An Overview of ADHD

PART #1: The first portion of this post is essentially a reposting of an old paper I did on ADHD in school….

Attention Deficit Hyperactivity Disorder (ADHD) is defined as a “persistent pattern of inattention and hyperactivity-impulsivity that interferes with functioning or development” (American Psychiatric Association, 2013, p59). Hyperactivity involves a persistently excessive level of motor activity that interferes with an child’s social and academic activities (American Psychiatric Association, 2013; Orvashel, et al, 2001). Impulsivity involves poorly thought out actions that reflect an attention toward immediate rewards that manifest as socially inappropriate (American Psychiatric Association, 2013; Orvashel, et al, 2001). Finally, inattentiveness produces an inability to maintain attention and difficulty sustaining focus on an activity (American Psychiatric Association, 2013; Orvashel, et al, 2001). Inaba & Cohen, (2014) note that ADHD is thought to be the result of dopamine depletion. Therefore, medications, which increase the availability of dopamine, are useful.  The next section provides a brief overview of various types of ADHD medication…

What are “Amphetamine Congers”

“Congers” & Dopamine

Our textbook provides a description of “Amphetamine Congers” for the treatment of ADHD (Inaba & Cohen, 2014, p. 3.29). This class of stimulant drugs, produce effects similar to methamphetamine, only not as strong. For example, Methylphenidate, also known as Ritalin, works by inhibiting the reuptake of dopamine and promoting its release by the transport system (Preston, et al, 2010). Since dopamine acts as a the reward molecule in the brain, this increases motivation and attention in ADHD sufferers. It is interesting to note that ADHD sufferers who are treated with Ritalin in childhood are “84% less likely to abuse drugs and alcohol when they get older” (Inaba & Cohen, 2014, p. 3.31).

“Congers” & Serotonin

Preston, et al, (2010) note that the effects of stimulants for ADHD only last “for a short period of time…[therefore] co-administration of antidepressants may be an option” (p. 257). SSRI’s like Wellbutrin, block the reuptake of Serotonin by the neurotransmitters and increase its activity in the brain. Our textbook notes this provides a useful “calming effect on those with ADHD” (Inaba & Cohen, 2014, p. 3.30).

Notable Controversies

Finally, our textbook provides several notable controversies surrounding ADHD and its treatment. Firstly, since no explicit diagnostic testing exists, controversy exist surrounding the accuracy of diagnosis in light of an epidemic rise of this issue in recent years (Inaba & Cohen, 2014). Secondly, controversy remains surrounding the pharmacological treatment of this disorder. In particular, stimulants have unknown long-term effects on children, and are associated with an increase risk of psychosis and mania (Inaba & Cohen, 2014).

 

Accurate Diagnosis

For accurate diagnosis, it is firstly important that they reach a level of clinical significance and exist a normal developmental range (American Psychiatric Association, 2013; Orvashel, et al, 2001). In order to assess this diagnostic factor accurately, it will be important for the therapist to have a knowledge of childhood development is important.   It is also worth noting that the DSM-5 manual requires these symptoms be present prior to the age of 12 (American Psychiatric Association, 2013, p61). Therefore, an understanding of childhood development up through the age of twelve is critical.

A second consideration involves a confirmation that these symptoms exist across several settings (American Psychiatric Association, 2013). In order to assess for this factor, it will be important to gather collaborative information from the child’s home and school environment.   In addition to interviewing teachers and parents, it will also be useful to examine the child’s school records. What is the home environment like? How do they describe family interactions? Is there a family history of psychiatric illness?   Regarding the child’s academic history, is there a learning disability or history of underachievement? How is the child interacting with peers? How have the child’s peer interactions influenced their overall self-esteem?

Finally, Orvashel, et al, (2001), state that this disorder rarely exists without a co-morbid diagnosis.   For example while 1/3 of all ADHD cases coincide with anxiety or depression, another ½ of all ADHD cases coincide with ODD or CD (Orvashel, et al, 2001).   It is also important to note that antisocial problems and substance abuse are frequent responses to prolonged levels of peer rejection. Additionally, individuals with ADHD often present with a learning disability, as a result of ADHD symptoms. It is at this point, at which diagnosis becomes quite complex. It will be important to carefully observe the client’s history of presenting symptoms to understand their underlying patterns.

