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Understanding and Management of Attention Deficit Hyperactivity Disorder: Psychological Case Study

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International Journal of Humanities and Social Science Vol. 9 • No. 6 • June 2019 doi:10.30845/ijhss.v9n6p12
96
Understanding and Management of Attention Deficit Hyperactivity Disorder:
Psychological Case Study
Dr Asma Perveen
Senior lecturer, clinical psychologist
Psychology and Counselling Department
Faculty of Human Development
Sultan Idris Education University
Dr Fauziah binti Mohd Sa'ad
Senior Lecturer
Psychology and Counselling Department
Faculty of Human Development
Sultan Idris Education University
Abstract
This case study examines the importance of psychological assessment and interventions to handle impulsivity and
inattention behavior of 8 years old boy. Case study finds are based on clinical interview, family sessions, teachers
recommendation plans, psychological assessment, and individual intervention plans. The child attended the sessions
for 12 weeks. The interventions have a significant effect on the behavior outcome and family understanding about the
child, emotional, cognitive and social issues. Child behavior was significantly improved in the classroom by engaging
in activities and providing positive verbal support and appreciation by teachers. Study shows the significant
importance of psychological management to manage childhood problems. The early detection of issues and
management can help the children to learn effectively in school and society. The implications of the study are
important for healthy development and early childhood education.
Keywords: Attention deficit hyperactive disorder, psychological intervention, assessment, management.
Introduction
A psychotherapy case report is a piece of research that makes a contribution, however modest, to current psychological
knowledge. The case study methodology is a set of principles for deriving clinically useful or socially relevant
knowledge from the material of cases. Historically, case study research has been marginalized in psychology and been
overshadowed by quantitative methods relying on group comparisons of scores on specific variables. Yet without a
case-based strategy of research, it is not possible to derive meaningful principles on which to base everyday practice
(Edwards, Dattilio& Bromley, 2004). Case studies are in-depth investigations of a single person, group, event or
community. Typically, data are gathered from a variety of sources and by using several different methods like
observation and interview and therapy intervention (Gulsecen 2006). Mcleods (2016) reported that case studies are
often conducted in clinical medicine and involve collecting and reporting descriptive information about a particular
person or specific environment, such as a school. In psychology, case studies are often confined to the study of a
particular individual (Bromley, 1998).
Attention-deficit/hyperactivity disorder (ADHD), a behavioral disorder characterized by functional impairments in the
areas of impulsivity, hyperactivity, and/or inattention, is one of the most frequently identified psychological disorders
of school-age children and adolescents (Langberg, Froehlich, Loren, Martin, & Epstein, 2008). Current prevalence
estimates suggest that as many as 3% 7% of children in the United States evidence clinically significant symptoms of
the disorder (Stein et al., 2009). ADHD is widely regarded as a chronic and biologically based disorder characterized
by specific deficits in executive functioning that persist into adulthood (Barkley, 2006). Youth with ADHD are at
greater risk for the development of co-morbid psychiatric problems, including conduct problems, substance abuse, and
mood disorders, and are also likely to evidence significant difficulties in the areas of academic performance and
interpersonal skills (American Academy of Child and Adolescent Psychiatry, 2007).
Attention Deficit Hyperactivity Disorder (ADHD) is not a disease or the result of damage to the brain but it a
dysfunction that means the brain doesn't function in the way it should. The exact cause is not clear.
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ADHD symptoms include trouble paying attention, trouble sitting still for even a short time and acting before thinking.
(Christina 2015)Attention Deficit Disorders require an in-depth examination of a child‟s medical, social, and family
history (Diamond et al, 1996). Difficult behaviors and academic concerns may develop secondary to medical problems,
language delays, learning disabilities, delayed cognition, and mood disorders. These issues must be explored to create a
comprehensive diagnostic and treatment plan. (Jon, 2014)
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as
characterized by (1) and/or (2): 1. Inattention: Six (or more) of the following symptoms have persisted for at least 6
months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and
academic/occupational activities. Diagnostic Statistical Manual, DSM V, (2013) included the symptoms of
hyperactivity, impulsivity, and inattention with criteria of (0= Not a problem), (1= Mild problem), (2= Severe
problem).
