J Abnorm Child Psychol (2009) 37:521–534

DOI 10.1007/s10802-008-9287-8

Hyperactivity in Boys with Attention-Deficit/Hyperactivity

Disorder (ADHD): A Ubiquitous Core Symptom
or Manifestation of Working Memory Deficits?
Mark D. Rapport & Jennifer Bolden & Michael J. Kofler &
Dustin E. Sarver & Joseph S. Raiker & R. Matt Alderson

Published online: 13 December 2008

# Springer Science + Business Media, LLC 2008

Abstract Hyperactivity is currently considered a core and Keywords ADHD . Working memory . Hyperactivity .
ubiquitous feature of attention-deficit/hyperactivity disorder Activity level . Attention-deficit/hyperactivity disorder
(ADHD); however, an alternative model challenges this
premise and hypothesizes a functional relationship between
working memory (WM) and activity level. The current The significance of excessive motor activity or hyperactiv-
study investigated whether children’s activity level is ity in the conceptualization of attention-deficit/hyperactivity
functionally related to WM demands associated with the disorder (ADHD) has varied considerably during the past
domain-general central executive and subsidiary storage/ century. Hyperactivity was initially considered the disorder’s
rehearsal components using tasks based on Baddeley’s dominant feature in early clinical (Still, 1902) and theoret-
(Working memory, thought, and action. New York: Oxford ical (Chess 1960; Laufer et al. 1957) descriptions, and
University Press 2007) WM model. Activity level was continued its primacy throughout the 1970s as reflected by
objectively measured 16 times per second using wrist- and the diagnostic monikers hyperkinetic impulse-disorder
ankle-worn actigraphs while 23 boys between 8 and (Laufer et al. 1957), hyperactive child syndrome (Chess
12 years of age completed control tasks and visuospatial/ 1960), and hyperkinetic reaction to childhood (American
phonological WM tasks of increasing memory demands. Psychiatric Association 1968). Empirical validation of
All children exhibited significantly higher activity rates motor excesses in ADHD was extensively documented
under all WM relative to control conditions, and children during this time and afterward using a broad range of
with ADHD (n = 12) moved significantly more than methodologies and technologies, ranging from rating scales
typically developing children (n=11) under all conditions. (Werry 1968), analogue measures (Barkley 1991) and direct
Activity level in all children was associated with central observations (Whalen et al. 1978) to pedometers (Plomin
executive but not storage/rehearsal functioning, and higher and Foch 1981), stabilimetric cushions (Conners and
activity rates exhibited by children with ADHD under Kronsberg 1985) and actigraphs (Porrino et al. 1983).
control conditions were fully attenuated by removing A paradigm shift occurred during the mid to late 1970s
variance directly related to central executive processes. following Douglas’s (Douglas 1972; Campbell et al. 1971)
seminal work documenting attentional difficulties in children
with ADHD relative to children with specific learning
disabilities and typically developing children. The relegation
of hyperactivity to a secondary role was consummated in the
M. D. Rapport (*) : J. Bolden : M. J. Kofler : D. E. Sarver : third edition of the Diagnostic and Statistical Manual of
J. S. Raiker
Department of Psychology, University of Central Florida, Mental Disorders nomenclature (American Psychiatric
Orlando, FL, USA Association 1980)—excessive movement was no longer con-
e-mail: [email protected] sidered a necessary criterion for diagnosing the disorder—
and, motor activity and impulsivity descriptors were grouped
R. M. Alderson
Department of Psychology, Oklahoma State University, together based on factor analytic findings (DuPaul et al.
Stillwater, OK, USA 1998).
522 J Abnorm Child Psychol (2009) 37:521–534

Cognitive and neurocognitive accounts of ADHD flour- portends a wide range of pejorative outcomes. These include
ished during the ensuing two decades and continue to externalizing behavior problems (Keown and Woodward
dominate contemporary theoretical models of the disorder. 2006), interpersonal and parent–child difficulties (Buss
These models vary considerably in their expositions of 1981; Fischer and Barkley 2006), scholastic underachieve-
hyperactivity. For example, the cognitive-energetic model ment (Fergusson et al. 1997) and deficient occupational
(Sergeant 2005) focuses exclusively on information pro- functioning (Barkley et al. 2006; Mannuzza et al. 1993)
cessing and consequently contains no testable or falsifiable among others. Excessive motor activity also appears to be
predictions concerning the role of activity level in ADHD. the only empirically documented symptom that uniquely
A second model views hyperactivity as incidental motor distinguishes children diagnosed with ADHD from those
behavior that accompanies attention shifts away from with other childhood disorders (Halperin et al. 1992).
non-novel tasks or activities. These shifts occur because Finally, the recognition that hyperactive symptoms are
behavior-consequence relationships that are usually strength- conventionally used to diagnose the research participants
ened through operant conditioning extinguish too rapidly in upon which contemporary models are based is fraught with
children with ADHD unless immediate reinforcement is irony.
provided (Sagvolden et al. 2005). A third model hypothesizes In contrast to other contemporary models, the nascent
that ADHD is due to a developmental delay in response working memory (WM) model makes specific, testable
inhibition (i.e., the ability to inhibit oneself in accordance predictions concerning the functional role of hyperactivity
with situational demands) that adversely influences executive in children with ADHD (Rapport et al. 2001, 2008b).
functions such as working memory, self-regulation of affect/ Specifically, the model postulates that challenges to under-
emotion/arousal, and internalization of speech. Ubiquitous, lying working memory components engender increased
non-goal directed motor movement (hyperactivity) reflects movement in all children as a process that augments arousal
children’s on-going struggle to inhibit task irrelevant behavior necessary for task performance. The relationships among
and regulate goal directed behavior (Barkley 1997). An CNS arousal, increased activity level, and task performance
alternative model envisions hyperactivity as a manifestation are well established (for reviews, see Andreassi 1995; Barry
of subcortical impairment that remains relatively static et al. 2005; Zentall and Zentall 1983). Higher rates of
throughout life and is unrelated to executive functions such movement are predicted to occur under WM conditions in
as working memory (Halperin et al. 2008). Other models children with ADHD relative to typically developing
imply that increased activity level represents children’s children to help compensate for the chronic cortical under-
attempt to minimize the aversive nature of delayed con- arousal associated with the disorder. Evidence for prefrontal
sequences by engaging in avoidance or escape behavior cortical hypo-activation1 as a core underlying physiological
(Sonuga-Barke et al. 1992), or combine elements of delay process in ADHD has been consistently verified by studies
and behavioral inhibition models (Sonuga-Barke 2002). reporting increased slow wave (theta) and decreased fast
Collectively, most contemporary models of ADHD largely wave (beta) activity in children with ADHD while
disregard the role of hyperactivity, view it as ubiquitous performing academic (Mann et al. 1992) and cognitive
behavior secondary to pervasive cognitive deficits, or tasks (Clark et al. 1998; Dickstein et al. 2006; El-Sayed et
envision it as corollary behavior that accompanies frequent al. 2002) relative to typically developing children. Similar
attentional shifts or efforts to escape situations involving evidence has emerged from fMRI studies (Castellanos et al.
delayed consequences. Only one study has empirically 1996; Rubia et al. 1999).
investigated the relationship between these model-implied Two studies recently examined predictions stemming
deficits and children’s activity level. The authors concluded from the WM model (Martinussen and Tannock 2006;
that activity level is a manifestation of subcortical impair- Willcutt et al. 2005a); however, neither found a significant
ment and independent of executive functions such as relationship between hyperactivity and WM performance
working memory (Halperin et al. 2008). despite finding deficient WM in children with ADHD
The negligible role most contemporary ADHD models relative to typically developing children. Two methodolog-
afford hyperactivity is at odds with the empirical literature. ical confounds may have precluded the detection of a WM-
Activity level is the first enduring trait or personality activity level relationship in the studies: (a) the discrepant
characteristic to develop in humans (Eaton et al. 1996), is time parameters for measuring hyperactivity relative to WM
highly heritable (Wood et al. 2007; Saudino and Eaton performance, and (b) the reliance on subjective parent/
1991), and remains remarkably stable during preschool teacher rating scale scores to estimate children’s activity
years despite differences in context and environment level. The ratings scales used by Willcutt et al. (2005a) and
(Rapport et al. 2006). Above average motor activity
predicts (beyond age four) a diagnosis of ADHD at age 1
Prefrontal cortical hypo-activation refers to deficient task-related
nine (Campbell and Ewing 1990; Palfrey et al. 1985) and changes in arousal.
J Abnorm Child Psychol (2009) 37:521–534 523

