REVIEW ARTICLE. Direct Observation Studies of Hyperactive Behaviors. SIU-LUEN LUK, M.B., B.S., M.R.e.PSYCH.

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1 REVIEW ARTICLE Direct Observation Studies of Hyperactive Behaviors SIU-LUEN LUK, M.B., B.S., M.R.e.PSYCH. A review of 25 direct observation studies on hyperactive children shows that current research supports clear differences between hyperactive and normal children. However, the data fail to answer the questionof the validityof hyperkinetic syndrome because of the lack of comparison with children sufferingfromother psychiatric disorders, particularlyconduct disorder. The research also suggests that increasing the complexity of the task generally increases the degree of manifestation of the symptoms, and that the structure of the environment affects the symptoms of hyperactivity, although the relationship is complex. There is some evidence, albeit slight, to suggest that hyperactivity associated with definite brain damage is less affectedby the structure of the environment. Journal of the AmericanAcademy of Child Psychiatry, 24, 3: , The validity of the clinical diagnosis of Hyperactive Syndrome has been sharply questioned (Shaffer and Greenhill, 1979). Further, it has been shown that the results of rating scales of hyperactive behaviors obed from different sources, such as teachers and parents, correlate poorly with one another (Sandberg et ai., 1978). The Hyperactive Syndrome has been suggested by some to be a myth created by clinicians (Schrag and Divoky, 1981). Consequently, there is a need to return to the fundamental questions of whether, and how, under direct observation, hyperactive children are different from non hyperactive children. The following is a review of observational studies of hyperactive behaviors. The main questions of the review are: (1) have direct observation studies provided evidence to support the validity of the concept of hyperkinetic syndrome? and (2) is hyperactive behavior influenced by changes in situational factors? Ifso, have direct observation studies helped us to understand how situational factors affect hyperactivity? Method A total of 25 papers were reviewed, which provided data comparing the behaviors of children diagnosed as hyperactive with a control group using direct ob- Received Nov. 29, 1983; revised March 12, 1984; accepted May 17, Dr. Luk is Lecturer, Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong. Formerly Research Worker, Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Denmark Hill, London, S.E.5. The author would like to express his gratitude to Dr. Eric Taylor for his encouragement and guidance throughout the preparation of this review and to Mrs. Catherine Buckley and Miss Ivy Wong for secretarial help /85/ $02.00/ by the American Academy of Child Psychiatry. 338 servation as the method of investigation. Several aspects of these papers were specifically noted: 1. Subjects A. According to likelihood of brain damage a) "Organic group" with definite brain damage (i.e., brain damage not inferred from soft neurological signs or abnormal behaviors), epilepsy or mental retardation b) "Community group" with no definite evidence of brain damage, or epilepsy, or mental retardation. Evidence of mild degrees of sensorimotor incoordination or minor abnormalities on neurodevelopmental examination can be present c) Mixed group B. According to source of information d) Pervasive-all sources of information show that the child is hyperactive e) Situational-only some sources of information show that the child is hyperactive f) Uncer 2. Situations: Generally these can be divided into two groups, classroom and laboratory settings. It is interesting to note that there is a marked lack of data comparing hyperactive children with control groups on home observation or psychiatric interview A. Classroom a) Structured-children are required to sit in their chair and concentrate on teachings or an assigned task b) Unstructured-children are allowed to move around B. Laboratory setting c) Free to wander in a room d) Free play in a play room