DSM-V diagnostic criteria for ADHD: symptoms of inattention, hyperactivity and impulsivity
Symptoms of inattention
Symptoms of hyperactivity and impulsivity
Often fails to give close attention to detail or makes
mistakes
Often fidgets with or taps hands and feet, or squirms in seat
Often has difficulty sustaining attention in tasks or
activities
Often leaves seat in situations when remaining seated is expected
Often does not seem to listen when spoken to directly
Often runs and climbs in situations where it is inappropriate (in
adolescents or adults, may be limited to feeling restless)
Often does not follow through on instructions and fails
to finish schoolwork or workplace duties
Often unable to play or engage in leisure activities quietly
Often has difficulty organizing tasks and activities
Is often „on the go‟, acting as if „driven by a motor‟
Often avoids, dislikes or is reluctant to engage in tasks
that require sustained mental effort
Often talks excessively
Often loses things necessary for tasks or activities
Often blurts out answers before a question has been completed
Is easily distracted by extraneous stimuli
Often has difficulty waiting their turn
Is often forgetful in daily activities
Often interrupts or intrudes on others
(DSM V 2013)
The exact etiology of ADHD is unknown, but it is thought to be caused by the combination of environmental, genetic,
and biological factors. (Stein et al, 2013)
Objectives:
1. To assess the behavior's problems
2. To evaluate therapeutic management
3. To increase family involvement in the management plan
Methodology:
This research case study is based on a single case study including clinical assessment, family, and teachers reports and
engagement in therapeutic plans for 12 weeks, 1/session per week. The client was assessed by multiple sources:
The client was assessed through the following psychological methods:
1- Clinical interview
2- Family information
3- School reports
Psychological assessment tools:
1-IQ assessment Test, P-Toni
2-Thematic Appreciation Test
3-Human Figure drawing test
4- ADHD scale
International Journal of Humanities and Social Science Vol. 9 • No. 6 • June 2019 doi:10.30845/ijhss.v9n6p12
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The client was assessed during the first week of January 2019, after three weeks of assessment Client received
psychological sessions for 12 weeks, 1/per week of 50 minutes, based on psychological interventions behavior
modification, and encouragement to participate in social engagement. Psychological interventions also included, token
economy, play therapy, expressive art activities, home-based appreciation and reinforcement for positive behavior,
school-based engagement and performance with reinforcement of positive appraisal from teachers, reducing the time of
gadgets use by increasing more time to play outside with family members. The client has been assessed three-time pre,
follow up and post-assessment by administering the checklist of inattention and impulsivity scale of (10=item) based on
ADHD scale. The item on the behavior checklist scale was rated on 5 points Likert scale, Never=0, sometime=1, most
of the time=2, frequently=3, and always=4. Pre-assessment was done after the overall assessment procedure of
diagnosing, follow up assessment was completed after 6 weeks of intervention and then after 12 weeks, the post-
assessment was completed. The pre and post results analysis proved the effectiveness of therapeutic interventions.
Procedure:
Referral source: Client was referred for assessment and management by the general physician in the 1st week of
January 2019.
Informed Consent: Informed consent was obtained from the parents and the child for psychological assessment and
interventions. Parents were informed about the therapeutic plans to improve the child's behavior. Parental and child
permission was taken for the case study publication without including any of their personal information. Parents were
informed that no personal information will be revealed in the case study.
Relevant Background Information: Parents informed that child‟s problems were significantly effecting for the last 4
years. Parents reported that the early millstones were normal, expect delayed speaking, and he started speaking at the
age of 5 years. There were no other specific developmental issues recorded. Presently he is 8 years old, studying in
Malaysian Government primary school in level 1 grade. His mother revealed that he has problems focusing on his
studies. He did not follow the instruction of his teacher and not cooperate with teachers in any classroom activities. His
school performance is declining and he has been labeled as a problematic child in his school. He was repeating the
same class the second time. He is eldest among his five siblings, his mother is a school teacher. Both parents are
working, so throughout his development, he has a lack of parental support and quality time. He liked to play games. He
frequently has fighting behavior with his other siblings. Client behaves most of the time stubborn to get what he wants
as compared to other siblings. According to the mother, he has a poor social relationship, as he has difficulty to
communicate with other kids. Teacher‟s Feedback: According to school reports by teachers, he hardly follows
instruction. He is inattentive in the classroom activities and spends most the time roaming around and disturb other kids
by using their books and pencils. Most of the teachers already declared him a problematic kid.
