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Chapter 9

Understanding ADHD: A Primer for Care Providers

Freeman M. Chakara Psy.D, ABPP-CN

Matt, a 17-year old high school senior, sat nervously between his parents as his father,

Paul, asked me what I thought was the cause of his son’s apparent behavior problems. His

mother, Joanne, nodded her head in agreement, sharing the same level of frustration as did her

husband. Before I could muster a response, Matt literally jumped out of his seat and ran out of

the office into the adjoining waiting area where he poured himself a cup of coffee and darted

back into my office. He slumped into another couch, stretched out his legs and started stirring

his coffee. Paul continued, “This past weekend I asked him to mow the yard. When I got back

home, three hours later, the grass was half-mowed, the mower was left unattended, and Matt was

nowhere in sight. I later found him at a nearby skating park, playing with some kids.” At this

point Matt ran out of the office again. This time he went upstairs to the restroom. Running back

down, he slid on the stairs, fell and sustained a bruise on his left hand. He walked back into my

office with a childish grin and shrugged his shoulders. He looked at me and said, “Kids in my

home school co-op and in my youth group think I have ADD, and my dad says I’m just lazy and

disorganized. What do you think?” Joanne spoke for the first time, “That is it in a nutshell. We

just don’t know what to think or where to turn. What are we dealing with here? Is Matt just being

a boy and we have to get used to him being this way?” As if on cue, Matt pulled out his cell

phone and started text messaging someone while his parents stared at each other, hands raised

as if bewildered by their son’s behavior.

<1>Getting Started

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Matt and his parents’ questions, along with this family’s expressed frustrations, are quite

typical among folks seeking to understand Attention Deficit Hyperactivity Disorder [ADHD].

Many children and adults experience difficulties with attention, hyperactivity, impulse control or

some permutation of these states and traits. The experience of misplacing one’s belongings is

virtually universal, but at what point should one be concerned about such attention problems?

Further, is there just one type of attention? These questions are fair and reasonable because

answers to such questions will enhance a better understanding of Matt’s challenges, and perhaps

prepare him and his parents negotiate these difficulties. Embedded in this opening story are

questions about what is normal behavior in contrast to manifestations of underlying

developmental or psychological difficulties (Stolzer, 2007). Despite Matt’s apparent efforts to

remain objective by asking what I thought of his reported problems, it was clear that he was

concerned about his self-image in home school co-op and at youth group. Perhaps a related

theme involves associated emotional experiences of those diagnosed with ADHD. Finally,

Matt’s parents raised the legitimate question of their son’s possible motivational problems as

opposed to attributing childhood rebellion to some purported medical condition. Christian

professional workers are familiar with the biblical account of Adam and Eve, specifically their

impulsive behavior of eating the forbidden fruit. The Old and New Testaments are equally

replete with other examples of poor impulse control: from Esau selling his birthright for lentil

soup to Peter cutting off someone’s ear. How are we in the faith community to think about the

condition known as ADHD in light of what others might consider lack of discipline?

<1>What We Know About ADHD

Although skeptics within the scientific community suggest that ADHD is a recent

phenomenon (Jureidini, 2002; Stolzer, 2007), early twentieth century researchers alluded to

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symptoms that resembled current descriptions of ADHD (Barkley, 2007; Langberg, Epstein,

Urbanowicz, Simon, & Graham, 2008). In 1850, George Still (Hathaway & Barkley, 2003)

highlighted two features suggestive of ADHD: 1. Poor volitional inhibition and 2. Defective

moral regulation of behavior. In the 1950’s and 1960’s researchers observed behavioral

hyperactivity in children previously considered to be suffering from impulsivity and

disinhibition(Hathaway & Barkley, 2003). In the 1970’s and 1980’s Douglass and her colleagues

emphasized attention problems in the populations of children displaying hyperactivity and

impulsive behaviors (Hathaway & Barkley, 2003; Hinshaw, 1996); she underscored deficits in

the investment, organization, and maintenance [sustaining] of attention resources. An underlying

theme of all these studies is that ADHD is best attributed to other causes than factors under the

direct control of the child.

