A 5-year follow-up study of 91 hyperactive school children

Review: Adult Outcome as Seen Through Controlled Prospective Follow-up Studies of Children With Attention-Deficit/Hyperactivity Disorder Followed Into Adulthood

OBJECTIVE

To describe adult outcome of people with attention-deficit/hyperactivity disorder (ADHD) diagnosed in childhood and its several key predictors via a review of 7 North American controlled prospective follow-up studies: Montreal, New York, Milwaukee, Pittsburgh, Massachusetts General Hospital (MGH), Berkeley, and 7-site Multimodal Treatment Study of Children With ADHD (MTA).

METHOD

All studies were prospective and followed children with a diagnosis of ADHD and an age- and gender-matched control group at regular intervals from childhood (6-12 years of age) through adolescence into adulthood (20-40 years of age), evaluating symptom and syndrome persistence, functional outcomes, and predictors of these outcomes.

RESULTS

The rates of ADHD syndrome persistence ranged from 5.7% to 77%, likely owing to varying diagnostic criteria and the source of information (self-report vs informant report) across the studies. However, all studies observed high rates of symptomatic persistence ranging from 60% to 86%. The 7 studies were largely consistent in finding that relative to control groups, research participants with childhood-diagnosed ADHD had significant impairments in the areas of educational functioning, occupational functioning, mental health, and physical health as well as higher rates of substance misuse, antisocial behavior, and unsafe driving. The most consistently observed predictors of functional outcomes included ADHD persistence and comorbidity, especially with disruptive behavior disorders.

CONCLUSION

Childhood ADHD has high rates of symptomatic persistence, which is associated with negative functional outcomes. Characteristics that predict these negative outcomes, such as comorbid disruptive behavior disorders, may be important targets for intervention.

Attention Deficit-Hyperactivity Disorder

Attention deficit-hyperactivity disorder (ADHD) is a common problem among school-aged children wherein a student exhibits significant difficulties with attention span, impulse control and activity level. Since children with ADHD often display these symptoms on a chronic basis resulting in impaired behavior control and academic productivity, the classroom environment must be modified to enhance their adjustment. Several contingency management procedures for teacher use are briefly discussed in this paper including token reinforcement programs, contingency contracting, response cost, time-out from positive reinforcement and home-based contingency management programs. When used in conjunction with other treatment modalities (e.g. stimulant medication, parent training in behavior modification), these classroom intervention strategies often lead to significant improvements in on-task behavior, work completion, behavioral control and accuracy on academic assignments.

Treatment of a 7-Year-Old Hyperactive Boy with Educational Problems

A 7-year-old hyperactive boy with multiple problems was treated using a combination of interventions, applied sequentially over 14 months. The first phase of treatment was participation in a drug trial (placebo, then drug) and this was followed by cognitive-behavioural training designed to teach strategies with which to approach academic work. Teacher and parent behaviour ratings showed improvement over the drug trial period and educational gains were made during the cognitive-behavioural training, both in the area specifically taught and other academic subjects. The problems choosing appropriate targets and of disentangling the effects of different treatment components are discussed.

Attention-deficit/hyperactivity disorder: an overview of the etiology and a review of the literature relating to the correlates and lifecourse outcomes for men and women

This paper provides a summary of the current conceptualization of what AD/HD is, and its etiology, and then reviews some of the recent literature on the correlates and lifecourse outcomes for individuals diagnosed with Attention-Deficit/Hyperactivity Disorder (AD/HD). The intention is to synthesize that which is known, and to identify important gaps in the literature and knowledge base, which secondary analysis of prospective large-scale longitudinal cohorts, tracking individuals from birth to adulthood, could help to fill. This review highlights the fact that such datasets are rare and that their analysis offers important opportunities for advancing knowledge, particularly of the adult outcomes of childhood AD/HD.

Developmental course of ADHD symptomatology during the transition from childhood to adolescence: a review with recommendations

Although historically conceptualized as a disorder that was limited to males during middle childhood, ADHD is currently conceptualized as a chronic disorder that persists into adolescence and adulthood for both sexes. Nonetheless, the veracity of adult ADHD continues to be the source of debate. In order to frame this debate, research leading to the conceptualization of ADHD as a chronic disorder is reviewed. A distinction is made between the developmental outcomes versus the developmental course of ADHD. It is concluded that although childhood ADHD is associated with negative developmental outcomes in adolescence and adulthood, questions about the developmental course of ADHD remain. Although it appears that ADHD diminishes with advancing age, a number of methodological limitations prohibit firm conclusions. Recommendations for future studies are made with an emphasis on 1) overcoming extant methodological limitations in the literature and 2) the need for theoretically derived hypotheses regarding continuity and change in ADHD symptomatology over time.

