ADHD in Children - Research Paper Example

?Running head: ADHD in Children ADHD in Children [Institute’s Table of Contents Page no Introduction………………………………………………………………………………3 2. Changing conceptualizations of ADHD………………………………………………….3 3. Studying the epidemiology of ADHD: problems and prospects………………………….4 3.1. Clinical and epidemiologic case definition of ADHD……………………………….5 3.2. Future directions for epidemiologic research on ADHD…………………………….6 4. Evidence-based practice for treatment of ADHD…………………………………………6 5. Cognitive-Behavioral treatments (CBT)…………………………………………………..8 6. Effects of pharmacological treatment on domains of cognition in ADHD……………...10 7. Behavioral treatments (BT)……………………………………………………………....11 8. Conceptual and theoretical considerations……………………………………………….11 9. ADHD in Children Introduction According to an epidemiological research of Attention Deficit/Hyperactivity Disorder (ADHD), the actual rate of prevalence could be two to three times more than what is actually cited (3-5%) (Paule, et al., 2000). Besides, from the data it was concluded that there is a frequent occurrence of under as well as over diagnosis. ADHD is normally diagnosed in childhood, although the symptoms may persist on as they become adolescents and then adults (American Psychiatric Association, 2000). Basic treatment approaches for ADHD formed on evidence are pharmacological and behavioral treatments. Nevertheless, researches still take place of cognitive-behavioral, cognitive, and neural-based intervention approaches which cannot come under evidence-based practice. These interventions can be other options for treatment of ADHD. The majority of the theories of ADHD feature a significant part to influenced executive and cognitive procedures (Barkley, Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment, 2006); still, the field has not yet developed an evidence-based mediation on the basis of cognitive-behavioral principles (Hinshaw, 2006). Undeniably, partly the challenge that we face is the changing conceptualization of the etiology and behavioral profile of ADHD. One problem with this disorder is that the patients cannot be completely cured of it. The various treatment approaches that are used are short term and their effects last only sometime. There is no long term or permanent solution of it yet, whether medication or behavioral. In fact, some of the proposed treatments for ADHD do not have any kind of result and are nonetheless, totally useless. Changing conceptualizations of ADHD Behind any treatment or intervention lies the theory which forms the basis of that treatment and supports it. ADHD has seen a great variety of changes undergoing in its theoretical conceptualizations in the past couple of years. The three subtypes of ADHD were given formal recognition only in the DSM-IV (American Psychological Association, 1995) and these include the inattentive subtype, hyperactive-impulsive subtype, and the combined subtype. Recent research has shed light on the significance of distinguishing the effects that these subtypes have. For instance, the first, inattentive subtype has an association with lower performance on executive, cognitive-based measures in comparison with those of the hyperactive-impulsive subtype. The last 20 years or so of research has majorly emphasized upon the impairment of executive functions, which include decreased performance on measures, for example inhibitory control, working memory, and set shifting (Barkley, 2006). This view has been further explained by the more current models. For instance, the dual pathway model has suggested that executive as well as motivational deficits having some kind of a relation with delay aversion can significantly predict ADHD symptoms. Likewise, there are arguments of there being several reasons (Nigg, 2006) or various endophenotypes which could hold the responsibility of the heterogeneity in the clinical expression of ADHD. The constant variations occurring in the conceptualization of ADHD has made the field to continuously analyze the competence of our treatment approaches, plus these treatment approaches are affected greatly by the working theory of ADHD. An illustration is an example of sensory integration therapy that had been suggested as to be used for children having ADHD. For this therapy there is an involvement of compensatory tactics, which may include changing or avoiding some stimulus features of the environment (for instance lowering aversive touch). This therapy was considered worthy because its foundation was on assuming that ADHD is an “input” problem, that the processing and interpretation of sensory and motor input may be faulty and the consequence would be inappropriate reactions to sensory stimuli (Waschbusch & Hill, 2003). Likewise, attempts at using problem-solving tactics and verbal mediation can turn out to be misguided in case one looks at the core deficits of ADHD as taking place pre-verbally (Hinshaw, 2006). To evaluate the usefulness of any kind of a treatment approach there is first of all a requirement of considering the theoretical rationale behind its expected utility. The actual thing that is being ameliorated needs to be clarified and focused upon. It has been found that for other child psychopathologies like anxiety and depression tactics for modifying cognitive distortions are pretty efficient (Kazdin & Weisz, 2003). However, when it is about ADHD it is cognitive deficiencies that would be being dealt with, as opposed to distortions, and it is more difficult to remediate these (Hinshaw, 2006). Studying the epidemiology of ADHD: problems and prospects The most common of the childhood disabilities is ADHD but still the epidemiologic literature regarding ADHD has huge holes which need to be filled in. The prevalence rates of ADHD vary to a great degree and there is not enough data currently available that would classify the prevalence of this disorder according to various factors such as age, race, gender or socio-economic status. Even data regarding the diagnosis and treatment within the communities are not enough and same is the case with long-term effectiveness of treatment. Clinical and epidemiologic case definition of ADHD For the clinical diagnosis of ADHD the diagnostic and statistical manual of the American Psychiatric Association (DSM-IV) has set up a criterion on which it may be based (American Psychiatric Association, 1994). This criterion was set after having collected a history of nine symptoms of hyperactivity/impulsivity or nine symptoms of inattention that were there for at least six months and it was evident that there was some kind of an impairment in two or more environments (for instance, at school and home). Besides, “clinically significant impairment” needs to be evidently present within social, academic or occupational functioning. The DSM-IV criteria for ADHD have set up three subtypes: a majorly hyperactive-impulsive subtype, a majorly inattentive subtype, and a combination of the subtypes wherein a person has displayed symptoms from both the other categories. These were talked about earlier in the paper as well. Several hurdles come underway when these standards are applied within a clinical environment or within an epidemiologic study. Among the several problems encountered at the diagnosis in a clinical setting, one is that children suffering from ADHD tend not to show symptoms in new environments (for instance, the doctor’s office) and it is possible for the differential diagnosis to be complicated in the case where the child is having other co-morbid conditions. Measuring ADHD has proven to be pretty difficult and because of that it has not been possible to progress the understanding and research regarding this disorder. Certain important issues have to be considered in epidemiologic studies: there is a requirement of considering the way the reports of various participants can be combined; what the real definition of impairment is; how we could dismiss out the other explanations for symptoms which may be common between ADHD and other disorders too; how co-morbid and co-occurring condition may be recognized; and how the age at onset may be handled. Reports that various participants have given frequently disagree and there is a requirement on the part of the epidemiologists to set up standard rules which would combine the symptoms. Such rules may have important consequences on which the children that are taken to be the cases, and resultantly, on prevalence. DSM-IV criteria for ADHD need evidence of clinically significant impairment. This is required for distinguishing between those who actually show the symptoms but are able to functional properly. Nevertheless, the epidemiologists find it challenging to define impairment although there is a complication in the basic construct of impairment and no universal method is present that could be used to measure it. For instance, according to certain researches it was suggested that ADHD children are at a higher risk of accidental injuries. However, it is still not sure whether details regarding accidental injuries should be used for defining injury. There is a discussion regarding whether ADHD is actually a “real” disorder due to the fact that it is heterogeneous, which means, ADHD also consists of children who are having a wide range of symptom profiles and is frequently in combination with other cognitive and psychological conditions which include learning problems, anxiety disorders or depression. It is the challenge of the epidemiologists and clinicians to distinguish real cases from those that may just appear to be due to them also showing ADHD related symptoms. Such unreal cases are not uncommon and a child could be showing ADHD symptoms without actually having the disorder due to a couple of reasons. For instance, it is possible that his/her family situation is dysfunctional, or that he has another related condition such as anxiety, depression or absence seizures, or could be having a negative reaction toward medical treatment (Overmeyer, et al., 1999). It is very important, not to mention difficult, to sort out the cases that are real and those that are under other co-morbid conditions. Future directions for epidemiologic research on ADHD Prevalence of ADHD is pretty high and therefore there is a requirement of further information regarding the disorder and its variation, about its medical treatment and how prevalent it is, the community treatment patterns and what hurdles may be found in it. Long-term safety and efficiency of treatment needs to be looked into (Rowland, et al., 2002). Besides, information regarding the natural history of ADHD plus the possible risk factors especially those that