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CH9 Chakara 1
Chapter 9
Understanding ADHD: A Primer for Care Providers
Freeman M. Chakara Psy.D, ABPP-CN
Matt, a 17-year old high school senior, sat nervously between his parents as his father,
Paul, asked me what I thought was the cause of his son’s apparent behavior problems. His
mother, Joanne, nodded her head in agreement, sharing the same level of frustration as did her
husband. Before I could muster a response, Matt literally jumped out of his seat and ran out of
the office into the adjoining waiting area where he poured himself a cup of coffee and darted
back into my office. He slumped into another couch, stretched out his legs and started stirring
his coffee. Paul continued, “This past weekend I asked him to mow the yard. When I got back
home, three hours later, the grass was half-mowed, the mower was left unattended, and Matt was
nowhere in sight. I later found him at a nearby skating park, playing with some kids.” At this
point Matt ran out of the office again. This time he went upstairs to the restroom. Running back
down, he slid on the stairs, fell and sustained a bruise on his left hand. He walked back into my
office with a childish grin and shrugged his shoulders. He looked at me and said, “Kids in my
home school co-op and in my youth group think I have ADD, and my dad says I’m just lazy and
disorganized. What do you think?” Joanne spoke for the first time, “That is it in a nutshell. We
just don’t know what to think or where to turn. What are we dealing with here? Is Matt just being
a boy and we have to get used to him being this way?” As if on cue, Matt pulled out his cell
phone and started text messaging someone while his parents stared at each other, hands raised
as if bewildered by their son’s behavior.
<1>Getting Started
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Matt and his parents’ questions, along with this family’s expressed frustrations, are quite
typical among folks seeking to understand Attention Deficit Hyperactivity Disorder [ADHD].
Many children and adults experience difficulties with attention, hyperactivity, impulse control or
some permutation of these states and traits. The experience of misplacing one’s belongings is
virtually universal, but at what point should one be concerned about such attention problems?
Further, is there just one type of attention? These questions are fair and reasonable because
answers to such questions will enhance a better understanding of Matt’s challenges, and perhaps
prepare him and his parents negotiate these difficulties. Embedded in this opening story are
questions about what is normal behavior in contrast to manifestations of underlying
developmental or psychological difficulties (Stolzer, 2007). Despite Matt’s apparent efforts to
remain objective by asking what I thought of his reported problems, it was clear that he was
concerned about his self-image in home school co-op and at youth group. Perhaps a related
theme involves associated emotional experiences of those diagnosed with ADHD. Finally,
Matt’s parents raised the legitimate question of their son’s possible motivational problems as
opposed to attributing childhood rebellion to some purported medical condition. Christian
professional workers are familiar with the biblical account of Adam and Eve, specifically their
impulsive behavior of eating the forbidden fruit. The Old and New Testaments are equally
replete with other examples of poor impulse control: from Esau selling his birthright for lentil
soup to Peter cutting off someone’s ear. How are we in the faith community to think about the
condition known as ADHD in light of what others might consider lack of discipline?
<1>What We Know About ADHD
Although skeptics within the scientific community suggest that ADHD is a recent
phenomenon (Jureidini, 2002; Stolzer, 2007), early twentieth century researchers alluded to
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symptoms that resembled current descriptions of ADHD (Barkley, 2007; Langberg, Epstein,
Urbanowicz, Simon, & Graham, 2008). In 1850, George Still (Hathaway & Barkley, 2003)
highlighted two features suggestive of ADHD: 1. Poor volitional inhibition and 2. Defective
moral regulation of behavior. In the 1950’s and 1960’s researchers observed behavioral
hyperactivity in children previously considered to be suffering from impulsivity and
disinhibition(Hathaway & Barkley, 2003). In the 1970’s and 1980’s Douglass and her colleagues
emphasized attention problems in the populations of children displaying hyperactivity and
impulsive behaviors (Hathaway & Barkley, 2003; Hinshaw, 1996); she underscored deficits in
the investment, organization, and maintenance [sustaining] of attention resources. An underlying
theme of all these studies is that ADHD is best attributed to other causes than factors under the
direct control of the child.
