Which path would you take for treatment of a child presenting with ADHD?

In this journal assignment, considering the readings Children and Behavioral Problems: Anxiety, Aggression, Depression and ADHD, a Biopsychological Model with Guidelines for Diagnostics and Treatment and Preterm Birth and Mortality and Morbidity: A Population Based Quasi-Experimental Study, which look at the differences between medicinal treatment and psychological interventions.
Which path would you take for treatment of a child presenting with ADHD? Defend your position with module readings and other research as necessary.
For additional details, please refer to the Journal Guidelines and Rubric document.

References

Delfos, M. F. (2004). Children and Behavioural Problems : Anxiety, Aggression, Depression and  ADHD – A Biopsychological Model with Guidelines for Diagnostics and Treatment.  London: Jessica Kingsley Publishers. Retrieved from  http://ezproxy.snhu.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&d b=e000xna&AN=129882&site=ehost-live&scope=site

D’Onofrio BM, Class QA, Rickert ME, Larsson H, Långström N, Lichtenstein P. Preterm Birth  and Mortality and Morbidity: A Population-Based Quasi-experimental Study. JAMA  Psychiatry. 2013;70(11):1231–1240. doi:10.1001/jamapsychiatry.2013.2107

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1743009

child is growing up in an accelerated pace of living, the childrearing situation will have to change significantly in order to let the child get back to himself again and continue his development at his own pace and within his own capabilities.

260 Children and Behavioural Problems

Table 12.1 The treatment aspects for ADHD

Coping with the disorder

Medication, if necessary

Behaviour regulation:

• structure • (cognitive) behaviour therapy • psychotherapy • behaviour contracts

Attention function:

• behaviour contracts • feedback when there is contact

Impulsivity:

• learning to postpone satisfaction of needs • learning to plan and order

Interacting with peers

Education and help for parents

Network around the family

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un de r U. S. o r ap pl ic ab le c op yr ig ht l aw .

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Appendix 1

Psychosomatics Model

In this appendix I introduce the psychosomatics model. It is the physical translation of the anxiety model, and in particular it is about what happens physically when the balance of hormones is disturbed. It is published for the first time here, though only in a brief summary.

I indicated in the anxiety model that the human body responds to danger with the production of hormones, but seeks a balance between adrenergic hormones like adrenlaline and androgenic ones like testosterone. I mentioned these two because they are the most important representatives. These hormones are thought to be related to the behaviour components ‘being able to take action’ and ‘actually taking action’. I mentioned earlier the difference in action that arises in the case of danger with men and women. Women prefer to look for safety, take care of the nest and nearest relations and talk to trusted people; men are more likely to react to the danger by fighting, fleeing or working for the nest, as a result of which the nest is protected against the outside world (Taylor et al. 2000). The women’s behaviour is hormonally supported by oxytocin. Women, when taking action, often remain dependent on others to cope with the danger. They therefore run more of a risk that the substances are not sufficiently converted.

An important problem with the production of stress hormones is adrenlaline. This hormone is necessary in order to take action, but at the same time this substance also has to be converted into action, otherwise there will be a toxic amount of adrenlaline in proportion to other substances. I take as a starting point the necessity for a balance with the amount of testosterone. Men have on average nine times as much testosterone in their body as women do (Bernards and Bouman 1993). They can therefore process more adrenlaline than women. Women therefore produce less adrenlaline than men. The body takes all sorts of measures to restrict the amount of adrenlaline and if necessary stop its production. The first way is to encourage the subject to take action. Even while sitting still the body will subconsciously start wriggling and trembling in order to lose excess adrenlaline when there is insufficient action.

We know the phenomenon where we bravely face danger, but afterwards start shaking. We have then produced more adrenlaline than necessary and the excess substances are converted into action. A second way is to sweat excess adrenlaline out of

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the body. The adrenlaline leaves the body through the pores. Cold sweat is an example of that.

When the production keeps increasing, the body, through cortisol as a neurotransmitter in the brain, will try to curb the production of adrenlaline. This is a paradoxical process, because at the same time the danger has not yet passed and the body will tend to stimulate the production and try, by means of adrenlaline at a hormonal level, to stimulate the action regarding the danger. In this way it is possible for there to be two contrary processes going on in the body at the same time: the attempt to keep the right balance between adrenlaline and other substances, and the necessity to produce adrenlaline in order to stimulate action. Testosterone could also be produced, and that does happen in situations which are exciting (Archer 1991); the problem is that the production of this basic hormone is so slow that it does not offer a fast solution. Testosterone is a very basic hormone that has many functions in the body, and the body will therefore, except when in danger, be aimed at having a stable amount of testosterone present. We can see this when testosterone can no longer be produced in the testicles because of castration. The body then starts to produce testosterone through other organs. That is why only chemical castration can stop the production of testosterone. However, large personality changes then take place, like listlessness and depression, and physical changes such as corpulence.

