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Attention deficit hyperactivity disorder (ADHD) is one of the overt behavioral problems that start as early as three years and peak at the school entrance. Prevalence varies between 3% to 5%, and up to 10%. It is now being recognized in the Arab world with increasing rate, as it has been the ”diagnosis of decade” for almost ten years. An Egyptian study for the prevalence of ADHD among school age children found a total prevalence rate of 6%. In another studies on an Egyptian samples found that the prevalence of ADHD children in the outpatient clinic to be ranging from 13% to 15% of the referred children. It is 3-5 times more common in boys than in girls.
ADHD is a developmental disorder that requires an onset of symptoms before age 7 years. Recent research indicates that this disorder is not outgrown in adulthood but it persists in many cases leading to serious consequences that affect the whole aspects of the patient’s life.
ADHD is considered a multifactorial neurobehavioral disorder. The dysregulation of neurotransmitters, namely norepinephrine and dopamine in the prefrontal cortex and subcortical structures, the prenatal, natal, postnatal risk factors like exposure to teratogen, birth hypoxia, and exposure to toxins in addition to genetic factors are all important factors in the etiology of this disorder.
ADHD subdivides into three types: a) predominantly inattentive type; b) predominantly hyperactive-impulsive type; c) combined type. The predominantly inattentive type is more common in females and, together with the combined type, seems to have a higher impact on academic performance. Children with the predominantly hyperactive-impulsive type are more aggressive and impulsive than those with the other two types of ADHD, and tend to be unpopular and highly rejected by their peers. The combined type causes more impairment to global functioning, comparatively to the other two types.
The core symptoms of ADHD which include inattention, hyperactivity and impulsivity all lead to marked psychological problems with social interactions, self esteem, leaning problems, academic difficulties, and underachievement, leading to marked dysfunction in the major domains of a person’s life. Thus a patient with ADHD has poor interpersonal relations in his family, marriage or work. This patient also has problems both in education and later in occupational functioning, such problems are substantial reasons for seeking medical advice.
Based on prior findings that often illustrate multiple serious consequences of untreated ADHD and related behaviors, it is necessary to clarify the nosology of ADHD in the preschool period of development in order to facilitate earlier identification and intervention. Early intervention has been shown to improve prognosis of a number of childhood disorders including disruptive and autistic spectrum disorders.
Also comorbid psychiatric conditions associated with ADHD have been identified as major obstacles to successful treatment and functional outcomes. The high prevalence of these conditions along with their negative impact on treatment outcomes has been documented in numerous studies of patients across their life spans. It is evident that comorbid conditions impose heavier burdens on patients with ADHD (as well as their families), and that they make it more difficult for clinicians to choose interventions that are likely to succeed with a high degree of certainty. Whereas the evidence base for multimodal treatment of ADHD ”simplex” in children and adolescents is well established, such is not the case for patients with complex forms of the disorder
A social skill is defined as an ‘‘ability to choose appropriate actions in social settings, such as being tactful, making friends, and settling conflicts peaceably’’. As a result of many children with ADHD having displayed numerous poor social skills, children with ADHD are looked upon as having a social disability, and the general public has created a bad reputation for these children that is difficult for children with ADHD to overcome. Effects of being labeled and prejudged can cause children with ADHD, who have been rejected by their peers, to display higher rates of negative, aggressive, and/or self-centered behavior than people who have been accepted by their peers.
