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164 Chapter 9 Attention-Deficit/Hyperactivity Disorder
There is ample evidence for a shared genetic risk
between ADHD and autism spectrum disorder and other
neurodevelopmental conditions (Shepard et al., 2022).
While genetic overlap with other disorders is clear, there are
also unique genetic risks associated with ADHD (Faraone
et al., 2021). Gene-by-environment-by-time research has
identified several promising interactions. For example,
genetic variants that have an effect on the regulation of
dopamine and serotonin interact with psychosocial factors
to influence the severity of ADHD symptoms (Faraone
et al., 2021; Nigg et al., 2020).
Physiological Factors
With increasingly sophisticated neuroimaging techniques,
brain structure and function can be usefully investigated.
Brain regions that have been examined include the frontal
lobes, the anterior cing ulate cortex (a key area for coordi nating
top-down and bottom-up processing, associated with the
attention system), the corpus callosum, the temporal lobes,
and the striatal regions. ADHD is associated with smaller
brains and reduced cortical thickness in regions linked
to reward and motivation. Atypical connectivity is also
observed (Faraone et al., 2021; Rohr et al., 2021). Keep
in mind, however, that many of these differences between
typically developing and atypically developing youth are
relatively modest (Bernanke et al., 2022).
Brain development is also the focus of research.
We know that “neural maturation processes include
hierarchical development, from childhood to adolescence
of sub-cortical-to-cortical, then cortical-to-sub-cortical,
and finally cortical-cortical circuitry,” and these processes
are different for youth with ADHD and youth without
ADHD (Nigg et al., 2020, p. 569). Later development of
the prefrontal cortex is hypothesized to underlie some of
the improvement in symptoms observed over time. This
variability in brain plasticity provides critical information
about developmental trajectories and the timing of windows
for both prevention and intervention (Johnson et al., 2015).
Atypical brain activation patterns are observed in multiple
regions associated with hot and cool executive function
(Zelazo, 2020). Better understanding of these EF brainbehavior pathways will help clarify the emergence and
course of ADHD.
Given the widespread influence of neurotransmitters
on prefrontal functions, many studies have focused
on neurotransmitter dysfunction in the development
and maintenance of ADHD (Campbell et al., 2014).
Investigations of dopamine, serotonin, and noradrenaline are
ongoing. Other aspects of neurophysiological functioning
are also implicated. Prenatal and postnatal complications
and low birth weight are associated with many aspects of
physiological regulation (Faraone et al., 2021; Nigg et al.,
2020). Prenatal maternal inflammation is a current focus
of research (Nigg et al., 2020; refer back to Figure 9.3). In
addition, the role of sleep disturbances and their effects on
efficient self-regulation are important to consider.
Psychological Factors
Among the most widely researched variables underlying
the development of ADHD are cognitive factors, especially
those related to decision making and executive function.
Meta-analyses suggest that children with ADHD exhibit
weaknesses in several aspects of EF, with the strongest effects
related to response inhibition, vigilance, working memory,
and planning (Nigg et al., 2020; Zelazo, 2020). Much of the
research on EF has focused on the distinction between hot
and cold EF and emphasizes that hot EF decision making is
particularly problematic (Zelazo, 2020).
Research on sluggish cognitive tempo, a distinctive
component of the clinical presentation of some children
(including Tamara), provides additional information
about ADHD. Sluggish cognitive tempo includes varied
combinations of drowsiness, daydreaming, lethargy, and
slowed thinking. It is associated with higher levels of
anxiety, depression, and withdrawn behavior and lower
levels of academic and social competence (Burns & Becker,
2021; Lee et al., 2014).
Temperament, personality, and the age of the child
also appear to have an impact on the development of
ADHD. As noted previously, temperamental reactivity and
regulation may increase a child’s risk for ADHD (Nigg
et al., 2020; Shepard et al., 2022; refer back to Figure 9.3).
The consolidation of emotion reactivity and regulation
with executive function over time may be especially
important (Nigg et al., 2020). Motivational deficits, related
to sensitivity to reward and punishment, have also been
observed (Campbell et al., 2014; Faraone et al., 2021).
Finally, as noted earlier with respect to relative age in
classroom settings, rates of ADHD in the youngest children
in elementary school grades are higher than for older
children. Younger children’s problematic behaviors may be
very notable in comparison to older classmates.
Family and Environmental Factors
There is almost no empirical evidence supporting the
hypothesis that family or environmental factors alone
contribute to the development of ADHD; however, numerous
studies have described ways in which these factors have a
role in the maintenance and exacerbation of the disorder.
With respect to the development of disorder, the gene-byenvironment-by-time interactions discussed previously
suggest that certain parent or family factors may influence
the emergence of disorder in at-risk children. There are data,
for example, suggesting that parent–child interactions differ
within families (i.e., nonshared environmental influence),
depending on a particular child’s ADHD status (Cartwright
et al., 2011). These results suggest that parental beliefs
about ADHD and about their children may contribute to
an increasingly destructive cycle of negative interpretations
and blame as well as harsh and intrusive parenting, making
it difficult to intervene effectively (Nigg et al., 2020). These
types of family factors may, in fact, tell us more about the
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Assessment and Diagnosis 165
risk for the development of additional comorbid disorders
such as oppositional defiant disorder or conduct disorder
than about the ADHD (Pliszka, 2015).