Martinussen and Tannock (2006) reflect adult retrospective attention), or rise incrementally in response to the greater
perceptions of children’s activity level throughout the day number of stimuli to be recalled (i.e., reflect storage/
across multiple settings for the preceding week and month, rehearsal processes). The issue was addressed statistically,
respectively, in contrast to the brief time (typically 5 to however, by isolating and subsequently comparing activity
15 min) required to complete the WM tasks in both studies level associated with the domain-general CE and subsystem
(i.e., digit and location span tasks). Controlling for setting (PH, VS) processes. Children with ADHD also were
and time parameter effects, however, does not remedy the predicted to exhibit significantly higher rates of motor
low agreement (r=0.32 to 0.58) conventionally found activity relative to typically developing children across both
between subjective (e.g., rating scale scores) and objective WM modalities. This prediction was based on recent
measures of children’s activity. These values indicate that experimental (Rapport et al. 2008a) and meta-analytic
66% to 91% of the variability in activity rating scale scores (Martinussen et al. 2005) findings demonstrating deficient
is not linearly related to variability in actigraph scores in the CE, phonological, and visuospatial WM processes in
same children measured at the same time in the same children with ADHD relative to typically developing
setting (Rapport et al. 2006). This discrepancy is potentially children. Finally, the two groups were compared under
problematic given (a) the ability of actigraphs but not minimal WM control conditions before and after removing
hyperactivity ratings to differentiate hyperactive from variance associated with WM performance to address the
impulsive subtypes of ADHD (Marks et al. 1999), and (b) conventionally held belief that hyperactivity in children
the improved predictive validity of actigraphs for differen- with ADHD is ubiquitous and unrelated to setting/task
tiating groups of ADHD children from both typically variables (Porrino et al. 1983).
developing and other clinical groups compared to hyperac-
tivity ratings (Halperin et al. 1992).
The present study is the first to investigate the Method
relationship between children’s WM and objectively mea-
sured activity level using experimental paradigms based on Participants
Baddeley’s (2007) model.2 Baddeley’s model views WM as
a multi-component system consisting of two independent The sample was comprised of 23 boys aged 8 to 12 years
subsystems—phonological (PH) and visuospatial (VS)— (M=9.04, SD=1.36), recruited by or referred to the Child-
that are each equipped with unique input processors, a ren’s Learning Clinic-IV (CLC-IV) through community
buffer for the temporary store of modality specific resources (e.g., pediatricians, community mental health
information (PH, VS), and a rehearsal mechanism. The clinics, school system personnel, self-referral). The CLC-
domain-general central executive (CE) provides oversight IV is a research-practitioner training clinic known to the
and coordination of the two subsystems, reacts to changing surrounding community for conducting developmental and
attentional/multi-task demands, and provides a link between clinical child research and providing pro bono comprehen-
WM and long-term memory. The distinct functioning of the sive diagnostic and psychoeducational services. Its client
two subsystems, their storage/rehearsal components, and base consists of children with suspected learning, behav-
the domain-general CE are supported by extensive neuro- ioral or emotional problems, as well as typically developing
psychological (Baddeley 2003), neuroanatomical (Smith et children (those without a suspected psychological disorder)
al. 1996), neuroimaging (Fassbender and Schweitzer 2006), whose parents agree to have them participate in develop-
and factor analytic (Alloway et al. 2006) investigations. mental/clinical research studies. A psychoeducational eval-
Children with ADHD and typically developing children uation was provided to the parents of all participants.
were both expected to exhibit increased motor activity Two groups of children participated in the study:
while performing WM tasks relative to control conditions children with ADHD, and typically developing children
as predicted by the WM model (Rapport et al. 2001, without a psychological disorder. All parents and children
2008b). No predictions were offered concerning whether gave their informed consent/assent to participate in the
motor activity would increase to some minimal threshold study, and the university’s Institutional Review Board
level to reflect general WM task demands (i.e., reflect approved the study prior to the onset of data collection.
primarily CE processing capabilities such as focused
Group Assignment

2
All children and their parents participated in a detailed,
Children with ADHD were previously shown to exhibit significant
semi-structured clinical interview using the Kiddie Schedule
WM deficits relative to typically developing children in CE and both
working memory subsystems using these paradigms (Rapport et al. for Affective Disorders and Schizophrenia for School-Aged
2008a). Children (K-SADS; Kaufman et al. 1997). The K-SADS
524 J Abnorm Child Psychol (2009) 37:521–534

assesses onset, course, duration, severity, and impairment of Eleven children met the following criteria and were
current and past episodes of psychopathology in children included in the typically developing group: (1) no evidence
and adolescents based on DSM-IV criteria. Its psychometric of any clinical disorder based on parent and child K-SADS
properties are well established, including interrater agree- interview; (2) normal developmental history by maternal
ment of 0.93 to 1.00, test–retest reliability of 0.63 to 1.00, report; (3) ratings below 1.5 SDs on the clinical syndrome
and concurrent (criterion) validity between the K-SADS and scales of the CBCL and TRF; and (4) parent and teacher
psychometrically established parent rating scales. ratings within the non-clinical range on all CSI subscales.
Twelve children met the following criteria and were Typically developing children were actively recruited through
included in the ADHD-Combined Type group: (1) an contact with neighborhood and community schools, family
independent diagnosis by the CLC-IV’s directing clinical friends of referred children, and other community resources.
psychologist using DSM-IV criteria for ADHD-Combined Children that presented with (a) gross neurological,
Type based on K-SADS interview with parent and child sensory, or motor impairment, (b) history of a seizure
which assesses symptom presence and severity across home disorder, (c) psychosis, or (d) Full Scale IQ score less than
and school settings; (2) parent ratings of at least 2 SDs 85 were excluded from the study. None of the children were
above the mean on the Attention Problems clinical receiving medication during the study—seven of the
syndrome scale of the Child Behavior Checklist (CBCL; children with ADHD had previously received trials of
Achenbach and Rescorla 2001), or exceeding the criterion psychostimulant medication. Demographic and rating scale
score for the parent version of the ADHD-Combined data for the two groups are provided in Table 1.
subtype subscale of the Child Symptom Inventory (CSI;
Gadow et al. 2004); and (3) teacher ratings of at least 2 SDs Measures and Statistical/Methodological Overview
above the mean on the Attention Problems clinical
syndrome scale of the Teacher Report Form (TRF; Measures
Achenbach and Rescorla 2001), or exceeding the criterion
score for the teacher version of the ADHD-Combined Actigraph An actigraph is an acceleration-sensitive device
subtype subscale of the CSI (Gadow et al. 2004). The CSI that measures motor activity. The estimated reliability for
requires parents and teachers to rate children’s behavioral actigraphs placed at the same site on the same person
and emotional problems based on DSM-IV criteria using a ranges from 0.90 to 0.99 (Tryon 1985). Actigraphs are
4-point Likert scale. The CBCL, TRF, and CSI are among moderately correlated with parent and teacher ratings of
the most widely used behavior rating scales for assessing activity level (r=0.32 to 0.58), and have superior predictive
psychopathology in children. Their psychometric properties validity relative to parent and teacher ratings of hyperac-
are well established (Rapport et al. 2008b). All children in tivity for differentiating among children with ADHD,
the ADHD group met criteria for ADHD-Combined Type, typically developing children, and children with other
and six were comorbid for Oppositional Defiant Disorder psychopathological disorders (Halperin et al. 1992; Rapport
(ODD). et al. 2006). Actigraphs generate a current (voltage) each

Table 1 Sample and Demographic Variables

Variable ADHD Typically developing

X SD X SD F

Age 8.75 1.29 9.36 1.43 1.17

FSIQ 100.92 15.22 110.18 13.11 2.43
SES 43.46 12.25 52.50 7.57 6.13*
CBCL
Attention problems 78.50 10.53 55.64 7.06 36.68***
TRF
Attention problems 66.25 8.83 48.73 16.92 9.94**
CSI-parent
ADHD, combined 12.67 3.85 3.00 4.98 27.42***
CSI-teacher
ADHD, combined 9.83 5.32 2.73 3.93 13.06**

