ADHD, or attention deficit hyperactivity disorder, is a common childhood problem affecting as much as 3-5% of the school-age population. The core symptoms of ADHD are inattention, hyperactivity and impulsivity. Children with ADHD exhibit functional impairment across multiple settings and engage in disruptive behaviors, thus inviting criticism from adults and peer rejection. Psycho stimulant medication has been shown to be reasonably successful, but may produce significant side effects in a school-age child. A multi-component model of intervention consisting of pharmacological treatment in consonance with contingency management and cognitive behavior modification techniques seems to be the answer for this very baffling problem. For practitioners to have confidence in the expected outcomes, specific procedures to implement behavioral management in school classrooms must be scientifically replicated.
What is ADHD?
Impact of ADHD
Related Disorders and Comorbidity
Review of literature
Findings and results
Conclusions and summary
Overview of ADHD
What is ADHD? ADHD, or attention deficit hyperactivity disorder, is a common childhood problem. It is estimated that ADHD affects 3-5% of the school-age population, which means that as many as 3.5 million children could be affected nationwide.
ADHD is not a defined biological entity, but a collection of related symptoms and behaviors that interfere with an individual's capacity to regulate activity level (hyperactivity), inhibit behavior (impulsivity), and attend to tasks (inattention) in ways that are developmentally appropriate. The core symptoms of ADHD include a proneness to being easily distracted, an inability to sustain attention and concentration, inappropriate levels of activity, and impulsivity.
Children with ADHD often fail to pay close attention to details or make careless mistakes in schoolwork. They are unable to follow through on instructions and fail to complete tasks on time, do not seem to listen when spoken to directly, and have difficulty organizing tasks and activities. They often avoid tasks that require sustained mental effort. Further, a child with ADHD often loses things needed for home or school, is easily distracted, and is often forgetful. Hyperactive behavior includes inability to sit still, and thereby fidgeting or squirming when sitting, talking out of turn, and the like. Thus, children having ADHD
Overview of ADHD exhibit functional impairment across multiple settings, which include the home, the school, and peer relationships.
According to Barkley (1997), behavioral inhibition is the main underlying component of ADHD. This impairment negatively influences nonverbal working memory, internalization of speech, self-regulation of affect/motivation / arousal, and analysis-synthesis processes.
Impact of ADHD. Besides long-term adverse effects on academic and vocational performance, ADHD has been observed to negatively impact social-emotional development. The academic and social difficulties experienced by individuals with ADHD have far-reaching consequences. Interestingly, the core symptoms of ADHD such as inattention, hyperactivity and impulsivity are traits also seen in children unaffected by ADHD. Such a study can however be meaningful only when comparison is made between children at the same developmental level. For example, while it is perfectly normal for an active three-year to be impulsive or to interrupt others, similar behavior by an eight-year-old would be a cause for concern.
Diagnostic standards. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition; DSM-IV (1997), American Psychological Association, lists the essential steps in diagnosing ADHD. The diagnosis of ADHD must be based on a number of observations
Overview of ADHD since no validated diagnostic text exists to confirm the clinical diagnosis of the disorder. Typically, parents and teachers complete questionnaires, children are observed at home and at school, psychological tests are administered, and a clinical interview of the child and the family is conducted.
The Conners Teacher's Rating Scale (CTRS), developed in 1969, is a behavioral rating scale that has been used extensively as an assessment tool in the identification of ADHD.
ADHD is also exhibited in forms where all the components of attention-deficit or hyperactive behavior may not be present. In the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychological Association, 1980), two distinct diagnostic categories were used to distinguish inattentive behavior that occurred on its own (Attention Deficit Disorder without Hyperactivity; ADD/WO) from such behavior that occurred with overactivity (Attention Deficit Disorder with Hyperactivity; ADD/H).
The distinction between the two disorders was dropped in next revision of the manual, the DSM-III-R (APA, 1987), in which all three symptoms were subsumed into one category of Attention Deficit Hyperactivity Disorder (ADHD). A residual category, Undifferentiated Attention Deficit Disorder (UADD), was included in the DSM-III-R for children who exhibit pure inattentive behavior.