It is important for professional Christian workers to realize that the medical community is

not necessarily unified concerning the legitimacy of ADHD. Further, healthy skepticism can only

serve to strengthen and advance our understanding and improve interventions aimed at reducing

the effects of ADHD. Unfortunately, skepticism may inadvertently lead to undesirable results for

those experiencing inattention and hyperactivity. For that reason, a consortium of more than 100

medical professionals signed a consensus statement recognizing the diagnosis of ADHD along

with treatments of choice (Barkley, Cook et al., 2002). In this statement, experts expressed

concern that failure to recognize ADHD would roll back decades of scientific research and

possibly jeopardize patients already at risk for social stigma; further concerns included the

possible reappearance of functional [academic, emotional, interpersonal, etc.] deficits following

reversals in treatment (Barkley, Cook et al., 2002). A review of ADHD is warranted as it would

likely help professionals recognize these symptoms and refer as needed.

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In talking with Paul and Joanne about Matt’s difficulties, we discussed ADHD in general

and we encouraged them to keep an open mind rather than risk a quick or inaccurate diagnosis of

their son. At the end of our consultation, Matt and his parents agreed that it would be beneficial

for him to participate in a formal evaluation. In addition, our discussion encompassed a review of

attention: types, deficits, impulse control and related difficulties. Finally, we acknowledged that

ADHD is a condition that may be managed akin to Diabetes (Barkley, Fischer, Smallish, &

Fletcher, 2002), not cured like the common cold.

<2>Types of ADHD

Children and adults who might meet the diagnostic requirements for ADHD are referred

to various professionals: physicians, psychologists, social workers, and counselors/therapists. To

render a diagnosis of ADHD, these professionals must interpret presenting problems in light of

criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders – 4th

Edition (APA,

1994) or the subsequent Text Revision [DSM-IV-TR] (APA, 2000). Although there are previous

versions of the DSM and older terms for this condition [e.g., ADD], the current DSM-IV

recognizes only three variants of ADHD: inattentive type, hyperactive/impulsive type, and the

combined subtype [APA, 1994]. The (A) inattentive type of ADHD is one in which the

individual fails to pay attention to important details. These individuals are often described as

making careless mistakes. Unfortunately, such mistakes may result in greater academic or

vocational costs. For example, I recently consulted with a fifty year old woman whose executive

position was in jeopardy because her employer was concerned that this woman’s mistakes cost

the company a lot more money than revenues she earned for the organization. (B) The

Hyperactive/Impulsive variant type involves behavioral excesses such as pacing or fidgeting and

the inability to wait before expressing one’s desires/impulses. Hyperactive individuals are

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overactive when peers are not as active, particularly in situations where such overactivity would

interfere with task completion [e.g., getting up from one’s seat when other students are sitting

down and taking notes or talking to a neighbor while the teacher is giving instructions for an

upcoming quiz]. Impulsive individuals often display difficulties delaying gratification; that is,

they may act without thinking, for the immediate benefit of the moment. For example, they may

break rules in order to enjoy the thrill of the moment. In 2000, I had an experience that seared

images of impulsivity in my memory. One Sunday afternoon I went to the home of my sister in

law to polish up a document. As I sat facing the computer, my children and my niece were

playing a game at the table behind me. My niece called my name and I responded, “Please give

me one second to complete my train of thought.” Within the minute she called my name a

second time, and, before I could respond, some projectile struck the back of my head and

disintegrated onto my neck and back. I whirled around as I wiped tomato pieces from my

sweater, and asked, “What was that about?” My 15-year old niece stared at me blankly and

blurted, “I don’t know.” She was close to tears with embarrassment and I could tell that her

impulse or desire to get my immediate attention got the better of her as she acted without

thinking. Herbert Quay described impulsivity as the condition in which individuals fail to inhibit

a behavioral response, once the impulse to act has been activated by the brain (Hathaway &

Barkley, 2003; Kratochvil, Greenhill, March, Burke, & Vaughan, 2004).

