Cognitive-behavioral therapies for hyperactive children: premises, problems, and prospects

The co-occurrence of autism and attention deficit hyperactivity disorder in children - what do we know?

Symptoms of attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD) often co-occur. The DSM-IV had specified that an ASD diagnosis is an exclusion criterion for ADHD, thereby limiting research of this common clinical co-occurrence. As neurodevelopmental disorders, both ASD and ADHD share some phenotypic similarities, but are characterized by distinct diagnostic criteria. The present review will examine the frequency and implications of this clinical co-occurrence in children, with an emphasis on the available data regarding pre-school age. The review will highlight possible etiologies explaining it, and suggest future research directions necessary to enhance our understanding of both etiology and therapeutic interventions, in light of the new DSM-V criteria, allowing for a dual diagnosis.

Preliminary data suggesting the efficacy of attention training for school-aged children with ADHD

A pilot randomized clinical trial was conducted to examine the initial efficacy of Pay Attention!, an intervention training sustained, selective, alternating, and divided attention, in children diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). After a diagnostic and baseline evaluation, school-aged children with ADHD were randomized to receive 16 bi-weekly sessions of Pay Attention! (n=54) or to a waitlist control group (n=51). Participants completed an outcome evaluation approximately 12 weeks after their baseline evaluation. Results showed significant treatment effects for parent and clinician ratings of ADHD symptoms, child self-report of ability to focus, and parent ratings of executive functioning. Child performance on neuropsychological tests showed significant treatment-related improvement on strategic planning efficiency, but no treatment effects were observed on other neuropsychological outcomes. Treatment effects were also not observed for teacher ratings of ADHD. These data add to a growing body of literature supporting effects of cognitive training on attention and behavior, however, additional research is warranted.

Cognitive Processes Underlying the Behavior Change in Cognitive Behavior Therapy with Childhood Disorders: A Review of Experimental Evidence

While Cognitive Behavior Therapy (CBT) has been widely used for treatment of childhood disorders, the process underlying the success of CBT in this area is still unclear. This paper attempts to examine empirically the above issue, using the literature from 1974 to 1989 to see whether there is support for the underlying changes in cognitive processes that are assumed to mediate the therapy. The results show that while CBT is relatively effective in treating some childhood disorders, there is little empirical evidence to support the underlying cognitive models of childhood disorders.

A Vygotskian critique of self-instructional training

Self-instructional training, a widely used intervention for treating the learning and behavioral difficulties of impulsive, attention deficit-hyperactivity disordered, and learning disabled children, has repeatedly failed to promote self-control or improve academic performance. In light of this failure, we critically examine four assumptions underlying self-instructional training: (a) children with learning and behavior problems show a lack and/or deficient use of self-regulatory private speech; (b) modeling of self-verbalizations will increase children's spontaneous production of private speech; (c) speech and action are intrinsically coordinated; and (d) internalization refers to subvocalization of private speech. We argue that self-instructional training interventions need to be thoroughly grounded in Soviet developmental theory of verbal self-regulation and in systematic research on the social origins and development of children's private speech. A new research agenda is suggested.

Is cognitive behavior therapy developmentally appropriate for young children? A critical review of the evidence

This paper questions the extent to which developmental considerations have been incorporated into the theory and practice of cognitive behavioral therapy (CBT). It focuses on children aged between 5 and 8 years because Piagetian developmental theory places them at a prelogical cognitive level, and thus, the use of a therapeutic approach that is based on a rationalist paradigm would be considered inappropriate. The cognitive demands made upon 5- to 8-year-old children by CBT are outlined, and the current developmental literature is reviewed in the light of this to evaluate the cognitive abilities of this age group. The models underpinning CBT are examined for evidence of the influence of developmental psychology, and the outcome literature of CBT techniques is then scrutinized to evaluate the efficacy of these techniques with young children. Conclusions are reached regarding the appropriateness of current cognitive-behavioral approaches with young children, and the implications for alternative approaches are briefly considered.

Use of the Child Behavior Checklist and DSM-III-R diagnosis in predicting outcome of children's social skills training

A standardized 12-week cognitive-behavioral social skills package in which parents assisted children with socialization homework assignments, was presented to 52 nonpsychotic outpatient boys, many of whom were diagnosed with DSM-III-R Attention Deficit-Hyperactivity Disorder and Oppositional Defiant Disorder. Results demonstrated that the Thought Problems factor of the mother-completed Child Behavior Checklist aided in predicting changes in teacher-rated aggression. DSM-III-R diagnosis of Oppositional Defiant Disorder predicted changes in teacher-rated withdrawal subsequent to treatment. The need for research to determine which children benefit from which treatment was discussed.

