Summaries of the assigned articles for School Neuropsychology

Summaries of the assigned articles for School Neuropsychology at the Rijksuniversiteit Groningen.


Topics that are discussed: ADHD, Autism, ASD, Special Education, Dyslexia, neuropsychology

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Developments in clinical neuropsychology: Implications for school psychological services - Cleary et. al. - 2011 - Article

Developments in clinical neuropsychology: Implications for school psychological services - Cleary et. al. - 2011 - Article

It is well known that there is a disparity between the mental health needs of school age children and the availability of mental health and social services. 16 to 22% of children and adolescents have emotional or behavioural problems serious enough to fit a mental health diagnosis. Also, research shows that 15% of children and adolescents suffer from a mental disorder severe enough to cause a certain level of functional impairment. The President’s New Freedom Commission was put up in 2002 and this tries to counterbalance the gap between mental health problems and available services. This programme enabled children and adults with mental health problems to participate fully in their communities. There are also two other programmes that support cognitive and behavioural development in children and adolescents, especially those with learning problems. These two programmes are The No Child Left Behind Act of 2001 and the Individuals WITH Disabilities Education Improvement Act of 2004 (IDEA). This article will look at the growing neuropsychological evidence for numerous behavioural and learning disorders (LD), the developments supporting neuropsychological testing in schools and the growing interest in school neuropsychology. The writers will also make suggestions regarding how school psychologists and clinical neuropsychologists can interface effectively on behalf of children and parents.

The history of clinical neuropsychology

After the 1975 passage of the Education for All Handicapped Children Act, school psychologists had to carry out psychological assessments of children for special education services. Around this time, researchers began examining the neurological bases of behavioural disorders and learning disabilities. Nowadays we have solid neurobiological evidence for attention-deficit hyperactivity disorder (ADHD), disorders of reading, calculating and persuasive developmental disorders such as Asperger’s syndrome. There is also information about neuropsychological abnormalities, like schizophrenia, obsessive-compulsive disorder and unipolar depression. Biological underpinnings of behaviour is becoming more relevant to the current health practitioners. There has been much work published recently about the application of neuropsychological principles in school settings. There are many school psychologists who want to bring together brain-behaviour research and neuropsychological principles into practice and they start to identify themselves as school neuropsychologists.

To better understand the trend for neuropsychology, it is important to look at the history of clinical neuropsychology. Researchers in the mid-19th century focused on global brain function and dysfunction and they relied upon performance on one single test to detect the presence of brain damage. From the 1940s to the 1970s multiple test batteries were developed to measure different neuropsychological constructs, like spatial abilities and memory. This was done in order to determine the source of possible brain dysfunction.

The Russian neuropsychologist Luria was the one who suggested that capacities (like language and attention) are comprised of interacting subcomponents and mediated by interactive neural networks. Because of his approach, researchers did not just look at test batteries to determine the components of impaired performance, but also looked at behavioural observations. Paediatric neuropsychologists started making test batteries for neuropsychological assessments of children. The modern paediatric neuropsychological evaluation consists of:

  • An interview and observations of the child

  • A parent conference

  • A look at the child’s school and medical records

  • A neuropsychological test

By looking at the brain-related strengths and weaknesses, neuropsychological test help explain why a student struggles. The clinical neuropsychologist is seen as a specialist in the diagnostic assessment and treatment of patients with brain injury or deficits. Neuropsychology is one of the fastest growing specialties within clinical psychology.

School neuropsychology

Many fields are interested in school neuropsychology. This is because of large number of children are affected by neurological conditions. Some are affected because they survived neonatal risk factors. Children with low birth weight are at risk for cognitive, behavioural and academic difficulties. 40% of the chronically ill children have school-related problems. Children with head injuries return to school shortly after they have been medically stabilized and the burden falls upon the teachers and families to support these children to reach their potential. Some researchers have suggested to children with traumatic brain injuries (TBI) be routinely monitored for changes in behavioural, social and academic functioning. However, due to outdated reporting protocols the prevalence of TBIs are greatly underestimated. Also, the growing use of medication is another factor which shapes school neuropsychology. Most medication to school children is prescribed for disruptive behavioural disorders. Sometimes medications are prescribed without knowing how they affect school performance. School psychologists also see an increase in the prevalence of behavioural and social-emotional problems. Many of which are the result of neuropsychological deficiencies. The school neuropsychologist can interpret the results of neuropsychological testing and make a right diagnosis.

Neuropsychological testing in school

The National Association of School Psychologists (NASP) made a service delivery system. Tier 1 services include educative and behavioural support for all students without a precise classification of what the student needs. Tier 2 services are for students who show a lack of academic progress and academic skills are directly assessed. The students who fail to respond to Tier 1 and Tier 2 interventions are categorized as Tier 3.

There is not much agreement about what needs to happen in Tier 3 before a diagnosis is made for special education services. Some scientists argue that only minimal assessment is necessary while others want a more detailed evaluation and the use of neurological tests. The writers believe that neuropsychological assessment must be seen as an essential component of the neurodiagnostic evaluation. The need for neuropsychological assessments in school is relatively high, but the access to a clinical neuropsychologist is sometimes difficult. There are many neuropsychologists that work only with adults while the majority of pediatric clinical neuropsychologists work in hospital settings with severely brain-injured children. The school psychologist needs to be trained in neuropsychology and he or she will be perfect for the school setting. He or she can interface with the clinical neuropsychologist to identify needed services. The American Board of School Neuropsychology was founded in 1999 to set standards of practice for school psychologists who claim to be school neuropsychologists.


The school psychologist and the community clinical psychologist must help other school-based professional become familiar with developments in neuropsychological assessment. This can be done with workshops and in-service presentations. School psychologists need to translate neuroscience research findings into language that social workers, parents, administrators and the school board can understand. When making websites about school neuropsychology, there needs to be a frequently asked questions section in which the most common definitions are explained. Models for the utilization of neuropsychological testing must be explored. School psychologists and clinical neuropsychologists need to work together to develop interprofessional assessment protocols which will result into more effective intervention services for students with neuropsychological conditions. School psychologists with training in neuropsychology could administer or interpret some of the test batteries employed by clinical neuropsychologists.

Assessment and intervention practices for children with ADHD and other frontal-striatal circuit disorders - Hale et. al. - 2010 - Article

Assessment and intervention practices for children with ADHD and other frontal-striatal circuit disorders - Hale et. al. - 2010 - Article

ADHD is widely recognized to be a frontal-subcortical circuit disorder, with the affected brain regions as possible contributors to both cognitive as well as behavioral symptoms. Frontal-subcortical circuit disorders most often lead to attention impairments, which implicates that differential diagnosis only based on behavioral criteria can be very difficult.

Cognitive and neuropsychological functions

The main area involved in ADHD is the prefrontal cortex and its associated structures, which are responsible for executive functions such as planning, problem solving and evaluating. Also, structures responsible for transferring information from one hemisphere to the other, like the corpus callosum, are found to be affected in children with ADHD. Also, research has shown that cerebellar regions like the right prefrontal are reduced in volume. This suggests that ADHD not only affects the frontal lobes, but a number of interrelated midline circuits and tracts extending from the subcortical cerebellar to the cortical prefrontal regions. This axis is likely the seat of most known psychopathologies, like ADHD. Therefore, symptoms like impulsivity, hyperactivity and inattention are probably just one facet of the disorder, with multiple other systems and area’s likely to be affected.

Impulsivity due to an impaired inhibitory control system results in maladaptive externalizing behaviors like fearlessness and carelessness. This should be regulated by the frontal lobes, like in typically developing children. Executive attention as well as behavioral regulation highly depends on inhibitory functions. Therefore, the theory of ADHD by Barkley states that deficits in multiple cortical and subcortical regions can be found in children with poor inhibitory control. A distinction can be made between top-down cortical inhibitory problem considering interference control and behavioral inhibition, and bottom-up subcortical problems which are related to (the lack of) response to reinforcement and punishment. It seems that the right prefrontal cortex is more involved in representation and maintenance of adaptive responding and suppressing irrelevant events, while the basal ganglia is more involved in suppression of response. All in all, inhibitory functions consist of multiple implicated areas.

It seems that children with ADHD not so much have a primary attention deficit, but experience difficulty with the executive control of attention. This can be explained by the specific abnormalities linked with attention dysfunction, which are also involved in the inhibitory process. The deficits in these brain area’s result in a disorder of attention control . Since dysfunctions in the frontal brain areas can be associated with multiple disorders, heterogeneity among children referred for attention problems must be considered.

A defect in the regulation of dopamine can lead to dysfunctional frontal-subcortical circuits, resulting in hyperactive behavior. Also, children with ADHD often experience impaired motor precision and consistency, which frequently results in comorbid Developmental Coordination Disorder. Since individuals with ADHD show impairments in both areas, it’s important to determine whether a motor deficit is the result of a cortical motor (e.g. basal ganglia), subcortical cerebellar problem or both. Furthermore, children with ADHD have more sensory processing deficits than controls. This could be due to impaired thalamatic functioning in individuals with ADHD or poor efficiency of connectivity of white matter connections between the anterior and posterior regions. Also, problems with transferring information because of a deficit in the corpus callosum like mentioned earlier could lead to problems with sensory-motor integration.

Executive functioning

Although deficits in executive functioning is probably the most consistent neuropsychological finding among children with ADHD, there is also still some controversy. We consider ADHD as best characterized by executive deficits in vigilance, response inhibition, planning and working memory. It’s important to mention that these impairments couldn’t be explained by intelligence, comorbidities or achievements. Because of its similarities with executive function, fluid reasoning can be considered as a cognitive test. Both require the abilitiy to solve novel problems, benefit from feedback and adaptive responding. As the complexity of problem solving increases, so does dorsolateral prefrontal functioning. Children with ADHD and social problems show impairments in their fluid reasoning and visual organization/praxis measures with high executive demands. This suggests that fluid reasoning is in part a measure of right dorsolateral prefrontal functioning, in which individuals with ADHD show deficits. A strong predictor of fluid abilities is working memory, which is also often impaired in individuals with ADHD. Especially spatial working memory appears to be impaired. Executive functions that include working memory have been found to be related to hyperactive-impulsive symptoms.

Children with ADHD exhibit deficits in processing speed and efficiency, possibly resulting from a lack of energy supply to rapidly firing neurons. This appears to be specific for the inattentive ADHD subtype. Because of all those deficits discussed, and its impact on encoding, storing, and retrieving information, it’s not surprising that children with ADHD often experience learning difficulties. Academic deficits have long been considered the final common pathway for children with ADHD. Specific Learning Disabilities (SLD) therefore is an often found comorbid disorder. Difficulties with attending to the novel information presented is what makes new learning especially hard for children with ADHD. Long-term memory storage on the other hand doesn't seem to be impaired. The difficulty with new information may be due to a working-memory overload because of the inability to filter out irrelevant information. Researchers found meaning to facilitate learning. When children ought something important, they more easily remember it. Therefore emotional salience increases episodic memory in children with ADHD. They also found that nucleus accumbens deficiencies may lead to deficient motivation or reinforcement during new learning situations.

Since the frontally mediated executive functions govern all other aspects of cognition, it’s not surprising that children with ADHD also experience visual-spatial-holistic right hemisphere and auditory-verbal-crystallized left hemisphere dysfunctions. These impairments can also influence the ability to process information. Especially visual working memory seems to be impaired, but luckily this can be improved with medication treatment. The problems with visual-spatial-holistic processing may be due to its strong relationship with executive function, which is often impaired in children with ADHD. Furthermore, attention deficits overlap with auditory processing and language disorders, which can interfere with the learning, behavioral and social outcomes of affected children. Poor internalization of language in ADHD is in part responsible for poor behavior regulation and impulse control. Children who do not process language efficiently will appear inattentive in the classroom, and could be diagnosed with comorbid ADHD. But do those children really have ADHD? Early research did not screen for comorbid SLD, but auditory processing and language deficits are more often associated with SLD than ADHD. It could be that language deficits in ADHD are more related to the executive and expressive aspects of language.


Children with ADHD often show impulsive, aggressive and noncompliant behavior which results in conflicts with their peers and family. They show impaired emotional and behavioral inhibition. These behaviors most often occur with children who have comorbid disorders like Conduct Disorder(CD) or Oppositional Defiant Disorder (ODD). The latter is the most common comorbid condition, with an occurrence of 40 to 60% of children with ADHD, mostly males.

Impaired executive functioning can result in low self-esteem, poor concentration and irritability. Therefore, children with ADHD may develop a depression. Rates of comorbidity range from 10 to 50%, and children with the inattentive type of ADHD are more likely to develop an internalizing disorder. Another highly common comorbid disorder is Bipolar Disorder (BPD) . This comorbidity increases the risk of neurocognitive deficits and poor treatment response because mania are often mistaken for ADHD in children, but require a different form of medication.

Anxiety disorders can be primarily linked to children who suffer from the inattentive subtype of ADHD. A more severe form of anxiety is Obsessive-Compulsive Disorder which also shows similarities with ADHD and therefore is a comorbid disorder. Many children with Tourette Syndrome also suffer from ADHD. This is probably because the involuntary tics wax and wane, with attentional problems found to precede or follow the onset of tics.

Function measures

Some executive function measures are more effective than others in the diagnosis of ADHD and for conducting school neuropsychological evaluations. Most tests measure response inhibition, interference control, working memory vigilance and planning, but are generally more sensitive to ADHD than they are specific. This is probably due to the fact that several other disorders also show impaired performance on these and other executive measures. School neuropsychologists should use a variety of direct assessment tools for ADHD diagnosis and intervention purposes, because no single assessment tool is sufficient enough. Indirect measures of ADHD symptoms, such as objective behavior rating scales are also important for a comprehensive ADHD evaluation, but not sufficient for a differential diagnosis of ADHD.

Because comorbidity is more the rule than the exception among psychiatric disorders including ADHD, interrelationships can only be clarified by examination of underlying deficits. It’s possible that children who meet behavioral criteria for ADHD actually suffer from their comorbid disorder as the primary disorder, with secondary attentional problems. Therefore it’s important to determine to what extent psychiatric disorders have similar or different etiologies, if these differences can lead to more accurate diagnostic techniques and whether these differences can lead to more effective treatment practices and outcomes.

Although research into these matters provide sometimes conflicting findings, the overall conclusion is that most (if not all) psychopathologies have a basis in the frontal-subcortical circuits, and that their dysfunctions lead to observable behavior and learning problems. There are at least five interdependent frontal-subcortical circuits with dozens of related executive functions. Therefore impairments in this area can lead to many different psychiatric disorders. So far there is no clear explanation for all these differences, but different gene environments are suggested as one of the reasons. Another important issue is how we define disorders. Because behavioral diagnostic methods lead to heterogeneous samples of children diagnosed with psychiatric disorders, this is often more meaningful for diagnosis than neuropsychological measures. However, to explain differences within the group of children with a certain disorder, neuropsychological assessment can be very useful. More information about differences within a disorder can lead to more targeted treatment plans and interventions, because those are currently quite ‘global’.

Neuropsychological assessment and its role in the functional outcomes of children with ADHD - Pritchard et. al. - 2012 - Article

Neuropsychological assessment and its role in the functional outcomes of children with ADHD - Pritchard et. al. - 2012 - Article

Increasingly, the effectiveness of clinical services must be justified by scientific evidence in order to be considered as an option for treatment. The necessity of evidence-based services has becoming more and more important for psychologists as well as physicians. Currently, there’s a lack of effectiveness data on neuropsychological assessment in ADHD. Therefore, the question’s raised whether neuropsychological assessments contribute to improved accuracy in diagnosis and to better outcomes than diagnoses made on the basis of clinical observations, rating scales and/or constructed interviews.

Neuropsychological assessment is defined as the evaluation of a child by a trained neuropsychologist. This considers the following skills, as appropriate to the case in question:
general intelligence and academic achievement, executive functions, attention, memory, motor skills, visual processing, language processing, adaptive skills, sensory and perceptual skills. Behavioral, emotional and social functioning are also part of the evaluation. This is accomplished by methods such as a clinical and history interview, observation, a flexible battery of standardized instruments and behavior and skill ratings completed by the patient itself and its family and teachers. In contrast to ADHD, more evidence exists for the effectiveness of neuropsychological assessment for other medical conditions such as epilepsy, neuro-oncology and traumatic brain injury.

It’s quite complex to diagnose a child with ADHD, because many symptoms observed in children with ADHD are also common among other behavioral and emotional disorders. The diagnosis is especially difficult in girls, due to later age of onset and more subtle clinical manifestations. Some of the co-occurring disorders which are regularly seen in combination with ADHD are anxiety disorders, depression, autism spectrum disorder, Tourette syndrome and pediatric Bipolar disorder. Sometimes there’s even co-occurrence between ADHD and multiple other disorders.

