Attention Deficit HyperactivITY Disorder (ADHD)

Attention Deficit Hyperactivity Disorder

Theories of child development and guidelines for parents are not cast in stone.

They are constantly changing and adapting to new information and new pressures.

There is no "right" way, just as there are no magic incantations that will always painlessly resolve a child's problems."

Lawrence Kutner (20th century) (Columbia, 1996)

Students Like C.J.

Something has to be done. C.J. cannot sit still.... His constant roaming around in the classroom disrupts the other students." Parents of ADHD students like C.J. frequently hear teachers' accounts similar to the one introducing this study. Student's like C.J. traditionally experience problems in school as rules, regulations and routines regularly require they remain seated at their desk, pay attention and focus on assignments and lessons. Some of these students "may receive some assistance from special education teachers who typically have smaller classes and who rely on the use of behavioral techniques in managing students. However, between 85% and 90% of ADHD students are still served in general education classrooms for all or part of the day (Montague & Wagner, 1997; cited by Webb and Myrick, 2003)

As a large number of students in a classroom simultaneously require a teacher's attention, teachers of students like C.J. may not know the "right" way to work with ADHD students. Teachers, as well as parents of children with ADHD, not only need training to help ensure children with ADHD develop to their best potentials, they also need information and support to help them and the ADHD child resolve related problems as painlessly as possible.

Diagnostic Label Attention deficit hyperactivity disorder (ADHD), a diagnostic label, identifies individuals with "developmentally inappropriate levels of inattention, hyperactivity, and impulsivity." (Webb and Myrick, 2003) Individuals with ADHD experience challenges completing routine tasks or concentrate for an extended period of time. They frequently fidget and have difficulty inhibiting behaviors that can distract others. An estimated 3% to 5% of the school age population has ADHD (American Psychiatric Association, 1994; cited by Webb and Myrick, 2003) with boys outnumbering girls. (Kauffman, 1993; Barkley, 1990; cited by Webb and Myrick, 2003) it is one of the most commonly diagnosed and studied disorders among children, and it is receiving increased attention by school administrators, teachers, and counselors. (Barkley, 1998; Shaywitz & Shaywitz, 1992; cited by Webb and Myrick, 2003) More than 100 Years Ago ADHD, as conceptualized today, does not constitute a new condition. More than 100 years ago, in three consecutive issues in the Lancet in 1902, Dr. Still described children displaying syndrome symptom, similar to the way researchers identify ADHD today.

When Dr. Still lectured to the Royal College of Physicians, he described children who "had an inhibition of the will....were not able to control themselves...not able to partake effectively as members of a group...seemed to have a moral defect and their defect...could not conform and be a contributing, supportive part of the group effort." (Prince, 1994-2008) Although the symptoms these children displayed, resembled challenges children with obvious brain injuries portrayed, neither the children nor the families of these children came from families with no apparent brain injuries. Consequently, two initial terminologies, "minimal brain disease" and "minimal brain dysfunction" evolved. Along with noting tics or "microkinesias," in these children, Dr. Still found they performed considerably better when working in smaller settings. He discovered that children experiencing traits resembling today's ADHD usually had someone else in the family also afflicted; that this problem ran in families, yet the affected children were primarily from "moral families." Numerous fathers of these children were reportedly 'smitten with' legal troubles; with alcoholism. Mothers were noted to be depressed more often than mothers of children who did not suffer from this malady and were prone to revealing struggles with suicidal ideations. Dr. Still initially described children displaying ADHD symptoms in England around 1900.

Basically, Dr. Still recognized and described the syndrome diagnosed today as ADHD more than100 years ago. The following figure (1) portrays a photo of Dr. Still.

Figure 1: Dr. George Still (Prince, 1994-2008)

In Time... In the 1930s, Benzedrine, a racemic mixture of dextro and levoamphetamine, sold over-the-counter to treat allergies and reactive airway disease became known as "the arithmetic pill," after children, initially given this drug for headaches related to a medical procedure, were noted to be able to complete their math problems better. One challenge test administered by physicians at this time involved giving Benzedrine to children displaying ADHD symptoms. If the child completed his/her math better, he/she was diagnosed as having minimal brain disease, and was put into this type treatment. If the child's math solving ability did not improve, he/she was sent into a different type of treatment. (Prince, 1994-2008)

Bradley and his colleagues wrote a series of articles over a long period of time looking at these treatments. It was met with skepticism at the time, much like today, but it was quite helpful. They first reported their findings in a study in the American Journal of Psychiatry in 1937. Decades later, methylphenidate was created in Switzerland as an alternative to the amphetamine.

Understanding of the condition evolved over the next few decades -- from minimal brain disease to minimal brain dysfunction. In the mid 1960s, Sam Clements, in a meeting for the Easter Seals, listed the different signs and symptoms of the condition, and noted that attention was a primary deficit. Up until that time, hyperkinesis had been the focus.

Later, these ideas were incorporated into the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), where...[physicians; psychiatrists; psychologists; mental health professionals] were able to diagnose patients with attention deficit disorder (ADD) with or without hyperactivity. This is evolved in the DSM-III-R, and now the DSM-IV-TR (Fourth Edition, Text Revision), into ADHD. Although in the 1930s someone's response to a stimulant was thought of as diagnostic, that is certainly no longer the case. (Prince, 1994-2008)

The following figure (2) denotes a timeline depicts milestones related to ADHD.

