Give a critical account of the theories and treatments of ADHD.

Psychology Level 2

Essay 2

4) Give a critical account of the theories and treatments of ADHD.

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Attention Deficit Hyperactivity Disorder (ADHD) is:

“A mental disorder, usually of children, characterized by a grossly excessive level of activity and a marked impairment of the ability to attend.

Learning is impaired as a result, and behaviour is disruptive and may be defiant or aggressive.” (Oxford Medical Dictionary 1998)

Every human being may have difficulty sitting still, paying attention or controlling impulsive behaviour. However for some people, the problem is so persevere and unrelenting that it interferes with their daily life, including home, educational, social and work settings.

Typically ADHD symptoms arise in early childhood and some symptoms persist into adult-hood, posing life-long challenges and difficulties.

According to the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV), the symptoms of ADHD fall into three categories: inattention, hyperactivity and impulsivity, and combined type.

Inattention is diagnosed by symptoms such as not paying attention, making careless mistakes, not listening, not finishing tasks, not following instructions, avoidance or dislike of tasks requiring sustained mental activities, losing things and being easily distracted.

Hyperactivity and impulsivity is diagnosed by symptoms including fidgeting, talking excessively, running around excessively, especially at inappropriate times. Interrupting others and difficulty waiting turns and in engaging in activities quietly.

The combined type is when the individual meets both sets of the inattention and hyperactivity and impulsivity disorders.

All children act in ways that could be viewed as inattentive or hyperactive and impulsive; the main symptoms of ADHD. Everyone daydreams, interrupts, blurts out information or becomes impatient and restless at times, but not everyone has ADHD. The determining whether a person has ADHD is very specific. Professionals such as school psychologists, social workers, nurse practitioners, neurologist, psychiatrists and other medical doctors diagnose ADHD only when the patient has displayed the symptomatic behaviours that argue with their development level. Patients have to have shown some of the symptoms before the age of seven.

They must be impaired by at least six or more symptoms of the disorder, which are consistent over the past six months. They must affect the ability to function in daily life and at least some of the symptoms should create a significant difficulty in at least two areas of life, such as home, social settings and school or work.

A medical examination by a physician is also important to rule out other medical problems that may be causing symptoms similar to ADHD. (DSM-IV, 1994. as cited in Bee 2002)

ADHD is considered as a neurological disorder because brain images of children with ADHD may show differences compared to children without ADHD. For example, in some children with ADHD, certain parts of the brain are smaller or less active than the brains of children without ADHD. These changes may be linked to specific brain chemicals that are needed for tasks such as sustaining attention and regulating activity levels.

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A medical examination by a physician is also important to rule out other medical problems that may be causing symptoms similar to ADHD. (DSM-IV, 1994. as cited in Bee 2002)

ADHD is thought to have many causes; however there are no definite answers yet. It has been found that ADHD often runs in families, therefore there may be some genetic reason for the disorder, and studies have found evidence for an inherited characteristic that causes individuals to develop ADHD. Studies of twins suggest there is a genetic contribution. If one twin is diagnosed as hyperactive, the other is highly likely to also be diagnosed. (Levy et al (1997) as cited in Levy & Hay 2001) It is however unclear what exactly this is. (Farone & Biederman, (1992) as cited in Holmes 1998)

Techniques using magnetic resonance imaging (MRI) suggests that children with ADHD seem to have specific changes in their brain compared to normal children. The corpus collosum which divides the two hemispheres of the brain has been found to differ in size in children with high levels of hyperactivity. (Hynd et al (1993) as cited in Bee 2002)

Abnormal brain development and brain injuries occurring before, during or immediately after birth also have been known to cause ADHD. A difficult or traumatic birth, pre-natal exposure to alcohol and drugs, lead poisoning, radiation exposure, stress, food allergies and vitamin B deficiencies all have been said to be possibilities for the disorder, but they are not liable for the largest part. (Harris 1993)

“Premature birth, maternal alcohol use during pregnancy and exposure to lead compounds in early childhood all seem to increase the risk of ADHD in a child but only slightly” (Barkley, (1998) as cited in Gleitman 2000)

Nutritional factors have also been suggested, for the cause of ADHD. The belief that food additives can cause hyperactivity in children stemmed from the research done by Benjamin Feingold in 1974. According to Feingold, perhaps 40 to 50% of hyperactive children are sensitive to artificial food colours, flavours and preservatives. (As cited in Holmes 1998) However Feingold’s work has been controversial, because it was based only on experience and theoretical studies rather than scientific validation.

There are serious consequences for people with ADHD who do not receive treatment. They may suffer form low self-esteem, social and academic failure, career underachievement and a possible increase in the risk of later antisocial and criminal behaviour. (Barkley (2001) as cited on Children and Adults with Attention Deficit Hyperactivity Disorder. (CHADD) 1996-2004)

There are no targeted prevention programs for ADHD, but steps such as minimizing exposures to potential neurotoxins such as lead, heavy metals and pesticides in the environment may help to reduce the risk of neurobehavioral disorders including ADHD. Screening children for high levels of lead in the blood and treating it immediately, obtaining appropriate health care during and immediately after pregnancy and addressing psychosocial stressors in the lives of children may also reduce the risk. This however is not scientifically proven and if ADHD occurs then proper treatment should be carried out.

Every person is different and treatment should be individualized for each patient. Biological, behavioural, educational and psychosocial treatments are all used in treating ADHD.

