Critically review the core characteristics of ADHD and the evidence for and against thepsychological factors

Essay: ADHD, one of the most common childhood disorders, is said to be on the rise in the western world. Critically review the core characteristics of ADHD and the evidence for and against the psychological factors/processes that are suggested to both develop and maintain the disorder.

Abstract

The essay provides a discussion to ADHD which is one of the common disorders among kids. The essay reviews the core characteristics of ADHD and the evidence for and against the psychological factors/processes that are suggested to both develop and maintain the disorder. The essay will have the definitions of neuropsychiatric developmental disorder or ADHD, its symptoms, diagnostics, psychological factors/processes influencing a patient suffering from ADHD and its limitations.

Introduction

In recent times, ADHD is considered to be one of the most common disorders in kids. It is on rise in western world (American Psychiatric Association, 2013). Hence, the essay critically reviews the core characteristics of ADHD and the evidence for and against the psychological factors/processes that are suggested to both develop and maintain the disorder.

Attention deficit hyperactivity disorder (ADHD) is one of the neuropsychiatric developmental disorders (Tidy, 2014). This disorder is related to the problems of executive functions. Attentional control and inhibitory control are two constituents of the functions. Attention deficits, hyperactivity or impulsiveness may occur due to the problems of executive functions and of course, these are not proper for the personality of the individual in relation to their age. However, these symptoms become evident during the age of six to twelve and if these persist for more than six months, then a diagnosis is necessary. The poor school performance may be ascribable to the effect of that. Yet, these people cannot avoid the impairment in the modern society due to that cause (The British Psychological Society and The Royal College of Psychiatrists, 2009). But one of the positive sides is that many children with ADHD can have a good attention span for interesting tasks. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published on May 18, 2013 and it superseded the DSM-IV-TR. In this recent version, definition of attention-deficit/hyperactivity disorder has been updated and concentrates on accurately characterizing the experience of affected adults (Grohol, 2015).

This essay intends to examine the neuropsychiatric developmental disorder or ADHD, its symptoms, diagnostics, psychological factors/processes influencing a patient suffering from ADHD and its limitations.

 

 

 

Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) is related to inattention and/or hyperactivity and impulsivity disorder of persistent nature (Swanson, 2013). These are more frequent and severe than the symptoms as usually observed among the individuals during the comparable level of development. The symptoms commonly found in person suffering from ADHD include attention deficits, hyperactivity and also impulsive behaviour. These symptoms usually start at the age of six. These symptoms might be visible between 6-12 years of person’s life. Also, the symptoms may persist for six months before a diagnosis takes place. In kids, these symptoms often lead to poor performance in studies and lacking behind other healthy kids. The disorder may also result in impairment but kids with ADHD have a good attention to tasks which are interesting to them (Kooij, 2010). There is no fix cause of ADHD in kids. There have been studies carried to examine the causes of ADHD in kids and effectively find a solution. But everything has been in vain since no reason has been found out yet.

In order to diagnose ADHD, counselling is considered as an effective solution. Besides counselling, change in lifestyle and carrying out meditation is also an effective way. Doctors also recommend some patients to take medications but these are only meant for kids who have intense symptoms and no other way is working on them (Lange, 2010). However, for the proper diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:

Meet the diagnostic criteria in DSM –5 or International Classification of Diseases and Related Health Problems (ICD-10): Meeting the diagnostic criteria in DSM –5 can be helpful in case the symptoms are severe.

Associate with at least moderate psychological, social and/or educational or occupational impairment on the basis of interview and/or direct observation in multiple settings

Be pervasive. It may occur in two or more important settings and includes social, familial, educational and/or occupational settings (Sroubek, 2013).

 

 

 

The DSM-5 Diagnostic Criteria

There will be evident and persistent pattern of inattention and/or hyperactivity –impulsivity among the ADHD people (Caroline, 2010). These symptoms interfere with functioning or development.

