Cognitive training in academically deficient ADDH boys receiving stimulant medication

Remediating organizational functioning in children with ADHD: immediate and long-term effects from a randomized controlled trial

OBJECTIVE

The study compared the efficacy of 2 behavioral interventions to ameliorate organization, time management, and planning (OTMP) difficulties in 3rd- to 5th-grade children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

In a dual-site randomized controlled trial, 158 children were assigned to organizational skills training (OST; N = 64); PATHKO, a performance-based intervention that precluded skills training (N = 61); or a wait-list control (WL, N = 33). Treatments were 20 individual clinic-based sessions over 10-12 weeks. OST involved skills building provided primarily to the child. PATHKO trained parents and teachers to reinforce children contingently for meeting end-point target goals. Primary outcomes were the Children's Organizational Skills Scales (COSS-Parent, COSS-Teacher). Other relevant functional outcomes were assessed. Percentage of participants no longer meeting inclusion criteria for OTMP impairments informed on clinical significance. Assessments occurred at post-treatment, 1-month post-treatment, and twice in the following school year.

RESULTS

OST was superior to WL on the COSS-P (Cohen's d = 2.77; p < .0001), COSS-T (d = 1.18; p < .0001), children's COSS self-ratings, academic performance and proficiency, homework, and family functioning. OST was significantly better than PATHKO only on the COSS-P (d = 0.63; p < .005). PATHKO was superior to WL on most outcomes but not on academic proficiency. Sixty percent of OST and PATHKO participants versus 3% of controls no longer met OTMP inclusion criteria. Significant maintenance effects were found for both treatments.

CONCLUSIONS

Two distinct treatments targeting OTMP problems in children with ADHD generated robust, sustained functional improvements. The interventions show promise of clinical utility in children with ADHD and organizational deficits.

Remediating organizational functioning in children with ADHD: immediate and long-term effects from a randomized controlled trial

OBJECTIVE

The study compared the efficacy of 2 behavioral interventions to ameliorate organization, time management, and planning (OTMP) difficulties in 3rd- to 5th-grade children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

In a dual-site randomized controlled trial, 158 children were assigned to organizational skills training (OST; N = 64); PATHKO, a performance-based intervention that precluded skills training (N = 61); or a wait-list control (WL, N = 33). Treatments were 20 individual clinic-based sessions over 10-12 weeks. OST involved skills building provided primarily to the child. PATHKO trained parents and teachers to reinforce children contingently for meeting end-point target goals. Primary outcomes were the Children's Organizational Skills Scales (COSS-Parent, COSS-Teacher). Other relevant functional outcomes were assessed. Percentage of participants no longer meeting inclusion criteria for OTMP impairments informed on clinical significance. Assessments occurred at post-treatment, 1-month post-treatment, and twice in the following school year.

RESULTS

OST was superior to WL on the COSS-P (Cohen's d = 2.77; p < .0001), COSS-T (d = 1.18; p < .0001), children's COSS self-ratings, academic performance and proficiency, homework, and family functioning. OST was significantly better than PATHKO only on the COSS-P (d = 0.63; p < .005). PATHKO was superior to WL on most outcomes but not on academic proficiency. Sixty percent of OST and PATHKO participants versus 3% of controls no longer met OTMP inclusion criteria. Significant maintenance effects were found for both treatments.

CONCLUSIONS

Two distinct treatments targeting OTMP problems in children with ADHD generated robust, sustained functional improvements. The interventions show promise of clinical utility in children with ADHD and organizational deficits.

Training cognition in ADHD: current findings, borrowed concepts, and future directions

With both its high prevalence and myriad of negative outcomes, Attention-Deficit/Hyperactivity Disorder (ADHD) demands a careful consideration of the efficacy of its treatment options. Although the benefits of medication have a robust empirical background, nonpharmaceutical interventions evoke particular interest, as they are often viewed more favorably by parents. This review pays special attention to the use of working memory and recent cognitive training attempts in ADHD, describing its cognitive, behavioral, and biological effects in relation to current neurological theory of the disorder. While these treatments have demonstrated positive effects on some measures, there are limitations, as studies have failed to demonstrate generalization to critical measures, such as teacher-rated classroom behaviors, and have provided limited but growing evidence of functionally significant improvements in behavior. There is also a clear lack of research on the effects of training on reward systems and self-control. These limitations may be addressed by broadening the scope and procedures of the training and incorporating research concepts from other fields of study. First, it is important to consider the developmental trajectories of brain regions in individuals with the disorder, as they may relate to the effectiveness of cognitive training. Notions from behavioral economics, including delay discounting and framing (i.e., context) manipulations that influence present orientation, also have applications in the study of cognitive training in ADHD. In considering these other domains, we may find new ways to conceptualize and enhance cognitive training in ADHD and, in turn, address current limitations of interventions that fall in this category.

