** A New Treatment for Children with Inattentive ADHD: Encouraging Findings **

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Subject: ** A New Treatment for Children with Inattentive ADHD: Encouraging

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**** ATTENTION RESEARCH UPDATE ****

**** January 2008 - A New Treatment for Children with Inattentive ADHD:

Encouraging Findings ****

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Dear Subscriber,

I hope that you had an enjoyable holiday and that the New Year is off to a good

start.

This issue of Attention Research Update reviews a recent study of a hew

home-school behavioral intervention for children with the inattentive type of

ADHD, i.e., children with high levels of inattentive symptoms but who do not

also show high rates of hyperactive-impulsive behavior. This is an important

study because despite the hundreds of medication and behavioral studies

conducted on children with ADHD, there has been remarkably little work that has

looked at treatment for inattentive children specifically. In fact, the MTA

Study - which is the largest treatment study of ADHD ever conducted - was

restricted to children with the combined type of ADHD, i.e., those who showed

high rates of both inattentive and hyperactive-impulsive symptoms. Thus, the

extent to which the behavioral intervention results from MTA would apply to

children with the inattentive form of ADHD are unknown.

As you will see below, the authors report some encouraging results for their

newly developed intervention.

*** Newsletter Sponsor - Thanks to Cogmed for supporting Attention Research

Update ***

Cogmed, a company I consult with closely,is introducing a new approach to help

children and adults with attention deficits that involves computerized training

of working memory, which is a key cognitive ability that underlies many

important tasks. You will find additional information about Cogmed Working

Memory Training below at the end of this issue. I encourage you to learn more

about this new training approach that has growing research support by visiting

www.cogmed.com.

Thanks again for your ongoing interest in the newsletter. I hope that you enjoy

today's issue.

Sincerely,

Rabiner, Ph.D.

Senior Research Scientist

Duke University

Durham, NC 27705

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** A New Treatment for Children with Inattentive ADHD: Encouraging Findings **

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The core symptoms of ADHD are inattention and hyperactivity-impulsivity.

Although most children with ADHD struggle in both areas, and are diagnosed as

having the combined subtype of ADHD, a substantial number show high levels of

inattentive symptoms only. These children are frequently described as having ADD

rather than ADHD; technically, however, the correct term is ADHD, Predominantly

Inattentive Type, or ADHD-I.

Some prominent ADHD researchers have suggested that although children with the

inattentive and combined subtypes of ADHD both show high rates of attention

difficulties, these are really very different disorders. Children with the

inattentive type tend of have more severe alertness/orientation problems,

including more symptoms of sluggish cognitive tempo and slower processing speed.

Socially, they are less aggressive but more highly withdrawn and passive and may

have even greater social difficulties.

Given the large number of ADHD treatment studies that have been conducted it is

surprising to note how little work has focused exclusively on treatment for

children with ADHD-I. The limited evidence that is available for the treatment

of ADHD-I is focused primarily on stimulant medication and initial results

suggest that medication treatment is about as effective for these children as

for children with the combined type of ADHD.

Behavioral interventions for children with ADHD-I, however, have not previously

examined and this is an important gap in the literature. The literature on

behavior therapy for ADHD has focused on evaluating programs that have been for

children whose ADHD includes both inattentive and hyperactive-impulsive

symptoms. These children have substantially greater problems with aggression and

other forms externalizing behavior than children with ADHD-I and tend to have

different types of social difficulties. Thus, programs that may be effective for

them may not adequately target the different types of problems experienced by

children whose difficulties are restricted to inattention.

Given the absence of research on behavioral therapy for children with

inattentive ADHD, a study published in a recent issue of the Journal of the

American Academy of Child and Adolescent Psychiatry represents an important

addition to the field [Pfiffner, L., et al. (2007). A randomized, controlled

trial of integrated home-school behavioral treatment for ADHD, Predominantly

Inattentive Type. JAACAP, 46, 1041-1050.]