The Over-diagnosis of ADHD

Attention Deficit Hyperactivity Disorder, (ADHD) is defined as a “persistent pattern of inattention and hyperactivity-impulsivity that interferes with functioning or development” (American Psychiatric Association, 2013, p59). The DSM-5 maintains the same symptomatic categories for ADHD (American Psychiatric Association, 2013). Nonetheless, the definition of these symptoms is expanded to include a list of examples on how they present in clientele (American Psychiatric Association, 2013). Other notable changes, include diagnostic criterion for adults with ADHD as well as an extensive list of differential diagnoses (American Psychiatric Association, 2013). This paper addresses public criticism regarding the over-diagnosis of ADHD.   Research at the heart of this controversy is reviewed.

The Origin of Controversy

LeFever’s Epidemiological Findings

This paper reviews research by Gretchen LeFever, a psychologist in southeastern Virginia, who noted high rates of ADHD diagnosis and drug treatment in her community (Watson, et al, 2014). Utilizing a pool of 29,734 children, LeFever discovered that just fewer than 10% of children in southeastern Virginia were being medicated for ADHD (Watson, et al, 2014). Additionally, 19% of all children in grades one through five were diagnosed with ADHD and 84% from this group were taking medication for the disorder (Watson, et al, 2014). LeFever also noted that a majority of participants were the youngest in their class. (Watson, et al, 2014)   This indicated to her, an underlying difficulty in distinguishing ADHD from normal development (Watson, et al, 2014).  Finally, LeFever’s research provided evidence that drug treatment alone was largely ineffective for study participants, (Watson, et al, 2014, p44). Published in the American Journal of Public Health during the mid 90’s, this study drew massive media attention (Watson, et al, 2014).

LeFever’s SHINE Program

On the basis of LeFever’s research results, she felt the problem was twofold.   Firstly, measures were needed to improve the identification of children with ADHD (Watson, et al, 2014).   Secondly, LeFever believed it was important to expand the treatment approach to ADHD, beyond the utilization of drug treatment regimens (Watson, et al, 2014).   In an effort to address these issues, she developed the School Health Initiative for Education (SHINE) program (Watson, et al, 2014). Receiving local, state, and federal support, the SHINE program addressed four key issues: “(1) systematic behavior management, (2) school-provider communication, (3) teacher training and education, and (4) parent training and support” (Watson, et al, 2014), p44). The SHINE program instituted community wide interventions including teacher training, parenting classes, as well as training for clinicians to accurately diagnose the disorder (Watson, et al, 2014). As a result of these efforts, a 32% decrease in ADHD diagnosis was seen in southeastern Virginia between 1998 and 2004 (Watson, et al, 2014). Participants also displayed improvements in academic performance.

Allegations of Scientific Misconduct

In 2004, LeFever received an anonymous allegation of scientific misconduct that questioned the legitimacy of her research (Watson, et al, 2014).   These allegations claimed she reported inflated rates of ADHD prevalence in order to support an anti-medication agenda (Watson, et al, 2014). Although LeFever was eventually cleared of all charges, the effects of this allegation were long lasting. Immediate consequences included an immediate end to the SHINE program as well as any ongoing research efforts (Watson, et al, 2014).   Long-term consequences included a career derailment, threatened firing, and public scrutiny (Watson, et al, 2014). In retrospect, Watson, et al, (2014) describe these attacks as “orchestrated” (p45) efforts on the part individuals with vested interests in the pharmaceutical industry. One individual, specifically mentioned in this claim is Russell Barkley, PhD., (her most vocal critic). While it is impossible to verify this, it is clear the heated debate resulting from these events is ongoing (Barkley, et al, 2004; Watson, et al, 2014).

