CENTER FOR THE PROFESSIONAL STUDY OF
ATTENTION DEFICIT HYPERACTIVITY DISORDER (AD/HD)
Dr. Robert R. Erk, Ed.D., is the Director of the Center for the Professional Study of Attention Deficit Hyperactivity Disorder. Dr. Erk is a Professor of Counselor Education and Educational Psychology in the Department of Educational Studies at the University of Tennessee at Martin, TN 38238. Dr. Erk teaches graduate coursework in school and mental health counseling, served as a public school counselor, founded the Professional Interest Network for Children With AD/HD for the American School Counselor Association, is a Licensed Professional Counselor and Marital and Family Therapist in Tennessee, and is the parent of a son diagnosed with AD/HD. Dr. Erk is a past president of the Southern Association for Counselor Education and Supervision.
The Center strives to provide resources or information on AD/HD for parents, counselors, and teachers, conducts inservices and workshops on AD/HD at the state, regional, and national levels, and maintains a research and publication agenda on the disorder. This content of this webpage is designed to be readable for parents, teachers, and counselors.
A SYSTEMS ORIENTED APPROACH TO AD/HD:
FAMILIES, SCHOOLS, AND COMMUNITIES WORKING TOGETHER
The Center is dedicated to advocating and promoting a Systems Oriented Approach To AD/HD: Families, Schools, and Communities Working Together. This approach is centered on the development of the child with AD/HD and their ability to function more effectively in the home, in the school, and in the community. The systems oriented approach focuses on the education and training on AD/HD that has been conducted or occurred in the major systems that are connected to the affected child's life. The major systems considered here are the following:
THE FAMILY SYSTEM. For example, the parents and siblings comprise the family system; the family system may also be composed of extended or blended family members. It is important for parents (or all family members) to increase their knowledge and understanding of the AD/HD, realize that the disorder has often brought about high stress levels for its members, and that the problem behaviors can be managed more effectively. Importantly, the family needs to understand that the unity of the parents and siblings in fully accepting the child with AD/HD and working collaboratively to foster a supportive and healthy family environment is crucial. This includes the parents' taking responsibility for seeking and supporting appropriate treatment interventions or regimens for the AD/HD.
THE SCHOOL SYSTEM. For example, the school officials, teachers, classmates, and peers comprise the school system. In many instances, by not being educated or trained on the symptoms and problematic behaviors that are often connected to the disorder, school personnel or educators may inadvertently exacerbate the symptoms or problematic behaviors of the child with AD/HD. Unfortunately, classmates or peers at school often relentlessly tease, taunt, devalue, and socially shun many children with AD/HD. For children with AD/HD, these social-emotional experiences with classmates or peers can be indelible in theirmemories. Therefore, schools are the place of choice for also educating students about the AD/HD symptoms and the problem behaviors they may observe.
THE SCHOOL TO FAMILY SYSTEM. For example, the school personnel or educators, parents, and siblings comprise the school to family system. The school and family system need to become clinical allies or form a therapeutic alliance for the identification and behavioral management of the child with AD/HD. Moreover, school systems may be subject to complying with the provisions of the federal acts such as the Individuals With Disabilities Education Act (IDEA), Section 504 of the Vocational Rehabilitation Act, and the Americans With Disabilities Act (ADA). These federal acts can apply to students diagnosed with AD/HD from elementary school through the college years. Schools are becoming increasingly aware of their legal obligation to appropriately serve children and adolescents with AD/HD. For example, these federal acts have often served as an impetus and pointed out the need to increase the inservice education and training for educators on AD/HD children. School systems may need to increase their vigilance for identifying and supplying appropriate interventions, accommodations or variations in classroom instruction and testing practices for AD/HD children. At school, the counselor may consent to serve as a resource person or a case manager for appropriate services or treatment for the child with AD/HD. By forming a school to home partnership and coordinating together the interventions or treatment plan, the likelihood that the AD/HD child can perform more satisfactorily is optimized.
THE FAMILY TO COMMUNITY SYSTEM. For example, the parents and siblings along with the individuals in their community comprise the family to community system. Locale and its prevailing attitudes and sentiments are often the principal components of the community system. However, for the family with an AD/HD child, the community system can refer moreappropriately to the development of social interaction, social cohesion, moral support, and contains the potential for fostering a therapeutic resource or alliance. For example, it is crucial that our communities become better informed or educated on children with AD/HD and their problematic behaviors, rather than focusing on and labeling the dysfunctional elements or parts of the child with AD/HD. The family to community system is the place where the family lives, attends school, engages in recreational activities, has intimate ties, and it is the community that can act as a facilitator for fostering the development of positive mental health for many children with AD/HD. Finally, it is the community that can strongly affect the course of events or the outcomes for families with an AD/HD child.
CHANGING AND RECONSTITUTING SYSTEMS
From a systems oriented approach to AD/HD, all of these systems can be perceived of as changing and reconstituting themselves by becoming more open to scientific, medical, and behavioral explanations for the disorder. For example, many persons who come into contact with an AD/HD child do not know that the child's behavior is not willfully or deliberately planned to confront, undermine, or provoke their parents, teachers, or peers. Instead, becoming educated and understanding how this complex disorder can have life-long effects (e. g., academic, social-emotional, occupational) on the child with AD/HD, and that the actions taken (e. g., positive or negative) in any one system can have reciprocal or circular effects. For example, the AD/HD child's problematic behaviors or actions in any one system can in-turn influence the family, school, and community's reactions to the child. It should be remembered that these reciprocal actions and their consequences can often be imprinted into the life of the child or adolescent with AD/HD.