Current Mental Status/Behavioural Observations: He was cooperative during the assessment. His thought process
was occupied with imaginative stories. His mood was pleasant.
Presenting Problem: Disturbed behavior at school, low performance, lack of interest in activities, unable to follow
instruction, behavior tantrum problem since last 4 years.
Assessment Test Results
TONI 4 (Test of Nonverbal Intelligence Fourth Edition
Raw Score: 40
Index Score: 126
Percentile Range: 92-98
Descriptive Term: Superior
Age Equivalent: 16-0
GARS 3 (Gilliam Autism Rating Scale Third Edition)
Sum of Scaled Scores: 60
Percentile Range: 50
Autism Index: 100
Severity Level: 2 (Requiring minimal Support)
ADHD (Attention Deficit Hyperactive Disorder Test)
Sum of Score: 40 ADHD Quotient: 117
Degree of severity: Above Average (Inattention (120)
Required special support for Attention
Children Thematic Appreciation Test
Most of the stories were about the Client‟s imagination and his emotional expressions
He builds a connection with the stories from different pictures cards.
Frequently mentioned feelings dizziness, bleeding, and death. He perceived the feelings of sadness, discomfort, disturbed interaction and relationship among
the characteries of the stories based on picture cards.
Client stated about the ghost, the zombie in a few picture cards.
Never mention the happy and comfortables feeling or thoughts about any picture card
Current Diagnostic Impression:
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Inattention issues, difficulty to express emotional response and cognitive style are distorted and having Autisms
symptoms with needed substantial Support. His Intellectual capacities are above average in the range of intelligence.
He obtained the severity level of the score on the ADHD scale.
The client is suffering from Attention Deficit Hyperactivity Disorder
Results and Discussion:
The therapeutic intervention was based on behaviors, cognitive and social involvement and improvement. Client
received face to face therapy sessions 12 weeks, 50 mints 1/session per week.
Table 1One-Sample Test to compare the mean of pre-test, follow and post-test score with 10 variables
of behavior scale
t
df
Mean Difference
95% Confidence Interval
of the Difference
Lower
Upper
Pre assessment
4.583
9
.70000
.3544
1.0456
Follow up
13.500
9
1.80000
1.4984
2.1016
Post assessment
21.604
9
3.30000
2.9544
3.6456
Table 2
Pre Assessment - Psychological Interventions
Psychological Interventions
Total
Behavior modification
Social skills
training
Play
therapy
Expressive
therapy
Pre assessment
Never
1
0
1
1
3
Sometime
1
2
1
3
7
Total
2
2
2
4
10
Follow up
Psychological Interventions
Total
Behavior modification
Social skills
training
Play therapy
Expressive
therapy
Follow up
Sometimes
1
0
1
0
2
Most of the time
1
2
1
4
8
Total
2
2
2
4
10
Post assessment
Psychological Interventions
Total
Behavior
modification
Social skills
training
play therapy
Expressive
therapy
Post assessment
Frequently
1
2
2
2
7
Always
1
0
0
2
3
Total
2
2
2
4
10
Table 3 Psychological Interventions repeated measure
Psychological Interventions
time
Mean
Std. Error
95% Confidence Interval
Lower Bound
Upper Bound
Behaviour modification
1
.500
.382
-.434
1.434
2
1.500
.289
.794
2.206
3
3.500
.354
2.635
4.365
Social skills training
1
1.000
.382
.066
1.934
2
2.000
.289
1.294
2.706
3
3.000
.354
2.135
3.865
Play therapy
1
.500
.382
-.434
1.434
2
1.500
.289
.794
2.206
3
3.000
.354
2.135
3.865
Expressive therapy
1
.750
.270
.089
1.411
2
2.000
.204
1.501
2.499
3
3.500
.250
2.888
4.112
International Journal of Humanities and Social Science Vol. 9 • No. 6 • June 2019 doi:10.30845/ijhss.v9n6p12
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Figure 1
Results revealed that the individual and family-based intervention highlighted the improvement in the Client‟s behavior
to increase social conversation in a friendly manner. Client received individual therapy session based on activities
expressive art, play, fixable toys, puzzle games, had toys, making stories from pictures and sharing about his daily
activities in each therapy session. The sessions were based on behavior modification, social skills training, play
therapy, and expressive therapy interventions. Table 1 results indicated that there was a significant mean difference
(mean=4.583) pre-assessment, follow up (mean=13.500) and post-assessment (mean=21.604)
Table 2 indicated that there was a significant difference of results in scale from never to some time score in pre-
assessment, and follow up indicated that there was reported score on some time to most of the time, and post-
assessment indicated that the client score on behavior checklist was most reported on frequently to always. The client
has positive changes in the checklist of behavior domains on the checklist as compare to pre-assessment, follow up
