A Case Study on Hyperactivity (HD)
by Marina Tonti (Nov, 2008)
In this essay, I will discuss a fictional case study of a 7 year old child who was diagnosed with hyperactivity since the age of three and a half, and I will suggest methods of treatment. It is important to note, that John1 is receiving medication (Ritalin) and it is stated that he does better at school. Hyperactivity disorder is a combination of overactivity and inattention. The symptoms may vary from restlessness, disorganized behavior, inattentiveness, as well as impulsive, and impatient excitability. The boys usually tend to be more restless and the girls more inattentive or daydreaming.
The above symptoms are handled as one disorder and it is called ADHD, thus combining the Hyperactivity Disorder (HD) with the Attention Deficit (AD). Furthermore there is a great controversy as to if we should consider Hyperactivity a main condition, or if it is simply a symptom of another disorder. A child with ADHD has difficulty finishing any activity that requires concentration, doesn't seem to listen, is impulsive and restless at home and in class, and is impatient during games or in groups.
According to the research criteria edition of (ICD-10), children under the age of 7 are diagnosed with hyperkinetic disorder, if for at least six months, they show ten or more signs from a list of inattentive, overactive, and impulsive symptoms. It is sometimes difficult to diagnose, that a child is suffering from ADHD, because there is not really any evidence of neurological differences, or the criteria of diagnosing the disorder are too broad (Hill et al,1999).
The fourth edition of the American Psychiatrist Association’s Diagnostic and Statistical Manual of Mental Disorders characterizes ADD symptoms as attention problems, low self esteem, difficulty in sticking with a task, and problems in group situations when attention is required. It is also suggested that there is a connection between depression and ADHD (Seitler, 2006). Further research presents that the capacity for children to self regulate, is depended on complex feedback mechanisms of the infant –carer relationship (Shackleford, 2003).
It is interesting that when an individual with ADHD is presented with an attentional task, such as reading or mathematics, his/her electroencephalograph (EGG) usually shifts down to slow frequency (theta), in comparison with an individual without ADHD that his/her EGG shifts to beta frequency. Research over the last 30 years has proven that ADHD children have a surplus of slow wave activity, and a deficiency in alpha and beta wave activity. The slow frequency activity is related to unfocused thought, mental wandering and nonvigilance.
Some of the causes of ADHD are suggested to be chemical imbalance in the brain, exposure to toxins during pregnancy or during childhood, genetic abnormalities, complications during pregnancy, such as oxygen deprivation, low birth weight, low Omega-3, smoking and/or alcohol use during pregnancy, metabolic circulatory and electrophysiological abnormalities. In addition ADHD has been associated with dysfunction in dopaminergic and possibly noradrenergic cortico-subcortical networks related to executive functioning and regulation of behavior. Children with ADHD appear to have a dysfunction in the central nervous system by a maturational-lag, or cortical underarousal. Noting all the above neurophysiological factors, ADHD is considered a psychiatric disorder diagnosed on the basis of behavioral evidence. The primary treatment for ADHD is medication Ritalin (methylphenidate) (Fox, 2005).
Besides Ritalin, other medications are also subjected for treating HD, such as amphetamine mixed salts and atomoxetine (Bilkey, 2008). Other studies of comparing the clinical efficacy of Ritalin or Equasym XL with placebo in children with Attention Deficit/Hyperactivity Disorder proved to be superior to placebo in reducing the ADHD symptoms. (Findling et al, 2006).
But there has been a controversy about the definition and classification of the disorder as «hyperactivity» for some years (Prior et al, 1986). Actually some researchers denied that Hyperactivity is a disorder, or even that medication is successful for its treatment. Breggin (1991) was among the first ones to attack and reject the trend to medicate. He condemns the damage done to those children and adolescents, whose only crime may be excessive enthusiasm, energy and exuberance. He excoriates researchers who dehumanize children, and calls Ritalin a cruel and unusual punishment. Other studies suggest that ADHD is nothing more than a childish moral panic (Leger, 2003).
Walker (1998), a neurologist and a psychiatrist, says that hyperactivity is a hoax perpetrated by doctors who have no idea what is really wrong with those children. Furthermore there are no standard research diagnostic methods for preschoolers such as psychometric data or diagnostic instruments. The FDA (Food and Drug Administration) of USA, has reported its concerns about Ritalin: there is no adequate research on Ritalin, normal kids are being drugged, it does not address the etiology of ADHD, and long term use of amphetamines can produce addiction (Bratter, 2007).
Therapists should not be «pill-pushers» and individuals with various issues should not long for their «next fix». Instead both the therapist and the patient should cooperate so as to the latter gain effective control over her/his life. Otherwise, the physicians will not be helping people to overcome a problem but instead they would provide them in many ways, with new and more dangerous problems (Jones et al, 2005).
