Journal of Consulting and Clinical Psychology Copyright 1992 by the American Psychological Association, Inc.

1992, Vol. 60, No. 6, 893-903 0022-006X/92/$3.00

Academic Underachievement, Attention Deficits, and Aggression:

Comorbidity and Implications for Intervention
Stephen R Hinshaw
University of California, Berkeley

Although comorbidity with specific learning disabilities is less frequent than commonly reported,
externalizing behavior disordersparticularly attention-deficit hyperactivity disorder (ADHD)
often overlap with various indices of academic underachievement during childhood. Furthermore,
by adolescence, delinquency is clearly associated with school failure. Because the link between
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behavioral and learning problems often appears before formal schooling, and because the comor-
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bid problems predict a negative course, early intervention is a necessity. Controlled treatment
investigations with youngsters who show these combined problems are rare, and such studies
present a host of methodologic and practical problems. I discuss issues surrounding multimodality
treatment programs and the potential for long-term interventions to break cycles of school failure
and externalizing behavior.

Overlap between achievement difficulties, particularly in
reading, and behavior problems of an externalizing or acting-
out nature has been noted for many decades. My purposes in
this article are to (a) highlight diagnostic issues that pertain to
each domain; (b) cover theoretical issues regarding the overlap
of these problem areas, including clarification of the specificity
of the linkage; (c) review validated intervention strategies for
the single disorders; (d) report on empirical treatment investi-
gations of children with comorbid achievement and behavior
problems; (e) discuss pertinent clinical, methodologic, and theo-
retical issues regarding such intervention; and (f) make recom-
mendations for subsequent research. As readers will discover,
the field has far to go before definitive treatment prescriptions
can be made with regard to youngsters who display the distress-
ingly persistent combination of externalizing behavior prob-
lems and academic failure.
Description of Domains
Academic Underachievement
Reflecting the variegated conceptions of academic attain-
ment and academic failure that currently exist, a wide variety of
terms is used to describe children whose school achievement is
found to be deficient (e.g., school failure, learning difficulty,
underachievement, specific learning disability, dyslexia, and
specific developmental disorder). Thus, in empirical investiga-
tions, outcome measures that pertain to suboptimal academic
performance are quite divergent; they include (to name a few)
placement in special education classes, retention, low grades,
This article was supported by National Institute of Mental Health
Grant 45064.
Correspondence concerning this article should be addressed to Ste-
phen P. Hinshaw, Department of Psychology, Tolman Hall, University
of California, Berkeley, California 94720.
893
suspension, poor absolute performance on standardized
achievement tests, and achievement test scores that fall below
the level predicted from the child's intelligence. This heteroge-
neous set of criteria for underachievement presents a major
methodologic and conceptual problem for those who wish to
appraise either comorbidity with behavioral disorders or effects
of interventions.
Over the past several decades, considerable research focus
has been directed to the subgroup of underachieving young-
sters whose test scores in academic areas, particularly reading,
fall substantially below levels that would be expected on the
basis of their intellectual abilities. The underlying conception is
to separate those children with demonstrable reasons for low
achievement (i.e., subaverage intelligence) from those whose aca-
demic deficiencies are not so readily explainable. The latter
group is considered to have specific learning disabilities (or, in
the nomenclature of the Diagnostic and Statistical Manual of
Mental Disorders [3rd ed., rev; DSM-HI-R; American Psychiat-
ric Association, 1987], specific developmental disorders). Be-
cause their deficient academic performance is not attributable
to subaverage cognitive potential, to obvious physical or sensory
deficits, or to inferior educational opportunities (see Rutter &
Yule, 1975; Yule & Rutter, 1985), these children are often pre-
sumed to have subtle neurological deficiencies that underlie the
achievement problems. (Note that because group-administered
general-ability tests place a premium on readingwhich
would confound a diagnosis on the basis of disparity between
intelligence and reading skillit is considered a necessity to
diagnose such specific learning disabilities on the basis of indi-
vidually administered IQ tests.)
The divergent validity of such IQ-discrepant learning diffi-
culties from so-called general problems in achievement has
been examined in a number of investigations. Recent evidence
indicates that, despite the importance of considering IQ in as-
sessing learning problems (Torgeson, 1989) and despite the sur-
prisingly slow progress made by children with specific learning
problems (Rutter & Yule, 1975), the patterns of difference be-
 894 STEPHEN P. HINSHAW
tween general and specific learning difficulties are less clear
and less stable over time than once thought (e.g., McGee, Wil-
liams, Share, Anderson, & Silva, 1986; Taylor, 1988), and sole
consideration of children with specific learning problems ne-
glects the very real achievement problems of children with IQ
scores below the normchildren who are likely to suffer addi-
tional problems of low social class and poor educational oppor-
tunities. Furthermore, because the majority of children with
poor achievement scores fall into the "general" category, exclu-
sive focus on specific learning disabilities limits representative-
ness. In short, the inclusionary criterion of an IQ-achievement
disparity may unduly restrict sampling of achievement prob-
lems and may lead to neglect of important motivational and
social factors that pertain to poor academic performance (Tay-
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lor, 1989).'
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Prevalence estimates for underachievement vary widely, de-
pending on the type and stringency of the criteria involved in
diagnosis. The epidemiologic work of Rutter and colleagues in
the United Kingdom indicated that general reading problems
were present at levels of 7% on the Isle of Wight and 20% in
inner London, whereas specific (IQ-discrepant) reading disabil-
ities had respective prevalences of 4% and 10% (Rutter et al.,
1974). These data reveal both the greater presence of general, as
opposed to specific, learning problems and the strong influ-
ence of psychosocial factors, particularly inner-city life and low
socioeconomic status (SES), on rates of severe underachieve-
ment. Data from the United States reveal similar prevalence
rates (e.g., American Psychiatric Association, 1987; Taylor,
1989). Although boys typically outnumber girls by a consider-
able margin with respect to diagnosed learning problems, re-
cent data from unselected populations indicate that this dispar-
ity may reflect gender-related differences in accompanying
behavior problems rather than in absolute levels of underachie-
vement (Shaywitz, Shaywitz, Fletcher, & Escobar, 1990). Severe
learning deficits in children are quite costly, in terms of both
the enormous expenses related to special education and the
personal suffering and frustration for children and families;
furthermore, they are quite persistent, with continuing achieve-
ment difficulties triggering accompanying problems in self-es-
teem, peer relations, and adult adjustment (e.g., Horn, O'Don-
nell, & Vitulano, 1983; Spreen, 1988). Thus, development of
effective intervention strategies for underachieving children
must be viewed as a major societal issue.
