overview for research paper

How to Write a Research Paper Introduction (with Examples)

Table of Contents

The research paper introduction section, along with the Title and Abstract, can be considered the face of any research paper. The following article is intended to guide you in organizing and writing the research paper introduction for a quality academic article or dissertation.

The research paper introduction aims to present the topic to the reader. A study will only be accepted for publishing if you can ascertain that the available literature cannot answer your research question. So it is important to ensure that you have read important studies on that particular topic, especially those within the last five to ten years, and that they are properly referenced in this section. 1

What should be included in the research paper introduction is decided by what you want to tell readers about the reason behind the research and how you plan to fill the knowledge gap. The best research paper introduction provides a systemic review of existing work and demonstrates additional work that needs to be done. It needs to be brief, captivating, and well-referenced; a well-drafted research paper introduction will help the researcher win half the battle.

The introduction for a research paper is where you set up your topic and approach for the reader. It has several key goals:

• Present your research topic
• Capture reader interest
• Summarize existing research
• Position your own approach
• Define your specific research problem and problem statement
• Highlight the novelty and contributions of the study
• Give an overview of the paper’s structure

The research paper introduction can vary in size and structure depending on whether your paper presents the results of original empirical research or is a review paper. Some research paper introduction examples are only half a page while others are a few pages long. In many cases, the introduction will be shorter than all of the other sections of your paper; its length depends on the size of your paper as a whole.

What is the introduction for a research paper?

The introduction in a research paper is placed at the beginning to guide the reader from a broad subject area to the specific topic that your research addresses. They present the following information to the reader

• Scope: The topic covered in the research paper
• Context: Background of your topic
• Importance: Why your research matters in that particular area of research and the industry problem that can be targeted

Why is the introduction important in a research paper?

The research paper introduction conveys a lot of information and can be considered an essential roadmap for the rest of your paper. A good introduction for a research paper is important for the following reasons:

• It stimulates your reader’s interest: A good introduction section can make your readers want to read your paper by capturing their interest. It informs the reader what they are going to learn and helps determine if the topic is of interest to them.
• It helps the reader understand the research background: Without a clear introduction, your readers may feel confused and even struggle when reading your paper. A good research paper introduction will prepare them for the in-depth research to come. It provides you the opportunity to engage with the readers and demonstrate your knowledge and authority on the specific topic.
• It explains why your research paper is worth reading: Your introduction can convey a lot of information to your readers. It introduces the topic, why the topic is important, and how you plan to proceed with your research.
• It helps guide the reader through the rest of the paper: The research paper introduction gives the reader a sense of the nature of the information that will support your arguments and the general organization of the paragraphs that will follow.

What are the parts of introduction in the research?

A good research paper introduction section should comprise three main elements: 2

• What is known: This sets the stage for your research. It informs the readers of what is known on the subject.
• What is lacking: This is aimed at justifying the reason for carrying out your research. This could involve investigating a new concept or method or building upon previous research.
• What you aim to do: This part briefly states the objectives of your research and its major contributions. Your detailed hypothesis will also form a part of this section.

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How to write a research paper introduction?

The first step in writing the research paper introduction is to inform the reader what your topic is and why it’s interesting or important. This is generally accomplished with a strong opening statement. The second step involves establishing the kinds of research that have been done and ending with limitations or gaps in the research that you intend to address.

Finally, the research paper introduction clarifies how your own research fits in and what problem it addresses. If your research involved testing hypotheses, these should be stated along with your research question. The hypothesis should be presented in the past tense since it will have been tested by the time you are writing the research paper introduction.

The following key points, with examples, can guide you when writing the research paper introduction section:

1. Introduce the research topic:

• Highlight the importance of the research field or topic
• Describe the background of the topic
• Present an overview of current research on the topic

Example: The inclusion of experiential and competency-based learning has benefitted electronics engineering education. Industry partnerships provide an excellent alternative for students wanting to engage in solving real-world challenges. Industry-academia participation has grown in recent years due to the need for skilled engineers with practical training and specialized expertise. However, from the educational perspective, many activities are needed to incorporate sustainable development goals into the university curricula and consolidate learning innovation in universities.

2. Determine a research niche:

• Reveal a gap in existing research or oppose an existing assumption
• Formulate the research question

Example: There have been plausible efforts to integrate educational activities in higher education electronics engineering programs. However, very few studies have considered using educational research methods for performance evaluation of competency-based higher engineering education, with a focus on technical and or transversal skills. To remedy the current need for evaluating competencies in STEM fields and providing sustainable development goals in engineering education, in this study, a comparison was drawn between study groups without and with industry partners.

3. Place your research within the research niche:

• State the purpose of your study
• Highlight the key characteristics of your study
• Describe important results
• Highlight the novelty of the study.
• Offer a brief overview of the structure of the paper.

Example: The study evaluates the main competency needed in the applied electronics course, which is a fundamental core subject for many electronics engineering undergraduate programs. We compared two groups, without and with an industrial partner, that offered real-world projects to solve during the semester. This comparison can help determine significant differences in both groups in terms of developing subject competency and achieving sustainable development goals.

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How to use Paperpal to write the Introduction section

Step 1: Sign up on Paperpal and click on the Copilot feature, under this choose Outlines > Research Article > Introduction

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Step 3: Fill in the specifics, such as your field of study, brief description or details you want to include, which will help the AI generate the outline for your Introduction.

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You can use the same process to develop each section of your article, and finally your research paper in half the time and without any of the stress.

Frequently Asked Questions

What is the purpose of the introduction in research papers.

The purpose of the research paper introduction is to introduce the reader to the problem definition, justify the need for the study, and describe the main theme of the study. The aim is to gain the reader’s attention by providing them with necessary background information and establishing the main purpose and direction of the research.

How long should the research paper introduction be?

The length of the research paper introduction can vary across journals and disciplines. While there are no strict word limits for writing the research paper introduction, an ideal length would be one page, with a maximum of 400 words over 1-4 paragraphs. Generally, it is one of the shorter sections of the paper as the reader is assumed to have at least a reasonable knowledge about the topic. 2

For example, for a study evaluating the role of building design in ensuring fire safety, there is no need to discuss definitions and nature of fire in the introduction; you could start by commenting upon the existing practices for fire safety and how your study will add to the existing knowledge and practice.

What should be included in the research paper introduction?

When deciding what to include in the research paper introduction, the rest of the paper should also be considered. The aim is to introduce the reader smoothly to the topic and facilitate an easy read without much dependency on external sources. 3

Below is a list of elements you can include to prepare a research paper introduction outline and follow it when you are writing the research paper introduction.

• Topic introduction: This can include key definitions and a brief history of the topic.
• Research context and background: Offer the readers some general information and then narrow it down to specific aspects.
• Details of the research you conducted: A brief literature review can be included to support your arguments or line of thought.
• Rationale for the study: This establishes the relevance of your study and establishes its importance.
• Importance of your research: The main contributions are highlighted to help establish the novelty of your study
• Research hypothesis: Introduce your research question and propose an expected outcome. Organization of the paper: Include a short paragraph of 3-4 sentences that highlights your plan for the entire paper

Should I include citations in the introduction for a research paper?

Cite only works that are most relevant to your topic; as a general rule, you can include one to three. Note that readers want to see evidence of original thinking. So it is better to avoid using too many references as it does not leave much room for your personal standpoint to shine through.

Citations in your research paper introduction support the key points, and the number of citations depend on the subject matter and the point discussed. If the research paper introduction is too long or overflowing with citations, it is better to cite a few review articles rather than the individual articles summarized in the review.

A good point to remember when citing research papers in the introduction section is to include at least one-third of the references in the introduction.

Should I provide a literature review in the research paper introduction?

The literature review plays a significant role in the research paper introduction section. A good literature review accomplishes the following:

• Introduces the topic
• Establishes the study’s significance
• Provides an overview of the relevant literature
• Provides context for the study using literature
• Identifies knowledge gaps

However, remember to avoid making the following mistakes when writing a research paper introduction:

• Do not use studies from the literature review to aggressively support your research
• Avoid direct quoting
• Do not allow literature review to be the focus of this section. Instead, the literature review should only aid in setting a foundation for the manuscript. 

Key points to remember

Remember the following key points for writing a good research paper introduction: 4

• Avoid stuffing too much general information: Avoid including what an average reader would know and include only that information related to the problem being addressed in the research paper introduction. For example, when describing a comparative study of non-traditional methods for mechanical design optimization, information related to the traditional methods and differences between traditional and non-traditional methods would not be relevant. In this case, the introduction for the research paper should begin with the state-of-the-art non-traditional methods and methods to evaluate the efficiency of newly developed algorithms.
• Avoid packing too many references: Cite only the required works in your research paper introduction. The other works can be included in the discussion section to strengthen your findings.
• Avoid extensive criticism of previous studies: Avoid being overly critical of earlier studies while setting the rationale for your study. A better place for this would be the Discussion section, where you can highlight the advantages of your method.
• Avoid describing conclusions of the study: When writing a research paper introduction remember not to include the findings of your study. The aim is to let the readers know what question is being answered. The actual answer should only be given in the Results and Discussion section.

To summarize, the research paper introduction section should be brief yet informative. It should convince the reader the need to conduct the study and motivate him to read further. If you’re feeling stuck or unsure, choose trusted AI academic writing assistants like Paperpal to effortlessly craft your research paper introduction and other sections of your research article.

• Jawaid, S. A., & Jawaid, M. (2019). How to write introduction and discussion. Saudi Journal of Anaesthesia, 13(Suppl 1), S18.
• Dewan, P., & Gupta, P. (2016). Writing the title, abstract and introduction: Looks matter!. Indian pediatrics, 53, 235-241.
• Cetin, S., & Hackam, D. J. (2005). An approach to the writing of a scientific Manuscript1. Journal of Surgical Research, 128(2), 165-167.
• Bavdekar, S. B. (2015). Writing introduction: Laying the foundations of a research paper. Journal of the Association of Physicians of India, 63(7), 44-6.

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Writing a Research Paper

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The Research Paper

There will come a time in most students' careers when they are assigned a research paper. Such an assignment often creates a great deal of unneeded anxiety in the student, which may result in procrastination and a feeling of confusion and inadequacy. This anxiety frequently stems from the fact that many students are unfamiliar and inexperienced with this genre of writing. Never fear—inexperience and unfamiliarity are situations you can change through practice! Writing a research paper is an essential aspect of academics and should not be avoided on account of one's anxiety. In fact, the process of writing a research paper can be one of the more rewarding experiences one may encounter in academics. What is more, many students will continue to do research throughout their careers, which is one of the reasons this topic is so important.

Becoming an experienced researcher and writer in any field or discipline takes a great deal of practice. There are few individuals for whom this process comes naturally. Remember, even the most seasoned academic veterans have had to learn how to write a research paper at some point in their career. Therefore, with diligence, organization, practice, a willingness to learn (and to make mistakes!), and, perhaps most important of all, patience, students will find that they can achieve great things through their research and writing.

The pages in this section cover the following topic areas related to the process of writing a research paper:

• Genre - This section will provide an overview for understanding the difference between an analytical and argumentative research paper.
• Choosing a Topic - This section will guide the student through the process of choosing topics, whether the topic be one that is assigned or one that the student chooses themselves.
• Identifying an Audience - This section will help the student understand the often times confusing topic of audience by offering some basic guidelines for the process.
• Where Do I Begin - This section concludes the handout by offering several links to resources at Purdue, and also provides an overview of the final stages of writing a research paper.

