Attention-Deficit Hyperactivity Disorder

I
INTRODUCTION
Attention-Deficit Hyperactivity Disorder or Hyperactivity (ADHD), disorder beginning in childhood, characterized by a persistent inability to sit still, focus attention on specific tasks, and control impulses. Children with ADHD show these behaviors more frequently and severely than other children of the same age. A person with ADHD may have difficulty with school, work, friendships, or family life. ADHD has also been referred to as attention-deficit disorder, hyperkinesis, minimal brain dysfunction, and minimal brain damage.
Attention-deficit hyperactivity disorder is one of the most common mental disorders of childhood, affecting 3 to 5 percent of school-age children. The disorder occurs at least four times more often in boys than in girls. Although the symptoms sometimes disappear with age, ADHD can persist into adolescence and adulthood. Some estimates show that up to 2 percent of adults have ADHD.
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DIAGNOSIS
Diagnosing ADHD is difficult because most children are inattentive, hyperactive, and impulsive at least some of the time. In diagnosing ADHD, experts use guidelines listed in the Diagnostic and Statistical Manual of Mental Disorders. These guidelines require that a child show behaviors typical of ADHD before the age of seven. The behaviors must last for at least six months, and must occur more frequently than in other children of the same age. The behaviors also must occur in at least two settings, such as classroom and home, rather than just at a single setting.
Controversy exists over the diagnosis of ADHD. Physicians in the United States diagnose the disorder more often than doctors elsewhere in the world. Critics regard this discrepancy as evidence that physicians and psychologists too often apply psychiatric labels to children who are naturally more active or simply nuisances to teachers and parents.
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CHARACTERISTICS
Children and adults with ADHD consistently show various degrees of inattention, hyperactivity, and impulsiveness. Inattention means that people with ADHD have difficulty keeping their minds on one thing. They may get bored with homework or other tasks after a few minutes, make careless mistakes, have trouble listening, and seem to daydream. However, children with ADHD sometimes can concentrate on and complete new or unusually interesting tasks. Hyperactivity involves almost constant motion, as if driven by a motor. Children may squirm and fidget at their desks in school, get up often to roam around the room, constantly touch things, disturb other people, tap pencils, and talk constantly. ADHD also makes children unusually impulsive, so that they act before thinking. They may run into the street without looking, blurt out inappropriate comments in class, interrupt conversations, and be unusually clumsy or accident-prone.
Children with ADHD often have severe learning problems because of their difficulties in paying attention, following instructions, and completing tasks. In addition, their disruptive, demanding behavior makes them unpopular with peers. Children with ADHD often receive constant criticism and correction from teachers and parents, who believe the behavior is intentional. The combination of negative feedback, poor academic achievement, and social problems may contribute to low self-esteem and other emotional problems.
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CAUSES
Scientists do not know what causes ADHD. However, they have discredited many theories that once were widely accepted. One theory contended that ADHD resulted from minor head injuries or undetectable brain damage due to infections or complications during birth. Experts called ADHD “minimal brain damage” and “minimal brain dysfunction” when this theory was popular in the early 1970s. Another theory linked ADHD with consumption of refined sugar and food additives. Scientists questioned this theory when studies showed that few children with ADHD benefited from diets restricting sugar and food colorings. Most experts also reject the idea that poor parenting or a dysfunctional home environment causes ADHD.
Most scientists regard ADHD as a biological disorder caused by abnormalities in the brain. Studies have shown that areas of the brain that control attention span and limit impulsive behavior are less active in people with ADHD. In addition, ADHD seems to run in families, suggesting that genetic factors may play an important role. One study showed that about one-third of fathers who had ADHD in childhood have children with ADHD.
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TREATMENT
Although there is no cure for ADHD, a variety of treatments may help children with this disorder. These include medication, counseling, social skills training, and other methods.
A
Medication
Drugs are the most common treatment for ADHD and can help reduce symptoms of the disorder. Physicians usually prescribe one of three drugs: methylphenidate (Ritalin), dextroamphetamine (Dexedrine or DextroStat), and pemoline (Cylert). These drugs are normally stimulants, yet they ease hyperactivity and other symptoms in 90 percent of children with ADHD. The drugs work by altering levels of neurotransmitters, brain chemicals that transmit nerve signals. A newer stimulant used to treat ADHD, Adderall, combines dextroamphetamine and amphetamine.
