EDFS 352 Research Paper Ellen Kerr

Attention-Deficit/Hyperactivity: Approaches to Treatment
The prevalence of attention deficit/hyperactivity disorder (ADHD) is considerably high in school age children. Three to five percent of students are diagnosed with ADHD. These students also account for fifty percent of the students that receive special education services. The number of adults that are being diagnosed with ADHD is also climbing. Currently, referrals of adults for ADHD are also increasing at a rapid pace; until the 1990s and even to date, this age groups has been a markedly underrecognized and underserved segment of the ADHD population (Barkley, page 1. 2014) People with ADHD exhibit symptoms such as excessive movement (mostly in younger children,) loud play, and academic difficulties due to inattentiveness and hyperactivity. ADHD is very often comorbid with other disabilities, especially with learning disabilities. These symptoms must have begun before seven years of age, persisted for at least three months, and symptoms must occur across multiple settings. ADHD must be medically diagnosed. Due to the prevalence of ADHD, there has been quite a significant importance on the different treatment approaches for individuals with ADHD. Some practices focus on the medical and psychopharmacutical approach for treating ADHD. There are also alternative approaches to the treatment of ADHD. Others choose to combine these different approaches and practices.
In the history of attention-deficit/hyperactivity disorder, there have been a number of different ideologies as well as treatment approaches. It appears that the first description of disorders of attention occurred in the medical textbook by Melchior Adam Weikard in German in 1775 which described adults and children who were inattentive, distractable, lacking in persistence, overactive, and impulsive, which is quite similar to today’s description of ADHD. Weikard implied that the disorder could result from poor childrearing but also suggests some biological predispositions as well. For treatment, he recommended sour milk, plant extracts, horseback riding and even seclusion for severe cases (Barkley, page 3.) This seems to be the beginning of treatment using the combination of medicine as well as behavioral approaches to treat attention disorders.
As far back as the year 1775, there have been practices such as horseback riding and the use of the outdoors to reduce ADHD symptoms. A study in the American Journal of Public Health called “A Potential Natural Treatment for Attention-Deficit/Hyperactivity Disorder: Evidence from a National Study,” concluded that green outdoor settings appear to reduce ADHD symptoms in children across a wide range of individual, residential, and case characteristics (Kuo, Taylor, page 1, 2004.) This study included a large random sample of children diagnosed with ADHD and children diagnosed with ADHD comorbid with other disabilities. Parents were given a rating scale consisting of 49 survey items and asked to rate their children across many different settings on whether their symptoms were “much worse than usual,” “same as usual,” “better than usual,” or “much better than usual” for the hour after the outdoor activity. Overall, the findings indicate that exposure to ordinary natural settings in the course of common afterschool and weekend activities may be widely effective in reducing attention deficit symptoms in children. In addition, the advantage for green outdoor activities held among both children with hyperactivity (i.e., those diagnosed with ADHD) and children without hyperactivity (i.e., those diagnosed with attention-deficit disorder); among children with relatively mild, average, and severe symptoms; among children without comorbid conditions; and among children with both ADHD and learning disorders. In 2 groups—children with “very severe” symptoms and children with both ADHD and oppositional defiant disorder—green outdoor activities were significantly more helpful than indoor activities but not more helpful than built outdoor activities such as parking lots or man-made outdoor areas (Kuo, Taylor, page 5, 2004.)
Another approach to the treatment of ADHD is physical activity. A study published by the Journal of Sport and Health Science called “Parental Perceptions of the Effects of Exercise on Behavior in Children and Adolescents with ADHD,” provides evidence relevant to the potential benefits of physical activity on ADHD symptoms. Although pharmacological treatment has shown positive effects on some individuals with ADHD, these interventions are not fully effective for some individuals in managing their ADHD symptoms. Given that current behavioral treatments have limitations, the identification of other forms of treatment is warranted (Gapin, Etnier, page 2, 2014.) This article provides evidence that parents noticed significant positive effects in the areas on inattention, hyperactivity, and academics, but not in the area of impulsivity. This leads to the option of a combination of treatments.
It has been proven that medications are highly effective for most children in reducing core symptoms of ADHD (American Academy of Pediatrics (AAP), page 10, 2011.) There are also data that suggest that other non-stimulant medications are effective in the treatment of ADHD as well. One selective norepinephrine-reuptake inhibitor (atomoxetine) and two selective adrenergic agonists (extended-release guanfacine and extended-release clonidine) have also demonstrated efficacy in reducing core symptoms (AAP, page 10, 2011.) Although the evidence shows a significant reduction of symptoms through pharmaceuticals, the studies also suggest that these medications be used in combination with evidence-based behavioral treatments.
Behavioral parent training provides behavior-modification principles to parents for implementing in home settings. This improves compliance with parental commands. It also gives parents an understanding of behavioral principles. This treatment has a high level of parent satisfaction (AAP, 2011.) Similar behavior-modification treatment methods are provided to teachers for classroom management as well as intervention methods for peers. In comprised studies, it has been concluded that behavioral interventions have positive effects on a range of other outcomes when used with patients with ADHD. There is blinded evidence that they improve parenting and decrease childhood conduct problems (Daley, PhD, Van Der Oord, PhD, Ferrin, MD, PhD, Danckaerts, MD, PhD, Doepfner, PhD, Cortese MD,Phd, Sonuga-Barke, PhD, 2014.)
Although evidence-based treatments for ADHD have been proven to be effective when combined with medication, it was not a significantly more efficacious than treatment with medication alone for the core symptoms of ADHD (AAP, page 12, 2011) Stimulant medication use is now recognized as gold standard evidence-based treatment for children with ADHD, and there are myriad studies supporting this status (Kapalka, part 5, 2015.) There is contradicting evidence about the effectiveness of stimulants in younger children that can be found in an article in the journal of Effective Health Care Program. This was a study was done to compare effectiveness and adverse events of interventions (pharmacological, psychosocial, or behavioral, and the combination of pharmacological and psychosocial or behavioral interventions) for preschoolers at high risk for ADHD. They concluded that the strength of evidence for parent behavior training as first-line intervention for improved behavior among preschoolers at risk for ADHD was high, while the strength of evidence for medication for improved behavior among preschoolers at risk for ADHD was low. This article does state that primary school-age children, mostly boys with ADHD combined type, showed improvements in symptomatic behavior maintained for 12 to 14 months using pharmacological agents. ((Effective Health Care Program, Comparative Effectiveness Reviews, No. 44, page 1, 2011.)
In conclusion, research shows the significance and effectiveness of both medical and behavioral intervention for the treatment of attention-deficit/hyperactivity disorder. All individuals are different and therefore, the benefits of treatment will differ among these individuals.

