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Chil­dren with the inat­ten­tive type of ADHD (ADHD‑I) show high rates of atten­tion dif­fi­cul­ties with­out the hyper­ac­tive and impul­sive behav­ior shown by chil­dren with ADHD Com­bined Type (ADHD‑C). The inat­ten­tive type of ADHD is quite com­mon and is asso­ci­at­ed with sig­nif­i­cant impair­ment with school work, plan­ning and orga­ni­za­tion­al skills, pro­cess­ing speed, and peer rela­tions. Even so, chil­dren with ADHD‑I tend to be iden­ti­fied lat­er than those with ADHD‑C, per­haps because they do not typ­i­cal­ly dis­play the dis­rup­tive behav­ior prob­lems that com­mand par­ents’ atten­tion ear­ly on. They are also less dis­rup­tive in the class­room and teach­ers may be less aware that they are strug­gling aca­d­e­m­i­cal­ly.

Most treat­ment research on ADHD has been focused on chil­dren with ADHD‑C. For exam­ple, the MTA Study — the largest ADHD treat­ment study ever con­duct­ed — includ­ed only chil­dren with ADHD‑C. The role of med­ica­tion treat­ment for ADHD‑I is less well doc­u­ment­ed than for ADHD‑C. Med­ica­tion ben­e­fits may be less obvi­ous in chil­dren with ADHD‑I because they exhib­it less dis­rup­tive and impul­sive behav­ior. Par­ents may be less will­ing to med­icate their chil­dren with ADHD‑I because their behav­ior prob­lems are less overt. And, med­ica­tion alone may be less effec­tive for the aca­d­e­m­ic strug­gles that are espe­cial­ly impor­tant in chil­dren with ADHD‑I.

Behav­ioral treat­ments for ADHD have also been devel­oped pri­mar­i­ly to meet the needs of chil­dren with ADHD‑C, as many behav­ioral inter­ven­tions focus on reduc­ing dis­rup­tive and impul­sive behav­ior and typ­i­cal­ly devote less atten­tion to pro­mot­ing alert­ness, orga­ni­za­tion and plan­ning skills. Because tra­di­tion­al behav­ioral treat­ments are not tai­lored to the spe­cif­ic needs of chil­dren with ADHD‑I they may be less effec­tive for these chil­dren.

The lack of inter­ven­tions specif­i­cal­ly matched to the impair­ments expe­ri­enced by most chil­dren with ADHD‑I was addressed in a study pub­lished recent­ly in the Jour­nal of Con­sult­ing and Clin­i­cal Psy­chol­o­gy [Pfiffn­er et al., (2014). A two-site ran­dom­ized clin­i­cal tri­al of inte­grat­ed psy­choso­cial treat­ment for ADHD-Inat­ten­tive Type.

Par­tic­i­pants were 199 7–11 year-old chil­dren (58% boys) diag­nosed with ADHD‑I. These chil­dren were recruit­ed from via mail­ings to prin­ci­ples, school men­tal health providers, pedi­a­tri­cians, and child men­tal health pro­fes­sion­als. Fol­low­ing an ini­tial phone screen­ing for ADHD‑I con­duct­ed with par­ents and teach­ers, struc­tured inter­views were con­duct­ed in per­son to con­firm that all par­tic­i­pants met full DSM-IV cri­te­ria for ADHD‑I.

These par­tic­i­pants were ran­dom­ly assigned to 1 of 3 treat­ment con­di­tions: Child Life and Atten­tion Skills (CLAS), a new­ly devel­oped treat­ment designed specif­i­cal­ly for chil­dren with ADHD‑I; Par­ent-focus treat­ment (PFT), a behav­ioral par­ent train­ing pro­gram, and Treat­ment as Usu­al (TAU), in which par­ents pur­sued what­ev­er treat­ment they chose to. These treat­ments are described below.

Child Life and Attention Skills (CLAS)

The CLAS inter­ven­tion includ­ed par­ent, teacher, and child com­po­nents.