Overview of ADHD
The DSM-IV (APA, 1994) differentiates three subtypes within ADHD. The first subtype encompasses inattention, overactivity, and impulsiveness (ADHD-COM, combined subtype). The second subtype is characterized by the presence of inattentive behavior without hyperactivity or impulsiveness (ADHD-I; predominantly inattentive subtype). The third subtype is distinguished by symptoms of hyperactivity and impulsivity in the context of appropriate attentive behaviors (ADHD-HI, predominantly hyperactive-impulsive subtype).
Related Disorders and Comorbidity. There has been increasing awareness that children and adults having AD/HD often experience other difficulties and may meet criteria for one or more other psychiatric diagnoses. Comorbidity means having two or more diagnosable conditions at the same time.
Other psychiatric disorders comorbid with ADHD may mask or complicate the process of diagnosis and treatment. Disorders of depression, anxiety, learning disability, substance abuse, aggression and behavior disorders, and sleep disorders, have all been reported to occur in persons with ADD. Close biological relatives of children with ADHD are far more likely to have ADHD and other comorbid disorders mentioned above, than relatives of children without ADHD, a clear sign of the heritable nature of the disorder.
Comorbidity may also arise from the stresses and strains of having to live with ADHD. Many people with ADHD experience intense frustration in their efforts to learn, to work, and to get along with other people from their early years. They suffer ongoing criticism from teachers, parents, and peers. Years of such chronic sustained frustration may produce disorders that are comorbid to the ADHD. Other disorders may similarly develop reactively.
Review of Articles.
The present study is a review of 35 Primary Peer Reviewed Ulrich's referenced journal articles written within the last 5 years. Some of the articles reviewed relate to the question of the efficacy of a multi-component program in the treatment of ADHD; a few of the articles
Overview of ADHD examine the exclusive use of medication as a way to treat children with symptoms of ADHD, and raise the question of the ethics of subjecting school-age and preschool-age children to medication; disorders comorbid to ADHD, their diagnoses and treatment are also covered in some of the articles.
Multi-component intervention. In a study on the effectiveness of a multi-component intervention program for the children with ADHD (Miranda, Jesus & Soriano, 2002), the objective was to evaluate the efficacy of such an intervention program for treating ADHD.
Fifty children with ADHD participated in the study. The program was conducted by teachers in natural settings without disruption of the ongoing class routine. The teachers of 29 of the 50 students were trained in the use of behavior modification techniques, cognitive behavior strategies, and instructional management strategies. The other 21 students formed the control group. After the implementation of the program, parents observed that there were significant improvements in attention-related difficulties as also in behavioral problems. The results also showed increased academic scores, and enhanced classroom behaviors. The parents of the control group also perceived improvement on some internalizing problems, such as somatic problems and psychopathological disorders.
Overview of ADHD
Importantly, teachers perceived a reduction in hyperactive / impulsive behaviors and a significant increase in self-control. Considerable reduction in the disruptive behavior of these students in the classroom was also observed. The program increased the academic performance in mathematics and natural sciences of students in the experimental group, and was also effective in increasing the teachers' knowledge about how to respond to the educational needs of children with ADHD.
In a similar approach, the author (Reis, 2002), of an article entitled Attention Deficit Hyperactivity Disorder: Implications for the Classroom Teacher, has outlined several strategies for teachers to adopt towards students with ADHD. The strategies are based on the lines of contingency management and cognitive behavior management techniques, and can serve as a set of tools to help children with ADHD achieve better classroom performance.
Positive reinforcement. A student with ADHD is given to indulging in distracting behavior in the classroom, such as the clicking of a pen or the bending of a paper clip, as also to talking out of turn. The common approach of teachers is to meet such behavior with sternness or recrimination. When it was suggested that they try a new approach using positive verbal reinforcement…