Indian Pediatrics - Editorial

Personal Practice

Indian Pediatrics 1998; 35:989-999

Attention Deficit Hyperactivity Disorder in School Aged Children: Approach and Principles of Management

Pratibha Singhi
Prahbhjot Malhi

From the Department of Pediatrics, Post Graduate Institute of Medical Education and Research Chandigarh 160012, India.

Reprint requests: Dr. Pratibha Singhi, Additional Professor and In-charge Neurodevelopment Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research,
Chandigarh 160012, India.

With increasing awareness about developmental disorders, pediatricians are often called upon for the management of children with attention deficit hyperactivity disorder (ADHD). It is a common problem seen in about 3 to 10 per cent of school age children in the West(1,2). In India, only a few studies have evaluated ADHD and they report prevalence rates ranging from 5 to 10 percent (3,4). It is 4-6 times commoner in boys as compared to girls(l,4). Unless managed properly it can be very disturbing to the parents and can lead to considerable secondary problems in the child such as low academic achievement, retention in grade, conduct and emotional problems and impaired social competence as they progress into adolescence and young adulthood(5,6). In this article we present an approach to and principles of management of children with ADHD based on recent literature and our own experience.

What is ADHD?

ADHD is characterized by developmentally inappropriate levels of inattentiveness, impulsivity and motoric activity that appears in at least two contexts (e.g., home and school) and has been present for at least six months before the age of seven years(7). In order to meet the criteria of ADHD it is important that the symptoms must be more frequent and severe than those of children of comparable develop- mental level and must cause significant functional impairment.

Currently, three types of Attention Deficit/Hyperactivity Disorders are recognized(7):

1. Attention Deficit/Hyperactivity Disorder, combined type.

2. Attention Deficit/Hyperactivity Disorder, predominantly inattentive type.

3. Attention Deficit/Hyperactivity Disorder, predominantly hyperactive impulsive type.

The most common type among school children is predominantly inattentive type followed by combined subtype and pre-dominantly hyperactive type(l,2). The diagnostic criteria are listed in Table I.

Earlier it was believed that children with ADHD outgrow their symptoms by adolescence(8). However, in recent years it has become increasingly evident that children with ADHD have a high risk for the continuation of their primary symptoms into adolescence and adulthood(9).

TABLE I-Diagnostic Criteria for Attention Deficit Hyperactivity Disorder (DSM-IV)

A) Either (1) or (2):
1. Six (or more) bf the following symptoms of inattention occur often and have persisted for at least 6 months

Inattention

(a) Failes to give close attention to details.
(b) Has difficulty sustaining attention in tasks or play activities.
(c) Does not seem to listen when spoken to directly.
(d) Does not follow through on instructions and fails to finish school work, chores, or duties in the workplace.
(e) Has difficulty organizing tasks and activities.
(f) Avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort.
(g) Loses things necessary for tasks or activities.
(h) Is often easily distracted by extraneous stimuli.
(i) Is forgetful in ,daily activities:
2. Six (or more) of the following symptom of hyperactivity/impulsivity occur often and have persisted for at least 6 months. '

Hyperactivity

(a) Fidgets with hands or feet or squirms in seat.
(b) Leaves seat in classroom or in other situations in which remaining seated is expected.
(c) Runs about or climbs excessively in situations in which it is inappropriate.
(d) Has difficulty playing or engaging in leisure activities quietly.
(e) Is "on the go" or acts as if "driven by motor".
(f) Talks excessively.

Impulsivity

(g) Blurts out answers before questions have been completed.
(h) Has difficulty awaiting turn.
(B) Some hyperactive impulsive or inattentive symptoms that caused impairment were present before age 7 years.
(C) Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
(D) There must be clear evidence of clinically significant impairment in social, academic or occupational functioning.
(E) The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Pyschotic Disorder and are not better accounted for by another mental disorder.

