Ongoing Thoughts on Aetiology, Intervention, and Rating Outcomes


This set of summaries begins with a questioning of the genetic, brain-condition based, view of ADHD and a focus, instead, upon nurture and environmental issues.

There follows a description of an intervention which involves exposure to outdoor and green environments.

The emphasis in the rest of the notes is upon the use of rating scales … consistency between child and adult ratings (of quality of life); teacher ratings and performance in visual search activities; and the need to base the identification of ADHD upon more than one classroom session on more than one day, and to have regard to the context as well as the match between teachers’ ratings and independent observations of positive and negative behaviours.


M.J.Connor                                                                                                     July 2006



A further View on the Causes of ADHD


A recent article in the national press (James 2006) has presented a different perspective upon what underlies the behaviours and symptoms which make up ADHD.


James questions the otherwise largely accepted view that ADHD is a relatively common neuro-developmental disorder with a significant genetic element in its aetiology; and he suggests that this heavily medical-model orientation or reference to a biological brain disorder misrepresents much day to day evidence.


James cites a case study in which, it is argued, the problem could be traced to a very disturbed pregnancy during which the mother experienced violence from her husband which led to depression and ultimately to a decision to end the marriage. 

The child became a major source of concern because of the disordered behaviour which included distractibility, poor concentration, hyperactivity, and poor social skills, as well as behaviour suggestive of oppositional defiance.

The argument continues that the observed behaviour could be linked to the disturbed pregnancy and the subsequent inability to bond with the infant (unlike the positive relationship which had been established with an older child).


Supportive evidence for this view is cited from a Danish study which suggested that maternal anxiety and distress during pregnancy is linked to high rates of cortisol production which, in turn, is associated with an enhanced risk of low birth weight. 

The cortisol effect is passed to the (unborn) child who faces an enhanced probability of anxiety or stress reflected in over-active behaviour indicative of fight or flight reactions. 

A further study is described where there was a significantly greater probability of ADHD symptoms among boys whose mothers had experienced emotional stresses during the later stages of pregnancy. 


In other words, whatever the contribution of nature (genetic inheritance), it appears that nurture (or, at least, an absence of adequate nurturing, and the interference in the early mother-child interaction) can play a role in ADHD in the child.


Additional evidence to support this hypothesis is gained from the observation that children removed from disturbed and disturbing homes and placed in institutions where the care may be described as impersonal and inconsistent are more likely to develop signs and symptoms of ADHD than similar children placed in foster homes where there is a higher level of nurturance and individual care.

Similarly, ADHD symptoms are a significantly greater risk among children of single parents, with the hypothesis that this is a reflection of the greater probability of feelings of harassment or management difficulties.


A final citation refers to the effectiveness of an intervention which simply ensures regular opportunities for the children showing ADHD symptoms to receive intensive hugging from the parent(s) as a form of nurturant compensation for the earlier unmet emotional needs.


In any event, James holds that it has not been possible to identify specific genes which are linked with given mental health conditions; and that the results of twin studies indicate that only a modest aetiological significance can be attributed to gene effects.


His conclusion supports the need more fully to acknowledge environmental factors in ADHD (including what he sees as the considerable weight of evidence linking ADHD to dietary inadequacies or intolerances.)  


(See Attention Deficit Disorder Update 32 for further notes on ADHD and maternal stress and for sleep disorder/snoring [also mentioned in Updates 23 and 35] as a further “environmental” issue.  See Updates 29, 31, 33, and 35 for dietary topics.)


An Alternative (Non-Invasive) Intervention


(This item is included as much for its novelty as for its scientific rigorousness or the meaningful applicability of implications …….)


A study by Kuo and Faber Taylor (2004) has suggested that increasing the amount of time children spend in natural, green settings could be effective in diminishing the symptoms of ADHD.


The study was a follow up to observations that children, albeit not formally diagnosed with ADHD, could display heightened attention and reduced impulsiveness after exposure to natural views and settings.

The hypothesis is that tasks or situations which require concentration and focus lead to rapid fatigue in the attention system, and exposure to the natural environment can assist in the rapid recovery from this fatigue given that the mind can be engaged with little conscious effort.  If this applies to the ability to focus, the argument continues, it could prove significant for children with ADHD.


These authors worked with a sample of parents of children diagnosed with ADHD who covered a range of ages and socio-economic backgrounds.


The parents were asked to rate the effect of a number of after-school or weekend activities upon the ADHD symptoms observed.  The target symptoms included difficulty in staying on unappealing tasks, difficulty in completing tasks, poor listening and following of instructions, and weakness in avoiding distractions.