It is frightening that health professionals with years of experience are pressured to use drugs because the prevalent belief has changed from providing psychotherapy treatment for problems related to psychosocial difficulties to the idea that problems are of chemical imbalance or faulty inner biochemistry. Besides no physical, mental or genetic test exists for diagnosing ADHD. Moreover, the use of psychostimulants have many side effects as tics, insomnia, headaches, edginess, increased pulse and blood pressure, delayed growth, as well as other debilitating neurologic sequels. Also cases of acute and chronic amphetamine psychosis, mania and depression are reported. Preliminary analysis of millions of medical records suggested risk of strokes and arrhythmias, as the chemical structures of the stimulants are similar to drugs like ephedrine (Seitler, 2006).
Some other studies though argue that untreated youths with central nervous system stimulants such as Ritalin, were three times more likely than their medicated peers to abuse substances during adolescence (Perina, 2002).
Up to date, there is no medication found that creates long-term improvement with ADHD, and once the medication is ceased, these children will return to their original level of deficit.
Several studies have shown long term sustained benefits and significant improvement on behavioral and neuropsychological measures of EEG neurofeedback or biofeedback. Neurofeedback works to help the patient modify the brainwave activity in order to improve attention, reduce impulsivity, control hyperactive behaviors and produce long –term change. Operant conditioning techniques are utilized to reinforce specific types of elelectrophysiological activity for treating ADHD. Patients are provided with a visual and auditory «feedback» for certain neuronal responses which showed improved attention and reduced hyperactive behavior. After comparative studies between the neurofeedback method of treatment and medication Ritalin, it was found that neurofeedback is an effective tool for treating ADHD. In order to have a sustained long term change, neurofeedback may require up to 60 sessions or 6 months of treatment (Fox, 2005).
Choice Theory (CT) and Reality Theory (RT) have also been proven a lot more effective than Ritalin to the treatment of ADHD. Choice Theory proposes that we are responsible for our choices and the ways we deal with what happens to us. Reality Theory proposes that we can determine what we want, what we are doing, and whether or not it will be working. CT and RT have an internally controlled motivation and value system that requires for the individual to take responsibility for their own actions to form goals, execute plans and value of their action and thinking (Jones et al, 2005).
Other studies point out, that Ritalin is often prescribed to soothe the parent’s anxieties, conflicts and exasperation, with their difficult children, irrespectively of the accuracy of the diagnosis, the long-term side effects of the drug, the needs of the children and the possibility of benefiting a lot more through psychological therapies (Pozzi, 2000).
Research done on the etiology of the disruptive behaviors has showed that studies using neuroimaging, identified certain structural cerebral anomalies in some of these children (Wallace, 2005).
It is also reported that parents of children with ADHD display higher levels of authoritarian parenting styles, and less parenting satisfaction than did normal controls. At the same time, social systems that are more tolerant to inattention, overactivity and impulsivity, and which offer structured and supportive opportunities, help adolescents vulnerable to ADHD to develop self regulating skills (Lange, 2005).
Although there is a controversy as to the etiology of ADHD, and what would be the best treatment, the bottom line remains, that it is of great concern that the needs of these children are not looked upon, and there is no government scheme to support them (Wallace, 2005).
The following suggestions are based on my personal understanding on the how a child with HD should be treated, and my point of view is supported by the previous literature review. In order to assist a family in coping with a child that has a special need, we need first of all to comprehend, what this special need is, how it could be healed, if there exists a way to be healed. Once we have done an investigation on the subject in a holistic matter, taking into the consideration, most of the updated research done on the subject, we need to educate the family, and communicate with the child’s school, how to properly handle the situation, in order to minimize the child’s sufferings, and to assist child’s intercommunication and daily activities.
Most of the sufferings we experience, which may be either personal sufferings, sufferings caused by other family members or relatives, or even sufferings caused from the interaction with our social environment, exist mainly because we are lacking the proper and holistic education and comprehension on those subjects, responsible for causing our suffering. If we, as society, contemplated over our problems in a satisfactory level, investigating, analyzing, experimenting, and exploring holistic and humanistic approaches of healing, lots of today’s sufferings would not exist anymore.
When the disorder is noticed on a child, in comparison to an adult, it is harder to confront with the matter, as the child cannot do psychotherapy, and analyze mentally his thoughts and feelings, in order to obtain control over the situation, or bring an order to his/her life.
