Attention Deficit Hyperactivity Disorder (ADHD)

What is ADHD?

The essential feature of attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development of an individual.

Here are some characteristic features of ADHD: 

  • Inattention

It is a behavioral manifestation with difficulty sustaining focus, lack persistence, and inability to maintain organization. 

  • Hyperactivity 

It refers to excessive motor activity (such as a child running about) when it is not appropriate, or excessive fidgeting, tapping, restlessness or talkativeness. 

  • Impulsivity 

Impulsivity includes hasty actions without forethought and that have high potential for harm to the individual (e.g., darting into the street without looking).

Impulsivity reflects a desire for immediate rewards and an inability to delay gratification. 

ADHD mostly begins in childhood with several symptoms present before age of 12 years.

The symptoms of attention-deficit/hyperactivity disorder are manifested in more than one setting (e.g., home and school, work).

What are Causes of Attention-Deficit/Hyperactivity Disorder?

  1. Biological factors 

Attention-deficit/hyperactivity disorder is a medical condition caused my dysfunctions in brain areas and functioning.

The executive functioning in attention-deficit/hyperactivity disorder is impaired.

Some executive functions include inhibition, working memory, self-monitoring, future planning, and verbal, motor and emotional regulation. 

Attention-deficit/hyperactivity disorder also occurs due to low levels of dopamine (neurotransmitter).

  1. Genetic factors

ADHD has a strong genetic basis in the most of the cases. A child with ADHD is four times as likely to have had a relative who was also diagnosed with attention deficit disorder.

Researchers are investigating the role of several genes involved in attention deficit hyperactivity disorder.

Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention.

  1. CNS insults                                                                                                                                                                CNS insults mean brain injury due to trauma and abnormality in brain anatomy function, cognition and exposure to toxic substances. 

Exposure to Toxic Substances as a Cause of ADHD 

Learning and behavioral problems arise in children’s whose mothers smoke tobacco and drink alcohol during their pregnancy.

Exposure to lead in first three years of child causes hyperactivity.

Nicotine, alcohol, and lead are extremely toxic for developing brain tissues and their long term exposure leads to behavioral and cognitive dysfunctions in a child. 

  1. Early Environmental Factors

Prenatal and prenatal complications can also cause attention deficit hyperactivity disorder.

These complications include low birth weight, fetal distress, prenatal alcohol or tobacco exposure, lead poisoning, pesticides, moderate to severe protein deficiency, head injuries. 

  1. Nutrition and Food                                                                                                                           Certain components of the diet, including food additives and sugar have clear effects on behavior. A popular belief is that refined sugar is the cause for a range of abnormal behaviors. Deficiency of omega-3 fatty acids is also liked to attention deficit hyperactivity disorder as; they serve an important function in brain development and functioning. Fish oil supplements helps to reduce attention deficit hyperactivity disorder’s symptoms in some children and improve performance at school. 

What Are Emotional Causes of ADHD Behavior?

Some emotional factors causing attention deficit hyperactivity disorder include: 

  • Death of loved one
  • Life stresses such as divorce of parents
  • Low self-esteem
  • Sexual abuse in childhood
  • Neglected by parents
  • Bullying 
  • Lack of discipline at home
  • Feelings of rejection

How To Manage People With Attention Deficit Hyperactivity Disorder ADHD

We can manage disruptive behaviors of people with ADHD by using medication, behavioral interventions, psychotherapy, play therapy and nutritional therapy. 

Attention Deficit Hyperactivity Disorder (ADHD)

Medication

Medication is the most widely used and effective interventions for attention deficit hyperactivity disorder (ADHD).

Psycho-stimulant Medications

These medications are prescribed to help in the management of ADHD, with improvement rates of 70-80 % compared to placebo response rates of 10-18 %.

The stimulant medications commonly prescribed for children with ADHD are:

  • Dextroamphetamine (Dexedrine)
  • Methylphenidate (Ritalian)

It is the most widely prescribed medicine of ADHD children.

Pemoline (Cylert)

Cylert is a long lasting, less addicting stimulant, but it may have more major side effects and less effectiveness than Ritalin.

Improvements in behavior by use of Stimulants Medications

Stimulant medications improve the performance of ADHD children across a variety of tasks. Stimulants have been shown to result in increased attention, reduced impulsivity, decreased over activity, decreased restlessness, increased compliance, reduced aggressiveness, improved memory, improved social interaction and improved classroom behavior. 

Side Effects of Stimulant Medications

The most common complaints about stimulant medication are side effects.

Stimulants are associated with decreased appetite, weight loss, headache, increased crying, slowing of growth, increased tension, and difficulty in some children. 

Psycho educating Parents

Psycho education is creating awareness among parents about the possible side effects of medicines and monitoring any changes in their child’s behavior to bring immediate attention of physician if it causes severe effects.  