Types

Attention-Deficit/Hyperactivity Disorder, Combined type: If both criteria Al and A2 are met for the past six months.
Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: If criterion Al is met but criterion A2 is not met for the past six months.
Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive Impulsive Type: if criterion A2 is met but criterion Al is ,not met for the past six months.

What Causes ADHD?

The exact etiology of the disorder is unknown(10). Research indicates that there is no single, primary cause which is associated with ADHD in all children. Indeed the disorder is heterogeneous both in its etiology and symptomatology.

Alteration in the function and/or structure of the frontal lobes has been demonstrated in a number of studies(11). Diminished blood flow on single Photon Emission Computerized Tomography(12) as well as diminished oxygen and glucose metabolism on Positron Emission Tomography have been found(13). Unusual electrical activity on Neurometrics(14) and smaller frontal lobes (particularly on the right side) and corpus callosal abnormalities on MRI(15) have also been found.

Several investigators argue that ADHD is a result of a complex interplay of biological and psychosocial factors(10). Biological risk factors that have been extensively investigated include inherited or congenital predisposition and neurotransmission dysregulation. Genetic factors have also been studied and there is some evidence to indicate that ADHD runs in families(16). Efforts to isolate a gene for ADHD have not met with success so far, although research is ongoing(17). Child rearing and socialization practices have also been implicated in the causation of ADHD(18); however, evidence is equivocal(19). Some environmental risk factors such as lead toxicity and food additives ingestion have also been investigated but none have received any empirical support(20).

Associated Difficulties in Children with ADHD

Children with ADHD display several other difficulties in addition to their core symptoms. It is now well established that two thirds of ADHD children have at least one other diagnosable psychiatric disorder(21,22). A significant number are academic underachievers and meet the criteria for learning disabilities(23,24). Among children diagnosed with ADHD, 36 to 50 per cent meet the criteria for oppositional defiant disorder(25) and 25 per cent have a comorbid specific developmental disorder(27). Moreover, a sizeable proportion also meet the criteria for anxiety and depressive disorder(28).

Evaluation

Although, the cardinal features. of ADHD are clearly defined, objective measures and differential diagnostic procedures are lacking. Since attention deficit symptoms can occur due to a wide variety of underlying conditions, a comprehensive approach to the evaluation of a child with ADHD involves several components including medical evaluation, assessment of specific components of attention and behavior, evaluation of cognitive and academic functioning; and assessment of secondary vumerabilities(29).

(i) A detailed history regarding the child's behavior in specific situations is elicited. Psychosocial aspects like academic and behavior problems in school, and sibling and peer relation- ships, fears, reactions to unfamiliar unpleasant situations, discipline in school and at home, etc. are inquired in depth.

(ii) Details of birth and developmental history are then elicited. Often it is found that these children have had difficult temperament and behavior since infancy(30). Infantile colic, feeding difficulties, sleep abnormalities, over activity, temper tantrums, etc. have generally been present in infancy. As the child enters preschool or school, most of the symptoms detailed in Table I are noticed.

'(iii) Complete physical and neurological examination is undertaken particularly to rule out other conditions which may be responsible for the child's problem, namely, mild mental sub-normality, deficits of hearing and/or vision or any other neurologic deficit. Some" soft neurological signs" may be found, e.g., overflow movements, dysdiadochokinesia, poor balance, etc. but their exact significance is not known.

(iv) Psychometric tests are asked for to assess (a) overall intelligence score (IQ), (b) skills in language, visuo-spatial organization, sequential analysis and motor tasks. Standardized intelligence tests such as Indian adaptations of Wechsler Intelligence Scale for children(31) and Standford Binet Intelligence Scale(32) are recommended. In addition, Draw-a-Man test(33), Colored Progressive Matrices(34) and Bender Gestalt Test(35) may also be used. Specific tests for achievement, learning disability, etc. may be needed in some cases. Several rating scales specific to attention deficit disorder have been developed while others evaluate broad band emotional and .behavioral dimensions. Rating scales are extremely useful as adjuncts to the diagnostic interview. However, no single scale is perfect nor can any scale make a diagnosis of ADHD. Table II lists some of the commonly used psychological scales grouped into two categories: Parent and Teacher questionnaires(36-39).

