Treatment approaches for Attention-Deficit
Hyperactivity Disorder (ADHD)
Harry is a thirteen-year-old
male, who was diagnosed with ADHD at the age of
eight. Living in a single-parent home with
his mother, Harry is the only son of a ten-year
marriage, which ended in divorce when he was
four years old. Through the years, Harry
has shown increasing difficulty in the academic
arena. When he was six, Harry's teachers
recommended that he remain in kindergarten,
because his emotional and physical maturity were
not sufficient to meet the demands of first
grade. Subsequently, Harry was enrolled in
a private kindergarten for six-year-olds.
A year later, Harry entered first grade in the
same private school setting. Within six
months, Harry's teachers were beginning to voice
concern about his schoolwork. Harry was
not a major behavioral problem, but he seemed to
lack self-confidence and was fearful of new
situations. Also, Harry was easily
distracted in the classroom and seemed to need
individualized attention from his teacher.
Testing was initiated to determine if Harry had
a learning disability. Although the tests
did not reveal any major problem areas, they did
show that Harry had a slight hearing loss and
scored at the low end of the average scale of
intelligence. Subsequently, Harry's mother
sought the help of a professional psychologist,
whose tests diagnosed Harry as also having ADHD.
Upon entering second grade, Harry
was placed in a resource class, where he was
given individualized attention. In this
environment, Harry showed some improvement, but
his father continually criticized the approach
and refused to assist with the funding, so Harry
was placed in public school. Within a
month, Harry's second grade teacher informed his
mother that Harry was not doing well in public
school, but agreed to do whatever possible to
help Harry catch up and be promoted to third
grade. A student support team was formed
for Harry, but he did not qualify for special,
or resource, education in the public school
system. One year later, a recurring theme
threatened Harry's chances of being promoted to
fourth grade. On a return visit to the
psychologist, who had performed Harry's
professional testing, a suggestion was made that
Harry see a psychiatrist for evaluation and
possible treatment with the drug, Ritalin.
Harry's mother agreed, and the boy was placed on
a five milligram, daily dosage. Seeing no
specific improvement, which could be attributed
to the medication, and having received negative
feedback from Harry's pediatrician on the
side-effects of Ritalin, Harry's mother stopped
administering the medication after a few months.
Finishing third grade with the combined help of
his mother and grandmother, Harry went on to
fourth grade and seemingly passed with no
problems. Fifth grade was another story,
however, and Harry struggled again just to pass.
Upon entering sixth grade in the fall of 1989,
Harry seemed to do better than expected in his
first quarter of middle school. However,
by the midterm of his second quarter, Harry was
failing four subjects, and earned grades of "C"
and "D" in the other two. Harry's mother
again sought the help and advice of the
psychologist and psychiatrist.
Subsequently, new tests revealed that Harry's
performance was significantly lower than his
intelligence scores, which had risen
considerably since the last testing. A
decision was made to place Harry on ten
milligrams of Ritalin twice daily.
Immediately, Harry expressed that the medication
helped him calm down and concentrate on his
schoolwork.
In recognizing that Harry needs
to drastically improve his study habits and his
social and organizational skills, which have
been underdeveloped because of his untreated
ADHD, it is important to explore possible
behavioral and cognitive treatment approaches
that might facilitate an improvement in Harry's
overall academic performance.
Attention-deficit hyperactivity disorder is
categorized by the American Psychiatric
Association (1987) as a disorder usually first
evident in infancy, childhood, or adolescence.
Diagnostic criteria are as follows:
A disturbance for at least six
months during which at least eight of the
following are present: (1) often fidgets
with hands or feet or squirms in seat (in
adolescents, may be limited to subjective
feelings of restlessness), (2) has difficulty
remaining seated when required to do so, (3) is
easily distracted by extraneous stimuli, (4) has
difficulty awaiting turn in games or group
situations, (5) often blurts out answers to
questions before they have been completed, (6)
has difficulty following through on instructions
from others (not due to oppositional behavior or
failure of comprehension), e.g., fails to finish
chores, (7) has difficulty sustaining attention
in tasks or play activities, (8) often shifts
from one uncompleted activity to another, (9)
has difficulty playing quietly, (10) often talks
excessively, (11) often intrudes on others,
e.g., butts into other children's games, (12)
often does not seem to listen to what is being
said to him or her, (13) often loses things
necessary for tasks or activities at school or
at home (e.g., toys, pencils, books,
assignments), (14) often engages in physically
dangerous activities without considering
possible consequences (not for the purpose of
thrill-seeking), e.g., runs into street without
looking (American Psychiatric Association, 1987,
pp. 52-53).