ADHD attention-deficit/hyperactivity disorder, CBCL Child Behavior Checklist, CSI Child Symptom Inventory, FSIQ full scale intelligence
quotient, SES socioeconomic status, TRF Teacher Report Form
*p≤0.05; **p≤0.01; ***p≤0.001
J Abnorm Child Psychol (2009) 37:521–534 525

time the instrument is moved. The current is passed through from a standard 3×3 grid to minimize the likelihood of
an amplifier and filtered, resulting in an analog waveform—a phonological coding of the stimuli (e.g., by equating the
histogram of measured voltage over time—from which data squares to numbers on a telephone pad). A series of 2.5 cm
regarding movement frequency, intensity, or duration may be diameter dots (3, 4, 5, or 6) were presented sequentially in
extracted and analyzed (for a detailed review, see Rapport et one of the nine squares during each trial, such that no two
al. 2006). MicroMini Motionlogger® (Ambulatory Monitor- dots appeared in the same square on a given trial. All but
ing Inc. 2004) actigraphs were used to measure children’s one dot presented within the squares was black—the
activity level. The acceleration-sensitive devices resemble exception being a red dot that was counterbalanced across
wristwatches and were set to Proportional Integrating trials to appear an equal number of times in each of the nine
Measure (low-PIM) mode, which measures the intensity of squares, but never presented as the first or last stimulus in
movement (i.e., quantifies gross activity level). Movement the sequence to minimize potential primacy and recency
was sampled 16 times per second (16 Hz) and collapsed into effects. Each dot was displayed for 800 ms followed by a
1-minute epochs. Data were downloaded via a hardware 200 ms interstimulus interval. A green light appeared at the
interface and analyzed using the Action-W2 software conclusion of each 3, 4, 5, and 6 stimulus sequence.
program (Ambulatory Monitoring Inc. 2004) to calculate Children were instructed to indicate the serial position of
mean activity rates for each child during the control and WM black dots in the order presented by pressing the
tasks described below. corresponding squares on a computer keyboard, and to
Children were told that the actigraphs were “special indicate the position of the red dot last. The last response
watches” that let them play the computer learning games. was followed by an intertrial interval of 1,000 ms and an
The Observer (Noldus Information Technology 2003) live auditory chime that signaled the onset of a new trial.
observation software was used to code start and stop times
for each task, which were matched to the time stamps from Control (C) Conditions Children’s activity level was
the actigraphs. Actigraphs were placed immediately above assessed while they used the Microsoft® Paint program
children’s left and right ankles using velcro watch bands. for five consecutive minutes both prior to (C1) and after
Ankle placement was used in lieu of trunk placement due to (C2) completing the phonological and visuospatial WM
the improved sensitivity of the former for detecting tasks during four consecutive Saturday assessment sessions.
movement (Eaton et al. 1996). A third actigraph was placed The Paint program served as pre and post conditions to
on children’s non-dominant wrist only, because the visuo- assess and control for potential within-day fluctuations in
spatial and both control tasks required movement using the activity level (e.g., fatigue effects). Children sat in the same
dominant hand. chair and interacted with the same computer used for the
WM tasks while interacting with a program that placed
Phonological (PH) Working Memory Task The phonolog- relatively modest demands on WM (i.e., the Paint program
ical WM task is similar to the Letter–Number Sequencing allows children to draw/paint anything they like on the
subtest on the WISC-IV (Wechsler 2003), and assesses monitor using a variety of interactive tools3). The four pre
phonological WM based on Baddeley’s (2007) model. and four post activity level control conditions were
Children were presented a series of jumbled numbers and separately averaged to create pre and post composite scores
a capital letter on a computer monitor. Each number and secondary to preliminary analyses that found no significant
letter (4 cm height) appeared on the screen for 800 ms, differences in children’s pre or post condition activity level
followed by a 200 ms interstimulus interval. The letter across days (all p>0.10).
never appeared in the first or last position of the sequence
to minimize potential primacy and recency effects, and was Measured Intelligence All children were administered
counterbalanced across trials to appear an equal number of either the Wechsler Intelligence Scale for Children third or
times in the other serial positions (i.e., position 2, 3, 4, or fourth edition to obtain an overall estimate of intellectual
5). Children were instructed to recall the numbers in order functioning. The changeover to the fourth edition was due
from smallest to largest, and to say the letter last (e.g., 4 H to its release during the conduct of the study and to provide
6 2 is correctly recalled as 2 4 6 H). Two trained research parents with the most up-to-date intellectual evaluation
assistants, shielded from the participant’s view, indepen- possible. Full Scale IQ (FSIQ) was not analyzed as a
dently recorded oral responses (interrater reliability=95.6% covariate because it shares significant variance with WM
agreement).
3
Successful interaction with the Paint program requires central
Visuospatial (VS) Working Memory Task Children were
executive processes such as focused attention and interaction with
shown nine 3.2 cm squares arranged in three vertical long-term memory, as well as limited phonological and visuospatial
columns on a computer monitor. The columns were offset storage/rehearsal processes.
526 J Abnorm Child Psychol (2009) 37:521–534

and would result in removing substantial variance associ- in movement across children’s extremities while completing
ated with WM from WM (Ackerman et al. 2005). Instead, a cognitive tasks (Eaton et al. 1996). This approach has the
residual FSIQ score was derived using a latent variable additional advantage of conserving power while providing
approach. Briefly, the derived central executive, phonolog- the broader sampling of children’s activity level needed to
ical storage/rehearsal, and visuospatial storage/rehearsal test hypotheses regarding the relationship between overall
performance variables described below were covaried out activity level and WM.
of FSIQ (R2 =0.31). Residual FSIQ scores represent IQ that Performance data (PH and VS stimuli correct per trial)
is unrelated to estimated WM functioning, and were were computed and used to statistically isolate the
examined as a potential covariate in the analyses described relationship between activity level and specific components
below. of WM.

Statistical Analysis
Procedures
A 4-tier analytic approach was used to examine (a)
The phonological and visuospatial tasks were programmed potential overall group differences in activity level between
using Superlab Pro 2.0 (2002). All children participated in WM modalities (PH,VS); (b) group differences and
four consecutive Saturday assessment sessions at the CLC. changes in activity level associated with overall phonolog-
The phonological, visuospatial, and control conditions were ical and visuospatial WM demands; (c) the extent to which
administered as part of a larger battery of laboratory-based activity level is directly related to individual WM compo-
tasks that required the child’s presence for approximately nent processes, and whether this relationship differs
2.5 h per session. Children completed all tasks while seated between children with ADHD and typically developing
alone in an assessment room. All children received brief children; and (d) whether hyperactivity is a ubiquitous
(2–3 min) breaks following every task, and preset longer feature of ADHD or functionally related to WM. Measure-
(10–15 min) breaks after every two to three tasks to ment of activity level while children performed WM tasks
minimize fatigue. Each child was administered eight control allowed direct examination of the relationship between WM
(pre and post on each of the 4 days), four phonological, and and hyperactivity, providing incremental benefit beyond the
four visuospatial conditions (i.e., PH and VS set sizes 3, 4, correlational studies described earlier. Hedges’ g effect
5, and 6) across the four testing sessions. Each phonolog- sizes were computed to estimate the magnitude of all
ical and visuospatial set size consisted of 24 trials. Details between-group differences while correcting for sample size
concerning the administration of practice blocks for the (Lipsey and Wilson 2001).
visuospatial and phonological paradigms are described in
Rapport et al. (2008a). The eight WM conditions were
counterbalanced to control for order effects. The control Results
conditions always occurred as the first and last tasks each
day. Children were seated in a caster-wheel swivel chair Data Screening
approximately 0.66 m from the computer monitor for all
tasks. Power Analysis An average effect size (ES) of 0.72 was
calculated from two studies providing actigraph means and
Dependent Variables SDs for children with ADHD and typically developing
(TD) children during laboratory tasks (Dane et al. 2000;
Total extremity scores (TES) were calculated by summing Halperin et al. 1992). GPower software version 3.0.5 (Faul
activity level across the three actigraph sites (2 ankle, 1 et al. 2007) was used to determine needed sample size
non-dominant hand) to compute an estimate of overall using this ES, with power set to 0.80 as recommended by
movement for each of the ten conditions (C1, PH and VS Cohen (1992). For an ES of 0.72, α=0.05, power (1–β)=
set sizes 3, 4, 5, and 6, and C2).4 An aggregate measure of 0.80, 2 groups, and six repetitions (C1, set sizes 3–6, C2 as
activity level was employed in lieu of reporting separate described below), 18 total subjects are needed for a
extremity activity rates or using data reduction techniques repeated measures ANOVA to detect differences and
such as averaging due to expected inter-individual differences reliably reject H0.
4
Site placement contrasts for each task revealed that non-dominant Outliers Each of the ten tasks (C1, PH set sizes 3–6, VS set
hand movement was greater than left and right foot movement across
sizes 3–6, C2) was screened for univariate outliers (i.e., ≥
most conditions (i.e., NH > LF = RF). The pattern of results across
conditions for the three actigraph recording sites, however, did not 3.5 SD above or below group mean). No univariate outliers
differ significantly from those reported for TES in the Results. were identified.
J Abnorm Child Psychol (2009) 37:521–534 527