(v) Psychosocial evaluation of the family and assessment of school environment is needed for planning appropriate intervention measures.

TABLE II - Parent and Teacher Rating Scales

Parent Rating Scales

Conners Parent Rating Scale
Child Behavior Checklist
Yale Children's Inventory Home Situations Questionnaire

Teacher Rating Scales

Conners Teacher Rating Scale
Child Behavior Checklist-Teacher Form School Situations Questionnaire

Differential Diagnosis

The diagnosis of ADHD is essentially clinical and is generally not difficult. There are no specific laboratory tests to confirm or exclude the diagnosis. Since many symptoms of ADHD are relatively non-specific, one must rule out the presence of other psychiatric disorders, developmental disorders, neurological and medical conditions and determine whether they are comorbid or whether they are mimicking "true" ADHD(40).

In young children, it is easy to mistake developmental delay, mental retardation, and borderline intellectual functioning for the signs of ADHD, although these conditions often co-occur( 41). Seizure disorders including Petit Mal or partial complex seizures may be mistaken for ADHD(41). Sensory deficiencies especially hearing or visual impairment can also mimic ADHD(40). Physical causes of poor attention may include acute or chronic illness, poor nutrition or sequelae to head trauma(40). Antiepileptic drugs such as phenobarbital may also interfere with attention(42).

Children with Tourettes disorder may be distraced by the effort to resist tics(40). Anxiety disorders, depression can also interfere with attention(40). Some normal children may have a difficult temperament and may be mistakenly labelled ADHD(43). Finally, adverse environmental factors such as family stresses, ineffective parenting, marital conflicts also cause in- attentiveness in a child and must be considered in the differential diagnosis of ADHD(29).

Management

The management of children with ADHD often poses a challenge to the pediatrician. Over the years, several treatment have been tried including dietary interventiors like Feingold-diet and mega-vitamin therapy. However, there is no scientific evidence to support their use(40). Several therapeutic approaches have been combined and research indicates that a multimodal approach combining medical and psychosocial management is more effective than any single form of inter- vention(29,44,4S). This requires the co-ordinated efforts of a team comprising of the pediatrician, clinical psychologist, educators and of course the parents. An individualized plan of management is made with specific outcome goals depending on the age of the child, severity of symptoms, and nature and degree of associated problems.

Medication

Psychostimulants are the treatment of choice among the pharmacological interventions for ADHD(46). The three psychostimulants that are usually used are methylphenidate, dextroamphetamine and pemoline. About 70-80 per cent children show a positive response to stimulants with increase in attention, decrease in hyperactivity, and improvement in behavior and visual motor skills(40,41). Behavioral changes are seen within 1/2-1 hour of oral ingestion and therapeutic effects last from 4 to 8 hours. Close attention to intake of adequate calories and timing and dosage of medication prevents the weight loss which can occur with stimulant use. The drugs are usually given at breakfast, and lunchtime. Their dosages are shown in Table III. Side effects include anorexia, abdominal discomfort and headache but these generally disappear after few days. Growth suppression after long term usage has been re- ported. It is, therefore, recommended to stop the medication for a few weeks during vacations. This also gives an observation period to re-evaluate the child for the need of further medication.

TABLE III - Medications Used in children with ADHD

Medication	Dosage (mg/kg/24 h)	Comment	Monitor	Side effects
1. Stimulants
(i) Methylphenidate	0.3-1.0	Given 20-30 min before meals. Not given after 4 P.M.	Heart rate, BP, growth parameters	Nervousness, Jitteriness, abdominal discomfort, sleeplessness, anorexia, preipitation of tics, long term growth suppresion, ↑ Heart rate.
(ii) Dextroamphetamine	0.2-0.5	Used if methylphenidate not effective/side effects	Liver functions	Hypersensitivity reactions usually involving the liver
(iii) Pemoline	1-3 or 18.75 mg initial ↑ by 1.2, tab/week maximum 112.5 mg/24h	Prolonged duration of action	ECG, BP
2. Antithypertensive
Clonidine	0.05-0.3 (4-5 µg/kg/24 h)	Particularly effective in Adhd with combined tic disorder	BP, heart rate	Bradycardia, hypotension, sedation
3. Tricyclic antidepressants
Desipramine/ Imipramine	1-4	Used if stimulants ineffective or ADHD with depressive symptoms	ECG, BP, Drug level	Cardiac arrhythmias, sudden death

