Sharp Brains: Brain Fitness and Cognitive Health News

Neuroplasticity, Brain Fitness and Cognitive Health News

Icon

Study shows why children with ADHD should be reevaluated each year: Attention problems perceived by teachers are far less stable than we imagine

While the study below was pub­lished a few years ago, it makes an impor­tant point that I think is worth revis­it­ing.

In the study, pub­lished in the Jour­nal of Devel­op­men­tal and Behav­ioral Pedi­atrics, my col­leagues and I looked at how fre­quent­ly teacher rat­ings of inat­ten­tive symp­toms per­sist in chil­dren from one grade to the next. We felt this was an impor­tant issue to exam­ine because recog­ni­tion that ADHD is often a chron­ic con­di­tion can obscure the fact that atten­tion prob­lems do not always reflect an endur­ing child char­ac­ter­is­tic, and that impor­tant changes are pos­si­ble when chil­dren move to a new class­room.

As you will see below, clin­i­cal­ly-ele­vat­ed atten­tion prob­lems as per­ceived by teach­ers are less sta­ble than you may have imag­ined. Our find­ings high­light the impor­tance of care­ful­ly reeval­u­at­ing chil­dren each year so that chil­dren do not con­tin­ue to car­ry a diag­no­sis that may no longer apply and to be treat­ed for prob­lems at school that are no longer evi­dent.

Summary and Implications

Data from 3 diverse sam­ples indi­cates that more than 50% of ele­men­tary school chil­dren rat­ed by their teacher as hav­ing clin­i­cal­ly sig­nif­i­cant inat­ten­tive symp­toms one year do not show sim­i­lar prob­lems the fol­low­ing year. This was true even for chil­dren with a care­ful­ly con­firmed diag­no­sis of ADHD, i.e., those from the MTA Study, who had not start­ed med­ica­tion treat­ment between the 2 rat­ings.

Why might cross-grade sta­bil­i­ty of ele­vat­ed teacher rat­ings of atten­tion dif­fi­cul­ties be so mod­est? Var­i­ous expla­na­tions are pos­si­ble includ­ing pos­i­tive change in the child asso­ci­at­ed with mat­u­ra­tion, the res­o­lu­tion of a sig­nif­i­cant life stres­sor, or per­haps improved nutri­tion and/or sleep. Teach­ers may also use rat­ing scales dif­fer­ent­ly, with some teach­ers prone to assign high­er rat­ings than oth­ers.

How­ev­er, it is also pos­si­ble that for some chil­dren, a change in class­room con­text is an impor­tant fac­tor. This echoes find­ings obtained with mid­dle school stu­dents, where rat­ings of ADHD symp­toms between teach­ers often do not show strong agree­ment. This dif­fer­ence has been attrib­uted by some researchers to the unique char­ac­ter­is­tics asso­ci­at­ed with dif­fer­ent class­rooms.

Because ele­men­tary school chil­dren typ­i­cal­ly have only a sin­gle teacher, how­ev­er, it is eas­i­er than with mid­dle school stu­dents to over­look class­room con­text as a pos­si­ble fac­tor in a child’s atten­tion dif­fi­cul­ties. To the extent that this is the case, it may inad­ver­tent­ly lead some chil­dren to be diag­nosed with ADHD.

We believe these find­ings have sev­er­al use­ful clin­i­cal impli­ca­tions for the use of teacher rat­ings in the assess­ment and man­age­ment of ADHD.

First, as is already wide­ly rec­og­nized, our find­ings under­score the impor­tance of not over-rely­ing on symp­tom counts in mak­ing an ADHD diag­no­sis; doing so may iden­ti­fy many chil­dren whose dif­fi­cul­ties at school are like­ly to be tran­sient. This was evi­dent in the fact that a reduc­tion to the nor­ma­tive range of atten­tion prob­lems was some­what less fre­quent for chil­dren from the MTA Study — who had been care­ful­ly diag­nosed with ADHD — than for chil­dren from the oth­er 2 sam­ples.