Preliminary Analyses more active than TD children across all tasks. The modality
by group interaction was not significant (p=0.80).
Demographic data are shown in Table 1. Sample ethnicity was
mixed with 16 Caucasian (69%), 5 Hispanic (22%), and 2 Tier II: Set Sizes
African American (9%) children. All parent and teacher
behavior rating scale scores were significantly higher for the The second set of analyses examined the effects of increasing
ADHD group relative to the TD group as expected (see phonological and visuospatial memory load on children’s
Table 1). Children with ADHD and TD children did not differ activity level (see Tables 3 and 4). Using Wilks’ criterion, a
on age (p=0.14), or intelligence (WISC-III or WISC-IV significant one-way MANOVA on all ten conditions (C1, set
FSIQ; p=0.13). A univariate ANOVA revealed significant sizes 3–6 for both modalities, C2) by group (ADHD, TD)
between-group differences in SES (p=0.02). On average, confirmed the overall relationship between activity level and
children with ADHD had lower Hollingshead (1975) SES WM, Wilks’ λ=0.19, F(10,11)=4.64, p=0.009. Phonologi-
scores than TD children. Age and SES were not significant cal and visuospatial Mixed-model ANOVAs with LSD post
covariates of any of the Tier I, II, III, or IV analyses (all p≥ hocs were conducted separately to examine group (ADHD,
0.24). Residual FSIQ did not differ between groups, F(1,21)= TD) by condition (C1, set sizes 3–6, C2) differences.
0.48, p=0.83. The residual FSIQ score was a significant
covariate of all Tier I, II, and IV analyses (all p≤0.05), but did Phonological ANOVA For activity level during the phonolog-
not change the pattern of any results. Residual FSIQ was not ical and control conditions (C1, PH set sizes 3–6, C2), the
a significant covariate of the Tier III analysis (p=0.97). We Mixed-model ANOVA was significant for group (p<0.0005)
therefore report simple model results with no covariates. and set size (p<0.0005). The post hoc test for set size is
Means, SDs, and F-values are presented in Tables 2, 3, and 4. reported in Table 3. The group by set size interaction was also
significant (p=0.001). LSD post hoc tests for the interaction
Tier I: Composite Scores revealed that children with ADHD demonstrated greater
activity level across all control and phonological set size
The initial analysis examined overall differences in activity conditions compared to TD children (all p≤0.04). The pattern
level between WM modalities (PH, VS) and groups (ADHD, of activity level between control and phonological conditions
TD). Results are depicted in Table 2. Phonological and for both groups was also similar. Both groups exhibited higher
visuospatial composite scores were computed separately by rates of activity under all phonological conditions (set sizes
averaging activity level across set sizes. A Mixed-model 3–6) relative to both control conditions (C1, C2; all p≤0.05).
ANOVA indicated significant main effects for WM modality Children with ADHD exhibited significantly higher rates of
(p=0.004) and group (p<0.001). Across groups, children were movement than TD children across all conditions, but their
significantly more active during the phonological relative to rates were not statistically different across the four phono-
the visuospatial task; children with ADHD were significantly logical set size conditions (i.e., ADHD PH 3=4=5=6; all p≥
0.31). Typically developing children also evidenced a stable
Table 2 Phonological and visuospatial Total Activity Level Composite pattern of activity level across the phonological condition with
Scores one exception—their activity level was moderately lower
under set size 3 relative to set sizes 4 (p=0.05) and 6 (p=
Phonological Visuospatial Composite
0.03). Computation of Hedges’ g indicated that the average
X X X magnitude difference between children with ADHD and TD
children was 1.49 standard deviation units (range: 0.93 to
(SD) (SD) (SE) F
2.10). Results are depicted in Table 3 and Fig. 1 (top).
ADHD 43785.61 39626.21 41705.91
(10504.79) (7071.20) (2136.72) Visuospatial ANOVA For activity level during the visuo-
TD 25477.21 20574.21 23025.71 spatial and control conditions (C1, VS set sizes 3–6, C2),
(7557.72) (6737.30) (2231.74) the Mixed-model ANOVA was significant for group (p<
Composite 35029.42 30514.39 – 10.14**
0.0005) and set size (p<0.0005). The post hoc test for set
(12983.89) (11845.82)
size is reported in Table 4. The group by set size interaction
F 36.55***
was also significant (p=0.02). LSD post hoc tests for the
Actigraph Proportional Integrating Measure (PIM) values can range interaction revealed that children with ADHD exhibited
from 0 (no movement) to 65,535 significantly higher rates of activity across all control and
ADHD attention-deficit/hyperactivity disorder; SE standard error; TD
typically developing children
visuospatial conditions relative to TD children (all p≤
a
Modality × group interaction, p=0.80, ns 0.003). The pattern of activity level between control and
**p<0.01; ***p<0.001 visuospatial conditions for both groups was similar. Both
528 J Abnorm Child Psychol (2009) 37:521–534

Table 3 Phonological Activity Level Set Size Analyses

Phonological set sizea

C1 PH 3 PH 4 PH 5 PH 6 C2 Group
composite

X X X X X X X

(SD) (SD) (SD) (SD) (SD) (SD) (SE) F Set size

contrasts

ADHD 16120.23 45963.33 41953.19 41776.05 46613.42 21346.11 35628.72 28.93*** C1<C2<
(7210.24) (13999.73) (17143.45) (11428.42) (10308.03) (9799.32) (2409.48) 3=4=5=6
TD 8582.92 19285.65 28141.98 23858.93 30622.28 12055.10 20424.48 14.77*** C1<C2<3<
(2703.27) (9933.66) (10161.86) (10360.81) (12623.68) (4557.34) (2409.48) 4=5=6; 3=5
Set size 12351.57 32624.49 35047.59 32817.49 38617.85 16700.59 – 42.16*** C1<C2<
composite (6566.19) (18075.29) (15462.29) (14049.54) (13908.84) (8844.52) 3=4=5=6
Group F 9.96** 28.10*** 4.85* 17.17*** 10.09** 8.13** 45.57***
Group A>TD A>TD A>TD A>TD A>TD A>TD A>TD
contrasts

Actigraph Proportional Integrating Measure (PIM) values can range from 0 (no movement) to 65,535; ADHD n=11 for all analyses involving C2
condition due to missing data for one participant; A = ADHD; C1 = control condition (pre); C2 = control condition (post); PH = phonological (3,
4, 5, & 6 set size); SE = standard error; TD = typically developing children
a
Phonological group x set size interaction, F (5,100)=4.28, p=0.001; *p<0.05; **p≤0.01; ***p≤0.001

groups exhibited higher levels of activity under all four magnitude of group differences from visuospatial WM tasks
visuospatial conditions (set sizes 3–6) relative to both control to C2, one-sample t(7)=2.67, p=0.03). When the control
conditions (C1, C2; all p≤0.006). In addition, activity level for conditions were removed from the analysis, neither the main
both groups of children (ADHD, TD) remained relatively effect for set size nor the group by set size interaction
stable across the four visuospatial set size conditions (all p≥ remained significant (both p≥0.61). Hedges’ g effect size
0.34). The significant interaction effect was due to the indicated that the average magnitude difference in activity
disproportionate decrease in activity level from WM to level between children with ADHD and TD children during
control conditions for children with ADHD relative to TD visuospatial WM tasks was 1.83 standard deviation units
children (i.e., a significant ES decrease of 0.66 in the (range=1.47 to 2.67). Children in both groups were some-

Table 4 Visuospatial Activity Level Set Size Analyses

Visuospatial set sizea

C1 VS 3 VS 4 VS 5 VS 6 C2 Group
composite

X X X X X X X

(SD) (SD) (SD) (SD) (SD) (SD) (SE) F Set size

contrasts

ADHD 16120.23 42156.64 39179.69 40050.91 39029.78 21346.11 32980.56 13.52*** C1<C2<
(7210.24)
(13138.28) (14222.47) (7751.39) (14447.63) (9799.32) (1847.52) 3=4=5=6
TD 8582.92 22673.08 21456.97 18403.58 19763.22 12055.10 17155.81 12.43*** C1<C2<
(2703.27)(9843.00) (7846.21) (7862.40) (7806.69) (4557.34) (1847.52) 3=4=5=6
Set size 12351.57 32414.86 30318.33 29227.24 29396.50 16700.59 – 23.63*** C1<C2<
composite (6566.19) (15091.54) (14418.80) (13445.39) (15021.23) (8844.52) 3=4=5=6
Group F 9.96** 16.68*** 11.45** 43.71*** 16.47*** 8.13** 22.63***
Group A>TD A>TD A>TD A>TD A>TD A>TD A>TD
contrasts

Actigraph Proportional Integrating Measure (PIM) values can range from 0 (no movement) to 65,535; ADHD n=11 for all analyses involving C2
condition due to missing data for one participant; A = ADHD; C1 = control condition (pre); C2 = control condition (post); SE = standard error;
TD = typically developing children; VS = visuospatial (3, 4, 5, & 6 indicate set size)
a
Visuospatial group x set size interaction, F (5,100)=2.94, p=0.016; **p≤0.01; ***p≤0.001
J Abnorm Child Psychol (2009) 37:521–534 529

50000
storage/rehearsal). Latent variable analysis is currently the
45000 best practice for estimating the independent contribution of
WM component processes (cf. Swanson and Kim 2007).
40000

