Be warned. This is a research paper, so it is kind of long. References are included at the bottom.
ADHD: Developmental Challenges
and Treatments
Attention
Deficit Hyperactivity Disorder, or ADHD, afflicts approximately three
to five percent of children in the United States. With a child
population of approximately 2 million, an average sized classroom of
30 children will have at least one ADHD child in it. It is difficult
for ADHD children to control their behavior, creating challenges for
teachers to educate them along side other children in their
classrooms. It also increases the normal challenges faced by parents
raising them at home.
Although
we may see ADHD as something new, knowledge of this as a disorder has
been around for over a century. It was first described by Doctor
Heinrich Hoffman in 1845. A poet, as well as a doctor, he wrote a
book called “The Story of Fidgety Phillip,” containing an
accurate description of a child with ADHD. In 1902, Sir George F.
Still published a series of lectures at the Royal College of
Physicians in England describing a group of children with significant
impulse and behavioral problems. He attributed the cause in the group
to genetic dysfunctions, not poor upbringing on the part of the
parent. Today, these children would easily be identified as having
ADHD.
Causes
of ADHD
While
the cause of ADHD remains unknown, research has shown it is likely
genetic and may be linked to exposure to toxic substances. Positive
correlations have been found between the use of cigarettes and
alcohol during pregnancy as well as lead exposure. (Mick E, Biederman
J, Faraone SV, Sayer J, Kleinman S. 2002)
Studies
involving brain injury have shown that some children with brain
damage exhibit ADHD like symptom, but only a small number of children
with ADHD have suffered traumatic brain injuries. Likewise, studies
involving diet, especially sugar, have shown no correlations. In one
study, where half the children were given aspartame and half sugar,
the only behavioral differences found were in the perceptions of
their mothers. The mothers who thought their kids were being given
sugar were more critical of their child’s behavior, whether the
child had actually received sugar or not. (Wolraich M, Milich R,
Stumbo P, Schultz F. 1985)
The
most positive correlations seem to be genetic. 25 percent of close
relatives in families with ADHD children also have ADHD. The ratio in
the general population is only five percent. Many studies with twins
show that both twins will likely have ADHD. Each of these factors
suggests a strong genetic influence. PET scans have shown a marked
difference in brain functioning between a normal child and a child
with ADHD, suggesting a neurological dysfunction, not just a
psychological one. (Faraone SV, et. al. 2005)
Delayed
Brain Development
Recent
studies conducted by the National Institute of Health suggest a delay
in brain development of children with ADHD, not a total dysfunction.
An earlier study found that thickening of the cerebral cortex was
delayed in ADHD, specifically those sections dealing with functions
such as attention, cognition, language, and sensory processing. This
study tracked children over a period of seven years, scanning their
brains and regular intervals between age 10 and 17, and measuring
both cortical thickness and cortical surface area, both of which
mature during childhood. These scans showed a marked delay in the
development of these areas. For example, a typical developing child attains 50
percent peak area in the right prefrontal cortex at an age of 12.7
years, on average. ADHD children didn’t reach this peak until an
average age of 14.6 years. (Elsevier
2012, July)
Psychosocial Stage 3,
the Preschool Years and ADHD
Because of this delay in brain development,
children with ADHD will, like other special needs children, be behind
their peers in some areas and may experience problems in school,
socially and academically. When we consider Erik Erikson’s stages
of psychosocial development, ADHD symptoms typically begin
manifesting during stage 3, the preschool years. This is a time when
children being to exert more control over their environment through
directing play and other social interactions. Lacking self-control,
such children will try to exert too much influence, meeting
resistance from their peers, teachers, parents, and siblings. Lacking
impulse control, this frustration is more likely to manifest as
aggressive behaviors such as yelling, hitting, or throwing objects.
At this stage, children also begin to physically
explore their world, taking on activities by themselves, and
developing a sense of independence. Lacking impulse control, ADHD
children are more likely to take on activities that are beyond their
capabilities and engage in risky behaviors such as crossing the
street alone or riding a bike without a helmet. They may also attempt
activities that interfere with other people’s plans and activities.
Adults who are supportive of the child’s attempts, and try to guide
them to make more realistic choices, help the child develop
initiative: independence in planning and undertaking activities.
Adults who dismiss the child’s attempts as silly or bothersome
contribute to the child developing feelings of guilt about their
needs and desires. Adults who are frustrated by the ADHD child’s
proclivity to respond in aggressive ways may be more likely to resist
the child’s efforts at independence, putting ADHD children at
greater risk for failure during this stage. (Berk
2010)
Psychosocial Stage 4,
Early Childhood and ADHD
As children enter early childhood, they learn to
cope with greater academic and social demands. Ideally this is a time
to learn more complex tasks such as reading, writing, and telling
time. They may also express their independence by talking back, being
disobedient and rebellious. It is also at this stage that children
develop a sense of morality, recognize cultural and individual
differences, and can manage most of their personal needs, such as
grooming and hygiene, with minimal assistance.
