g.,
strengths and
weaknesses) of the
selected topic.

Makes some attempt to
critically evaluate the
topic &/or literature.
Essay covers some of
the key
arguments/perspective
s (e.g., strengths and
weaknesses) of the
selected topic.

Attempts to critically
evaluate the topic
&/or literature are not
always supported.
Essay covers the
selected topic, but key
arguments/perspectiv
es (e.g., strengths and
weaknesses) are
missing.

Little to no attempt
to critically evaluate
the topic or
literature. Key
arguments/perspecti
ve that should be
considered in
exploring the
selected topic are
missing &/or the
selected topic is not
addressed.

4. Conclusion that is
justifiable on the
basis of research
findings

A strong conclusion that
clearly addresses the essay
question and is supported
and consistent with the
information presented in
the essay. Conclusion
shows a strong
understanding and
application of the evidence
covered in the essay and
applies this evidence to a
broader perspective.

Conclusion addresses the
essay question and is
overall supported and
consistent with the
information presented in
the essay. Conclusion
shows a good
understanding and
application of the
evidence covered in the
essay &/or applies this
evidence to a broader
perspective.

Conclusion attempts to
address the essay
question in line with
the information
presented, but is
missing some elements.
Conclusion shows some
understanding about
the broader application
of the evidence covered
in the essay.

Conclusion is not well
supported &/or does
not adequately
address the essay
question in line with
information
presented.
Conclusion shows
limited understanding
about the broader
application of the
evidence covered in
the essay.

Conclusion shows
little to no attempt
to address the essay
question in line with
the information
presented.

5. Strong and
coherent structure
for the essay

Information is well
organised, with a clear and
logical structure of ideas
within and between
paragraphs

Information is well
organised overall, with a
few problems in the
structure of ideas within
and between paragraphs

Information is generally
organised coherently;
some paragraphs may
be too short/long or
contain too many ideas
or the relevance of
some ideas may be
unclear.

Information is poorly
organised; paragraphs
are too short/long
&/or contain too
many ideas or the
relevance of some
ideas is unclear.

Problems with essay
structure and
organisation make
the argument
difficult to follow.

6. English expression
and grammar,
presentation, proof-
reading and use of
APA style

Expression is clear &
precise. Appropriate
academic language used.
No errors in vocabulary,
grammar, spelling, or
punctuation. Accurate
APA-6 (or 7) formatting
and referencing.

Expression is clear.
Appropriate academic
language used. Minor
errors in vocabulary,
grammar, spelling, or
punctuation. Few errors
in APA-6 (or 7)
formatting and
referencing.

Occasional problems
with expression clarity.
(e.g., idiomatic
language). Several
errors in vocabulary,
grammar, spelling, or
punctuation. Several
Errors in APA-6 (or 7)
formatting and
referencing.

Problems with
expression clarity
(e.g., idiomatic
language) and errors
in grammar,
vocabulary, spelling
or punctuation
sometimes interfere
with understanding.
Frequent errors in
APA-6 (or 7)
formatting and
referencing.

Problems with
expression clarity
(e.g., idiomatic
language) and
errors in grammar,
vocabulary, spelling
or punctuation
frequently interfere
with understanding.
Limited use of APA-6
(or 7) formatting and
referencing.

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