For children with excessive aggression, hyperactivity, tics and sleep difficulties, clonidine (1-4 µg/kg/day) is useful(47). Open trials suggests that it is most useful in combination with a stimulant, especially when the stimulant response is partial, or when the stimulant dose is limited by side effects ( 48).

Children with ADHD and co-morbid anxiety disorders or depression have been found to respond better to tricyclic antidepressants than to stimulants(49). Adverse side effects of tricyclics include cardiovascular effects, gastric distress, dizziness, urinary retention and decreased seizure threshold(41) and hence should be used with caution.

Selective Serotonin Reuptake Inhibitors may also be useful in children with associated depression, anxiety or obsessive compulsive disorders (40). Buspirone has also been tried and we have found it useful in a few cases.

Although stimulants are quite effective when they are being used, there is, considerable controversy regarding the long term gains as the benefits rapidly dissipate once the medication is withdrawn(50).

Psychosocial Interventions

These include

(i) Parent Training

Parent behavior modification training programmes, based on social learning principles, have been developed for parents of non-compliant, aggressive ADHD children(51). The parents are advised about home interventions which entail modification of the daily routine and home environment of the child and implementation of behavior management techniques. A structured daily routine is charted out for the child. Praise, affection and other rewards are given to the child for successful efforts to maintain positive behavior. Some guidelines for parents are depicted in Table IV.

Such training is supplemented by providing parents reading material which describes in detail behavior contingency management techniques(40). Parents are also instructed to work in close collaboration with school teachers. Ideally the training consists of weekly sessions with parents in the clinics and weekly sessions with teachers for 8-20 weeks.

Parent training has been found to be associated with several positive effects including reduction in disruptive behavior and improvement in parents' self confidence(52). Although, parent training programmes have been associated with clinical improvement in children as assessed by parents' and teachers' reports, these children do not fall within the normal range of functioning(53,54). This is partly due to non compliance by the parents, with the suggested management regimen thus leading to only partial success of the program.

(ii) Child Training.

Cognitive behavioral procedures have gained importance in the management of ADHD children in recent years(55). These procedures are designed to foster planned self regulated behavior through self-instructional and self-monitoring strategies which foster a more reflecting, problem solving style in ADHD children. The children are explicitly trained to "talk to themselves" in order to slow down, approach a task logically, analyze the task components and self-reward. Key aspects of the programme include cognitive modelling by an adult trainee, overt and covert rehearsal by the child, feedback and social reinforcement(55). Despite initial enthusiasm with cognitive behavioral procedures, a number of investigators have reported that this treatment approach has not led to significant cognitive, behavioral, or academic enhancement in the ADHD children(56). Psychologist trained in the understanding of ADHD can help in applying effective behavior management techniques.

TABLE IV - Some Guidelines for Parents' of Children with ADHD

1. Formulate a regular daily routine and ensure that the child follows it.
2. Give short term simple tasks and on completion, praise the child.
3. Avoid over stimulation and excessive fatigue. Give time for relaxation.
4. Keep valuable, breakable and dangerous articles out of reach of the child.
5. Ensure quiet and peaceful bedtime. Avoid exciting T.V. programmes, games
    during night.
6. Encourage peer relationships and teach social skil.ls.
7. Give clear instructions and positively reinforce good behavior.
8. Use more salient, frequent and immediate consequences for appropriate and
     inappropriate behavior.
9.   Provide time and opportunity for the child to express his creativity.
10. Be loving but also consistent and firm with the child.

