Diagnosis, Assessment and Treatment, Essay Example

Abstract

This paper examines the effects of EEG biofeedback therapy for children with Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder including subtypes of inattentive, hyperactivity-impulsive type, or combined types. The EEG biofeedback increases in morbidity and mortality rates of mental disorders that cause the children to have acute medical illness or even death due to insufficient psychological/physiological examination (s) were given. Across studies showed that clinicians, researchers, and other mental health professionals made careless mistakes on the diagnostic evaluation processes. The paper argued on the effectiveness of utilization of Diathesis Stress Model using the American Deficit Disorder Association guidelines in the diagnostic reporting processes and the reduction of misdiagnosing for children with Attention Hyperactivity Deficit Disorder with an emphasis on the full psychological and physiological evaluation processes and the use of EEG Biofeedback Therapy effectively.  In addition to the studies, it explained the complexities of mental disorders and its disturbances, in which, overlaps the behavior negativistic symptoms. They are often difficult to dissemble the predispositions (disturbance, onset, severity and persistence) and the lack of utilization of diathesis-stress approaches in the medication therapy often misdiagnosis in children. The paper hopes to maintain the use of EEG biofeedback therapy to be recognized as an effective therapeutic method, as it is not purported to have this type of therapy to be the last resort of treatment.

Key words: ADD, ADHD, attention-deficit disorder, attention-deficit hyperactivity disorder, Ritalin, psychotherapy, cognitive-behavioral therapy, misdiagnosis, medication, treatment

Diagnosis, Assessment and Treatment

The essential feature of Attention Deficit/ Hyperactivity Disorder (AD/HD)is a persistent pattern of inattention and / or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in children at a comparable level of development.  Some hyperactive-impulsive or inattentive symptoms that cause impairment must have been present before age 7 years, although many children are diagnosed after the symptoms have been present for a numbers of years, especially in the case of children with the Predominantly Inattentive Type associated with Pervasive Development Disorder. These children with the predominantly inattentive type usually have a characteristic symptom presentation with marked defects in social relatedness, serious delays in language, and a restricted range of interests and behaviors.  For instance, some children avoid or have a strong dislike for activities that demand sustained self-application and mental effort or that require organizational demands or close concentration (e.g., homework or paperwork).  Usually, this avoidance must be the reason for the difficulties with attention and not due to a primary oppositional attitude, although secondary oppositionalism may also occur. According to the DSM-IV(2000) estimated that this disorder is more frequent in males than in females, with male-to-female ratios ranging from 2:1 to 9:1, depending on the type (i.e., the Predominantly Inattentive Type may have a gender ratio that is less pronounced) and setting (i.e., clinic-referred children are more likely to be male).  In oppose to the research, which suggested that Attention-Deficit Disorder with Hyperactive-Impulsive Type  is more common in boys than girls, with the ratio of the male-to-female ranging from 2-to 1 to 10-to-1 (Brue, et .al, 2002). In fact, evidenced- based studies indicated that AD/HD is drawn from biological factors (genetic traits) on levels of hyperactivity, impulsively, and inattention as measured dimensionally.  One in first-degree biological relatives of children with AD/HD ranged from 25% to 35% compared to the extended family members of undiagnosed children with AD/HD ranged from 4% to 6% than in the general population (American Deficit Disorder Association, 2010). According to the study, children of aged 3 to older, intended to have attention, impulsive, and destructive behaviors at home and at school, in which affects their relationships with their parents and their academic performance at school (Burns, et .al, 1999). Contrary to common knowledge, ADD and ADHD does not just cause a child to be jumpy and Roadrunner-like; it can eventually lead to “academic underachievement, poor interpersonal relationships, anxiety, depression, and increased risk of involvement in crime,” if untreated (Lloyd, Bret, & Wesnes, 2010, p. 34). Attention deficit disorder is a chronic mental health disorder in children — which causes impairment in social situations, in family life, and in school. Unfortunately, there are limited amounts of effective interventions for this disorder, and the focus seems to be on prescribing medications (Kuo, 2004). It takes an individual who is well versed in treating ADD and/ or ADHD and who is open to alternative treatment methods, to help these children (Brue, et .al, 2002; Kuo, 2004).

