Abnormal Psychology Discussion ***Answer must be minimum 200 words***Please respond the following question and incorporate citations and information from your reading (attached)1. What do you see as some of the pros and cons of placing a child with ADHD on medication? Why would some refer to this as a behavioral diagnosis? ADHD and Behavior Disorders in Children by Richard Milich and Walter Roberts is licensed under a Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 International license. © 2015, Diener Education Fund.
ADHD and Behavior Disorders in Children
By Richard Milich and Walter Roberts
University of Kentucky
Attention-Deficit/Hyperactivity Disorder (ADHD) is a psychiatric disorder that is most often diagnosed in
school-aged children. Many children with ADHD find it difficult to focus on tasks and follow instructions,
and these characteristics can lead to problems in school and at home. How children with ADHD are
diagnosed and treated is a topic of controversy, and many people, including scientists and nonscientists
alike, hold strong beliefs about what ADHD is and how people with the disorder should be treated. This
module will familiarize the reader with the scientific literature on ADHD. First, we will review how ADHD
is diagnosed in children, with a focus on how mental health professionals distinguish between ADHD and
normal behavior problems in childhood. Second, we will describe what is known about the causes of
ADHD. Third, we will describe the treatments that are used to help children with ADHD and their families.
The module will conclude with a brief discussion of how we expect that the diagnosis and treatment of
ADHD will change over the coming decades.
Distinguish childhood behavior disorders from phases of typical child development.
Describe the factors contributing to Attention-Deficit/Hyperactivity Disorder (ADHD)
Understand the controversies surrounding the legitimacy and treatment of childhood behavior
Describe the empirically supported treatments for Attention-Deficit/Hyperactivity Disorder
Childhood is a stage of life characterized by rapid and profound development. Starting at birth, children
develop the skills necessary to function in the world around them at a rate that is faster than any other
time in life. This is no small accomplishment! By the end of their first decade of life, most children have
mastered the complex cognitive operations required to comply with rules, such as stopping themselves
from acting impulsively, paying attention to parents and teachers in the face of distraction, and sitting
still despite boredom. Indeed, acquiring self-control is an important developmental task for children
(Mischel, Shoda, & Rodriguez, 1989), because they are expected to comply with directions from adults,
stay on task at school, and play appropriately with peers. For children with Attention-Deficit/Hyperactivity
Disorder (ADHD), however, exercising self-control is a unique challenge. These children, oftentimes
despite their best intentions, struggle to comply with adults instructions, and they are often labeled as
problem children and rule breakers. Historically, people viewed these children as willfully
noncompliant due to moral or motivational defect (Still, 1902). However, scientists now know that the
noncompliance observed in children with ADHD can be explained by a number of factors, including
The goal of this module is to review the classification, causes, consequences, and treatment of ADHD.
ADHD is somewhat unique among the psychiatric disorders in that most people hold strong opinions about
the disorder, perhaps due to its more controversial qualities. When applicable, we will discuss some of the
controversial beliefs held by social critics and laypeople, as well as scientists who study the disorder. Our
hope is that a discussion of these controversies will allow you to reach your own conclusions about the
legitimacy of the disorder.
Why Diagnose Childrens Behavior Problems?
When a family is referred to a mental health professional for help dealing with their childs problematic
behaviors, the clinicians first goal is to identify the nature and cause of the childs problems. Accurately
diagnosing childrens behavior problems is an important step in the intervention process, because a childs
diagnosis can guide clinical decision making. Childhood behavior problems often arise from different
causes, require different methods for treating, and have different developmental courses. Arriving at a
diagnosis will allow the clinician to make inferences about how each child will respond to different
treatments and provide predictive information to the family about how the disorder will affect the child
as he or she develops.