Predictors of long-term outcome in children with attention-deficit/hyperactivity disorder

In determining the influence of various factors on outcome, one must keep in mind that these parameters do not act alone but probably exert their influence in a cumulative and interactive manner. Thus, characteristics of the child such as severity of symptoms, comorbidity, and IQ interact with family parameters such as parental pathology, socioeconomic status, family adversity, and treatment to influence long-term outcome. Some of these variables (e.g., comorbid CD, low IQ, parental pathology) have been important in influencing negative outcome. Treatment, particularly stimulant treatment, has been shown to be effective in many short-term studies, but the long-term impact of treatment remains uncertain. The continuation of treatment may be crucial in influencing positive long-term outcome. Particular treatment modalities or combinations (e.g., multimodal treatment) may be required for specific patient subgroups (e.g., subjects comorbid for LD, CD, or anxiety; subjects with low socioeconomic status or high parental pathology). Research in the area continues to evolve. New findings hopefully will continue to improve both the quality of life for patients and families and positive influence of long-term outcome.

Educational and occupational outcome of hyperactive boys grown up

OBJECTIVE

Little is known about the adult outcome of attention-deficit hyperactivity disorder (ADHD), a very prevalent childhood disorder that is known to affect deleteriously academic performance and other areas of child functioning. This study represents a third wave of evaluations that examine the long-term educational achievement and occupational rank of children with ADHD.

METHOD

This is a prospective follow-up of white boys of average intelligence whose ADHD was clinically diagnosed according to systematic criteria at an average age of 7 years. Follow-up intervals range from 15 to 21 years (mean, 17 years). At average age 24 years, 85 probands (representing 82% of the childhood cohort) and 73 controls (84%) were directly interviewed by trained clinicians who were blind to group membership.

RESULTS

First, probands completed significantly less formal schooling than controls (about 2 years less, on average). Second, probands had lower-ranking occupational positions than controls. Finally, these disadvantages were not accounted for by adult mental status.

CONCLUSIONS

The present study suggests that childhood ADHD predisposes to specific disadvantages and continues to affect important functional domains unrelated to current psychiatric diagnosis.

Developmental change in attention-deficit hyperactivity disorder in boys: a four-year longitudinal study

One hundred six clinic-referred boys meeting criteria for DSM-III-R attention-deficit hyperactivity disorder (ADHD) (mean age 9.4 years) were assessed annually for 4 years using structured interviews of multiple informants. Hyperactivity-impulsivity symptoms declined with increasing age, but inattention symptoms did not. Rather, inattention declined only from the first to the second assessment and remained stable thereafter in boys of all ages. The rate of decline in hyperactivity-impulsivity symptoms was independent of the amount and type of treatment received. Boys who still met criteria for ADHD in Years 3 and 4 were significantly younger, more hyperactive-impulsive, and more likely to exhibit conduct disorder in Year 1 than boys who no longer met criteria in Years 3 and 4.

Correlates of family functioning when a child has attention deficit disorder

The purpose of this study was to examine the relationship among selected demographic and psychosocial family characteristics and family functioning and to identify which combination of variables best predicts family functioning when a child has attention deficit disorder. Seventy-six mothers and 47 fathers from 79 families participated in the study. The target child had been previously diagnosed with attention deficit disorder either with or without hyperactivity and aggressive symptoms. A significant correlation between family functioning and age of the hyperactive child was supported. Families of older children reported poorer functioning, and parenting competence was negatively related to parental perception of the child's behavior. Older age of the child in combination with higher levels of impulsivity/hyperactivity were significant in predicting family functioning.

