TOPIC. Diagnosis and treatment of attention deficit/hyperactivity disorder.
PURPOSE. To describe a multidimensional approach to treatment of children with attention deficit/ hyperactivity and their parents.
SOURCES. Review of the literature and of the author's clinical work.
CONCLUSIONS. A great deal of controversy surrounds this diagnosis. The nurse psychotherapist helps children and families through the diagnostic process and into the treatment phase. Emphasis is on psychotherapy of the child and family, parent education, and attention to the child's school environment and social adjustment.
Key words: Attention-deficit/hyperactivity disorder, comorbidity, obsessive-compulsive disorder, psychotherapy, TOVA
Attention-deficit/hyperactivity disorder (ADHD), sometimes referred to as ADD, is a very common label used, overused, and misused to identify difficult, impulsive, overactive, inattentive children. In fact there is some question whether ADHD is myth or reality. Many professionals suggest parents use it as a rationalization for children's academic underachievement or socially unacceptable behavior. Carol Gilligan (1997) has referred to "the drugging of America's young boys," saying one in five boys in Illinois is on Ritalin. Recently, I saw a young man who is now studying law. Concerned about his inability to focus at work, he said, "You know I have ADHD. When I was in college and couldn't focus on the football field, my father took me to the doctor, and I was placed on Ritalin. It improved my game. Maybe it can improve my work."
Thomas Armstrong (1997), in The Myth of the A.D.D. Child, writes about his belief that "ADD does not exist" and that many children labeled with ADD are not disordered. He adds, "Even when biological issues appear to predominate, biological predispositions need to interact with the cultural, social, educational, and/or psychological factors in order to give birth to the ADD symptoms" (p. 34).
Many see ADHD as a complex problem that has no psychological tool to validate its existence. Identifying ADHD is akin to slowly putting together a multidimensional puzzle. Because it is so complex, it requires complex, comprehensive treatment. Dulcan et al. (1997) leading researchers in ADHD, write about the need for multimodal treatment studies.
Nurse psychotherapists are challenged to treat and meet the needs of children identified and labeled ADHD. We must be savvy and educated about the phenomenon of ADHD to truly provide the psychotherapy needed with this special population.
This article addresses several concerns, beginning with the identification and diagnosis of ADHD, comorbidity with ADHD, medication management, and, most important, psychotherapeutic treatment approaches from an interpersonal framework.
ADHD, according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, revised (DSM-IVR) (APA, 1994), has several subcategories: attention deficit/predominately inattentive type, attention deficit/hyperactivity/predominantly hyperactive impulsive type, and ADHD combined. Jensen, Martin, and Cantwell (1997) propose adding two new subclasses: ADHD aggressive and ADHD anxious types. Together, these types occur in as many as 10% of boys of elementary school age and 5% of girls. Prevalence declines with age, although 65% of hyperactive children are still symptomatic as adults.
Identification of ADHD beyond the DSM-IVR criteria is achieved via parent interviews, child and school assessments, rating scales, structured behavioral assessments, medical evaluations, and ancillary evaluations of speech and language. Many parents and children have reported extreme frustration and anxiety awaiting the results of all the data. Sometimes the sophisticated assessment process exacerbates families' anxieties, when in the end there is no real test for ADHD. Hallowel and Ratey (1994), in Driven to Distraction, write: "Professionals can miss the diagnosis if they rely too heavily on testing--rather teachers' reports, parents' reports, evidence of human eyes and ears over time must take precedence" (p. …