It is important for professional Christian workers to realize that the medical community is
not necessarily unified concerning the legitimacy of ADHD. Further, healthy skepticism can only
serve to strengthen and advance our understanding and improve interventions aimed at reducing
the effects of ADHD. Unfortunately, skepticism may inadvertently lead to undesirable results for
those experiencing inattention and hyperactivity. For that reason, a consortium of more than 100
medical professionals signed a consensus statement recognizing the diagnosis of ADHD along
with treatments of choice (Barkley, Cook et al., 2002). In this statement, experts expressed
concern that failure to recognize ADHD would roll back decades of scientific research and
possibly jeopardize patients already at risk for social stigma; further concerns included the
possible reappearance of functional [academic, emotional, interpersonal, etc.] deficits following
reversals in treatment (Barkley, Cook et al., 2002). A review of ADHD is warranted as it would
likely help professionals recognize these symptoms and refer as needed.
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In talking with Paul and Joanne about Matt’s difficulties, we discussed ADHD in general
and we encouraged them to keep an open mind rather than risk a quick or inaccurate diagnosis of
their son. At the end of our consultation, Matt and his parents agreed that it would be beneficial
for him to participate in a formal evaluation. In addition, our discussion encompassed a review of
attention: types, deficits, impulse control and related difficulties. Finally, we acknowledged that
ADHD is a condition that may be managed akin to Diabetes (Barkley, Fischer, Smallish, &
Fletcher, 2002), not cured like the common cold.
<2>Types of ADHD
Children and adults who might meet the diagnostic requirements for ADHD are referred
to various professionals: physicians, psychologists, social workers, and counselors/therapists. To
render a diagnosis of ADHD, these professionals must interpret presenting problems in light of
criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders – 4th
Edition (APA,
1994) or the subsequent Text Revision [DSM-IV-TR] (APA, 2000). Although there are previous
versions of the DSM and older terms for this condition [e.g., ADD], the current DSM-IV
recognizes only three variants of ADHD: inattentive type, hyperactive/impulsive type, and the
combined subtype [APA, 1994]. The (A) inattentive type of ADHD is one in which the
individual fails to pay attention to important details. These individuals are often described as
making careless mistakes. Unfortunately, such mistakes may result in greater academic or
vocational costs. For example, I recently consulted with a fifty year old woman whose executive
position was in jeopardy because her employer was concerned that this woman’s mistakes cost
the company a lot more money than revenues she earned for the organization. (B) The
Hyperactive/Impulsive variant type involves behavioral excesses such as pacing or fidgeting and
the inability to wait before expressing one’s desires/impulses. Hyperactive individuals are
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overactive when peers are not as active, particularly in situations where such overactivity would
interfere with task completion [e.g., getting up from one’s seat when other students are sitting
down and taking notes or talking to a neighbor while the teacher is giving instructions for an
upcoming quiz]. Impulsive individuals often display difficulties delaying gratification; that is,
they may act without thinking, for the immediate benefit of the moment. For example, they may
break rules in order to enjoy the thrill of the moment. In 2000, I had an experience that seared
images of impulsivity in my memory. One Sunday afternoon I went to the home of my sister in
law to polish up a document. As I sat facing the computer, my children and my niece were
playing a game at the table behind me. My niece called my name and I responded, “Please give
me one second to complete my train of thought.” Within the minute she called my name a
second time, and, before I could respond, some projectile struck the back of my head and
disintegrated onto my neck and back. I whirled around as I wiped tomato pieces from my
sweater, and asked, “What was that about?” My 15-year old niece stared at me blankly and
blurted, “I don’t know.” She was close to tears with embarrassment and I could tell that her
impulse or desire to get my immediate attention got the better of her as she acted without
thinking. Herbert Quay described impulsivity as the condition in which individuals fail to inhibit
a behavioral response, once the impulse to act has been activated by the brain (Hathaway &
Barkley, 2003; Kratochvil, Greenhill, March, Burke, & Vaughan, 2004).