The impor­tance of reeval­u­at­ing chil­dren annu­al­ly to learn whether inat­ten­tive symp­toms report­ed by one teacher are evi­dent in the child’s new class­room is also high­light­ed. For chil­dren who have been tak­ing med­ica­tion, this should be done when the child has been off med­ica­tion for a brief peri­od. In the absence of such a pro­ce­dure, some chil­dren are like­ly to be main­tained on med­ica­tion to address dif­fi­cul­ties that may no longer be present.

If rat­ings made by the child’s new teacher indi­cate that atten­tion dif­fi­cul­ties are no longer promi­nent, it must be rec­og­nized that this does not nec­es­sar­i­ly mean that a child’s prob­lems have resolved in an endur­ing way. In such instances, a more exten­sive assess­ment would be war­rant­ed to bet­ter under­stand the rea­son for the appar­ent change so that well-informed deci­sions about pos­si­ble treat­ment mod­i­fi­ca­tions can be made.

Our study has sev­er­al lim­i­ta­tions that should be acknowl­edged. First, the num­ber of chil­dren in each sam­ple is rel­a­tive­ly small. Sec­ond, because we did not have good data on med­ica­tion treat­ment for chil­dren in sam­ples 1 and 2, we do not know how many may have shown nor­mal­ized symp­toms in year 2 in response to such treat­ment. Final­ly, we have no infor­ma­tion for why symp­tom reports often declined so sub­stan­tial­ly. Although we believe that a change in class­room con­text may have played an impor­tant role, we did not exam­ine this direct­ly.

Two final points are impor­tant to make. First, cur­rent diag­nos­tic cri­te­ria for ADHD enable the diag­no­sis to be made even if a child’s symp­toms have only been evi­dent in a sin­gle grade. Our find­ings sug­gest that requir­ing symp­toms to have been evi­dent in mul­ti­ple grades might help pre­vent diag­nos­ing with ADHD chil­dren whose atten­tion prob­lems at school have a good chance of being tran­sient.

Final­ly, these data should not be con­strued as under­min­ing the valid­i­ty of ADHD as a dis­or­der or as indi­cat­ing that ADHD is sim­ply in the ‘eye of the behold­er’. In each sam­ple, a sig­nif­i­cant per­cent­age of chil­dren showed atten­tion prob­lems that per­sist­ed across grade. In addi­tion, we did not fol­low chil­dren long enough to deter­mine how often such prob­lems may reemerge in chil­dren for whom sub­stan­tial declines were evi­dent.

Thus, while our find­ings high­light the impor­tance of not treat­ing chil­dren based on the assump­tion that ADHD symp­toms will per­sist, they also indi­cate that such prob­lems cut across grades for many chil­dren. How­ev­er, the fact that this is fre­quent­ly not the case under­scores the val­ue of care­ful­ly reeval­u­at­ing chil­dren with ADHD when they have tran­si­tioned to a new class­room.

The Study in More Detail

How sta­ble are teacher reports of clin­i­cal­ly ele­vat­ed atten­tion prob­lems in chil­dren? The answer to this ques­tion has impor­tant impli­ca­tions about the neces­si­ty of reeval­u­at­ing chil­dren with ADHD on an annu­al basis.

Because ADHD is often a chron­ic con­di­tion, it can lead par­ents and pro­fes­sion­als to assume that chil­dren with sig­nif­i­cant atten­tion prob­lems at school will dis­play these dif­fi­cul­ties the fol­low­ing year. How­ev­er, atten­tion prob­lems do not always reflect an endur­ing child char­ac­ter­is­tic and may be exac­er­bat­ed by aspects of the child’s class­room con­text in a par­tic­u­lar year.

For exam­ple, when placed in a dis­or­ga­nized class­room with a teacher who strug­gles with behav­ior man­age­ment issues, some chil­dren may dis­play ele­vat­ed atten­tion prob­lems. How­ev­er, when placed in a bet­ter orga­nized class­room the fol­low­ing year with a teacher who con­sis­tent­ly rewards atten­tive, on-task behav­ior, these same chil­dren may show far few­er dif­fi­cul­ties.