Despite the utility of the current diagnostic system, the practice of diagnosing childrens behavior
problems is controversial. Many adults feel strongly that labeling children as disordered is stigmatizing
and harmful to childrens self-concept. There is some truth in this concern. One study found that children
have more negative attitudes toward a play partner if they are led to believe that their partner has ADHD,
regardless of whether or not their partner actually has the disorder (Harris, Milich, Corbitt, Hoover, &
Brady, 1992). Others have criticized the use of the diagnostic system because they believe it pathologizes
normal behavior in children. Despite these criticisms, the diagnostic system has played a central role in
research and treatment of child behavior disorders, and it is unlikely to change substantially in the near
future. This section will describe ADHD as a diagnostic category and discuss controversies surrounding
the legitimacy of this disorder.
ADHD is the most commonly diagnosed childhood behavior disorder. It affects 3% to 7% of children in
the United States (American Psychiatric Association, 2000), and approximately 65% of children diagnosed
with ADHD will continue to experience symptoms as adults (Faraone, Biederman, & Mick, 2006). The
core symptoms of ADHD are organized into two clusters, including clusters of hyperactivity/impulsivity
and inattention. The hyperactive symptom cluster describes children who are perpetually in motion
even during times when they are expected to be still, such as during class or in the car. The impulsive
symptom cluster describes difficulty in delaying response and acting without considering the repercussions
of behavior. Hyperactive and impulsive symptoms are closely related, and boys are more likely than girls
to experience symptoms from this cluster (Hartung & Widiger, 1998). Inattentive symptoms describe
difficulty with organization and task follow-through, as well as a tendency to be distracted by external
stimuli. Two children diagnosed with ADHD can have very different symptom presentations. In fact,
children can be diagnosed with different subtypes of the disorder (i.e., Combined Type, Predominantly
Inattentive Type, or Predominantly Hyperactive-Impulsive Type) according to the number of symptoms
they have in each cluster.
Are These Diagnoses Valid?
Many laypeople and social critics argue that ADHD is not a real disorder. These individuals claim that
children with ADHD are only disordered because parents and school officials have trouble managing
their behavior. These criticisms raise an interesting question about what constitutes a psychiatric disorder
in children: How do scientists distinguish between clinically significant ADHD symptoms and normal
instances of childhood impulsivity, hyperactivity, and inattention? After all, many 4-year-old boys are
hyperactive and cannot focus on a task for very long. To address this issue, several criteria are used to
distinguish between normal and disordered behavior:
1. The symptoms must significantly impair the childs functioning in important life domains (e.g.,
2. The symptoms must be inappropriate for the childs developmental level.
One goal of this module will be to examine whether ADHD meets the criteria of a true disorder. The
first criterion states that children with ADHD should show impairment in major functional domains. This
is certainly true for children with ADHD. These children have lower academic achievement compared
with their peers. They are more likely to repeat a grade or be suspended and less likely to graduate from
high school (Loe & Feldman, 2007). Children with ADHD are often unpopular among their peers, and
many of these children are actively disliked and socially rejected (Landau, Milich, & Diener, 1998).
Children with ADHD are likely to experience comorbid psychological problems such as learning disorders,
depression, anxiety, and oppositional defiant disorder. As they grow up, adolescents and adults with
ADHD are at risk to abuse alcohol and other drugs (Molina & Pelham, 2003) and experience other adverse
outcomes (see Box 1). In sum, there is sufficient evidence to conclude that children diagnosed with ADHD
are significantly impaired by their symptoms.
It is also important to determine that a childs symptoms are not caused by normal patterns of
development. Many of the behaviors that are diagnostic of ADHD in some children would be considered
developmentally appropriate for a younger child. This is true for many psychological and psychiatric
disorders in childhood. For example, bedwetting is quite common in 3-year-old children; at this age,
most children have not gained control over nighttime urination. For this reason, a 3-year-old child who
wets the bed would not be diagnosed with enuresis (i.e., the clinical term for chronic bedwetting), because
his or her behavior is developmentally appropriate. Bedwetting in an 8-year-old child, however, is
developmentally inappropriate. At this age, children are expected to remain dry overnight, and failure to
master this skill would prevent children from sleeping over at friends houses or attending overnight
camps. A similar example of developmentally appropriate versus inappropriate hyperactivity and
noncompliance is provided in Box 2.
Why Do Some Children Develop Behavior Disorders?
