Attention Deficit Hyperactivity Disorder - Research Paper Example

ADHD: MEDICATION VERSUS BEHAVIORAL THERAPY English 102 OUTLINE Thesis: In the current of evidence, the best outcome in the management of attention deficit hyperactivity disorder (ADHD) is possible through behavioral therapy complemented by medical therapy. I. Introduction. II. Aim and objective of this research III. Thesis IV. Focus question for review of literature V. Methodology VI. Definition of ADHD. VII. Current state of affairs in management of ADHD VIII. Medical therapy in brief IX. Behavioral therapy in brief X. Summary of findings and conclusion XI. Work cited page. Introduction Currently, attention deficit hyperactivity disorder (ADHD) is in sharp focus of research attention and has drawn considerable media attention due to many issues related to its prevalence, occurrence, management, treatment with amphetamines, long-term outcomes, and the social impact thereof. Doggett (2004) indicated that despite continued research, there is hardly any professional agreement regarding the true nature of this problem and consequently (Doggett, 2004), as Barkley et al. (2002) had highlighted that there is no consensus regarding the science, diagnosis, and treatment of ADHD. Since then research had progressed further, but the position had changed little. As of now both neurologists and psychiatrists are trying to manage this problem, but the fact is that there is no identifiable cognitive, metabolic, or neurological marker for this problem, and the diagnosis of ADHD cannot be established with any medical tests (Barkley et al., 2002) Therefore, there is a lack of definition of criteria based on which the professionals can arrive at a diagnosis, and research reports indicate exceedingly differing rates of prevalence across continents. Till date no neuroimaging study has been acceptably standardized that can corroborate a clinical suspicion of ADHD through irrevocable objective means, and the faults in the designs of these studies throw considerable doubt about the feasibility of these means to offer a diagnostic platform for this disorder. Although genetic studies have indicated specific traits for ADHD, all studies have indicated normalcy of brain. In many cases, high incidence of other comorbidities makes a clear-cut diagnosis impossible. Although there has been no accepted specific treatment for ADHD, the widely debated therapeutic agent methylphenidate has been demonstrated to have similar pharmacologic effects on otherwise normal children (Goldstein and Ellison, 2002). Meanwhile, backed up by poor-quality research which has evident publication bias and unethical practices associated with it, the pharmaceutical industry is making huge revenues on many dubious agents with doubtful efficacy. This brings us to the current state of affairs relating to ADHD where many models have been proposed namely genetic model, social and cultural model, medical model, and psychiatric model with no correlation or consensus among them. While research can offer no clarity, it seems that all these models have something to offer to the management of ADHD where some authorities have suggested an integrated model of care (Adler and Chua, 2002). In this assignment the issues concerning this debate will be examined critically from evidence in literature, both seminal and research, to find out which approach would be better to glean success in management of this apparently difficult disease. Aim and objective of this research Therefore, there is evident disagreement between authors and their findings regarding the appropriate method of therapy in ADHD. To find out the answer to this debate and to form a practice guideline, there is a need to update the current knowledge in this area. Before going into this array of recent literature, it would be prudent to summarize the therapies available for ADHD. Thesis In the current state of evidence, the best outcome in the management of attention deficit hyperactivity disorder (ADHD) is possible through behavioral therapy complemented by medical therapy. Focus question for review of literature As evident in the literature what is the best form of treatment, medical, behavioral, or combined Methodology To this end from databases, literature and seminal texts were searched with the key words, "ADHD", "medical therapy", "behavioral therapy", "efficacy of treatment", and "treatment outcome" were searched. Three text book sources and six recent research articles were chosen for review, and the findings are presented below. Definition of ADHD Thapar et al. (2007) have defined ADHD to be "a neurodevelopmental disorder of childhood onset characterised by severe, developmentally inappropriate motor hyperactivity, inattention and impulsiveness that results in impairment (for example, school failure) and must be present in more than one setting - usually home and school." (Thapar et al., 2007, p. 1) Observational studies have indicated that these symptoms and clinically defined disease may continue to persist in the adult life. In many cases as indicated in Thapar et al. (2006) the presence of this disorder can be predictably associated with substance misuse which can aggravate the inherent coping issues associated with this disorder further in both the social and work arenas. Even early on in the childhood, a large proportion of the affected children may demonstrate criminal and antisocial behavior, and this ominous association makes both the problems more severe and persistent with higher incidence of neurocognitive disorders (Thapar et al. 2006). Therefore, this disorder has a strong potential to develop into serious comorbid psychiatric disease in future life if unattended. Current state of affairs in management of ADHD Since children diagnosed with ADHD can be at higher risk of emotional problems, learning deficits, and behavioral problems and it has been documented that these problems may persist throughout childhood and adolescence eventually into adulthood in most of the cases. The educational achievements are essentially less due to reduction in the years in formal schooling, occupational underperformance, development of antisocial personalities, eventually ending up with a range of psychiatric problems including substance abuse. Presence of comorbidity affects the social interactions of these