These systems can be viewed as forces working for either the good or to the detriment of the child with AD/HD. There is an interconnectedness among the systems, the actions in one system or any part of it can affect the health or dysfunctionality of the child. The child with AD/HD is an interacting and interactive member of these systems. They are powerful parts of the child's life and they frequently exert a strong influence over not only the child's behaviors, but certainly how their feelings, values, and attitudes evolve towards themselves and others.
A note of caution is probably in order, change in how these systems view and interact with AD/HD children and adolescents will likely be gradual or long-term. By necessity there will need to be a heavy investment in education and training on the disorder.
MULTIDIMENSIONAL TREATMENT FOR AD/HD
Through a systems oriented approach to AD/HD and a multidimensional treatment plan the development of children and adolescents with AD/HD can be enhanced. Perhaps the most important point of information to emerge from the last several years of research on AD/HD is that no single intervention alone is probably going to be successful. The multidimensional treatment approach, moreover, needs to be long-term so as to optimize the child's development. The goal of multidimensional treatment should not be to find a cure. The goal is to provide interventions or strategies that can be important for managing this often chronic and disabling condition. The multidimensional treatment plan enables the professionals and parents to attack the AD/HD from as many avenues as are feasible. Interventions or treatment typically includes some combination of the following:
PARENT EDUCATION. Education for parents and siblings on the AD/HD symptoms and problem behaviors that are associated with the disorder is the necessary first-step. Parent education can be the benchmark upon which further progress for the family may be measured. For example, parent education can explain how the AD/HD symptoms can frequently create in the home and at school, the myriad of problematic behaviors that are often considered disruptive or maladaptive to parents and teachers. Parent education can normally be accomplished in four to six well-planned one-hour sessions from a professional (or a parent support group) that is well-informed and experienced with the disorder. From parent education on AD/HD, parents can be relieved of the guilt that they were somehow the cause of the disorder, they can acquire a better understanding of the disorder, and they can focus their efforts towards improving the quality of life for their AD/HD child.
TEACHER EDUCATION. Educating teachers and school officials on the academic, behavioral, and personal-social problems that students with AD/HD often exhibit provides them the information that they need to work more effectively with these children. As teachers and school officials become better educated about AD/HD students, they can work collaboratively to maximize the interventions or strategies that are targeted at improving the academic, behavioral, and social functioning of these children. Through teacher education on the AD/HD, issues such as educational negligence or malpractice with AD/HD children can then be taken out of the equation. Increasingly, many state departments of education are urging local educational agencies or school districts to come into compliance with federal acts or statutes that can address the need for the identification and treatment of children with AD/HD.
INDIVIDUAL COUNSELING. Professional counselors who work with AD/HD children and adolescents should acknowledge at the onset that many of these children can be a formidable challenge. Often children with AD/HD tend to be in a state of denial about their disorder and their problems. Moreover, many of these children can be oppositional in their attitudes, distrustful of authority figures, have low self-esteem, and see most of their difficulties or problems as being caused by others such as teachers, parents, and peers. Counselors who are remarkably patient and understanding, who can endure more relapses than progress in the beginning sessions or phases of counseling, and who can remain a positive force in the lives of these children often have the most success in forging a therapeutic relationship. Professional counselors should be aware that many children with AD/HD can have coexisting conditions such as learning disabilities, oppositional defiant behavior, excessive anxiety, language usage problems, anger control problems, and can experience depression.
BEHAVIORAL MANAGEMENT TECHNIQUES. Educators and parents should consider that behavioral management techniques or strategies such as time-out, negative reinforcement, cost response measures for inappropriate behavior, contracting, earning rewards and special privileges for appropriate behavior, and cognitive behavioral training (e. g., self-instructional training) coupled with appropriate medical treatment seems to be the most effective treatment for many children with AD/HD. In collaboration with the parents and the school, professionals, parents, and teachers can develop priorities for employing behavioral management techniques that target or address the child's problematic behaviors at school and in the home. It needs to be remembered that behavioral techniques or strategies often need to be varied, adjusted, or changed to meet the problematic behaviors or situations that AD/HD children typically exhibit. It should also be remembered that there is a neurobiological basis for the AD/HD. This suggests that AD/HD children will often need more behavioral structure, more time to come into compliance, and more varied or unique reward systems to effectively promote change in their lives. Furthermore, in June, 1997 changes in IDEA were signed intolaw by President Clinton. One of the key changes, for example, that could be pertinent to schools and parents is the provision dealing with discipline. It is not usual for a child with AD/HD to become involved at some point in their school career, in a disciplinary process thatinvolves their behavior. In determining whether suspension or expulsion from school is allowable, the school or committee must consider: (a) the child's ability to understand or comprehend accurately what he or she did, and (b) their ability to control the behavior involved in the event or problem. The control part of this change can have important factorssuch as did the child have the opportunity to receive appropriate medication and interventions or treatment for the disorder.