2 STUDIES OF HYPERACTIVE BEHAVIORS 339 e) Structured play in a play room f) Performance of a simple task g) Performance of a difficult task 3. Instruments used a) Mechanical instrument b) Direct observation and rating of defined behaviors 4. Choice of behaviors to be measured. The behaviors are classified into two categories: behaviors pering to activity level and behaviors pering to attention. Most of the studies have only small numbers of subjects (mean = 20, range = 5-60). Apparent lack of difference between groups can therefore be a result of low power in the designs. Accordingly, nonsignificant findings are differentiated into two types. In the first type, there is a substantial difference that nevertheless falls short of statistical significance. In the othertype, there is little difference between groups. Results Results are summarized in Table 1. Papers that studied an organic group come first, followed by those comparing a community group with controls. The latter section is divided into classroom observations, followed by laboratory setting observations. Discussion 1. Have direct observation studies provided evidence to support the validity of the concept of hyperkinetic syndrome? Broadly speaking, all but one of the studies support the idea that hyperactive subjects as a group are different from the control groups in terms of level of activity and behavior pering to attentiveness. These are either statistically significant differences or there is a substantial trend in the same direction. The one study that produced results in the opposite direction (Plomin and Foch, 1981) stands apart from other studies in the way the experimental subjects were selected. They were diagnosed by private pediatricians in the community and the finding raises some question about diagnostic standards in that setting. Most of the studies measured hyperactivity in specified situations over a short period of time. Only two studies have measured hyperactivity in its natural setting over a prolonged period of time. Porrino et al, (1983), using a portable solid-state monitor, measured activity of hyperactive boys in their natural settings for 1 week with normal children as controls. The result showed significant differences between the two groups. The other study is by Plomin and Foch (1981), which produced results in the opposite direction. The weakness of these studies is that most of their control groups comprised normal subjects instead of psychiatric clinic subjects. Only Barkley and Ullman (1975), Firestone and Martin (1979) and Sandberg et a1. (1978), have used clinic controls. Barkley and Ullman's study produced a good deal of nonsignificant results and Sandberg et a1.'s and Firestone and Martin's study used limited measures. Although they followed the general trend of the results of this review, the evidence is not solid. One has to conclude that, from the data provided by direct observation studies, it is still uncer whether or not the differences demonstrated are specific to hyperactive syndrome. In fact the most important comparison is between hyperactive subjects and conduct disorder subjects. None of the studies has included such a comparison. Thus, the data available fail to conclusively answer the question of the validity of hyperkinetic syndrome, although they provide some verification. 2. Is hyperactive behavior influenced by change of situational factors and how? Three groups of studies provide a discussion of this question. The first group compares different kinds of classroom situations. This includes studies by Jacob et a1. (1978), Klein and Young (1979), Whalen et a1. (1979), and Zentall (1980). The second group investigates the demand of the task on the child, namely simple and more difficult tasks. This includes studies by Pope (1970) and Steinkamp (1980). The thirdgroup compares the experimental and control groups in different playroom situations, including free to wander, free play and structured play. Studies by Hutt and Hutt (1964), Routh and Schroeder (1976), Schleifer et a1. (1975), Tizard (1968), and Ullman et a1. (1978) fall into this group. Jacob et a1. (1978) studied hyperactive children without brain damage in formal and informal classroom situations. The result showed that individual hyperactive behaviors varied greatly in the two situations, and in different directions. Taking the two most frequently occurring behaviors, change-of-position increased markedly from formal to informal situations, whereas day-dreaming decreased sharply. Whalen and her colleagues considered two kinds of situational factors: the noise of the background, and self-paced against other-paced setting. (During selfpaced periods, the boys could work at their own pace: during other-paced periods, they were required to modulate their activity in accord with external stimuli.) They found that noise decreased attention in hyperactive children on placebo, hyperactive children on stimulant drugs, and normal controls, but the hyperactive children on placebo had a greater decrease of attention compared with the other two groups. The effect of self-paced against other-paced setting is less cer (Whalen et ai., 1979).

3 340 s. L. LUK Author (Year) TABLE 1 Studies of Hyperactive Behavior' Subjects Situations Instrument Choice of Behavior and Results Activity Attention 1. Hutt and Hutt E -Organic pervasive- Free to Observation E vs. C, vs. C 2 No difference (1964) ness uncer wander E vs. C, vs. C 2 (n = 8) C,-Organic (n = 8) C 2-Hospital patient Free play Observation E>C," E>C," with minor psychi- E > C2" E> C2" atric problem C I>C2 C, > C 2" (n = 12) Structured Observation E>C," E>C," play E > C2" E > C2" C,>C 2 C1> C2" 2. Tizard (1968) E,-Organic pervasive Free play Observation E, > E2" E,> E 2 (n=8) E.-Organic situational Free to Photoelectronic E, vs. E 2 (n = 11) wander room 3. Pope (1970) E-Organic, normal IQ Free Actometer E>C pervasiveness uncer- play Observation E>C" E>C" Simple Actometer E vs. C (n = 19 in each task Observation E>C" E vs. C Difficult Actometer E>C" task Observation E>C" E>C" 4. Routh and E,-?Organic IQ mean Free Observation E, >C" E, vs. E. vs. C Schroeder (1976) 62.2 pervasiveness play E 2> C" uncer E, vs. E 2 E 2-Community pervasiveness uncer C -Normal Restricted Observation E, >C" E, >C" (n = 16 in each play E 2>C" E.> C" E, >E 2 E, > E. 5. Montagu (1975) E-Mixed pervasiveness Free play Ultrasonic system E>C" uncer and electronic pressure mats (n = 10 in each group, and microphone age 2-11) 6. Abikoff et al. E-Community group Classroom Observation E>C" E>C" (1977) pervasive structured (n = 60 in each 7. Jacob et al. E-Community group Classroom Observation E>C E>C" (1978) pervasiveness 5 out of structured 8 (n = 8) (n = 16) Classroom Observation Evs. C C>E unstructured 8. Klein and Young E-Community group Classroom Observation E>C" E>C" (1979) pervasiveness uncer- structured active Classroom Observation E>C" E>C" (n = 17 in each unstructured 9. Whalen et al. E -Community group Classroom Observation E>C," E>C," (1979) pervasiveness uncer- structured E>C" on placebo C l vs. C 2 E>C" c, vs. C 2 C,-Normal C 2- E medicated (n = 22 for E and C 2 ) (n = 39 for C,)