The range of activities were available in any green outdoor settings (such as a park or farm or any natural area) or in a built outdoor setting such as a disused car park within the town area, or indoors.


With controls inserted to manage the differences in symptom severity, gender, and home location, the authors concluded that parental ratings indicated improvements in behaviours following exposure to activities in the green settings.


However, there were caveats in terms of the possible difference in activities according to the setting … although a follow up study showed a similarly positive effect of the green outdoor setting when the activities were identical across settings.


(While interesting, the results may be thought a little limited if the ratings are completed only by parents, and one would want to examine whether in-class effects are observable, how long the effects are maintained, how frequently there has to be a topping-up of the exposure to “green” activities, and whether the effects could be attributed to exposure to fresh air and healthy tiredness, or to some novelty factor.)


Comparing Parent and Child Reports on the Quality of Life


The contribution by Klassen et al (2006) begins by noting that self-report is the usual method for assessing a person’s quality of life but that it may not be practicable to depend on this approach with children since they may not have the ability to express what they really feel, or the required attention skills, so that parents commonly offer ideas or information on their behalf.


They report that, recently, there have appeared a number of instruments by which to sample the opinions and experiences of children with ADHD and these can provide important information about the quality of life as perceived by the children … but few research studies have examined the degree of correspondence between the views of the children and those of their parents.

Only one such study has been identified, and this showed a moderate correlation between parent and child ratings with correlations increasing with the age of the child.


The study completed by these present authors set out to explore whether correlation would be greater in the case of children with physical health needs than in the case of psychosocial needs; or if, in the case of discrepancies, whether the parents’ ratings would be more positive or more negative than those produced by the children.


The sample of children covered a range of demographic, socio-economic, and clinical features and included 58 children formally diagnosed with ADHD about whom completed rating questionnaires were returned (including information about the three ADHD subtypes as well as about physical health.)


The analysis of returns indicated stronger agreement between parents and children in those areas dealing with the most observable elements of conditions, such as physical health and capacities, and poorer agreement in respect of less directly observable elements such as mental health or self esteem. 


Children with ADHD produced ratings of their own self-esteem and mental health and behaviour which were closer to the typical ratings produced by a non-ADHD control group than to the parental ratings.  The parents tended to attribute to the children substantial deficits in psycho-social and family-functioning areas.

(This kind of pattern … ie child-child agreement stronger than child-parent agreement  … is comparable to what has been found among other studies which have examined quality of life ratings.)


In respect of any association between parent-child discrepancies and social or clinical factors, it was found that children with more overt behavioural difficulties

(oppositional defiance or conduct disorder) were more likely than their parents to rate their mental health positively; and children with the inattentive or combined type of ADHD rated their self-esteem more highly than their parents did.


The authors speculated about why this pattern should emerge. 

One possibility was that some children could be concerned lest their parents see their responses and felt it necessary to give more positive ratings than were true in order to conceal some of their (behaviour) problems.

Alternatively, the impulsive style and tendency to rush through given tasks of many of the children could have reduced the validity or reliability of their responses.

Over-positive ratings by the children could also reflect a need to compensate for negative experiences and to protect their own self images.

There was the further possibility that the more negative ratings produced by the parents reflected a motive to demonstrate a stronger case for access to support provisions.

(The authors also acknowledged that their sample of families referred to specialist clinics may not be reflective of ADHD more generally.)  


Nevertheless, the general conclusion underlined the converging view about the need for assessments of possible ADHD to involve multi-sources of information, and that a view of the effects of the condition should be based upon the perspectives of both child and parent(s). 


Differentiation of Pre-School Children’s Attention by Teacher Ratings 


It is argued by Wilding and Burke (2006) that there is a “vast” literature exploring the cognitive deficits associated with ADHD but no real consensus about the real and core nature of the condition … albeit with some converging opinions that it is likely to involve impairments in elements of executive function such as control of attention rather than a deficit in a specific attentional process such as the selection of attention.


Other hypotheses involve delay aversion, and an inefficient arousal system.


The outcome of this lack of consensus or the pinpointing of precise variables linked to ADHD has included the use of a range of measures to explore cognitive weaknesses and no agreed “package” of measures to aid identification.

Visual search tasks have been used to discriminate among the attentional capacities of children, with indications that discrimination is easier when the task becomes more difficult (and associated speculation that cases formally identified with ADHD represent the lower end of a continuum covering the whole age group). 


