1.     INTRODUCTION

Attention Deficit/Hyperactivity Disorder, most of the time abbreviated as (ADHD) is a syndrome first appearing in childhood that is characterized by abnormal levels of inattention, hyperactivity, or both (Barkley, 1990).  Despite the fact that children with ADHD form only a small numbers of all children, they frequently come to the attention of their parents and teachers, because they exhibit a high degree of externalizing behaviors.

This review paper is intended to show the historical background of ADHD, the definition of ADHD, the causes of AHDH, the intervention mechanisms of ADHD  and eventually summary of the review and try to make some link with in the Ethiopian context, even though study has hardly made regarding to this issue. Predominantly this paper focuses on the early intervention mechanisms of children with ADHD.

Early intervention can be preventive intervention and/or treatment intervention. Due to the nature of ADHD, treatment intervention gets much attention by researchers and practitioners. In the same analogy the reviewer gave due attention for treatment intervention than preventive intervention.

There are two kinds of treatment intervention mechanisms that have been discussed by different researchers/authors/. These are pharmacological intervention and non-pharmacological intervention. Both pharmacological and non-pharmacological /behavioral/ methods are reviewed as an intervention mechanism of ADHD. However, in non-pharmacological intervention, behavioral/psychological intervention got due attention by the reviewer, since it draws the attention of clinician currently and assuming it is more applicable and relevant to Ethiopian children in the existing situation.

2. HISTORICAL BACKGROUND OF ATTENTION DEFICIT HYPER- ACTIVITY DISORDER

The condition now called "Attention-Deficit/Hyperactivity Disorder" (ADHD) has been recognized for at least the last half-century. Although descriptions of ADHD-associated behaviors have been remarkably consistent over the years, the name of the syndrome has changed several times.

It is during the 1980s and early 1990s, that the emphasis changed again, favoring neither the attentional nor the hyperactivity/impulsivity features, but recognizing the unique contributions of each. In 1968 the second edition of the Diagnostic and Statistical Manual of Mental Disorders, (DSM-II), published by the American Psychiatric Association (APA), was the first to name this syndrome. It was called "Hyperkinetic Reaction of Childhood" and described more as clinical impressions than multi-faceted, interactive behavioral symptoms. The DSM also improved by different researchers and the DSM-IV R, published in May of 1994, has named the syndrome "Attention-Deficit/Hyperactivity Disorder" (ADHD) in order to preserve continuity. ADHD is now divided into four major types, however, with a separation of attention problems from those of hyperactivity and impulsivity in the first three, which the reviewer gave due attention in this paper.

3. DEFINITION AND DIAGNOSTIC TOOLS

The following example illustrated by Kutscher L. about the child under consideration, makes the concepts of Attention Deficit Hyperactivity Disorder more clear and understandable.

     "I cannot take it anymore! We scream all morning to get out of the house. Homework takes hours. If I do not help him with his work, he is so disorganized that he will never do well. If I do help him, he screams at me. Since he never finishes anything, everyone thinks he does not care. No matter how much we beg or punish, he keeps doing the same stupid things repeatedly. He never considers the consequences of his actions, and does not seem to care if they hurt me. It is so easy for him to get overwhelmed. Sometimes, he just wants to ‘turn the noise off.'

 

       He is so inflexible, and then blows up over anything. It gets me so angry that I scream back, which makes everything even worse. Now that he is getting older, the lies and the cursing are getting worse, too. I know he has trouble paying attention, but why does he have all of these other problems as well?"(Kutscher L., 2002).

 

It is not a twist of fate that children with ADHD often manifest so much more than the classic triad of inattention, impulsivity, and hyperactivity.

According to the fourth and current edition of the DSM (DSM-IV), Attention-Deficit/Hyperactivity Disorder is a disorder characterized by a "persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development" (APA, 1994).