Our starting point is that there must be a balance between testosterone and adrenlaline. We can put this in a quotient, with the numerator being adrenlaline and the denominator being testosterone:

A

T

The numerator is adrenlaline because this fluctuates more easily than testosterone. In a healthy situation this quotient could be put at:

A

T �1

With the help of this quotient we can measure for everyone personally what the right pro- portion of adrenlaline and testosterone is under normal circumstances. With men we can expect that the denominator and numerator are nine times higher than with women. When this quotient is available we can register a deviating situation. Being ‘stressed’ is then no longer ‘between the ears’, but can be measured. When people are under stress for a long period of time, their quotient will start to deviate.

When the balance is disturbed, the human being will notice this first in the behaviour. The activity of the adrenlaline takes on unpleasant forms and this is experienced as a feeling of agitation, of not being able to stop doing something. A phase later, physical symptoms arise, the psychosomatic conditions. We speak of psychosomatic conditions because they are not based on a physical, somatic deviation. It is now known that physical deviations can result from them and that long-term stress can have life-threatening consequences. Research showed that physically and sexually abused

262 Children and Behavioural Problems

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women had significantly more frequent chronic pain and complaints like fybromyalgia (Finestone et al. 2000). The stress reaction can reach a structurally high level, resulting in a general state of anxiety, alertness and physical complaints (Kendall-Tackett 2000).

The diseases that can arise depend on the nature of the disturbance of the balance. Too much adrenlaline in relation to testosterone has different consequences from too much testosterone in relation to adrenlaline. In the first case we might want to take action, but we cannot get round to doing it. In the second case we might get round to doing it, but we cannot perform the action. The latter is always a bit more difficult to understand. The example of an operation explains this. With an operation, when someone is put under anaesthetic, a lot of testosterone is produced by the body. During the anaesthetic and the period afterwards it is hard to take physical action.

In the psychosomatics model represented below in Figure A1.1 we can see the various problems fanned out according to the nature of how much the balance is disturbed. Which disease will break out depends on the physical constitution. The predisposition of the human being has its weak spots. If it is the muscular system then it is more likely that muscular problems will arise; if it is the heart then heart problems may arise. The digestive system is sensitive to any disturbance of the balance. There are two kinds of imbalance: too much adrenlaline for the testosterone available, or too much testosterone for the adrenlaline available:

A

T � 1 and

A

T �1

The reaction of the body under stress is often the same as under a physical exertion. This makes it difficult to distinguish whether a complaint is caused by stress or whether it is based on an actual physical problem. This is an important breeding ground for anxiety. People who are suffering from stress will start to be bothered by physical complaints, which in turn can be a cause for fear of serious diseases. What follows is a simple example of how to cope with this. People who have heart palpitations are often scared that this has something to do with a heart condition. The heart is a muscle and this muscle does not register why it has to work, whether this is because of stress or a physical exertion. When it is a matter of a heart condition, the problem will always occur, both in the case of stress and in the case of a physical exertion. When it is a stress problem, the heart will, in princi- ple, function normally during physical exertion. This normally means that the heart rate increases during exertion, without actual heart palpitations, and that after the exertion the heart rate recovers itself reasonably quickly, with a short period of irregularity in order to reach the average number of beats.

When we put the anxiety model and the psychosomatics model together, the message is clear: stress has consequences for emotional and physical conditions. The most effective thing to do is to take action in relation to the danger, and all kinds of action can help. Even vacuuming or pacing up and down temporarily decreases the anxiety. With many conditions like ME, RSI and tiredness, the tendency and the advice is to rest. However, this proves to weaken the situation rather than curing it. The conditions are a

Appendix 1 Psychosomatics Model 263

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sign of a disturbance of the balance caused by a surplus of adrenalin, which means that the substances have to be converted in order to restore the balance.

The most important danger known to western people is the thought process. The danger is no longer a real bear on the road, but an imaginary one. A thought can conjure up stress, but a constructive thought is an action which reduces it. By experiencing the situation the stress may be varied. Influencing thoughts is therefore of the greatest importance. But sitting still causes problems rather than being helpful. When the situation has already worsened to a high degree, one can hardly force oneself to take action – this is the emotional condition of depression; nevertheless it is important to get the metabolism going again with the help of making small efforts.

