Controversies Relating to Treatment of ADHD

Abstract

Attention-deficit/hyperactivity disorder is an extremely wide-spread condition that is commonly diagnosed in children and adolescents. The disorder is associated with various symptoms, including inattentiveness, impulsiveness, hyperactivity, learning difficulties, affective, and other issues, which can detrimentally impact individuals’ quality of life and interfere with their normal functioning in the society. Therefore, the need to develop effective treatment options has become extremely topical. Nowadays, medication seems to be the most preferred treatment option for ADHD despite adverse effects that it is associated with. However, there is another safer and not less effective treatment option, which relates to behavioral intervention therapy. In addition to being safe and effective, therapies have a unique capability to address essential psychosocial problems experienced by the overwhelming majority of individuals diagnosed with ADHD. Hence, the current paper is aimed at proving that behavioral interventions should become the preferred treatment option and be used instead of medication, which, in turn, should be considered in case all other available options have failed.

Attention-deficit/hyperactivity disorder (hereinafter referred to as ADHD) is an extremely prevalent condition in the USA, where hundreds of children are diagnosed with it annually. Irrespective of age, individuals diagnosed with ADHD require effective treatment that would allow them to cope with symptoms and diminish the influence of the illness on their daily functioning and quality of life. Nowadays, ADHD seems to be among the most frequently researched neuropsychological issues and a wide range of treatment options are available. The most conventional one is medication that is prescribed to the overwhelming majority of patients diagnosed with ADHD, especially children and adolescents. Although many studies support effectiveness of medication, it is still associated with versatile adverse effects and does not eliminate the problem. On contrary, it may alleviate some of its symptoms. Moreover, long-term use of medications may result in serious health problems and be extremely cost-intensive for many families. In turn, behavioral interventions and some other non-medication treatment options are available to treat patients with ADHD. It is clear that such option may take more time to produce some tangible results. Still, the results tend to be long-term and can significantly improve the individuals’ quality of life. Based on the overview of medication and behavioral therapies as two most prevalent treatment options for ADHD, it may be hypothesized that due to their effectiveness and unique benefits therapies should prefer the medication that is connected with emergence of adverse effects, health complications, and significant life-time costs.

Brief Overview of Attention-Deficit/Hyperactivity Disorder

In the USA, ADHD is among the most frequently diagnosed neurobehavioral disorders, especially among children, with 5-10% of all school-aged children (Conway, 2014). The range in the percentage identified is so wide due to different sources from which statistics is derived. Some studies indicate more than 11% of children suffering from the disease (Esparham et al., 2014). In turn, other sources provide the statistical date of 2-9% of school-aged children having ADHD (McCarthy et al., 2009). Irrespective of the differences in the estimations, the overwhelming majority of researchers agree that ADHD is a serious and prevalent concern for children and adolescents. In addition, many cases remain unreported due to various reasons, for instance, parents’ inability to detect the problem, lack of access to quality healthcare, or consideration of children’s problems at school as a result of poor performance and low intelligence level rather than as a symptom of the disease. In any case, ADHD is defined as “a common neurodevelopmental disorder defined by the ‘core’ signs of inattention, hyperactivity and impulsiveness” (McCarthy et al., 2009). Other common symptoms associated with ADHD include increased anger, risk of depression, volatile emotions, cognitive problems, educational problems, and social issues. It has been proved that ADHD is “clearly associated with social cognition impairments involving emotional face and prosody perception” (Uekermann et al., 2010). Severity of symptoms and comorbidities associated with ADHD varies depending on the individual’s peculiarities and treatment options chosen for each particular instance.

An exact pathogenesis of the disease under consideration is still unknown, primarily due to the complex nature of the condition and a wide range of symptoms and factors related to it. Most studies emphasize that ADHD is significantly influenced by environmental and genetic influences with the latter ones being more reliable as predictors of the disease onset (Esparham et al., 2014). Besides, some studies indicate that the occurrence of ADHD may be related to nutritional issues, physical and emotional traumas, environmental factors, such as exposure to toxins, oxidative stress, and neurological abnormalities in the brain (Esparham et al., 2014). Some studies show that ADHD is accompanied by neurotransmitter dysregulation, “increased dopamine transporter density”, endocrine dysregulation, “decreased dopamine D2/D3 receptors”, as well as abnormalities in basal and fronto-striatal ganglia network (Farr et al., 2014). Individuals diagnosed with ADHD can develop educational, psychosocial, and neuropsychological impairment, as well as suffer from the lack of achievements in education and subsequently in employment. Therefore, ADHD is a condition that requires effective treatment that would improve the quality of patients’ lives.