Cognitive Processes Underlying the Behavior Change in Cognitive Behavior Therapy with Childhood Disorders: A Review of Experimental Evidence

While Cognitive Behavior Therapy (CBT) has been widely used for treatment of childhood disorders, the process underlying the success of CBT in this area is still unclear. This paper attempts to examine empirically the above issue, using the literature from 1974 to 1989 to see whether there is support for the underlying changes in cognitive processes that are assumed to mediate the therapy. The results show that while CBT is relatively effective in treating some childhood disorders, there is little empirical evidence to support the underlying cognitive models of childhood disorders.

A Vygotskian critique of self-instructional training

Self-instructional training, a widely used intervention for treating the learning and behavioral difficulties of impulsive, attention deficit-hyperactivity disordered, and learning disabled children, has repeatedly failed to promote self-control or improve academic performance. In light of this failure, we critically examine four assumptions underlying self-instructional training: (a) children with learning and behavior problems show a lack and/or deficient use of self-regulatory private speech; (b) modeling of self-verbalizations will increase children's spontaneous production of private speech; (c) speech and action are intrinsically coordinated; and (d) internalization refers to subvocalization of private speech. We argue that self-instructional training interventions need to be thoroughly grounded in Soviet developmental theory of verbal self-regulation and in systematic research on the social origins and development of children's private speech. A new research agenda is suggested.

Review of cognitive, cognitive-behavioral, and neural-based interventions for Attention-Deficit/Hyperactivity Disorder (ADHD)

Primary evidence-based treatment approaches for ADHD involve pharmacological and behavioral treatments. However, there continue to be investigations of cognitive-behavioral, cognitive, and neural-based intervention approaches that are not considered evidence-based practice. These particular treatments are summarized, as they all involve training in cognitive skills or cognitive strategies. We identified 26 studies (six cognitive-behavioral, six cognitive, and 14 neural-based), and calculated effect sizes where appropriate. Overall, our analysis suggests that further research is needed to determine the efficacy of these approaches on both cognitive and behavioral outcome measures, but that some of these methods show promise for treating ADHD. We discuss some important conceptual and methodological issues that need to be taken into account for future research in order to evaluate the clinical efficacy of these approaches.

Testing effectiveness of a community-based aggression management program for children 7 to 11 years old and their families

OBJECTIVE

There are few well-evaluated uncomplicated community-based interventions for childhood aggression. The authors assess the impact of a community-based anger management group on child aggressive behaviors, using a randomized, controlled trial (RCT).

METHOD

Families with children 7 to 11 years old were recruited through advertisements and randomized (N = 123). Inclusion required parent concern about anger/aggressive behavior, RCT agreement, and a telephone behavior screen. Intervention participants were offered three parent education/skill-building group sessions, 10 weekly child group sessions, and three in-home family practice sessions. Nine groups ran from August 2002 to August 2004. Interviewers naïve to randomization collected data on all participants pre- and postgroup. Outcomes included child-rated anger and parent-rated child aggressive behavior, externalizing behavior and hostility, parent-child relationship, and parenting stress. Intent-to-treat analyses were done.

RESULTS

Pre/postoutcome comparisons indicated no significant differences between intervention versus control, with small effect sizes for most outcomes (0.27-0.29). Although not significant, the magnitude of improvement favored intervention families on all parent-rated measures.

CONCLUSIONS

Overall, there was no differential impact of participating in a community-based anger management group versus control on child aggressive behaviors and other associated measures. The impact of regression to the mean, effect, and sample size estimates; child comorbidity; and programmatic and methodological issues are discussed.

