ADHD Intervention Analysis: Is ADHD Medication Being Overprescribed? Moses Stutzman Mid-Michigan Community College Abstract Attention Deficit Hyperactivity Disorder has drastically increased in recent decades. Medication to treat this disorder has become an easy way out is overused. There are many alternatives to the use of medication to treat the symptoms of ADHD (non-medical treatments). This essay reviews the main symptoms of ADHD and the methods that are used to diagnose ADHD. It is also important to understand the various medical and non-medical treatments that are available to the patient with ADHD.
This essay will go through these treatments and conduct an in-depth analysis of each one in order to educate the reader and hopefully a parent of an ADHD child. An analysis of the long and short term effects of medication and non-medical treatment will also be performed so that the best possible treatment will be chosen. ADHD Intervention Analysis: Is ADHD Medication Being Overprescribed? Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD), in recent decades, have become the most diagnosed mental/behavioral disorders among children, teenagers, and adults.
Most of the increases in ADHD are seen in children. According to Rafalovich (2001), there have been an increasing number of diagnoses of ADHD and about four million children in the United States alone have been diagnosed with ADHD. More diagnosis of this mental/behavioral disorder brings forth different methods of intervention. Pharmaceutical intervention is one of the most common interventions when dealing with ADD and ADHD. Along with an increasing number of diagnoses in ADHD, a soaring number of medications are being prescribed to these patients.
Rafalovich (2001) also mentions this increase in prescribed medication and discusses the fact that since 1990 pharmaceutical interventions have gone up by 700 percent which could be considered a massive increase. As it would be in all realms of prescription medication, this increase is reflected as controversial and the notion that there should be more done to prevent such an increase is not an uncommon one. Medical intervention for ADHD has many side effects on the patient to which it is being prescribed.
Many are not beneficial to the patient and may in fact limit the ability to truly control the symptoms that ADHD patients endure. It is not solely the medication that has become problematic, however; the significant increase is what is concerning. DuPont (2006) explores this increase in medication which has become an issue. He explains that a long term controversy has been re-highlighted due to the increasing use of medication to remedy mental disorders, such as ADHD, as opposed to non-medicinal treatments including better education and social forbearance of one’s environment.
Although an increase in the medical realm of intervention has been frequently observed there are alternative methods of mediation when looking at ADHD. Briefly, interventions such as parent education and psychological analysis and therapy are both common forms of non-medical intervention pertaining to ADHD. The problem is not that these interventions are not being incorporated into these alternative methods; the problem is that these methods of intervention are used exactly as they are being described: as alternatives. Medication to remedy characteristics of ADHD such as inattention, hyperactivity, and impulsivity are overused and worn-out.
The use of medication in ADHD could be decreased significantly if finding alternative methods to treat behavioral symptoms became a priority rather than an alternative second choice technique. Effects of ADHD When one thinks of ADHD, hyper, disruptive, inattentive, class-clown imagery might be something that enters the mind. While these descriptions may be somewhat accurate, ADHD has a bigger effect on a child than allowing them to become a “funny man”. A poor self-image has been seen through analysis of children with ADHD when compared to children without ADHD according to Waschbusch, Craig, Pelham, and King (2006).
Poor self-esteem may develop due to the child with ADHD falling behind the child without the disorder when it comes to behavioral growth. The authors outline another possibility to an ADHD child’s low self-esteem. They suggest that something called self-handicapping is a likelihood and define self-handicapping as an “… attempt by an individual, when faced with a diagnostic task, to provide him or herself with an excuse for poor performance by obscuring the relationship between actual performance and inferred ability” (p. 276). In other words these children will make themselves believe that they cannot accomplish a ask because they are simply “not good enough. ” These symptoms can only be overcome through the use of a non-medical intervention such as counseling or therapy. Medication would not help such symptoms as low self-esteem and may in fact be an in-direct cause of a poor self-image. Medication to treat ADHD has many positive and negative effects. It helps control many of the symptoms that children with the disorder possess such as calming the hyperactivity and controlling the disruptiveness and inattentiveness Waschbusch, Craig, Pelham, and King (2006), explore the question of whether or not medication has an impact on self-handicapping.
