The case being analyzed this week deals with a patient who harnesses one of the most commonly diagnosed neurodevelopmental disorders— Attention Deficit Hyperactivity Disorder (ADHD). ADHD is often characterized by symptoms of inattention, impulsivity, and hyperactivity, which present themselves outside the boundaries of “normal” development (Hamblin and Gross, 2012). This condition is reported to afflict 3% to 5% of youth populations within the United States alone; however, the symptoms have been discovered and studied in myriad other countries (Hamblin and Gross, 2012). There are three primary types of ADHD, they include: predominantly inattentive type, predominantly hyperactive-impulsive type, and combined type (Hamblin and Gross, 2012). The symptoms of ADHD can vary in terms of severity; however, symptoms are often linked to impairments in academia, relationships, and overall emotional well-being. Thus, it is imperative to seek treatment in an effort to improve the patient’s quality of life, and subsequently the lives of all those impacted by the disorder. In this paper, we will analyze and discuss a number of treatments that may be used to effectively manage symptoms and behaviors of ADHD.
To begin, we will go over a little background information on the patient. The patient is an eight-year-old male named Billy. From an early age Billy’s parents noticed that Billy had an extremely high activity level. In his toddler years, his parents believed that it was “just an exaggeration of tendencies that most toddlers exhibit” (Gorenstein & Comer, 2015, p. 251). However, as Billy became older, his issues became more prominent and problematic, especially once he entered school. Billy’s activity level and issues with inattention began to take a major toll on Billy’s overall academic achievement. Now in the third grade, Billy is falling behind in a large number of academic tasks. Due to the severity of Billy’s issues, Billy’s parents, at the insistence of Billy’s teacher, have sought help for Billy.
Dr. Remoc, Billy’s doctor, employs behavioral and psychosocial theoretical orientations in combination with a biological orientation seen in the use of medication to come up with her proposed treatment interventions. Each of the proposed interventions is designed to assist Billy in adopting adequate and appropriate behaviors in a number of settings. Both behavioral and psychosocial approaches work to shift behavior from its undesirable state to a more suitable and desirable state. Billy’s parents have been encouraged to attend parental training, which provides them with effective ways to address Billy’s behavior adequately and to help him learn acceptable ways of conducting himself within the family dynamic. Billy is required to go through social skills training in an effort to help him learn to behave in more socially acceptable ways. This intervention endeavors to help Billy learn how to speak calmly, make polite requests, and cooperate within both school and home environments. The hope is that Billy will build skills that will help him in forming positive relationships, something that his condition makes extremely difficult. The token economy intervention is designed to produce desired actions and behaviors through a tangible reward/consequence system. Finally, Billy will receive medication as a combined intervention. The medication is designed to combat symptoms that produce disruptive behavior.
Dr. Remoc’s decision to implement more than one theoretical framework to guide her treatment plan was quite prudent. Literature on ADHD reveals times and again how integrative approaches, which typically include a combination of behavior interventions and psychostimulants, are best suited for patients with this disorder (Reiber and McLaughlin, 2004; DuPaul, Weyandt & Janusis, 2011). Furthermore, due to this unique integration, Billy’s behavior at home and school was substantially improved, as well as his academic achievement. It should be noted, however, that consistency is a key component in the effectiveness of any treatment plan, but most especially in treatment plans that are endeavoring to modify behavior and condition a patient to conduct themselves in more socially acceptable ways. Thus, that brings us to the issue with using just psychostimulants to treat ADHD. Using only medication to treat ADHD could be problematic for many reasons; however, the most primary reason why psychostimulants should not be used as a solitary intervention is that they are only designed to combat some symptoms. While ADHD medication may work to alleviate some of the behavioral issues associated with the condition in the short interim, it does not teach the patient how to manage and self-regulate their behavior in the long-term. Moreover, the longer a patient takes medication, the more their body will adjust, metabolize and a build up a tolerance to/for the medication, which can subsequently lead to the drug becoming ineffective and create the need for higher dosages. But again, even at higher dosages, the medication only works to lessen symptoms…it does not teach a patient HOW to manage and regulate their own behavior in appropriate and acceptable fashions.