With these criteria in mind, one
can readily see the potential for a behavioral
treatment program. Franzoni (1990) points
out that these are the kids who drive both their
parents and their teachers crazy; you put them
on a behavioral program and ask them to check
the items listed on a card as they are
completed, and then they forget the card!
In spite of such frustration, however, ADHD can
be analyzed via an operant conditioning model.
According to Copeland (1987),
ADHD children do not respond to the usual
punishments, particularly physical punishment.
In ADHD children, deficiencies exist in the
reticular activating system and prefrontal
cortex, which are neurologically responsible for
organization, planning and judgment.
Consequently, ADHD children are notably
disorganized, forgetful, and unable to plan
ahead or decide upon priorities. Normal,
everyday stimuli, such as a bird flying by the
window of a classroom (SD), can draw the ADHD
child's attention away from classroom
activities, as he watches the bird (R) instead
of paying attention to the teacher and doing his
class work. Such discriminative stimuli
can trigger a behavioral response that becomes
self-reinforcing (maintainer), because the ADHD
child, who is already frustrated with a
consistently poor performance in school, would
rather mentally soar with a bird (S+), than do
tedious, below-average class work for his
teacher.
From a cognitive perspective,
children with ADHD are often noncompliant and
exhibit poor self-control and problem-solving
skills. These behavioral attributes are
deficits in what Copeland (1987) terms
rule-governed behavior. Language;
neurological processes for acquiring language,
generating language, and converting language
into motor behavior; and training in rules of
community, self-control, and problem-solving,
are fundamental for appropriate rule-governed
behavior. Mediation of behavior by
language is, therefore, crucial in developing
higher mental functioning in behavior. In
ADHD children, problems with auditory
processing, auditory memory, and language
deficits are common. Festinger's model of
cognitive dissonance is very descriptive of the
irresolvable conflict that exists in ADHD
children (cited in Lefrancois, 1982). By
capitalizing on the child's natural motivation
to reduce cognitive dissonance, effective
education and training can, theoretically, lead
to positive changes in attitude and behavior
related to ADHD symptoms.
As Copeland (1987) discusses, it
can be beneficial to develop a behavioral
program for ADHD children to selectively
reinforce such behaviors as impulse control,
self-discipline, organization skills, and
conformity to parental, school, and societal
expectations through the use of positive
reinforcement for appropriate behavior and
negative consequences for inappropriate
behavior. By training the child to attend
to relevant stimuli, to develop a system of
stop, look, and listen to improve alertness and
to increase attention to adults when they speak,
to count to three before acting, and to repeat
instructions before attempting a task, the child
can be conditioned to respond to the
discriminative stimuli in their everyday
environments with more appropriate behavior.
Copeland (1987) further pointed
out that behavioral management strategies alone
are not found to be as effective as the use of
medication (Ritalin) alone, but that together,
these treatments provide a winning combination.
Medication enables the child to function
normally; however, it doesn't teach the child
anything. ADHD children appear to take
three to ten times longer to internalize
behavior and rules than their non-ADHD peers;
without medication, they may not learn them at
all. One danger, according to Sarason and
Sarason (1980), is that drug therapy can lead
the child to falsely conclude that any
improvement in behavior is the result of a pill.
Consequently, the child and others may feel no
involvement and no responsibility for behavior
changes, a reaction that would be seen by social
psychologists as an example of attribution
theory. Therefore, training the ADHD child
and the parents in understanding the importance
of drug therapy in combination with behavioral
therapy is foundational to the success of a
treatment approach.
Copeland (1987) employs a
treatment approach using three behavioral
methods that are appropriate for Harry.
First, Harry's parents should be trained in the
concepts of responsibility, organization, and
structure. Establishing structure,
routines, and responsibilities expected of Harry
and communicating these effectively are of
foremost importance to his treatment.
