Autumn2016
Attention-Deficit
Hyperactivity
Disorder (ADHD)
PSX_003 Counselling Psychology
PSX_006 Psychotherapy
PhDr. PavelHumpolíček, Ph.D
Students
Cristiana Leite 464345,MónicaCardoso 464323, Rita Almeida 464279
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History of ADHD
Although ADHD presents an increasing number of studies and remarkable interest
around itself, there were several and distinct view of this disorders along the different
decades. Based on those different views we can get a better understanding of the disorder
and its components until nowadays.
The modern history of “ADHD-like medical descriptions” start to appears around 200
years ago, not existing a description of this disorder in the ancient literature (Matthews et
al, 2013). It seems that one of the first examples of something close to ADHD date to
1798 by Sir Alexander Crichton, that in one of his books about mental illness
characterizes a disorder that is based in ‘‘the incapacity of attending with a necessary
degree of constancy to any one object’’. Crichton then defines two possibilities for
abnormal inattention that are the oppositional increase or decrease ‘‘sensibility of the
nerves’’ (Crichton 1798; Lange et al, 2010). After that, some authors acknowledge
Frederic Still as the scientific starting point of the history of ADHD in 1902 (Barkley,
2006) after he described 20 cases of children with a ‘‘defect of moral control as a morbid
manifestation, without general impairment of intellect and without physical disease’’.
An important aspect concerns the encephalitis epidemics of 1915–1920 given the fact
that to several children who were infected and survived started having problems with
impulsivity and over-activity – descriptions that showed many similarities with what is
now known as ADHD (Matthews et al, 2013). This condition had some designations
along the years and then came to be known as “minimal brain dysfunction” (MBD).
It was in 1932 that physicians Kramer and Hans mentioned “a hyperkinetic disease of
infancy” that had as primary and most obvious symptom a marked motor restlessness.
These children showed a remarkable motor activity, an urgency and could not stand still
for very long, running up and down the room. Also, they were extremely displeased when
someone would stop them from acting according to their impulses (Lange et al, 2010).
By the late 1950s, the label as “hyperkinetic impulse disorder” or “hyperactive
child syndrome” had become very used and theories of cortical overstimulation, cortical
under-arousal, psychoanalytic and psychosocial theories started to arise in search for an
explanation or better description (Burks 1960; Chess 1960). When the second edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) came out, it
presented for the first time a range of childhood disorders that were all interpreted as
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reactions, like a psychological defense or an adaptive behavior, including the
“hyperkinetic reaction of childhood” (Association, 1968). This showed the start of an
argument that still lasts to the present days, regarding the opposite views about this
disorder being a neurobiological or a behavioral/psychosocial problem.
In the 1970s, researchers were motivated by the progress in cognitive and
experimental psychology and emphasized problems with sustained attention and impulse
control in addition to hyperactivity. As a result of this interest and work, the Douglas’s
Model (1972), which highlighted the inclination to seek immediate reinforcement, helped
to rename this disorder as “Attention Deficit Disorder” (ADD) in the 1980 version of
DSM, third edition (Association, 1980). This lead the MBD term to be abandoned and a
few years later, in 1987, the DSM-III revised edition came out and the disorder had been
renamed as “attention-deficit hyperactivity disorder” (ADHD). The 1980s and 1990s
extensive research on information and reward-processing features associated with ADHD
suggested that the hyperactivity and impulsivity formed a single dimension of behavior
and, as a result, in the DSM-IV (1994) this disorder had two distinct yet correlated
dimensions or domains of behavior: a set of symptoms for inattention and another for
hyperactive–impulsive behavior.
In the last years, ADHD has been connected to an impressive and still growing
literature that includes structural and functional brain imaging as well as molecular
genetic studies and there is still a lot to learn and discover about this disorder (Matthews
et al, 2013).
Definition and Classification
There are two main classification systems for diagnosing ADHD: the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – 5th
Edition (DSM-5) and the International Classification of Mental and Behavioural
Disorders 10th revision (ICD-10).
DSM-V
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V),
attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of inattention
and/or hyperactivity-impulsivity, which interferes with the functionality or with the
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development of the person. This disorder’s manifestations must be present, not only in
school or at home, but in more than one context in which the person is usually inserted.
By inattention we mean behaviors such as manifesting some difficulties in
maintaining the focus and, consequently, difficulties in performing tasks that need the
attention of the person over an extended period of time. Also, lack of persistence and lack
of organization are examples of inattention behaviors.
Hyperactivity is linked to motor activity that is excessive or inappropriate to the
occasion. This excessive restlessness usually tires people who share their days with
people with ADHD.
Impulsivity has to do with precipitous choice of actions without first reflecting on
them as to the consequent benefits and damages. Impulsivity may also be linked to the
desire for immediate rewards and a lack of ability to wait for them. This type of behavior
can have consequences on the personal and social levels of the individual with ADHD,
such as social intrusiveness and non-pondered decisions about important situations (APA,
2013).
Diagnostic Criteria
According to the DSM-V, an individual has ADHD if he presents a persistent pattern
of inattention and/or hyperactivity - impulsivity that interferes with the functioning or
development (criterion A).
For inattention, the individual must present 6 or more of the following symptoms that
are inconsistent with his developmental level and that have a direct negative impact on
social and occupational activities, for at least 6 months (criterion A1):
a. Often fails to give close attention to details or makes careless mistakes in
schoolwork, at work, or during other activities;
b. Often has difficulty sustaining attention in tasks or play activities;
c. Often does not seem to listen when spoken to directly;
d. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace;
e. Often has difficulty organizing tasks and activities;
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort;
g. Often loses things necessary for tasks or activities;
h. Is often easily distracted by extraneous stimuli;
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i. Is often forgetful in daily activities.
For hyperactivity and impulsivity, the individual must present 6 or more of the
following symptoms that are inconsistent with his developmental level and that have a
direct negative impact on social and occupational activities, for at least 6 months
(criterion A2):
a. Often fidgets with or taps hands or feet or squirms in seat;
b. Often leaves seat in situations when remaining seated is expected;
c. Often runs about or climbs in situations where it is inappropriate;
d. Often unable to play or engage in leisure activities quietly;
e. Is often “on the go,” acting as if “driven by a motor”;
f. Often talks excessively;
g. Often blurts out an answer before a question has been completed;
h. Often has difficulty waiting his turn;
i. Often interrupts or intrudes on others.
These symptoms are not only about failure of understanding of tasks and instructions
or manifestations of oppositional, defiant or hostile behavior. For adults or adolescents
over 17 years of age, only 5 or more of the previously reported symptoms for both
inattention and hyperactivity-impulsivity are necessary to be diagnosed with ADHD.
In addition, these symptoms for both inattention and hyperactivity-impulsivity must
be present before the individual is 12 years old (criterion B), be present in two or more
settings (criterion C) and interfere or reduce the quality of social, academic, or
occupational functioning (criterion D). Besides that, the symptoms must not occur
exclusively during the course of schizophrenia or another psychotic disorder and aren’t
better explained by another mental disorder (criterion E) (APA, 2013).