To establish a rational basis on which to develop effective
treatments, investigators have attempted to discern meaningful
subgroups of the wide array of children with deficient academic
skills (e.g., Lyon, 1985). Indeed, proponents of such subtyping
efforts contend that a given group of children with similar lev-
els of deficient academic performance in, say, reading often
display markedly divergent neuropsychological or motivational
deficits (Rourke, 1985; Snowling, 1991), differences that are
masked by classification on the basis of achievement-related
performance per se. Whereas protracted discussion of the
various theoretical bases for such subtyping is beyond the
scope of this article, the overarching point is that establishment
of a learning disability by way of documentation of low aca-
demic test scores, whether or not IQ is considered, is only the
beginning of treatment planning. Consideration of a host of
additional factors both within the child (e.g., presence of lan-
guage delays, neuropsychological strengths and weaknesses)
and in the environment (e.g., classroom composition, familial
attitudes) is required before lasting gains from intervention can
be expected (Taylor, 1989; but see also Gittelman & Feingold,
1983).
Disruptive Behavior Disorders
Whereas diagnosis of learning/achievement difficulties is
typically based on test scores gained from administration of
individual assessments of IQ and academic performance, chil-
dren are categorized as behaviorally disordered chiefly by
means of parental or teacher ratings (or, more recently, struc-
tured interviews). Externalizing behavior disorderspresently
called disruptive behavior disorders in DSM-HI-Rhave a long
psychometric history; they incorporate such features as impul-
sivity, defiance, disruption, inattention, overactivity, and a host
of antisocial acts. These behaviors are psychometrically separa-
ble from internalizing tendencies, which constitute sadness,
withdrawal, somatic concerns, and anxiety. In addition, most
evidence reveals that externalizing or disruptive behavioral
problems are more likely to persist over time than are interna-
lizing behaviors. Furthermore, they are quite refractory to typi-
cal interventions and, like severe underachievement, comprise
a major psychological, economic, and social problem (Kazdin,
1987; Loeber, 1990; Robins, 1991).
Although the various externalizing behavior problems tend
to load together on higher order factorial dimensions, mean-
ingful subdivisions exist within this domain. In particular, di-
mensions or categories of inattentive and impulsive actions are
separable from defiant, aggressive, and antisocial behaviors on
the basis of criteria that are both internal (i.e., different factor
structure) and external (e.g., divergent family history, correlates,
and course; see Hinshaw, 1987). In DSM-HI-R, the pertinent
categories include attention-deficit hyperactivity disorder
(ADHD), which is marked by developmentally inappropriate
and persistent dysregulation of attention, impulse control, and
motoric activity. (In several of the investigations reviewed be-
low, earlier diagnostic procedures mandate the use of prior
terms for ADHD-related syndromes, including both hyperactiv-
ity and attention-deficit disorder with hyperactivity, or ADDH.)
More frankly antisocial disorders include oppositional-defiant
disorder (ODD) and conduct disorder (CD). ODD and CD are
syndromes marked by excessive levels of hostility, defiance, and
noncompliance and by recurrent antisocial and aggressive ac-
tions, including assault, bullying, stealing, and fighting, respec-
tively. Whereas extensive comorbidity exists between ADHD
and these more aggressive disruptive behavior disorders (see
Abikoff & Klein, 1992; Hinshaw, 1987) and whereas latent vari-
ables of these constructs correlate at extremely high levels (Fer-
gusson, Horwood, & Lloyd, 1991), their divergence with re-
spect to important external criteria is important to take into
account both theoretically and clinically (see Szatmari, Offord,
& Boyle, 1989a). That is, despite their overlap, they constitute
partially independent dimensions or diagnoses, and such inde-
1
I do not consider the behavioral problems of children with clear
mental retardation in this article.
 SPECIAL SECTION: UNDERACHIEVEMENT, ATTENTION, AND AGGRESSION
pendence pertains even to their differential overlap with under-
achievement (see Comorbidity Between Domains section).
The prevalence of behavioral disorders that are defined
chiefly through quantitative ratings is somewhat arbitrary, re-
flecting the choice of cutoff scores used to define deviant status
and the choice of constituent behaviors believed, at any given
time, to constitute the disorder. Thus, prevalence estimates for
the disruptive behavior disorders have varied over the past sev-
eral decades. Currently, ADHD is thought to occur with a fre-
quency of 3% to 6% in school-aged populations (American Psy-
chiatric Association, 1987; Szatmari, Offord, & Boyle, 1989b).
Boys outnumber girls with a ratio of approximately 3:1 in epide-
miologic surveys; the ratio is considerably higher in clinic sam-
ples. Similar figures apply to conduct disorder, which occurs in
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3% to 7% of children and which shows a 2:1 to 3:1 male-to-fe-
male predominance (Robins, 1991). ODD, a relatively new
diagnostic category containing milder symptoms of noncom-
pliant behavior that may represent precursors of later CD
(Loeber, Lahey, & Thomas, 1991), has an apparently higher
prevalence rate, although definitive figures are not available.
The externalizing behavior disorders have several associated
features that are deserving of mention. First, children with
these conditions have noteworthy problems with peers. Young-
sters with exclusive aggression are often categorized as socio-
metrically controversial, meaning that they are liked by some
classmates and disliked by others; children with ADHD are
quite frequently rejected by their peers, and those with comor-
bid ADHD and aggressive features are almost universally re-
jected by agemates (Milich & Landau, 1989). Given the strong
predictive power of peer rejection in childhood for a host of
negative outcomes later in life (Parker & Asher, 1987), the nega-
tive peer status of children with externalizing behavior prob-
lems is quite salient. Second, lowered self-esteem is common in
children with a history of acting-out behavior; by preadoles-
cence, conduct disorder co-occurs at high rates with major de-
pression (see Puig-Antich, 1982). The latter association is clini-
cally important; theoretically, it calls into question any simplis-
tic notions about the separability of severe internalizing from
severe externalizing disorders. Third, overlap with academic
underachievement, which is the focus of this article, is widely
cited (e.g., McGee & Share, 1988).
