Psychological Interventions for the Treatment of the Hyperactive Type of ADHD

Introduction

Childhood behavior has become a source of intense focus over the last several decades. With the introduction of behavioral treatment for various reactions in and out of the classroom, extensive research has occurred, and various philosophies and opinions have resulted. Some are contradictory. Some encourage Adderall medication, while others emphasize behavioral management strategies. Some encourage both options. Within these various research studies, there only seems to be one continuous theme: family.

Family is something of a tender area. First researchers focused on genetic inheritance or chemical imbalance in the brain. Others focused on relational experiences and socio-demographic norms. While all of these are very likely contributing factors to behavior, the nature versus nurture competition has no real winner. So, methods designed to treat behavior, such as hyperactivity become complex and controversial to address.

More often than not, traditional parenting styles and classroom management involves keeping the children under control and ensuring they remain in constant vigilance of their own impulsive behaviors. For students who suffer with impulse control, this can become a living nightmare for them. This nightmare becomes a hard-fast reality with the official diagnosis. From that diagnosis, procedures become their daily reality. Outsiders constantly judging, critiquing and analyzing every thought and move had by the student become daily practice. There is no peace to one’s day. It becomes a world where it is nearly impossible to please the people the student wants to feel acknowledged and approved by. Success is so far out of reach.

No child desires this. No child wishes to have their own parents or teachers feel frustrated with them day in and day out. No child wants to feel so unappreciated and unloved. No child wants to fail. The belief that there are children who don’t care is a fallacy. Children are part of a social group and as members of a social group, they desire to belong. They desire approval by their own family. They desire approval by those held in authority, tasked to educate them. These children want to have successful relationships and successful lives. They want their lives to mean something as much as anyone else does. This factor often fails to be acknowledged by the system designed to treat their behavioral challenges. It becomes a message of the child against the world. That is a very difficult position to begin one’s life.

Attention Deficit Hyperactivity Disorder (ADHD) is a growing issue in schools across the globe. “To receive this diagnosis from a health care professional, a child must exhibit chronic, developmentally inappropriate levels of inattention, impulse hyperactivity, or both - and these behaviors must be manifested in more than one environment” (McClure, 2008, p. 78). Research by Yeschin also elaborates in how the inability to inhibit responses, or to delay responses, to various stimuli appears to be the crux of the ADHD challenge (Yeschin, 2000). She believes that the degree of constant criticism and negativity experienced in one’s life exacerbates the inability to contain impulsive behavior and it effects personal relationships (Yeschin, 2000). The primary focus of this paper is to delve more deeply into the understanding of what ADHD is and to investigate the various psychological interventions that can be utilized in the treatment of the hyperactivity associated with an ADHD diagnosis.

As discussed previously, the crux of the issue is inability to contain impulsive behavior. There appears to be a growing contention that ADHD may not necessarily be a pathologically generated disorder, but one also created by environment and circumstances. The conflicting reports in regard to this contention generates conflicting responses to treatment. Since children are clearly in physical and emotional development, including brain development and cognitive function development, it is crucial that any method of treatment be carefully analyzed for its long-term effects on the diagnosed person. Convenience for the sake of child-rearing or classroom management cannot be the forefront of the focus of the diagnosis and treatment. There is also growing concern that prescribed stimulant use contributes to illicit drug use in teens and adults (Expert, 2003). It is obviously essential to ensure that the diagnosed receive guidance and treatment that enables them to have the highest outcomes for their future success as independent individuals in the workforce and world at large. Ensuring that they receive the fullest support in their development, without any alteration to their cognitive function and brain development in such formative years is crucial, if not the most pressing concern.

The increase in diagnosis, paired with the increase in medication for these individuals’ merits another look at alternative solutions that are not as risky for brain development and cognitive function because not all children benefit from ADHD medication anyway. This paper will address the various methods of treatment and research related to non-medicated treatment of individuals diagnosed with ADHD. More specifically, treatments that address the hyperactivity component will be deeply analyzed and considered for further investigation and application with cases specifically concerned with the hyperactivity component of the diagnosis. The methodology which will be utilized in this study will be addressed first.

Methodology

The methodology utilized for this paper will be a thorough literature review of peer-reviewed studies published. A literature review consists of a compilation of credible published sources that have been offered up for publication in fields where the peer groups are also experts in their field. With this type of peer-review, the likelihood for validation of points made is more consistent and verifies reliability of information obtained. However, it is also understood that even with such peer-review, the information is always subject to the limitations of the group knowledge as evolution of theory and practice continues to expand and comprehend the phenomenon studied. The literature review will include real world examples of the information obtained, applications in utilizing the methods suggested and further questions may be asked for need of deeper investigation either in this study or for future studies. The goal of this paper is to not only deeply understand effective treatment options, but to perhaps also add to the collective knowledge through suggested expansion of treatments as pertinent to the situation. This will by no means be an exhaustive list of options available, but a thorough analysis of the generally accepted efforts used by many in the field.