Specifiers
Depending on the presence of certain symptoms, we can specify whether there is a
Combined presentation, 314.01 (F90.2), - if both criterion A1 and criterion A2 coexist
for the past 6 months -; Predominantly inattentive presentation, 314.00 (F90.0), - if
criterion A1 is verified but criterion A2 is not met for the past 6 months - ; Predominantly
hyperactive/impulsive presentation, 314.01 (F90.1), - if criterion A2 is met but criterion
A1 is not met for the past 6 months. We can also specify if the individual is in partial
remission. This happens when full criteria were previously met, less than the full criteria
have been met for the past 6 months, and the symptoms still result in impairment in social,
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academic, or occupational functioning. Taking the severity of symptoms into account we
can distinguish between Mild - if few, or none, symptoms in excess of those required to
make the diagnosis are present, and symptoms result in no more impairment minor in
social or occupational functioning -; Moderate - if symptoms or functional impairment
between “mild” and “severe” are present - and Severe - if many symptoms in excess of
those required to make the diagnosis, or several symptoms that are particularly severe,
are present, or the symptoms result in marked impairment in social or occupational
functioning (APA, 2013).
Comorbility – DSM-V
The existence of a diagnosis of ADHD is often accompanied by another disease in
the individuals, and, therefore, the existence of comorbid disorders in ADHD is very
frequent. In approximately half of the children with a combined presentation and in
approximately a quarter of children with predominantly inattentive presentation cooccurs
the oppositional defiant disorder. About a quarter of children and adolescents with
a combined presentation, although depending on age and setting, also presents conduct
disorder. Although only occurring in a small percentage of children with ADHD, anxiety
disorders occur more commonly in these children than in the general population. It is also
common for children with ADHD to have a specific learning disorder. Even if it happens
only in a very small percentage of children with ADHD, it can coexist with disruptive
mood dysregulation disorder (APA, 2013).
ICD-10
F90 - Hyperkinetic disorders
ICD-10 referes to ADHD as Hyperkinetic Disorder (HKD), a term widely used in
Europe and included in European clinical guidelines. This classification system defines
HKD as a persistent and severe impairment of psychological development, characterised
by "early onset; a combination of overactive, poorly modulated behaviour with marked
inattention and lack of persistent task involvement; and pervasiveness over situations and
persistence over time of these behavioural characteristics" (Organization, 1992, p.206).
ICD-10 refers to the characteristic problems as lack of persistence in activities
that require cognitive involvement, a tendency to move between activities without
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completion and disorganized and excessive activity. All of these problems always arise
early in development, usually in the first 5 years of life, but usually continue through
school years and can persist into adult life. However, an individual affected with this
disorder show a gradual improvement in activity and attention. Besides these problems,
some other abnormalities are usually associatedwith HKD: hyperkinetic children are
often reckless and impulsive, prone to accidents, and they normally breache rules without
thinking which means that they do not intend to be deliberately defiant. For that reason
very often they find themselves in disciplinary trouble. While they are commonly
incautious and unreserved with adults being often socially disinhibited in their presence,
they may be isolated and unpopular with other children, which can be hard for
maintaining relationships with them. Cognitive impairment, specific delays in motor and
language development and scholastic problems such as reading dificulties are more
common in this group than in the general population. Therefore, as a consequence of the
disorder, children may engage in dissocial behaviour and experience low self esteem
(Organization, 1992).
Diagnostic guidelines
For a diagnosis of HKD, ICD-10 requires evidence of both impaired attention and
overactivity in more than one situation (e.g. home, classroom, clinic). However, deficits
in persistence and attention should be diagnosed only if they are excessive for the child's
age and IQ; and the overactivity feature should be judged based on if the activity is
excessive in the context of what is expected in the situation and by comparison with other
children of the same age and IQ (Organization, 1992).
Impaired attention is related with a lack of preserverance in tasks involving
thought and attention, and the tendency to move from one activity to the next without
completing any (although laboratory studies do not generally show an unusual degree of
sensory or perceptual distractibility) (Organization, 1992).
Overactivity implies excessive restlessness, could involve the child running and
jumping around, leaving their seats in situations in which remaining seated is expected,
excessive talkativeness and noisiness, or fidgeting and wriggling. This behavioural
feature is most evident in structured, organized situations that require a high degree of
behavioural self-control (Organization, 1992).
There are some associated features with this disorder. They are not sufficient for
the diagnosis or even necessary, but help to sustain it. For example, chidren with HKD
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frequently show disinhibition in social relationships, recklessness in situations involving
some danger, and impulsive flouting of social rules (interrupting or intruding on others’s
conversations or activities, blurting out answers before questions have been completed,
and showing difficulty in waiting turns).
So, although ICD-10 criteria for HKD describe similar symptoms to DSM-V for
ADHD, the ICD-10 criteria are more restrictive because they require hyperactivity,
impulsivity, and inattention all to be present for the diagnosis of HKD to be made (in
addition the presence of at least 6 inattention symptoms, at least 3 hyperactive symptoms
and at least 1 impulsive symptom). In addition, symptoms should occur before the age of
6 years, be of long duration and be present in more than one setting. Besides that, the
presence of another disorder, such as mania, depression, and/or anxiety disorder, is in
itself an exclusion criterion, whereas DSM-V allows these diagnoses to be made as
comorbid conditions (Döpfner, 2010).
Diagnosis of HKD may also be made in adult life using the same criteria, however,
attention and activity must be judged with reference to developmentally appropriate
norms.
Caution is recommended in children of pre-school age and only extreme levels of
hyperactivity should lead to a diagnosis in these individuals.
The application of these more restrictive criteria defines hyperkinetic disorder as the
subgroup of those patients with combined type ADHD with the most severely
impairing symptomatology, characterized by greater impairment and more impulsecontrol
difficulties than typical ADHD (Döpfner, 2010).
Diferential Diagnosis
The major problems in diagnosis lie in differentiation from conduct disorder.
According to ICD-10, the code “Disturbance of activity and attention” should
be used when the overall criteria for hyperkinetic disorder (F90.-) are met but those for
conduct disorders (F91.-) are not. However, milder degrees of overactivity and
inattention are common in conduct disorder. So, when criteria of both hyperactivity and
conduct disorder are present, and the hyperactivity is pervasive and severe,
"hyperkinetic conduct disorder" (F90.1) should be the diagnosis.
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A further problem it’s related to the fact that overactivity and inattention, of a
rather different kind from that which is characteristic of a hyperkinetic disorder, may arise
as a symptom of many other disorders. Therefore, if the criteria for anxiety disorders,
mood affective disorders, pervasive developmental disorders and schizophrenia are met,
this should take precedence over hyperkinetic disorder.
Epidemiology
The prevalence of the more restrictive ICD-10 hyperkinetic disorder diagnosis has
been estimated to be around 1.5% in school-age children (Döpfner, 2010).
Concerning to ADHD, prevalence rates may vary depending on several factors.
Regarding to gender, it seems that ADHD is more frequent in males than in
females in the general population, with a ratio of approximately 2:1 in children and 1.6:1
in adults (Association, 2013).
Concerning to age, ADHD is most commonly diagnosed in school-aged children.
According to DSM-V, population surveys suggest that ADHD occurs in most cultures in
about 5% of children and about 2.5% of adults (Association, 2013). Also, results from
meta-regression analyses have estimated a worldwide prevalence of ADHD in people
aged ≤18 years of between 5.29% and 7.1% (Polanczyk et al., 2007). A recent study
(2014) which updated these analyses concluded that there was no evidence to suggest an
increase in the prevalence of ADHD in children and adolescents over the past three
decades (Polanczyk et al,. 2014). The worldwide ADHD prevalence in adults (aged 18–
44 years) was estimated at 3.4% overall (range 1.2–7.3%) by the World Health
Organization across 10 countries in Europe, the Americas, Columbia, Mexico and the
Middle East (Fayyad et al., 2007).