The reasons that some children develop ADHD are complex, and it is generally recognized that a single
cause is insufficient to explain why an individual child does or does not have the disorder. Researchers
have attempted to identify risk factors that predispose a child to develop ADHD. These risk factors range
in scope from genetic (e.g., specific gene polymorphisms) to familial (e.g., poor parenting) to cultural
(e.g., low socioeconomic status). This section will identify some of the risk factors that are thought to
contribute to ADHD. It will conclude by reviewing some of the more controversial ideas about the causes
of ADHD, such as poor parenting and childrens diets, and review some of the evidence pertaining to
Most experts believe that genetic and neurophysiological factors cause the majority of ADHD cases.
Indeed, ADHD is primarily a genetic disordertwin studies find that whether or not a child develops
ADHD is due in large part (75%) to genetic variations (Faraone et al., 2005). Further, children with a
family history of ADHD are more likely to develop ADHD themselves (Faraone & Biederman, 1994).
Specific genes that have been associated with ADHD are linked to neurotransmitters such as dopamine
and serotonin. In addition, neuroimagining studies have found that children with ADHD show reduced
brain volume in some regions of the brain, such as the prefrontal cortex, the corpus callosum, the
anterior cingulate cortex, the basal ganglia, and the cerebellum (Seidman, Valera, & Makris, 2005).
Among their other functions, these regions of the brain are implicated in organization, impulse control,
and motor activity, so the reduced volume of these structures in children with ADHD may cause some of
Although genetics appear to be a main cause of ADHD, recent studies have shown that environmental
risk factors may cause a minority of ADHD cases. Many of these environmental risk factors increase the
risk for ADHD by disrupting early development and compromising the integrity of the central nervous
system. Environmental influences such as low birth weight, malnutrition, and maternal alcohol and
nicotine use during pregnancy can increase the likelihood that a child will develop ADHD (Mick, Biederman,
Faraone, Sayer, & Kleinman, 2002). Additionally, recent studies have shown that exposure to
environmental toxins, such as lead and pesticides, early in a childs life may also increase risk of developing
ADHD (Nigg, 2006).
Controversies on Causes of ADHD
Controversial explanations for the development of ADHD have risen and fallen in popularity since the
1960s. Some of these ideas arise from cultural folklore, others can be traced to specialists trying to
market an easy fix for ADHD based on their proposed cause. Some other ideas contain a kernel of truth
but have been falsely cast as causing the majority of ADHD cases.
Some critics have proposed that poor parenting is a major cause of ADHD. This explanation is popular
because it is intuitively appealingone can imagine how a child who is not being disciplined at home
may be noncompliant in other settings. Although it is true that parents of children with ADHD use
discipline less consistently, and a lack of structure and discipline in the home can exacerbate symptoms
in children with ADHD (Campbell, 2002), it is unlikely that poor parenting alone causes ADHD in the first
place. To the contrary, research suggests that the noncompliance and impulsivity on the childs part can
cause caregivers to use discipline less effectively.
In a classic series of studies, Cunningham and Barkley (1979) showed that mothers of children with
ADHD were less attentive to their children and imposed more structure to their playtime relative to
mothers of typically developing children. However, these researchers also showed that when the
children were given stimulant medication, their compliance increased and their mothers parenting
behavior improved to the point where it was comparable to that of the mothers of children without
ADHD (Barkley & Cunningham, 1979). This research suggests that instead of poor parenting causing
children to develop ADHD, it is the stressful effects of managing an impulsive child that causes parenting
problems in their caregivers. One can imagine how raising a child with ADHD could be stressful for
parents. In fact, one study showed that a brief interaction with an impulsive and noncompliant child
caused parents to increase their alcohol consumptionpresumably these parents were drinking to cope
with the stress of dealing with the impulsive child (Pelham et al., 1997). It is, therefore, important to
consider the reciprocal effects of noncompliant children on parenting behavior, rather than assuming
that parenting ability has a unidirectional effect on child behavior.
