Highly Active Children with Short Attention Spans

Introduction

Dear Writer,

Thank you for choosing our research team to aid you in collecting relevant information regarding highly active children with short attention spans. We have decided to focus on children who have been clinically diagnosed with Attention Deficit Hyperactivity Disorder in order to clearly specify the group of subjects being studied. We have highlighted a wide range of medicinal and therapeutic approaches to treating children with ADHD and have also included a few alternative approaches for your consideration. We hope that you find our annotated resources most helpful in your endeavors.

Sincerely,

T. Caroll, A. Khemraj, L. Reddicks-Clarke & L. Yeung

Operational Definitions

  • Highly Active - Clinically diagnosed with Attention Deficit Hyperactivity Disorder
  • Medication - Any chemical or natural treatment administered orally or by injection
  • ADHD Therapy - Any social treatment acknowledged in at least one scientific journal or official medical, psychological of governmental website to be a possible treatment for ADHD
  • Child - Any person under the age of 18

Diagnosis of ADHD

The diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) is not a straightforward process. There is no single test that can diagnose ADHD, and its symptoms can be easily confused with the symptoms of other learning disabilities or psychiatric problems such as anxiety or depression.

In the DSM-IV, ADHD is a psychological disorder characterized by a pattern of behaviour, present in a variety of settings, that can have a negative impact in social, educational or occupational settings. Symptoms are divided into two categories: Inattention, and Hyperactivity and Impulsivity. Symptoms from the Inattention category include: failure to pay attention to detail, is often easily distracted and shows signs of trouble organizing tasks. Symptoms from the Hyperactivity and Impulsivity category include: often fidgets, often talks excessively and often has trouble waiting her or his turn. In order to be diagnosed with ADHD, children must exhibit six or more symptoms in each category, up to age 16, or five or more for adolescents 17 and older; symptoms need to be present for at least 6 months, and must be considered inappropriate for the child's age level.

Centers for Disease Control and Prevention, Division of Human Development, National Center on Birth Defects and Developmental Disabilities. (2014). Attention deficit / hyperactivity disorder. Retrieved from Centers for Disease Control and Prevention website: http: //www.cdc.gov/ncbddd/adhd/diagnosis.html

The impact of symptoms found in persons with ADHD varies on many levels throughout an individual's life span. For example, younger children and adolescents suffer symptoms such as impaired peer relationships, poorer academic performance (and therefore increased risk of dropping out) and increased risk of injuries and accidents. On the other hand younger adults are shown to have greater social difficulties, earlier sexual activity which links to higher pregnancy rates, transmission of STDs. Furthermore adult individuals diagnosed with ADHD are known to likely commit driving violations, obtain lower job status:frequent job loss, higher chance of unemployment; less stable relationships, and higher divorce rates. In short those who are diagnosed with ADHD are subject to overall decreased quality of life.

Weiss, M.D., Childress, A.C., Pucci, M.L., Hechtman, L. (2011). //Review of Long-Acting Stimulant and Nonstimulant ADHD Pharmacotherapy in Canada Supplement Journal of the Canadian Academy of Child and Adolescent Psychiatry. 20(2). S1-20. http: www.cacap-acpea.org/uploads/documentsSupplement_2010_11_Shire_May_2011_final.pdf//

Symptoms

There are three types of ADHD symptoms, these are :

Trouble Paying Attention (inattention)
Those affected by this are easily distracted and fins it hard to focus on one task

Trouble sitting still for even short time periods (hyperactivity)
Those affected by this may squirm, fidget or run around at the wrong times. They tend to feel restless and/or fidgety

Acting before thinking (impulsivity)
Those affected by this tend to speak/laugh too loudly, become angrier than necessary given the situation. Lack of patience, make quick decisions only thinking of short-term gain.
Symptoms are least identifiable in preschool aged children because it tends to be seen as regular behaviour, but becomes most identifiable in the teenage years as symptoms may get worse.

Gender Differences
When it comes to differences in symptoms among boys and girls in some cases there are quite a few. Boys have been found to be more hyperactive than girls, while girls are more inattentive than boys. Girls also have more problems with depression and anxiety. A very important factor noted were the rates of suicide and self-harm among boys and girls with ADHD. Girls having a rate of 17.9% while boys have a rate of 5.7%.