Although symptom lists for the disruptive behavior disorders
continue to be modified and sharpened on the basis of empiri-
cal findings, the presence of systematic compilations of acting
out or inattentive and hyperactive behaviors is not sufficient to
establish individualized treatment plans for such youngsters.
For one thing, the symptoms of ADHD, ODD, and CD are
embedded within familial, peer, and school contexts; consider-
ation of such environmental factors is critical if treatment ef-
forts are to be initiated, much less maintained. In particular,
the effects of behavioral interventions for acting-out behavior
do not persist or generalize without systematic efforts to pro-
mote transfer (e.g., McMahon & Wells, 1989); such efforts must
be directed toward the particular family configuration and
school setting in which the child interacts. In addition, such
individual variables as readiness to acknowledge problems,
motivation for change, and concurrent anxious or depressed
symptoms may weigh heavily in treatment recommendations.
In short, evaluations that incorporate pertinent social system
895
and intraindividual factors are necessary to provide for com-
prehensive treatment of disruptive behavior disorders.
Comorbidity Between Domains
I recently completed an extensive review of issues pertaining
to the Comorbidity between externalizing behavior problems
and academic underachievement (Hinshaw, 1992). Space here
allows only a brief summary of the key conclusions from this
work. First, overlap between externalizing behavioral syn-
dromes and underachievement occurs at levels that are far
above chance rates, with estimates ranging quite widely (from
less than 10% to more than 50%). Critical to such figures is the
precise definition of underachievement that is used. Indeed,
the percentage of externalizing children who have specific
learning disabilities, defined by IQ-achievement discrepancies,
is lower than commonly believed, in the range of 6% to 20%
(e.g., Forness, Youpa, Hanna, Cantwell, & Swanson, 1992). Yet,
with broader definitions of school failure that include reten-
tion, low grades, and suspensions, the figures rise dramatically
(see Barkley, Fischer, Edelbrock, & Smallish, 1990). It is note-
worthy that Comorbidity in the other direction is not nearly so
specific; that is, among carefully diagnosed learning disabled
youngsters, the most frequent pattern of accompanying behav-
ior problems appears to be in the internalizing domain (Fuerst,
Fisk, & Rourke, 1989), and only a minority of learning disabled
children have diagnosable externalizing disorders.
Second, in opposition to many earlier reports that posited
links between aggressive behavior and underachievement, the
specific relation in childhood pertains to ADHD (e.g., McGee,
Williams, & Silva, 1985). The overlap between childhood ag-
gression and underachievement is mediated chiefly through
the Comorbidity of aggression with ADHD (Frick et al., 1991).
By adolescence, however, a clear association exists between de-
linquency and underachievement, clarifying the need for aware-
ness of developmental change factors in specifying comorbidity
between these domains.
Third, despite considerable theorizing about unidirectional
paths from early underachievement to subsequent behavior
problems, or from early externalizing tendencies to later learn-
ing difficulties, the overlap between externalizing behavior
problems and learning difficulty often begins during the pre-
school years, with significant association documented before
the onset of formal schooling (see the review by Hinshaw, 1992).
Thus, whereas early behavior problems may precipitate later
underachievement or acting-out behavior may emerge afresh
from a history of school failure in selected subgroups of young-
sters (e.g., Maughan, Gray, & Rutter, 1985), the overlap between
domains typically appears quite early in development, suggest-
ing the operation of underlying causal factors (e.g., mild to mod-
erate language deficits, poor verbal skills, familial distress or
discord, neurodevelopmental delay) in shaping eventual Co-
morbidity. Developmental progressions are likely to be com-
plex in this regard: For example, children with the combination
of attentional problems, aggression, and verbal/neuropsycho-
logical deficits during the preschool years are at greatly in-
creased risk for delinquency by adolescence (Moffitt, 1990).
Attacking preachievement and behavior problems during early
 896 STEPHEN P. HINSHAW
developmental phases thus appears crucial for averting negative
outcomes.
Fourth, youngsters with learning disabilities who show con-
comitant problem behaviors of an acting-out variety (atten-
tional difficulties, conduct problems, or both) are at higher risk
for displaying continuing deficits in achievement during the
grade-school years than are those children with internalizing
tendencies or those without concurrent problem behavior
(McKinney, 1989). Thus, comorbidity is important prognosti-
cally.
In summary, externalizing behavior disorders overlap consid-
erably with at least some degree of academic underachieve-
ment, with the predominant link between ADHD and achieve-
ment delays in childhood giving way to a strong association
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between delinquency and school failure in adolescence. Be-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
cause inattention and impulse-control problems are correlated
with readiness difficulties early in development, and because
externalizing behavior problems and severe learning failure are
quite difficult to treat once established, early intervention ef-
forts are strongly encouraged, as I will highlight in more depth
subsequently. At this point, I turn to coverage of established
intervention strategies for each problem domain. After this nec-
essarily brief review, I take up, in some detail, those treatment
studies that have explicitly investigated youngsters with comor-
bid externalizing behavior problems and learning deficiencies.
Intervention Strategies for Underachievement
and Learning Disabilities
The education and treatment of children with severe learning
deficits entail significant costs. Indeed, in terms of the public
education system alone, provision of special education services
to children with learning handicaps is a multibillion dollar
enterprise each year (Ceci, 1986). Yet the empirical database on
which remedial programs for such youngsters is based is dis-
tressingly thin. Virtually no evidence is available regarding
long-term efficacy of special educational efforts, and only a
handful of well-controlled short-term investigations have
yielded promising leads (see the excellent review in Taylor,
1989).
Perhaps the firmest conclusion that can be drawn from the
literature is that the long history of intervention efforts directed
toward ameliorating basic perceptual processes, psychological
processes, or both that allegedly underlie learning difficulties is
misguided. For example, training in perceptual-motor skills is
simply not a sufficient intervention for learning disabled chil-
dren (Kavale & Mattson, 1983). Although holding considerable
promise, more modern efforts to specify and treat relevant pro-
cess variables (e.g., metacognitive skills, A. L. Brown & Cam-
pione, 1986; or learning strategies, Deshler, Warner, Schu-
maker, & Alley, 1983) lack empirical support for children with
severe learning difficulties.