Literature Review

The literature review shall contain numerous sources of invaluable research and insight into the treatment of ADHD with particular emphasis on non-medicated treatment of the hyperactivity component. As stated previously, there is a contention between whether or not the diagnosis is entirely pathological, but perhaps also circumstantial. Although the emphasis that the behavior must be exhibited in more than one scenario (ex. home and school), it is not entirely out of the possibility that the manner in which the child is treated either at home or at school can exacerbate feelings of inadequacy or anxiety which can contribute to impulse control challenges. The more aggressively a child is criticized, especially negatively, the more likely they will find themselves responding to situations of stress with inappropriate reaction which may alleviate their feelings of anxiety or it may become merely a coping mechanism.

There is reason to believe that this hyper-vigilant criticism stems from parents who feel pressured to be that way with their children. (The) research on the link between changes in parental states of mind and the symptomatic behaviour in children…(found that when) children (are) treated along with their families in psychoanalytic parent–child psychotherapy improved considerably. It was argued that when parents feel understood and have the experience of being emotionally contained by the therapist in treatment, their state of mind is likely to move along a continuum from being predominantly reactive and persecuted to be more reflective and reparative. The parents’ shifts were analyzed through a quantitative methodology, while the children’s improvement through a qualitative one (Pozzi-Monzo, 2012, p. 50).

This insight is quite contrasting to decades of research that predominantly focused on the child as the instigator of behavior issues. Although, in reality, that cannot be the entire truth. If parents were feeling the need to be so critical and were feeling “reactive and persecuted,” then clearly they have their own personal stories to address. Perhaps they have domineering relatives in their lives that continuously critique their parenting. Perhaps they feel that the school is constantly judging their parenting based upon their child’s behavior or performance in class. Perhaps their own peer groups have pitted their children against one another in some kind of competitive parenting match that isn’t verbally acknowledged, but subversively and manipulatively done to create insecurity in the parents, who then feel compelled to push their kids to perform up to expectation. This world of adult expectation placed upon adults and then directed toward the children is something that hasn’t been fully discussed. It definitely merits more consideration.

Another fact worthy of consideration is something that Ladnier and Massanari (2000) have re-described as Attachment Deficit Hyperactivity Disorder. Their research has addressed the consistency found with children who had some form of paternal break in the first two years of life. This could also be generated through material trauma during fetal development. Emotional experiences affect the development of the fetus, which continues to impact the child in its most formative years. Parental breaks can also include childcare usage or emotional detachment of the maternal figure due to stress or other factors (Pozzi-Monzo, 2012). Childcare plays a larger role as more and more women are either choosing or financially obligated to work in order to provide for their families. This ever-increasing need for working mothers leaving their children in the care of non-relative persons, especially in the form of a childcare facility where numerous children are being cared for, exacerbates the formative development of attachment, which subsequently contributes to hyperactive behaviors as the child enters toddlerhood and early elementary years. The continuation of non-attachment treatment by parents and caregivers (punishment and criticism for inappropriate behavior responses) exacerbates the attachment challenge that the child is dealing with and begins to take even deeper root into the psychological development of the child as he or she enters adolescence. Further discussion regarding solutions that could be utilized to circumvent the exacerbation of such development will be discussed further in the discussion segment. For now, further investigation of current responses to cases will be continued and reflected upon in the discussion segment.

Hinshaw (2007) does offer the insight that the level of aggressive behavior management at home does contribute to overall behavior challenges outside of the home. This correlates with the attachment challenge mentioned previously and correlates with some of the beliefs often found in parenting methodologies and even in some school settings. Zero tolerance policies are very exclusionary and negative in their response. Their overall goal is to ensure safety for the other students, but the negative message sent to the guilty party only serves to exacerbate the behavior that is attempting to be changed. Negative reinforcement has not proven to be successful with rectifying behavior of those suffering from ADHD (Hinshaw, 2007). However, this same study also recommends behavior management strategies which also specifies control factors for parents to follow when interacting with their children. The question that comes to mind is whether additional limitations on expectation truly facilitates the deepening attachment healing necessary or if it becomes another component that the child learns to navigate in order to get their needs met. Is the actual response the child’s self-facilitation of needs being met through the attempts of the adults to control them actually beneficial or only a semi-effective means at repairing the actual issue?