According to DSM-V, it also seems to be differences in ADHD prevalence rates
across regions, which appear to be attributable mainly to different diagnostic and
methodological practices. There’s also suggestions that cultural variation in attitudes
towards the interpretation of behaviour may contribute to the differences found
(Association, 2013). However, a worldwide meta-analysis of 86 studies in children and
adolescents and 11 studies in adults, found no significant prevalence differences between
countries, after controlling for differences in the diagnostic algorithms used to define
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ADHD (Willcutt, 2012). Researchers therefore argue that ADHD is not a cultural
construct associated with a particular geographical location.
In general, it appears that ADHD is a worldwide disorder and that, as long as
similar methodologies are used, the prevalence rates are similar in most ethnic
communities (Döpfner, 2010).
Etiology
Although ADHD is an extensively researched disorder, its origin is still a
controversial subject between different authors. The etiology of ADHD is multifactorial
so there are several factors that can be in the starting point of this disorder and that can
be divided according to a very common question – “does ADHD qualify as a “nature” or
a “nurture” disorder, or some combination of factors?” (Evans, 2013).
On one hand, the majority of researchers claim that ADHD has a genetic cause
and point several aspects to support this point. Firstly, family/twin and adoption studies
support that ADHD is a highly heritable disorder being that the majority of patients have
a first or second-degree relative with a history of ADHD or learning disorder. Dopheide
(2001) says that there is a 55% to 90% concordance rate for ADHD for monozygotic
twins while Millichap (2007) points that there is a 79% concordance in monozygotic
twins against 32% in same-gender dizygotic twins, thus supporting the genetic factor.
Another possible cause of ADHD that falls in the genetic domain is the claim that
there is a chemical imbalance in the brain - a dopamine deficiency (Evans, 2013). In one
meta-analysis, there were identified seven candidate genes that demonstrated significant
pooled odds ratios for conferring risk for ADHD being that 5 of the genetic variants were
explicitly involved in dopamine neurotransmission (Kollins & Adcock, 2013). One of
Dopamine’s effects is that it helps to regulate emotional responses, take action to achieve
specific rewards and it’s important for concentration or sustained attention. People with
ADHD show lower levels of dopamine due to the fact that their nervous system and
neurons in the brain present a higher concentration of dopamine transporters, which
prevent the dopamine from going to the next cell and lessens its effect (Legg, 2016).
Finally, another aspect related with “nature” makes part of the Organic theory of
ADHD and it’s about the activity and constitution of the brain. Evidence shows that the
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activity on prefrontal cortex and cingulate brain regions, which are involved in inhibitory
control and the executive command, is deficient in people with ADHD (Millichap, 2007;
Evans, 2013). Also, the prefrontal cortex, caudate nucleus and globus pallidus are smaller
than usual, suggesting a “lack of connectivity of key brain regions that modulate
attention…processing, and impulsivity” (Dopheide, 2001).
On the other hand, there are some aspects about ADHD that fall on the “nurture”
domain, regarding Environmental Factors. Factors like having an imbalanced diet, food
allergies, low levels of zinc/calcium/magnesium and omega-3 acids seem to have to effect
of triggering ADHD and are not natural or genetic components (Millichap, 2007; Evans,
2013). The mentioned factors are all postnatal but there are also prenatal and perinatal
factors associated with ADHD, such as maternal smoking and anemia, prematurity, low
birth weight, small head circumference, cocaine and alcohol exposure, iodine and thyroid
deficiency. Some illnesses in childhood can also trigger ADHD in certain cases, being
some of them viral infections, meningitis, encephalitis, otitis, cardiac disease, thyroid
disease, epilepsy and autoimmune and metabolic disorders. All of these are not only
causes but also risk factors that people can see and take into account, helping to prevent
further developments ((Millichap, 2007).
Nowadays, the “nurture” aspects have been disregarded as primary causes of the
disorder, being that in the majority of the cases a genetic factor is a likely base cause and
the environmental factors is probably secondary, acting as a trigger of what is already
there (Dopheide 2001; Millichap, 2007). Taking this into account, the etiology of ADHD
is probably a combination of both genetic and acquired factors, “nature” and “nurture”
combined.
Regarding some theories of ADHD that can give us an important insight about the
disorders and sometimes a starting point for an intervention and treatment, we can focus
on neurobiological theories, which have been centered on two models (Matthews et al,
2013). One models focuses on top-down, controlled processing problems, associated with
“cognitive control or executive functioning” (Barkley 1997). The other emphasizes
bottom-up, motivational and incentive/reward response (Sagvolden et al. 2005). There is
no consensus regarding these two models but evidence supports both and suggest both
types of psychobiological systems are involved in ADHD.
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Focusing on top-down model, one of the most know supports of this argument is
the unifying theory of Barkley (1997) which suggests that symptoms of the disorder, such
as atypical behavioral inhibition, “were caused by deficits in response inhibition that in
turn disrupted four specific executive functions” - (a) nonverbal working memory; (b)
internalization of speech (or verbal working memory); (c) self-regulation of affect,
motivation, and arousal; and (d) reconstitution. Supporting this idea of Barkley, afterward
studies show that ADHD appears to be related to impairment in response inhibition
(Matthews et al, 2013) which is the ability to inhibit or suppress an inappropriate response
in a specific context. This, along with response selection, are extremely importing in
facilitating goal-directed behavior, having an important connection with ADHD.
Regarding the bottom down and emotional regulation theories, these view ADHD
concerning people’s problems with emotions, such as the difficulties with anger, and
affect regulation (Matthews et al, 2013). Motivational or reward responding are typically
viewed in terms of “approach” behavior, which can also be construed as positive
affectivity, or “avoid” behavior, construed as negative affectivity. Children with ADHD
present difficulties regarding this regulation, not always knowing what to avoid in certain
contexts and what behavior would be positive certain time, therefore the connection
between this aspects and the disorders.
As mention, there isn’t consensus about these and other referred
theories/approaches, although there seems to be evidence supporting the connection of
various and different aspects, enlightening the multidimensional nature of ADHD.
Consequences
The consequences of this disorder go through several levels, from the social and
the family level to the occupational level. The most significant consequences for children
with ADHD are reduced school performance and academic achievement. These
consequences result, although depending on the case, in a low level of schooling, a lower
vocational performance, as well as in a low intellectual score. The consequences also
depend on the type of symptoms that the individual presents, so if he presents more
symptoms related to inattention, academic deficits, problems related to school and neglect
of the peers are more likely to happen, whereas symptoms more related to hyperactivityimpulsivity
have accidental peer rejection and injury as the most likely consequences. A
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failure in consistency in performing tasks that require sustained effort is often seen as a
sign of laziness, irresponsibility or unwillingness to cooperate. Also family relationships
suffer from some consequences, such as discord and negative interactions between family
members. Peer relationships also have some consequences, which may lead to peer
rejection, neglect or teasing towards the child with ADHD (APA, 2013).
Assessment
The diagnosis of ADHD is based on clinical judgment of integrated data gathered
from multiple sources to resolve conflicting observations and opinions. Since ADHD
manifests itself behaviourally, three general and complementary clinical procedures are
used to empirically assess the child: interviews, questionnaires, and observations
(Coghill & Sergeant, 2010).
The aims of the ADHD assessment are to evaluate whether or not patient meets
diagnostic criteria for ADHD, to distinguish ADHD from other disorders and exclude
other explanations for behaviours, and to assess whether patient is suffering from any
comorbid disorders. A full assessment for ADHD is not a simple tasks ans requires skill,
specialist training and experience with a broad range of mental health and developmental
disorders. Also, it is something that requires more than one meeting and should include:
Clinical interview with the parents; A separate interview with the child; Preshool,
Kindergarten and school information; School observation and investigations;
Intelligence/cognitive tests if there is a specific indication (Coghill & Sergeant, 2010).