Those interventions with the most empirical justification
are those that provide instruction in the precise academic skills
that are deficient, such as phonetic word decoding or oral and
written language skills. Carefully designed investigations using
these approaches have yielded solid evidence for impressive
treatment efficacy in children with specific reading disabilities
(Gittelman & Feingold, 1983; Lovett, Ransby, Hardwick, Johns,
& Donaldson, 1989). It is important to consider that if the
achievement gains are to be maintained, interventionists must
also take into account ancillary aspects of academic learning
problems in children, including motivational variables and the
child's attribution of failures and gains to controllable versus
uncontrollable causes (e.g., Licht & Kistner, 1986). Indeed, far
more research is needed on the ability of remedial interven-
tions to effect long-term gains for children with learning defi-
cits.
The pharmacologic treatment of underachievement is a con-
troversial area. Earlier reports contending that stimulant medi-
cation provided little or no benefit in the academic domain
were plagued by methodologic and conceptual problems. In
fact, it is now clear that for children with ADHD, stimulant
medications yield a significant and positive impact on a host of
variables that are related to academic attainment, including
attention span, academic productivity, reading comprehension,
and even complex problem solving (e.g., Douglas, Barr, Amin,
O'Neill, & Britton, 1988; see review in Pelham, 1986). Yet,
achievement test performance in reading is not significantly
altered by medication treatment, and the use of stimulants for
children with learning disabilities that are unaccompanied by
externalizing behavior problems has not been successful (Git-
telman, Klein, & Feingold, 1983).2 Whether combinations of
stimulant medication with psychosocial and academic inter-
ventions can yield benefits for children with comorbid under-
achievement and disruptive behavior patterns is discussed in a
subsequent section.
Several additional comments are in order. First, most of the
intervention research in the field is directed toward children
with specific (IQ-discrepant) learning disabilities, with reading
skill receiving, by far, the most attention. Thus, despite their
massive numbers, very real problems with academic attain-
ment, and ability to make noteworthy gains (Rutter & Yule,
1975), children with general achievement difficulties comprise
a neglected population with regard to treatment research. As
noted earlier, a related point is that consideration of this large
domain would force confrontation with a host of policy and
school system issues and on the need to direct systematic inter-
vention toward the social and environmental factors that are
associated with globally deficient academic performance.
Next, learning problems other than those in reading (e.g., spel-
ling, mathematics, and nonverbal learning disabilities) have
only recently been recognized as separable problems deserving
of selective intervention (e.g., Rourke, 1985). Increased research
density in these domains is likely. Finally, it has been contended
that gaps in knowledge about effective intervention strategies
2
A fascinating, recent investigation by Balthazor, Wagner, and Pel-
ham (1991) indicated that methylphenidate's positive effects on read-
ing comprehension and letter-matching tasks were apparently not me-
diated by any ability of the medication to enhance phonologic process-
ing or to retrieve name codes from long-term memory. Rather, the
benefits of the medication appeared to be related to nonspecific fac-
tors, possibly including enhancement of sustained attention or amelio-
ration of controlled processing. Thus, stimulants apparently do not
directly improve the skills thought to underlie reading but enhance
academic functioning as a result of more general facilitation of motiva-
tion, attention, and performance.
 SPECIAL SECTION: UNDERACHIEVEMENT, ATTENTION, AND AGGRESSION
relate, in part, to mistaken assumptions about the homogeneity
of children with achievement problems and that intervention
tailored to empirically validated subtypes of learning deficits is
crucial (Lyon, 1985). On the other side of this debate are those
(e.g., Gittelman & Feingold, 1983) who contend that the search
for Subtype X Treatment interactions is premature until evi-
dence for any sustained, meaningful improvements from inter-
vention with learning problems can be demonstrated. Indeed,
on the basis of their controlled outcome investigation, in which
systematic instruction in phonics led to significant and lasting
reading gains in severely disabled readers that persisted for up
to 8 months postintervention, Gittelman and Feingold (1983)
stated that "intensive training of reading skills should be used
to improve reading performance in children with reading dis-
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orders, regardless of other diagnostic refinementswhether
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based on perceptual, motor, or neuropsychological test perfor-
mance" (p. 189).
Intervention Strategies for Externalizing
Behavior Problems
Like underachievement, the domain of externalizing behav-
ior problems has proven distressingly resistant to long-term
amelioration with existing treatment regimens. \et, both psy-
chosocial and pharmacologic interventions can each lead to
substantial short-term improvement for disruptive and external-
izing disorders, and I review highlights of these treatment mo-
dalities later in this article.
Whereas the most commonly used intervention strategy in
clinic settings for children with disruptive disorders is probably
individual play therapy, such dynamic approaches to psycho-
therapy are not effective in ameliorating the core symptoms of
these conditions (Kazdin, 1987). The wide range of behavioral
approaches, on the other hand, has a solid empirical base for
this population. A rough subdivision of behavioral interven-
tions includes (a) direct contingency management, in which
systematic reward and response cost procedures are imple-
mented, usually in classroom settings; (b) clinical behavior ther-
apy, in which the therapist teaches behavioral programing pro-
cedures to key adults in the environment (i.e., parents and
teachers); (c) cognitive-behavioral approaches, in which prob-
lem solving and mediational strategies are taught directly to the
child with the goal of facilitating generalization and mainte-
nance; and (d) residential treatment options for conduct-disor-
dered adolescents (see McMahon & Wells, 1989, and Pelham &
Hinshaw, 1992, for elaboration of these subcategories).
Whereas direct contingency management programs yield
powerful effects on disruptive behavior, they can be costly to
implement, and their benefits do not automatically generalize
outside the demonstration classroom setting. It is noteworthy
that the use of prudent negative consequences (e.g., response
cost and time-out) is a critical adjunct to reward systems for
externalizing children, particularly those with ADHD (Bark-
ley, 1990; Pfiffner & O'Leary, in press). Clinical behavior ther-
apy approaches, which are far more commonly used, can also
produce significant effects, particularly when systematic par-
ent training is applied with defiant and aggressive youngsters
(see the review in McMahon & Wells, 1989). Encouragingly,
parent-based approaches with these populations have begun to
897
yield generalized, durable effects for periods of 1 year or longer,
with parental motivation a key ingredient in mediating success.