35000 Phonological Storage/Rehearsal Latent variable analyses

Activity Level (PIM)

were used to estimate shared variance between the derived

30000
phonological storage/rehearsal performance variables (de-
25000 scribed above) and phonological activity level at each set
size (i.e., activity level directly related to PH storage/
20000
rehearsal functioning). Results indicated that phonological
15000 storage/rehearsal functioning was not a significant contrib-
10000
utor to objectively measured activity level (average R2 =
0.10; values ranged from 0.06 to 0.21 and were all
5000 nonsignificant with one exception5). The planned t-test for
group differences was not conducted because children’s
C1 PH 3 PH 4 PH 5 PH 6 C2 activity level and phonological storage/rehearsal function-
Experimental Conditions ing were not significantly related.
50000
Visuospatial Storage/Rehearsal An identical latent variable
45000 approach was used to estimate activity level directly related
to visuospatial storage/rehearsal functioning. Results indi-
40000
cated that visuospatial storage/rehearsal functioning was not
35000 a significant contributor to objectively measured activity
level (average R2 =0.07; values ranged from less than 0.001
Activity Level (PIM)

30000
to 0.14 and were all nonsignificant). The planned t-test for
25000 group differences was not conducted because children’s
activity level and visuospatial storage/rehearsal functioning
20000
were not significantly related.
15000

10000
Central Executive Latent variable analyses were again used
to derive predicted scores that reflect shared variance
5000 between the derived CE performance variables (described
above) and children’s activity level during the phonological
C1 VS 3 VS 4 VS 5 VS 6 C2 and visuospatial tasks at each set size (i.e., activity level
Experimental Conditions directly related to CE functioning). Results indicated that
CE functioning was a significant contributor of objectively
Fig. 1 Total extremity activity level (right foot, left foot, and non- measured activity level (average R2 =0.32; values ranged
dominant hand) expressed in PIM (Proportional Integrated Measure)
units for children with ADHD (triangles) and typically developing from 0.17 to 0.61; all p≤0.04). A composite score was
children (circles) under control (C1, C2) and four phonological (top computed by averaging the four predicted scores for each
graph: PH 3, 4, 5, 6) and four visuospatial (bottom graph: VS 3, 4, 5, task to provide an overall estimate of children’s activity level
6) working memory set size conditions. Vertical bars represent directly associated with CE functioning. An independent
standard error
samples t-test on the derived CE-activity level variable
what more active during the second relative to the first indicated a significant between-group difference, t(21)=7.54,
control condition (both p≤0.01). Results are depicted in p<0.0005, with children with ADHD evincing higher rates
Fig. 1 (bottom). of activity directly associated with CE functioning relative to
TD children. Hedges’ g effect size indicated that the average
magnitude difference between children with ADHD and TD
Tier III: Components of Working Memory children was 3.03 standard deviation units (SE=0.60).

Latent variable analyses were undertaken to determine the

extent to which group differences in activity level reported
above were associated with the domain-general central 5
The relationship between phonological storage/rehearsal functioning
executive relative to the two subsidiary systems (PH or VS and activity level at set size 5 (R2 =0.21) was significant at p=0.03.
530 J Abnorm Child Psychol (2009) 37:521–534

Tier IV: Control Conditions repeated rehearsal and/or at final recall (Baddeley 2007).
The visuospatial subsystem cannot adopt this strategy to
Latent variable analyses were used in the final tier to assess help recall unfamiliar material such as a novel matrix
the extent to which observed group differences in activity pattern. Coupled with our related finding that activity level
level during the two control conditions (C1, C2) represent is associated with CE and not storage/rehearsal processes,
ubiquitous hyperactivity in children with ADHD (Porrino et the higher activity rates under the phonological relative to
al. 1983) or the influence of minimal WM demands the visuospatial WM conditions may reflect the increased
associated with the Paint program (Rapport et al. 2008a). demands on CE resources that facilitate the interplay
Residual scores were computed for both control tasks by between WM and long-term memory. An alternative
regressing the CE composite performance variable onto C1 explanation for the finding is that the moderately higher
(R2 =0.26) and C2 (R2 =0.25) activity level to remove activity rates during the phonological relative to visuospa-
variance associated with CE functioning.6 A 2 (group) by tial conditions reflect subtle differences in response
2 (condition: C1, C2) Mixed-model ANOVA was nonsig- demands between the two tasks. Children attend to a
nificant for group, condition, and the group by condition computer monitor to view WM stimuli during both tasks;
interaction (all p≥0.52), indicating that children with however, the phonological task requires a verbal response
ADHD were not ubiquitously more motorically active than (which can be emitted while moving), whereas the
typically developing children during the control conditions visuospatial task requires a keyboard response that neces-
after accounting for task-related WM demands. Hedges’ g sarily restricts movement to some extent.
effect size indicated that the average magnitude difference Examination of between-group activity level differences
between children with ADHD and TD children was 0.20 revealed a relatively consistent pattern of results. Children
standard deviation units (SE=0.29), with a confidence with ADHD were more active than typically developing
interval that included 0.0. children across both modalities, and their activity level
remained stable despite increases in cognitive demand.
Typically developing children also evidenced a stable
Discussion pattern of activity level across the phonological and
visuospatial conditions with one exception—their activity
This is the first experiment to demonstrate a functional level was moderately lower under the smallest phonological
relationship between working memory and children’s set size condition. The similar pattern of results across
activity level. Children with ADHD and typically develop- groups suggests that increases in children’s activity level
ing children both exhibited significantly higher rates of between control and phonological/visuospatial WM condi-
movement while performing phonological and visuospatial tions primarily reflect general task demands associated with
WM tasks relative to minimal WM control conditions. This central executive processing rather than increases in cognitive
finding contradicts the subcortical impairment model load imposed on the storage/rehearsal loop subsidiary
(Halperin et al. 2008), but is consistent with WM model systems. This interpretation was confirmed statistically by
predictions and provides initial evidence that movement is isolating the unique contributions of the domain-general
functionally related to the imposition of WM demands central executive, phonological storage/rehearsal, and visuo-
(Rapport et al. 2001, 2008b). Children’s activity level was spatial storage/rehearsal to children’s activity level. Latent
also moderately higher under the four phonological relative variable analysis revealed that WM performance attributable
to visuospatial set size conditions, which may reflect to central executive functioning—but not phonological or
differences in children’s developing phonological and visuospatial storage/rehearsal functioning—was significantly
visuospatial abilities despite using identical cognitive loads related to children’s activity level.
across the two modalities (Alloway et al. 2006). The The significant relationship between CE functioning and
finding may also reflect subtle differences in processing activity level appears at odds with previous correlational
demands and strategic resource use between the two tasks. studies that failed to find a significant relationship between
Maintaining a limited set of over-learned items such as WM and activity level (Martinussen and Tannock 2006;
digits and letters within the phonological storage/rehearsal Willcutt et al. 2005a). This apparent discrepancy may
subsystem typically relies to some extent on long-term reflect previously discussed methodological differences
memory knowledge to clean up the memory trace during among the studies (e.g., nonconcurrent measurement of
WM and activity level, subjective measures of activity
level). A more likely explanation is that the WM tasks used
6
Phonological and visuospatial storage/rehearsal composite scores
in earlier studies (e.g., digits forward and backward tasks)
were also used in the analysis initially but did not share significant primarily reflect visuospatial and phonological storage/
variance with C1 and C2 activity level. rehearsal processes (Swanson and Kim 2007), whereas
J Abnorm Child Psychol (2009) 37:521–534 531

