1. What Are The Effects Of Multimodal Treatment Approaches on Children with ADHD & Co-morbid Disorders? Rachel Golub Argosy University Psy492 Advanced General Psychology 6-22-2011

2. HYPOTHESIS I believe that a multimodal biopsychosocial approach is the most effective approach to treatment for childhood ADHD. Through medication, behavioral modification, parent and teacher education as well as support for families of children with ADHD, this disorder can be effectively managed and in many cases, symptoms may be overcome.

3. What is ADHD? According to the Diagnostic and Statistical Manual of Mental Health Disorders (4th ed.). (1994), attention deficit hyperactivity disorder (ADHD) “is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development (criterion A)” (p.78).

4. Challenges of ADHD ADHD can pose many problems for children and adolescents all the way into adulthood. It can cause stress for children both at home and school. It can be challenging to treat this disorder with medication as well as behavior modification, especially when co-morbid disorders are present. It can be particularly frustrating for parents and teachers as they try to understand and modify teaching and parenting approaches to accommodate the disorder, and help the child to succeed. Much patience is required by parents and health professionals when treating a child with ADHD in order to match the appropriate treatment interventions to the child. It is important for teachers to have some knowledge and understanding of ADHD, as well as treatment and behavior modification options in order to help the child to be successful in the classroom.

5. Psychosocial Environment Research demonstrates that the psychosocial environment contributes to the degree to which children with ADHD learn to manage their attention and over activity (Lange, Sheerin, Carr & Dooley, 2005). Lange et al., (2005) state “social systems which contain members who are most tolerant of inattention, over activity and impulsivity, and which offer structured and supportive opportunities for developing self-regulation skills, probably help youngsters vulnerable to ADHD symptomology to learn self-regulatory skills” (p.78). Therefore, effective treatment includes “behavioral parent training, school-based contingency management and home-school reporting systems, and self-instructional training” (Lange et al., 2005, p.78).

6. Risks and Social Dilemma’s We need to be aware of certain risks and social dilemmas in the diagnosis and treatment of ADHD that could impact the child. For example, Kean (2005) offers a contrasting viewpoint with concerns regarding the frequent and increasing number of ADHD diagnosis performed in pediatrician’s clinics today. In fact, Kean (2005) points out “the subjective nature of the diagnosis and lack of a clinical test for ADHD opens the possibility that any child in conflict with parents or the school system can be given the diagnosis” (p.134). In addition, Kean (2005) claims that in his research on the risks of society and ADHD, it was demonstrated that ADHD diagnosis is frequently given in only a few minutes during the first doctor visit. Furthermore, doctors often use a trial and error approach using a drug trial as their way of determining if treatment applies to a particular child (Kean, 2005).

7. Contrasting View Points Kean (2005) shows concern about other social problems concerning ADHD that should be considered. These are certain problems at school that can contribute to the disorder such as a lack of supervision or behavioral management, dissatisfaction, bullying as well as labeling of the child (Kean, 2005). Kean (2005) states “problems of educational practice, including behavior problems or learning failure, have now been transferred to a model that potentially identifies any child who does not fit with the system as having a medical disorder” (p.134).

8. Adams, Finn, Moes, Flannery & Rizzo (2009) support the previous research and authors mentioned above, as they confirm that besides affecting a child’s academic performance, ADHD also affects the child’s personal and social development and is also a risk factor for other co- morbid disorders. Adams et al., (2009) state that despite such negative and frequent consequences of ADHD, the specific mechanisms behind the disorder have not yet been defined.

9. Family Factors As we attempt to understand the effects and treatment methods of ADHD, family factors that are involved in the disorder must be considered. According to Deault (2010), “the most recent research evidence uses correlational designs to show that ADHD is associated with problematic family functioning, including greater stress within the family, higher rates of parental psychopathology and conflicted parent-child relationships, which appears to be exacerbated in children with co-morbid oppositional and conduct problems” (p.168). Parents need to understand how they can assist their children with ADHD to manage their emotions and behavior, as well as helping them to develop friends and social networks (Deault, 2010). It becomes more challenging for parents as the child gets older, and moves through different developmental stages, which requires some fine tuning of parental abilities (Deault, 2010). Therefore, the more education, help and support the parents can receive, the better equipped they will be to handle their child’s disorder. This requires ongoing education, help and support for the parents.

10. Co-Morbid Disorders Deault (2010) explains that children who have ADHD are also more at risk for co morbid disorders. For example, oppositional defiant disorder occurs in 35-60% of ADHD cases, conduct disorder occurs in 30-50%, and anxiety and mood disorder occur in 20-40% of cases (Deault, 2010). In addition, functional impairments such as academic failure, negative social behavior and impaired peer relationships can also accompany ADHD (Deault, 2010). Deault (2010) explains that research results “indicate that parenting stress and conflict within the family show more robust associations with oppositional and conduct problems, than with ADHD symptoms alone, both for families of school-aged and adolescent children with ADHD” (p.176).

