ADHD - Review of Literature - Effects on Development Within Family, Education, and Social Systems

Attention Deficit Hyper Activity Disorder according to Singh (2002) is a developmental disorder that is brain based and most often affects children. This developmental disorder can be characterized as a disorder in which affects ones self control; primary aspects include difficulty with attention, impulse control, and activity levels usually diagnosed prior to the age of 7yrs. of age (Willoughby, 2003).

There are primarily three sub-types of ADHD. Inattentive sub-type 1 is ADHD which those who manifest inattention without the presence of hyperactivity and impulsivity (Barkley, 2005). There is also ADHD sub-type 2 with symptomolgy related to hyperactivity and impulsivity (Barkley, 2005). Finally there is ADHD combined sub-type (Visser & Lesesne, 2005). For the purpose of my paper, I will utilize information that represents all subtypes in various degrees and the affects of these difficulties upon the individual, educational, family, and social development as well as issues of social justice and cultural issues for those children who suffer from this disorder.

Historically the modern symptoms of ADHD were first identified (Barkley 1996, Rafalovich 2001, & Stubbe 2001), by English physician George Still in 1902 (Neufeld & Foy, 2006). Rafalovich (2001), explains that in a series of historical events from 1917-1918 in North America that led to an encephalitis outbreak there was a dramatic increase in research of characteristics that are similar to modern day ADHD symptomology. Through out the early years of research there was even research and investigations into medical conditions which promoted swelling in certain aspects of the brain, which many believe led to impulsivity and hyperactivity (Stubbe, 2000). As research evolved so did the diagnostic criteria for the disorder; shaping identifiable factors believed to contribute to the causation of ADHD (Barkley, 2005). Physiologically, there seems to be less dopamine and nor-epinephrine within the brains of those with ADHD and four genes that regulate dopamine have been identified as ADHD causal agents; however a definite causal agent has not been confirmed (Barkley, 2005). Brain activity is considerably lower in the pre-frontal lobe regions in those with ADHD and there is also decrease in blood flow (Hans, Henricksen & Bruhn, 1984), (Barkley, 2005). According to Barkley (2005), psychological characteristics of ADHD are that it is about the "behavioral inhibition." These children do not benefit from what may happen later based upon what they do now; which can be compared to a "time near sightedness", (Barkley, 2005). They have difficulty identifying their past, preparing for the future, organizing, scheduling, and working independently, with social and occupational issues (Barkley, 2005). It is these difficulties when intermingled with the development of the individual that could clearly cause great difficulties especially when enrolled in formalized schooling and onward into the demands of school and adulthood.

The prevalence rates regarding the diagnosis of ADHD has been from ranges of 4 % to 18 % depending upon the community, types of populations, and areas of analysis (Visser & Lesesne, 2005). ADHD is one of the most common childhood disorders with 2.5 million children with this disorder (Barkley, 2005). Estimates show (Biederman, 1996), that nearly 6 % of boys and 1.5 % of girls have ADHD (Singh, 2002). It cost nearly 3.3 billion dollars to medically treat ADHD every year in the United States (Visser & Lesesne, 2005). Currently causation factors under consistent follow up according to Barkley (2005) include;

1. Genetics

2. Premature Birth

3. Traumatic Brain Injury

4. Spine and Brain Infections

5. Early exposure to substances during pregnancy

6. Early exposure to lead

7. Less blood flow and lower brain activity

Because ADHD is a representation of physical imperfections within the brain and actually manifests a decrease of activity in the pre-frontal lobe regions; certain treatment options with amphetamines, stimulants and non-amphetamines have been utilized to increase brain activity (Barkley, 2005). The size and anomalies within the brain have been verified and examined through many technological processes such as Positron Emission Tomography and MRI scanning (Vance & Luk, 2000). Other physical abnormalities of development according to Barkley (2005), include appearances of slight deformities including; longer than average index finger, third toe that is longer than second toe, ears that are slightly lower upon the head, no earlobes or a furrowed tongue. Up to 80% of children suffering with ADHD will continue to struggle with this disorder into adolescents and as many as 50 to 60 percent will continue to struggle into adulthood (Barkley, 2005). With the affects upon a child's school, family, and social environments a large emotional toll can be identified. Emotionally, children can feel isolated, angry, guilty, frustrated and many other emotions due to the disruption of relationships, opportunities and lack of clear decision making skills (Barkley, 2005). Many of these children can become depressed and exhibit anxiety (Barkley, 2005). Many affective behaviors include stubbornness, defiance and at times can be verbally or physically violent to others (Barkley, 2005).