only CE processes appear to be functionally related to The current study’s unique contribution was the objec-
children’s activity based on the current results. In this tive measurement of activity level during concurrent
case, our finding that storage/rehearsal processes are not manipulation of domain-general CE processing and subsid-
significantly related to children’s activity level is consis- iary storage/rehearsal demands while controlling for IQ,
tent with previous correlational findings. age, and SES. Several caveats require consideration when
Collectively, children with ADHD showed dispropor- interpreting the present findings despite these and other
tionately higher motor activity relative to typically devel- methodological refinements (i.e., controlling IQ-WM co-
oping children under both control and all WM conditions. variation, pre/post activity level measurement, and WM
This finding is consistent with those reported in previous component partitioning). The generalization of results from
investigations of actigraph-measured activity in laboratory highly controlled, laboratory-based experimental investiga-
and classroom settings. Extant studies uniformly reported tions with stringent inclusion criteria to the larger popula-
higher activity level in children with ADHD relative to tion of children with ADHD is always limited to some
typically developing controls during laboratory-based exper- extent. Independent experimental replication with larger
imental tasks (Dane et al. 2000; Halperin et al. 1992, 1993; samples that include females, older children, and other
Inoue et al. 1998). The extent to which performance on these ADHD subtypes is recommended to address these potential
tasks (e.g., CPT, Stop-signal Task) is mediated by WM limitations. Our cell sizes were nevertheless sufficient
processes, however, is currently unknown. Higher activity based on the a priori power analysis. The large magnitude
rates are also consistently observed in children with ADHD between-group differences in motor activity associated with
relative to typically developing children while completing in- the imposition of WM demands observed in the study may
seat academic assignments (Porrino et al. 1983; Tsujii et al. be related to our stringent inclusion criteria, and would
20077), which are known to place moderate to heavy likely be attenuated to the extent that children exhibit fewer
demands on WM resources (Gathercole et al. 2004). or less disabling ADHD-related symptoms. This supposi-
Although previous actigraph studies are consistent in tion is consistent with the strong genetic contribution
documenting higher activity rates in children with ADHD, associated with activity level (Wood et al. 2007; Saudino
little is known about the underlying processes responsible and Eaton 1991) and evidence that ADHD behavioral
for these differences. Prevailing hypotheses suggest that symptoms represent continuous rather than categorical
higher activity in children with ADHD relative to typically dimensions (Gjone et al. 1996). Several of the children
developing children is ubiquitous and largely independent with ADHD also met diagnostic criteria for ODD; however,
of task and situational demands (Porrino et al. 1983, the degree of comorbidity may be viewed as typical of the
p. 685). Our finding that children with ADHD were more ADHD population based on recent epidemiological find-
motorically active relative to their peers under minimal ings (i.e., 59%; Wilens et al. 2002), and previous inves-
WM conditions appeared consistent with this view, but at tigations indicate that the excess motor activity observed in
odds with predictions stemming from the WM model of ADHD is independent of ODD (Halperin et al. 1992). The
ADHD (Rapport et al. 2001, 2008b). Their higher motor specificity of disproportionately high activity rates found
activity during control conditions, however, was fully in our ADHD sample is currently unknown and merits
attenuated by removing the influence of WM demands investigation. Actigraph studies comparing children with
associated with these tasks. This finding, coupled with the ADHD and children with other clinical disorders, such as
previously discussed results, suggests that activity may anxiety and conduct disorder, are thus far inconclusive
serve a purposeful function in all children to the extent due to insufficient statistical power (Halperin et al. 1993).
that arousal is necessary for CE processing, and becomes Children with other clinical disorders are likely to exhibit
excessive in some children to compensate for chronic lower activity rates than children with ADHD but higher
cortical under-arousal (Dickstein et al. 2006; El-Sayed rates than typically developing children to the extent that
et al. 2002; Mann et al. 1992). Experimental studies CE processes are disrupted. A final caveat worth noting
concurrently examining WM performance, motor activity, is that actigraph-measured activity reported herein may
physiological arousal, and cortical activity are needed to differ from rates reported in other studies due to measure-
further explicate the complex interplay among these ment differences. Proportional integrating measure, rather
processes. The outcome of these studies will help clarify than the zero-crossing mode used in previous studies, was
whether hyperactivity might be better characterized as an selected because it quantifies movement intensity over
effect educed by CE processing deficits rather than as a time (i.e., how much movement occurs) rather than
core causal variable. counting the frequency that a child’s movement crosses
a preset intensity threshold (which may underestimate
7
Tsujii et al. 2007 found these differences only during the afternoon activity). The use of multiple actigraphs provided a
hours. broader sampling of children’s activity level, and wrist/
532 J Abnorm Child Psychol (2009) 37:521–534

ankle actigraph placements provided enhanced precision information key rings, and audio devices (cf. Gathercole and
over truncal placement for assessing both gross and distal Alloway 2008).
movements (cf. Rapport et al. 2006, and Eaton et al. 1996,
for reviews).
The current findings indirectly address anecdotal parent References
and teacher reports that children with ADHD remain engaged
in particular tasks and activities with no apparent excessive Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA
motor activity (e.g., computer activities, playing LEGO® or school-age forms & profiles. Burlington, VT: University of
video games, watching TV), yet move excessively during Vermont Research Center for Children, Youth, & Families.
Ackerman, P. L., Beier, M. E., & Boyle, M. O. (2005). Working memory
most in-seat academic/learning activities (e.g., homework, and intelligence: the same or different constructs? Psychological
classroom academic assignments). Volitional control deficits Bulletin, 131, 30–60. doi:10.1037/0033-2909.131.1.30.
are often invoked to explain this apparent incongruity Alloway, T. P., Gathercole, S. E., & Pickering, S. J. (2006). Verbal and
(McInerney and Kerns 2003). The current findings, however, visualspatial short-term and working memory in children: are
they separable? Child Development, 77, 1698–1716. doi:10.1111/
suggest that activity rates in children with ADHD may vary j.1467-8624.2006.00968.x.
among these activities as a function of differences in CE Ambulatory Monitoring (2004). The micromini motionlogger
demands. Experimental paradigms that systematically vary a actigraph and family of single-sensor recorders [User’s manual
wider range of CE processing demands than used in the to the accompany Act Millennium version 3.5.0.0 and higher (3rd
ed.)]. New York: Author. Retrieved from http://www.ambulatory
current study, while simultaneously measuring activity level, monitoring.com/, 7 December 2007.
are needed to address this issue. The results also potentially American Psychiatric Association (1968). Diagnostic and statistical
shed light on the reduced motor movement observed in manual of mental disorders (2nd ed.). Washington, DC: Author.
children prescribed psychostimulants—an effect described as American Psychiatric Association (1980). Diagnostic and statistical
manual of mental disorders (3rd ed.). Washington, DC: Author.
paradoxical in years past. Psychostimulants are known to Andreassi, J. L. (1995). Psychophysiology: Human behavior and
enhance cognitive performance in children (Douglas et al. physiological response (3rd ed.). Hillsdale, NJ: Erlbaum.
1995; Rapport and Kelly 1991) and WM in particular Baddeley, A. (2003). Working memory: looking back and looking forward.
(Bedard et al. 2007). The accompanying reduced motor Nature Reviews. Neuroscience, 4, 829–839. doi:10.1038/nrn1201.
Baddeley, A. (2007). Working memory, thought, and action. New
activity (Bedard and Tannock 2008) may reflect increased York: Oxford University Press.
cortical arousal and improved CE processing (Lawrence et Barkley, R. A. (1991). The ecological validity of laboratory and analogue
al. 2005). assessment methods of ADHD symptoms. Journal of Abnormal
Considering hyperactivity as a secondary symptom— Child Psychology, 19, 149–178. doi:10.1007/BF00909976.
Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and
whose presence reflects ongoing CE processing demands in executive functions: constructing a unifying theory of ADHD.
the environment, rather than a core causal feature of the Psychological Bulletin, 121, 65–94. doi:10.1037/0033-2909.
disorder—has several implications for intervention planning 121.1.65.
and treatment. Behavioral programs designed to reduce Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2006).
Young adult outcome of hyperactive children: adaptive function-
excessive gross motor activity in children through conven- ing in major life activities. Journal of the American Academy of
tional behavior management techniques may be counterpro- Child and Adolescent Psychiatry, 45, 192–202. doi:10.1097/01.
ductive and unintentionally decrease CE functioning. chi.0000189134.97436.e2.
Programs specifically targeting CE functions such as focused Barry, R. J., Clarke, A. R., McCarthy, R., Selikowitz, M., & Rushby,
J. A. (2005). Arousal and activation in a continuous performance
attention, in contrast, are likely to prove beneficial as
task: an exploration of state effects in normal children. Journal of
evidenced in past outcome studies (DuPaul et al. 1992). Psychophysiology, 19, 91–99. doi:10.1027/0269-8803.19.2.91.
Efforts to develop interventions that promote the early Bedard, A. C., & Tannock, R. (2008). Anxiety, methylphenidate response,
development of WM abilities in children at risk for ADHD and working memory in children with ADHD. Journal of Attention
Disorders, 11, 546–557. doi:10.1177/1087054707311213.
also appear warranted based on accumulating evidence from
Bedard, A. C., Jain, U., Hogg-Johnson, S., & Tannock, R. (2007).
recent experimental investigations (Rapport et al. 2008a) and Effects of methylphenidate on working memory components:
meta-analytic reviews (Martinussen et al. 2005; Willcutt et influence of measurement. Journal of Child Psychology and
al. 2005b). To date, however, there is scant empirical support Psychiatry, and Allied Disciplines, 48, 872–880. doi:10.1111/
to indicate that direct training of WM capacity in children is j.1469-7610.2007.01760.x.
Buss, D. M. (1981). Predicting parent–child interactions from children’s
beneficial (for an exception, cf. Klingberg et al. 2005). An activity level. Developmental Psychology, 17, 59–65. doi:10.1037/
alternative intervention approach—with growing empirical 0012-1649.17.1.59.
support—is to adopt curricula systems and methods that Campbell, S. B., & Ewing, L. J. (1990). Follow-up of hard-to-manage
avoid and/or minimize WM failure in children. These preschoolers: adjustment at age 9 and predictors of continuing
symptoms. Journal of Child Psychology and Psychiatry, and Allied
include a wide variety of techniques that involve restructur- Disciplines, 31, 871–889. doi:10.1111/j.1469-7610.1990.tb00831.x.
ing complex tasks, simplifying mental processing, and Campbell, S. B., Douglas, V., & Morgenstern, G. (1971). Cognitive
encouraging the use of memory aids such as memory cards, styles in hyperactive children and the effect of methylphenidate.
J Abnorm Child Psychol (2009) 37:521–534 533