Figure 2: ADHD Historical Timeline (Prince, 1994-2008; Writing Matters, 2008)

Contemporary Consensus Regarding Diagnosis of ADHD

Clinical Presentation ADHD in School-Aged Child (6-12 Years Old):

May have a sense of inner restlessness (rather than hyperactivity)

School work disorganized and show support to follow-through; fails to work independently

Engaging and "risky" behaviors (speeding and driving mishaps)

Poor self-esteem

Poor peer relationships

Difficulty with authority figures (Prince, 1994-2008)

American Academy of Pediatrics: Guidelines for ADHD Assessment

The American Academy of Pediatrics relates the following guidelines for the diagnosis and evaluation of the tile with attention deficit hyperactive disorder.

Evaluate children (age 6 to 12 years) the exhibit the following:

Inattention

Hyperactivity

Impulsivity

Academic underachievement

Behavioral problems

DSM-IV criteria

Evidence from parents/caretakers in teachers/school officials of core symptoms of ADHD in school, home, and social settings

Assessment for co-existing conditions

Other diagnostic test are not routinely indicated (AAP. Clinical practice guidelines: diagnoses an evaluation of the child with attention deficit hyperactivity disorder. Pediatrics. 2000; 105:1158 -1170; cited by Prince, 1994-2008)

Diagnosis of ADHD DSM-IV- TR Criteria

Symptoms of inattention or impulsivity/hyperactivity (hyperactivity is not required for a diagnosis)" have persisted for more than six months are more frequent and severe than is typical of the individuals level of development have onset prior to age seven cause some impairment in two or more settings

Cause significant impairment in social, academic, or occupational functioning are not better accounted for by another mental disorder (Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, Text Revision, 2000; cited by Prince, 1994-2008)

Three primary types of ADHD have been identified and include:

ADHD Combined Type, the most common type ADHD, approximately 80%, is indicated with symptoms of impulsivity/hyperactivity, along with inattention.

ADHD Predominantly Inattentive Type, the second most common, is indicated when patients display symptoms of inattention without hyperactivity/impulsivity.

ADHD Predominantly Hyperactive/Impulsive Type, noted as the least understand type, predominantly occurs in preschool children. (Prince, 1994-2008)

The following figure (3) depicts the three primary types of ADHD currently diagnosed:

Figure 3: Three Primary Types of ADHD (Prince, 1994-2008)

The following depicts the SNAP-IV Teacher and Parent Rating Scale, developed by James M. Swanson, Ph.D.

The SNAP-IV Teacher and Parent Rating Scale

James M. Swanson, Ph.D., University of California, Irvine, CA 92715

Gender:

Age: ____ Grade:

Ethnicity (circle one which best applies): African-American Asian Caucasian Hispanic

Other

Completed by:____ Type of Class:

Class size:

For each item, check the column which best describes this child:

