Effective Strategies For Decreasing Aggressiveness And Improving Behavior

Non-medicinal interventions are highly effective in preventing the behavioral and academic problems associated with Attention Deficit Hyperactivity Disorder (ADHD), according to a five-year study led by researchers at Lehigh University’s College of Education.

The study, titled “Project Achieve” and funded by the National Institute of Mental Health (NIMH), was the largest of its kind focusing on children aged 3 to 5 who have shown significant symptoms of ADHD. It also involved researchers from Lehigh Valley Hospital in Allentown, Pa.

The researchers, led by George DuPaul, professor of school psychology at Lehigh; Lee Kern, professor of special education at Lehigh; and Dr. John Van Brakle, chair of the pediatrics department at Lehigh Valley Hospital, studied 135 preschool students with ADHD symptoms. They evaluated the effectiveness of early intervention techniques in helping children decrease defiant behavior and aggression, while improving academic and social skills.

The study’s results are reported in a special series on ADHD in the most recent issue of School Psychology Review. Published by the National Association of School Psychologists, the quarterly is the world’s second-largest peer-reviewed psychology journal.

“Early identification and intervention are essential, but there has been a lack of research on how to identify and intervene effectively with these children during their preschool years,” said Thomas Power, editor of the journal and program director with the Center for Management of ADHD at The Children’s Hospital of Philadelphia.

“The investigation by Kern, DuPaul and their colleagues is the most ambitious study ever conducted of non-pharmacological, psychosocial interventions for young children with ADHD.”

The results were significant. Using a variety of early intervention strategies, parents reported, on average, a 17-percent decrease in aggression and a 21-percent improvement in their children’s social skills. Teachers saw similarly strong results; in the classroom, there was a 28-percent improvement in both categories. Early literacy skills improved up to three times over their baseline status.

“Medication may address the symptoms of ADHD,” says DuPaul, “but it does not necessarily improve children’s academic and social skills. And because this is a lifelong disorder, without any cure, it’s important that we start understanding what tools and strategies are effective for children with ADHD at such an early age.

“There’s simply a lack of understanding about the type of non-medicinal services that are available to preschool children and their families. Our goal is to address behavioral and academic issues before they become more problematic in elementary school.”

Early intervention techniques include highly individualized programs that often rely on positive supports to reinforce behavior. For example, in consultation with parents and preschool teachers, Project Achieve researchers modified the environments in home and school (such as altering tasks and activities in the classroom to accommodate for ADHD students) in an effort to improve behavior. The highly interactive techniques were presented as alternatives to medicine.

ADHD is a lifelong mental disorder that may become apparent in a child’s formative preschool years. The disorder, which makes it difficult for children to control their behavior and pay attention, affects about 7 percent of the school-aged population. The disorder has become a public health concern, however, because 40 percent of children who show signs of ADHD are suspended from preschool, while approximately 16 percent are eventually expelled.

The researchers suggest that a multi-tiered approach to intervention, offering more traditional services to at-risk children and more intensive services to children in greatest need, may be the most practical and cost-effective strategy for helping preschoolers overcome behavioral and academic challenges.

“While parents of children with ADHD usually trace the characteristic behaviors back to the preschool years,” says Van Brakle, “pediatricians have long questioned whether such children can accurately be identified, given the overlap with normal behaviors in young children. And if so, whether any intervention that does not involve medicine can be of value. Project Achieve suggests that with careful assessment, such children can be accurately identified and that appropriate behavioral interventions are an important part of the treatment plan.”

School Psychology Review’s special ADHD issue features two ADHD articles co-authored by researchers at Lehigh’s College of Education. DuPaul also contributed the Forward for the issue, which is titled, “School-Based Interventions for Students With Attention Deficit Hyperactivity Disorder: Current Status and Future Directions.”