·         Inattention – There may be six or more symptoms of inattention for children up to 16 years of age. There may be five or more for adolescents aged 17 and older as well as adults. This kind of inattention should persist for six months and of course they are inappropriate during the developmental level.

o   Failure to pay minute attention to detail. Careless mistakes in schoolwork, at work or with other activities.

o   Trouble in keeping the attention on tasks or play activities.

o   Seems not to listen when directly speaking with the person.

o    Not following through the instructions and unable to finish the schoolwork, chores, or duties in the workplace (e.g. Losing focus, sidetracked).

o   Trouble in organizing tasks and activities.

o   Evading, dislikes or unwilling to do tasks requiring mental effort for a long period of time (e.g. Schoolwork or homework).

o   Losing necessary things related to tasks and activities (e.g. School materials, pencils, tools, keys, spectacles, mobile etc.).

o   Easily distracted very often.

o   Forgetful about daily activities.

·         Hyperactivity and Impulsivity – Till now the research has identified six or more symptoms of hyperactivity-Impulsivity for children up to age 16 and five or more for adolescents of 17 and older as well as adults (Malenka, 2009). These should be persistent symptoms for at least six months and of course, disruptive and inappropriate for the developmental level of the person. Some of the symptoms are–

o   Fidgeting with or tapping hands or feet, or the person may be squirm while seating.

o   Leaving seats in cases while remaining in seats is expected.

o   Running about or climbing while the situation is inappropriate (adolescents or adults, may be limited to restless feelings).          

o   Unable to be quiet while playing or during leisure activities.

o    Very often acted as ‘on the go’ as if ‘driven by a motor’.

o   Excessive talking

o   Blurting out the answer before completion of the question.

o   Trouble in keeping patience while waiting for the turn.

o    Interrupting or intruding on others very often (e.g. Butts into conversations or games).

However, in addition to the above following conditions should be fulfilled–

·         There should be several inattentive or hyperactive-Impulsive symptoms existing before the age of 12 years.

·         Several symptoms must be present in two or more settings (e.g. At home, school or work, with friends or relatives, in other activities).

·         It should be clear and evident that the symptoms must interfere with or reduce the quality of school, social or work functioning).

·         During the course of schizophrenia or other psychotic disorder these symptoms do not occur.

·         Other types of mental disorder (e.g. Mood disorder, anxiety disorder, dissociative disorder or personality disorder) can not be able to explain these symptoms.

From the above symptoms, different types of ADHD can be known. This are-

·         Combined presentation– In this case there must exist enough symptoms of both criteria inattention and hyperactivity- Impulsivity for the past six months.                                                                     Predominantly inattentive presentation– There should be enough symptoms of inattention excluding hyperactivity-Impulsivity for past six months.

·         Predominantly hyperactive-Impulsive presentation– The symptoms of hyperactivity-Impulsivity excluding inattention must be present for past six months.

 

The critical review of research

The critical review of epidemiologic research has suggested that ADHD is not overdiagnosed universally. There exists some evidence of substantial ADHD overdiagnosis among the US community and adverse educational outcomes is generally treated for disorder among children (Diamond, 2013). There exists suboptimal management for childhood behavior problems. The evidence related to this problem is obscured as from the findings, irrespective of geographic location, race, gender and age we came to know about the facts. However, the sophisticated epidemiologic tracking of ADHD treatment trends and examination of associated outcomes is necessary for appreciation of the scope of the problem at the national level (Childress, 2012). The public health approach to ADHD involves development and implementation of data-driven and community based interventions. These are warranted and underway in some communities. Meanwhile, there exist guidelines for judicious use of psychotropic drugs.  

Psychological factors/ processes

There are so many opinions exist for the treatment of ADHD. It is necessary for the comprehensive treatment of ADHD to include a strong psychosocial or non medical component. Nevertheless, the effective psychosocial treatment is the backbone of proper treatment for ADHD (Dulcan, 2011). The effective psychosocial treatment in combination of medication is a very useful approach in most of the cases. National Institute of Mental Health and many other professional organizations opines that there exist two treatments for short-term effectiveness and these have a solid basis of logical evidence. This are-

·         Behavioral psychosocial treatment or behavior therapy

·         Stimulant Medication

In this perspective, we can say that behavior therapy is the only nonmedical approach for the treatment of ADHD and it has a large scientific evidence basis.