Therefore, the process of diagnostic evaluation necessarily involves collection of
data from every possible sources as each can provide complementary information. So, for
that it’s important to know the patient's history, make observations of the patient's current
behaviour and the account of parents and teachers about the child's functioning in his/her
places. Usually there is poor agreement between informants (children, parents, and
teachers) about the child's mental health. Children often do not reliably inform about their
own behavioural symptoms and can make invaluable comments about other aspects of
their life and their inner worlds. Parents seem to be good informants with respect to
ADHD symptoms but often are less accurate at describing emotional difficulties.
Teachers have a tendency to overestimate the presence of ADHD symptoms, especially
when another disruptive behavioural disorder is also present. With adolescents, the value
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of the information given by teachers is often much less, as they have several teachers each
of whom spends little time with each class, which prevents them from knowing each
student well enough to comment accurately (Coghill & Sergeant, 2010).
Interview schedules
There are two types of interview schedule available: Structured interview, where
the questions are fixed and there is an algorithm converting answers into a diagnosis, and
the semi-structured clinical interview, where the clinician is given a degree of flexibility
with respect to the questions asked and then evaluates the respondents answers and
reaches a decision as to whether the symptom is present or not.
Examples of these two types of interviews are the structured Child and Adolescent
Psychiatric Assessment (CAPA) and the semi-structured PACS-Parental Account of
Children’s Symptoms (Taylor et al., 1986). Also, the Development and Well-being
Assessment (DAWBA; Goodman 2000) may be of particular interest in some settings as
it is possible for parents to complete the interview online and for it to be scored prior to
attendance at the clinic for a face to face assessment.
Clinical interview with the parents
Tasks can be divided into a general evaluation of the child, their problems and the
context within which they are occuring and specific questioning about ADHD and its
common comorbidities. Past clinical history of behaviour is essential for diagnostic
definition, since only a small number of patients present the characteristic signs and
symptoms of ADHD at the assessment appointments. The absence of symptoms at the
office does not rule out the diagnosis. A detailed social and family history is also of very
importance. Clinicians should pay attention to family history of ADHD, perinatal history,
since various studies have found a higher prevalence of ADHD in preterm babies and low
birth weight infants (Coghill & Sergeant, 2010).
The assessment can be seen as the start of a relationship between the clinical
services and the family and as those with a diagnosis of ADHD will often require a
prolonged period of treatment it is important to start to cultivate a strong therapeutic
alliance from the beginning, llowing space and time for the parents to describe the
difficulties from their perspective (Coghill & Sergeant, 2010).
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Here, the use of standardized interview schedules and scales questionnaires to
identify the signs and symptoms of ADHD are widely accepted, although many clinicians
do not yet employ them on a routine basis.
Separate interview with the child
This is usually more helpful in addressing general adjustment and comorbidity
than for assessing the presence or absence of diagnostic criteria which are usually more
accurately described by parents, family members, teachers and other observers.
The interview should focus on: Functioning in the family, the school and the peer
group; A general evaluation of psychopathology (especially emotional problems and self
esteem); and the child’s attitude to, and coping with, their disorder. Self report rating
scales may be helpful as an adjunct to an interview (especially for detecting emotional
problems) (Coghill & Sergeant, 2010).
Observation of behaviour during the interview can be useful especially if ADHD
or other behavioural problems are observed. An observer should focus on assessing: The
presence of social disinhibition; Ability to concentrate and persist; and any evidence of
language disorder (Coghill & Sergeant, 2010).
With respect to the observation of ADHD behaviours within the clinic setting it is
important to remember that children with ADHD will often moderate their behavioturs in
novel settings. It is therefore not uncommon for these children to appear well controlled
for the first few clinic appointments. So, this should not usually be used as evidence
against the presence of ADHD (Coghill & Sergeant, 2010).
Questionnaires
Questionnaires also fall into two classes: Broadband, that assess for a wide range
of psychopathology and allow the clinician to screen for several disorders and; narrow
band, which are specific instruments designed to screen for a particular condition. An
example of the former is the Child Behaviour Checklist (CBCL, Achenbach, 1991) and
the Teacher Rating Form (TRF, Achenbach, 1991) and of the latter is the Conners Parent
and Teachers Rating Scales (Conners, 1978).
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In clinical practice, it is useful to have a standardized teacher telephone interview
to ensure standardized practice. Several tools specifically designed for this purpose are
available. Alternatively, it is possible to use the ADHD-RS (ADHD Rating Scale) as a
semi-structured interview (Coghill & Sergeant, 2010).
Since children referred for ADHD often present with a considerable variety of
associated disorders and deficits, it should be of interest use some instruments for
screening and do initial evaluation in these areas. Not all these need to be included as
routine but should be used if the information gathered as a part of clinical observation,
history taking and evaluation of input from parents, teachers and the child is suggestive
of other difficulties (Coghill & Sergeant, 2010).
Preschool, kindergarten and school information and school observations
Information from school is essential for the diagnosis of ADHD, which can be
obtained from the teacher, including information about: Behaviour and behaviour
problems; Development; Social functioning; and Situational variation in behaviour and
symptoms that may indicate comorbid or differential diagnoses. Standardized
questionnaires can help to obtain a broad coverage of information (e.g. SDQ , CBCL and
Conners’). Further written reports or structure telephoned interview may also be needed
to assess the coping style of the teacher, the teacher child relationship, and also to have a
full view of the child at school (Coghill & Sergeant, 2010).
If there is still doubt about the diagnosis or other aspects of functioning, a school
observation is conducted. Whilst there are few validated observational measures for
ADHD it is known from clinical experience that a structured approach to recording
observations is often very helpful. In fact although not explicitly an observational
measure the SKAMP, that was designed to specifically measure the classroom
manifestations of ADHD, has been used to rate observed behaviour in the laboratory
school study setting (Coghill & Sergeant, 2010).
Potential domains of interest in a school observation include general information
about age of child, time of day, setting, number os children, number os adults, activity
(e.g. math’s class, quiet time, group or individual working, etc.), room type and set up
(e.g. traditional class room, open plan, individual or group desks, etc.). Our focus should
be also in some observed behaviours such as overactivity (e.g. out of seat, climbing,
CounsellingPsychologyandPsychotherapy
16
fidgeting, etc.), impulsivity (e.g. answering questions directed at others, butting in,
shouting out, unable to wait, etc.), inattention (e.g. needs reminding to stay on task,
difficulty getting started, poor task completing, etc.), oppositional behaviours (argues
with teacher or peers, aggressive to others, etc.), evidence of mood lability, level of
communication and interaction with others, ability to use comprehend and use language,
ability to socially interact with others, reciprocal social interactions, repetitive
behaviours, ability to imitate others, ability to play appropriately, evidence of anxiety
(Coghill & Sergeant, 2010).
Treatments
Approaches used to the treatment of ADHD may vary depending on many factors.
These include the professional background and training of the clinician, where there is
usually a difference between medically and non-medically trained clinicians, with the
first ones being more likely to select pharmacologic approaches to intervention and the
second one’s tending to employ psychosocial treatments at the individual or family level.
Treatments for ADHD can also range from those that are relatively straightforward and
involve a single approach to intervention to those that are maximally complex and require
intervention at multiple levels (Johnson, McAlister, & Reader, 2008).