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Home » Research Summary – Structure, Examples and Writing Guide

Research Summary – Structure, Examples and Writing Guide

Table of Contents

Research Summary

Definition:

A research summary is a brief and concise overview of a research project or study that highlights its key findings, main points, and conclusions. It typically includes a description of the research problem, the research methods used, the results obtained, and the implications or significance of the findings. It is often used as a tool to quickly communicate the main findings of a study to other researchers, stakeholders, or decision-makers.

Structure of Research Summary

The Structure of a Research Summary typically include:

• Introduction : This section provides a brief background of the research problem or question, explains the purpose of the study, and outlines the research objectives.
• Methodology : This section explains the research design, methods, and procedures used to conduct the study. It describes the sample size, data collection methods, and data analysis techniques.
• Results : This section presents the main findings of the study, including statistical analysis if applicable. It may include tables, charts, or graphs to visually represent the data.
• Discussion : This section interprets the results and explains their implications. It discusses the significance of the findings, compares them to previous research, and identifies any limitations or future directions for research.
• Conclusion : This section summarizes the main points of the research and provides a conclusion based on the findings. It may also suggest implications for future research or practical applications of the results.
• References : This section lists the sources cited in the research summary, following the appropriate citation style.

How to Write Research Summary

Here are the steps you can follow to write a research summary:

• Read the research article or study thoroughly: To write a summary, you must understand the research article or study you are summarizing. Therefore, read the article or study carefully to understand its purpose, research design, methodology, results, and conclusions.
• Identify the main points : Once you have read the research article or study, identify the main points, key findings, and research question. You can highlight or take notes of the essential points and findings to use as a reference when writing your summary.
• Write the introduction: Start your summary by introducing the research problem, research question, and purpose of the study. Briefly explain why the research is important and its significance.
• Summarize the methodology : In this section, summarize the research design, methods, and procedures used to conduct the study. Explain the sample size, data collection methods, and data analysis techniques.
• Present the results: Summarize the main findings of the study. Use tables, charts, or graphs to visually represent the data if necessary.
• Interpret the results: In this section, interpret the results and explain their implications. Discuss the significance of the findings, compare them to previous research, and identify any limitations or future directions for research.
• Conclude the summary : Summarize the main points of the research and provide a conclusion based on the findings. Suggest implications for future research or practical applications of the results.
• Revise and edit : Once you have written the summary, revise and edit it to ensure that it is clear, concise, and free of errors. Make sure that your summary accurately represents the research article or study.
• Add references: Include a list of references cited in the research summary, following the appropriate citation style.

Example of Research Summary

Here is an example of a research summary:

Title: The Effects of Yoga on Mental Health: A Meta-Analysis

Introduction: This meta-analysis examines the effects of yoga on mental health. The study aimed to investigate whether yoga practice can improve mental health outcomes such as anxiety, depression, stress, and quality of life.

Methodology : The study analyzed data from 14 randomized controlled trials that investigated the effects of yoga on mental health outcomes. The sample included a total of 862 participants. The yoga interventions varied in length and frequency, ranging from four to twelve weeks, with sessions lasting from 45 to 90 minutes.

Results : The meta-analysis found that yoga practice significantly improved mental health outcomes. Participants who practiced yoga showed a significant reduction in anxiety and depression symptoms, as well as stress levels. Quality of life also improved in those who practiced yoga.

Discussion : The findings of this study suggest that yoga can be an effective intervention for improving mental health outcomes. The study supports the growing body of evidence that suggests that yoga can have a positive impact on mental health. Limitations of the study include the variability of the yoga interventions, which may affect the generalizability of the findings.

Conclusion : Overall, the findings of this meta-analysis support the use of yoga as an effective intervention for improving mental health outcomes. Further research is needed to determine the optimal length and frequency of yoga interventions for different populations.

References :

• Cramer, H., Lauche, R., Langhorst, J., Dobos, G., & Berger, B. (2013). Yoga for depression: a systematic review and meta-analysis. Depression and anxiety, 30(11), 1068-1083.
• Khalsa, S. B. (2004). Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian journal of physiology and pharmacology, 48(3), 269-285.
• Ross, A., & Thomas, S. (2010). The health benefits of yoga and exercise: a review of comparison studies. The Journal of Alternative and Complementary Medicine, 16(1), 3-12.

Purpose of Research Summary

The purpose of a research summary is to provide a brief overview of a research project or study, including its main points, findings, and conclusions. The summary allows readers to quickly understand the essential aspects of the research without having to read the entire article or study.

Research summaries serve several purposes, including:

• Facilitating comprehension: A research summary allows readers to quickly understand the main points and findings of a research project or study without having to read the entire article or study. This makes it easier for readers to comprehend the research and its significance.
• Communicating research findings: Research summaries are often used to communicate research findings to a wider audience, such as policymakers, practitioners, or the general public. The summary presents the essential aspects of the research in a clear and concise manner, making it easier for non-experts to understand.
• Supporting decision-making: Research summaries can be used to support decision-making processes by providing a summary of the research evidence on a particular topic. This information can be used by policymakers or practitioners to make informed decisions about interventions, programs, or policies.
• Saving time: Research summaries save time for researchers, practitioners, policymakers, and other stakeholders who need to review multiple research studies. Rather than having to read the entire article or study, they can quickly review the summary to determine whether the research is relevant to their needs.

Characteristics of Research Summary

The following are some of the key characteristics of a research summary:

• Concise : A research summary should be brief and to the point, providing a clear and concise overview of the main points of the research.
• Objective : A research summary should be written in an objective tone, presenting the research findings without bias or personal opinion.
• Comprehensive : A research summary should cover all the essential aspects of the research, including the research question, methodology, results, and conclusions.
• Accurate : A research summary should accurately reflect the key findings and conclusions of the research.
• Clear and well-organized: A research summary should be easy to read and understand, with a clear structure and logical flow.
• Relevant : A research summary should focus on the most important and relevant aspects of the research, highlighting the key findings and their implications.
• Audience-specific: A research summary should be tailored to the intended audience, using language and terminology that is appropriate and accessible to the reader.
• Citations : A research summary should include citations to the original research articles or studies, allowing readers to access the full text of the research if desired.

When to write Research Summary

Here are some situations when it may be appropriate to write a research summary:

• Proposal stage: A research summary can be included in a research proposal to provide a brief overview of the research aims, objectives, methodology, and expected outcomes.
• Conference presentation: A research summary can be prepared for a conference presentation to summarize the main findings of a study or research project.
• Journal submission: Many academic journals require authors to submit a research summary along with their research article or study. The summary provides a brief overview of the study’s main points, findings, and conclusions and helps readers quickly understand the research.
• Funding application: A research summary can be included in a funding application to provide a brief summary of the research aims, objectives, and expected outcomes.
• Policy brief: A research summary can be prepared as a policy brief to communicate research findings to policymakers or stakeholders in a concise and accessible manner.

Advantages of Research Summary

Research summaries offer several advantages, including:

• Time-saving: A research summary saves time for readers who need to understand the key findings and conclusions of a research project quickly. Rather than reading the entire research article or study, readers can quickly review the summary to determine whether the research is relevant to their needs.
• Clarity and accessibility: A research summary provides a clear and accessible overview of the research project’s main points, making it easier for readers to understand the research without having to be experts in the field.
• Improved comprehension: A research summary helps readers comprehend the research by providing a brief and focused overview of the key findings and conclusions, making it easier to understand the research and its significance.
• Enhanced communication: Research summaries can be used to communicate research findings to a wider audience, such as policymakers, practitioners, or the general public, in a concise and accessible manner.
• Facilitated decision-making: Research summaries can support decision-making processes by providing a summary of the research evidence on a particular topic. Policymakers or practitioners can use this information to make informed decisions about interventions, programs, or policies.
• Increased dissemination: Research summaries can be easily shared and disseminated, allowing research findings to reach a wider audience.

Limitations of Research Summary

Limitations of the Research Summary are as follows:

• Limited scope: Research summaries provide a brief overview of the research project’s main points, findings, and conclusions, which can be limiting. They may not include all the details, nuances, and complexities of the research that readers may need to fully understand the study’s implications.
• Risk of oversimplification: Research summaries can be oversimplified, reducing the complexity of the research and potentially distorting the findings or conclusions.
• Lack of context: Research summaries may not provide sufficient context to fully understand the research findings, such as the research background, methodology, or limitations. This may lead to misunderstandings or misinterpretations of the research.
• Possible bias: Research summaries may be biased if they selectively emphasize certain findings or conclusions over others, potentially distorting the overall picture of the research.
• Format limitations: Research summaries may be constrained by the format or length requirements, making it challenging to fully convey the research’s main points, findings, and conclusions.
• Accessibility: Research summaries may not be accessible to all readers, particularly those with limited literacy skills, visual impairments, or language barriers.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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APA Research Paper Outline: Examples and Template

Table of contents

• 1 Why Is Research Paper Format Necessary?
• 2.1 Purpose of research paper outline
• 2.2 APA outline example
• 3.1 APA paper outline example
• 3.2 Introduction:
• 3.4 Conclusion:
• 4 The Basic APA Outline Format
• 5 APA Style Outline Template Breakdown
• 6.1 APA Research Paper Outline Example
• 6.2 APA Paper Outline Format Example
• 7.1 First Paragraph: Hook and Thesis
• 7.2 Main Body
• 7.3 Conclusion
• 7.4 Decimal APA outline format example
• 7.5 Decimal APA outline format layout
• 8.1 A definite goal
• 8.2 Division
• 8.3 Parallelism
• 8.4 Coordination
• 8.5 Subordination
• 8.6 Avoid Redundancy
• 8.7 Wrap it up in a good way
• 8.8 Conclusion

Formatting your paper in APA can be daunting if this is your first time. The American Psychological Association (APA) offers a guide or rules to follow when conducting projects in the social sciences or writing papers. The standard APA fromat a research paper outline includes a proper layout from the title page to the final reference pages. There are formatting samples to create outlines before writing a paper. Amongst other strategies, creating an outline is the easiest way to APA format outline template.

Why Is Research Paper Format Necessary?

Consistency in the sequence, structure, and format when writing a research paper encourages readers to concentrate on the substance of a paper rather than how it is presented. The requirements for paper format apply to student assignments and papers submitted for publication in a peer-reviewed publication. APA paper outline template style may be used to create a website, conference poster, or PowerPoint presentation . If you plan to use the style for other types of work like a website, conference poster, or even PowerPoint presentation, you must format your work accordingly to adjust to requirements. For example, you may need different line spacing and font sizes. Follow the formatting rules provided by your institution or publication to ensure its formatting standards are followed as closely as possible. However, to logically structure your document, you need a research paper outline in APA format. You may ask: why is it necessary to create an outline for an APA research paper? Crafting a well-organized APA outline is crucial for any research paper. If you’re struggling with this process, consider seeking help from a professional research paper writer , who can guide you through each step.

Concept & Purposes of Research Paper Outline

A path, direction, or action plan! Writing short essays without a layout may seem easy, but not for 10,000 or more words. Yet, confusing a table of contents with an outline is a major issue. The table of contents is an orderly list of all the chapters’ front matter, primary, and back matter. It includes sections and, often, figures in your work, labeled by page number. On the other hand, a research APA-style paper outline is a proper structure to follow.