The table below shows the differences of symptoms among gender

Variable Boys vs Girls
Hyperactivity/impulsivity B>G
Inattention G>B
Tactile defensiveness (sensory processing) G>B
Low self-esteem G>B
Poorer coping skills G>B
Deficit in IQ G>B
Deficit in executive functioning G=B
Motor function deficits B>G
Anxiety G>B
Depression G>B
Substance abuse G>B
Treatment response to psychosocial interventions G=B
Rates of school suspensions B>G

Rucklidge, J. (2010). Gender Differences in Attention-Deficit/ Hyperactivity Disorder. Psychiatric Clincs of Norht America , 357-373.

It has also been found that it is easier to diagnosis females with ADHD rather than males due to the self-reported anxiety symptoms in females with ADHD.

Skogli, E., Teicher, M., Andersen, P., Hovik, K., & Oie, M. (2013). ADHD in girls and boys- gender differences in co-existing symptoms and executive function measures. BMC Psychiatry.

Causes (risk factors)

Genetics
ADHD (attention deficit hyperactivity disorder) like many other disorders can be inherited. The chances of a person having ADHD are two to eight time more likely once a relative has it. Several studies have been done with children who have been adopted that have ADHD. These studies have strengthened the argument of the disorder being hereditary and not based on environmental factors.

Pre/perinatal risks associated with ADHD
Maternal smoking during pregnancy has been one of the most cited prenatal risks associated with increased rates of ADHD. This risk increase with the amount of smoking the mother does. It has been noted that as the rates of maternal smoking during pregnancy have decreased the ADHD rates have similarly dropped. Another risk noted is maternal stress during pregnancy this has also been associated with ADHD for the child. Intake of alcoholic beverages has also been seen as a risk factor by some but not all studies.

Environmental toxins risk
Studies show that exposure to organic pollutants and lead has led to damage in the neural system and therefore ADHD. The environmental toxins include but are not limited to pesticides, toxic industrial products and lead.

Pre/perinatal factors Environmental toxins Dietary factors Psychosocial adversity
Maternal smoking, alcohol and substance misuse (risk but not proven causal risk factor) Organophosphate pesticides (risk but not proven causal risk factor) Nutritional deficiencies eg zinc, magnesium, polyunsaturated fatty acids (correlate not yet proven risk factor) Family adversity & low income (correlate not yet proven risk factor)
Maternal stress (risk but not proven causal risk factor) Polychlorinated biphenyls (risk but not proven causal risk factor) Nutritional surpluses eg sugar, artificial food colourings (correlate not yet proven risk factor) Conflict/parent–child hostility (correlate not yet proven risk factor)
Low birth weight and prematurity (risk but not proven causal risk factor) Lead (risk but not proven causal risk factor) Low/high IgG foods (correlate not yet proven risk factor) Severe early deprivation (risk, likely causal risk factor)

Thapar, A., Cooper, M., Eyre, O., & Langley, K. (2013). Practitioner Review: What have we learnt about the causes of ADHD? The Journal of Child Psychology and Psychiatry , 3-16.

Another great source that affirms that ADHD is chemically produced and genetically transmitted is ADHD: Attention-Deficit Hyperactivity Disorder in Children, Adolescents and Adults. This book is important because it gives credence to the belief that ADHD is inborn and assures readers that it is not a product of child rearing techniques. However, it does explain that these techniques can affect the seriousness of the problems and provides behavioural techniques that can be utilized early in order to minimize severity. This book also includes interesting theories about prenatal causes for ADHD like small birth size due to prematurity and other variations in the mother's biological processes during pregnancy that could result in fetal maldevelopment. An important point that guardians of children with ADHD should be aware of is that they did not raise their children to behave with the symptoms of ADHD because it is biologically unavoidable but there are measures they could take to minimize the seriousness.