This latter issue is far from inconsequential, given the tendency
for aggressive externalizing youngsters to have family histories
marked by substance abuse and antisocial behavior and family
climates highlighted by disruption and discord (Hetherington
& Martin, 1986; Lahey et al., 1988; Schachar & Wachsmuth,
1990).
Cognitive-behavioral approaches, which combine problem-
solving training with reinforcement, have led to clear improve-
ments in the behavior of young, aggressive children (e.g., Kaz-
din, Bass, Siegel, & Thomas, 1989). Yet, with few short-term
exceptions in the realms of anger control and playground social
behavior, they have not proven successful for children with
ADHD (see Abikoff, 1991; Hinshaw & Erhardt, 1991). Further-
more, it is safe to say that these treatments have not lived up to
their initial promise of enhanced generalization and mainte-
nance for clinical populations of externalizing children. Fi-
nally, as with most interventions for adolescents with delin-
quent/disruptive behavior, residential treatment options have
produced limited benefits.
For ADHD, stimulant medications are the most efficacious
short-term intervention (Gittelman et al., 1980). A host of well-
controlled investigations document the ability of methylpheni-
date (Ritalin) and dextroamphetamine (Dexedrine) to amelio-
rate the disorder's core symptoms of inattention, impulsivity,
and overactivity as well as to effect improvements in the impor-
tant domains of peer relations and aggressive behavior (see re-
views in Barkley, 1990; Hinshaw, 1991).3 Yet, as noted previ-
ously, whereas the stimulants yield impressive gains in aca-
demic productivity and accuracy, their effects on standardized
achievement test scores are far weaker, and there is still consid-
erable debate as to their clinical impact on the learning of new
material (Swanson, Cantwell, Lerner, McBurnett, & Hanna,
1991). Overall, perhaps the most salient issues with regard to
pharmacologic intervention are that, despite the clear medica-
tion-related improvements that can be expected for 70% to 80%
of ADHD children with stimulant intervention, stimulants
alone typically do not bring all social and academic behavior
into the normal range, and the long-range efficacy of pharmaco-
logic treatment is not impressive (e.g., Pelham & Hinshaw, 1992;
Weiss & Hechtman, 1986). As a result, combinations of behav-
ioral and pharmacologic intervention are receiving attention as
the intervention strategy of choice for ADHD (see Pelham &
Murphy, 1986).
In summary, as cogently argued by Kazdin (1987), investiga-
tors must begin to view externalizing behavior disorders as
chronic behavioral conditions, requiring long-term interven-
tion strategies across childhood and adolescence. In this re-
gard, externalizing behavior is similar to the persistent prob-
lem of severe academic underachievement, which resists signifi-
cant amelioration with treatments that are acute in nature. It
3
The actions of stimulants are not specific to ADHD. In fact, nor-
mal children often show a beneficial response, and recent investiga-
tions with adolescents who have primary diagnoses of conduct dis-
order reveal gains with stimulant treatment (e.g., R. T. Brown, Jaffe,
Silverstein, & Magee, 1991).
 898 STEPHEN P. HINSHAW
should come as no surprise, given this discussion, that I subse-
quently recommend the use of long-term intervention pro-
grams for the comorbid group of children with externalizing
behavior disorders and underachievement.
Intervention for Comorbid \bungsters:
Empirical Investigations
Overview
Although some treatment studies for learning disabled chil-
dren include behavioral adjustment as an outcome, and al-
though some interventions for externalizing youngsters incor-
porate dependent variables of school performance, most re-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ports contain outcome assessments that are focused rather
This document is copyrighted by the American Psychological Association or one of its allied publishers.
narrowly, indexing either achievement or externalizing behav-
ior, but not both. In addition, there are surprisingly few con-
trolled intervention studies that explicitly address children
with comorbid underachievement and disruptive behavior dis-
orders. One factor contributing to the lack of such investiga-
tions may be the difficulty of finding externalizing subjects
with severe discrepancy-based learning disabilities (see Abikoff
et al, 1988). Regardless of the precise reasons, there is an in-
creasing appeal for intervention researchers to broaden both
treatment approaches and outcome evaluations for externaliz-
ing or underachieving children into comorbid problem areas
(McMahon & Wells, 1989). In reviewing the few intervention-
related investigations of comorbid externalizing-underachiev-
ing children, I do not consider a larger number of multimodal-
ity treatment studies of ADHD children in which academic
measures were obtained but in which formal assessment of co-
morbid learning disabilities was not performed (e.g., Pelham et
al., 1988; Satterfield, Cantwell, & Satterfield, 1979; see review
in Gadow, 1985).
Pertinent Investigations
Conrad, Dworkin, Shai, and Tobiessen (1971) performed a
study of 68 low-SES children diagnosed as hyperkinetic (on the
basis of a teacher rating scale) and learning disabled (on the
basis of poor performance on at least one of three perceptual-
motor tests). They crossed the experimental treatment vari-
ables of stimulant medication (dextroamphetamine) and twice-
weekly prescriptive tutoring (focusing on such process variables
as fine and gross motor skills, sequencing abilities, and visual
and auditory memory) in this 20-week investigation; outcome
measures included IQ and achievement tests, behavior ratings
from parents and teachers, and performance on individual as-
sessments of perceptual-motor skills. Although the statistical
analyses that were performed preclude clear interpretation of
the pattern of findings, treatment effects were relatively few,
and none were found for measures of academic achievement.
Those significant effects that did occur for behavior ratings and
for perceptual-motor skills tended to favor medication rather
than tutoring. On the basis of current knowledge, it can be
argued that the decision to focus the tutoring on underlying
process variables rather than on academic attainment per se
contributed strongly to the weak pattern of effects.