Purpose of research paper outline

An outline is a formalized essay in which you give your own argument to support your point of view. And when you write your apa outline template, you expand on what you already know about the topic. Academic writing papers examine an area of expertise to get the latest and most accurate information to work on that topic. It serves various purposes, including:

• APA paper outline discusses the study’s core concepts.
• The research paper outlines to define the link between your ideas and the thesis.
• It provides you with manageable portions that you can handle.
• The research paper’s APA outline enables the detection of structural faults or gaps.
• As shown in the example, it must clearly comprehend the subject at hand.

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APA outline example

This research paper outline example will guide you in formatting the layout for a clear direction to work on. It eliminates the inconsistency along with lacking proper substance in the paper.

Understanding the APA Outline Format

It would not be wrong to say there is no standard outline format. The official publishing handbook does not give precise guidelines for preparing an outline. But, it requires certain basic guidelines to follow regarding typeface, font size, structure, margins, etc.

APA paper outline example

Moreover, the final shape of your work relies on your instructor’s specifications and your particular preferences for APA citation format. Though, it would be better to follow some standards for formatting your outline, for instance:

Times New Roman is a widely accessible standard typeface for an APA essay format in 12-point font. However, serif and sans serif fonts like Arial and Georgia are acceptable in font size 11pt.

The text of your paper format should be double-spaced.

The primary headlines use Roman and Arabic numerals to write an outline.

Headings & Subheadings

While writing an APA essay, there are particular standards for utilizing headings in your outline: I – Main headings are numbered by Roman numerals like I, II, III, IV A  – Subheadings are numbered with Capital letters (A, B, C, D) 1  – The APA outline uses Arabic numerals (1-9 type numbers) within those subheadings. a  – Below Arabic number subheadings, lower-case letters are used (a, b, a). [1] – Headings below those subheadings use Arabic numbers enclosed in parenthesis.

APA format offers a standard layout for each paper, such as

• 1-inch margins on the top, bottom, left, and right.
• The page number on the upper right corner.

The structure of writing an outline consists of three major sections:

• Introduction

Introduction:

This section highlights crucial background information.

Explain the primary points that support your ideas.

Conclusion:

• Summarize your key arguments.
• Explain how these concepts support your ultimate stance, as shown in APA outline example below.

An outline in APA has three common formats that vary in the numeric sequence of all. To make it easier for you, we have compiled all three templates. You can format your document using these examples for added coherence and structure.

The Basic APA Outline Format

APA Style Outline Template Breakdown

Numbering the APA style format follows five levels of headings that use different alphabets and numbers. For instance, I – Headings use Roman numerals like I, II, and III. A – CAPITAL ALPHABETS”, such as A, B, C, etc. 1 – Headings and subheadings use Arabic numbers (1, 2, 3). a – If there are further headings (the fourth level), use lower-case alphabets. [1] – Headings below that (the fifth level) use Arabic numerals enclosed in parentheses, such as [1], [2], [3].

Full Sentence Outline Format

As the name specifies, the full-sentence style outline format requires every line to be a proper sentence. Full-sentence APA style outline is best recommended for essays and speeches. It gives your writing process an idea or a logical path to follow.

APA Research Paper Outline Example

If you are looking for how to write a research paper outline APA in Full Sentence Format, here is an example:

Full Sentence APA format heading utilizes Roman numerals I, II, and III. Every heading must be a full sentence. Here is an APA style paper outline template for the full-sentence format that will clear all your confusion on how to write an outline in full-sentence format.

APA Paper Outline Format Example

I. Introduction

III. Conclusion

Decimal Outline Format

The decimal outline format for APA research papers differs from other formats. The decimal APA style is simple and uses paragraphs for structure. It contains three main paragraphs, introduction, main body, and conclusion.

First Paragraph: Hook and Thesis

• The first paragraph is a sentence or two that introduces the central concept of your article.
• Introduce your topic or subject of study where your research is applicable as a context for further research.
• Explain why the mentioned issue is essential or relevant to the audience.
• A thesis statement is a claim that you make throughout your whole essay.
• The topic phrase is the first point in any writing to support a thesis statement.
• Give an explanation or provide evidence to support your point.
• Provide verifiable facts, figures, and/or citations from credible sources in your writing. It helps in the substantiating assertion.
• Include as many supporting statements and related evidence in your decimal outline.

Finally, when you write an outline, provide a concluding remark to support your claims.

Decimal APA outline format example

1.0 The main heading 1.1 Subheading under the main heading 1.2 Second digit is represented by subheadings under the main headings 1.2.1 Further division adds another digit in decimal format 1.2.2 You can number them as per the number of paragraphs or points, or lines An easy way to write in decimal APA outline format is to remember the structure, i.e.; 1.1.1 = Heading.Paragraph.Sentence/point under paragraph.”

Decimal APA outline format layout

1.0 Main heading 1.1 First paragraph for first heading. 1.2 Second paragraph for first heading. 1.2.1 First point or sentence for the second paragraph. 2.0 Second heading 2.1 Second heading, first paragraph. 2.2 Second heading, second paragraph. 2.2.1 Second, heading, second paragraph, first sentence, or point. 3.0 Decimal working 3.1 You must remember that each digit represents a segment. 3.2 It is easier to remember the placement of numbers. 3.2.1 First digit represents the heading 3.2.2 Second digit represents the paragraph under the main heading <3.2.3 The third digit represents any point or sentence under the paragraph.

Tips for Writing an Outline: Organize Your Ideas

You may feel it is easier to write without outlines, but once you start writing, organizing your ideas or thoughts becomes hard. Even if you have some fantastic ideas, producing an engaging story is practically hard. If you are not first creating an outline or conceptual guides while writing a research paper, you may lose track. A well-written outline is essential in completing your paper and maintaining quality. Establishing your point in paper writing is easy if you create an outline first. You can find an APA research paper outline template that best suits your requirement. Moreover, these tips can help you polish your writing. These tips and sample papers can help you write outstanding outlines without making any hassle.

A definite goal

For better expression, make a list of primary objectives on a title page in a single phrase or less. Your goal should be specific and measurable. If it is too broad or imprecise, you will not achieve anything. If you are working on a large paper format that covers a variety of themes or topics, you may have a more general purpose in mind. But, if you plan to write an essay, the aim should be as specific and clear as possible to be effective.

Breaking things up rather than allowing them to become verbose is known as the division rule. Make sure that each subsection in the document corresponds to its parent heading. If it doesn’t compare to the section, removing it or moving it to another location is better.

Parallelism

It is mainly related to the consistency and structure of the document. It keeps your paper’s layout tidy and also ensures relevancy. For instance, if you begin one heading with a verb, make sure all other headings and subheadings also start with a verb.

Coordination

Having headings aligned is critical to creating a well-organized outline. This rule also applies to subheadings, which is a good thing. If one title is less important than another, consider changing your layout by incorporating it into a subsection instead.

Subordination

Subordination deals with maintaining a connection between your paper’s headings and subheadings. It helps in the proper sequencing of headings and subheadings. Headings should be broad at the outset. At the same time, the subheadings become more particular as they go further into the document.

Avoid Redundancy

While writing a paper outline, look through it many times and cross out any items that aren’t necessary or have no significance. While outlining, make sure to be specific and concise. It will prevent you from adding information that does not supporting your final essay. Remove all the extra information and points while c that weighs you down while you write.

Wrap it up in a good way

Creating an outline does not only help in writing a coherent term paper, but it also helps in ending with precise understanding. Be considerate of your audience’s time and effort when you write an outline in APA, and ensure it serves its purpose. If you still have any doubts about formatting your paper outline, you can use this APA-style research paper outline template to write your document. We have provided Outline Format Example for every style.

People find it hard to write an outline in APA, but if you are aware of the requirements and structure, it’s no breeze. Sometimes, your instructor may alter your paper format by introducing or removing existing sections. As a result, if you come across any templates for an outline in APA, pay close attention to them. If you are looking for a quick answer to how to outline an APA paper, here’s a standard logical sequence of typical parts to include when writing an outline in APA:

• Thesis statement
• Techniques employed
• Body of paper
• Conclusions section
• List of references

A well-written outline is an excellent tool for presenting an outstanding paper. Including the key components while writing an outline for a research paper is necessary.

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How to Write the Methods Section of a Research Paper

Writing a research paper is both an art and a skill, and knowing how to write the methods section of a research paper is the first crucial step in mastering scientific writing. If, like the majority of early career researchers, you believe that the methods section is the simplest to write and needs little in the way of careful consideration or thought, this article will help you understand it is not 1 .

We have all probably asked our supervisors, coworkers, or search engines “ how to write a methods section of a research paper ” at some point in our scientific careers, so you are not alone if that’s how you ended up here.  Even for seasoned researchers, selecting what to include in the methods section from a wealth of experimental information can occasionally be a source of distress and perplexity.   

Additionally, journal specifications, in some cases, may make it more of a requirement rather than a choice to provide a selective yet descriptive account of the experimental procedure. Hence, knowing these nuances of how to write the methods section of a research paper is critical to its success. The methods section of the research paper is not supposed to be a detailed heavy, dull section that some researchers tend to write; rather, it should be the central component of the study that justifies the validity and reliability of the research.

Are you still unsure of how the methods section of a research paper forms the basis of every investigation? Consider the last article you read but ignore the methods section and concentrate on the other parts of the paper . Now think whether you could repeat the study and be sure of the credibility of the findings despite knowing the literature review and even having the data in front of you. You have the answer!   

Having established the importance of the methods section , the next question is how to write the methods section of a research paper that unifies the overall study. The purpose of the methods section , which was earlier called as Materials and Methods , is to describe how the authors went about answering the “research question” at hand. Here, the objective is to tell a coherent story that gives a detailed account of how the study was conducted, the rationale behind specific experimental procedures, the experimental setup, objects (variables) involved, the research protocol employed, tools utilized to measure, calculations and measurements, and the analysis of the collected data 2 .

In this article, we will take a deep dive into this topic and provide a detailed overview of how to write the methods section of a research paper . For the sake of clarity, we have separated the subject into various sections with corresponding subheadings.  

Table of Contents

What is the methods section of a research paper ?  

The methods section is a fundamental section of any paper since it typically discusses the ‘ what ’, ‘ how ’, ‘ which ’, and ‘ why ’ of the study, which is necessary to arrive at the final conclusions. In a research article, the introduction, which serves to set the foundation for comprehending the background and results is usually followed by the methods section, which precedes the result and discussion sections. The methods section must explicitly state what was done, how it was done, which equipment, tools and techniques were utilized, how were the measurements/calculations taken, and why specific research protocols, software, and analytical methods were employed.  

Why is the methods section important?  

The primary goal of the methods section is to provide pertinent details about the experimental approach so that the reader may put the results in perspective and, if necessary, replicate the findings 3 .  This section offers readers the chance to evaluate the reliability and validity of any study. In short, it also serves as the study’s blueprint, assisting researchers who might be unsure about any other portion in establishing the study’s context and validity. The methods plays a rather crucial role in determining the fate of the article; an incomplete and unreliable methods section can frequently result in early rejections and may lead to numerous rounds of modifications during the publication process. This means that the reviewers also often use methods section to assess the reliability and validity of the research protocol and the data analysis employed to address the research topic. In other words, the purpose of the methods section is to demonstrate the research acumen and subject-matter expertise of the author(s) in their field.  