can be prevented. Evidence-based practice for treatment of ADHD The Multimodal Treatment Study of children with ADHD study happens to be the biggest and very significant research (Paule, et al., 2000) and it consisted of a sample of 579 children having ADHD Combined subtype, of ages 7-9.9 years, and they were looked upon for 14 months for the research. From the results it was interpreted that medication management led to a significant decrease in the ADHD symptoms in comparison with just the behavior program, and that medication and behavior treatment together did not lead to any more benefit than either of them alone. This research had turned out to be extremely significant and has had led to the doctors in the field to believe that it is only medication that can be termed as an actual and feasible option for the treatment of children suffering from ADHD, and that behavioral intervention strategies do not turn out to be so effective for the treatment of the major symptoms of this disorder (Hinshaw, 2006). Nevertheless, not everyone is in agreement with this statement and there are some who say that the data collected are not absolutely agreeing with the conclusion that medication treatments are better and more feasible in comparison with the behavioral ones; rather, the suggestion they put forward tis that there is a need to highlight the effectiveness of medication as well as behavioral treatments (Waschbusch & Hill, 2003). Medication is the easiest option; it is available widely and is pretty efficient with just a couple of side effects. However, there are certain limitations in using medication including that treatment gains are only for the duration the child is under medication, around 20-30% of the ADHD children give an unfavorable response, and there are also questions as to whether this method gives long-term gains or not (Waschbusch & Hill, 2003). Then there is stimulant medication as well which may result in differential effects upon the various areas of functioning; the current literature suggests that this is efficient in decreasing ADHD and internalizing symptoms and that it has a positive impact upon the patients’ social behavior. However, the evidence does not support better academic performance (Schachar, et al., 2002). Evidence-based psychosocial treatments for children and adolescents suffering from ADHD had been reviewed recently and it suggested that enough evidence exists for behavioral parent training and behavioral school interventions which consequently lead to these kinds of treatments categorized as empirically authorized treatment (Chronis, Jones, & Raggi, 2006). Behavioral parent training and classroom behavior management both involve training parents and teachers to the usage of behavioral and adjustment rules that have been formed on the basis of social learning rules, praising, attending positively, rewarding as a response to bring about more positive behaviors, employing tactics such as overlooking, break and non-physical restraint. Behavioral approaches share some of the limitations that medication treatment has which include the short-term effects that last only during the time period the treatment is being carried out, and children reacting unfavorably to the treatment (this could be due to the way they are being treated, how willing their parents are and what is the status of the therapist in regard to his skills) (Waschbusch & Hill, 2003). On the whole, medication and behavioral treatment both tend to be efficient but still there are limitations which suggest a requirement to come up with and use further strategies and methods. Cognitive-Behavioral treatments (CBT) Cognitive-behavioral approaches include training in self-instructions, problem solving, self-reinforcement, and self-redirection that would allow for coping with any kind of mistakes made. This treatment approach has a certain background to it (Abikoff, 1991). Generally no gains have been found from such treatment studies (Abikoff, 1991) (Hinshaw, 2006), therefore, it is said that they are inefficient (Waschbusch & Hill, 2003). The theoretical foundation behind such kinds of treatments is the belief that it is possible to increase behavioral self-control if certain cognitive or metacognitive talents can be enhanced, and these are thought to motivate and support impulse control and/or goal-directed behavior (Meichenbaum, 1977). Researches wherein a group of children suffering from ADHD were given intensive cognitive training for sixteen weeks did not show any major effects on their studies, cognitive or behavioral measures in comparison with the normal support control or the ones who were not trained. The review that Abikoff (1991) conducted of cognitive training interventions was made up of 21 controlled investigations. The influence that the interventions had upon cognitive, academic and behavioral functioning were examined and it was found that there were not many important differences between each of them. Regarding the academic effectiveness it was found that the reading ability was not influenced significantly and only a negligible effect was noticed for math functioning. A little effect was also found to be upon cognitive training reported on behavioral change. Still, certain cases were found wherein it was found that the cognitive-behavioral approaches were efficient. One such