According to Barkley (2005) nearly 57% of preschool children are likely to be rated as inattentive and over-reactive by their parents up to the age of four. As many as 40% according to Barkley (2005), may have these problems for up to three to six months, concerning parents and teachers. According to Lavigne, Gibbons, Christoffel, Rosenbaum and Binns (1996), however, it is estimated that 2% of preschool children truly meet the criteria for ADHD, and (Biederman, 1996), clarified that possibly 10 % of all children meet diagnostic criteria for ADHD (Singh, 2002). Barkley clearly indicates that the earlier the symptoms of ADHD appear and the length of time they last in childhood will determine the severity of its course and prognosis (Barkley, 2005). Individually there are many distressing problems for children suffering from this disorder. Some features that Barkley (2005) indicate are important to recognize as the individual child develops into school age include;

1. An emergence of high demanding ness of preschool age

2. Critical directive behavior by parents to control circumstances

3. Problems reported by preschool / formal school staff regarding child's behavior

4. Problems with learning and reading

5. Decisions to withhold a child an educational grade

6. Excessive temper tantrums / difficulty in getting child to do chores

7. Social exclusion from activities

According to Spira & Fischel (2005), within the pre-school environment at the age of 3 yrs. old, children's attention controls, and self control mechanisms begin developing. Increased self control and speech development continues from age 3yrs. old (Spira & Fischel, 2005). Self control processes continue to well develop through the age of 4yrs. old (Spira & Fischel, 2005). These processes work together allowing the child to maintain self-control and through 4 yrs. of age the child develops the ability to direct attention to relavent environmental stimuli (Spira & Fischel, 2005). Together, the maintaining of attention and control over responses emerges and of course is very important in identifying task's and working functionally within the educational environment, however; these processes indicated do not emerge for those with ADHD due to the manifestation of hyper-activity and impulsivity around the age of 3 to 4 yrs. of age, and inattention manifesting near 5 to 6 yrs. of age (Spira & Fischel, 2005). As children develop into school age and adolescents, Barkley (2005) indicated that 30 to 50 percent of children will be retained one grade during their school years. According to Vance & Luk (2000), 20 to 30 percent of children with ADHD will manifest comorbidity with learning disorders; reading, arithmetic, writing or spelling. If a child is diagnosed with ADHD and Conduct Disorder the percentages increase for a co morbid learning disorder (Vance & Luk, 2000). One theoretical position (Velting & Whitehurst, 1997), is that according to Spira and Fischel, (2005) those children with ADHD do not acquire the literacy skills necessary for early reading and learning. Furthermore, it is hypothesized that the frustration due to lack of ability perpetuates acting out behaviors consistently witnessed by school staff of children with ADHD (Spira & Fischel, 2005).

As children move through adolescents it is abundantly clear that with vast developmental changes; finding ones role identity as clarified by Eric Erickson (Berger, 2006), relational dating, peer pressure, and other demands of adolescents become extraordinarily difficult with individual difficulties of impulsiveness, hyperactivity and inattentiveness (D. Moilanen CMSW, Personal Communication, January 25, 2007). According to Gordon (2006), adolescents continue to have many difficulties especially;

1. Disorganization

2. Planning long term assignments

3. Completing homework

4. Complying with parental rules.

5. Sustaining attention and focus

Because adolescents are seeking to find a competent and healthy identity, conflicts with parental and academic systems can leave an adolescent to feel diminished, angry and frustrated before the entry into adulthood (D. Moilanen CMSW, Personal Communication, January 25, 2007).