Structure of methods section of a research paper  

Similar to the research paper, the methods section also follows a defined structure; this may be dictated by the guidelines of a specific journal or can be presented in a chronological or thematic manner based on the study type. When writing the methods section , authors should keep in mind that they are telling a story about how the research was conducted. They should only report relevant information to avoid confusing the reader and include details that would aid in connecting various aspects of the entire research activity together. It is generally advisable to present experiments in the order in which they were conducted. This facilitates the logical flow of the research and allows readers to follow the progression of the study design.   

It is also essential to clearly state the rationale behind each experiment and how the findings of earlier experiments informed the design or interpretation of later experiments. This allows the readers to understand the overall purpose of the study design and the significance of each experiment within that context. However, depending on the particular research question and method, it may make sense to present information in a different order; therefore, authors must select the best structure and strategy for their individual studies.   

In cases where there is a lot of information, divide the sections into subheadings to cover the pertinent details. If the journal guidelines pose restrictions on the word limit , additional important information can be supplied in the supplementary files. A simple rule of thumb for sectioning the method section is to begin by explaining the methodological approach ( what was done ), describing the data collection methods ( how it was done ), providing the analysis method ( how the data was analyzed ), and explaining the rationale for choosing the methodological strategy. This is described in detail in the upcoming sections.    

How to write the methods section of a research paper  

Contrary to widespread assumption, the methods section of a research paper should be prepared once the study is complete to prevent missing any key parameter. Hence, please make sure that all relevant experiments are done before you start writing a methods section . The next step for authors is to look up any applicable academic style manuals or journal-specific standards to ensure that the methods section is formatted correctly. The methods section of a research paper typically constitutes materials and methods; while writing this section, authors usually arrange the information under each category.

The materials category describes the samples, materials, treatments, and instruments, while experimental design, sample preparation, data collection, and data analysis are a part of the method category. According to the nature of the study, authors should include additional subsections within the methods section, such as ethical considerations like the declaration of Helsinki (for studies involving human subjects), demographic information of the participants, and any other crucial information that can affect the output of the study. Simply put, the methods section has two major components: content and format. Here is an easy checklist for you to consider if you are struggling with how to write the methods section of a research paper .   

• Explain the research design, subjects, and sample details  
• Include information on inclusion and exclusion criteria  
• Mention ethical or any other permission required for the study  
• Include information about materials, experimental setup, tools, and software  
• Add details of data collection and analysis methods  
• Incorporate how research biases were avoided or confounding variables were controlled  
• Evaluate and justify the experimental procedure selected to address the research question  
• Provide precise and clear details of each experiment  
• Flowcharts, infographics, or tables can be used to present complex information     
• Use past tense to show that the experiments have been done   
• Follow academic style guides (such as APA or MLA ) to structure the content  
• Citations should be included as per standard protocols in the field  

Now that you know how to write the methods section of a research paper , let’s address another challenge researchers face while writing the methods section —what to include in the methods section .  How much information is too much is not always obvious when it comes to trying to include data in the methods section of a paper. In the next section, we examine this issue and explore potential solutions.   

What to include in the methods section of a research paper  

The technical nature of the methods section occasionally makes it harder to present the information clearly and concisely while staying within the study context. Many young researchers tend to veer off subject significantly, and they frequently commit the sin of becoming bogged down in itty bitty details, making the text harder to read and impairing its overall flow. However, the best way to write the methods section is to start with crucial components of the experiments. If you have trouble deciding which elements are essential, think about leaving out those that would make it more challenging to comprehend the context or replicate the results. The top-down approach helps to ensure all relevant information is incorporated and vital information is not lost in technicalities. Next, remember to add details that are significant to assess the validity and reliability of the study. Here is a simple checklist for you to follow ( bonus tip: you can also make a checklist for your own study to avoid missing any critical information while writing the methods section ).  

• Structuring the methods section : Authors should diligently follow journal guidelines and adhere to the specific author instructions provided when writing the methods section . Journals typically have specific guidelines for formatting the methods section ; for example, Frontiers in Plant Sciences advises arranging the materials and methods section by subheading and citing relevant literature. There are several standardized checklists available for different study types in the biomedical field, including CONSORT (Consolidated Standards of Reporting Trials) for randomized clinical trials, PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) for systematic reviews and meta-analysis, and STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) for cohort, case-control, cross-sectional studies. Before starting the methods section , check the checklist available in your field that can function as a guide.     
• Organizing different sections to tell a story : Once you are sure of the format required for structuring the methods section , the next is to present the sections in a logical manner; as mentioned earlier, the sections can be organized according to the chronology or themes. In the chronological arrangement, you should discuss the methods in accordance with how the experiments were carried out. An example of the method section of a research paper of an animal study should first ideally include information about the species, weight, sex, strain, and age. Next, the number of animals, their initial conditions, and their living and housing conditions should also be mentioned. Second, how the groups are assigned and the intervention (drug treatment, stress, or other) given to each group, and finally, the details of tools and techniques used to measure, collect, and analyze the data. Experiments involving animal or human subjects should additionally state an ethics approval statement. It is best to arrange the section using the thematic approach when discussing distinct experiments not following a sequential order.  
• Define and explain the objects and procedure: Experimental procedure should clearly be stated in the methods section . Samples, necessary preparations (samples, treatment, and drug), and methods for manipulation need to be included. All variables (control, dependent, independent, and confounding) must be clearly defined, particularly if the confounding variables can affect the outcome of the study.  
• Match the order of the methods section with the order of results: Though not mandatory, organizing the manuscript in a logical and coherent manner can improve the readability and clarity of the paper. This can be done by following a consistent structure throughout the manuscript; readers can easily navigate through the different sections and understand the methods and results in relation to each other. Using experiment names as headings for both the methods and results sections can also make it simpler for readers to locate specific information and corroborate it if needed.   
• Relevant information must always be included: The methods section should have information on all experiments conducted and their details clearly mentioned. Ask the journal whether there is a way to offer more information in the supplemental files or external repositories if your target journal has strict word limitations. For example, Nature communications encourages authors to deposit their step-by-step protocols in an open-resource depository, Protocol Exchange which allows the protocols to be linked with the manuscript upon publication. Providing access to detailed protocols also helps to increase the transparency and reproducibility of the research.  
• It’s all in the details: The methods section should meticulously list all the materials, tools, instruments, and software used for different experiments. Specify the testing equipment on which data was obtained, together with its manufacturer’s information, location, city, and state or any other stimuli used to manipulate the variables. Provide specifics on the research process you employed; if it was a standard protocol, cite previous studies that also used the protocol.  Include any protocol modifications that were made, as well as any other factors that were taken into account when planning the study or gathering data. Any new or modified techniques should be explained by the authors. Typically, readers evaluate the reliability and validity of the procedures using the cited literature, and a widely accepted checklist helps to support the credibility of the methodology. Note: Authors should include a statement on sample size estimation (if applicable), which is often missed. It enables the reader to determine how many subjects will be required to detect the expected change in the outcome variables within a given confidence interval.  
• Write for the audience: While explaining the details in the methods section , authors should be mindful of their target audience, as some of the rationale or assumptions on which specific procedures are based might not always be obvious to the audience, particularly for a general audience. Therefore, when in doubt, the objective of a procedure should be specified either in relation to the research question or to the entire protocol.  
• Data interpretation and analysis : Information on data processing, statistical testing, levels of significance, and analysis tools and software should be added. Mention if the recommendations and expertise of an experienced statistician were followed. Also, evaluate and justify the preferred statistical method used in the study and its significance.  

What NOT to include in the methods section of a research paper  

To address “ how to write the methods section of a research paper ”, authors should not only pay careful attention to what to include but also what not to include in the methods section of a research paper . Here is a list of do not’s when writing the methods section :  

• Do not elaborate on specifics of standard methods/procedures: You should refrain from adding unnecessary details of experiments and practices that are well established and cited previously.  Instead, simply cite relevant literature or mention if the manufacturer’s protocol was followed.  
• Do not add unnecessary details : Do not include minute details of the experimental procedure and materials/instruments used that are not significant for the outcome of the experiment. For example, there is no need to mention the brand name of the water bath used for incubation.    
• Do not discuss the results: The methods section is not to discuss the results or refer to the tables and figures; save it for the results and discussion section. Also, focus on the methods selected to conduct the study and avoid diverting to other methods or commenting on their pros or cons.  
• Do not make the section bulky : For extensive methods and protocols, provide the essential details and share the rest of the information in the supplemental files. The writing should be clear yet concise to maintain the flow of the section.  

We hope that by this point, you understand how crucial it is to write a thoughtful and precise methods section and the ins and outs of how to write the methods section of a research paper . To restate, the entire purpose of the methods section is to enable others to reproduce the results or verify the research. We sincerely hope that this post has cleared up any confusion and given you a fresh perspective on the methods section .

As a parting gift, we’re leaving you with a handy checklist that will help you understand how to write the methods section of a research paper . Feel free to download this checklist and use or share this with those who you think may benefit from it.  

References  

• Bhattacharya, D. How to write the Methods section of a research paper. Editage Insights, 2018. https://www.editage.com/insights/how-to-write-the-methods-section-of-a-research-paper (2018).
• Kallet, R. H. How to Write the Methods Section of a Research Paper. Respiratory Care 49, 1229–1232 (2004). https://pubmed.ncbi.nlm.nih.gov/15447808/
• Grindstaff, T. L. & Saliba, S. A. AVOIDING MANUSCRIPT MISTAKES. Int J Sports Phys Ther 7, 518–524 (2012). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3474299/

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Writing a Research Paper

For most areas of science, from biology to physics, writing a research paper is one of the most important skills.

This article is a part of the guide:

• Outline Examples
• Example of a Paper
• Write a Hypothesis
• Introduction

Browse Full Outline

• 1 Write a Research Paper
• 2 Writing a Paper
• 3.1 Write an Outline
• 3.2 Outline Examples
• 4.1 Thesis Statement
• 4.2 Write a Hypothesis
• 5.2 Abstract
• 5.3 Introduction
• 5.4 Methods
• 5.5 Results
• 5.6 Discussion
• 5.7 Conclusion
• 5.8 Bibliography
• 6.1 Table of Contents
• 6.2 Acknowledgements
• 6.3 Appendix
• 7.1 In Text Citations
• 7.2 Footnotes
• 7.3.1 Floating Blocks
• 7.4 Example of a Paper
• 7.5 Example of a Paper 2
• 7.6.1 Citations
• 7.7.1 Writing Style
• 7.7.2 Citations
• 8.1.1 Sham Peer Review
• 8.1.2 Advantages
• 8.1.3 Disadvantages
• 8.2 Publication Bias
• 8.3.1 Journal Rejection
• 9.1 Article Writing
• 9.2 Ideas for Topics

You can design the greatest experiment on earth but if you cannot write a good report then nobody will take your results seriously.

The first thing you must do is make sure that you have designed and performed a good experiment . Once it is finished and you have lots of results , you can present them to the world.

Most science reports should have the same layout:

Most use this or a similar outline when writing a research paper .

The title must not be too long but must describe exactly what your experiment is about.

For example, "Mold Growth" tells us nothing whereas "The Effect Of Temperature On Mold Growth" lets everybody know what the experiment is about.