Not at Just a Quite

Bit

Much

1. Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks

2. Often has difficulty sustaining attention in tasks or play activities

3. Often does not seem to listen when spoken to directly

4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort

7. Often loses things necessary for activities (e.g., toys, school assignments, pencils, or books)

8. Often is distracted by extraneous stimuli

9. Often is forgetful in daily activities

10. Often has difficulty maintaining alertness, orienting to requests, or executing directions

11. Often fidgets with hands or feet or squirms in seat

12. Often leaves seat in classroom or in other situations in which remaining seated is expected

13. Often runs about or climbs excessively in situations in which it is inappropriate

14. Often has difficulty playing or engaging in leisure activities quietly

15. Often is "on the go" or often acts as if "driven by a motor"

16. Often talks excessively

17. Often blurts out answers before questions have been completed

18. Often has difficulty awaiting turn

19. Often interrupts or intrudes on others (e.g., butts into conversations/games)

20. Often has difficulty sitting still, being quiet,... inhibiting impulses in...classroom or at home

21. Often loses temper

22. Often argues with adults

23. Often actively defies or refuses adult requests or rules

24. Often deliberately does things that annoy other people

25. Often blames others for his or her mistakes or misbehavior

26. Often touchy or easily annoyed by others

27 Often is angry and resentful

28. Often is spiteful or vindictive

29. Often is quarrelsome

30. Often is negative, defiant, disobedient, or hostile toward authority figures

31. Often makes noises (e.g., humming or odd sounds)

32. Often is excitable, impulsive

33. Often cries easily

34. Often is uncooperative

35. Often acts "smart"

36. Often is restless or overactive

37. Often disturbs other children

38. Often changes mood quickly and drastically

39. Often easily frustrated if demand are not met immediately

40. Often teases other children and interferes with their activities

Check the column which best describes this child: Not at Just a Quite Very

Bit Much

41. Often is aggressive to other children (e.g., picks fights or bullies)

42. Often is destructive with property of others (e.g., vandalism)

43. Often is deceitful (e.g., steals, lies, forges, copies the work of others, or "cons" others)

44. Often and seriously violates rules (e.g....truant, runs away, or completely ignores class rules)

45. Has persistent pattern of violating the basic rights of others or major societal norms

46. Has episodes of failure to resist aggressive impulses (to assault others or to destroy property)

47. Has motor or verbal tics (sudden, rapid, recurrent, nonrhythmic motor or verbal activity)

48. Has repetitive motor behavior (e.g., hand waving, body rocking, or picking at skin)

49. Has obsessions (persistent and intrusive inappropriate ideas, thoughts, or impulses)

50. Has compulsions (repetitive behaviors or mental acts to reduce anxiety or distress)

51. Often is restless or seems keyed up or on edge

52. Often is easily fatigued

53. Often has difficulty concentrating (mind goes blank)

54. Often is irritable

55. Often has muscle tension

56. Often has excessive anxiety and worry (e.g., apprehensive expectation)

57. Often has daytime sleepiness (unintended sleeping in inappropriate situations)

58. Often has excessive emotionality and attention-seeking behavior

59. Often has need for undue admiration, grandiose behavior, or lack of empathy

60. Often has instability in relationships with others, reactive mood, and impulsivity

61 Sometimes for at least a week has inflated self-esteem or grandiosity

62. Sometimes for at least a week is more talkative than usual or seems pressured to keep talking

63. Sometimes for at least a week has flight of ideas or says that thoughts are racing

64. Sometimes for at least a week has elevated, expansive or euphoric mood

65. Sometimes for at least a week is excessively involved in pleasurable but risky activities

66. Sometimes for at least 2 weeks has depressed mood (sad, hopeless, discouraged)

67. Sometimes for at least 2 weeks has irritable or cranky mood (not just when frustrated)

68. Sometimes for at least 2 weeks has markedly diminished interest or pleasure in most activities

69. Sometimes for at least 2 weeks has psychomotor agitation (even more active than usual)

70. Sometimes for at least 2 weeks has psychomotor retardation (slowed down in most activities)

71. Sometimes for at least 2 weeks is fatigued or has loss of energy

72. Sometimes for at least 2 weeks has feelings of worthlessness or excessive, inappropriate guilt

73. Sometimes for at least 2 weeks has diminished ability to think or concentrate

74. Chronic low self-esteem most of the time for at least a year

75. Chronic poor concentration or difficulty making decisions most of the time for at least a year

76. Chronic feelings of hopelessness most of the time for at least a year

77. Currently is hypervigilant (overly watchful or alert) or has exaggerated startle response

78. Currently is irritable, has anger outbursts, or has difficulty concentrating

79. Currently has an emotional (e.g., nervous, worried, hopeless, tearful) response to stress

80. Currently has a behavioral (e.g., fighting, vandalism, truancy) response to stress

81. Has difficulty getting started on classroom assignments

82. Has difficulty staying on task for an entire classroom period

83. Has problems in completion of work on classroom assignments

84. Has problems in accuracy or neatness of written work in the classroom

85. Has difficulty attending to a group classroom activity or discussion

86. Has difficulty making transitions to the next topic or classroom period

87. Has problems in interactions with peers in the classroom

88. Has problems in interactions with staff (teacher or aide)

89. Has difficulty remaining quiet according to classroom rules ____ ____ ____ ____ 90. Has difficulty staying seated according to classroom rules

Swanson, N.d.; see Appendix B for "Scoring Instructions for the SNAP-IV-C Rating Scale")

Treatment Tactics

Antipsychotic Medicines the following excerpts from 2006 University Wire release relate critical concerns regarding treatment of ADHD with drugs.

The Daily Universe) (U-WIRE) PROVO, Utah -- Risks of serious injury and even death associated with stimulants to treat attention-deficit (hyperactivity) disorder merit stricter warning labels for those drugs, a federal panel said

The panel advised the Food and Drug Administration to add a "black box" warning to methylphenidates like Ritalin to emphasize potential cardiovascular problems the drugs could cause. Although the FDA doesn't need to heed the panel's advice, it often does.

The panel's announcement came after an FDA database search found 25 deaths -- including 19 children -- linked to the stimulants in the past five years.

Utah has the 10th lowest rate of ADHD diagnosis in the nation, but local pharmacists and psychiatrists still see plenty of cases in both children and adults.

According to the Utah Health Data Committee Web site, psychiatrists in Utah prescribed more than 1.7 million doses of methylphenidates in 2003. Ritalin, Concerta, Methylin and Metadate -- all candidates for the label change -- were prescribed most frequently.

Marianne Hawkins, a nurse at Utah Valley Regional Medical Center's outpatient psychology office, said the psychiatrists she works with try to avoid prescribing medication if at all possible.

ADHD occurs in people of all ages, but until 2001, only children were diagnosed. Hawkins said adults are rarely diagnosed and treated for ADHD in her office. She estimated about 97% of ADHD patients she worked with were children.

When a child is diagnosed with ADHD, psychiatrists meet with the child's parents to map out a behavior modification plan. This includes setting goals and counseling with the parents and child to reach those goals. Teachers are often involved, too.

If behavior therapy doesn't work, a psychiatrist will prescribe methylphenidates. Usually mixing behavior therapy with a low dose of the drugs is the best cure. Dosage tapers off as the child grows up until the drugs are no longer needed.

Ritalin, the most well-known methylphenidate, has been on the market since 1955. Laurie Ostroff-Landau, spokesperson for Ritalin's producer, Novaris, said extensive clinical trials were run before Ritalin hit the market 50 years ago. Research on its safety has continued since.