It is explained that research on medication has shown a positive effect on ADHD symptoms, but when it comes to the self-handicapping concept, prescribed medication is observed to have little effect. So even though medication is generally observed as a positive method of intervention to control some symptoms of ADHD, it is by no means a “cure-all” to the disorder, as seen in this case. ADHD affects all who are diagnosed differently and a poor self-image is one of the many effects it has. When it comes to the use of prescription medication, this is one symptom that a prescribed medicine will not be able to treat. ADHD Diagnosis Criteria
In order to complete a thorough analysis of ADHD interventions and the possible prescription of medication, it is important to understand what constitutes an ADD and ADHD diagnosis; several behavioral and mental factors are considered in both diagnoses. These diagnoses can also be used to help determine what method of intervention would be the most suitable for the patient. The things that define ADD and ADHD are things like inattention, hyperactivity, and impulsivity. ADD would be considered a more moderate disorder compared to ADHD because out of the three defining characteristics, ADD includes only inattention and impulsivity.
All three behavioral characteristics are seen in the ADHD diagnosis. Wolraich and Baumgaertel (1996), discuss a few of the criteria that are used to diagnose these mental disorders. The authors not only define the three common characteristics seen in ADD and ADHD, but they define each individual characteristic. For example, the inattention characteristic can be defined through nine different behaviors that relate to inattention. These behaviors include, but are not limited to, careless mistakes, forgetfulness, being easily distracted, and a failure to finish tasks.
In order for a child to be considered inattentive the authors explain that at least six of the nine structures will be evident. Using this criteria, a mediator (psychologist or doctor) is able to not only diagnose the patient with ADHD, he is also able to examine what intervention would be the best match according to the symptoms that are shown. This includes both medical and non-medical forms of intervention. The criteria for ADHD diagnosis are updated periodically and with each amendment to the criteria it becomes gradually more difficult to actually diagnose a patient.
While the method for diagnosing ADD and ADHD is complex, prescribing medication to “treat” the disorders has become progressively less formal. One would assume that the effects of an amplified conditional difficulty should have an adverse effect, such that an increase in the difficulty of the criteria would show a decrease in the prescription of medication. This is not the case, however; the changing criteria to diagnose ADHD are not a significant part of the issue when it comes to an overuse of medical interventions. Advantages of Non-medical Interventions
There have been many works published about the use of medication to treat ADHD; these works focus mainly on the advantages and disadvantages of using medication as the primary method of intervention. The same attention has not been given to the review of non-medical interventions that are used when treating ADHD. Trout, Lienemann, and Reid (2007) discuss the advantages of using non-medical interventions to treat ADHD. The authors note that there is a wide range of traditional and nontraditional non-medical interventions being used to help control the symptoms of ADHD, but there is a lack of sufficient research on these types of interventions.
When there were research studies conducted, the means of the research was unclear and the methods were poorly used and undefined, according to Trout, Lienemann, and Reid (2007). Compared to medical treatments, though, non-medical interventions are much more useful to help control the symptoms shown by ADHD patients. Medication, compared to non-medical treatment, has some limitations; Trout, Lienemann, and Reid (2007) explain that about a quarter of the response seen by children on ADHD medication is not favorable for the mediator or the child.
There is also a problem when administering medications to children at school because teachers and administration have no control when it comes to the medication schedules that these individuals have. When the medication gets to a minimal effectiveness stage, the behavior of the child, as well as the attentiveness, starts to dissipate. When compared to non-medical interventions, this specific disadvantage when treating with a prescribed medication is one that is not seen in the aforementioned non-medical aspect.
With non-pharmaceutical intervention, educators and administrators can maintain control within the realm of the child’s behavior. Furthermore, the behavior of the child will not be seen as “on and off” because there is no lapse when the child is not on medication. Identifying the advantages and disadvantages of both the medical and non-medical realm of the interventions used to control ADHD symptoms is a vital part of understanding the overall advantages of moving away from the medical side of treatment.
These advantages of non-medical intervention methods can be seen even more clearly when analyzing the individual methods. Non-Medical Intervention Examination Although there has been a substantial rise in the prescription and use of medicinal interventions, there are still many non-medical methods that are effective in treating the behavioral conditions of ADHD. These controls are numerous and it is imperative to individually analyze these treatments and how they affect the ADHD patient in order to fully understand why these non-medical alternatives would, in fact, become better methods to control ADHD symptoms.
A variety of approaches to the non-medical treatment of ADHD are outlined by Purdie, Hattie, and Carroll (2002) on the research on interventions of ADHD. According to the authors, most of the literature on ADHD is focused on the medical treatment of the disorder which can make it difficult to complete an in-depth analysis of the non-medical management. The article, however, outlines a handful of the above-mentioned non-medical treatments. These methods include behavioral, cognitive behavioral, parental, and educational interventions. Each individual intervention involves a different approach and, in turn, yields a different outcome.