When other causes for behavioral and emotional symptoms haven’t been considered, the accuracy of an ADHD diagnosis can be questioned. If the child isn’t properly diagnosed, the treatment is likely to be less effective and more expensive. When co-occurring conditions aren’t recognized, children may not get the treatment they need and provided treatments for ADHD may be less effective. An extensive neuropsychological assessment evaluates all functional domains and generates recommendations for treatment of ADHD that consider co-occurring conditions. Where visits to the routine pediatric or general practitioners often don’t include a broad-based evaluation of a child’s overall functioning, neuropsychological assessments offer recommendations addressing areas of need that include the three most important agents of change in the life of a child: family, school and treatment providers.

Prevalence of ADHD in children

ADHD is the most commonly diagnosed disorder in child psychiatry, and the prevalence of ADHD continues to grow. The disorder is more common among boys, they are diagnosed with ADHD twice as much as girls. Prevalence increases with age. There’s little to no difference in prevalence rates between white, black and Hispanic children. Diagnoses among Mexican children are considerably lower. Rates of diagnosis are consistent between North America, South America, Europe, Asia, Australia and the South Pacific. They differ from rates found in Africa and the Middle East. The rate of ADHD diagnosis is also associated with socioeconomic factors such as growing up in an impoverished community and living in a single parent household. The prevalence also varies by subtype, although this is difficult to interpret because subtypes generally change over time.

ADHD: Structural and Functional Brain Differences

Children with ADHD show structural brain differences such as total brain volume and delayed cortical maturation. This is especially seen in the frontal and temporal brain regions in combination with abnormalities within the corpus callosum, temporal and parietal cortex, prefrontal regions and as the most consistent finding an abnormal development of the basal ganglia. The latter is associated with the behavioral phenotype of children with ADHD. The neuroanatomic differences observed in children with ADHD are related with deficits in motor skills and eye coordination. They can also explain the often experienced deficits in children with ADHD regarding inhibition and temporal processing. Given these considerations, structural and functional developmental brain differences in ADHD emphasizes the involvement of multiple neural systems which all contribute to very complex symptoms of the disorder. Conditions that coexist with ADHD, such as Developmental Coordination Disorder (DCD) and developmental dyspraxia, may not be assessed without the use of neuropsychological examinations.

Behaviorally-Based Diagnoses and its Inherent Difficulties for Clinical Neuropsychology

For the classification of childhood disorders in the clinical setting, child neuropsychologists use two general approaches: one emphasizing behavior and the other emphasizing neurology. Seen from the behavioral perspective, developmental disorders are classified on the basis of behavioral or cognitive symptoms alone, without paying attention to its etiology. This mostly happens using the DSM. It often occurs though that children with known neurological impairment show symptoms of several behavioral disorders, but do not fit in the full diagnostic criteria for a single disorder. Moreover, the DSM criteria rarely provide information about the developmental nature of childhood disorders such as ADHD. Neuropsychological assessment offers a thorough consideration of all of the presenting symptoms, allowing for a better understanding of the interconnections among symptoms and working towards more effective treatment recommendations.

Primary Care Settings and the Diagnosis of ADHD

At least half of the individuals diagnosed with ADHD are identified and treated within primary care settings instead of a mental health professional. Therefore, the American Academy of Pediatrics (AAP) has set some guidelines for the assessment and diagnosis ADHD. This concerns the following:

  1. Documentation of the DSM-criteria

  2. Evidence of the core ADHD symptoms, manifested as well at school as at home

  3. Evaluation of possible coexisting conditions

These guidelines further state that neuropsychological tests are not obligated for the diagnosis of ADHD, but that they should be performed when there is not enough information about a patients history, when they show low academic achievement or low cognitive abilities. Research unfortunately shows that most of the time the AAP guidelines are not completely followed within primary care settings. This seems to have to reasons. First of all, many pediatricians receive limited mental health training. Second, there isn’t enough time in routine visits to conduct an assessment that would adhere to the guidelines. Because most ADHD patients get diagnosed within primary care settings, considering the findings above, we can call into question the accuracy and completeness of diagnosis for the majority of individuals of ADHD.

Currently, the diagnosis of ADHD is made by exclusion, so by ruling out other conditions that could explain the patients behavior and complaints. Considering that ADHD occurs more often with comorbidities than without, this strategy is questionable. Standardized psychometric tests alone are also not sufficient enough for making a reliable diagnosis but use of this tests could increase the validity of the diagnostic decision-making process in combination with observation, parent and teacher ratings, interviews and the history of the child.

Behavior and outcomes associated with ADHD

Social cognition seems to be impaired among children with ADHD. Therefore they often have trouble functioning in social situations and making friends with peers. Children with ADHD also less often show prosocial behavior such as turn-taking, sharing and cooperation. Moreover, they show higher levels of problematic social behavior such as impulsivity and aggression. Consequently, they do not only have trouble with making friends but also experience more conflict with their parents. Their parents themselves show a loss of confidence in their parenting skills, poorer coping and experience a lot of stress.

Compared with typically developing children, those with ADHD are more likely to receive special education services, be retrained at higher rates, drop out of school, have a lower grade point average and receive more suspensions and expulsions. College students with ADHD have a lot of trouble organizing and planning. Subsequently, individuals with ADHD experience poorer employment outcomes and therefore tend to attain lower socioeconomic status.

Adolescents with ADHD are at increased risk for developing substance use disorders. The disorder develops earlier in life in individuals with ADHD and they have more trouble with cessation. A conduct disorder seems to mediate the association between substance abuse and ADHD, and further research has shown a link between certain genes that people with substance abuse and people with ADHD have in common. Considering this information, it is not surprising that adolescents with ADHD are also at a higher risk for involvement in criminal activity.

Children with ADHD use the health care system more often and make higher costs than children without the disorder. They visit the emergency room more frequently and are more likely to be hospitalized. Their injuries are mostly more severe and often the cause of their impulsivity. Family members of the children with ADHD show higher costs due to disability and absenteeism. Most of the extra costs that children with ADHD make for society and themselves can be attributed to the treatment of co-occurring conditions rather than the treatment for ADHD itself. Because a neuropsychological assessment can show a child’s strengths and weaknesses, provide a good differential diagnosis and thorough interventions, a lot of money can be saved for the individual with ADHD as well as society as a whole if we would use this kind of research more often.

The Quality of Life for an individual with ADHD seems particularly affected by psychosocial and achievement-related aspects. In comparison with children with chronic physical conditions, children with ADHD experience equal, and sometimes even greater reductions in many domains of the Quality of Life. Their parents also show some impairments in their Quality of Life.

There are several treatments for ADHD that have shown to reduce symptoms and that induce functional improvement. The best known alternative is stimulant medication, followed by psychotherapeutic treatments and educational support services. In contrast with the findings that these treatments reduce symptoms, studies clearly indicate that treatment for the ADHD population is not being optimized, as many individuals with ADHD show both symptoms and functional impairment despite of receiving treatment. This is often due to the fact that many of the positive effects that are found in the beginning of the treatment quickly dissolve. When the intensity of the treatment is reduced, symptoms and functional impairment return. The treatments thus may not be targeting all of the appropriate domains or disorders necessary to create a longstanding change.

Recently, a lot of different studies have been done regarding medical treatment, and their general conclusion was that treatment with medication has the potential to reduce symptoms and high-risk behaviors and improve the quality of life, though not consistently or completely. Furthermore, psychopharmacological treatment reduces the core symptoms of ADHD, but do not have this desired effect on co-occuring impairments. The same goes for behavioral treatment. Considering these findings, it is safe to suggest that even when treatment reduces symptoms, if it’s not specifically designed to address other areas of impairment or concern, quality of life will still be impacted. Here lies a chance to use neuropsychological assessment, as it has the potential for a better understanding of the symptomatology of ADHD and co-occurring disorders. You have to know someone’s strengths and weaknesses in order to make recommendations for optimizing treatment to address all factors included, and this is something neuropsychological assessment can offer.


Thorough neuropsychological assessment of children suspected having ADHD can offer the following benefits:

  1. Use of a wide variety of measures so there’s an understanding of the child as a whole

  2. Consideration of co-occurring conditions and disorders

  3. Optimized recommendations for treatment

  4. Psychometrically-defined baseline level of functioning against which treatment effects can be measured

Difficulties with Handwriting in Children with Autism Spectrum Disorder - Kushki et. al. - 2011 - Article

Difficulties with Handwriting in Children with Autism Spectrum Disorder - Kushki et. al. - 2011 - Article

The simultaneous processing of motor and cognitive demands is necessary for the production of written text. Children develop automaticity in their handwriting while learning to write, such that motor demands of writing doesn’t interfere with higher-order cognitive processes related to composition. When this automaticity isn’t present, the flow and planning of ideas and their translation into written form may be disrupted, which affects the complexity of the text.

Furthermore, the quality of handwriting is significantly correlated with the level of academic achievement during school years, and is a predictor of more general learning difficulties later in life. The World Health Organization (WHO) therefore identifies the skill of writing as part of the Activities and Participation Domain of health. Poor handwriting can also affect the perception of a child’s abilities, self-esteem, personal relationships and psychosocial well-being.

Children with neurodevelopment disorders such as ADHD, DCD and ASD often experience handwriting difficulties. Autism Spectrum Disorder concerns neurodevelopmental disorders characterized by symptoms such as presence of restrictive, repetitive and stereotypical behaviors, activities and interests plus impairments in communication and social interaction. ASD is also often associated with fine motor difficulties and executive function impairments which are necessary for the performance of skilled motor task. This explains why ASD in children is often related with handwriting difficulties.

Determinants of handwriting function

Learning and acquisition of handwriting is a function of the interaction between the child, the writing task and the environment. The Sequential Handwriting Process argues that the handwriting process starts with the presentation of the text to be written. This can be a visual, audial or self-intended presentation. Second, a series of cognitive steps have to be taken to retrieve the motor program for the appropriate letter allograph. This translates into specific control instructions for muscle groups concerning the size and speed of the required movement. Appropriate force on the pen and paper, movements within strict spatial limits and the use of the correct velocity are all necessary factors for fluid handwriting. Sensory perceptual feedback provides information for error correction.

Fine motor skills enable fluent manipulation of the writing and thereby producing letters with the desired specific form, size and position on the writing surface. The quality of handwriting therefor logically correlates with aspects of fine motor control. Deficits to the fine motor skills often occur in children with ASD, especially in children with Asperger’s syndrome. Proper timing and force control of the arm, hand and finger movements derive from fine motor skills, and are all necessary to produce accurately formed letters. Children with ASD also regularly experience difficulties with planning, executing and organizing movements or suffer from dyspraxia which both affect coordination, fluency and speed of motor activities. Since movement planning is necessary to produce handwriting, these impairments also cause problems producing written text. They therefore develop a certain slowness in their movement preparation and reaction times. Muscle tone, muscle stress and tension and pencil grip are also important factors in producing handwriting but are often impaired in individuals suffering from ASD.

Another integral part of proficient handwriting, specifically in the planning and execution of the written product, are visual perception skills. Not only do those skills allows to discriminate between letter forms, they also provide information for error monitoring. Interestingly, since handwriting movements are highly pre-structured and organized, the reliance on vision generally diminishes as skilled handwriting develops. ASD is particularly associated with atypical patterns in visual processing, including differences in perception of motion, superior processing of fine details and atypical processing of global structure. Overall, ASD is not associated with global deficits in visual reasoning and discrimination, but the atypical patterns of visual perception in ASD might contribute to handwriting difficulties.

Visual-motor integration is the ability to integrate the visual images of letters or shapes with the appropriate motor response. This is typically assessed by examining the ability of children to copy geometric forms using pencil and paper. It is therefore considered as a degree of coordination between visual perception and hand-finger movements. The ability of visual-motor integration significantly correlates with the production of legible handwriting. So far, no strong evidence has been found that children with ADHD exhibit deficits in visual-motor integration. Sins visual-motor integration combines both motor abilities and visual perception, poor performances may result from impairments in one of these two domains or in the integration of the two domains.

The awareness of the movement and position of limbs in space as well as information regarding touch, pressure and pain are referred to as kinesthesia and proprioception. Kinesthesia provides feedback and a monitoring of extent and force or speed of movements for the purpose of error correction. The ability to improve performances over time could be hindered by deficits in kinesthetic perception. Currently there is no significant evidence suggesting deficits in kinesthesia and proprioception in children with ASD.

Studies on handwriting in individuals with ASD

Officially, the quality of handwriting is measured in terms of speed and legibility. Legibility refers to the recognizability of handwriting and includes factors such as sizing, alignment, letter form and spacing. Several studies have reported poor legibility in children with ASD, especially in the area of letter formation. The quality of letters is measured by letter form which considers factors such as shape reversals, distortions and rotations. Commonly found mistakes in the handwriting of children with ASD are sharp edges instead of smooth curves and larger letter extensions. Poor letter formation may be due to difficulties with fine motor skills and pencil manipulation.

Several researches show a lot of discordance with regard to alignment, spacing and sizing. Although deficits in all of these areas are expected considering the impairments in visual perception and visual motor integration, only one study has shown poorer performances than peers without ASD. The same accounts for speed. Interestingly though, increased consistency in letter formation was reported to be associated with a decrease in speed in children with ASD but not in typically developing peers.

Very few research has been conducted on the nature of handwriting difficulties in children with ASD. The most consistent finding is that legibility, especially letter formation, is impaired in children with ASD. This impairment positively correlates with deficits in motor skills. The great amount of disparity in several researches may be due to differences in the nature of the writing tasks used in the studies and the heterogeneity of the ability profiles in children with ASD. Also, the current studies have mainly focused on the final, static written product while writing is a dynamic process involving changes in direction, forces, velocities and accelerations. So far no research has been conducted on these process-related aspects.

Graphonomics, automaticity and handwriting assessment - Tucha et. al. - 2008 - Article

Graphonomics, automaticity and handwriting assessment - Tucha et. al. - 2008 - Article

With respect to handwriting, the present focus is on well-formed, joined handwriting. Speed, fluency and automaticity of handwriting are mostly neglected. On the one hand, automatic processes are carried out rapidly and with minimal conscious effort. On the other hand, controlled processes are effort demanding. Processes are automatic under certain conditions and controlled under other conditions. There is a need for a screening instrument to identify children with difficulties regarding the automaticity of handwriting. Graphonomics is a research field that analyses the relationships between the planning and generation of handwriting and drawing movements, the resulting spatial traces of writing and drawing instruments and the resulting dynamic features.

In graphonomic research, handwriting is understood as a process of kinematic and spatial parameters. One can measure for example position, time course, velocity, and acceleration. The parameter ‘number of inversions in the velocity profile’ (NIV) of a movement has been demonstrated to be of importance for the assessment of highly skilled motor activities. Automated movements are those performed with the least motor effort possible: only one change in velocity. By profiles of velocity, one can distinguish between non-automated and automated movements. The analysis of these profiles provides evidence for the being of simple motor programmes. The fluent execution is not dependent of the speed of movement execution.

Five factors influencing the production of automated handwriting movements

This article explored five factors influencing the production of automated handwriting movements.

  • Direction of writing (explored by mirror writing). Mirror writing has been spontaneous in left-handed adults. These adults perform better in mirror writing tasks. However, when asked to write in mirror script, a significant increase in the number of inversions in velocity is reported. So, when writing reversely, a significant impairment of handwriting automatically emerges.

  • Lexical status of writing (explored by writing nonwords). The number of inversions in velocity was increased when writing nonwords. Attention has to be allocated to the writing process, which results in an increase of processing time.

  • Visual and mental control of writing movement. Loss of vision has no effect on handwriting automaticity. Visual feedback is not used for controlling the writing movement, but to monitor the stroke size, form and positioning of letters. When participants were asked to visually track the pen tip or mentally track the highest position in a letter, movement were less fluent.

  • Style of writing (explored by neat handwriting). When participants engage in neat handwriting, the velocity profile is typified by multiple inversions of velocity per stroke. This indicates a non-automated movement.

  • Promise of a reward. If children and adults were asked to write neatly, the number of inversions in velocity profiles was significantly increased. A further increase happened when the promise of a reward existed. Both motivational factors and the instruction given can influence handwriting automaticity.

Automaticity of handwriting is crucial, and impaired by attentional control to any characteristic of the writing process. We must keep in mind that we put too much emphasis on writing style and neatness. We neglect the automation of handwriting, which is important because it frees up mental resources for the understanding of the content.

