Scientific Background of ADHD - Research Paper Example

 Does ADHD exist? Over the years, ADHD has been identified by many different names including hyperkinesias, hyperkinetic syndrome, minimal brain dysfunction (MBD), attention deficit disorder, with or without hyperactivity (ADD or ADDH), attention deficit hyperactivity disorder (ADHD) and currently attention-deficit/hyperactivity disorder (ADHD)(Wilmshurst, 2009). The term attention deficit hyperactivity disorder (ADHD) has elicited much criticism and debate. Perhaps the most important debate is whether ADHD is a disorder that really exists or not. Because of this, ADHD has received significant research attention and is a problem that is rarely out of the news (TIMIMI & TAYLOR, 2004). Barkley and many others (2004) said that the presentation of ADHD as a disorder is based on solid, scientific ground, and any debate in this regard does not exist in the scientific community. They note that the only area where the existence of ADHD exists is in the popular media. These media accounts have been encouraged by dubious claims by some in the medical field that state that ADHD does not exist because it can not be detected by existing examination technologies such as physical examinations, lab tests and x-rays. They argue that in the absence of data to the contrary, the patient must be considered normal; therefore ADHD is not a disorder with any link to physical abnormalities (Lloyd et al., 2006). However, The International Consensus Statement on ADHD (Barkley 2002) declares that despite claims by clinical mavericks and self-appointed experts in the popular media (Strydom 2000; Rosemond 2005) ADHD is not a fictitious disorder. It further asserts that ADHD has been scientifically proven to be real. Irrefutable proof as to the existence of ADHD can be found in the countless activities that are conducted by the afflicted to cope with ADHD in all spheres of life (Lloyd et al, 2006). Of special note is the fact that when ADHD left unmanaged, patients exhibit a statistically significant increase in a broad range of negative social and educational outcomes, failure to complete high school or college, social isolation, a poor employment history, criminal activity, a higher number of car wrecks, teenage pregnancy and exposure to STDs, and other unfortunate outcomes. How is ADHD defined and what are the symptoms? Despite all the research surrounding ADHD, it has been difficult to gain and maintain professional agreement on a definition of ADHD (TIMIMI & TAYLOR, 2004). Currently, ADHD, is considered a diagnostic label for children presenting with significant problems focusing attention on a broad range of tasks, often coupled with impulsiveness and excessive physical activity (Barkley, 2006). It is one of the most dominant childhood psychiatric disorders, and it is one of the leading causes behind children being sent to medical and/or mental-health experts (Barkley, 2006). According to the National Institute of Mental Health, ADHD affects 5 percent of school-age children. ADHD is three times more prevalent in boys than it is in girls (APA, 2002). This disorder has been part of the official classification system of the American Psychological Association (APA) since 1968 (Silver, 2004). The increase in the number of children and adolescents given the diagnosis of ADHD is a direct result of educational efforts and the increased level of awareness within schools, among parents, and among health and mental health professionals. Similarly, the impact of the media and of many popular books has led to an increasing number of adults being given the diagnosis of ADHD (Silver, 2004). ADHD is defined as “…a developmental failure in the brain circuitry that underlies inhibition and self control.” (Lloyd et al., 2006). This definition is not accepted word for word by all scientific and medical researchers, but most definitions are similar to this one. As more is learned about the causes of ADHD, the definition is sure to evolve. Aside from the three to one ration of boys to girls with the ADHD, no real factor seems to be typical of a majority of children with the disorder. Children with ADHD normally come from diverse backgrounds. The level of disability, age of onset, and “cross-situational pervasiveness” of their symptoms also vary considerably (Barkley, 2006). It has been said that ADHD symptoms normally manifest before the child is seven (Lloyd et al., 2006). Children with ADHD can have academic and school difficulties, emotional or behavioural problems, difficulties with peer relationships, and family stress (Silver, 2004). Children are typically not diagnosed with ADHD until they cause disturbances a six month period during which at least eight of the following symptoms are present: continuous fidgeting with hands or feet or squirming in seat, difficulty remaining seated when required to do so, easily distracted by extraneous stimuli, difficulty awaiting turn in games or group situations, blurting out answers to questions before they have been completed, difficulty following through on instructions from others (not due to oppositional behaviour