Environmental factors have also received renewed
attention. Many prenatal and perinatal environmental
risks, such as exposure to lead, nicotine, alcohol and other
drugs, and poor prenatal nutrition, increase the risk for
ADHD (Faraone et al., 2021; Georgieff et al., 2018; Nigg
et al., 2020). Accumulating stressful experiences, including
poverty and other adversities, increase the risk as well
(Faraone et al., 2021; Nigg et al., 2020; Zelazo, 2020).
Assessment and Diagnosis
We know that ADHD is a disorder that is often mistaken
for a child’s lack of ability or effort, stubborn willfulness, or
the result of lackadaisical parenting. In addition, perhaps
more so than any other childhood disorder, ADHD is a
disorder that frequently co-occurs with other disorders.
Given these circumstances and the fact that there is no
specific neurological or physiological test for ADHD, we
must pay careful attention to the particular criteria that lead
to an accurate diagnosis of ADHD. As already emphasized,
ADHD reflects deficits and/or delays in key behavioral,
cognitive, and emotional abilities.
Assessment of children, adolescents, and adults
depends, first and foremost, on appropriate knowledge
of typical development. “Children with ADHD are
most often referred for assessment between the ages of
five and eight, when their high energy level, fidgetiness,
and difficulty sitting still, disorganization, lack of
persistence on cognitive tasks, poor concentration,
difficulty regulating their behavior in social situations,
and lack of social judgment lead to a myriad of social
and academic problems” (Campbell et al., 2014,
p. 430). Clinicians must look for more frequent behaviors,
more intense behaviors, and more impairment, and decide
whether a child’s pattern of difficulties reflects ADHD
or subclinical problems. In addition to the continuity
between typical and atypical patterns, onset-related and
developmental transitions must be considered because, as
described previously, the pattern and severity of symptoms
may change over time.
Diagnostic Interviews
Interviews are often conducted with children, parents,
and teachers. Parents and teachers usually provide more
useful data because children (and even adolescents) are not
always aware of or able to describe their difficult behaviors.
Information provided by parent and teacher reports is almost
never exact ly the same, but these reports c ontribute importa nt
information about children’s behaviors in different settings
with different challenges. Teacher reports may be especially
valuable as teachers are likely to have more knowledge and
experience about typical development and appreciate when
children’s behavior patterns are meaningfully different from
the norm. It is also important to take cultural variation in
mental health attitudes and knowledge within and across
countries into account. Parents may under-report or overreport ADHD symptoms for many reasons, including
behavioral expectations, salience of ADHD symptoms, and
school policies (MacDonald et al., 2019).
Comprehensive interviews, in addition to providing
baseline data, may reveal information about a family
history of ADHD or the presence of additional disorders.
In addition, a careful review of the relations between the
particular patterns of deficits and the demands of particular
settings is important. With ADHD, the assumption is that
the core difficulties are present from early childhood and
are not the result of a specific stressor. Diagnosis of adult
ADHD remains clinically problematic, given that there is no
clear consensus on the criteria for adult ADHD. Additional
work in this area is essential and ongoing (Barkley,
2017b). Another consideration in judging the presence of
ADHD and making differential diagnoses is whether the
identified symptoms are better accounted for by another
disorder. Many disorders, such as depression, generalized
anxiety disorder, or schizophrenia, can disrupt the basic
cognitive and behavioral processes that are the core features
of ADHD. In the case of these other disorders, however,
symptoms such as poor concentration and impulsivity
are secondary problems relative to the primary disorder.
A final consideration is that, most often, primary care
physicians (such as pediatricians) rather than mental health
professionals (e.g., clinical psychologists or psychiatrists)
assess and diagnose ADHD in children and adolescents and
prescribe medications as treatment.
Rating Scales and Observations
In addition to interview data, there are a number of
available rating scales for parents and teachers specifically
designed to assess the symptoms of ADHD and provide
information about the degree to which an individual
departs from well-established norms. For the most part,
these scales provide reasonably accurate and, in some
cases, compelling information about the likely presence
of ADHD. The widespread use of teacher rating scales,
however, has been the focus of several investigations
concerning the assessment of students of various racial
and ethnic backgrounds. The role of race and culture, as
well as the potential for bias, must be carefully addressed
(Nigg, 2013). The increased presence and expanding role
of school psychologists provide valuable perspective on
school-based referrals and treatments (DuPaul & Stoner,
2014). Most assessment observations are done in the school
because some children’s abilities to exhibit self-control and
maintain attention in the structured office setting may
not reflect typical behavior. Ideally, observations should
be made in a variety of settings (e.g., in school and at
home) with different environmental demands so patterns
of difficulties are clearly identified, and specific treatment
plans can be designed.