Par­ent com­po­nent — The par­ent com­po­nent includ­ed 10 90-minute par­ent group meet­ings and up to 6 30-minute fam­i­ly meet­ings. Dur­ing group meet­ings, par­ents were edu­cat­ed about ADHD‑I and how it impact­ed chil­dren’s func­tion­ing. They learned strate­gies that includ­ed effec­tive­ly using rewards and pos­i­tive con­se­quences, estab­lish­ing dai­ly rou­tines, giv­ing effec­tive direc­tions, avoid­ing pow­er strug­gles, stress man­age­ment, how to orga­nize and struc­ture their home to pro­mote their child’s adap­tive func­tion­ing, and how to use neg­a­tive con­se­quences.

Rel­a­tive to tra­di­tion­al ADHD par­ent­ing pro­grams, greater atten­tion was paid to teach­ing par­ents how to address exec­u­tive func­tion­ing deficits that char­ac­ter­ize many chil­dren with ADHD‑I, e.g., plan­ning, orga­niz­ing, work­ing mem­o­ry, pri­or­i­tiz­ing). For exam­ple, they were taught how to set up spe­cif­ic rou­tines for get­ting home­work done and for help­ing chil­dren to orga­nize the var­i­ous tasks they need­ed to com­plete. Each week they were giv­en home­work that involved prac­tic­ing and imple­ment­ing spe­cif­ic skills at home; these assign­ments and trou­bleshoot­ing prob­lems par­ents had imple­ment­ing new strate­gies were dis­cuss at each ses­sion before new con­tent was intro­duced. Par­ents were also taught skills for inter­act­ing effec­tive­ly with teach­ers and how to help devel­op, eval­u­ate, and rein­force class­room inter­ven­tions devel­oped in con­junc­tion with their child’s teacher.

Child com­po­nent — The child com­po­nent includ­ed 10 90-minute child group meet­ings focused on teach­ing chil­dren skills for inde­pen­dence, e.g., aca­d­e­m­ic, study, and orga­ni­za­tion­al skills, and social skills, e.g., con­ver­sa­tion­al skills, deal­ing with teas­ing, friend­ship mak­ing, etc. Chil­dren were also taught strate­gies to pro­mote atten­tion, time man­age­ment skills, and task com­ple­tion. Spe­cif­ic plans were devel­oped for morn­ing, after school and evening rou­tines with tasks and activ­i­ties spec­i­fied clear­ly. Role plays were used fre­quent­ly in teach­ing and prac­tic­ing the skills and rewards were pro­vid­ed to improve the use of skills taught. The lat­ter was done through hav­ing chil­dren bring in records from their par­ents and teacher indi­cat­ing how well they had done in meet­ing spe­cif­ic home and school chal­lenges that required the use of new­ly devel­op­ing skills.

Teacher com­po­nent — The teacher com­po­nent includ­ed an ini­tial 30-minute ori­en­ta­tion meet­ing with the teacher, child, parent(s) and ther­a­pist fol­lowed by up to 5 sub­se­quent meet­ings. Teach­ers were giv­en an overview of ADHD‑I, how it affects chil­dren in the class­room, and taught strate­gies for pro­mot­ing chil­dren’s atten­tion and orga­ni­za­tion­al skills. They also set up a dai­ly report card sys­tem called the Class­room Chal­lenge in which they rat­ed chil­dren 3 times per day on up to 4 spe­cif­ic goal behav­iors. These includ­ed such behav­iors as ‘get­ting start­ed right away’, ‘fin­ish­ing work on time’, and ‘turn­ing in home­work’. Spe­cif­ic social behav­iors, e.g., ‘play­ing with a peer at recess’, were also includ­ed. These rat­ings were tak­en home dai­ly so that par­ents were informed about their child’s progress on impor­tant school goals. Teach­ers were instruct­ed on the skills chil­dren were work­ing on in the child group and how to sup­port and rein­force those skills.

