The Treatment of Attention Deficit Hyperactive Disorder in Children - Research Proposal Example

Research Proposal: How effective is the behavioural therapy approach in the treatment of Attention Deficit Hyperactive Disorder (ADHD) in children? Rationale Children with Attention Deficit Hyperactivity Disorder (ADHD) face the daily challenge of focusing their motor and mental skills into complicated and even simple tasks. In order to treat the different manifestations of their disorder, various options have been made available to them. Ritalin (methylphenidate) has become the most popular drug of choice, but other practitioners are recommending other options for treatment. The US Centers for Disease Control and Prevention (2005) define the disease as a “neurobehavioral disorder characterized by pervasive inattention and hyperactivity-impulsivity that often results in substantial functional impairment”. Estimates from the CDC (2005) reveal that in school age children, 2% to 18% have ADHD. In these cases, most of these children have been placed on stimulant medication for the management of their symptoms. The CDC also reports that in 2003, there were about 4.4 million children aged 4-17 years of age who were diagnosed with the disease; and about 2.5 million of these children given medications for their disorder. In Australia, the Howard Florey Institute (2007) estimates that about 3% to 5% of Australian children in primary school have ADHD; and about one in every hundred of these children is presently taking drugs for their disorder. Australia is currently the third country (following the United States and Canada) considered the highest consumer of stimulant drugs for ADHD in children; in Western Australia alone, there are “five times as many children diagnosed with ADHD on stimulants than in Victoria” (Howard Florey Institute, 2007). Research into the effectiveness of behavioural therapy for children with ADHD is considered a top priority because the use of stimulant medications like Ritalin have been known to produce adverse effects which are very dangerous to the health of ADHD children. Leveque (2009) points out that ADHD drugs like Ritalin have been known to cause cardiac deaths. It is a drug that carries deadly risks to children with ADHD and these risks cannot be ignored just because a great percentage of children do benefit from the overall effects of the drug. Leveque (2009) points out that many children benefit better from behavioural therapy or other alternate forms of treatment for children with ADHD. Even if Ritalin and other ADHD drugs do help children mentally concentrate on their work, behavioural therapy and tutoring are alternate forms of treatment which help achieve similar results for the ADHD child (Leveque, 2009). Many practitioners are arguing that the use of Ritalin to treat or manage ADHD has been a thoroughly abused practice. Since 1990, in the United States production and use of this drug has had a six-fold increase (Drug Enforcement Administration, 1995). There have even been reports of abuse in some children and these reports and scientific studies of abuse potential have been down-played by the medical community and some drug companies (Drug Enforcement Administration, 1995). There is a need therefore to consider if other forms of treatment would be more suitable for children with ADHD. A study by Whalen (2001, pp. 136-140) published in the Journal of Clinical Child and Adolescent Psychology revealed that evidence-based therapy is needed in the treatment of ADHD. Through the Multimodal Treatment Study of Children with ADHD, it was revealed that pharmacotherapy is the best choice in the treatment of ADHD. This same study was able to reveal crucial goals in using psychosocial techniques in order to improve the effect of the stimulant medications and also to minimize the effects of the long-term usage of these stimulants (Whalen, 2001, p. 136). Using stimulants alone can produce adverse effects for the child, but in combination with other forms of therapy, these effects can be minimized. The study was also able to reveal that there would be persistent queries on the effectiveness of the drugs and of the psychosocial therapeutic options being used for ADHD. Research on ways to enhance effects beyond pharmaceutical outcomes through psychosocial techniques is required in order to demonstrate promising outcomes and treatment goals and treatment targets. This research triggers doubts on the effectiveness of diverse methods of treating ADHD in children (Whalen, 2001, pp. 136-140). The above figures considering, this paper is now being proposed as a means of evaluating the effectiveness of the behavioural therapy approach in treating Attention Deficit Hyperactive Disorder (ADHD) in children. This study tentatively answers this query by indicating that behavioural therapy with be very effective in treating Attention Deficit Hyperactivity Disorder (ADHD) in children. Aims of the Research This study aims to establish the effectiveness of behavioural therapy to treat Attention Deficit Hyperactivity