Eighteen individual diagnostic criteria distinguish ADHD from either normal child development or other childhood disorders.  The diagnostic criteria are divided into two groups: nine are considered primarily symptoms of inattention, while the remaining nine are considered indicators of hyperactive or impulsive behavior.

Based upon the findings of recent research, the DSM- IV relies upon a series of decision rules for diagnosing ADHD that allows for the identification of three possible subtypes as follows (APA, 1994).

• If a combination of at least six of the nine inattention symptoms and six of the nine hyperactivity-impulsivity indicators are endorsed, the client should be diagnosed as ADHD, Combined Type.

• If at least six of the nine inattention symptoms are endorsed, but fewer than six hyperactive/impulsive indicators are found to be present, the client should be identified as ADHD, Predominantly Inattentive Type.
• If at least six of the nine hyperactive-impulsive symptoms are endorsed, but fewer than six inattention indicators are confirmed, the client should be identified as ADHD, Predominantly Hyperactive-Impulsive Type.

The following are the DSM-IV Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder:

1. Symptoms of Inattention: Six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities;

b. Often has difficulty sustaining attention in tasks or play activities;

c. Often does not seem to listen when spoken to directly;

d. Often does not follow through on instructions and fails to finish schoolwork, or chores (not due to oppositional behavior or failure to understand instructions);

e. Often has difficulty organizing tasks or activities;

f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework);

g. Often loses things necessary for tasks or activities (e.g. toys, school assignment);

h. Is often easily distracted by extraneous stimuli;

i. Is often forgetful in daily activities

2. Symptoms of Hyperactivity/Impulsivity: Six or more of the following symptoms of hyperactivity /impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

   Hyperactivity

a. Often fidgets with hands or feet or squirms in seat;

b. Often leaves seat in classroom or in other situations in which remaining seated are expected;

c. Often runs about or climbs excessively in situations in which it is inappropriate;

d. Often has difficulty playing or engaging in leisure activities quietly;

e. Is often "on the go" or often acts as if "driven by a motor";

f. Often talks excessively.

Impulsivity

g. Often blurts out answers before questions have been completed;

h. Often has difficulty awaiting turn;

i. Often interrupts or intrudes on others (e.g., butts into conversations or games).

In addition to the above behavioral criteria, the children must:

 1. Display hyperactive-impulsive or inattentive symptoms severe enough to cause impairment prior to the age of 7 years;

 2. Display impairment from symptoms in two or more settings (e.g., school and home);

 3. Must demonstrate clinically significant impairment in social or academic functioning; and

 4. Not have another disorder that can account for the behavioral symptoms.

                                  Connecticut ADHD Task Force 3rd Edition, 2005

 

 

In Ethiopian case, whether this instrument is applicable or not, national level evaluation is not yet done. However, a thesis was made by a student who was attended his master of public health on the equivalent diagnosis tool (DICA-R). He evaluated this instrument in Addis Ababa and concluded that the Amharic version of DICA-R is reliable, acceptable and feasible for use (Megerssa K., 1997).

4. WHY ADHD OCCURS?

ADHD has traditionally been viewed as a problem related to attention, stemming from an inability of the brain to filter competing sensory inputs such as sight and sound. Recent research, however, has shown that children with ADHD do not have difficulty in that area. Instead, researchers now believe that children with ADHD are unable to inhibit their impulsive motor responses to such input (Barkley, 1997).

It is still unclear what the direct and immediate causes of ADHD are, although scientific and technological advances in the field of neurological imaging techniques and genetics promise to clarify this issue in the near future. Most researchers suspect that the cause of ADHD is genetic or biological, although they acknowledge that the child's environment helps determine specific behaviors.