In this section it is important to give the reasons why you picked this experiment and show the background research you did for it.

You have to assume that somebody reading your experiment may know nothing about the subject so you must give them a quick summary.

You could let them know a little about 'The Life Cycle of Mold' or 'The History of Pendulums'. There is one problem; how do you keep your introduction short whilst trying to teach somebody about your subject?

This is where you use references, sometimes called citations. For every piece of information included, you should let the reader know where it came from.

Whether from books, magazines, the internet or your teacher, if you include your references, somebody interested in your subject can easily read them and find out more.

Finally, you should include your hypothesis statement . This is what you are trying to prove or disprove. For example 'Mold grows quicker at higher temperatures' or 'Expensive brands of paper towel absorb more water than cheaper ones' are testable hypotheses .

Here you must describe exactly the equipment and methods you used.

What you must remember is that somebody might want to test your results so you must make sure that they are able to perform exactly the same experiment with exactly the same equipment.

It is a good idea to include a list of all the equipment you used and step by step instructions on what you did.

Here you describe what you found. In this section , you should not discuss what your results mean; only what you found. You must try to be exact and give numbers instead of just observations.

Use graphs and tables as they are easier for people to understand easily. Be careful not to put in lots of graphs just for the sake of it. Every graph and table should be clear and referred to in the text.

The discussion is where you interpret your results and try to explain what they mean. This is called significance. You should point out whether your hypothesis is proved, disproved or inconclusive, if you are not sure one way or the other.

If your hypothesis is proved, great, but the world of science does not stay still. Here you should speculate where science goes next or what experiments you could do next.

For example, in the case of the mold bread experiment , after testing the effect of temperature, you could check whether the amount of light has an effect on the rate of growth.

If your hypothesis was wrong or unproven, this is not a problem. There is no right and wrong in science, only answers. Even if your hypothesis was wrong, the world of science has still learned something.

In the discussion you must describe why the experiment did not give the results you expected. Maybe your initial hypothesis was wrong, but maybe there were some flaws in your experimental design or method.

You should describe why it might be wrong or what changes you would make if you were to repeat the experiment again. Be honest. Nobody is going to punish you for having these problems, only for not understanding why.

Even great scientists like Charles Darwin and Stephen Hawking have had flaws in their theories so you are in good company if your experiment did not work out exactly how you planned!

It is always a good idea to write a short summary of the conclusion at the end of the report to make everything a little clearer to the reader.

Bibliography

It is good practice to list the books, magazines and websites from where you found out your background research when writing a research paper. This makes sure that somebody who is interested in your subject can find out a little more.

For a book, you should include the name of the author, the title, the date it was written and the page numbers of where you found the information.

For magazines you should include the name of the author, the title of the magazine, the issue number and/or date, and the name of the article.

For a website you should put the exact website address and the date you looked at it.

Not every science report or article insists that you have a bibliography but if you want to follow a career as a scientist it is a good idea to get used to it now.

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Martyn Shuttleworth (May 23, 2008). Writing a Research Paper. Retrieved Oct 24, 2024 from Explorable.com: https://explorable.com/writing-a-research-paper

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Overview of Attention Deficit Hyperactivity Disorder in Young Children

Chia jung yeh, nidhi verma, ajay kumar das.

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Department of Early Childhood and Elementary Education, College of Education and Human Services, Murray State University 3103, Alexander Hall, Murray, KY 42071, USA +1.270.809.3098. [email protected]

Contributions: AS, NV contributed equally as first authors.

Conflict of interest: the authors declare no potential conflict of interest.

Received 2014 Nov 17; Revised 2014 Dec 17; Accepted 2014 Dec 18; Collection date 2015 Sep 30.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/ ) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Attention deficit hyperactivity disorder (ADHD) is a complex disorder, which can be seen as a disorder of life time, developing in preschool years and manifesting symptoms (full and/or partial) throughout the adulthood; therefore, it is not surprising that there are no simple solutions. The aim of this paper is to provide a short and concise review which can be used to inform affected children and adults; family members of affected children and adults, and other medical, paramedical, non-medical, and educational professionals about the disorder. This paper has also tried to look into the process of how ADHD develops; what are the associated problems; and how many other children and adults are affected by such problems all over the world basically to understand ADHD more precisely in order to develop a better medical and or non-medical multimodal intervention plan. If preschool teachers and clinicians are aware of what the research tells us about ADHD, the varying theories of its cause, and which areas need further research, the knowledge will assist them in supporting the families of children with ADHD. By including information in this review about the connection between biological behavior, it is hoped that preschool teachers and clinicians at all levels will feel more confident about explaining to parents of ADHD children, and older ADHD children themselves about the probable causes of ADHD.

Key words: Attention deficit hyperactivity disorder, preschool, children, families, intervention

Overview of attention deficit hyperactivity disorder in young children

Literally thousands of studies have been conducted on attention deficit hyperactivity disorder (ADHD) and it’s various predecessors in diagnostic nomenclatures prior to DSM-V (The Diagnostic and Statistical Manual of Mental Disorders-V). Despite this long research history, ADHD is not necessarily well understood among the lay public, given the many controversies and public misconceptions concerning the disorder. 1 , 2 Longitudinal evidence suggests that childhood ADHD persists into young adulthood in 60-70% of the cases when defined relative to same-age peers and in 58% of the cases when DSM-V criteria and parental reports are used. 3-6 These early studies of childhood hyperactivity excluded many children that would currently meet the DSM criteria for ADHD, particularly the inactive sub-type. 7 The scientific status of ADHD is one of the most controversial issues in child health. 8-10 This paper examines the overview of ADHD in children in relation to its genetics, taxonomy, neurobiology, comorbidity, diet, treatment, and concludes with a discussion.

Précis of attention deficit hyperactivity disorder

ADHD is recognized as a common childhood psychiatric disorder and has a strong genetic, neuro-biologic, and neurochemical basis. 11 , 12 It is characterized by symptoms of inattention and/or impulsivity and hyperactivity which can significantly impact many aspects of behavior as well as performance, both at school and at home. 13 ADHD is characterized by pervasive and impairing symptoms of inattention, hyperactivity, and impulsivity according to DSM-V. 14-16 The World Health Organization (WHO) uses a different name hyperkinetic disorder (HD)-but lists similar operational criteria for the disorder. 17 Regardless of name used, ADHD is one of the most thoroughly researched disorders in medicine. 18 The DSM diagnostic criteria for ADHD were based on reviews of existing research and a field trial in which alternative diagnostic criteria were evaluated. 19

Classification of what constitutes ADHD has changed dramatically over the last 32 years, with each successive revision of the Diagnostic and Statistical Manual, the diagnostic criteria used to describe the disorder. Current classification for combined type ADHD requires a minimum of six out of nine symptoms of inattention of hyperactivity/impulsivity. 16 , 17 , 20 In addition there must be some impairment from symptoms in two or more settings ( e.g . home and school) and clear evidence of significant impairment in social, school or work functioning. The DSM also allows the classification of two sub-type disorders: i) predominantly inattentive where the child only meets criteria for inattention; and ii) predominantly hyperactive-impulsive where only the hyperactive-impulsive criteria are met.

Prevalence of attention deficit hyperactivity disorder

The relatively prevalence of the disorder is high, affecting approximately 4% of all children, although estimates vary widely from 3% to 11% or more. 21 , 22 The disorder usually begins in early childhood and is characterized by excessive activity, even when developmental level and limited behavioral control are taken into consideration. 23 , 24 reviewed the findings of six large epidemiological studies that identified cases of ADHD within these samples. The prevalences found in these studies ranged from a low of 2% to a high of 6.3%, with most falling within the range of 4.2% to 6.3%. Other studies have found similar prevalence rates in elementary school-age children (4-5.5%; in Breton et al ., 25 7.9% in Briggs-Gowan et al. , 26 5-6% in DuPaul, 27 and 2.5-4% in Pelham et al . 28 Lower rates result from using complete DSM criteria and parent reports (2-6% in Breton et al ., 25 and higher ones if just a cutoff on teacher ratings is used (up to 23% in DuPaul, 27 15.8% in Nolan et al ., 29 14.3% in Trites et al . 30 Sex and age differences in prevalence are routinely found in research. For instance, prevalence rates may be 4% in girls and 8% in boys in the preschool age group, 29 yet fall to 2-4% in girls and 6-9% in boys during the 6- to 12-year-old age period based on parent reports. 25 The prevalence decreases again to 0.9-2% in girls and 1-5.6% in boys by adolescence. 25 , 31-33 Overall ADHD affects 2% to 9% in school age children.

Etiological elucidation of attention deficit hyperactivity disorder

Underlying etiological explanations of ADHD can be simply divided into biological and environmental. In simple terms biological explanations include genetics, brain structure and their influence on neuropsychology, while predominant environmental explanations include problems during and after birth, exposure to environmental toxins, parenting and diet.

Heredity of attention deficit hyperactivity disorder

Heredity of ADHD has been an important issue. 34 For years, researchers have noted the higher prevalence of psychopathology in the parents and other relatives of children with ADHD. Between 10% and 35% of the immediate family members of children with ADHD are also likely to have the disorder, with the risk to siblings being approximately 32%. 35-37

Even more striking is the finding that if a parent has ADHD, the risk to the offspring is 57%. 12 Thus, ADHD clusters significantly among the biological relatives of children with the disorder, strongly implying a hereditary basis to this condition. 38 Subsequently, these elevated rates of disorders have been noted in African American samples with ADHD, 39 as well as in girls with ADHD compared to boys. 40

Genetic factor

The heredity basis for psychiatric disorders was already recognized at the turn of the nineteenth century by Enail Kraepelin. 41 There is now little doubt that ADHD is a condition in which genetic factors (genetic differences between children) make a substantial contribution to the risk of the disorder. 42 Genetic factors are accounted for 80% of the etiology of ADHD, while more recent studies have begun to examine which particular genes might be implicated in ADHD, 43 , 44 reported an association between ADHD and a null allele of the C4B complement locus in the MHC -gene region of chromosome 6, a locus also associated with reading disability. 45 Interest in a potential genetic mechanism underlying ADHD increased with reports of an association with a single dopamine transporter gene, 46 and with reports of variations within the D4 receptor gene. 47 Genetic studies have focused mainly on candidate genes involved in dopaminergic transmission. Several reasons exist for this particular focus, dopaminergic drugs (methylphenidate) are clinically efficacious in addressing the core problems associated with ADHD. A gene related to dopamine, the DRD4 (repeater gene), has been the most reliably found in samples of children with ADHD. 48 It is the seven-repeat form of this gene that has been found to be overrepresented in children with ADHD. 47 Such a finding is quite interesting, because this gene has previously been associated with the personality trait of high novelty-seeking behavior; because this variant of the gene affects pharmacological responsiveness; and because the gene’s impact on postsynaptic sensitivity is primarily found in frontal and prefrontal cortical regions believed to be associated with executive functions and attention. 49 The finding of an overrepresentation of the seven-repeat DRD4 gene has now been replicated in a number of other studies, not only of children with ADHD, but also of adolescents and adults with the disorder. 42 , 48