While most children are likely to experience attention problems or display
hyperactive/impulsive behaviors, when such difficulties are more pronounced than might be
experienced by most children of the same age [e.g., 95-98 percent of peers], then such deficits
may be considered significant enough to warrant possible diagnosis (Root & Resnick, 2003). In
order to consider a formal diagnosis of ADHD, these symptoms must be present in at least two
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contexts (APA, 1994). Thus, for children, difficulties could be observed at home, at school, at
church, at play, etc. Adults with ADHD may experience problems at work, in relationships, at
school, etc. This criterion anticipates questions about what to do if difficulties are observed only
at home or just at school. Another criterion for diagnosis is that the individual experiencing
ADHD symptoms must display clinically significant impairment in social, academic, or
occupational functioning (APA, 1994). In my last year as a graduate student I evaluated a man
who was referred to our facility by his employer as a final step prior to dismissal from his
position. Although he was considered one of the brightest workers in his line of work, several of
his customers submitted complaints about his failure to meet deadlines and glaring errors on
projects that he completed. During my interview with this man, he reported that his wife
complained about his lack of attention to detail as supported by errors in recording his Automatic
Teller Machine [ATM] activity. The DSM-IV (APA, 1994) stipulates that ADHD may not be
diagnosed if the symptoms occur exclusively during the course of a developmental disorder [e.g.,
Autism], a thought disorder [e.g., Schizophrenia], or another mental disorder [e.g., Antisocial
Personality Disorder].
It is important for professional Christian workers to recognize that the threshold for
diagnosing ADHD is sufficiently high and the criteria are necessarily rigorous. It should be
evident by now that the callous use of the term ADHD to describe childish immaturity or adult
carelessness is unwise; after all, greater than 80% of children display inattentive and hyperactive
features that fail to meet formal diagnostic criteria for ADHD (Durston, 2003). Further, those
experiencing symptoms of ADHD resemble a diverse group of individuals whose challenges do
not conform to a homogenous set of behaviors (Ostrander, Weinfurt, Yarnold, & August, 1998).
At this point, it is necessary to review what we know or the epidemiology of ADHD [prevalence,
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course, etiology and comorbidity] as well as explore some of the purported causes of this
condition (Jarratt, Riccio, & Siekierski, 2005).
<2>Epidemiology
Is ADHD overdiagnosed in the USA? Does it exist in other cultures? Who is likely to
show symptoms of this condition? What do we know about its causes?
About 3-7% of school aged children are diagnosed with ADHD (Anastopoulos et al.,
1996; Jarratt et al., 2005; Kratochvil et al., 2004; Langberg et al., 2008; Ostrander et al., 1998;
Root & Resnick, 2003). 4 % of adults in the USA (Barkley, Fischer et al., 2002) and the same
percentage of adults in England (Engelhardt, Nigg, Carr, & Ferreira, 2008) are diagnosed with
ADHD. Prevalence rates of ADHD ranged from 2-9% in the following countries: Australia,
Brazil, (Schlachter, 2008) Canada, England, Germany, Japan, Kenya, Netherlands, New Zealand,
and Norway (Moffitt & Melchior, 2007; Monastra, 2008a; Roessner, Becker, Rothenberger,
Rohde, & Banaschewski, 2007). One reason for concern is that ADHD is reported to be up to
nine times higher in boys compared to girls (Dietz & Montague, 2006; Hathaway & Barkley,
2003). Are we not being unusually hard on American boys? These rates are generally consistent
across cultural settings (Monastra, 2008b). It is also quite conceivable that some adults with
ADHD may not have been diagnosed in childhood; however, the absence of a diagnosis should
not be taken to suggest the absence of a condition.
With respect to the course of ADHD, symptoms are often evident in childhood, before
preschool. Recent approaches question the validity of age seven as a cut off point for considering
ADHD (Barkley, 2007). One study reported that 2% of children between the ages of 3-5 met
criteria for ADHD (Kratochvil et al., 2004). Although more boys are likely to be diagnosed with
ADHD, the inattentive variant of this condition is generally higher in girls than in boys
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(Hinshaw, 2002; Hinshaw, Carte, Fan, Jassy, & Owens, 2007; Hinshaw, Carte, Sami, Treuting,
& Zupan, 2002; Monastra, 2008a). Similarly, adolescent boys are more likely to be referred for
mental health services than are younger children, girls and minorities with ADHD symptoms
(Bussing, Zima, Gary, & Garvan, 2003). Individuals with ADHD are unlike those with generic
brain injury in that their symptoms do not worsen; however, this is a condition that will not
improve by itself. Therefore, professional Christian workers should encourage those concerned
about possible ADHD to seek professional help as this will clarify whether or not interventions
are needed; after all, when a diagnosis is confirmed, interventions often extend well into
adulthood (Anastopoulos et al., 1996; Barkley, Fischer et al., 2002; Mirsky et al., 1999). Given
the global effects of ADHD, it is important to recommend early assessment.