Nevertheless, psychological interventions relating to ADHD encompass a wide array of cognitive behavioral approaches. These include behavioral interventions and parent training, cognitive training and social skills training (Walitza, 2012). In this respect we should remember that ‘parent training’ or ‘parent-training/education program’ is very often used in ADHD. Parents usually denote carers and guardians. Even if involvements of parents or carers of children relating to ADHD, not falling into the parent training category are also taken care of. Psychoeducation written material is a good example of that.

We should remember the following points in this respect-

·         Parent-training involvement is the focal point of research for the ADHD children up to 6 years

·         Cognitive Behavioral Therapy (CBT), social skills training, self-instructional training coupled with parent training is used to predominate in older children

·         The main focus of research for adults with ADHD emphasizes on CBT as psychological involvement for them are less developed. These may be in the form of individual interference or in the brief workshop-style involvement.

The research is going on other types of ADHD therapy. Biofeedback and relaxation training is one of them.

Short-term effects of medication

The use of medications does not have long-term effectiveness, although they can reduce the core symptoms. If we follow the studies we can deduce that the improvements may not be either long-term or do not give long-term effects into adolescence (Willcutt, 2012). This stimulant-medication is usually have state-dependent effects and lasts only for the time period the medication is received. As the situation will not generalize in absence of treatment, therefore other types of treatment are considered for prolonging drug effects.

Narrow clinical benefits of medication

The medication cannot resolve the problems of secondary types among children and adults with ADHD (Cowen, 2012). The research has established that stimulants may improve parent-child interactions in analogue settings, but families may be dysfunctional in multiple domains. Because there may be several problems like maternal stress, depression, paternal alcohol misuse, inappropriate parenting skills, etc. Besides these, problems like low self-esteem, poor peer relationships and other secondary problems also coexist and these will increase the symptoms and it is not possible for medication alone to tackle the situation.   

Non-responsiveness to medication

Sometimes, the responsiveness to stimulant medication is a total failure for ADHD people. Weak responsiveness to medication is also a big headache of the doctors. Therefore, it is advised to either increasing the dosage or a legitimate intervention.

Intolerance to medication

There should be intolerance to medication among a significant number of people with ADHD. Side effects can cause interference with treatment or discontinuation. If the side effects occur during the early stage, then it can be removed by dosage adjustments. This is an important factor for complementary psychological approaches as 15% of children treated with methylphenidate discontinued treatment for side effects (Faraone, 2011).

Clinical needs and ethical objections

Some types of medication like dexamfetamine are prohibited for the children of fewer than 6 years. Since the medication is not the permanent solution therefore professionals, parents and carers raise objection and concern about it. The sole cause behind this mental attitude is their concern about using psychotropic medication (Emond, 2009). These medications not only have side effects and long term effects, but the focal point also remove from individual responsibility of the problem, i.e. interface of the ADHD people with the social and educational systems.

Behaviour Modification

Behavior modification is not the traditional psychotherapeutic treatment, family therapy or individual therapy. But the focal point is evidence-based psychosocial approach in order to realize effective behavioral treatment and in the long term improve the function of ADHD people.

We will discuss about these approaches-

Parent Training-

·         Behavioural approach: Parents can bring modifications to their behaviour and treat them more patently instead of being irritating on everything.

·         Emphasis on parenting skills, child behavior in home and neighborhood and family relationships

·         Implementation of skills by the parents taught by therapist

·         Attending group-based weekly sessions initially and then move to booster sessions

·         Continuous evaluation and modification of steps to be taken

·         In case of major developmental transitions, consult with a therapist

School Intervention-

·         Behavioural approach: School is one of the places where a kid spends most of his time. Hence, changes in behaviour are recommended specially at schools.