Biological treatment is generally extremely effective in reducing or eliminating the behaviour associated with ADHD. The most popular and probably most effective are stimulant medications such as methylphenidate, more commonly known as the brand name Ritalin. Approximately 70 to 90% of children respond positively to this drug, (Spencer et al (1995) as cited on CHADD. 1996-2004)By showing improvement such as increased attention and concentration, compliance and effort on tasks, and decreased activity levels, impulsivity, negative behaviours in social interactions and physical and verbally hostility. (Swanson et al (1993) as cited on CHADD. 1996-2004) Ritalin is an amphetamine derivative, but ironically does not make patients ‘high’ but works by stimulating part of the brain that retains attention.

Despite the effectiveness of such medications, there are also problems as some people simply do not want to receive medication and parents may not want their children to receive it. The side-effects of the drug must also be taken into consideration; Ritalin is not addictive but can however reduce appetites or disturb sleep.

Often when the medication is removed children return to the previous behaviour which suggests they have not learned any skills for improved behaviour.

“Drugs teach nothing; they merely alter the likelihood of occurrence of behaviours already in the child’s repertoire. The numerous skill deficits of these children will still require attention” (Barkley (1991) as cited in Fisher & Lerner 1994)

Behavioural modification treatment is an alternative to medication. Methods such as cognitive-behavioural programs have been introduced.

Most programmes involve positive reinforcement, attempting to reduce unwanted behaviours and shape new ones. It is important to choose a sufficient reinforcement to match the nature of the disorder and the patients’ level of development in order to produce the maximum improvement in behaviour. For example, a token economy could be used to encourage positive behaviour. The patient earns a number of tokens for good behaviour, which they are able to exchange for a reward. The level of development is considered; young children benefit from immediate rewards such as sweets, whereas social rewards tend to work for older children and adolescents. (Fisher & Lerner 1994)

However it is possible, that ADHD patients may become distracted by the anticipation of receiving rewards, and therefore their behaviour suffers.

Educational treatment involves educating sufferers and their families about the disorder and its nature and management. By involving parents of children with ADHD, they gain skills in coping with their child’s behaviour.

Adult ADHD sufferers sometimes find psychosocial treatments such as counselling and support groups helpful when dealing with their condition.

However the most effective treatment involves using all four treatments together. This is known as a multimodal treatment plan, combining medication, education, behaviour modification and psychosocial treatments. It allows sufferers to understand their disorder, learn new behaviours and the medication will hopefully stop the symptoms from occurring.

ADHD is a disorder which can cause serious problems for sufferers in their daily lives. Its cause is unknown. Until scientists can discover what exactly it is and how to prevent it, sufferers need the support to deal with it. Early identification and treatment suited to the individual can be successful.

References

Adapted from the American Psychiatric Association, (1994). Diagnostic and Statistical Manual of Mental Disorders. 4th edn., pp 83-85 © 1994 American Psychiatric Association. As cited in Bee, H. (2002) The Developing Child. 9th edn., Allyn & Bacon. UK.

Barkley, R.A. (1990) Attention Deficit Disorders: History, definition, and diagnosis. In M. Lewis & S.M. Miller (Eds) Handbook of Developmental Psychopathology (pp. 65-76) Plenum Press, New York. As cited in Fisher, C.B. & Lerner, R.M. (1994) Applied Developmental Psychology. McGraw-Hill Inc., USA.

Barkley, R.A. (1998) Attention Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment. 2nd edn., Guilford, New York. As cited in Gleitman, H. (2000) Basic Psychology. 5th edn. W.W. Norton & Company Ltd., USA.

Barkley, R.A., Fischer, M., Fletcher, K., & Smallish, L. (2001) Young Adult outcome of hyperactive children as a function of severity of childhood conduct problems, I: Psychiatric status and mental health treatment. Submitted for publication. As cited on Children & Adults with Attention deficit hyperactivity disorder. ©1996-2004 CHADD.

Last viewed: 12/2/04

Faraone. S.V., Biederman, J., et al. (1992) Segregation analysis of Attention Deficit Hyperactivity Disorder. Psychiatric Genetics, 2, 257-275. As cited in Holmes, D., (1998) The Essence of Abnormal Psychology. Prentice-Hall Europe, UK.

Feingold, B. (1974) Why is your child hyperactive? Random House, New York. As cited in Holmes, D., (1998) The Essence of Abnormal Psychology. Prentice-Hall Europe, UK.

Fisher, C.B. & Lerner, R.M. (1994) Applied Developmental Psychology. McGraw-Hill Inc., USA.

Harris, A.C. (1993) Child Development. 2nd edn. West publishing company, USA.

Hynd, G. W. et al. (1993) Attention deficit hyperactivity disorder and asymmetry of the caudate nucleus. Journal of Child Neurology, 8, 339-347. As cited in Bee, H. (2002) The Developing Child. 9th edn., Allyn & Bacon. UK.

Levy, F., Hay, D.A., McStephen, M., Wood, C., & Waldham, I.D. (1997) Attention Deficit Hyperactivity Disorder: A category or a continuum? Genetic analysis of a large-scale twin study. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 736-744. As cited in Levy, F. & Hay, D.A. (2001) Attention, Genes and ADHD. Brunner & Routledge, UK.

Oxford Medical Dictionary (1998) 2nd edn. Oxford University Press, New York.

Spencer, T. et al (1995) A double-blind crossover comparison of methylphenidate and placebo in adults with childhood- onset attention deficit hyperactivity disorder. Archives of General Psychiatry, 52, 434-443. As cited on Children & Adults with Attention deficit hyperactivity disorder. ©1996-2004 CHADD.

Last viewed: 12/2/04

Swanson, J.M., McBurnett, K., et al (1993) Effect of stimulant medication on children with attention deficit disorder: A “review of reviews.” Exceptional Children, 60, 154-162. As cited on Children & Adults with Attention deficit hyperactivity disorder. ©1996-2004 CHADD.

Last viewed: 12/2/04