Monitoring the correspondence between the intended and actually executed action, a fundamental mechanism of behavioral regulation, is reflected by error-related negativity (ERN), an ERP component generated by the anterior cingulate cortex. Based on this process assumption, a study by LaHoste et al . 50 examined genetic influences on the ERN and other components related to action monitoring (correct negativity, CRN, and error positivity, P e ). A flanker task was administered to adolescent twins (age 12) including 99 monozygotic (MZ) and 175 dizygotic (DZ) pairs. Genetic analysis showed substantial heritability of all three ERP components (40-60%) and significant genetic correlations between them. This study provides the first evidence for heritable individual differences in the neural substrates of action monitoring and suggests that ERN, CRN, and P e can potentially serve as endophenotypes for genetic studies of personality traits and psychopathology associated with abnormal regulation of behavior. 50

Cognitive genetics

The sequencing of the human genome and the identification of a vast array of DNA polymorphisms has afforded cognitive scientists with the opportunity to interrogate the genetic basis of cognition with renewed vigor. Advances in the understanding of the neural substrates of sustained and spatial attention arising from the cognitive neurosciences can help guide putative linkages in cognitive genetics. 51 In line with catecholamine models of sustained attention, associations have been reported between sustained attention and allelic variation in the dopamine beta hydroxylase gene ( DBH ), the dopamine D2 and D4 receptor genes ( DRD2, DRD4 ) and the dopamine transporter gene ( DAT1 ). 51 Much evidence implicates the cholinergic system in spatial attention. Accordingly, individual differences in spatial attention have been associated with variation in an alpha-4 cholinergic receptor gene (CHRNA4). APOE-4 allele dosage has been shown to influence the speed of attentional reorienting in independent samples of nonaffected individuals. Preliminary evidence in both healthy children and children with ADHD suggests association with variants of the DAT1 gene and the control of spatial attention across the hemifields. 51

Fronto-striatal circuitry in attention deficit hyperactivity disorder

Imaging studies using positron emission tomography (PET), and magnetic resonance imaging (MRI) techniques have implicated the fronto-striatal circuitry in ADHD, an area rich in dopaminergic activity. However certain meta-analytic studies have questioned the robust association between dopaminergic genes and ADHD. 52 Other candidate genes have also been investigated including serotonin transporter genes. 53 Genetic investigations aim to examine whether different genes contribute to specific aspects of ADHD. For example, a meta-analysis by Bellgrove and Mattingley has shown that the dopamine transporter gene DAT1 is more closely associated with the ADHD combined sub-type than with the inattentive +sub-type. 54 Future molecular genetic studies aim to examine gene-environment interactions, the extent to which environmental factors moderate genetic risks for ADHD. As well as gene-gene interactions, the extent to which having a cocktail of different genetic influences might elevate risk for ADHD.

Brain structure

A wealth of literature has examined the anatomical structure of the brain in children with ADHD. Using brain scanning technology such as MRI these studies suggest that the brain circuits linking the prefrontal cortex, striatum and cerebellum are not functioning normally in children with ADHD. 55 Further evidence has examined the relationship between brain structure and behavioral measures of inhibition and attention. These results suggest that compromised brain morphology of selected regions is related to behavioral measures of inhibition and attention. 56 Another study suggests that abnormalities in circuits important for motor response selection contribute to deficits in response inhibition in children with ADHD. 57 This lends support to the growing awareness of ADHD-associated anomalies in medial frontal regions which are important for the control of voluntary actions. Studies using PET to assess cerebral glucose metabolism have found diminished metabolism in adults with ADHD, particularly in the frontal region. 58 , 59 Using a radioactive tracer that indicates dopamine activity, 60 found abnormal dopamine activity in the right midbrain region of children with ADHD, and discovered that severity of symptoms was correlated with the degree of this abnormality. Another study pointed that children with ADHD were found to have a smaller corpus callosum, particularly in the area of the genu and splenium and that region just anterior to the splenium. 61 Interestingly, the study by Zametkin et al. 62 also found smaller cerebellar volume in those with ADHD. This would be consistent with views that the cerebellum plays a major role in executive functioning and the motor presetting aspects of sensory perception that derive from planning and other executive actions. 63 MRI showed no differences between groups in the regions of the corpus callosum in either of the other studies. 62 , 64 Further investigations of anatomical structure may allow the development of pharmacological interventions for ADHD, 65 which are better targeted to specific sites of action in the brain.

Neurobiology of attention deficit hyperactivity disorder

Neurobiology of ADHD has been another valued topic of investigation. 66 Researchers describe at least 11 different neuroanatomical theories of ADHD. 67 These theories can be categorized into two domains. The bottom-up theories propose disturbances in subcortical regions, such as the thalamus, and hypothalamus and reticular activating systems are responsible for ADHD symptomology. The top-down theories attribute the dysfunction to frontal and prefrontal and sagittal cortices. Smaller frontal lobe or right prefrontal cortex was found for the ADHD groups in all studies that examined this measure. Five of six studies found a smaller anterior or posterior corpus callosum. Four of six found loss of the normal caudate asymmetry, and these four also found a smaller left or right globus pallidus. 68 Neuroimaging studies of children with ADHD have investigated and found evidence of abnormalities in the frontal cortex, basal ganglia, corpus callosum, and cerebellum. 69-72 The cerebellum is functionally linked with the pre-frontal cortex, and three anatomical measures, namely the right globus pallidus volume, caudate asymmetry, and left cerebellum volume, correlate highly with ADHD in children. 68 Preliminary evidence has not found differences in the thalamus in children with ADHD. 62 , 73

Role of the basal ganglia

The role of the basal ganglia in ADHD has been given serious importance in neuropsychological research. The basal ganglia are a collection of large subcortical structures that can be divided into two sets of core structures: i) the striatum consisting of the caudate, putamen, and ventral striatum and ii) the pallidum or globus pallidus consisting of the external segment, internal segment, and ventral pallidum. The striatum receives input from the entire cerebral cortex, thalamus, substantia nigra, and amygdala and sends projections to the pallidum and substantia nigra. The pallidum sends input to the thalamic nuclei and additional subcortical nuclei, where information will be sent back to the frontal or pre-frontal cortex. 74 The organization of the striatum is important in the execution of motor planning, sequencing, and coordination, as well as feedback and learning after motor execution, 75 suggest that the striatum serves as a crossroads , combining sensory-motor information with emotional processing from the amygdala and dopamine mediated reinforcement. The primary neurotransmitter involved in modulation of the basal ganglia is dopamine, and disruption of this system has been found in ADHD. Initial studies found higher levels of the dopamine metabolite, and homovanillic acid in cerebral spinal fluid were positively correlated with the amount of hyperactivity in boys. 62 A recent genetic study found that alleles of the gene encoding dopamine beta hydroxylase, an enzyme that breaks down dopamine, may be related to the expression of ADHD. 76 Further support for dopamine dysfunction in ADHD comes from a functional MRI study that found children with ADHD had reduced activity in the frontal-striatal regions and impaired performance on response inhibition tasks. 77 Additionally, methylphenidate, which acts on the dopamine transporter (DAT), increased both frontal-striatal activity and performance on response inhibition tasks. A study using single PET-CT found that adults with ADHD had increased levels of striatal DAT compared to normal controls, which may lead to decreased availability of striatal dopamine in ADHD. 78

Research on the role of the basal ganglia in ADHD has primarily focused on the caudate. 79 The caudate has been implicated in a complex loop , receiving information from the association cortices and indirectly sending it via the thalamus to the prefrontal cortex. 80 Studies have found neuroanatomical differences in the caudate of children with ADHD with mixed results. 56 , 62 ,69, 81-83 Found that boys with ADHD had a smaller right caudate; recently, this finding was not replicated in ADHD girls. 69 In boys with ADHD, smaller right caudate volumes were found to significantly correlate with poor accuracy on sensory selection tasks, and left and right caudate volumes were negatively correlated with mean reaction times. 81 Conflicting results found ADHD adolescents had larger right caudate than normal adolescents, and the right caudate volume was associated with poorer performance on attention tasks and higher ratings of hyperactivity and impulsivity. 83 Another study found that children with ADHD had smaller left caudate volumes. 73 , 82 More recently, Manor et al . 56 reported that boys with ADHD were found to have a decreased volume of the left head of the caudate. These children were also more likely to show a reversed caudate asymmetry when compared to healthy controls, with the left being smaller than right. Moreover, a significant relationship between the reduction in left caudate volume and performance on behavioral inhibition tasks was found. In addition, children displaying reversed caudate asymmetry (L<R) were more likely to perform poorly on tasks of behavioral inhibition and attention regardless of group membership. 56 , 81 It has been also previously found that reversed caudate asymmetry was related to deficits in response execution tasks in ADHD. This evidence suggests that asymmetry of the caudate regardless of volume has important implications in attention and behavioral control. Finally, functional imaging studies have found decreases in blood flow to the caudate in ADHD. 62 , 84

Role of the putamen

The role of the putamen has also been studied as an etiological factor for the ADHD. 85 The putamen is hypothesized to be part of the motor loop because it receives information from the sensory-motor cortex and then sends it indirectly back to the premotor regions of the frontal cortex. Based on the putamen’s anatomical connections and function, a role for the putamen in ADHD is possible although currently unclear because of equivocal evidence. 80 There are relatively few studies investigating the neuroanatomical role of the putamen in ADHD. 69 Another study have not found volumetric differences in the putamen between children with ADHD and healthy controls. 62 In addition, they found that the volume of the putamen did not correlate with performance on response inhibition tasks. However, two studies suggest that the putamen may actually be important in the expression of ADHD symptomology. Researchers found that the ADHD diagnosis was significantly associated with the titer of two ant streptococcal antibodies. 86

In addition, they found that higher antibodies titers were associated with larger volumes in the left putamen and right globus pallidus in children with ADHD. 86 Although this study found structural evidence for the role of the putamen in ADHD, the second study demonstrates functional differences in the putamen of children with ADHD. Recent advances in functional MRI technology have provided new methods to investigate blood flow to various regions of the brain. Functional MRI relaxometry allows researchers to investigate the resting or steady state conditions and medication-related changes and were able to indirectly assess blood volume to the striatum (caudate and putamen). 75 They found that blood flow to both sides of the putamen was decreased in ADHD children compared to normal children. In addition, they found that blood flow to the left was more decreased than blood flow to the right side. They found no differences in blood flow to the thalamus and caudate, although there was a non-significant trend in the right caudate. Methylphenidate administration significantly altered the blood flow to the right and left putamen, and changes were correlated to the child’s unmedicated state.

There were no significant differences in blood flow to the caudate off or on medication. Filipek et al . 75 found strong associations between measures of activity and inattention with T2-RT measures in the putamen. They propose that ADHD symptoms are closely related to functional abnormalities in the putamen, which is closely involved in the control of motor behavior. These hypotheses lay the foundation for our study of the neuroanatomy of the putamen in children with ADHD. Investigators in their study using magnetic resonance imaging scans of boys in residential treatment with symptoms of ADHDand psychopathic traits found no differences in the total, left and right putamen volumes across the ADHD or control group. A significant reversal of asymmetry across groups was found; children with ADHD more frequently had a smaller left putamen than right. In contrast, the control group more frequently has a smaller right than left putamen.