There are always going to be risks involved with medication," [Jim Averett, a pharmacist at the BYU Student Health Center,] said."You as the patient need to decide if the benefits outweigh the risks." (Cloward, 2006)

William Cooper, M.D., M.P.H., associate professor of Pediatrics in the Child and Adolescent Health Research Unit, a lead researcher at the Monroe Carell Jr. Children's Hospital at Vanderbilt, documents a disturbing trend that doctors currently prescribe "antipsychotic medicines for children with behavioral problems that are not defined as 'psychosis,' such as attention deficit hyperactivity disorder (ADHD)." ("Vanderbilt Children's Hospital Research" 2006) Cooper states the antipsychotic medications are particularly prescribed for boys with behavioral problems and ADHD.

The study, "Trends in Prescribing of Antipsychotic Medications for U.S. Children" was released today in the March-April issue of the journal Ambulatory Pediatrics. It documented that the overall frequency of antipsychotic prescribing in the U.S. increased fivefold -- from out of 1,000 U.S. children in 1995-1996 to 39.4 out of 1,000 children in 2001-2002. ("Vanderbilt Children's Hospital Research" 2006)

The following figure (4) depicts the increase in the number of children per 1000 prescribed antipsychotic drugs.

Figure 4: Increase of Prescribed Antipsychotic Drugs for Children ("Vanderbilt Children's Hospital Research" 2006)

Medication With Therapy Approximately two-thirds of parents (66) and teenagers (61) in the ADHD Teen & Parent survey conducted for the National Mental Health Association (NMHA) by Harris Interactive (supported through a grant from McNeil Consumer & Specialty Pharmaceuticals) report their treatment, consisting of medication, counseling and/or behavior therapy, and school services, contributed to higher self-esteem, improved social relationships and enhanced participation in extracurricular activities, as well as - better grades in school. "ADHD amplifies the issues that all teens grapple with, such as heavy demands at school, more complicated social situations, and a growing desire for independence," according to Michael Faenza (cited by "Parents and Teens Finally Agree on Something: ADHD Treatment Works," 2005, MSSW, President and CEO, National Mental Health Association (NMHA). Consequently, it proves critical for teens to receive the support and treatment they need.

Music Therapy Jackson (2003) posits that because occurrences of Attention Deficit Hyperactivity Disorder (ADHD) are reportedly, consistently increasing in the general population, I t has begun to receive more attention in professional circles, as well as, in the press.

As music therapists regularly work with preschool and school-age children, they will likely begin to treat more children with a diagnosis of ADHD.

Jackson (2003) notes, albeit, that a dearth of information music therapy literature exist regarding music therapy treatment for ADHD. Jackson's (2003) survey aims to ascertain: "what music therapy methods are being used for children with an ADHD diagnosis, how effective this treatment is perceived to be, and the role that music therapy treatment plays in relation to other forms of treatment." (Jackson 2003) Generally, music therapists who treat children with ADHD routinely address multiple kinds of goals, with treatment outcomes proving favorable as they incorporate a variety of music therapy methods into their sessions. Parents and teachers generally refer ADHD children, who also usually receive other kinds of treatments, for music therapy.

Other than the general agreement regarding the basic description of ADHD, Jackson (2003) purports, little agreement exists regarding a specific definition of the disorder, as various sources report that "anywhere from two to seven sub-types, each of which suggests differing etiologies (Amen, 2001; American Psychiatric Association, 2000; August & Garfinkle, 1989; Marshall, Hynd, Handwerk, & Hall, 1997." Consequently "proper treatment of the disorder is also a matter of controversy." (Jackson, 2003) Clinicians reportedly basically agree, albeit, that treatment with stimulant medication, generally methylphenidate, proves to be the most efficacious treatment (Johnson, 1988; cited by Jackson, 2003). Volkmar, Hoder, and Cohen (1985; cited by Jackson, 2003, however, argue that the dearth of "careful and comprehensive assessment, the poor monitoring of patient response to medication, and the lack of careful consideration of 'the risks associated with stimulant medications can lead to the inappropriate use of stimulant therapy.'" Reported concerns, such as this, alongside unconvincing demonstrations in follow-up studies related to stimulant treatment for ADHD (Barkley & Cunningham, 1978; Johnson, 1988; cited by Jackson, 2003) suggest ADHD treatment by medication treatment does not constitute the single or ultimate answer. Utilizing music's potential to impact attention, brain function, social behavior, activity and learning, lends to support to explore the potential of music to effectively treat children with ADHD. Jackson's study included a sample of board-certified music therapists, randomly selected the American Music Therapy Association (AMTA) who work with populations of early elementary school children. From AMTA identifying 1116 music therapists matching this study's criteria, Jackson (2003) randomly selected 500 to complete the experimenter-designed questionnaire. From the 500 questionnaires distributed, 268 responses were received from music therapists in 43 states. Respondents related utilizing a variety of music therapy methods in treatment sessions with ADHD children, with no particular trends noted. More than 50% of the respondents, however, identified "music and movement, instrumental improvisation, musical play, and group singing" (Jackson (2003) to be used in treatment. "In general," Jackson (2003) concludes that music therapists perceive music therapy treatment for children with ADHD as effective; that others, based on their feedback, also perceive music therapy to be effective. "Interestingly, the perception of effectiveness was relatively the same regardless of methods used, or the types of goals being addressed, or the other types of treatment used in conjunction with music therapy." (Jackson, 2003) the study Jackson (2003) completed basically portrays ways music therapists treat early elementary school children diagnosed with of ADHD, along with the influence music therapy extends to the overall treatment of these children. New questions evolving from this study include:

What particular component/s of music therapy is/are bring about the most effective results?