(iii) Role of Teachers

Since ADHD children are often first noticed in the school context because of the greater demands for attention and self- regulatory behavior that the school imposes on the child, the teacher is one of the key players in the management of ADHD children. In our country, active involvement of school teachers is often not easy. Nevertheless, the doctor can. persuade the school authorities for some co-operation in the management of the child by providing simple guidelines which are give in Table V.

Outcome

Although ADHD can be managed, it is not really 'cured'. About 80 per cent of children with ADHD continue to fulfill some criteria of the disorder as adolescents(S7) and frequently have problems in adult-hood(40). Most children, however, learn to cope with ADHD and so will not need ongoing stimulant medication. Early identification and treatment prevents or minimizes many of the negative effects of the disorder.

Conclusion

The evaluation and management of a child with ADHD involves a multi- disciplinary team effort. A combination of stimulants and psychosocial interventions in which the parents and teachers work as partners with the pediatrician and clinical psychologist, can help a vast majority of children with this disorder.

TABLE V - Some Guidelines for Teachers for Managing Children with ADHD

1. Structure the classroom environment and child's routine.
2. Seat the child near the teacher's desk and make frequent eye contact.
3. Allow intermittent activities like cleaning the blackboard, distributing papers, etc.
4. Teach concepts, reduce memory burden.
5. Give one task at a time with simple, precise directions.
6. Divide work into "small chunks" with frequent breaks.
7. Use simple behavior modification techniques to reinforce positive behavior.
8. Give regular non-accusatory feedback to child regarding his attentional control.
9. Permit child to do something with his hands while engaged in sustained listening. 10. Promote the child's strengths and praise his achievements to build his self
confidence.

References

1. Baumgaertel A, Wolraich ML, Dietrich M. Comparison of diagnostic criteria for attention deficit disorders in a German elementary school sample. J Am Acad Child Adol Psychiatry 1995; 34: 629-638.

2. Wolraich ML, Hannah JN, Pinnock TY, Baumgaertel A, Brown J. Comparison of diagnostic criteria for attention deficit hyperactivity disorders in a country-wide sample. J Am Acad Child Adol Psychiatry 1996; 35: 319-324.

3. Malhotra S, Chaturvedi SK. Patterns of childhood psychiatric disorders in India, Indian J Pediatr 1984; 51: 235-239.

4. Bhatia MS, Nigam VR, Bohra N, Malik Sc. Attention deficit disorder with hyperactivity among pediatric outpatients. J Child Psychol Psychiatry 1991; 32: 297- 306.

5. Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria: 1. An 8 year prospective follow-up study. J Am Acad Adol Psychiatry 1990; 29: 546-557.

6. Fischer M, Barkley RA, Edelbrock, CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria: II Academic, attentional, and neuropsychological status. J Consult Child Psychology 1990; 58: 580-588.

7. American Psychiatric Associaton. Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV). Washington DC, American Psychiatric Association, 1993; pp 63-65.

8. Laufer MW, Denhoff E. Hyperkinetic behavior syndrome in children. J Pediatr 1957;50:463-474.

9. Gittelman R, Mannuzza S, Shenker R, Bonagura N. Hyperactive boys almost grown up; 1. Psychiatric status. Arch Gen Psychiatry 1985; 42: 937-947.

10. Cantwell DP. Attention deficit disorder: A review of past 10 years. J Am Acad Child Adol Psychiatry 1996; 35: 978-987.

11. Hynd GW, Semrud-Clikeman M, Lorys AR, Novay ES, Elloplus D. Brain morphology in developmental dyslexia and attention deficit disorders with hyperactivity. Arch Neuro11990, 47: 919-926.

12. Lou HC HenriKsen L, Bruh P. Focal cerebral dysfunction in developmental learning disabilities. Lancet 1990; 335: 8-11.

13. Zametkin AI, Nordahl TE, Gross M. Cerebral glucose metabolism in adults with hyperactivity of childhood onset. N Engl J Med 1990; 153: 1361-1366.