Wender, P.H. (2001). ADHD: Attention-Deficit Hyperactivity Disorder in Children, Adolescents and Adults. Retrieved from http://site.ebrary.com.ezproxy.library.yorku.ca/lib/oculyork/docDetail.action?docID=10269063

Determining Whether Medication Is Necessary

The severity of the symptoms that are displayed by children that are diagnosed with ADHD can vary widely and it is important to be able to determine when medication is necessary. Young Children with ADHD: Early Identification and Intervention is a great source that outlines the point at which medication is usually recommended. It elaborates on how it is not uncommon for preschool children to display signs of ADHD. It is only when behavioural interventions have failed and the severity of the symptoms begins to affect crucial factors of the child's life such as stress in the home atmosphere and academic and social functioning that medication should be considered. Ultimately the decision must be made by the child's guardian and should be done with great consideration.

DuPaul, G. J., Kern, L. (2011). Young Children with ADHD: Early Identification and Intervention. Retrieved from http://books1.scholarsportal.info.ezproxy.library.yorku.ca/viewdoc.html?id=/ebooks/ebooks0/apa/2012-05-14/1/201021507

Medicinal Approaches

In the scholarly article, Caught in a Balancing Act: Parents' Dilemmas Regarding Their ADHD Child's Treatment With Stimulant Medication, the authors interviewed 10 Canadian couples with children diagnosed with ADHD. The parents' views and experiences involving their children being on stimulant medication were recorded. The most common theme of the interviews were the parents' ambivalence towards the benefits of the medication; many of the participants saw both desirable and undesirable effects of the stimulants.

Regarding benefits, many participants reported that their children were receiving better grades and appeared much more focused on their school work. Improvements at home were also reported; the children fought less frequently with their siblings, were able to conduct calm and rational conversations with their parents, and were generally less disruptive in their home environment.

However, several side effects of the medication were also discussed; many parents reported a decrease in appetite and difficulty sleeping. Some even reported a "zombie-like" quality in their child, where she or he would become pale and be so focused on the task at hand that they stopped talking. One mother also revealed that her son had developed a facial tic after being on medication for over three years. Concerns were also expressed by many couples regarding possible long-term side effects of the medication.

This study is an important first-hand account of the experiences and concerns of parents with children diagnosed with ADHD. The information gathered is truly representative of the dilemma many parents face when deciding whether or not to put their child on stimulant medication; one must weigh the positives and the negatives. In order to make an informed decision, it is evident that further qualitative research regarding the benefits and side effects of stimulant medication should be undertaken, especially with the ever-increasing number of children being diagnosed with ADHD.

Hansen, D. L., & Hansen, E. H. (2006). Caught in a balancing act: Parents' dilemmas regarding their ADHD child's treatment with stimulant medication. Qualitative Health Research, 16(9), 1267-1285. doi:http: dx.doi.org/10.1177/1049732306292543//

There is often cognitive dissonance involved with parents dealing with the decision making process of administering medication for their child with ADHD. ADHD symptoms have been shown to decrease after stimulant medication is administered; it is also often used in conjunction with behavioural therapy. Despite this, medicating children has become a controversial topic amongst parents and patrons with ADHD. Discontinuation of medication may link to recurring symptoms such as psychological affects, mood changes, irritability, depression and personality change. Although improvement and efficacy of drugs are of top priority, treatments should also be accepted and willing to be used by affected patrons, otherwise the treatment cannot be deemed effective. Overall satisfaction of a drug can be measured by prolonged use without interruption – also know as pre-mature termination. The continuation of the treatment is largely contingent upon the patient's perception on the efficacy and adherence to the drug, and parental attitudes. In fact parents have been largely opposed to adhering to medication, having stopped initiating the medicine shortly after it is administered. As for the reasons why, it may be due to concerns with stigmatization (even though medication has been proven efficacious) and perceived lack of efficacy. Therefore parental attitudes towards medication is important when considering the use of medicinal approaches.There are also other factors which need to be considered in order to otherwise prevent pre-mature termination. Healthcare providers may also play a big role in the decision-making process, as well as school personnel who contribute to additional insight and further influence on the decision making.

Gortz-Dorten, A., Breuer, D., Hautmann, C., Rothenberger, A., Dopfner, M. (2011).
What contributes to patient and parent satisfaction with medication in the treatment of children with ADHD? A report on the development of a new rating scale. European Child Adolescence Psychiatry. 20(2). S297-307.

