Attention deficit disorder, in earlier times, was given a variety of names including: minimal brain dysfunction, minimal brain damage, hyperkinetic syndrome and hyperactive child syndrome. DSM III (1980), published by the American Psychiatric Association describes two subtypes of attention deficit disorder: attention deficit disorder with hyperactivity (ADD-H) and attention deficit disorder without hyperactivity (ADD). The child with ADD/ADD-H is described as one who shows signs of a short attention span, inability to concentrate and impulsivity. This impulsivity often causes the ADD/ADD-H child to act before thinking, which in turn leads to social friction, academic failure and self-esteem issues, which can lead to further problems such as suicide.
Attention deficit disorders can be treated in a number of ways: psychotherapy, family systems therapy, parent training, biofeedback and medication (both stimulant and anti-depressant) are some of the most widely used treatments. Proper diagnosis is important to the outcome of any of the above treatments. Whalen (1983) cautions against diagnosing children who are overactive, rambunctious and even a bit distractible as ADD/ADD-H as many young children tend to display these symptoms at one time or another. Because of the overlap of symptoms between ADD and ADD-H, DSM IV (1987) has three subcategories: 1. For children whose difficulties are primarily from hyperactive-impulsive behavior, 2. For those whose difficulties are primarily those of poor attention, and 3. For those who have both sets of problems. Barkley (199) suggests that ADD/ADD-H should be treated as two separate, but related disorders. Presently, the majority of the research combines ADD and ADD-H when studying different treatments.
Currently, treatment of children diagnosed with ADD or ADD-H largely involves the use of medication. A few studies suggest that family therapy is the best cure for this disorder. A more comprehensive and more logical theory is a combination of medication and family therapy.
Treatment of ADD/ADD-H with either a stimulant or an antidepressant does have positive effects on the patient; however, there are many side effects and there is a risk of abuse and dependence (Goyer et al., 1979). Also, there is proof that a majority of adolescents dislike taking stimulants and therefore, do not comply with the treatment regimen. In a study which was conducted to determine normal drug usage patterns in ADD children, Firestone (1982) found that about 20% of his patients had stopped taking their medication by the fourth month and by the 10th month, only 55% of his patients were still taking the medication.
Methylpehidate (Ritalin, a stimulant) is perhaps the most popular and common therapy for children with ADD, whether or not it is paired with hyperactivity (Klorman et al, 1990). Ritalin therapy has shown positive effects in some studies. One study (Rapport et al., 1986) utilized several different testing methods and compared scores of children between the ages of six and ten years who were split into two groups; the first group was given a placebo and the second group was given Ritalin. The children involved in the study met certain criteria, including their pediatrician s evaluation according the DSM III and a parental rating of behavioral problems. Children were seen once per week at the Children s Learning Clinic (CLC) at the University of Rhode Island, for individual testing. During each weekly session, a number of tests were administered, one being the Continuous Performance Test (CPT). The CPT (Rosvold et al., 1956) is an experimenter-based test designed to detect deficits in attention and impulsivity. A child s behavior was categorized as either on task or off task. Off task behavior was defined as visual non-attention to one s materials for more than two consecutive seconds within each 15 second observation interval, unless the child was involved in some other on-task behavior, such as talking to the teacher of sharpening a broken pencil. Significant overall effects were found for children s percentage of on-task behaviors and for CPT omission.
In another study by Gastfriend, Biederman and Jellinek (1984), children with ADD/ADD-H were treated with Despiramine, an antidepressant. The twelve children involved in the study ranged from 12-17 years of age. Eleven of the 12 adolescents had previously received Ritalin as a form of treatment and had either experienced inadequate results or side effects such as insomnia, weight loss, loss of appetite, dry mouth or occasional tremors. Participants in this study were rated on the Clinical Global Impression (CGI) and the Parent-Teacher Rating scales and showed much improvement in attention level as well as lower levels of hyperactivity and impulsivity as a result of taking the Desipramine. Antidepressant medication also has side effects: drowsiness, dizziness, weight loss, decreased appetite, insomnia and racing thoughts. The advantage of antidepressant use is the single-dose administration, which would prevent the child from having to take medication while in school, as opposed to Ritalin which usually requires a morning and an early afternoon dose.