Although formal assessment of underachieving status was
not performed, an experimental single-case intervention study
by Ayllon, Layman, and Kandel (1975) is noteworthy for its
considerable influence on conceptualizations of how to inter-
vene with the academic and behavioral problems of externaliz-
ing youngsters. For the 3 hyperactive subjects, all of whom at-
tended learning disabilities classes, use of the stimulant Ritalin
was contrasted with the behavioral intervention of rewarding
correct performance on academic assignments in a multiple-
baseline design; outcomes included both an observational com-
posite of hyperactive and disruptive behavior in class and per-
centage of correct responses on the worksheets. Whereas Rita-
lin led to improvement only in terms of classroom behavior, the
behavioral intervention both increased the accurate perfor-
mance of academic tasks in math and reading and reduced the
problematic behavior. Closer examination of the academic
tasks, however, reveals that the worksheets comprised relatively
simple problems; it seems more accurate to contend that the
behavioral intervention enhanced task completion rather than
learning or achievement per se. Furthermore, there was no indi-
cation that Ritalin dosages were carefully evaluated. Indeed, no
child was receiving more than 0.17 mg/kg, a dose level that is
considered quite low. Nonetheless, the investigation was influ-
ential in promoting the treatment approach of reducing prob-
lem behavior in the classroom indirectly, by way of reinforce-
ment of the incompatible behavior of academic performance.
An extremely heuristic study by Coie and Krehbiel (1984)
involved 40 fourth graders who were comorbidly underachiev-
ing (indexed by group achievement test scores in reading or
math that were below the 36th percentile of national norms)
and socially rejected (assessed by sociometric nominations
from peers and teacher nominations of disruption and social
difficulties). Although peer rejection does not, in itself, signify
an externalizing behavior disorder, it is well known that low
social status with peers significantly predicts a host of negative
outcomes in later life (Parker & Asher, 1987) and covaries posi-
tively with disruptive and particularly aggressive behavior (Er-
hardt & Hinshaw, 1992). These comorbid youngsters were as-
signed randomly to academic skills training, social skills train-
ing, combined academic and social skills training, or
no-treatment control conditions, with an explicit goal of ascer-
taining whether intervention with one problem area would lead
to change in the reciprocal domain. The intervention programs
spanned 6 months, with academic tutoring performed twice
per week and social skills training once per week. The tutoring
focused on direct enhancement of reading and math skills; the
social skills curriculum was based on validated procedures for
promoting prosocial functioning.
Both immediately after the intervention programs and at 1-
year follow-up, children receiving the academic tutoring made
significant improvements not only in academic achievement
but also in observed classroom behavior and in peer sociome-
tric status. In contrast, the social skills intervention (which was
admittedly less intensive than the tutoring in terms of contact
time with adults) produced only transitory change in some so-
cial preference measures and no reciprocal effects on academic
skills. Few interactions between the two treatment types were
found. Although it could be argued strongly that the most ap-
propriate social skills intervention for socially rejected or exter-
nalizing children would focus directly on reducing aggressive
 SPECIAL SECTION: UNDERACHIEVEMENT, ATTENTION, AND AGGRESSION
and antisocial behavior rather than on promoting social ap-
proach skills, these results echo the findings of Ayllon et al.
(1975). That is, direct amelioration of academic skills has recip-
rocal effects on social competence, perhaps mediated through
such factors as enhancement of on-task behavior, positive
teacher response, and increased self-esteem. In addition to pro-
viding clinical guidelines for treatment, well-designed inter-
vention programs such as this are potentially valuable theoreti-
cally through their specification of patterns of reciprocal rela-
tions across behavioral and achievement-related domains.
The effects of three dosages of methylphenidate, paired with
direct tutoring in reading, were assessed on behavior, cognitive
performance, and academic achievement in carefully diag-
nosed children with comorbid ADDH and reading disabilities
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
(Kupietz, Winsberg, Richardson, Maitinsky, & Mendell, 1988;
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Richardson, Kupietz, Winsberg, Maitinsky, & Mendell, 1988).
In a between-subjects design, children in these companion re-
ports were assigned randomly to double-blind administration
of placebo or Ritalin (0.3 mg/kg, 0.5 mg/kg, or 0.7 mg/kg) for a
6-month period; each child received weekly reading tutoring
(by means of a thorough program aimed at sight-word vocabu-
lary, phonics, and comprehension skills) and daily instruction
in the same skills from parents. In combination with the tutor-
ing, stimulant medication (i.e., Ritalin; particularly the highest
dosage level of 0.7 mg/kg) led to improvements in adult-rated
behavior and on some cognitive processing measures; in addi-
tion, the medication enhanced word recognition skills during
postassessments. Methylphenidate's effects on the latter skills
were correlated with its amelioration of hyperactive, inatten-
tive, and aggressive behaviors, suggesting that pharmacologic
improvement of externalizing behaviors may mediate achieve-
ment-related gains in children with comorbid hyperactivity and
learning disabilities. Thus, although the study design (in which
all children received tutoring) precluded ascertainment of truly
interactive effects of educational therapy with medication, im-
portant change in behavior, cognition, and achievement may
well occur when effective tutoring strategies are combined with
stimulant medication in comorbid youngsters.4
Abikoff et al. (1988) attempted to ascertain the efficacy of a
16-week, academically oriented, cognitive-behavioral training
program for boys with comorbid ADDH and academic defi-
ciencies (defined as reading or math scores significantly below
expected performance). In the three-group design, in which all
subjects received moderate to high dosages of stimulant medica-
tion, the boys were assigned randomly to academic cognitive
training, remedial reading and math tutoring, or no-interven-
tion conditions; the first two conditions included direct in-
struction in academic skills. Although all three groups yielded
a number of significant within-subjects improvements in aca-
demic measures, there were virtually no between-subjects dif-
ferences across approximately 45 outcome measures at postin-
tervention or 6-month follow-up assessments. These results in-
dicate that stimulant treatment alone, when administered over
sufficient time periods, can facilitate gains in reading and math
achievement but that remedial tutoring and cognitive training
fail to increment such gains, at least when stimulant dosages are
high. Thus, despite some earlier evidence for the facilitation of
academic performance with cognitive-behavioral procedures
(e.g., Cameron & Robinson, 1980), children with comorbid
899
ADHD and learning disabilities may be refractory to such ben-
efit.
Conclusions
The divergent subject selection criteria, intervention proce-
dures, and outcome measures used in the previously described
investigations render premature sweeping generalizations
about intervention for children with comorbid underachieve-
ment and externalizing behavior problems (see also Gadow,
1985). One point to be made, however, is that promoting scho-
lastic success through direct instruction in and reinforcement
of academic work may yield some benefits in behavioral and
peer domains as well (Ayllon et al., 1975; Coie & Krehbiel, 1984;
see also Gittelman & Feingold, 1983). Furthermore, even when
pharmacologic intervention (particularly stimulant medica-
tion) has a positive influence on achievement-related measures,
the benefits usually occur in the presence of intervention that
emphasizes direct teaching of the academic material (e.g., Ku-
pietz et al., 1988; Richardson et al., 1988; but see Abikoff et al.,
1988). Overall, reducing problem behavior is not a sufficient
intervention for youngsters with overlapping achievement and
behavior problems; the promotion of academic success is criti-
cal for these children.
