The Primary Treatments for Attention Deficit Hyperactivity Disorder - Essay Example

? ADHD ADHD Introduction The paper pursues to review evidence on the effectiveness or efficacy of cognitive behavioural therapies in addressing ADHD. According to Dobson & Dobson (2009), attention deficit hyperactivity disorder (ADHD) can be regarded as one of the prevalent childhood disorders that can continue throughout adolescence to adulthood. ADHD is typified by inattentiveness, impulsivity, over-activity, or a combination of the three. Toplak, Connors, Shuster, Knezevic & Parks (2008) argue that the primary evidence-based treatments for ADHD have tended to involve pharmacological and behaviour treatments. Nevertheless, continuous growth has been registered in investigations on the efficacy of cognitive-behavioural and neural-based approaches that are not necessarily considered the evidence-based practice. Presently, the two most effective interventions for minimizing the symptomatic behaviours of ADHD encompass central nervous system stimulant medication and behaviour modification processes. Although stimulant therapy is the most commonly used treatment for ADHD, the treatment fails to alleviate some ADHD related impairments; appears in effective in minimizing behavioural symptoms for close to 30% of the cases; and, is usually rejected or abandoned by a significant section of youth and care givers (Sinah, 2005). This is informed by the fact that, regardless of the effectiveness of stimulants in attaining a reduction in core symptoms, there have been lingering questions over their long-term effectiveness. Some studies indicate that the application of behavioural treatment along with medication may minimize the dose of medication crucial for effective treatment (Grant, 2010). A Brief Overview of ADHD The diagnosis of the majority of children with ADHD is highly controversial owing to the blurry line between ordinary developmental changes and symptoms of ADHD (Wolraich, 2006). This is informed by the fact that the ADHD symptoms are quite ubiquitous and age-relevant (Wood, Piacentini, Southam-Gerow, Chu, & Sigman, 2006). ADHD sums up as the most prevalent behavioural disorder of childhood and affects about 3-5% of school going children (Weiss & Weiss, 2004). Statistics indicate that ADHD is diagnosed most prominently among boys compared to girls (Reid, Trout & Schartz, 2005). Although, ADHD may run in families, it is still unclear on what precisely causes the disorder (Weiss & Weiss, 2004). ADHD can be categorized into three categories defined according to which symptoms that stands out, namely: predominantly inattentive type in which the individual finds it challenging to organize or finish a task; predominantly hyperactive-impulsive type in which the individual finds it challenging to keep still, and combined type in which the person manifest symptoms of category 1 and 2 (Wolraich, 2008). Causes of ADHD According to (Somer, Burleson, Lopez, Axelson, Lyengar and Birmaher (2007), scientists are not confident on the precise causes of ADHD, although, multiple studies suggest that genes play a significant role. Some studies have indicated that children with ADHD normally carry a version of a certain gene associated with a thinner brain tissue in areas linked to attention. Similarly, some studies suggest a potential link of ADHD to environmental factors enveloping smoking or alcohol abuse during pregnancy. Symptoms Millichap (2010) asserts that the symptoms of ADHD can be categorized into three groups. These include lack of attention (inattentiveness), hyperactivity, and impulse behaviour (impulsivity). Most children with ADHD essentially have the inattentive type, while others have a combination of types. The diagnosis of ADHD is grounded in extraordinarily symptoms that must be present in more than one setting. According to Millichap (2010), the symptoms ought to be present at least six months and observed in two or more settings, and not necessarily caused by another problem. Treatment for ADHD works best by a combination of medication and behavioural treatment. Some of the ADHD medications include psychostimulants that normally produce a restful effect on individuals with ADHD. Therapeutic Interventions for ADHD: Cognitive Behavioural Therapies Pliszka (2007) contends that cognitive-based therapies seek to help the child with ADHD to self-direct behavioural changes. There are diverse forms of cognitive behavioural therapies including problem solving strategies, cognitive reconstruction, relaxation training, and self monitoring, social skills training, and counselling inclusive of family therapy. As demonstrated by Dobson, there are also other forms of ADHD therapies encompassing biofeedback and relaxation training linked to the use of environmental manipulation and management. Cognitive-behaviour therapies manifest two aspects; behaviour therapy and cognitive therapy. Behaviour therapy hinges on the theory that the behaviour is learned and hence can be altered (Dobson, 2010). Cognitive therapy, on the other hand, is grounded in the theory that behaviour distressing emotions and maladaptive behaviours may emanate from faulty patterns of thinking (Pliszka, 2007). Hence, therapeutic interventions such as cognitive restructuring and self- instructional training directed at alleviating dysfunctional cognitions, behaviour and emotions (Hinshaw, 2007). There have been exceptional cases in which cognitive-behavioural therapies have reported positive results. For instance, Hinshaw (2007) has demonstrated