SELF-ESTEEM EDUCATION. The major goal of parents, teachers, and counselors for many children with AD/HD needs to be the restoration of their self-esteem. Without realizing it, many parents, teachers, and peers have often been excessively critical of the child, repeatedly complained about their misbehaviors, and unfortunately demeaned or belittled many of their efforts or struggles to improve themselves. For persons who come into contact with AD/HD children, it should be remembered that they have endured many more frustrations and failure experiences in their young lives than other children. At every opportunity, parents and teachers should seek to create or take advantage of opportunities that can foster self-esteem and accomplishment in AD/HD children.
SOCIAL SKILLS EDUCATION. There usually needs to be a strong instructional and training program on social skills education. Unfortunately due to their disorder, many AD/HD children often have a limited or inadequate repertoire of social skills available to them. From the standpoint of many teachers and peers, poor or deficient personal-social skills stand-out almost immediately as the area most in need of improvement. For example, almost everything the child with AD/HD does is viewed as socially different or inappropriate, they often feel that they are being excluded from active participation in their classrooms, and they often feel that their peers further exclude them from many social activities or games at recess. In many instances, the child with AD/HD can also be disinvited by classmates or peers from attempting to play with them after school or on weekends. Instruction and real-life practice in acquiring an improved repertoire of social skills across settings (e. g., school, home) often needs to be a priority for many AD/HD children.
FAMILY COUNSELING. Family counseling is frequently recommended because the AD/HD typically disables the family's communication patterns, is a root cause of family disagreements or arguments, and can lead to marital dysfunction, sibling dissension, and the social shunning of the family by others in their community. Many families need to come to the realization that the child cannot be separated from their disorder. Accepting and nurturing the child with AD/HD from childhood, to adolescence, to adulthood despite the multiple frustrations can be the best form of therapy. For children with AD/HD, the unity of the parents can be crucial to the future direction of their young lives.
In summary, a systems oriented approach to AD/HD and multidimensional treatment for the disorder can compliment and reinforce each other. They share the priority of providing and sharing education on the disorder and fostering a safer psychological environment for providing treatment or services for AD/HD children. It is within the family, school, and community systems that children with AD/HD can learn how to live more successfully and have more fulfilling lives.
THE COLLABORATIVE MULTIMODAL TREATMENT STUDY OF CHILDREN WITH ATTENTION DEFICIT/HYPERACTIVITY DISORDER (AD/HD)(MTA STUDY)
The MTA Study constitutes a landmark in the history of treatment research in child psychopathology; it is the largest single study of its kind ever undertaken for one disorder (AD/HD)(Barkley, 2000). Because the answers to such questions can only be pursued through large scale efforts that generate sufficient sample sizes for powerful tests of treatment effectiveness (e. g., so treatment outcomes can be more properly compared and evaluated), the National Institute of Mental Health (NIMH) launched a collaborative multisite (N=6) clinical trial of Multimodal Treatment of children diagnosed with AD/HD. The NIMH-MTA Study has been in the field since 1992; between 1992 and 1994, 579 children (aged 7-9 years, 11 months) were recruited at participating sites in the United States and one in Canada (Montreal). All the children had primary diagnoses of AD/HD, Combined Type, using Diagnostic and Statistical Manual for Mental Disorders (DSM-IV; American Psychiatric Association, 1994) criteria. In addition to the AD/HD, comorbid or co-occurring aggressive spectrum disorders (e. g., oppositional defiant disorder [ODD], conduct disorder [CD]), anxiety disorders, and affective disorders occurred in the MTA sample at these respective prevalence rates 54%, 34%, and 4%. The subjects in the sample were 61% Caucasian, 20% African-Americans, and 8% Hispanic; males constituted 80% and females 20% of the sample. Children were randomly assigned to one of four experimental groups: (1) an intensive, multifaceted behavior therapy program (BEH) comprised of three integrated components (Parent Training, School Intervention, Child Treatment anchored in a Summer Treatment Program): this program can be referred to as "psychosocial treatment" because of its largely behavioral procedures; (2) a carefully dose-adjusted and monitored medication management program consisting of methylphenidate and other stimulants (MED-MGT); (3) a careful and well integrated combination of the previous two (COMB); and (4) a community comparison group (CC). The CC comparison group allowed for a comparison of the three intensive manual-based treatments to the treatment delivered in the community (e. g., local community care resources). Treatment occurred over 14 months, and assessments were taken at baselines of 3, 9, and 14 months. After this comprehensive assessment, the global effects of the treatment for the MTA Study of BEH, MED, COMB, and CC groups are summarized below. It should be kept in mind that the MTA Study was indeed large; many of the variables contained in the study are yet to be fully scrutinized for their specific roles. Nonetheless, here are some of the essential findings gleaned from the study.
First, there were generally superior effects for COMB and MED-MGT compared to BEH or CC on the primary characteristics of AD/HD, including some comorbid conditions. This should not be unexpected; an array of interventions or a multidimensional approach to treatment has long been advocated in the management of this disorder (Barkley, 1990, 1995; Erk, 1995, 1997, 2000).
