Researching Interventions for Treating Childhood ADHD:

An Annotated Bibliography

Ed D 561 A

Instructor: Todd Milford

June 5, 2011. My proposed project was to create a “toolkit” for the elementary school counsellor on the topic of Attention Deficit/Hyperactivity Disorder, describing how best to support the student himself, his functioning in the classroom, his teacher in teaching him, and his parents as all these parties are affected by the behaviours that accompany ADHD. For this reason, I chose articles from a wide variety of topics related to ADHD, with emphasis on treatment interventions. As I progressed with this assignment, I realized that my topic was far too large in scope to be manageable. So, while not all my articles herein are related to my new proposal, I believe these readings have given me an extensive overview of the range of interventions that have been proposed for treating child ADHD. Now, as I come to the end of this assignment, I have decided to narrow my focus to novel approaches to treating ADHD: neurofeedback, mindfulness, and attention restoration theory. What has excited me in this research process has been the discovery of these interventions and the fact that they have literally no adverse side effects, hold promising long-term results, and are being proven effective.

Annotated Bibliography

Drabick, D.A.G., Gadow, K. D., & Sprafkin, J. (2006). Co-occurrence of conduct disorder and depression in a clinic-based sample of boys with ADHD. Journal of Child Psychology and Psychiatry, 47(8), 766-774.

This article describes the results of a study conducted to investigate risk factors for development of co-morbid conduct disorder (CD) and/or depression in boys with ADHD. The risk factors were comprised of four areas that are associated with ADHD, CD, and depression: inconsistent and coercive parenting, adverse family environment, and difficulties in academic and social functioning. Using structural equation modeling (SEM), researchers compared these risk factors to CD and depressive symptoms in a sample of 248 boys with ADHD. It was hypothesized that CD and depression would be related concurrently and that each of the risk factors would predict the development of both conditions. The method of investigation involved the mothers of the participants filling out forms and ratings scales: the Child Symptom Inventory-4 for ADHD symptoms, conduct problems, and depressive symptoms; the Parent’s Report for assessing parent-child interactions; and the Family Environment Scale, Form R, which considers the family environment. Academic and cognitive performance was assessed using the Revised Wide Range Achievement Test, the Wechsler Intelligence Scale for Children-Third Edition, and the Academic Functioning scale of the Teacher Report Form (TRF) of the Child Behaviour Checklist. Teachers also used the TRF to rate social difficulties of these children. Clinical evaluations were also included. SEM was performed on the data to investigate relationships between ADHD, CD, depression, and the risk factors. Results indicated that conduct problems are predicted by hostile, inconsistent and detached parenting; depression by social difficulties; and both CD and depression by a stressful, fragmented family environment. While academic and cognitive difficulties often co-exist with ADHD, results of the study showed that they are not predictive of co-morbid CD or depression.

Relevance and Value This article speaks to the importance of prevention efforts and therapeutic interventions. Given that parenting and family environment appear to be risk factors in the development of co-morbid CD and depression in boys with ADHD, it is clear that parents of children with ADHD need to be educated on positive parenting approaches and the importance of maintaining healthy relationship with one’s spouse and children. The information presented in this article might be helpful to me when creating the parent portion of the toolbox.

Research Path I found this article using Ebsco Host PsychInfo Advanced Search with the terms “ADHD,” “child*,” and “co-morbid*.” I simply scrolled down the list, reading the abstracts until I found this article.

Fox, D.J., Tharp, D.F., & Fox, L. (2005). Neurofeedback: An alternative and efficacious treatment for attention deficit hyperactivity disorder. Applied Psychophysiology and Biofeedback, 30 (4), 365-373.