Because of the delay in development in areas of
the brain crucial to this stage, children with ADHD are more likely
to have difficulties in the early years. Children who are encouraged
to make and do things, and then praised for their accomplishments,
will develop diligence and perseverance in completing tasks. They
will learn to delay gratification. If they are ridiculed or punished
when they are incapable of meeting adult expectations, they will
develop feelings of inferiority about their abilities. It should be
noted, however, that because development is these crucial brain areas
are delayed, the development of diligence and delay of gratification
are likely to be delayed, as well.(Berk
2010)
Psychosocial Stage 5,
Adolescence and ADHD
During adolescence, children explore their
independence and develop a sense of self or personal identity. This
transition is marked by a need to re-establish boundaries for
themselves in a potentially hostile world. No matter how the child
has been raised, this is the time they will choose a personal
ideology for themselves. This often leads to conflicts between adults
and the developing child, especially over religious, political, and
sexual orientations.
Because of the developmental delays of children
with ADHD, this stage is often prolonged, well into early adulthood.
It is of note that this Erikson noted this same delay in person’s
of particular genius. This delay can also be prolonged by the demands
of taking a longer time to master certain skills within our highly
technological society. It is, perhaps, because of this natural delay,
that many ADHD children grow into very intelligent and technically
skilled adults. The psychosocial demand for prolonging this stage may
coincide with their biological delays.
Because of this natural delay, there can still be
problems. Early in this stage, peers and adults may see the child as
acting “like a child” and react negatively. If adults are too
insistent in choosing an identity, “acting their age,” and force
closure of the normal identity moratorium early, the child may give
up and take on an less health identity foreclosure status. They will
be less likely to integrate their sense of self within a diverse
society as they enter adulthood. (Berk
2010)
Modern Treatment
Modalities
Current ADHD treatments focus on reducing symptoms
and improving functioning. They include medications, various forms of
psychotherapy, and education. One size does not fit all. The best
results seem to be from a combination of therapies. (National
Institute of Mental Health 2008)
The Risks of ADHD
Medications
Stimulants are
the most common type of medications prescribed for ADHD ,and are by
far the most controversial. The exact medication and dosage must be
individualized, and it is common to try several out before finding
one that seems to work, best for that patient. As with all
medications, stimulants come with a wide range of side-effects,
however. These side-effects, and a general misunderstanding of the
causes of ADHD, create additional stresses for parents seeking to
help their children, as well as the children themselves.
The most common side-effects of stimulant
medications are decreased appetite and sleep problems. Some children
experience upset stomach and headaches. A few children may experience
slight “tics” or personality changes such as appearing to be
without emotion. These side-effects are often mitigated by changing
the dosage or using a different medication.
Many people are concerned that using stimulants in
this way to treat ADHD may lead to substance abuse and addiction
later in life. There is little evidence to support such a claim, and
far more that suggests they do not. Children who take these
medications do not “get high,” although some report feeling
slightly different or “funny.”
In spite of being generally considered safe, there
are some rare side-effects that must be noted. Patients with existing
cardiovascular disease or psychological problems may have their
symptoms exacerbated by stimulants, leading to stroke, heart-attack,
or sudden death. A few patients report hearing voices,
hallucinations, experience mania, or paranoia even when they do not
have existing psychological conditions.
Non-stimulant medications also pose risks,
especially in teens. Children and teens who take medications such as
atoxometine more often report thoughts of suicide than their peers
who do not take such medication.
The long term effects of ADHD medication on
development are not known. Some researchers are concerned that
administering stimulants to children will have an adverse effect on
brain development. (NIMH 2008)
The Benefits of
Treatment
Because a combination of therapies seems to be the
best approach, removing medication as an option seems
counterproductive. The question becomes do the benefits of
medications outweigh the risks? There seems to be no consensus within
the medical community on this. My own research has shown that many
scientists cherry pick the data to support their own theories, while
ignoring the rest of the data. In some cases, medication seems to
have been the key element that allowed the child to participate in
other forms of therapy as well as educational activities.
When a developmental perspective is taken, it
seems clear that, untreated, ADHD poses severe and known risks in the
long term. Failing to achieve the developmental milestones, as given
in the previous examples, creates greater risk for not developing the
coping and life skills required by modern living as adults, as well
as greater risk for psychological disorders that may lead to physical
problems, as well. They may have lower self-esteem and be unable to
cope with stress, develop expertise in vocational and leisure
pursuits, have healthy intimate relationships.
References
Berk, Laura E. (2010) Development
Through the Lifespan (5th ed.).
Boston, MA. Pearson Education, Inc.
Elsevier (2012, July). Brain
development delayed in ADHD, study shows. ScienceDaily. Retrieved
December 11, 2012, from
http://www.sciencedaily.com/releases/2012/07/120730094822.html
Faraone SV, Perlis RH, Doyle AE,
Smoller JW, Goralnick JJ, Holmgren MA, Sklar P. (2005). Molecular
genetics of attention-deficit/hyperactivity disorder. Biological
Psychiatry, 57, 1313-1323.
Mick E, Biederman J, Faraone SV,
Sayer J, Kleinman S. (2002). Case-control study of attention-deficit
hyperactivity disorder and maternal smoking, alcohol use, and drug
use during pregnancy. Journal
of the American Academy of Child and Adolescent Psychiatry 41 (4)
378-385.
National Institute of Mental
Health (2008). Attention-deficit
Hyperactivity Disorder (ADHD)
(No. 08-3572). U.S. Department of Health and Human Services; Author.
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