Medical experts regard stimulants as safe. The most common side effects include stomachaches, loss of appetite, nervousness, and insomnia. Drug therapy may slow a child’s rate of growth temporarily, but growth usually returns to normal during adolescence. Low doses of stimulants do not cause a “high” sensation, sedate the child, or cause addiction. Experts often recommend that children take medication only during school, with medication breaks on weekends and holidays to reduce unwanted side effects. Doctors may prescribe other types of drugs if stimulants do not prove effective.
Critics argue that physicians medicate too many children who do not have ADHD. They point out that allergies, depression, anxiety, conflicts with teachers or parents, and other problems can make normal children seem hyperactive, impulsive, and distracted.
B
Other Therapies
Most children with ADHD need more than medication. Drugs only relieve symptoms of ADHD, which usually return when medication is discontinued. Although drugs help a child to concentrate and complete schoolwork, they cannot increase a child’s knowledge, teach academic skills, or directly alter underlying learning disorders or other problems. Experts cite the need for more information on whether medication improves a child’s chances for a successful career.
Children may benefit from several different kinds of therapy. Psychological counseling, for instance, can help them recognize and deal with negative feelings that result from their symptoms. Social skills training can help them recognize how their behavior affects other people and help them develop more appropriate behavior. Children with ADHD also may benefit from special academic tutors who show them how to break school assignments down into small parts that can be completed one at a time.
Because children with ADHD often cause family turmoil, parents and other family members may benefit from therapy or support groups in which other parents share their experiences. Parental skills training can teach parents to manage a child’s behavior with praise and other rewards, and with penalties such as “time-outs” in which a child must sit alone to calm down.
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ADHD IN ADULTS
Many children with ADHD continue to have problems as adolescents and adults. Adults with ADHD may be unusually impatient and restless and may become bored before finishing a task. They may constantly arrive late for appointments, lose things, change jobs often, fail to organize their time or set priorities, and have difficulty maintaining friendships and other relationships. Studies suggest they are more likely than others to develop other mental illnesses such as anxiety and depression, as well as substance-abuse problems such as alcoholism and drug dependence.

Impulse control disorders

Definition
Impulse control disorders are characterized by an inability to resist the impulse to perform an action that is harmful to one's self or others. This is a relatively new class of personality disorders, and the most common of these are intermittent explosive disorder, kleptomania, pyromania, compulsive gambling disorder, and trichotillomania.
Description
All of these impulse control disorders involve the loss or lack of control in certain specific situations. The hallmark of these disorders is the individual's inability to stop impulses that may cause harm to themselves or others. Affected individuals often feel anxiety or tension in considering these behaviors. This anxiety or tension is relieved or diminished once the action is performed.
Intermittent explosive disorder is more common among men, and involves aggressive outbursts that lead to assaults on others or destruction of property. These outburst are unprovoked or seem to be out of proportion to the event that precedes them.
Kleptomania is more common among women, and involves the theft of objects that are seemingly worthless. The act of stealing relieves tension and is seen by the individual to be rewarding. The actual stealing is not preplanned, and the concept of punishment for the crime does not occur to these individuals, although they are aware that what they are doing is wrong.
Pyromania is more common among men, and involves setting fires in order to feel pleasure and relieve tension.
Pathological gambling occurs in roughly 1-3% of the population, and involves excessive gambling despite heavy monetary losses. These losses actually act as a motivating factor in continuing gambling in order to recoup some of what was lost.
Trichotillomania involves pulling hair from one's own scalp, face, or body, and is more common in women. It often begins in childhood, and is often associated with major depression or attention-deficit/hyperactivity disorder.
Causes and symptoms
The exact causes of impulse control disorders are not fully understood as of 2004. Individuals who have had serious head injuries, however, can be at a higher risk for developing impulse control disorders, as are those with epilepsy.
Some cases of impulse control disorders appear to be side effects of general medical conditions. As of 2004, several groups of researchers have noted that some older adults with Parkinson's disease become compulsive gamblers as the disease progresses. It is thought that this gambling behavior is a side effect of dopaminergic drugs, as it does not respond to standard treatments for compulsive gambling but only to changes in the patient's medication.