4 STUDIES OF HYPERACTIVE BEHAVIORS 341 Author (Year) TABLE I-Continued Subjects Situations Instrument Choice of Behavior and Results Activity 10. Zentall (980) E-Community group Classroom Observation E> C E>C pervasiveness uncer (n = 31 each II. Abikoffet al. E-Community group Classroom Observation E>C E>C (980) pervasive structured (n = 61 in each 12. Schleifer et al. E,-Community group Free play Observation E, vs. E 2 E, vs. E 2 (975) pervasive (n = 10) vs. C vs. C E 2-Community group Structured Observation E, >C situational hyperac- play E 2> C tive (n = 18) E, > E 2 C -Normal (n = 28; age 3-4) 13. Saxon et al. E,-Community group Free play Ultrasonic sound E, vs. E 2 (977) pervasiveness uncer- system vs. C. Drug responder E 2-Community group pervasiveness uncer. Drug nonresponder C -Normal (n = 5 in each 14. Cunningham and E-Community group Structured Actometer E>C Barkley (979) pervasiveness uncer- play (n = 20 in each 15. Worland et al. E-Community group Psychological Stabilimeter E>C (973) pervasiveness uncer- test Observation Combined score E>C (n = 25 in each 16. Juliano (974) E-Community group Psychological Stabilimeter E>C pervasiveness uncer- (n = 40) (n = 80) 17. Barkley and VIl- E -Community group Free play Actometer E>C, man (975) pervasiveness uncer- E>C" test (n = 16) C, vs. C 2 C,-Clinical control (n = 16) C 2-Normal (n = 20) Pedometer E vs. C, vs. C 2 Attention Observation E vs. C, vs. C 2 E vs. C, vs. C 2 Psychological Actometer E vs. C, vs, C 2 test Pedometer E vs. C, vs. C Worland (976) E-Community group Psychological Observation E>C pervasiveness uncer- test (coding) Psychological Observation (n = 16 in each test (spell E>C ing)

5 342 S. L. LUK TABLE I-Continued Author Choice of Behavior and Results Subjects Situations Instrument (Year) Activity Attention 19. Sandberg et al. E-Community group Psychological Observation Combined score (1978) pervasiveness uncer- test E>C (n = 7) C-Conduct problem (n = 22) 20. Ullman et al. E-Community group Free play Actometer E>C' (1978) pervasiveness uncer- Observation E>C' E>C' drug responder Restricted Actometer E>C' (n = 18 in each play Observation E>C' E vs. C Psychological Actometer E>C' test Stabilimeter E>C' Observation E>C' 2l. Firestone and E -Community group Psychological Stabilimeter E>C\' Martin (1970) pervasiveness uncer- test (reac- E>C. (n = 12) tion time E>C: C\-Behavior problem test) (n = 8) C.-Asthmatic children (n = 15) C.-Normal children (n = 15) 22. Sergeant et al. E-Community group Psychological Observation E>C' (1970) pervasiveness uncer- test (n = 10 in each 23. Steinkamp E-Community group Psychological Observation E>C' (1980) pervasiveness uncer- test (n = 13) (n = 11) Psychological Observation E vs. C test (simple: picture completion) 24. Plomin and Foch E-Community group Normal daily Pedometer C>E' (1981) pervasiveness uncer- activity for (n = 18) 1 week (n = 198) Structured Observation Evs. C play 25. Porrino et al. B-Community group Normalactiv- Acceleration sensi- E>C' (1983) pervasive (n = 12) ity for 1 tive device with (n = 12) week a memory sampling truncal movement E = hyperactive, C = nonhyperactive, = not significant, > = more than but nonsignificant trend, and >' = significantly more than. Klein and Young (1979) compared hyperactive subjects with normal subjects (who were considered active by their teacher) in structured and unstructured classroom settings. They found that the hyperactive boys did differ from the active normal boys in a number of classroom behaviors, but the differences were not more apparent under any particular type of classroom structure. However, they also noted that, in individual hyperactive boys, some became more hyperactive and some less hyperactive with an increase of structure in the situation. Zentall (1980) studied the effects of several different situations in the classroom on hyperactivity. Although he showed that situational factors did affect hyperactive behavior, as well as normal subjects, he did not find a consistent picture of the effect of situational factors on hyperactivity. To summarize, situational factors in the classroom probably influence hyperactive behavior, but there is yet no clear picture as to which are the salient factors and what are their effects.