Can other settings generally contribute to music therapy's success in ADHD treatment?

In what ways does music therapy treatment for ADHD compare to treatment with medication?

Six-Session Study in their article, Webb and Myrick (2003) report that because ADHD confront particular challenges related to academic accomplishments, this "can lead to oppositional defiant and conduct disorders (Biederman, Faraone, & Lapey, 1992; cited by Webb and Myrick, 2003) and result in troublesome conflicts. Learning skills such as listening, attending, following directions, and exhibiting social competence have a strong correlation with successful social and academic achievement in school (Cartledge & Milburn, 1978; Eisenberg et al., 1997; Masten & Coatworth, 1998; cited by Webb and Myrick, 2003) Webb and Myrick (2003 present a theoretical framework which aims to help student increase their learning skills and also to enhance school counselors' understanding and bolster support for counselor intervention for students diagnosed with attention deficit hyperactivity disorder (ADHD). The six-session group counseling intervention to help students with ADHD understand its effects on their classroom performance, also helps the students "learn and practice a repertoire of school success skills." (Webb and Myrick, 2003) the students are taught they are on a journey in life with ADHD, and are, in a sense "different travelers in the world of education and often take alternate routes to their destinations (academic, personal-social, and career goals)." After fourteen elementary school counselors completed this particular training, conducted the intervention, and filled out a post-intervention survey, their reports, as well as, those by student noted the six-session intervention to be a success in promoting positive behaviors. Although the long-term prognosis for ADHD children treated with stimulant medication alone equates to the same as those who do not receive treatment, (Weiss & Hechtman, 1993; Webb and Myrick, 2003), "stimulant medication does not teach appropriate behaviors

According to Barkley (1998), the difficulty for ADHD students is not knowing what to do, but doing what they know. In addition, it has been shown that there is a difference between possessing a skill and using it effectively." (Stein, Szumowski, Blondis, & Roizen, 1995; cited by Webb and Myrick, 2003) This researcher contend that an intervention targeting school success behaviors, as well as, appropriate behaviors in other settings, that incorporates practice and application into session, increases likelihood behaviors of ADHD students will improve.

As following directions, listening, attending, and exhibiting social competence, along with other learning skills, strongly correlate with successful academic and social and achievement in school (Cartledge & Milburn, 1978; Eisenberg et al., 1997; Masten & Coatworth, 1998; cited by Webb and Myrick, 2003), this researcher recommends that therapies that enhance these skills without medication could

THE MTA STUDY Edwards (2002) reports that the Multimodal Treatment Study of Children with ADHD (MTA; MTA Cooperative Group, 1999a) constitutes is the largest, best-controlled study in child mental health. He explains that this study's overall purpose explores:

the most efficacious treatment for child ADHD (combined type) over a 14-month period of time: medication (MED), behavioral treatment (BEH), combined treatment (COMB; medication and behavioral treatment), and routine community care (CC; "treatment-as-usual" which turned out to be medication for approximately 67% of the children). In essence, "Cadillac" versions of intensive state-of-the-art treatment approaches (MED, BEH, and COMB) were compared with each other and with "treatment-as-usual" (CC). (Edwards, 2002)

Edwards concludes that for children experiencing ADHD and their families:

multimodal, multisystem approach that includes parent management training, school interventions, and medication seems to be the current treatment of choice based on the recent MTA study. Mental health counselors might consider integrating this empirically supported approach into their day-to-day outpatient practice with 7- to 10-year-olds experiencing ADHD (combined type) and their families. It might be most helpful to conceptualize the approach as consisting of intensive courses of treatment over time with monitoring of progress in terms of checkups or booster sessions after a course of treatment. Moreover, treatment needs to be flexible in addressing the developmental needs of the child and family over time. (Edwards, 2002)

Considerations in the treatment of ADHD, noted by Edwards (2002), need to include:

ADHD symptoms, aggression-oppositional defiant disorder, internalizing symptoms, social skills, (e) parent-child relations, and (f) academic achievement. (Edwards, 2002)

Answers from Research Stimulates New Question

Wadsworth and Harper (2007) report that: "a child with ADHD may outgrow the DSM [Diagnostic and Statistical Manual of Mental Disorders] criteria but not necessarily outgrow the disorder." Barkely (2002, 12; cited by Wadsworth and Harper 2007). They report that:

Longitudinal studies of individuals with ADHD show a persistence of symptoms from childhood through adulthood in 66% to 85% of cases (Biederman et al., 2000). Biederman (2004) reported that approximately 40% of adults who were diagnosed with ADHD as children continue to meet the full diagnostic criteria for ADHD, whereas 60% continue to report partial symptoms. Biederman also noted that 90% of adults diagnosed with ADHD in childhood report continued low levels of overall functioning, although they do not meet the full diagnostic criteria for ADHD because they only report one or two areas of functional impairment. (Wadsworth and Harper, 2007)