that, indeed, reinforced self-evaluation that incorporates explicit training in self-monitoring and assessing one’s performance with relevant skills and concepts such as anger management was superior compared to other forms of interventions. The Effectiveness of Therapeutic Interventions for ADHD An investigation on the effectiveness of cognitive behavioural therapies for ADHD suggests that the interventions are promising in treating the cognitive and behavioural manifestations of ADHD (Chandler, 2010). These approaches mainly encompass cognitive-based interventions, contingency based interventions, and cognitive therapy (self-management) combined with other interventions (Tusaie & Fitzpatrick, 2013). In general, these treatments have not demonstrated significant treatment gains (Hishaw, 2007) and are hence considered being unsupported and ineffective treatments (Retz & Klein, 2010). Self Monitoring Self regulation infers the capability to process and control thoughts, impulses, feelings and behaviours. ADHD is known to cause self-regulation difficulties for children, especially centring on academic and behavioural situations (Reid, Trout, & Schartz, 2005). Self monitoring plus reinforcement encompasses the step outlined in self-monitoring; however, in addition to the self assessment, and self-recording of the target behaviour, the student is rewarded with reinforcement from an external agent for the registered change in the target behaviour. The goal of self monitoring is to enable the individual to develop sufficient levels of self-control by recognizing their limits. There is some evidence that self-monitoring strategies can be effective for children with mild ADHD symptoms, especially in improving organization skills. Self-regulation interventions enable the child to implement in intervention aiding in enhancing their self control on academic and behavioural difficulties (Rock, 2005). Self monitoring strategies are employed to enhance independent functioning in self-help, academic, behavioural, and social areas. Instead of spotlighting reduction of a student’s undesired behaviour, self monitoring strategies shape skills that lead to increase in appropriate behaviour. The student in this case may need prompting, and support from instructors as to self assess the given behaviour (Harlacher, Roberts & Merrell, 2006). Self-monitoring can be a helpful tool as part of an intervention package that may also embrace consequence-based contingencies such as reinforcement (Brown, 2009). This intervention is in cognizance of the assertion that the most of students with ADHD bear the skill to perform desired behaviours, but they are not able to perform consistently over time owing to challenges with the self-regulation (Morris & Mather, 2008). How Self- Monitoring Works with patients A program for self monitoring for students may incorporate components such as a self-monitoring cue tape, a self-monitoring card in which the child (a student in this case) is expected to answer self-assessment questions probing whether the student was paying attention. This transforms self-monitoring into a critical intervention tool, especially with regard to students with ADHD as it has been found to enhance on-task behaviour. Self-monitoring is critical in enhancing self-control in individuals with ADHD. Hence, during self-monitoring, external cues may be progressively phased out as students control off-task behaviours internally. Increased effectiveness of self-monitoring technique may be observed mainly in the context of the intervention phases and not necessarily in the follow-up phases (Amato-Zech, Hoff & Doepke, 2006). Studies on the Effectiveness Self Monitoring As stated, treatments for ADHD using self-monitoring are not effective over an extended period after the intervention. Furthermore, individual differences play a critical role accepting treating and guiding treatment (Mayer, 2009). The moment the student shows the accuracy in evaluating his or her behaviour, the student will then be reinforced for enhancements in the on-task behaviour (Stahr, Cushing, Lane & Fox, 2006). Once the student has demonstrated adequate capability for monitoring and reinforcing their behaviours, fading can be employed to decrease any external monitoring and reinforcement (Amato-Zech, Hoff & Doepke, 2006). Self monitoring remains successful, especially when the targeted behaviours or desired outcomes considered valuable by the students. Irrespective of whether or not a child with ADHD reacts positively to medication, self-monitoring strategies have found to yield gains in on-task medication, improvements in selective and sustained attention, besides minimizing impulsivity. These findings suggest that self-monitoring may be a significantly promising technique for children whose challenging behaviours are effected by medication (Buitelaar, Kan & Asherson, 2010). Self-monitoring of both attention and performance bear significant positive effects on the student’s on-task and spelling study behaviours (Harrris, 2005). The study found that improvement in the on-task behaviour matched the two interventions; however, self-monitoring of attention produced considerably higher gains in spelling study behaviour (Rafferty, Arroyo, Ginnane & Wilcznski, 2011). This contrasted with similar studies with students with learning disabilities in self-monitoring of performance tended to yield higher rates of spelling study compared to self-monitoring of attention (Buitelaar, Kan & Asherson, 2010). Advantages of Self Monitoring in Treating