Second, the BEH or psychosocial treatment approach "alone" did produce some effects despite being limited. The amount of gain here probably should have occurred because the study seemed heavily weighted toward the BEH or psychosocial treatment approach. However, Barkley (2000) questioned if such an extensive BEH program could be justified (e. g., now or ever) in homes and schools (e. g., due to its extensive scale). Relevant to the gains made in this approach, Barkley (2000) speculated that the modest differences found between the BEH and CC groups in the MTA Study might be more due to information and therapist attention; these could have accounted for the small differences (e. g., in favor of the BEH group). For example, numerous parent education and behavioral training programs for parents with children diagnosed with AD/HD are already in existence and might obtain much the same results when properly employed. The BEH approach to treatment "means" parents are willingly becoming involved in parent education and training on the AD/HD, and they are learning and actively practicing a range of behavioral interventions designed to benefit the family and the child.
Third, the MED component, which entails no skill training for parents or teachers, achieved equal or superior effects to BEH across nearly all of the outcome domains (e. g., parent-child relations, familial and school functioning) examined in the study (Barkley, 2000). The MTA Study, coupled with the incoming lines of scientific and medical information (e. g., PET scans, Human Genome Project), should further serve to prompt parents and practitioners to be increasingly receptive to MED-MGT as one of the key players for obtaining improved therapeutic results (e. g., especially where the AD/HD is moderate to severe).
Fourth, only in COMB treatment, not in BEH alone, were there the greatest reductions in negative-ineffective discipline. This finding should be considered among the most vital when treatment options are being planned. For example, success for COMB treatment was evident for important school-related outcomes (e. g., reduction in teacher reported disruptive behavior). Moreover, this finding would appear to be related to reductions in negative and ineffective parenting practices in the home (e. g., reciprocal or parent-child interactions; Erk, 1997). Therefore, the home and school environments benefited reciprocally from the COMB treatment.
Fifth, when comorbid symptomatology (e. g., ODD, CD) and functional skills (e. g., academic and social skills) were considered, the group differences among all the treatment groups were smaller. For example, only the COMB treatment was consistently superior to CC when the comorbid conditions were identified. It should be remembered that comorbid symptomatology can be a major disrupter to any treatment that is being utilized; what this finding from the study reinforces is the need for careful assessment of comorbid conditions and that these conditions deserve as much attention (e. g., treatment) as the AD/HD itself. Unfortunately for the child, if the comorbid conditions remain undiagnosed and untreated, the comorbid conditions will often be mistakenly identified as the primary problems. This can lead to the AD/HD remaining at the "core" of the person's difficulties while the disorder can continue as undiagnosed and untreated (Erk, 1997, 2000).
Sixth, COMB significantly outperformed MED-MGT with a small-to-moderate effect size (Hinshaw et al., 2000). This should not be entirely a surprising result; MED-MGT alone is not considered a prudent approach when it is to be used in isolation. Barkley (1990, 1995) recommended that parents should not invest in a MED-MGT only treatment plan. This is because with a MED-MGT only plan, the child is obviously deprived of opportunities to learn or acquire an improved behavioral repertoire (e. g., social and academic skills, enhanced and self-esteem).
Seventh, and last, although overall findings were consistent for boys versus girls, for children with and without prior medication treatment, and subjects with and without disruptive comorbidity, two baseline variables (e. g., comorbidity with anxiety disorder and socioeconomic status) had the effect of moderating some treatment outcomes. A major limitation of the MTA Study may be the exclusive use of the AD/HD Combined Subtype; it was presumed that hyperactivity, impulsivity and inattention components are incorporated into the Combined Subtype. However, for example, in the Inattentive Subtype there may be different findings and implications for treatment identified for children who are diagnosed with this specific subtype (e. g., see Erk, 2000). Future studies will need to address issues such as this one (e. g., specific subtypes) and the comorbidities that most often co-occur. The MTA Study and its employment of a multimodal treatment model paves the way for further research and treatment appropriate for children with AD/HD. For example, earlier clinical research (e. g., using parent behavioral training with medication management) for AD/HD children has yielded positive results; this is reinforced by findings contained in the MTA Study (Barkley, 2000). For professionals and practitioners, there is certainly much that is positive and informative from the MTA Study. Undoubtedly, more clinical results will emanate from this research for years to come; the MTA Study should be clinically, scientifically, and educationally examined for every drop of information it can yield on AD/HD and its management. The MTA Study was mammoth and unparalleled in the field of child treatment; for this reason it can be expected to take years, if not decades, to tease out all data that is has to offer researchers and professional practitioners (e. g., teachers, school and mental health counselors, psychologists, physicians).
REFERENCES/SUGGESTED READINGS ON AD/HD
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.), Washington, DC: Author.
Barkley, R. A. (1990). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: Guilford Press.
Barkley, R. A. (1995). Taking Charge of AD/HD: The Complete Authoritative Guide for Parents. New York: Guilford Press.
Barkley, R. A. (2000). Commentary on the multimodal treatment study of children with AD/HD. Journal of Abnormal Child Psychology, 28, 595-598.