Contrary to Still's (1902) proposition that the etiology of ADHD lay in moral failure, current evidence purports that ADHD symptoms of ADHD composing an adult's typical clinical presentation by adults "are an expression of a genetic disorder that affects the neurobiology of the frontal lobes." (Faraone, 2004; cited by Wadsworth and Harper, 2007) Events triggering the symptomatic expression of ADHD, albeit, remain evasive and are unclear, even though familial risk factors implicate a genetic basis for ADHD. (Biederman et al., 1995; cited by Wadsworth and Harper, 2007) Hudziak et al. (1995; cited by Wadsworth and Harper, 2007) point out that approximately 70% of children of parents with ADHD inherit the disorder. As noted at this study's start, "Theories of child development and guidelines for parents are not cast in stone. They are constantly changing and adapting to new information and new pressures. There is no 'right' way, just as there are no magic incantations that will always painlessly resolve a child's problems." (Columbia, 1996) the same contention, this researcher contends, applies to ADHD.

References

The Columbia World of Quotations. New York: Columbia University Press, 1996. Retrieved April 16, 2008, at http://www.bartleby.com/66/3/33503.html

Cloward, Janessa. "ADHD drugs pose heart risks, federal panel says," University Wire, February 15, 2006. Retrieved April 17, 2008, at http://www.highbeam.com/doc/1P1118518952.html

DeMarle, Daniel J.;Denk, Larry;Ernsthausen, Catherine S.. "Working with the family of a child with Attention Deficit Hyperactivity Disorder.(Family Matters)," Pediatric Nursing, July 1, 2003. Retrieved April 16, 2008, at http://www.highbeam.com/doc/1G1107215868.html

Edwards, Jason H.. "Evidenced-based treatment for child ADHD: "real-world" practice implications." Journal of Mental Health Counseling, April 1, 2002. Retrieved April 17, 2008, at http://www.highbeam.com/doc/1G1-87015306.html

Effect of ADHD drugs questionedSunday Tribune (So." uth Africa), February 3, 2008. Retrieved April 17, 2008, at http://www.highbeam.com/doc/1G1-174197869.html

Jackson, Nancy a. "A Survey of Music Therapy Methods and Their Role in the Treatment of Early Elementary School Children with ADHD," Journal of Music Therapy, January 1, 2003. Retrieved April 17, 2008, at http://www.highbeam.com/Search.aspx?q=ADHD+effects+the+development+children20publiation:([%22Journal+of+Music+Therapy%22]

Parents and Teens Finally Agree on Something: ADHD Treatment Works; Families Credit Therapy With Better Grades, Higher Self-Esteem, Improved Relationships.," PR Newswire, March 8, 2005. April 17, 2008, at http://www.highbeam.com/doc/1G1129890558.html

Prince, Jefferson B., MD. (1994-2008) "Making the Most Appropriate Diagnosis of ADHD: Recognizing Important Behavioral Elements" Retrieved 17 April 2008, at http://www.medscape.com/viewarticle/545471_1

Scoring Instructions for the SNAP-IV-C Rating Scale." (N.d.). Retrieved 17 April 2008, at http://www.adhd.net/snap-iv-instructions.pdf

Swanson, James M., Ph.D., "The SNAP-IV Teacher and Parent Rating Scale" University of California, Irvine, CA. Retrieved 17 April 2008, at http://www.adhd.net/snap-ivform.pdf

Vanderbilt Children's Hospital Research Finds Nationwide Increase in Antipsychotic Medications Used for Children With Attention Deficit Hyperactivity Disorder." Ascribe Health News Service, March 16, 2006. Retrieved April 17, 2008, at http://www.highbeam.com/doc/1G1-143284441.html

Wadsworth, John S.; Harper, Dennis C.. "Adults with attention deficit hyperactivity disorder: assessment and treatment strategies." Journal of Counseling and Development, January 1, 2007. Retrieved April 16, 2008, at http://www.highbeam.com/doc/1G1158682749.html

Webb, Linda D.; Myrick, Robert D.. "A group counseling intervention for children with Attention deficit hyperactivity disorder.," Professional School Counseling, December 1, 2003. Retrieved April 16, 2008, at http://www.highbeam.com/doc/1G1-12905225.html

APPENDICES

Appendix a VANDERBILT ADHD DIAGNOSTIC PARENT RATING SCALE

Child's Name: ____ Today's Date:

Date of Birth: ____ Age:

Grade:

Each rating should be considered in the context of what is appropriate for the age of your child. Frequency Code: 0 = Never I = Occasionally 2= Often 3 Very Often

Does not pay attention to details or makes careless mistakes, for example homework 0-1-2 3

Has difficulty sustaining attention to tasks or activities 0-1-2 3

Does not seem to listen when spoken to directly 0-1-2 3

Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand) 0-1-2 3

5, Has difficulty organizing tasks and activities 0-1-2 3

Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort 0-1-2 3

Loses things necessary for tasks or activities (school assignments, pencils or books) 0-1-2 3