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166 Chapter 9 Attention-Deficit/Hyperactivity Disorder
There are many commonly used rating scales that allow
for varied perspectives beyond the school setting. The
Vanderbilt ADHD Diagnostic Rating Scale (VADRS),
for example, is used as part of the American Academy
of Pediatrics guidelines for the assessment of ADHD
symptoms for children seen in pediatric health care settings
(Anderson et al., 2022; Leslie et al., 2004). The Brown
Attention-Deficit Disorder Scale measures the executive
function impairment typically associated with a diagnosis
of ADHD (Brown, 2001). There are normed versions
appropriate for use with preschool-aged children, youth,
and adults. The adolescent and adult versions include a selfreport format which is especially helpful in documenting
the cognitive (vs. behavioral) symptoms that are often less
obvious to others but distressing to the individual with
ADHD (Brown, 2009).
Although not definitive by themselves, a variety of
continuous performance tests are often used as part of an
ADHD assessment. These tests generally involve monitoring
stimuli (visual, auditory, or both) and responding selectively
to instructions. For example, letters might be presented on
a computer screen and the child told to respond to a certain
target letter but not to others. These tests measure various
attention and impulse control skills, including the ability to
remain vigilant, to demonstrate consistency of attentional
focus, to respond quickly, and to inhibit responding. In
many cases, additional assessments related to academic
achievement are often conducted, including intelligence
testing and an assessment of learning disabilities. Medical
evaluations are also sometimes included as part of the
assessment plan.
Differential Diagnosis
As described earlier, an important consideration in the
assessment and treatment of ADHD involves differential
diagnosis and the identification of comorbid problems.
These tasks are especially important because many of the
symptoms of ADHD, such as executive function, attention
deficits, and poor self-regulation, are also observed in
other disorders (e.g., oppositional defiant disorder, anxiety
disorders, autism spectrum disorders, motor coordination
problems, and learning disabilities) (Rommelse et al.,
2009). Whether the child or adolescent presentation best
fits a single diagnosis of ADHD or multiple diagnoses has
implications for treatment planning. For example, more
comprehensive treatments for ADHD combined with
oppositional defiant disorder are indicated. It is also critical
to determine if an anxiety or mood disorder complicates the
clinical presentation and must be addressed in treatment.
Intervention
Given children’s ADHD-related experiences a nd impairment,
many different interventions have been proposed, with
varying success. Interventions for preschoolers, elementaryschool-aged children, adolescents, and adults have all been
investigated. Medications and psychosocial treatments
receive the most empirical and clinical support (Faraone et
al., 2021; Nigg et al., 2020). Multicomponent treatments that
include medication, cognitive-behavior therapy, and social
skills training for children along with parent training and
education are particularly successful. There is also a current
focus on integrated interventions for children, parents, and
teachers (Faraone et al., 2021; Pfiffner et al., 2014).
Even with data suggesting that combined treatments are
more effective for many children, the cost effectiveness of
treatments certainly comes into play. Medication treatments
are the least expensive, followed by psychosocial treatments
and then combined treatments. There is considerable
variation in treatment strategies and implementation
in countries around the world, depending in part on
economic and sociocultural factors. Some countries, for
example, display more anti-psychiatry and anti-medication
attitudes; others are more likely to use a combination of
treatments (Hinshaw et al., 2011). One necessary aspect
of all treatments involves parent and child education,
including information about medication and psychosocial
interventions, available special educational services, and
access to mental health resources such as parent support
groups and individual counseling. Much of our current
understanding of treatment has been enhanced by one
of the most impressive and comprehensive longitudinal
studies of the treatment of ADHD: the National Institute
of Mental Health’s Collaborative Multisite Multimodal
Treatment Study of Children with ADHD, which combines
rigorous experimental protocols with particular attention to
individual differences (refer to Box 9.1).
Continuous Performance Tests use computers to assess
selective attention and impulse control.
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Pharmacological Treatment
Syda Productions/Shutterstock.com
In hundreds of studies with thousands of children, the
use of central nervous system (CNS) stimulants, as well
as newer nonstimulant medications, to treat ADHD has
Box 9.1 Clinical Perspectives
The MTA Cooperative Group Study
Intervention 167
There are frequent criticisms that research in developmental
psychopathology often fails to take into account the realities
of actual children and their complicated day-to-day lives.
In ADHD outcome-oriented research, such criticism
has often focused on studies of the short-term impact of
stimulant medications (neglecting possible long-range
negative consequences) and the inadequate consideration of
multicomponent intervention strategies (neglecting the whole
child to focus on problematic symptoms). The Multimodal
Treatment Study of Children with Attention-Deficit/
Hyperactivity Disorder (MTA) Cooperative Group Study,
launched over 20 years ago, is an effort to comprehensively
address previous research shortcomings (MTA Cooperative
Group, 2004; Molina et al., 2009; Swanson et al., 2018).
The original MTA Cooperative Group Study included six
independent research teams (in San Francisco; Los Angeles;
Durham, North Carolina; New York; and Pittsburgh) working in
collaboration with the National Institute of Mental Health and
the U.S. Department of Education. Comparisons of the longrange efficacy of a 14-month-long intervention (i.e., looking at
14-month, 24-month, 36-month, and eight-year outcomes) in
579 children with ADHD were conducted for medication
management, intensive behavioral treatment, a combined
approach, and community care. Numerous outcome measures
were identif ied, including reduction in t he core ADHD symptoms,
personal adjustment, academic achievements, and improvements
in social skills and relationships. The initial 14-month MTA study
then transitioned into a long-term observational study that also
included a matched comparison group.