Disorder (ADHD) in children. Objectives of the Research More specifically, the goals of this study include the following: 1. To establish the degree of effectiveness of the behavioural therapy approach in the treatment of ADHD in children 2. To compare the degree of effectiveness of the behavioural therapy approach with Ritalin in the treatment of ADHD in children 3. To compare the adverse effects which may be seen in the application of the behavioural therapy approach with those seen in patients given Ritalin Review of Related Literature ADHD is usually diagnosed in about 3-7% of school age children. Their treatment often consists of the stimulant medication Ritalin. The disorder is also often treated with various psychosocial and psychoeducational interventions for parents and for children. This treatment is often combined with the use of the stimulant medications. However, about 10-13% of the patients prefer not to take the stimulant medications. A paper by Bjornstad & Montgomery (2005) sought to review whether the use of family therapy without having to resort to stimulant medications can actually minimize the primary symptoms of ADHD. This review was also able to establish that there is no significant difference between the effectiveness of the behavioural family therapy approach as compared to the use of community-based treatment approach for ADHD. Another paper, this time by Klein & Abikoff (1997, pp. 89-114) attempted to compare the effectiveness of using behaviour therapy, using methylphenidate, or using their combination in treating ADHD. It also sought to assess the effects of methylphenidate withdrawal after applying the combination treatment and the normalization effects of the combination therapy approach. Eighty nine children were randomly chosen for this study; children who were placed under the combined treatment approach were later switched to placebo. The ratings from the child’s parents, teachers, and clinicians were obtained for this study. When the results were assessed, parents and teachers observed the children who underwent behaviour therapy as having improved behaviour, but their objective observations did not represent behavioural change. On the other hand, children under methylphenidate and behaviour therapy manifested marked improvement in the different aspects of measurement. The combination treatment showed a better outcome over behaviour therapy alone and methylphenidate treatment alone. Children who were switched to placebo showed deterioration in their behaviour. In conclusion, the study revealed that behaviour therapy is not as effective as methylphenidate in the treatment of ADHD, but it is a useful addition to the methylphenidate treatment. This paper endorses the combination therapy for ADHD. Wood, et.al. (2007, pp. 341-350) attempted to review information on the use of nonstimulant medications in the treatment of ADHD. Studies on the use of nonstimulant drugs were evaluated, including the “discussions on the use of antidepressants, antihypertensives, atypical antipsychotics, anticonvulsants, and cholinergic agents” (Wood, et.al., 2007, 341). This review revealed several choices of treatment in situations where the use of stimulants would not be recommended and in situations where it would provide limited effectiveness. This review concluded that each type of medication has its limitations and adverse effects. And still various researches support the use of stimulants in the treatment of ADHD. The review also reveals several other successful choices for those who do not work well with stimulants or to those who are bothered by the side effects produced by the medication. The MTA cooperative group conducted a review of literature on ADHD and in the process they were able to reveal that stimulant drugs have limited effectiveness; and using behaviour therapy alone has already shown limited effectiveness for treating children with ADHD; no sustained reviews have been conducted comparing these 2 treatments or their combination. 579 children with ADHD were included in this research and were subsequently assigned to 14 months of stimulant drug use, “to intensive behavioural treatment, to a combination of the 2, and to standard community care” (MTA Cooperative Group, 1999, p. 1073). The study revealed that all 4 groups who underwent treatment exhibited significant declines in their symptoms over time. Children who underwent combined treatment showed the most improvement in their condition. However, differences with the group who underwent the medication treatment only did not indicate significant differences in effectiveness. So, et.al. (2008, pp. 983-992) sought to evaluate the efficacy of a combined methylphenidate/behavioural treatment against a methylphenidate only treatment for Chinese children with ADHD. There were 90 children with ADHD chosen to participate in this study. They underwent two modes of treatment for 6 months. Rating scales were then used to measure the children’s changes in behaviour. The study revealed that children who underwent the combination of behavioural