Attention Deficit Hyperactivity Disorder - Research Paper Example

? Number 28th March Case Study Jon is a 14-year-old Asian American male who was referred for a number of school-related issues, including behavior and truancy. Jon’s mother has reported that he has always been a difficult and hyperactive child, but is getting more difficult with age. Jon’s parents got divorced a year ago but were having marital problems frequency, so family issues may be a problem, especially as Jon feels that they are focused on themselves. Jon himself has admitted to finding school work difficult due to a lack of concentration and bullying for being ‘stupid’. Jon does take drugs and drink alcohol with his friends at weekends, but doesn’t seem to think this is a problem. His main problem areas are, therefore, his conduct and appreciation of the rules, as well as his hyperactivity and difficulties at school. Diagnosis Axis I 314.01 Attention Deficit Hyperactivity Disorder, Combined Type Symptoms include six or more listed examples of inattention, six or more listed symptoms of hyperactivity-impulsivity, some symptoms were present before the age of seven, and impairment from the symptoms is present in two or more settings (American Psychiatric Association [DSM-IV-TR], 2000). 312.81 Conduct Disorder, Childhood-Onset Type (Moderate) Child-Onset Type Conduct Disorder requires that the individual shows characteristics of the disorder prior to being 10 years old. The individual must have presented with three of the following (in the past 12 months) and at least one in the last six months: aggression to people or animals, destruction of property, deceitfulness or theft and serious violations of the rules (American Psychiatric Association [DSM-IV-TR], 2000). Axis IV Parental divorce, school-related stress (American Psychiatric Association [DSM-IV-TR], 2000) Axis V GAF = 54 (American Psychiatric Association [DSM-IV-TR], 2000) Differential Diagnosis Some of the symptoms of ADHD combined type can occur when children are placed in situations that are not academically stimulating enough for them (American Psychiatric Association [DSM-IV-TR], 2000). This does not seem to be the case here, as Jon recognizes that he has difficulties with a number of the projects at school and often gets bullied for being ‘stupid’. Oppositional behaviors cannot be completely excluded from the diagnosis but are likely to have occurred secondary to ADHD problems, particularly when considering that Jon recognizes that he has difficulty concentrating and there are clear examples of hyperactivity and impulsivity which suggest that there is an underlying problem to the oppositional behaviors. Many types of misconduct can occur as a result of a mood disorder (American Psychiatric Association [DSM-IV-TR], 2000). However, Jon does not seem to be displaying any major symptoms of a mood disorder. He is still enjoying a number of social activities and there are references to sporting activity, suggesting that problems are limited to home and school. There does not seem to be a substance abuse problem, although the individual is young, as the use of marijuana and alcohol seems to be limited socially. This seems to be primarily linked to the conduct disorder, although this should be carefully monitored. There do seem to be some difficulty with adjusting to the parental divorce situation, but the symptoms have persisted for longer than six months and therefore cannot be diagnosed as an adjustment disorder (American Psychiatric Association [DSM-IV-TR], 2000). Jon also shows a number of symptoms of antisocial personality disorder. This must be ruled out due to his young age, as this personality disorder cannot be diagnosed in anyone under the age of 18 (American Psychiatric Association [DSM-IV-TR], 2000). Etiology Epidemiology The epidemiology of ADHD is controversial, as although the DSM-IV-TR does give symptoms to aid with diagnosis, the final decision is up to the clinician. This has led to estimates of prevalence varying from 2% to as high as 18% (Roland, Lesesne & Abramowitz, 2002). ADHD does seem to be generally more common in males than females (American Psychiatric Association [DSM-IV-TR], 2000). What makes the prevalence even more difficult to ascertain is that it is frequently co-morbid with a number of conditions which may complicate the symptoms (Roland et al, 2002). One of these conditions is conduct disorder, as the case study has been diagnosed with. Similar problems come from trying to ascertain the epidemiology of conduct disorder. However, it is known that conduct disorder is more common in males than females and increases in prevalence with age (Maughan, Rowe, Messer, Goodman & Meltzer, 2004). Biological/Developmental There is a huge amount of evidence to suggest that ADHD is partly due to genetics, with twin-studies supporting this notion (Elia & Devoto, 2007). Whilst the precise genetic mechanism behind ADHD is not known, dopamine transporters seem to be affected primarily (Nigg, 2007). Additionally, there are a number of risk-factors for ADHD that come from the developmental environment. One of the most important environment aspect that has been implicated in ADHD are related to the actions of the mother whilst the child is developing, including tobacco and alcohol use as well as other potentially toxic environmental effects (Elia & Devoto, 2007). Other birth complications such as premature birth have some level of correlation with ADHD children. Infections, such as measles and rubella, during the pregnancy have also been implicated (American Psychiatric Association [DSM-IV-TR], 2000). There are a number of competing theories about the actual pathophysiology of ADHD. It is suggested that there is a decrease in overall brain volume in children with ADHD, particularly in the left-sided prefrontal cortex. Frontal lobe dysfunction may also play a part, as this area is linked with hyperactivity and impulsivity (Krain & Castellanos, 2006). This may also be involved in conduct disorders which have an element of impulse associated with symptoms. Psychological Although there are signs of ADHD being linked to genetics, it is often hard to separate this from early psychological influences, particularly as siblings and even parents generally have very similar psycho-social upbringings (Barkley, 1997). The World Health Organization has made a statement that family dysfunction and problems in the school