With regard to genetic perspective, imaging studies conducted during the past decade have indicated which brain regions may malfunction in patients with ADHD, and thus account for symptoms of the condition. A 1996 study conducted at the National Institutes for Mental Health (NIMH) in USA found that the right prefrontal cortex (part of the cerebellum) and at least two of the clusters of nerve cells known collectively as the basal ganglia are significantly smaller in children with ADHD. It appears that these areas of the brain relate to the regulation of attention. Why these areas of the brain are smaller for some children is yet unknown, but researchers have suggested mutations in several genes that are active in the prefrontal cortex and basal ganglia may play a significant role.

In addition, researches indicated that some no genetic factors have been linked to ADHD including premature birth, maternal alcohol and tobacco use, high levels of exposure to lead and prenatal neurological damage. Although some people claim that food additives, sugar, yeast, or poor child rearing methods lead to ADHD, there is no conclusive evidence to support these beliefs (Neuwirth, 1994).

5. INTERVENTION OF (ADHD) IN CHILDHOOD

Although there is an argument on the causes of ADHD, mental health professionals are striving for the intervention of it. There are two mechanisms of intervening ADHD, which is dealt by researchers and practitioners. These are pharmacological and non-pharmacological intervention. However, the effect and the healing power of these intervention methods depend on the nature and conditions of disorders. In some circumstances, pharmacological approaches of intervention become successful. On the other conditions, non-pharmacological approaches can be successful without the aid of medication. There is also evidence, which shows that non-pharmacological interventions are associated with reductions in levels of medication in some cases (Hinshaw et al., 1998).

Based on these concepts, the reviewer developed the intervention model that might be appropriate for most children and Ethiopian children too. The model gives chance to the interventionist to choose and use the appropriate method of intervention depending on their culture, availability of professionals, facilities, materials, the nature of the problem etc. This model describes, first diagnose whether the child is infatuated by ADHD, and next identify the appropriate method of intervention. If neither of the mechanisms is effective, try them in combined form.

         

Suspicion and Diagnosis of ADHD

   

Assurance or refer as necessary

   

                                                                                                    No  

                                                                     Yes

     

                                            

                                          No                                                          No

                                                                                                                                      

                                                                                                                     

              Yes                                                                                     No           

                                                                                                                           Yes

Refer to child psychiatrist or Clinical psychologist

                                                                         Yes

                                                                                                              

                                                                      

                                                   

              

                                   Fig.1 Treatment (intervention) model of ADHD

6. TYPES OF INTERVENTION

Prominently, the intervention of ADHD was only focused on medical treatment, though; today clinicians turn their attention to the non-pharmacological /behavioral/ approaches of intervention. Now a day's clinicians proved that, there are conditions when non-pharmacological /psychological/ intervention becomes effective without the use of medical intervention, in other situation intervention might need both pharmacological and non-pharmacological intervention.

          

 6.1 PHARMACOLOGICAL INTERVENTION

It is over 70 years since the unforeseen observation that stimulant drugs can improve hyperactive behavior in children (Bradley, 1937). The stimulant medications methylphenidate and dexamfetamine have been available since 1955 in the US. From the mid-1990s, the level of drug prescribing for ADHD has increased markedly in the UK, coinciding initially with changes in the regulatory framework.

According to the British Psychological society ADHD guidelines and management, 2009, in UK, methylphenidate and atomoxetine are licensed for the treatment of ADHD (hyperkinetic disorders) in children aged 6 years and older while dexamfetamine is Pharmacological treatment licensed for children from age 3 years. Atomoxetine is licensed for the continued treatment of ADHD in adults when treatment was initiated in childhood.

Other less frequently used drugs such as clonidine, bupropion, modafinil, imipramine, risperidone and nicotine patches are not licensed for the treatment of ADHD. However, there is some clinical experience of their use in young people with ADHD, particularly those with coexisting conditions.

Methylphenidate as a stimulant, by which it reduces symptoms in ADHD is not completely clear, it is believed that it increases intrasynaptic concentrations of dopamine and noradrenaline in the frontal cortex as well as subcortical brain regions associated with motivation and reward (Volkow et al., 2004). Methylphenidate blocks the presynaptic membrane dopamine transporter (DAT) and thereby inhibits the reuptake of dopamine and noradrenaline into the presynaptic neuron.