The stability of dimensions of behavior in ADHD and normal children over an 8-year followup

The present study reports on standardized behavioral ratings received by a large sample of hyperactive children meeting research diagnostic criteria (n = 108) and a community control sample of normal children (n = 61) who were followed prospectively over 8 years into adolescence. On some parent-report measures both groups declined in the severity of their behavior problems across time, while on other measures only the hyperactive group declined, but the hyperactives always remained more deviant than the controls at followup. The hyperactives and controls also differed on most teacher and self-report ratings at followup. The greatest degree of agreement between raters at adolescence was between parent and youth ratings. These results are consistent with previous research demonstrating more deviant scores for hyperactive children than controls on various rating scales at adolescent followup. They also are consistent with research showing significant longitudinal continuity of both internalizing and externalizing behavioral pathology.

Effects of methylphenidate on impulsive responding in children with attention-deficit hyperactivity disorder

The present investigation examined the effects of methylphenidate on impulsivity in children with attention-deficit hyperactivity disorder (ADHD). A task was designed to measure empirically the ADHD child's proclivity to blurt out incorrect answers before giving a final and/or correct response. Twenty-six ADHD children referred for double-blind placebo-controlled assessment of medication responsiveness and 14 non-ADHD controls were given a visual search word-matching task to assess impulsive responding. An analysis of covariance showed that ADHD children on methylphenidate made fewer impulsive errors than ADHD children on placebo. The control group made fewer impulsive errors than the ADHD children in the placebo condition, but the performance of the ADHD children on medication approximated the performance of the children without ADHD. These preliminary findings suggest that the word-matching task may be a useful tool for assessing impulsive responding and determining the benefits of stimulant medication on impulsivity.

Family functioning as perceived by parents of boys with attention deficit disorder

The purpose of this study was to describe adaptability, cohesion, and family type in families of boys with attention deficit disorder. Comparisons were made across diagnostic groups for boys with and without hyperactivity and aggressive symptoms. Parents (N = 123) of 79 boys with attention deficit disorder (ADD), attention deficit hyperactivity disorder and attention deficit hyperactivity disorder plus aggressive symptoms participated in the study. The families were not significantly different in their functioning when compared to family norms established by Olson, Portner, and Lavee (1985). There were, however, significant differences in functioning across diagnostic categories. Parents of boys with ADD only, without the additional problem of hyperactivity or aggressive symptoms, reported the highest level of family functioning, and a larger percentage of parents whose child had hyperactivity or hyperactivity plus aggression reported extreme family functioning.

Long-term outcome of hyperactive children: a review

Reports of adolescent outcome in attention deficit hyperactivity disorder have uniformly indicated high rates of behavioral problems including cognitive impairment. Dysfunction is markedly reduced in adulthood, but the pattern of outcome remains unchanged except for failure to document cognitive deficits. In adulthood, dysfunction is characterized by antisocial personality and substance (nonalcohol) use disorders. These are in turn associated with criminality. The little existing information on girls with attention deficit hyperactivity disorder does not suggest a worse outcome than for boys. Attempts to identify the children most likely to have a poor outcome have been largely unsuccessful.

Attention deficit disorder with hyperactivity among paediatric outpatients

Out of 1,000 children (aged 3-12 years) screened in a paediatric outpatient department over a 3 1/2-year period, 112 were found to have attention deficit disorder with hyperactivity (ADDH). The prevalence of ADDH increased with age, from 5.2% in those aged 3-4 years, up to 29.2% in those aged 11-12 years. There were four times as many boys as girls with ADDH. ADDH was most common in first born children and those from a lower social class. Children with ADDH had a higher rate of complications during pregnancy and delivery relative to a comparison group. Delayed development, temper-tantrums, enuresis, tics, broken homes, persistent parental discord and psychiatric illness in parents were all more common in children with ADDH than in the comparison group.

A twin study of hyperactivity--I. An examination of hyperactivity scores and categories derived from Rutter teacher and parent questionnaires

In a representative sample of 570 13-yr-old twins, higher hyperactivity scores from parent and teacher ratings were associated with male sex, lower intelligence, inattention, specific learning problems, and behavioural deviance (mainly antisocial). This pattern of correlates also characterized all three hyperactivity categories: to a marked degree in pervasive hyperactivity; less markedly in school hyperactivity; and least markedly in home hyperactivity. Children with pervasive hyperactivity had more attentional and educational problems than non-hyperactive children who were pervasively antisocial. By contrast, children with school or home hyperactivity resembled non-hyperactive children who were situationally antisocial. These findings cast doubt on the validity of combining situational and pervasive hyperactivity into a single diagnostic category such as Attentional Deficit Disorder with Hyperactivity (ADDH).