or failure of comprehension), difficulty sustaining attention in tasks or play activities, shifting from one uncompleted activity to another, difficulty playing quietly, talking excessively, interrupting others, appearing not to listen to what is being said, loosening things necessary for tasks or activities at school or at home and engaging in physically dangerous activities without considering possible consequences (Barkley, 2006). According to The Diagnostic and Statistical Manual of Mental Disorders, 4th ed., the symptoms of ADHD are significantly greater than what would be expected for a child of the patient’s age group, and they present in at least two different settings (typically home, school, or work) and are not exclusively situational (i.e. occurring only during test taking). These symptoms must demonstrably interfere with social, academic, or occupational progress, and should not be part of a psychotic disease, or a feature of autism, or be otherwise better accounted for by other diagnoses of mental disorder (DSM-IV: American Psychiatric Association Task force on DSM-IV 2005, 78). The causes of ADHD: Difficulties in establishing a conclusive definition of ADHD is linked to the difficulty in establishing a uniform ADHD aetiology (Sava, 2000). ADHD is thought to be caused by neurological factors such as brain damage and deficient brain mechanisms (Barkley, 2006). Many studies have been undertaken to explore the correlation between neurology and ADHD. One study finds that the percentage of global cerebral glucose metabolism in the brain was lower in the adults with ADHD than in the normal control group. This reduction is seen to have an effect on the control of attention and motor activity (Zametkin et al, 1990). Another study shows that ADHD patients have inadequate perfusion in the white matter of the frontal lobes which is the responsible for executive functions (Lou, Hendrickson and Bruhn, 1984). Environmental factors are also thought to have an influence on the course of ADHD over a lifetime (Shelley-Tremblay and Rosen, 1996). The diet of children as well as the behavioural management of their parents is considered as possible causes of ADHD like behaviour (Barkley, 2006). This is why some question the existence of a disorder that causes ADHD. Some feel that the real source is a variety of environmental factors. More recently, environmental perspectives have considered conditions like overcrowded classrooms, poverty, sexism and exposure to violence as possible causes in the occurrence of ADHD symptoms (Gold, 1997; Levine, 1997 cited in Sava, 2000). Researchers have pointed out that television exposure at ages one to three years is associated with attention problems at age seven. In this study, the researchers found a correlation stating that each hour of daily viewing increased the risk of ADHD by almost 10% at age seven (Christakis, Zimmerman, DiGiuseppe, & McCarty, 2004). However, as pointed out by Barkley (as cited in Hornby et al., 1997), by the end of the 1980s it was established that ADHD is caused due to a hereditary tendency in the children. It has been shown that there is a significant genetic contribution to individual differences in activity levels and attention abilities (Stevenson, 1991). Results of a study carried by Gillis et al. (1992) indicate that ADHD could be highly heritable. In addition, Comings (1993) proposed that a site on the D2 gene coding for one type of dopamine action is likely to be a cause of ADHD. Another genetic study concluded that attention deficit-hyperactivity disorder is strongly associated with generalized resistance to thyroid hormone (Hauser et al, 1993). The amount of disagreement surrounding causes of ADHD is considerable. Research has shown how brain function may indicate a propensity for ADHD. This lack of brain functioning may be something that is actually inherited or could be the result of brain damage. Others feel that the real cause may be environmental factors such as excessive viewing of television, parenting style or classroom conditions. Treatments: The treatment provided for ADHD has changed with time. Treatment has evolved as the medical and psychological understanding of ADHD has changed (Hornby et al., 1997). The perceived causes of ADHD determine the type of treatment used. The work on ADHD treatment owes its primary allegiance to the psycho-medical paradigm, which continues to exert a strong influence on the type of treatments employed. Advocates of this concept consider the difficulties in learning as arising from deficits in the neurological or psychological make-up of the child, analogous to an illness or medical condition. In the U.S. literature on learning disabilities, this is quite explicit, in the form of the ‘minimal brain dysfunction’ hypothesis, which ascribes difficulties in learning to otherwise undetected cortical lesions (Coles 1987). Much effort by writers in this paradigm is bent towards refining screening instruments designed to assist in the diagnosis of the supposed syndrome or condition, and the interventions prescribed tend to be quasi-clinical in character. The weakness