14. Mann CA, Lubar JF, Zimmerman AW, Miller CA, Muenchen RA. Quantitative analysis of EEG in boys with attention deficit/hyperactivity disorder: Controlled study with clinical implication. Pediatr Neuro11992; 8: 30-36.

15. Castellanos FX, Giedd JN, Marsh WH, Hamburger SD, Vaituzis AC. Quantitative brain magnetic resonance imaging in attention deficit hyperactivity disorder. Arch Gen Psychiatry 1996; 53: 607-616.

16. Biederman J, Baldessarini RI, Wright V, Knee D, Harmatz JS. A double-blind placebo controlled study of desipramine in the treatment of ADD: 1. Efficacy. J Am Acad Child Adol Psychiatry 1989; 28: 777- 784.

17. Alessi N, Hottois, MD, Coates DO. The gene for ADHD? Not yet! J Am Acad Child Adol Psychiatry 1993; 32: 1073- 1074.

18. Whalen, CK. Attention deficit and hyperactivity disorder. In: Handbook of Child Psychopathology, 2nd edn. Eds. Ollendick TH, Hersen M New York, Plenum, 1989;pp 131-169.

19. Paternite CE, Loney J. Childhood hyperkinesis: Relationship between symptomatology and home environment. In: Hyperactive Children: The Social Ecology of Identification and Treatment. Eds. Whalen CK, Henker B. Orlando, Academic Press, 1980; pp 105-141.

20. Arnold LE, Jensen PS. Attention deficit disorders: In: Comprehensive Textbook of Psychiatry, Eds. Kaplan HI, Sadock BJ. Baltimore, Williams and Wilkins, 1995; pp 2295-2310.

21. Cantwell DP. Therapeutic Management of Attention Deficit Disorder: Participant Workbook, New York, SCP Communication, 1994; pp 4-20.

22. Nottelmann E, Jensen P. Comorbidity of disorders in children and adolescent. Adv Clin Child Psychology 1995; 17: 109-155.

23. Cantwell DR, Satterfield JH. The prevalence of academic underachievement in hyperactive children. J Pediatr Psychology 1978; 3: 168-171.

24. Hinshaw SP. Externalizing behavior problems and academic underachievement in childhood and adolescence: Causal relationships and underlying mechanisms. Psychol Bull 1992; 111: 127- 155.

25. Munir K, Biederman J, Knee D. Psychiatric comorbidity in patients with attention deficit disorder: A controlled study. J Am Acad Child Adol Psychiatry 1987; 6: 844- 848.

26. Szatmari P, Offord DR, Boyle MH. Ontario Child Health Study: Prevalence of attention deficit hyperactivity disorder with hyperactivity. J Child Psychol Psychiatry 1989; 30: 219-230.

27. Holborow PL, Berry PS. Hyperactivity and learning disabilities. J Learning Disab 1986; 19: 426-431.

28. Anderson J, William S, McGee R, Silva P. DSM-IIl disorders in pre-adolescent children, Arch Gen Psychiatry 1987; 44: 69- 76.

29. Kelly DP, Aylward GP. Attention deficits in school-aged children and adolescents. Pediatr Clin North Am 1992; 39: 487-512.

30. Weiss G. Hyperactivity: Overview and new directions. Pediatr Clin North Am 1985; 8: 737-753.

31. Malin AJ. Malin's Intelligence Scale for Indian Children. Child Guidance Centre, Nagpur, 1969.

32. Kulshreshta SK. Manual of Stanford-Binet Intelligence Scale, Hindi Adaptation. Allahabad, Manav Sena Sansthan Prakashan, 1971.

