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- 1. Liam Sprague Advanced General ADHD in our Youth While all children are naturally chaotic and experience spurts of over excitement, there is a portion of our youth that experience this type of behavior in a more extreme and dysfunctional way. One explanation for this type of behavior may be Attention Deficit/ Hyperactivity Disorder (ADHD). ADHD is a “pattern of behavior, present in multiple settings (e.g., school and home), that can result in performance issues in social, educational or work settings.” (American Psychiatric Association, 2013). This disorder has come to revolve around the three core diagnostic dimensions of inattention, hyperactivity, and impulsiveness (Ferrin, Vance, 2012). These symptoms can present themselves singularly or in a combined manner. Over the last two decades the diagnosis of this disorder has exploded amongst our children, and the CDC has recently reported it as the most abundant disorder among children age 3- 17 (Graf, Miller, Nagel, 2014). With the serious eruption of this diagnosis among our youth, a schism has split the psychological community on whether ADHD should be a diagnosable disorder or not. The problem with diagnosing ADHD stems from three main areas. The issues are that there is no definitive cause that can completely explain the disorder, there is no definitive set treatment regime, and the diagnosis can be generalized to too many traits. Despite these problems, with the available research it is clear that certain children do suffer from chronic inattention and hyperactivity and these problems need to be addressed for the benefits of our youth.
- 2. The causes of ADHD As with any topic in psychology, arguments can be made that both nature, and the nurturing of a child contributes to their ADHD. Whether ADHD should be in the DSM-5 or not, research has clearly shown that it is a Bio-psychosocial issue that is both highly heritable and has many social causes (Harold, Leve, Barrett, Elam, Neiderhiser, Misaki, Natsuaki, Shaw, Reiss, Thapar, 2013). One way of analyzing nurture’s effect on ADHD is by examining family relationships and more specifically parent- child relationships. The majority of past studies that analyze parental effects on ADHD fail to control for biological effects because they use biologically related parents and children (Harold et al., 2013). A more recent study attempts to analyze the nurture aspect of parental effects while controlling for biologically confounding variables. This study analyzes parent-child relationships by looking at two separate groups, children adopted-at-birth and children conceived through in-vitro fertilization (IVF). The goal of this study was to assess possible associations between maternal hostility and ADHD in children. In both groups biological mothers and rearing mothers were analyzed on several different types of topics such as ADHD symptoms, maternal hostility, and temperament. Both groups of mothers were also asked to evaluate their child’s ADHD symptoms. The final test the authors used to gather data was for the fathers in both studies to indicate their child’s ADHD symptoms. The father’s evaluation was used as a control and so that the analyses were not relying fully on maternal reports. The authors found significant associations between the rearing mothers ADHD symptoms and her hostility when compared with the father’s report of their child’s symptoms. The correlation
- 3. between mothers ADHD symptoms was r=. 37 and her hostility was r= .33, which indicates a moderate correlation. Not surprisingly, the rearing mothers reports on her hostility correlated with her self-reports on her ADHD symptoms r=29. Although these r values are low they still show a positive correlation. These results throw into sharp relief the effect and association that maternal hostility has on ADHD symptoms when there are controls for genetic confounds. This study has serious implications for clinical psychologists that deal with ADHD in children. While it doesn’t imply that all hostile mothers will have children with ADHD, it highlights the importance of early intervention with hostile parents, and illustrates the detrimental effects their hostility can have on their children (Harold et al., 2013). The majority of all psychiatric disorders have been found to have some amount of heritability and ADHD is no different (Stergiakouli, Martin, Hamshere, Langley, Evans, Pourcain, Smith, 2015). Recent research has found that a variation in a single nucleotide of someone’s genome can explain up to 29% of some psychiatric disorders such as ADHD (Stergiakouli, et al, 2015). In the study, researchers attempted to use Genome-wide association studies (GWAS) to see if there are certain alleles associated with higher levels of ADHD and severity of the disorder. A GWAS is simply a comprehensive examination of genetic variations among individuals in the attempt to find a variant that is associated with a certain trait; in this case that trait is ADHD. 508 British children with a DSM-IV diagnosis of ADHD were used as the experimental group for this experiment, and the control group comprised of 6,000 individuals. After analyzing the risk alleles from the
