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Greetings:
I hope you are doing well. We've got a foot of snow on the
ground in Durham, NC and it looks beautiful. I'm sure school
will be closed for the week.
Below is an article that appeared in a prior issue of ADHD
RESEARCH UPDATE. The article summarizes an interesting study
on the long-term outcomes for children who are persistently
hyperactive, aggressive, or oppositional. The data presented
in this study are important and I think you will find it
to be interesting.
If you have been finding the information you have been receiving
about new research on ADHD to be helpful, I'd like to encourage
you to become a regular subscriber to ADHD RESEARCH UPDATE.
You'll find information about this at the end of the article
below.
** FREE GIFT **
I'd like to offer you a gift that I think you will find quite
valuable.
I have developed a system that makes it easy for parents
to monitor how their child is doing at school and to
determine when changes to their child's treatment may
be necessary.
In the past, I have provided the ADHD Monitoring System as a
for new subscribers, but I'd be happy to send it to you regardless
of whether you choose to become a regular subscriber at this time.
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in elementary school rather than for middle school and
high school students.
Please feel free to forward this information to others you
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I hope you are doing well.
Sincerely,
David Rabiner, Ph.D.
Duke University
P.S. If you sent me a question after the last mailing I apologize
if I have not answered. As this list has grown, I now receive
over 100 questions after each mailing and am no longer able to
keep up with replying. Sorry.
==================================================================
* LONG-TERM OUTCOMES FOR CHILDREN WHO ARE
PERSISTENTLY HYPERACTIVE, OPPOSITIONAL, OR
AGGRESSIVE
A recent issue of Child Development contains a very interesting
study on the long-term outcomes for children who are persistently
hyperactive, persistently oppositional, or persistently aggressive
(Nagin, D., & Tremblay, R.E. (1999). Trajectories of boys'
physical aggression, opposition, and hyperactivity on the path to
physically violent and nonviolent juvenile delinquency (1999).
Child Development, 70, 1181-1196. This study highlights the
importance of considering separately hyperactivity, oppositional
behavior, and actual aggression - three different aspects of
children's behavior that often are incorrectly lumped together as
being reflective of ADHD.
This is a complex study in which some very arcane statistical
techniques are employed. What follows is my best effort to
present these important data in a simple and straight-forward
way.
Here's what the authors did. At the start of the study, behavior
ratings on almost 1200 boys were obtained from their kindergarten
teachers at the end of the school year. These ratings were used
to classify boys as being high, moderate, or low on three different
types of behavior: hyperactivity (i.e. symptoms of ADHD such as
being fidgety and unable to be still), oppositionality (e.g.
irritable, disobedient, refuses to share), and aggressive (e.g.
bullies others, fights with others, kicks or hits others. Boys
were considered to be high, moderate, or low on these 3 types
of problem behaviors based on how their score on each compared
to the overall group average.
Several years later the authors tracked down over 1000 of these
boys, and had their current teachers complete these same
behavioral ratings again. These behavior ratings were then
obtained annually from boys' teachers until they turned 15.
All told, therefore, ratings for aggression, oppositionality,
and hyperactivity were obtained on the boys a total of 7
different times from 7 different teachers. As best the authors
could tell, there were no major differences between the boys they
were able to track down and the ones who were lost to
the study.
Finally, subsequent to these 7 waves of teacher behavior ratings,
each boy was interviewed at 15, 16, and 17 and asked about their i
involvement in a variety of delinquent and antisocial acts during
the past 12 months. All in all, this was a monumental data
collection effort and an exceptionally rich longitudinal set.
(Too bad, however, that girls were not included).
RESULTS
The first question the authors were interested in concerns
how children's scores on the 3 types of problem behaviors
tended to change over the course of their development.
Using a very complicated set of statistical tests, the
authors first identified the most commonly occurring "pathways"
for each of the 3 problem behaviors. (By "pathway", I
simply mean how children's problems in these 3 areas
changed over time - e.g. did they get worse, stay the
same, or get better?)
Four different pathways were identified. These were:
1. Persistently high - children who had high scores compared
to their peers at each assessment;
2. High decliners - children who started out high compared
to their peers but whose scores declined into an average
range over time.
3. Moderate decliners - children who stared out moderately
high compared to peers but who also declined over time.
4. Persistently low - children who received low scores compared
to their peers at each assessment.
(Interestingly, there was no group of boys that started out
with low ratings on any of the 3 problem behaviors and then
increased over time. This may certainly have occurred for
some boys, but not enough for this to show up as a common
pathway like those noted above. It may also reflect problems
in how the behaviors were measured in this study.)
Each child was then assigned to 1 of these 4 pathways for each
behavior. Thus, it is possible for a child to have been in the
persistently high group for aggression, and in the persistently
low group for hyperactivity and oppositionality. Or, a child
could have been in the high group for all 3 behaviors. A number
of different combinations are of course possible.