The Education of Dyslexic Children from Childhood to Young Adulthood - Shaywitz et. al. - 2008 - Article

The Education of Dyslexic Children from Childhood to Young Adulthood - Shaywitz et. al. - 2008 - Article

Defining dyslexia

Nowadays, dyslexia is defined as a specific learning disability with a neurobiological origin. It causes difficulties with the accurate and fluent recognition of words, is characterized by poor spelling and impairs decoding abilities. This symptoms often result in a deficit in the phonological component of language, which is often unexpected in relation to other cognitive abilities. Therefore, dyslexia has also been called ‘the unexpected difficulty in reading’. This means that a child who possesses all factors necessary to be a good reader, such as intelligence and motivation, still struggles.

To measure dyslexia as a unexpected difficulty, IQ and reading achievement were compared to look for a discrepancy between those two. Unfortunately, this means that in real-life children often had to fail before they got diagnosed and received help. Therefore this was also called the wait-to-fail-model. Alternative approaches were needed. One such an approach focuses on a more dynamic assessment, which is also applicable to early grades and therefore early recognition. The ongoing development or fluency in component reading skills such as letter recognition is measured frequently and compared with expected norms. Another approach provides all children with a evidence-based reading instruction and frequently monitors their progress. Children who do not make any progress are selected to receive additional support. This is called the response to intervention.

Recent data has suggested that reading difficulties occur as part of a continuum that includes nonimpaired as well as disabled readers. This also includes dyslexia, which therefore seems to occur in degrees of severity. This dimensional model also suggests that cut of points may be implemented to define groups but only differentiate in degree, not kind. These arbitrary points thus may haven no biological validity. Given these findings, children who do not meet these arbitrary criteria may still require and profit from some help.

Epidemiology of dyslexia

Dyslexia is highly prevalent, though exact numbers depend on the definition and cut-off points established as criteria. There is a string misbelief that reading problems are outgrown or represent a developmental lag. It is important to address reading problems expressed early in life, otherwise they will persist with time. Furthermore, research shows a much better response to interventions provided in the first years of school compared with those presented in the later years of primary school.

A lot more boys than girls get diagnosed with dyslexia. This seems partially due to the often more disruptive behavior of boys in the classroom, which leads to earlier recognition through the traditional school identifications. Mostly, girls are more quit but they may struggle with reading on their own. The identification of dyslexia should not rely on behavioral difficulties. Using ‘response to intervention’ could prevent this.

Phonological awareness

The language system is a hierarchy of different modules, starting with the phonological module, which is dedicated to processing the fundamental units of language: phonemes. We consider language to be generative, since it can produce thousands of words out of just 44 phonemes (in the English language). The phonological module assembles the phonemes into words for the speakers, and disassembles the words into phonemes for the listener. Coarticulation is the term used to describe the process of different segments sounding seamless to the listener. The fact that spoken language doesn’t give any clue to its underlying segmental nature can be a challenge for the reader-to-be.

Spoken language is innate, whereas written language is acquired and must be taught. The literature suggests that the prime challenge for beginning readers is to link the letters to spoken language: the phonemes. Therefore this should serve as the major focus of early reading instruction.

The core of reading is the ability to identify, recognize and manipulate syllables and phonemes within spoken language. We refer to this as phonological awareness (PA), what also seems to be the core of reading difficulties. Reading acquisition can be predicted by PA, it differentiates good and poor readers and instructions with the intention to improve PA improve reading. Children first develop an awareness to words as a whole, followed by syllables and then phonemes: phonemic awareness. Research suggests that reading itself is necessary for developing PA, and emphasis the importance of reading instruction to the development of this critical skill.

Alphabetic orthographies use letters and clusters of letters in order to produce phonemes and words, where logographic orthographies use characters (like for example in China and Japan). Dyslexia occurs in both orthographies. Children learn to read words more accurately when the letter-sound mappings are very consistent, like in the Italian language where there’s a great predictability of sound-symbol linkages. Variations in consistency will influence the expression of dyslexia across different languages. In consistent orthographies it is relatively easy for good readers as well as dyslectics to learn reading words accurately. Therefore, dyslexia may only just be recognized until later on in school because only reading fluency is affected while reading accuracy is relatively intact. Spelling may be effected because dyslectics have trouble with inconsistencies between sound and spelling.


Dyslexia appears to be inheritable, interestingly enough especially in in children with high IQ’s. Nowadays, half of the variance in dyslectics can be explained by genetic factors while the rest can be attributed to environmental factors. Taking this information into account, children from dyslectic parents or with dyslectic siblings should be considered at risk for developing dyslexia. Therefore they should be carefully observed for signs of reading difficulties. It’s important to emphasize that a genetic aetiology doesn’t mean that interventions do not work for this group of children. They can still benefit from evidence-based intervention and deserve this extra help.

By using neuroimaging technology, neuroscientists have been able to identify several interrelated neural networks of reading in the left hemisphere (for example Broca’s area). Functional brain imaging studies have shown deficits in the left hemispheres of disabled readers, explaining their reading difficulties. Nevertheless, they seem to have developed compensatory systems in both hemispheres. Several studies have shown that neural systems for reading can be improved and influenced by reading interventions. The way children are taught can foster the development of those automatic neural systems that serve skilled reading, so teaching matters. It is still necessary to determine the precise relationship between types of interventions, changes in brain activation and clinical improvements.

Studies using fMRI have indicated that dyslexics are not able to use sound-symbol linkages growing into adulthood, and start to rely on memorized words. By reading words from memorization, familiar words are recognized and easy to read but they show difficulties reading unfamiliar words. This is a problem because memory has limited capacity. The fMRI scans showed linkages between reading systems in the left hemisphere in non-impaired readers, while linkages between the left hemisphere and neural systems associated with memory in the right hemisphere were found in poor readers.

The diagnosis and treatment of dyslexia

Phonological processing isn’t only critical to written language, but also greatly influences spoken language. Therefore, although they may be more subtle, children with dyslexia can also show problems in spoken language. Furthermore, the clinical picture of dyslexia consists of reading problems, difficulties in handwriting and spelling, problems with mastering a foreign language and attentional problems. Reading fluency can be severely impaired in individuals with dyslexia thereby tremendously draining attentional resources. This makes attention a secondary problem next to the primary reading problems. On the other hand, dyslexia is highly comorbid with ADHD, which makes it a primary problem in some cases. In contrast to all those impairments, other cognitive abilities are usually intact.

Dyslexia is a clinical diagnose, best made by a trained clinician who uses history of the child, observes the child while reading and administers a battery of tests that assess the child’s cognitive abilities.

Effective reading instruction should include five essential elements, namely phonemic awareness, phonics, comprehension, awareness and fluency. These skills have to be taught systematically and explicitly. Early interventions for children with dyslexia have shown to be very promising in many studies. Classroom interventions, pullout remedial approaches and combinations of those two can improve phonological processing and initial word identification skills. Prevention programs that specifically focus on phonemic awareness, phonics and the meaning of text in the earliest stages of reading instruction reduce the base rates of at-risk students. Interventions for older students unfortunately show less promising results. It appears to be quite difficult to bring children or adults up to the expected grade levels once they fall behind, although significant improvements are still possible. Many studies have proven phonologically based decoding and word recognition to be teachable aspects of reading for most individuals. This evidence indicates that focused, intense, systematic and explicit interventions can positively impact word-reading development.

To increase fluency, fluency programs use repeated reading of connected text. More recent programs also focus on building semantic knowledge and orthographic pattern awareness. When these skills are improved, less strategic attention on the act of reading is necessary as it becomes automatic and therefore the reader can direct more cognitive energy and focus on comprehension and meaning.

Reading comprehension can be enhanced by strategy-related programs, which teach critical thinking skills related to understanding text and constructing its meaning based on the prior knowledge of the reader. The programs focus on finding ideas and facts, developing multiple meaning of words, summarizing text and increasing vocabulary. Unfortunately, applying those strategies in comprehension situations and new text reading has found to be a less consistent.

Although treatment plans can have a lot of positive effects, not all dyslexics respond to these programs. The dyslexia population is heterogeneous and there is no remedial instruction program that will cover the needs of all poor readers.

In order to help children with dyslexia to perform better at school, accommodations in the classroom are necessary. These accommodations occur in three different types:

  1. Providing information through an auditory made, thereby by-passing the reading difficulties

  2. Providing compensatory assistive technologies, such as computers

  3. Provide students with additional time so that they can demonstrate their knowledge despite of dysfluent reading.

Number development and developmental dyscalculia - Von Aster et. al. - 2007 - Article

Number development and developmental dyscalculia - Von Aster et. al. - 2007 - Article

Researchers more and more agree on the fact that the underpinnings of developmental dyscalculia (DD) are a genetically determined disorder of number sense. Number sense is the ability to internally and nonverbally represent and manipulate numbers. To develop this skill (usually during elementary school) you also need additional cognitive components such as number symbolization (language), visual imagery and working memory. Therefore it’s possible that children only developed DD because of genetic factors, but comorbidities such as ADHD, dyslexia and language delay are also very common (two-thirds of the children with DD are comorbid). fMRI studies show that the parietal and frontal regions are under activated in children with DD.

The four step developmental model

The four step developmental model shows the different pathways presented in DD. The core-system representation of numerical magnitude, cardinality (step 1) provides the meaning of ‘number’, a precondition to acquiring linguistic (step 2) and Arabic number symbols (step 3, digits), while a growing working memory enables neuroplastic development of an expanding mental number line during school years (step 4).

If there are any problems developing step 1, the names of numbers can be phonologically learned by memory, but may only function as words without meaning. Many children with DD have a neuropsychological profile comparable with Developmental Right Hemisphere Syndrome and Non-Verbal Learning Disability Syndrome, which both show deficits in visual-spatial and psychomotor functioning.

If primary core-system abilities are preserved but language development is perturbed, the association between nonverbal numerical properties (***) and their linguistic symbolization (three) cannot be established in an age-appropriate manner such as developed in step 2. This could result in deficits in counting routines, arithmetic, counting strategies and number fact storage.

Many children experience problems with the Arabic notation system in preschool, because of the transcoding rules and its place value syntax (which number comes first: twenty-five becomes 25, but with fünf-und-zwanzig, first a five and then a 2, this gets very confusing (step 3).

When children start to identify the ordinal positions of numbers, with reference to the neighboring numbers around them, the mental number line (step 4) comes into play. This seems to work differently in every individual and could be a more complex structure than the theoretical straight line.

Developmental dyscalculia

The normal acquisition of numeracy skills is impaired in the specific learning disorder d evelopmental dyscalculia (DD). This disorder is brain-based, but environmental deprivation and poor teaching also play a role in its development. For the development of numerical concepts in preschool children, it is very important to have intact counting skills. Therefore children with specific language impairment may demonstrate impairments requiring mathematical skills.

The SNARC-effect reflects the observation that people are faster to make a judgment about a number if the hand they use to respond is congruous with the size of the number in question: the left hand quicker for smaller numbers and the right hand faster for larger numbers. This shows that a mental number line is spacially oriented from left (small numbers) to right (larger numbers). The SNARC-effect develops around the third grade. Boys and girls develop the SNARC-effect at the same time, but girls seem not as prepared as girls to use their newly acquired skill. The suggested reason for this phenomenon seems to be that female prefer language dependent strategies, while males prefer visual-spatial and functional-motor strategies.

DD also has a differential diagnosis. Even in a total absence of any basic neuropsychological dysfunction or comorbid disorder, DD may occur as a result of early dysfunctional learning experiences.

When needed, psychotherapy, pharmacotherapy and spelling and reading training should be instituted to treat DD and comorbid disorders. There should be an individual design to train the enhance of calculation abilities and number processing. This should take the profile of individual strengths and weaknesses into account.

ADHD and academic performance: why does ADHD impact on academic performance and what can be done to support ADHD children in the classroom? - Daley, D. et. al. - 2010 - Article

ADHD and academic performance: why does ADHD impact on academic performance and what can be done to support ADHD children in the classroom? - Daley, D. et. al. - 2010 - Article


This paper is about the relationship between ADHD and academic performance and covers the relationship at different developmental stages (pre-school, children, adolescents, adults) and the factors underpinning the relationship between ADHD and underperformance.


Attention deficit hyperactivity disorder (ADHD) is a developmental, neurobiological condition defined by the presence of severe aand pervasive symptoms of inattention, hyperactivity and impulsivity [American Psychiatric Association (APA) 1994]. The concerned child must exhibit a number of inattentive, impulsive and hyperactive behaviours over a period of 6 months, before the age of 7, which should be present in school and at home, and which significantly impair daily functioning (DSM-IV criteria). The child has difficulties in taking turns, he talks excessively and often appears not to be listening when being spoken to. He also tends to interrupt and intrude on others in games, conversations and classroom discussions. ADHD exists in pre-school children, school-age children, adolescence and adulthood.

The co-occurence in ADHD is that 30-50% of ADHD children also have oppositional defiant disorder (ODD) and/or conduct disorder (CD). 20-30% of them experience anxiety and 11-22% also have bipolar disorder. 20-30% of the ADHD children additionally experience a learning disorder of reading, spelling, writing and arithmetic. ADHD children do have a decreased size of the prefrontal cortex and, therefore, experience for example deficits in response inhibition and working memory. ADHD is a disorder of dysregulation of thought and action associated with poor inhibitory control. It also is the manifestation of a motivational style associated with altered reward mechanisms. These two are independent coexisting characteristics of ADHD.

The academic disadvantage of ADHD individuals. A developmental perspective, from pre-school to university

The pre-school years are a key period for the ADHD children, because social, behavioural and  academic skills are developed for the success in academic performance. 2% of the pre-school children may experience difficulties in developing those skills as they are  identified  with ADHD. They may experience difficulties with memory, reasoning, academic skills, conceptual development, general cognitive ability and acquiring basic pre-reading and mathematics skills. Not all individuals who show early signs of ADHD go on to express fully the disorder and experience the associated academic impairments. A proactive, firm limit-setting at home and appropriately structured classrooms can help. However, once at school, children with ADHD will struggle with academic work. ADHD is associated with poor grades, poor reading and mathematics standardized test scores, and an increased likelihood of repeating a school year. The academic performance of adolescents with ADHD has faced less empirical scrutiny. However, it is suggested that they, too, are likely to struggle at school. Childhood hyperactivity has been shown to predict adolescent behavioural problems and adolescent academic problems, which tend to culminate in leaving school with no qualifications. Research shows that ADHD symptoms persist into adulthood, with between 11 and 40% of childhood cases continuing to meet criteria for the disorder in adulthood. Adolescent research shows that individuals with ADHD are likely to perform poorly at school, and leave with few or no qualifications, therefore university prospects seem bleak and are controversery. From a developmental prospective the negative impact of ADHD symptoms on academic attainment can be seen across the lifespan of children, adolescents and young adults.

Why do ADHD individuals experience academic problems?

As ADHD individuals often are likely to experience many other associated problems, such as a CD diagnosis, they are likely to experience future academic problems and offending problems. Also, research has shown that negative associations exist between ADHD and intelligence. 

Cognitive deficits and academic performance

The cognitive deficits – or executive function (EF) deficits – experienced by ADHD individuals include response inhibition and working memory. EF deficits are not common to all ADHD children. However, the implication of EFs in research suggests that deficits in executive functioning could be at the heart of ADHD-related academic underperformance.

Academic intervention

Inattentive symptoms and executive function (EF) deficitis, such as working memory , planning, and response inhibition, are associated with academic problems. Therefore, academic interventions should focus on these. The most common ADHD treatments include medication and behavioural interventions, from which the impact of academic performance is smaller and less studied. 

Peer and parent tutoring

Being placed in a large class may increase the ADHD childs' academic difficulties. In contrast, research on peer tutoring (a strategy whereby an ADHD individual is paired with a peer tutor to work on a certain academic activity, with the peer tutor providing one-on-one instruction and assistance at the ADHD individual’s own pace) has shown that it improves classroom behaviour and academic performance. Also parent-tutoring (through one-in-one instruction, feedback and active responding) may help to increase the reading performance at school and home. 

Task/Instructional modifications

Manipulating tasks through reducing the task length, dividing tasks into sub-units, giving explicit instruc-
tions, and modifying the delivery or modality of instruction according to the ADHD  pupil’s learning style may help in improving, for example, mathematics performance. 

Classroom functional assessment procedures

Developing an intervention, specific to the child, through manipulating environmental variables that initiate, maintain and/or increase the child’s problematic behaviour in a particular setting, could be used  to reduce disruptive behaviour in ADHD individuals.


Setting goals for classwork completion and accuracy, monitoring these goals and administering rewards upon successful completion may help the ADHD individual to improve academic performance, especially in combination with stimulant medication.