therapy and methylphenidate treatment showed significant improvement as compared to those who were taking methylphenidate only. The attitudes of parents about the use of stimulants in both groups also showed improvement. This study concluded that a combination of behavioural therapy and medication is the better option for children with ADHD. In a study by Wagner, et.al. (2008), pp. 231-256), they attempted to assess behavioural therapy, more specifically, parent-child interaction therapy in the treatment of ADHD. The study reviewed and assessed literature on the topic and in the course of their research, they were able to establish that the PCIT is actually “effective for young children with ADHD. However, future research is needed to assess in detail the effects of PCIT on ADHD” (Wagner, et.al., 2008, p. 256). Ramsay & Rostain (2007, pp. 338-346) attempted to assess the existing database regarding the more psychosocial and behavioural interventions for ADHD. They sought to “compare the effect sizes of methylphenidate and psychosocial treatment and their combination on ADHD, concurrent oppositional, conduct symptoms, social behaviours, and academic functioning” (Ramsay & Rostain, 2007, p. 338). In their study, they were able to establish that both methylphenidate and psychosocial or behavioural therapy treatments are actually useful in minimizing the symptoms for ADHD. They however point out that psychosocial treatments produce limited effects as compared to other interventions. The study also revealed that in terms of social behaviour and parent-rated ODD, Ritalin, methylphenidate and behavioural therapy were effective forms of treatment for ADHD (Ramsay & Rostain, 2007, p. 345). Jackson (2003, pp. 302-323) attempted to assess interventions which can be used as alternatives to pharmacological interventions for ADHD. The study wanted to assess the music therapy methods being used for children with ADHD, the effectiveness of this method and the relationship of this treatment with other forms of treatment for ADHD. The study revealed that music therapists used a variety of music therapy methods in treating children with ADHD. The outcome of this therapy is more or less favourable for ADHD sufferers. These children usually received other forms of treatment aside from the music therapy, with most of them receiving medications for their condition. Various articles on the subject matter have also been published in newspapers, and most of them suggest the favoured efficacy of behavioural therapy in relation to the treatment of ADHD. However, these studies were not undertaken in the format of evidence-based research. This paper is an attempt to come up with adequate materials on the issue. Materials and Methodology A. Study Design This paper shall be a randomized prospective clinical study. B. Study Period Data Collection: October – November, 2009 Data Analysis: December 2009 C. Sample Size Caregivers (parents, staff nurses, teachers, and other caregivers) involved in caring for children 2 years to 12 years old diagnosed with ADHD who are admitted to the treatment centre and given any of the following interventions for their disorder: Ritalin only, Behavioural Therapy only, combination of Behavioural therapy and Ritalin. D. Setting Setting: _____ E. Study Population: Inclusion Criteria: 1. Parents of children age 2 to 12 years of age with ADHD who are undergoing treatment with Ritalin, behavioural therapy or a combination of the two 2. Staff Nurses working in the mental health unit caring for children 2-12 years of age with ADHD who are undergoing treatment with Ritalin, behavioural therapy or a combination of the two 3. Psychologists, psychiatrists, and other attending physicians of patients with ADHD who are undergoing treatment with Ritalin, behavioural therapy or a combination of the two. 4. Teachers of children with ADHD who are undergoing treatment with Ritalin, behavioural therapy or a combination of the two. F. Exclusion Criteria 1. Caregivers with patients not fully meeting the criteria to fully define an ADHD diagnosis 2. Caregivers with patients who are opting not to be treated for the disorder 3. Caregivers of patients with adolescent or adult ADHD G. Procedure/Methodology After the approval of the ethics committee is acquired; after the informed consent of the respondents are gained; and after assessing that these patients/respondents fulfil the inclusion and exclusion criteria for this paper, they shall now be divided into 4 groups. Group A shall be the parents of children with ADHD patients. Group B shall be the staff nurses caring for children with ADHD. Group C shall be the psychiatrists, psychologists, and the attending physicians of children with ADHD. And Group D shall be the teachers of these children with ADHD. A structured questionnaire shall be distributed to the parents, nurses, teachers, and doctors of the children with ADHD. The questionnaire shall set forth a series of questions which would assess the degree of effectiveness of the form of treatment they have opted for. It shall also assess