I should make explicit that instruction in academic skills will
not, in all likelihood, succeed for youngsters with comorbid
underachievement and externalizing behavior unless motiva-
tion is enhanced through the use of incentives such as rein-
forcers and response cost procedures. That is, tutoring or in-
struction in phonics, sight-word vocabulary, or reading com-
prehension approaches will probably be quite frustrating for
children with histories of both academic failure and inattentive
and disruptive behaviors; extrinsic motivational procedures are
typically necessary, particularly at the outset. In short, children
with comorbid achievement and behavior problems require in-
tervention that combines the best of behavioral programing
and educational instruction.
Next, because the overlap with underachievement in child-
hood most often occurs with the externalizing behavior pattern
of ADHD, as opposed to aggression per se, the appropriateness
of stimulant treatment is an extremely salient issue. As detailed
previously, stimulant medications can clearly enhance attention
and impulse control and many aspects of academic perfor-
mance in comorbid youngsters (e.g., Abikoff et al., 1988; Ku-
pietz et al., 1988; Richardson et al., 1988). These effects stand in
contrast to the limited efficacy of stimulants for children with
severe learning problems that are unaccompanied by behavior
problems (Gittelman et al., 1983). As just noted, however, the
pairing of medication with direct instruction in academic skills
(accompanied by behavioral procedures to enhance motivation)
4
For many of the outcome measures that yielded significant effects
of medication, the gains were salient during the first 3 months of the
investigation, but some decrements were noted in the last 3-month
period, suggesting that long-term stimulant treatment is associated
with the development of tolerance effects in children. This provocative
finding may constitute another potential reason for the failure of
chronic stimulant treatment to lead to long-term improvements in hy-
peractive or in hyperactive-learning disabled youngsters.
 900 STEPHEN P. HINSHAW
is usually necessary to effect improved performance. Overall,
although supporting evidence is not consistent (e.g., Abikoffet
al., 1988), children with comorbid underachievement and at-
tention deficits will most often require stimulant medication in
addition to exemplary educational and behavioral programing.
\bungsters with the combination of underachievement and
purely oppositional/aggressive behavior have been investigated
far less frequently.
Third, I must reiterate that truly long-term benefits of any
intervention program have rarely been demonstrated for un-
derachievement or for externalizing behavior, and much less for
their combination. Despite the substantial gains produced by
phonics-based tutoring for reading disabled children (Gittel-
man & Feingold, 1983) and despite the clear improvements that
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can accrue to family-based behavioral programs with external-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
izing youngsters (see McMahon & Wells, 1989)with gains
from each type of intervention persisting months or even years
after treatmentthe stark fact is that severe underachievement
and severe levels of ADHD and aggressive behavior are quite
persistent, and long-range treatment-related benefits are the
exception rather than the rule. Particularly for the group of
youngsters with comorbid underachievement and externaliz-
ing behavior problems, whose problems are quite likely to be-
come more rather than less severe over time, the field must
realize the need to extend treatment regimens over lengthy time
periods rather than to expect short-term interventions to pro-
mote lasting change (e.g., Kazdin, 1987). A related realization is
that such intervention programs will, of necessity, be costly to
implement. Yet, given the severe risk for delinquency posed by
the combination of learning and neuropsychological deficits
and externalizing behavior patterns early in life (see Moffitt,
1990), the costs to individuals, families, and society will un-
doubtedly be greater without such long-term interventions.
Critical Issues
A question of clinical and theoretical importance is whether
the present diagnostic criteria for underachievement or for
disruptive behavior disorders are sufficient to specify interven-
tion strategies. Although there is some apparent evidence for
the affirmative (e.g., a diagnosis of ADHD strongly invites con-
sideration of a stimulant trial, and specific reading disabilities
mandate academic remediation that is directed specifically to-
ward reading skills and not toward underlying perceptual-mo-
tor processes), the picture becomes less clear on further consid-
eration. First, if ADHD overlaps with significant internalizing
features or with disordered thinking, stimulant medications
may exacerbate such symptoms rather than improve behavioral
regulation (see the discussion in Barkley, 1990). Thus, it is cru-
cial to record the comorbidity of ADHD with other behavioral
and emotional disorders in treatment planning. Second, as
noted earlier, the externalizing behavior disorders are often
embedded in networks of discordant family interaction, psy-
chosocial deprivation, and peer rejection (particularly when se-
vere aggression is present); these systemic factors need to be
addressed in any comprehensive treatment plan. Third, I have
noted the ongoing debate regarding the need for better-speci-
fied interventions to extend evaluation of underachievement
into neuropsychological domains, with clearly stated opinions
both for (Lyon, 1985) and against (Gittelman & Feingold, 1983)
this practice. Regardless of one's stand on this issue, it is clear
that assessment of such factors as the child's motivation, the
family's structure and attitudes, and the classroom climate (e.g.,
the teacher's readiness to incorporate special materials or ap-
proaches) will be crucial to the success of any intervention pro-
gram for an underachieving child. In short, the brevity of any
diagnostic label, coupled with the rather focused nature of the
inclusionary criteria themselves, mandate thorough evaluation
of a wealth of additional factors if optimal intervention is to
ensue.
A related issue concerns subcategorization of each domain.
A key goal of such subtyping would be to clarify Treatment X
Subtype interactions, with the hope of specifying more accu-
rately the interventions to be directed toward homogeneous
clusters of academic deficit areas or problem behaviors. Al-
though discussion of the methodologic and statistical difficul-
ties that arise from subtyping efforts is well beyond the scope of
this article, I should mention that Subtype X Treatment re-
search models require substantial sample sizes if there is to be
any power to detect pertinent interactions; and with more than
two subtypes or treatment conditions, intervention research de-
signs quickly become unwieldy, particularly in the context of
the investigation of youngsters who are comorbidly externaliz-
ing and underachieving. At present, the field is perched on the
horns of a dilemma: Should the top priority be placed on find-
ing any effective treatment strategy (see Gittelman & Feingold,
1983)? Or will the only real success emerge from matching in-
terventions to particular processing deficits (Lyon, 1985)? Reso-
lution of this issue is far from certain, particularly given the
nonspecificity of many extant treatment strategies (e.g., stimu-
lant medication and behavior management).