Strategy training

Teaching ADHD individuals a specific skill to implement in academic situations may help to improve their performance.

Homework-focused interventions

As homework is the best predictor of student grades and achievement, it may help to teach parents homework strategies based around the problems of ADHD individuals. However, parental ADHD levels should be taken into account. Altering teachers' attitudes towards ADHD behaviours may also help in generating a more positive classroom environment. 


ADHD is associated with academic underachievement from pre-schoolers to adults. Inattentive symptoms and executive function (EF) are associated with academic problems. Hyperactivity/impulsivity and co-morbid conduct problems are not. Future research should focus on the neuropsychological underpinnings of the relationship between ADHD and acadmic underperformance across the ADHD developmental spectrum.

The impact of teacher factors on achievement and behavioural outcomes of children with Attention Deficit/ Hyperactivity Disorder (ADHD): a review of the literature - Sherman et. al. - 2008 - Article

The impact of teacher factors on achievement and behavioural outcomes of children with Attention Deficit/ Hyperactivity Disorder (ADHD): a review of the literature - Sherman et. al. - 2008 - Article


ADHD is the most common psychiatric disorder in childhood, affecting approximately 3–7% of school-age children. These predominantly display inattentive behaviours. The core-symptoms of ADHD frequently lead to academic difficulties. The teacher often is the first one to suspect the disorder and to initiate a referral to a health care professional. As the use of medication may be influenced in part by the teacher having suggested the diagnosis, it is important to look at the impact of teacher attitudes, beliefs and practices on treatment, behavior and education of children with ADHD. The first goal of this review is to determine how teacher factors influence education and health outcomes. The second goal is to describe factors that influence teachers’ acceptability, understanding and tolerance of ADHD and treatment options for their students, as well as teacher factors that relate to their likelihood to refer students for diagnosis.

Review process

Search strategy and inclusion criteria

Medical, educational and psychological databases were used for the review, including peer-reviewed articles, dissertation abstracts, review and opinion papers, and conference presentations or posters. Teacher factors were considered the predictor. The population of interest was North American elementary school-aged children with ADHD. Only studies with North American students were included to increase the generalisibility of conclusions. The dependent variable was changed from student outcomes to related issues such as diagnosis, teacher detection and implementation of treatments.

Screening and categorising

All english sources were screened and reviewed if they met the inclusion criteria. Selected sources were divided among the authors for review and summarizing. Two goals of the review were defined:

  1. Finding out more about the influence of teacher factors on various health and education outcome measures for elementary children with ADHD

  2. Examining factors that influence teachers' views and referral decisions when it comes to treating or diagnosing stzudents with ADHD symptoms.


The relation between teacher factors and student outcomes

Teacher factors include teachers’ perceptions of ADHD, philosophies on interventions, job satisfaction, experience and tolerance levels with respect to behaviour in the classroom. They are not included in the "gold standard of ADHD research", which is the Multimodal Treatment Study of Children with Attention-deficit/Hyperactivity Disorder (MTA). However, as Greene (1995) notes, that teachers rate children differently and thereby can affect children's behaviour and academic performance, it is important to identify teacher factors. He reviewd two types of compatibility issues that have been largely ignored in the literature: teacher–treatment compatibility and teacher–student compatibility. How teachers react to ADHD-typical behaviour is suggested to be associated with how children with ADHD perceive social acceptrance and support from their peers. It is also suggested, that children with ADHD might benefit from teachers who employ a more preventative outlook with respect to disruptive behaviours. This preventative outlook incorporates the notion that classroom problems are temporary, and can be modified with interventions. The perception about intervention effectiveness may then influence treatment outcomes and the information that teachers provide for parents. Furthermore, the perceived social appropriateness and acceptability of treatment procedures by students, teachers and parents are important factors in designing interventions.For example, teachers' time involvement may be a critically important factor for determining how acceptable treatments are in the classroom. 

The relation between teacher factors and ADHD: belief in, referrals for and tolerance of the disorder

Examining the knowledge about and belief in the effectiveness of particular treatment options of teachers is useful for understading the factors thatinfluence teacher's acceptability of treatment and their likelihood to manage behvaiours or refer for diagnosis. Teachers are often the primary source of referral for students with ADHD. Teacher factors have been identified as characteristics that can relate to how teachers refer, tolerate, rate and view students with ADHD. however, not only teacher factors are important to consider, but also child characteristics, such as gender, can influence teachers' acceptability ratings for treatment options. Thus, teachers’ perceptions of treatment acceptability in relation to student characteristics – in this case, gender – can directly impact the type of treatment they support in the classroom, as well as the extent to which teachers pursue a referral (or not). For example, teachers are more likely to refer boys than girls for clinical diagnosis.


First, teacher factors (e.g. tolerance, teaching style, experience with students who have ADHD, communication style, but also potentially subtle factors such as the degree to which teachers use hand gestures in coordination with speech) can significantly impact a variety of outcomes among students with ADHD. Second, there are too few sources that directly assess the important link between various teacher factors and many critical cognitive, health, social and academic outcomes.There has been a ot of literature relevant to the study, but not directly related to the two main goals. More research is needed to understand the various factors that contribute to successfully identifying and treating ADHD. The challenge of ensuring optimal development is multifaceted.

Executive functions after age 5: Changes and correlates - Best et. al. - 2009 - Article

Executive functions after age 5: Changes and correlates - Best et. al. - 2009 - Article


Research on executive functioning (EF) has been predominantly focused on preschool children. This paper outlines why it is important to examine EF throughout childhood and across the lifespan:

  1. Examining EF in older children can address the question of whether EF is a unitary construct. 

  2. Much of the development of EF, especially working memory, shifting, and planning, occurs after age 5.

  3. Important applications of EF research concern the role of school-age children’s EF in various aspects of school performance, as well as social functioning and emotional control. 


The prefrontal cortex (PFC) is critical to the planning, organization, and regulation of cognition and behavior. Executive function (EF) serves as an umbrella term to encompass the goal-oriented control functions of the PFC. Relatively complex neuropsychological instruments such as the Wisconsin Card Sorting Test (WCST) were first employed to evaluate frontal lobe functioning and later to assess EF. Research with a focus on preschoolers is great, because such work identifies the very beginnings of each component of EF. Also, as it is needed to work with simplified tasks, suitable for young children, it is possible to assess a single EF component, thus avoiding the problem of task impurity. Finally the focus on preschoolers has revealed important relations between EF and theory of mind. However, assessing EF in school-age children allows us to ask questions that cannot be answered in research with preschoolers. Research on further changes in the development of each EF component and in the relations among the components during later childhood and adolescence would not only clarify EF as a construct but also provide insight into processes underlying the development of EF. Furthermore, significant improvements in EF tasks occur during the school years. It is, therefore, important to examine EF in school-age children in order to get a developmental picture of EF. As with studying the developmental trajectories of EF components in childhood and adolescence, the course of typical EF decline should clarify the interaction of EF components to produce goal-oriented behavior and the nature of brain processes supporting EF.

Like brain development in general, PFC development involves both progressive (e.g., neuron proliferation, synaptogenesis, myelination) and regressive (e.g., cell death, synaptic pruning) changes. The general finding that EF (behavioural development) develops throughout adolescence is affirmed by the protracted development of the PFC (neural development).

EF as a construct

In order to explore EF as a construct, it is necessary to involve older children and adolescents as well as preschoolers in research. Two questions arise:

  1. Is EF best thought of as a unitary process or as a set of multiple, distinct component processes?

  2. If EF does refer to distinct component processes, how are these processes related and how does this relationship change as the child develops?

Concerning the first question: Most studies support the view that EF consists of related but separable components (which is also called the unity-but-diversity view) and purport that a common mechanism (or mechanisms) underlies all EF processes. Other evidence supports the unity-but diversity view through, first, showing that the different developmental trajectories over childhood and adolescence undermine the notion of a completely unified EF. Second, through neuroimaging research that indicates that multiple EF tasks that span different EF domains recruit slightly different regions of the PFC. Third, through research at multiple time points and finally, through the fact that a particular deficit, such as poor academic performance in a specific area (see below) is associated with a greater impairment for some EF components than others, which suggests some independence. A remaining methodological challenge is to create EF tasks that isolate and assess one or the other EF component.

Concerning the second question: Structural equation modeling (SEM) is used as a method that allows the researcher to examine what (and how) EF domains are recruited during complex problem solving. Research shows, that the relations among EF components change with age. Knowledge of what EF skills are recruited during successful completion of complex problem solving is important not only for theoretical reasons, but also for practical ones, such as developing interventions for school children with poor EF. This knowledge can only be gained through including older children and adolescents, as well as preschoolers in research.

The developmental trajectories of EF's


Inhibition commonly refers to the ability to suppress a dominant, automatic or prepotent response, but inhibition also entails interference control, directed forgetting, emotional control, and motor control. Research documents rapid improvements in early childhood on tasks such as the Day/Night task, Luria’s fist and finger game, and the A-not-B task. In the preschool years children significantly reduce their inhibition errors. Although improved inhibition during the preschool years is striking, significant improvements also occur later, particularly between ages 5 and 8. Unlike the fundamental changes during preschool, changes during adolescence mainly consist of refinements in speed and accuracy. Behavioral improvements in inhibition appear to be paralleled by refinements in the underlying brain activity in the PFC and in networks that include the PFC. Neuroimaging (fMRI), EEG and Diffusion Tensor Imaging (DTI) suggest that in addition to the focalization and migration of activity, perhaps increasing connectivity of frontal brain regions serves to enhance inhibition in later childhood.

Working Memory (WM)

Generally speaking, WM involves the ability to maintain and manipulate information over brief periods of time. Research shows a linear increase in performance from age 4 to 15 for a battery of WM tasks of varying complexity. The age-related changes in performance depended on the complexity of the particular task. Thus, it is important to consider the complexity of the task when extrapolating a general trajectory of WM development. Research shows that WM development apparently continues through adolescence, and easier WM tasks are mastered before more complex ones. Neuroimaging studies also point to continued changes in brain activity associated with WM through childhood and adolescence. Results of the studies suggest further refinement of WM through adolescence as the prefrontal regions become more specialized for WM. Paralleling the behavioral findings on inhibition, these results suggest that the large improvements in WM in early childhood, along with qualitative changes in brain recruitment, are followed by more subtle refinements consisting of quantitative changes in activation and focalization of brain regions related to WM.


Shifting regards the ability to shift between mental states, operations, or tasks. The WCST is the classic shifting task, whereby the participant is asked to sort cards based on a specific dimension (e.g., shape). Then,  the sorting rule changes and the participant must determine the new sorting rule (e.g., color) and sort accordingly. Successful task switching involves inhibition of previously activated mental sets. The ability to shift between more complex task sets, each with more numerous and complex rules improves with age, typically until early adolescence. Shifting ability may be measured in terms of shift cost, which is the difference either in response time or accuracy between shift trials and non-shift trials. Results show an increasing awareness of the relationship between speed and accuracy in childhood. This suggests the emerging presence of metacognition and its contributions to developmental differences in task performance. Mature task shifting is related to inferior frontal and parietal regions as well as superior temporal regions in adults. 


Planning is a critical part of goal-oriented behavior; it embodies the ability to formulate actions in advance and to approach a task in an organized, strategic and efficient manner. Tasks that evaluate planning ability require the child to prepare multiple steps of action in advance, to evaluate those actions, and to change course if necessary. The most frequently used tasks are the Tower of Hanoi (TOH) and the Tower of London (TOL). The particular age at which mastery is reached depends on the difficulty of the TOL or TOH task condition. The ability to effectively plan up to three moves is present by middle childhood, but the ability to effectively create more complex plans of 4 or 5 moves seems to develop at some point in late childhood or adolescence. Thus, planning ability seems to follow a protracted developmental course such that performance improves at least into late childhood and often adolescence. Little is known about the brain changes related to the development of planning skills.

Aging and executive function

EF seems to be particularly vulnerable to age-related cognitive declines. In contrast, non-executive abilities such as procedural memory, vocabulary, and numeric abilities are relatively spared by the aging process. In accord with the specific vulnerability of EF, normal aging is not characterized by widespread neural changes but instead by selective cell loss, dendritic deterioration, and chemical dysregulation in the PFC and hippocampus. Research suggest that with age dopamine (DA) projections to the dorsolateral preforantal cortex (DL-PFC) are disrupted, causing impairments to the gating mechanism. Such disruptions equally impair WM and inhibition, which supports the finding that performance on a variety of executive tasks deteriorates with age. Multiple executive processes begin to show impairment by the 7th decade of life. Functional neuroimaging studies point to the complexity of the neural correlates of EF. 


Inhibition shows prominent improvement during the preschool years and less change later on. WM and shifting, on the other hand, appear to emerge in the preschool years but really improve the most afterwards in a more linear fashion. Planning ability, which typically is measured by more complex tasks, seems to make the largest gains in later childhood or adolescence. EF is particularly vulnerable to the aging process as multiple executive processes (e.g., resistance to interference, WM) begin to show impairment by the 7th decade of life.

Uses of executive function in daily life

After age 5, children enter more social settings and go to school.

Social functioning and emotional control

The same general brain structures appear to underlie both cognitive and emotional processing. EF appears to be related to social and emotional self regulation. The link between one aspect of self-regulation, effortful control (which includes attention control, inhibitory control and low-intensity pleasure and is assessed by the Children’s Behavior Questionnaire), and EF is likely due to the development of the anterior attention network. Attention training may improve children’s cognitive and emotional regulation. The link between EF and social functioning continues during aging. 

School performance

EF might affect school performance (e.g. through not being able to remember instructions, performing mental calculations, poor writing, unmoral behaviours or language impairment, which is associated with WM). In turn, by providing situations that encourage EF practice, EF development may be facilitated, too. By expanding EF research to school-age children, the relations to an important aspect of childhood—schooling—can be examined. Different academic activities (e.g., mathematics, reading, and writing) appear to involve different combinations of EF components. Attempts to uncover causality between EF and school functioning have been inconclusive. Likewise, more research is needed to reveal the contextual factors (e.g., type of classroom environment) that enhance EF. Once these relations are clarified, interventions can be developed to bolster the specific EF domains underlying each academic skill.

Conclusions and directions for future research

EF as a construct

We know that the specific relations among the various EF components change across development, which suggests that the components are somewhat separate, even though related. Future research could employ a training study design in order to address whether EF consists of largely independent components or a single, unified ability.

Developmental trajectories of each EF component

The review of subsequent developments shows continued improvement of all components, probably even into adolescence, as well as somewhat different developmental trajectories for each component. Particular sorts of studies with school-age children and elderly adults would be especially useful for examining key questions
about development. These may for example clarify why children of different ages differ in the particular components of EF they find difficult to recruit.

Uses of EF in daily life

Research has shown a possible link of EF to social problems. Although peer relationships are known to become increasingly important during middle childhood and adolescence, we know little about the connections between EF and peer interaction. The work on older children expands the domains for which EF might be important, in particular, formal schooling. The EF components appear to be related differentially to various academic subjects. In both children and adults, inhibition and updating of WM, but not shifting, are related to monitoring performance in a time-based prospective memory task. More research and theorizing on EF in children older than 5 would provide a more complete picture of the development of EF. Such work would shift the research focus from the early emergence of EF to its refinement and application to daily life.

The learning brain: Lessons for education: a précis - Blakemore & Frith - 2005 - Article

The learning brain: Lessons for education: a précis - Blakemore & Frith - 2005 - Article

This study focusses on the role of neuroscience on education. According to the researchers, the brain has evolved to educate and to be educated. Understanding the rain and underlying mechanisms will lead to design educational programmes that optimize learning for all people. The researchers want to share their knowledge with teachers. They think that because it is sometimes hard to transform scientific evidence in a way that teachers think that is valuable and therefore they try to share the knowledge in an understandable manner so that teachers can make use of it.

Plasticity in the brain

The adult brain seems to be flexible: it can grow new cells and make new connections in regions such as the hippocampus. There is no age limit for learning. This is called plasticity: the capacity to adapt to changing circumstances. Research suggests that learning early has positive effects, but there seems to be no biological necessity to rush and start teaching earlier and earlier.

Synaptogenesis means that the brain begins to form new synapses early in postnatal development. This lasts for time, depending on the species of animal. This process is followed by synaptic pruning, in which frequently used connections are strengthened and the others are eliminated. Which connections grow and which die is determined by the genes and by the environment of the baby. But this does not mean that babies should be exposed to many learning experiences in their early life. The assumption was that this whole process is the same for humans as for monkeys: 3 years. But, since monkeys are sexually mature at their 3rd year, for humans this may be 12 or 13 years.