A Heated Debate

Lefever’s Criticism

In the years since LeFever’s work was shut down, the CDC has reported a continual rise in the diagnosis of ADHD (Watson, et al, 2014).   As a result of this continual rise, today “14% of American children are being diagnosed before reaching adulthood” (Watson, et al, 2014, p43). Additionally, Watson, et al, (2014) provide alarming statistics on the rise of antipsychotics and antidepressants as a treatment regiment for ADHD. Finally, although LeFever, (now Mrs. Watson), appears to deny an anti-drug agenda, her criticism centers on this argument (Watson, et al, 2014).   For example, this article concludes with a citation of evidence from the National Institutes of Health on the ineffectiveness of drug treatments (Watson, et al, 2014).   With this evidence in mind, she strongly encourages scientists to “address the inflation of benefits of drug therapies and the minimization of risks” (Watson, et al, 2014, p52).

Barkley’s Support

In a desire to hear the other side of the story, I uncovered an article by LeFever’s strongest critic (Barkley, et al, 2004). In this article, Barkley responds to LeFever’s allegations that his actions represented an agenda to promote drug treatments (Barkley, et al, 2004). Barkley states that in addition to misconstruing his motives, critics such as LeFever are guilty of misrepresenting evidence (Barkley, et al, 2004). Critical of the standards they utilize in their arguments regarding ADHD, Barkley, et al, (2004) state the following: “To them genuine disorders: (1) cannot exist without some “medical test” being available for their diagnosis; (2) cannot change in having their defining features revised or improved upon across their history; (3) cannot vary in prevalence across segments of society, countries, or geographic regions; (4) cannot have other disorders coexist with them (comorbidity); (5) must have a distinct and specific neurobiological lesion identifiable as their etiology; and (6) cannot have heritability or other contributing factors that may overlap with other disorders” (p66).

Conclusions

After completing this assignment, I am unsure what to feel about the issue. The arguments presented from both articles have strong points worthy of consideration. The biggest lesson is the importance of objectivity and the scientific method as discussed in the DSM-5. It is important for researchers and clinicians to set aside any agendas in search of the truth.

PART #2: The second portion of this post will consists of some pragmatic research I’m doing to formulate a realistic treatment for a child with ADHD….
 

Addressing symptoms of Inattention

A Behavioral Description of Inattention…

  1. “Short attention span; difficulty sustaining attention on a consistent basis.
  2. Susceptibility to distraction by extraneous stimuli and internal thoughts.
  3. Gives impression that he/she is not listening well.
  4. Repeated failure to follow through on instructions or complete school assignments or chores in a timely manner.
  5. Poor organizational skills as demonstrated by forgetfulness, inattention to details, and losing things necessary (Jongsma, et al, 2014, p. 74)”

Treatment Plan Goal Ideas…

Where I work, we must first write the client’s goals in their own words. Then we must include a deadline for this goal.  Finally, we need to include what specific evidence to look for as proof that this goal is met.  My way of conceptualizing this process is to first simply ask the client what they wish to achieve in therapy.  Then, with the diagnosis and IDI information in mind, I need to develop a DSM-5 based description of the client’s goal in the evidenced by section.  What follows is a listing of ADHD-relevant treatment goals I’ve found., as time progresses, I will include examples of how client describes these goals in their own words…

  1. “Client will be able to sustain attention and concentration for consistently longer periods of time by (Date) as demonstrated by an increase frequency of completion of school assignments, chores, and household responsibilities.
  2. Better schoolwork (e.g., completing class work or homework ­assignments)
    More independence in self-care or homework (e.g., getting ready for school in the morning without supervision)

Addressing Symptoms of Hyperactivity & Impulsivity

A Behavioral Description of Hyperactivity & Impulsivity

  1. “Hyperactivity as evidenced by a high energy level, restlessness, difficulty sitting still, or loud or excessive talking.
  2. Impulsivity as evidenced by difficulty awaiting turn in group situations, blurting out answers to questions before the questions have been completed, and frequent intrusions into others’ personal business.
  3. Frequent disruptive aggressive attention seeking behavior
  4. Tendency to engage in carelessness or potentially dangerous activities.
  5. Difficulty accepting responsibility for actions, projecting blame for problems onto others, and failing to learn from experience.
  6. Low self-esteem and poor social skills (Jongsma, et al, 2014, p. 74)”