Diagnosis

In order to determine if a child has Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder, the professional care provider must consider each symptom listed in the DSM-IV that demonstrates this condition. The DSM-IV recommends diagnosing a child client with ADD or ADHD when six or more of the symptoms of either inattention or hyperactivity-compulsivity are met during a continuous, six-month period to a degree that is maladaptive and developmentally prohibitive (more on that to follow), when some symptoms were present prior to reaching the age of seven, the impairment caused by symptoms overlaps and influences two or more settings, and there is clear evidence of a clinically-significant deficiency in social, academic, or occupational functioning . Although, Attention Deficit Hyperactivity Disorder is not diagnosed if the symptoms are better accounted for by another mental disorder (e.g., Mood Disorder [Especially Bipolar Disorder], Anxiety Disorder, Dissociative Disorder, Personality Disorder, Personality Change Due to a General Medical Condition, or a Substance-Related Disorder) and during the course of a Pervasive Development Disorder or a Psychotic Disorder. (American Psychiatric Association, 2000). A discussion on Axis 1 disorders, Inattention and Hyperactivity-Compulsively symptoms are essential to assesses the true effects of destructive behaviors and dissemble into parts on where a treatment(s) is needed.

Inattention

DSM-IV-TR diagnosis which indicates the presence of a mental disorder which is maladaptive to inconsistence in nature and is not a transient reactive disorder; the impairment of functioning in at least one of the following: a lack of detail orientation and making careless mistakes in school, work, or other activities; having difficulty maintaining a focus on tasks or play activities; having the appearance of being oblivious during direct conversation; displaying repeated failure to complete schoolwork, chores, or duties (not due to rebellion), having difficulty organizing, displaying avoidance, dislike, or reluctance to tackle tasks that necessitate a long-term, focused mental effort, frequently misplacing items needed to complete a task, being easily distracted by other goings-on, and exhibiting a forgetfulness in the performance of everyday tasks or, Not Otherwise specified, unless individuals did meet the Attention-Deficit Hyperactivity Disorder criteria, predominantly in Attentive Type, but whose age at  onset is 7 years old or after (American Psychiatric Association, 2000).

Hyperactivity-Impulsivity

Axis 1 of DSM-IV-TR presents the infunctioning of the hyperactivity-Impulsivity symptoms, of six or more of the following symptoms are: fidgeting or squirming, inappropriately leaving the seat in the classroom, meeting, or in other similar situations, having difficulty playing quietly, demonstrating actions which are “on the go” as if “driven by a motor”, running or climbing in inappropriate situations, and excessively talking.  Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified criteria is based on individuals with clinically significant impairment who present with inattention and whose symptom pattern does not meet the full criteria for the disorder but have a behavioral pattern marked by sluggishness, daydreaming and hypoactivity (American Psychiatric Association, 2000).

Misdiagnosis

As indicated here, the symptoms are similar to the behavior children experience in their development. Because these symptoms are closely related to behavioral problems, it provides caregivers those diagnosis children with ADD and or ADHD room for error Goldman, et al., 1998). Many researchers argued that ADHD behavioral symptoms are not necessary determined that the characteristics as specified in the DSM-IV-TR (American Psychiatric Association, 2000).  In addition, adolescents that are undiagnosed use stimulants are usually experimental with 60% of the students who have tried a stimulant reporting use fewer than six times against the DSM-IV initial criteria of ADHD (Burns, 1999).

With the benefit of hindsight, one of the most prominent examples is the use of medication as a tool for diagnosis rather than as a pharmaceutical treatment. Using the prescription of medicines as a diagnostic tool can hide other symptoms and other disorders that may be present, as well as cause severe side effects, and learning disabilities. Ritalin is by far, the most popular prescription for persons with ADD or ADHD. Overextended caregivers often arbitrarily prescribe drugs, such as Ritalin, check periodically to see if there is an improvement, and- if there is- assume that the person has ADD or ADHD (American Deficit Disorder Association, 2010). Several other medications used to treat ADHD in children are Adderall, Dexedrine, Concerta, and Cylert (American Deficit Disorder Association, 2010).  An experiment of psychostimulant drugs are used constantly in the study for a better outcome other than it indicated in the previous studies.