assessment and post-assessment. Table 3 and figure 1, reported that the intervention significantly increased the score on
the behavior checklist domains, which shows that the client have reported positive changes in the behavior of
involvement with family and friends. The client has reported positive engagement in classroom activities and play
activities with other peers. Behaviour related to the task, like managing the task, waiting for a turn, following
instruction, reduced distracted behavior and loud voices behavior. There is a wide range of therapies which fall under
the term “behavioral interventions” (Cognitive Behavioural Therapy, Meta Cognitive Therapy, Psychosocial Therapy,
Organizational Skill Training, and Multimodal Psychosocial Treatment), (Robb, 2017). This review, however, does not
individually explore the efficacy of the different interventions, rather, the different behavior interventions were
reviewed under the heading of “Behavioural Interventions”. There were very few studies looking into the effect of CBT
(Cognitive Behaviour Therapy) in un-medicated ADHD patients (Solanto et al, 2010).
Follow up with the client family and teachers to record the progress report, and involvement of teachers and parents
improved clients functioning academically and socially. Therapeutic processes such as developing a strong working
alliance and engaging parents and students are key elements of treatment delivery and receipt in school-based mental
health programming and should be explicitly trained and monitored. (Breaux et al, 2018) Parents and teacher were
recommended to follow the behavior intervention to increase the better behavior outcome. Education to parents was
provided in begging of interventions, as understanding the problem is better in management (Gureasko et al, 2006).
Education of family about ADHD should include an explanation of the symptoms of the disorder and how it can affect
learning, behavior, social skills and family functioning. Better understanding enhanced Client level of self-esteem, as
the family and teacher handle the problem in positive ay rather than labeling the behavior problems.
These findings support clinical practice guidelines and suggest that parenting interventions are effective. There is a
need to ensure the availability of parenting interventions in community settings (Coates et al, 2015). Parental and
teachers involvement helped to improve and keep follow up for good progress. Parents and teachers were very
cooperative to increase the positive behavior of the client.
0
1
2
3
4
5
6
7
8
Behavior Assessment
Pre
Follow up
Post
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Cognitive level or thinking skills, Language abilities, and Age-appropriate skills needed to complete daily activities.
(National Institute of Mental Health 2017) Psychological intervention includes using token economy systems to
motivate a child to achieve a goal identified in a behavioral contract (Barkley, 2015). A child can earn points for each
homework assignment completed on time (Owens et al 2012). In some cases, students also lose points for each
homework assignment not completed on time. After earning a specified number of points, the student receives a
tangible reward, such as extra time on a computer or a "free" period on Friday afternoon. (McLeod, 2016)
Behavior therapy requires both time and effort, but it can lead to improved functioning at home, at school, and socially
(CDC, 2016). American Association of Psychology (2011) defines "behavior therapy" as follows: Behaviour therapy
represents a broad set of specific interventions that have a common goal of modifying the physical and social
environment to alter or change behavior. Although behavior therapy shares a set of principles, individual programs
introduce different techniques and strategies to achieve the same ends. Psychological sessions enhanced sitting
behavior, social greeting, and task accomplishment through engaging the client in social interaction and playing with
siblings during the sessions. Behavior therapy helps children learn to better control their own behavior, which leads to
improved functioning at school, home, and relationships (CDC, 2016). Although learning and practicing new behaviors
requires time and effort, it has lasting benefits for children. Research suggests the benefits of psychological
interventions reliant on skill-building and conditioning, academic organization and planning skills development, social
skills training. During the therapy sessions, Client established behavioral or academic goals. The client was facilitated
to choose different activities to participate like coloring, drawing, using clay to make different objects to express his
skills. With family and teacher, the therapist chooses several target situations and breakdown the situation (task) into
smaller units. Tokens (points, stickers) provided immediately.