Probably two-thirds of ADHD children experience peer rejection. ADHD children are less often chosen by peers to be best friends, partners in activities, or seatmates. As children age, social issues seem to worsen. Their inappropriate behavior leads to further social rejection and exacerbates their inability to relate to others appropriately. Long term these children are more likely to have difficulty finding and maintaining successful careers. This is not surprising since social aptitude can make or break careers and relationships in the adult world. Peer rejection in childhood is a devastating experience, associated with subjective feelings of loneliness, low self-esteem, poor schoolwork, juvenile delinquency, and dropping out of school’’
Thus children with ADHD who are more hyperactive and impulsive often show other types of social problems. For example, they may stand too close to another child, be verbally aggressive, or intrude inappropriately into the social interactions of other children. In contrast to inattentive children, who may be socially “neglected,” hyperactive/impulsive children are often socially “rejected” that is, their peers may actively avoid interacting with them due to their loud, aggressive, inappropriate or immature behavior. It is not clear that having poor peer relations directly results in later problems in life, but the need for positive peer relationships is necessary for children with ADHD when they are young, in order to ‘‘provide a critical buffer against stress as well as psychological and psychiatric problems’’
Research finds that ADHD affects the interactions of children with their parents and, hence, the manner in which parents may respond to these children. Those with ADHD are more talkative, negative and defiant, less compliant and cooperative, more demanding of assistance from others, and less able to play and work independently of their mothers. Their mothers are less responsive to the questions of their children, more negative and directive, and less rewarding of their children’s behavior. Mothers of ADHD children have been shown to give both more commands as well as more rewards to their ADHD sons than daughters but also to be more emotional and acrimonious in their interactions with their sons.
These interaction conflicts in families with ADHD children are not limited to just parent-child interactions. Increased conflicts have been observed between ADHD children and their siblings relative to normal child-sibling dyads. Research on the larger domain of family functioning has shown that parents of ADHD children experience more parenting stress and decreased sense of parenting competence, increased alcohol consumption in parents, decreased extended family contacts, and increased marital conflict, separations, and divorce as well as maternal depression.
However, the role of family environments has been markedly downplayed in many quarters. Information is still lacking on the role of family climate and parent child interactions. The problem present with utmost urgency requiring immediate attention and advocacy work at all levels to increase community awareness, to enhance proper management of parents and children, and to prevent secondary complications in both families and children.
There are three important skills that can cause unsuccessful social interactions for children with ADHD which are not having the ability to make positive statements toward others, not engaging in rough play appropriately and not making appropriate verbal requests. Children with ADHD also have the tendency to be unaware of the impact they have on others, such as showing inattention to usual social signals and cues that are used by most people. Such a lack of awareness results in feelings of confusion if someone becomes upset with them.
Practical and theoretical issues have been used to identify children with social disability. For example, the Social Adjustment Inventory for Children and Adolescents (SAICA) provides valid and effective technology that assesses social functioning. Researchers have employed SAICA to demonstrate that an impairment in social functioning is significantly seen in children with ADHD. Another example is the Family Environment Scale which enabled mothers to provide information about any family conflict. This measure assessed the quality of the interpersonal relationships among the family member.
Research has documented the negative long-term effects of social rejection on these children. Such rejection increasingly results in substance abuse, conduct disturbance, school failure, and, ultimately, school dropouts and delinquent offenses. Early identification of social disability can result in provision of preventative services. This method of identifying children with social disabilities could help determine the predictive value of social disability in the outcome of ADHD and better identify and characterize a subset of children with ADHD with unique clinical needs and at high risk for a more complicated course and poor outcome.
The treatment of ADHD includes both pharmacological and psychotherapeutic approaches which help the patients hand in hand in improving the core symptoms of the disorder and in ameliorating the psychological impacts and improving the dysfunctional domains of the patient’s life.
Pharmacotherapy include both stimulant and non stimulant medications. For long time stimulants have been the mainstays for treating patients with ADHD, recent studies indicated its efficacy in treating the disorder however they are major concerns about its abuse potential especially in the presence of high incidence of comorbidity between ADHD and substance use disorders.
Although ”under medical supervision, stimulant medications are considered safe”, the use of stimulant medications for the treatment of ADHD has generated controversy because of undesirable side effects, uncertain long term effects, and social and ethical issues regarding their use and dispensation. The American Heart Association and the American Academy of Pediatrics feels that it is prudent to carefully assess children for heart conditions before treating them with stimulant medications. The FDA has added black-box warnings to some ADHD medications
Non stimulant medications include tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRIs), Bupropion, Atomoxetine. Only one of them which is atomoxetine is approved by the FDA in 2003 in treating patients with adult ADHD. With regard to psychosocial interventions, it is fundamental that psychiatrists educate the family about the disorder, giving them clear and accurate information. It is important that parents know the best strategies so as to help their children organize and plan their activities. For instance, these children need a study environment that is quiet, consistent, and does not have many visual stimuli.