·         Concentrates on classroom behavior, academic performance and peer relationships

·         Implementation of classroom management skills by the teacher

·         Continuous evaluation and modification of steps to be taken

·         Planning of backsliding and spread, involving all relevant school staff and arrangement of parenting classes to give them feedback

Child Intervention-

·         Behavioral and developmental approach

·         Integrated with school and parent treatments

·         Concentrates on teaching academic, recreational and social/behavioral competencies

·         Emphasis on decreasing aggression, developing close friendships and building self-efficacy

·         Implementation of paraprofessional under the supervision of professionals

·         Arrangement of clinic-based weekly group sessions, after-school or Saturday sessions and summer camps

Cognitive Behavior Therapy-

The most popular approach is self-instructional training in this type of psychological treatment of ADHD. It constitutes of cognitive modelling, self-evaluation, self-reinforcement and response cost. This therapy helps the younger ones to develop a planned and reflective approach of thinking and encourages for systematic, reflective and goal-directed approach towards tasks and problem solving (Singh, 2008). The learning strategy may involve abstract self-instructional techniques with concise step-by-step process. In Cognitive Modelling the adults at first encourage to verbalize their response to problem-solving task. It involves following three steps-

·         Talking out loud

·         Whispering

·         Self-talk

There exist so many programs to encourage self-evaluation. It emphasizes on self-reinforcement and response cost techniques. In this technique the young person either be penalized for mistakes or rewarded for successful implementation of strategies.

Limitations

In the past significant amount of research demonstrated that only medication won’t help the ADHD people get rid of the core issues. But some skills are needed to live with the disorder. The focal point of future research is that issue (Wigal, 2009). The following points should be kept in mind in this regard-

·         The Genetic contribution to ADHD and their interference with an environmental factor affecting the inherited variant of ADHD

·         The development of new medication delivery systems and new medicines for ADHD

·         The knowledge development relating to adult outcomes of children with ADHD combined with that on clinic-referred adults with ADHD

However, in the future research emphasis is on psychosocial treatment like training on working memory, time management training for children, cognitive behavioral training for adults and after-school supplemental services for teens etc.

Recommendations for future research in ADHD

For future research, there are many areas related to ADHD that needs exhaustive research. First area is the parent training which needs be made more effective. There are further investigations needed in this area since it has a significant success rate in treating kids with ADHD (Castells, 2011). There have been many studies which emphasised on the need of PBT (Parental Behavioural training) to treat ADHD. But further evaluation is needed to provide more assistance to children with ADHD. Thirdly, there is high need to research in the role of psycho education to address ADHD (McDonagh, 2011). This is one of the cost effective methods to treat ADHD. Fourthly, the role of teacher to address ADHD and her intervention needs more research to examine the potential benefits for ADHD kids. Fifth, there is high need to carry out research on DSM-5 Diagnostic Criteria to examine whether or not it is able to diagnose adults like kids (Prasad., 2013). These are some of the research areas where further evaluation is required.

Conclusion

In nutshell, it is estimated that ADHD is common among 2 to 5% of kids. Also, kids who tend to have this disorder in early stages of life also continue to have it in later life as well. As per stats, around 25% of kids continue to suffer from ADHD in adulthood as well while rest 75% don’t have any symptoms once they grow up. Also, the probability of expensing from ADHD becomes very low or legible once kids grow up. Many kids when grow up remain untreated from ADHD. However, many adults who suffer from ADHD take alcohol or medications that aren’t prescribed by doctors to cope up with the disorder. The symptoms of the disorder also create problems in the personal life and professional life. Patients don’t find good jobs and also find it difficult to express themselves in front of spouse or other family members. There is a difference between ADHD in kids and adults. Kids with ADHD can run, climb or walk briskly without being restless. However, adults get restless and also experience inability to talk and relax. The DSM-5 Diagnostic Criteria is often not found effective in adults while it is effective in kids.