The core symptoms of ADHD and associated features can be manifested in a child
in many different ways, therefore, treatment approaches and their degree of complexity
need to be matched with an individual child’s needs and with the degree to which the
child displays impairment in important areas such as family, school, and social
functioning. For this reason, treatment may require multimodal interventions at the
individual, family, school, and perhaps community levels (Johnson et al., 2008).
In selecting treatment approaches it is also important to focus on interventions
supported by research findings. Currently, interventions that enjoy the strongest empirical
support include the use of stimulant medications, behaviorally oriented parent training
programs, behavioural classroom-based interventions and ADHD summer treatment
programs (Johnson et al., 2008; Döpfner, 2010).
Stimulant medications are generally considered to be most effective in managing
the core symptoms of ADHD whereas psychosocial treatments are usually most
valuable in dealing with the psychological and behavioral problems that children with
CounsellingPsychologyandPsychotherapy
17
ADHD often display, and thus increase the psychosocial functioning of the patient and
their quality of life (Johnson et al., 2008; Döpfner, 2010).
PsychosocialTreatments
Well established psychosocial interventions for reducing ADHD symptoms
include psychoeducation of the patient and the parents/teachers, behavioural parent
training including family interventions, teacher training, behavioural classroom
management strategies as well as peer-focused behavioural interventions with social
skills training and cognitive behavioural therapy of the patient (Taylor et al., 2004;
Pelham & Fabiano, 2008, cited in Döpfner, 2010).
To date, it seems that the behavioural parent training and school based behavioural
interventions are empirically the best established psychosocial interventions while the
effects of the others mentioned above have been less well studied. Several other nonpharmacological
interventions (diet, neurofeedback, play therapy) have at least some
support (Döpfner, 2010).
A multimodal psychosocial treatment, which includes a combination of several of
these interventions is often required since each of these interventions has its own
particular strengths and treatment objectives (Döpfner, 2010).
 Psychoeducation
Psychoeducation is an intervention aimed at developing a therapeutic
relationship with the patient and his family, in order to collect information about the
individual/family beliefs and attributions regarding the disorder in question, ADHD in
this specific case. Based on these beliefs about ADHD, new information about the
disorder is given, like especially symptoms, etiology, course, prognosis and treatment.
Then treatment goals are defined as well as a conjoint treatment plan. If there is a family
agreement, teachers can be interviewed to verified their beliefs about ADHD and then
provide new information about this disorder. About the treatment, teachers learns about
specific behavioral techniques that they can apply in their classrooms, such as techniques
including praise, planned ignoring, effective commands and time out, as well as the daily
report card. It is important for teachers to know more about ADHD so that the likelihood
of implementing psychosocial interventions within the school is increased. Depending on
CounsellingPsychologyandPsychotherapy
18
the developmental level of the child, the education of the children must be adapted
according to that level and psychoeducation is gaining more importance as the child
grows. Although it is considered by many authors as essential for a mental illness therapy,
psychoeducation does not present essays that support its effects for ADHD (Döpfner,
2010).
Individual Approaches to Intervention
 School-based Interventions (Behavioural school interventions)
Many of the difficulties that characterize ADHD may interfere with a child's
classroom behavior and their ability to learn, resulting in lower academic achievement.
As such, researchers have long examined effective ways of helping children with ADHD
to behave appropriately in school and to perform better academically (Chronis, Jones, &
Raggi, 2006). For this approach to be effective it is very important that the school can
cooperate and enable the teacher to be active in the treatment of the child. It’s also crucial
the establishment of an effective collaboration between the home and the school,
otherwise conflicts between the two can lead to frustration of the teacher and/or the
parents and reduce the effectiveness of the intervention (Döpfner, 2010).
School based interventions include two main components, which are classroom
interventions and academic interventions.
Classroom interventions
These include modifications of the classroom itself and strategies of behavioural
classroom management.
Regarding the classroom structure, a common intervention is the use of
individual and separated desks to achieve a decrease of distraction and the use of visual
aids as posters and signals. Studies also show that traditional classroom settings with rows
and opposite-sex seating can increase task engagement and lead to lower levels of
distractability (Döpfner, 2010).
Behavioural classroom management generally involve regular consultation
with the child's teacher regarding the use of behavior modification strategies.
Consultation usually begins with psychoeducation about ADHD and identification of
specific target behaviors, based upon a functional assessment of behavior (i.e.,
CounsellingPsychologyandPsychotherapy
19
examination of antecedents, behaviors, and consequences). Teachers are then instructed
regarding the use of specific behavioral techniques as praise, planned ignoring, effective
commands, daily report cards as well as the use of contingency management techniques
(e.g. incentives, reward programs, point systems, time-out) (Chronis et al., 2006;
Döpfner, 2010). The DRC is a school-based intervention in which specific, challenging
but attainable behavioral goals are set and the child is rewarded at home based on the
attainment of these goals. It also provides parents with daily feedback regarding their
child's behavior and perfonnance at school, and allows them to provide back-up
reinforcement for classroom behavior. Many researchers have reported beneficial effects
of the DRC intervention (Chronis et al., 2006).
Most studies show effects of the behavioral classroom management on both
classroom behaviour and social adjustment but the effects on academic performance are
less clear (Döpfner, 2010). Miranda (2006) demonstrated the effects of a multicomponent
classroom intervention which included psychoeducation for the teacher, use
of contingency management, instructional management procedures as well as changes in
classroom environment and use of self-instructional procedures. This programme resulted
in significant improvements in ADHD symptoms, and reduced school problems and
antisocial behaviour rated by both parents and teachers.
Academic interventions
Children with ADHD frequently evidence difficulties in academic achievement,
high risk of comorbid learning disabilities, and high rates of expulsion, dropout, and grade
retention (Daly et al., 2007). For this reason, emphasis on academic interventions is vital
to the comprehensive treatment of ADHD. This approach focus primarily on
manipulating antecedent conditions such as academic instruction or materials in order to
improve both behavioral and academic outcomes. Academic approaches that show some
preliminary support include task and instructional modifications, peer tutoring, computerassisted
instruction, and strategy training (Chronis et al., 2006).
Peer tutoring is an instructional strategy whereby two students work together on
an academic task with one student providing assistance, instruction and feedback to the
other, thereby simultaneously working on academic and social skill goals. The aim is to
increase of on-task behaviour and enhance attention (Chronis et al., 2006 ; Döpfner,
2010).
CounsellingPsychologyandPsychotherapy
20
A well described model is the classwide peer tutoring (CWPT), where tutoring is
carried out by tutoring pairs with praise and points for correct answers and correction
with subsequent practicing for wrong answers. CWTP has been shown to result in
increased active engagement in academic tasks and reduced in off-task behaviour with a
subsequent improvement in academic performance by ADHD students (Chronis et al.,
2006).
Another method of academic intervention uses the modification of tasks and
instructions. Task modifications involve revision of the curricula, whereas modification
of instructions involves adapting the content and delivery of instructions to meet the needs
of ADHD children (Döpfner, 2010).
For task modification it is recommended to match the tasks to each child’s ability,
reduce task length, divide tasks into subunits and sett goals for the child to achieve in
shorter time intervals, increase specificity or visual stimulation in instruction, use
enthusiastic yet task-focused presentation with the possibility of frequent and active child
participation, use brief and one-at-a-time presentation of academic assignments,
intercalate academic periods with brief periods of physical exercise, schedule the more
academic subjects into the morning hours, allow extra time for written tests (Barkley,
2006; DuPaul & Eckert, 1998).