Participants were 69 2nd-5th grade children (23 females) all of whom were

diagnosed with ADHD-I. The sample had a good representation of minorities and

included families from a wide range of socioeconomic backgrounds. Only 2

children were taking medication at the beginning of the study and none began

medication during the 12-week program.

Participants were randomly assigned to the newly developed intervention called

the CLAS Program (Child Life and Attention Skills) or to a " treatment as usual "

control group. (Unfortunately, details on what treatment as usual consisted of

are not provided.) Unlike existing behavioral treatments for ADHD, The CLAS

Program was designed to target the most prominent difficulties for children with

ADHD-I and included the three inter-related components described below.

- Teacher Consultation -

Each child's teacher was given an overview of behavioral interventions and

classroom-based accommodations for ADHD-I, followed by 4-5 1/2 hour meetings of

teacher, parent, child, and therapist over 12 weeks. In addition, a daily report

card system in which teachers rated key target behaviors for each child, e.g.,

completion of assigned work, accuracy of completed work, appropriate social

behavior) was implemented so that parents were kept informed of their child's

progress in these key areas. This enabled parents to reward children on a daily

basis for attaining important classroom goals. Environmental and academic

accommodations such as preferential seating, reduction in assigned work, help

with organization) were provided as needed to each child.

- Parent Training -

A 12-week parent-training program that included 6-8 families began with an

overview of ADHD-I followed by a set of strategies for managing ADHD-I and

associated impairments. Strategies covered included the use of positive

attention, rewards, establishing effective routines, planning activities, giving

directions and commands, and using prudent negative consequences.

In contrast to parent training programs developed for children with the combined

type of ADHD, where acting out behavior problems are more common, there was less

focus on disciplinary strategies and greater focus on improving homework

routines, independence, and organizational and time-management skills to improve

academic performance. Parents were also taught ways to promote and reinforce

their child's use of social skills that were covered in the children's groups

(see below).

- Child Skills Training -

The Child Skills Training Groups met concurrently with the parent training

groups. Child groups were divided into modules focused on skills for

independence, e.g., academic, study and organizational skills) and skills for

social competence, e.g., being a good sport, combating " spaciness " , being

assertive, dealing with teasing, and initiating friendships.

Each module provided children with knowledge about the specific skills being

addressed as well as providing ample opportunity for rehearsal and practice.

Children were helped to become more " alert " by group-reinforced attention checks

during which the children were prompted to repeat the last comment made or the

last activity that had occurred. Role-plays of common problem situations for

children with ADHD-I were included in each module. Each week children brought in

a record of rewards they had earned at home and school to exchange for rewards

in the group setting. This was done both to motivate the children and to promote

the generalization of desired behaviors across settings.

- Measures -

A wide variety of measures were collected before, immediately following, and

approximately 4-6 months after treatment ended to evaluate the impact of the

CLAS program. The primary outcome measure was the average ratings made by

parents and teachers for the 9 inattentive symptoms of ADHD. Parents and

teachers also completed ratings of behavior indicative of " sluggish cognitive

tempo " , e.g., daydreaming, lost in a fog, sluggish/drowsy, which were also

averaged.

In addition to these primary outcomes, parents and teachers rated each child's

social skills, organizational skills, and overall degree of improvement. As with

the primary outcome measures, parent and teacher ratings for these secondary

measures were averaged.

- Results -

Compared to the treatment as usual group, children in CLAS showed a significant

decline in DSM-IV inattentive symptoms. Both groups started with an average of

approximately 6.3 symptoms (out of 9) before treatment. Immediately following

treatment this had dropped to 3.0 symptoms for the CLAS group and to 5.1

symptoms for the control group. Symptoms levels at follow up were 3.2 and 4.4

respectively. Following treatment, 55% of the treated group had scores in the

normal range compared to only 27% of the control group. Similar results were

found for ratings of sluggish cognitive tempo.

In addition to these positive results for the primary outcome measures, children

in the CLAS group were also rated as showing greater improvement in social

skills, organizational skills, and on overall impressions of improvement.