Following on from the anxiety model we can see that women tend to act less than men. They will therefore be bothered more by these psychosomatic conditions. In addition, when they are suffering from these conditions they have the tendency to act less and therefore have more chance of the condition dragging on. Having a condition in itself creates stress again and ensures that the adrenergic mill keeps turning.

264 Children and Behavioural Problems

Figure A1.1 The psychosomatics model

s.f. = susceptibility to

S.f. diseases

DANGER

Stress Hormones ADRENALINE AMONG OTHERS

ADRENERGIC < ANDROGENIC

Cardiac

arrhythmia

Tachycardia

Hypertension

Heart Breathing

Immune

System

HEAD MUSCLES LUNGS

Dizziness

Reduced

vision

Concentration

disorders

Headache Muscle ache

Back pains

S.f.

instability of

pelvis

S.f. repetitive

strain injury

Tiredness

Hyperventilation

ME

Sleeping

disorders

Digestiv e

System

ACCELERATE

(TESTOSTERONE)

SLOW DOWN

(ADRENALINE)

Stomach

complaints

Weight loss

Intestine

problems

Weight gain

Stomach-ache

or

Infections

Skin

conditions

S.f. whiplash

Fybromyalglin

Burn-out

ADRENERGIC > ANDROGENIC

� A

T

1adrenaline testosterone

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Appendix 2

Behaviour Contract

Example of a behaviour contract A behaviour contract should first of all be considered as a contract. That means that it should be reciprocal and demand the efforts of all concerned. With children a contract is easily formed as one-way traffic; the child has a task, the adult does not. In this example the child and the adult both have to make an effort and both are being reinforced:

Janet is an only child. She has ADHD, is intelligent and is a hindrance to herself. She really wants to do well at school, but she cannot manage to show the desired behaviour and to spend sufficient time on her homework. She is resitting the first year of secondary school and is in danger of having to repeat the year again. The therapist who is treating her has drawn up a behaviour contract in consultation with her.

Behaviour contract for Father, Janet and Mother

The contract consists of two stages. When the first stage goes well, the second stage may start. If not, then this contract will lapse.

FIRST STAGE

‘Hanging up your coat’ has been chosen as the starting behaviour. This behaviour is limited, surveyable and easy to verify. It does not, however, appeal to Janet because it seems so trivial. She would prefer something that would make things better at school. Nevertheless, a simple start is necessary (reading starts with the alphabet).

DESCRIPTION

When Janet comes home from school she hangs up her coat on a coat hook. Because this is easy to verify this means in a practical sense: when her father or mother are at home, Janet will hang her coat on the coat hook; when her father or mother come home and Janet is already at home, then the coat will already be hanging on the coat hook. It is also accept- able if Janet accidentally hangs up her coat a bit later but before father or mother comes home. What it is all about in the end is that Janet learns to programme herself to think of something. Janet’s father or mother will check this behaviour.

265

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PERIOD

1 November until 28 November.

SCORE

For each school day that Janet hangs up her coat, she will get one point. If her father or mother forget to check and Janet points that out when she goes to bed, she will also get a point. Janet and her father or mother will check on the spot whether the coat is on the coat hook. For this she will get a point whether she has hung up her coat or not! If she did hang it up, she will get two. Both behaviours of Janet (thinking about hanging up her coat and thinking about whether her parents checked whether she has hung up her coat) ensure that she has to enter ‘hang up coat’ in her memory. In this way Janet can get a maximum of 40 points: 20 because she hung up her coat and 20 if her father and mother forgot to check it, while she did think about it.

Moving to the second stage takes place when Janet has obtained at least 17 points. Her mother or father hangs a sheet of paper up at a convenient spot and on which the

weeks are entered in squares next to or underneath each other. Janet makes a drawing to go with it so it also looks nice!

REWARD

The final reward is appreciation and access to the second stage. No other reward is offered like money, a meal out or something similar. This reward

has been chosen by Janet herself in consultation with her therapist. It is therefore important to respect this choice.

SECOND STAGE

This stage takes four school weeks and follows directly on from the first stage. The subject Janet chose for the second stage is the homework she has to do, in particular doing exer- cises, sums and the like. In a next stage learning the theory can be the subject. When the first stage has gone well, the next contract will be entered into.

No matter how childish this may seem, all three parties and the therapist sign this contract, so that it is clear that everyone is bound to it.

Therapist Janet

Father Mother

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