A very specific form of instructional modification is the use of computer-assisted
instruction (CAI) with the aim to improve academic performance of children with
ADHD. CAI entails the manipulation of the task format through presentation of specific
instructional objectives, highlighting of essential material, using of multiple sensory
modalities, dividing content material into smaller chunks of information, providing
immediate feedback about response accuracy, and limiting the presentation of
nonessential and distracting features (Chronis et al., 2006; Döpfner, 2010). The few
studies of CAI that have been conducted report na increase in academic achievement
across multiple areas of performance such as mathematics science, oral reading fluency,
and attention and concentration (Daly et al., 2007; Döpfner, 2010).
Strategy training is another form of academic intervention that involves training
children in procedures to meet the requirements of a specific academic situation and
which can directly address the students needs, e.g. notetaking, study skills, homework
completion, or self-reinforcement procedures (Döpfner, 2010; DuPaul & Eckert, 1998).
Strategy training that focuses on note-taking skills has demonstrated some preliminary
efficacy with adolescents (Daly et al., 2007).
CounsellingPsychologyandPsychotherapy
21
 Peer interventions and social skills trainings
Inumerous studies have come to the conclusion that most children with ADHD
experience difficulties in developing and sustaining peer relationships due to symptoms
associated with their disorder, including hyperactivity and impulsivity (Pelham, Fabiano,
& Massetti, 2005).
Children with ADHD tend to be more impulsive, argumentative, and aggressive than
their typically developing peers, and are often rejected by their peers. In addiction, it is
also know that deficits in peer relationships and social functioning continue well into
adolescence and even adulthood (Daly et al., 2007).
Therefore, these findings suggesting that peer rejection it’s not only very common,
but may also lead to serious long-term consequences, led to the design of psychosocial
interventions that specifically target peer relationships.
These interventions include instruction in social skills, social problem-solving, and
behavioral competencies. The aim is to enhance social competence by encouraging close
friendships, and decreasing undesirable and antisocial behaviors (Daly et al., 2007).
Because the children with ADHD do not perceive themselves as less socially effective
than their peers, the primary goal of social skills training is to promote prosocial
behaviours that include cooperation, communication, participation and validation
(Döpfner, 2010).
Surprisingly, interventions that employ social skills training as a stand-alone
treatment for children with ADHD have not demonstrated significant effects on the
children’s social status or on their overall social behavior. On the other hand, social skills
training envolving groups seems to represent better outcomes, with groups typically being
conducted at a clinic, summer treatment program, or in school-based settings and often
including parent and teacher participation. The reason to work better in a group format is
because of the difficulty children with ADHD have with self-observation and selfmonitoring
and the opportunity in groups for feedback, modeling, and contingent
reinforcement (Pelham, Fabiano, & Massetti, 2005; Daly et al., 2007).
There is evidence that combining social skills interventions with behavior
management programs and parent training does improve ADHD children’s behavior
toward their peers. The Summer Treatment Program, developed by Pelham and
colleagues (Pelham et al., 2005), is one example of a combining intervention components.
It’s an intensive 8-week behavioral treatment intervention for children with ADHD that
includes social skills training, a reward and response cost system, group practice and
CounsellingPsychologyandPsychotherapy
22
instruction in sports skills and team membership. Positive effects of this program
including enhanced social functioning have been shown in several randomized controlled
studies (Döpfner, 2010)
Therefore, knowing that children with ADHD who overcome their social
problems do better in the long term (Daly et al., 2007) and that it’s possible to have
positive outcomes from social skills training, it is crucial to implement effective
psychosocial interventions of this kind.
 Cognitive Behavior Therapy
Cognitive Behavior Therapy has as main objective to promote the self-control of
behavior using problem-solving strategies. There are several types of cognitive
behavioral treatments for intervention in children with ADHD, using various techniques
such as self-reinforcement, self-evaluation and self-monitoring (Döpfner, 2010). Selfreinforcement
is an intervention in which the child with ADHD performs a desirable
behavior within the predetermined performance standards and when performing this
behavior receives a stimulus that increases the probability of the behavior to be repeated
in the future. Self-management or self-evaluation is an intervention in which the child
with ADHD is proposed to monitor, classify and compare aspects of their behavior with
an external pattern of behavior. Finally, the child should assess their behavior in the light
of this comparison and, if the child's assessment resembles the assessment of external
observers, the child is reinforced. Self-monitoring is an intervention in which the child
with ADHD when performing a desired behavior should be aware that he / she has
performed and should register its occurrence. This intervention can be performed more
linked to attention (self-monitoring of attention) or to performance (self-monitoring of
performance). Self-monitoring of attention is intended to stimulate the child's awareness
of the attention he expends in a task that needs attention to be accomplished. Selfmonitoring
of performance I aim to stimulate the child's awareness for the accuracy of
the work they performed, during or after the task accomplishment (Reid et al., 2005).
Focusing cognitive behavior therapy on the specific case of ADHD, the goal is to
improve behavioral and adaptive skills of children with ADHD by teaching them how to
monitor their behavior, consider, implement and evaluate the various solutions in problem
situations and provide contingent reinforcement for their behavior. This goal is important
since children with ADHD do not have sufficient self-regulation skills due to their
hyperactivity and impulsivity. Although there is much research about the various types
CounsellingPsychologyandPsychotherapy
23
of cognitive-behavioral intervention, the evidence does not show significant differences
in the behavior or academic performance of children with ADHD. These results are
related to the fact that children have difficulties in generalizing their abilities to different
contexts, especially when they feel lack of inspiration in others (Chronis et al., 2006).
Family-based psychosocial interventions
 Behavioral Parent Training (BPT)
Several studies with ADHD with children and their parent showed conflicted
parent–child interaction patterns and less positive parenting practice (Deault, 2010), being
that daily activities became more difficult with this children, such as going to sleep or
doing their homework, and their parents showed a significant increase of parenting stress
(Lee et al, 2012). This enlightens the importance and need for the parents of children with
ADHD to have tools and skills to manage their kid’s disorder, help them cope and help
them improve their kid’s behavior. A known intervention to help stop stressful patterns
between parents and children is the Behavioral parent training (BPT), which helps parents
to ”create a structured, predictable environment in which they reward positive behaviors
- such as raise, positive attention, or tangible rewards - and apply negative contingencies
in response to problem behaviors” that depending on the severity of the inappropriate
behavior can be the loss of previously earned rewards, time-out or other contingencies
such as ignoring (Johnson et al, 2008). Basically, this approach focus on reducing any
positive reinforcement being unintentionally provided to the child for engaging in
disruptive/defiant behavior, while simultaneously increasing the reinforcement parents
provide for appropriate and compliant behavior.
A very well-known example of parent-training regimen is based on the coercion
theory by Gerald Patterson (1982) that was used in his book specifically written for the
use of parents and teachers, Living With Children. This program is applicable for parents
with children between the ages of 6 to 16 and it leads parents to identify their sons’
specific problematic behaviors that will be the targets of the treatment, ignoring or using
negative consequences to deal and monitoring and rewarding positive behaviors (Johnson
et al, 2008). Several studies approve the effectiveness of this social learning approach in
fostering positive interactions between parents and children, being this usually developed
CounsellingPsychologyandPsychotherapy
24
in sessions with parents in order to discuss the problems and respective reinforcements or
contingencies.
A similar treatment which effectiveness is also empirically supported is Videotape
Modeling Parent Training developed by Carolyn Webster-Stratton that consists on the
use of videotaped lessons that are showed in group situation and in which a therapist
presents and discusses the most appropriated ways to approach a certain behavior and
what responses show parents use (Johnson et al, 2008). Behavioral parent training is then
a good example of a family-based treatment that has been proved to be highly effective
in managing many of the disruptive behaviors displayed by children with ADHD and
show be applied by the parent in a continuous way, being that studies also show that the
problematic behavior of the children can start to occur again if the parent stop applying
the reinforcements or punishments (Lee et al, 2012).