the comparative effectiveness of the form of treatment they have opted for with regard to other forms of treatment available for ADHD. The respondents shall be assured of the confidentiality of their answers. Respondents who shall choose not to be a part of this research shall not be prompted or convinced further. The data gathered in the course of this research shall be encoded in the computer and only the researcher shall have access to this information. The data gathered shall be filed in a folder and kept in a cabinet file and only the researcher shall have access to these data. Such data shall be kept no more than five years after this research shall have been completed. After 5 years, the data shall be destroyed and dispensed with. Data Processing and Analysis Data gathered will be analyzed using quantitative data analysis of the respondents included in this paper. The tabulation of the data shall be conducted by the researcher and verified by a research assistant. The research assistant shall be knowledgeable and well-versed in statistical analysis and data configuration. The assistant shall ensure that the data and variables entered in the SPSS program for statistical analysis shall be accurate. The ANOVA test is deemed to be the most appropriate statistical test for this study as it shall measure the variance among means. In this instance, there are three population means to be compared in this paper and each mean is given a different treatment. Hence, the ANOVA test is the most appropriate test which can be undertaken for this study. The formula for the ANOVA test is as follows: SST=∑ (T2c ÷ nc) – (∑X)2 ÷ N Where : SST is the sum of squares Tc is the column total for all observations in the treatment Nc is the number of observations (sample size) for each respective treatment ∑X is the sum of all observations N is the total number of observations Timetable September (4 weeks) October (4 weeks) November (3 weeks) December (4 weeks) January (3 weeks) February (1 week) Research Proposal (done) Ethics and Approval of Proposal with necessary revisions (pending) Distribution and Retrieval of Questionnaires (depending on approval by Ethics Committee) Tabulation of data and statistical Analysis Research write-up Research Presentation Reference Bjornstad, G. & Montgomery, P., 20 April 2005, ‘Family therapy for attention-deficit disorder or attention-deficit/hyperactivity disorder in children and adolescents’, Cochran Database of Systematic Reviews, Issue 2 Brinkman, W., Sherman, S., Zmitrovich, Visscher, M., Phelan, K., and Donovan, E., 2 August 2009, ‘Parental Angst Making and Revisiting Decisions About Treatment of Attention Deficit/Hyperactivity Disorder’, Official Journal of American Academy of Pediatrics, volume 124, no. 2, pp. 580-589. Chu, S. & Reynolds, F., October 2007, ‘Occupational Therapy for Children with Attention Deficit Hyperactivity Disorder (ADHD), Part 2: a Multicentre Evaluation of an Assessment and Treatment Package’, British Journal of Occupational Therapy, volume 70, no. 10, pp. 440-448. Jackson, N., November 2003, ‘A Survey of Music Therapy Methods and Their Role in the Treatment of Early Elementary School Children with ADHD’, Journal of Music Therapy, volume 40, no. 4, pp. 302-323 Janols, Lo., Liliemark, J., Klintberg, K., von Knorring, A., August 2009, ‘Central stimulants in the treatment of attention-deficit hyperactivity disorder (ADHD) in children and adolescents’, Official Journal of the American Academy of Pediatrics, volume 25, pp. 1-9 Jensen, P., Kettle, L., Roper, M., Sloan, M., Dulcan, M., Hoven, C., Bird, H., Bauermeister, J., & Payne, J., 1999, ‘Are Stimulants Overprescribed? Treatment of ADHD in Four communities’, Journal of the American Academy of Child and Adolescent Psychiatry, volume 38, pp. 797-804 Klein, R. & Abikoff, H. 1997 ‘Behavior therapy and methylphenidate in the treatment of children with ADHD, Journal of Attention Disorders’, volume 2, no. 2, pp. 89-114 Kratochvil, C., 27 July 2009, ‘New ADHD Treatment options on the horizon’, Advanced Studies in Medicine, volume 2, no. 25, pp. 915-918. MTA Cooperative Group, December 1999, ‘A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder’, Archives of General Psychiatry, volume 56, pp. 1073-1086 Pelham, W., Vodde-Hamilton, M., Murphy, D., Greenstein, J., Vallano, G., September 1991, ‘The Effects of Methylphenidate on ADHD Adolescents in Recreational , Peer Group, and Classroom Settings’, Journal of Clinical Child Psychology, volume 20, no. 3, pp. 293-300 Ramsay, J. & Rostain, A., August 2007, Psychosocial Treatments for Attention-Deficit/Hyperactivity Disorder in Adults: Current Evidence and Future Directions, Professional Psychology: Research and Practice, volume 38, number 4, pp. 338-346 So, C., Leung, P., and Hung, S., 2008, ‘Treatment effectiveness of combined medication/behavioural treatment with Chinese ADHD children in routine practice’, Behaviour Research and Therapy, volume 46, no. 9, pp. 983-992. Vernacchio, L., Kelly, J., Kaufman, D., Mitchell, A., August 2009, ‘Medication Use Among Children Read More