The psychological therapies used to treat ADHD include psychoeducational input, behavior therapy, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy, school-based interventions, social skills training, and parent management training. Parent training and education have been found to have short term benefits. Family therapy has shown to be of little use in the treatment of ADHD, though it may be worth noting that parents of children with ADHD are more likely to divorce than parents of children without ADHD, particularly when their children are under the age of 8 years.
Interventions at school also are important. In this regard, teachers should ideally be aware of the necessity of a well-structured classroom, with few students. Consistent daily routines and a predictable school environment help these children to keep their emotional control.
In psychosocial interventions focused on children and adolescents, cognitive-behavioral therapy is the most widely studied modality, with scientifically proven efficacy in the treatment of central symptoms (inattention, hyperactivity, impulsivity), and associated behavioral symptoms (opposition, defiance, stubbornness), especially behavioral treatments. Among behavioral treatments, parental training seems to be the most efficient modality.
Congnitive behavioral therapy (CBT) is one of the most effective form of psychotherapy that can applied to patients with ADHD either on an individual or group basis. Also family therapy and marital therapy are essential.
Parent Training (PT) is a treatment program whose objective is to inform the parents about ADHD and to teach them how to use behavioral therapy techniques to improve the management of their children, increase the confidence of the parents and improve the parent-child relationship through better communication and attention to the child’s development. The programs are structured, developed in a specific number of sessions and generally done in a group.
Social Skills Training (SST) is done, for example, by teaching patients how to make visual contact, smile, and maintain an appropriate body posture. It uses CBT techniques and is usually performed in group format. Although SST has demonstrated efficacy in children with ADHD, it is necessary to define a well-established standard intervention program and also to determine exactly what the necessary components are for it to be effective. Its objective is to develop the necessary behaviors and abilities to establish and maintain constructive social relationships.
Consequently, a reasonably sound conclusion is that SST studies incorporate both behavioral and cognitive techniques both independently and jointly—in the latter case reflecting a cognitive-behavioral orientation. Cognitive behavioral interventions (CBI) focus on targeting a youngster’s private speech self-instruction training, problem-solving training, attribution retraining, and cognitive restructuring approaches. In addition, virtually all effective CBI techniques with youngsters include behavioral components such as modeling, role playing, and positive reinforcement. These techniques may work well for students who display cognitive deficits or distortions that interfere with accessing and performing social skills in their repertoire.
Helping children with ADHD build close peer relationships is an important goal to focus on, and is one that often may be over looked. Parents, have the ability to help their child accomplish this important social goal. They should attempt to help their child with this. His psychological health and his happiness, both now and in the future, are very much dependent upon how successful he is at making and maintaining childhood friendships.
Psychosocial interventions like Interpersonal Cognitive Problem Solving (ICPS) have recently been found effective for youth with ADHD. When conducted under specific conditions, we believe the ICPS model can have a significant effect on the behaviors of children with ADHD and can generalize to settings outside of the one in which the child was initially trained. For ICPS to have an optimal effect on children with ADHD, three specific conditions to foster generalization must be met: (a) parents are included to teach their child ICPS skills; (b) parents learn to implement ICPS childrearing techniques with their child; and (c) the child learns to internalize newly acquired ICPS skills for application to real life.
Researchers do not claim that problem solving alone will improve the ability of the brain to focus or stop severe symptoms of ADHD. It can contribute to a reduction in impulsivity, however, by teaching children that other problem-solving techniques exist besides a fight-or-flight response. These strategies may also reduce the severity of comorbid conduct disorders and emotional problems and improve the ability to plan, initiate tasks, and self-monitor. They conclude that cognitive problem-solving approaches can be suitable “for treatment of adjunctive issues (such as parent-child conflict),” which reduced parental stress on issues related to their child.
Therefore it is recommended that there should be more studies applied on patients to make a well established social skills training program and to provide more data about its efficacy in the Egyptian society.