 

References

1.      American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th edition). Arlington, VA; Author

2.      Tidy, C. (2014). Attention deficit Hyperactivity Disorder Pro.

3.      The British Psychological Society and The Royal College of Psychiatrists (2009) Bookshelf ID: NBK 53656

4.      Grohol, M. (2015), PsychCentral.com

5.      Swanson, M. (2013). Understanding –ADHD, Parents-caregivers-of-children-with-ADHD, Symptoms and causes, Researches on ADHD Research

6.      Kooij, S. (2010). "European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD". BMC Psychiatry 10: 67.

 

7.      Lange, K. (2010). "The history of attention deficit hyperactivity disorder". Attention Deficit and Hyperactivity Disorders 2 (4): 241–55.

 

8.      Sroubek, A (2013). "Inattentiveness in attention-deficit/hyperactivity disorder". Neuroscience Bulletin 29 (1): 103–10.

 

9.      Caroline, S. (2010). Encyclopedia of Cross-Cultural School Psychology. Springer Science & Business Media. p. 133.

 

10.  Malenka, R. (2009). "Ch. 13: Higher Cognitive Function and Behavioral Control". In Sydor, A; Brown, RY. Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.). New York: McGraw-Hill Medical. pp. 313–21.

 

11.  Diamond, A (2013). "Executive functions". Annual Review of Psychology 64: 135–68. doi:10.1146/annurev-psych-113011-143750.

12.  Childress, A. (2012). "Pharmacotherapy of attention-deficit hyperactivity disorder in adolescents". Drugs 72 (3): 309–25.

 

13.  Dulcan, M. (2011). Concise Guide to Child and Adolescent Psychiatry (4th ed.). American Psychiatric Publishing. p. 34.

 

14.  Walitza, S. (2012). "Das schulkind mit ADHS" [The school child with ADHD]. Ther Umsch (in German) 69 (8): 467–73.

 

15.  Willcutt, E. (2012). "The prevalence of DSM-IV attention-deficit/hyperactivity disorder: A meta-analytic review". Neurotherapeutics 9 (3): 490–9.

 

16.  Cowen, P; (2012). Shorter Oxford Textbook of Psychiatry (6th ed.). Oxford University Press. p. 546.

 

17.  Faraone, SV (2011). "Ch. 25: Epidemiology of Attention Deficit Hyperactivity Disorder". In Tsuang, MT; Tohen, M; Jones, P. Textbook of Psychiatric Epidemiology (3rd ed.). John Wiley & Sons. p. 450.

 

18.  Emond, V. (2009). "Neuroanatomie structurelle et fonctionnelle du trouble déficitaire d’attention avec ou sans hyperactivité (TDAH)" [Structural and functional neuroanatomy of attention-deficit hyperactivity disorder (ADHD)]. Encephale (in French) 35 (2): 107–14.

 

19.  Singh, I (2008). "Beyond polemics: Science and ethics of ADHD". Nature Reviews Neuroscience 9 (12): 957–64.

 

20.  Wigal. S. (2009). "Efficacy and safety limitations of attention-deficit hyperactivity disorder pharmacotherapy in children and adults". CNS Drugs. 23 Suppl 1: 21–31

21.  Castells X. (2011). Castells X, ed. "Amphetamines for Attention Deficit Hyperactivity Disorder (ADHD) in adults". Cochrane Database Syst. Rev. (6): CD007813.

22.  McDonagh, M. (2011). "Drug Class Review: Pharmacologic Treatments for Attention Deficit Hyperactivity Disorder". United States Library of Medicine.

23.  Prasad. V. (2013). "How effective are drug treatments for children with ADHD at improving on-task behaviour and academic achievement in the school classroom? A systematic review and meta-analysis". Eur Child Adolesc Psychiatry 22 (4): 203–216.

24.  Greenhill, L.  (2008). "Attention deficit hyperactivity disorder in preschool children". Child and Adolescent Psychiatric Clinics of North America 17 (2): 347–366.

25.  Hazell P ( 2011). "The challenges to demonstrating long-term effects of psychostimulant treatment for attention-deficit/hyperactivity disorder". Current Opinion in Psychiatry 24 (4): 286–290.