6 343 STUDIES OF HYPERACTIVE BEHAVIORS In laboratory observations, behavior pering to attention is influenced by the demand of the task situation. In Pope's (1970) study comparing hyperactivity with brain damage to normal controls, no significant differences were found in the inattentive behaviors during a simple task situation, but significant differences were found in situations where the task was more difficult. In the study by Steinkamp (1980), comparing hyperactive children from the community with normal control, again there was no significant difference in simple task situations, but differences were found in a more difficult task situation. Steinkamp's study suggests that, in a simple task, not enough demand is made on the hyperactive child to reveal his inattentiveness. A previous study by Sykes et al. (1973) suggested that hyperactive children were not different from normal controls in the ability to direct their attention for brief periods of time but were limited in their ability to main attention over prolonged time periods. Conners (1975) reported an experiment in which hyperactive children were asked to make a simple perceptual discrimination, with only the amount of information in the display varying between tasks. The effect of the "distraction" became apparent only at the higher information level. He suggested that a distractible child will often show his distractibility only under conditions of increased information load. Concerning different play room situations, Hutt and Hutt (1964) compared hyperactive children with epileptic brain-damaged, nonhyperactive children with epileptic brain damage and psychiatric clinic attenders across three play room situations: "free to wander," "free play" and "structured play." The hyperactive children with brain damage showed little variability of overactivity or inattention across all three situations, whereas the other two groups varied with the situation-especially the psychiatric clinic attenders. Routh and Schroeder (1976) compared mental retardation with hyperactivity groups with clinic hyperactive children without brain damage and normal controls in free play and restricted play situations. Their results showed that subjects with hyperactivity associated with mental retardation varied their activity much less with situational changes than the other two groups. Tizard (1968) studied two groups of severely mentally retarded children rated either as very overactive or not overactive in two different situations, with and without toys. The amount and nature of the movements were measured. Stimulus variation did not affect the overall movement score, although it did affect the nature of the children's activity. With toys present, both groups of children explored their environ- ments less and decreased rocking and head-banging behavior. Schleifer et al. (1975) compared pervasive hyperactive preschool children without brain damage, situational hyperactive preschool children without brain damage, and normal preschool children in free play and structured play situations. There was no difference among the three groups in the free play situations but significant differences in structured play situations. From the limited data provided, no further inference about situational effects was possible. Ullman et al. (1978) compared a group of hyperactive children, diagnosed by pediatricians and responsive to methyphenidate, with a group of normal controls in free play and restricted play situations. The authors did not analyze the situational effects, but there is a trend suggesting that the hyperactive behaviors of the hyperactive children varied with situation change, with less overactive and inattentive behaviors in a restrictive play situation. In summary, if one looks at hyperactive children without brain damage, studies comparing different play situations suggest that restricted or structured play situation will reduce the hyperactive behaviors. However, this result applies only to play situations of short duration, e.g., about 5-10 minutes. If we consider hyperactivity associated with brain damage, it seems to be much less affected by situational factors. Only a small number of studies, however, have reported on hyperactive children associated with brain damage. Thus any conclusion drawn about them will be very tentative. Limitation of the Review Two points of caution should be noted. First, this review is based on results of comparisons of groups of hyperactive children with control groups. The review does not look at individual hyperactive children. Although as a group the hyperactive children were more overactive and inattentive than control groups, it does not follow that a hyperactive child is always both overactive and inattentive. Some studies have shown that activity level was not significantly related to the measures of attention in individual children (Barkley and Ullman, 1975; Ullman et al., 1978). This would emphasize the heterogeneity of the hyperactive children, especially in the non-brain-damaged group. Second, one of the controversies in the study of hyperactivity is whether the syndrome is the same as conduct disorder. This review does not attempt to answer this question. References H., GITIELMAN, R. & KLEIN, D. F. (1977), Validation of a classroom observation code for hyperactive children. J. Consult. Clin. Psychol. 45: ABIKOFF,

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