The varying outcomes of these control methods are very important to the treatment of ADHD because of the various symptoms that are shown by different patients. This variation in results is positive to the treatment of ADHD. Behavioral interventions are often referred to as “behavioral therapy” or “response cost” due to the methods that they incorporate. This non-medical approach can easily be defined. Purdie, Hattie, and Carroll (2002) note that this method of control is used to produce appropriate behavior by use of penalty when this requirement is not met.
In other words, to effectively re-shape the patient/child’s behavior, a positive support system incorporated with punishment for “wrong-doing” is put into place. The aforementioned “wrong-doing” is most commonly defined as off task behaviors in the classroom and is the objective task in the realm of behavioral intervention. The use of medication alongside this sort of intervention is not uncommon and has actually been observed to be more effective than using prescribed medication by itself. In turn, inhibiting the behavioral management technique by itself, or alongside pharmaceuticals, is one way to help decrease the dependency on medication.
Another non-medical intervention that is outlined by Purdie, Hattie, and Carroll (2002), is called Cognitive Behavioral Intervention/Therapy, (CBT). Similar to behavioral therapy, CBT is a therapy that helps children control the symptoms of ADHD such as inattention and impulsive behaviors. The underlying difference in this technique, however, is the emphasis on “self-control”. Instead of the instructor or therapist punishing the patient’s wrong-doing, the patient is taught to evaluate the situation themselves, and to critically identify the best fitting solution to the problem.
This intervention encompasses the child’s cognitive behavior and is an attempt to fully develop the social problem-solving skills needed to succeed, even with ADHD. One such skill that is needed to make these decisions is the ability to delay the patient’s response to a difficult situation. In other words, one goal of this intervention is to reverse the impulsivity that the patient has to face and take a second look at any given situation in order to make an acceptable choice for response. The research and information on this intervention has been primarily based on clinical examination as opposed to classroom inquiry.
This type of non-medical intervention can be incorporated with almost any patient’s needs, unlike many medical alternatives, allowing this treatment to be more useful in controlling ADHD symptoms than many pharmaceutical methods. The previous examination of the non-medical interventions mentioned, have been interventions that focus primarily on the therapy and treatment of the patient/child. Purdie et al. (2002) outlines interventions involving parental figures that are also very useful in the treatment of ADHD.
Even though the direct focus is not put solely on the patient/child(in this case it is the child), parental interventions are useful and effective in equipping the parent/guardian with tools to help their child with ADHD fulfill their full potential. Purdie et al. (2002) explains that in order for this method of intervention to be effective, the specific needs of the child have to be taken into account. These needs include the age of the child, the impact that the disorder has on the child, and even the individual needs of the family members involved.
This method was observed among preschool children and their parents. The results showed an increase in the willingness of the child to listen to the parent and also enhancements in the parent’s skills to identify with their child. Although this method has mostly positive effects in an ideal situation, the transition to a situation that displays dysfunction among the family and its members may show different results. This method, again, is one that, if implemented into the family dynamic, would help reduce the amount of medications that are prescribed to patients with ADD and ADHD.
Alongside parental interventions come educational interventions, when referring back to Purdie, Hattie, and Carroll (2002). Educational interventions can be analyzed alongside parental interventions because of the similarities they display in the implementation of each method. Intervention in the education of the student, similar to parental intervention, is not a direct process or therapy on the child. Instead, this process involves a change in the educational environment that the child is taught in.
This intervention involves making subtle, but effective, changes to the level of clamor, the seating placement of the child, and the overall structure of the classroom. These changes can be achieved by practicing group based activities, involving the family in the academics of the child as much as possible, and the constant evaluation of the child’s level of inattention, impulsivity, and/or hyperactivity. Improvements in the symptoms of ADHD are frequently observed when some, or all, of these changes are implemented into an educational environment.
However, Purdie et al. (2002) also explains that some of the literature on this method of intervention suggests that the academic performance of the student will not necessarily improve with the progress made on the symptoms. This means that while a parent/teacher will see improvement in the way the student subconsciously analyzes a situation, a positive change in academics may not always be observed. The improvements made on symptoms such as impulsivity and hyperactivity opens the door for additional development which directly transitions to a better academic report.