Kean (2004) further investigates the summer treatment program which was also addressed in the study by Hinshaw. Kean’s study delves into the increased intervention occurring in earlier years, even as young as two years old. The fact that identification could occur as young as two also correlates very strongly with the attachment study focusing on the level of maternal attachment and emotional availability of the mother with the child in the first two years of life performed by Ladnier and Massanari (2000). Interventions Kean (2004) found successful with the summer treatment program included sports activities, parent training classes, peer social skills training, reward systems, among other educational focused treatments. The common thread found thus far seems to be consistent that parent training is a crucial factor. The manner in which the parent training focuses is the segment which clearly needs further investigation. As mentioned by the Hinshaw study, negative parental enforcement can exacerbate the already derogatory behavior. Similarly, the potential that the children are perhaps only finding a pseudo-connection with parents through participating in the structured behavior management attempts by parents may not necessarily be the actual “cure-all” solution essential to truly remedying the behavior. If the method should backfire, the child would not truly be any more attached to the parent than before. In fact, they may find themselves feeling manipulated and less trusting of the parent, which would in turn have adverse effects on overall behavior modification. It is, however, constructive that there seems to be a consistency across the various studies, that parent behavior modification is key to enacting change in the relational dynamic.

Bauermeister et al (2007) also bring an additional factor to the table that is also of substantial importance. The focus on gender. There is a disproportionately large percentage of male diagnoses than there are of female diagnoses. This is something that could also be reflected upon within context of parenting styles in America. The less attached beliefs about boys as opposed to girls to their parents are encouraged quite prevalently and may very well be contributing factors to the disproportionate levels of male diagnoses over female diagnoses. The belief that boys need to be tough and independent is encouraged at young ages and the manner in which parents may treat their boys differently than they do their girls may play a considerable role in the attachment deficit challenge which appears to contribute to hyperactive behavior.

Miranda and Presentacion ( 2000) focused on the use of self-control training and anger management training in their study. The students were in aggressive and non-aggressive categories, but all exhibited the hyperactivity trait. “Specific techniques included in this program were training in problem-solving, self-instruction, modeling, exercises in role-playing, and contingency management (self-reinforcement, social reinforcement, token systems, response cost, and reinforcement for carrying out household tasks)” (Miranda and Presentacion, 2000, p. 169). The focus of aggressive and anger responses related to maladapted awareness of situational stimuli also seems to contribute to the suggestion offered by Ladnier and Massanari (2000). That lack of attachment suggestion that offered the inappropriate learned responses to address their lack of security or ability to adequately respond to situational anxiety. Heavy criticism also contributes substantially to aggressive behavior as a response to assumed threat, whether substantiated or believed.

Travell and Visser (2006) performed a unique study offering the insights from the students and the parents that covered the entire experience from diagnosis, dealing with symptoms and treatment. Some of the students in the study felt that their feelings of ‘stupidity’ or being ‘naughty” consumed their thoughts. The study also suggested that the likelihood that these beliefs were learned from adults in their care through daily interactions may have played a role in such beliefs (Travell & Visser, 2006). This, once again, reinforces the negative and highly critical treatment by parents and teachers, as suggested by Pozzi-Monzo (2012) is a very real factor. Negative self-talk, which contributes to impulse control challenges, is originated by external sources, and not necessarily originating in the students themselves.

Harlacher et al (2008) addressed specific approaches within the context of the classroom. Their strategy is to establish classroom-wide rules and protocols that can be implemented across the board so that students with or without ADHD have similar behavior modification expectations, rewards, and contingencies. The potential challenge with this unilateral application, is that those who suffer from ADHD are more likely to have challenges with upholding these classroom expectations, which undermines the concept of the “positive” reinforcement encouraged and ultimately creates a scenario where continuous negative reinforcement by always failing to excel at the behavior expectations as astutely as other classmates who do not face similar behavioral management challenges.

Thapar et al (2013) conducted a study to discern if ADHD is genetically transferred and they found that it is not necessarily genetically transferred, which also alludes to the devaluation of biology being an actual factor in diagnosis. The familial commonalities between siblings or parent/child are more indicative of familial relationship than of biological contribution. With this knowledge, the reinforcement of research by Ladnier and Massanari (2000) seems to be even further validated.

