Attention Deficit Hyperactivity Disorder (ADHD) according to National Institute of Mental Health is a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development .It is a neuropsychiatric condition affecting preschoolers , children and adults. ICD -10 refers to ADHD as hyperkinetic disorder(HKD). The research diagnosis of hyperkinetic disorder requires the definite presence of abnormal levels of intention, hyperactivity, and restlessness that are pervasive across situations and persistent over time and that are not caused by other disorder such as autism or affective disorders (WHO, 1994). This disorder interests me as I have been cases of children with ADHD in my fieldwork place .So I would like to learn more about management plan for clients with ADHD.
The main symptoms of HKD are impaired attention and overactivity and both are necessary for diagnosis. Early onset – behavioural symptoms present prior to 6 years of age, and of long duration are also part of the criteria. Also the impairment must be present in two or more settings (e.g. home, classroom, clinic).Diagnosis of anxiety disorders, mood affective disorders, pervasive developmental disorders and schizophrenia must be excluded. According to the DSM-IV-TR diagnosis of the three types of ADHD are: predominantly inattentive type (ADHD-PI), predominantly hyperactive impulsive type (ADHD-PHI), or combined type (ADHD-C), depends on whether criteria are met for inattention, hyperactivity-impulsivity or both.
Hasan (2005) in his thesis titled ‘Identification of children with attention deficit hyperactivity disorder ADHD and their cognitive profile’ quotes the prevalence rates of ADHD in India , which is around one per cent of total general population , whereas 3-3.5 per cent of children may suffer with ADHD. In India there is very little systematic research in ADHD in children (Singhi P, Malhi P, 1998) . The few studies that are available report prevalence rates ranging from 10 to 20% (Bhatia MS, 1999). The reason for fewer studies in India is attributed to the lack of awareness about the disorder .
Manchanda (2010) in his study ‘School based comparative study of cognitive behavioral and psychological features of DSM IV subtypes of attention deficit hyperactivity disorder in children’ found the overall prevalence of ADHD in India to be 20.1% and nearly one-fifth of the school going population in the age group of 6 to 14 years met the teacher rated diagnosis of ADHD. Prevalence of ADHD was higher for older children than for younger children, moreover the ADHD-Inattentive type was the most prevalent in the older ages, which is primarily due to more children being identified as inattentive type in the older ages. The study also found that ADHD and all its sub-groups were 2.5% more prevalent in males than in females. The reason for this as suggested by researcher is that girls with inattention and/or hyperactive problems are more likely to be unrecognized or under evaluated than boys. A cross-sectional epidemiological study from Bangalore reported the prevalence of ADHD at 1.6% among children aged 4-16 years. The prevalence was higher (3.7%) in urban setting as compared to the rural setting (0.5%)( Srinath et al. 2005)
Counseling and Educational Strategies
Khan(2008) in his study ‘Improving scholastic performance of children with symptoms of attention deficit hyperactive disorder, ADHD through parental counseling and educational strategies’ examined the effectiveness of counseling parents and teachers(18 sittings) and equipping them with educational strategies .Significant improvement was seen in scholastic performance of the children when both parents and teachers were given the management plan. The major objectives of counselling in dealing with the problems of children showing the symptoms of ADHD are to understand the emotional problems of these children and empowering them to develop the habit of doing their work in integrated and somewhat desirable manner. It involves a conscious effort to create and maintain an environment in which such type of children helped in modifying the behaviour, thinking and performance . Alleviating feelings of guilt, anger, denial, and grief reactions of the parents in an empathetic manner is another objective.
Multimodal Treatment approach
A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder was conducted by the MTA Cooperative Group which employed a multimodal treatment study of children with ADHD in which 579 children aged 7 to 9.9 years who were assigned to four treatment groups: (1) state-of-the-art medication; (2) intensive behavioral intervention; (3) combination medication and behavioral intervention; and (4) community treatment (usual care).The results showed that though the combined treatment did not yield significantly greater benefits than medication management for core ADHD symptoms, but may have provided modest advantages for non-ADHD symptom and positive functioning outcomes.
