Term Paper: ADHD, or Attention Deficit Hyperactivity

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[. . .] Students not only showed improved ability to complete tasks on time, they also exhibited reduced negative behavior. When students recognize that they can succeed at school-related tasks, they develop a better sense of self-

Overview of ADHD worth, feel reassured and are motivated to do better. Such a technique of positive reinforcement could be used to develop positive outcomes.

Bridging from previously taught concepts to new concepts. Students with ADHD, burdened with learning disabilities, need help with processing the material that is being taught. "By providing opportunities for students to look for connections between what they have learned and what they are now studying, students are better able to expand on the ideas that they are learning (Howell, Fox, & Morehead, 1993)."

Providing opportunities for students to apply new concepts to the reality of their daily lives. Students with ADHD tend to be very egocentric and are often unaware of important day-to-day events that are taking place in the world around them. When classroom teachers employed the technique of using focus journals to help them apply concepts that they studied, to the reality of their daily lives, results were very encouraging. Students could express their opinions on diverse topics, integrating what they learnt with their experiences.

Using cueing systems. Students with ADHD have difficulty sustaining attention on what is taught in the classroom. Teachers used the technique of visual cueing - through the use of ordinal words like first, second etc. - and also used overhead transparencies to reinforce the presentation of ideas with graphics. This strategy helped involve students beyond listening and reading, to the actual articulation of ideas based on the material that was being presented.

Overview of ADHD

The transparencies serve as a visual organizer that the student can refer to at a later point, to complete some assignment based on this learning.

Using contingency-based self-management techniques. This strategy usually involves a reward system that encourages students to keep track of their own behavior. In the contingency-based self-management system, the student evaluates his own behavior on a 5-point scale (0=unacceptable to 5=excellent) at the end of an agreed time period, and the points earned could be used for privileges, leading to positive behavioral changes.

Self-monitoring of attention to increase on-task behavior. Students with ADHD have difficulty in remaining on-task for extended periods of time. To overcome this, students are helped to use self-monitoring techniques in which they ask themselves questions like: "Was I paying attention?" And recording a "Yes" or a "No" on a score sheet every time they hear a tone on a tape recorder, to begin with. They begin to understand what triggers their off task behavior and thus learn to return to on task behaviors.

In an article titled: Are Students with ADHD More Stressful to Teach? The authors (Greene, Beszterczey, Katzenstein, Park, & Goring, 2002), research the question of whether students with ADHD contribute to increased levels of stress in teachers.

Overview of ADHD

Using the Index of Teaching Stress (ITS) as an instrument to assess a teacher's subjective level of stress and frustration (in response to teaching and interacting with a particular student), it was found that elementary school teachers rated students with ADHD as significantly more stressful to teach than their classmates without ADHD. Students with ADHD who also exhibited oppositional or aggressive behavior, were rated as significantly more stressful to teach than students with ADHD.

The article provides insights into the problems facing teachers as well as parents when having to deal with children having ADHD.

A review of twenty six experimental articles on interventions for treating and managing preschool children with ADHD is presented the article: Early Intervention for Preschool-Age Children with ADHD: A Literature Review (McGoey, Eckert & Dupaul, 2002).

Children with ADHD often are described as careless, disorganized, carefree, and non-reflective, even as preschoolers. They are frequently disruptive, non-compliant and defiant in response to commands and authority figures. Thus, even at preschool-age, children with ADHD are often at-risk for expulsion. Removal from preschool will mean a denial of opportunities to practice and develop pre-academic and social skills, and to be exposed to the structured setting of the classroom. In this review, the authors emphasize the need to take initiatives for early intervention in the case of children with ADHD. Failure to take

Overview of ADHD cognizance of this need with the urgency it deserves, could put children at risk in terms of escalation of the problems as they grow older.

The authors also suggest that practitioners should tailor the intervention to match the needs of the child. For example, while psychostimulant medication has been shown to be successful, it may produce significant side effects in a preschool-age child. School practitioners therefore should take an active role in monitoring the effects of medication. Also, systems should be in place, whereby immediate and consistent feedback is given, supplemented by age-appropriate rewards and procedures. Parents must be enabled to provide support and guidance to affected children, and need appropriate training. A well designed program incorporating the efforts of all concerned, could result in a potentially successful treatment approach.

The AAP Guideline on Treatment of Children with ADHD (Chatfield, 2002) reviews the clinical practice guideline for the treatment of school-aged children with ADHD issued by The Committee on Quality Improvement and the Subcommittee on Attention Deficit Hyperactivity Disorder of the American Academy of Pediatrics (AAP).

The guideline is intended for primary care physicians who have accurately established the diagnosis of ADHD, and focuses on the treatment of children with ADHD without major comorbidity.

Overview of ADHD

The following are the complete recommendations from the guideline:

1. Primary care physicians should foster a partnership with the family, the child having ADHD, teachers, psychologists and counselors. They should also provide resources and coordinate health and other services together with the development of child-specific treatment plans and goals, including plans for follow-up.

2. Development of three to six specific outcomes are recommended, such as improvements in relationships, self-esteem, and school performance, and a decrease in disruptive behaviors before developing a treatment plan. Because the core symptoms of ADHD (inattention, impulsivity, hyperactivity) impact the child's performance in many areas, the main focus of treatment should be to maximize function.

3. The physician should recommend stimulant medication Short-term efficacy in improving the core symptoms of ADHD and social and classroom behaviors, has been demonstrated. Stimulants comprise the first-line treatment and include methylphenidate or dextroamphetamine. Second-line treatment includes antidepressants (imipramine, desipramine) and bupropion.

If one stimulant does not work for a child at the highest feasible dose, the physician should recommend another.

Overview of ADHD

4. Physicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions, when the selected management has not met target outcomes for a child with ADHD.

5. The physician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child.

In addition to a system of follow-up office visits, the AAP recommends that primary care physicians be in continued communication with others involved, like parents, teachers and counselors). Behavior report cards and checklists are two methods of obtaining ongoing information.

Child-specific treatment plans, increased treatment options, and long-term efficacy are areas in which the AAP recommends further research.

In an article titled Tailored Psychosocial Treatments for ADHD: The Search for a Good Fit (Abikoff, 2001), the author advocates the need for drawing up a treatment plan that meets the needs of individual patients. Such a plan still remains elusive, given the complex design and needs assessment methodologies that are involved.

Overview of ADHD

Goal attainment scaling (GAS) to identify and evaluate outcome measures, hybrid efficacy-effectiveness designs to assess the impact of treatment preference on outcome, are two suggested techniques.

Goal attainment scaling recognizes that a focus on individualized target behaviors is a central theme of behavioral treatment, and provides for the identification, prioritization, and measurement of change in behaviors, domains, or both that are specifically relevant and important to the individual patient as well as to significant others. In effect, GAS is similar to some aspects of clinical practice wherein the clinician, in concert with the patient, integrates the problems and treatment goals into a treatment plan. These goals are periodically evaluated and changed as needed.

Treatment Preference is another tailoring strategy, which is especially relevant in the treatment of ADHD, where parents often have strong attitudes and beliefs regarding the use of medication as well as psychosocial treatments (MTA Cooperative Group, 1999a).

Hybrid study designs, in which parallel efficacy and effectiveness studies would be conducted concurrently, can be used to evaluate the impact of treatment preference on outcome (Abikoff, 1998, in press). The findings from hybrid designs can be especially relevant to clinical practice.

Overview of ADHD

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