was through the research of Hinshaw, Henker & Whalen (1984) who showed that a properly reinforced self-analysis treatment is much better than other kinds, and this treatment consisted of clear training in monitoring oneself and analyzing one’s own presentation having extremely relevant talents and ideas, for instance controlling anger. Besides, it was found that those children and young adults who have subclinical levels improved, and cognitive tactics together with behavioral programs were functional for certain areas, for instance social skills and anger management, and these were shown to have proven effective (Hinshaw, 2006). Hinshaw’s argument is that any cognitive-based process should be clearly having behavioral or contingency based management tactics if it is to be successful. It is possible that behavioral approaches turn out to be quite serious when supporting a change from the extrinsic rewards to internalized cognitive, self-regulated behaviors. In the researches Fehlings (Toplak, et al., 2008) conducted, they made the kids go through a learning process wherein they were taught about cognitive-behavioral strategies, for instance problem solving and they used to symbolically reward the children on performing the deed correctly. The 5 step process of problem solving were what the children learnt at the research and these steps include clarifying what the actual problem is, what the aim of the person should be, how he should generate the strategies for solving the problem at hand, what solution he should choose and, finally, how he needs to analyze the result with self-reinforcement. The children were taught these ideas very well and thoroughly and the teaching methodology was modeling and exercises involving role playing, instructional training, homework, behavioral approaches for example token system. There was a control group as well for the research and it was basically a supportive therapy group. This group was exposed to the same therapist and given the same problems to solve; however, they were not trained for cognitive-behavioral strategies. The results did not show any major differences in the two groups regarding a cognitive measure of impulsivity (Toplak, et al., 2008) but from what the parents said there was indeed a major decrease in child activity level after CBT as compared to the control group. Just like Fehlings, there were two other researches that employed cognitive-behavioral approaches with kids. Hall & Kataria (1992) made a comparison of three groups; the first group was for behavior modification, the second for cognitive training while the third group was just as a control. Each of these three groups was monitored for the effect that medication had on them. It was deduced that the second group, that undergoing cognitive training was found to be receiving training as to how they may deal with cognitive result measure of attention, while the first group of behavior modification was given direct support when they gave accurate answers while the outcome measures were being taught. The reports showed an important influence upon the cognitive training treatment in combination with stimulant medicine on maintained attention. Another research by Semrud-Clikeman, et al., (1999) carried out a comparison between attention training in combination with tactics to a control group for problem solving among kids. While treatment was in progress the training group was taught how they can set their goals and they were also guided regarding how to select the most efficient tactics for the cognitive outcome measures of attention. The reports showed that the measures of cognitive outcome had been affected vastly and more so in the sustained visual and auditory attention. There was another research in the past decade that employed a cognitive-behavioral procedure for adolescents (Barkley, et al., 2001), and the focus was upon “problem-solving, communication training, and cognitive restructuring” for bringing about an improvement in the conflicts that exist between a parent and his adolescent. First and foremost was the problem solving section, the training of which was made up of five steps. The participants were taught that they need to define their problem first and then brain-storm some solutions that might be appropriate for them. Following that they need to negotiate with the solutions and their wishes and then reach a decision as to what they actually want and what would be most suitable for them. Lastly they need to the implement whatever the solution they have come to a conclusion at. Through communication training the parents and their adolescents ended up having better and more efficient communication tactics at the time of talking about the conflicts between them. Cognitive restructuring was made up of recognizing and then appropriately changing the useless belief systems. This was a plain CBT approach and later a comparison was made of it with this together with behavioral contingencies. On the whole, each of these two approaches showed pre-post betterment on various behavioral resultant measures, which included decreased ADHD and ODD symptoms by the parents as well as their adolescents. Besides, the research did not show any such major differences between these groups. Effects of pharmacological treatment on domains of cognition in ADHD Studies have been