Though there has been a lack of data to support the effectiveness of alternate therapies, D’Cruz (2007) examined the effect of music and dance therapy on 90 boys aged 10-12 years to reduce ADHD symptoms as measured by The ADHD Rating Scale- IV by DuPaul (1998). The intervention groups received 30 sessions of newline40 minutes each of Dance and Music intervention respectively over a period of approximately six weeks. The subscales of the Rating Scale were selected as parameters of ADHD symptoms and were taken at the pretest as well as after the intervention Both Music and Dance interventions, post test scores were significantly lower than those of the comparison group on all parameters.
Behavioral Management and Play Therapy
Bahrani(2011) , in his study on the prevalence of attention deficit disorder among primary schools population of boushehr city-Iran examines the effectiveness of behavior therapy and play therapy in it’s treatment. A sample of 90 individuals were selected from the students who were confirmed as having ADHD inclusive of the three types to form three groups of thirty individuals: A) Control group B) Behavior -therapy group C) Play-therapy group. Group B and C were treated for 24 session therapy for period of 12 weeks at the rate of 2 session per week . B group were subjected to play therapy techniques and C group to behavior therapy techniques. After completing therapy sessions each of the 3 groups were assessed by Vanderbilt Child Symptom Inventory – 4 questionnaire and the rate of effectiveness of each therapy method was compared with control group. Both the therapies were found to be effective in reducing the symptoms of ADHD . Play therapy was found to be effective in reducing inattentiveness whereas Behavior therapy was found effective in reducing hyperactivity.
The commonly used pharmacological drugs are stimulants which act on the dopamine and/or norepinephrine receptors .According to Verma et al (2011), Stimulants taken orally, such as methylphenidate (MPH), dextroamphetamine, and the combination of amphetamine (AMP) and dextroamphetamine, are considered first-line treatment for ADHD. The mechanism of action involves pre-synaptic inhibition of the reuptake through stimulation of inhibitory auto-receptors and alteration in the functional activity levels of catecholamines(Spencer et al,1996). Atomoxetine is the only non-stimulant medication approved by the FDA for the treatment of ADHD in children, adolescents, and adults (Kaplan & Sadock,2015).
Lifestyle management would require requires the combined efforts of a multi-disciplinary team comprising of a pediatrician, clinical psychologist, and special educator. Treatment plans need to be tailor-made according to the spectrum of target symptoms, nature and degree of associated problems, parents, and teacher’s motivation, and family’s strengths and weaknesses. The treatment plans need to be modified to the changing symptoms, family, and environmental conditions (American Academy of Child and Adolescent Psychiatry, 1997).
NIMH?»Attention Deficit Hyperactivity Disorder. (n.d.). Retrieved January 13, 2018, from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
Hasan, M. (2015). Identification of children with attention deficit hyperactivity disorder ADHD and their cognitive profile. INFLIBNET. Retrieved from http://shodhganga.inflibnet.ac.in:8080/jspui/handle/10603/126553
Bhatia, M.S., Choudhary, S., & Sidana, A. (1999). Attention deficit hyperactivity disorder among psychiatric out patients. Indian Pediatrics; 36:583-7.
Singhi, P., & Malhi, P. (1998) Attention deficit hyper-activity disorder in school aged children: Approach and principles of management. Indian Pediatrics, 35: 989-999
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Khan, S. (2008). Improving scholastic performance of children with symptoms of attention deficit hyperactive disorder, ADHD through parental counselling and educational strategies. University. Retrieved from http://shodhganga.inflibnet.ac.in:8080/jspui/handle/10603/49931
Srinath S, Girimaji SC, Gururaj G, Seshadri S, Subbakrishna DK, Bhola P, et al. Epidemiological study of child and adolescent psychiatric disorders in urban and rural areas of Bangalore. India. Indian J Med Res. 2005;122:67–79
MTA Cooperative Group. The multimodal treatment study of children with ADHD: A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56:1073–86.
D’Cruz, N. (2007). The effect of music and dance on children with attention deficit hyperactivity disorder (ADHD). INFLIBNET. Retrieved from http://shodhganga.inflibnet.ac.in:8080/jspui/handle/10603/2016
Verma, R., Balhara, Y. P. S., & Mathur, S. (2011). Management of attention-deficit hyperactivity disorder. Journal of Pediatric Neurosciences, 6(1), 13–18. https://doi.org/10.4103/1817-1745.84400
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (Eleventh edition.). Philadelphia: Wolters Kluwer