While most children are likely to experience attention problems or display

hyperactive/impulsive behaviors, when such difficulties are more pronounced than might be

experienced by most children of the same age [e.g., 95-98 percent of peers], then such deficits

may be considered significant enough to warrant possible diagnosis (Root & Resnick, 2003). In

order to consider a formal diagnosis of ADHD, these symptoms must be present in at least two

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contexts (APA, 1994). Thus, for children, difficulties could be observed at home, at school, at

church, at play, etc. Adults with ADHD may experience problems at work, in relationships, at

school, etc. This criterion anticipates questions about what to do if difficulties are observed only

at home or just at school. Another criterion for diagnosis is that the individual experiencing

ADHD symptoms must display clinically significant impairment in social, academic, or

occupational functioning (APA, 1994). In my last year as a graduate student I evaluated a man

who was referred to our facility by his employer as a final step prior to dismissal from his

position. Although he was considered one of the brightest workers in his line of work, several of

his customers submitted complaints about his failure to meet deadlines and glaring errors on

projects that he completed. During my interview with this man, he reported that his wife

complained about his lack of attention to detail as supported by errors in recording his Automatic

Teller Machine [ATM] activity. The DSM-IV (APA, 1994) stipulates that ADHD may not be

diagnosed if the symptoms occur exclusively during the course of a developmental disorder [e.g.,

Autism], a thought disorder [e.g., Schizophrenia], or another mental disorder [e.g., Antisocial

Personality Disorder].

It is important for professional Christian workers to recognize that the threshold for

diagnosing ADHD is sufficiently high and the criteria are necessarily rigorous. It should be

evident by now that the callous use of the term ADHD to describe childish immaturity or adult

carelessness is unwise; after all, greater than 80% of children display inattentive and hyperactive

features that fail to meet formal diagnostic criteria for ADHD (Durston, 2003). Further, those

experiencing symptoms of ADHD resemble a diverse group of individuals whose challenges do

not conform to a homogenous set of behaviors (Ostrander, Weinfurt, Yarnold, & August, 1998).

At this point, it is necessary to review what we know or the epidemiology of ADHD [prevalence,

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course, etiology and comorbidity] as well as explore some of the purported causes of this

condition (Jarratt, Riccio, & Siekierski, 2005).

<2>Epidemiology

Is ADHD overdiagnosed in the USA? Does it exist in other cultures? Who is likely to

show symptoms of this condition? What do we know about its causes?

About 3-7% of school aged children are diagnosed with ADHD (Anastopoulos et al.,

1996; Jarratt et al., 2005; Kratochvil et al., 2004; Langberg et al., 2008; Ostrander et al., 1998;

Root & Resnick, 2003). 4 % of adults in the USA (Barkley, Fischer et al., 2002) and the same

percentage of adults in England (Engelhardt, Nigg, Carr, & Ferreira, 2008) are diagnosed with

ADHD. Prevalence rates of ADHD ranged from 2-9% in the following countries: Australia,

Brazil, (Schlachter, 2008) Canada, England, Germany, Japan, Kenya, Netherlands, New Zealand,

and Norway (Moffitt & Melchior, 2007; Monastra, 2008a; Roessner, Becker, Rothenberger,

Rohde, & Banaschewski, 2007). One reason for concern is that ADHD is reported to be up to

nine times higher in boys compared to girls (Dietz & Montague, 2006; Hathaway & Barkley,

2003). Are we not being unusually hard on American boys? These rates are generally consistent

across cultural settings (Monastra, 2008b). It is also quite conceivable that some adults with

ADHD may not have been diagnosed in childhood; however, the absence of a diagnosis should

not be taken to suggest the absence of a condition.

With respect to the course of ADHD, symptoms are often evident in childhood, before

preschool. Recent approaches question the validity of age seven as a cut off point for considering

ADHD (Barkley, 2007). One study reported that 2% of children between the ages of 3-5 met

criteria for ADHD (Kratochvil et al., 2004). Although more boys are likely to be diagnosed with

ADHD, the inattentive variant of this condition is generally higher in girls than in boys

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(Hinshaw, 2002; Hinshaw, Carte, Fan, Jassy, & Owens, 2007; Hinshaw, Carte, Sami, Treuting,

& Zupan, 2002; Monastra, 2008a). Similarly, adolescent boys are more likely to be referred for

mental health services than are younger children, girls and minorities with ADHD symptoms

(Bussing, Zima, Gary, & Garvan, 2003). Individuals with ADHD are unlike those with generic

brain injury in that their symptoms do not worsen; however, this is a condition that will not

improve by itself. Therefore, professional Christian workers should encourage those concerned

about possible ADHD to seek professional help as this will clarify whether or not interventions

are needed; after all, when a diagnosis is confirmed, interventions often extend well into

adulthood (Anastopoulos et al., 1996; Barkley, Fischer et al., 2002; Mirsky et al., 1999). Given

the global effects of ADHD, it is important to recommend early assessment.