about this approach is the fact that it does little to address the real life situations experienced by teachers in the classroom. It is mentioned in this approach, but is not a focus of these researchers. Medication is at the centre of the debate surrounding ADHD treatment. Many medications have proven effective in lessening the effects of ADHD, making it possible for children to focus more on assigned tasks and to be less impulsive. These medications have side effects, however that is undesirable. This conflict brings to bear the ethical concerns about making children more pliable to the demands of a teacher by medicating the child. Some proscribed pharmaceutical regimens include giving medication to children at an early age, sometimes even before they start speaking or walking. In addition to this, prescription medication is given before conducting a physical examination that indicates ADHD in the child (Lloyd et al., 2006). Others such as Dykman and Ackerman (1993 cited in David) go on to argue the need for an even further refined system of categorization, and for the identification of ‘biological markers’ (for example adrenalin secretion salivation), before advocating the use of drugs to control the aggressive behaviour of children with ADHD. They conclude that teachers and counsellors should find the medicated defiant/aggressive child more open to suggestions regarding socially acceptable ways to handle irritation and frustration. The practice of drugging defiant children to make them more compliant is casually condoned as if the ethics of such a form of intervention required no further consideration. The criticism about medication treatments exists not only because of the ethical issues and concerns that surround it. It is also criticised because studies show that it has no effect on academic performance. Some studies show that drugs may amend the cognitive difficulties of ADHD patients, but still do not necessarily normalise cognition (Gualtieri, 2008). As Advokat (2009) pointed out, even though drugs overcome the attention and concentration deficit problems, they are not proven to improve academic and/or occupational performance. Because of the above concerns, the behavioural treatment for a child with ADHD has been found to be a more acceptable method. This approach has been used for children specifically diagnosed as having ADHD for more than 20 years (Rosenbaum & Price, 1976). In addition to treatment for diagnosed ADHD children, behaviour modification has been used for 30 years to treat children labelled as disruptive although not diagnosed as ADHD (K. D. O'Leary & Becker, 1967). Many different types of cognitive-behavioural treatments have been applied to children with ADHD, including verbal self-instructions, problem-solving strategies, cognitive modelling, self-monitoring, self-evaluation, and self-reinforcement. The underlying theme of these types of treatments is the promotion of self-controlled behaviour through the enhancement of problem-solving strategies (Hinshaw and Erhardt, 1991). Research has demonstrated the behavioural approach is more effective when it includes parent-training programs. These programs are considered important components in the treatment of children with ADHD (McKee, Harvey, & Danforth, 2004). The importance of such programs should be emphasised especially because self-report and observational studies across a wide developmental range indicate that parents of children with ADHD experience more stress, use more directives and commands, display more disapproval, use more physical punishment, cope less efficiently with their children's behaviour, and exhibit more overall negative behaviour than parents of non-ADHD children (Danforth, Barkley, & Stokes, 1991; Fischer, 1990; Johnston, 1996; Johnston & Mash, 2001; Woodward, Taylor, & Dewdney, 1998). These negative parenting methods may lead to further complexity in their children’ behaviour. Behavioural parent training programs that teach parents how to manage their children's inappropriate behaviour and encourage pro-social behaviour are well-established treatments for children with ADHD from preschool age through middle childhood (Pelham, Wheeler, & Chronis, 1998). Treating students in the classroom without medication is another source of disagreement in educational and professional circles. The fact that medication has not been shown to improve the academic success of students causes some to look beyond brain physiology and genetics as the real reason ADHD kids do not learn well in the classroom. Some feel that sociological theories and the structure of school may be the real reasons children with ADHD have a difficult time learning. Borrowing the theory of cultural reproduction from the general sociology of education, sociologists apply it to the case of special education, developing and modifying its conceptual framework in the process. This results in an analysis of special education as a sorting mechanism contributing to the reproduction of existing social inequalities by siphoning off a proportion of the school population and assigning them to an alternative, lower-status