ADHD is considered as distinct from other conditions in which attention may also be
impaired as a symptom of another health concern. Thus, individuals suffering from depression
often report disruptions in attention as well as poor concentration. Similarly, ADHD may co-
occur with other emotional disorders such that an individual displays symptoms that reach the
diagnostic threshold for at least two separate conditions (Abikoff & Klein, 1992; Dietz &
Montague, 2006; Hazell et al., 2006). We will now shift our attention to conditions that are
comorbid to ADHD.
The number of comorbid conditions to ADHD varies, with studies suggesting the
following ranges:
� 44% exhibit one other disorder [e.g., ADHD + Anxiety ]
� 33% exhibit two other disorders [e.g., ADHD + Anxiety + Eating Disorder]
� 10% exhibit three disorders [e.g., ADHD + Anxiety + Eating Disorder + Tourette]
� 33% met criteria for Oppositional Defiant Disorder(Loo & Barkley, 2005)
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� 25% met criteria for Conduct Disorder (Monastra, 2008a).
<2>ADHD and Spiritual Development
Given the host of related emotional difficulties associated with ADHD, it is not surprising
that those suffering from related symptoms report difficulties in several functional areas. Specific
to people of faith, Hathaway and Barkley (Hathaway & Barkley, 2003) studied the relationship
between ADHD and Religiousness. They concluded that individuals with ADHD experienced
religious alienation as supported by difficulties in three areas: 1) religious socialization [i.e.,
maintaining the rituals associated with congregational worship], 2) religious worship [i.e.,
communing with God in tranquility], and 3) stable spiritual growth [i.e., maintaining a consistent
faith walk].
Those serving in pastoral ministry, including lay church leaders, need to consider these
findings when structuring curricular for religious instruction. As such, it may be beneficial to
integrate upbeat music and visual imagery in order to assist some parishioners better appreciate
elements of the Eucharist. Youth ministers might integrate mime and drama to underscore key
points of a sermon on forgiveness. Left untreated, symptoms of ADHD may result in greater
difficulties for the help seekers and their families.
<2>Etiology
Although the authors of the DSM-IV described necessary and sufficient criteria for the
diagnosis of ADHD and other mental disorders, they do not provide causal hypotheses about
these conditions; similarly, treatment and intervention options are generally left to the discretion
of the clinician. Thus the question of what causes ADHD is critical to our understanding of this
condition. Those who assert that it does not exist (Stolzer, 2007) would argue that millions of
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children are being mislabeled with a condition that may simply reflect typical childish
overactivity and poor concentration.
Before reviewing studies on the purported causes of ADHD, it is important to
acknowledge popular ideas that we encounter regularly in clinical practice. These culprits
include: environmental Toxins; food additives, with dietary modifications proposed as solution;
refined sugar, with an emphasis shifts to natural foods; poor nutrition, with balanced nutrition
considered the cure; natural light deficiency; food allergies; heavy metal toxicity; subluxation,
corrected by chiropractic adjustment; and poor teaching/parenting methods combined with lack
of discipline (Silver, 1987; Sinha & Efron, 2005).
Although it is possible that these conditions might exacerbate symptoms of ADHD, it is
highly unlikely that they are the primary causes of this condition. A key problem with such
hypotheses is that they have not been subjected to the rigors of scientific research, and
proponents of such views tend to suggest alternative treatments that have not been supported by
randomized studies (Barkley, Cook et al., 2002; Durston, 2003). Encouraging those with ADHD
symptoms to consider such questionable causes is tantamount to poor counsel – word of mouth
testimonial notwithstanding. Such experiences are more challenging when the help seeking
family is referred to a practitioner of alternative therapy who happens to attend the same house of
worship.
One study investigated the causes of ADHD as perceived by medical and allied health
professionals, comparing these responses to findings obtained from parents and educators
(Dryer, Kiernan, & Tyson, 2006). Professionals concurred with parents’ opinions that ADHD is
the result of three interrelated causes: neurological compromise that occurs during development
of the nervous system [pregnancy or after birth], neurochemical imbalance or dysfunction and
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hereditary disposition (Martin, Levy, Pieka, & Hay, 2006; Nigg, Blaskey, Stawicki, & Sachek,
2004). Professionals and parents agreed with research that found no relationship between ADHD
and environmental variables; these include deficits in the home environment along with
psychosocial factor theories that attribute ADHD to parent behaviors [poor management, poor
monitoring, and parent-child conflict], and unstable family environments (Dryer et al., 2006). As
demonstrated by several studies, environmental factors tend to exacerbate and magnify ADHD
symptoms (Barkley, 1997; Monastra, 2008b; Root & Resnick, 2003).