Adulthood brings new challenges and according to Jaffe, Benedictis, Segal & Segal, (2006), the following are just a few of the challenges for adults living with ADHD;

1. Managing money

2. "Zoning out in conversations"

3. Speaking without thinking

4. Procrastination

5. Becoming easily frustrated

Eric Erickson in Berger (2006) clarifies his theory of Psycho-Social Development and indicates that as early adults we want to find intimacy or we will face isolation. It seems clear that these adults due to their disability will continue to confront difficulties with their families, social relationships, and negative individual perceptions onward into adulthood. These difficulties could place them at risk to become isolated.

The individual within their family is greatly impacted by this developmental disorder. According to Barkley (2005) ADHD is 25 to 30% acquired by heredity, and if a parent has ADHD the child is 8 to 10 times more likely at acquiring the disorder. Barkley (2005) also indicated that parents at the beginning of preschool attend and manage their child fairly well, however; parents tend to lose what they feel as control over their child the further the child develops through school. Parents can feel drained, overwhelmed and exhausted; even feeling depressed, and begin blaming themselves for their child's behavior (Barkley, 2005). Over time these difficulties can lead to perceptions by parents that may be less than positive (Maniadaki, Sonuga, Kakouros, & Karaba, 2006).

Research shows that parental perceptions within the family can clearly have implications regarding how a child is treated and the negative affects and perceptions that affect the child's developmental stages (Maniadaki et al., 2006). According to Maniadaki et al., (2006), parental perceptions do have significant impact upon children suffering from ADHD due to the likelihood of the parents not obtaining mental health services for their children; the difficulty parents had identifying the impact the child's behavior would have on the child's development; and the parents inability to identify the severity of the child's symptoms, all have dramatic affects on the child's developmental processes. Siblings can also have negative perceptions of the child's behavior, affecting the degree of support siblings bring to each other within a family. According to Gordon (2006), siblings can feel sorry for their sibling with ADHD or they can get angry and resentful. These reactions create dynamic challenges for any family and or individual dealing with ADHD. Other possible hindering perceptions by parents within the family system can be identified by comparing Erickson's, Psycho Social Developmental Perspectives (Berger, 2000). According to Erickson, children from the age of 3 yrs. old to 6 yrs. of age will develop through a series of challenges to parents, taking the "initiative" or "failing," bringing feelings of "guilt" (Berger, 2000). When the child's challenging behavior takes place however, as Camparo, Christensen, Buhrmester & Hinshaw, (1994) states, that parents may not allow these children to have the benefit of the doubt, due to past excessive behavior under normal circumstances, and the parents may see their child as an "easy target." According to the evidence, miscalculating the child's natural challenging behavior could take place and disallow the child to develop in a healthy, "guilt free" way, having significant affects on their psycho-social development. Excessive amounts of guilt can produce significant amounts of anxiety and depression (Burns, 1990). These negative processes in variable degrees can clearly lead to negative affects on social and emotional processes (Burns, 1990).

Other family processes affecting ADHD and development according to Peris & Hinshaw (2003), is that core symptoms of impulse control and inattention are primarily heritable, and parental practices do not warrant significant (Barkley, 1998; Hinshaw 1994; Johnston & Mash, 2001), causation for ADHD. However, the family interaction patterns and external influences may have a significant impact on severity and the developmental course of ADHD (Peris & Hinshaw, 2003). Furthermore, evidence suggests (Barkley, 1985; Battle & Lacey, 1972; Buhrmester, Camparo, Christensen, Gonsalez, & Hinshaw, 1992; Campbell, 1973; Cunningham & Barkley, 1979; MacDonald, 1988; Mash & Johnston, 1982; Tallmadge & Barkley, 1983) that mothers of ADHD children are less affectionate. Other disturbing findings indicate that parents can be more critically demanding and parents independently report a greater tendency to blame their ADHD child for problems they actually had with their spouses; thus proving further that family systemic patterns can play a major role in the perpetuation and affects of ADHD upon child development (Camparo et al., 1994). Of course these processes clearly affect a school-age child within their families and external systems in ways which reduce a child's self worth, confidence, and abilities to properly interact and function within their environment; proving this, Dumas & Pelletier (1999) indicated that pre-adolescents were found to have lower levels of self esteem in areas of scholastic competence, behavioral conduct, and social acceptance.