Other purported causes of ADHD are dietary. For example, it was long believed that excessive sugar
intake can cause children to become hyperactive. This myth is largely disproven (Milich, Wolraich, &
Lindgren, 1986). However, other diet-oriented explanations for ADHD, such as sensitivity to certain food
additives, have been proposed (Feingold, 1976). These theories have received a bit more support than
the sugar hypothesis (Pelsser et al., 2011). In fact, the possibility that certain food additives may cause
hyperactivity in children led to a ban on several artificial food colorings in the United Kingdom, although
the Food and Drug Administration rejected similar measures in the United States. Even if artificial food
dyes do cause hyperactivity in a subgroup of children, research does not support these food additives as
a primary cause of ADHD. Further, research support for elimination diets as a treatment for ADHD has
been inconsistent at best.
In sum, scientists are still working to determine what causes children to develop ADHD, and despite
substantial progress over the past four decades, there are still many unanswered questions. In most
cases, ADHD is probably caused by a combination of genetic and environmental factors. For example, a
child with a genetic predisposition to ADHD may develop the disorder after his or her mother uses
tobacco during her pregnancy, whereas a child without the genetic predisposition may not develop the
disorder in the same environment. Fortunately, the causes of ADHD are relatively unimportant for the
families of children with ADHD who wish to receive treatment, because what caused the disorder for an
individual child generally does not influence how it is treated.
Methods of Treating ADHD in Children
There are several types of evidence-based treatment available to families of children with ADHD. The
type of treatment that might be used depends on many factors, including the childs diagnosis and
treatment history, as well as parent preference. To treat children with less severe noncompliance
problems, parents can be trained to systematically use contingency management (i.e., rewards and
punishments) to manage their childrens behavior more effectively (Kazdin, 2005). For the children with
ADHD, however, more intensive treatments often are necessary.
The most common method of treating ADHD is to prescribe stimulant medications such as Adderall.
These medications treat many of the core symptoms of ADHDtreated children will show improved
impulse control, time-on-task, and compliance with adults, and decreased hyperactivity and disruptive
behavior. However, there are also negative side effects to stimulant medication, such as growth and
appetite suppression, increased blood pressure, insomnia, and changes in mood (Barkley, 2006). Although
these side effects can be unpleasant for children, they can often be avoided with careful monitoring and
Opinions differ on whether stimulants should be used to treat children with ADHD. Proponents argue
that stimulants are relatively safe and effective, and that untreated ADHD poses a much greater risk to
children (Barkley, 2006). Critics argue that because many stimulant medications are similar to illicit
drugs, such as cocaine and methamphetamine, long-term use may cause cardiovascular problems or
predispose children to abuse illicit drugs. However, longitudinal studies have shown that people taking
these medications are not more likely to experience cardiovascular problems or to abuse drugs
(Biederman, Wilens, Mick, Spencer, & Faraone, 1999; Cooper et al., 2011). On the other hand, it is not
entirely clear how long-term stimulant treatment can affect the brain, particularly in adults who have
been medicated for ADHD since childhood.
Finally, critics of psychostimulant medication have proposed that stimulants are increasingly being used
to manage energetic but otherwise healthy children. It is true that the percentage of children prescribed
stimulant medication has increased since the 1980s. This increase in use is not unique to stimulant
medication, however. Prescription rates have similarly increased for most types of psychiatric medication
(Olfson, Marcus, Weissman, & Jensen, 2002). As parents and teachers become more aware of ADHD,
one would expect that more children with ADHD will be identified and treated with stimulant medication.
Further, the percentage of children in the United States being treated with stimulant medication is
lower than the estimated prevalence of children with ADHD in the general population (Nigg, 2006).
Parent Management Training
Parenting children with ADHD can be challenging. Parents of these children are understandably frustrated
by their childrens misbehavior. Standard discipline tactics, such as warnings and privilege removal, can
feel ineffective for children with ADHD. This often leads to ineffective parenting, such as yelling at or
ridiculing the child with ADHD. This cycle can leave parents feeling hopeless and children with ADHD
feeling alienated from their family. Fortunately, parent management train…
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