Neurobiological deficits render individuals with ADHD vulnerable in environments that
require attention vigilance or consistent behavioral self-control. Thus, symptoms likely reflect
the interaction between underlying brain-based deficits and external / environmental demands (T.
W. Frazier et al., 2007). This interactive paradigm, sometimes termed the diathesis model (West,
Schenkel, & Pavuluri, 2008), has been associated with various conditions ranging from medical
[e.g., Arthritis] to mental health [e.g., Schizophrenia]. As applied to ADHD, the diathesis model
argues that symptom presentation is likely to be more pronounced in more chaotic environments.
This does not mean that the environment [home, school, work, etc.] causes the disorder; rather,
the environment, along with the presence of other conditions [e.g., Oppositional Defiant
Disorder], serves to magnify the outward manifestation of underlying ADHD (Pelham, Wheeler,
& Chronis, 1998; Rapport et al., 2001). The presumption of genetic vulnerability in ADHD
implies only that among plausible causes of ADHD, evidence for neurobiological factors is quite
compelling (Barkley, 1997; T. W. Frazier et al., 2007).
Durston (2003) reported deficiencies in the supply and function of the brain chemical
dopamine; she found high rates of heritability among identical twins [80%] as opposed to
fraternal twins and other family members; she observed differences in brain volume and blood
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flow in ADHD compared to nonADHD peers. Other researchers demonstrated differences in
brain electrical activity that mirrored types of ADHD (Loo & Barkley, 2005). Consistent brain
volume differences were found in association with the prefrontal region; specifically, patients
with ADHD demonstrated less brain volume in this area (Barkley, 1997; Halperin & Schulz,
2006; Hill et al., 2003). These findings further suggest that treatments targeting brain chemistry
should result in improved functioning.
While brain dysfunction may be an underlying cause of ADHD, those working with
ADHD patients often focus on cognitive and behavioral symptoms of this condition. Cognitive
theories of ADHD propose that some component of the attention or working memory system is
compromised (Barkley, 1997; Bayliss & Roodenrys, 2000; Daugherty, Quay, & Ramos, 1993;
Karatekin, 2004; Mirsky et al., 1999; Posner, 1982; Semrud-Clikeman, Pliszka, & Liotti, 2008).
According to these approaches, brain functioning may be a legitimate concern in ADHD, but
family and friends experience symptoms associated with thinking and acting. Most families often
express relief learning that a loved one’s difficulties are not the byproduct of poor parenting or
intentional and defiant behavior. Such knowledge can facilitate empathy, particularly in worship
settings where the normative behaviors require sustained attention and behavioral control
(Hathaway & Barkley, 2003).
<2>Assessment
When referring congregants for evaluation of possible ADHD, church leaders need to
demonstrate a basic appreciation of the steps involved in such assessments. A few weeks ago, we
received email communication from the concerned aunt of a preschooler wondering what we
thought about her nephew being diagnosed with ADHD at such a young age. After providing
necessary disclaimers about our inability to diagnose a child we had not met, much less on the
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internet, to someone who was not even the parent, we inquired about how the diagnosis came
about. The writer responded that one of her nephew’s teachers suggested the diagnosis. After we
reviewed the structure of a comprehensive evaluation, the writer expressed relief and stated that
she felt equipped to advise her sister, ultimately alleviating her own frustrations. At the heart of
this woman’s alarm was the question, how should ADHD be evaluated?
There are five basic steps that we recommend in assessing ADHD: 1. Interviews, 2.
observations, 3. record reviews, 4. behavior rating scales, and 5. formal cognitive testing. These
will be reviewed briefly. Interviews afford the examiner an opportunity to gather meaningful
information that provides a context and a history of presenting concerns. During a recent
interview with parents of a nine year old boy, they informed us that they were frustrated with
their son’s perpetual misplacement of assignments; teachers echoed parents’ concerns by noting
that Mike’s poor grades reflected low scores from inadequate late work or work not submitted at
all. Such discussions provide a richer context for understanding the effects of some symptoms.