Electroencephalographic biofeedback in the treatment of attention-deficit/hyperactivity disorder

Historically, pharmacological treatments for attention-deficit/hyperactivity disorder (ADHD) have been considered to be the only type of interventions effective for reducing the core symptoms of this condition. However, during the past three decades, a series of case and controlled group studies examining the effects of EEG biofeedback have reported improved attention and behavioral control, increased cortical activation on quantitative electroencephalographic examination, and gains on tests of intelligence and academic achievement in response to this type of treatment. This review paper critically examines the empirical evidence, applying the efficacy guidelines jointly established by the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal Regulation (ISNR). On the basis of these scientific principles, EEG biofeedback was determined to be "probably efficacious" for the treatment of ADHD. Although significant clinical improvement was reported in approximately 75% of the patients in each of the published research studies, additional randomized, controlled group studies are needed in order to provide a better estimate of the percentage of patients with ADHD who will demonstrate such gains in clinical practice.

Attention deficit hyperactivity disorder and borderline personality disorder

To evaluate the association between attention deficit hyperactivity disorder (ADHD) and the diagnosis of borderline personality disorder (BPD) in adulthood, a systematic review of published follow-up data, mainly from observational studies was done. Electronic databases Medline, PsychInfo and PSYNDEXplus were searched from their earliest entries. All studies suggested significant relationships between ADHD and BPD. From a phenomenological point of view there seem to exist some similarities between these two disorders: deficits in affect regulation and impulse control, substance abuse, low self esteem and disturbed interpersonal relationship are common in both conditions. From a neuropsychological point of view dissociation in BPD might be regarded as a special form of behavioral inhibition and sustained attention comparable to ADHD. Possible therapeutic strategies of comorbid ADHD and BPD are discussed.

Academic achievement and emotional status of children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment

OBJECTIVE

To test the hypothesis that intensive multimodal psychosocial intervention (that includes academic assistance and psychotherapy) combined with methylphenidate significantly enhances the academic performance and emotional status of children with attention-deficit/hyperactivity disorder (ADHD) compared with methylphenidate alone and with methylphenidate combined with nonspecific psychosocial treatment (attention control).

METHOD

One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate were randomized for 2 years to receive one of three treatments: (1) methylphenidate alone, (2) methylphenidate plus psychosocial treatment that included academic remediation, organizational skills training, and psychotherapy as well as parent training and counseling and social skills training, or (3) methylphenidate plus attention control treatment. Children's function was assessed through academic testing, parent ratings of homework problems, and self-ratings of depression and self-esteem.

RESULTS

No advantage was found on any measure of academic performance or emotional status for the combination treatment over methylphenidate alone and over methylphenidate plus attention control. Significant improvement occurred across all treatments and was maintained over 2 years.

CONCLUSIONS

In stimulant-responsive young children with ADHD without learning and conduct disorders, there is no support for academic assistance and psychotherapy to enhance academic achievement or emotional adjustment. Significant short-term improvements were maintained over 2 years.

Design and rationale of controlled study of long-term methylphenidate and multimodal psychosocial treatment in children with ADHD

OBJECTIVE

To describe the rationale, methodology, and sample characteristics of a dual-site treatment study (New York and Montreal) of children with attention-deficit/hyperactivity disorder (ADHD) conducted between 1990 and 1995. The hypotheses were that (1) methylphenidate combined with comprehensive multimodal psychosocial treatment was superior to methylphenidate alone in improving multiple functions and (2) the efficacy of the psychosocial intervention resulted from its specific components and not from nonspecific treatment effects.

METHOD

One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to methylphenidate, were randomized for 2 years to (1) methylphenidate treatment alone; (2) methylphenidate combined with multimodal psychosocial treatment that included parent training and counseling, academic assistance, psychotherapy, and social skills training; or (3) methylphenidate plus attention control treatment that excluded specific aspects of the psychosocial intervention. Children were switched to single-blind placebo after 12 months; methylphenidate was reinstituted when clinically indicated. Assessments included ratings by parents, teachers, children, and psychiatrists; school observations in academic and gym classes; and academic performance tests. Almost 80% of families completed the 2-year study. Companion papers present treatment effects.