Structural Family Therapy (SFT)
According to Anastopoulos and collaborators (2005), family therapy tries to help
families developing some patterns of organization to conduce to better child management,
being some of those patterns a high level of parental cooperation in order to solve
problems, a better defined hierarchy between parents and children and “supportive family
relationships, clear communication, clear and moderately flexible rules, roles and
routines”. A meta-analysis show that this approach is effective in decreasing the ADHD
symptoms (Farmer et al, 2001) and another study by Kazdin (2001) also supports the
effectiveness for family based and child based intervention. However, there are different
models of family therapy, such as Structural Family Therapy that is based on the
mentioned assumption that families must have a well-functioning hierarchy and its role
it’s to challenge the family and the difficult interpersonal relationships in order to enable
the existing disorganization; Strategic family therapy that views family difficulties has a
result of multiple and repeated dysfunctional communications; and Brief solution-focused
therapy occurs when the problems aren’t so evident and tries to demonstrate to the family
that they already have the solution to these problems.
Focusing on the Structural Family Therapy, Barkley and collaborators (1992)
applied it on a study comparing three different approaches to for treating family conflicts
in Adolescents with ADHD, being that their description of it can help us understand how
it is applied. Following the principles set by Minnuchin (1974) and described by Aponte
and Van Deusen (1981) in helping families to identify and alter maladaptive family
CounsellingPsychologyandPsychotherapy
25
systems or interaction processes” (Barkley et al, 1992) the therapist should focus on
creating transactions in the family and help to restructure the previously existing
maladaptive transactions. During 8-10 weekly one hour sessions, the family dynamics are
observed - including the family boundaries and the different powers applied – and the
possible changes are proposed to the family. Homework involved instructions to replace
ineffective family transactions with new strategies, such as empowering a weak parent
authority. A meta-analysis review of studies using this treatment showed that it was more
effective than alternative therapies (Hazelrigg, Cooper, & Borduin, 1987) and other
authors (Mann et al, 1990) found that a multisystemic version of this therapy could be
equivalent or even superior to individual child psychodynamic therapy and “more
effective than a control treatment condition in treating clinic-referred boys with
behavioral problems" (Barkley et al, 1992).
Psychodynamic Psychotherapy of ADHD
Psychoanalytic conceptualizations of ADHD diagnosis tends to center in two major
theoretical camps – Ego Psychology and Object Relations. Ego Psychology oriented
therapists conceptualize ADHD as deficits in the ego functions to synthesize, analyze,
and integrate experiences and difficulty with reality. Object Relations therapists adopt a
more relational view of ADHD as stemming from disturbances in object relations. These
two approaches are not mutually exclusive and Ego Psychology is seen as a foundation
for interpersonal relations. Additional psychoanalytic conceptualizations of ADHD
include the notion of trauma and the resulting role of early interventions, explaining that
trauma may be one reason for the disturbance in object relations and is being considered
more in clinical work with ADHD diagnosed children (Conway, 2012).
Therefore, both the main theoretical camps seem to be key concepts used to
understand the child’s pathology, and for that it is important for a psychodynamic
psychotherapist to consider both the quality of the object relations and the child’s ego
functioning when treating the child.
Key practice components for the positive outcomes of psychodynamic psychotherapy
with ADHD children include working with positive transference; establishing a
therapeutic relationship with the child; developing ego functions; educative supportive
interventions; encouragement, reassurance and empathy; expressive component; active
CounsellingPsychologyandPsychotherapy
26
listening; facilitative comments to encourage expression and reflection; summarizing a
child’s statement; directing attention; interpretations; “here-and-now” interpretations;
parent work; collaborative conferences with teacher(s) (Conway, 2012).
By subscribing to a theoretical orientation, that determines the goal of treatment.
Object relations therapist value the relationship with the client and believes that the ability
to establish a therapeutic relation with a therapist offers another opportunity to examine
and possibly correct or amend existing object relations. Certainly, a child’s development
sets the stage on which the relations with objects are built (Conway, 2012).
Overall, both object relations and ego psychology are given equal attention in regard
to their importance in changing the child’s behavior in therapy.
Neurofeedback and BCI
Neurofeedback is a technique that focus on helping people train themselves in
order to directly affect brain function, to self-regulate a single measure of brain activity
and it does so by providing the individual feedback of their brain waves (Delaimi et al,
2016; Micoulaud-Franchi et al 2014). It involves a non-invasive measurement of an
individual’s live brain activity using electroencephalography (EEG), which consists of
using electrodes on the head of the person to collect information that will be then provided
through an ongoing simplified feedback on the computer (Johnstone, 2013). This training
is based on an operant conditioning process in which only the desired brain activity is
rewarded (Mayer et al, 2015), trying to achieve self-control through feedback and positive
reinforcement hoping to implement these self-regulation skills in every day activities
(Micoulaud-Franchi et al 2014). There’s been an increasing interest in applying this kind
of treatment in children with ADHD, being that a series of studies support its effectiveness
and the fact that it significantly improves “attention, behavior control, increases cortical
activity and improves their score of IQ test and academic achievements” (Deilami et al,
2016).
A more practical and efficient way of using this method in children is using it
games and brain-computer-interface (BCI) systems, which uses neurofeedback to control
and extern program or device. Children like games and it has been shown that games with
hidden exercises have helped overcome their concentration, control and memory
problems (Ali & Puthusserypady, 2015). Focusing in more specific examples, Ali and
Puthusserypady (2015) describe an application made for children with ADHD with a
CounsellingPsychologyandPsychotherapy
27
virtual 3D learning playground based on the steady state visual evoked potentials
(SSVEP) and that does not require any special training. “The system consists of a virtual
3D classroom where the subjects play 2D games on the blackboard while 3D distractions
run inside the 3D environment. This naturalistic and realistic environment serves as
training to motivate with familiarity and brings the achieved results inside the 3D
classroom to the real classroom without any issues” (Ali & Puthusserypady, 2015). The
mentioned distraction are realistic things, such as paper planes, children running in the
hallway or peeking through the window, in order to make the experience more applicable
in real life, working real aspects that would distract the child in school. The game helps
children with ADHD to keep attention providing certain consequences on the movement
of the character or the point score if the subjects derail the SSVEP paradigm or the objects
falling down, being that neurofeedback its being collect in real time and used on the
development of the game according to the child’s answer and attention.
Another example it’s given by Wrońska and collaborators (2015) regarding a trial
that was made using an iPad, since nowadays children are more and more attached to this
kind of technology. A game was installed in which children were asked to do several tasks
carefully and without hurry, monitoring their points gained and the time needed to
perform the tasks. This trial didn’t apply neurofeedback in this instance, using it to have
the opinion of the children about the visual details, difficulty and to see if they feel any
difference while playing the game on a regular bases - the results were positive, the
children feeling more concentrated when they could play during their day. Another study
corroborates this occurrence, being that Wegrzyn (2012) analyzed the effect of playing
this kind of designed games and the participants indicated that when they stopped playing,
no matter what specific game they were using, they felt less focused and starting having
more problem in being attentive during their school classes, were more fidgety and felt
bored more easily. This shows perhaps the use of brain games is indeed effective, can
help treating certain symptoms of ADHD and that in order to achieve the best results it
must be a continuous application (Marcus & Mattiko, 2007).
Dietary Interventions
The numerous alternative or nonmedical treatments that have been proposed for
ADHD over the years include several kinds of dietary interventions.