Cognitive-behavioral treatments

The present paper provides an overview of the guiding theory and descriptive features of the cognitive-behavioral approach to psychosocial interventions for youths. Cognitive-behavioral treatment has been applied to various disorders including anxiety, aggression, depression, attention deficit-hyperactivity disorder, pain, and learning disabilities. Research on the nature of these disorders, a description of related treatment strategies, and an illustrative review of treatment outcome data is provided. Discussion focuses on a consideration of familial involvement, developmental factors, and methodological issues (i.e., comorbidity and normative comparisons) that require research attention.

Verbal-nonverbal correspondence training with ADHD children

This study presents a general description of the applicability of verbal-nonverbal correspondence-training procedures in the management of five cases with Attention-Deficit Hyperactive Disorder (ADHD). Two cases additionally met criteria for conduct problems. These five cases, males aged 6 to 10 years were intervened with one of three correspondence-training procedures: (a) reinforcement of do-report, (b) reinforcement of report-do, and (c) reinforcement set-up on report. A changing-criterion design with multiple-baseline features was used with all cases. Consistently lower levels of hyperactivity and conduct problems were noted during the introduction of each procedure. Generalization and maintenance (follow-up) data are also reported. The strengths, limitations, and cost-effectiveness of correspondence training and future research with the present population are discussed.

Effects of two treatment techniques on delay and vigilance tasks with attention deficit hyperactive disorder (ADHD) children

In this study, we examined the effects of two treatment techniques under on-medication and off-medication conditions on the hyperactive behavior patterns of children. Three groups of subjects were compared: a control group, a behavior modification group, and a cognitive training group. The Gordon Diagnostic System (Gordon, McClure, & Post, 1986) was used to assess the subjects at the initial screening, during treatment without medication, and during treatment with medication. The two medication conditions were counterbalanced during the second and third testing sessions. Results showed that when the cognitive intervention was combined with medication, there was a significant improvement in the subjects' ability to delay impulsive responding. However, no significant effects were seen for sustained vigilance for either the behavioral or cognitive groups. Parents rated children in the cognitive group significantly higher than those in the control group.

Study strategies and story recall in attention deficit disorder and reading disability

The role of metacognition and executive processes in mediating use of study skills was examined in groups of attention deficit disorder with hyperactivity (ADD-H), normal, and non-ADD-H reading-disabled (RD) boys, matched on age and verbal IQ. On a story recall task, ADD-H boys did not differ from normals in their immediate gist recall of a story or in their recall following a study period. RD boys demonstrated inferior recall in both conditions. Study skills of the ADD-H boys were poorer than those of normal boys on all measures. They spent less time studying, expended less effort, and employed more superficial strategies. However, their poor strategies did not appear to reflect a lack of metacognitive awareness. Results are discussed in terms of the impact of motivational variables in modulating strategy use in ADD-H boys and the impact of verbal processing problems in reading disabilities. Implications for treatment and the relationship between ADD-H and RD are discussed.

Development and functional significance of private speech among attention-deficit hyperactivity disordered and normal boys

We compared the development of spontaneous private speech and its relationship to self-controlled behavior in a sample of 6- to 12-year-olds with attention-deficit hyperactivity disorder (ADHD) and matched normal controls. Thirty-eight boys were observed in their classrooms while engaged in math seatwork. Results revealed that ADHD children were delayed in private speech development in that they engaged in more externalized, self-fuiding and less inaudible, internalized speech than normal youngsters. Several findings suggest that the developmental lag was a consequence of a highly unmanageable attentional system that prevents ADHD children's private speech from gaining efficient mastery over behavior. First, self-guiding speech was associated with greater attentional focus only among the least distractible ADHD boys. Second, the most mature, internalized speech forms were correlated with self-stimulating behavior for ADHD subjects but not for controls. Third, observations of ADHD children both on and off stimulant medication indicated that reducing their symptoms substantially increased the maturity of private speech and its association with motor quiescence and attention to task. Results suggest that the Vygotskian hypothesis of a unidirectional path of influence from private speech to self-controlled behavior should be expanded into a bidirectional model. These findings may also shed light on why treatment programs that train children with attentional deficits in speech-to-self have shown limited efficacy.

Cognitive effects of psychostimulant medication in hyperactive children

Hyperactive and normal children were given a test of selective attention (Stroop test) and a neurocognitive test sensitive to a functional deficit of prefrontal cortex (Wisconsin Card Sorting Test). Hyperactive children showed significant deficits on both measures. After a year of psychostimulant medication, the hyperactive children all showed clinical and neurocognitive improvement, but continued to show a selective attention deficit compared with normal children. The results indicate a dissociation between the cognitive processes measured by the Wisconsin test and selective attention as measured by the Stroop, and that the selective attention deficit is more resistant to psychostimulant intervention.