Hoza (2007) studied the implications of peer relationships with children who suffer from ADHD. The significance of this study is that peers offer a unique relational experience of non-adult nature, which offers the student opportunity to have validation, connectivity and less critical attack as they traditionally experience from the adults in their lives. That does not mean that the children never experience criticism or negative responses to their impulsivity. It does, however, offer opportunity for the child to form potentially therapeutic relationships to alleviate the attachment issue that was not met through parental, guardian, or teacher interaction. The challenge found in peer relationships are the rejection factor that may come from exclusivity methods utilized in the classroom intended to keep the student from disturbing the other students. This segregation tactic often has disastrous effects on peer relations and can exacerbate feelings of negativity in the student suffering from ADHD.

Smith et al (2000) address the effectiveness of treatment for students in schools and also acknowledge the shift from elementary to upper level schools creating a challenging obstacle with regard to continuation of appropriate behavior management application with the drastic shift from one teacher all day to numerous teachers per day. The classroom sizes also increase in the upper grades, and the likelihood of each teacher having a specific protocol within their classroom that is designed to address the special needs of the ADHD diagnosed student becomes more problematic. Additional factors include the behavior changes that occur with puberty add a new level of response that may not have been prevalent in the younger years. This probably also has a lot to do with why so much emphasis on early treatment has been made over treatment for adolescents. Additional developmental needs related to providing room for independence is essential at this developmental milestone. As such, behavioral treatment and protocols must adapt to the shifting needs of the developing adolescent. Increased respect for autonomy is crucial.

Sobanski et al (2010) focused on the emotional lability of students suffering from ADHD. Emotional lability covers symptoms such as irritability, hot temper, low frustration tolerance, and rapid emotional shifts toward anger, depression and other similar emotions. The inclusion of this factor (EL) is very indicative of the suggestion placed by Ladnier and Massanari (2000) with emphasis on attachment creating dissociation behavior, coping mechanisms which can be related to inappropriate responses and impulsive behavior. This type of behavioral response is likely a result of years of not having attachment needs met, being exacerbated by negative criticism from parents and schools, as well as peer rejection. This is not the ideal outcome and definitely requires more assertive attention to remedy the behavior as well as the psycho-emotional healing necessary to form new attachment bonds and constructive relational development.

Johnson et al (2009) offers one of the most compelling studies of all. Within this study, the various types of ADHD symptoms are measured and addressed through neuroimaging scans and various biological connections. However, the hyperactivity component does not appear to be something that can be measured through the various tests which substantiate brain connective function or biological inheritance. Of all of the studies researched in this literature review, this particular study offers much more conclusive evidence validating that the suggestions offered by Ladnier and Massanari (2000) and reinforced by Pozzi-Monzo (2012) have been incredibly accurate. Additionally, this addresses more crucial aspects for effective treatment for hyperactivity in students suffering from ADHD.

Discussion

This revelation is of imperative concern as the move to bring children into education at earlier and earlier years, saying that it enhances their educational development and shows significant achievements in their latter educational endeavors is actually quite contradictory to what the research has shown with regard to child development and its responses discovered through the ADHD phenomenon, especially when considering the insight that attachment to parent plays such a significant role. Removing children from their mothers at younger and younger ages does nothing to facilitate healthier educational development if the child subsequently struggles to handle the lack of attachment so essential to their emotional development. The need to create more childcare resources in order to facilitate working mothers to the detriment of the development of children, which ultimately leads to treatment or therapy sessions for the mother and child does not seem to be the most appropriate solution to warding of the ever increasing number of ADHD cases.

Clearly single mothers and less advantaged families have no other choice than to seek childcare services for their children in order for them to earn a living and support their families. There are certain aspects about the economic realities that cannot be avoided and as such, must be addressed as constructively as possible without exacerbating the issues already forming from the unfortunate reality that cannot be alleviated. Ideally, more supportive systems would be in place that would alleviate the need to seek childcare by external parties in formative years. Without such support, the next step is acknowledging that this phenomenon will continue and will need to be handled in a much more constructive manner than it has been over the last several decades.

As discussed previously, peer relations are the next potential arena for facilitating healthy attachment where potential for meaningful connection and consciously constructed approaches to developing healthy relationships where nurturing respect for development and impulsivity challenges is encouraged and not driven to create further damage. Students are in a unique position to help their peers overcome their obstacles and to help them feel normal and equal. Mutual respect is completely essential to healthy human development. This respect is just as crucial, if not more so, coming from adult mentors and parental influence.

How can adult interactions change while remain effective for behavior management? Adult interactions need to shift from a need to control to a need to understand. When the adults who are entrusted to care for a child stop forming needs to criticize and correct, and shift their focus to attempting to understand behavior and to understand emotional contributions to behavior, the dynamic shifts dramatically and students are more capable of responding with less impulsivity and more conscious intention. This requires extensive self-awareness on the part of the adults in care of the student. Attention to their own reactionary behavior, which is often increased when outside pressures are placed upon their performance or internal need for competition arises.