system may contribute to ADHD (Nigg, 2007). There is strong evidence that the psychological state of early caregivers can influence the attention span and impulsivity of children, again suggesting that psychological influences may play a part. However, it should be noted that there are significant amounts of overlap between the cognitive and emotional stimulation for a child and their genetic relatives, so caution must be taken when drawing inferences from this information. Very similar findings have been found with respect to conduct disorders of the type that the patient has. Perhaps what is interesting is that it has been theorized that those with ADHD have potentially lower capacities for arousal and this is what causes their abnormal behaviors, such as excess fidgeting. The problems with the attention span of these children may come from the fact that their arousal can only be piqued by external stimuli, which means that they are constantly being interrupted and their attention being drawn away from the task at hand (Nigg, 2007). Interestingly, conduct disorders may be due to lower capacities for arousal, with more risque behavior being needed to satisfy the individual compared to what is considered to be clinically normal for a person of their age. Social As previously mentioned, the World Health Organization suggests that there may be a number of social factors involved with the diagnosis. One of these is related to the fact that children who have spent significant amounts of time in care homes or with foster families have a larger chance of developing ADHD with their peers (Nigg, 2007). This suggests that there is definitely an environmental factor behind the disorder. To develop antisocial personality disorder, the DSM-IV-TR (American Psychiatric Association, 2000) suggests that there be a presence of a conduct disorder in adolescence. Similar social factors seem to influence the prevalence of antisocial personality disorder, which suggests that conduct disorders may have a number of social factors involved. Proposed Treatment 314.01 Attention Deficit Hyperactivity Disorder, Combined Type The primary option for controlling the symptoms of attention deficit hyperactivity disorder for a child of 14 is a stimulant drug, such as methylphenidate (Nigg, 2007). The use of medication can be accompanied by a behavioral therapy such as cognitive behavior therapy (CBT). The treatments have been shown to be more effective when used in conjunction. It would therefore be recommended that Jon take 10mg twice a day (Nigg, 2007), with adjustments being made if necessary. This should be accompanied by a weekly session of CBT for a period of 6-10 weeks (Nigg, 2007). 312.81 Conduct Disorder, Childhood-Onset Type (Moderate) There are currently no officially approved treatments for conduct disorders. Experimentally, riseperidone has been shown to have some beneficial effects (Snyder et al, 2002), although there are few studies on the topic. General Treatment Information Abikoff & Klein (1992) make the suggestion that ADHD and conduct disorder are commonly co-morbid and therefore should be treated as one. This paper suggests that many individuals with ADHD and conduct disorders have family problems, such as the marital discord between Jon’s parents in the case study. Abikoff & Klein (1992) suggest that there may be reasoning to treat the underlying social problems, using therapies and counseling. This may be beneficial to Jon, particularly as his behavior has reportedly been aggravated by his parent’s divorce and the fact that he is struggling with his school work. Jon should also be encouraged to tackle his drinking and drug habits before they develop into a substance abuse disorder, which are more frequently found in individuals who had conduct disorders in their youth (American Psychiatric Association [DSM-IV-TR], 2000). It may be beneficial to encourage Jon to focus on his strengths in school to help him appreciate his experience there. Rather than banning him from sport teams because of his behavior, it may be beneficial to encourage him into sport as he feels he is good at it, which may in turn reduce his misconduct. Jon is also evidently a social individual when it comes to those who he feels understand him, and this activity should be encouraged. There are a number of barriers to Jon’s treatment, however. Firstly, he feels that he is made fun of in school for being stupid, and teachers tend to favor the better students. This should be examined for truth, and tackled in the appropriate manner to allow Jon to flourish properly in this environment. Jon’s parents also pose a problem, as he has a difficult relationship with both following the divorce. It may be useful for the parents to undergo some forms of therapy and be encouraged to have more appropriate behavior around their son so that he does not pick up on their depression and anger. References Abikoff, H., & Klein, R. G. (1992). Attention-deficit hyperactivity and conduct disorder: Comorbidity and implications for treatment. Journal of Consulting and Clinical Psychology, 60(6), 881–892. doi:10.1037/0022-006X.60.6.881 Association, A. P. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR®. American Psychiatric Pub. Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychological bulletin, 121(1), 65. Elia, J., & Devoto, M. (2007). ADHD genetics: 2007 update. Current psychiatry reports, 9(5), 434–439. Krain, A. L., & Castellanos, F. X. (2006). Brain development and ADHD. Clinical psychology review, 26(4), 433–444. Maughan, B., Rowe, R., Messer, J., Goodman, R., & Meltzer, H. (2004). Conduct Disorder and Oppositional Defiant Disorder in a national sample: developmental epidemiology. Journal of Child Psychology and Psychiatry, 45(3), 609–621. doi:10.1111/j.1469-7610.2004.00250.x Nigg, J. T. (2009). What causes ADHD?: Understanding what goes wrong and why. The Guilford Press. Rowland, A. S., Lesesne, C. A., & Abramowitz, A. J. (2002). The epidemiology of attention?deficit/hyperactivity disorder (ADHD): A public health view. Mental Retardation and Developmental Disabilities Research Reviews, 8(3), 162–170. doi:10.1002/mrdd.10036 Snyder, R., Turgay, A., Aman, M., Binder, C., Fisman, S., & Carroll, A. (2002). Effects of risperidone on conduct and disruptive behavior disorders in children with subaverage IQs. Journal of the American Academy of Child & Adolescent Psychiatry, 41(9), 1026–1036. Read More