As Cortex Normalizes In Teens With ADHD, Better Outcome Predicted By Gene

Brain areas that control attention were thinnest in children with attention deficit hyperactivity disorder (ADHD) who carried a particular version of a gene in a study by the National Institutes of Health’s (NIH) National Institute of Mental Health (NIMH). However, the areas, on the right side of the brain’s outer mantle, or cortex, normalized in thickness during the teen years in these children, coinciding with clinical improvement. Although this particular gene version increased risk for ADHD, it also predicted better clinical outcomes and higher IQ than two other common versions of the same gene in youth with ADHD.

“Since this gene version had similar structural effects in healthy children as in children with the disorder, our findings suggest that ADHD is at the far end of a continuum of normal traits,” said Philip Shaw, M.D., NIMH Child Psychiatry Branch, who led the research. “ADHD likely stems from interactions between several such genes and non-genetic factors.”

Shaw, Judith Rapoport M.D., and colleagues report on their magnetic resonance imaging (MRI) study in the August 2007 Archives of General Psychiatry.

“This study provides us with a first glimpse of how variation in a specific gene influences both brain development and clinical prognosis in ADHD,” said NIMH Director Thomas R. Insel, M.D.

When the NIMH researchers first reported last year that normalization of right cortex thickening was associated with better clinical outcomes in ADHD, there were few hints of a genetic connection. Yet evidence from several previous studies led them to suspect involvement of an ADHD-implicated version of a gene that codes for a receptor protein that binds to the brain chemical messenger dopamine.

This version of the dopamine D4 receptor gene, called the 7-repeat variant, accounts for about 30 percent of the genetic risk for ADHD, making it by far the strongest candidate gene implicated in the disorder. It’s called the 7-repeat because it contains the same repeating sequence in its genetic code seven times. Everyone inherits two copies of the D4 receptor gene, one from each parent, so some people have two copies of the same version while others may carry two different versions.

For the current study, the researchers scanned and determined the D4 gene types of 105 children with ADHD and 103 healthy controls and re-scanned them through their teen years.

They found that nearly one-fourth of youth with ADHD and in about one-sixth of the healthy controls had at least one copy of the 7-repeat version. Nearly two thirds of the ADHD youth and three-fourths of the healthy controls had the most common 4-repeat version; fewer than one-tenth in each group had a 2-repeat version.

While the 7-repeat version was linked to thinner attention-controlling cortex in both ADHD and healthy subjects, it appeared to confer advantage only among youth with ADHD. For example, participants with ADHD who lacked at least one copy of this 7-repeat variant had significantly lower IQs, and more than half of them still had pronounced ADHD symptoms when followed-up about six years later, compared to only 21 percent of those with at least one copy of the 7-repeat variant. There was also a trend toward better overall functioning among those with at least one copy of the 7-repeat variant at follow-up.

The MRI scans revealed that 7-repeat carriers with ADHD started out with the thinnest cortex areas important for controlling attention (right orbitofrontal and posterior parieto-occipital). The next thinnest were children with ADHD who did not have the 7-repeat version, followed by healthy children with the 7-repeat. Healthy children lacking the 7-repeat had the thickest cortex, but this did not appear to affect their IQ. However, the researchers note that other studies have found correlations between cortex thickness and certain measures of memory and intelligence.

In 7-repeat carriers with ADHD, the attention-controlling areas thickened to normal by age 16 (see time-lapse image below). Gene variants of two other dopamine system components showed few such anatomic correlates, confirming that the findings were specific to the D4 receptor gene.

“Some genes have a good side, even though they’re linked to disorder,” said Shaw, who noted that other traits linked to the 7-repeat version, such as novelty seeking and impulsiveness, might confer advantage in some settings. “Evidence suggests that the 7-repeat may be a relatively new variant that may have been favored through evolution because such traits proved adaptive for survival.”

The researchers are following up with studies on the relationship between cortex thickness and cognitive features of ADHD, such as working memory and the ability to inhibit responses.