Across multiple settings, the diverse sample of children in the
MTA study demonstrated clear benefits from medication, with
some additional benefits observed for the combined medication/
behavioral treatment strategy. Early follow-up assessments
indicated that peer-related functioning continued to be
problematic, although treatment appeared to reduce additional
diagnoses of oppositional defiant disorder, conduct disorder, and
anxiety disorder (Hoza et al., 2005). By 36 months, some of the
advantages of the combined treatment had diminished, although
all treatment groups maintained improvements over baseline.
Over the course of the study, many of the participants
displayed clinically significant improvements across multiple
domains of functioning. Others showed improvements that
were less dramatic and less far reaching (Karpenko et al.,
2009). Certain types of treatments were associated with
particular outcomes. For example, behavioral treatments were
associated with better homework performance (Langberg
et al., 2010). At the eight-year follow-up, the adolescents’
current status was best predicted by their early symptom
trajectories. That is, those “children with behavioral and
sociodemographic advantage, with the best response to any
treatment, will have the best long-term prognosis” (Molina
et al., 2009, p. 484). Overall, however, the adolescents, in
comparison with typically developing peers, continued to
display significant impairments.
The original MTA cohort has now been followed into
adulthood, improving our understanding of the varied longterm outcomes of children diagnosed with ADHD (Erskine
et al., 2016). For example, long-term outcomes for individuals
whose core ADHD symptoms persisted into adulthood
included more problems in domains such as occupational
security, substance abuse, and co-occurring psychiatric
disorders (Hechtman et al., 2016). Other longitudinal data,
however, demonstrated that early, effective treatment for
ADHD was associated with long-term improvements for
related difficulties such as negative emotionality (Fernandez
et al., 2015). The longitudinal design of the MTA study also
allowed for variable patterns of symptom expression, functional
interference, and remission to be observed (Sibley et al., 2022).
This type of research collaboration is expensive and difficult to
coordinate. It is, however, absolutely necessary if we—
researchers, clinicians, parents, teachers, and others—want to
be able to describe and offer optimal care to individuals with
ADHD.
received significant support. This is why medication is
often viewed as a first-line intervention. The majority
of children who are treated with long-used medications
such as methylphenidate (Ritalin) and newer types of
long-acting stimulants (such as Adderall and Concerta)
exhibit real and substantive improvement in ADHD
symptoms, measured by parent–teacher ratings, direct
observations, and performance in lab tasks (Faraone
et al., 2021; Nigg et al., 2020). Findings from many
studies over many decades provide strong evidence that
ADHD medications work across sex/gender, for youth
from various racial/ethnic backgrounds, and for youth
from a variety of SES backgrounds. In addition, the
positive effects of stimulant treatments are observed in
relationships with parents, teachers, and peers, although
parents and teachers report different patterns of benefits
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
and side effects (Campbell et al., 2014; Spencer et al.,
2016).
Worldwide use of stimulant-based medications varies
greatly and has significantly increased over several
decades. In the United States, methylphenidate use,
for example, peaked in 2012 and declined somewhat
in subsequent years (Piper et al., 2018). A newer trend
in ADHD treatment is combined pharmacotherapy, or
polypharmacy, using combinations of medications to treat
the disorder. Explanations for this trend include the higher
rates of comorbid psychopathologies, better symptom
control, and the synergy of combined medications.
Polypharmacy patterns differ by client characteristics
(e.g., sex, US region) and require additional study with
respect to safety, appropriateness, and outcomes (Girand
et al., 2020).
168 Chapter 9 Attention-Deficit/Hyperactivity Disorder
There are, however, a number of cautions. Improvements
in ADHD symptoms last as long as the medication use
continues and, in some cases, do not persist (Faraone et
al., 2021; Spencer et al., 2016). This lack of sustained
improvement may reflect poor adherence and early
termination related to medication use. Adherence and
termination may be influenced by adverse effects (e.g.,
poor sleeping and poor appetite) and small decreases
in growth rates (Faraone et al., 2021). Adolescents, in
particular, display poor medication compliance (Nigg
Box 9.2 Clinical Perspectives
ADHD, Youth, and Pharmacotherapy
While estimates vary depending on methods and exact
diagnostic criteria, rates of ADHD among US youth are
generally estimated to be between 5% and 10% (Chung
et al., 2019; Xu et al., 2018). Of those diagnosed with
ADHD, estimates of those treated with medication—
pharmacotherapy—vary considerably. The percentage is likely
higher than it is for most mental health diagnoses (Danielson,
2018). One study found that approximately 19% of children
diagnosed with ADHD were prescribed medication to treat the
disorder (Massuti, 2021).