Treatment Plan Goal Ideas…

Where I work, we must first write the client’s goals in their own words. Then we must include a deadline for this goal.  Finally, we need to include what specific evidence to look for as proof that this goal is met.  My way of conceptualizing this process is to first simply ask the client what they wish to achieve in therapy.  Then, with the diagnosis and IDI information in mind, I need to develop a DSM-5 based description of the client’s goal in the evidenced by section.  What follows is a listing of ADHD-relevant treatment goals I’ve found., as time progresses, I will include examples of how client describes these goals in their own words…

Hyperactivity & Impulsivity Goals…
  1. Client will be able to develop positive social skills to help maintain lasting peer friendships by (Date) by increasing the frequency of socially appropriate behaviors with peers.
  2. Client will be able to identify stressors or painful emotions that trigger increase in hyperactivity and impulsivity by (Date) by exploring and identifying stressful events or factors that contribute to and increase in impulsivity.
  3. Client’s parents/teachers’ will set firm, consistent limits, and maintain appropriate parent-child boundaries by (Date) implementing parenting techniques and approaches in which parents utilize reward/punishment system, contingency contract, and/or token economy.
Impulsivity Goals…
  1. The  Client will be able to demonstrate marked improvement in impulse control by (Date) by identifying and listing constructive ways to utilize energy.
  2. The client will increase on task behaviors by March 1, 2010 as demonstrated by the completion of homework and chores daily.
  3. The client will decrease the motor activity by March 1, 2010 as demonstrated by the client being able to remain in their seat for longer periods of time.
  4. The client will reduce the severity of temper tantrums by March 1, 2010 as demonstrated by the client not using any physically aggressive acts.
  5. The client’s parents will set firm and consistent limits for the client by March 1, 2010 as demonstrated by the family setting up a behavior reward chart and using it for 4 weeks consistently.
  6. The client’s parents or teacher will use a reward system by March 1, 2010 as demonstrated by them completing the system and using it daily.
  7. The client will improve their self esteem by March 1, 2010 as demonstrated by the client making 3 positive statements about themselves a day.
  8. The client will maintain lasting peer relationships by March 1, 2010 as demonstrated by journaling and playing with the same kid 3 out of 5 school days a week.
  9. The client will demonstrate improvement in impulse control by March 1, 2010 as demonstrated by decrease in negative attention seeking behaviors and the elimination of physically aggressive behaviors.

References

American Psychiatric Association, (2013). Diagnostic and statistical manual of mental  disorders, (5th ed, ). Washington DC: American Psychiatric Association.
Barkley, R.A. (2004). Critique or misrepresentation? A reply to timimi et al. Clinical Child and Family Psychology Review, 7(1), 65-69. Doi: 10.1023/B:CCFP.0000020193.4817.30
Inaba, D.S. & Cohen, W.E. (2014). Uppers, downers, all-arounders. Ashland, OR: Cimed.
Jongsma, A. E., Peterson, L. M., & McInnis, W. P. (2014). The child and adolescent psychotherapy treatment planner. New York: Wiley.
Orvaschel, H., Faust, J., & Hersen, M. (Eds.). (2001). Handbook of conceptualization and treatment of child psychopathology. Oxford, UL: Elsevier LTD.
Preston, J., O’Neal, J. H., & Talaga, M. C. (2010). Handbook of clinical psychopharmacology for therapists. New Harbinger Publications.
Watson, G.L, Arcona, A.P., Antonuccio, D.O., & Healy, D. (2014). Shooting the messenger: The case of ADHD. Journal of Contemporary Psychotherapy, 44(1), 43-52. doi: 10.1007/s10879-013-9244-x.

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