Several studies have examined cerebral blood flow using single-photon emission computed tomography (SPECT) in children with ADHD and normal children. 68 , 72 They have consistently shown decreased blood flow to the prefrontal regions (most recently in the right frontal area), and to pathways connecting these regions with the limbic system via the striatum and specifically its anterior region known as the caudate, and with the cerebellum. 87 , 88

Neuropsychology of attention deficit hyperactivity disorder

Studies examining the neuropsychology of ADHD provide an opportunity to understand the relationship between underlying biological processes and symptoms of ADHD. For many years it was accepted that symptoms of ADHD were the result of cognitive dysregulation. 89 The behavior of a child with ADHD resulted from insufficient forethought, planning and control. 90 Evidence to support this view point came from many studies using neuropsychological tests which demonstrated that children with ADHD performed less well on these tests than did matched controls to match familiar figures, children with ADHD demonstrated more impulsive responding and higher error rates than did matched controls. 91 , 92

Cognitive dysregulation

A summary of ADHD as a disorder of cognitive dysregulation suggested that the relationship between biology and behavior in children with ADHD was mediated by inhibitory dysfunction. 93 In contrast to the dominant view, researchers offered an alternative view of ADHD, not as a disorder of cognitive dysregulation, but as a motivational style. This viewed ADHD as a functional response by the child, aimed at avoiding delay. This alternative viewpoint of ADHD was based on other studies, 92 which showed that most of the neuropsychological evidence to support ADHD as a result of cognitive dysregulation was confounded by delay. To demonstrate this, researchers got children with ADHD and match control children to participate in the matching familiar figures test, and found the same results as previous studies. 92 Children with ADHD made more impulsive responses and more errors. However, researchers pointed out that all these studies involved trial constraints where as soon as one trial ended the next began and were confounded with delay. 92 In order words, children with ADHD made more impulsive responses because it allowed them to complete the task quicker and therefore escape delay. When researchers re-ran their study under time constraint (for a fixed period of time where early or impulsive responses had no influence on delay), children with ADHD performed no differently from controls. 92 Results of these studies lead to the development of the delay aversion hypothesis, 94 which characterized the influence of delay on behavior dependent upon whether the child has control over their environment or not. When the child is in control of their environment they can choose to minimize delay by acting impulsively, e.g. by skipping the queue at the end of the slide! When the child is not in control of their environment, or at least where they are expected to behave in certain ways or face sanctions, the child would choose to distract themselves from the passing of time. For example, in a classroom context during literacy lessons the child could achieve this either by daydreaming (inattention) or by fidgeting (hyperactivity). A summary of ADHD as a motivational style suggests that the relationship between biology and behavior in ADHD is mediated by delay aversion.

Traditionally these two different accounts of ADHD have both sought to independently explain the disorder. However, a study by Sonuga-Barke et al . 95 compared the measurement of both of these hypotheses in a head-to-head study. Results of this study showed that measures used to test each hypothesis were uncorrelated, demonstrating that they measured different constructs. Both sets of measures were correlated with ADHD, and when combined were highly diagnostic, correctly distinguishing 87.5 of cases from non-cases. These results suggested that both accounts appeared to help to explain ADHD, but that neither explanation was the single theory of ADHD which both theoretical camps had been searching for. Based on these findings, researchers proposed his dual pathway model of ADHD. 93 This model proposed two possible routes between biology and ADHD behavior. The first one is through cognitive dysregulation and another via motivational style. Clinically the dual pathway model suggests that there may be merit in targeting different sub-types with specific treatments, as well as allowing the development of novel interventions, perhaps aimed at desensitizing delay. Some have suggested ways in which the greater understanding about the influence of delay aversion on the development of ADHD could be used to develop alternative interventions. 93 , 96 These suggestions include the use of delay fading, a technique to systematically reorganize the child’s delay experience, as a means of increasing tolerance for delay, and reducing ADHD symptoms.

Some studies have not found a greater incidence of prenatal (pregnancy or birth complications) in children with ADHD compared to normal children whereas others have found a slightly higher prevalence of unusually short or long labor, fetal distress, low forceps delivery, and toxemia or eclampsia in children with ADHD. 97 Nevertheless, though children with ADHD may not experience greater pregnancy complications, prematurity, or lower birth-weight as a group, children born prematurely or who have markedly lower birth-weights are at high risk for later hyperactivity or ADHD.

Researchers found that smoking and maternal stress during the pregnancy is associated with onset of ADHD during early childhood. Similarly observed that parental smoking during pregnancy predicts non-responsiveness to intervention targeting ADHD symptoms in elementary school children. Hartsough et al . observed that behavioral symptoms of ADHD were predicted by a lower ponderal index (kg/m 3 ), 98 a smaller head circumference, and a smaller head-circumference-to-length ratio. Length of gestation, mother’s age, tobacco and alcohol during pregnancy and pre-pregnancy, body mass index or parity, the monthly gross income of family, child’s BMI at the age of five or six years or gender didn’t have any significant effect on the behavioral symptoms of ADHD at the age of five or six.

Exposure to environmental toxins

Exposure to environmental toxins specifically lead has also been reviewed as a causal factor for ADHD. An amazing variety of toxins extent in the modern environment have deleterious effects on the central nervous system that range from severe organic destruction to subtle brain dysfunction. 99 , 100 Toxic metals are ubiquitous in the modern environment, as are organohalide pesticides, herbicides, and fumigants, and a wide range of aromatic and aliphatic solvents. 101 All these categories of environmental pollutants have been linked to abnormalities in behavior, perception, cognition, and motor ability that can be subtle during early childhood but disabling over the long term. 102 Children exposed acutely or chronically to lead, arsenic, aluminum, mercury, or cadmium are often left with permanent neurological sequelae that include attentional deficits, emotional lability, and behavioral reactivity. 101 Elevated body lead burden has been shown to have a small but consistent and statistically significant relationship to the symptoms of ADHD. 103 , 104 However, even at relatively high levels of lead, fewer than 38% of children in one study were rated as having the behavior of hyperactivity on a teacher rating scale, 104 implying that most lead-poisoned children do not develop symptoms of ADHD. And most children with ADHD likewise, do not have significantly elevated lead burdens. 105

Environmental influences

Environmental influences on ADHD have also been reviewed extensively. Attention deficit hyperactivity disorder is best viewed as a gene × environment interaction. 106 Children who have a genetic predisposition will express the disorder when put in the correct environment, typically one characterized by chaotic parenting. 107 The best evidence for environmental influences on ADHD come from intervention studies which have demonstrated improvements in ADHD symptoms, when parents have been taught alternative parenting skills. 108 , 109 Results of these studies do not necessarily imply that parents of children with ADHD are bad parents. In fact, influence of parenting on ADHD is best viewed from an interactionist viewpoint. The relationship between ADHD and parenting may result from both negative aspects of the child influencing the parents’ behavior, and negative aspects of the parents influencing the child’s behavior. Studies examining mother-child interaction have found that children with ADHD are less often on task, less compliant, less responsive and more active than controls; researchers investigated both mother-son and father-son interactions and found that parents of boys with ADHD were more demanding, aversive and power assertive; 110-112 while the findings of Buhrmester et al. 113 have demonstrated that mothers of children with ADHD have been found to be more negative, controlling, intrusive and disapproving, and less rewarding and responsive than mothers of children without ADHD.

Research finds that ADHD affects the interactions of children with their parents, and hence the manner in which parents may respond to these children. 114 Those with ADHD are more talkative, negative and defiant; less compliant and cooperative; more demanding of assistance from others; and less able to play and work independently of their mothers. 115-118 Their mothers are less responsive to the questions of their children, more negative and directive, and less rewarding of their children’s behavior. 107 , 116 Mothers of children with ADHD have been shown to give both more commands and more rewards to sons with ADHD than to daughters with the disorder, 119 , 120 but also to be more emotional and acrimonious in their interactions with sons. 112 Children and teens with ADHD seem to be nearly as problematic for their fathers as their mothers. 112 , 118 , 121 Contrary to what may be seen in normal mother-child interactions, the conflicts between children and teens with ADHD (especially boys) and their mothers may actually increase when fathers join the interactions. 112 , 121 So while parents of children with ADHD may engage in less than optimal parenting, it is easy to see how such responses might have evolved.

In addition, genetic studies highlight the familial basis of ADHD. 122 , 123 Children with ADHD are more likely to have a parent with ADHD. ADHD symptoms in parents usually interfere with consistent and appropriate parenting. Researchers found that ADHD in parents prevented effective parental monitoring and consistent use of constructive parenting techniques. 124 Other researchers found that parental ADHD symptoms were associated with lax discipline, 125 while Harvey et al. 126 found that high ADHD symptoms in mothers were a barrier to successful psychosocial intervention for pre-school children with ADHD.

Most widely researched and commonly prescribed treatments for ADHD are the psychostimulants, including methylphenidate, amphetamine, and pemoline. 2 , 127 Several studies have demonstrated the short-term efficacy of stimulant compared to placebo conditions in improving both core ADHD symptoms and important ancillary features of the disorder. 128 Controlled studies of stimulants have shown their effect on reducing interrupting in class, reducing task-irrelevant activity in school, improving performance on spelling and arithmetic tasks, improving sustained attention during play, and improving parent-child interaction.

Meaningful effects have been documented across a wide array of outcome domains, cognitive attentional performance, school behavior, and learning, parent-child interactions, interaction with peers, and with a wide variety of assessment approaches, direct observations of behavior in natural and laboratory settings, and objective laboratory performance. 129

Diet is another environmental influence, often cited by parents as having an adverse influence on the ADHD symptoms of their child. 130 Specifically, food additives, refined sugars and fatty acid deficiencies have all been associated with ADHD symptoms. 131

However, the majority of this literature comes from older studies, with a variety of methodological problems, and small sample sizes. 131 In fact, a large recent randomized control trial examined the influence of food colorings and benzoate preservatives on pre-school hyperactivity. Results demonstrated a general adverse effect of food coloring and benzoate preservatives on hyperactive behavior of preschool children, based on parental reports, but not on simple clinic assessment. Children with high levels of hyperactivity were no more vulnerable to this effect than children with low levels of hyperactivity. 132 While improving children’s diet might impact on their general health and improve their overall behavior, the clinical importance of dietary change as a means of remediating ADHD remains doubtful. 133

Co-morbidity

ADHD appears to be associated with a wide variety of other psychiatry problems, which are often co-morbid with it. ADHD co-occurs with other childhood disorders far more often than it appears alone. 134 Notable associations exist with Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), tic disorder, mood disorder, autism spectrum disorder, specific learning disorder such as dyslexia, 135 , 136 depression and anxiety. About 50-60% of children with ADHD meet criteria for ODD, even in the pre-school period. 137 Busch and colleagues (2002) reported that ADHD children in primary care settings were significantly more likely than non-ADHD clinic controls to demonstrate mood disorders (57%) such as depression, multiple anxiety disorders (31%), and substance use disorders (11.5%). However, in the recent British Child Mental Health Survey, 138 anxiety was not associated with ADHD when adjustment was made for the presence of a third disorder. It is widely accepted that ADHD is a co-morbid disorder. Copeland et al. 135 point out that co-morbidity can mean a common underlying etiology which leads to two or more different disorders, or that one disorder leads to another, or even that two unrelated disorders co-occur. The term co-morbid also implies that their entities are morbid conditions, i.e. diseases. High rates of comorbidity with either other neurodevelopmental disorders ( e.g ., mental retardation, and learning disabilities) or psychiatric disorders ( e.g ., anxiety) make delineation of the phenotype difficult. 139

Some studies found that 47% children with ADHD have co-morbid ODD, 140-142 27% have anxiety disorder and 7% have mood disorder. 38% of children with ADHD were found to have CD and 13% have depression. In fact, the vast majority of co-morbidities with ADHD represent functional impairments and symptoms, which are not rooted in specific diseases. 135 Studies of clinic-referred children with ADHD find that between 54% and 67% will meet criteria for a diagnosis of ODD by 7 years of age or later. ODD is a frequent precursor to CD, a more severe and often (though not always) later occurring stage of ODD. 143. The co-occurrence of CD with ADHD may be 20-50% in children and 44-50% in adolescence with ADHD. 144 By adulthood, up to 26% may continue to have CD, while 12–21% will qualify for a diagnosis of antisocial personality disorder (ASPD).