Another medical condition that is associated with impulse control disorders is carcinoid syndrome. In one group of 20 consecutive patients with the syndrome, 75% met DSM-IV diagnostic criteria for one or another impulse control disorder. The researchers attribute the connection to the high levels of serotonin (a neurotransmitter) produced by carcinoid tumors.
Diagnosis
A diagnosis of any of these impulse control disorders can be made only after other medical and psychiatric disorders that may cause the same symptoms have been ruled out.
Some doctors may administer questionnaires or similar psychiatric screeners as part of the differential diagnosis. Two instruments that have been devised in the early 2000s to specifically target impulsive behavior are the Gambling Urge Scale (GUS) and the Lifetime History of Impulsive Behaviors (LHIB) Interview.
Intermittent explosive disorder involves severe acts of assault or destruction of property. The aggression seen during these acts is vastly out of proportion to events that may seem to have precipitated the acts.
Kleptomania involves stealing objects that are unnecessary and of little monetary value. The act of stealing is not an expression of anger or vengeance. Again, there is an increased tension before the act is committed, and this is resolved or relieved once the object is stolen.
Pyromania is classified by the deliberate setting of fires more than once. The individual will exhibit a fascination and attraction to fire and any objects associated with it. Before the fire is set, there is tension, with a resolving relief once the fire is set. Acts of true pyromania are not done for monetary gain, to express anger, to conceal criminal behavior, or in response to hallucination.
Pathological gambling is a disorder to gamble despite continuing losses and monetary insufficiency. This disorder typically begins in youth, and affected individuals are often competitive, easily bored, restless, and generous.
For a diagnosis of pathological gambling, five or more of the following symptoms must be present:
a preoccupation with gambling
a need to gamble with more money to achieve the thrill of winning
repeated attempts to control or stop gambling
irritability or restlessness due to repeated attempts of control
gambling as an escape from stress
lying to cover up gambling
conducting illegal activities, such as embezzling or fraud, to finance gambling
losing a job or personal relationship due to gambling
borrowing money to fund gambling
Trichotillomania is the continuous pulling out of one's own hair. Again, there is an increased sense of tension before pulling the hair, which is relieved once it is pulled out. Recurrent pulling out of one's hair resulting in noticeable hair loss. Affected individuals can undergo significant distress and impaired social, occupational, and functional behavior.
Treatment
A combination of psychological counseling and medication are the preferred treatments for the impulse control disorders. For kleptomania, pyromania, and trichotillomania, behavior modification is usually the treatment of choice. Children with trichotillomania are often helped by antidepressant medication. For pathological gambling, treatment usually involves an adaptation of the model set forth by Alcoholics Anonymous. Individuals are counseled with the goal of eventual response to appropriate social limits. In the case of intermittent explosive disorder, anger management and medication may be used in extreme cases of aggression.
Prognosis
These disorders can usually be controlled with medication, although it may need to be continued long-term to help prevent further aggressive outbursts. Long-term counseling is usually necessary as well. Support groups and meetings may also help these individuals.
The prognosis for intermittent explosive disorder, kleptomania, and pyromania is fair. Little is known about the prognosis for trichotillomania, and studies have shown that the condition can disappear for long periods (months to years) without any psychological counseling. For pathological gambling, the prognosis varies greatly from person to person. While total cure for this condition is unlikely, much like alcoholism, long periods of abstinence or continuous abstinence are possible.
Prevention
There are no known preventive treatments or measures for impulse control disorders.
Key Terms
Carcinoid syndrome
The pattern of symptoms (often including asthma and diarrhea) associated with carcinoid tumors of the digestive tract or lungs.
Compulsive gambling disorder
An impulse control disorder in which an individual cannot resist gambling despite repeated losses.
Intermittent explosive disorder
A personality disorder in which an individual is prone to intermittent explosive episodes of aggression during which he or she causes bodily harm or destroys property.
Kleptomania
An impulse control disorder in which one steals objects that are of little or no value.
Pyromania
An impulse control disorder in which one sets fires.
Trichotillomania
An impulse or compulsion to pull out one's own hair.