Follow-up: Every week client attended the session based on different behavioral, cognitive and social activities.
Client‟s family and teacher were contacted regularly after two weeks to follow up on the improvement reports. Client‟s
family and teacher followed the recommendations and actively participated in intervention for the improvement of
child behavior and performance at home and school.
Treatment Outcome: Therapeutic interventions positively changed the child behavior problems an inattention from
severe to moderate problems within 12 weeks. Clients received positive feedback from school and healthy
encouragement from parents.
Discussion and Implications:
ADHD is a multifaceted, behavioral and neurological disorder that is associated with deficits in multiple areas of
functioning. Psychological behavioral strategies are effective in decreasing ADHD symptoms over the long term.
Empirical studies of psychological interventions have supported the efficacy of two major approaches: behavioral (both
antecedent-based and consequent-based) and academic interventions. Furthermore, some promising interventions for
addressing social relationship difficulties among students with this disorder have been developed. Parental involvement
and education are highly significant in the management of ADHD symptoms. School-based professionals are urged to
implement empirically supported strategies through individualizing interventions based on assessment. Furthermore, a
long-term approach to treatment across school years will necessitate ongoing, consistent communication among
parents, teachers, physicians, and other health professionals. Through the long-term implementation of evidence-based
strategies, it is hoped that the deficits characteristic of ADHD will be minimized and the likelihood of school success
for these students will be optimized.
Recommendations:
Need supportive interventions to work on ADHD symptoms in the school system. Further researches are required to
increase the efficacy of the psychological intervention. Need to highlight the individual teaching plan in classroom
activities with support and behavior modification techniques.
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Exercise has attracted attention as a potential helpful intervention in children with ADHD. Effects are emphasized on cognition, social-emotional, and motor development. A systematic literature search was conducted using the electronic databases Web of Science, PubMed, Scopus, and ERIC to analyze the efficacy of different types of exercise interventions in children and adolescents with ADHD. Seven studies examining the acute and 14 studies examining the long-term effects were included. The largest effects were reported for mixed exercise programs on ADHD symptomatology and fine motor precision. However, because of the large differences in the study designs, the comparability is limited. At that time, no evidence-based recommendation can be formulated regarding frequency, intensity, or duration of exercise. Nevertheless, some first trends regarding the effects of certain types of exercise can be identified. When focusing on long-term health benefits in children and adolescents with ADHD, qualitative exercise characteristics might play an important role. © 2015 SAGE Publications.
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Objective: To evaluate the evidence base relating to the effectiveness of parent-administered behavioral interventions for ADHD. Method: A systematic review of randomized controlled trials or non-randomized but adequately controlled trials for children with ADHD or high levels of ADHD symptoms was carried out across multiple databases. For meta-analyses, the most proximal ratings of child symptoms were used as the primary outcome measure. Results: Eleven studies met inclusion criteria (603 children, age range = 33-144 months). Parenting interventions were associated with reduction in ADHD symptoms (Standardized Mean Difference [SMD] = 0.68; 95% confidence interval [CI] [0.32, 1.04]). There was no evidence of attenuation of effectiveness after excluding studies where medication was also used. Parenting interventions were also effective for comorbid conduct problems (SMD = 0.59; 95% CI [0.29, 0.90]) and parenting self-esteem (SMD = 0.93; 95% CI [0.48, 1.39]). Conclusion: These findings support clinical practice guidelines and suggest that parenting interventions are effective. There is a need to ensure the availability of parenting interventions in community settings.