Par­ent focused train­ing (PFT) — PFT includ­ed only the par­ent train­ing com­po­nent from CLAS. The skills taught were iden­ti­cal to those described above but did not include train­ing par­ents to work effec­tive­ly with teach­ers. There was no child skills group,direct con­sul­ta­tion with teach­ers, or home-school dai­ly report card.

Treat­ment as usu­al (TAU) — When chil­dren were assigned to this con­di­tion, par­ents received a list of com­mu­ni­ty treat­ment providers but were not giv­en spe­cif­ic treat­ment rec­om­men­da­tions — what they pur­sued was up to them. Four­teen per­cent of these chil­dren went on to receive med­ica­tion treat­ment, one-third received some form of psy­chother­a­py (child ther­a­py or par­ent­ing group), 51% received edu­ca­tion­al inter­ven­tion at school, and 53% received some type of class­room accom­mo­da­tion.

Mea­sures — Data was col­lect­ed from both par­ents and teach­ers before treat­ment began, imme­di­ate­ly fol­low­ing treat­ment, and 5 to 7 months after treat­ment end­ed. The lat­ter assess­ment occurred dur­ing the fol­low­ing school year when chil­dren were with a new teacher. At each time point,ratings were col­lect­ed to mea­sure the pres­ence of DSM-IV inat­ten­tive symp­toms, orga­ni­za­tion­al skills rel­e­vant to aca­d­e­m­ic suc­cess, and social skills. Par­ents and teach­ers rat­ed chil­dren’s over­all improve­ment from base­line imme­di­ate­ly after treat­ment; par­ents com­plet­ed a sim­i­lar rat­ing at the long-term fol­low up.

Results

Post-treat­ment — Imme­di­ate­ly fol­low­ing treat­ment, par­ent and teacher rat­ings indi­cat­ed that com­pared to chil­dren in TAU chil­dren in CLAS showed few­er inat­ten­tive symp­toms, bet­ter orga­ni­za­tion­al skills, bet­ter social skills, and greater over­all improve­ment. The mag­ni­tude of the group dif­fer­ences were in the mod­er­ate to large range. Accord­ing to par­ents, near­ly 55% of CLAS par­tic­i­pants now showed ‘nor­mal­ized’ lev­els of inat­ten­tive symp­toms com­pared to only 30% TAU chil­dren. For teach­ers, the cor­re­spond­ing fig­ures 58% vs. 33%

Dif­fer­ences between CLAS and PFT were more mod­est but still evi­dent on teacher rat­ings of inat­ten­tive symp­toms, par­ent and teacher rat­ings of orga­ni­za­tion­al skills, teacher rat­ings of social skills, and teacher rat­ings of over­all improve­ment. Effect sizes were small to mod­er­ate. Nor­mal­ized inat­ten­tive symp­toms for PFT chil­dren were report­ed by 43% of par­ents (vs. 55% for CLAS) and 44% of teach­ers (vs. 58% for CLAS). These dif­fer­ences were not sig­nif­i­cant.

Fol­low-up — At the 5–7 month fol­low-up CLAS remained supe­ri­or to TAU based on par­ent rat­ings of inat­ten­tive symp­toms, orga­ni­za­tion­al skills, and over­all improve­ment. Dif­fer­ences between CLAS and PFT were only evi­dent for orga­ni­za­tion­al skills and the effect size was mod­est. For teacher rat­ings (as not­ed above, these were rat­ings pro­vid­ed by a new teacher as chil­dren had advanced to the next grade) CLAS was not supe­ri­or to TAU or PFT on any mea­sure.

Con­sumer sat­is­fac­tion — Par­ents and teach­ers report­ed a high lev­el of sat­is­fac­tion with CLAS. Over 95% felt the child and par­ent skills taught were very use­ful and 96% would rec­om­mend the pro­gram to oth­ers. Nine­ty-four per­cent of teach­ers in CLAS felt the inter­ven­tion was help­ful and 83% said they would be like­ly to con­tin­ue to pro­gram. In addi­tion, approx­i­mate­ly 80% of par­ents in the PFT would have pre­ferred to have had the child and teacher com­po­nents to sup­ple­ment the par­ent train­ing they received.