ADHD is considered as distinct from other conditions in which attention may also be

impaired as a symptom of another health concern. Thus, individuals suffering from depression

often report disruptions in attention as well as poor concentration. Similarly, ADHD may co-

occur with other emotional disorders such that an individual displays symptoms that reach the

diagnostic threshold for at least two separate conditions (Abikoff & Klein, 1992; Dietz &

Montague, 2006; Hazell et al., 2006). We will now shift our attention to conditions that are

comorbid to ADHD.

The number of comorbid conditions to ADHD varies, with studies suggesting the

following ranges:

� 44% exhibit one other disorder [e.g., ADHD + Anxiety ]

� 33% exhibit two other disorders [e.g., ADHD + Anxiety + Eating Disorder]

� 10% exhibit three disorders [e.g., ADHD + Anxiety + Eating Disorder + Tourette]

� 33% met criteria for Oppositional Defiant Disorder(Loo & Barkley, 2005)

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� 25% met criteria for Conduct Disorder (Monastra, 2008a).

<2>ADHD and Spiritual Development

Given the host of related emotional difficulties associated with ADHD, it is not surprising

that those suffering from related symptoms report difficulties in several functional areas. Specific

to people of faith, Hathaway and Barkley (Hathaway & Barkley, 2003) studied the relationship

between ADHD and Religiousness. They concluded that individuals with ADHD experienced

religious alienation as supported by difficulties in three areas: 1) religious socialization [i.e.,

maintaining the rituals associated with congregational worship], 2) religious worship [i.e.,

communing with God in tranquility], and 3) stable spiritual growth [i.e., maintaining a consistent

faith walk].

Those serving in pastoral ministry, including lay church leaders, need to consider these

findings when structuring curricular for religious instruction. As such, it may be beneficial to

integrate upbeat music and visual imagery in order to assist some parishioners better appreciate

elements of the Eucharist. Youth ministers might integrate mime and drama to underscore key

points of a sermon on forgiveness. Left untreated, symptoms of ADHD may result in greater

difficulties for the help seekers and their families.

<2>Etiology

Although the authors of the DSM-IV described necessary and sufficient criteria for the

diagnosis of ADHD and other mental disorders, they do not provide causal hypotheses about

these conditions; similarly, treatment and intervention options are generally left to the discretion

of the clinician. Thus the question of what causes ADHD is critical to our understanding of this

condition. Those who assert that it does not exist (Stolzer, 2007) would argue that millions of

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children are being mislabeled with a condition that may simply reflect typical childish

overactivity and poor concentration.

Before reviewing studies on the purported causes of ADHD, it is important to

acknowledge popular ideas that we encounter regularly in clinical practice. These culprits

include: environmental Toxins; food additives, with dietary modifications proposed as solution;

refined sugar, with an emphasis shifts to natural foods; poor nutrition, with balanced nutrition

considered the cure; natural light deficiency; food allergies; heavy metal toxicity; subluxation,

corrected by chiropractic adjustment; and poor teaching/parenting methods combined with lack

of discipline (Silver, 1987; Sinha & Efron, 2005).

Although it is possible that these conditions might exacerbate symptoms of ADHD, it is

highly unlikely that they are the primary causes of this condition. A key problem with such

hypotheses is that they have not been subjected to the rigors of scientific research, and

proponents of such views tend to suggest alternative treatments that have not been supported by

randomized studies (Barkley, Cook et al., 2002; Durston, 2003). Encouraging those with ADHD

symptoms to consider such questionable causes is tantamount to poor counsel – word of mouth

testimonial notwithstanding. Such experiences are more challenging when the help seeking

family is referred to a practitioner of alternative therapy who happens to attend the same house of

worship.

One study investigated the causes of ADHD as perceived by medical and allied health

professionals, comparing these responses to findings obtained from parents and educators

(Dryer, Kiernan, & Tyson, 2006). Professionals concurred with parents’ opinions that ADHD is

the result of three interrelated causes: neurological compromise that occurs during development

of the nervous system [pregnancy or after birth], neurochemical imbalance or dysfunction and

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hereditary disposition (Martin, Levy, Pieka, & Hay, 2006; Nigg, Blaskey, Stawicki, & Sachek,

2004). Professionals and parents agreed with research that found no relationship between ADHD

and environmental variables; these include deficits in the home environment along with

psychosocial factor theories that attribute ADHD to parent behaviors [poor management, poor

monitoring, and parent-child conflict], and unstable family environments (Dryer et al., 2006). As

demonstrated by several studies, environmental factors tend to exacerbate and magnify ADHD

symptoms (Barkley, 1997; Monastra, 2008b; Root & Resnick, 2003).