Case Study

Amen (1998) cited the example of Bradley, a young male patient whose case typified the negative results of treating with medication alone, and ignoring the need for psychoeducation. During his early adolescent, Bradley was involved in frequent incidents of aggression and violence and was expelled from several schools. After being prescribed a significant amount of Ritalin, he returned to normal functioning and even progressed through three reading levels in one year. Nevertheless, Bradley was not happy about the medicine’s effects, saying that it made him “feel stupid and different” (Amen, 1998, p. 247). He was not undergoing psychotherapy, or educated about his medication, so he did not know the expectations, its drawbacks, and benefits.  He stopped taking his medication and withdrew socially. He frequently self-medicated with alcohol or marijuana. While he was intoxicated, Bradley was approached by his uncle who wanted Bradley’s help with robbing women. Bradley agreed to help, and they kidnapped a woman, forced her to withdraw money from an ATM, and both raped her repeatedly (Amen, 1998).Upon psychiatric examination, it was discovered that Bradley’s ADHD had produced a chronic, behavioral aggression. Two tests/techniques were used to look at Bradley’s brain, an EEG, to examine his brain waves, and a SPECT to identify brain function. The SPECT revealed that the Ritalin had concealed the dysfunction of his frontal lobe enhancing aggressive behavior. Due to medication, this tendency for violence was not discovered and much-needed psychoeducation and information about his medication was not provided. Bradley stopped taking Ritalin and- unbeknownst to him- was instead increasing his own proneness to violence through self-medication of alcohol and substances. While incarcerated, this information and more medication was provided, and he was incident-free at the time the book, in which his case was included, Change Your Brain, Change Your Life, was written (Amen, 1998).

New Assessments

The new American Deficit Disorder Association (2010) describes the notion of ADHD theory, “One early theory was that attention disorders were caused by minor head injuries or damage to the brain, and thus for many years ADHD was called “minimal brain damage” or “minimal brain dysfunction.” Hence, the theory is not far too complex to comprehend the reasoning of the attention disorders.  American Deficit Disorder Association (ADDA) provides an insurmountable information on diagnosis, and treatment guidelines include provisions for the patient’s complete physical, mental and development assessment before reaching the diagnosis of ADD, the exclusion of medication from the primary care physician’s diagnostic tools, familiarity with current research and diagnostic techniques relevant to ADD and ADHD, and the referral of patients to ADD/ADHD specialists after confirming the diagnosis for appropriate follow up thereafter with a continuous help. In addition to the use of the new guidelines and the DSM-IV pointers for child diagnosis, there are several methods of assessment that can be utilized by the entire treatment team (American Deficit Disorder Association, 2010). Teachers, parents, caregivers, and medical professionals need to be simultaneously involved in the care for those children. For physicians, it is critical to rule out other possible issues that could be causing ADHD– like symptoms. If the DSM-IV is the only source to diagnose, you may find that the child meets the criteria for ADHD, when something else could actually be wrong. Sometimes a physician is needed to ensure that you are diagnosing appropriately. As a psychologist or other diagnostician, using the DSM-IV and the new guidelines provided by the ADDA are the best starting points for diagnosis (Morrison, 1995). In 2003, there were 6 million children in America diagnosed with ADHD (Stolzer, 2005). Surprisingly, the diagnosing of ADHD did not exist as a diagnosis before 1950 was unheard of, and only 2000 children were diagnosed with hyperactivity at that time (Stolzer, 2005). There are those that believe this increase in diagnosed cases of ADHD as a result of government participate the earmarks endeavors in exchange for getting elected officials into office. The Bush Administration’s- “New Freedom Commission on Mental Health”- wanted to have every school- aged child screened for brain disorder (Sharav, 2004). In 2004, George W. Bush’s administration sought screenings at the benefit of Eli Lily Pharmaceutical Company, which was raising campaign funds for Bush, Jr. (Stolzer, 2005).