- 4. GWAS, researchers were able to utilize ADHD trait polygenic scores to differentiate between participants with ADHD from the control group with a 95% confidence interval. Likewise the study found that there is also a 95% confidence interval between trait polygenic scores and DSM-IV ADHD symptom severity. Having a larger amount for ADHD traits predicted higher ADHD symptoms severity. This study is one of the first to show how genes are a contributing factor in ADHD. This study was able to find that there are polygenic alleles that can confer both the risk of ADHD and the severity of the symptoms (Stergiakouli, et al, 2015). In the future the use of polygenic risk score analysis will be critical in helping physicians diagnose ADHD more accurately in people. While social treatment and genetics obviously have an effect on the prevalence of ADHD, something as simple as changing a child’s diet may also impact ADHD. Obesity rates have grown from 5 to 17% in children over the past 30 years (Marwitz, Woodie, Blythe, 2015). Recent research has shown that children that were overweight had a 1.5- fold greater risk for developing ADHD and that children with ADHD were 1.9 times more likely to be overweight. In an attempt to study the relationship between energy dense diets and ADHD like behaviors, scientists used rats to test the hypothesis that a western-style diet (WSD) will promote obesity, impulsivity and hyperactivity that can be likened to ADHD symptoms. A WSD was a diet high in saturated fats and sugars. Rats were randomly selected to be in the control group (n=9) and the experimental group (n=9). The researchers analyzed the rats body weight, blood glucose and insulin levels to determine their physiological differences. Rats’ behaviors were analyzed by conducting three types
- 5. of tests, the open field test, novel object recognition task and attentional set-shifting task. After nine weeks the WSD rats weighed 30 grams more on average then the control rats. Similarly after 10 weeks the fasting insulin levels were higher in the WSD rats (67.4pmol/l) when compared to the controls (28.8pmol/l). The behavioral tests demonstrate interesting differences between the groups also. The open field test illustrated the levels of hyperactivity and impulsiveness in both groups. WSD rats spent significantly more time moving, mean 275 seconds out of eight minutes, whereas the control group moved on average 200 seconds out of eight minutes. As can be expected, the control group spent more time standing still (average=250 seconds) while the WSD group was standing still less (average= 190 seconds). These results show a higher level of hyperactivity in the WSD group. The WSD group also spent almost twice the amount of time in the center of the open field apparatus (30.8 entries compared to 16.8 entries), which is indicative to impulsivity. The novel object recognition task tested rodent’s reaction to a novel object compared to a familiar one. The researchers assessed this by using an exploration ratio, which is the amount of time examining a new object divided by the total exploration time. An exploration ratio of .05 implies that the rodent had no preference between new or old objects. While the control rodent was much higher than the .05 middle ground (.0707) the WSD group average was much closer to the .05 level of chance. The Varying kinds of Treatment One of the most highly debated and controversial aspects of the discussion on ADHD is the treatment we use to mitigate it. One of the most common forms of
- 6. treatment for ADHD is the use of neuroenhancement drugs such as methylphenidate (MPH) and amphetamines (Graf, Miller, Nagel, 2014). There has been push back from the ADHD community due to these medications being stimulants and in some cases having side effects. While some of this medical avoidance is warranted there are also cases when medication can seriously aid in functionality. A recent article attempts to illustrate the benefits and effectiveness of medication. The authors conducted a longitudinal study that lasted for a year and analyzed 250 patients that have never received medication for their ADHD (Fredriksen, Dahl, Martinsen, Klungsoyr, Haavik, Peleikis, 2014). The patients were evaluated on ADHD symptoms according to the DSMIV-TR (Fredriksen, et al., 2014). MPH was used as the first-line treatment for all patients and they also received psychosocial treatment. The patients were again checked for ADHD symptoms and possible side effects at 6 weeks, 6 months, and 12 months. Of the 250 patients that began the study it ended with 232 patients. Of those 232, 69 patients completed the study off medication due to a multitude of reasons. The authors found that there was a large reduction of total ADHD symptoms within the group that stayed on medication compared to the group that stopped medication. At 3 months the median percent of reduction was 36% and at 1 year the median amount was 39% (Fredriksen, et al., 2014). These results illustrate some of the potential benefits of medication. To those suffering from severe ADHD that has a dramatic impact on one’s life, stimulant medication can help alleviate the symptoms of ADHD.
