Philippians 4:13

Treatment approaches for Attention-Deficit Hyperactivity Disorder (ADHD)

Author: Margie Y. Cash, B.B.A., M.S.

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.