In this case study a 7-year old boy, is diagnosed with hyperactivity since the age of three and a half, and he is taking prescribed medication (Ritalin) in order to cope with his family, school or social environment. We are informed that his parents are divorced, and his mother, with whom he lives with, seems to be frustrated, and confused how to handle properly her child’s hyperactivity issue. Actually, in a family system, in order to heal a disorder experienced either in a child’s behavior, or even in the relationship of the child with the rest of the family, it is important to start our research, by exploring the psychological state that the mother in the family is experiencing.
In most situations, when a family is out of order, is due to the Mother of the family being sick. Unfortunately if the mother is not capable to keep the members of the family together, sharing healthy feelings with one another, the whole family tends to fall apart. Mothers of children with disorders, might feel frustrated, and might even experience manic/depressive episodes or long lasting depression symptoms, which makes it hard for the whole family to function, when the head of the family (the mother) is experiencing a psychological disorder.
Thus, in order to assist a child with a special need, we need first of all to assist his family environment and especially his/her mom. We need to have a session with mom, and investigate how much she is willing to explore her feelings, and understand that her child will be helped very much, when she will help herself, to take control over her life, and feel happier with her life, choosing the gift of life instead of suffering. A child is always very much emotionally attached to what his/her mother is feeling, and if the mother is feeling happy, the child learns to get satisfaction from his/her life too.
The child especially in the early years, copies his/her parents’s behavior, and it is important for the parents to feel happy in order to give their child, a good example to look forward to. If the mother is willing to explore her feelings and even make a commitment to heal her hurt feelings, due to probable past traumatic situations or inner complexes, certainly the child will be greatly helped. But if the mother is not willing to look deep down inside her, and make those changes, then we need to try to find another person, in the family system, that will be willing to assist the child, by acting as a «guide» or a «parent substitute» to the child’s maturing and growing. In this case study, little John, seems to be attached to his grandfather, and looks upon him as a father figure, in the place of his missing father. His grandfather is like a father to little John, and they seem to have a healthy relationship between them.
So, one suggestion that could be made is for John to spend more time with his grandfather, as this relationship would assist John to heal his frustration and the anxiety that he is feeling, that may be contributing to his hyperactivity. His grandfather also did not agree, with prescribing medication to little John, and that is a relief, as the above studies has shown that we should avoid drugging people and especially little children, as the prescription of medication is not for treating the child, but for relieving the parents, from extra duties, concerns, or responsibilities.
I actually consider it an immoral act, to drug a little child, taking into consideration, all the above side effects proven through research. So we could explore solutions with the aid of the grandfather, in order to ease down little John’s frustration and slowly cut down the medication, to total extinction. Another person that we should talked to, is little John’s father, who seems to have distanced himself from the family.
It would be nice to try to discuss with him the situation of little John, as to analyze his feelings about the situation, and his part in the responsibility of helping his child ease out his disorder. If his father is willing to cooperate, that will be a great help for John, as he will get the chance to be seeing his father, and thus balance out his feelings of missing him, in the family.
A schedule could be arranged, with the father taking out John, so John can be creative with various activities that will give him pleasure to explore with his father, and release much of his frustration or energy surplus. John’s father and grandfather could be a very useful aid, in order to help John, balance out the need of a father figure, in a single parent family, and also help greatly in the task, of taking some of the burden out of the mother that is taking care of John alone.
Next we should visit John’s school environment and talk to the teacher about how hard really is handling John’s behavior in class, and if some days it is better than others. Also suggest on giving out to John more activities to do, than other children, so he can spend much of his energy in being creative. It could be simply that the child has just a different rhythm of activities than other children in his age, and a special schedule might be needed to be made for him, in order to spend out as much of the energy surplus he has.
A good investigation should be made in the particular society, if there are any other special schools or extra curriculum activities that John could attend, in order to try to work out his hyperactivity (his energy surplus) and learn to cope with it in a constructive manner becoming educated trough creative games or art therapy. Last but not least, we should talk with John, asking him, how he feels, if there is anything that troubles him, or bother’s him, if there is anything that he would like it to be different. After talking with John, and understanding more of his needs, we could arrange a meeting again with his family and his school environment, in order to make the appropriate adjustments if necessary, so that John’s environment, become even more comfortable and a lot friendlier.
After working out one by one all these adjustments, we should be able to diminish or simply «creatively redirect» John’s hyperactivity, so as there would be no need finally for taking the medication, which would be slowly cut down. Thus in the end, John as well as his family and school environment, would be educated properly in understanding as well as handling John’s hyperactivity disorder, and John would have learned that he was born actually with a great gift, that gave him the ability to be a lot more energetic or even more creative than the average children. A gift that had to learn how to cope with, how to manage it properly so that it will not be an obstacle anymore in his life, but instead it could turn out to be a very useful tool, that could give him, and his family, a lot of pleasure in life.
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1 John is not a real name but it is used as an alias for the purposes of discussing this fictional case study.