Despite a large literature supporting the short-term benefits of stimulant medication in children with ADHD, uncertainty still surrounds the balance of risks and benefits of long-term drug treatment (Poulton, 2006). Little empirical evidence is available to guide clinicians on questions such as the optimum duration of treatment, when it is appropriate to consider drug discontinuation and how and when to combine pharmacological and psychological treatments. Furthermore, the increasing use of stimulants in clinical practice has raised concerns about the potential for stimulant drug misuse and diversion.

Important clinical questions also relate to the balance of risks and benefits of ADHD drug treatment in less well-studied groups including pre-school children, adults and those with coexisting mental health problems or learning disabilities.

Some of the above drugs are in use in Ethiopia for not only on children but also on adults who has epilepsy or hyperactivities to make them calm and treat effectively. However, it is practiced only rarely since mental health institutions are relatively non-existent compared to the individuals who need the service.

          

 

 

 6.2 NON-PHARMACOLOGICAL INTERVENTIONS

It is a recent phenomenon to take non-pharmacological intervention as a treatment mechanism of ADHD. Non-pharmacological intervention includes; behavioral intervention, dietary intervention, complementary and alternative interventions, social and community intervention and multimodal intervention which are identified and used. However, behavioral intervention draws the attention of clinicians as intervention method of ADHD alone and/or in combination with pharmacological treatment/intervention due to reasons set out below.

               a. Short-term effects of medication

Despite the effectiveness of stimulants in achieving a reduction in core symptoms, there have been questions over their long-term effectiveness, with some studies indicating that improvements may not be maintained over the longer term and into adolescence. Similarly, some studies have indicated that many of the benefits of stimulant medication may be state-dependent-effects may only last for as long as the person is receiving the medication and may not generalize to situations in which treatment is absent (Whalen & Henker, 1991). Therefore, other forms of intervention have been considered as a way perhaps of prolonging drug effects.

             b. Non-responsiveness to medication

A significant number of children and adults with ADHD fail to respond to stimulant medication (Safren et al., 2005). These significant sub-groups of those with ADHD have legitimate interventional needs.

Weak responsiveness of ADHD symptoms to medication of those children who do respond to medication, the improvement may not necessarily bring them within the clinically normal range (Pelham & Murphy, 1986) and so, even if medication has some beneficial effects, there may be a need to enhance them.

              c. Intolerance to medication

A significant number of children and adults with ADHD may be intolerant to stimulant medication. Side effects of stimulants can be significant and interfere with treatment adherence or cause treatment discontinuation. Side effects sometimes occur only in the early stages of treatment as they may be removed by adjustments to dosage. However, Schachar and colleagues (1997) found that 15% of children treated with methylphenidate terminated treatment at 4 months because of side effects. Therefore, an alternative or complementary psychological approach is needed.

            d. Ethical and other objections to medication

Even if medication has proved to be a complete solution; some professionals, parents or careers and children and adults with ADHD have objections and ethical concerns about the use of medication (Perring, 1997). The use of psychotropic medication in children makes unhappy in different reasons. The concern is about not only possible side effects and long-term harms, but medication may take away individual responsibility for problems. It makes in an unease that the focus of treatment should be solely on the child instead of the interface between them and the social and educational systems of which they are a part.

These all are global truth and they might be true in Ethiopia. Even though there are hardly studies on this issue in Ethiopia, it can be observed empirically that behavioral intervention of ADHD is preferable due to the following reasons in addition to the above stated limitation of pharmacological treatment.

1. It is not easy to get and prescribe pharmacological treatment in Ethiopian situation due to inaccessibility of mental health institutions and drugs.

2. Behavioral treatment involves; the society, family, and parents, which seem too much appropriate to the culture of Ethiopia, having extended family living together, help each other etc. Behavioral therapists also need this type of relationship to develop effective social skill and treat children who are with ADHD.