Is easily distracted by extraneous stimuli 0-1-2 3

Is forgetful in daily activities 0-1-2 3

Fidgets with hands or feet or squirms in seat 0-1-2 3

Leaves seat when remaining seated is expected 0-1-2 3

Runs about or climbs excessively in situations when remaining seated is expected 0-1-2 3

Has difficulty playing or engaging in leisure/play activities quietly 0-1-2 3

Is "on the go" or often acts as if "drive by a motor" 0-1-2 3

Talks too much 0-1-2 3

Blurts out answers before questions have been completed 0-1-2 3

Has difficulty waiting his/her turn 0-1-2 3

Interrupts or intrudes on others (e.g., butts into conversations or games) 0-1-2 3

Argues with adults 0-1-2 3

Loses temper 0-1-2 3

Actively defies or refuses to comply with adults' requests or rules 0-1-2 3

Deliberately annoys people 0-1-2 3

Blames others for his or her mistakes or misbehaviors 0-1-2 3

Is touchy or easily annoyed by others 0-1-2 3

Is angry or resentful 0-1-2 3

Is spiteful and vindictive 0-1-2 3

Bullies, threatens, or intimidates others 0-1-2 3

Initiates physical fights 0-1-2 3

Lies to obtain goods for favors or to avoid obligations (i.e., "cons" others) 0-1-2 3

Is truant from school (skips school) without permission 0-1-2 3

Is physically cruel to people 0-1-2 3

Has stolen items of nontrivial value 0-1-2 3

Deliberately destroys others' property 0-1-2 3

Has used a weapon that can cause serious harm (bat, knife, brick, gun) 0-1-2 3

Is physically cruel to animals 0-1-2 3

Has deliberately set fires to cause damage 0-1-2 3

Has broken into someone else's home, business, or car 0-1-2 3

Has stayed out at night without permission 0-1-2 3

Has run away from home overnight 0-1-2 3

Has forced someone into sexual activity 0-1-2 3

Is fearful, anxious, or worried 0-1-2 3

Is afraid to try new things for fear of making mistakes 0-1-2 3

4a Feels worthless or inferior 0-1-2 3

Blames self for problems, feels guilty 0-1-2 3

Feels lonely, unwanted, or unloved: complains that "no one loves him/her" 0-1-2 3

Is sad, unhappy, or depressed 0-1-2 3

Is self-conscious or easily embarrassed c0 1-2 3

PERFORMANCE

Problematic Average Above Average

1. Overall Academic Performance 1-2 3-4 5

Reading 1-2 3-4 5

Mathematics 1-2 3-4 5

C. Written Expression 1-2 3-4 5

PERFORMANCE

Problematic

Average

Above Average

2. Overall Classroom Behavior a. Relationship with peers b. Following Directions/Rules

C. Disrupting Class d. Assignment Completion e. Organizational Skills

Scoring Instructions for the ADTRS

Predominately inattentive subtype requires 6 or 9 behaviors, (scores of 2 or 3 are positive) on items 1 through 9, and a performance problem (scores of 1 or 2) in any of the items on the performance section.

Predominately hyperactive/impulsive subtype requires 6 or 9 behaviors (scores of 2 or 3 are positive) on items 10 through 18 and a problem (scores of 1 or 2) in any of the items on the performance section.

The Combined Subtype requires the above criteria on both inattention and hyperactivity/impulsivity.

Oppositional-defiant disorder is screened by 4 of 8 behaviors, (scores of 2 or 3 are positive) (19 through 26).

Conduct disorder is screened by 3 of 15 behaviors, (scores of 2 or 3 are positive) (27 through 40).

Anxiety or depression are screened by behaviors 41 through 47, scores of 3 of 7 are required, (scores of 2 or 3 are positive).

Appendix B

Scoring Instructions for the SNAP-IV-C Rating Scale

The SNAP-IV Rating Scale is a revision of the Swanson, Nolan and Pelham (SNAP) Questionnaire (Swanson et al., 1983). The items from the DSM-IV

1994) criteria for Attention Deficit Hyperactivity Disorder (ADHD) are included for the two subsets of symptoms: inattention (items #1-#9) and hyperactivity / impulsivity (items #11-#19). Also, items are included from the DSM-IV criteria for Oppositional Defiant Disorder (items #21-#28) since it often is present in children with ADHD. Items have been added to summarize the Inattention domain (#10) and the Hyperactivity/Impulsivity domain (#20) of ADHD. Two other items were added: an item from DSM-III-R (#29) that was not included in the DSM-IV list for ODD, and an item to summarize the ODD domain (#30).

In addition to the DSM-IV items for ADHD and ODD, the SNAP-IV contains items from the Conners Index Questionnaire (Conners, 1968) and the IOWA

Conners Questionnaire (Loney and Milich, 1985). The IOWA was developed using divergent validity to separate items which measure inattention/overactivity (I / items #4, #8, #11, #31, #32) from those items which measure aggression/defiance (a/D -- " items #21, #23, #29, #34, #35). The Conners Index (items #4, #8, 11, #21, #32, #33, #36, #37, #38, #39) was developed by selecting the items which loaded highest on the multiple factors of the Conners Questionnaire, and thus represents a general index of childhood problems.