With rapidly rising rates of psychopharmacological
interventions for very young children, school-aged children,
adolescents, and adults, we must thoughtfully address various
public health and ethical concerns. With respect to the
youngest group, are actual disorders increasing in younger
samples? Are our methods of detection and diagnosis
improving, or are we confusing expected behavioral, emotional,
and cognitive variations in preschoolers with problematic
behavioral, emotional, and cognitive displays in older children
and adolescents? What are the costs and benefits of using drugs
that have not been investigated or approved for young children?
And what are the societal, clinical, and personal meanings
associated with the prescription of stimulant medication, or
any other psychotropic medication, to a very young child?
As we have repeatedly emphasized throughout this textbook,
taking a developmental view of distress, dysfunction, and
disorder provides us with valuable perspective. Children
experience the “terrible twos,” the “often still thorny threes,”
and the “formidable fours.” Some of their worrisome behaviors
fade with time, and some continue. We must acknowledge that
developmental bumps in the road are inevitable, and that there
are no alternatives to patient, loving, and individualized
caregiving. But we also acknowledge that psychopathology
does occur in the early years.
We know that, for example, troubled preschoolers often
present with a mix of clinical difficulties in many psychological
domains. Whether a child is appropriately understood as
anxious, depressed, learning disabled, or as having ADHD is
difficult to determine. Parents are often desperate to find out
exactly what is “wrong” with a child and do something to “fix”
that child as fully and as quickly as possible. It is a public policy
shame that in many ways, mental health professionals cannot
et al., 2020). Finally, the misuse of ADHD medications
by youth and adults, especially by college students,
is a significant public health problem. Individuals
frequently report motivation to misuse medications in
connection with academic or job performance, but there
is little evidence that the use of ADHD medications
in individuals without ADHD is helpful (Faraone et
al., 2020, 2021). Discussions related to the history and
current use of medications for children and adolescents
are ongoing (refer to Box 9.2).
offer the kinds of educational services, family support, and
nonmedical interventions that may be exactly what many
families need. In addition, strong evidence exists that supports
the importance of sequencing interventions. For example, in
treating children with an ADHD diagnosis, adding medication
after first initiating a behavioral intervention has been linked
to better outcomes in both home and school settings (Pelham
et al., 2015).
Of course, we must also consider the very small number of
young children with well-defined ADHD that results in
significant impairments. These children might be suitable
candidates for what is clearly an effective intervention strategy
in older children. Research shows, however, that once preschool
children diagnosed with ADHD begin pharmacotherapy, they
are likely to continue on stimulant medication, and in some
cases, on other psychotropic medications as well (Vitiello et al.,
2015). Safety concerns involve the use of testing protocols that
focus on older children, adolescents, and adults and whether
the effects of medication on still-developing brain–behavior
systems are well understood. Consequently, the careful
balancing of risks and benefits of pharmacotherapy is especially
important in the treatment of young children (Young et al.,
2021).
With the increasing use of multiple medications, concerns
become even more compelling. Some have expressed reservations
about threats to children’s autonomy and everyday experiences of
childhood. But in genera l, children with ADHD take medication
following careful diagnosis. Further, ADHD diagnosis and
medication treatment, particularly in combination with other
evidence-based interventions, have been found to positively
affect children’s self-image and sense of agency.
During adolescence, addressing clinical and ethical issues
concerning ADHD medications becomes especially important as
the abuse potential (mainly for youth who are not diagnosed with
ADHD) becomes more relevant (Carolan, 2021). There is,
however, also evidence that the use of medication to treat ADHD
during childhood decreases the risk of developing a range of other
disorders including depression and substance abuse as well as
other academic and health problems (Boland et al., 2020; Chang
et al., 2019). Increasingly, longitudinal studies suggest that early
diagnosis and treatment of ADHD, including the appropriate use
of medication, is associated with better long-term outcomes.
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Intervention 169
Psychosocial Treatment
Although medications are clearly effective for many children,
many parents prefer psychosocial interventions for their
children (Ca mpbell et al., 2014). Evidence-ba sed psychosocia l
interventions include parenting interventions, cognitivebehavioral interventions for youth, behaviorally-oriented
peer interventions, and social skills training (Faraone et al.,
2021; Shepard et al., 2022). Neurofeedback training has
produced mixed results (Faraone et al., 2021). Interventions
that target emotion dysregulation and executive function are
increasingly part of comprehensive treatment plans (Nigg et
al., 2020; Zelazo, 2020). Positive outcomes are most often
related to the amelioration of problems related to self, school,
families, and peers rather than the core ADHD symptoms
(Faraone et al., 2021).
Psychosocial interventions that are focused on the
particular challenges of adolescents are increasingly
implemented (e.g., Evans et a l., 2011). For youth with multiple
disorders, comprehensive interventions are critical. For girls
and young women with persistent and severe ADHD, for
example, treatments must also address the potential for
risk taking, self-harm, and suicidality (Guendelman et al.,
2016; Swanson et al., 2014). Overall, the data suggest that
psychosocial treatments, like medications, may be usefully
understood as effective interventions.