Behavioral Intervention

Medications are frequently combined with behavioral treatments in a package to reduce the child’s negative behavior while enhancing attention and concentration.

Next to medications behavior treatments are widely used for treatment of attention deficit hyperactivity disorder (ADHD). 

The behavior of hyperactive children can be annoying and disruptive, leading to negative attention from adults.

This attention reinforces hyperactive behavior or anger of the child.

Behavioral interventions aims to reinforce task-focused behavior while ignoring or punishing hyperactive and inappropriate behaviors.

Most such interventions involve teaching parents or teachers strategies to reduce the child’s ADHD behaviors. 

Nearly all behavioral interventions for ADHD have several basic principles in common:

  1. Through pre-treatment assessment, using cognitive tests and behavior checklists in addition to interview data
  2. Evaluation of the child and hi/her environment
  3. Involvement of the parents and or teachers in the treatment of the child
  4. Psycho education of the parents or family about attention deficit hyperactivity disorder (ADHD)
  5. Screening and treatment for problems that may hamper the  implementation of a behavioral plan, such as marital dysfunction or lack of motivation 
  6. Homework assignments to be performed between sessions
  7. Understanding of the stress of parenting or teaching a child with ADHD , with appropriate attention to parent and teacher difficulties in implementing a behavioral plan
  8. Flexibility in how the plan is implemented according to the needs of family or classroom
  9. Frequent monitoring of the child’s behavior
  10. Immediate feedback and reinforcement
  11. Ongoing assessment of plan effectiveness
  12. Modification of the plan based on feedback about its effectiveness

Home-Behavioral Plan

Five-step Behavioral Plan

Phase 1- Assessment and Psycho education

First. The family is thoroughly assessed for problems and symptoms, particularly as they relate to the child with ADHD.

Second. ADHD is explained in detail, with attention to specific symptoms, etiology, appearance, features, prevalence, course and treatment.

Third. Behavior management is explained as general technique principles of reinforcement schedules, attention as reinforcement, punishment and operant conditioning.

Fourth. These principles are then specifically applied to ADHD, with particular attention to the effects of ADHD on the parent-child relationship.

Fifth. Fifth three special issues about the use of behavior techniques with ADHD children are covered need for immediate reinforces, need for consistency, and need for the identification of specific behaviors

Phase 2 Attention Training

In this phase, parents are encouraged to spend a certain amount of positive time (typically 15-20 minutes per day) with their child, during which they interact with him or her in a nondirective and nonjudgmental way. 

This special time allows parents to make attention salient to the child, to improve the quality of attention, to make the child’s range of behavior salient to the parent, and to improve the parent-child relationship.

Parents are eventually encouraged to provide attention when their child is behaving appropriately and to ignore inappropriate, off-task behavior. Punishment is not used at this time.

Secondly, parents are encouraged to use attention as a reinforcer in other situations, providing attention when the child is engaged in appropriate behavior and withdrawing attention during hyperactive, off-task behavior.

Lastly, Parents are taught to increase the child’s frequency of independent behavior by giving occasional attention-reinforcement when the child is not depending on the parent for entrainment.

Phase 3 Reinforcement Techniques

Initially in this phase, parents select a single behavior to be controlled, and this behavior is tied to a clear reinforcement system.

A system of token reinforcement may be used, or primary reinforces may be provided at the time of correct manifestation of behavior.

The selected behavior should be easily observable, clearly defined, and relatively frequent. 

Let’s have a look at an example.

Select compliance with initial parental request as the target behavior, using a token system a reinforcer must be selected and administered.

Reinforces that have shown the greatest effect on ADHD children’s behavior are delivered immediately following the behavior. 

Phase 4 Maintenance

This phase deals with the future implementation of the behavior plan to new situations, without the therapist as a guide.

Parents review and plan with the therapist about future implementation of behavioral management in home, anticipating problems and events.

Follow-up sessions are scheduled, and the parents are encouraged to continue monitoring of behavior for discussion at follow-up.

Phase 5 Follow-Up

Finally, several weeks after termination of week therapy, the parents meet with the therapist to discuss their progress.

Follow up observational data are collected and problems are discussed.

If the system has completely broken down, several weeks of additional therapy may be required.

Contingency Management

School-based behavioral techniques also emphasize modification of contingencies to change ADHD.

Behaviors that are inappropriate but not dangerous, destructive or disruptive may be ignored by the teacher. 

Certain behaviors exhibited by the ADHD child cannot be ignored.

Generally these behaviors are disruptive, dangerous, or impinge on the freedom of other children.

In these cases punishment techniques can be effective if properly administered.

Token Economies

Token economy could be established in the classroom in some cases of children with attention deficit hyperactivity disorder.

In this technique the child is awarded with points for desirable behaviors and sometimes points are removed for undesirable behaviors (response cost).