According to Barkley (2005), those with ADHD, at times do not give themselves time to evaluate their emotions objectively before a reaction, fail to separate their feelings from fact. Being able to internalize our emotions, evaluate them, and analyze them before displaying them publicly assist in self control and is difficult for those suffering from ADHD (Barkley, 2005). Those who suffer from ADHD develop a pattern of social rejection due to inappropriate interactions beginning during formalized schooling according to Barkley (2005). According to Nixon (2001), those children suffering from ADHD lack significant social skills that affect the quality of their interactions, such as; verbal & physical aggression, disruptive attempts to enter new groups, negative classroom behaviors, being quick tempered and violating the rules. Nixon (2001) presents more evidence that social cognition is clearly affected and children with ADHD can have great difficulty in making clear interpretations of their environmental interactions with others. These variables clearly lead to inhibited social contact, and a dysfunction in psycho-social development. According to Eric Erickson in Berger (2000), he clearly indicates that formalized school age children from 7 to 11 years old need to develop confidence that allow them to feel as if they have mastered "Industry" (Berger, 2000). If this stage is not mastered, they may feel inferior (Berger, 2000). How can these children who are excluded due to their ADHD manifestations of behavior, be given the chance to participate and prove themselves to resist negative aspects of "Inferiority?" As these children develop into adolescents and adults, one can hypothesize when comparing ADHD behavior and social reactions with the Erickson Psycho-Social Framework (Berger, 2000). Erickson states that adolescents attempt to find their roles in the world and if they fail, role confusion develops (Berger, 2000). Confusion for those suffering from ADHD would come easily due to their exclusion from social groups and activities (Barkley, 2005). In order for adolescents to find their role and their identity; they must interact with others and feel accepted in their participation (Berger, 2000). Further into adulthood Erickson in Berger (2000), indicates that as adult's, individuals will seek intimacy with others or become isolated. The factor of isolation relates to the extent in which those developing fear rejection and disappointment (Berger, 2000). Unfortunately, prior social experiences of those suffering from ADHD can be littered with social rejection, feelings of disappointment and unacceptance due to impulsiveness and hyperactive behaviors (Barkley, 2005). Furthermore, (Pope, Bierman, & Mumma, 1999), these authors according to Nixon (2001), also claim that hyperactivity and the inattentive / immature nature of a child's behavior with ADHD contributes greatly to interpersonal problems.

In regards to social justice and cultural issues; according to Bender (2006), African American children may be under represented and under diagnosed in regards to ADHD. Experts such as (Dr. Rahn Bailey, 2006) according to Bender (2006), claim that as science is pursuing new technological processes to diagnose and treat ADHD, cultures like the African American community are subjected to propaganda, suspicion due to past and current discrimination, and negative stereotyping regarding mental illness; thus forming cultural decisions to avoid diagnosis and treatment of ADHD. This cultural-lens, based upon discriminatory and fear based experiences with the dominant culture dis-allows ethical decisions to help and assist African American children (Bender, 2006). These decisions according to experts (Bailey, 2006), is contributing to high rates of African American children disproportionately over represented in remedial programs and disproportionate amounts of African American children over represented in the criminal justice system (Bender, 2006). The issues of classism and impoverishment can also be a topic of concern regarding those who suffer from ADHD. According to Visser & Lesesne, (2005), ADHD diagnosis among males was reported significantly more often in families with incomes below the poverty threshold than in families with incomes at or above the poverty threshold. Here again, poverty makes a clear and consistent statement of risk for our developing children.

In conclusion, I believe that ADHD seems to be an elusive, devastating, developmental disorder. This disorder for my self is so destructive because of its manifesting elements of hyperactivity, impulsivity and inattentiveness. These variables are processes that if represented to certain degrees are perfect for destroying social, educational, emotional and individual development across the life span. Because our lives are so dependent upon not just our biological construction but also our social and environmental interaction; this disorder can be serious and detrimentally disruptive. I do however believe that new technologies are hopeful in understanding this disability in greater measures. I also have gained ideas regarding the new information regarding neuro-plastisity and the changing mind based upon therapeutic thought. I feel this may be a possible frontier of research that should be a priority in better understanding how the brain can change forms; especially the pre-frontal cortex regions.