Observations reflect a second source of information. When working with children, evaluators
need to observe students in structured situations [e.g., in the classroom] and in unstructured
setting [e.g., during recess or over lunch]. As with interviews, there are several instruments
available for observing children and comparing their behaviors to those of peers. Observations
allow clinicians to compare behaviors of identified children in relation to peers. Further, such
documentation provides a rejoinder to the notion that boys are just being boys (Stolzer, 2007),
particularly when disruptive behaviors exceed 95% of peers (Root & Resnick, 2003). The notion
of observing adults may be difficult although others have been successful at doing so. I recall
one of my colleagues telling of the time she went to her client’s place of employment to observe
him at work, as part of a determination about this gentleman’s fitness for the job. As it turned
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out, the man in question worked in a restaurant and he made several errors in processing my
colleague’s order. This was remarkable as he did not know that his patron was actually an
evaluator. The third component of a comprehensive evaluation involves review of records; these
range from medical, academic, military and employment data. As noted earlier, to diagnose
ADHD, impairment must be present in at least two settings (APA, 2000). In this regard, I
recently met with a 22-year old college student whose examination grades showed considerable
fluctuations over three testing periods. He wondered out loud about learning disability, voicing
further doubts about ADHD. When he realized that learning disabilities typically reflect
consistently poor performance in a given area, he produced a letter from his employer
threatening dismissal from his part time job at a local printing company. As with his schoolwork,
concerns were associated with inconsistency of performance, a hallmark of ADHD (Barkley,
2007). A fourth source of information comes from behavior ratings scales. A benefit of such
instruments is that they yield information about several conditions [depression, anxiety,
withdrawal, hyperactivity, etc.]. Given that ADHD is primarily a behavior condition (Daugherty
et al., 1993), rating scales help clarify diagnostic questions. Two studies demonstrated the
sensitivity of rating scales to confirm the diagnosis of ADHD (Jarratt et al., 2005; Ostrander et
al., 1998). Cognitive neurodevelopmental assessment comprises the final component of
comprehensive evaluations. This aspect may include review of intellectual reasoning, evaluation
of attention systems, memory testing, sensory-motor assessment, executive functions, etc.
(Ottowitz et al., 2002). Although ADHD is generally characterized by behavioral deficits,
cognitive difficulties often accompany these symptoms. To that end, we will now turn our
attention to treatments and interventions for ADHD.
<1>What We Can Do: Best Approaches for helping
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In this final section we will discuss treatment options for ADHD, with a focus of research
supported effective interventions. Prior to addressing three primary interventions for managing
ADHD [medications, school interventions and family / psychosocial approaches] it important to
make brief mention of four alternative treatments to this condition. One study examined research
related to the purported effects of neurofeedback on the symptoms of ADHD and concluded that
there was not enough evidence to promote this treatment approach (Loo & Barkley, 2005).
Another researcher analyzed the purported benefits of St. John’s Wort on ADHD and found no
meaningful improvement in functioning (Weber et al., 2008). A third study assessed the benefits
of diet modification on ADHD and found no meaningful changes in behavior (Schnoll,
Burshteyn, & Cea-Aravena, 2003). A somewhat more ambitious attempt involved multiple
elements for treating ADHD; these included chelation, environmental control, and nutritional
changes. Again, this study failed to demonstrate meaningful results (Benda, 2007). Following a
review of numerous homeopathic treatments, Jacobs concluded that these approaches were
wholly unsupportable (Jacobs, Williams, Girard, Njike, & Katz, 2005).
Almost invariably when we present on ADHD, to Christian and mixed professional
audiences alike, we have noticed more questions about homeopathic cures from the religious
community than other groups. In most cases, these concerns are framed within the context of not
wanting to pump drugs into one’s body or that of an innocent child. The unstated assumption in
such questions is that homeopathic treatments are not chemical. It may be more accurate to note
that these chemical approaches have not satisfied the requirements of the Food and Drug
Administration [FDA]. Although the concept of natural cure may sound appealing, the truth is
that these approaches are chemical in nature; what is worse is that we do not fully understand
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their mechanism of action. Indeed those in pastoral care situations need to highlight these
concerns for church members who may tout alternative treatments for ADHD.