3. Behavioral intervention assures the effectiveness of treatment, since participants are found in the immediate environment of the needy and it makes easy the follow up activity. Moreover, parents are eager and committed and work hard for the long-term betterment of their children.

Due to all these facts advocated worldwide and the existing situations in Ethiopia non-pharmacological intervention, particularly behavioral intervention should get attention and encouraged for the long-term effective treatment of ADHD.

              

Although there are many types of behavioral interventions /therapies/, the three main types used to treat ADHD effectively are cognitive behavioral therapy (CBT), social skills training and family therapy.

               [ 

        6.2.1 Cognitive Behavioral Therapy

Cognitive Behavioral Therapy approaches that are relevant to the treatment of children with ADHD include; behavioral therapy, parent training and cognitive therapy. CBT techniques have been extensively used with the aim of helping to improve motor behavior, inattention and impulsivity. CBT helps clients understand links between; thoughts, feelings and behaviors and how these may result in unhelpful, inappropriate or maladaptive consequences. Cognitive behavioral therapy includes:

 a.Behavior therapy: The chief technique involves the use of rewards or reinforcers that are judged likely to encourage the young person to implement targeted changes in motor, impulse or attentional control. This may involve tangible rewards such as extra time for recreational and leisure activities or the means to obtain items that the young person values. For younger children, schemes using ‘tokens', (such as stars, chips, marbles etc) in their own right may be rewarding. For older children tokens may be exchanged for items of value to them. Another type of reward is social approval such as praise or achievement certificates and this may include self-praise.

Care is required in the choice of rewards because they may be specific to an individual-what is of value to one child is not necessarily of value to another. There are also practical, financial, cultural and moral issues that make some rewards more suitable for some parents than others do.

A further set of techniques involve negative consequences. Although less frequently used than rewards, this approach may have a valuable function, especially where a particular behavior is disruptive or offensive to others and needs to be stopped immediately impulsive behavior frequently falls into this category. Verbal reprimands, which have the merit of being simple and effective, may be delivered by parents, other careers and teaching staff. Response cost techniques involve the loss of potential reinforcers. These can take the form either of deductions from rewards already earned or from an agreed set of rewards given in advance but from which deductions can be made for inappropriate behavior.

The third most common technique is ‘time out' (short for ‘time out from social reinforcement'), which involves the young person being placed away from the psychological interventions and parent training attention of others for a set period during which time they are expected to be quiet and co-operative, otherwise the procedure is implemented again. This particular approach is helpful where it is felt that inappropriate, overactive or impulsive behavior is being maintained by the attention of others such as parents, siblings or peers.

 b. Parent training:  It is also called parent-effectiveness training. Teach parents the techniques of behavior therapy so that they will execute on their children. The intervention has developed further into addressing issues such as beliefs, emotions and wider social issues along with issues that hinder the effectiveness of parents such as poor self-confidence, depression, social isolation   and marital difficulties (Scott, 2002).

The main goals of parent-training programmes are to teach the principles of child behavior management, increase parental competence and confidence in raising children and to improve the parent/career-child relationship by using good communication and positive attention to aid the child's development. The curriculum is set for several weeks, structured and they are mainly conducted in groups, but can be modified for individual treatments.

 c. Cognitive therapy: Self-instructional training is probably the most commonly used cognitive therapeutic approach in the psychological treatment of ADHD. It comprises several different techniques, including cognitive modeling, self-evaluation, self-reinforcement and response cost.

The therapy involves helping the young person develop a more planned and reflective way of thinking and behaving by learning how to adopt a more reflective, systematic and goal-directed approach to tasks and problem solving. The learning strategies typically involve abstract self-instructional schemas along with more concrete systematic approaches and perhaps physical cues and reminders.