Copeland, E. D., & Love, V. L. (1991). Attention, Please!: A Comprehensive Guide to Parenting Children With Attention Disorders and Hyperactivity. Atlanta, GA: Southeastern Psychological Institute Press.
Erk, R. R. (1995). The Conundrum of Attention Deficit Disorder. Journal of Mental Health Counseling, 17, 131-145.
Erk, R. R. (1995). A Diagnosis of Attention Deficit Disorder: What Does It Mean For School Counselors? The School Counselor , 42, 292-299.
Erk, R. R. (1995). The Evolution of Attention Deficit Terminology. Elementary School Guidance and Counseling, 29, 243-248.
Erk, R. R. (1997). Multidimensional Treatment of Attention Deficit Disorder: A Family Oriented Approach, Journal of Mental Health Counseling, 19, 3-22.
Erk, R. R. (1999). Attention deficit hyperactivity disorders: Counselors, laws, and implications for practice. Professional School Counseling, 2, 318-326.
Erk, R. R. (2000). Five frameworks for increasing understanding and effective treatment of attention-deficit/hyperactivity disorder: Predominantly inattentive type. Journal of Counseling and Development, 78, 389-399.
Erk, R. R. (2004). Counseling treatment for children and adolescents with DSM-IV-TR disorders. Upper Saddle River, NJ: Merrill Prentice Hall.
Friedman, R. J., & Doyal, G. T. (1992). Management of Children and Adolescents With Attention Deficit Hyperactivity Disorder. Austin, TX: Pro-Ed.
Hallowell, E. M., & Ratey, J. J. (1994). Driven to Distraction: Recognizing and Coping With Attention Deficit Disorder from Childhood through Adulthood. New York: Touchstone.
Hinshaw, S. P. et al., (2000). Family processes and treatment outcome in the MTA: Negative/ineffective parenting practices in relation to multimodal treatment. Journal of Abnormal Child Psychology, 28, 555-564.
Hosie, T. W., & Erk, R. R. (1993, January). American Counseling Association Reading Program: Attention Deficit Disorder. American Counseling Association Guidepost, 35, 15-18.
Learner, J. W., Lowenthal, B. & Learner, S. R. (1995). Attention Deficit Disorders: Assessment and Teaching. Pacific Grove, CA: Brooks/Cole.
Nadeau, K. G. (1995). A Comprehensive Guide to Attention Deficit Disorder in Adults: Research, Diagnosis, and Treatment. New York: Brunner/Mazel.
Reif, S. F. (1993). How To Reach And Teach ADD Children. West Nyack, NY: Center for Applied Research In Education
Shaywitz, S. E., & Shaywitz, B. A. (1992). Attention Deficit Disorder Comes of Age: Toward the Twenty-First Century. Austin, TX: Pro-Ed.
QUALITY OF LIFE
IN CHILDREN, ADOLESCENTS, AND YOUNG ADULTS DIAGNOSED WITH ATTENITION-DEFICIT/HYPERACTIVITY DISORDER
Attention-Deficit/ Hyperactivity Disorder (AD/HD) significantly affects the health-related quality of life for children, adolescents, and adults. There is a substantially lower health-related quality of life across multiple domains (e.g., physical, psychosocial) when compared with normative data for individuals without AD/HD (Klassen et al., 2004). Physical domains can include: physical health and functioning (e.g., including role and/or social limitations as a result of physical health). Psychosocial domains can include: social-emotional-behavioral problems, mental health, self-esteem, self-neglect, and impact on family functioning.
Klassen et al. (2004) found that the health-related quality of life was correlated with two factors: (1) AD/HD symptom severity, and (2) the presence of comorbid or co-occurring psychiatric disorders. Research has established that comorbidity or co-occurring disorders are common in cases of AD/HD (Barkley, 1998; Pliszka et al., 1999). Simply put, the severity of the AD/HD and the co-occurring disorders are an important predictor of the health-related quality of life for many of these individuals. The toll taken due to the AD/HD and co-occurring disorders on his/her health and/or safety cannot be emphasized strongly enough.
AD/HD: A LIFESPAN DISORDER
Although AD/HD has historically been categorized as a childhood disorder, it is now regarded as a lifespan condition (e.g., into the adult years) (Barkley, 1998; Resnick, 2000). Follow-up studies of AD/HD children into adolescence and the adult years indicate the disorder frequently persists and it is associated with significant psychopathology and dysfunction (e.g., social, emotional, occupational) in later life (Wilens et al., 2002; Weiss & Murray, 2003). Moreover, follow-up clinical studies provide compelling evidence for the continuation of AD/HD into adulthood, though the rate at which this occurs remains unclear. For example, prior studies showed the persistence of AD/HD symptoms into adolescence (e.g., 50%-75%) and adulthood (e.g., 4%-60%) (Hechtman, 1992; Mannuzza et al., 1993). However, more recent clinical studies based on the DSM-III-R (when compared to previous research) have indicated higher persistence rates of 75% for AD/HD into young adulthood (Biederman et al., 1993).
Barkley (2003) emphasized this point: Simply because the severity levels of symptoms might decline over development, this did not mean that children and adolescents with AD/HD are necessarily out growing their disorder relative to normal children. In many cases of AD/HD, the disorder is associated with profound impairment in the adult years (Weiss & Murray, 2003). While the AD/HD remains at the core of their lives, the assessment and treatment of co-occurring disorders cannot be left unattended (Erk, 2004a).
