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Attention Deficit Activity Disorder (ADHD) is a heterogeneous disorder as there are three subtypes of the disorder that can present quite differently (American Psychiatric Association [APA], 2000). Moreover, the symptoms must occur before the age of seven years old (thus the so-called adult ADHD is NOT ADHD unless that criteria was present early). As a rule then, a child should not be diagnosed with ADHD unless the main symptoms of the disorder have been present early in life and these symptoms create significant problems in at least TWO different environments (e.g., at home and at school). Children who are diagnosed with ADHD have been symptomatic for a relatively long period of time (diagnostic criteria state for at least six months). These children often exhibit difficulties during stressful and mentally demanding situations or during activities that command sustained attention. Typically children with ADHD will exhibit difficulties with reading (loner passages), performing math or arithmetic problems, or playing certain games such as board games (surprisingly they may do well at video games as many of these games involve rapid shits of attention).
Contrary to what many believe, there is no specific medical test to diagnose ADHD. The assessment is accomplished by gathering information about the child's behavior from several different sources and there may even be formal psychological testing involved. In order to fulfill the diagnostic criteria for ADHD the child must meet the criteria that are listed in the Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM-IV-TR; APA, 2000). In order to be diagnosed with ADHD the child would need to have at least six symptoms from one of two categories below or six or symptoms from each of the two categories. The major categories are:
Inattention. The symptoms here have to do with attentional difficulties such as: the child often fails to give close attention to details or makes careless mistakes in schoolwork and other activities, often exhibits difficulty sustaining attention in tasks or play activities; does not often appear to listen when spoken to directly; does not often follow through on instructions and fails to finish schoolwork or chores (this is not due to oppositional behavior or due to a failure to understand directions/instructions); often experiences difficulty organizing tasks and activities; regularly avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework); frequently loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books); Is habitually easily distracted; frequently is forgetful in daily activities.
Hyperactivity and impulsivity. These are the behavioral features of ADHD that often receive the most attention from parents and teachers. These features include the child: frequently fidgeting with hands or feet or squirms in seat; repeatedly leaving seat in classroom or in other situations in which remaining seated is expected; regularly runs about or climbs excessively in situations in which it is inappropriate; habitually has difficulty playing or engaging in leisure activities quietly; regularly "on the go" often acting as if "driven by a motor"; habitually talks excessively; frequently blurts out answers before questions are completed; regularly exhibits difficulty awaiting turn; frequently interrupts or intrudes on others.
As stated above in addition to having at least six of the aforementioned symptoms the child: (1) has displayed inattentive and/or hyperactive-impulsive symptoms that lead to functional impairment before the age of seven, (2) displays behaviors that are not considered normal for children the same age without ADHD; and (3) symptoms have been present for at least six months; (4) symptoms affect the child's functioning in more than one setting.
The symptom presentation can lead to the child diagnosed with one of the three subtypes of ADHD in order to target the predominant problems. These subtypes are:
1. ADHD predominantly inattentive-type: Many people wrongly refer to this as ADD, but the DSM-IV does not recognize ADD as a separate disorder (outside of lay terminology ADD does not exist). Instead a child with this subtype of ADHD has at least six symptoms from the inattention category sand few from the hyperactivity/impulsivity category.
2. ADHD predominantly hyperactive-impulsive-type: Here the child has at least six symptoms from the hyperactivity and impulsivity category and few inattentive symptoms.
3. ADHD combined type: The child has six or more symptoms from each of the two categories.
The prevalence rate of ADHD is estimated at between five and eight percent of all U.S. children (boys are nearly two times as likely as girls to receive the diagnosis; APA, 2000). However, APA is most likely one of the most overly diagnosed disorders in children as well due to physicians not considering the diagnostic criteria for the disorder and being too willing to place problem-children on medications at the first complaint. The diagnosis should be accomplished by a multi-disciplinary team that includes a pediatrician, pediatric psychiatrist, and pediatric psychologist. A combination of a thorough medical examination, history, observational data, parent/teacher observations and surveys, and psychometric testing should lead the diagnostic impressions (Sadock & Sadock, 2007).