individuals. The above factors indicate that effective management of ADHD is critical in order to avoid or prevent these adverse outcomes. As indicated in seminal and research literature, currently three general approaches are available, which include pharmacological with drug therapy, behavioral intervention or psychosocial approach, and a integrative or combination of approaches. It would be prudent to seek evidence as to which would be the most effective approach due to reasons discussed above, the most prominent of which is disagreement among the proponents of different approaches. In fact, the clinical presentations of ADHD may be so varying that it is difficult to address all aspects of this problem through a single approach. For example as indicated in the study of Purdie et al. (2000) in a meta-analysis of 74 studies, the effect size of pharmacological interventions for improvement of behavioral manifestations were higher with negligible impact on educational impacts. On the contrary as indicated by Abramowitz et al. (1992) the treatment of choice should be a multimodal intervention involving pharmacotherapy and behavior therapy. The results of their study indicated that in some cases of childhood ADHD, an intensive simple behavioral intervention can achieve better clinical outcomes than that with medication therapy alone. This article indicated that educational treatment as a stand-alone modality of therapy can result in a more acceptable cognitive outcome than both these approaches (Abramowitz et al. 1992). Medical Therapy in Brief Medical therapy is at least a part of the treatment plan offered to an ADHD patient. Current evidence suggests that it should never be used as a single-entity management strategy apart from other available interventions. The physician offering medical management must be experienced in its use, and the patient must be in close collaboration with the treating physician. As precondition to medical therapy, there must be an elaborate assessment of the medical, psychiatric, social, and cognitive status of the patient. The pharmacologic agents used belong to the category of cerebral stimulants, and they represent the first-line pharmacotherapy agents. It is also to be noted that drug therapy may be useful for the symptomatic treatments. Even for the children with mild diseases, specialists suggest drug therapy, and as indicated earlier they appear to have superior effects. Quite a number of pharmacologic agents have been recommended for treatment of ADHD. These belong mainly to two classes of compounds, namely, methylphenidate and amphetamine compounds. These have different therapeutic effects and their pharmacokinetics are also different. While ADHD is known for significant comorbid conditions, it is to be remembered that these agents are not suitable for treatment of comorbid conditions. Except for the agents that belong to monoamino oxidase inhibitor class, these agents generally have no adverse effects. Although studies show different grades of therapeutic effects including some indicating that these agents are useless in the management of ADHD, current evidence indicates that dexamfetamine, an amphetamine analogue and methylphenidate have usually been uses as the drugs of first choice in ADHD. However, there is lack of consensus as to which could be the more effective agent. Selective noradrenalin reuptake inhibitor atomoxetine has been recently claimed to have better therapeutic efficacy. Pemoline is a comparatively recent agent with better pharmacologic action, but further studies indicated hepatotoxicity as a potential side effect which might preclude its use in practice. To be effective clinically medical therapy must be used for a prolonged period of time in the range of years. Some studies indicated that such prolonged use may result in growth retardation. This problem has been addressed by recommendation of drug holidays interspersed between treatment periods to allow growth of the child. Due to incomplete therapeutic efficacy and adverse effects, many authorities have recommended that young children should better not be prescribed cerebral stimulants, which can better be used when ADHD persists into adulthood. Recently, tricyclic antidepressants have been recommended, and they have been tried successfully in ADHD with comorbid depression. Two agents, namely, desipramine and imipramine have been effective in both children and adults. However, it has been recommended that these agents should be reserved patients with inadequate response or with intolerance to central stimulants. These agents need dietary restrictions and can have potential drug interactions. In all cases of medical therapy, careful monitoring is an absolute necessity. Fluoxetine or other SSRIs have been demonstrated to have beneficial effects as an adjunct to central stimulants, but the best efficacy is available in comorbid depression or obsessive compulsive disorder, not with isolated ADHD (Barkley & Murphy, 1998). Behavioral therapy in brief Given the pervasive nature of ADHD, current research indicates multimodal therapeutic approach which includes psychotherapy. The cognitive behavioral approach has been accepted to be one of the modalities which intend to provide psychological support in specific behavioral areas of deficit that a child may have. As research has indicated and many authors have recommended, a combined treatment approach involving pharmacotherapy and psychotherapy with cognitive behavioral therapy would be the best method. While the neurochemical aspects of the brain dysfunction can be addressed by the pharmacologic agents with improvement in the executive functions, cognitive behavioral therapy can work in a top-down fashion where the affected individuals may have improved awareness about the ADHD symptoms which are essentially behavioral and psychological in nature. This would also help individuals to develop strategies on their own to change these patterns. There would, however, be behavior patterns that would be resilient, and behavior therapy may help them to accept these patterns. While considering the adult patients, in about 50% of the cases, medical therapy alone fails to produce any results, and improvement of executive functioning with drugs may be inadequate to lead to improved overall functions. For example, psychostimulants may improve