Changes in brain chemistry, particularly the dopamine system, have been associated with
ADHD (Durston, 2003; Root & Resnick, 2003). Stimulant medications [e.g., Ritalin] are
generally prescribed to correct such chemical problems. The American Association of Child and
Adolescent Psychiatry issued a statement indicating that stimulant medications are safe and
effective, even when administered to preschoolers (Semrud-Clikeman et al., 2008). As can be
expected, the same body clarified that treating physicians should closely monitor dosages for
such medications. Other benefits of stimulants include reduced impulsivity and behavioral
dyscontrol (Ottowitz et al., 2002). In response to concerns about the negative effects of
medications, a review of numerous studies found minimal risk associated with use of stimulants.
Although medications are quite effective in managing some of the behavioral excesses associated
with ADHD, these agents work best in conjunction with cognitive and behavioral interventions
(Voeller, 2004). We now review how such approaches may be utilized within the school setting.
School represents an important domain in which ADHD symptoms lead to negative
results. As noted, students with ADHD are likely to exhibit functional deficits on academic tasks
as well social interactions at school (Barkley, 2007; Root & Resnick, 2003). Children with
ADHD are eligible for remedial services within the school setting as stipulated by the Individuals
with Disabilities Education Act of 1973, revised in 1997 and 2004 (Durston, 2003; Monastra,
2008b; Pelham et al., 1998). Sometimes school interventions entail using the services of an aide
to assist the child with academic tasks that require sustained attention (Pelham et al., 1998).
Other times the child may be afforded time accommodations, modified instructions, reduced
homework or other modifications in instruction.
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One study demonstrated academic improvement for ADHD students who learned three
functional skills: organization, homework management, and assignment completion (Langberg et
al., 2008). This approach seems like the logical extension of theories that associate ADHD with
dysfunction of the prefrontal area and related impairment of executive functions (Barkley, 1997;
Halperin & Schulz, 2006). In the organization stage, students were trained to use color coded
binders to store assignments and instructions for later completion. Management included
providing a structure and devising a way to complete specific assignments. Finally, completion
entailed addressing all details related to an assigned activity. The success of this intervention was
attributed to parental involvement as well as consistency of reinforcement. Again, we cannot
over emphasize the role of consistent reinforcement in teaching and maintaining target
behaviors.
Within the family context, one model of behavior management targeted three types of
interactions between parents and their ADHD children. Walton (2007) observed categorized
these relationships as follows: 1) child is viewed as the center of the universe, 2) parent threatens
discipline but takes no action, and 3) parent is overly punitive and extremely controlling. In the
first scenario, parents were trained to set limits and maintain firm boundaries for their disruptive
children. The parents who issued empty threats were trained to say less but consistently enforce
established rules. Third, controlling parents were encouraged to back off their rigid rules and
admit to their children that they were excessively punitive. This show of healthy parental
vulnerability was often accompanied by improved child self-esteem because children viewed
their parents as individuals who were willing to learn from their mistakes (Walton, 2007).
Frazier reported that children and adults receiving behavioral interventions showed overall
improvement in functioning relative to untreated peers (M. R. Frazier & Merrell, 1997). It should
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be clear from these findings that behavior management techniques can only work when
administered consistently. Inconsistency is likely to yield chaotic results in managing ADHD.
Cognitive behavioral interventions were used successful to reduce ADHD symptoms in
the home setting. In one study, parent training was most helpful for younger, school aged
children whereas family based counseling was most beneficial for adolescents (Anastopoulos et
al., 1996; Pelham et al., 1998). Cognitive behavioral interventions entail connecting a client’s
thoughts to her emotions, and ultimately to her behaviors. This approach to managing ADHD
symptoms was not effective in three conditions: 1) when symptoms were too severe, 2) when the
client’s intelligence was low, and 3) when the primary parent was suffering from depression
(Hinshaw, 1996). Cognitive behavioral interventions yielded symptom reduction in ADHD,
particularly with parents that showed effective parenting (Walton, 2007). When combined with
medications, psychosocial treatments were quite effective in reducing ADHD symptoms in
adults (Ramsay & Rostain, 2007).
<1> Conclusion: ADHD is a difficult condition affecting children and adults alike. In this
chapter, we provided several tools to equip the professional Christian worker engaged in ministry
to individuals and families dealing with ADHD. It is hoped that educated professionals will
facilitate an atmosphere where worshippers suffering from this and other mental disorders will
feel understood, accepted and supported. It is our conviction that an attitude of affirmation
toward those with ADHD truly reflects Christ’s mandate to his followers to love one another.