The differential diagnosis of comorbid conditions can be difficult, but it is necessary because individuals with AD/HD have high rates of oppositional, conduct, mood, anxiety, learning, and personality disorders, substance use and abuse, and increased risk of suicide (e.g., at a higher rate than found in the general population) (Barkley, 1998, 2003; Biederman et al., 1991,1993; Brown, 2000; James et al. 2004).
AD/HD AND NEUROBIOLOGY
Theories and research on AD/HD have been constructed along both neurobiological and neurochemical lines (see Barkley, 1997, 1998, 2003; Castellanos et al., 1994; 1996; Erk, 2000, 2004b). Barkley (1997) believed a “lack of behavioral inhibition” in individuals with AD/HD is at the core of the disorder. For example, behavioral inhibition and/or executive brain functions are impaired and cannot come online to work effectively (e.g., to serve the best interests of the individual). In other words, there are executive and inhibitory brain deficits that are affiliated with the AD/HD itself (as cited in Barkley, 2003). In essence, this is due to the neurobiology and neurochemistry of the brain. There is sufficient neuroscientific data to document that AD/HD is the result of neuroanatomical and neurochemical abnormalities that reside in the brain (Barkley, 1997, 2003; Lavenstein, 1995; Quinn, 1995). Fundamentally, AD/HD can be conceived of as a neurobiological or neurobehavioral disorder.
A biological explanation is not inclusive and there is not a biological destiny for persons with AD/HD. There is an important role for environment and/or learning in the lives of all individuals (Gredler, 2005). However, there remains an “inseparability” of the brain, thinking, and behavior, Therefore, a parent, teacher, clinician or counselor, cannot assess and/or understand how “problem areas” might have developed without a basic grounding in how these problems originated, evolved, and progressed (for more information on AD/HD and neurobiology see Barkley, 1997, 1998, 2003; Castellanos et al., 1994, 1996; Erk, 2000; 2004a; Nadeau, 1995; Quay, 1997; Zemetkin et al., 1986,1990,1996).
Mohr (1995) emphasized that client deterioration tends to be more prevalent when disorders or psychopathologies in the client are misunderstood, under-evaluated or under-estimated. Enlarging the understanding or comprehension of the cognitive, emotional, and behavioral dysfunctions of individuals with AD/HD; particularly, how they have come into being is vital to an enhanced perspective for treatment planning (Erk, 2000; 2004a).
AD/HD AND COMORBID DISORDERS:
A POTENTIALLY LIFE-THREATENING MIXTURE
The impact that mixtures of AD/HD and co-occurring disorders have on the lives of these individuals can be described as potentially “life-threatening.” Life-threatening, in the sense, the lives of these individuals contain increased “risk factors.” It is clear that the impact of AD/HD and co-occurring disorders need to be evaluated on a case-by-case basis. However, individuals who have severe AD/HD symptoms and comorbid disorders, impairment and/or dysfunction across domains, psychopathologies in their parents and/or family, and a dysfunctional family structure are likely to be on a trajectory that can threaten his/her health and/or safety.
Therefore, it is crucial to ascertain the “current state” and/or “level of functioning” of these individuals. It is often not satisfactory to take the client’s word (e.g., client and/or family deceit is not uncommon). For example, there might be families where the diagnosis of AD/HD was made in childhood and/or adolescence and no medication or behavioral treatment was made available (e.g., often allowing the AD/HD and comorbid conditions to advance).
Thus, a “fact-finding” process that encompasses every family member and/or relative as well as teachers, friends and/or peers must be undertaken. Think of the fact-finding as the “required preparation” for the intervention or treatment. Clearly, assessing and knowing about comorbidity in young people is critical and will impact treatment in a number of ways, including the need to intervene and address the “multiple problems” presented (Field & Seligman, 2004).
It is beyond the scope of this web page to include all the co-occurring disorders that might be coexisting with the AD/HD (for more information on these see Biederman et al., 1991; Pliszka et al., 1999; Barkley, 1998, 2003; Erk, 2004a).
The two co-occurring disorders that are the focus of this webpage are: Mood Disorders/Depression and Substance-Related Disorders. There is a concluding section on suicidal behavior since more that 90% of people who kill themselves have a diagnosable mental disorder, commonly a Depressive Disorder and/or a Substance Abuse Disorder (Conwell et. al., 1995).
Mood Disorders encompass Major Depressive Disorder, Dysthymic Disorder, and Bipolar Disorder (Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision [DSM-IV-TR] American Psychiatric Association [APA], 2000). Bipolar is included because people with this illness have depressive episodes as well as manic episodes (for more information on Bipolar Disorder see DSM-IV-TR, Geller & Luby, 1997; Field & Seligman, 2004). The diagnostic criteria listed in the DSM-IV-TR for these Mood Disorders must be met for a diagnosis.