This article presents a convincing argument for the use of neurofeedback as an alternative to pharmacotherapy for helping people with ADHD. Neurofeedback targets brainwave activity and is thought to ameliorate attentional, impulsive and hyperactive behaviours. The authors cite four studies that demonstrate neurofeedback as being as equally helpful as stimulant medication in symptom reduction. In fact, it is noted that students treated with neurofeedback showed significant improvements in IQ tests, achievement scores on standardized tests, and on parent/teacher ratings of behaviour. These improvements persisted, as evidenced by long-term follow-up testing. Other treatments for ADHD are briefly described, those of psychostimulants, cognitive behaviour therapy, and behaviour-modification plus medication. None of these have been shown to have long lasting results. In contrast, the authors argue that neurofeedback is a feasible alternative to these treatment options, highlighting the additional benefit neurofeedback boasts in its long-term maintenance of positive effects.

Relevance and Value I found this article to be enlightening and encouraging in its description of neurofeedback as a treatment option that is entirely safe, drug-free, and sustains its positive effects over time. I believe such an option would be well-received by most parents who are hesitant or refusing to try medication on their children. Neurofeedback presents a real alternative. In fact, the Special Services department of our school board is looking into purchasing some neurofeedback computer programs for use at our Behaviour Resource program. One very real drawback is the amount of time and money required to effect positive change.

Research Path I had found another article somewhere along the line, and had added it to my RefWorks account, but when I began reading it, I began to think it didn’t look peer-reviewed. So, I tried to check it out by typing the title into Summon, making sure to limit my search to “peer reviewed” articles, and several other articles came up instead of my original one. This was one of them. Klimkeit, E., Graham, C., Lee, P., Morling, M., Russo, D., & Tonge, B. (2006). Children should be seen and heard: Self-report of feelings and behaviours in primary-school-age children with ADHD. Journal of Attention Disorders, 10(2), 181-191.

This article reports the results of a study done to examine to what extent children with ADHD are able to rate their behaviours as compared to controls using a newly developed rating scale, the Self-Evaluation Scale for Children (SES-C). It had been proposed in earlier literature (Zucker, Morris, Ingram, Morris, & Bakeman, 2002) that children with ADHD are not able to accurately self-evaluate their own behaviour, but other literature suggests otherwise (Fischer, Barkley, Fletcher, and Smallish, 1993; Lufi and Parish-Plass, 1995). The authors (C.G., P.L., M.M., and D.R.) created this self-report ratings scale consisting of 22 items displayed as a visual analogue scale because of the lack of self-report measures in existence for children. The self- report scale was also designed to help therapists identify what areas might need to be addressed in interventions, and to investigate whether children with ADHD are able to reflect on their feelings and behaviours. Participants included a group of 65 children with ADHD who were screened for cognitive, learning, and language deficits and a control group of 65 children all of whom completed the SES-C. Parent and teacher reports were included using the Attention Deficit Disorder Evaluation Scale (ADDES). Results indicate that, in using the SES-C, children with ADHD are indeed aware of their difficulties, and are able to self-assess in such a way that may be helpful to clinicians.

Relevance and Value I consider this article to be quite a wonderful discovery because it includes the actual SES-C as an appendix. I will use this ratings scale with my elementary school aged clients who are exhibiting attentional challenges. The scale also showed me how simple a scale can be. I could modify this scale for use with students with other disorders, such as anxiety for example.

Research Path I cannot remember how I found this article. I think I came upon it while making related searches under PsychInfo Advanced Search.

Lofthouse, N., McBurnett, K., Arnold, L.E., & Hurt, E. (2011). Biofeedback and neurofeedback treatment for ADHD. Psychiatric Annals, 41 (1), 42-48.

This article reviews the research done to date on biofeedback (BF) and neurofeedback (NF) as complementary and/or alternative interventions for treating child and adult ADHD. The thinking is that through immediate feedback (video/audio/tactile) provided by BF and/or NF, the brain changes its physiological activity as a result of operant and classical conditioning. BF has been used to measure a host of physiologic responses, such as muscle tension, skin temperature, and blood pressure. NF is a type of BF that moderates the brain’s electrical activity. Research done on the effects of BF on child ADHD is reported to have been promising when done two decades ago. Because of limitations with how the research was conducted, evidence of the efficacy of BF is not conclusive, and it is recommended that practitioners do an initial trial of progressive muscle relaxation first, since muscle relaxation accompanied most BF studies and is easy, cheap, and safe to administer. Research done on the effects of NF on child ADHD is more recent, with four of the five published randomized studies performed since 2006, and demonstrates efficacy of a medium effect size (d = 0.58). Little research on adult ADHD and NF has been done. Authors conclude by stating that NF is a promising, but expensive venture in terms of both time and money.