This method of intervention also helps fight the massive increases that have been seen referring to the use of prescription medication to combat the symptoms of ADHD. Non-medical behavioral type interventions that directly affect the patient with ADHD have been analyzed and discussed. There are other types of behavioral intervention, though, that direct the focus of the treatment method on different figures involved in the situation. Behavioral parent training is one such intervention. Heriot, Evans, and Foster (2001), discuss these behavioral methods of intervention.
This type of intervention is defined as a parent training that helps the parent(s) manage their child’s behavior by defining more effective methods of control. This treatment, when researched, has seen various levels of success. This sort of treatment can also be defined as an equal non-medical treatment and works much like a stimulant medication. These treatments are seen as equivalent because they both focus on the behavioral aspects of the disorder and are most often used simultaneously to achieve the highest level of success. Though similarities can be noted, the medical and non-medical behavioral interventions are still very different.
The non-medical approach is an attempt to change the patient’s behavioral environment not by directly treating the patient, but by working on the patient’s parents or teachers behavior which, in turn, will constitute a change in the child’s behavior. When looking at the medical behavioral treatment, the child is directly affected by medication and the environment the child is in and the behavior of the parents are not affected. In order for this behavioral parent training method to work, Heriot et al. (2001) note that there are some standards that need to be met.
First and foremost, the parent that goes through this sort of training needs to cooperate with every aspect of the treatment. If the methods that are taught are not fully implemented, there is a greater chance that the outcome of the training will not be significant and, therefore, a change will not be seen. Implementation is another vital aspect of this type of intervention; if the parent does not show that he/she is fully implementing behavior standards, than a positive change may not be seen. The behavioral parent training treatment method is one of the methods that most closely relates to the medical treatment of ADHD.
The similar results that are achieved by these methods show that the medical aspect of treatment can easily be reduced, or overtaken, by this non-medical training. Non-medical Intervention Research Procedures The research conducted on the implementation of non-medical interventions to control the symptoms of ADHD is limited because of the restrictions that have been placed social research methods such as this; ethics are also a huge factor in this realm. The analyses that have been performed on these non-medical control methods, as explained by S. P. Hinshaw (2007), share certain research criteria.
There are two variables that should be incorporated into any research method: the moderator and the mediator. “Moderator variables refer to characteristics of a treatment sample that may influence the outcomes of interest, thereby identifying subgroups with greater or lesser chances for positive response. Mediator variables signify processes occurring during treatment that explain how and why the intervention is exerting its effects” (Hinshaw, 2007). So, moderator variables are the specific features of the sample taken that might influence the overall outcome of the study.
This, in turn, is used to identify the chances of a positive reaction to the intervention. Mediator variables are, simply, the results seen during an intervention study that show the ways the intervention is applying the effects it has, specifically, how and why. These variables are necessary in order to verify that the results are genuine and to eventually isolate the best outcomes the majority of the time. The known truth about the research aspect of non-medical interventions is that, it is hard to conduct an accurate study because the results will not be the same for every person treated.
On the other side of the argument, though, it is seen that there have been hundreds of studies conducted that demonstrate the general outcome of medications on ADHD, according to Poncin, Sukhodolsky, McGuire, and Scahill (2007). Even though the current goal of intervention research should be to reduce the use of stimulant medications, the combination of medication with non-medical treatment/therapy is something that could also have a positive effect on the symptoms of ADHD.
This combination would help in the shorter time frame to control the patient during psychotherapy sessions, while the patient is slowly “weaned” off the medication altogether. This will eventually virtually eliminate the need for the medication one patient at a time. Medications Used to Treat ADHD Right beside the non-medical interventions used to treat ADHD symptoms are the medical interventions used to treat ADHD symptoms. The medical aspect of ADHD control is one that has been controversial since an increase of both the patients diagnosed and the medication prescribed.
Unlike the non-medical interventions that are used to help control the symptoms of ADHD, medication is not a long term solution; this factor contributes to the satisfaction and the outcome that is seen among the patients taking the medications, the doctors prescribing the medication, and the parents giving the medication. Different medications bring forth different levels of satisfaction in patients, parent, and teachers. Gortz-Dorten, Breuer, Hautmann, Rothenberger, and Dopfner (2011) study the satisfaction, or a lack of satisfaction, that is shared between patients and parents.