The present study investigated whether 3 and 4 year old children, rated for attentional capacities by their teachers, would demonstrate a correlation between performance on a visual search task and the ratings given to them.

103 children were in the sample (48 girls and 55 boys) drawn from nursery schools, whose teachers completed the Swan ADHD Scale (Swanson et al 2001) to gain a measure of their (in)attention and hyperactivity/impulsivity.  A measure of verbal mental ability was also used.

The search task assessed speed and accuracy of responding to stimuli on a computer screen.


The results indicated that there was a clear and positive relationship between the accuracy observed (fewest errors) and the better attention ratings.  Further, there was an inverse correlation between errors made and verbal mental age.


What emerged, too, was that the pattern of errors compared to attentional ratings was not linear in that the error scores did not differentiate the children until the attentional ratings indicated quite severe deficits … from which point on the mean error rate increased sharply.

This pattern had been observed in a previous trial with older children.


There was no evidence that the higher error rate was due to faster and more impulsive responding, and support was claimed for the hypothesis that the deficit is not in some specific area such as discrimination or attention-shifting, but is a matter of a general weakness which might be defined somewhat loosely as attentional capacity or be related to motivation interacting with task difficulty.


It appears that it is the planning and control aspects which are inefficient, not some more basic component like selective attention, with the implication that simple tasks may not tap the difficulties and that the postulated weaknesses in responding to demands upon executive function will only be evident in more difficult versions of a search task.

Some support is offered to the view that attention deficits can be attributed to weaknesses in the inhibition of inappropriate responses (a key aspect of executive functioning), but this seems an inadequate concept by which to explain the variation in performance among different samples of participants, or differential effects upon various forms of inhibition, without reference also to likely impairments in other control processes.


ADHD in Different Classroom Contexts


The study by Lauth et al (2006) examined the extent to which teachers’ ratings are directly linked to actual classroom behaviours (and how the behaviour of the children with ADHD can be clearly differentiated from that of peers). There was an interest in assessing not just disruptive and inattentive behaviours but also on-task behaviours.

The interaction between context (classroom activity) and behaviour was also to be explored.


In their introduction, the authors justified the focus upon classroom behaviour on the grounds that ADHD problems can be particularly salient to that context because of the enhanced need for sustained attention and self control; but it was noted that classroom research has emphasised teachers’ reports and ratings with few instances of direct observation of children’s performance …. with possible implications for some bias (halo effect). 


What data do exist indicate that there is a small to moderate correlation between teachers’ ratings and independent observations, and questions that arise concern precisely which classroom behaviours most influence the teachers’ perceptions, and whether or not positive behaviours are given sufficient regard.


From their review of existing studies, the authors describe how children with ADHD have been variously differentiated from peers in terms of the amount of off-task behaviour (such as day dreaming) or behaviours other than those relevant to the task, more talking to other pupils, more disruptive activity where other children are distracted and interrupted, attention seeking actions, greater motor activity of a self stimulating type, and negative social behaviours.

The most frequent behaviours used to mark out the children with ADHD appear to be negative vocalisations, general (motor) activity level, and inappropriate attention demanding actions.  Interference with other children or off-task behaviour are also salient.


Concerns include the likelihood that assessments or/ratings will not involve a number of (class) settings or of occasions, when a better picture may emerge from a reflection of several different lessons and more than one day. There may also have been, typically, insufficient focus upon appropriate behaviours such that disruptive behaviours are highlighted one-sidedly given that some evidence can be cited that there may be a surprisingly high level of positive involvement on the part of at least some children with ADHD.


Further, it has been argued that the impact of the specific context or situation has been underestimated as significant in any analysis of behaviour with the risk that it may not actually be clear whether the problem behaviours are situationally specific or generalised.  One factor, for example may involve the level of structure imposed by the teacher and the corresponding level of freedom left to the children to determine their own actions (or inactions) ….. there is support available from existing studies for the hypothesis that maladaptive behaviours increase with the degree of informality of the context.


The study by Lauth et al set out to examine some of the issues raised such as the correlation between ratings and observable behaviours, or the behavioural criteria  most often used to differentiate the ADHD child from peers, or the way in which context may effect behaviours.


A large sample of children (N=569) between the ages of 7 and 11 were targeted of whom a sub-sample were identified by teacher ratings or the application of psychiatric diagnostic criteria as showing a significant level of inattention or hyperactivity.

A structured observation schedule assisted systematic observation of the children’s attentional behaviour during lessons, with use made of a time sampling procedure by which to code aspects of behaviour and the particular context.