ADHD should really only be formally diagnosed by a physician (the team makes the recommendation) as there are several medical conditions or medical treatments that may produce symptoms similar to those of ADHD. These include: learning disabilities, language problems, problems with vision or hearing, depression or other mood disorders, anxiety disorders, sleep disorders, seizure disorders, Tourette's syndrome, thyroid medications, food allergies, and others.
Treatment for ADHD falls into two categories: Pharmacological and behavioral treatment. They work better in tandem.
Pharmacological treatments for ADHD include medications like Ritalin, Adderall, Strattera and others. Most of these like Ritalin and Adderall are stimulant medications. The hypothesis behind these medications is that the brain of the ADHD child in "underaroused" so the child self-medicates by maintaining high levels of activity and shifting attention. The stimulant effect normalizes brain functioning and the child's behavior normalizes (Sadock & Sadock, 2007). That is probably why these medications work better for hyperactivity and impulsivity and not as well for attentional issues only.
The only non-stimulant medication approved by the FDA for the treatment of ADHD is Strattera, which has shown to be effective in treating inattention. Other medications may be used such as antidepressants, but these are not approved for the treatment of ADHD specifically. The major drawback to medications is their potential side-effect profile which can range from sleeplessness to anxiety, Obsessive Compulsive disorder, psychosis, or Tourette-disorder like symptoms (Sadock and Sadock, 2007). Side-effects are the main reason many psychotropic medications are discontinued. Moreover, often the response to a side-effect by a physician is to add another medication which can result in overly medicated children.
Behavioral treatments have been empirically demonstrated to be effective with treating ADHD children, but require an investment of time and energy on the part of parents, teachers, and others. Some of the more effective treatments for school include:
The Daily Report Card (DRC): The DRC is an empirically supported intervention wherein specific behavioral goals are set for the child in the classroom and the child is rewarded in class with positive reinforcement and at home based on their realization of those goals (O'Leary, Pelham, Rosenbaum, & Price, 1976). The goals are set at an attainable but still challenging level and can be made increasingly difficult (at the child's pace) until the child's behavior is within developmentally acceptable levels. These programs are based on the shaping principle of behavioral psychology. Parents get daily feedback regarding the child's behavior and progress towards their goals and this allows parents to provide reinforcement for attained objectives. The goals, frequency of feedback, and reinforcement are based on the developmental level of the child (Pelham, et al., 2004). Typically younger or impulsive children may need fewer goals and more frequent feedback and frequent reinforcement. The beneficial effects of DRC on improving behaviors in ADHD children are well-documented (Fabiano & Pelham, 2003; O'Leary et al., 1976).
Social Skills Training: Interpersonal difficulties are prevalent in children with an ADHD diagnosis. Children with hyperactivity, aggression, or noncompliance are rated negatively by their peers and are more likely to be rejected by them (Hinshaw & Melnick, 1995). Poor peer relationships predict long-term negative outcomes for these children. Consequently, improving social skills can be an important goal of a comprehensive treatment program for ADHD. Social skills training is a technique that aims at developing and reinforcing the use of appropriate social skills both in and out of the classroom. This includes improving communication skills, learning cooperation and participation in groups, and validation skills (Kavale, Forness, & Walker, 1999). Combining parental training with social skills training improves the effectiveness of a social skills training program in school.
Behaviorally-based classroom interventions target issues such as engagement in classroom tasks and disrupting behaviors. Academic interventions for children with ADHD concentrate on improving both behavioral and academic issues. Some of these are:
Task and instructional modifications: These methods involve procedures such as reducing the length of a task either by breaking it up or cutting steps (e.g., dividing long assignments into smaller units),…[continue]
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