Toomey, S.L., Sox, M.S., Rusinak, D., Finkelstein, J.A. (2012). //Why do children With ADHD
discontinue their medication?
. Clinical Pediatrics, 51(8). 763-769. http://journals1.scholarsportal.info.ezproxy.library.yorku.ca/pdf/00099228/v51i0008/763_wdcwadtm.xml//

Pharmacotherapy: Stimulant Medication versus Non-stimulant Medication

Attention-deficit/hyperactivity disorder (ADHD) affects approximately 5.4 million children worldwide, with the most prevalent age group ranging from 4-17 years old. Generally there are two ways to treat those affected with ADHD: pharmacological or psychosocial approaches.
Pharmacotherapies are categorized by ingredients that induce stimulant or non-stimulant effects ranging from long, intermediate or short-acting durations. According to the Canadian ADHD
Resource Alliance (CADDRA) guidelines, suggestions have been made that the best pharmacotherapy approach for children, adolescents and adults is one-daily, long-lasting medication -if their case is uncomplicated. Any other method should be a second resort. Short-acting medications such as amphetamine and methylphehnidate (MPH) are also effective, however it takes away from an individual's sense of medical privacy with the addition of inconvenience having to repeat doses of medication several times daily. If a young child must bring medications to school it may potentially trigger some sort of stigma or embarrassment which can additionally worsen their lack of self-confidence, depression and other existing social difficulties. In addition the presence of drugs in a school setting may subject the pupil to peer-pressure and other potential sources of trouble including theft, and pressure to divert or abuse the drugs amongst peers.
Long-acting treatments hold several advantages over their short-lasting counterparts as its effects extend beyond the classroom setting. Some examples include after-school programs and extra-curricular activities where personal and social development is developed. This vital time period during their development may be hindered with the use of short-acting formulas that would otherwise wear off quickly. Secondly long-lasting formulas may be favoured by ADHD individuals as it is proven to improve adherence. It is important however, to also recognize the importance of short-lasting treatments. Some patients may prefer certain time frames throughout the day in which they wish to be treated for their symptoms (for example during class or driving). After all prolonged use of long-acting treatments may cause an individual to feel more prominent side-effects. As patients are more conscious of the time frame associated with related tasks, s/he may feel that long-lasting treatments are not as efficacious as short-last treatments. Short-lasting treatments provides its users with quicker release and initiation of therapy. Lastly there are several risks which need to be considered in regards to stimulant-therapy, especially in a school setting; particularly use, misuse and diversion of medication.

Toomey, S.L., Sox, M.S., Rusinak, D., Finkelstein, J.A. (2012). Why do children With ADHD
discontinue their medication?
. Clinical Pediatrics, 51(8). 763-769. http://journals1.scholarsportal.info.ezproxy.library.yorku.ca/pdf/00099228/v51i0008/763_wdcwadtm.xml

Weiss, M.D., Childress, A.C., Pucci, M.L., Hechtman, L. (2011). Review of Long-Acting Stimulant and Nonstimulant ADHD Pharmacotherapy in Canada Supplement Journal of the Canadian Academy of Child and Adolescent Psychiatry. 20(2). S1-20. http://www.cacap-acpea.org/uploads/documents//Supplement_2010_11_Shire_May_2011_final.pdf

Treating Childhood Psychopathology and Developmental Disabilities highlights a study that was done in 1992 by the National Institute of Mental Health with the hopes of determining the effectiveness of stimulant medications and behavioural treatments for children diagnosed with ADHD. For the study, 576 children (ages 7-9) were evenly distributed among four groups with different treatment conditions. These treatment conditions included a medication management-only strategy, a behavioural treatment-only strategy, a combination strategy and a community-care comparison group. After the 14 month treatment period, the study found that the combination strategy was clearly superior to the others. This study is an asset to the medication in comparison to therapy debate because it provides statistical evidence that is reassuring to those who may be skeptical of stimulant medications. It also is excellent for research because it gives a detailed account of why the combination strategy is the best and the research is well known and credited.