Critical vs. sensitive periods in the brain

An animal needs certain kinds of stimulation for adequate development in a specific time called the critical period. But it seems that even when the animal does not get this, some recovery of function is possible depending on the severity of deprivation and the circumstances following that deprivation. Researchers therefore see critical periods as “sensitive periods”, because of this flexibility.

For humans, interaction with other human beings is especially important.

There is no suggestion that the richer the environment, the better the development. But, a normal environment leads to more synaptic connections than a deprived environment.

It seems that the excess of synapses that are present during puberty only get specialized after puberty. The brain is still developing and needs to be molded. The focus in adolescents should be on internal control, self-paced learning, critical evaluation of transmitted knowledge and meta-study skills.

Developmental disorders

The specificity in developmental disorders is remarkable. One idea is that the newborn infant is equipped with start-up mechanisms which allow fast-track learning in important domains, such as learning language, learning numbers or learning music. In dyslexia or autism these modules may be working incorrectly.

It is also assumed that there is a “mind-machine” which can be seen as a general learning system that responds to experience. It seems that this mechanism might take over if  module is faulty.

One study has shown that the hippocampus of taxi drivers changed as a result of navigation experience. 

Methods of learning

There are different methods of learning:

  1. Visual imagery

  2. Imitation: Observing someone’s actions makes that behavior seem easier.

  3. Exercising the brain: Physical exercise increases brain functioning. Is proof that even adults can grow new cells.

  4. Learning while you sleep: the brain regions that are involved in learning the day before are activated during sleep.

Functional assessment: a method that develops classroom-based interventions and accommodations for children with ADHD - Reid et. al. - Article

Functional assessment: a method that develops classroom-based interventions and accommodations for children with ADHD - Reid et. al. - Article

There has little to no research conducted that addresses school-based interventions to give teachers some tools to handle children in their classroom with ADHD. This lack of information is partly due to the fact that ADHD is conceptualized as a psychiatric construct, and thus it is most often approached from a medical perspective.

Most of the responsibility for meeting educational needs of children with ADHD lies with their general education teachers, while this particular group in several researches expressed that they need assistance and more information about managing children with ADHD. Currently, most schools do not have a general approach to handle classroom problems caused by children with ADHD systematically. Also, teachers mostly rely on punishing approaches only and tend to deny the problems of children with ADHD.

A solution for these problems could be the multimodal model, which involves coordinated treatment planning by all involved parties (parents, teachers, psychologists etc.). The model incorporates different kinds of treatments such as medical approaches, behavior modification, educational accommodations and psychological support. There is a considerable amount of research that has shown the effectiveness of the multimodal model.

Functional assessment is an approach to the multimodal treatment of ADHD which focuses on manipulating the environment variables to determine the best conditions under which children may perform appropriate classroom behaviors. Thereby it empowers teachers to fulfill the following three goals:

  1. Prevent inappropriate classroom behavior from occurring by analyzing and modifying environmental events.

  2. Determine what children try to achieve with their inappropriate behavior and seek for replacements of appropriate behavior with a similar function.

  3. Develop interventions which enables children with ADHD to perform socially desirable classroom behavior.

Overview of the traditional approach and its critique

The goal of traditional assessment is quite the same as that of functional assessment, but the traditional assessment has had little implication for changing the behavior of ADHD children. Traditional assessment is based on Cronbach’s ideas about correlation. He hypothesized that the aptitude by treatment interaction approach (ATI) was the most effective way for assessment. This approach is based on the two principles that (1) inappropriate behaviors are due to underlying characteristics of the individual and (2) it is necessary to identify the underlying trait that is causing the behavior in order to remediate the behavior. Unfortunately, correlation was erroneously equated with causation. When there is relation between two variables, it doesn’t necessary mean that the one variable caused the other to occur. Therefore it is very uncertain to select an intervention based on a prediction from a variable. The effectiveness s ATI has never been proven and consequently is not a functional approach. The same thing can be said for a lot of current treatments for ADHD; token strategies, classroom interventions and even Ritalin cannot be differentiated between children with and without ADHD.

When Cronbach realized that ATI didn’t work, he replaced it with a context-specific approach. The main difference between those two approaches was the shift from aptitudes to context. Seen from the ecological perspective, which considers environment and behavior as a ongoing interaction, context provides meaning to behavior. The best way to change a child’s behavior is to take the context under which these behaviors occur into account. The context-specific approach focuses on the outcomes of interventions. The child gets the best possible treatment, the desired progress gets observed and if the treatment doesn’t work it gets modified.

Overview of the functional perspective

The functional perspective is a logical extension of the context-specific approach. It addresses the interaction between specific behaviors of a child and the environmental factors. These specific behaviors are cued by antecedents and decreased, increased or maintained by followed consequences. Therefore the purpose of functional assessment is to find the relation between behavior and the environment, and hereby identifying the most effective method to modify behavior.

Stages of functional assessment

An approach that has shown to be effective for classroom use in several studies is the framework developed by Dunlap and Kern. Their approach consists of three levels: hypothesis development, hypothesis testing and intervention development.

Hypothesis development is a process that should embody three activities and thus consists of three stages:

  1. Developing a precise definition of the behavior in question.

  2. Collecting information during the conditions under which the specific behavior occurs.

  3. Analyzing whether the information obtained shows any patterns that might indicate a functional relation.

There are a few conditions which a definition of behavior should meet to qualify as well-defined. First, it should pass the ‘stranger test’. This means that a stranger should be able to determine when a behavior occurs does or doesn’t occur on basis of the definition, in reasonable agreement with those observations of the teacher. Second, a behavior should pass the ‘so what test’. This implies that behavior that doesn’t interfere with the learning targets of the child with ADHD or its peers should be ignored. Because a child with ADHD shows many behaviors that could be a target for intervention but time and resources are limited, this is very important. Also, this minimizes the effect of the teacher’s own standards of what is normal. Third, a good target behavior is one that is also a ‘fair pair’. This concept states that for every inappropriate behavior that should be decreased, there’s an incompatible behavior that should be targeted to increase. Finally, the description should pass the dead man’s test. This test shows whether a fair pair is targeted. If a dead man can perform the target behavior, then you do not have a fair pair. If he cannot, you do.

Information can be collected through multiple techniques such as interviews, observation, archival records and rating scales. Any functional assessment should include direct observation and interviews because these are the most reliable sources of information. However, most of the time it’s very useful to start an investigation with examining archival records and completing behavior rating scales. The latter two can be used to get a fix on the problem and thereby help select behaviors and settings most salient for observation. Furthermore, it’s advisable to interview multiple people to determine in which settings certain behavior does and doesn’t occur. This information gives a contextual starting point to formulate hypothesis which can be tested using direct observation methods. The most ecologically valid assessment technique is to define the target behaviors, observe and record their occurrence or nonoccurrence in their natural environment and analyze this data. This not only confirms or denies expectations about relationships between environments and certain behavior, it also provides baseline information about the behavior before treatment. The most commonly used method to do a functional assessment behavioral observation is an antecedent-behavior-consequence analysis (ABC).

Next, it’s important to collect information on behavioral intent. Why does a child perform certain behavior and what does it want to achieve with its acts? In order to determine these intentions, the Outcome Analysis Worksheet was developed. This is quite similar to the ABC-analysis with the added component of hypothesizing on the possible outcome. As from now, replacement behaviors – appropriate behaviors to replace the inappropriate – can be conducted for hypotheses testing.

Hypotheses testing aims to identify the conditions where the variables thought to be related to the behavior can be controlled and manipulated directly. This can be done using in vivo (naturalistic) or analogue (role play) assessment.

In vivo assessments observe students performing the target behavior in their natural habitat while the practitioner systematically controls and manipulates situational and contextual events. In order to determine the validity of the hypothesized functional relation, multiple observations would be required. Disadvantages of this approach are that it’s difficult to control all situational variables, and that target behavior must occur during the observations while not all naturalistic situations encourage children to perform the target behavior.

The analogue assessment involves a role play in which a child’s behavior during staged situations gets observed. The advantage of this approach is that target behavior can be elicited and observed while situational and contextual events are controlled or manipulated. Analogue assessment also has a therapeutic value, for students with ADHD might learn appropriate behavior from their peers. When they receive reinforcement from children their own age, they are more likely to perform this appropriate behavior more often. The limitation of this approach is that because of the artificial nature of the method, the information obtained often doesn’t correspond with naturalistic observations. It is therefore recommended to use the analogue assessment combined with in vivo assessment.

It takes a lot of time to test hypotheses, and consequently, teachers often tend to skip this step. However, it takes even more time to implement ineffective accommodations and interventions which have to be changed afterwards. Determining which environmental variables have the greatest impact on a child’s behavior can help to avoid this.

Accommodations and interventions

Information obtained from testing hypotheses can be translated into accommodations and interventions by using the most important variables that have come forward from the testing and operationalizing them into specific, practical interventions. The process of testing hypotheses should be seen as part of the intervention process, because the environmental variables are constantly being manipulated while observing their effect on behavior.

Manipulating antecedents is a form of prevention. Most classroom accommodations focus on antecedents to prevent inappropriate behavior from occurring, a proactive strategy. Changing antecedents can result in a major change of behavior and usually arise from logically thinking, therefore they are practical, simple to implement and require minimal time.

of the categories of accommodation is the physical location of a child in the classroom. This may have to do with where the student is seated, group composition, activity grouping (group vs. independently working) and the type of work station a child gets assigned to (lots of materials on it?). There’s a new approach for children with high motor activity, which provides them with multiple desks: one in the front of the classroom and one on each side of the back of the room. That way, when a child feels restless it can pick up its stuff and move to another part of the classroom. Most important when implementing accommodations is to be flexible, creative and broad-minded.

The manipulation of task material can also be very useful. The amount and type of feedback provided during task performance, degree of stimulation, the response mode, the degree of task structure and the amount of interest students show in a task are all variables worth manipulating to enhance appropriate behavior.

Letting students with ADHD complete assignments independently can lead to a few problems. They might not have the skills to work independently. It is very important to ensure that a child with ADHD fully understands the assignment before moving to independent practice activities. Teacher-led small-group question and answer sessions is a method to clarify the degree of accuracy in which the student has mastered the concept. Furthermore, students with ADHD can experience some difficulty in obtaining help during seatwork activities, or the teacher is unable to provide assistance at that very moment. To asses this problem, teachers can construct assistance cards. On one side of the card, the teacher writes ‘Please help me’, and on the other side ‘Please keep working’. When a child is in need of assistance, it can flip the card to ‘Please help me’ and but it on his table. If the teacher isn’t able to provide help at that moment, he can flip the card to ‘Please keep working’. He thereby acknowledges the child’s request, and the child knows the teacher will assist him as soon as possible. Finally, children with ADHD often misbehave when too much work is required during independent seatwork. Short assignments and frequent breaks can be helpful. It’s very important that breaks or transitions are highly structured.

Curricular instructions can also be manipulated and thereby prevent certain behavior from occurring. The curriculum is a structured set of learning outcomes. To accommodate students with ADHD, the sequence of the curriculum may be shuffled, its tasks may divided into smaller pieces or combined into larger ones, organizational structure can be altered and different instructors may help to teach the program. The most important factor to make children feel involved with the curriculum, is to make them see the learning material as meaningful. The otherwise short attention-span of children with ADHD is much longer when they are engaged in high-interest activities: also called the Nintendo-effect. When de study material gets linked with topics that interest the child, they will try a lot harder to engage.

The length, format and difficulty of lessons can me modified to better fit the needs of a child with ADHD. Giving students the opportunity to answer questions they’ve been asked instead of letting them wait for a long time before they can respond is crucial for their engagement.

Instructional strategies are meant to enhance a student’s acquisition. Cognitive strategy instruction teaches students to use self-instructions and mental imagery to accomplish academic tasks independently. Mnemonic instruction is a related strategy and designed to improve memory. By reconstructing study material and connecting it to existing knowledge of the student, they remember the content better. By using the students frame of reference, they add a personal meaning to the task. Peer tutoring also seems to be a relative technique.

Moving from one group, classroom, activity or subject to another is called a transition. By setting aside certain times on which the transitions are performed, establish the expectation that the students move quickly from one place to another and tell them that any lost time is made up during free time, transitions become more efficient and instructions more effective.

We call events that follow behavior consequences: they can increase, decrease or maintain certain behavior by ignoring, punishing or reinforcing. When a certain behavior is ignored, an appropriate behavior should be reinforced. In order to effectively ignore undesired behavior, the child performing the behavior should also be excluded from positive or negative attention from its peers. Punishment is not very effective when it’s not combined with positive reinforcement, which focuses on increasing desired behavior. 

ADHD in the classroom: Effective intervention strategies (2011) - DuPaul et. al. - Article

ADHD in the classroom: Effective intervention strategies (2011) - DuPaul et. al. - Article

Teachers sometimes tend to perceive a child with ADHD as less favorably with respect to behavior, intelligence and personality. Children with ADHD more often attend schools for special education, they are more likely to have lower grades and have a higher risk of dropping out of school. Because of these impairments, it’s important that empirically supported interventions are implemented early in the development and starting the first years of school.

Types of strategies

Stimulant medication is often used as a treatment for the symptoms of ADHD, but this is rarely sufficient to solve all problems a student with ADHD faces. Therefore behavioral interventions have been developed for students with ADHD, including both antecedent- and consequence based strategies. Antecedent strategies try to prevent disruptive and/or inattentive behavior. An example of an antecedent strategy is for a teacher to review the classroom rules. There should be a few, short and positive phrased rules, posted in full view of all students and especially those with ADHD. When children with ADHD follow those rules, they should be praised frequently for their behavior. Another example is to reduce task demands by modifying the length and/or content of assignment in combination with a teachers praise. This matches the attention span of a child with ADHD, and therefore may reduce off-task, disruptive behavior. The length of assignments can be gradually increased thereby shaping task-related behavior to match classroom norms. The last example of an antecedent-based strategy is a choice-making intervention. Students have the possibility to choose from two or more presented options. When children with AHDH had the chance to choose between different assignments (which all have similar outcomes: they practice the same academic skills), they showed higher rates of task engagement and lower frequency of disruptive behavior. The advantage of antecedent-based strategies is that it addresses academic functioning directly.

Consequence based strategies are manipulations following specific (undesired) behavior to alter the frequency of that behavior. The most common intervention is praise or token reinforcement. When children show positive behavior they can be rewarded with tokens (positive reinforcement) which they can later on exchange for preferred activities such as gaming and watching television.

Given the fact that children with ADHD may have trouble with demonstrating consistent behavior under conditions of intermittent reinforcement, it’s important to provide reinforcement as often as possible. The rewards should be based on the interests and preferences of the specific child, and the rewards have to be changed over time so the child doesn’t get bored with it.

An example of a consequence-based intervention in which tokens are removed when the children show off-task, disruptive behavior is response cost. The combination of token reinforcement and response cost has shown to be significantly effective. Teachers can also use a time-out as negative reinforcement by placing the child out of the classroom for a little while following disruptive behavior. This is only useful when the child experiences the classroom as a positive environment, otherwise it isn’t a negative consequence.

Self-management or self-regulation interventions encourage students with ADHD to evaluate their own behavior. For example, they learn to evaluate their work performance and behavior using a Likert-scale (ranging from poor to excellent). Sometimes the act of consistently monitoring behavior results in improvements. This seems a particularly effective strategy for students with milder levels of ADHD.

For many students with ADHD, interventions that directly address academic skills are needed. A good is example is providing teacher-mediated direct instruction in relevant skills that require remediation. Furthermore, studies have shown that computer assisted instructions in math and reading also lead to academic improvements. This also accounts for peer tutoring.

Daily report cards (DRC) are an example of a home-school communication program. A DRC usually contains 3 to 5 goals on which teachers indicate the performance of a student on a Likert’s scale. By communicating these ratings with the parents, they can provide the child with fitting reinforcement at home. When the students show progress, the goals can be increased in complexity. This program yet again works best for students with milder levels of ADHD symptom severity.

Interventions that address problems with social difficulties, such as group therapy formats, haven not yet been found to lead to prolonged changes in interpersonal functioning. More comprehensive strategies to improve social relations for children with ADHD are therefore needed. Peers without ADHD could be involved in these engagements to encourage generality of outcomes.

What also seems to be necessary to effectively treat ADHD is collaborative consultation. This means that there should be an equal partnership between for example a teacher and a school psychologist, who together define the problem and come up with interventions. This results in the most effective outcomes when teachers take charge in defining the problem and consultants lead when possible interventions are discussed.

The best treatment plans involve a combination of home- and school based behavioral therapy and optionally stimulant medication. The treatment should be an effective combination of consequence-based (reactive) and antecedent-based (proactive) strategies. Multiple interventions should be used, such as computer technologies, so the teacher gets spared in some of the responsibility. More research is needed especially for students with ADHD who go to secondary school.