School Interventions
Most children with ADHD are placed in mainstream
classes, but some may require individual tutoring and
specialized plans to support academic achievement. Both
the National Rehabilitation Act and the Individuals with
Disabilities Education Act (IDEA) are legislative efforts
requiring appropriate educational services for children with
ADHD. Special accommodations such as having children
with ADHD sit in a place with fewer distractions (e.g., in
the front of the class, next to the teacher’s desk), receiving
written as well as oral instructions, and providing visual
aids and reminders are common. The learning disorders
displayed by many children and adolescents with ADHD
must also be addressed.
Among the most effective school-based interventions
involve behavior contingency management in the classroom
(Faraone et al., 2021). These interventions include reward
programs, point systems, and time-outs for inappropriate
behavior. They are designed to target multiple difficulties,
including academic, behavioral, and social functioning
(DuPaul et al., 2011). Participation, collaboration, and
coordination among service providers, teachers, and
parents are essential. The Family–School Success model
is one example of a successful intervention that combines
psychosocial approaches across settings for improved child
outcomes (Power et al., 2012).
Interventions with Adults
As previously noted, medications are effective in treating
the symptoms of ADHD in adults. Adults with ADHD,
however, are not likely to receive medication treatment
(Faraone et al., 2021). Adult interventions, similar to
interventions for children and adolescents, need to account
for developmentally-relevant challenges. In adults, these
include challenges involving relationships, workplace/career
difficulties, and self-esteem issues.
Future Directions
There are efforts to design prevention protocols that target
underlying causes, alter developmental trajectories, and
improve outcomes. Early identification of ADHD precursors
and interventions to improve self-regulation, executive
function, and emotional reactivity are designed to reduce the
prevalence and severity of ADHD. Early train ing and support
of effect ive parenting for at-risk ch ildren is another prevention
strategy (Nigg et al., 2020; Zelazo, 2020). Interventions that
target transition periods such as adolescence, with increased
attention to contextual factors (social and environmental
supports), are yet another promising development
(Nigg et al., 2020).
Key Terms
Attention-deficit/hyperactivity disorder (ADHD) (156)
Self-regulation (156)
Effortful control (156)
Executive function (156)
Chapter Summary
●
Attention-deficit/hyperactivity disorder (ADHD) is
characterized by a combination of symptoms related to
impulsivity, hyperactivity, and inattentiveness.
●
Self-regulation, effortful control, and executive functioning
skills are important developmental achievements that are
compromised by ADHD.
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●
The diagnosis of ADHD reflects compromised
functioning in the domains of inattention, hyperactivity
/impulsivity, or both.
●
Boys receive diagnoses of ADHD four to five times more
often than girls.
●
In general, ADHD is an exceptionally stable diagnosis
over time.
170 Chapter 9 Attention-Deficit/Hyperactivity Disorder
●
Rates of co-occurring internalizing and externalizing
disorders increase for children with ADHD over time.
●
Diagnoses most commonly occurring along with
ADHD include oppositional defiant disorder, depressive
disorders, anxiety disorders, learning disorders, and
substance use disorders.
●
Genetic and neurophysiological factors are central to the
development of ADHD, while psychosocial factors play
an important role in the maintenance and exacerbation
of the disorder.
●
Atypical executive function is associated with many of
the core symptoms of ADHD.
●
Because the core symptoms of ADHD (e.g., distractibility
and impulsivity) are present in many children, variable,
and continuous with typical behavior, it is especially
important that an assessment include multiple data
sources from multiple settings.
●
The majority of youth treated with stimulant medication
show significant improvement.
●
Although medication is especially helpful in the shortterm, psychological interventions, such as parent training,
and environmental interventions, such as classroom
adaptations, are important for sustained improvement in
functioning.
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Chapter Outline
Oppositional Defiant Disorder
and Conduct Disorder
10
Developmental Tasks and Challenges Related
to Prosociality 172
Box 10:1 The Child in Context: Historical Perspectives on
Bad Behavior
A Developmental Perspective on Bullying
Oppositional Defiant Disorder 176
The Case of Ava
The Case of Liam
Conduct Disorder 177
The Case of Mateo
The Case of Riley
Developmental Course 179
Oppositional Defiant Disorder
Conduct Disorder
Learning Objectives
1. Summarize the tasks and challenges related to prosociality.
2. Describe pathways of antagonistic and aggressive behaviors
in typically-developing youth.
3. Summarize the most important issues related to bullying
across childhood and adolescence.
4. Compare and contrast the diagnostic criteria for
oppositional defiant disorder (ODD) and conduct disorder
(CD).
5. Explain the role of irritability in the emergence of ODD.
6. Explain the role of callous-unemotional traits in the clinical
presentation and course of some youth with CD.
Etiology 183
Genes and Heredity
Physiological Factors
Child and Adolescent Factors
Parent and Family Factors
Peer Factors
Sociocultural Factors
Assessment and Diagnosis 187
Intervention 187
Box 10:2 Clinical Perspectives: The Early Risers Program
Youth Treatments
Parent Treatments
Systems-focused, Peer, and School Programs
Prevention
7. Compare and contrast various developmental pathways for
youth with ODD.
8. Compare and contrast various developmental pathways for
youth with CD.
9. Summarize the etiological factors that contribute to the
emergence and maintenance of ODD.