Next, a positive incentive program could be
utilized to reinforce desired behaviors and
values. When Harry does what is expected,
he earns chips toward activities and things he
wants to do. When Harry doesn't do what's
expected, he loses privileges and purchases,
because he has not earned them. Finally,
Harry's parents could employ the thinking room
concept, which is a variation of the time out
concept, for inappropriate behavior. This
concept is useful in teaching appropriate
behavior and in developing cognitive
understanding and appropriate social skills.
When behavior is inappropriate, Harry would be
sent to the thinking room, where he would be
required to sit alone and think about
alternative, appropriate behaviors that could
have been substituted for the problem behavior.
It is important that Harry's parents be firm,
but kind, in administering this program.
Talking is important, but so is a hug and
saying, "I love you."
A cognitive supplemental
treatment program, that Copeland (1987)
advocates, in addition to the primary,
behavioral approach, recognizes that the goals
for cognitive therapy should be to utilize
language for problem-solving, rather than
impulsively responding to various stimuli;
internalizing rules for behavior; learning
self-control; and using mental dialog for
problem-solving. Meichenbaum & Goodman
(1971) showed that impulsive children can be
trained successfully to talk to themselves as a
means of self-control. The child's
self-talk then assumes a self-governing role in
the treatment process. Douglas, Parry,
Martin, & Garson (1976) modeled cognitive
strategies to hyperactive children through a
trainer, who verbalized such strategies as:
stopping to define a problem and its associated
steps, considering more than one solution to a
problem before acting, checking and correcting
errors calmly, and praising oneself for a job
well done. Cognitive therapy is very
affective with self-esteem problems, such as
underachievement, poor peer relations, and
constant negative feedback. Once such
problems have been normalized, the child is left
with a sense of stability, predictability,
self-control, and confidence (Copeland, 1987).
Drug dosage effectiveness can be
judged on the basis of how well Harry's
attention-span is normalized. Behavioral
treatment effectiveness can be judged on the
basis of Harry's changes in behavior related to
impulse control, self-discipline, organization
skills, and conformity to parental, school, and
societal expectations. Cognitive treatment
effectiveness can judged on the basis of how
successfully Harry's self-esteem problems are
resolved. Adjunctive therapies might
include such activities as Karate or Boy Scouts,
which emphasize discipline, self-control,
thought before action, physical skills mastery,
goal-setting, and structured projects.
Computerized self-instruction might also improve
self-confidence in the classroom. As a
general rule, each of these treatment methods
should be closely monitored by a professional
psychologist or counselor and fine-tuned on a
recurring basis to achieve maximal success.
In summary, the best treatment
for Harry is a cognitive-behavioral approach,
which educates, trains, provides structure,
organizes, models, encourages self-management,
and reinforces appropriate behaviors.
Recognizing that ADHD is a physiological problem
with behavioral symptoms and cognitive
consequences, and that the psychological issues
are complex and overlapping, support for a
combined treatment program is inherent to the
confusion and the ineffectiveness that are
generated by a more simplistic approach.
References
American Psychiatric Association.
(1987). The diagnostic categories: Text
and criteria. Diagnostic and statistical manual
of mental disorders (3rd rev. ed., pp. 50-53).
Washington, DC: Author.
Copeland, E. D. (Speaker).
(1987). A.D.D. Treatment
Approaches [Cassette Recording].
Atlanta, GA: 3C's of Childhood, Inc..
Douglas, V., Parry, P., Martin,
P., & Garson, C. (1976). Assessment
of a cognitive training program for hyperactive
children. Journal of Abnormal Child
Psychology, 4, 389-410.
Franzoni, J. (Speaker).
(1990). Attention-deficit hyperactivity
disorder [Lecture]. Atlanta, GA: Georgia
State University.
Lefrancois, G. R. (1982).
Motivation. Psychological theories and
human learning (2nd ed., pp. 267-271).
Monterey, CA: Brooks/Cole.
Meichenbaum, D., & Goodman, J.
(1971). Training impulsive children to
talk to themselves: A means of developing
self-control. Journal of Abnormal
Psychology, 77, 115-126.
Sarason, I. G., & Sarason, B. R.
(1980). Maladaptive behaviors of
childhood. In M. Harrison (Ed.), Abnormal
psychology (3rd ed., pp. 409-413).
Englewood Cliffs, NJ: Prentice-Hall.
|