As a positive reinforcement strategy, the token economy is very common. Because social reinforcement like praise isn’t always working for students with ADHD, they can earn tokens by showing appropriate behavior that later on can be exchanged for rewards. A behavioral contract is a written document that states which positive behavior results in which specified rewards, such as a favorite activity not often available at school. These contracts can be very useful for increasing the quantity and quality of homework assignments students complete. A third positive reinforcement strategy are group-oriented contingencies, which can be divided into two subtypes. For a dependent group-oriented contingency, reinforcement relies on the behavior of an individual student. The hero procedure is an example of this strategy, where a student with ADHD has to answer three questions in order to receive a reward for the entire group. It’s hoped that peers provide encouragement or appreciation for the target child. For In an interdependent group-oriented contingency all the members of a group have to fulfill certain criteria in order to receive reinforcement. A good example is the Good Behavior Game, in which students get divided into two groups and the group that performs the best receives a reward. This way, cooperation among group members is stimulated and special attention towards the target child gets avoided. It is very important to monitor group-oriented strategies very carefully to avoid the occurrence of negative peer pressure.


A serious concern is whether it’s practical conducting functional assessment is school settings. This approach is very time intensive and expertise not normally available is required. Therefore it is necessary to train practitioners to perform functional assessment in everyday settings. This way functional assessment is both practical in terms of time and effort. The most important fact is that this strategy is effective.

Finally, adapting a functional perspective on ADHD means teachers no longer have an excuse for avoiding the issue by saying it is a medical problem beyond their purview. Currently, teachers see it as their major responsibility to promote the student’s academic skills. Students with ADHD will continue to cause problems in the classroom if teachers do not start to devote as much time developing accommodations and interventions as they do in planning academic lessons.

Because of the extensive amount of time functional assessment costs, it’s advisable to let teachers and exports work collaboratively. Furthermore, in contrast with the rather dichotomous traditional assessment, functional assessment is fluid. Therefore the information obtained should be seen as fluid and not as ‘set in stone’. The environment is also fluent and functional relationships are ongoing. Accommodations and interventions can be modified continuously until they meet the changing aspects of the environment. It’s important to keep a paper trail of all implemented accommodations and interventions to determine the effectiveness of environmental manipulations.

The Effects of Classroom Interventions on Off-Task and Disruptive Classroom Behavior in Children with Symptoms of Attention- Deficit/Hyperactivity Disorder - Gaastra et. al. - 2016 - Article

The Effects of Classroom Interventions on Off-Task and Disruptive Classroom Behavior in Children with Symptoms of Attention- Deficit/Hyperactivity Disorder - Gaastra et. al. - 2016 - Article


Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention and/or hyperactivity-impulsivity. Approximately 5 to 7% of all children meet criteria for ADHD. Due to inattentive and disruptive behavior in class, children with ADHD are at risk of academic difficulties, including underachievement, retaining grade, special educational placement, and suspension or drop-out from school. As ADHD related behaviors may disturb the learning process of classmates and may elicit maladaptive behavior of both classmates and teacher, overall classroom functioning may decrease, both academically and socially.

Teachers play an important role in considering interventions. They may be confronted daily with children with ADHD and they need to have the ability to manage these children. Providing teachers with effective tools may benefit children with ADHD as well as their classmates, but moreover, may improve confidence and wellbeing of teachers themselves. As the most common treatment for children with ADHD is stimulant medication, which is limited by several factors (e.g. side effects, compliance problems), there is a need for non-pharmacological interventions, including school-based interventions. 

Previous studies on the effectiveness of school-based interventions show inconsistent results. 

The present study

The present study provides a meta-analytic review of published studies on classroom interventions for ADHD covering a period of 33 years of research. It aims to first, determine the effectiveness of several types of classroom interventions (antecedent-based, con-sequence-based, self-regulation, combined) that can be applied by teachers in order to decrease off-task and disruptive classroom behavior in children with symptoms of ADHD, second, to identify potential moderators (classroom setting, type of measure, students’ age, gender, intelligence, and medication use) and third, to qualitatively explore the direct or indirect affect of the classroom interventions on behavioral and academic outcomes of classmates.


The guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed.

Inclusion and exclusion criteria

For the review, the studies needed to meet the following inclusion criteria:

  1. Written in english

  2. Participants attended grade 1-12 and had ADHD/ADD difficulties and an IQ of 70 or above

  3. Intervention had to be implemented by the teacher in the classroom and required no prental involvement

  4. The interventions could be classified into one or more out of these categories:

    1. Antecedent-based intervention: An intervention that manipulates antecedent conditions, such as the environment, task, or instruction (e.g., seating, music, tutoring, choice making, computer-assisted instruction)

    2. Consequence-based intervention: An intervention that uses reinforcement and punishment to alter the frequency of target behavior (e.g., praise, reprimands, prizes, privileges, response-cost)

    3. Self-regulation intervention: An intervention aimed at the development of self-control and problem-solving skills to regulate cognition and behavior (e.g., self-instruction, self-monitoring, self-reinforcement)

  5. The outcome measures were either teacher ratings or direct observations of off-task behavior (e.g., not attending to task or teacher, looking around), disruptive behavior (e.g., disturbing classmates, playing with objects, out of seat), and ADHD behavior (e.g., teacher rating on an ADHD rating scale) in the classroom.

  6. The study could be classified into one of the following categories of experimental design categories:

    1. Between-subjects group design: A design that uses an intervention group and a non-intervention control group.

    2. Within-subjects group design (WSD): A design that applies the same intervention on each participant and assesses outcomes on at least two occasions.

    3. Single-subject design (SSD): A design that documents changes in behavior for an individual participant during intervention phases and non-intervention control phases.

  7. Sufficient data were provided to compute effect sizes.

Search procedure

It was systematically searched for literature through online databases and manuals.

Coding procedure and moderating variables

Each study meeting inclusion criteria was systematically coded on several variables by the first
author. Variables that were examined as potential moderators included intervention type, classroom setting, type of measure, and characteristics of participants receiving the intervention, including age, gender, intelligence, and medication use. The categories antecedent-based, consequence-based, self-regulation, and combined were used to classify intervention type. The following codes were used:

  • Classroom setting - general education or other

  • Type of measure: teacher ratings, direct observations, or both

  • Participants: children or adolescents, gender, IQ

  • It is looked at the study quality (high quality, acceptable quality, unacceptable quality) and secondary quality indicators (evidence or no evidence). 

Statistical analyses

SPSS is used for the statistical analyses. Separate meta-analyses were performed on standardized mean differences (SMDs) for 24 within-subjects design (WSD) and 76 single-subject design (SSD) studies.


A total of 4,553 records were identified through electronic databases and an additional 230 records were identified by the manual searches. A total of 89 articles meeting inclusion criteria were considered in the present meta-analytic review, yielding to 100 studies. 

Study characteristics

Different study characteristics are summarized in the article. These are year of publication, experimental design, examination classmates (yes or no), type of measure, intervention type, classroom setting, number of participants, age, a differentiation between children and adolescents, gender, IQ, medication use, and study quality. (see table in the article for more details)

The majority of WSD (within-subject design) studies (83%) obtained a weak rating of study quality and half of the SSD (single-subject design) studies (54%) had an adequate study quality and 43% were rated as weak.

Within-subject design studies

Effect sizes for WSD studies ranged from −0.08 to 3.00 (Winsorized value) with a median of 0.92. The mean weighted effect size was 0.92 and reached significance (95% CI [0.59, 1.25]).

Single-subject design studies

Effect sizes for SSD studies ranged from 0.42 to 7.00 (Winsorized value) with a median of 2.63. The mean weighted effect size was 3.08.

Direct effects on classmates

For all four WSD studies applying antecedent-based interventions, effect sizes for behavioral outcomes of classmates were positive, ranging from 0.21 to 1.97. Positive effects on classmates were also found for all four SSD studies.

Indirect effects on classmates

Positive indirect effects on behavioral outcomes of classmates were found for two out of three studies.


Regarding the first aim of this study: The results indicate that classroom interventions reduce off-task and disruptive classroom behavior in children with symptoms of ADHD, which is in accordance with previous meta-analyses. It is indicated that interventions implemented in general education classrooms lead to a larger reduction in off-task and disruptive classroom behavior in children with symptoms of ADHD than interventions implemented in other classroom settings. 

Regarding the second aim of this study: no reliable conclusions can be drawn about potential moderators.

Regarding the third aim of this study: Results imply that classroom interventions for children with symptoms of ADHD have both direct effects on classmates, i.e., improvement of classmates’ behavior because they also benefit from the intervention, and indirect effects on classmates, i.e., profit from less classroom disturbance by children with symptoms of ADHD.

In summary

Results showed that classroom interventions reduce off-task and disruptive classroom behavior in children with symptoms of ADHD. No reliable conclusions could be formulated about moderating effects of type of measure and students’ age, gender, intelligence, and medication use, mainly because of power problems. Finally, classroom interventions appeared to also benefit classmates’ behavioral and academic outcomes.


First, the meta-analytic review was restricted to studies published in academic journals. Second, there was a trend for the smaller studies to show larger treatment effects than the larger studies. Third, most studies employed SSDs, for which exact expressions of effect size variances have not been derived. Fourth, potential moderators had to be analyzed using subgroup analyses instead of meta-regression analysis because the data were not normally distributed and therefore violated the assumptions for regression analysis. Finally, the results are most representative for boys in the age of 6 to 11 years, as only a minority of studies reported about samples including females and/or adolescents.

Future Research

First, girls should be more included in research onthis field, second, additional factors influencing the effectiveness of classroom interventions for children with symptoms of ADHD should be further examined, and finally, there is a need for higher quality studies in this field.

Implications for practice

As this review shows that teachers can effectively implement classroom interventions to reduce off-task and disruptive classroom behavior in children with symptoms of ADHD, it is important that classroom management training is offered to teachers.


This review indicates that classroom interventions reduce off-task and disruptive classroom behavior in children with symptoms of ADHD. WSD studies showed that consequence-based interventions are more effective than antecedent-based, self-regulation, and combined interventions. However, SSD studies showed largest effects for self-regulation interventions. Larger effects were obtained for children with symptoms of ADHD in general education classrooms than for those in other classroom settings. No reliable conclusions can be formulated about moderating effects of type of measure, and student’s age, gender, intelligence, and medication use. Finally, the study also indicates positive direct and indirect effects of these classroom interventions on classmates’ behavioral and academic outcomes. The results of this study may be used for educating and training teachers in dealing with children with symptoms of ADHD.

Executive Function Treatment and Intervention in Schools - Otero et. al. - 2014 - Article

Executive Function Treatment and Intervention in Schools - Otero et. al. - 2014 - Article


Executive function (EF)  refers to a variety of cognitive processes. These are largely mediated by the prefrontal areas of the frontal lobes that encompass both cognitive and affective constructs including planning, working memory, attention, inhibition, self-monitoring, self-regulation, and initiation. Success in various aspects of life is highly dependent on having intact EF abilities, especially within the educational environment. EF deficits in childhood have been shown to have a negative impact on academic, social-emotional, and adaptive functioning later in life, and they are present at all stages throughout development in children both with and without neurodevelopmental disorders. The extensive nature of EF deficits among all populations of school-aged children results in a critical need to begin developing and identifying research-based interventions that target both global and narrow aspects of EF.

How do children with EF deficits present in the school environment?

EF deficits in the school environment can be cognitive (which often manifest in academic difficulties) or affective (which are often viewed as behavioral problems) in nature. Students with deficits in EF may struggle with shifting between activities and/or may have difficulty prioritizing important tasks, as well as with time management and meeting deadlines. Planning for the future is difficult; they tend to only focus on the immediate and may struggle with resisting temptation, are impulsive, and do not think before they act. They may not appear to be paying attention and frequently get out of their seat or ask to leave the room, usually at inappropriate times.

Identification of EF deficits in the school setting

The multidimensional nature of EF requires the use of various diverse methods of assessment that take into
account the fact that EF constructs such as response inhibition, working memory, planning, and response preparation are independent in various ways, but also interrelated. Qualitatively, behavioral observations of how students approach and complete a task, as well as anecdotal reports from teachers and related school personnel are often a precursor to a referral for a standardized assessment of EF. Quantitative methods of assessment, such as the Cognitive Assessment System, Second Edition [CAS-2], Delis-Kaplan Executive Function System, NEPSY-II, Wisconsin Card-Sorting Test or behavior rating scales or frequency measures such as the Comprehensive Executive Function Inventory or Behavior Rating Inventory of Executive Function. 

Considerations for the selection of treatment methods and interventions in the school setting

6 general principles regarding EF training that must be considered when selecting EF interventions for children:

  • Those who most need improvement benefit the most.
  • Transfer effects from EF training are narrow.

  • EFs should be challenged throughout training (i.e. demands must continue to increase to see effects).

  • Repeated practice is key.

  • Whether EF gains are produced depends on how an activity is done.

  • Outcome measures must test the limits of the children’s EF abilities to see a benefit from training.

Before an intervention, it is important to consider:

  • the age of the children

  • the current level of developmental functioning of the child

  • certain neurodevelopmental disorders such as ADHD and ASD

  • a careful review of the diagnostic information available

  • demographic, cultural, and other environmental factors to determine if the child exhibits a pattern of strengths and weaknesses across settings, and they should use this information when designing treatment plans, as interventions that focus on a child’s strengths and involve the support of the family are often more successful

  • school personnel must answer the question of what is feasible to implement within the confines of the educational environment

Treatment methods and intervention strategies

Treatments Outside of the Scope of the School Setting

Intervention methods, such as psychopharmocology and neurofeedback treatment, are outside of the scope of the local education agency as they are considered medical and must be initiated by a parent or physician. The potential impact on outcome is critical when developing a comprehensive treatment plan to be implemented in the school setting, as well as considering the effectiveness of school-based interventions.

Computerized Training

Computerized training of EF typically targets working memory and/or attention. Within the school setting, computerized EF interventions implemented within a group setting are appealing, as they reduce the need for additional resources such as increased personnel, quickly provide rich data with minimal effort on the part of the interventionist, and monitor and continuously adapt the difficulty of the task based on the child’s performance on a given trial. However, research conducted on the efficacy of these interventions and the transfer of skills to other cognitive-processing tasks has presented with mixed results.

Strategy Instruction

Strategy instruction can be defined as a student-centered approach that supplies struggling learners with tools and techniques to understand and learn new material or skills while allowing for the direct and immediate application to practice in various areas of school and life. Strategy instruction is global by nature and targets a constellation of cognitive-processing abilities, including EF skills that are necessary to be successful in multiple settings. Strategy instruction is a preferred approach over behavioral interventions targeting EF deficits because not only do we help the child understand their weaknesses, but we also give them the tools to help remediate those deficits.


The Educational Services Department of the Rush NeuroBehavioral Center (RNBC) has developed an EF Curriculum series utilizing a research-based framework combined with a classroom-based orientation. The RNBC EF Program identifies the following EF constructs as important for classroom instruction: self-regulation, self-awareness, goal-directed behavior, self-monitoring, and flexibility to solve problems and revise plans. Reviewing studies about the EF curriculum, it becomes clear that there is a need for future research using stricter methodology to examine the effectiveness of this curriculum across the four age levels (primary curriculum (kindergarten through 2nd grade), intermediate curriculum (3rd through 5th grades), middle school curriculum (6th through 8th grade) and high school curriculum (9th through 12th grade)), for which it is designed.

Mindfulness and Physical Activities

Mindfulness and physical activities that can positively impact EFs in children include meditation, martial arts, yoga, and aerobics, and they require repetition and continued practice to gain maximum benefits. 


Traditional childhood games can help improve EFs in children and are easy to implement in the school setting. Games may help in the development of working memory and response inhibition. The development of EF through shared activities with peers is an enjoyable, low-cost way for students and schools to aid in the development of EF.

Future directions for the school setting

As interventions, such as psychopharmacology and neurofeedback are on the rise and have been found to be effective, particularly with special populations, such as children with ADHD, schools may find it wise to consult with medical practitioners and perhaps consider/providing families with referrals to outside service providers. Neurofeedback is an intervention that could be implemented in the school setting. 

Schools must also consider financial constraints when selecting interventions. Strategy instruction and mind/body approaches are both interventions that can be implemented in the school setting at little to no cost.

However, as the research base for EF interventions in schools is in its infancy, future studies should include factors that look at generalization and optimal developmental periods to achieve maximum effectiveness.