- 7. While there are clear implications that the drugs that treat ADHD can be effective, there is also a portion of the psychology community this suggests this type of treatment is unnecessary (Graf, Miller, Nagel, 2014). The DSM-5 has re-labeled ADHD as a neurodevelopmental disorder that consists of a number of indicators. Neurodevelopmental disorders such as autism, learning disabilities and ADHD are structured on a spectrum of mild, moderate and severe conditions. Despite this spectrum, the DSM-5 fails to define the difference between mild and severe ADHD. The rise, and subsequent medical treatment, of ADHD could be a result of this failure, which allows for mild ADHD symptoms to be treated the same way as detrimental ADHD symptoms. Although Neurodevelopmental disorders are seen on a spectrum, ADHD has become an either/ or diagnosis. Two actively practicing pediatric neurologists suggest that the causation of the either/or diagnosis stems from the diagnosis of ADHD having a close association with medical intervention. Also they suggest that, physician’s attempt to use positive treatment responses as the sole justification for prescribing medication. This attempt is one of the main reasons ADHD medication has become so prevalent regardless of the severity of the disorder. While medication has serious benefits to the most severe symptoms of ADHD, “medicalization of ambiguous ADHD leads to the trivialization of severe ADHD.” (Graf, Miller, Nagel, 2014). The diagnosis of ADHD needs to be more stringent and have clearly defined categories that place this disorder into a spectrum. The utilization of this spectrum will allow for enhanced treatment options that are more prudent to the different levels of ADHD severity. Issues withthe diagnosis of ADHD
- 8. The specifics on how ADHD is diagnosed are another problem that leads to the question of whether it should be a disorder or not. The diagnosis of this disorder is accomplished by adults in the children’s life, such as parents, teachers and school psychologists, filling out assessments on the children’s behavior (Graf, Miller, Nagel, 2014). These assessments are then compiled and a physician has the final say on diagnosing the child (Graf, Miller, Nagel, 2014). While these assessments have the benefit of giving a more holistic picture of the child’s behavior, they may be flawed and present the physician with over-exaggerated observations and poor reliability (Graf, Miller, Nagel, 2014). This poor evaluation system illustrates the need for more reliable diagnostic criteria. Research conducted by Maite Ferrin and Alasdair Vance may provide diagnosticians with the tools they need to refine the diagnosis of ADHD. In the article, Examination of Neurological subtle signs in ADHD as a clinical tool for the diagnosis and their relationship to spatial working memory, Ferrin and Vance have three goals (2012). They wanted to study neurological subtle signs (NSS) and the associations with ADHD, create a clinical threshold of NSS to aid in diagnosis, and try to explain how NSS and short-term working memory (SWM) are connected (Ferrin, Vance, 2012). With a total of 1,055 children with ADHD and 130 typically developing children as a control, the authors began analyzing NSS and SWM (Ferrin, Vance, 2012). The authors defined NSS as, “Minor neurological abnormalities in motor sensory and integrative functions” including athetoid and choreiform movements, fine motor movements and conjugate eye gaze (Ferrin, Vance, 2012). Ferrin and Vance used the Scored Developmental Neurological Examination (SDNE) to analyze NSS, an IQ test to analyze overall comprehension
- 9. and verbal ability, and the Cambridge Neuropsychological Test Automated battery to analyze spatial working memory (Ferrin, Vance, 2012). The authors found that the adolescents with ADHD had a higher number of total NSS and a lower verbal and nonverbal IQ than the control children (Ferrin, Vance, 2012). With the understanding that there was a connection between ADHD and NSS, Ferrin and Vance needed to create a threshold that would be able to aid diagnosticisons (2012). The authors utilized a ROC analysis to identify that the significant threshold was have 13 or more NSS (Ferrin, Vance, 2012). This threshold was strong enough to predict that, “when a child presents with more than 13 on the SDNE total score, they are six times more likely to present ADHD” (Ferrin, Vance, 2012). Working memory and the spatial aspect of in is directly connected with attention and the ability to fix and correctly use information (Ferrin, Vance, 2012). Total NSS in ADHD children and children with poor SWM were compared against children with good SWM and there was a good connection between poor SWM and NSS (Ferrin, Vance, 2012). This study is beneficial by providing researchers another tool that is more reliable than a simple lickert scale questionnaire that could possibly be misrepresenting the child. Diagnosing a patient with ADHD can have far reaching effects. Some patient’s quality of life can improve through treatment and understanding of the disorder, while others can deteriorate through the development of comorbid disorders and poor self-efficacy. Internalizing is the process of assimilating different attributes and behaviors into your opinion of yourself (Chen, Wang, Lichtenstein, Larsson, Chang,
- 10. 2015). A huge issue that is connected with ADHD is the tendency for patients to have problems with internalizing negative aspects. A study conducted in china based on Chinese twins, analyzed the connection between ADHD and the internalizing problems of depression, being withdrawn, and somatic complaints (Chen, et al. 2015). The study looked at 1,316 twins in china and found that there is a significant correlation between ADHD and internalizing problems (Chen, et al. 2015). Having anxiety or depression was the most likely internalized problem connected with ADHD (Chen, et al. 2015). 34% of the children had symptoms of both ADHD and depression (Chen, et al. 2015). While depression and anxiety were the most connected, 30% of the children were also considered withdrawn and 19% had somatic problems (Chen, et al. 2015). While these statistics are important to understanding the scope of ADHD there are also some limitations to this study. The first is that the researchers found that both genetic and environmental influences affected the amount of comorbidity (Chen, et al. 2015). Not controlling for one of these influences makes it difficult to extrapolate whether genetic or environmental factors are more connected to ADHD. Another limitation of the study is that, researchers were unable to determine whether the internalizing issues were an antecedent of ADHD or if they followed the diagnosis (Chen, et al. 2015). Despite these limitations and need for further research, this article highlights the larger picture of ADHD. This disorder, like so many others, is accompanied not only by ADHD symptoms but also the likelihood of being diagnosed with other disorders.