Relevance and Value I appreciate how the authors treated BF and NF independently, as well as their proven efficacy (or lack thereof) on both child and adult ADHD. In particular, the article cites sources of further information for the reader, such as the Biofeedback Certification Institute of America (BCIA) Practitioner Directory, the International Society for Neurofeedback and Research (ISNR), and the support organization, Children and Adults with Attention Deficit/Hyperactivity Disorder (CH.A.D.D.). It also lists places to download SNAP-IV and Vanderbilt scales and scoring guidelines.

Research Path I found this article within PsychInfo when I used the search terms “ADHD,” “child*,” and “biofeedback” together in the advanced search section. I limited my search to peer-reviewed journals and linked to full text. This article came up as first on the resultant list.

Reid, R., Trout, A.L., & Schartz, M. (2005). Self-regulation interventions for children with attention deficit/hyperactivity disorder. Exceptional Children, 71 (4), 361-377.

This article provides a meta-analysis of literature on self-regulation interventions for child ADHD. Self-regulation interventions reported include self-monitoring (SM), self-monitoring plus reinforcement (SM+R), self-reinforcement (SRF), and self-management (SMGT). Criteria for studies included in this meta-analysis were: one of the four interventions had to have been used; observational data needed to document academic or behavioural outcomes; a quantitative research design had to have been used; and the research participants had to be students 18 years or younger with ADHD. Despite these criteria, many limitations were found in this study. Almost 50% of the participants had no confirmed and reported diagnosis of ADHD. Some participants were taking medication for their symptoms, others were not. There were very few female participants (three of 51), and adolescent participants (three of 51) reported in this study. In addition, there was not enough data collected to compare effects of self-regulation techniques. It is therefore, difficult to draw definitive conclusions as to the generalizability of the effects of self-regulation on students with ADHD. Nevertheless, the results do show substantial effect sizes, and the techniques have been empirically validated and are conducive to use by classroom teachers. For these reasons, the authors recommend adding self-monitoring interventions to multimodal treatments for students with ADHD.

Relevance and Value I found the three tables within this article particularly helpful. The first summarized the self- regulation studies and included the authors’ names and year the study was done, the intervention type, the number and age of participants, the setting, the dependent variables, and the results. I appreciate that I can see at a glance the outcomes reported, such as “number of misbehaviours in large group activity,” as well as the setting. This table illuminates studies that might be relevant in a school setting. The second table lists the mean effect size of each study, and the third reports the mean effect size and number of participants across interventions. These tables provide a concise summary of the self-regulation methods used and their relevance for work within the school setting.

Research Path I came across this article as a citation within Zentall’s article. I then had its full title, so I retrieved it directly from Summon on the UVic library’s webpage.

Roman, M. W. (2010). Treatments for childhood ADHD part II: Non-pharmalogical and novel treatments. Issues in Mental Health Nursing, 31, 616-618.

This article provides a brief introduction of non-pharmalogical treatments for child ADHD, with an emphasis on neurofeedback as a treatment that is gaining acceptance within the scientific community. Neuroimaging and electroencephalographs (EEG) have shown that children with ADHD exhibit cortical underarousal; through EEG therapies, the child essentially rewires the pathways in his brain, training it become more responsive. Several studies are cited that support neurotherapy as a treatment for child ADHD that matches medication in efficacy and exceeds it in duration of effect and lack of side effects.

Relevance and Value While this article is very brief, it is nevertheless helpful in that it lists recent research done on EEG and neurofeedback. For my final project, this paper has provided me some further research to investigate. For example, I am interested to read the extensive literature review of evidence- based treatments by Brown (2005), Monastra’s (2005) work on the empirical foundation for neurotherapy as a treatment for ADHD, and Hirshberg’s (2007) review of electroencephalographic biofeedback for ADHD. Had I read this article at the beginning of this assignment, I would have investigated these readings in lieu of a few of the others I chose.