Using Physical Activity to Manage ADHD Symptoms:The State of the Evidence - Hoza et. al. - 2016 - Article

Using Physical Activity to Manage ADHD Symptoms:The State of the Evidence - Hoza et. al. - 2016 - Article


The body of research studies evaluating the potential for physical activity (PA) to improve ADHD symptoms and functioning, especially those employing well-controlled designs, is quite limited. This review gives evidence for the potential benefits of promising research in this field, as well as five key points that researchers and practitioners should keep in mind while reading and evaluating this evidence.

Point I: From neuroscience and developmental perspectives, there is reason to be optimistic about the potential of PA for improving ADHD symptoms and functioning

From a brain science perspective, research shows that PA may promote more adaptive functioning in individuals with ADHD (e.g. changes in neurotransmitter levels, enhanced cerebral capillary growth and blood flow to the brain, promotion of neurogenesis, and growth in brain tissue volume). PA may have a corrective effect on neurodevelopment for those at risk for ADHD, potentially preventing or altering the course of the

Point II: Despite this optimism, the amount of actual wellcontrolled research employing designs that meet strict research standards is quite limited

In discussing the PA intervention literature, an important distinction is made between acute and chronic applications of PA. As the goal of the review is to consider the evidence for the use of PA to manage ADHD symptoms over the long term, the discussion is restricted to studies of chronic effects of PA. Unfortunately, the literature is quite limited.

Current status of the literature 

The current status of literature show limitations, that include small sample sizes, nonrandom assignment to conditions, insufficient control groups to rule out competing interpretations of results, raters not blind to condition, and biased analyses that only consider treatment completers.These limitations reflect the level of difficulty associated with fitting chronic PA studies into the rigid confines of well-controlled research.

Point III: The limited amount of research conducted to date reflects the difficulties associated with venturing beyond the ivory tower to conduct the type of research that is needed

Studies of chronic PA, administered multiple times per week, are most likely to succeed in the settings where children live their daily lives. Three key challenges are particularly daunting in research conducted in natural settings:

  1. Random assignment to condition

  2. Blinded raters

  3. Adequate control groups

Point IV: Despite these limitations, the current literature shows promise

For all categories of outcomes, in order to consider PA as beneficial, either (1) a statistically significant between-groups effect or time by treatment interaction or (2) a reported between-groups or simple effect size (Cohen’s d) of at least .20 favoring PA is required.

What we know:

  1. In most studies, aerobic PA shows beneficial effects on parent- or teacher-rated ADHD symptoms

  2. PA shows benefit on a variety of cognitive capacities, measured primarily using neuropsychological or executive function (EF) tasks.

  3. Systematic PA appears to benefit additional functional domains in ADHD (social functioning, motor skills, behavior, and the affective/emotional domain)

  4. The benefits noted above are derived from studies using unmedicated participants, medicated (for ADHD) participants, and studies where medication is not systematically considered

  5. In at least one study, beneficial effects of PA are associated with measurable changes in brain activity

Point V: What we do not know is just as important as what we know

What we do not know about PA as a symptom management strategy for ADHD:

  1. What is the optimal “dose” in terms of individual session length and frequency, and program length, for obtaining PA effects in children with ADHD?

  2. Is there an age when the effects of PA are optimized?

  3. How does PA perform when compared directly to established treatments for ADHD?

  4. Do the effects of PA persist beyond the period of time when PA is actively administered?


Much more is unknown than is known about PA as a management strategy for ADHD. However, preliminary work suggests beneficial impact in multiple areas of dysfunction, with none of the available studies reporting adverse effects. There is currently insufficient research to warrant recommending PA as a sole intervention; an adequate body of well-designed research studies is greatly needed.

Neurofeedback - Enriquez-Geppert S. et. al - 2017 - Article

Neurofeedback - Enriquez-Geppert S. et. al - 2017 - Article


The rhythmic and repetitive brain activity, which can be measured through EEG, is ranging from delta (0–4 Hz) to gamma (30–100 Hz). The study of brain oscillations is attracting substantial amount of scientific attention and is one of the fastest growing research areas in neuroscience. Oscillations represent a major mechanism of communication within the brain and have been consistently related to cognitive functions. An example of such an association is the link between frontal-midline (fm) theta oscillations and executive control. Power increases of fm-theta have been associated with enhanced cognitive processing and can predict successful behavioral performance.

Definition of neurofeedback: Neurofeedback is a technique, for dealing with brain-based functional disorders without the use of medication or invasive procedures, in which brain activity is recorded using electrodes and presented visually or audibly so that the patient can know the state of the function he or she is trying to control.

Mechanism of Action

The goal of neurofeedback is the self-regulation of endogenous neural oscillations. Neural parameters of ongoing neural activity are fed back to the participant on a trial-by-trial fashion to up- or downregulate one’s own brain activity. Thereby implementation of neurofeedback is realized by a software system and a processing pipeline consisting of five basic elements, including data acquisition, online data processing, online feature extraction, online feedback generation, and the learning participant.

Enhancement of Cognition by Neurofeedback

A considerable amount of literature reported associations of alpha oscillations with cognition. Alpha brain oscillations are associated with working memory, covert attention and behavioral performance. For example, upper alpha frequency training led to enhanced strategic and top-down processes as reflected in associative
memory, whereas training of the sensory motor rhythm (SMR, 13–15 Hz) led to enhanced performance in less-effortful and less-strategic memory task as reflected in improved item memory. The results in research provide support that the modulation of endogenous oscillations is possible by neurofeedback and that such self-regulation transfers to enhanced cognition.

Effects of Neurofeedback on Everyday Life Performance

Studies investigating the transfer of neurofeedback on everyday life performance show, for instance, that participants demonstrated improved surgical skills after learned self-regulation of SMR. Another study in the field of sports showed that self-regulation of SMR in neurofeedback transferred to enhanced SMR power during action preparation while golfing. In the domain of creativity in the arts, research shows that alpha-theta training increased performance of professional and novice musicians and increased dancing performance of professional dancers. 

Conceptualization of Self-control of Brain Activity

Control of brain activity during neurofeedback is more than merely learning to regulate the activity in one specific neural network that is targeted directly by neurofeedback. It is rather the result of conjugated labor of different brain networks tuned to optimize the control of the specific brain signals under training by means of feedback, thereby giving rise to different forms of brain plasticity.

Neuroplastic Effects of Neurofeedback

For neurofeedback, and in analogy to general learning, plasticity implies a progressive and long-term change - of at least >20–30 min - of a measure during or after training.

A collection of studies confirmed that the plasticity of oscillatory patterns may be Hebbian. Another body of research points to the existence of a complementary form of plasticity which is anti-Hebbian, or homeostatic. This appears to be the consequence of intrinsic regulatory mechanisms that prevent brain activities reaching extremes, such as pathologically high/low synaptic strengths or oscillatory states.

Results show that neurofeedback may lead to plastic changes in cortical regions responsible for cognitive control such as the anterior cingulate, associated with improvements in attention-deficit or on-task mind wandering. It may also impact white matter pathways, in addition to changes in gray matter volume. 

Interindividual Differences in Neurofeedback: Responders and Nonresponders

While review papers are full of examples of positive neurofeedback effects, only a few studies so far have investigated negative effects of neurofeedback systematically. One may distinguish at least four reasons for individual variability in the responsivity to neurofeedback:

  1. Physical reasons (poor signal detection)

  2. Physiological reasons (initial signal intensity of the brain feature)

  3. Cognitive reasons (reserve capacity)

  4. Metacognitive reasons (training instructions and strategies of self-regulation)

Specificity and Efficacy

What factors constitute a training that maximizes the pre- to post-changes in neural parameters and behavioral performance measures? The following factors could be considered:

  • Since neurofeedback usually aims at the enhancement of a specific cognitive function, it seems straightforward to optimize those neural systems and processes that give rise to these cognitive processes.

  • it is likely that induced plasticity closely relates to those neural mechanisms providing the underpinnings of cognitive processes in the first place.

  • Increased neurofeedback specificity may be achieved by enriching standard EEG frequency features through spatial filters.

  • The majority of studies seem to indicate that reliable training effects occur after about ten training sessions


By feeding back neural parameters of ongoing neural activity to the participants on a trial-by-trial fashion, self-regulation of brain activity can be achieved. Different brain networks might be engaged to adjust control over a brain signal during neurofeedback training. Regarding the physiological mechanism responsible for neurofeedback-induced plasticity, which might even impact brain morphology; two forms are in focus, Hebbian/associative plasticity and a complementary form, which is known as anti-Hebbian/homeostatic plasticity

Regarding the responsivity to neurofeedback large individual variability has been reported and four different reasons have been suggested to play a role. The responsiveness to neurofeedback and hence its efficacy may further be moderated by methodological factors. One such group of factors considers how to best address a given neural system and its means of communication. Here, the combination of frequency-specific feedback with EEG source analysis offers one approach. A further group of factors focuses on the optimization of training designs that follow the principles of basic learning mechanisms. 

Whereas many factors can be derived from our knowledge on the neural underpinnings of cognition, available measurement techniques, as well as basic learning mechanisms, much more systematic work needs to be conducted to optimize neurofeedback protocols for basic research and clinical applications.

In-School Neurofeedback Training for ADHD: Sustained improvements from a randomized control trial - Steiner et. al. - 2014 - Article

In-School Neurofeedback Training for ADHD: Sustained improvements from a randomized control trial - Steiner et. al. - 2014 - Article

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with core symptoms of inattention, hyperactivity, and/or impulsivity and has a prevalence of 9.5% for 4-to 17-year-olds in the United States. Executive functioning is typically impaired in children with ADHD, affecting their academic achievement. Computer Attention Training is used to decrease ADHD symptoms and improve executive functioning skills. Two types of CompAT interventions were evaluated in the current study: neurofeedback and cognitive training (CT). Neurofeedback trains users to monitor and change their brainwave patterns, leading to behavioral changes. CT uses specifically designed exercises to train attention, working memory, and impulsivity through ongoing feedback to reinforce correct responses.



Students with ADHD attending 1 of 19 public elementary suburban or urban schools in the Greater Boston area were eligible to participate in the randomized trial. Inclusion criteria in-cluded the following:

  1. Child in secondor fourth grade

  2. Clinical diagnosis of ADHD made by the child’s clinician

  3. Ability to speak and understand English well enough to follow the protocol

One hundred four children were randomly assigned to receive neurofeedback, CT, or a control condition and were evaluated 6 months postintervention.


Participants received in-school 45-minute intervention sessions 3 times per week, monitored by a trained research assistant (RA), for 40 sessions over 5 months.

Primary Outcome Measures

Outcome measures included parent reports of ADHD symptoms and executive functioning, medication use, and systematic classroom observations of behavior. All outcome measures were obtained pre- and postintervention, and 6 months later. A 3-point growth model assessed change over time across the conditions on the Conners 3–Parent Assessment Report (Conners 3-P), the Behavior Rating Inventory of Executive Function Parent Form (BRIEF), and a systematic double-blinded classroom observation (Behavioral Observation of Students in Schools).

Data Analysis

Because this study investigated whether the 2 CompAT interventions are superior to community treatment alone, and whether neurofeedback is superior to CT, the randomized controlled trial is considered a superiority trial and analyses are presented with 1-tailed tests. The central focus of the analyses was to evaluate whether the observed changes in core ADHD symptoms between the startand end of the treatment period were sustained at the 6-month follow-up. Comparisons between neurofeedback and CT were undertaken using multivariate general linear hypothesis tests. Paired t tests were conducted to evaluate stimulant medication differences in methylphenidate equivalencies within randomization conditions between pre-intervention and the 6-month follow-up. An analysis of covariance was conducted to evaluate medication dosage differences among the randomization conditions at 6-month follow-up. 


Of the 104 children in the study, 102 completed the intervention. Of these, only 4 did not complete the 6-month follow-up assessment. At baseline, 95% of participants showed clinically significant scores on the DSM,
Fourth Edition, ADHD Inattention and/or ADHD Hyperactive-Impulsive subscales. At baseline, 49% of participants were taking medication.

Growth Model Analysis

Parent-Reported Measures

Six months postintervention, neurofeedback participants maintained significant gains on Conners 3-P (Inattention effect size [ES] = 0.34, Executive Functioning ES = 0.25, Hyperactivity/Impulsivity ES = 0.23) and BRIEF subscales including the Global Executive Composite (ES = 0.31), which remained significantly greater than gains found among children in CT and control conditions. Children in the CT condition showed delayed improvement over immediate postintervention ratings only on Conners 3-P Executive Functioning (ES = 0.18) and 2 BRIEF subscales.

Classroom Observation

There were no differences found between neurofeedback and CT conditions on classroom observation measures. 

Medication Analysis

At the 6-month follow-up, neurofeedback participants maintained the same stimulant medication dosage, whereas participants in both CT and control conditions showed statistically and clinically significant increases
(9 mg [P = .002] and 13 mg [P , .001], respectively).


The outcomes of the analyses are promising, as children in the  neurofeedback condition reported sustained improvements 6 months after the intervention, compared with those in the control condition. In the CT condition, areas of executive functioning that did not show statistically significant change immediately after the intervention showed a significant change by the 6-month follow-up assessment compared with the control condition. The inclusion of the systematic classroom observations provided a valid double-blinded representation of the children’s behavior in the classroom. This study used multiple sources and types of data including questionnaires from parents, systematic classroom observations of behavior, and medication.


Neurofeedback participants made more prompt and greater improvements in ADHD symptoms, which were sustained at the 6-month follow-up, than did CT participants or those in the control group. This finding suggests that neurofeedback is a promising attention training treatment for children with ADHD.

The psychotherapeutic utility of the five-factor model of personality: A clinician's experience - Miller - 1991 - Artikel

The psychotherapeutic utility of the five-factor model of personality: A clinician's experience - Miller - 1991 - Artikel

Dit artikel is een samenvatting die Miller’s persoonlijke klinische ervaringen met het vijffactor model omschrijft. Miller is een fulltime psycholoog met eigen praktijk die hoofdzakelijk psychotherapie geeft. Om het vijffactor model (ook wel The Big Five genoemd) te testen, gebruikt Miller de NEO-PI (personality inventory). De NEO-PI geeft een gedetailleerd en accuraat beeld van de behoeftes, gevoelens, motieven en inter-persoonlijke stijl van de cliënt. Hoewel er meerdere manieren zijn om het vijffactor model te testen kiest Miller voor de NEO-PI vanwege de volgende vijf voordelen:

  1. De NEO-PI komt duidelijk overeen met het onderliggende model.

  2. De psychometrische eigenschappen zijn uitstekend.

  3. Er is een zelfrapportage formulier en een formulier voor de observant beschikbaar.

  4. Er is een korte versie beschikbaar (de NEO-FFI)

  5. De resultaten zijn met behulp van de handleiding goed te interpreteren voor klinische doeleinden.

De klinische waarde van een persoonlijkheidstaxonomie

Doordat mensen onderling enorm divers zijn, is psychotherapie niet alleen moeilijk te beoefenen, maar zelfs onmogelijk om volledig te beheersen. Patiënten denken, voelen en/of gedragen zich zelden zoals in de boeken wordt geschreven. De ene patiënt neemt graag iets aan van de therapeut en gaat zonder twijfel aan de slag met de huiswerkopdrachten; de ander is sceptisch en totaal niet bereidwillig om inzet te leveren De vijf factoren in het vijffactor model, die onthouden kunnen worden a.d.h.v. het acroniem OCEAN, kunnen de gedragingen en gevoelens van een cliënt tijdens de therapie als volgt beïnvloeden:

  • Openness (openheid/autonomie): beïnvloedt de reactie op de interventies.

  • Conscientiousness (ordelijkheid): beïnvloedt de bereidheid om je best te doen.

  • Extraversion (extraversie): beïnvloedt het enthousiasme voor het behandelingsproces en de expressiviteit tijdens de behandelingsessies.

  • Agreeableness (mildheid): beïnvloedt de reactie op de therapeut.

  • Neuroticism (neuroticisme): beïnvloedt de intensiteit en duur van de gepaarde stress.

Het vijffactor model is een beschrijvende, classificerende theorie van karaktertrekken. Veel therapeuten zijn geen fan van theorieën aangaande karaktertrekken, omdat deze impliciet drie belangrijke aannames van de praktijk tegenspreken: 1) therapeuten hebben geleerd dat bepaalde karaktertrekken pathologisch zijn, 2) dat de oorsprong van deze trekken gevonden kan worden in de geschiedenis van de cliënt, en 3) dat zodra de oorsprong bekend is, de trek aangepast kan worden (hoofdzakelijk door het verkregen inzicht). De theorieën daarentegen maken geen onderscheid tussen normale en pathologische trekken, impliceren dat het misschien niet mogelijk is dat de therapeut achter de oorsprong van deze trekken komt en impliceren dat het misschien niet mogelijk is dat psychotherapie de persoonlijkheid kan beïnvloeden. Elke theorie over karaktertrekken, inclusief het vijffactor model, brengt echter wel voordelen mee voor de therapeut. Zo helpt het de therapeut om de ervaring van de cliënt (en dus ook de problemen tijdens de behandeling) te begrijpen en hierop te anticiperen. Met behulp van de sterke en zwakke punten kan er zodoende een praktisch behandelplan op maat worden opgesteld.