33. Phatak P. Draw-a-Man Test for Indian Children. Pune, Natraj, 1993.

34. Raven JC. The Coloured Progressive Matrices Test. London, Lewis, 1960.

35. Koppitz EM. The Bender Gestalt Test for Young Children. New York, Grune and Stratton, 1964.

36. Conners CK, Manual for Conner's Rating Scales. North Tomananda, New York, Multi Health Systems, 1989.

37. Achenback TM, Edelbrock e. Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, University of Vermont, 1983.

38. Shaywitz SE, Shaywitz BA, Schnell e. Concurrent and predictive validity of the Yale Children's Inventory: An instrument to assess children with attentional deficits and learning disabilities. Pediatrics 1988; 81: 562-571.

39. Barkely RA, Edelbrock e. Assessing situational variation in children's problem behavior: The home and school situations questionnaires. . In: Advances in Behavioral Assessement of Children and Families. Ed. Prinz RJ. Greenwich, TAl Press, 1987; pp 157-176.

40. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention- deficit/hyperactivity disorder. J Am Acad Child Adol Psychiatry 1997; 36 (Suppl): 885-121S.

41. Rostain AL. Attention deficit disorders in children and adolescents. Pediatr Clin North Am 1991; 38: 607-635.

42. Burd L, Kerbeshian J, Fisher W. Does the use of phenobarbital as an anticonvulsant permanently exacerbate hyperactivity? Can J Psychiatry 1987; 32: 10-13.

43. Carey WB. Temperament issues in the school-aged child. Pediatr Clin North Am 1992; 39: 569-584.

44. Horn WF, lalongo NS. Multimodal treatment of attention deficit disorder in children. In: Theory and Research in Behavioral Pediatrics, Eds. Fitzgerald H, Lester B, Yogman M. New York, Plenum Press, 1988; pp 175-220.

45. Hechtman L. Aims and methodological problems in multimodal treatment studies. Can J Psychiatry'1993; 38: 458-464.

46. Safer DJ, Krager JM. A survey of medication treatment for hyperactive/inattentive students. JAMA 1988; 266: 2256-2258.

47. Hunt RD, Capper L. O'Connell P. Clonidine in child and adolescent psychiatry; J Child Adolesc Pscychopharmacology 1990; 1: 87-102. .

48. Hunt RD, Lau S, Ryu J. Alternative therapics for ADHD. In: Ritalin: Theory and Patient Management. Eds. Greenhill LL, Osman BB. New York, Mary Ann Liebert, 1991; pp 75-95.

49. Spencer T, Biederman J, Wilens T, Harding M, O'Donnell D, Griffin S. Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. J Am Acad Child Adol Psychiatry 1996; 35: 409-432.

50. Gittelman R, Kanner A. Psycho pharmacotherapy. In: Psychopathological Disorders of Childhood. Eds. Quay H, Werry T. New York, Wiley, 1986; pp 455- 495.

51. Forehand RL, McMahon RJ. Helping the Noncompliant Child: A Clinician's Guide to Parent Training. New York, Guilford, 1981.

52. O'Leary SG, Pelham WE. Behavior therapy and withdrawal of stimulant medication with hyperactive children. Pediatrics 1978; 61: 211-217.

53. Pelham WE, Schnedler RW, Bologna N, Contreras JA. Behavioral and stimulant treatment of hyperactive children: A therapy study with methylphenidate probes in a within-subject design. J Appl Behav Analysis 1980;13: 221-236.

54. Pelham WE, Hinshaw SP. Behavioral intervention for attention deficit hyperactivity disorder. In: Handbook of Clinical Behavior Therapy. Eds. Turner SM, Calhouns KS, Adams HE. New York, Wiley, 1992; pp 259-283.

55. Hinshaw SP, Erhardt D. Attention deficit hyperactivity disorder. In: Childhood and Adolescent Therapy: Cognitive Behavioral Procedures. Eds Kendall Pc. New York; Guilford Press, 1991; pp 98-128.

56. Abikoff H, Gittelman R. Hyperactive children treated with stimulants: Is cognitive training a useful adjunct? Arch Gen Psychiatry 1985; 42: 953-961.

57. Barkley, RA, Fischer C, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria-IlI J Child Psychol Psychiatry 1991; 32: 233-255.