Aside from the many side effects of both stimulant and antidepressant treatment, and the fact that many children do not like taking the medication, the largest problem with using pharmacological treatment alone, is that when the ADD/ADD-H child or adolescent is taken off medication, behavior tends to regress back to its original state and the child/adolescent has no other way to deal with the lack of attention, hyperactivity or impulsivity.
Family and behavior therapies are also widely studied treatments for ADD/ADD-H children and adolescents. Behavior therapy focuses more on the patient whereas family therapy involves the entire family as a means of alleviating and treating symptoms that accompany ADD/ADD-H.
Behavior therapy has demonstrated at least short-term success in both social and academic settings. In this type of therapy, the behavior of the child is monitored both at home and in school and the appropriate behavior is reinforced (O Leary et al., 1976). Point systems and star charts (frequently used for younger children) are a large part of this type of therapy; children earn points (younger children earn stars) for behaving in certain ways. After points or stars add up, the children can then spend their earnings for rewards. The focus of this type of treatment is improving one s academic work, completing tasks around the house, learning certain social skills instead of reducing hyperactivity such as running around. Therapists who utilize this type of behavior modification view hyperactivity as a lack in certain skills rather than an excess of disruptive behavior or as a biological imbalance in the child.
Research on family therapy is a bit more in depth than that on behavior modification therapy. Ziegler and Holden suggest that family therapy is a more comprehensive treatment for ADD/ADD-H because it involves several different factors. When a child suffers from ADD/ADD-H, the family is affected as well. Family therapy helps all involved parties by utilizing individual and family therapy as well as parent training. The therapy focuses on helping both parents and children accomplish key tasks such as self-control, self-esteem, and frustration tolerance. Ziegler and Holden also mention that children with ADD/ADD-H seem to do best with families whose lives reflect traits such as: the ADD/ADD-H child is expected to function with normal children, concentrated efforts in both learning and self-control are reinforced, aspects of the child s difficulty are accepted as medically determined and not fully under the child s or the family s control and the parents maintain their commitment and concern for the child at the same time as a detachment from the problem so no one involved is overwhelmed by frustration. Parent training, as well as family therapy helps in developing the above traits if they are not already possessed by the involved members.
The disadvantage to both family therapy and behavior modification therapy is that they sometimes do not take into account that ADD and ADD-H are biologically caused, usually by a chemical imbalance in the brain and medication is sometimes needed in order to alleviate the imbalance within the child. Barkley (1990) suggests that although children with ADD/ADD-H do improve as a result of these types of therapies, the optimal treatment for these children involves both the use of medication and behavior and/or family therapy. Gittelman et al. (1980) suggests that medication, whether it is stimulant or antidepressant, plays several non-medical as well as medical roles that enhance therapy when coupled with behavior modification/family therapy. By enhancing the fact that the child has an organic problem, it removes blame from both the parents and the child, which diminishes a sense of guilt in either party. The need to take medication regularly underlines the fact that this is an ongoing problem and all involved parties need to work at alleviating it. In addition, medication has been proved to be helpful with hyperactivity, inattention and impulsivity. Acceptance of therapy, both medication and behavioral/family by all involved parties is vital to treatment of this disorder, and without it, the child may experience a more difficult time adjusting to changing social and academic environments.
When researching attention deficit disorder, there are many conflicting ideas and bodies of evidence. Medication therapy has shown improvements in academic and social settings, but is often prescribed as the only solution to the problem. Additionally, simply using medication offers the child nothing to fall back on when medication can no longer be taken. Family and behavior modification therapies display short-term, but positive effects in the ADD/ADD-H child s behavior patterns and academic performance, but do not offer the biological treatment for an organic problem. A more comprehensive and long-term solution is needed and this is found in the combination of pharmacological and behavior modification and family therapies. When combining these therapies, the child s biological and chemical needs are met, coping strategies for all involved parties are learned, and a more long-term solution is offered for both the child and the parents.