Patiënten presenteren zich in de praktijk met alle vijf factoren tegelijkertijd, terwijl het artikel van Miller deze factoren één voor één (apart) bespreekt. Elke factor ligt op een dimensie waarop hoog of laag gescoord kan worden:

  • O: houdt van nieuwheid (hoog) vs. voelt zich ongemakkelijk in nieuwe situaties (laag).

  • C: houdt van presteren (hoog) vs. houdt van vrije tijd (laag).

  • E: moet veel praten en heeft mensen nodig (hoog) vs. wil liever niet praten (laag).

  • A: is oprecht sympathiek en gul, is vaak een positivist (hoog) vs. wil bewondering, is eerder een pessimist (laag).

  • N: ervaart veel pijnlijke gevoelens (hoog) vs. is emotioneel afgevlakt (laag).

Miller baseert zijn conclusies op drie bronnen: dat wat al bekend is over de vijf factoren bij de gewone mensen in het dagelijkse leven, dat wat bekend is over de factoren in de literatuur, en wat Miller afleidt van zijn eigen klinische ervaring de afgelopen 2 jaar.

De vijf factoren in de klinische context

Neuroticisme (N)

N beïnvloedt de intensiteit en duur van de stress bij behandeling. De mensen die in behandeling voor een gediagnosticeerde mentale stoornis scoren in Miller’s steekproef veel hoger op N dan de algemene populatie. Als de steekproef van Miller typisch is, zien de meeste therapeuten dus veel patiënten die hoog scoren op N. Om een patiënt goed te kunnen helpen, moet de therapeut weten waar hij/zij scoort op N. Bijvoorbeeld: patiënten die laag scoren zullen waarschijnlijk geen huwelijksgerelateerde depressieklachten rapporteren tenzij de problemen ernstig zijn, terwijl patiënten die hoog scoren eerder “overreageren”. Bij deze laatste groep is de spanning en het piekeren (gerelateerd aan een hoge N) chronisch en kan de depressie zowel een oorzaak als een gevolg zijn van de huwelijksproblemen. Patiënten die laag scoren op N hebben meer baat bij een behandeling waar de focus ligt op een relatief geïsoleerd zelfvernietigend gedragspatroon of een sterke emotionele reactie op een recente stressor. Bij hoge N patiënten is het logischer als de focus van de behandeling ligt op algemene(re) factoren, zoals stemmingsregulatie, angstmanagement of chronische zelfvernietigende gedragspatronen. Ook is het voor (het moraal van) hoge N patiënten extra belangrijk om heldere en realistische behandelingsdoelen op te stellen. Miller vindt dat deze groep patiënten zich overigens goed aangepast heeft. Lage N patiënten zijn rustig en onbezorgd. Hun negatieve gevoelens zijn kortdurend en niet intens. Hoewel het logisch zou zijn om aan te nemen dat het primaire behandelingsdoel het verlagen van N is, denkt Miller dat de behandeling N hoogstens een beetje zal doen dalen. Iemand die hoog scoort op N, zal hier na de behandeling zeker niet laag op scoren. Dit komt overeen met Costa en McCrae (1988) die stellen dat alle vijf de factoren redelijk stabiel zijn over tijd, ondanks alles wat er in die periode kan gebeuren. In Miller’s steekproef was N significant gecorreleerd met de behandeluitkomst: r = -.31, p .01.

Extraversie (E)

E beïnvloedt het enthousiasme voor het behandelingsproces en de expressiviteit tijdens de behandeling. In vergelijking met patiënten die laag scoren op E, zijn hoge E patiënten vrolijker en lachen ze vaak om hun klachten, praten ze veel en zijn ze open over alles, geven ze hun mening tijdens de behandeling en ervaren ze emoties met meer intensiteit. Na de behandeling is het waarschijnlijker dat hoge E patiënten zichzelf voorbij lopen en zo terugvallen. De therapeut moet bij deze groep oppassen dat er geen pseudo-alliantie ontstaat. Het is makkelijk om de intensiteit van lijden te onderschatten in hoge E patiënten. Miller raadt daarom aan om concrete vragen te stellen (“op een schaal van 1 t/m 10..”). De sobere presentatie van lage E patiënten maakt de therapeut daarentegen onterecht pessimistisch. De mate van E is verantwoordelijk voor het onderscheid tussen patiënten die graag meedoen aan/in de behandeling (hoog: willen veel praten) en zij die tegen een behandeling opzien. In Miller’s steekproef was E positief gecorreleerd met de behandelingsuitkomst, r = .30, p

Openheid (O)

O beïnvloedt de reactie op de interventies van de therapeut. Lage O patiënten werden door Lesser (1981) beschreven als “alexithyme”: zij kunnen niet fantaseren of symboliseren, hun spraak is saai en overdreven gewoontjes, en ze hebben moeite met het begrijpen en/of accepteren van de basisprincipes van psychotherapie. Net als hoge E patiënten, worden hoge O patiënten vaak door de therapeut gezien als goede patiënten. Extreem hoge O patiënten zijn echter ook nadelig: zeer hoge N en zeer hoge O patiënten maken hun eigen, ingewikkelde metaforen en symboliseren vrijwel continu. Psychotherapie kan begrepen worden als het proces waarin nieuwe oplossingen worden gevonden voor bestaande problemen: de mate van O geeft aan in hoeverre zo’n oplossing uitdagend moet zijn, of juist niet. Bepaalde behandelmethoden vereisen verschillende mate van openheid van de patiënt: gedragstherapie is redelijk conventioneel (lage O) terwijl imaginaire technieken wat nieuwer zijn (hoge O voor nodig). Methoden kunnen ook ingedeeld worden op basis van de mate van spontane spraak en sociale interactie die vereist is (ook gerelateerd aan E). Bijvoorbeeld, een psychoanalyse waarin de patiënt vrijuit praat over gevoelens en fantasieën is geschikt voor een open extravert, terwijl een gesloten introvert zich fijner voelt bij een (systematisch interview van) cognitieve therapie. De relatie tussen O en de behandelingsuitkomst is complex: O is middelmatig gecorreleerd met IQ en het opleidingsniveau die beiden de uitkomst beïnvloeden. Een kleine positieve relatie tussen O en uitkomst lijkt dus logisch, maar de correlatie kan beïnvloed worden door meerdere andere factoren, zoals de voorkeur van de therapeut voor hoge O patiënten.

Mildheid (A – “Agreeableness”)

A beïnvloedt de subjectieve reactie op de therapeut. Hoge A patiënten hebben of respect voor de mensen om hen heen, of juist medelijden met hen. Ze lachen vaak en veel, hebben onschuldige humor (weinig ironie en sarcasme), willen altijd aardig gevonden worden en gebruiken zelden grove woorden om de wereld of de mensen om hen heen te beschrijven. Ze zijn bang voor afkeuring en ruzie en accepteren sociale ondergeschiktheid om dit te voorkomen. Hogan (1986) noemde deze factor dan ook “likeability”. Ironisch gezien zien hoge A patiënten zichzelf vaak niet als naïef en/of dat ze gebruikt worden: omdat zij aangelegd zijn om te vergeten en vergeven zien zij dit patroon niet. Lage A patiënten klagen hier wel vaak over omdat ze zich duidelijk elke keer kunnen herinneren. Bij lage A patiënten kan de Miller (of een andere therapeut) gerust wat scepticisme verwachten, evenals een uitvergroting van de kleine fouten en een langzaam proces wat betreft het vormen van een therapeutische relatie. Om een goede uitkomst te bewerkstelligen moet de therapeut bereid zijn om te “worstelen” met de problemen. Hoge A patiënten nemen vaak van alles klakkeloos aan en zijn makkelijk om een therapeutische relatie mee te vormen. In Miller’s steekproef heeft A geen invloed op de behandeluitkomst. In de toekomst zal moeten onderzocht worden of lage A patiënten eerder geneigd zijn om te stoppen met de behandeling.

Ordelijkheid (C – “Conscientiousness”)

C beïnvloedt de mate van inzet tijdens de behandeling. Zij die hoog scoren op C zijn verrassend bereid om samen te werken en doen meer hun best tijdens de behandeling, kunnen discomfort beter tolereren, en zijn beter in staat om impulsen en wensen uit te stellen voor de eigen bestwil, in vergelijking met lage C patiënten. Ondanks dat C niet gecorreleerd is met IQ, worden zij die hoog scoren op C vaak door anderen gezien als intelligente mensen. In Miller’s steekproef scoorden de meeste patiënten lager op C dan de populatie zonder mentale stoornissen. Waarom dit zo is, is nog onduidelijk. Misschien hebben lage C scores een nog onduidelijke relatie met de aard en ernst van psychopathologie, of lossen mensen die hoog scoren op C hun eigen problemen op zonder de bemoeienis van een derde partij (de therapeut). Volgens Miller is de combinatie van een hoge N, lage E en lage C een “misery triad” (ellendige combinatie). In de behandelkamer willen patiënten met een lage C af van hun symptomen en problemen, maar zijn ze minder bereid om ook werkelijk iets te veranderen of psychologisch discomfort te verdragen, zelfs wanneer ze het belang ervan inzien. Een lage C is dan ook een absolute killer voor de therapie. Miller heeft veel dingen geprobeerd, maar is nog niet succesvol geweest in het bewerkstelligen van verandering bij lage C patiënten. C is significant gecorreleerd met de uitkomst, r = .35, p

Een belangrijke opmerking is dat het C domein in de MMPI erg ondervertegenwoordigd is. Sterker nog: de MMPI meet primair N en E, redelijk O en de A, maar weinig C.

Knowledge and attitudes about ADHD and its treatment - Moldavsky et. al. - 2013 - Article

Knowledge and attitudes about ADHD and its treatment - Moldavsky et. al. - 2013 - Article

A lot of parents, teachers and health care professionals find that despite of the large amount of research on ADHD, the disorder is often over-diagnosed and children get over-medicated. They question the validity of diagnosis and emphasis the importance of collaboration between health care professionals, the educational system and family. The knowledge and perspectives on ADHD of all individuals involved highly influences the process of identification, referral, diagnosis and treatment of children with ADHD. It’s essential to address differences in perspectives in order to achieve a common goal and shared understanding.

There still seem to be a lot of misunderstanding about ADHD, even among teachers, physicians and parents. Some still believe ADHD to be the result of bad upbringing, think a chaotic and dysfunctional family is the etiology of ADHD, don’t know about the importance of genetic factors, believe in a sugar etiology or think children with ADHD misbehave because they don’t want to obey rules.

Research into the perspectives of children against ADHD found that some children viewed ADHD as a disorder of academic achievement (performance niche)while the others thought it to be a disorder of aggression and anger (conduct niche). The study was performed amongst 151 children who were diagnosed with ADHD or did not have any psychiatric diagnosis. The children in the performance niche (mostly found in the USA) wanted to do well and felt that medication helped their academic achievement. Children in the conduct niche (mostly found in the UK) wanted to be ‘good’ and expected stimulants to improve their self-control.

Children and adolescents with ADHD and their parents often feel stigmatized which greatly influences their self-esteem and the effect of their treatment. Especially adolescents seem to be more prejudiced and less accepting towards individuals with ADHD. Parents often show their concerns about the fact that they feel they and their child are being labelled by society and thereby rejected and isolated. New insights into the experience of stigmatization amongst children was found in the VOICES study. The children in the performance niche didn’t experience a lot of stigmatization, bit did fear it. Children in the conduct niche did experience stigma related to having an ‘anger problem’. Children with ADHD are increasingly using online social networks to neutralize stigma. Parents sometimes felt stigmatized for having a child with the diagnose of ADHD and accepting medication as a treatment (courtesy stigma). In teachers, the label ADHD increases the perception that the behavior of a child is disruptive and that they would have trouble handling the child. On the other hand, it elicited more willingness to help implement learning assistance, medication and changes to the classroom environment.

A lot of international studies have showed evidence for the improvement of knowledge on ADHD by educational interventions. Workshops about ADHD, not-attendance education, and web-based interventions have shown to provide at least short-term effectiveness. It remains unclear if there is any long-term maintenance in the behavior of professionals because there are little to no follow-ups.

There seem to be differences in the way parents, teachers, children and health care professional view a shared decision-making process (SDM). Parents ought to think that it’s an equal partnership and want clinicians to provide them with information about all treatment options, while clinicians see it as a process of explaining their own views on treatment options and encourage parents to accept them by providing supporting information. These differences emphasize the need to negotiate a common understanding and shared goals in from the beginning of a SDM process.

Researchers concluded that adolescents with ADHD should be involved in the informed consent process, but consideration should be given to their cognitive abilities. It’s important to involve adolescents in their own treatment plan because it appears that their willingness to consider treatment is significantly lower than that of their teachers and parents.

A multidisciplinary approach to the diagnosis of ADHD is recommended by the guidelines, but often fails to be followed. Pediatricians often diagnose ADHD and subscribe medication without consulting a psychiatrist, while when psychiatrist diagnose ADHD they don’t communicate this with the pediatricians who have to refill prescriptions.

To identify the obstacles to treatment success, a tool has been developed that includes a medication preference scale, a goal scale and a behavior therapy preference scale which can be filled in by parents and children. Other tools are the Questionnaire on Attitudes Towards Treatment of ADHD and the ADHD Medication Attitude Scale. The latter has shown that treatment adherence is lower in adolescents.

Thus, there is a need for continued education of teachers, health care professionals and the public about ADHD, and especially about its etiology and treatment. These areas seem to provide the most misconceptions and reinforce stigma attached to ADHD.

EEG neurofeedback treatments in children with ADHD: an updated meta-analysis of randomized controlled trials - Micoulaud-Franchi et. al. - 2014 - Article

EEG neurofeedback treatments in children with ADHD: an updated meta-analysis of randomized controlled trials - Micoulaud-Franchi et. al. - 2014 - Article


The techniques of neurofeedback (NF) enable a patient to train him or herself to self-regulate a single measure of brain activity, which can be measured through EEG. EEG-NF (EEG and neurofeedback) training aims to achieve self-control over specific aspects of electrical brain activity through real-time feedback and positive reinforcement and implement these self-regulation skills in daily life. The aim of this study was to focus on recent major developments in the field of NF and ADHD. 


The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations are used  to undertake the search and analysis of the international scientific literature. Studies were included if they met the following criteria:

  1. Design: randomized controlled trials (RCT).

  2. Intervention: standard protocol EEG-NF with Theta/Beta Ratio training—TBR (or likely to standard TBR training) or Slow Cortical Potentials (SCP) training.

  3. Control group: semi-active (i.e., cognitive remediation and EMG-biofeedback) and sham-NF.

  4. Participants: participants with an established clinical diagnosis of ADHD thanks to DSM or CIM criteria.

  5. Evaluation of ADHD severity based on a validated scale with probably blinded assessment (teacher assessment) data available.

  6. No secondary analyses of previously included trials.


Results of the literature search

Five identified studies met the eligibility criteria.

Results of the meta-analysis

Studies and Population characteristics

263 patients with ADHD were included, 146 patients were trained with EEG-NF.

Effects of EEG-NF on parent assessment (probably no-blinded assessment)

On parent assessment (probably unblinded assessment), the overall ADHD score (SMD = −0.49 [−0.74, −0.24]), the inattention score (SMD = −0.46 [−0.76, −0.15]) and the hyperactivity/impulsivity score (SMD = −0.34 [−0.59, −0.09]) were significantly improved in patients receiving EEG-NF compared to controls.

Effect of EEG-NF on teacher assessment (probably blinded assessment)

On teacher assessment (probably blinded assessment), only the inattention score was significantly improved in patients receiving EEG-NF compared to controls (SMD = −0.30 [−0.58, −0.03]).

Sensitivity analysis to test for medication effects

A significant correlation was found between the ES on the overall ADHD score assessed by teacher and percentage of patient treated with methylphenidate (rs[5] = 0.9, p = 0.037).


This meta-analysis of EEG-NF in children with ADHD highlights improvement in the inattention dimension of ADHD symptoms. Future investigations should pay greater attention to adequately blinded studies and EEG-NF protocols that carefully control the implementation and embedding of training.

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