Measures of attention deficit. Part II: Clinical perspectives and test interpretation

After a detailed behavioral and developmental history has been supplemented by the use of formal questionnaires, the diagnosis of an attentional disorder can be further clarified by the judicious selection of psychoeducational and pediatric physical and neurodevelopmental examinations. The most common difficulty in the interpretation of psychoeducational test subscores and profiles is the significant overlap between the patterns generated by attentional deficits and those associated with memory-based learning disabilities. Certain other medical and behavioral conditions need to receive careful consideration prior to finalizing the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). A thorough but focused general examination coupled with the pediatric neurodevelopmental examination can contribute to this differentiation.

Behavior therapy with children and adolescents: a twenty-year overview

A twenty-year overview of behavior therapy with children and adolescents is presented. The various techniques and their application to relevant major DSM-III-R categories are critically discussed. It is concluded that behavior therapy has made great progress and has proven applications in child and adolescent disorders but that its precise roles, comparative efficacy, and complementarity to other forms of psychotherapy and other treatments remain to be demonstrated. Much uncertainty stems from the relatively poor state of research in other forms of psychotherapy.

Piagetian conservation and response to cognitive therapy in attention deficit disordered children

Cognitive therapy is often used in treating attention-deficit-disordered (ADD) children because of its purported ability to address this population's attentional deficits and behavioral difficulties and to create durable therapeutic effects. Nonetheless, research findings on these treatments have been inconsistent. This study sought to explain these inconsistencies by examining the influence of cognitive development on children's ability to benefit from such treatment. The ability to conserve number and substance was shown to influence treatment outcome, as measured by laboratory tasks of cognitive style and impulsivity. No effects were found on standardized academic achievement measures or on behavioral ratings by teachers or parents. Further study of individual development will be important in understanding the outcomes of cognitive therapy.

Psychophysiological effects of methylphenidate (Ritalin)

The nature and psychophysiological effects of methylphenidate whose metabolism, pharmacokinetics, and effects on human behavior are not well known are the focus of this review. Methylphenidate treatment of attention deficit disorder with hyperactivity is presented summarily.

Cognitive styles of school-age children showing attention deficit disorders with hyperactivity

Attention deficit disorder with hyperactivity (ADDH) children (23 boys and 5 girls) and 28 normal children (23 boys and 5 girls) were matched by age. The ADDH group had a mean score of 2.06 on the hyperactivity scale of the Parent Symptom Questionnaire; a mean score of 1.5 is accepted as the lower limit for establishing hyperactivity. Both groups were individually administered The Wechsler Intelligence Scale for Children—Revised, Children's Embedded Figures Test, and Matching Familiar Figures Test. No significant difference appeared on the Matching Familiar Figures Test, a measure of cognitive styles of reflection-impulsivity with intelligence statistically controlled; however, a significant main effect was found on the Children's Embedded Figures Test which suggests that ADDH children are field-dependent. Some therapeutic implications were discussed.

Methylphenidate and cognitive therapy with ADD children: a methodological reconsideration

The present double-blind study examined the effects of methylphenidate, cognitive therapy, and their combination in attention deficit-disordered (ADD) children. Four treatment groups were compared on measures of attentional deployment and cognitive style, tests of academic achievement, and behavioral rating scales. In contrast to a previous study conducted in this laboratory, children in this study were not receiving medication during post-testing. Results were interpreted to suggest that measurable effects of stimulant medication dissipate rapidly upon discontinuation of pharmacotherapy. The combination of methylphenidate and cognitive therapy was not found to be any more efficacious than either of the treatments studied alone. Discussion suggests that medication status at follow-up is an essential feature of research design.

Cognitive-behavioral approaches to children's problems

Selected issues in theory, research, methodology, assessment, and outcome are briefly discussed in the context of cognitive-behavioral approaches to children's problems. Distinctions between rationalistic and developmental varieties of cognitive approaches are delineated. Different assumptions are explored regarding the function and nature of cognitive processes, the nature and mechanisms of psychological change, and the relationship between cognitive and emotional processes. It is concluded that the empirical status of cognitive-behavioral approaches to children's problems is equivocal. The theoretical status of traditional (rationalistic) cognitive treatments is also challenged, and developmental, process-oriented conceptualizations and research are endorsed as more adequate and promising perspectives in this area.

Conceptual, methodological, and clinical issues in cognitive-behavioral assessment

This article reviews cognitive-behavioral assessment principles and procedures. The functions of such assessments are noted, and issues and advances in cognitive assessment are discussed. The need for integrated cognitive, behavioral, and affective assessments is then explored. Finally, conceptual methodological, and clinical issues in the integration of assessments and study of reciprocal determinants are presented.