ADHD The review investigating the application of self monitoring for children with ADHD suggests that self monitoring can be an effective and efficient intervention program for children with ADHD. The combined effect of self-monitoring plus reinforcement has been registered in enhancing on-task behaviour, appropriate behaviour, academic accuracy and productivity, pointing out that self regulation intervention is effective and beneficial for children with ADHD. Self-monitoring has been pivotal in making children be conscious of their own poor choices so as to enhance instances of appropriate behaviour and giving the children more independence (Rafferty, Arroyo, Ginnane & Wilcznski, 2011). The results from the studies suggest that self-monitoring intervention can yield meaningful enhancements within the student's on-task behaviour reduction of inappropriate behaviour (disruptive behaviours), academic productivity and accuracy. The effects derived from the application of self-monitoring can be classified as large, although there was still a probability of differential effectiveness on certain dependent measures (Morris & Mather, 2008). Disadvantages of Self Monitoring in Treating ADHD Self-monitoring is an easy escape from over-medicating children who possess attention problems and sums up as a welcome addition to treatment. Self-monitoring aids individuals with ADHD to alter their behaviour and thought patterns which is a significant way of overcoming the symptomatic deficiencies associated with ADHD (Arias, Steinberg & Trestman, 2006). Obviously, self-monitoring alone fails to offer a complete answer to alleviating ADHD symptoms. Although, the application of self-monitoring as an intervention for the treatment of symptoms of ADHD has documented record of effectiveness, the intervention cannot be recommended in isolation (Amato-Zech, Hoff & Doepke, 2006). Relaxation Training Relaxation training undertaken by parents has been found to be successful in enhancing behaviour and other symptoms, besides enhancing overall relaxation when assessed by biofeedback equipment (Wolraich, 2008). Relaxation training is a form of attention management skills and seeks to address the problem of inattention that is a primary characteristic of living with ADHD. Relaxation therapy incorporates a number of techniques designed to instruct individuals on ways of relaxing voluntarily. Programs in relaxation therapy include training individuals in specific breathing and progressive muscle relaxation exercises fashioned at minimizing physical and mental tension (Arias, Steinberg & Trestman, 2006). The main focus, in this case, rests on establishing self-regulation skills that play a role in enhancing health and wellbeing. Autogenic training utilizes both visual imagery and body awareness to move the client into a relaxation state. The goal of relaxation training is to enhance attention span. Relaxation techniques such as meditation can aid the individual with ADHD to refresh and attain mental balance (Arias, Steinberg & Trestman, 2006). How Relaxation Techniques Work with patients Researchers stipulate that, in the long run, meditation enhances the activity within the prefrontal cortex, the section of the brain responsible for attention, planning, and impulse control. The objective of relaxation is to train the individuals with ADHD to focus with the aim of gaining insight. When individuals are stressed, their bodies engage in “fight or flight response” or changes that occur within the body such as increased heart rate, rate of breathing, and blood pressure. Relaxation response brings the body to a deep state of relaxation (Norton & Price, 2007). These changes aid to counter the ill effects of fight or flight response and herald an enhanced state of alertness (Norton & Price, 2007). Studies on the Effectiveness of Relaxation Training Majority of symptoms of ADHD, especially in adults, can be alleviated through relaxation techniques such as meditation. When undertaken constantly, relaxation therapies can contribute to enhancing of attention and focus and minimize impulsivity, anxiety, and depression. Equipping children with attention deficit with modalities for relaxing can be an effective means of reducing hyperactivity and disruptive behaviour, besides enhancing attention span and task completion (Buitelaar, Kan & Asherson, 2010). Findings on several studies indicate highlight relaxation training as at least as successful as related intervention approaches for diverse learning, behavioural, physiological disorders. Goldbeck and Schmid (2003) found that autogenic relaxation training was an effective intervention for slightly disturbed outpatient population of children and adolescents manifesting internal disturbances such as some hostile, impetuous, or attention deficit symptoms. Advantages of Relaxation Training in Treating ADHD Relaxation techniques and other means of thinking through stressful situations may be helpful to children with ADHD. Relaxation techniques aid ADHD children to feel more relaxed be less hyperactive, fidgets less, and focus on tasks. According to the studies, relaxation techniques bear the potential to enhance attention, behaviour regulation, and executive attention by naturally minimizing stress and anxiety and enhancing brain function. Relaxation training helps individuals with ADHD to monitor their behaviour and gain productivity. The efficacy of relaxation training in treating attention deficit among adults has strongly been demonstrated in outcome studies (Wolraich, 2008). Studies