Neurobiological deficits render individuals with ADHD vulnerable in environments that

require attention vigilance or consistent behavioral self-control. Thus, symptoms likely reflect

the interaction between underlying brain-based deficits and external / environmental demands (T.

W. Frazier et al., 2007). This interactive paradigm, sometimes termed the diathesis model (West,

Schenkel, & Pavuluri, 2008), has been associated with various conditions ranging from medical

[e.g., Arthritis] to mental health [e.g., Schizophrenia]. As applied to ADHD, the diathesis model

argues that symptom presentation is likely to be more pronounced in more chaotic environments.

This does not mean that the environment [home, school, work, etc.] causes the disorder; rather,

the environment, along with the presence of other conditions [e.g., Oppositional Defiant

Disorder], serves to magnify the outward manifestation of underlying ADHD (Pelham, Wheeler,

& Chronis, 1998; Rapport et al., 2001). The presumption of genetic vulnerability in ADHD

implies only that among plausible causes of ADHD, evidence for neurobiological factors is quite

compelling (Barkley, 1997; T. W. Frazier et al., 2007).

Durston (2003) reported deficiencies in the supply and function of the brain chemical

dopamine; she found high rates of heritability among identical twins [80%] as opposed to

fraternal twins and other family members; she observed differences in brain volume and blood

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flow in ADHD compared to nonADHD peers. Other researchers demonstrated differences in

brain electrical activity that mirrored types of ADHD (Loo & Barkley, 2005). Consistent brain

volume differences were found in association with the prefrontal region; specifically, patients

with ADHD demonstrated less brain volume in this area (Barkley, 1997; Halperin & Schulz,

2006; Hill et al., 2003). These findings further suggest that treatments targeting brain chemistry

should result in improved functioning.

While brain dysfunction may be an underlying cause of ADHD, those working with

ADHD patients often focus on cognitive and behavioral symptoms of this condition. Cognitive

theories of ADHD propose that some component of the attention or working memory system is

compromised (Barkley, 1997; Bayliss & Roodenrys, 2000; Daugherty, Quay, & Ramos, 1993;

Karatekin, 2004; Mirsky et al., 1999; Posner, 1982; Semrud-Clikeman, Pliszka, & Liotti, 2008).

According to these approaches, brain functioning may be a legitimate concern in ADHD, but

family and friends experience symptoms associated with thinking and acting. Most families often

express relief learning that a loved one’s difficulties are not the byproduct of poor parenting or

intentional and defiant behavior. Such knowledge can facilitate empathy, particularly in worship

settings where the normative behaviors require sustained attention and behavioral control

(Hathaway & Barkley, 2003).

<2>Assessment

When referring congregants for evaluation of possible ADHD, church leaders need to

demonstrate a basic appreciation of the steps involved in such assessments. A few weeks ago, we

received email communication from the concerned aunt of a preschooler wondering what we

thought about her nephew being diagnosed with ADHD at such a young age. After providing

necessary disclaimers about our inability to diagnose a child we had not met, much less on the

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internet, to someone who was not even the parent, we inquired about how the diagnosis came

about. The writer responded that one of her nephew’s teachers suggested the diagnosis. After we

reviewed the structure of a comprehensive evaluation, the writer expressed relief and stated that

she felt equipped to advise her sister, ultimately alleviating her own frustrations. At the heart of

this woman’s alarm was the question, how should ADHD be evaluated?

There are five basic steps that we recommend in assessing ADHD: 1. Interviews, 2.

observations, 3. record reviews, 4. behavior rating scales, and 5. formal cognitive testing. These

will be reviewed briefly. Interviews afford the examiner an opportunity to gather meaningful

information that provides a context and a history of presenting concerns. During a recent

interview with parents of a nine year old boy, they informed us that they were frustrated with

their son’s perpetual misplacement of assignments; teachers echoed parents’ concerns by noting

that Mike’s poor grades reflected low scores from inadequate late work or work not submitted at

all. Such discussions provide a richer context for understanding the effects of some symptoms.

