Sunday, January 13, 2013

ADHD: Developmental Challenges and Treatments

This was my final paper for Human Development Across the Lifespan. It deals with the developmental challenges facing children with ADHD, specifically, but I believe it may be beneficial for understanding many children with special needs, similar to ADHD. To be honest, I was was surprised where the research took me, in some cases. It was enlightening for me so, I thought it might be useful for others, as well.

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.

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

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.

Wolraich M, Milich R, Stumbo P, Schultz F. (1985) The effects of sucrose ingestion on the behavior of hyperactive boys. Pediatrics, 106 (4):657-682.