Two subgroups of hyperactives as adults: correlations of outcome

This prospective study explored the association of continuing symptoms of the hyperactive syndrome with adult outcome. A fifteen year follow-up compared 61 hyperactive subjects and 41 matched controls. Outcome measures examined included continuing symptoms of the hyperactive syndrome, antisocial behaviour, substance use, and emotional difficulties. Two subgroups of the hyperactive population were identified. Those hyperactive subjects with moderate or severe continuing symptoms were characterized by significant emotional difficulties, alcohol use, and antisocial behaviour. By contrast, hyperactive subjects with none or only mild continuing symptoms at follow-up did not have other difficulties in psychosocial functioning, and were, in addition, similar to the control group in many respects. The importance of continuing symptoms in determining the adult outcome of children with a diagnosis of ADDH is discussed. Accordingly, the need for comprehensive early, and ongoing interventions is emphasized.

Assessing and treating attention deficit disorder in adolescents. The clinical application of a single-case research design

Psychiatric assessment strategies that integrate research findings with daily practice are necessary and clinically useful. This paper uses the example of an attention deficit disordered adolescent to illustrate how double-blind placebo controlled and multi-dose adjustment designs can be successfully implemented in routine clinical practice. These designs are especially valuable in evaluating the therapeutic effect of methylphenidate because of biases that may lead to clinical misuse of this stimulant medication.

Controlled prospective fifteen year follow-up of hyperactives as adults: non-medical drug and alcohol use and anti-social behaviour

This is a fifteen year prospective controlled study of the non-medical drug and alcohol use and antisocial behaviour of 61 hyperactives, and 41 matched control subjects, (mean age 25 years). The data was collected from detailed interviews with the subjects as well as computerized court records to verify subjects reports. Generally hyperactives did not differ significantly from controls on current drug and alcohol use and antisocial behaviour. However one sees trends of greater drug alcohol and antisocial involvement in the hyperactive group. All the subjects who have antisocial behaviour at 15 year follow-up (mean age 25) had early and persistent histories of antisocial behaviour beginning at initial assessment (mean age 8) or at 5 year follow-up (mean age 13). However many hyperactives do not continue their antisocial behaviour into adulthood (mean age 25). There thus appears to be a small subgroup of hyperactive subjects who have more negative outcomes with significantly greater social, emotional and psychological difficulties. It is this subgroup which we need to identify early and treat vigorously.

Attention and impulsivity characteristics of the biological and adoptive parents of hyperactive and normal control children

On tests comparing 176 biological and adoptive parents of hyperactive and normal control children, biological parents of hyperactives evidenced more attentional difficulties, slower mean reaction times, and fewer correct recognitions than did the other parents. They showed no significant differences in impulsivity. A familial association between childhood hyperactivity and attentional deficits in the biological parents was suggested, as was the persistence of attentional difficulties as compared to impulse control problems.

Factors which predict the persistence of aggressive conduct disorder

Fifty-three boys with aggressive conduct disorder were followed up 2 years after their original examination. Twenty-four (45%) no longer had the disorder and were classified as improved. A discriminant function analysis identified characteristics of the boys and their families which accurately predicted the outcome for 85% of the boys. Among the predictors of persisting conduct disorder were a variety of antisocial or aggressive symptoms, firesetting, early age of onset and family deviance.

Stimulant medications in adults with attention deficit disorder

The long-term prospective studies done in the last two decades on children suffering from attention deficit disorder with hyperactivity (ADD-H) give evidence of persistent disability in a majority of them when they reach adulthood. The literature on the use of stimulant medication in adults suffering from attention deficit disorder, residual type (ADD-R), is critically reviewed. After optimistic case reports two controlled double-blind studies have recently showed contradictory results. Some adults appear clearly to be helped by stimulant medication, but more investigations, especially with children diagnosed in childhood and followed-up, are needed before any firm conclusion can be made about the usefulness or non-usefulness of stimulants in ADD-R. There, as it is the case in childhood, medication might be insufficient by itself and might have to be associated with other forms of treatment.