Observations reflect a second source of information. When working with children, evaluators

need to observe students in structured situations [e.g., in the classroom] and in unstructured

setting [e.g., during recess or over lunch]. As with interviews, there are several instruments

available for observing children and comparing their behaviors to those of peers. Observations

allow clinicians to compare behaviors of identified children in relation to peers. Further, such

documentation provides a rejoinder to the notion that boys are just being boys (Stolzer, 2007),

particularly when disruptive behaviors exceed 95% of peers (Root & Resnick, 2003). The notion

of observing adults may be difficult although others have been successful at doing so. I recall

one of my colleagues telling of the time she went to her client’s place of employment to observe

him at work, as part of a determination about this gentleman’s fitness for the job. As it turned

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out, the man in question worked in a restaurant and he made several errors in processing my

colleague’s order. This was remarkable as he did not know that his patron was actually an

evaluator. The third component of a comprehensive evaluation involves review of records; these

range from medical, academic, military and employment data. As noted earlier, to diagnose

ADHD, impairment must be present in at least two settings (APA, 2000). In this regard, I

recently met with a 22-year old college student whose examination grades showed considerable

fluctuations over three testing periods. He wondered out loud about learning disability, voicing

further doubts about ADHD. When he realized that learning disabilities typically reflect

consistently poor performance in a given area, he produced a letter from his employer

threatening dismissal from his part time job at a local printing company. As with his schoolwork,

concerns were associated with inconsistency of performance, a hallmark of ADHD (Barkley,

2007). A fourth source of information comes from behavior ratings scales. A benefit of such

instruments is that they yield information about several conditions [depression, anxiety,

withdrawal, hyperactivity, etc.]. Given that ADHD is primarily a behavior condition (Daugherty

et al., 1993), rating scales help clarify diagnostic questions. Two studies demonstrated the

sensitivity of rating scales to confirm the diagnosis of ADHD (Jarratt et al., 2005; Ostrander et

al., 1998). Cognitive neurodevelopmental assessment comprises the final component of

comprehensive evaluations. This aspect may include review of intellectual reasoning, evaluation

of attention systems, memory testing, sensory-motor assessment, executive functions, etc.

(Ottowitz et al., 2002). Although ADHD is generally characterized by behavioral deficits,

cognitive difficulties often accompany these symptoms. To that end, we will now turn our

attention to treatments and interventions for ADHD.

<1>What We Can Do: Best Approaches for helping

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In this final section we will discuss treatment options for ADHD, with a focus of research

supported effective interventions. Prior to addressing three primary interventions for managing

ADHD [medications, school interventions and family / psychosocial approaches] it important to

make brief mention of four alternative treatments to this condition. One study examined research

related to the purported effects of neurofeedback on the symptoms of ADHD and concluded that

there was not enough evidence to promote this treatment approach (Loo & Barkley, 2005).

Another researcher analyzed the purported benefits of St. John’s Wort on ADHD and found no

meaningful improvement in functioning (Weber et al., 2008). A third study assessed the benefits

of diet modification on ADHD and found no meaningful changes in behavior (Schnoll,

Burshteyn, & Cea-Aravena, 2003). A somewhat more ambitious attempt involved multiple

elements for treating ADHD; these included chelation, environmental control, and nutritional

changes. Again, this study failed to demonstrate meaningful results (Benda, 2007). Following a

review of numerous homeopathic treatments, Jacobs concluded that these approaches were

wholly unsupportable (Jacobs, Williams, Girard, Njike, & Katz, 2005).

Almost invariably when we present on ADHD, to Christian and mixed professional

audiences alike, we have noticed more questions about homeopathic cures from the religious

community than other groups. In most cases, these concerns are framed within the context of not

wanting to pump drugs into one’s body or that of an innocent child. The unstated assumption in

such questions is that homeopathic treatments are not chemical. It may be more accurate to note

that these chemical approaches have not satisfied the requirements of the Food and Drug

Administration [FDA]. Although the concept of natural cure may sound appealing, the truth is

that these approaches are chemical in nature; what is worse is that we do not fully understand

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their mechanism of action. Indeed those in pastoral care situations need to highlight these

concerns for church members who may tout alternative treatments for ADHD.