To begin with, it is interesting to note the percentage of the
sample that fell into the different groups (i.e. persistently
low, moderate decliners, high decliners, and persistently high
for each of the 3 behaviors. Across the 3 types of behavior,
the percentages were as follows:
Persistently high - about 5% of the sample for each behavior;
High decliners - between 20-30%, depending on which behavior
is being considered;
Moderate decliners - about 50% of the sample for each behavior;
Persistently low - between 15-25% of the sample depending on
the behavior;
Thus, it was quite unusual for a child to show consistent
elevations - relative to his peers - on teacher ratings of
hyperactivity, oppositional behavior, or physical aggression.
Next, the authors examined the degree of overlap that existed
across the behaviors for children in the different groups. In
other words, how likely was it for a child to be in the
same grouping for each type of problem behavior?
Of particular interest here is the overlap that existed between
children who were in the persistently high group for any of the
3 behaviors. Let's focus on children who were persistently high
for hyperactivity. How likely were these children to also show
persistently elevated levels for either oppositional behavior or
physical aggression?
The answer is more than children who were not persistently
high for hyperactivity, but not nearly so often as you might
expect. Only 13% of the boys who were persistently high on
hyperactivity were also persistently high for physically aggression.
Only 23% were persistently high on oppositional behavior. These
data make it clear that the vast majority of persistently
hyperactive boys were not showing persistent difficulties in
either of the other two problem behaviors.
The message here is simple and very important: oppositional
behavior and aggression often develop and persist for reasons
that have little or nothing to do with a child's having ADHD.
When a child with ADHD also displays these other behaviors
it should not be understood as being "part of the child's ADHD".
In the second set of analyses the authors examined how well
children's classification on hyperactivity, oppositional
behavior, and aggression (e.g. were they persistently high
or persistently low) predicted their involvement in antisocial
and delinquent behavior at age 17. For children in the high
and low groups for hyperactivity, oppositionality, and physical
aggression the average number of offenses reported during the
prior 12 months were as shown below:
Hyperactivity Oppositionality Aggression
High 2.34 6.38 7.17
Low .33 .01 .06
An examination of these numbers clearly indicates that persistently
hyperactive boys actually reported far fewer offenses than boys
who were persistently oppositional or persistently aggressive.
(Note: It would have been nice to consider these outcomes for
boys who were persistently high on 2 or 3 of the different
problem behaviors. This was not done, however, primarily because
even with such a large sample, the number of children required
to do this type of analysis were not sufficient.)
Even more telling are results of analyses in which boys' grouping
on all 3 behaviors were used simultaneously to predict their
involvement in delinquent and antisocial behavior at ages 15,
16, and 17. These results are a bit complicated but here is
an overall summary:
* Boys' classification for physical aggression was the only
significant predictor of both self-reported violence and
self-reported serious delinquency. What this means is that
boys' classification on either hyperactivity or oppositional
behavior did not really matter when trying to predict these
outcomes - only their classification for aggressive behavior
mattered.
* For self-reported theft, only boys' classification on the
oppositional behavior dimension was a significant predictor.
* Boys who show high levels of hyperactivity from kindergarten
through high school are at much less risk of juvenile delinquency
than those who show high levels of physical aggression or
oppositional behavior.
IMPLICATIONS
These results have very important implications. The very good
news, I think, is that hyperactivity by itself does not increase
a child's risk for the types of antisocial outcomes considered
in this study. Now, it is important to recognize that the
ratings of hyperactivity that were used in this study were not
sufficient to determine whether a child had ADHD, but I think
it is reasonable to extend the conclusion above to make this
statement:
"When a male child has ADHD but does not also show persistently
high levels of either oppositional or aggressive behavior, he
is not likely to become involved in any serious antisocial
behavior as an adolescent."
I make this statement recognizing that it is going a bit beyond
what can be clearly concluded from the data of this study, but
it is a stretch that is supported by the efforts of other
researchers as well.
There are a number of reasons why this is quite important but
the one that really sticks out in my mind concerns just how often
parents may confuse oppositional and/or aggressive behavior with
ADHD. Typically, what I have seen happen is that after a child
has been diagnosed with ADHD, these other types of behavior
get explained away as being part of the child's ADHD. This
is incorrect, however. These other behaviors are not symptoms
of ADHD, and as this study clearly indicates, high levels of
these other behaviors are often not even associated with
ADHD and lead to very different outcomes than do ADHD symptoms
alone.
The take-home message from this study is that if a child with
ADHD is also displaying high levels of oppositional and/or
aggressive behavior, do not assume that treating the ADHD by
whatever means is tantamount to addressing these other
difficulties as well. Instead, it is essential to make sure
that these other problems are being specifically targeted in
a child's treatment plan, and these difficulties need to
be treated every bit as aggressively as the child's primary
ADHD symptoms themselves.
______________________________________________________________________
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Licensed Psychologist
Duke University
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