Treatments

Treatment plans that consist of two or more approaches are increasingly utilized. Especially as the concern about misdiagnosis and potential prescription side effects increase. The British Psychological Society, and many physicians, educators, and counselors agree that medication theories should discriminate critically to shift into one cohesive treatment plan (Lloyd et al., 2010).Failure to appropriately assess, treat and diagnose children does not only mask other possibly serious issues that may be occurring, but can also cause poor emotional and social development, and severe health issues. Many of the treatment methods, especially medications have not been tested on children under the age of 16, although they are readily used on children under the age of five (Attention Deficit Disorder Association, 2010).

The scrutiny of helping hands as the ordinary citizens, demands an inclusive approach, which means including parents, physicians, counselors and teachers in the process. It is critical to gather data using qualitative analysis method, acknowledge the similarities and differences of medication effects, and then conclude the findings through the evidenced-based research. The American Academy of Pediatrics stresses the importance of research on occupational therapy, biofeedback, herbs, vitamins, and other holistic approaches. It is commonly believed that dietary factors have a significant impact on the mental processes of ADD and ADHD patients. There is currently no evidence to support the most popular holistic theories of treatment, such as neuro-biologic pathways (Sadiq, 2007).

Pharmaceuticals

There are evidenced-based medications that help children diagnosed with ADHD. Stimulant based medication has been proven to be the most effective medication to treat ADHD. Atomoxetine (Strattera) and methylphenidate improve the symptoms of ADHD. Methylphenidate and clonidine (Catapres) improve symptoms in children with both ADHD and tics. Clonidine is less effective alone and has significant side effects (Friemoth, 2005). However, it is not 100% effective pharmaceutical treatment.  The researchers reported that there are four cases of sudden death have been reported in children taking methylphenidate (Ritalin) and clonidine (Catapres) together (Burns, et .al, 1999; Swanson, et. al., 1995a; Swanson, 1995b.). The issue has rise a suspection that the body mass index of a child cannot always be accurate with proper dose, intake and care for long-term use (Klein & Mannuzza, 1988; Vincent, Varley, & Leger, 1990). Both psychostimulant drugs are the antihypertension drugs that treat high blood pressure. Thus, a further research is much needed to find the causation of ADHD sudden death (s) in children.

Therapy and Support

In a double-blind study, the withholding of sugar and artificial food coloring had no effect on the presentation of symptoms in ADHD. A similar study, which was limited to artificial food coloring, also showed no change in the perception of the patient’s behavior (Ballard, et .al, 2010). Another common theory, biofeedback, was proven false when it was discovered that polyunsaturated fatty acids did not actually improve brain function and effectiveness (Ballard & Hall, 2010). Even supporters of biofeedback theories claimed that this food artificial coloring information is relevant and sustainable. Supporting the claim, such as the Harvard Mental Health Letter (2010), acknowledge the drawbacks. The completion of an eight-year study of biofeedback revealed that patients presenting mild symptoms of ADD or ADHD were the most likely to improve and thus provided further cause for skepticism, even explicitly stating: “the type of treatment they received didn’t matter” (Harvard Mental Health Letter, 2010). Within the past year, the National Attention Deficit Disorder Association (NADDA) has put into place a series of new guidelines for the treatment and diagnosis of ADD and ADHD. These guidelines have been prepared in order to develop newer and better care and assessment for patients (American Deficit Disorder Association, 2010).  An examination on disorder specifiers brought about an insight on what to assess the characteristics of Attention-deficit/Hyperactivity disorders are analyzed in the review. California’s Institute of HeartMath has extensively studied what they have termed psychophysiological coherence, which is the harmony and synchronization of positive emotions, and an improved physiological state. This subsequently to broadened positive regarded, in which, encouraging children and adolescent to think and act accordingly; leading a better health, a long life, developing aesthetic creativity, and increases cognitive flexibility. The primary focus of the institute seems to be on the heart rate variability (HRV) in such correlations; it is a crucial indicator of the degree to which a person has already achieved- or not achieved- the coherence. ADHD is among the large number of conditions, which lower the HRV, and thus produce negative short-term and long-term psychophysiological effects of involuntary autonomic response (e.g., blood pressure, heart rate, or alpha rhythm in the brain) by watching the output of a device that monitors the response stimulantly (Lloyd et al., 2010).