Particular note was taken of off-task behaviour (talking to neighbour, moving round the class, clowning), passive inattention (looking out of the window, or preoccupation with something not related to the task), and on-task behaviour which was coded as inconspicuous but expected behaviour (eg  reading quietly), self-initiated activity (eg  raising hand, or helping a peer), and other-initiated activity (eg  answering a question [ of another child ?]). 

The contexts included regular lessons with whole class instruction and some group work, minimal interaction (silent work), and non-instructional time (eg  a more free discussion, or play-oriented session).


The general outcome confirmed the significance of teacher involvement in the identification of ADHD, and the likelihood that a false negative attribution might well be established if information is not gained from the teacher(s).

It was also confirmed that the relatively global reports or ratings from teachers were related meaningfully to child behaviours recorded by an independent observer.


However, some unexpected findings were noted such as the way in which disruptive behaviours did not provide the major role in determining ADHD.  Moderate correlations existed but there was no support for the existence of a negative halo effect. Observed inattention was a stronger influence in reporting ADHD.


(It could be speculated – MJC – that this reflects a view by teachers of what constitutes ADHD in that they perceive inattention as primary; while disruptive behaviours are not seen as insignificant for the classroom but are attributed to some other causal source rather than to ADHD  ??).


More significant still was the influence upon the teachers’ views of the amount of expected inconspicuous on-task behaviour ( …. so that non-ADHD children are readily identified and the ADHD children identified by default ….); with the authors speculating that classroom order depends upon conformity to rules and routine and the teacher’s work and relationship with the whole class are put at risk when a child starts to act outside the rules and routine.

Self-directed on-task behaviours were not actually welcomed by teachers, possibly being viewed as indicative of too much spare energy or as potentially distracting, or even as signs of procrastination. Further, other-initiated on-task behaviours were also seen as contravening the expectation that no further direction should be required beyond that given to the whole class.


In other words, conformity expectations are central to teachers’ ratings (such that a passive form of inattention may not always contribute much to ADHD identification by the teacher if the class as a whole is not affected and if the passive identification can be (mis)-interpreted as the child’s being on-task).


The authors repeat their view, therefore, that teachers’ reports need to demonstrate a link to actual child behaviours; and that there is scope for independent observation to complement the teachers’ reports.


This conclusion was underlined by the further finding of a relatively high level of on-task behaviours by the putatively ADHD children according to observations spread over several observation days (albeit below the rate shown by controls), with the implication that scope may well exist for enhancing and shaping existing behaviours as much as suppressing the maladaptive behaviours.


Context was seen as significant in that whole class teaching elicited the highest rates of passive inattentive behaviours, and more self or other initiated on-task behaviours.

Individual silent work elicited the highest rates of active disruptive behaviour.

It was noted that the children seen as showing ADHD behaviours and controls were  actually quite similar in this above pattern.


A practical problem in comparing current findings with existing data is the lack of agreement over definitions of context although there does seem a growing consensus that teacher-structured situations can give rise to more off-task and disruptive behaviours and non-instructional contexts give rise to more inattention.


One might summarise the implications by highlighting the likely significance of situation and task demand as much as any attribution of behaviour to some pervasive trait or condition in the child.

Further, the question would best not simply involve determining where things go wrong, but also where they go right !



                                   *          *          *          *          *


M.J.Connor                                                                                                     July 2006





James O.  2006   Can maternal anxiety lead to ADHD ?  Health-Monday : The Times (page 10-11)  19th June 2006


Klassen A., Miller A., and Fine S.  2006   Agreement between parent and child report of quality of life in children with attention deficit/hyperactivity disorder.   Child : Care, Health, and Development  32(4)  397-406


Kuo F. and Faber Taylor A.  2004   A potential natural treatment for ADHD.  The American Journal of Public Health  94  1580-1586


Lauth G., Heubeck B., and Mackowiak K.  2006   Observation of children with ADHD problems in three natural classroom contexts.   British Journal of Educational Psychology  76  385-404


Swanson J., McStephen M., Hay D., and Levy F.  2001   The potential of the Swan Rating Scale in genetic analysis of ADHD.   Presentation to the 10th Scientific Meeting of the International Society for Research in Child and Adolescent Psychiatry.

Vancouver : June 2001


Wilding J. and Burke K.  2006   Attentional differences between groups of preschool children differentiated by teacher ratings of attention and hyperactivity.   British Journal of Developmental Psychology  24  283-291             

This article is reproduced by kind permission of the author.

© Mike Connor 2006.

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