11. Sleep Disturbances To add to the list of difficulties caused by ADHD, sleep disturbances are also a concern. In fact, Weiss & Salpekar (2010) state that parent-reported sleep problems occur in approximately 25-50% of children with ADHD. Weis & Salpekar (2010) also explain that the most frequent sleep problems amongst this group include resistance to going to bed, problems staying asleep, morning tiredness and feeling tired during the daytime hours. Other studies also reveal other sleeping problems such as “sleep latency, decreased rapid eye movement stage sleep, decreased overall sleep time and increased nocturnal activity in children with ADHD” (Weiss & Salpekar, 2010, p.812). There are also studies that report a greater number of sleep disorders including restless leg syndrome, periodic limb movement disorder and sleep disordered breathing (Weiss & Salpekar, 2010).

12. This research reveals the need to evaluate sleep difficulties in children when considering an ADHD diagnosis. This is because sleep disturbances can have a negative impact on the child’s quality of life (QoL) as well as their emotional well being (Weiss & Salpekar, 2010). This also adds more stress for the parents and can also have a negative effect on parenting skills. Weiss & Salpekar (2010) explain that parents of children with ADHD, who lose sleep due to the child’s sleep disorder, are more likely to be clinically depressed or anxious than parents of children with ADHD who do not have sleep disturbances.

13. ADHD in Adults? Many individuals believe that ADHD only occurs in children and adolescents. In fact, according to Garnier-Dykstra, Pinchevsky, Caldeira, Vincento & Arria (2010), 4.5 million children in the United States are affected by ADHD. Even though the disorder is believed to improve with age, still one-third to one-half of those children still suffers the symptoms into adulthood (Garnier-Dykstra et al., 2010). Unfortunately, many more college students never even receive a diagnosis due to the failure to recognize their symptoms or associate them with ADHD.

14. Stimulant Medication Even though more research is still needed, over the last ten years, great strides have been made in the treatment and understanding of ADHD (Wigal, 2009). This includes newer stimulant medications, combined use of medication and behavioral therapies as well as a broader comprehension of the neurobiology of ADHD in 6-12 year old children (Wigal, 2009). According to Wigal (2009), stimulant medication is the US FDA-approved medical treatment of choice for ADHD and has an impressive rate of response. Most patients however, benefit from combined medical and behavioral therapy (Wigal, 2009). Unfortunately, some patients are not able to take stimulant drug therapy and may be better suited to non-stimulants such as bupropion, guanfacine and clonidine as an alternative (Wigal, 2009). Often this is the case with patients who have co morbid disorders such as anxiety disorders, due to being contraindicated for stimulant use due to other problems or risks for stimulant abuse (Wigal, 2009).

15. Risks of Stimulant Medication Stimulant medications which include amphetamines and methylphenidate are considered to be safe as well as effective in treating ADHD, but unfortunately do come with the potential for abuse (Wigal, 2009). Stimulant medication can also come with certain side effects and so should be carefully considered before being prescribed. Side effects can include weight loss, reduced appetite, cardiovascular symptoms, heart palpitations, increased blood pressure, aggression and depression (Janols, Lilliemark, Klintberg & Von Knorring, 2009). However, amphetamines have proved to have positive effects both on overactive and impulsive behavior since 1937 (Janols et al., 2009).

16. Stimulant Medication Response Rates The response rate to stimulant drug therapy has been so high that 70% of patients have a response to the first stimulant, and over 90% response rates have been reported by switching non-responders to a different stimulant (Wigal, 2009). For these reasons, “stimulants continue to be the mainstay of ADHD medical treatment” (Wigal, 2009, p.23). There are also newer formulations of drug therapy which include extended release to assist with symptom control throughout the whole day (Wigal, 2009).

17. Quality of Life (QoL) I believe that the quality of life (QoL) for children with ADHD is significantly affected by the disorder, especially when treatment is not effective. Danckaerts, Sonuga-Barke, Banaschewski, Buitelaar, Dopfner, Hollis, Santosh, Rothenberger, Sergeant, Steinhausen, Taylor, Zuddas and Coghill (2009) reviewed several studies in children with ADHD to determine the impact of ADHD on QoL as well as other related issues. Danckaerts et al., (2009) discovered that parents of children with ADHD reported strong negative effects on QoL across a wide spectrum of psycho-social, achievement and self-evaluation areas. Interestingly, studies showed that children with ADHD often do not see themselves as functioning any differently from children without ADHD (Danckaerts et al., 2009). Danckaerts et al., (2009) note that “ADHD has a comparable overall impact on QoL compared to other mental health conditions and severe physical disorders” (p.84).

18. Treating ADHD with Co-Morbid Disorders It is a challenge to treat ADHD when it is accompanied with co-morbid disorders such as oppositional defiant disorder (ODD), depression and anxiety. While stimulant medication in combination with psychosocial and behavioral approaches can help to successfully manage symptoms, some children experience negative side effects and are unable to take them. Stimulant medications can further agitate anxiety and increase symptoms and difficulties, thus making the situation worse. Much patience is needed on the part of the child, physician, parents and schools in order to successfully treat ADHD and co-morbid disorders. Danckaerts et al., (2009) point out that several studies have shown that children with ADHD and co morbid disorders have poorer QoL than those with ADHD alone. For these reasons, it is imperative that future research is continued towards finding solutions and treatments to help such children to better function and succeed.