In a study pub­lished in the Jour­nal of Devel­op­men­tal and Behav­ioral Pedi­atrics, my col­leagues and I exam­ined the sim­ple ques­tion of how fre­quent­ly clin­i­cal­ly ele­vat­ed teacher rat­ings of atten­tion dif­fi­cul­ties per­sist from one grade to the next. We felt this was an impor­tant ques­tion to exam­ine because if such rat­ings are fre­quent­ly not sta­ble across grade, it would high­light the need for care­ful annu­al reeval­u­a­tions for chil­dren diag­nosed with ADHD. Oth­er­wise, some chil­dren could con­tin­ue to car­ry a diag­no­sis that may no longer apply and to receive med­ical treat­ment for prob­lems at school that are no longer evi­dent.

We exam­ined this ques­tion in 3 sam­ples of ele­men­tary school chil­dren with clin­i­cal­ly ele­vat­ed teacher rat­ings of atten­tion dif­fi­cul­ties, i.e., rat­ings that fell in the top 10% of the pop­u­la­tion for chil­dren their age. Par­tic­i­pants in Sam­ple 1 were 27 first graders, those in Sam­ple 2 were 24 4th graders, and those in Sam­ple 3 were 28 7- to 9-year-old chil­dren from the Mul­ti­modal Treat­ment Study of ADHD (MTA Study).

Chil­dren in sam­ples 1 and 2 did not have a for­mal ADHD diag­no­sis but were iden­ti­fied sim­ply by hav­ing ele­vat­ed teacher rat­ings of inat­ten­tive symp­toms. Those from the MTA Study had all been care­ful­ly diag­nosed with ADHD Com­bined Type; the chil­dren we select­ed were those who had been ran­dom­ly assigned to the Com­mu­ni­ty Care con­di­tion and who did not receive any med­ica­tion treat­ment dur­ing the ini­tial study peri­od.

As not­ed above, all chil­dren had ele­vat­ed teacher rat­ings of inat­ten­tive symp­toms at base­line. These rat­ings were obtained the fol­low­ing year from children’s new teacher so that the cross-grade sta­bil­i­ty of ele­vat­ed rat­ings could be com­put­ed. On aver­age, fol­low-up rat­ings were obtained 12–14 months lat­er.

Summary Results

In all 3 sam­ples, few­er than 50% of chil­dren were rat­ed with clin­i­cal­ly-ele­vat­ed atten­tion prob­lems by their new teacher. The per­cent­ages were 37% of chil­dren in the 1st grade sam­ple, 33% of chil­dren in the 4th grade sam­ple, and 46% of chil­dren from the MTA sam­ple. The per­cent­age of chil­dren whose rat­ings of atten­tion dif­fi­cul­ties had declined to the nor­mal range was 44% for the 1st grade sam­ple, 50% for the 4th grade sam­ple, and 25% for the MTA sam­ple.

In the 1st grade sam­ple, for exam­ple, 14 chil­dren had at least 6 inat­ten­tive symp­toms rat­ed at the high­est lev­el at base­line. At fol­low-up, 10 had 2 or few­er symp­toms (70%) includ­ing 5 who were report­ed to show 0 symp­toms (36%); only 2 chil­dren (14%) were still rat­ed with 6 or more symp­toms.

These find­ings high­light the impor­tance of care­ful­ly reeval­u­at­ing chil­dren each year so that chil­dren do not con­tin­ue to car­ry a diag­no­sis that may no longer apply and to be treat­ed for prob­lems at school that are no longer evi­dent.

Rabiner_David– 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 the Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and helped pre­pare the self-paced, online course How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

Related articles by Dr. Rabiner:

Leave a Reply...

Loading Facebook Comments ...

Leave a Reply

Categories: Attention and ADD/ADHD, Cognitive Neuroscience, Education & Lifelong Learning, Health & Wellness, Technology

Tags: , , , , , , ,

Watch All Recordings Now (40+ Speakers, 12+ Hours)

About SharpBrains

As seen in The New York Times, The Wall Street Journal, BBC News, CNN, Reuters and more, SharpBrains is an independent market research firm tracking health and performance applications of brain science.

Follow us and Engage via…

twitter_logo_header
RSS Feed

Search for anything brain-related in our article archives