- 11. Disorders have a need to be clear and concise in their definition. The lack of clarity in the definition of ADHD allows for misinterpretation and misdiagnosis of disorders. Recently researchers have attempted to determine if some disorders were over diagnosed or under diagnosed (Chilakamarri, filkowski, 2011). This study analyzed patients whom had already been diagnosed with bipolar disorder (BD), ADHD and major depressive disorder (MDD) (Chilakamarri, filkowski, 2011). Researchers then utilized the DSM-4 as the gold standard for defining these disorders and re-diagnosed the patients (Chilakamarri, filkowski, 2011). The researchers were able to find that ADHD was over diagnosed (Chilakamarri, filkowski, 2011). The authors of the study found that 38% of the patients that had been originally diagnosed with ADHD really had MDD (Chilakamarri, filkowski, 2011). Similarly, 29% of the patients that had BD were also misdiagnosed with ADHD originally (Chilakamarri, filkowski, 2011). This information brings forth some of the issues that develop from poor diagnostic criteria. When a disorder has too broad a range of symptoms and characteristics, it can be confused with other disorders and health issues. This confusion can have detrimental effects on patients that are receiving the wrong types of treatments. Without proper treatment it is unlikely for patients to improve. All children can be rambunctious at times. For most this is seen as perfectly normal and even expected. However, there is a point when this behavior becomes perverse and is a real issue for children. Sometimes these children are challenged with serious problems of inattention and hyperactivity that disrupt multiple aspects of their life. As these problems become more rampant in our youth the need for a
- 12. way to categorize and treat these behaviors is also essential. Many professionals have used Attention Deficit/ Hyperactivity Disorder as the diagnosis to explain these traits. Unfortunately the entire psychological community isn’t convinced this disorder is being implemented correctly and the disagreement is with how these symptoms are caused, treated and can be generalized to children by laypersons. The diagnosis of ADHD needs to be refined and made more specific because despite the psychological community’s disparity on this topic, hyperactivity and inattention are serious problems effecting children.
- 13. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association Chen, T., Ji, C., Wang, S., Lichtenstein, P., Larsson, H., & Chang, Z. (2015). Genetic and environmental influences on the relationship between adhd symptoms and internalizing problems: A chinese twin study. American Journal Of Medical Genetics Part B: Neuropsychiatric Genetics, doi:10.1002/ajmg.b.32411 Chilakamarri, J. K., Filkowski, M. M., & Ghaemi, S. N. (2011). Misdiagnosis of bipolar disorder in children and adolescents: A comparison with ADHD and major depressive disorder. Annals Of Clinical Psychiatry, 23(1), 25-29. Ferrin, M., & Vance, A. (2012). Examination of neurological subtle signs in ADHD as a clinical tool for the diagnosis and their relationship to spatial working memory. Journal Of Child Psychology And Psychiatry, 53(4), 390-400. doi:10.1111/j.1469-7610.2011.02496.x Fredriksen, M., Dahl, A. A., Martinsen, E. W., Klungsøyr, O., Haavik, J., & Peleikis, D. E. (2014). Effectiveness of one-year pharmacological treatment of adult attention-deficit/hyperactivity disorder (ADHD): An open-label prospective study of time in treatment, dose, side-effects and comorbidity. European Neuropsychopharmacology, 24(12), 1873-1884. doi:10.1016/j.euroneuro.2014.09.013 Graf, W. D., Miller, G., & Nagel, S. K. (2014). Addressing the problem of ADHD medication as neuroenhancements. Expert Review Of Neurotherapeutics, 14(5), 569-581. doi:10.1586/14737175.2014.908707
- 14. Harold, G. T., Leve, L. D., Barrett, D., Elam, K., Neiderhiser, J. M., Natsuaki, M. N., & ... Thapar, A. (2013). Biological and rearing mother influences on child ADHD symptoms: Revisiting the developmental interface between nature and nurture. Journal Of Child Psychology And Psychiatry, 54(10), 1038-1046. doi:10.1111/jcpp.12100 Klein, S. B., Gangi, C. E., & Lax, M. L. (2011). Memory and self-knowledge in young adults with ADHD. Self And Identity,10(2), 213-230. doi:10.1080/15298861003741604 Marwitz, S. E., Woodie, L. N., & Blythe, S. N. (2015). Western-style diet induces insulin insensitivity and hyperactivity in adolescent male rats. Physiology & Behavior, 151147-154. doi:10.1016/j.physbeh.2015.07.023