10. Summarize the etiological factors that contribute to the
emergence and maintenance of CD.
11. Summarize the goals and processes of assessment and
diagnosis for ODD and CD.
12. Summarize the evidence-based interventions for ODD
and CD.
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171
172 Chapter 10 Oppositional Defiant Disorder and Conduct Disorder
Four-year-old Marissa yells at her mother when her mother
reminds her to brush her teeth. Six-year-old Jonah sits
in time-out for hours because he refuses to apologize for
disrespectful behavior at the dinner table. For the third
time in a week, 11-year-old Emery is sent to the principal’s
office, this time for ignoring their teacher’s repeated
requests for them to sit down and complete their math
assignment.
Are these children headstrong, or spoiled, or bad?
Are their parents and teachers too lenient or too harsh?
Is anyone to blame in these battles for control? And why
do some argumentative and disobedient children grow
up into adolescents who lie, cheat, and steal? How do we
explain adolescents who flout rules and exploit others?
How can we comprehend the heartbreaking episodes of
adolescent rage and violence that destroy families, schools,
and communities? Understanding oppositional defiant
disorder and conduct disorder involves thinking carefully
and critically about “bad” behavior throughout history and
the apparent increases in externalizing behaviors in recent
decades (Collishaw, 2015; Robins, 1999; refer to Box 10.1).
As we think about the various pathways toward and away
from externalizing behaviors, it is essential that we continue
to use a developmental framework. With such a framework,
bridges connecting research, treatment, and public policy
may be built.
Developmental Tasks
andChallenges Related
toProsociality
Prosociality includes prosocial behaviors—behaviors that
benefit others such as helping, sharing, and comforting—
and prosocial motivation—motives that influence
prosocial behavior (Eisenberg et al., 2016). Young children
who are prosocial cooperate with their parents, share with
their peers, and help in their communities. Developmental
pathways of prosociality depend on individual, relationship,
and environmental factors. This brief overview summarizes
information about typical patterns of prosociality and
provides a framework for comparison and contrast for
upcoming discussions of oppositional defiant disorder and
conduct disorder.
Children’s prosocial behavior is frequent, occurs in a
variety of contexts, and involves a variety of motivations.
Prosocial behavior may be focused on others’ emotional
needs or pragmatic goals and may be observed in interactions
with parents, siblings, peers, and strangers (Grueneisen
& Warneken, 2020). Prosocial motivations range from
motives such as empathy, sympathy, justice principles, or
social norms (motives focused on others) to avoidance of
negative emotion, social and material reward, and avoidance
Box 10.1 The Child in Context
Historical Perspectives on Bad Behavior
Over the centuries, adults have sought to teach, control, and
socialize children, and to respond appropriately to children’s
good and bad behaviors. In specific times and places, the
predominant view has been that “children are naturally immoral,
aggressive, and selfish, needing to be taught generosity,” while
in other times and places, the prevailing view has been that
“children are innately kind and fair and that only later, through
development, teaching, or socialization, do they become selfish
and corrupt” (Martin & Olson, 2015, p. 159). These varied
perspectives provide meaningful information about the nature
of children and the emergence of responsibility for one’s own
behaviors, the relations between the family and the larger social
group with respect to control of children and adolescents, and
institutions for youth whose behavior is unmanageable or who
fail to conform to rules and expectations.
With respect to explanations of child and adolescent
behavior, Costello and Angold (2001) describe approaches that
focus on the children’s behavior as the result of innate
syndromes or disease (e.g., genetic and hereditary explanations),
disposition, motivation, immaturity or below-average
intelligence, or problematic environments (e.g., distressed
fami lies or dysfunc tional neighborhood s). Hostile, oppositiona l,
defiant, and aggressive behavior is, at times, the sole
responsibility of the child, sometimes the responsibility of the
parents, and sometimes the responsibility of society. Blame and
recriminations are pervasive.
In various eras, adults have alternately viewed children as
similar to adults (judging and punishing them accordingly)
and as different from adults (responding with compassion and
leniency). Societies have struggled to balance their obligations
to children and to the communities in which children live.
Many societies developed separate legal and institutional
systems for dealing with difficult children and adolescents.
The consequences of unacceptable behaviors have ranged from
education, treatment, and rehabilitation to punishment,
ostracism, and isolation.
Some discussions of disruptive behavior have held out the
possibility that some types of bad behavior may, in fact, be
adaptive for some children and adolescents. The benefits of bad
behavior may be understood within an evolutionary context or
within more circumscribed settings, including SES, ethnic
background, and family environments (Ellis & Del Giudice,
2019; Smith & Pollak, 2020). The role of developmental level
and the impact of specific developmental challenges remain to
be fully explored. As we grapple with our concerns, we need to
remind ourselves that the questions we frame about children
and adolescents will need to be as complex, difficult, and
genuine as they are.
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Developmental Tasks andChallenges Related toProsociality 173
of punishment (motives focused on the self) (Batson, 2022;
Eisenberg et al., 2016). Children’s prosociality is influenced
by characteristics of the recipient (such as familiarity and
level of distress or need), characteristics of the situation
(such as likelihood of reward or punishment, costs and
benefits of sharing, or the presence of others), and their own
temperament, age, and history (Decety & Steinbeis, 2020;
Martin & Olson, 2015).