educational track. Tomlinson, for instance, deploys the metaphor of a ‘safety valve’ (Tomlinson, 1982) to describe the function of the special school system, referring to the way in which its existence allows troublesome and disruptive children to be removed from the mainstream system, which is thereby permitted to continue undisturbed in its task of delivering an unreconstructed academic curriculum to the majority. However, the later sociological writings of Tomlinson and others (Tomlinson, 1985) question whether this change in terminology masks a practice of stratification which continues to determine children’s educational careers by assigning to them an identity defined by an administrative label. There is some evidence, however, that recent work influenced by the tradition of sociological critique has begun to formulate a more explicit vision of alternative forms of policy and provision (Oliver 1992). This theory holds that the disabled must be able to engage in political discourse as a means of altering the systems that make them powerless. An interesting question that has occurred in research centres on the lack of studies examining educational intervention on behalf of students with ADHD. Although Rabiner & Malone (2004) showed that academic tutoring did not improve the academic performance of children suffering from ADHD, they stressed on the need for having effective academic interventions for such children, especially those among them who face reading difficulties. In this regard, Gualtieri (2008) concluded in his study that some ADHD patients may require additional educational assistance, even in the face of successful medication treatment. The educational interventions have been supported by the advocates of the organisational paradigm who see difficulties in learning as arising from deficiencies in the way in which schools are currently organized. Concomitantly, the solution advocated is to restructure schools to remove these deficiencies. Properly implemented policy of school restructuring will produce a system of schooling which is better adapted to meeting the educational needs of all pupils, and which will therefore eliminate or reduce to a minimum the problem of students who fail to fulfil their learning potential in the formal education system. Villa and Thousand propose that schools should be reformed to ‘accommodate for greater student variance,’ that is to cater adequately for the educational needs of all students in the local community, including students with severe behaviour disorders and physical and sensory impairments who would previously have attended a separate special school. This model is termed the ‘zero reject’ or heterogeneous school (Thousand and Villa 1991; Villa et al. 1992). The heterogeneous school theory holds that difficulties in learning are caused by pathologies in the way schools are currently organized, and that reforming schools as organizations can overcome them. Presently, the views of this paradigm have directed to the notion of the ‘inclusive school,’ which, its advocates suggest, would be adapted to respond to the full diversity of learning needs found in the student population. In this model, no group would be identified as ‘special’ and requiring a qualitatively different form of educational provision (Clark et al. 1995a). Some empirical evidence has been presented of school restructuring programmes which appear to be successful in promoting the social integration of students identified as having special needs, and which do not have an adverse impact on learning outcomes, and may be associated with improved attainment. All of this research has altered how we treat ADHD. Researchers are more likely, now, to study and recommend the use of a blend of treatments. For example, Power et al. (as cited in Sherman, Rasmussen & Baydala, 2008) pointed out, teachers took a favourable view on medication when it was coupled with a behavioural intervention approach. In this regard, a study undertaken by Tamm and Carlson in 2007 demonstrated that a combination of medication and contingency strategies (reward or response cost) was more effective than either of them was alone. However, the positive effect of coupling medication with contingency strategies on academic tasks is still an assumption; all the above studies proved the effectiveness of drug and behavioural strategies in controlling the activities of children with ADHD, but not in improving their academic performance. The possibility of the effectiveness of multiple treatments makes researchers such as David argue that the three paradigms share the common fault of reductionism, that is the tendency to explain an intrinsically complex phenomenon in terms of a single, unidirectional model of causation, and (concomitantly) to propose a single form of intervention as a complete and adequate solution to the problem learning difficulties are conceptualized as the product of factors located within the individual, or society at large, or the school. He said that there is a possibility of interaction between factors operating at different levels of analysis, which is overlooked. Read More