As noted in an earlier section, comorbidity between the do-
mains of interest often begins quite early in development, prior
to the start of formal schooling. A clear implication is that
optimal treatment efforts must begin during such key develop-
mental periods, before difficulties become entrenched and be-
fore other associated problems emerge. In speculating as to
what components early intervention programs for children with
early signs of comorbid underachievement and externalizing
behavior might entail, I emphasize the caveat that because of
the infancy of research in this area, these ideas are not empiri-
cally validated.
For example, how should early intervention for underachieve-
ment be conceptualized, if, as is the case in preschool years,
formal academic work has not yet begun? In this regard, those
types of deficits in the preschool years that have been found to
predict subsequent underachievement (e.g., mild language de-
lays, poor visual-motor integration, and subaverage global intel-
ligence) would seem likely targets; yet these are difficult to treat
directly. Nonetheless, language stimulation programs for pre-
school-aged children with expressive language delays, which are
predictive of both subsequent learning disabilities and behavior
problems (Beitchman et al., 1992; Hinshaw, 1992) could well be
indicated. As kindergarten age approaches, such language stim-
ulation intervention could profitably be combined with inten-
sive tutoring of other readiness skills, such as letter recognition
and letter-sound correspondence. To the extent that the under-
lying linguistic skill deficits are predictive of the emerging co-
 SPECIAL SECTION: UNDERACHIEVEMENT, ATTENTION, AND AGGRESSION
morbidity of learning problems and behavior problems, such
treatment could be truly preventive in nature.
Yet, because of the distinct possibility that partially indepen-
dent causal factors operate to shape comorbidity (Hinshaw,
1992), it seems unlikely that intervention in any one modality
could circumvent the development of conjoint externalizing be-
havior and underachievement, even if delivered sufficiently
early. Active engagement of the child and family in home- and
school-based behavior management programs would also seem
a necessity for the young child with language and behavioral
problems, with the goals of (a) promoting better parent-child
interactions, (b) reducing problem behavior, and (c) preventing
the ensuing cycles of low self-worth and peer relationship diffi-
culties that often emanate from acting-out behavior. Indeed,
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clear behavioral and familial precursors of subsequent atten-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
tion-disordered and aggressive patterns have been identified
for preschoolers (Campbell, 1990; Richman, Stevenson, & Gra-
ham, 1982), and successful behavioral parent education pro-
grams have been documented for young externalizing children
(Pisterman et al, 1989). In general, however, early intervention
efforts lag considerably behind tertiary treatments, partly be-
cause salient developmental pathways have yet to be clearly
elucidated.
Finally, how should we best intervene for children in grade
school with comorbid underachievement and externalizing be-
havior? Given the partial independence of the two domains,
and given the limited evidence for spillover of intervention
gains from one area to the other, the main recommendation
would be to direct treatment toward each problem area: fo-
cused educational intervention on academic skills for the un-
derachievement and combined pharmacological and psychoso-
cial treatment for the externalizing behavior patterns. Hence,
multimodal treatments should be considered a necessity. Re-
garding underachievement, I have repeatedly stated that the
preponderance of evidence favors direct enhancement of aca-
demic skills rather than intervention with underlying pro-
cesses; and behavioral incentives will, in all likelihood, need to
be paired with the educational procedures. As for externalizing
behavior, if ADHD appears to be present, any consideration of
a stimulant medication trial requires systematic assessment of
its efficacy (e.g., Fischer & Newby, 1991); and practitioners
should remember that medication alone rarely provides clini-
cally sufficient benefits (Pelham & Hinshaw, 1992). Further-
more, parents and teachers need to be engaged in behaviorally
based intervention programs for children with either attention
deficits or aggressive behavior patterns, as solely child-directed
intervention is rarely adequate for such youngsters. Although
there is some limited evidence that ameliorating academic per-
formance will have reciprocal effects on behavioral domains
(Ayllon et al., 1975; Coie & Krehbiel, 1984), such generalization
has largely been confined to classroom behavior, and it would
be naive to expect that improved academic performance alone
can reduce severe acting-out behavior at home or in social envi-
ronments. Overall, the types of multimodality treatments nec-
essary to intervene with comorbid youngsters need to be sys-
tematic, extensive, and lengthy in duration.
In summary, despite the prognostic, theoretical, and clinical
importance of the linkage between externalizing behavior dis-
orders and severe academic underachievement (Hinshaw,
901
1992), extremely few empirical treatment investigations have
been undertaken with children who display this comorbid con-
figuration. Whereas some evidence exists that intervention for
academic problems has reciprocal effects on reducing problem
behavior (Ayllon et al., 1975; Coie & Krehbiel, 1984), youngsters
in the investigations supporting this claim did not meet formal
criteria for the joint presence of disruptive behavior disorders
and learning difficulties, and the preponderance of evidence
suggests strongly that multimodal intervention must occur to
address both the learning problems and the behavioral prob-
lems that comorbid children exhibit. Because the overlap be-
tween domains often appears during the preschool years, I ad-
vocate the adoption of early intervention procedures for lan-
guage and readiness skills and disruptive behavioral problems;
yet, such preventive treatments must contend with such prob-
lems as the imperfect prediction of later comorbidity from early
difficulties and a dearth of supportive empirical evidence for
their efficacy. An exciting aspect about the development of
both preventive and tertiary interventions for comorbid under-
achievement and externalizing disorders is that well-designed
and well-executed treatment investigations are potentially ben-
eficial both clinically and theoretically. That is, not only can
appropriate interventions provide an extremely important ben-
efit to children, families, and society by helping to prevent the
bleak course faced by comorbid youngsters, but also, because
of the potential for demonstration of reciprocal benefits across
domains, they can potentially elucidate causal pathways link-
ing behavior and achievement. The next decade should witness
the accumulation of considerably more supporting evidence
regarding both clinical efficacy and causal paths.
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Received December 2,1991
Revision received February 17,1992
Accepted June 23,1992