Matson, J.L., Matson, M.L., Andrasik, F. (2009). Retrieved from http://books2.scholarsportal.info.ezproxy.library.yorku.ca/viewdoc.html?id=/ebooks/ebooks0/springer/2010-02-11/1/9780387095301

Stimulant Medication

A drug known as Clonidine hydrochloride extended-release tablets (CLON-XR), combined with stimulants such as methylphenidate or amphetamine have been tested for effectiveness in treating attention-deficit/hyperactivity disorder (ADHD). The drug was tested in a double-blind, placebo-controlled study, using children and adolescents with ADHD who only exhibited partial responses to taking stimulants on their own. The subjects received either CLON-XR or a placebo, both in combination with a stimulant medication. Patients were studied for five weeks and all adverse events, vital signs, electrocardiogram recordings, and relevant clinical values were recorded. When subjects were evaluated at the end of the fifth week, a statistically significant improvement was observed in the CLON-XR and stimulant group in contrast the placebo and stimulant group. Improvements proved to be statistically significant when using several different clinically-acceptable ADHD rating scales. Adverse effects in the CLON-XR group were generally mild. However, it is important to note that this study took place over the course of five weeks, which is a very short time frame, considering that patients might use ADHD medication over the course of several years. Therefore, long-term effects of the medication are unknown. Nevertheless, overall results of the 5-week study show that CLON-XR in combination with stimulants is useful in reducing ADHD in children and adolescents who only exhibit partial responses to the stimulants on their own.

Kollins, S. H., Jain, R., Brams, M., Segal, S., Findling, R. L., Wigal, S. B., & Khayrallah, M. (2011). Clonidine extended-release tablets as add-on therapy to psychostimulants in children and adolescents with ADHD. Pediatrics, 127(6), e1406-e1413. doi:http: dx.doi.org/10.1542/peds.2010-1260//

Mental Health Medications is another extremely useful source when conducting research about stimulant medication because it covers the side effects of the most commonly prescribed medications for treating ADHD including Dextroamphetamine (Dexedrine and Dextrostat), Methylphenidate (Ritalin, Metadate, Concerta, Daytrana), and Amphetamine (Adderall). This article affirms that the side effects are only minor and include stomachaches, headaches, loss of weight caused by loss of appetite, sleep problems and rare cases of children developing tics. Also, these minor side effects will disappear when the dosage levels the child is receiving are lowered. Another informative aspect of this article is the section that provides a list of other possible rare side effects that people considering stimulant medication should take into account. These side effects are irritability, aggressive or violent behaviour, sudden changes in behaviour, extreme worry, new or worsening depression, acting withdrawn, panic attacks, abnormal excitement, acting without thinking and feeling hopeless or worthless. When using stimulant medication with children it is recommended that regular examinations be conducted by a doctor and that they are watched closely.

Maguire, R. (2012). Mental Health Medications. Retrieved from https://www-library-yorku-ca.ezproxy.library.yorku.ca/find/Record/2642777

Therapy and Combined Approaches

The study titled A Survey of Music Therapy Methods and Their Role in the Treatment of Early Elementary School Children with ADHD looks at the effectiveness of music therapy methods administered by the American Music Therapy Association (AMTA) on children diagnosed with ADHD. Two hundred sixty-eight music therapists were surveyed about the methods and effectiveness of music therapy on the elementary school-aged children they were working with. Music therapists often use several types of music therapy when treating children with ADHD; these methods include movement to music, group singing and music-assisted relaxation. Music therapists strive to improve both cognitive performance as well as the behaviour of the children, and many therapists work with the children in both a group as well as in a one-on-one setting.

The results of the therapy was generally reported to be favourable. However, although feedback from parents, teachers and the children themselves were primarily what the subjects were asked to report on, it is important to note that the results of this study are based off of surveys from the music therapists themselves, thereby producing a bias. Another noteworthy point is that most of the children in the music therapy program were also receiving other forms of treatment, with a majority taking medication.

Based on the result of this study, music therapy seems promising as a non-medicinal form of treatment when used in combination with other treatments, and should be investigated further using a more objective analysis.