Changes in brain chemistry, particularly the dopamine system, have been associated with

ADHD (Durston, 2003; Root & Resnick, 2003). Stimulant medications [e.g., Ritalin] are

generally prescribed to correct such chemical problems. The American Association of Child and

Adolescent Psychiatry issued a statement indicating that stimulant medications are safe and

effective, even when administered to preschoolers (Semrud-Clikeman et al., 2008). As can be

expected, the same body clarified that treating physicians should closely monitor dosages for

such medications. Other benefits of stimulants include reduced impulsivity and behavioral

dyscontrol (Ottowitz et al., 2002). In response to concerns about the negative effects of

medications, a review of numerous studies found minimal risk associated with use of stimulants.

Although medications are quite effective in managing some of the behavioral excesses associated

with ADHD, these agents work best in conjunction with cognitive and behavioral interventions

(Voeller, 2004). We now review how such approaches may be utilized within the school setting.

School represents an important domain in which ADHD symptoms lead to negative

results. As noted, students with ADHD are likely to exhibit functional deficits on academic tasks

as well social interactions at school (Barkley, 2007; Root & Resnick, 2003). Children with

ADHD are eligible for remedial services within the school setting as stipulated by the Individuals

with Disabilities Education Act of 1973, revised in 1997 and 2004 (Durston, 2003; Monastra,

2008b; Pelham et al., 1998). Sometimes school interventions entail using the services of an aide

to assist the child with academic tasks that require sustained attention (Pelham et al., 1998).

Other times the child may be afforded time accommodations, modified instructions, reduced

homework or other modifications in instruction.

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One study demonstrated academic improvement for ADHD students who learned three

functional skills: organization, homework management, and assignment completion (Langberg et

al., 2008). This approach seems like the logical extension of theories that associate ADHD with

dysfunction of the prefrontal area and related impairment of executive functions (Barkley, 1997;

Halperin & Schulz, 2006). In the organization stage, students were trained to use color coded

binders to store assignments and instructions for later completion. Management included

providing a structure and devising a way to complete specific assignments. Finally, completion

entailed addressing all details related to an assigned activity. The success of this intervention was

attributed to parental involvement as well as consistency of reinforcement. Again, we cannot

over emphasize the role of consistent reinforcement in teaching and maintaining target

behaviors.

Within the family context, one model of behavior management targeted three types of

interactions between parents and their ADHD children. Walton (2007) observed categorized

these relationships as follows: 1) child is viewed as the center of the universe, 2) parent threatens

discipline but takes no action, and 3) parent is overly punitive and extremely controlling. In the

first scenario, parents were trained to set limits and maintain firm boundaries for their disruptive

children. The parents who issued empty threats were trained to say less but consistently enforce

established rules. Third, controlling parents were encouraged to back off their rigid rules and

admit to their children that they were excessively punitive. This show of healthy parental

vulnerability was often accompanied by improved child self-esteem because children viewed

their parents as individuals who were willing to learn from their mistakes (Walton, 2007).

Frazier reported that children and adults receiving behavioral interventions showed overall

improvement in functioning relative to untreated peers (M. R. Frazier & Merrell, 1997). It should

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be clear from these findings that behavior management techniques can only work when

administered consistently. Inconsistency is likely to yield chaotic results in managing ADHD.

Cognitive behavioral interventions were used successful to reduce ADHD symptoms in

the home setting. In one study, parent training was most helpful for younger, school aged

children whereas family based counseling was most beneficial for adolescents (Anastopoulos et

al., 1996; Pelham et al., 1998). Cognitive behavioral interventions entail connecting a client’s

thoughts to her emotions, and ultimately to her behaviors. This approach to managing ADHD

symptoms was not effective in three conditions: 1) when symptoms were too severe, 2) when the

client’s intelligence was low, and 3) when the primary parent was suffering from depression

(Hinshaw, 1996). Cognitive behavioral interventions yielded symptom reduction in ADHD,

particularly with parents that showed effective parenting (Walton, 2007). When combined with

medications, psychosocial treatments were quite effective in reducing ADHD symptoms in

adults (Ramsay & Rostain, 2007).

<1> Conclusion: ADHD is a difficult condition affecting children and adults alike. In this

chapter, we provided several tools to equip the professional Christian worker engaged in ministry

to individuals and families dealing with ADHD. It is hoped that educated professionals will

facilitate an atmosphere where worshippers suffering from this and other mental disorders will

feel understood, accepted and supported. It is our conviction that an attitude of affirmation

toward those with ADHD truly reflects Christ’s mandate to his followers to love one another.