References
Barkley, R. A. (2014). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). Guilford Publications.
Kuo, F. E., & Taylor, A. F. (2004). A Potential Natural Treatment for Attention-Deficit/Hyperactivity Disorder: Evidence From a National Study. American Journal of Public Health, 94(9), 1580-1586. doi:10.2105/AJPH.94.9.1580
Gapin, J. I., & Etnier, J. L. (2013). Parental perceptions of the effects of exercise on behavior in children and adolescents with ADHD. Journal of Sport and Health Science. doi:10.1016/j.jshs.2013.03.002
Subcommittee on attention-deficit/hyperactivity disorder, Steering committee on quality improvement and management. (2011). ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, Official Journal of the American Academy of Pediatrics, 128(5), 1-18. doi:10.1542/peds.2011-2654
Daley, D., PhD, Van der Oord, S., PhD, Ferrin, M., MD, PhD, Danckaerts, M., MD, PhD, Doepfner, M., PhD, Cortese, S., MD, PhD, & Sonuga-Barke, E. J., PhD. (2014). Behavioral Interventions in Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis of Randomized Controlled Trials Accross Multiple Outcome Domains. Behavioral Interventions in Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis of Randomized Controlled Trials Accross Multiple Outcome Domains, 53(8). http://dx.doi.org/10.1016/j.jaac.2014.05.013
Kapalka, G. M. (2015). Treating disruptive disorders: A guide to psychological, pharmacological, and combined therapies. Routledge Publications.

Charach, A. (2011). Attention deficit hyperactivity disorder effectiveness of treatment in at-risk preschoolers; long-term effectiveness in all ages; and variability in prevalence, diagnosis, and treatment (Vol. 44). Rockville, MD: Agency for Healthcare Research and Quality.

References: Barkley, R. A. (2014). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). Guilford Publications. Kuo, F. E., & Taylor, A. F. (2004). A Potential Natural Treatment for Attention-Deficit/Hyperactivity Disorder: Evidence From a National Study. American Journal of Public Health, 94(9), 1580-1586. doi:10.2105/AJPH.94.9.1580 Gapin, J. I., & Etnier, J. L. (2013). Parental perceptions of the effects of exercise on behavior in children and adolescents with ADHD. Journal of Sport and Health Science. doi:10.1016/j.jshs.2013.03.002 Subcommittee on attention-deficit/hyperactivity disorder, Steering committee on quality improvement and management. (2011). ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, Official Journal of the American Academy of Pediatrics, 128(5), 1-18. doi:10.1542/peds.2011-2654 Daley, D., PhD, Van der Oord, S., PhD, Ferrin, M., MD, PhD, Danckaerts, M., MD, PhD, Doepfner, M., PhD, Cortese, S., MD, PhD, & Sonuga-Barke, E. J., PhD. (2014). Behavioral Interventions in Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis of Randomized Controlled Trials Accross Multiple Outcome Domains. Behavioral Interventions in Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis of Randomized Controlled Trials Accross Multiple Outcome Domains, 53(8). http://dx.doi.org/10.1016/j.jaac.2014.05.013 Kapalka, G. M. (2015). Treating disruptive disorders: A guide to psychological, pharmacological, and combined therapies. Routledge Publications. Charach, A. (2011). Attention deficit hyperactivity disorder effectiveness of treatment in at-risk preschoolers; long-term effectiveness in all ages; and variability in prevalence, diagnosis, and treatment (Vol. 44). Rockville, MD: Agency for Healthcare Research and Quality.