One of the interventions implemented in Billy’s treatment plan is a “Token Economy” wherein Billy receives tangible rewards when he exhibits and carries out desired behaviors and actions. Billy has an extremely difficult time with playing nicely with his peers, this is true at home and at school. Thus, another task that can be added to Billy’s token economy chart is playing nicely with peers. This would include sharing, taking turns, and not being bossy. Another issue Billy has is staying in his seat. Therefore, another task to be added to his chart is to stay in his seat during class instruction time. While the stickers are a great way for Billy to see how well he is doing, another token method could be teacher bucks. Every time Billy fulfills a task on his economy chart, his teacher can present him with a teacher buck, which can later be used to buy something from the class store or the treasure box. If Billy gets a minimum of five teacher bucks by the end of the week, some positive reinforcement at home could include staying up 30 minutes to an hour past Billy’s bedtime, going on a movie date with mom and dad, having a friend sleep over, or even allowing Billy to purchase a special item and/or toy.
The four interventions effected by Dr. Remoc are largely efficacious in treating Billy’s ADHD. The use of medication has been applied for years to help treat and manage ADHD symptoms (Gorenstein & Comer, 2015; Reiber and McLaughlin, 2004). Although the medication helped significantly with controlling some of Billy’s behavior, it did not completely rid Billy of behavioral symptoms and issues at home and in school. Having Billy’s parents attend parental training classes was another intervention that was purposed to complement the use of psychostimulants. This intervention helped Billy’s parents learn effective ways to modify Billy’s behavior in a way that was more conducive to their home environment. A major problem at home was Billy’s inability not to interrupt his mother whilst she was on the phone. He would aggressively demand things of his mother (e.g. snacks) when she was on the phone. The classes enabled Billy’s mother to come up with an efficient solution that allowed both Billy and his mother to have their needs addressed. Having Billy attend social skills training is highly beneficial in that it will empower and support Billy in creating more positive relationships at home and with his peers. DuPaul, Weyandt & Janusis (2011) point out that children who harness ADHD have an extremely difficult time with peer relationships; authors state: “interventions designed to address peer relations must be implemented for a sufficient duration to counteract the high risk for problematic outcome” (p. 39). Finally, the token economy intervention has been well-documented in reducing disruptive behaviors frequently associated with ADHD. For instance, in a (2012) study, author Nicole Chevalier revealed and concluded that the application of token economies was significantly efficacious in “reducing off-task and disruptive behavior” (p. 14). Thus, with the substantial amount of literature supporting each of the aforementioned interventions, it is highly plausible that Billy is well on his way to leading a more positive, fulfilling, and rewarding life. Subsequently, these interventions will help reduce the stress and strain on Billy’s relationships with his parents, peers, and teacher(s).
To conclude, in addition to these four interventions proposed by Dr. Remoc, three other interventions I would recommend for Billy would be: classroom structure interventions (both physical structure and schedule structure), peer interventions wherein peers help keep Billy on task via monitoring and rewarding appropriate academic and social behavior, and perhaps curricular modifications would be beneficial in Billy’s case. Each of these additional interventions would work to help encourage and support desirable behavior inside the classroom. This is important in Billy’s case because the class environment seems to present more opportunities for distraction. Overall, with the combination of Dr. Remoc’s interventions and the additional proposed interventions, there would be a suitable balance for managing symptoms and behaviors in a variety of settings.
References
Chevalier, N. T. (2012). The token economy: Reducing the disruptive and off-task behaviorLinks to an external site. [PDF]. Retrieved from http://files.eric.ed.gov/fulltext/ED534397.pdf
DuPaul, G. J., Weyandt, L. L., & Janusis, G. M. (2011). ADHD in the classroom: Effective intervention strategies, 50(1), 35-42. doi:10.1080/00405841.2011.534935
Gorenstein, E. E., & Comer, R. J. (2015). Case studies in abnormal psychology (2nd ed.). New York, NY: Worth Publishers.
Hamblin, R. J., & Gross, A. M. (2012). Attention-Deficit/Hyperactivity disorders. In P. Sturmey & M. Hersen (Series Eds.), Handbook of evidence-based practice in clinical psychology: Vol. 1. Child and adolescent disorders [E-book] (pp. 243-266). Hoboken, N.J.: John Wiley & Sons.
Reiber, C., & McLaughlin, T. F. (2004). Classroom interventions: Methods to improve academic performance and classroom behavior for students with attention-deficit/hyperactivity disorder (Links to an external site.)Links to an external site.. International Journal of Special Education, 19(1), 1-13. Retrieved from http://eric.ed.gov/?id=EJ852038
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