Numerous food additives have been proposed to have a substantial impact on
ADHD symptoms. Essential omega-3 and omega-6 fatty acids (phospholipids which are
CounsellingPsychologyandPsychotherapy
28
contained in neuronal cell membranes of the brain), are supposed to exert a positive effect
on neurotransmission and so it has been hypothesized that a lack of those polyunsaturated
fatty acids may play a major role in the pathogenesis of ADHD. These fatty acids cannot
be synthesized by the human body and therefore have to be obtained from foodstuffs or
added as food supplements. However, it seems that investigations of the effects of omega-
3 and omega-6 fatty acid supplementation have reported inconsistent results, so a sensible
conclusion would appear to be that these treatments are still in an experimental phase
(Döpfner, 2010).
Also, some food components have been postulated to have a negative impact on
behaviour and it has been supposed that the elimination or restriction of those components
from the diets of children with ADHD will decrease ADHD-symptoms. Such substances
include sugar, several preservatives, food colourings, and potentially allergenic
foodstuffs. In the main evidence for their effects on ADHD symptoms is rather weak and
for sugars there is considerable evidence that it does not result in hyperactivity (Döpfner,
2010). Therefore, further studies are needed to address the question whether restricting
these additives in the diets of children with ADHD will reduce their symptoms.
Relaxation Therapies and Mindfullness
Relaxation therapies have been studied in the treatment of ADHD. Since
hyperactivity symptoms exacerbate when there is an inability of relaxation and muscle
tension, the practice of yoga seems to be a good answer to this problem, having a calming
effect, such as the reduction of hypertension and heart and respiratory rate. An
intervention taking into account the practice of yoga has also revealed influence on the
activity and neurological and physiological behavior. Relaxation can be performed
according to different activities, such as respiratory training - selectively using the nasal
and oral routes for the respiratory flow, so as to raise awareness of the child's breathing
and to train the child to breathe with both nostrils; postural training - using stretching,
backward, forward and side pushing, and also extensions and inversions made in sitting,
standing, supine, and prone positions -; relaxation training - relaxing the body and
tensing and relaxing muscles, in order to help the child to be aware of his own body - and
concentration training - using Trataka, a technique in which children focus on a word
or form and They see with their eyes closed, and then on a sheet of white paper. The
efficacy of this treatment modality in children with ADHD is not yet widely studied, but
CounsellingPsychologyandPsychotherapy
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according to existing literacy, yoga is important for stabilizing emotions and reducing
oppositional behavior (Jensen & Kenny, 2004).
Stress can interfere in several areas responsible for executive functions, such as
behavioral, cognitive inhibition and working memory. Thus, it is important to intervene
in children with ADHD in order to reduce stress, since interventions for reducing stress
in ADHD are usually focused on parents and their interaction with the child. Meditation
techniques are a habitual way of dealing with stress and improving psychosocial factors.
Meditation may be oriented toward concentration techniques or contemplation
techniques, each of which has different process and consequently different effects.
Concentration techniques are, for example, Zen meditation, in which the individual
focuses on something specific (event, image, sound), turning all his attention to that single
focus. Contemplation techniques, such as mindfulness, aim to make the individual aware
of all his thoughts and feelings while trying not to judge or become actively involved in
the thoughts. According to existing research, meditation is capable of altering neuronal
activity and dopamine levels in the brain, as well as improving the self-esteem and family
relationships of children with ADHD (Grosswald et al., 2008). The practice of
mindfulness is meant to sift all attention into purpose, giving full attention to that task.
Thus, it allows a greater capacity to focus, sustain attention and attribute cognitive
resources. Although it may seem an easy practice, for children with ADHD who find it
difficult to sit quietly for a long period of time or to focus their attention on a single point,
it can be an uncomfortable practice. Therefore, it is important that there are strategies For
cases where the discomfort is becoming harmful (Murrell et al., 2015). By focusing
attention on the present moment, attention is directed to internal experiences such as
bodily sensations, emotions, thoughts and tendencies of action, and to environmental
stimuli such as smells and sounds. This practice gives children greater control over their
own attention by helping children respond to stimuli, rather than reacting to stimuli, since
by being aware of their thinking, emotion, and reaction patterns, the child may interrupt
and change them. Although the existing studies demonstrate that the practice of
mindfulness presents improvements in the life of the children with ADHD, this is not a
field well studied and needs more studies of effectiveness (Meppelink et al., 2016).
Another stress reduction technique that helps in intervention with children with ADHD
is transcendental meditation. This technique is not part of the techniques neither of
contemplation nor of the techniques of concentration, being a technique to transcend
without effort. In this sense, it is suggested that the child feels with his eyes closed for 10
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30
to 20 minutes, in the morning and again in the afternoon. While performing this activity
the active mind settles down to a silent yet fully awake state of awareness, the mind being
alert while the body is in relaxation. During this process, there is activation in frontal and
parietal attentional areas of the brain responsible for attention, executive function and
emotional stability. This technique, although with little literature that supports its
effectiveness, shows improvements in behavior and school performance, decrease in
oppositional behavior, better emotional regulation and well-being (Grosswald et al, 2008).
Pharmachological Treatments
Clinical guidelines support the use of pharmacotherapy as one of several treatment
options for ADHD in children and adults (American Academy of Child and Adolescent
Psychiatry, 2002) being that this has been one of the most widely known and
recommended interventions for the last 30 years (Pelham et al, 2000). Methylphenidate
(MPH) or mostly know as Ritalin is the most prescribed stimulant in these cases and it’s
responsible for produce psycho stimulation by inhibiting the presynaptic uptake of
impulse-released dopamine. Untreated ADHD patients show a significant increase of the
dopamine transporter and after being treated with methylphenidate this concentration
decreases (Roman et al, 2002) and so do the restless behaviors, the unthoughtful actions
and there’s a better ability to concentrate and focus. It seems to modulate dopamine and
noradrenaline signaling in brain regions associated with motivation and reward and, by
blocking the dopamine transporter molecules, it increases the extracellular levels of
dopamine – being that lower levels of dopamine represent less concentration (Pelham et
al, 2000). Although, it is important to mention that stimulants have not been shown to
produce long-term changes in achievement or long-term prognosis, only 70–80% of
children with ADHD respond positively to a stimulant regimen and few show sufficient
improvement for their behavior to fall entirely within the normal range (Pelham et al,
2000).
CounsellingPsychologyandPsychotherapy
31
Multimodal Interventions - Conclusion
As a result of the limitations associated with employing either stimulant therapy
or behavior modification as a stand-alone treatment, combined or multimodal
interventions often are viewed as the gold standard for ADHD treatment (Daly et al.,
2007).
Behavioral techniques seem to be useful to improve ADHD symptoms and they
may have a larger impact than stimulant medication on associated impairments, while
stimulants may have a larger impact on specific symptoms associated with ADHD (Daly
et al., 2007).
Specifically, Bennett and colleagues (1999) argued that to effectively increase
prosocial behaviors in children with ADHD it may be necessary to combine stimulant use
with adjunctive psychosocial therapies, such as social skills training or behavioral
management.
Also, Hinshaw and colleagues (2006) found that the combined intervention was
most effective in mitigating related areas of functional impairments including troubled
family relationships, social skills deficits, defiant and oppositional behavior, and poor
academic achievement.
Therefore, as a conclusion, it seems that the inherent limitations of both behavioral
approaches and pharmacotherapy may be best addressed through a combination of
pharmacotherapy and behavioral treatment.
CounsellingPsychologyandPsychotherapy
32
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