Token economy are not without risk.

Other children in the class room may be jealous of the ADHD child and misbehave in the hopes of getting their own token economy.

Keep the target behaviors simple initially then increase their difficulty with time.

Repeat this token reinforcement until child acquires intrinsic motivation for good behavior.

The token economy must be kept as simple for the child to understand.

You should not generalize the system of token economy at all places like home and other class rooms. 

Token economies require consistent attention and application from the teacher, which might be difficult in some cases. 

Psychotherapy

Cognitive-Behavioral Intervention

Cognitive-behavioral interventions for attention deficit hyperactivity disorder directly address attention and concentration deficits with cognitive self-control strategies.

These interventions teach the children to use a combination of self-talk, cognitive problem solving strategies that enhance attention, motivation and behavioral self-control.

Self Talk

In self-talk you have to remind yourself about the appropriate cognitions and behaviors to achieve a desired goal.

It is like you reinforce yourself and get motivated to solve problems effectively. 

Match Game

In this game a target behavior (sitting still, for example) is chosen, and positive and negative examples of the behavior are demonstrated by the therapist, along with ratings for each behavior on a 1 (bad) to 5 (good) scale. 

The child is then engaged in an activity with other children.

Following the activity, the therapist and the child independently rate the child’s performance on the target behavior.

The ratings are then compared and discussed. Discussion promotes the child’s self-awareness and self-monitoring of the target behavior.

Reinforcement for correct matches can be used to increase the child’s motivation.

Attention Deficit Hyperactivity Disorder (ADHD)

Problem Solving

Five-step solution was proposed by Fehling et al. (1991) which is shown below:

Attention Deficit Hyperactivity Disorder (ADHD)

Various techniques including modeling, role playing, homework, and reinforcement could be used to teach problem-solving process.

Cognitive behavioral interventions are often found to be less effective than medication or behavioral treatment.

Play Therapy/Psychodynamic Psychotherapy

Play therapy is effective for younger children and supportive/ psychodynamic psychotherapy is effective for older children in managing low self-esteem, anger, frustration and aggression that accompany attention deficit hyperactivity disorder.

Play therapy addresses anxious, depressive, and anger symptoms resulting from the experiences of a child with attention deficit hyperactivity disorder (ADHD).

Dietary Interventions

Certain toxins (e.g. lead, mercury) can lead to disorganized or overactive behavior.

Foods rich in protein are beneficial for ADHD. For instance lean beef, pork, poultry, fish, eggs, beans, nuts, soy, and low-fat dairy products.

Adding minerals and vitamins like Zinc, Iron, and Magnesium also improves dopamine levels in brain.

Conclusion

When we talk about the management of Attention Deficit Hyperactivity Disorder we used different interventions according to the severity level and presenting complaints of the ADHD children.

The goal of therapy is to cope with, not cure ADHD, and to provide a good, improved quality of life to the individuals. Major interventions used for the management of the ADHD children are Medications, Behavioral Interventions, Psychotherapy and Parental counseling. 

Behavioral interventions reinforce task-focused behavior while ignoring inappropriate behaviors.

We used token economy, contingency management and time out in some cases punishment can also be used to manage behavioral problems of people with attention deficit hyperactivity disorder. 

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Frequently Asked Question about Attention Deficit Hyperactivity Disorder (ADHD) (FAQ)

What are types of ADHD?

There are three major types of ADHD:

– Inattentive type: They make careless mistakes as they have difficulty maintaining and sustaining attention, and easily get distracted.

– Hyperactive type: They have difficulty to remain at a position; they run excessively, do fidgeting, talkativeness and interrupts others. 

– Mixed type: They express symptoms of inattention and hyperactivity. 

What are causes of ADHD?

Attention deficit hyperactivity disorder is caused by alterations in the brain and its functioning.

Imbalances in neurotransmitters particularly dopamine leads to symptoms of ADHD.  

Can ADHD be treated?

Yes it is treatable but symptoms may return.

Treatment includes medication (stimulants) and behavioral modification techniques. 

Please ask any questions or write your opinion about the article in the comments section below.

Citations

Barkley, R. A. (1997). ADHD and the nature of self-control. Guilford Press.  

Comer, R. J. (2012). Abnormal psychology (8th ed.). USA: Worth Publishers.

Greenhill,L.L. (1989). Pharmacologic treatment of Attention Deficit Hyperactivity Disorder. Pediatric    Psychopharmacology, 15, 1-27.

Newby,R.F.,Fischer,M., and Roman ,M.A. (1991). Parent training for families of children with ADHD. School psychology Review, 20,252-265.Anastopoulos,A.D., Dupaul,G,J., and Barkley,R.A.(1991). Stimulant medication and parent training therapies for Attention Deficit Hyperactivity Disorder. Journal of Learning Disabilities, 24,210-217.

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