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Appendix1: Sample of report recommendations for ADHD patients.
1. PEDIATRIC PSYCHIATRY: It is important for Child’s parents to consult Pediatrician’s
office to consider medications. Studies have shown the benefit of stimulant medications as well
as (recently) non-stimulant agents. Such a decision might require several follow up meetings
with the pediatrician in order to review matters of tolerance, dosage, and efficacy for Child’s
purposes. This approach may enhance his focus and increase achievement on some tasks.
2. SCHOOL: (a) Child will need to participate in formal psychoeducational assessment;
this might include measures such as the WIAT-II. From his performance on the current
evaluation, however, the following recommendations are being recommended: (b) Sitting: Given
his susceptibility to environmental distractions, it is advisable that Child learns in a relative
disruption-free environment; as such, it may be necessary that he enroll in small classes and sit
close enough to the instructor in order to derive maximum benefit from the learning experience.
(c) Note-taking: his organizational, planning, and listening comprehension difficulties are noted.
He will need to augment regular note-taking through the use of audio-recording devices. It is
also important that he obtains thorough outlines of all lectures so as not to tax his concentration
by having to write notes while attending to new and unfamiliar learning material. He will need
assistance with organizing his work for study and later testing. This process will require
guidance by an individual familiar with ADHD and learning disabilities in adolescents, an
educator capable of providing guidance in a non-anxious manner. (d) New Learning: Child
needs multiple repetitions to enhance learning of new material. He benefits from learning when
material is well-organized (concrete and easy to follow) presented in small, self-contained,
manageable units/”chunks.” As noted earlier, he needs a few breaks when undertaking tasks that
require sustained mental effort. In this case, he will come back to the task with greater focus and
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feeling “recharged.” It is helpful to present new material in various modalities to enhance
efficient encoding of the same. (e) Evaluations: On account of impulsivity when engaging in
rapid mental processing, this student will require extra consideration on timed tasks. Thus an
extra 30-40% time accommodation is recommended so as to enhance efficient academic problem
solving. In this regard, the volume of reading assignments outside the classroom should reflect
an appreciation of his difficulties with reading speed and comprehension. In the same process,
however, it is recommended that he be rewarded for deliberate/careful processing of new
material. That is, instructors and parents need to be intentional about reinforcing thoughtful and
well-paced work habits rather than inadvertently commend him for being fast while, in fact, he
might just be impulsive. (f) Tutorship: He would benefit from individualized support for reading
comprehension (highlighting, anticipation, freedom from context-dependence, etc.) as well as
numerical operations. (g) Planning: As he considers high school education, Child will need
further assistance with essays and all long-term ancillary projects. All these services would best
be delivered under the coordination of faculty familiar with his needs and relative strengths. (g)
Accountability: Parents and educators are encouraged to develop a joint-accountability
program to ensure that these recommendations are instituted and revised as needed.
3. HOME: (a) Owing to the presence of the difficulties noted in the diagnosis section
(above), Child would qualify for academic (high school) support services under the guidelines of
the Individuals with Disabilities Educational Act (most recently revised 2000). (b) It is important
that Child have a predictable schedule. He needs to be afforded considerable breaks during long
homework assignments. That is, he should be allowed to take breaks, say, every 30 minutes
during tasks that require sustained mental effort. This will enable him to re-focus his energy and
maintain his attention on tasks at hand. (c) It is also beneficial for parents to coordinate projects
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(homework, take-home assignments, etc.) and other school tasks with his teachers. That is, some
form of communication between home and school in the form of e-mail, notes or telephone calls
will facilitate better organization and completion of homework assignments. This observation
comes from literature (Barkley, 2007) suggesting that most ADHD students will function at the
maturity level of children who are generally 30% younger. Comments provided during the
clinical interview also confirmed this finding.
4. THERAPY: It is highly recommended that Child continues his course of cognitive
behavioral therapy. Counseling will provide opportunities for him to discuss feelings as well as
behavioral consequences to some of his ongoing struggles related social and academic
difficulties and adjustments thereof.
5. FOLLOW UP EVALUATION: It is recommended that Child participate in a vocational
assessment. This process will provide opportunities to better describe his interests and skills as
well as assist with selection of the most appropriate academic program.