19. Risk Factors If ADHD is left undiagnosed and untreated, children are at risk for behavior problems, as well as failing to reach their academic potential. They can regrettably be punished at school and home due to negative behaviors caused by the disorder. This can lead to other problems which include low self-esteem, anger, and frustration, and later even possible self-medication through substance abuse.

20. Summary The effects and treatment of ADHD in children can be challenging, as well as being a long and arduous journey for both the child and the parents involved. Finding the best treatment involves dedication, determination and patience. Treating ADHD involves more than medication alone. It involves diligent management and follow-up by the parents as well as clear communication and co-operation with the school. Psychosocial and behavioral modification training is needed as well as a strong support system for the child and parents.

21. Additional Research All the research in my literature review confirms that more research on ADHD and co-morbid disorders is needed as well as on the most effective ways to intervene with treatment. In order to further develop this area of study, future research questions would be of value as follows: What are the risks and protective factors involved in childhood ADHD? What are the most effective methods of treatment for ADHD when co-morbid disorders are present? What are the affects of family factors such as problematic family functioning, stress, parent psychopathology and conflicted parent-child relationships on ADHD in children? How does the psychosocial environment contribute to the success of ADHD treatment in children? What role does diet and nutrition play in ADHD?

22. Multimodal Biopsychosocial Approach After considering all the above research, I support the belief that an integrated, multimodal biopsychosocial approach is the best method of treatment for ADHD. Treatment must be individually tailored to the child and involve medication, behavioral modification, parent and teacher education. Furthermore, additional support for families of children with ADHD should be provided. By taking this approach to treatment, this disorder can be effectively managed and in many cases symptoms may be overcome. Children with ADHD may then experience success both academically and socially, as well as enjoy a well deserved and improved quality of life so that they will be fully functioning, happy and successful members of our society.

23. References Adams, R., Finn, P., Moes, E., Flannery, K., & Rizzo, A. (2009). Distractibility in Attention/Deficit/ Hyperactivity Disorder (ADHD): The Virtual Reality Classroom. Child Neuropsychology, 15(2), 120-135. Retrieved May 12, 2011 from EBSCOhost. Danckaerts, M., Sonuga-Barke, E. S., Banaschewski, T., Buitelaar, J., Döpfner, M., Hollis, C., & ... Coghill, D. (2010). The quality of life of children with attention deficit/hyperactivity disorder: a systematic review. European Child & Adolescent Psychiatry, 19(2), 83-105. Retrieved May 12, 2011, from EBSCOhost. Deault, L. C. (2010). A Systematic Review of Parenting in Relation to the Development of Comorbidities and Functional Impairments in Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Child Psychiatry & Human Development, 41(2), 168-192. Retrieved May 12, 2011 from EBSCOhost. Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (1994). American Psychiatric Association, Washington, DC Garnier-Dykstra, L. M., Pinchevsky, G. M., Caldeira, K. M., Vincent, K. B., & Arria, A. M. (2010). Self-reported Adult Attention-Deficit/Hyperactivity Disorder Symptoms Among College Students. Journal of American College Health, 59(2), 133-136. Retrieved May 12, 2011 from EBSCOhost.

24. Janols, L., Liliemark, J., Klintberg, K., & von Knorring, A. (2009). Central stimulants in the treatment of attention-deficit hyperactivity disorder (ADHD) in children and adolescents. A naturalistic study of the prescription in Sweden, 1977–2007. Nordic Journal of Psychiatry, 63(6), 501-516. Retrieved May 12, 2011, from EBSCOhost Kean, B. (2005). The Risk Society and Attention Deficit Hyperactivity Disorder (ADHD): A Critical Social Research Analysis Concerning the Development and Social Impact of the ADHD Diagnosis. Ethical Human Psychology & Psychiatry, 7(2), 131-142. Retrieved May 12, 2011, from EBSCOhost. Lange, G., Sheerin, D., Carr, A., Dooley, B., Barton, V., Marshall, D., & ... Doyle, M. (2005). Family factors associated with attention deficit hyperactivity disorder and emotional disorders in children. Journal of Family Therapy, 27(1), 76-96. Retrieved May 12, 2011, from EBSCOhost. Sherman, J., Rasmussen, C., & Baydala, L. (2008). The impact of teacher factors on achievement and behavioural outcomes of children with Attention Deficit/Hyperactivity Disorder (ADHD): a review of the literature. Educational Research, 50(4), 347-360. Retrieved May 12, 2011, from EBSCOhost Weiss, M. D., & Salpekar, J. (2010). Sleep Problems in the Child with Attention-Deficit Hyperactivity Disorder. CNS Drugs, 24(10), 811-828. Retrieved May 12, 2011, from EBSCOhost.

25. Wigal, S. B. (2009). Efficacy and Safety Limitations of Attention-Deficit Hyperactivity Disorder Pharmacotherapy in Children and Adults. CNS Drugs, 2321-31. Retrieved May 12, 2011, from EBSCOhost.