The SNAP-IV is based on a 0 to 3 rating scale: Not at All = 0, Just a Little = 1, Quite a Bit = 2, and Very Much = 3. Subscale scores on the SNAP-IV are calculated by summing the scores on the items in the subset and dividing by the number of items in the subset. The score for any subset is expressed as the Average

Rating-Per-Item, as shown for ratings on the ADHD-Inattentive (ADHD-I) subset:

Not at Just a Quite Very Item

All Little a Bit Much Score

1. Makes careless mistakes ____ ____ __X_

2. Can't pay attention ____ ____ ____ __X_ 3

3. Doesn't listen ____ ____ ____ __X_ 3

4. Fails to finish work ____ ____ __X_

5. Disorganized ____ __X_ ____ ____ 1 ADHD-in Total = 18, Average = 18/9 = 2.0

6. Can't concentrate ____ ____ ____ __X_ 3

7. Loses things ____ __X_ ____

8. Distractible ____ ____ ____ __X_ 3

9. Forgetful __X_ ____ ____ ____ 0 scoring template for the DSM-IV subtypes of ADHD (in and H/Im), for ODD; for the dimensions of the CLAM (I/O and a/D); and for the Conners

Index are presented below:

ADHD-in ADHD-H/Im ODD I/O a/D Conners Index

____ #11 ____ #21 ____ # 4 ____ #21 ____ # 4

____ #12 ____ #22 ____ # 8 ____ #23 ____ # 8

____ #13 ____ #23 ____ #11 ____ #29 ____ #11

____ #14 ____ #24 ____ #31 ____ #34 ____ #21

____ #15 ____ #25 ____ #32 ____ #35 ____ #32

____ #16 ____ #26 ____ #33

____ #17 ____ #27 ____ #36

____ #18 ____ #28 ____ #37

____ #19 ____ #38

Total in = ____ H/Im = ____ ODD = ____ I/O = ____ a/D = ____ CI =

Average = ____ = ____ = ____ = ____ = ____ =

Teacher Parent

Tentative 5% Cutoffs: ADHD-in 2.56 1.78

ADHD-H/Im 1.78 1.44

ADHD-C 2.00 1.67

ODD 1.38 1.88

The items on page 2 of the SNAP-IV Rating Scale are from other DSM-IV disorders which may overlap with or masquerade as symptoms of ADHD. In some cases, these may be comorbid disorders, but in other cases the presence of one or more of these disorders may be sufficient to exclude a diagnosis of ADHD.

The SNAP-IV is not designed to be used in the formal process of diagnosing these non-ADHD disorders, but if symptoms on page 2 of the SNAP-IV receive a high

Quite a Bit" or "Very Much") rating, then an assessment of the implicated non-ADHD disorders may be warranted.

The DSM-IV Manual should be consulted to follow-up with an evaluation of these non-ADHD disorders. The DSM Codes and the page numbers in the DSM Manual are specified below to help in the assessment of possible conditions which may exclude or qualify a diagnosis of ADHD. A referral to a psychiatrist or a clinical psychologist may be required.

41-#45 Conduct Disorder (DSM 312.8, p. 85)

46 Intermittent Explosive Disorder (DSM 312.34, p. 609)

47 Tourette's Disorder (DSM 307.23, p. 103)

48 Stereotypic Movement Disorder (DSM 307.3, p. 121)

49-#50 Obsessive-Compulsive Disorder (DSM 300.3, p. 417)

51-#56 Generalized Anxiety Disorder (DSM 300.02, p. 432)

57 Narcolepsy (DSM 347, p. 562)

58 Histrionic Personality Disorder (DSM 301.50, p. 655)

59 Narcissistic Personality Disorder (DSM 301.81, p. 658)

60 Borderline Personality Disorder (DSM 301.83, p. 650)

61-#65 Manic Episode (DSM 296.00, p. 328)

66-#73 Major Depressive Episode (DSM 296.2, p. 320)

74-#76 Dysthymic Disorder (DSM 300.4, p. 345)

77-#78 Posttraumatic Stress Disorder (DSM 309.81, p. 424)

79-#80 Adjustment Disorder (DSM 309, p. 623)

Finally, the SNAP-IV includes the 10 items of the Swanson, Kotkin, Agler, Mylnn, and Pelham (SKAMP) Rating Scale. These items are classroom manifestations of inattention, hyperactivity, and impulsivity (i.e., getting started, staying on task, interactions with others, completing work, and shifting activities).

The SKAMP may be used to estimate severity of impairment in the classroom.

It is important to note that many disorders may produce impairment in the classroom setting, not just ADHD. Therefore, this rating scale is presented last to the possible exclusion conditions (on page 2 of the SNAP-IV) will be considered in addition to the inclusion criteria for ADHD (on page 1 of the SNAP-IV).

Both should be considered before interpreting the SKAMP measure of classroom impairment or attributing high ratings on the SKAMP to ADHD.

ACADEMIC DEPORTMENT

81 ____ #87

82 ____ #88

83 ____ #89

84 ____ #90

Total = ____ =

Avg. = ____ =

Orienting (#81,#86) = ____ Attention to Other (#87,#88) =

Maintaining (#82,#83) = ____ Attention to Rules (#89,#90) =

Directing (#84,#85) = ____ ("Scoring Instructions," N.d.)

Pseudonym