CONCLUSIONS

A comprehensive 2-year psychosocial treatment was delivered successfully to children with ADHD and their families.

International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions

Researchers and clinicians worldwide share concerns that many youngsters with attention-deficit/hyperactivity disorder (ADHD) and/or disruptive behaviour disorders (DBDs) do not receive appropriate treatment despite availability of effective therapies. At the request of Johnson and Johnson (sponsor), 11 international experts in child and adolescent psychiatry were selected by Professor Stan Kutcher (chair) to address these concerns. This paper describes the experts' consensus conclusions, including treatment practice suggestions for physicians involved in the early treatment of youngsters with ADHD (or hyperkinetic disorder, in countries preferring this classification) and/or DBDs internationally: suggested first-line treatment for ADHD without comorbidity is psychostimulant medication aided by psychosocial intervention. For ADHD with comorbid conduct disorder (CD), psychosocial intervention combined with pharmacotherapy is suggested. For primary CD, suggested first-line treatment is psychosocial intervention, with pharmacotherapy considered as an 'add-on' when aggression/impulsivity is marked and persistent. Pharmacotherapy requires careful titration; full-day coverage is the suggested goal. Regular long-term follow-up is recommended.

Review of the evidence base for treatment of childhood psychopathology: externalizing disorders

This article reviews controlled research on treatments for childhood externalizing behavior disorders. The review is organized around 2 subsets of such disorders: disruptive behavior disorders (i.e., conduct disorder, oppositional defiant disorder) and attention-deficit/hyperactivity disorder (ADHD). The review was based on a literature review of nonresidential treatments for youths ages 6-12. The pool of studies for this age group was limited, but results suggest positive outcomes for a variety of interventions (particularly parent training and community-based interventions for disruptive behavior disorders and medication for ADHD). The review also highlights the need for additional research examining effectiveness of treatments for this age range and strategies to enhance the implementation of effective practices.

An intervention approach for children with teacher- and parent-identified attentional difficulties

Using a multimodal and multi-informant method for diagnosis, we selected 33 children by teacher and parent nomination for attention and work completion problems that met DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD). Of the 33 children in this group, 21 participated in the initial intervention, and 12 were placed in an ADHD control group and received the intervention after pre- and posttesting. A similarly selected group of 21 children without difficulties in attention and work completion served as a control group. Each child was assessed on pre- and posttest measures of visual and auditory attention. After an 18-week intervention period that included attention and problem-solving training, all children in the intervention and control groups were retested on visual and auditory tasks. Children in both ADHD groups showed significantly poorer initial performance on the visual attention task. Whereas the ADHD intervention group showed commensurate performance to the nondisabled control group after training, the ADHD control group did not show significant improvement over the same period. Auditory attention was poorer compared to the control group for both ADHD groups initially and improved only for the ADHD intervention group. These findings are discussed as a possible intervention for children with difficulties in strategy selection in a classroom setting.

Empirically supported psychosocial treatments for attention deficit hyperactivity disorder

Reviews and evaluates psychosocial treatments for attention deficit hyperactivity disorder (ADHD) in children and adolescents according to Task Force Criteria (Lonigan, Elbert, & Johnson, this issue). It is concluded that behavioral parent training and behavioral interventions in the classroom meet criteria for well-established treatments. Cognitive interventions do not meet criteria for well-established or probably efficacious treatments. Issues regarding the evaluative process are discussed and future directions for psychosocial treatment for ADHD are outlined.

Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children, adolescents, and adults with attention-deficit/hyperactivity disorder (ADHD). There are three types of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Together, they occur in as many as 10% of boys and 5% of girls of elementary school age. Prevalence declines with age, although up to 65% of hyperactive children are still symptomatic as adults. Frequency in adults is estimated to be 2% to 7%. Assessment includes clinical interviews and standardized rating scales from parents and teachers. Testing of intelligence and academic achievement usually are required. Comorbidity is common. The cornerstones of treatment are support and education of parents, appropriate school placement, and pharmacology. The primary medications are psychostimulants, but antidepressants and alpha-adrenergic agonists are used in special circumstances. Other treatments such as behavior modification, school consultation, family therapy, and group therapy address remaining symptoms.

NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale

OBJECTIVE

The National Institute of Mental Health's recently initiated 5-year, multisite, multimodal treatment study of children with attention-deficit hyperactivity disorder (MTA) is the first major clinical trial in its history focused on a childhood mental disorder. This article reviews the major scientific and clinical bases for initiating the MTA.

METHOD

A selective review of the literature is presented in the service of describing the estimated prevalence of ADHD among children and adolescents, its core clinical features, evidence concerning psychopharmacological and psychosocial treatment effects, and related research issues and trends leading to the development of the MTA.

RESULTS

Despite decades of treatment research and clinical practice, there is an insufficient basis for answering the following manifold question: under what circumstances and with what child characteristics (comorbid conditions, gender, family history, home environment, age, nutritional/metabolic status, etc.) do which treatments or combinations of treatment (stimulants, behavior therapy, parent training, school-based intervention) have what impacts (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, neurophysiological, neuropsychological, peer relations, family relations), for how long (short versus long term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)?

CONCLUSIONS

The important scientific, clinical, and public health issues nested within this manifold question provide both the impetus and scaffolding for the MTA.

Childhood hyperactivity and psychostimulants: a review of extended treatment studies

ABSTRACT Clinical trials with a treatment duration of at least 3 months were reviewed to determine the effect of psychostimulants on the core symptoms of attention-deficit hyperactivity disorder (ADHD) and on its commonly associated features. Eighteen studies were identified: 17 were studies of methylphenidate, 1 was a study of dextroamphetamine, and none involved pemoline or slow-release stimulants. Eleven of these studies were randomized controlled trials, whereas seven employed quasi-experimental designs without randomization. The results of randomized controlled trials showed that psychostimulants provided greater benefit than did the nonrandomized trials, suggesting that the efficacy of extended treatment may have been underestimated because more seriously disturbed children were assigned to medication treatment than to control treatments in nonrandomized trials. Evidence from the more definitive randomized controlled trials indicates that stimulants are more effective in ameliorating the core behavioral symptoms of ADHD (restlessness, inattentiveness, impulsiveness) than placebos, nonpharmacological therapies, or no treatment-at least in 3-7-month trials. During extended psychostimulant treatment, few children become symptom-free, clinical effects may diminish with time, and improvement dissipates rapidly upon discontinuation of medication. There is minimal evidence that extended stimulant treatment improves cognitive deficits or associated problems such as conduct disturbance, low self-esteem, poor peer relationships, or academic underachievement. The belief that stimulants do not improve the long-term prognosis of children with ADHD may be based on weakly designed studies that focus on associated rather than core symptoms. A failure to assign patients of similar clinical severity to different treatment conditions may also have contributed to obscuring the efficacy of extended psychostimulant treatments.

Self-management therapies and attention-deficit hyperactivity disorder. Reinforced self-evaluation and anger control interventions

The lack of sufficiency of the primary treatment modalities for children with Attention-Deficit Hyperactivity Disorder (ADHD)-operant behaviormodification procedures and psychostimulant medications-have prompted exploration of cognitive-behavioral self-management treatments as altematives or adjuncts. Although self-instructional treatments are not adequate interventions for such children, reinforcement-and rehearsal-based behavioral interventions can be combined with self-management approaches to supplement and extend the gains induced by behavioral procedures. After presenting background material regarding cognitive-behavioral treatments for ADHD, we present case material related to multimodality treatment, with focus on training in anger management and self-evaluation skills. We argue against unsubstantiated claims for the efficacy of cognitive-behavioral interventions but contend that, when combined with pharnacologic and behavioral approaches, self-management procedures deserve consideration for the difficult social and behavioral problems of ADHD children.