Finally, all parents rated their overall level of satisfaction with the CLAS

program as " very satisfied " and all but one rated their child's attention

problems as improved. More than 90% rated the strategies and skills taught as

either " useful " or " very useful " . The vast majority of children - roughly 80% -

reported enjoying the program and that it helped them to do better at home and

school.

- Summary and Implications -

Results from this study support the efficacy of behaviorally based psychosocial

treatment for children with ADHD-I. As noted above, the CLAS Program " ..led to

statistically and clinically significant reductions in attention problems and

improvement in organizational and social skills relative to the control group,

and these reductions were maintained at follow-up. " The magnitude of the effect

on inattentive symptoms was similar to what has been reported in studies of

stimulant medication treatment for children with ADHD-I.

These are extremely encouraging results and the authors are to be commended for

developing and beginning to evaluate a psychosocial intervention specifically

geared to children with ADHD-I. There are several important limitations to this

study, however, several of which are acknowledged by the authors, which makes it

premature to consider this an established treatment.

First, there is limited information provided on the services received by

children in the treatment as usual control group. We are told that only 2 of

these children began medication during the study, which is a strikingly low

rate. How results for the CLAS Program would compare to children who received

adequate medication treatment is thus unknown.

Second, because the authors averaged parent and teacher ratings for all

outcomes, it is not possible to know whether similar improvements were observed

by both parents and teachers, or whether the overall effects were primarily

attributed to greater improvements seen by only one of these groups. In

particular, because parents committed significant time to the program, it is

possible that they were " biased " to see improvement in their child. If both

parents and teachers observed similar improvements, this would be quite

impressive but the data is not presented in a way that enables this to be

determined.

Third, there were no objective measures provided of children's academic

performance. Thus, whether the program resulted in tangible gains in children's

academic success is unknown.

Despite these important limitations, results from this study are certainly

encouraging and suggest that a psychosocial intervention that specifically

targets the difficulties experienced by children with ADHD-I can be effective.

As the authors note, " future randomized, controlled trials are needed to compare

and contrast the CLAS Program and medication treatment and examine their

combination in multimodal approaches to identify the most efficacious approach

to treating ADHD-I over time. " As such studies are hopefully published, I will

be sure to include them in future issues of Attention Research Update.

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** Sponsor's Message from Cogmed **

** Learn About Working Memory Training from Cogmed - A New, Research-Based

Intervention for Children and Adults with Working Memory Problems and Attention

Deficits **

Working memory - the ability to hold information in one's mind for subsequent

use - is a cognitive skill that is important for a variety of learning related

tasks. Cogmed, a company I consult with, is introducing a computerized training

program for working memory as a new intervention to help children and adults

with ADHD and/or working memory difficulties.

The use of working memory training for individuals with ADHD is based on several

interrelated findings:

1) A number of studies have documented that individuals with ADHD show

significant deficits in working memory; 2) Accumulating research evidence that

working memory is a cognitive skill that can be improved with practice; and, 3)

Improvements in working memory functioning have been shown to be associated with

meaningful declines in ADHD symptoms and enhanced functioning for many

individuals with ADHD.

Working memory training has been offered for several years in Europe and is now

being introduced to the US by Cogmed via a growing network of carefully selected

clinics. This is an intensive 5-week program that children and adults complete

in the convenience of their home with support provided by a Cogmed-trained

coach.

Although I do not endorse or recommend any specific intervention for ADHD,

working memory training represents a new and promising approach that nicely

complements existing interventions for attention and learning problems. You can

learn more about this new treatment approach by visiting www.cogmed.com

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Thanks again for your ongoing interest in the newsletter. I hope you enjoyed the

above article and found it to be useful to you.

Sincerely,

Rabiner, Ph.D.

Senior Research Scientist

Center for Child and Family Policy

Duke University

Durham, NC 27708

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© 2008 Rabiner, Ph.D.

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