conducted of the pharmacological management of ADHD plus similar disorders among kids since the past 50 years or so, and the very first controlled studies of stimulant treatment were published during the initial years of 1960s (Conners, Eisenberg & Sharpe, 1964). An interesting fact was that such earlier studies concluded that there certainly are advantageous effects resulting from amphetamine (AMP) and methylphenidate (MPH) on endpoints having an association with cognitive application. Another research by Conners showed that if those kids undergoing treatment for extreme problem behaviors were administered MPH or AMP they certainly reported major betterments in the way they performed the Porteus Maze test, which is used for measuring generalized cognitive application. There are many researches that have reported what such interventions have resulted in having been employed for several cognitive procedures within clinical samples, and these steadily agree with the background that research has upon clinical effects of medications and behavioral interventions for ADHD plus other such disorders. Behavioral Treatments (BT) Behavioral treatments have been in use since a very long time period and it is used for treating those children who may be displaying aggressive attitude or having ADHD. It is said that behavioral treatments have turned out to be pretty successful and helped them in the facilitation of the management of unwanted behavior, academic performance, social skills and so on. In spite of this, there is controversy regarding the proof for incremental advantages of BT to medication. From certain researches it was concluded that BT had no incremental benefits once the patient had received optimal treatment effects with increasing dosages of methylphenidate (So, Leung, & Hung, 2008). Nevertheless, if the patient is treated with lower dosages of methylphenidate together with BT the results would be good and pretty much the same as when he is treated just with the high dosages. Contingency management (CM) happens to come under this category as well since it is a kind of behavioral treatment, only more extreme and intense than behavior modification. This approach is normally carried out in special rooms where there are complete treatment facilities available. Intensive behavioral treatments basically focus upon bringing together CBT and CM and make it one intense program in order that there is improvement in the self-control of the patients and they become more social. Conceptual and Theoretical Considerations There is a requirement of further studies examining what influence is brought about when medication is combined with other options of treating. However, there should also be a thorough examination of the effect that medication has as compared to the other treatment options. Through the research of (Hall & Kataria, 1992) it was shown that cognitive and behavioral interventional together, with medication, produced important effect on maintained attention. Besides, (Hinshaw, 2006) has recommended that behavioral approach should be used together with the other options available. In fact, a meta-analysis recently conducted made a comparison of the studies that used combined psychosocial and pharmacological treatments with those that only used the latter, and the treatment that was a combination of the two led to not-very-significant effects as compared to the pharmacological treatments only (Toplak, et al., 2008). Certain proof also exists that shows efficiency of cognitive tactics in combination with behavioral approaches that are applicable to certain areas, for instance that of social skills and anger management (Hinshaw, 2006). There is a requirement to consider the various developmental levels in order to be able to fulfill a person’s cognitive and developmental requirements (Chronis, Jones, & Raggi, 2006). For instance, it is possible for those kids having ADHD to be unable to make use of cognitive-behavioral tactics for modifying lacking thinking strategies (Hinshaw, 2006), and this could be a reason behind the earlier attempts of using CBT for kids not bearing fruit. However, in no certainty does this dismiss the likelihood of such programs being more efficient for adolescents and/or adults suffering from ADHD. In fact, there is certain proof to demonstrate the effectiveness of such programs in adults with ADHD (Stevenson, et al., 2002). Using such treatments for adolescents has been pretty much ignored (Chronis, Jones, & Raggi, 2006), and there is a need to especially consider this developmental period during which the person comes across challenges which necessitate other approaches, for instance parent-teen training approaches in order to solve problems and to enhance communication (Barkley, et al., 2001). References Abikoff, H. (1991). Cognitive training in ADHD children: Less to it than meets the eye. Journal of Learning Disabilities, 24, 205–209. American Psychiatric Association. (1994). Attention-deficit and disruptive behavior disorders. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, American Psychiatric Association, 78–85. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: American Psychiatric Association. American Psychological Association; Task Force on Psychological Intervention Guidelines. (1995). 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