Pediatric psychopharmacotherapy: a review of recent research

In the past 5 years, we have witnessed the continuation of important trends in clinical research that began earlier in the decade. With regard to the treatment of specific disorders in children and adolescents, the most significant developments have been the examination of the tricyclics for the treatment of depression and the initiation of controlled studies for the treatment of Tourette syndrome. Unfortunately, the findings from the depression studies have been uniformly negative, and the results of research on both depression and tic disorders show a relatively high rate of placebo responsivity, which raises nagging questions about the role of case reports and open trials. Another important trend in pediatric psychopharmacotherapy is the search for substitutes for the neuroleptics. Potential candidates include agents such as lithium, naltrexone, fenfluramine, clonidine, and carbamazepine. The most underresearched disorders are a combination of the least common (e.g. schizophrenia, mania) and those that are apparently perceived as less serious (e.g. sleep disorders, certain anxiety disorders). Not surprisingly, the most studied disorder and treatment is hyperactivity and stimulant medication, respectively. Considerable progress has been made in understanding the social implications of the associated symptoms and their response to stimulant drugs, aided greatly by the use of direct observation procedures. Researchers are beginning to attend to the implications of comorbidity for assessing response to medication. There has been additional confirmation of efficacy of stimulant treatment for preschoolers and adolescents. Dose-response issues remain to some extent unresolved, the primary impediments being interpretive misconceptions associated with trend analysis, an overreliance on the syndromal perspective and too little attention to target behaviors and their clinical implications, and the failure to operationalize the minimal effective dose with regard to the normalization and supranormalization of target and collateral behaviors. Disagreement over whether hyperactivity is a learning or a behavior disorder (or both) and what academic underproductivity means clinically and socially is also impeding progress. With regard to developmental disorders, controlled studies indicate that fenfluramine and naltrexone are effective for managing associated symptoms in some individuals. However, given the limited amount of research on these agents, their status as clinically useful palliatives must be considered tentative.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of two treatment techniques on delay and vigilance tasks with attention deficit hyperactive disorder (ADHD) children

In this study, we examined the effects of two treatment techniques under on-medication and off-medication conditions on the hyperactive behavior patterns of children. Three groups of subjects were compared: a control group, a behavior modification group, and a cognitive training group. The Gordon Diagnostic System (Gordon, McClure, & Post, 1986) was used to assess the subjects at the initial screening, during treatment without medication, and during treatment with medication. The two medication conditions were counterbalanced during the second and third testing sessions. Results showed that when the cognitive intervention was combined with medication, there was a significant improvement in the subjects' ability to delay impulsive responding. However, no significant effects were seen for sustained vigilance for either the behavioral or cognitive groups. Parents rated children in the cognitive group significantly higher than those in the control group.

Study strategies and story recall in attention deficit disorder and reading disability

The role of metacognition and executive processes in mediating use of study skills was examined in groups of attention deficit disorder with hyperactivity (ADD-H), normal, and non-ADD-H reading-disabled (RD) boys, matched on age and verbal IQ. On a story recall task, ADD-H boys did not differ from normals in their immediate gist recall of a story or in their recall following a study period. RD boys demonstrated inferior recall in both conditions. Study skills of the ADD-H boys were poorer than those of normal boys on all measures. They spent less time studying, expended less effort, and employed more superficial strategies. However, their poor strategies did not appear to reflect a lack of metacognitive awareness. Results are discussed in terms of the impact of motivational variables in modulating strategy use in ADD-H boys and the impact of verbal processing problems in reading disabilities. Implications for treatment and the relationship between ADD-H and RD are discussed.

Development and functional significance of private speech among attention-deficit hyperactivity disordered and normal boys

We compared the development of spontaneous private speech and its relationship to self-controlled behavior in a sample of 6- to 12-year-olds with attention-deficit hyperactivity disorder (ADHD) and matched normal controls. Thirty-eight boys were observed in their classrooms while engaged in math seatwork. Results revealed that ADHD children were delayed in private speech development in that they engaged in more externalized, self-fuiding and less inaudible, internalized speech than normal youngsters. Several findings suggest that the developmental lag was a consequence of a highly unmanageable attentional system that prevents ADHD children's private speech from gaining efficient mastery over behavior. First, self-guiding speech was associated with greater attentional focus only among the least distractible ADHD boys. Second, the most mature, internalized speech forms were correlated with self-stimulating behavior for ADHD subjects but not for controls. Third, observations of ADHD children both on and off stimulant medication indicated that reducing their symptoms substantially increased the maturity of private speech and its association with motor quiescence and attention to task. Results suggest that the Vygotskian hypothesis of a unidirectional path of influence from private speech to self-controlled behavior should be expanded into a bidirectional model. These findings may also shed light on why treatment programs that train children with attentional deficits in speech-to-self have shown limited efficacy.