Hyperactives as young adults: past and current substance abuse and antisocial behavior

In a ten-year prospective follow-up study, young adults who had been diagnosed as hyperactive in childhood were found to have had greater involvement with alcohol and drug use and with courts and police than did matched controls during the five years preceding evaluation. However, differences between groups were generally not significant in the year prior to evaluation, and tests indicate that they had attained similar levels of moral development. Results suggest a more encouraging adult outcome than has previously been expected for hyperactive children.

Hyperactivity: nature of the syndrome and its natural history

The composition of hyperactivity as a syndrome is discussed from a historical perspective, and the principal events leading to the recent emphasis on attentional characteristics of hyperactive children are summarized. Some of the major challenges to the legitimacy of hyperactivity as a valid syndrome are set forth, and after critical examination of the most influential work, it is concluded that hyperactivity has not been disproved. This is followed by a survey of the large follow-up literature dealing with the natural history of children diagnosed as hyperactive. It is noted that the manifestations of the syndrome appear to change with age but there is little indication that problems simply remit with maturity. The evidence indicates that hyperactivity, as diagnosed in the past, is often a serious disorder with long-term and far-reaching consequences for the children and their families. Multivariate studies are also discussed, as they have important implications for differential outcome. Different symptoms such as aggression, overactivity, and learning disability appear to contain unique information about current and future status, and therefore it appears useful to retain these distinctions rather than view such children as part of an undifferentiated group. It is unknown whether the recent guidelines for diagnosing Attention Deficit Disorder with Hyperactivity will alter or refine the outlook for children so identified, but this is an active area of research at present.

An analysis of attentional components in hyperactive and normal boys

Attentional performance was examined in hyperactive and normal 10 and 14 yearold boys. The children participating in the present study were administered a series of measures hypothesized to test three components of attention: coming to attention, decision making, and sustaining attention to a task over time. Multivariate analyses followed by univariate tests indicated that both age groups of normal children were superior to hyperactive children in attentional performance while hyperactive adolescents demonstrated significant improvement with age only in the area of coming to attention. Findings were interpreted to suggest that while activity levels of hyperactive children may diminish at adolescence, hyperactive adolescents still continue to be impulsive and impaired in attention. Correlational analyses yielded low but statistically significant relationships among the attentional measures, but no significant relationships between IQ and the attention test scores. Findings were consistent with the interpretation that the three hypothesized components of attention are independent of intelligence.

Contribution of predispositional factors to the diagnosis of hyperactivity

Hyperactivity is a complex childhood problem and may represent several groups or syndromes, each with its own etiological patterns. This paper presents results of analyses indicating that, although biological and demographic factors may predispose children to being identified and treated as hyperactive, the major contributions to the condition are early manifestations of temperament and the quality of the family's interaction with the child.

Long-term outcome of hyperactive children

A review of outcome studies of hyperactive children suggests that they experience significant academic, social, and conduct difficulties during adolescence, and that social, emotional, and impulse problems persist into young adulthood for the majority. While some hyperactive children were found to be functioning normally as adults, a troublesome minority were experiencing severe psychiatric or antisocial problems.

The child with school problems: an analysis of physician participation

Pediatric participation in the care of children with learning disorders and related problems is undergoing considerable growth. Physicians, to varying degrees, are increasingly involved in diagnostic formulation, collaborative intervention, and advocacy. The traditional role was a limited one. There is now a greater emphasis on family assessments, neurodevelopmental examination, medical treatments, counseling, actual collaboration, and independent evaluation. A number of political, educational, economic, and logistic questions regarding these activities remain problematic and, as yet, unanswered.

A four-year follow-up study of the effects of methylphenidate on the behavior and academic achievement of hyperactive children

Sixty-two children were evaluated 4 years after their initial referral for symptoms of hyperactivity. Behavioral measures included parent and teacher judgments of behavior and social adjustment. Academic achievement was assessed by teachers' reports, number of failed grades, special education services, and two individually administered achievement tests. Data were analyzed for the total group to determine both the extent to which presenting problems diminished over time and the major problems still present. The effects of stimulant drug therapy on outcome were assessed by dividing the children into groups according to the duration of time they had taken stimulants. Total duration of time on stimulants ranged from less than 6 months (group 1) to 4 years (group 5). Results indicated that the symptoms of hyperactivity significantly lessened, but remained higher in these children than in normal peers. Behavioral and social problems were less pervasive than academic underachievement. There were no group differences, indicating that the duration of stimulant intervention did not have a significant effect on outcome. The clinical implication of this study is that the beneficial effects of stimulant drug intervention occur within the first months after initiation of therapy. Long-term treatment does not appear to be of value in producing better outcome.