Overview and Effectiveness of Behavioral Interventions and Some Other Non-Medication Methods in the Treatment of ADHD

Behavioral interventions and medication are two most wide-spread conventional treatment options recommended to patients with ADHD. At the same time, the medication supersedes the interventions in prevalence due to several reasons. Behavioral therapies have been proved to be highly effective in helping individuals cope with their ADHD symptoms and learn to socialize with others and function effectively in the society. It is caused by the fact that approximately 35% of all patients diagnosed with the disease in the USA do not respond to prescribed medication and display sever adverse effects that result in discontinuation of treatment (Esparham et al., 2014). Besides, ADHD is defined as a neurobehavioral disorder, which is why many of its symptoms can be addressed through appropriate behavioral therapies. Some studies have proved that cognitive approaches and parenting interventions as two common psychotherapeutic treatment options are extremely effective in the short-term without their combination with medication (Conway, 2014).

With respect to long-term influence, psychodynamic treatment has proved to be effective and offer many significant benefits to patients (Conway, 2014). Although almost none of such benefits emerge immediately after the start of the therapy, they tend to appear gradually and have a lasting impact on the behavior of the patient. With time, such behavior only intensifies as his/her relationship with the therapist becomes stronger and more influential. Concerning behavioral interventions, it has been proved that empathy is an essential component of the therapy, while work with idealized and mirroring transference is also beneficial for the patient. It is especially important if the patient is a child whose ADHD condition has been worsened by some psychological, emotional, or physical trauma (Conway, 2014). Research shows that integration of empathy into the therapy “provides the patient with an opportunity to reflect and monitor their affective states” (Conway, 2014). Additionally, it assists the patients who have prominent problems with perception, which is common for ADHD patients who easily identify and associate with anger, and lack comprehension and ability to identify other emotions (Uekermann et al., 2010). Behavioral interventions that incorporate empathy show that children with ADHD may have difficulties with properly recognizing their internal emotions and states and may not know how to express their internal experiences. Consequently, it leads to destructive behavior and disorganization. Such issues cannot be resolved with the help of medication that can merely subdue the emotions, yet cannot help patients express them in a socially acceptable and understandable way.

Thus, psychosocial therapies become essential as they teach patients how to develop reflective capacities and deal with volatile emotions without resorting to the seemingly destructive behavior. Empirical evidence suggests that therapeutic sessions with inclusion of empathy can really help patients deal with their internal experiences and verbalization of their emotions. Anyway, such practice requires time that is also needed for building trusting and empathetic relationships between a patient and a therapist (Conway, 2014). Once such relationships are established, transference interpretations can be exploited by the therapist to boost self-esteem and confidence of the patient suffering from social isolation and marginalization. Numerous empirical studies have proved that transference interpretations, in particular idealized and mirroring transference, “serve to organize ego functions…, stimulate mental growth…, promote the ability to mentalize and develop higher ordered thinking…, and develop stability in internal states” (Conway, 2014). None of such essential tasks can be ensured by medications as only behavioral interventions can assist patients in coping with emotions and learning to socialize in the community.

Nowadays, complementary and alternative therapies increase in popularity in the USA as more families strive to move away from medication to other available option treatments. For instance, in 2007, 12% of children diagnosed with ADHD were reported to undergo some complementary and alternative therapy and such figure could have been higher if more parents had been aware of such treatment options (Esparham et al., 2014). Such options are usually termed as integrative medicine aimed at delivering “personalized care to the patient” and “emphasizing diet, nutrients, gut health, and environmental influences” as effective ways of decreasing ADHD-related symptoms (Esparham et al., 2014). Hence, physicians recommend restricted elimination diet, whole foods diet, exclusion of glutens, consumption of various essential micronutrients, for instance, zinc, iron, vitamin B6, magnesium, iodine, vitamin D, and others. In addition, it is important to consume pre- and probiotics as means of promoting good health, and monitoring of the environment with a view to decreasing severity of ADHD symptoms and improving patients’ quality of life. The scope of empirical evidences supporting effectiveness of such non-medication interventions as treatment options, specifically intended for ADHD, may be limited due to the lack of researches dedicated to studying such issues. Anyway, the existing literature allows concluding that the above listed options cannot harm patients and, on the contrary, can make them healthier.