Research Path While using Summon I typed in “treatments for childhood ADHD” and this article appeared first on the list.

Singh, N. N., Singh, A. N., Lancioni, G. E., Singh, J., Winton, A. S. W., & Adkins, A. D. (2010). Mindfulness training for parents and their children with ADHD increases the children’s compliance. Journal of Child and Family Studies, 19 (2), 157-166.

The authors of this article communicate findings of the effects of mindfulness training on the compliance of children with ADHD with parental instructions. Non-compliant behaviour frequently accompanies the hallmark symptoms of inattention, hyperactivity, and impulsivity in children diagnosed with ADHD. While pharmacotherapy and behaviour management interventions have been shown to be effective in treating ADHD, there are limitations inherent in each, and neither method helps children learn how to develop internal, intrinsically motivated self-control. This study used a multiple baseline across participants design, and included a parent training portion in mindfulness, followed by a similar, but developmentally appropriate, mindfulness training portion for their children. Baselines were established prior to beginning, and a follow-up phase was also included. It is important to note that the study’s focus was quite narrow and interested only in the children’s compliance to their mothers’ requests. The results showed that this mindfulness training program delivered to both parent and child yielded very positive results, and suggests that mindfulness training improves mother-child interactions, as well as children’s rate of compliance with parental requests.

Relevance and Value I found this article to be extremely valuable to me because it has inspired me to recommit to my own personal meditation practice and to further investigate mindfulness as a therapeutic option for treating child ADHD. Some sources cited within the article I will seek out, such as the research method multiple baseline across participants design, the children’s books, Teaching Meditation to Children and A Pebble in Your Pocket and research done by Segal et al in 2002 and Singh et al in 2008. I have many questions for the researchers that were left unanswered. For example, I would like to know how long mother and child had to devote each day to the practice and how and when mother and child agreed upon the definitions for “compliance performed within a timely manner.” I plan to contact the authors of this article for more information on this subject and also for possible training options.

Research Path I found this article within PsychInfo when I used the search terms “ADHD,” “child*,” and “mindfulness” together in the advanced search section. I limited my search to peer-reviewed journals and linked to full text.

Taylor, A. F., Kuo, F. E., & Sullivan, W. C. (2001). Coping with add: The surprising connection to green play settings. Environment and Behavior, 33 (1), 54-77.

Informed by Attention Restoration Theory, which suggests that attentional functioning improves with time spent in nature, this article reports the results of a study done to examine the effects of nature on the attentional functioning of children with ADD. Two positive directional hypotheses were proposed: (1) that attention deficit symptoms would be more manageable following time spent in green environments, and (2) that attentional functioning would show a positive correlation to the greenness of the child’s daily environment, in general. Qualitative data was gathered through questionnaires, interviews, and a focus group. Results of this correlational research supported the first hypothesis, but not the second. The authors argue that time spent outdoors in green environments may support attentional functioning in children with ADD, and that this finding has implications for the management of ADD, the design of schools and daycares, and future research. This is important, as it is noted that the commonly accepted and utilized treatments of medication and behavioural and cognitive behavioural procedures have sizable limitations, including lack of long-term positive academic and social functioning, in the case of pharmacotherapy, and lack of ability to bring children’s functioning within the normal range, in the latter case.

Relevance and Value This article has value in the simplicity of its implications for managing ADD: simply spending time outdoors in green areas may improve the attentional functioning of children with ADD. This is valuable information for educators and parents, especially given the ease with which it can be implemented. This article was helpful to me because the authors described how they derived questions for their questionnaire from the DSM-IV diagnostic criteria for ADHD, and I am planning to create a questionnaire for children who have been diagnosed with ADHD.

Research Path While reading the article by Zental, I became interested in the research done by these authors. I got the title of this article from the Zental article, and then retrieved it easily from Summon on the UVic library website.

Toplak, M., Connors, L., Shuster, J., Knezevic, B., & Parks, S. (2008). Review of cognitive, cognitive-behavioural, and neural-based interventions for attention-deficit/hyperactivity disorder (ADHD). Clinical Psychology Review 28 (5), 801-823.