School dysfunction in the adolescent

The adolescent with school dysfunction presents a multifaceted problem to his parents, to the school, to his physician, and to himself. He struggles with the developmental tasks of adolescence against great odds, entering this important period of life discouraged by school failure and poor self-esteem. Follow-up studies demonstrate that he is at high risk for social, emotional, and psychiatric problems. Despite the pessimistic nature of most of this research, the field holds much promise. New techniques of prevention, assessment, and teaching, as well as prediction of response to education and medication, are being explored and recent research has demonstrated that adolescents with learning disabilities and hyperactivity can continue to make progress and develop into successful, happy adults.

Psychotropic drugs and learning problems--a selective review

Past research into psychotropic drugs can be divided conveniently into laboratory studies that have generally looked at the more immediate effects on learning and follow-up studies that have investigated long-term effects as they pertain to academic attainment. Many of the commonly used drugs in childhood disorders appear to have beneficial effects in the short term and in the laboratory situation, though there are notable exceptions. Long-term assessments, however, have generally been unable to document lasting educational gains due to the psychotropic drugs.

Historically the application of diagnostic labels has frequently been inaccurate, giving vent to the false impression that certain drugs are of demonstrated benefit in children with specific learning problems. The research relating to drug effects on academic attainment in children with pronounced learning problems was reviewed. The evidence attesting to educational gains was found to be negligible, and possible directions for future research were indicated.

Hyperkinesis comes of age: what do we know and where should we go?

The first heuristic description of the hyperkinetic impulse disorder made its appearance in the literature just over twenty years ago. Although there are many who are made restless and irritable by continuing ambiguities and controversies surrounding the hyperkinetic syndrome, the past two decades have brought considerable maturation in our knowledge of this concept. The present paper sketches the state of the art in regard to hyperkinesis, and draws conclusions about directions for both research and clinical work.

Hyperactive boys in their classroom: assessment of teacher and peer perceptions, interactions, and classroom behaviors

Teacher ratings, peer perceptions, peer interactions, and classroom behaviors of 17 hyperactive and 17 active elementary school-age boys, nominated by their teachers, were compared using multivariate analyses and planned comparisons in order to better describe and assess hyperactivity in its most probable setting--the classroom. Hyperactive boys were found to be significantly different from actives on measures from all data sources in that they were perceived and interacted more negatively. Cluster analyses of teacher ratings of 90 hyperactives from a clinical sample and 17 hyperactives from the current sample were used to discriminate among different types of hyperactives. Four types were named anxious, conduct problems, inattentive, and low problem hyperactives. The fact that six conduct problem hyperactives were found to be more disruptive and have higher activity level ratings than six inattentive hyperactives, when observed in their classrooms, points to the need to study and treat hyperactives as heterogeneous groups.

The hyperactive child at adolescence: cognitive, emotional, and social functioning

In view of the paucity of detailed follow-up studies on hyperactive children, the performance of 15 adolescents diagnosed hyperactive 5 years previously was compared to that of a control group of equivalent age, sex, intelligence, and social class. Eleven cognitive tests measuring sustained attention, visual-motor and motor skills, abstraction, and reading ability, as well as three self-assessment tests examining self-esteem, activity level, social functioning, academic status, and career aspirations were administered. The hyperactives performed significantly worse than the controls on the sustained attention, visual-motor, and motor tasks, and on two of the four reading tests. They also gave themselves significantly lower ratings on some of the self-esteem and sociability items. It would appear that the hyperactives at adolescence still have attentional and stimulus-processing difficulties, which affect not only their academic performance but also their social functioning.

Home management of hyperkinetic children

Six clinical programs and one controlled, experimental program are described in which parents of hyperkinetic children were trained to alleviate behavior problems in the home. Parents attended educational workshops in which basic general principles of behavior modification were taught. As a result of the training workshops, parents were able to achieve significant reductions in their children's hyperactivity and in the severity of behavioral problems, as well as significant gains in their knowledge of behavior management. All gains were maintained at the time of follow-up assessments. Parent-training workshops are considered to be a useful adjunct to other services provided to the hyperkinetic child and his family.