Case Study: Attention Deficit Hyperactivity Disorder
by Eric M. Fortier, B.A.
In the case presented by Oltmanns et al. (2015), seven-year-old Ken exhibits several behaviors that interfere with his basic functioning. Various sources say Ken is hyperactive, distracted, temperamental, easily frustrated, often fidgeting, not wanting to sit still, rarely finishing assignments, and having poor relationships with peers and siblings. Importantly, he has been abnormally distractible, moody, aggressive and lacking discipline since kindergarten. As a result, Ken is struggling academically and socially.
Ken’s father often works away from home, leaving Ken’s mother alone with him and their daughter. His mother believes in severe physical punishment for correcting misbehavior, while his father thinks little of his misdoings, leading to inconsistent parenting; both of which likely exacerbate Ken’s disorder. This dynamic may act as an environmental trigger for a known genetic polymorphism that predisposes individuals to ADHD. Furthermore, Ken’s mother and father are experiencing marital strain over how to raise him.
Diagnosis and Treatment
Using the DSM-5 as a guide to diagnosis, Ken displays persistent age-inappropriate symptoms of inattention, hyperactivity and impulsivity that cause large impairments in daily functioning. According to multiple reports, he exhibits at least five of six minimum symptoms of inattention: often has trouble holding attention on tasks or play activities, does not seem to listen when spoken to directly, does not follow through on instructions and does not finish schoolwork, dislikes tasks that require mental effort over a long period, and is easily distracted; and at least six of six minimum symptoms of inattention: fidgets constantly, leaves his seat in situations when remaining seated is expected, runs about or climbs in situations where it is not appropriate and even dangerous, cannot play or take part in leisure activities quietly, appears “on the go” acting as if “driven by a motor,” and interrupts or intrudes on others. Reports from more than one source suggest a number of these symptoms began in early childhood, were present in more than one setting (at school, at home, and with peers), and interfered with academic performance, quality of social relationships, and family functioning. Based on the limited description provided in the case study, it does not appear like Ken meets the full criteria for ODD, CD, or other similar diagnoses, although some early symptoms such as aggression should be monitored throughout early development. According to these criteria, Ken presents a fairly typical case of ADHD with Combined Presentation, with at least eleven (albeit of minimum 12) symptoms distributed relatively evenly across the inattention and hyperactivity-impulsivity dimensions for the past six months. Although he may not meet the full criteria in this diagnostic guide, typical ADHD treatment approaches may work well for Ken.
Since the family situation is likely a contributing factor to Ken’s disorder, the therapist’s approach in this given case appears sound and effective. Gradually implementing a set of contingency systems with rewards for desired behaviors such as staying seated, paying attention and engaging positively with others, and consequences for other behaviors such as being disruptive, the therapist applies contemporary parent management training along with an educational intervention into Ken’s social surrounding. Focusing on Ken’s caretakers who will raise him for many years will be key in helping him develop self-regulating practices and a positive social life. A psycho-educational intervention may be of additional benefit, aimed at teaching parents and teachers about ADHD symptoms, how to build on his strengths, and about the course of the disorder.
The link of Ken’s disorder to added stress on the family is bi-directional rather than simply cause or effect. For example, his disruptive and sometimes uncontrollable behavior, such as at the table and at school, can raise alarm in family, peers and teachers, who must adjust and cope with the uncomfortable and often stressful situation; they may react with social rejection, and in Ken’s case even severe physical punishment. The father’s nonchalance coupled with the severity of the mother’s punishments along with her resulting remorse represents a fairly typical case of inconsistent parenting, which is known to trigger ADHD symptoms in those carrying a heritable genetic polymorphism involving homozygous dopamine receptor alleles (Martel et al., 2010). This may be even more likely, seeing as Ken’s father states that he had the same symptoms as a child. Dealing with Ken has further led to marital discord, damaging his primary protective and guiding factor: the family unit.
The therapist’s contingency management approached appears in this case to have been highly successful. His reasons for deciding not to prescribe medication may have been manifold, besides the recommendation of behavioral therapy as the first line of treatment for preschoolers and in less severe cases of ADHD (and Ken only met 11 of 12 minimum symptoms). Stimulant medications involve multiple side-effects, and ADHD symptoms return when the medication leaves the body. It is not advised to take stimulants late in the day because they may interfere with sleep (exacerbating concentration difficulties, etc.), and as a result ADHD symptoms often return in the evening, disrupting home life. Stimulants have the potential to aggravate Ken’s already poor appetite, induce physiological stress, can cause weight loss, hair loss, headaches, increases in blood pressure and pulse and later heart conditions. It is a lifetime treatment, expensive in the long run, and generally less effective than behavioral approaches.
Kids on amphetamine?
Oltmanns et al. (2015) ask why one in five children are taking stimulant medication while the rates of ADHD are not one in five. Though a preliminary literature search did not return any results confirming this finding, it is important to keep in mind that stimulant medication is FDA-approved for other conditions such as narcolepsy, obesity, and as an adjunct treatment for obstructive sleep apnea. Still, mis-prescription does occur. For example, children with birthdays in August are significantly more likely to be diagnosed with ADHD compared to those born in September, a finding attributed to their low neurocognitive maturity relative to relatively much older peers when entering school (Chen et al., 2016).
It is impossible to address this question without openly acknowledging that pharmaceutical companies spend many millions of dollars a year in promoting their drugs to physicians. Moreover, it is no secret that medical professionals sometimes casually substitute standardized questionnaires with brief conversations, leading to prescription without critical evaluation, especially in the instance of long-term doctor-patient familiarity. Finally, students commonly share stimulants as gifts or as barter. Amphetamine has been widely used for sustaining alertness and accelerating the passage of time during arduous tasks as well as widely abused for its euphoric and sometimes manic effects. Since its primary function is to stimulate the reward system, it is inherently addictive. The powerfully rewarding effect (as well as the barter value) of Adderall for non-ADHD youth may also make it more likely that some will learn how to fill an ADHD questionnaire in order to obtain prescription stimulants.
A note on television
Research has also linked watching a lot of television during the toddler years with later attention problems. According to Gutnick, Robb, Takeuchi, & Kotler (2010), children ages 2-5 watched over three and a half hours of television a day on average, about a third of toddlers had a television in their bedrooms, sixty percent of toddlers were consuming online video, and one third of toddlers were doing this on a daily basis. Now it is crucial to consider the advent of mobile devices, and particularly short-form media, available on-line and on-demand. According to a 2017 survey by Elias & Sulkin, “online viewing is integrated into the basic daily routine of parents with very young children who use online viewing platforms to fulfill a wide range of their childrearing needs.” Current statistics of toddler television viewing were not found in typical academic studies, and purchasing data available for commercial interest was beyond the scope of this study. The AAP recommends severely restricting television and mobile device use in toddlers, if not eliminating it altogether.