Many studies preferred to use one of the primary methods used by counselors in creation of congruence positive regarded paradigm and operant conditioning techniques to a patient in psychotherapy. In “CBT for Adult ADHD: Adaptations and Hypothesized Mechanisms of Change”, Ramsay (2010) focused specifically on the relationship between Cognitive-Behavioral therapy (CBT) and ADHD. Unlike medication, CBT therapy aims to help a patient to redirect mental dichotomies, in order to reduce its cognitive stressors and learn how to cope stress. However, CBT is not altogether suited for ADHD without adaptations, because ADHD is essentially characterized by “impaired executive functions that result in downstream self-regulation problems” (Ramsay, 2010, p. 38).

One such self-regulation problem is behavioral inhibition, the ability to control a behavioral response, to discontinue ongoing behavior, and to resist the distractions brought about by distractions inside and outside of the patient’s mind (Ramsey, 2010). Medication may address some behavioral inhibition but cannot aid in the secondary effects of a disorder: depression and some other mood disorders, social difficulties, role-specific difficulties with and trial-and-error learning, to name a few. Cognitive-behavioral interventions that Ramsey (2010) suggest, include instilling a short habitual mental delay which allows for alternate CBT techniques to lengthen in time ( prolongation), and to facilitate in school, home and Clinical settings. All of the settings provides a psychoeducation therapy—building a series of basic small behaviors: Teaching a patient to grow (scaffolding); Making an arrangement on one reinforced behavior at home and at work to aid success (environmental engineering); Providing a day-to-day functional training, and behavioral reinforcement strategies, and maintaining cognitive interferences against the negative thoughts which further limit individual’s day-to-day progress (Ramsay, 2010).

Environmental engineering was specifically studied by F. Kuo in his 2010 publication “A Potential Natural Treatment for Attention-Deficit/Hyperactivity Disorder: Evidence From a National Study”. F. Kuo (2010) studied the effects of engineering a “green” environment and its effects on ADD and ADHD. Having trees and grass nearby, gardening, backpacking, and even seeing slides of nature are linked with desirable changes in attention and mental longevity and processing in patients with ADD and ADHD. Recalled the effects of thought and action, which were examined by Lloyd et. al (2010) on HRV psychophysiological effects and Ramsey (2010) on CBT modification techniques discussed earlier in this paper. Interestingly, the positive side effects of environmental engineering also contributed to positive work results in the individuals without attention deficit disorder(s) (Kuo, 2010).

In response to theories of accelerated evolution, intended to explain the ADD or ADHD diagnosis of millions during the last fifty years and the dramatic increase in the last fifteen years, Stolzer (2007) balked, citing behavioral patterns and environmental engineering as more culprits that are probable. Compulsory regular schooling even has restricted movement, creativity, outdoor activity, which adds to the negative impacts both physically and mentally that are being observed in the youth and adults of today, which many believe to contribute to an increase in ADD and ADHD like symptoms (Burns, et .al, 1999). However, Children are not out in the “green environment” as much anymore. From the ages of six weeks to eighteen years- and, in some cases, longer- individuals are confined indoors, in artificial light with relative strangers in a uniform and predictable environment, which does not create a need for a long attention span. Furthermore, leisure typically now consists of indoor activities, such as gaming or watching televisions, which, require little concentration and are mainly meant to entertain (Stolzer, 2007).

Progress

There are also scales and tests used in the diagnosis and monitor the progress of children diagnosed with ADD and ADHD (Parker, 2010). Some of the tests available are: Conners Teacher Rating Scale (CTRS) and Conners Parent Rating Scale (CPRS), ADD-H: Comprehensive Teacher Rating Scale (ACTeRS), ADHD Rating Scale, Child Attention Profile, Child Behavior Checklist (CBCL), Home Situations Questionnaire, School Situations Questionnaire, and Academic Performance Rating Scale (APRS) (Parker, 2010).  Along with these tests, it is extremely important to assess all issues and circumstances surrounding the child’s life, including, but not limited to: socioeconomic status, culture, development of skills, diet, activity level and relationships (both with peers and family). Many times in our schools, children with ADD and ADHD are placed outside of their regular classrooms and cast out away from their peers. Studies have shown that students who are pushed away from their support systems because of a diagnosis, often tend to develop an increase in negative symptoms and act out more often than before they were diagnosed. As a counselor, it is imperative to provide information and methods of instruction to assist in the home and school environment that these children are returning to. The relationship between habitually-positive cognition and behavior is documented, so it would follow that health professionals would take this into advisement. As Ramsay (2010) stated:

“In addition to the chronic functional difficulties associated with ADHD, recurring frustrations in these life domains can lead to the development of                  pessimistic outlooks, negative assumptions about one’s abilities, and dysfunctional belief systems…they tend to be overgeneralized and engender self-              defeating thoughts and behaviors. These…interfere with the implementation of effective coping strategies, diminish one’s perceived ability to take proactive steps to change circumstances, and erode the sense of resilience necessary to manage ADHD. Namely, speaking of positive aspects of the child will produce a    healthier response from the child and the professional himself. Rewarding the positive behaviors will help with the child’s development, as well as the team acknowledging and understanding the behaviors that are considered negative, and plan accordingly of what types of interventions maybe needed to help the child” (Ramsay, 2010, 40).

The arguments on this topic surround the overuse of medications and the lack of support for these children. It is appropriate to medicate, and sometimes necessary to place a child in a special school environment in order to have improvement on symptoms. However, many times those two choices are what are tried first and foremost- without consideration of other possibilities. Another prominent accrediting body expressed the concerns of under diagnosing and over diagnosing children with ADD/Hyperactivity Disorder, mentioned that the American Academy of Pediatrics published a policy statement, explicitly explained of the use on medication for children with attentional disorders, resulting that use of medication should not be take into account that children with ADHD with medication treatment plan has successfully completed the program. (American Academy of Pediatrics Committee on Children With Disabilities and Committee on Drugs, 1996).

Situational Factors

When treating a child, it is necessary to provide the best possible learning environment, for the child as an individual. There are many possibilities to which treatment can be gained. Sometimes children with ADD/ADHD do not have their needs met by the traditional educational environment and need individual placement in order to promote an increase in concentration and fewer distractions. There are many opportunities in schools that can help ADD/ADHD children. These students have the right to attend public schools, and there are laws that ensure that children can get the required help that they need, for free (Burns, et .al, 2010).

A wonderful technique that helps promote learning and has a calming effect for some children is to take a child with ADD/ADHD outside when they were attempting to complete their homework. Set up some chairs and tables outdoors, have the child start to do the work in this environment. At first, there were distractions for the child, such as birds flying by, insect noise, and watching the horses. In this situation, the child wanted to ride and pet the horses. Speak to the child and set up a reward system if he completes the homework. The reward for this example was the child being able to ride the horse. The child had wanted to ride so badly that shifted the focus and completed the work well. It was amazing to see the child was able to make that shift. One of many that can be utilized to help children with this diagnosis. An article posted on Psych Central, Children with ADHD, states some special accommodations to help them learn. The situation above, for example, the teacher sat the child in an area with few distractions, provided an area where the child can move around and release excess energy, or established a clearly posted system of rules and reward appropriate behavior. Sometimes just keeping a card or a picture on the desk can serve as a visual reminder to use the right school behavior, like raising a hand instead of shouting out or staying in a seat instead of wandering around the room without a person in present of a child ( The National Institute of Mental Health, 2006).

Conclusion

It has been proven that ideas as well as many other experiential methods are terrific ways to help children learn how to deal with their ADD/ADHD, and provide caregivers, teachers and families with means of coping with the child. As a counselor, it is extremely pertinent to continue to look at as many options for treatment as possible, and not to be stuck on specific methods and patterns. Every client that comes into our care is different and as counselors, we need to remember that the same treatments will not work for every patient. Medicating is not always the answer. With all diagnoses, one of the most important aspects is to learn about it as well as teach those who also come into contact with that person what their diagnosis is, and provide methods and interventions that can be applied in the persons other environments, such as work and school. Many of the symptoms of certain diagnoses in the DSM-IV, such as ADD/ADHD can be improved with increased knowledge (American Psychiatric Association, 2000).

References

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American Psychiatric Publishing, Inc. (1995).  Diagnostic and Statistical manual of  mental disorders: Primary Care version (4^th Edition).  Arlington, VA. Print.

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