Jackson, N. A. (2003). A survey of music therapy methods and their role in the treatment of early elementary school children with ADHD. Journal of Music Therapy, 40(4), 302-23. Retrieved from http: search.proquest.com.ezproxy.library.yorku.ca/docview/223564275?accountid=15182//

Having a child with ADHD can put a lot of stress on not only the child, but on the parents and the rest of the child's immediate family as well. The purpose of the study, Family systems multi-group therapy for ADHD children and their families, is to determine whether or not ADHD and its negative impact on the family dynamic could be treated effectively with a family systems group therapy model. The studied model combined individual therapy with the child, structural family therapy, and cognitive-behavioral strategies. The goals of the study were to reduce parenting stress and improve family life in the home environment. One hundred twenty-four families participated in the study; half were put into the experimental group, while the other half was used as the control group. The parents completed clinical tests to measure their parenting stress level, while both the parents and the children used the Family Satisfaction Scale (FSS) to determine how satisfied they were with their home life. The families met weekly for group sessions and practised the skills learned at their individual homes during the week. The results of the study show that that treating the child individually as well as the rest of the family is beneficial in reducing stress and conflict within the domestic environment. Due to a decrease in parental stress, parents will be more capable of helping their children cope with ADHD, generating a high degree of success for the child in both school and home environments. Medication and individual therapy may help a child with ADHD, but the family systems therapy model focuses on strengthening families by providing parents with support as well.

Aman, L. A. (2001). Family systems multi-group therapy for ADHD children and their families. (Order No. AAI9989722, Dissertation Abstracts International: Section B: The Sciences and Engineering, , 5548. Retrieved from http: search.proquest.com.ezproxy.library.yorku.ca/docview/619713973?accountid=15182. (619713973; 2001-95008-140).//

For those who do not consider stimulant medication an option, one of the biggest challenges can be finding adequate information about behavioural treatments seeing as the majority of available literature revolves around prescriptions and medications. That being said, an excellent source that can provide information and techniques for those individuals who are seeking behavioural treatment is ADD/ADHD Drug Free: Natural Alternatives and Practical Exercises to Help Your Child Focus. The book covers a variety of alternative treatment options from parenting programs that set up meetings for parents with qualified therapists who are knowledgable about the skills needed to control hyperactive children, to providing tips for managing a hyperactive child's behaviour like being more enthusiastic about rewarding desirable behaviour and responding to undesirable behaviour less dramatically. Lastly, this book also educates the reader about why children diagnosed with ADHD act how they do (with simple neurological explanations) and helps the reader develop a better understanding of both treatment and prevention.

Jacobelli, F., Watson, L.A. (2008). ADD/ADHD Drug Free: Natural Alternatives and Practical Exercises to Help Your Child Focus. Retrieved from http://library.books24x7.com.ezproxy.library.yorku.ca/assetviewer.aspx?bookid=23788&chunkid=980473569&rowid=130

Alternative approaches

Some members of the psychological and medical community do not believe ADHD to be a psychiatric condition at all. Dr David Nylund, a behavioural healthcare professional and author of Treating huckleberry finn: A new narrative approach to working with kids diagnosed ADD/ADHD believes there is no scientific evidence that ADD or ADHD exists. He believes ADHD to be a label for active, spirited, creative children. Nylund suggests a family-centred approach to help such children thrive by harnessing their strengths and abilities. His proposed approach consists of 5 steps : (1) separating the problem of ADHD from the child, (2) mapping the influence of ADHD on the child and family, (3) attending to exceptions to the ADHD story, (4) reclaiming special abilities of children diagnosed with ADHD, and (5) telling and celebrating the new story (Nylund).

Nylund's book is offers an alternate point of view on ADHD and those who have been diagnosed with this disorder. Nylund does not acknowledge ADHD as a disorder, and therefore does not endorse any medication that may reduce some of the disorders associated symptoms. He does, however, take an interesting approach by focusing on enhancing the child's strengths rather than attempting to reduce her or his weaknesses, as nearly all ADHD medications and some therapies may do. Nyland's method has not been clinically tested, nor has his book been acclaimed by peers, but it is interesting to know that there are alternate approaches to helping children cope with symptom associated with ADHD.

Nylund, D. (2000). Treating huckleberry finn: A new narrative approach to working with kids diagnosed ADD/ADHD Jossey-Bass, San Francisco, CA. Retrieved from http: search.proquest.com.ezproxy.library.yorku.ca/docview/619469742?accountid=15182//

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