An early example of teaching an abstract strategy was the ‘Think Aloud' programme by Camp and Bash (1981) based on ideas by Meichenbaum (1977), Meichenbaum, and Goodman (1971). Children are encouraged to adopt a four-point schema when faced with a problem or task:

1. What is the problem?

2. What is my plan?

3. Do I use my plan?

4. How did I do?

The strategy is taught initially using cognitive modeling involving an adult verbalizing their response to a problem-solving task. The young person then emulates psychological interventions and parent training this first by talking out aloud, then whispering and finally using covert (inner) self-talk. Self-evaluation is then encouraged.

         6.2.2 Social skills training

Social skills training was developed in the early 1970s and according to Jacobs (2002) its aim is to teach the micro skills of social interaction such as eye contact, smiling and body posture. Children and young people who have ADHD often present with difficult family relationships and may have poor social skills and peer relationships. Social skills are described as the behaviors and skills necessary to engage in developing and maintaining constructive social relationships. The techniques of social skills training are from cognitive and behavioral approaches and are conducted within groups.

In addition, the concern of social skills training and problem-solving approaches is to develop the child and young person's ability to self-regulate and cope with stress (the ability to self-regulate responses to perceived stressful events) (Compas et al., 2002).

        

             6.2.3 Family therapy

The practice of family therapy depends on the recognition of interpersonal relationships within families. Family therapy aims to produce changes in the ways that families function. The British psychologist society ADHD guidelines and management 2009, summarizes different researcher's models of family therapy as follows:

a.Structural family therapy is based on the assumption that all well-functioning families have an intergenerational hierarchy with demarcated roles and boundaries. The role of the therapist is to challenge family functioning and difficult interpersonal relationships, and thereby enable family disorganization to be resolved.

1. b.   Strategic family therapyis based on the view that difficulties stem from repeated patterns of dysfunctional family communications.
   1. c.    Brief solution-focused therapy focuses on when the problems are not evident or less problematic in order to examine what is different about these interactions to prove that the family already possess the solution.

 6.3 COMBINED INTERVENTIONS FOR CHILDREN WITH ADHD

Although pharmacological and non-pharmacological interventions are each important disjointedly, there are several reasons why non-pharmacological /psychological/ intervention might be combined with pharmacological intervention. TheBritish Psychological Society guidelines and management of ADHD, (2009) summarized and presented the findings of different researcher's reasons as follows:

ü  In severe presentations of ADHD, the impairment is such that medication when combined with psychological therapy might offer the prospect of a more rapid improvement than with psychological interventions alone, which are likely to take longer to work. This may be particularly necessary if there is marked social dysfunction present, if there is severe pressure on family or marital relationships or if the child is faced with imminent exclusion from school.

ü  Even if a psychological intervention is the preferred option, some young people have such severe clinical presentations that they and/or their parents may not be in a position to make use of psychological techniques. The potential for medication to deliver an initial rapid improvement in the early weeks of a combined intervention might enable them to benefit from psychological techniques.

ü  It has been argued that stimulants may enhance conditionality, a key element of behavioral learning. In other words, stimulants may enhance the effectiveness of psychological interventions that employ behavioral and social learning principles.

ü  Combining stimulants with a psychological intervention may be a way of reducing the dosage and duration of medication treatment, and thus may address concerns about the use of medication.

ü  It has been suggested that there may be complementary benefits in combining approaches in that stimulants may enhance attentional processes and reduce impulsive responding, whereas social reinforcement may help the child to internalize the value of appropriate behaviors.

ü  There is little evidence that stimulant medication alters the relatively poor long-term outcome for many of those with ADHD. Adding psychological and other therapies might therefore yield better long-term outcomes.

Due to these and other unstated reasons, interventionist advocates the use of both intervention mechanisms in combined form. However, it might not be necessary to use both mechanisms at all times. Rather it depends on the disorder under consideration. When the condition demands the use of both mechanisms in complementary form makes interventionist effective.