Book
Recent years have seen tremendous advances in understanding and treating Attention-Deficit/Hyperactivity Disorder (ADHD). Now in a revised and expanded third edition, this authoritative handbook brings the field up to date with current, practical information on nearly every aspect of the disorder. Drawing on his own and others' ongoing, influential research - and the wisdom gleaned from decades of front-line clinical experience - Russell A. Barkley provides insights and tools for professionals working with children, adolescents, or adults. Part I presents foundational knowledge about the nature and developmental course of ADHD and its neurological, genetic, and environmental underpinnings. The symptoms and subtypes of the disorder are discussed, as are associated cognitive and developmental challenges and psychiatric comorbidities. In Parts II and III, Barkley is joined by other leading experts who offer state-of-the-art guidelines for clinical management. Assessment instruments and procedures are described in detail, with expanded coverage of adult assessment. Treatment chapters then review the full array of available approaches - parent training programs, family-focused intervention for teens, school- and classroom-based approaches, psychological counseling, and pharmacotherapy - integrating findings from hundreds of new studies. The volume also addresses such developments as once-daily sustained delivery systems for stimulant medications and a new medication, atomoxetine. Of special note, a new chapter has been added on combined therapies. Chapters in the third edition now conclude with user-friendly Key Clinical Points. This comprehensive volume is intended for a broad range of professionals, including child and adult clinical psychologists and psychiatrists, school psychologists, and pediatricians. It serves as a scholarly yet accessible text for graduate-level courses. Note: Practitioners wishing to implement the assessment and treatment recommendations in the Handbook are advised to purchase the companion Workbook, which contains a complete set of forms, questionnaires, and handouts, in a large-size format with permission to photocopy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)(jacket)
Article
This study examined the percentage of children who respond positively to a daily report card (DRC) intervention and the extent to which students achieve incremental benefits with each month of intervention in a general education classroom. Participants were 66 children (87% male) with attention-deficit hyperactivity disorder or disruptive behavior problems who were enrolled in a school-based intervention program in rural, low-income school districts in a Midwest state. The DRC was implemented by each child's teacher, who received consultation from a graduate student clinician, school district counselor, or school district social worker. A latent class analysis using growth-mixture modeling identified two classes of response patterns (i.e., significant improvement and significant decline). Results indicated that 72% of the sample had all of their target behaviors classified as improved, 8% had all of their targets classified as declining, and 20% had one target behavior in each class. To examine the monthly incremental benefit of the DRC, individual effect sizes were calculated. Results for the overall sample indicated that most children experience a benefit of large magnitude (.78) within the first month, with continued incremental benefits through Month 4. The differential pattern of effect sizes for the group of improvers and the group of decliners offer data to determine when and if the DRC should be discontinued and an alternative strategy attempted. Evidence-based guidelines for practical implementation of the DRC are discussed.
Article
Attention-deficit/hyperactivity disorder, the most common childhood behavioral condition, is one that pediatricians think they should identify and treat/manage. Our goals were to explore the relationships between pediatricians' self-reports of their practice behaviors concerning usually inquiring about and treating/managing attention-deficit/hyperactivity disorder and (1) attitudes regarding perceived responsibility for attention-deficit/hyperactivity disorder and (2) personal and practice characteristics. We analyzed data from the 59th Periodic Survey of the American Academy of Pediatrics for the 447 respondents who practice exclusively in general pediatrics. Bivariate and logistic regression analyses were used to identify attitudes and personal and practice characteristics associated with usually identifying and treating/managing attention-deficit/hyperactivity disorder. A total of 67% reported that they usually inquire about and 65% reported that they usually treat/manage attention-deficit/hyperactivity disorder. Factors positively associated with usually inquiring about attention-deficit/hyperactivity disorder in adjusted multivariable analyses include perceived high prevalence among current patients, attendance at a lecture/conference on child mental health in the past 2 years, having patients who are assigned or can select a specific pediatrician, practicing in suburban communities, practicing for > or =10 years, and being female. Pediatricians' attitudes about responsibility for identification of attention-deficit/hyperactivity disorder were not associated with usually inquiring about attention-deficit/hyperactivity disorder in either unadjusted or adjusted analyses. Attitudes about treating/managing attention-deficit/hyperactivity disorder were significantly associated with usually treating/managing attention-deficit/hyperactivity disorder in unadjusted and adjusted analyses. Those who perceived that pediatricians should be responsible for treating/managing had almost 12 times the odds of reporting treating/managing attention-deficit/hyperactivity disorder, whereas those who believe physicians should refer had threefold decreased odds of treating/managing. Other physician/practice characteristics significantly associated with the odds of usually treating/managing attention-deficit/hyperactivity disorder include belief that attention-deficit/hyperactivity disorder is very prevalent among current patients, seeing patients who are assigned or can select a specific pediatrician, and practice location. Taking responsibility for treating attention-deficit/hyperactivity disorder and practice characteristics seem to be important correlates of pediatrician self-reported behavior toward caring for children with attention-deficit/hyperactivity disorder.