When it comes to the satisfaction of the parents that is observed on certain medications, it is clear that the majority of parents prefer a long-acting formula. A long-acting formula is one that releases its affects throughout the course of a day and only needs to be taken once daily. Most ADHD medications are moving to the long-acting formulas because of the efficiency that it has shown in studies. There are also formulated medications that have to be taken multiple times daily known as short-acting formulations; these medications have to be taken two to three times a day in order to “tame” the symptoms of ADHD.
There are other factors that influence the satisfaction of patients and parents when it comes to the medical treatment of ADHD. Gortz-Dorten et al. (2011) explain that things like the effectiveness that is displayed with the treatment, expectations that the consumer has in place, and the social validity that is demonstrated by the medication also come into play when gauging patient/parent satisfaction. Medication may seem like a decent solution when attempting to control the symptoms of ADHD, but the process to prescribe one with an ADHD medicine is much simpler than a non-medical treatment process would be.
This points to the notion that medication may not be an effective long-term treatment for ADHD, so it is vital to look at some of the long term effects, along with short-term effects, that these medical treatments of have on the patient with ADHD. Long Term and Short Term Effects of ADHD Medication Similar to all medications, the medical treatment options that correlate with ADHD display various side effects. Some side effects are seen and felt when first starting the ADHD medication and others are observed once the medication has been taken for a longer period of time.
Lerner (2008) outlines the importance of research on ADHD medications and also goes over the various side effects that a patient may display. The short-term side effects are the effects that are seen when the ADHD patient initially starts taking the medical treatment; these side short-term side effects can be things like an aching abdomen, weight loss, loss of appetite, and sleep loss. Though these side effects are generally considered to be mild, they would not have to be endured if a non-medical alternative was used in the place of the medication.
One considerably more significant effect that has been seen in patients taking these medications, as stated by Lerner (2008), is a cardiovascular influence. This side effect includes things like changes in blood pressure and in heart rate. A well-known ADHD medication, known as Adderall®, was taken off the shelves by the U. S. Food and Drug Administration (FDA) when 12 cases of sudden death were reported. The cause of these 12 child deaths was an extended use of ADHD medication that had a significant cardiovascular effect. “. . . stimulants create cardiovascular risk through their action as sympathomimetic agents . . . hanges in some cardiovascular parameters are typical” (p. 40). This means that even through research, a change in the circulatory health of the patient must have been observed. The risk of a change in blood pressure and a change in heart indicates that medication can be dangerous. When comparing the medication to non-medical treatments, one can see that there haven’t been any reported dangers in behavioral therapy or parent training which makes the later a more plausible, and safer, choice. ADHD Medication Abuse In medication, one of the most difficult reactions to overcome when regularly taking the drug is addiction.
The combination of chemicals that are used to engineer a medicine that controls someone’s impulsive behavior enhances the “need” for the medication. DuPont (2006) explains that the rise of ADHD prescription medication also raises the concern that these medications may be abused. This abuse is known as the non-medical use of a medication, which includes the use of the medication by anyone else but the person to which it is prescribed and the use of the medication in a way that has not been directed and approved by a physician. There are ADHD medications that have been known to be used non-medically such as Adderall® or Ritalin.
According to Sutcliffe, Bishop, Houghton, and Taylor (2006) there are certain factors that contribute to the abuse of these medications. ADHD medications are meant to combat the symptoms felt by the patient (hyperactivity, impulsivity, and inattentiveness) by raising the level of activity, alertness, and arousal. Sutcliffe et al. (2006) explain that these outcomes are achieved through medication by mocking the action that neurotransmitters perform in the brain. This process has one common side effect and that is that it can lead to addiction and a growing dependency on the medication.
This factor alone is one of the main concerns of parents and some doctors. The dependency shown by a single patient, and the ADHD realm as a whole, can be drastically decreased if more non-medical treatments were implemented. Understanding the underlying characteristics of ADHD is vital in order to choose the best method of treatment. The use of medication as a remedy to these characteristics can be significantly decreased through the analysis of interventions involving medication and interventions that incorporate other methods of treatment. There are several underlined ways to begin decreasing he reliance on medication when treating ADHD. This starts by examining the criteria used to diagnose ADHD which will help identify how the intervention needs to be used. The exploration of the quality or the lack of quality, that is achieved by using medication as a sole method of treatment is also an important step. The next step is to look at the many alternatives to stimulant medication that can be used. This examination of interventions will show various treatments that would be considered more suitable for the patient and will also have more success as a long term treatment method of ADHD characteristics.
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