Journal of Child Psychology and Psychiatry, and Allied International Journal of Disability Development and Education,
Disciplines, 12, 55–67. doi:10.1111/j.1469-7610.1971.tb01050.x. 53, 229–245. doi:10.1080/10349120600716182.
Castellanos, F. X., Giedd, J. N., Marsh, W. L., Hamburger, S. D., Gadow, K. D., Sprafkin, J., & Salisbury, H. (2004). Further validity
Vaituzis, A. C., & Dickstein, D. P. (1996). Quantitative brain evidence for the teacher version of the child symptom inventory-
magnetic resonance imaging in attention-deficit/hyperactivity 4. School Psychology Quarterly, 19, 50–71. doi:10.1521/
disorder. Archives of General Psychiatry, 53, 607–616. scpq.19.1.50.29408.
Chess, S. (1960). Diagnosis and treatment of the hyperactive child. Gathercole, S. E., & Alloway, T. P. (2008). Working memory &
New York State Journal of Medicine, 60, 2379–2385. learning: A practical guide for teachers. London Sage.
Clark, V. P., Maisog, J. M., & Haxby, J. V. (1998). An fMRI study of Gathercole, S. E., Pickering, S. J., Knight, C., & Stegmann, Z. (2004).
face perception and memory using random stimulus sequences. Working memory skills and educational attainment: evidence
Journal of Neurophysiology, 79, 3257–3265. from national curriculum assessments at 7 and 14 years of age.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155– Applied Cognitive Psychology, 18, 1–16. doi:10.1002/acp.934.
159. doi:10.1037/0033-2909.112.1.155. Gjone, H., Stevenson, J., & Sundet, J. M. (1996). Genetic influence on
Conners, C. K., & Kronsberg, S. (1985). Measuring activity level in parent-reported attention-related problems in a Norwegian general
children. Psychopharmacology Bulletin, 21, 893–897. population twin sample. Journal of the American Academy of
Dane, A. V., Schachar, R. J., & Tannock, R. (2000). Does actigraphy Child and Adolescent Psychiatry, 35, 588–596. doi:10.1097/
differentiate ADHD subtypes in a clinical research setting? Journal 00004583-199605000-00013.
of the American Academy of Child and Adolescent Psychiatry, 39, Halperin, J. M., Matier, K., Bedi, G., Sharma, V., & Newcorn, J. H.
752–760. doi:10.1097/00004583-200006000-00014. (1992). Specificity of inattention, impulsivity, and hyperactivity
Dickstein, S. G., Bannon, K., Castellanos, F. X., & Milham, M. P. to the diagnosis of attention-deficit hyperactivity disorder. Journal
(2006). The neural correlates of attention deficit hyperactivity of the American Academy of Child and Adolescent Psychiatry,
disorder. an ALE meta-analysis. Journal of Child Psychology 31, 190–196. doi:10.1097/00004583-199203000-00002.
and Psychiatry, and Allied Disciplines, 47, 1051–1062. Halperin, J. M., Newcorn, J. H., Matier, K., Sharma, V., McKay, K. E.,
doi:10.1111/j.1469-7610.2006.01671.x. & Schwartz, S. (1993). Discriminant validity of attention-deficit
Douglas, V. I. (1972). Stop, look and listen: the problem of sustained hyperactivity disorder. Journal of the American Academy of
attention and impulsive control in hyperactive and normal Child and Adolescent Psychiatry, 32, 1038–1043. doi:10.1097/
children. Canadian Journal of Behavioural Science, 4, 259– 00004583-199309000-00024.
282. doi:10.1037/h0082313. Halperin, J. M., Trampush, J. W., Miller, C. J., Marks, D. J., & Newcorn,
Douglas, V. I., Barr, R. G., Desilets, J., & Sherman, E. (1995). Do J. H. (2008). Neuropsychological outcome in adolescents/young
high doses of methylphenidate impair flexible thinking in adults with childhood ADHD: Profiles of persisters, remitters, and
attention-deficit hyperactivity disorder? Journal of the American controls. Journal of Child Psychology and Psychiatry, 49, 958–966.
Academy of Child and Adolescent Psychiatry, 34, 877–885. Hollingshead, A. (1975). Four factor index of social status. New
DuPaul, G. J., Guevremont, D. C., & Barkley, R. A. (1992). Haven, CT: Yale University, Department of Sociology.
Behavioral treatment of attention-deficit hyperactivity disorder Inoue, K., Nadaoka, T., Oiji, A., Morioka, Y., Totsuka, S., Kanbayashi, Y., &
in the classroom: the use of the attention training system. Behavior Hukui, T. (1998). Clinical evaluation of attention-deficit hyperactivity
Modification, 16, 204–225. doi:10.1177/01454455920162004. disorder by objective quantitative measures. Child Psychiatry and
DuPaul, G. J., Anastopoulous, A. D., Power, T. J., Reid, R., Ikeda, M. J., Human Development, 28, 179–188. doi:10.1023/A:1022885827086.
& McGoey, K. E. (1998). Parent ratings of attention-deficit/ Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P.,
hyperactivity disorder symptoms: factor structure and normative et al. (1997). Schedule for affective disorders and schizophrenia
data. Journal of Psychopathology and Behavioral Assessment, 20, for school-age children-present and lifetime version (K-SADS-
83–102. doi:10.1023/A:1023087410712. PL): initial reliability and validity data. Journal of the American
Eaton, W. O., McKeen, N. A., & Saudino, K. J. (1996). Measuring Academy of Child and Adolescent Psychiatry, 36, 980–988.
human individual differences in general motor activity with doi:10.1097/00004583-199707000-00021.
actometers. In K. P. Ossenkopp, M. Kavaliers, & P. R. Sanberg Keown, L. J., & Woodward, L. J. (2006). Preschool boys with
(Eds.), Measuring movement and locomotion: From invertebrates pervasive hyperactivity: early peer functioning and mother-child
in humans (pp. 79–92). Auxtin, TX: R. G. Landes. relationship influences. Social Development, 15, 23–45.
El-Sayed, E., Larsson, J. O., Persson, H. E., & Rydelius, P. A. (2002). doi:10.1111/j.1467-9507.2006.00328.x.
Altered cortical activity in children with attention-deficit/ Klingberg, T., Fernell, E., Olesen, P. J., Johnson, M., Gustafsson, P.,
hyperactivity disorder during attentional load task. Journal of Dahlstrom, K., et al. (2005). Computerized training of working
the American Academy of Child and Adolescent Psychiatry, 41, memory in children with ADHD—a randomized control trial.
811–819. doi:10.1097/00004583-200207000-00013. Journal of the American Academy of Child and Adolescent
Fassbender, C., & Schweitzer, J. B. (2006). Is there evidence for Psychiatry, 44, 177–186. doi:10.1097/00004583-200502000-00010.
neural compensation in attention deficit hyperactivity disorder? A Laufer, M., Denhoff, E., & Solomons, G. (1957). Hyperkinetic
review of the functional neuroimaging literature. Clinical impulse disorder in children’s behavior problems. Psychosomatic
Psychology Review, 26, 445–465. doi:10.1016/j.cpr.2006.01.003. Medicine, 19, 38–49.
Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power3: Lawrence, C. A., Barry, R. J., Clarke, A. R., Johnstone, S. J.,
a flexible statistical power analysis program for the social, McCarthy, R., Selikowitz, M., et al. (2005). Methylphenidate effects
behavioral, and biomedical sciences. Behavior Research Meth- in attention deficit/hyperactivity disorder: electrodermal and ERP
ods, 39, 175–191. measures during a continuous performance task. Psychopharma-
Fergusson, D. M., Lynskey, M. T., & Horwood, L. J. (1997). Attention cology, 183, 81–91. doi:10.1007/s00213-005-0144-y.
difficulties in middle childhood and psychosocial outcomes in Lipsey, M. W., & Wilson, D. B. (2001). Practical meta-analysis.
young adulthood. Journal of Child Psychology and Psychiatry, California: Sage.
and Allied Disciplines, 38, 633–644. doi:10.1111/j.1469- Mann, C., Lubar, J., Zimmerman, A., Miller, C., & Muenchen, R. (1992).
7610.1997.tb01690.x. Quantitative analysis of EEG in boys with attention deficit
Fischer, M., & Barkley, R. A. (2006). Young adult outcomes of hyperactivity disorder: controlled study with clinical implications.
children with hyperactivity: leisure, financial, and social activities. Pediatric Neurology, 8, 30–36. doi:10.1016/0887-8994(92)90049-5.
534 J Abnorm Child Psychol (2009) 37:521–534