attention but may fail to produce limitation of procrastination and confidence. Thus translation to further improvement would call for additional psychosocial and behavioral intervention. Cognitive behavioral therapy focuses on cognitive parameters, namely, thoughts, images, and beliefs. It is an established modality of therapy used for certain psychiatric disorders. The desired outcome out of behavioral therapy is to help the affected patients to understand their innate patterns of cognition and existing beliefs. This would also foster the ability to modify behavior to generate alternate thought patterns and beliefs. In this way the emotional experiences of the individuals would change leading to clinical improvements (Ramsay and Rostain, 2008). Although ADHD is caused by genetic and neurobiological factors, the experience of having ADHD and going through life in itself has very severe consequences on the belief systems about the self, the environment including the society, and the future. Since these thoughts and beliefs are known to interact with the behaviors and emotions, and they together create the construct for the intricate experiences, and cognitive behavioral therapy has been demonstrated to be a very effective route of intervention to comprehend and modify certain patterns of thoughts in ADHD (Safren et al., 2005). Summary of Findings As reported by Buchner (2000), in the United States population, ADHD is considered by the American Academy of Pediatrics to be the most commonly referred, reported, and encountered neurobehavioral disorder of childhood. In their position statement, they have termed its reported prevalence, diagnosis, and treatment to be controversial due mainly to absence of well established diagnostic criteria, tendency to overdiagnose, and inappropriate use of psychoactive medications (Bauchner, 2000). To clear the clout, the American Academy of Pediatrics based on review of accumulated research has published a guideline which state that 7 to 10% of the children, commonly boys are diagnosed of ADHD with significant variance among sample sources. For a diagnosis, ADHD specific questionnaires are more useful and confirmation of diagnosis should be done on the basis of information from various sources. The clinician must be aware about the comorbid conditions such as conduct disorder, oppositional defiant disorder, and depression in about one-third of these children affected with ADHD and hence these conditions must be assessed. Although behavior patterns are important parameters in this disorder, the findings from National Institute of Health controlled randomised clinical trials indicate that comparison of 14 months of medication treatment to intensive behavior therapy do not support this. Their current recommendations hence go in favor of the superiority of medications in comparison to behavior therapy both in family and routinely in the community. An integrative approach with both medication and behavior therapy did not yield better benefits in ADHD than a medication alone treatment regimen (Bauchner, 2000). Conclusion Despite confronting views, ADHD is a disease with established psychopharmacology. Controlled studies have established positive role of stimulant medications in ADHD. However, most studies also indicated that many patients fail to respond to first line drug therapy. In about 50% of the cases, the core symptoms fail to respond with progress of treatment and in the long run. These findings along with potential adverse effects of these drugs indicate that all guidelines should include behavioral treatment through psychotherapy, preferably with a cognitive behavioral model or framework. Although studies have failed to strongly establish the efficacy of behavioral interventions as stand-alone therapeutic regimen, drugs alone also have been demonstrated to be less effective in practice. This is probably due to the fact that drugs cannot alter experiences and beliefs which tend to occur in the experiential realm of the ADHD individuals when they interact with the environment. Give the current state of affairs an integrative and customized approach would be the best strategy in managing these cases, however medical therapy is still recognized to be better and more effective in symptomatic cases, and behavioral therapy is reserved for cases where assessment indicates behavioral components. Further research is indicated to create a definitive guideline. WorkCited Page Abramowitz, AJ., Eckstrand, D., O'leary, SG., and Dulcan, MK., (1992). ADHD Children's Responses to Stimulant Medication and Two Intensities of a Behavioral Intervention. Behav Modif; 16: 193 - 203. Adler, L., and Chua, H. (2002). Management of ADHD in adults. Journal of Clinical Psychiatry, 63, 29-35. Barkley, R., & Murphy, K. (1998). Attention-deficit hyperactivity disorder: a clinical workbook (2nd ed.). New York: Guilford Press. Barkley, RA., Murphy, KR., Dupaul, GI., and Bush, T., (2002) Driving in young adults with attention deficit hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning. J Int Neuropsychol Soc; 8(5): 655-72. Doggett, AM., (2004). ADHD and Drug Therapy: is it Still a Valid Treatment J Child Health Care; 8; 69 BAUCHNER, H., (2000). ADHD: A new practice guideline from the American Academy of Pediatrics. Arch. Dis. Child.; 83: 63. Goldstein, S. and Ellison, AT., (2002) Clinicians' Guide To Adult ADHD: Assessment and Intervention. Elsevier Science (USA) 148-165. Purdie, N., Hattie, J. and Carroll, A. (2002) 'A Review of the Research on Interventions for Attention-Deficit Hyperactivity Disorder: What Works Best', Review of Educational Research 72(1): 61-99. Ramsay, JR. and Rostain, AL. (2008). Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach. Taylor & Francis Group, LLC, P. 85-103. Safren, SA., Otto, MW., Sprich, S., Winett, CL., Wilens, TE., and Biederman, J., (2005). Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behav Res Ther, Jul 2005; 43(7): 831-42. Thapar, A., van den Bree, M., Fowler, T., Langley, K., and Whittinger, N., (2006). Predictors of antisocial behaviour in children with attention deficit hyperactivity disorder. Eur Child Adolesc Psychiatry; 15(2): 118-25. Thapar, A., Langley, K., Owen, MJ., and O'Donovan, MC., (2007). Advances in genetic findings on attention deficit hyperactivity disorder. Psychol Med; 37(12): 1681-92. Read More