Summary and Implications

The authors of this study made a laud­able effort to design a psy­choso­cial inter­ven­tion specif­i­cal­ly tai­lored to meet the needs of chil­dren with ADHD‑I. The inter­ven­tion they designed was thor­ough and com­pre­hen­sive, and care­ful­ly inte­grat­ed work with par­ents, teach­ers and chil­dren. Teach­ing par­ents how to work effec­tive­ly with teach­ers to sup­port their child — some­thing that often proves chal­leng­ing for par­ents — was an espe­cial­ly nice fea­ture of the inter­ven­tion.

In many ways, results from the study are high­ly encour­ag­ing. Imme­di­ate­ly fol­low­ing treat­ment, both par­ents and teach­ers report­ed supe­ri­or gains across mul­ti­ple areas for chil­dren who received CLAS com­pared to either PFT or TAU. In sev­er­al instances, dif­fer­ences between CLAS and the oth­er groups were of sub­stan­tial mag­ni­tude. And, it was clear that par­ents and teacher were high­ly sat­is­fied with the pro­gram and believed that it had real val­ue.

Against this pos­i­tive back­drop, there are sev­er­al con­cerns to keep in mind. The first con­cerns the fea­si­bil­i­ty of pro­vid­ing this inter­ven­tion out­side of a grant fund­ed research project. CLAS involved 10 1.5 hour meet­ings with par­ents and chil­dren, and up to 6 30-minute meet­ings with teach­ers. Deliv­er­ing this in a reg­u­lar com­mu­ni­ty set­ting could be chal­leng­ing and the extend to which this could hap­pen remains unknown.

Sec­ond, an impor­tant study lim­i­ta­tion is that out­come mea­sures were restrict­ed to the par­ents and teach­ers who par­tic­i­pat­ed in the inter­ven­tion. One could argue that they had a vest­ed inter­est in the treat­men­t’s suc­cess, giv­en the time and effort they had devot­ed to it. Although par­ents in PFT had also devot­ed sig­nif­i­cant time, the effort required by CLAS was still greater. As a result, the rat­ings pro­vid­ed by par­ents — and espe­cial­ly by teach­ers — may have been influ­enced by this fac­tor in favor of CLAS rel­a­tive to the oth­er inter­ven­tions.

This is espe­cial­ly con­cern­ing giv­en that teacher rat­ings at fol­low-up showed no ben­e­fi­cial effects of CLAS com­pared to PFT or TAU. Recall that these rat­ings were com­plet­ed by a new teacher who may have been unaware of treat­ments chil­dren and par­ents had received. In a sense, these were the only ‘blind’ rat­ings in the study, and the fact that no effects were found on any of the mea­sures rais­es some ques­tions about the valid­i­ty of the oth­er rat­ings. This is an impor­tant study lim­i­ta­tion that the authors appro­pri­ate­ly acknowl­edge, and they note that includ­ing objec­tive mea­sures of out­come such as ‘blind’ obser­va­tions of “…par­ent-child inter­ac­tions, class­room behav­ior and/or peer inter­ac­tions, home­work prod­ucts, or tests of aca­d­e­m­ic achieve­ment would avoid these rater bias­es and are impor­tant to include in future stud­ies.”

These lim­i­ta­tions not with­stand­ing, the valu­able con­tri­bu­tion of this study is in devel­op­ing a psy­choso­cial inter­ven­tion that is specif­i­cal­ly tai­lored to the needs of chil­dren with ADHD‑I, some­thing that is long over­due. I par­tic­u­lar­ly appre­ci­at­ed the efforts to help par­ents devel­op the skills and knowl­edge to work effec­tive­ly with their child’s teacher to pro­mote his/her suc­cess at school. This is an impor­tant effort and pro­vides a strong foun­da­tion on which oth­er researchers can build.

– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teach­es the online course How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

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