In general, the presence of a Mood Disorder/ Depression in children and adolescents was found to significantly increase the likelihood of another mental disorder also being present. Conduct Disorder, Oppositional Defiant Disorder, Anxiety Disorders, Learning Disorders, and AD/HD are particularly common “co-occurring disorders” (Barkley, 1998; Field & Seligman, 2004). Lewinsohn et al. (1995, 1998) found significant consequences to comorbidity of Mood Disorders including an increase in suicide, a negative impact on academic performance, impaired role functioning, and increased conflict with parents/family.
The co-occurrence of Major Depressive Disorder and a Substance Use Disorder appears to be the most destructive combination for individuals with AD/HD. Depression and alcohol abuse, in particular, both increase considerably during adolescence (Johnson et al., 1993; Lewinsohn et al., 1991). Coexisting depression and alcohol or substance abuse might be particularly problematic, particularly for some adolescents or young adults who use a variety of substances to self-medicate.
Stowell and Estroff (1992) in their study of substance-abusing adolescents found that 50% had a Major Depressive Disorder and Dysthymic Disorder. King et al. (1996) explored the predicators of co-occurring alcohol and/or substance abuse and depression in 103 adolescents. These researchers found that the depressed substance-abusing adolescents experienced longer and more often persistent episodes of depression than depressed adolescents who were not substance abusers. Moreover, depressed adolescents who abused alcohol or drugs reported more overall behavior impairment than those who were not substance abusers.
Kovacs et al. (1993) found people with a history of Mood Disorders are five times as likely to make a suicide attempt during their lives compared to people with a history of other mental diagnoses. Schaffer et al. (1996) found that 61% of children and adolescents who committed suicide met the criteria for Mood Disorder, and of that 61%, 52% met the criteria for Major Depressive Disorder, 22% for Dysthymic Disorder, 10% for Adjustment Disorder with Depressed Mood, 4% for Bipolar Disorder, and 12% for Depression, Not Otherwise Specified.
Because Mood Disorders and/or Depression are found to have a tendency to “follow” rather than precede the onset of a co-occurring disorder, identifying and treating other mental disorders (e.g., that preceded the Mood Disorder and/or Depression) might prevent, delay, or reduce the impact of depressive symptoms (Lewinsohn et al., 1998). Parents, clinicians, and counselors should keep in mind that young people with comorbid disorders are at an increased risk for further episodes of depression and manifest a greater number of social-skills and problem-solving deficits (Reinecke, 1995). When alcohol or drugs are present with these factors, there is added risk for suicide (Field & Seligman, 2004).
The causes or origins of Substance-Related Disorders are multifactorial (e.g., based on interactions of biological, environmental, and personality factors). Researchers have long noted the “biological” or “family” transmission of substance use disorders, especially alcoholism (Piazza, 2004). Children and adolescents with AD/HD are at increased risk for developing alcoholism and other drug addictions, especially if alcoholism exists in other family members (Wilens, 1998). The odds of this increased risk for alcohol dependence was 45% greater among individuals with problem-drinking second- or third-degree relative only, 86% greater among individuals with a problem-drinking first-degree relative only, and 167% greater among individuals with at least one problem drinking first-degree relative and at least one problem-drinking second- or third-degree relative (Department of Health and Human Services [DHHS], 1997).
Overall, inherited individual and/or biological differences in the brain are believed to regulate the individual’s sensitivity to the effects of certain substances and place them at “increased risk” of compulsive substance use (Piazza, 2004).
“Environmental” risk factors (e.g., discordant parent-child interactions, unfavorable family structure and function, problems at school and/or in the community, and economic adversity) cannot be discounted for their potential roles in the development of alcoholism and other drug disorders. Wilens (1998) believed that AD/HD-related alcohol and other drug abuse can develop early in youth (e.g., mid- adolescence) as an attempt to alleviate symptoms of mental distress associated with chronic failure, feelings of inadequacy, and conflict with parents and peers.
The “personality structure” is genetically and environmentally determined; it is built on and modified by environmental influences or experiences (Harris, 1995). The person’s personality cannot be separated from its genetically embedded components. It should be remembered that the AD/HD would be carried along with the personality into the environment (e.g., school, community). Affecting, for example, the way that others will react to the individual with the disorder (Erk, 2000). Werry (1995) believed that AD/HD should be considered characteristic of the personality structure of individuals with the disorder.
The “key” here is to understand that the presence of AD/HD is an important risk factor for the development of Substance Use and Substance-Related Disorders. For example, disorders associated with alcohol and other drugs tend to appear earlier and progress more rapidly in persons with AD/HD (Wilens, 1998). Approximately 50% of adults with AD/HD exhibit alcohol and other drug abuse or dependence (Wilens et al., 1996). Data suggest that the risk of developing alcohol and other drug disorders at anytime over the lifespan of an adult with AD/HD is twice that of adults without AD/HD (52% versus 27% respectively) (Biederman et al., 1995). Elevated rates of alcoholism are consistently found in the parents of youth with AD/HD (Wilens et al., 1996).
For individuals with AD/HD, who were never treated for the disorder in childhood or adolescence, substance abuse is a common outcome (Resnick, 2000). In these particular cases, the potential for alcohol and/or substance addiction is high. Unfortunately, alcoholics with AD/HD are less likely than those without AD/HD to remain in alcoholism treatment programs or to achieve moderation or abstinence (Tarter & Edwards, 1988).