Medication as a Conventional Means of Treating ADHD

Nonetheless, irrespective of the above-mentioned potential effectiveness of behavioral interventions and some other non-medication options, “medication remains the mainstay of pediatric ADHD treatment” (Jellinek, 2008). Such option has been developed alongside with current treatment protocols in the result of the Multimodal Treatment Study of Children with ADHD (Jellinek, 2008). Some of commonly prescribed medications under such protocols include atomoxetine, dexamfetamine, and methylphenidate (McCarthy et al., 2009). Effectiveness of such drugs has been tested by numerous studies both in the USA and in other countries of the world where ADHD is recognized as a serious problem. The medication treatment targets neurological abnormalities detected in patients with ADHD and attempts to diminish associated symptoms like inattention or impulsiveness, as well as associated comorbidities, such as depression. Thus, methylphenidate is aimed at increasing “catecholamines in the prefrontal cortex and striatum through blockage of dopamine and norepinephrine transporters”, which improves cognitive performance of different tasks (Farr et al., 2014). It has become the most wide-spread medication prescribed for treatment of ADHD among school-aged children (Greenhill et al., 2006).

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Although its safety and efficacy for preschoolers have not been proved and the US FDA does not recommend prescribing it for them, methylphenidate is nowadays the most commonly used drug for treatment of ADHD among the given group of the population (Greenhill et al., 2006). Several empirical studies have been aimed at analyzing efficacy of the drug for preschoolers diagnosed with ADHD. Hence, it has been proved that methylphenidate in the optimal dose of 14.2+/- 8.1 mg/day can significantly reduce manifestation of ADHD symptoms in preschoolers. However, such reductions are less pronounced than in school-aged children taking the same medication albeit in a slightly different dosage (Greenhill et al., 2006). Overall, it seems that the overwhelming majority of parents and physicians consider medication to be an effective and convenient treatment option for ADHD. At the same time, they do not account for adverse effects, possible health complications, and inability of the option to solve psychosocial issues associated with the disease and mentioned in more detail above. The most common adverse effects evoked by medication include trouble sleeping, emotional outbursts, repetitive thoughts and behaviors, weight loss, decreased appetite, irritability, and even seizures in rare cases (Wigal et al., 2006). Elevation of pulse and blood pressure are also associated with ADHD medication. Besides, one study has shown a correlation with medication intake and the increased risk of suicide, while the US researchers have reported some cases of sudden death among ADHD patients taking respective medications (McCarthy et al., 2009). Although a direct connection between such fatal events and medication has not been decisively proved, a risk of high suicide and sudden death chances cannot be discarded.

Summary and Conclusion

Various treatment options of ADHD have their supporters and opponents among professionals, parents, and the general public. It, in turn, has given rise to numerous debates. Thus, all available treatment options have become controversial and open to further researches. Consequently, the further investigations should be aimed at providing solid and conclusive evidences proving some options as being more effective than the other ones. However, available studies show that medication is connected with versatile adverse effects of varying severity that may cause serious health problems in patients. Besides, instances of sudden death and elevated suicide moods may be other adverse consequences of prolonged intake of prescribed ADHD medication. In turn, behavioral therapies represent a safe and effective treatment option that can produce long-term effects with no associated health risks. Moreover, behavioral therapies address some ADHD-related psychosocial issues that cannot be solved through intake of some drugs. It means that the capability of the therapy is its unique strength that should encourage parents to seek diverse treatment option for their children. Due to professionally developed and customized therapies, children and adolescents can learn to live with ADHD symptoms, as well as socialize with other people and effectively function in the society without a need of taking life-long medications with severe adverse effects. Therefore, behavioral interventions and some other non-medication options can be regarded as a safer and more effective alternative to medication. As a result, it should be viewed as a final solution of the problem when all other available treatment options fail.