Mannuzza, S., Klein, R. G., Bessler, A., Malloy, P., & LaPadula, M. disorder (ADHD) predominantly hyperactive/impulsive and
(1993). Adult outcome of hyperactive boys: educational combined subtypes. The Behavioral and Brain Sciences, 28,
achievement, occupational rank, and psychiatric status. 397–468. doi:10.1017/S0140525X05000075.
Archives of General Psychiatry, 50, 565–576. Saudino, K. J., & Eaton, W. O. (1991). Infant temperament and
Marks, D. J., Himelstein, J., Newcorn, J. H., & Halperin, J. M. (1999). genetics: an objective twin study of motor activity level. Child
Identification of AD/HD subtypes using laboratory-based Development, 62, 1167–1174. doi:10.2307/1131160.
measures: a cluster analysis. Journal of Abnormal Child Sergeant, J. A. (2005). Modeling attention-deficit/hyperactivity disorder:
Psychology, 27, 167–175. doi:10.1023/A:1021967632515. a critical appraisal of the cognitive-energetic model. Biological
Martinussen, R., & Tannock, R. (2006). Working memory impair- Psychiatry, 57, 1248–1255. doi:10.1016/j.biopsych.2004.09.010.
ments in children with attention-deficit hyperactivity disorder Smith, E. E., Jonides, J., & Koeppe, R. A. (1996). Dissociating verbal
with and without comorbid language learning disorders. Journal and spatial working memory using PET. Cerebral Cortex, 6,
of Clinical and Experimental Neuropsychology, 28, 1073–1094. 11–20. doi:10.1093/cercor/6.1.11.
doi:10.1080/13803390500205700. Sonuga-Barke, E. J. (2002). Psychological homogeneity in AD/HD—
Martinussen, R., Hayden, J., Hogg-Johnson, S., & Tannock, R. a dual pathway model of behaviour and cognition. Behavioural
(2005). A meta-analysis of working memory impairments in Brain Research, 130, 29–36. doi:10.1016/S0166-4328(01)00432-6.
children with attention-deficit/hyperactivity disorder. Journal of Sonuga-Barke, E. J., Taylor, E., Sembi, S., & Smith, J. (1992).
the American Academy of Child and Adolescent Psychiatry, 44, Hyperactivity and delay aversion: I. the effect of delay on
377–384. doi:10.1097/01.chi.0000153228.72591.73. choice. Journal of Child Psychology and Psychiatry, and Allied
McInerney, R. J., & Kerns, K. A. (2003). Time reproduction in Disciplines, 33, 387–398. doi:10.1111/j.1469-7610.1992.tb00874.x.
children with ADHD: motivation matters. Journal of Child Still, G. F. (1902). Some abnormal psychical conditions in children.
Neuropsychology, 9, 91–108. Lancet, 1008-1012, 1077–1082.
Noldus Information Technology (2003). The observer reference SuperLab Pro (Version 2) [Computer program]. (2002). San Pedro,
manual 5.0. Wageningen, The Netherlands: Author. California. (http://www.cedrus.com): Cedrus Corporation.
Palfrey, J. S., Levine, M. D., & Walker, D. K. (1985). The emergence Swanson, L., & Kim, K. (2007). Working memory, short-term memory,
of attention deficits in early childhood: a prospective study. and naming speed as predictors of children’s mathematical perfor-
Journal of Developmental and Behavioral Pediatrics, 6, 339– mance. Intelligence, 35, 151–168. doi:10.1016/j.intell.2006.07.001.
348. doi:10.1097/00004703-198512000-00004. Tryon, W. W. (1985). Human activity: a review of quantitative
Plomin, R., & Foch, T. T. (1981). Hyperactivity and pediatrician findings. In W. W. Tryon (Ed.), Behavioral assessment in
diagnosis, parent ratings, specific cognitive abilities, and labora- behavioral medicine (pp. 257–299). New York: Springer.
tory measures. Journal of Abnormal Child Psychology, 9, 55–64. Tsujii, N., Okada, A., & Kaku, R. (2007). Association between activity
doi:10.1007/BF00917857. level and situational factors in children with attention deficit/
Porrino, L. J., Rapoport, J. L., Behar, D., Sceery, W., Ismond, D. R., & hyperactivity disorder in elementary school. Psychiatry and Clinical
Bunney Jr., W. E. (1983). A naturalistic assessment of the motor Neurosciences, 61, 181–185. doi:10.1111/j.1440-1819.2007.01634.x.
activity of hyperactive boys. I. comparison with normal controls. Wechsler, D. (2003). Wechsler intelligence scale for children—fourth
Archives of General Psychiatry, 40, 681–687. edition. San Antonio, TX: Psychological Corporation.
Rapport, M. D., & Kelly, K. L. (1991). Psychostimulant effects on Werry, J. S. (1968). Developmental hyperactivity. Pediatric Clinics of
learning and cognitive function: findings and implications for children North America, 15, 581–599.
with attention deficit hyperactivity disorder. Clinical Psychology Whalen, C. K., Collins, B. E., Henker, B., Alkus, S. R., Douglas, A., &
Review, 11, 61–92. doi:10.1016/0272-7358(91)90138-K. Stapp, J. (1978). Behavior observations of hyperactive children and
Rapport, M. D., Chung, K., Shore, G., & Isaacs, P. (2001). A methylphenidate (Ritalin) effects in systematically structured class-
conceptual model of child psychopathology: implications for room environments: now you see them, now you don’t. Journal of
understanding attention deficit hyperactivity disorder and treat- Pediatric Psychology, 3, 177–187. doi:10.1093/jpepsy/3.4.177.
ment efficacy. Journal of Clinical Child Psychology, 30, 48–58. Wilens, T. E., Biederman, J., Brown, S., Tanguay, S., Monuteaux, M.
doi:10.1207/S15374424JCCP3001_6. C., Blake, C., et al. (2002). Psychiatric comorbidity and
Rapport, M. D., Kofler, M. J., & Himmerich, C. (2006). Activity functioning in clinically referred preschool children and school-
measurement. In M. Hersen (Ed.), Clinician’s Handbook of Child age youths with ADHD. Journal of the American Academy of
Behavioral Assessment (pp. 125–157). New York: Elsevier Child and Adolescent Psychiatry, 41, 262–268. doi:10.1097/
Academic Press. 00004583-200203000-00005.
Rapport, M. D., Alderson, R. M., Kofler, M. J., Sarver, D. E., Bolden, J., Willcutt, E. G., Pennington, B. F., Olson, R. K., Chhabildas, N., &
& Sims, V. (2008a). Working memory deficits in boys with attention- Hulslander, J. (2005a). Neuropsychological analysis of comor-
deficit/hyperactivity disorder (ADHD): the contribution of the bidity between reading disability and attention deficit hyperac-
central executive and subsystem processes. Journal of Abnormal tivity disorder: in search of the common deficit. Developmental
Child Psychology, 36, 825–837. doi:10.1007/s10802-008-9215-y. Neuropsychology, 27, 35–78. doi:10.1207/s15326942dn2701_3.
Rapport, M. D., Kofler, M., Alderson, M., & Raiker, J. S. (2008b). Willcutt, E. G., Doyle, A., Nigg, J., Faraone, S., & Pennington, B. F.
Attention-deficit/hyperactivity disorder. In M. Hersen, & D. (2005b). Validity of the executive function theory of attention-
Reitman (Eds.), Handbook of Psychological Assessment, Case deficit/hyperactivity disorder: a meta-analytic review. Biological
Conceptualization and Treatment, Volume 2: Children and Psychiatry, 57, 1336–1346. doi:10.1016/j.biopsych.2005.02.006.
Adolescents (pp. 349–404). NJ: Wiley & Sons. Wood, A. C., Saudino, K. J., Rogers, H., Asherson, P., & Kuntsi, J. (2007).
Rubia, K., Overmeyer, S., Taylor, E., Brammer, M., Williams, S. Genetic influences on mechanically-assessed activity level in
C. R., Simmons, A., et al. (1999). Hypofrontality in attention children. Journal of Child Psychology and Psychiatry, and Allied
deficit hyperactivity disorder during higher-order motor con- Disciplines, 48, 695–702. doi:10.1111/j.1469-7610.2007.01739.x.
trol: a study with functional MRI. The American Journal of Zentall, S. S., & Zentall, T. R. (1983). Optimal stimulation: a model of
Psychiatry, 156, 891–896. disordered activity and performance in normal and deviant
Sagvolden, T., Aase, H., Johansen, E. B., & Russell, V. A. (2005). A children. Psychological Bulletin, 94, 446–471. doi:10.1037/
dynamic developmental theory of attention-deficit/hyperactivity 0033-2909.94.3.446.