This article constitutes a review of cognitive, cognitive-behavioural, and neural-based interventions that have been used to treat ADHD. The authors note that the conceptualization of ADHD is evolving, and approaches must be grounded in theory. Two evidence-based treatments are briefly reviewed: pharmacotherapy and psychosocial treatments, including behavioural parent training and behavioural school interventions. While both interventions have been reported to be efficacious, limitations such as refusal to try medication or the lack of long-term effects, highlight the importance of investigating other therapeutic possibilities. In comparison, cognitive, cognitive-behavioural, and neural-based treatments have not been found to be empirically valid due to some important limitations within the studies’ designs, namely, the lack of controlling for medication status and expectancy effects, small sample sizes, and not accounting for the differences among the ADHD subtypes. However, results of this review indicate these interventions hold promise and, with more careful attention to study design, may prove to be empirically valid approaches to treating ADHD.

Relevance and Value This article was an important discovery for me, as it compared evidence-based treatments to alternative treatments, and argued for the need for further research on alternative treatments such as neurofeedback because of the promise they hold for effecting lasting therapeutic change. The authors’ comprehensive review of existing literature and suggestions for future directions was very valuable. Reading this article has given me a framework with which to view ADHD. I appreciate and will incorporate into my project several strong suggestions, including the suggestion that researchers should not be trying to demonstrate the superiority of one approach over another, but should rather be seeking to add complementary layers to the treatment of ADHD; that interventions should be informed by current ADHD theory; and that attention needs to be paid to varying developmental levels. I believe this article will help me read future articles with a more critical and informed eye: I will look for clearer and more consistent outcome measures, for how the research addresses the three subtypes of ADHD, and/or for whether or not developmental levels have been taken into account. This article has helped bring my thoughts around my project topic into better focus. For example, I now know that I am particularly interested in learning about interventions that effect long- lasting change.

Research Path I found this article within PsychInfo when I used the search terms “ADHD,” “child*,” and “behaviour*” together. I then scrolled down through the list that came up and thought this one looked helpful.

Zentall, S.S. (2005). Theory- and evidence-based strategies for children with attentional problems. Psychology in the Schools, 42 (8), 821-836.

This article looks specifically at selective and sustained attention as they relate to child attention- deficit hyperactivity disorder (ADHD) and provides a brief review of interventions aimed at improving attention. Selective attention requires identifying relevant information from within a complex field. Children with ADHD selectively attend to novel stimuli more than the average child. The author points out that those children with ADHD do not have an attention deficit; rather, they have an attentional bias for novelty. This bias means that children with ADHD spend more time and energy attending to their physical and social surroundings, and less time and energy noticing internal stimuli, such as thoughts, beliefs, and feelings. This attentional bias toward novelty can cause these children to have difficulties identifying what messages might be important to extract from interactions with others or from their own inner selves. Interventions that target selective inattention are presented in table format, and include numerous evidence- based educational practices. Sustained attention is the ability to maintain attention on tasks. Children with ADHD find it difficult to attend to tasks that are long, monotonous, or are not active. Psychostimulant medication is noted to be the best intervention for improving sustained attention. The use of novelty and self-direction in education settings has also shown promise in improving sustained attention. The author concludes by saying that many strategies exist to help these children within the classroom and ends by noting the importance of discovering preferred types of stimulation (sensory, cognitive, emotional, social) in these children.

Relevance and Value This article is relevant to my final project because it summarizes a number of educational interventions that have been shown to be helpful in improving attention in students with ADHD. It is valuable to have inattention broken down into the two subtypes of selective inattention and sustained inattention, with descriptions and interventions listed for both. I intend to use this information in the section of my project on how to support the classroom teacher by providing some strategies to improve the attention of children with attentional difficulties. Research Path I began within the UVIC library website, and went to Databases. There, I found PsychInfo and did an advanced search using the search terms, ADHD and evidence based practice. I scrolled down the list for relevant articles and found this one.