indicate that relaxation outcomes compare positively to those of stimulant medications. Relaxation training helps individuals’ to control their symptoms of ADHD by aiding the individuals exercise concentration and focus on the task at hand. For some measures, (such as a reduction of anxiety), one can possess a considerable degree of assurance in the effectiveness of relaxation intervention (Buitelaar, Kan & Asherson, 2010). Disadvantages of relaxation training in treating ADHD There have been a few studies probing the effect of relaxation therapy for individuals with ADHD. In the examined studies, relaxation therapy was found to be as effective as an antidepressant in the short-term. The long-term impact of relaxation therapy in treating ADHD symptoms remains evidently uncertain. There are no known disadvantages of using this intervention in treating ADHD. Relaxation training has largely been examined only children between ages 7 to 14 with inattention, impulsivity, and/or hyperactivity (Buitelaar, Kan & Asherson, 2010). This approach has successfully been implemented in both individual and group formats and employed with significant success within school settings. However, these early promising findings coupled with the simplicity of the intervention, relaxation training has not been entirely examined as a stand-alone intervention with children diagnosed with anxiety disorder. Instead, relaxation training has been integrated into both exposure-based therapies and cognitive behavioural therapies. In view of these findings, relaxation training may be a helpful intervention for children diagnosed with ADHD, but it is unclear whether relaxation alone would yield clinically significant benefits for children diagnosed with ADHD (Reid, Trout & Schartz, 2005). Although relaxation training has been a worthwhile recommendation for children manifesting more anger or aggression than others, it is still unclear whether the intervention would yield significant benefits for children diagnosed with conduct problems (Dobson & Dobson, 2009). Discussion It is essential to appreciate that the outcomes of the effectiveness of both self-monitoring and relaxation training should be viewed with caution, and should not be a vindication on the efficacy of the two interventions. First, review on the effectiveness of both self-monitoring and relaxation training is limited to published studies and hence, the results may be positively biased as studies manifesting significant results are highly likely to be published (Dobson & Dobson, 2009). Undoubtedly, there is a lack of sufficient data on the long-term effectiveness of both self-monitoring and relaxation training. For the effectiveness of treatment of ADHD using relaxation to be considered truly effective, extensive documentation on lasting efficacy on critical ecological markers of functioning in key life activities such as sustained peer relations is needed. Both interventions have failed to satisfy this observation, which, in turn, renders the overall effectiveness of both interventions to be considered as minor. However, this observation does not bring into disrepute the efficacy of both self-monitoring and relaxation training in minimizing the symptomatic deficiencies of ADHD. Emerging evidence from recent studies suggests a probable role for cognitive behavioural therapies alongside medication amid the treatment of ADHD (Toplak, Connors, Shuster, Knezevic & Parks, 2008). A significant problem apparent within ADHD literature is the absence of documentation of long-term effectiveness of the discussed interventions. Almost all of the explored studies have focused on the short-term impacts of the interventions (within three months). Another prominent concern centring on the explored treatment research on ADHD has been that regardless of the consistent findings of improvements in chief ADHD symptoms there have been limited reports exploring the psychosocial treatment impacts on key indicators of functioning such as social skills (Sinah, 2005). Clearly, additional investigations are necessary to compare these interventions to determine if one of the interventions emerges to produce greater effects across dependent variables and evaluate whether the treatments may yield greater effects in one domain over another (Brown, 2009). Conclusion Although, cognitive, behavioural therapies (CBT) have been criticized for their scarcity of evidence-based data, some studies have reported positive impacts of CBT techniques on children suffering from ADHD. While medications can aid a child with ADHD to cope with everyday life, the child may be well suited in controlling some of the manifested behavioural problems by undoing blame, frustration, and anger; cognitive behavioural therapies may be used to help adults establish strategies, and learn practical techniques, that can minimize the influence of their ADHD symptoms on their functioning. The current recommendations for the treatment of ADHD require the application of a multimodal approach inclusive of combination of medication, behaviour modification, and ancillary services. This can only mean that self monitoring or relaxation training, alone, cannot alleviate the symptoms of ADHD unless they are employed in conjunction with other interventions such as medication (Grant, 2010). Hence, whereas some studies pinpoint the effectiveness of either self monitoring (with reinforcement) or relaxation training, the two cannot by themselves be successful in treating ADHD. 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