In addition to associations with other psychiatric disorders children with ADHD are also more likely than their non-ADHD counterparts to experience a substantial array of developmental, social and health risks. It therefore seems important to discuss associated problems along with co-morbidity.

Motor coordination

Children with ADHD often demonstrate poor motor co-ordination or motor performance and balance. 145-147 Substantial evidences have been observed for problems in motor development and motor execution children with ADHD. 148 Clinical and epidemiological studies report that 30% to 50% of children with ADHD suffer from motor coordination problems. 146 These percentage are dependent of the type of motor assessment, referral sources and the cut-off points used. 149-151 As noted by Needleman et al ., 105 children with ADHD display greater difficulties with the development of motor coordination, planning and execution of complex, lengthy tasks, and novel chains of goal directed responses.

Academic functioning

Children with ADHD have an impaired academic functioning and are usually at an educational disadvantage upon school entry. 152 , 153 ADHD children are more likely than their non-ADHD peers to demonstrate difficulties with basic mathematics and pre-reading skills during their first year at school. 147 , 154 , 155 Executive academic functions were found to be core deficits specific to ADHD. Girls with ADHD were found to be less impaired than boys with ADHD. 156 Even pre-school children with ADHD demonstrate educational disadvantage, DuPaul et al . 157 demonstrated that their sample of pre-school ADHD children demonstrated deficits in pre-academic skills even prior to formal school entry. The pre-school ADHD children in their sample scored on average one standard deviation lower on the Battelle Developmental Index, 158 than did their non-ADHD control group. Researchers emphasized the importance of look away behavior (inattention) as a major reason for poor academic achievement. 159

Clinic-referred children with ADHD often present with lower scores on intelligence tests than control groups, specifically verbal intelligence with differences ranging from 7 to 10 standard score points. 160 Studies with community samples of ADHD children have also demonstrated negative associations between ADHD and intelligence. 161 , 162

Children with ADHD demonstrate serious difficulties with psychosocial functioning. Social adjustment is often given little attention on assessment protocols, given its designation as an associated feature of ADHD. 15 However, the high levels of disruptive behavior demonstrated by ADHD children increases the likelihood of negative reactions from parent, teachers and also peers. 163 In addition, negative social interactions with peers ultimately lead to peer’s rejection, 164 because these social difficulties are often resistant to psychosocial and pharmacological treatment, 165 they are expected to continue into adolescence, and even adulthood when criteria for the disorder may no longer be met. 166 The patterns of disruptive, intrusive, excessive, negative, and emotional social interactions that have been found between children with ADHD and their parents, have also been found to occur in the children’s interactions with teachers and peers. 157 , 167 , 168 It should come as no surprise, then, that those with ADHD receive more correction, punishment, censure, and criticism than other children from their teachers, as well as more school suspensions and expulsions, particularly if they have ODD/CD. 168 , 169 In their social relationships, children with ADHD are less liked by other children, have fewer friends, and are overwhelmingly rejected as a consequence, 170 particularly if they have comorbid conduct problems. 107 , 125 , 171 , 172 Another research study demonstrated that the co-occurrence of conduct disorder and anxiety disorder with ADHD in childhood predicted a more severe course for ADHD in adolescence. 173

Unintentional physical injury

Children with ADHD appear to be at a greater risk for unintentional physical injury and accidental poisoning. 157 , 174 In one of the first studies of the issue, Stewart and colleagues found that four times as many hyperactive children as control children (43% vs . 11%) were described by parents as accidentprone. Later studies have also identified such risks; up to 57% of children with hyperactivity or ADHD are said to be accident-prone by parents, relative to 11% or fewer of control children. 175 , 176 Most studies find that children with ADHD experience more injuries of various sorts than control children. In one study, 16% of the hyperactive sample had at least four or more serious accidental injuries (broken bones, lacerations, head injuries, severe bruises, lost teeth, etc.), compared to just 5% of control children. 2 , 177 found that 68% of children with DSM-IV-TR ADD, compared to 39% of control children, had experienced physical trauma sufficient to warrant sutures, hospitalization, or extensive/painful procedures. Several other studies likewise found a greater frequency of accidental injuries than among control children. Researchers found that children with ADHD were at a greater risk for suffering fractures, 178 most likely as a result of hyperactive and impulsive behavior. Children with AD/HD are also more likely than their non-ADHD counterparts to be injured as pedestrians, to inflict injuries to themselves, to sustain injuries to multiple body regions and to experience head injury. 179 Knowledge about safety does not appear to be lower in these children; implying interventions aimed at increasing knowledge about safety may have little impact. 180

Sleep disturbances

Studies report an association between ADHD and sleep disturbances found that sleep problems occurred twice as often in ADHD as in control children. 181-184 The problems are mainly more behavioral and include settling difficulties, a longer time to fall asleep, and instability of sleep duration, tiredness at awakening or frequent night waking. The direction of effect, between ADHD and sleep problems is unclear. It is possible that sleep difficulties increase ADHD symptoms during the daytime, as the research on normal children implies. 105 Yet some research finds that the sleep problems of children with ADHD are not associated with the severity of their symptoms; this suggests that the disorder, not the impaired sleeping, is what contributes to impaired daytime alertness, inattention, and behavioral problems. 184 , 185

While knowledge about the associations between ADHD and other related variables is useful in terms of diagnostic profiles, less is known about the impact of related variables on the long-term outcome for the disorder. Even less is known about the specificity of these associated problems to ADHD. In the preschool years a wealth of evidence now exists comparing the symptoms of pre-school ADHD symptoms to its school-aged counterpart. Children with a pre-school variant of ADHD present with the same symptom structure, 186 , 187 similar associated impairment and developmental risk, 187 and similar patterns of neuropsychology. 188 Despite the similarities between pre-school ADHD and school-aged ADHD, little is known about what constitutes impairment during the pre-school years although school readiness should be what clinicians focus on. And even less is known about the relationship between early hyperactivity and later expression of the ADHD disorder. 189

While originally conceived of as a disorder of childhood and adolescence, evidence suggests scientific merit and clinical value in examining ADHD in adulthood, 40 , 189 as well as the pre-school period. 189 ADHD symptoms have been shown to persist into later life with up to 40% of childhood cases continuing to meet full criteria in the adult years. 190 , 191 Adult ADHD appears to share many characteristics of the childhood disorder. Similar to their childhood counterparts, adults with ADHD display impairment in the interpersonal, vocational and cognitive domains. 192-194 The adult and childhood disorders also appear to share a common neuropathology, 195 , 196 and demonstrate a similar response to treatment. 197

Conclusions

We have discussed two different possible causes of ADHD in neurological research. The top down theory says that ADHD begins with frontal and pre-frontal lobe dysfunction. The other theory says that the sub-cortical regions, the thalamus and the hypothalamus are responsible for ADHD. Neuro-imaging doesn’t show abnormality in the thalamus, but does show changes in the frontal and prefrontal area. Researchers agree that genetic factors are a strong contribution to the occurrence of ADHD.

DSM-IV has an aura of scientific legitimacy, many authors have written about its shortcomings in terms of reliability and validity. 198 , 199 The primary function and goal of the DSM, 200 is to lend credibility to the claim that certain (mis) behaviors are mental disorders and that such disorders are medical diseases. Although the DSM-IV is often used when discussing mental illnesses, be it in a research setting or a clinical practice setting. Researchers apply points out that such extensive use does not in itself guarantee either its validity or reliability. 201 The DSM-IV is purely descriptive and presents no new scientific insights about the causes of the many mental disorders it lists. Despite a wide level of acceptance, ADHD is not an uncontested condition. 202 For example, another researcher has argued that ….the working dogma that ADHD is a disease or neurobehavioral condition does not at this time hold up . 203 , 204 A more recent perspective presented by Lollar has also stated that there are no valid neurological markers for the diagnosis of ADHD. 205 Additionally, Shaw et al . 206 observe that there is currently no verifiable objective evidence to support the claims of ADHD advocates. Given the lack of validity as a medical condition, it is important to ask why the label of ADHD is applied, and under what conditions?

Another researcher found no association between DAT1 and ADHD. 207 Another gene for which there have been many studies is the dopamine receptor D4, DRD4, on chromosome 11. Another researchers found no evidence of an association between ADHD and DRD4. 208 Environmental effects could also include child-specific experiences of salient environmental influences such as maternal lifestyle or parenting. 209 Childhood ADHD symptoms do remit across time for some, 4 , 210 but not all children. 209

Some of the controversial treatments have involved dietary management, herbs and antioxidants. The removal of artificial food colorings and preservatives from the diet is an indispensable and practicable clinical intervention in ADHD, but rarely is sufficient to eliminate symptomatology. 102 Up to 88 percent of ADHD children react to these substances in sublingual challenge testing, but in blinded studies no child reacted to these alone. Allergies to the foods themselves must also be identified and eliminated. 211 Sugar intake makes a marked contribution to hyperactive, aggressive, and destructive behavior. 212 , 213-222 Overall body of evidence currently does not support dietary use as sole therapy for ADHD. There is a group of children with ADHD who do not respond well to treatment. More resources should be made available to help them, through clinical research and clinical-based treatment. 214

The actual degree to which genetic heritability may predispose to childhood onset of ADHD is still an open question. 102 Population studies indicate attentional problems, conduct problems, and emotional problems tend to cluster within families. 215 , 223 , 224 Genetics and environment are notoriously difficult to separate within the family unit, and researchers suggested the genetic predisposition to ADHD might fuel a negative family atmosphere that exacerbates latent ADHD in the child, 102 , 225 , 226

It is unknown whether the association of motor coordination problems with ADHD is comparable across ages. The limitation in daily life caused by poor motor performance varies with age. 146 Four to six years old children mainly have problems with dressing, use of scissors, drawing, trying shoelaces, and riding a bike. Children seven to ten years old encounter difficulties in writing, dressing, swimming, constructional play, ball skills and outdoor play, while eleven to nineteen year olds have problems of clumsiness in writing, drawing, ball skills, poor table manners and tool use. 218

Research on long term effects and safety of ADHD medications has been especially lacking. 36 , 219 According to researchers of a study of psychotropic drugs used with preschoolers, earlier ages of initiation and longer duration of treatment means that the possibility of adverse effects on the developing brain cannot be ruled out . Another research study of longer term ADHD treatments suggested the side effects such as depression, worrying, and irritability from ADHD medications. 227 , 228 In some of these children, drug therapy is insufficient because of persistent symptoms of coexisting conditions. 228 , 229 Future studies will be needed to define the subgroups clearly. There is much to learn about it.

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