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<1>References

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Appendix1: Sample of report recommendations for ADHD patients.

1. PEDIATRIC PSYCHIATRY: It is important for Child’s parents to consult Pediatrician’s

office to consider medications. Studies have shown the benefit of stimulant medications as well

as (recently) non-stimulant agents. Such a decision might require several follow up meetings

with the pediatrician in order to review matters of tolerance, dosage, and efficacy for Child’s

purposes. This approach may enhance his focus and increase achievement on some tasks.

2. SCHOOL: (a) Child will need to participate in formal psychoeducational assessment;

this might include measures such as the WIAT-II. From his performance on the current

evaluation, however, the following recommendations are being recommended: (b) Sitting: Given

his susceptibility to environmental distractions, it is advisable that Child learns in a relative

disruption-free environment; as such, it may be necessary that he enroll in small classes and sit

close enough to the instructor in order to derive maximum benefit from the learning experience.

(c) Note-taking: his organizational, planning, and listening comprehension difficulties are noted.

He will need to augment regular note-taking through the use of audio-recording devices. It is

also important that he obtains thorough outlines of all lectures so as not to tax his concentration

by having to write notes while attending to new and unfamiliar learning material. He will need

assistance with organizing his work for study and later testing. This process will require

guidance by an individual familiar with ADHD and learning disabilities in adolescents, an

educator capable of providing guidance in a non-anxious manner. (d) New Learning: Child

needs multiple repetitions to enhance learning of new material. He benefits from learning when

material is well-organized (concrete and easy to follow) presented in small, self-contained,

manageable units/”chunks.” As noted earlier, he needs a few breaks when undertaking tasks that

require sustained mental effort. In this case, he will come back to the task with greater focus and

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feeling “recharged.” It is helpful to present new material in various modalities to enhance

efficient encoding of the same. (e) Evaluations: On account of impulsivity when engaging in

rapid mental processing, this student will require extra consideration on timed tasks. Thus an

extra 30-40% time accommodation is recommended so as to enhance efficient academic problem

solving. In this regard, the volume of reading assignments outside the classroom should reflect

an appreciation of his difficulties with reading speed and comprehension. In the same process,

however, it is recommended that he be rewarded for deliberate/careful processing of new

material. That is, instructors and parents need to be intentional about reinforcing thoughtful and

well-paced work habits rather than inadvertently commend him for being fast while, in fact, he

might just be impulsive. (f) Tutorship: He would benefit from individualized support for reading

comprehension (highlighting, anticipation, freedom from context-dependence, etc.) as well as

numerical operations. (g) Planning: As he considers high school education, Child will need

further assistance with essays and all long-term ancillary projects. All these services would best

be delivered under the coordination of faculty familiar with his needs and relative strengths. (g)

Accountability: Parents and educators are encouraged to develop a joint-accountability

program to ensure that these recommendations are instituted and revised as needed.

3. HOME: (a) Owing to the presence of the difficulties noted in the diagnosis section

(above), Child would qualify for academic (high school) support services under the guidelines of

the Individuals with Disabilities Educational Act (most recently revised 2000). (b) It is important

that Child have a predictable schedule. He needs to be afforded considerable breaks during long

homework assignments. That is, he should be allowed to take breaks, say, every 30 minutes

during tasks that require sustained mental effort. This will enable him to re-focus his energy and

maintain his attention on tasks at hand. (c) It is also beneficial for parents to coordinate projects

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(homework, take-home assignments, etc.) and other school tasks with his teachers. That is, some

form of communication between home and school in the form of e-mail, notes or telephone calls

will facilitate better organization and completion of homework assignments. This observation

comes from literature (Barkley, 2007) suggesting that most ADHD students will function at the

maturity level of children who are generally 30% younger. Comments provided during the

clinical interview also confirmed this finding.

4. THERAPY: It is highly recommended that Child continues his course of cognitive

behavioral therapy. Counseling will provide opportunities for him to discuss feelings as well as

behavioral consequences to some of his ongoing struggles related social and academic

difficulties and adjustments thereof.

5. FOLLOW UP EVALUATION: It is recommended that Child participate in a vocational

assessment. This process will provide opportunities to better describe his interests and skills as

well as assist with selection of the most appropriate academic program.