Two related constructs, conscientiousness and
conscience, contribute to our understanding of prosociality
across development. Conscientiousness is one of the Big 5
personality characteristics and is evident in displays
of self-control, purposefulness, and responsibility.
Conscientiousness supports children’s compliance and
the internalization of social and personal norms and
expectations (Eisenberg et al., 2014). Conscientiousness
and effortful control have much in common: self-discipline,
planning ability, and impulse control. Early effortful control,
influenced by temperament variables such as emotionality,
leads to compliant behavior in young children and is
linked to conscientiousness displayed by older children and
adolescents (Kim & Kochanska, 2019).
Conscience refers to one’s inner sense of right and
wrong. Ongoing emotional, cognitive, and behavioral
development underlies the development of conscience,
conscientiousness, and prosociality. With respect to
emotion, for example, experiences of empathy help children
respond to others with concern and kindness. Experiences
of guilt, shame, or regret following transgressions or
inaction decrease the likelihood of problematic behavior.
With respect to cognition, better perspective-taking skills
lead to an increased appreciation of others’ needs or goals
and the increasing ability to balance or prioritize multiple
motivations. With respect to behavior, improved selfregulation influences cooperation and compliance. Taken
together over time, a prosocial orientation—a “moral
self”—can help organize children’s and adolescents’
patterns of thinking, feeling, and behaving (Batson, 2022;
Decety & Steinbeis, 2020; Thompson, 2020).
Of course, children and adolescents do not develop
parent–child relationship, attachment patterns, and
parental discipline style are important influences on young
children’s prosociality (Augustine & Stifter, 2019; Boldt et
al., 2020; Eisenberg et al., 2016; Stern & Cassidy, 2018).
Research on prosocial development emphasizes the parent–
child mutually responsive orientation (Kim et al., 2015;
Kochanska et al., 2019). With parent-child mutuality,
the child exhibits a willingness to be socialized within
a relationship characterized by security, warmth, and
support. This responsiveness toward parents is enduring
and generalized, consistently associated with children’s
internalization of parental values, and evident in rule-based
behavior. Responsiveness is the link between the parent’s
behaviors and the child’s conscience and prosocial behavior
(Kim et al., 2015; Kochanska et al., 2019).
Differential sensitivity models related to parenting,
attachment, empathy, and prosociality have been described,
with some children displaying greater reactivity to both
supportive and unsupportive environments (Sulik et al.,
2011; Stern & Cassidy, 2018). Early individual differences
in prosociality persist over childhood (Schachner et al.,
2018). Cultural variation in prosociality is also observed in
empathy, helping, and sharing (Coppens & Rogoff, 2022;
Kozloff et al., 2021; Samek et al., 2020).
Research on youth in risky and vulnerable environments
provides evidence for variations in developmental pathways
for prosociality (Taylor & Carlo, 2021). In a study of schoolbased prosocial behavior, for example, several Grade 1 to
Grade 12 trajectories were identified: low and stable levels of
prosocial beh avior; moderate and increasing level s of prosocia l
behavior; high levels of prosocial behavior that declined
over time; and high and stable levels of prosocial behavior
(Shi et al., 2021). The majority of youth in these school
environments displayed persistently high levels of prosocial
behavior. Combinations of personal and relationship factors
were associated with different outcomes. In another study
of youth experiencing adversity (sociocultural conflicts in
Northern Ireland), higher levels of empathy were associated
with more positive attitudes toward out-group youth and
more frequent prosocial behaviors (Taylor et al., 2019).
As noted, prosociality develops throughout childhood
and adolescence. The parent–child relationship that
supports (or hinders) prosociality also changes over
time. Relationships in general, and close relationships in
particular, are characterized by dimensions of permanence,
power, and gender (Laursen & Bukowski, 1997; Laursen
& Collins, 2009). Permanence has to do with the stability
of the relationship. Parent–child and sibling relationships
are among the most enduring, although there are
certainly individual differences in the degree of closeness
in family relationships. Power has to do with control and
responsibility. Parents and children provide a good example
of a vertical relationship, where parents are typically invested
with most of the power. Sibling and peer relationships tend
to be horizontal, characterized by more egalitarian roles
and shared control and responsibility. In some families
and in some cultures, however, older siblings may have
more power and greater responsibility for younger siblings.
Less hierarchical relationships are observed in adolescence,
and adolescents increasingly influence their relationships
with their parents (Laursen & Collins, 2009). Even after
considering changes related to age and types of interactions,
most adolescents and parents report continuing positive
relationships as well as ongoing parent influence on youth
behavior (Arnett, 1999; McGue et al., 2005).
Patterns of prosociality across childhood and adolescence
increasingly involve peer-related behaviors, and bidirectional
inf luences on prosocia lity are frequently described. Although
overlapping somewhat with relationships with parents,
relationships with peers offer unique experiences. Some of the
most important aspects of later childhood and adolescence
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