Research supports a significant relationship between AD/HD and alcohol and other drug disorders, with many symptoms of AD/HD, appearing many years before the earliest onset of abuse. When alcohol and other drug disorders begin in adolescence, they run a more severe course than those that appear in adulthood. Therefore, early treatment strategies should be directed at children and adolescents with AD/HD before alcohol and other drug use problems develop and become chronic (Wilens et al., 1997).
KEEP YOUR EYE ON SUICIDE
In the year 2000, there were approximately 30,000 suicides. Suicide was the third leading cause of death among 15- to 24-year olds. Suicide was also the third leading cause of death among children ages 10-14 (National Institute of Mental Heath [NIMH], 2003). It is the second largest killer of students in the college population.
Suicide is a tragic; yet, potentially preventable public health problem. Suicidal behavior is complex. With each case, there are risk factors. Some risk factors vary with age, gender (e.g., more males are completers, more females are attempters), and ethic group. Risk factors might include: childhood trauma (e.g., physical or sexual abuse, domestic violence, disruptions to attachment figures), mood disorders (e.g., are involved in the development of suicidal thoughts and behaviors) and addictions (e.g., especially alcoholism). Risk factors for suicide can change with the individual case. Over time, they may decrease or multiply.
Roberts et al. (1998) explored the risk of suicidal plans and ideation, depression, and factors such as self-esteem, loneliness, and pessimism among adolescents with a lifetime history of attempted suicide. Those with a lifetime history of suicide attempts were more likely to think about death, wish to be dead, think about suicide, and plan suicide. In examining the role of depression in relation to suicidal thinking and attempts, these researchers determined that depression clearly played a significant role, and in combination with a history of previous attempts, the risk of recent ideation was high. Additionally, it was determined that those who exhibited more suicidal ideation were most likely to be lonely, fatalistic, and pessimistic and to have lower self-esteem and higher levels of stress.
Boergers et al. (1998) explored psychological functioning and self-reported reasons for suicide attempts in 120 adolescents. They determined that more than half of the adolescents indicated that their attempts to die were to escape or obtain relief. Those who indicated that the suicide attempts were in order to die were significantly more depressed, hopeless, angry, and perfectionistic. Depression in this study was found to be the most reliable predictor of the motivation to die. Clearly, Mood Disorders put this population (e.g., adolescents) at risk for suicide. Assessing this risk potential and taking steps to ensure the person’s safety is a top priority.
Adverse life events in combination with Depression and/or Substance-Related Disorders may also lead to suicide. Other related factors may include: prior suicide attempt, family history of mental disorder or substance abuse, firearms in the residence, impulsive or aggressive tendencies or behaviors, incarceration, and exposure to the suicidal behavior of others (e.g., family, peers).
A “benchmark” finding on suicide has been established in persons where a Mood Disorder and/or Substance Abuse Disorder is at work. Research has shown that more than 90% of people who kill themselves have Depression and/or another diagnosable mental or Substance Abuse Disorder, often in combination with other mental disorders (Conwell et al., 1995; NIMH, 2003; Moscicki, 2001; Minino et al., 2002).
Suicide completers can be divided into at least three subgroups according to co-occurring disorders or comorbidity: a low comorbidity group, a substance-dependent group, and a group exhibiting childhood onset of psychopathology or mental disorders (Kim et al., 2003). James et. al. (2004) reviewed the evidence of a possible association between AD/HD and suicide. The electronic databases--Medline and Psy Lit--for 1966 through 2003 were searched looking for articles on AD/HD and suicide. An association of AD/HD and completed suicide was found, especially for young males. These researchers concluded that AD/HD appears to increase the risk for suicide in males via the “severity of comorbid disorders.” Identification and careful monitoring of those at-risk, particularly males, may represent a clinically useful means of reducing suicide in these cases.
Many interventions designed to reduce suicidality also include the treatment of “mental” and “substance abuse” disorders. Preventive efforts to reduce suicide should be based on research that shows which “risk factors” and “protective factors” can be modified. Research continues to reinforce the crucial variable of family members and close friends being involved in the intervention and treatment process.
Just as people can die of heart disease or cancer, people can die from mental illness. Suicide is almost always complicated, resulting from a combination of painful suffering, desperate hopelessness, and underlying psychiatric illness.
Is it possible to predict suicide? At the present time, there is no definitive measure to predict suicide or suicidal behavior; very few persons will actually commit suicide. However, we need to be fully aware that researchers have identified risk factors pertinent to suicidal behavior. The alarming numbers of suicide deaths and attempts emphasize the need for carefully designed prevention programs. The “early” recognition, identification, and treatment of the risk factors associated with suicide is the single most important intervention for preventing and reducing suicidal behavior.
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Disclaimer: The information contained on this web page is intended to be for informational purposes only. It is not intended as psychological or medical advice. Individuals who are diagnosed with AD/HD should secure information and recommendations on AD/HD from their treating professional. A systems oriented approach to AD/HD with families, schools, and communities working together and multidimensional treatment for AD/HD are the focus of this web page and its contents. The University of Tennessee at Martin is not responsible for the information or views expressed herein. Last updated June, 2005. Copyright 1997. All rights reserved. Email: firstname.lastname@example.org
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