While it is true that competition is part of the world we live in, it is not necessarily essential to early childhood development and the implementation of such adult-minded behavior being introduced and reinforced upon young children is developmentally inappropriate and only contributes to the anxiety and detachment felt by the students suffering from ADHD symptoms. Increased teacher to child ratios are essential to ensure adequate attachment needs are met for those whose family circumstances do not support the level of attachment required by the child for healthy development. Additional changes would have to include more adaptive group behavior expectations that respect the feelings of the children and are not necessarily centric to the convenience of the adults in charge.

Children are constantly evolving, and they do not operate like clockwork the way that schools and daycares try to reinforce them to be. The expectation for them to be robotic in nature is highly dis-intuitive to their instincts and does nothing to remedy the anxiety or behavioral impulse control issues related to detachment challenges. Without actual acknowledgement that adult behavior and expectation within the classroom is essential to alleviating hyperactivity responsiveness, constant application of reactionary treatment will be necessary.

There is much talk about giving students choices. There is little, if no discussion, relating to adult choices creating the challenges that they end up creating by their lack of child development acknowledgement (either by lack of information or unwillingness to change). Hyperactivity is a symptom of a larger issue. It is not something that can be remedied by constant control. Constant control is a reactionary response to uncontrolled stimuli. Control the stimuli and the behavior will change. The stimuli is not the child. The child is the reactionary container. The stimuli is the emotional trigger that is not being met. Meet the emotional need that alleviates the anxiety or impulsive behavior, and the child will respond differently. When the child feels that their personal boundaries are not being violated, they will feel safe. This safety will render them less reactionary and more present to participate in the activity of the group.

Conclusion

Students who suffer from ADHD do not want to be different from their peers. They do not desire to be treated in a manner which requires more control of them, and they do not desire to be criticized incessantly for not being able to comply to expectations. Their behavior is not intentional response to manipulate adult behavior. Their desire is to have their needs met, as we all do. They are less able to identify what that need is because it is rooted in early childhood development that was not met due to various circumstances related to lack of healthy attachment to a significant parent, most often the mother. This does not villainize mothers as the goal is not to make them feel more vulnerable and attacked than they already do. The goal should be to focus on ensuring that the child’s boundaries are respected, their insecurities are addressed, and that they are nurtured in a healthy manner through their emotional challenges so that they can further develop strong and constructive responses to difficult situations as they grow older and independence becomes more prominent in their development.

What can be done is the extensive acknowledgement and support for parents, especially mothers. Mothers are often the target for all childhood misbehavior and lack of thriving. Although there are cases of blatant neglect and abuse, most mothers really are trying to do the best they can with what they know. Support that offers them stress management tools, ways in which they can more closely engage and attach with their children and the deeper learning of meaningful respect and connectivity with their children is of utmost importance. This is probably even more important with the boys than with girls as it appears that the boys are the most commonly affected by the detachment in early childhood.

A shift in societal behavior toward childrearing, parental involvement, and school involvement needs to take place. A respect for family and its healthiest development needs to be more centric and the need for competition and creating perfect children less emphasized. Respecting mothers needs to be with their children in the most formative years is the crux of the issue and without that, all responses will be reactionary to the detachment created by having not been able to provide this. As important as it is to have a thriving workforce, it is just as important, if not more so, to have a psychologically healthy society that can succeed in the workforce without developmental challenges and need for remediation or therapy for numerous years.

Other contributions which can be offered by the schools is less emphasis on homework and more emphasis on respecting family time. Over-enrollment in school activities for the sake of keeping the children busy isn’t necessarily the best strategy to foster healthy attachment to parental influence. For the children who do not have positive parental influence at home or insufficient connectivity to parental influence for various reasons, a nurturing relationship with a trusted mentor or teacher is essential.

Cognitive development is tied to socio-emotional development. In order to have healthy cognitive development that garners strong impulse control and appropriate response to challenges, much more substantiated support for healthy attachment development must take place. Without this, continuation of treatments that only partially address the problem will be questioned over and over for their lack of complete validation of effectiveness. After 30+ years of research, a solution would have been found if it were as simple as strategies used to manipulate behavior. It appears that only in the last decade have researchers finally acknowledged that the health of the family unit is the primary source for contention and should be looked at and supported much more deeply than ever addressed before. This is the real starting point to treatment for hyperactivity in ADHD students.

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