Behavior Modification

I
INTRODUCTION
Behavior Modification, psychological methods for treating maladjustment and for changing observable behavior patterns. In the behavior modification process, the procedures used are monitored so that changes can be made when necessary. Physical and mental coercion, brain surgery, brainwashing, drug use, and psychotherapy are often considered methods of behavior modification because they try to, and frequently do, change behavior. None of them, however, is behavior modification as the term is used in present-day psychology.
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HISTORICAL DEVELOPMENT
The foundation for behavior modification was laid at the beginning of the 20th century in the experimental laboratory of the Russian physiologist Ivan P. Pavlov. A dog was being trained to salivate when a circle was projected on a screen and not to salivate when an ellipse was shown. The shape of the ellipse was gradually modified to resemble the circle. When only a slight difference between the circle and the ellipse could be perceived, the dog became agitated and no longer displayed the conditioned response it had acquired. This type of disturbance was called an “experimentally induced neurosis.”
A second landmark event for behavior modification took place when Pavlov's conditioning principles were extended to humans. In 1920 the American psychologists John B. Watson and Rosalie Rayner reported an experimental study in which an 11-month-old baby who had previously played with a white laboratory rat was conditioned to be fearful of the rat by associating a loud noise with the animal, a process known as pairing. The psychologist Mary Cover Jones later performed experiments designed to reduce already established fears in children. She found two methods particularly effective: (1) associating a feared object with a different stimulus capable of arousing a positive reaction, and (2) placing the child who feared a certain object with other children who did not.
Behavior modification techniques were used in the 1940s and '50s by psychologists in South Africa, England, and the United States. Joseph P. Wolpe, a South African physician, questioned the effectiveness of psychotherapy for treating disturbed young adults, especially those with disabling fear reactions. To deal with anxiety disturbances, Wolpe devised treatment procedures based on Pavlov's classical-conditioning model. At about the same time, a group of psychologists in London, headed by Hans J. Eysenck and M. B. Shapiro, launched a new program of research on the development of treatment techniques, basing their investigations on the learning theory of the American psychologists Clark L. Hull and Kenneth W. Spence.
In the U.S. two kinds of investigations helped to establish the field of behavior modification. One was a further extension of the classical-conditioning principles to clinical problems such as bed-wetting and alcoholism. The other was the application of the operant-conditioning principles developed by B. F. Skinner to the education and training of handicapped children in schools and institutions and to the treatment of adults in psychiatric hospitals.
By the early 1960s, behavior modification had become a clearly identifiable applied psychology movement with two components: behavior therapy and applied behavior analysis.
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BEHAVIOR MODIFICATION TECHNIQUES
Some of the treatment techniques used in behavior therapy became prominent enough to acquire specific names. Among them are systematic desensitization, aversion therapy, and biofeedback.
Systematic desensitization, the most widely used technique, attempts to treat disturbances having identifiable sources, such as a paralyzing fear of closed spaces. This method usually involves training the individual to relax in the presence of fear-producing stimuli. The therapist assumes that the anxiety reaction will be replaced gradually with the new relaxation response; this is called reciprocal inhibition.
Aversion therapy is used to break disabling bad habits. An aversive stimulus, such as an electric shock, is given together with the “bad habit,” such as an alcoholic drink. Repeated pairings result in changing the values of such stimuli from positive attraction to repulsion.
Biofeedback is most often used in treating disturbed behavior that has a physical basis. It provides an individual with information about an ongoing physiological process such as blood pressure or heartbeat rate. By the use of a mechanical device, indications of moment-to-moment variations in bodily functioning can be observed and monitored by the individual. The therapist may provide some reward for desirable changes, such as a decrease in blood pressure.
Applied behavior analysis is used to develop educational and treatment techniques that can be tailored to each individual's requirements while still following a constant format, whether the patients are retarded or disturbed children in a school or residential setting, or adults in a psychiatric hospital or rehabilitation center. Five essential steps characterize this approach: (1) deciding what the individual can do to ameliorate the problem; (2) devising a program to weaken undesirable behavior and strengthen desirable substitute behavior; (3) carrying out the treatment program according to behavioral principles; (4) keeping careful and objective records; and (5) altering the program if progress can thereby be improved.

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